Clinical Notes For MRCGP (INT)

OUTLINE FOR ALL OSCE STATIONS BRIEFLY
1. OPENING CONSULTATION
Hello
I am Dr. Raheel.
One of the GP in the surgery.
May I know your good name please?
Ok Mr. Qureshi what brings you to surgery today?
SP reveals some symptoms of his condition freely.
Ask anything more he likes to add twice.
When SP says that’s all then
Explore details of symptoms described or Ask few more relevant symptoms.
2. DATA GATHERING
HISTORY OF PRESENT ILLNESS

Ask open ended questions about each symptom described by the patient then
Ask closed ended questions
Ask three to five differential diagnosis questions then
Ask few questions about red flags of his condition
HISTORY OF PAST ILLNESS

PERSONAL HISTORY
FAMILY HISTORY
DRUG HISTORY
SEXUAL, MENSTRUAL, OBSTETRICAL & GYNAECOLOGICAL HISTORY
TRAVEL HISTORY IF RELEVANT, NOT IN ALL CASES.
ILLNESS
IDEA
CONCERN
EXPECTATION
SUMMARIZATION
EXAMINATION
INVESTIGATIONS
SUMMARIZATION
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MANAGEMENT
REASSURANCE OR EXPLANATION
NON-PHARMACOLOGICAL MANAGEMENT
(LIFE STYLE CHANGES)
PHARMACOLOGICAL MANAGEMENT
PREVENTION, HEALTH PROMOTION & EDUCATION
Referral
FOLLOW UP
SAFETY NETTING
CLOSING & SEE OFF

In the end ask once again
If patient has anything else to discuss or share today?
Deal with the hidden agenda appropriately
End the consultation by saying
You can collect leaflet about your condition from the reception desk
Further information from the internet
Thank you very much for your cooperation and visit
Good bye with the smile and shake hand
Remember never to shake hand with rabies or scabies patient.
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WORDINGS OF QUESTIONS
FOR OUTLINE IN BRIEF
1. OPENING CONSULTATION
Hello
I am Dr. Raheel.
One of the GP in the surgery
SP reveals some symptoms of his condition freely.
Ask anything more he likes to add twice.
When SP says that’s all then
Explore details of symptoms described or Ask few more relevant questions.
2. DATA GATHERING
Ask open ended questions about each symptom described by the patient or new relevant
symptoms
Ask closed ended questions
Ask three to five differential diagnosis questions then
Ask few questions about red flags of his condition
Is there any similar history in the past?
Any hospitalization in the past?
PERSONAL HISTORY
Do you smoke. How much? Do you intent to quit?
Do you drink alcohol. How much? Any intention to cut down?
Any recreational drugs?
Any high blood sugar?
Any high blood pressure?
What sort of food do you like?
Do you like to exercise?
How do you rate your weight? Do you know your BMI?
Are you married?
Any kids?
How are the things at home?
What do you do for living?
How are the things at work?
What about your mood?
What about your sleep? (Any sleep disturbance)
What about your appetite?
FAMILY HISTORY
Is there any major medical illness in your immediate family members?
Like high blood sugar?
High blood pressure?
Any heart problem?
DRUG HISTORY
Are you taking any medicine regularly prescribed or from over the counter?
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If yes, which medicine in what dose you are taking?
Any drug allergies?
SEXUAL, MENSTRUAL, OBSTETRICAL & GYNAECOLOGICAL HISTORY
Always forewarn the patient before asking sensitive private matters such as sexual history.
Say
Now I would like to ask few personal and private questions but before that let me assure you
that our whole conversation will remain confidential between you and me & nobody else will
ever know about it.
Is it ok with you?
Patient will say, yes, you may proceed.
I thank you for trusting me.
(Confidentiality point is very very important.)
TRAVEL HISTORY
Ask travel history only if relevant.
For example, If patient has travel to Africa where Malaria or Dengue is prevalent or he has
traveled to endemic area of India where there is high prevalence of HIV or tuberculosis
patients.
ILLNESS
What is the impact of this condition on your life?
Or how this condition has affected your life?
IDEA
What do you think is the cause of your symptoms?
Or how do you understand your problem?
CONCERN
Are you worried about anything in particular or specifically?
EXPECTATION
What do you hope to gain from today’s consultation?
SUMMARIZATION
Now at the end of data gathering summarize the whole history taken in few sentences.
Summarize only positive points pointing towards your working diagnosis briefly in 2 or 3
sentences.
Then ask, It is that all or you want to add something to it?
EXAMINATION
In order to reach my diagnosis I need to examine you.
Can I examine you?
Ok.
Thank for allowing or trusting me for examination.
Do only focus clinical examination according to the history of patient as we do in our daily
clinical practice.
Remember we are general practitioners and not specialist.
INVESTIGATIONS
In order to confirm my diagnosis I offer you certain tests. How it sounds to you if we arrange
certain blood tests & X-rays etc.
SUMMARIZATION
Again summarize only key positive findings briefly along with the points gathered during
examination and from investigations already done.
Tell him
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What I have gathered from information you have shared with me and from examination I
performed, is that most probably or most likely you are having a condition which we call in
our medical terminology as COPD or migraine or diabetes or hypothyroid.
Do you know anything about hypothyroid.
No Doc.
Would you like me to explain what is hypothyroid.
Yes Doc.
MANAGEMENT
REASSURANCE OR EXPLANATION
Reassure if the problem is a minor one e.g.
If it is a simple viral illness reassure the patient that it is a common condition and it is self-
limiting. It will go away in few days or
You are having a condition what we call as benign prostate hypertrophy. It is a common
condition in people aged more than 60. It is easily treatable with some medicines or with
some surgery.
If it is a serious life threatening problem then explain as breaking bad news e.g. the lump in
your breast on investigations shows that it could be a growth or a tumor which is malignant.
Don’t use word cancer.
Or Your urinary symptoms are not due to simple enlargement of prostate gland. The
ultrasound report, DRE report and PSA report confirms that your symptoms of significant
weight loss and backache are due to prostate cancer.
NON-PHARMACOLOGICAL MANAGEMENT
(LIFE STYLE CHANGES)
While dealing with the management it is consider better if you deal life style changes first but
you can start the medicine part first if appropriate. The life style changes include.
Rest
Activity
Diet
Exercise and weight management
Smoking cessation
Alcohol cut down to safe limit
Proper posture advice
Any sleep disturbance
What about your appetite & mood
After every step ask the patient for his agreement by saying. Can you do it for me?
Is it ok with you?
Can you comply with the changes?
Can you manage it?
This is called a negotiated or shared management plan with patient centered approach.
Pharmacological management starts by saying
I offer you a tablet, syrup or injection which you are supposed to take three times a day for
two weeks.
Doctor is supposed to give generic name of the drug. Prescribe the right drug, in right dose,
right time, (Day or night) & for how long (Duration) & right route.
Also explain the side effects of drugs prescribed. Do Safety Netting.
Check whether you are understood by the patient. Check whether your plan is acceptable to
him.
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PREVENTION HEALTH PROMOTION & EDUCATION
Do not forget to give opportunistic health promotion advice about smoking cessation, safe
drinking, safe sex etc. etc.
Influenza Vaccine every year and Pneumococcal vaccination once in life time in diabetic
patients or immuno-compromised patients.
Smoking is harmful in a condition like Asthma or Diabetes so I offer you to quit smoking.
Is it ok with you?
I am offering you hepatitis B vaccine as you work in medical laboratory.
I offer you Aspirin and statin tablets to prevent 2nd attack of MI or stroke.
Is it ok with you?
RREFERRAL
In order to have better understanding of your condition I offer you to refer you to a specialist
who is expert in your condition.
I will be issuing a referral letter to neurology department (or oncology) department to find out
the exact cause of your symptoms.
FOLLOW UP
I offer you a second follow up visit within 24 or 48 hours (After two weeks or one month)
However if you develop any new symptoms or problem you can come earlier.
Is it convenient to you.
If patient do not agree alter it according to the patient’s convenience.
SAFETY NETTING
Many a times diagnosis is based on most probable cause.
Rarely may it turn out to be a serious cause.
Always say, most probably or most likely it is a simple viral flue which will go away in few
days but if you feel increase in fever, headache, pain or stiffness in neck please seek
immediate medical help.
If your fever does not improve in three days we may consider offering you some blood tests
and prescribing antibiotics.
The child seems fine at the moment but if you notice that child is getting drowsy or stop
feeding or getting unwell instead of improving or deteriorate in any way, you should take him
to the hospital.
CLOSING & SEE OFF
In the end before concluding your consultation ask once again
Is there anything else you would like to ask or share or discuss with me today?
Patient may tell his hidden agenda in the last minute. Postpone it till the next meeting by
saying
Would it be a good idea if we discuss your knee pain (or any other symptoms he says)
in a next meeting in detail in coming few days?
End the consultation by saying
You can collect leaflet about your condition from the reception desk
Further information from the internet
Thank you very much for your cooperation and visit
Good bye with the smile and shake hand
Remember never to shake hand with rabies or scabies patient.
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LIST OF USUALLY ASKED EXAMINATIONS IN OSCE
1. General Physical Examination
2. CVS examination includes GPE, inspection, palpation, percussion and auscultation.
3. Respiratory examination system GPE Also inspection, palpation, percussion and
auscultation.
4. GIT examination According to latest guide lines always start with auscultation. If no bowl
sounds, do not proceed for palpation & percussion. If bowel sounds present, start with
GPE; inspection, palpation, percussion.
5. Appendicitis GPE complete abdominal exam (Mc burney’s Point Illustration and
Rovsing Sign)
6. Cholecystitis GPE complete abdominal exam , (Murphy’s Sign Illustration)
7. Brief neurological Exam.
8. 12 cranial nerves examination
9. Vertigo
10. Thyroid examination
11. Diabetic Foot Examination. Includes inspection, palpation, movement, motor system
(power, tone, reflexes) & sensory system (position, vibration, sensation by 10 gm
monofilament )
12. Neck pain Exam. (All 5 movements plus one or two shoulder movement)
13. Backache Exam. Inspection, palpation of spinal & paraspinal muscle from cervical to
sacrum. Movement including flexion, extension, lateral bending right and left, rotation plus
SLR.
14. Shoulder Examination in shoulder pain station (look , feel & move.
15. Tennis Elbow Exam. Inspection, palpation, movement (Resisted wrist extension)
16. Golfers Elbow Exam. Inspection, palpation
Movement & (Resisted Pronation)
17. Carpal Tunnel Syndrome Exam. Inspection, palpation, movement & (Phenel & Tinnel
Tests)
18. Seizure - Ruling out sensory motor deficit in seizure
19. Examination in case of sinusitis
20. Mumps (Inspection & palpation)
21. Deep Vein Thrombosis (GPE, inspection, palpation ,movement and heart sound).
22. Renal Colic (Bimanual Palpation of both kidneys, Renal Punch & illicit Tenderness and
percussion Over Bladder Area + Rule out Cholecystitis & Appendicitis in right sided renal
collic.
23. Rheumatorid Arthritis.
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24. Fibromyalgia.
25. Giant Cell Arteritis.
26. Varicose Vein.
27. Meningitis Examination
28. T.I.A. Examination
29. Sinusities Examination
NOTE:
No intimate examination is required e.g. Breast Examination & Per Rectal or Vaginal
Examination.
Also no painful examination is required e.g. Eye (Ophthamoscopy) Ear (Otoscopy), no nose
examination.
No Paeds Examination (only pictures will be shown)
Similarly, no skin examination (only pictures will be shown)
No BP measurement,
No temperature checking.
Findings will be given.
_______________________________________________________________________
Website for Videos of Examinations:
www.youtube.com
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LIST OF RECOMMENDED BOOKS FOR MRCGP PART II OSCE
1. AN INTRODUCTION TO MRCGP [INT] UK SOUTH ASIA OSCE
BY DR. RAHEEL AKBAR
2. OXFORD HAND BOOK OF GENERAL PRACTICE
(LATEST EDITION)
3. GET THROUGH MRCGP

BY BRUNO RUSHFORTH & VAL WASS
(FOREWORD BY JACKY HAYDEN)
4. SUCCEEDING IN THE MRCGP CSA
BY MILAN MEHTA, CHIRAG MEHTA
& KHIZZER MAJID
5. RAHEEL MRCGP MADE EASY NOTES
(OVER 100 READY MADE SOLVED CASES)
(CAN NOT BE PUBLISHED)
AVAILABLE FROM FAMILY MEDICINE DEPARTMENT OF FATIMA MEMORIAL
HOSPITAL. LAHORE. PAKISTAN (ALI)
6. CLINICAL METHODS
By: Dr. Mohammad Ali
7. SHORT TEXT BOOK OF MEDICAL DIAGNOSIS & MANAGEMENT

BY MUHAMMAD INAM DANISH
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LIST OF RECOMMENDED WEBSITES
(1) WEB SITES FOR PREPARATION OF OSCE

• WWW.PATIENT.CO.UK
• MRCGP CSA COURSE PREP.CO.UK
(2) WEB SITES FOR OSCE CONSULTATION VIDEOS

• WWW.EFFECTIVECONSULTING.COM
• WWW.YOUTUBE.COM(SEARCH FOR)
VIDEOS FOR MRCGP OSCE
VIDEOS FOR AMC OSCE
VIDEOS FOR PLAB OSCE
(3) WEB SITES FOR EXAMINATION VIDEOS

• WWW.YOUTUBE.COM
• WWW.MEDQUARTERLY.COM
• WWW.GEEKYMEDICS.COM
Note:
As you open web site for examination video, kindly keep in mind that examination techniques
for undergraduate candidates and post graduate candidates are a little different in their detail.
In post graduate exam, you need to be brief and quick.
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CHEST PAIN D/D
Ask all questions about pain (OD-PARA-MI) On set, Duration, Progression,

Associated features, Relieving factors, Aggravating factors, Medicines taken, any
Investigation done so far.
D/D
MI, Unstable Angina, Pericarditis, Dissecting thoracic aneurysm, Pulmonary
Embolism, Pleurisy, Pneumothorax, Oesophagitis, Musculoskeletal pain, Costochondritis,
Shingles, Bornholm’s disease, Idiopathic chest pain, Non-cardiac chest pain
You can do the D/D by the following sentences asked in laymen’s language.
Do you have one swollen tender leg (DVT).
Did you travel for more than five hours at a stretch.(PE).
Any surgical procedure done recently.
Do you have difficulty in breathing.
Did you ever coughed out blood.
Do you have any rash on one side of the chest (Shingles).
Can you pin point your pain with one finger (Musculoskeletal Pain)
Is your pain worse on movement (Costocondritis)
Any Burning in this centre of chest which is relieved by antacid (Esophagitis)
Any difficulty in swallowing (Esophageal Cancer)
Any history of recent chest trauma and increasing breathlessness (Pneumothorax)
Do you have sharp central chest pain which is relieved by sitting forward or made
worse on lying on left side (Pericarditis)
Do you have sudden tearing chest pain radiating to back (Dissecting thoraxic
Aneurysm)
Is your chest pain accompanied by sudden mild breathlessness, worse on breathing
in and blood in phlegm? (Pulmonary Embolism) with history of travel or immobilization.
Do you have sharp localized chest pain with H/o worse on breathing in? (Pleurisy)
RED FLAG
Any significant weight loss (Malignancy)
Any temperature (TB, Pneumonia)
Any night sweats (TB)
Any coughed out blood (TB)
EMERGENCY MANAGEMENT OF MI
(Read emergency management of MI from OSCE book Page 53)
Also read Page 1081 Oxford Book of GP 4th Edition)
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MYOCARDIAL INFARCTION IN EMERGENCY
Mr. Allah Rakha, 51 years presents in surgery with severe chest pain for the last 10
minutes.
Please gather data and manage.
Proceed.
Hello.
I am Dr. Raheel. One of the GPs in this surgery.
I am Allah Rakha, 51 years.
What brings you to he surgery today?
Or Mr. Allah Rakha how can I help you today?
Doctor I have severe chest pain for the last 10 minutes.
Doctor its like a heavy weight on my chest & I am short of breath as well.
Is there anything else you want to share with me today?
No doctor that’s all.
In order to reach my diagnosis I need to ask you few questions but as you are in severe chest
pain. May I offer you some pain killer before we proceed.
No doctor I can bear it for a while you can proceed with your questions.
SOD – Para – MI
Since when you are having this pain? (10 Minutes)
What were doing when pain started?
I was walking uphill, back to my home carrying grocery for week end.
Where is the pain? (It is in the center & left side of chest)
Is it constant or comes & goes?
It is constant.
How severe is the pain on the scale 0 to 10?
Its around 7.
Does it go anywhere else up or down?
It goes to my left arm upto little finger also to neck & jaw.
What relieves the pain? (Nothing seems to relieve the pain neither stopping from activity or
taking rest)
Note: Mycardial Infarction pain does not subside with rest or stopping activity. Infact
you need a strong pain killer like morphene or pathedine toe stop the pain. But Anginal
pain is relieved by stopping the activity and taking rest.
What aggravates the pain? (Exertion)
Is there any associated feature with pain?
Yes I feel nausea & perfuse sweating.
Have you taken any medicine so far?
Paracytamol from OTC but no relief.
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Have you gone through any investigation so far?
Yes I have this ECG done.
Doctor takes ECG & reads carefully.
ECG show anterior infarction.
Well Mr. Allah Rakha I am a little concerned about your condition. May I ask you few more
questions quickly if you allow me?
DIFFERNTIAL DIAGNOSIS
Can you pin point this pain with one finger? (No its all over chest particularly left side.)
(Musculoskelatal pain)
Is it related to movement? (No) (Costochondritis)
Did you have any chest trauma with increasing breathlessness? (No) (Pneumothorax)
Do you have fever & with blood in phelem with chest pain? (No) (Pulmonary Embolism)
Did you travel for more than 5 hours recently at a stretch? (No)
Is there any unilateral pain with vesicular rash (Fluid filled rash)? (No) (Shingles) (Imporatnt
Question)
___________________________________
Just few more questions quickly
Do you smoke? (Yes 2 packs a day)
Do you drink Alcohol? (Yes 4 units/day)
Do you have some heart problem running in your family?
(Yes my father died of heart attack at the age of 60)
Do you have high blood sugar? (No)
Do you have high Blood Pressure? (Yes)
How are the things at work? (Very stressful)
My company is down sizing & I may loose job anytime.
How are the things at home? (My wife left me few days ago)
Well Mr. Allah Rakha your ECG show certain changes which could be as serious as heart
attack. I offer you admission in cardiology in emergency.
Is it ok with you?
Do you agree?
But doctor my flight is booked to the other city in next few hours where I am supposed to visit
my new born grand daughter.
It is my considered opinion as your doctor that it is better to get yourself admitted in
emergency and visit your grand daughter once you have recovered.
Ok doctor. If you say it could be as serious as heart attack. I agree to get myself admitted.
Is anybody accompanying you at the moment? (No)
Would you like me to inform your family? (Yest doctor please)
I am calling ambulance right away now. While ambulance is on its way. I offer some pain
killer injection morphene 2.5mg in muscle along with anti-vomiting injection Metoclopramide
10mg I/M or I/V.
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This will relieve your pain & nausea.
is it ok with you? (Yes doctor)
I offer you 2 tablets of dispersible asprin (300mg) in glass of water.
This will help to dissolve the clot in blood vessel.
I offer you 100% oxygen as pulse oximetry show your oxygen saturation less than 92%.
I offer to establish I/V line.
I offer to take some blood samples for cardiac enzymes Tropnin I & T.
Blood C/E, urea Cr. & Electrolytes, LFT
This will save some time in emergency.
I will give written record of all the medicine given at surgery in order to avoid duplication in
emergency.
In emergency they will try to dissolve the clot with some medicine in drip which is blocking
your heart blood supply (which is only 20 minutes away)
Is there anything else you want to discuss with me now?
No doctor.
I will continue to take care of you once you are reovered from your heart attack.
Thank you for your cooperation.
Good bye.
________________________________________
Please consult page 56 & 57 from Green Book An Introduction to MRCGP for 4 types
infarctions.
Also CVS examination at page 10 & 11 from Blue Book clinical examination in written form &
over 150 images.
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ANGINA
SCENARIO
Mr. Ashraf Butt presents in your surgery with chest pain. Take a relevant history
and manage. Proceed.
UNSTABLE ANGINA
Chest Pain on minimal or no exertion pain at rest or Angina which is rapidly worsening.
urgent referel to Cardiology. Admit if attack are severe, occur at rest, or last more than 10
minutes even with GTN spray.
MEET & GREET
Hello Mr. Butt: I am Dr. Raheel. How can I help you today?
INFORMATION FREELY REVEALED
Well Doctor I had heart attack last year. Since then I used to have chest pain on
exertion which used to get relieved by GTN spray but now I get chest pain more frequently,
more severe in intensity & its duration has increased.
(Ask all questions (SOD-PARRA-MI) about pain in open ended questions e.g.
O – Onset – How did your pain started? What was you doing when pain started?
S - Site _ Where is the pain? (Its in the centre of chest & its crushing in nature)
D – Duration - When did your pain started? (about 10 minutes ago)
P – Progression – It is increasing in intensity? (Yes its constant)
A – Associated feature – Is there any associated symptom along with pain? (yes Nausea &
Vomiting & profuse Sweating)
R – Radiation – Does the chest pain go anywhere else? (Yes to my left arm also to neck &
Jaw)
R – Any relieving Factor – Any thing that relieves your pain? (Yes with rest and GTN spray it
is relieved)
A – Aggravating Factor – Any thing which aggravates your pain. (yes – Cold weather,
Emotions, heavy meal & exertion)
M – medicine - Have you taken any medicine so far (Yes, pain killer Paracytamol but not
relief)
I – Investigation – Have you undergone any investigation so far. No ECG done.
Have you undergone exercise tolerance test and thallium scan so that Angiography and
possible stenting could be done.
No Doctor, I have severe osteoarthritis of both knee joints so exercise tolerance tests could
not be done. I was a little hesitant about radioactive thallium scan so my angiography is still
pending.
RED FLAG
Have duration of your pain ever exceeded 15 minutes. (No, it stops in less than
10 minutes)
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D/D
Do D/D of chest pain.
Is your chest pain relieved by taking antacids (No) (Not Indigestion or gas)
Can you localize your pain with one finger (No) (Not mechanical) (Muscularsckeletal)
Is pain aggravated on movement (No) (Costochondritis)
Is there any trauma to chest (No) (Pneumothorax)
Is it worse on lying down (CCF)
Is it relieved on sitting forward and worsened on lying on left side. (Pericarditis)
SUMMARISE
Well Mr. Butt you have chest pain for the last 10 minutes which radiates to your Neck
& left arm & is associated with sweating & nausea & it is relieved with rest & GTN spray.
Is it all or you want to add something to it?
No thats all.
PAST HISTORY
Did you have similar attacks in the past? (Yes, I get it off & on).
Any history of hospitalization due to chest pain? (No)
PERSONAL HISTORY
Do you smoke, How much? (Yes) intent to stop all together. (Yes 2 packs)
Do you drink, How much? (No) intent to cut down. (Yes more than 3 units)
How are the things at home. (Any Stress) Wife left me few days ago.
How are the things at work. (Any Stress) (Company downsizing likely to be
unemployed. Great stress.
Are you Asthametic. (B. Blocker contraindicated as cause bronco constriction) (No.)
What is the nature of your job (Cashier) (Big responsible) (All ways under stress)
FAMILY HISTORY
Any history of heart problem in immediate family. (Yes) My father died of heart attack
at 60 years.
Any history of high blood pressure. (Yes) Father Brother has increased B.P.
Any history of high blood sugar. (No)
DRUG HISTORY
Are you taking any medicine regularly. (No, Not other than GTN spray)
ILLNESS
How this chest pain has affected your life. (I can no longer do heavy manual work)
IDEA
What do you think you are suffering from. (I am told its anginal pain)
CONCERN
Are you worried about somethings specifically? (I might die of another heart attack)
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EXPECTATION
What do you hope to gain out of today’s consultation.
(I hope you will prescribe some more medicines besides GTN spray which will relieve
my pain)
SUMMARIZE
So Mr. Butt you have chest pain radiating to your neck & left arm which is relieved with
rest. You are a heavy smoker with strong family history of similar complaints. You are afraid
of having another heart attack and expect to be given some medicine to get relief from pain.
Is it all or you want to add anything else to it?
No that’s all
EXAMINATION
In order the confirm my diagnosis. I need to examine you. Can I examine you?
Will you move to the Couch and take your shirt off for me.
Check General Physical Examination, CVS System and Briefly lungs
Check pulse.
Check blood pressure.
Listen to the heart sounds of all areas (Formula for 4 areas) (All Patients Take
medicine) (Aortic, Pulmonary, Tricuspid, Mitral)
Listen to the chest from back, on apex, middle and lower zone & basis for crepts.
INVESTIGATION
I offer you a 12 lead ECG urgently.
Is it OK with you?
Also I offer you the following blood tests.
Cardiac enzymes (Troponin I & T)
Fasting Lipid profile (For Hyperipidemia)
FBC ESR (To exclude Arteritis)
Fasting Blood Glucose (For Diabetes Mellitis)
TFT
MANAGEMENT
REASSURANCE AND EXPLANATION
As you know your blood supply to the heart is compromise due to narrowing of heart
blood vessels. During exertion when demand of blood is increased and not met with, Anginal
pain occurs.
We need to take care of measures regarding your diet and exercise hypertension,
smoking, along with some drugs on regular basis. Hopefully with these measure your pain
will be relieved and you might not need surgical treatment. We will talk about all these steps
of management one by one. Is it OK with you?
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1. NON DRUG TREATMENT (Life Style changes offered)
SMOKING CESSATION
Smoking increase narrowing of heart blood vessles so you need to stop smoking all
together. Can you do it? (Yes)
ALCOHOL
You need to decrease excess of Alcohol consumption and bring it to less than 2 units
per day. (Safe limit three unit per day for male & two unit females). Do you agree? (Yes)
DIET
I offer healthy diet no red meat poultryok, fish good, low salt low fat diet,  fruit 5
portions of and vegetable) and. Aim to  weight until BMI <25. Can you do it.
EXERCISE
Try to have regular exercise 30 minutes per 5 day per week or as limit set by disease.
Immediately stop exercise and rests if pain occurs.
HYPERTENSION
We need to maintain your B.P. less than 140/90 mmHg.
Check BP and treat if > 140/90 mmHg.
DIABETES MELLITUS
Treat any underlying DM.
DRIVING
Group – 1 (Cases) stop driving until symptoms are controlled if attack while at wheel,
at rest or with emotion.
Group – 2 (Buses) inform DVLA Licence cancelled until symptom free more than 6
weeks.
2. DRUG TREATMENT
As you are having >2 attacks of Angina per week and GTN spray is not enough so
you will be needing following drugs on regular basis.
(1) Use GTN Spray as on needed basis, 1 to 2 puff under the tongue. Repeat dose
after 5 minutes if pain persist. Call Ambulance after second repeat. Side effects include
headache, flushing, light headedness and decreased B.P.
(2) B.Blocker
I offer you Bisoprolol 1.25mg once a day for symptomatic relief.
This drug  rate of heart beating. We need your resting heart rate <65 beats per
minutes or <90 beats per minutes after walking or climbing 2 flights of stairs.
This drug is not without side effects. Excess of it can  heart rate abnormally & cause
 Blood Pressure. It also causes narrowing of airways hence C/I in asthma. It can cause
depression and ED.
SAFTY NETTING
If you feel dizzy please contact me immediately. We may need to  dose. Don’t stop
the drug suddenly or run out of stock. If you needed to stop the drug, it will be tapered off
over 4 weeks.
Remember this is not the end, if your symptoms are not controlled with Bisoprolol we
still have drugs like CCB e.g. amlodipine 5mg once a day and Isosorbidnitrate as 2nd & 3rd
step.
SECONDARY PREVENTION
Along with B.Blocker I offer you Aspirin Statin & ACE1 to prevent further attacks.
(3) ASPIRIN
18
you need to take 75mg of Aspirin daily (If you are allergic to Aspirin or have stomach
problem then clopidogrel is an alternative. Can you take it? If you have stomach pain burning
or black stool please report immediately.
(4) STATIN
These drugs lower bad cholesterol LDL and are beneficial. I offer you simvastatin
40mg daily at night. Can you take it?
(5) ACE INHIBITOR
These drugs have proven benefit of  mortality. Hence I offer you Ramipril once daily.
Is there any thing else you would like to ask me today. (No)
You can get information leaflets from reception desk.
Further information from the internet.
Is there is any thing else to discuss with me today.
Thank you for your cooperation & visit.
Smile hand shake. Good bye.
FOLLOW UP
After two weeks.
IMPORTANT NOTE
If patient is all ready taking all medicines but his angina is not controlled, refer him to
cardiology soon. They may do new ECG, ECO, exercise tolerance test & Thallium Sean.
After the tests they may do Angiography & stenting as appropriate.
KNOWLEDGE BASE
Long acting nitrates e.g. Isosorbid nitrate can cause side effects like headache, low
decreased blood pressure & dizziness. It effect wear off with use. Many patients develop
tolerance with  therapeutic effect. To avoid this, allow a nitrate free period of 4-8 hr/d over
night by removing patches at night or giving the 2 nd dose of nitrates at 4PM.
Note No.1
In this scenario patient says that his Angiography is not done yet. His exercise
tolerance test could not be done due to bilateral severe osteoarthritis of knees and thalium
scan he refused and he wants some addition of drugs to control his Angina. Besides GTN
sprey.
In this scenario doctor should say that I will be offering you certain life style changes
for life time and addition of certain drugs like bisoprolol tablet ACE inhibitor tablet and asprin
and statins. Hopefully your anginal pains will be controlled but since you had heart attack a
year ago there could be some narrowing of coronary arteries which need to be addressed
immediately with passing of stent or bypass surgery.
Side effect of B-Blocker
1. ↓ Blood Pressure
2. Broncho – Constriction C/I in Asthma & Heart Failure
3. Depression
4. Erectile dysfunction
5. Cold hands & feet (↓ Peripheral circulation)
6. ↑ Triglycerides
7. ↓ Awareness of low sugar
19
POST MI COUNSELING
Two minute Scenario out side Station
Mr. Muhammad Mahmood 51 year has been discharged from the hospital after
having MI 7 days ago. Counsel him about life style changes and medicines he has to
take proceed.
1. Meet & Greet
Hello Mr. Muhammad Mahmood I am Dr. Raheel. One of the GP in this surgery. How
can I help you today?
As you know things are not the same after heart attack, so I wish to suggest few things
which you should do and few things you should not do from now onwards. Most importantly
I will try to answer all your questions.
SUMMARY
I need to ask you few questions before I answer your worries.
Take a proper history about each of the following thing & then advise accordingly:
(1) Diet (Like oily fried food)
(2) Exercise (No time for exercise)
(3) Weight reduction (BMI > 30)
(4) Smoking (Heavy smoker for years)
(5) Alcohol (> 4 units daily)
(6) HTN (> 140/90)
(7) DM (No)
(8) Driving (Yes Car Driver)
(9) Flying (Has to fly back home in 2 weeks time)
(10) Psycological Effects (Depression) (Feeling low but not loss interest in life)
(11) Sex (Yes married, sex two time per week)
(12) Job (Labourer)
________________________
1. Diet
Take healthy diet. Increase fruits and vegetables, decreased fatty food (i.e. oily fried
food, no red meat) white meat such as poultry is OK but should preferably be grilled. Fish is
very good. Omega 3 and Omega 6 are found in oily fish is good. Decreased salt intake.
2. Exercise
Initially some rest is advisable for 2 weeks. Gradually increase your activity. Increased
aerobic exercises within the limits set by disease.
(1) Rest for 2 weeks.
(2) Stroll in garden after 2 weeks.
(3) Walk half mile / day after 4 weeks.
(4) Walk 1 to 2 miles/ day after 6 weeks.
(5) Aim to cover 2 miles from 6 weeks onward post MI.
You can return to work after some time depending upon what kind of work you
do.
Sedentary work 4 weeks or 1 month
Light manual work 8 weeks or 2 months
Heavy manual labour After 3 months.
If you like swimming, you can start that after 6 weeks.
You can go for exercise tolerance test after 6 weeks. Unless contra indicated.
Patient are advised to take their usual medication prior to going for the test.
Contraindications to ETT are
20
Symptoms uncontrolled despite maximum medical treatment.
Results of Stress (ETT) testing would not affect management.
LBBB on ECG
Incapable of performing test e.g. OA
Proven Aortic stenosis or HOCM.
3. Weight
If obese, aim to decrease weight until BMI < 25. You can reduce your weight by diet &
exercise.
4. Smoking
You are suppose to give up smoking completely. I can tell you hazards of smoking
and benefits of stop smoking. I can offer Nicotine Replacement therapy and other
alternatives. I can refer you to smoking cessation clinic and self help groups. We can discuss
this in detail in next session.
5. Alcohol
Occasional glass of wine is ok but you need to cut down your alcohol consumption if
drinking excess of 3 unit per day males & two unit females).
6. Hypertension
Check you blood pressure and treat if > 140/90.
7. Diabetes Mellitus
Have your Blood Glucose checked by GP and treat any underline diabetes mellitus.
8. Driving
No driving for one week after MI. Driving may be allowed after assessment. You are
oblige to inform DVLA of the diagnosis but inform you insurance company. If you drive heavy
vehicle like Lorry or Public transport like bus, then your license may not be renewed.
9. Flying
No flying until 2 weeks post MI and that too if able to climb one flight of stairs or 10
stairs without getting breathless.
10. Psychological effects
50% are depressed one week after MI.
25% are depressed one year after MI.
Check for depression. Counsel and treat if needed.
Coronary prone behaviours like competitiveness, aggression, feeling under time
pressure need to be amended to decreased coronary risk.
11. Sex
Sexual activity can be resumed 6 weeks after MI.
Sildenafil can be taken 6 months after MI.
Sex is safe if you can climb two flights of stairs without getting breathless or chest pain.
Avoid sex after a hot bath or full stomach.
Important Note:
Sex is not likely to cause any symptoms when engaged in after a good night sleep. If
you develop pain during sex then stop the activity at once. Please do not take GTN spray. If
you have taken sildenafil for sex call emergency ambulance.. Both sildenafil & GTN spray
lower BP. Never give GTN spray if BP less than 90/60.
FOLLOW UP
GP Follow up 4 to 6 week.
(1) Doctor, What is Heart attack?
21
Heart gets its blood surpply from vessel called coronary arteries. They get narrowed
or blocked, so heart muscles can not get its blood supply and therefore dies. This is called
Heart Attack. A Scar will replace this dead muscle in 4 to 6 weeks time.
(2) Doctor: Can I have another Heart attack.
One can not be sure that that you will not have another heart attack.
When you will come back for follow up, we will do some investigation to access blood
supply of your heart. If investigation showed that no other treatment is needed at that time,
then changing life style and taking medication regularly should decrease the chance of
another heart attack.
(3) Doctor: What is Angiography?
It is a special investigation in which some colored material is injection into heart blood
vessels and X-rays are taken. This allow us to see whether there is any narrowing or blockage
in the heart blood vessels.
(4) Doctor: What is treadmill test (Exercise Tolerance Test)?
In this test you will be asked to walk on treadmill (Moving pavement) while your Blood
Pressure and heart rate etc. is monitored by a Doctor or nurse. So this test tells us about
health of your heart during exercise. This test can be stopped at any time if you have any
chest pain or wish so. You will come for this test after taking your usual medication.
________________________
DRESSLER SYNDROME (Post – MI Syndrome)
Developes 2 to 10 weeks after MI on heart surgery, auto Antibody to heart
muscle.
Present with recurrent fever, chest pain, pleural / pericardial effusion.
Refer urgently to cardiology.
Treatment is with steroid and NSAID.
_______________________
Rate limiting CCB = Virapamil or Diltiazem
Dihydro pyridine CCB – Amlodopin
Swimming after 6 weeks
Exercise tolerance test after 6 weeks
Sex after 6 weeks
Seldanafil after 6 months
Driving – stopped for one week after MI
Flying – Two weeks after MI
Depression – 50% are depressed one week after MI.
______________
Sputum Phelem Color
White – Bronchitis
Cup full of pus like – Bronchectasis
Greyish yellow – Infection
Rusty color – Pneumonia
Pink color frothy - CCF
ADVICE ON MEDICATION OR SECONDARY PREVENTION AFTER MI
Mr. Muhammad Mahmood as you are aware you had heart attack and have recovered
quite well. You are being discharged from hospital today. I will explain to you about your
medication before you go home. I will also try to answer all your questions
22
Let me emphasize that it is essential that you take all your medication everyday
regularly. You should not stopped any medication at your own even if you are feeling well. If
you think any medicine does not suit you, you should inform your doctor immediately.
You should take Beta blocker (Atenolol) (Bisoprolol), ACE, (Perindopril) Asprin and
Statin regularly.
GTN TABLET or Spray
This drug is for emergency onset of chest pain. It is a good idea to carry this drug with
you all the time. It is to be taken on as per needed basis, besides regular medicines. If you
suffer from chest pain (Angina) you should place one tablet under the tongue and close
mouth. Tablet is not be swallowed. If pain does not subside, you may repeat the tablet upto
3 tablets over 10 minutes (i.e. upto to 1 mg). If pain persist despite sublingual tablet or spray
you should ring for ambulance to take you to the emergency. This drug has side effect like
headache, sudden drop of blood pressure (Postural Hypotension), Facial flushing and
dizziness.
Beta Blocker (Atenolol)
Unless contraindicated, start soon after MI and continue indefinitely.
This drug will slow your heart besides protecting it, it needs to be taken once a day.
Some side effects include slowing of heart rate, lowering of BP, fatigue, cold hand and
feet, it may effect sleep and cause night mare or excessive drowsiness. It can cause
impotence. You should not take this tablet if you have poor blood circulation or asthma. You
might have to careful if you are a diabetic as it decreases the awareness of low blood sugar
level. But the good thing is that these side effects may not occur in every person. Beta Blocker
can cause depression and ED. If contraindicated, Virapamil is an alternative (Rate Limiting
CCB). Never combine Beta Blocker and rate limiting CCB.
ACE1
This drug decreases heart work and decreases death within one month post MI. This
drug helps to strengthen heart pumping action. Contra Indication pregnancy where rate
limiting CCB can be given (Verapamil or Diltizium) or if it causes cough.
Asprin
This is to be started within 24 hours after MI unless contraindicated and is to be
continued life long. The usual practice is to give 150mg daily for month after MI and then
decrease to 75mg per day from then onwards.
Those patient who cannot tolerate aspirin can take 75mg of clopidogrel.
You need to take Aspirin everyday. This will thin your blood and help prevent further
chance of clot formation in the heart blood vessel.
Side Effects of aspirin include heavy nose bleed and heart burn. If you experience
heavy nose bleed that does not abate with pressure over nares, you should see your GP or
ring emergency.
If you suffer from heart burn you should see your GP and take gaviscon or antacid in
the meantime (You can combine PPI and H2 Receptors with Aspirin) If you have stomach
ulcer or acidity. You should not take aspirin as it may cause bleeding from stomach. It is
important to take aspirin with food as otherwise it may irritate the lining of your stomach.
SAFTYNETTING
Contact me if you have blackish stool, excessive bleeding from the wounds or
shortness of breath or wheezing. Particularly if patient has past history of asthma or COPD.
23
Statin
As your cholesterol is high. This statin drug will lower your cholesterol. Lowering
cholesterol by 25-35% decreases the chance of death by 25-35%. Your total cholesterol
should not be more than 200mg or 5mmol/l. Blood cholesterol level decreased after MI and
remain decreased for several weeks. You should take this tablet every day at night. It can
cause muscle weakness and musle pain. If you have any such problem contact you GP, you
might need to change this drug to a different drug. We will repeat cholesterol level in three
months time. Statin reduce the risk of future heart attack by lowering cholesterol. If depressed
then no B. Blocker, No C.C.B. as both cause depression. Give long acting nitrats like
micorandil.
G.T.N. Tablet (Emergency)
B – Blocker
ACE1
Aspirin
Statin
___________________
Statin at night
Steriods in morning in single dose
24
HYPERTENSION
TWO MINUTE SCENARIO OUT SIDE THE STATION
Mr. Fazal Ahmad , 52 years has noticed high blood pressure on repeated occasions.
He complains of low mood and impotence.
Please manage.
Proceed.
MEET GREET, INTRODUCTION & OPEN CONSULTATION
Hello I am Dr. Raheel.
One of the GP in this surgery.
I am Fazal Ahmad, 52 year.
Ok Mr. Fazal Ahmad what brings you to the surgery today?
Doc. I was diagnosed as having high blood pressure for the last two months. Doctor
prescribed me some medicine but now I feel as if I have low mood & energy. I find it difficult
to perform fully during sex with my wife.
Tell me more about your condition?
I have high bad LDL cholesterol & increased triglycerides on blood test.
Anything else you want to share with me today?
No Doctor. That’s all.
Mr. Fazal Ahmad I will try to solve your problem to the best of my abilities but before I come
to the management part can I ask you few questions.
Since when you were diagnosed as having high blood pressure?
For the last two months.
Why did you had your B.P. checked?
I had no symptom except occational headache & blurring of vision. It was a coincidental
finding on routine examination.
In the last one month have you felt down depressed and hopeless? (Yes)
In the last one month have you lost interest in daily life activity? (No)
Any past history of heart problem? (Not yet) (Heart)
Any past history of weakness of limbs? (No) (Brain)
Any kidney problem? (No) (End organ damage) (Kidney)
Any problem with vision? (No) (End organ damage) (Eye)
PERSONAL HISTORY
Do you smoke? (Yes)
How much? (one to 2 packs a day)
Intend to quit? (Yes)
Ok good we will have a detailed session in next appointment. I will help you in quit smoking.
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Do you take Alcohol?
Yes I take about 4 units/d
Any intention to cut down to safe limits.
Yes Doctor If you say so.
Any high blood sugar? (No)
Are you married? (Yes)
Any kids? (Yes 2)
How are the things at home? (Wife giving hard time)
What do you do for living? (I am a business man)
How are the things at work? (I am under great stress due to loss in business)
Do you know your BMI? (Yes my BMI is 28)
Do you like to take exercise? (No)
FAMILY HISTORY
Does anybody else in family have similar ↑ B.P.
Yes, my father & brother has increase blood pressure
Any heart problem in family?
Yes, my father died of heart attack at the age of 60 years.
DRUG HISTORY
Are you taking any medicine prescribed or from over the counter? (If yes) which medicine in
which dose you are taking?
I am taking Atenolol B. Blocker 50mg once a day.
Any drug allergy? (No)
ILLNESS
How high B.P. has affected your life?
I am suffering from low mood & unable to come up to expectations of my wife during sex.
Doctor this is awful.
IDEA
What do you think is the cause of your illness?
I think this medicine has something to do with my low mood & inability about sex.
CONCERN
Is there anything you are worried about in particular?
I am worried I may have heart attack or paralysis in near future.
EXPECTATION
I hope you will change medicine to some other safer medicine. (160/100)
SUMMARY
So Mr. Fazal Ahmad you have told me that you have high B.P. since 2 months, for which you
are taking Atenolol. You are heavy smoker & drinker. You are obese & do not like to exercise.
You have a sedentary job & you are worried about having heart attack or paralysis in near
future.
Is this all or you like to add anything else?
That’s all doctor.
EXAMINATION & INVESTIGATION
Mr. Ahmad in order to reach my diagnosis I need to examine you.
Can I examine you?
26
Yes please.
Doctor washes his hand with sanitizer.
Would you please move on to couch.
Would you please take your shirt off for me.
General Physical Examination
B.P. Palpatory method first then ausculatory Method.
Pulse Findings will be given
B.P. 160/100 & 78/min pulse.
Heart Auscultate heart from front on all four areas.
Lungs Auscultate on Apex, Middle, lower zone & basis from back.
Thank you for allowing me to examine.
May I know examination findings (Ask SP or Examiner)
Doctor washes hands with sanitizer.
You may wear your shirt & come back to chair.
Wait till patient is seated in his chair & then start concluding.
REASSURANCE & EXPLANATION
Mr. Ahmad from the information you shared with me & the examination I have performed, It
is most likely that you are having a condition what we call in our medical terminology as
Essential Hypertension.
Do you know what is Essential Hypertension? (No doctor)
Would you like me to explain it for you? (Yes please)
Due to increased cholesterol, our blood vessels get narrowed & hard so heart has to push
blood with greater force. So our blood pressure increases. In your case there is no obvious
cause. So increased blood pressure without any cause is called Essential Hypertension. Do
you understand? Can I proceed? (Yes)
INVESTIGATIONS
In order to confirm my diagnosis I need to do certain investigation . Have you already gone
through any investigation. I offer you certain tests e.g.
ECG
Complete Lipid Profile
Liver Function Tests (as base line)
HbA1C
Urine complete examination for Glucose protein & blood cells
Urea Cratinin with eGFR Electrolytes
GGT (as excessive Alcohol is a possibility)
For fundoscopy I will refer you to Eye specialist.
Is it ok with you?
May I know investigation findings if any test done already.
27
MANAGEMENT
While reports of these test come, we can still do a lot of things. Few are life style changes &
few are medicines.
Which way would you like me to go first?
Life style changes first please.
(1) DIET
You need to adopt healthy diet. Which includes:
Decreased salt
Decreased fats
5 portions of fruits & vegetables/day
Decreased Coffee consumption
Cut down Alcohol to safe limits that is not more than 3 units/day for males & 2 units for
females.
You need to stop smoking altogether?
Yes doctor if you say so.
Can you comply with these life style changes?
Yes doctor.
(2) EXERCISE
Try to do light exrcise regularly i.e. 30 minutes/day of brisk walk (5 days a week)
Exercise help decreased blood pressure by 5-7 mm.
Can you do it for me? (Yes doctor)
(3) WEIGHT
Your BMI is 28. Try to reduce your weight by diet & exercise.
Decreased weight helps lower blood pressure as well.
(4) STOP SMOKING
Smoking is not good in a condition like yours.
Consider quit smoking completely. As you agreed with me earlier so. I will help you by offering
Nicotene Gums or patches. I can also refer you to stop smoking clinic.
Is it ok wity you?
Keep your B.P. controlled less than 140/90. (If diabetic then BP less than 130/80)
(5) RELAXATION
Reduce stress in your life.
Try to relax and take life easy.
You can listen to relaxation tapes.
You can do Yoga or meditation.
Spend some time in leisure activity like persuing your hobbies.
Go out for a picnic with friends & family.
Please don’t use Ca, Mg or K supplements to decreased blood pressure.
28
REASSURANCE & EXAPLANATION
This is a common problem. Although the cause is unkown we can treat this with medication.
Which I will offer you today. I will also suggest some life changes.
I offer you certain medicine. You are taking Atenolol for your B.P. It is my considered opinion
that most likely this medicine is responsible for your low mood & impotence. We will taper it
off within one month & start ramipril 5mg daily instead of Atenolol. This medicine can cause
some cough complaint. If it does so. Please let me know. Hopefully this will solve your mood
and sex problem.
Do you agree with this plan? (Yes doctor)
Can you take this medicine for me? (Yes doctor)
I offer you simvastatin 20mg at bed time.
It reduces bad cholesterol or blood fats.
This medicine can cause some muscle pain & muscle weakness. WE will keep a watch on
your liver function test. If you develop any muscle pain or Liver Function Test increase
abnormally beyond certain limits we will stop the medicine.
Did the other doctor prescribed me wrong medicine?
The medicine other doctor prescribed has certain side effects. These side effects do not affect
all the persons. So the doctor may be right in prescribing that medicine.
(Don’t blame other colleague doctor)
FOLLOW UP & SAFTY NETTING
I am arranging a second follow up visit after one month.
Is it convenient to you?
Do you agree? (Yes doctor)
SAFETY NETTING
If your B.P. is not controlled or you develop some muscle pain or any other problem.
Please seek immediate medical help.
CLOSING & SEE OFF
Is there anything else you like to ask me today? (No)
You can get some leaflets about your condition from reception desk.
You can get further information from internet.
Thank you for your cooperation & visit.
Good bye (Smile & Shake hand)
Anti Hypertensive medicine according to latest NICE guide line according to age.
< 55 year > 55 year
Step 1 A C or D
Step 2 A+C or A+D
Step 3 A+C+D
A = ACE1
C = Calcium Channel Blocker
D = Thiazide like duretic (Indepamide)
Step 4 Alpha blocker
29
In a women of child bearing age & less than 55 don’t offer ACE I/ARBs ACEI/ARBs
Contraindicated in pregnancy & we never know when women of child bearing age become
pregnant.
Prescribe her B-Blocker (Labetolol or Methydopa). If BP not controlled adequately with
beta blockers combine it with calcium channel blocker non rate limiting type e.g. Amlodipine.
(Oxford Page 221)
Elderly people are prone to postural hypotension. Check for postural drop (Drop of
more than 20mm) (Sitting and standing) BP. If present ↓ dose of antihypertensive.
SIDE EFFECTS OF ANTIHYPERTENSIVE DRUGS
Explain Side Effects if Anti-Hypertensive Drugs are Prescribed
BETA BLOCKER
May cause depression or importance and less awareness of low blood sugar and ↑
TG, Contra Indicated in Asthma and Heart Failure. Don’t stop abruptly taper off over 4
weeks.
ACE1
Contra Indicated in pregnancy and cough.
DIURETIC
May cause impotence or depression (Low mood) precipitate GOUT, disturb blood
glucose control, postural drop.
CCB
May cause Ankle edema, Flushing of face and Depression.
ALPHA BLOCKER
May cause postural hypo tension & worsoning of urinary incontinence.
_________________________
SIDE EFFECTS OF BETA BLOCKERS
Depression
Erectile Dysfunction
Increased triaglycerides
Decreased awareness of low blood sugar
Decreased prepheral circulation (Cold hand and feet)
Decreased heart rate (Never combine with rate limiting calcium channel
blocker)
Decreased heart rate
Decreased blood pressure
Contraindicated in asthma as cause broncoconstriction
MOST FREQUENTLY ASKED QUESTIONS
SP may ask the family physician few questions like given below:
Doctor why do I have take the medicine. I have no symtoms.
I feel fine. Do I really need to take the medicine.
30
Well Mr. Fazal we have measured your blood pressure on quite a few occasions and
every time it has been high. We have done a few tests to see if there is any cause for this.
All these tests have been –ve. I think, you have a condition called essential hypertension in
our Medical terms i.e. high Blood Pressure without any apparent cause. We will do few
more tests to make sure that high BP is not due to any other condition which can be
treated. Secondary hypertension is usually found in young people and is resistant to
treatment.
Doctor: Why is it important to treat BP.
Mainly because we need to reduce risk of damage to heart, brain, kidney & eyes.
Persistently very high BP can cause heart attack and heart enlargement. It can cause
paralysis. Kidney failure and loss of vision.
Doctor: How does high BP affect sex life?
As long as BP is under control you should not have any problem with your sex life but
beware that Beta Blocker type of medicine can cause impotence and for which alternate
medicine can be prescribed such as non rate limiting CCB and ACE1.
Doctor can my Children have it?
The answer is yes if your HTN is due to familial high cholesterol.
In the end let me tell you that high BP can be controlled but not cured. Once high BP,
you need to take medication, probably for the rest of your life. You have to continue
take medicine even if you are feeling completely normal.
It normally takes a few days for BP to come down to normal.
POSTURAL HYPERTENSION
(FORMULA HANDI)
CAUSES
H - Hypo Volume (Loss of blood or dehydration & hypopitutariasm
A - Addison’s disease
N - Neuropathy – Diabetic Autoneuropathy
D - Drug – vasodilators (Labitolol) Hydralazine, GTN)
TCA, Anti Psychotic, Diuretics, Alpha blockers
I - Idiopathic orthostatic Hypotension ↓ BP on standing suddenly.
31
SECONDARY HYPERTENSION
Hypertension without any known cause is called Essential Hypertension but if there is
any known cause or reversible cause of hypertension it is called Secondary Hypertension i.e.
hypertension secondary to some cause. Hypertension due to any identifyable cause is called
secondary hypertension. Usually starts before the age of 35.
Secondary hypertension makes only small fraction (5 to 10% of all hypertension
cases).
Secondary hypertension should be considered in the presence of suggestive signs
and symptoms such as severe or resistant hypertension onset before 30 years of age
(especially before puberty), malignant or accelerated hypertension and an acute rise in blood
pressure from previously stable readings.
AGE:
Patients under 30 years who have high blood pressure with not family history or other
risk factors of high blood pressure.
RESISTANT HYPERTENSION:
Patients who have resistant hypertension have high blood pressure that has not
improve despite optimal treatment with at least three blood pressure medications.
OBESITY:
Overweight patients with high blood pressure that does not respond to treatment over
time.
SIGN OR SYMPTOMS:
Symptoms of high blood pressure.
Symptons of end organ damage i.e., Stroke, Heart attack, blindness and kidney failure.
LABORATORY ABNORMALITIES:
Such as low potassium or high calcium.
CAUSES OF SECONDARY HYPERTENSION
• Hyperaldosteronism
• Hyper Thyroid
• Obstructive sleep apnea
• Cushing syndrome
• Pheochromocytoma
• Renal artery Stenosis
• Renal failure
• Renal parenchymal disease
• Coarctation of the aorta
TESTS ADVISED
Blood test include:
• Creatinine and blood urea nitrogen (BUN) tests if suspecting renal parenchymal
disease.
• Serum electrolyte levels in blood if suspecting adrenal cause.
• Thyroid function tests if suspecting hyprthyroidism.
32
• Urinary VMA Test if suspecting Pheochromocytoma.
• 24 hours urine cortisole if suspecting cushing disease.
• Echo cardiography if suspecting coarctation of Aorta.
• Doppler renal arteries if suspecting renal and renal arterial cause.
• Polysomnography if suspecting obstruction sleep apnea.
Medications include:
• Hormonal contraceptive (Birth control pills, COC Pill)
• Non-steroidal anti-inflammatory agents (NSAIDs)
• Orliastat diet pills
• Stimulants e.g., Illicit drugs (Amphetamine, Cocaine)
• Antidepressants (SSRI, SNRI, Clozapine, Buspirone)
• Immune system suppressants
• Decongestants
• Steroids (Methylprednisolone, prednisolone)
• Anti-fungal (Ketoconazole)
• DMARD (Leflunamide)
TREATMENT
Family physician has done his job very well if he has recognized secondary
hypertension patient and proved by appropriate test then family physician should refer the
patient to specialist for the treatment of the cause.
Treatment for Secondary hypertension will depend on the secondary condition.
Secondary hypertension will last as long as you have the secondary condition. It is best to
follow several tips for controlling high blood pressure (Hypertension) while being treated for
your underlying condition. These tips include:
• Eating a healthy diet that is low in sodium
• Exercising regularly
• Avoiding smoking
• Maintaining a healthy body weight
• Limiting alcohol
In cases where a tumor is found to be the cause of the Secondary hypertension,
surgery may be needed to treat the condition.
For hormonal imbalances and other conditions, medication may be used to treat
Secondary hypertension.
33
CHRONIC CONGESTIVE CARDIAC FAILURE
Hello.
I am Dr. Raheel.
One of the family physician in this surgery.
I am Abdullah 51 years old.
Ok Mr. Abdullah what brings you to the surgery today?
Doctor, I am breathless for the last six months. I cannot walk long distance.
There is a whisteling sound in my breath. Most of the time I am fatigued and lethargic.
I some time feels some pain in my right upper tummy.
There is a swelling around my ankle joints as well.
I will try to the best of my abilities to solve your problem but before I come to the management
part I would like to ask few questions. Can I ask you few questions.
______________________________
Do you produced pink colored frothy sputum? (Yes)
Do you have engorged veins in you neck?
What happens when you lie down? (My breathlessness increased)
Do you have to take pillows to prop up while sleeping? (Two thick pillows)
Is there any night time cough? (Yes)
Do you produce pink color frothy sputum? (Yes).
Are your muscles getting wasted? (Yes my muscle are wasted)
Are you fond of salty foods? (Yes)
Are you using any pain killer Nsaids? (No)
Do you have any neck gland problem? (No I do not have hyperthyroid)
Do you know your hemoglobin? (Yes my hemoglobin is low. Doctor advised blood transfusion
to ease breathlessness)
In the past one month have you felt down, depressed and low? (Yes my mood is low)
In the past one month have you lost interest in daily life activities? (I still take part in daily
activity)
PAST HISTORY
Is there any previous history of heart attack? (No heart attack)
Is there any previous history of high blood pressure? (Yes I have high blood pressure)
34
PERSONAL HISTORY
Do you smoke? (If yes, would you like to quit smoking)
Do you take excessive alcohol? (Excessive alcohol comsumption may cause Alcoholic
Cardio magaly or direct toxic effects to the heart muscle)
Can you cut down your alcohol intake to safe limit i.e. less than 3 units per day.
DRUG HISTORY
Are you taking any medicine prescribed or from over the counter? (No)
Is there any past history of any drug allergies? (No)
EXAMINATION
Ok Mr. Abdullah in order to reach my diagnosis, I need to examine you.
Can I examine you?
Yes doctor you may proceed.
Thank you for trusting and allowing me for examination.
1. Check JVP (Increased JVP)
2. Check liver (There may be hepatomegaly)
3. Check for basal crepitations at the basis of both lungs (Coarse wet Sounding Crepts
positive)
4. Check ankles for any swelling (There may be pitting edema of ankles)
5. Check pulse (Increased rate of pulse) (May be pulsus alternens)
6. Count to the breath rate (There may be fast and labored breathing)
7. Check for position of Apex beat (Apex beat may be displaced due to enlarge heart)
8. Check heart sounds. (Third heart sound may be audible)
9. Check abdomen for ascites (There may be fluid in the Tummy)
10. Patient may look cachexic due to musle wasting.
May I know the examination findings ask SP or examiner.
_____________________________________
INVESTIGATIONS
Mr. Abdullah in order to confirm my diagnosis I need to do certain investigations like
Hb
Serum Natri Uretic Peptide (Pro BNP) B-type natriuretic peptide (More than 400 Pg/ml refer
to be seen by the specialist with doppler echocardiography.
ECG (Look for Ischemia, infarction and left ventricular hypertrophy)
ECG may show aterial flutter which is an important cause of heart failure.
35
Xray chest (There may be cardiomegaly, plural effusion or diffuse patchy lung opacities)
Spirometry
Peak Flow Meter (Peak flow rate of less than 200 L/min is more likely due to respiratory
cause rather than heart failure)
Check urine for proteneuria (Proteneuria positive)
Check blood pressure (Hypertension an important cause for heart failure)
Check for temperature, fever may suggest Pneumonia which may precipitate heart failure.
FBC
Renal Function
Refer for specialist assessment & echo-cardigraphy e.g. (Cardiac breathlessness
clinic to be seen in less than 2 weeks.
MANAGEMENT
Life style changes.
Limit the fluid in take but be aware of dehydration.
Try to decrease you weight.
Please engage in regular low intensity exercise like walking.
Try to decrease salt in take to less than 6 gram
Decreased fatty food.
Try to reduce excess of alcohol.
Try to quit smoking.
Give oxygen (Iif less than 92%)(Aim for peripheral O2 saturation of 88-98%)
Pnumococcal vaccination once in life time.
Influenza vaccination every year.
If breathless at rest, restlessness, anxiety and feeling of suffocation also patient is sweaty
pale. He should prefer to sit up right with prop up pillows.
Stands slowly from lying to sitting position to avoid postural hypotention and dizziness.
1. Frusumide
Frusamide 20 to 40mg once daily per oral or I/V to decreased crepts in lung.
Monitor for decreased potasium and give potasium supplements if needed.
Thiazide Diuretic may be added if continued problem with odema or hypertension.
2. Give ACE Inhibitor like Ramipiril 1.25mg once a day (It increases exercise capacity,
improves symptoms and increase survival)
36
3. Give Beta blocker for example Bisoprolol 1.25mg at night. Start in low dose and
gradually increase the dose while maintaining pulse and blood pressure.
4. Asprin like Ascard 75mg once a day.
5. Statins if previous MI and increased cholesterol (Monitor liver function test)
Simvastatin 40mg at night
6. Digoxin If there is atrial flutter. Digoxin has positive Inotropic effects 0.5 mg improve
your symtoms.
7. Treat hyperthyroid if free T3 and free T4 are raised.
SAFETY NETTING
Patient with heart failure should weigh themselves at a set time each day and any increase
in weight over 2kg over two days should be reported to family physician.
Heart failure is progressive disease. Severe heart failure may lead to death within one
year.
Warn the patient he may die suddenly due to cardiac irregular heart beat.
He may discuss any unfinish business and concerns.
FOLLOW UP
I would like to review your condition every month, earlier if there is any new symptoms or
problem.
Is it convenience to you.
Is there anything you want to discuss with me today? (No)
Please collect leaflet about heart failure from the reception desk.
Thank you for your cooperation and visit.
Good bye.
____________________________
ACUTE CONGESTIVE CARDIAC FAILURE

Read from
Oxford Hand Book of General Practice Fifth Edition Page 1068 & 1069
37
SUPRAVENTRICULAR TACHYCARDIA
Tachycardia means your heart is beating too fast. It can reach more than 100 beats a
minute while resting. In supraventricular Tachycardia cause is a problem with electrical
signals.
Children and adult can get SVT (Supraventricular Tachycardia). Woman get it more
than men.
SYMPTOMS
Patient may present with palpitation or fast heart beat.
Can have chest pain.
Can feel short of breath
Can have light headedness or dizziness
Pass out or faint
People can become unconscious or can have cardiac arrest
If patient in your clinic presents with palpitation but by the time you perform ECG in your clinic
is palpitation are gone. In such cases 24 hours ECG monitoring holder ia advised.
Ask the patient if he can produce the findings of holter showing supraventrical tachy
cardia.
In acute cases, when patient is having palpitations.
• Advise him or her to lie down.
• Cough
• Put ice cold towel on the face due valsalva
• Valsalva maneuver can be done.
Valsalva maneuver means you try to blow air out of your mouth but close off your nose
and mouth with your fist as if you were trying to poop or lift a weight.
• Carotid massage on one side only can be done at a time.
LONG TERM TREATMENT
Ask the patient to reduce smoking better if you can quit.
Drink less alcohol.
Drink less tea or coffee.
Treat your anxiety by Yoga and meditation etc.
Some people may feel better after having rest.
People who are tired and need rest should sleep.
PHARMACOLOGICAL TREATMENT OF SVT
Several medicine can slow down the heart rate.
A– Adenosine
B– Beta Blockers (Bisoprolol)
C- Calcium channel blockers (Rate limiting type like diltiazem or verapamil)
D- Digitalis (digoxin)
P- Potassium channel blockers
People who required therapy in the form of catheter ablation to eliminate areas
responsible for abnormal electricity can be cured.
38
ASTHMA (Breathlessness)
SCENARIO
Miss Noor 24 year comes to you complaining of breathlessness. Gather relevant
data or do focus examination and reach a shared management plan. Proceed.
Meet & Greet (Grips)
DATA GATHERING
HISTORY OF PRESENT (Breathlessness, Wheeze, Chest pain & tightness, cough)
ROUTINE QUESTIONS
Since when you are having SOB. ( ½ hour)
Are you normal in between the attacks? (Yes)
Do you feel any tightness or pain in chest? (Yes)
Do you hear any musical or whistling sound while breathingout? (Yes)
Do you have cough? (Yes)
How often do you get SOB. (Mote than 3 times per week)
Do you feel difficulty in breathing? (Yes)
Is it constant or comes & go? (Comes & goes)
Anything that increases it? (Exercise)
Anything that decreases it? (Inhaler) Reliver inhaler of salbutamol
Any associated symptoms? (No)
Any specific timing? (More often at night time)
________________________________
DIFFERENTIAL DIAGNOSIS
Any history of chest trauma? (No) (Pneumothorax)
Any history of travel for more than 5 hours? (No) PE
Is there by any chance you could be pregnant? (No)
(Pregnancy may leads to deep vain thrombosis and clot may travel to lungs causing
pulmonary Embolism.)
=====================================================================
Red Flag
Any fever along with SOB (Pneumonia) (No)
Any significant weight loss recently (lung cancer) (No)
Any blood in sputum (T.B.)
PAST HISTORY
Have you ever had similar problem in the past. (Yes)
Any past history of admission in hospital due SOB. (Yes once in 2 years ago)
FAMILY HISTORY
Any history similar condition in your family. (Asthma) (Yes)
Any allergies (Atopy)
Any long standing skin problem (Eczeme) Yes at my elbows.
DRUG HISTORY
Are you taking any medicine regularly prescribed or from OTC
Like Pain Killer, Asprin or Nsaid (NSAID for Knee pain)
Any drug for high blood pressure. (B. Blockers) (Atenolol for increased B.P.)
39
Any drug Allergies (No)
BIOPSYCHO SOCIAL & PERSONAL HISTORY
Do you smoke? (Yes > 15 cigarettes / day.
Do you drink? (No)
Any recreational drug? Do you dope? (Never)
What is the nature of your job? (Student and Football Player) (No)
Does you occupation involve working with some chemical or paint factory. (No)
(Occopational Asthma) (Pneumoconeosis & Aspergelosis) (Asbestosis) (No)
Do you have these attacks when you are emotionally upset (Emotions Trigger) (Yes)
How are the things at home (No stress) Is your breathlessness associated with
emotional upsets. (Yes)
How are the things at work. (Stress) Just ok
What about your mood (Depression) Any life long chronic disease can cause
depression. A bit low when breathless but I take interest in life events.
Any financial or marital or legal problem. (Psychogenic Causes) (No)
ICE
Summarization
Anything else you will like to add
EXAMINATION
GPE & full respiratory examination
PEAK FLOW METER
This is any instrument or device use to monitor progression of disease & effectiveness
of medical treatment. I will demonstrate, how to use it.
We use it in standing position.
Bring the pointer to zero.
Hold it horizontally or 90o to your body.
Take a deep breath in & Cover mouth piece of peak flow meter with your lips to make
a tight seal.
Now breath out forcibly & quickly in one breath.
Repeat the same procedure three time & count best of three readings.
You should use PFM regularly to monitor progression of disease and effectiveness of
treatment.
If PEFR is < 50% of your best predicted then seek immediate medical help.
INVESTIGATION
I offer you chest X-ray & Spirometry for obstructive and restrictive diseases I offer to
check PEV1, FVC, PEV1/FVC.
MANAGEMENT
REASSURENCE & EXPLANATION
What I have gathered from your history and examination is that most likely you are
having a condition what we call in our medical terms Asthma. Do you know anything about
Asthma.
In this condition there is narrowing of air pipes & which get blocked by bodily secretions
& hence cause difficulty in breathing.
It is a common condition. There is no “once for all” cure for it. But certain effective
drugs are now available which can control the condition.
40
About half of children who develop Asthma in childhood, grow out of it by the time they
are adults.
Do you understand.
Should I proceed.
LIFE STYLE CHANGES
Try to avoid these trigger (AEIOU-DS-G) which bring on attack of breathness e.g.
A Avoid Allergies like dust, House Dustmite. Pets carpets.
If Allergic to pollen then close the windows of house & car, wear black goggles, mask
& during spring season.
E If exercise causes breathlessless then take 2 puffs of reliever inhaler before exercise.
E Avoid emotional situation
E Avoid extremes of cold & heat
I Avoid infections
O Avoid occupation which cause SOB
U There are certain unknown causes.
D Avoid pain killer (NSAID, Asprin change of paracytamol) & certain drugs used for ↑
B.P. (B. Blocker) (Change to Ramipril)
S Avoid smoking & other fumes.
G Treat indigestion properly (GORD) (Take Anacid gaviscon)
(Page 283 5th Edition)
Algoriham for management of Asthma
STEP 1
Mild intermittent asthma inhaled short-acting ß2 agonist as required. (Salbutamol)
STEP 2
Regular preventer therapy Add inhaled low dose steroid a if: Asthma attack in the last 2y.
Using inhaled ß2 agonists or symptomatic ≥ 3x/wk (Carticosteroids)
STEP 3
Initial add-on therapy. Add inhaled long-acting ß2 agonist (LABA) as combination inhalerb
consider MART regime if history of asthma attacks. (Salmetrol + Steroid)
STEP 4
Additional controller therapies consider. Increasing inhaled corticosteroid to medium dose or
adding leukotriene receptor agonist. If no response to LABA, consider stopping. (LRT)
STEP 5
Specialist therapies refer for specialist care.
Includes two types of inhaler. Reliever inhaler which you will use during attack of
breathlessness & preventer inhaler which you will use regularly to prevent further attacks.
Reliever inhaler can ↑ your heart beat. Preventer inhaler is steroid but it is safe to use steroid
in inhaler form as very minute amount of drug is released. However it can promote the growth
of fungus in your mouth so rinse your mouth with water after its use. Steroid inhaler can also
cause bleeding from stomach & thinning of bone, horsiness of voice.
41
CORRECT INHALER TECHNIQUE
I will demonstrate to you how to use these inhalers.
Remove the cap, Hold it between your thumb & index finger
& Shake the inhaler for 3 seconds
Breath out completely
& Place the inhaler in your mouth securing your lips around the mouth piece
Begin to breath in deeply & activate the inhaler at the same time.
Complete the inhalation & hold your breath for 10 Sec.
Now breath out & breath in normally.
SAFTY NETTING
If your symptoms are not control with inhalers. Consult your doctor or call for
emergency help. If you have to wake up at night once a week or had admission in hospital
once in previous 2 years, consult your GP.
You should also consult your doctor if your PEFR reading is < 50% your best or you
develop fever or phlegm.
Kindly seek immediate medical help or consult you GP doctor.
PREVENTION
As Asthmatic patients are prone to infections so I offer influenza vaccine every autumn
regularly & also pneumoccal vaccine once in life time.
Smoking is harmful in condition like Asthma. It is suggested to give up this habit
completely. Can you do it?
Since you are not ready to give up smoking at present. We will discuss this issue in
detail later in the next meeting. I will help you in giving up this habit.
SOCIAL SUPPORT
I offer you addresses of certain social groups where people with similar condition sit
together & discuss their problem. This well help you build your moral.
You can take leaflets about your condition from reception desk.
You can get further information about your condition from internet.
Is that ok.
FOLLOW UP
I am arranging a 2nd follow up visit in < 48 hours time. Is it convenient to you?
If your symptoms are controlled then we will review all your symptoms, medications,
their side effects, Inhaler techniques etc. at least annually thoroughly.
I there any thing else you would like to ask.
If no then
Good bye
Shake hand.
RCP THREE QUESTIONS
To identify patient with poor asthma control:
1. In the last month, have you have any difficulty, sleeping because of your symptom.
2. In the last month, have you had usual symptoms?
3. Has your Asthma interfered with your usual activity.
No to all questions = Low morbidity
One yes answer = medium morbidity
Two or three yes = high morbidity
42
KNOWLEDGE BASE BREATHLESSNESS
Tip
Assess the duration of symptoms whether acute or chronic and do D/D accordingly.
Acute Causes
– Acute Asthma
– Pneumothorax – Did you have any chest trauma causing increasing
breathlessness
– Foreign Body Aspiration – Did you inhale any foreign body recently
– Pulmonary Embolism
– Acute Pulmonary Odema
Chronic Causes
– COPD
– Cardiac Failure
Infective Causes
– Do you have any fever alongwith shortness of breath
– TB
– Pneumonia
– Bronchiactasis
– Lung Effusion
– Lung Abscess (swinging fever)
– Empyema
Psychiatric Causes
– Hyper Ventilation Hysteria
MISCELLANEOUS Causes
– Thyrotoxicosis – Any problem with neck gland?
– DM (Ketoacidosis) – Have you given up your diabetes medicines for the last
few days.
– Anaemia – Have you ever passed black stool (Malena).
What about your periods (Hevy mensis cause anaemia)
Did you recently lost some blood in any accident.
– Malignancy Any significant weight loss.
43
ACUTE SUBACUTE AND CHRONIC CAUSES
ACUTE CAUSES
What about your weight? (Obese)
Do you do regular exercise (No exercise, normal but unfit)
Have you ever passed Black Stool (Malena) (Anaemia)
What about your menses. (Heavy) (Anaemia)
Did you recently lost Blood in some Accidental (Anaemia)
Did you inhaled any foreign body recently. (Foreign Body Aspiration)
SUBACUTE CAUSES
Did you have any chest trauma recently (Pneumonorax)
Are you expecting (P.E. from DVT) DVT due to pregnancy can cause thrombo
embolism and cause pulmonary embolism.
Did you travel more than 5 hrs (P.E.)
CHRONIC CUASES
Do you have high Blood Sugar.
Have you given up your diabetics Medicine for last few days (Diabetic Kofoacidosis)
Do you have any problem with your neck gland (Thyrotoxicosis)
Do you through Cup ful of pus like spulum, every day. (Bronchiectasis)
Do you throughout Blood in phlegm (Bronchiectasis & T.B.)
_____________________________________
SPIROMETERY
1. Restrictive (Asthama)
2. Obstructive (COPD)
44
COPD (Breathlessness)
PRESENTING COMPLAINT
Consider COPD in any patient more than 35 years with risk factor for COPD (Smoking) and
more than one of the following.
- SOB on exertion
- Chronic Cough
- Regular Sputum Production
- Frequent winter bronchitis
- Wheeze
1. Your age (> 35 years)? 60 years
2. Are you a smoker (Chronic smoker)?
3. Since when your are having SOB (Since many years)
4. How often you have SOB? (All the time)
5. Any SOB on lying down. (No CCF)
6. Do you have any long standing cough? (Yes)
7. Do you regularly produce phlegm? (Yes)
8. Is there any musical sound while breathing (weheeze +ve) (Yes)
9. Are your symptoms worse in winter? (Frequent winter bronchitis) (Yes)
10.
D/D
11. Any fever (No) (T.B.)
12. Any night sweats (No)
13. Any significant weight loss (No)
14. Any history of travel for more than 5 hours. (No) (P.E.)
15. Do you feel short of breath on exertion? (Yes)
Do grading of SOB from MRC dyspnoea scale
MRC DYSPNOEA SCALE
GRADE 1
Not troubled by breathlessness except on strenuous exercise
GRADE 2
Short of breath when hurrying or walking up a slight hill.
GRADE 3
Walks slower than contemporaries because of breathlessness or has to stop for breath
when walking on level ground at own pace.
GRADE 4
Stops for breath afer walking about 100m or after a few minutes on level ground
GRADE 5
Too breathless to leave the house or breathless on dressing / undressing.
45
D/D (Asthma, lung cancer, CCF, Bronchiactasis, TB )
Is there any variation in your breathlessness during day or night? (In COPD is your
Breathlessness is persistent progressive or it varies throughout the day and from day to day)
1. Are you normal in between attacks of breathlessness (Asthma). (No)
2. Have you lost any significant weight recently (weight decreased) (lung cancer)
3. What happens to your breathlessness. When you lie down (Worse in CCF)
4. Do you produce cup full of pus like sputum (Bronchiactasis)
5. Do you ever wake up at night feeling SOB (CCF)
6. Have you ever cough up blood and have fever (TB)
7. What happens to your breathlessness when you take inhaled corticosteroids
(Poor response in case of COPD but good response in case of Asthma)
RED FLAG
Shortnes of breath on exertion (Angina / COPD)
No night sweats (No TB)
No significant weight loss. (No malignancy)
No history of travel for more than 5 hours. (P.E) (No)
Heavy smomker for years together.
Any Chest pain (Not in COPD)
Any Blood in Phelgm (Not in COPD)
Any Fever (Not in COPD)
Any ankle swelling
Any fatigue
PERSONAL HISTORY
Smoker (Yes chronic smoker since childhood)
Do you drink.
Increase BP (No)
Increased Blood Sugar (No)
Who else live with you at your home (Very important question)
Got family
Any kids
How are things at home?
Occupational Hazards (Stress Causes breathlessness )
What is the nature of your job (Occupational hazards) (Retired) (Worked in cement
factory)
FAMILY HISTORY
Is any other members of your family suffered from similar condition in young age
(Alpha 1 anti-tripsin deficiency). (No)
DRUG HISTORY
Are you taking any medicine for your breathlessness and cough. (No)
46
Any drug allergies. (No)
Illness How this condition has affected your life? (Miss my morning walk)
ICE
(Concern – lung cancer)
SUMMARIZE & Ask
Is there anything else you would like to add.
EXAMINATION
G.P.E.
Anaemia (Look up)
Jaundice (Look Down)
Clubbing (Fingers)
Cyanosis nails positive
Ankle Odema Postive
Flapping Tremers, Pulse
Inspection of chest
Increased breath rate, purse lip breathing, use of accessory muscles, Paradoxical
movement of lower ribs
PALPITATION
Poor chest expansion on palpation.
PERCUSSION
Hyper resonant chest
AUSCULATION
Wheeze.
Also auscultate 4 areas of heart.
INVESTIGATION
PEFR (Monitor at home, find its best)
Spirometry (Diagnostic)
CXR
FBC
BMI Do you know your height and weight
Sputum culture if persistent purulent phlegm.
ECG and ECO if heart also involved with lungs (Corpulmonale)
Alpha 1 anti-tripsin if history of deficiency in family in young age.
__________________
MANAGEMENT Formula (Sven) + (Drug Treatment) + (Treatment for exacerbation)

Stop smoking
I offer you stop smoking. It is the single most important thing to improve out come of
treatment. Do you agree – Stop smoking is the treatment of COPD.
VACCINATION
I offer you vaccination against influenza annually and pneumoccocal infection once in
life time. Is it OK with you.
47
EXERCISE
Gradually increase exercise through pulmonary rehabilitation help improve
breathlessness.
NUTRITION
Can you decreased your weight (if obese)
It will help you to improve exercise tolerance.
Can you do it for me.
PHARMACOLOGICAL MANAGEMENT (Page 286, 5th Edition)
Step 1
Short acting B2 agonist (SABA) e.g. salbutamol inhaler.
Short acting muscarinic Antagonist (SAMA) e.g. Ipratropium.
Step 2
If asthamatic features:
Long acting B2 agonist (LABA) e.g. Salmetrol
Inhaled corticosteroid e.g. fluticasone
If no Asthma features:
LAMA + LABA (e.g. vilanterol)
Step 3
Continue SABA Add LABA + LAMA + inhaled corticosteroid e.g. Fluticsone.
If acute exacerbation then decide whether to treat at home or hospital.
If home treatment is choosen.
1. Add or increased bronchodilator, Check inhaler technique.
2. Start antibiotic
Erythormycin 250-500mg OID
(i) If Sputum became purulant
(ii) If Clinical signs of pneumonia
(iii) If Consolidation on CXR
3. Oral Corticosteroid
Start early if breathlessness interfere with daily activities. Prednisolone 30 mg/d for 1-
2 weeks (Single Dose morning).
Consider prophylacsis with bisphosphonates, if frequent course of oral steroid
required.
4. In severe case reassess the need LTOT (Long tem oxygen Therapy) and home
nebulizer (Specialist initiation)
48
REASONS FOR HOSPITAL ADMISSION
If decide to treat at hospital due to poor ability to cope at home, living alone, confined
to bed, acute confusion, impaired level of consciousness or
if cynosis and ankle odema present or
if significant co-morbidity like cardiac diseases or type 1 DM present, and changes in
X-ray present then treat at hospital.
PREVENTION
Emphasize potential benefits of stop smoking, decreased weight, exercise.
FOLLOW UP
I would like to see you in 4 to 6 weeks after discharge from hospital and shell check
FEV1 After 2 weeks If treatment at home.
SAFETY NETTING
If you have any chest pain or Blood in phlegm or develop fever
Please seek immediate medical help.
CLOSING AND SEE OFF

Is there anything else you would like discuss with me today_ (NO).
I offer you some written material about your condition, you can read at home.
You can get further information from the internet.
I thank you for your cooperation.
Good bye.
_______________________
Steroid in mornings.
Statins at night.
__________________________
Ref. to specialist for iniciation of Treatment Family Physician will monitor side effects
of medicines.
Ref. to Endocrinology Deptt. Hypothyroid
Ref. to Neurology Epilepsy
Ref. to Chest Clinic Tuberculosis
Ref. to Rheumatology Rheumatoid Arthritis (For DMRD)
Refer to specialist for iniciation of Treatment
Family Physician will monitor side effects of Medicians.
49
PNEUMONIA
Hello
Introduction
Abdullah 28 years
How can I help you today?
H/O
I feel breathless (For the last 1 day)
High grade fever with chills & shivers 102oF
Bodyache Tell me more about it
Anything else (NO that’s all)
H/O Present Illness
Is fever high grade? (Yes)
Is fever associated with shivering & chills? (Yes)
Any cough? (Yes)
Any Phlegm? (Yes)
What is the color of sputum? (Rusty color sputum)
Is there any breathing difficulty? (Yes)
Is there any chest pain while breathing in? (Pleuricsy) (No)
Chest pain increase with breathing or coughing? (Yes)
D/D
Are you undergoing any condition which need Radiation (Pneumonits due Radio
therapy). Any sudden chest pain with breathlessness & Fever (P.E.)
Have you recently been exposed to chemical Inhalation like Asbestos?
Any contact with ill person (Pneumonia) (visited a friend in hospital who had same
symptoms as I have)
Have you got any frothy sputum (Pulmonary odema)
Do you feel breathless while lying down? (C.C.F)
Red Flags
- Any significant weight loss (Malignancy)
- Any night sweating (T.B.)
- Any blood in sputum (T.B.)
- Any blueish colouration of fingers & toes. No to some extent (yes).
Past History
Any past history similar condition (No)
Any previous hospitalization (No)
PERSONAL/SOCIAL HISTORY
Do you smoke? How much? (Yes 2 Packs / day)
50
Do you drink? How much? (In safe limits)
Do you have high Blood Sugar (No)
Do you have high Blood Pressure (No)
How do you rate your weight? (BMI – 28)
Do you like to do some exercises? (No)
What sort of food do you usually take? (Healthy food)
What do you do for living? (Teacher)
Any stress at work? (No)
You got family? Any Kids? (Yes 2 kids)
Any stress at home? (Very peaceful)
FAMILY HISTORY
Any major medical problem in immediate family members? (No)
DRUG HISTORY
You taking any medicine regularly, prescribed or over the counter or herbal. (No)
Any drug allergies? (No)
Illness and ICE
Summarise
EXAMINATION
In order to reach my diagnosis I need to examine you. Can I examine you? Thanks for
allowing me to examine. Please move on to couch & take your shirt off for me.
General Physical Examination and full respiratory examination
_____________________
General Physical Examination + Full Respiratory System Examination)
Fundings are
_______________________
Breath rate per minute (Inspection) (From foot end) (>18/min) 25/min
Use of accessory muscles Movement (Inspection) (No)
Palpation for expansion of chest (reduced) (Palpation)
Vocal fremetus say 99 (↓)
Vocal Resonance (↓)
Purcurssion for consolidation (Percussion) (Dull at middle of left lung)
Ausculation (Bronchial Breathing) (Auscultation)
CURB-65 U-urea > 7 mmols (1) Presence of Confusion. Do you know where you are sitting
now. In your surgery (Confusion –ve)
(2) Respiratory rate ≥ 30/min (25/min)
(3) Blood Pressure less then 90/60 (120/80)
(4) Age more than 65 ≥ (28 years)
In CRB 65 scale each item score 1
Treat at home if score is zero.
51
Consider hospital admission if score is 2.
Consider urgent hospital admission if score is 3 or 4.
EXPLANATION
I am very much concerned about your condition. Probably some bug has enter your
chest cavity and causing a condition which we call in our medical terminology pneumonia.
Do you know anything about Pneumonia?
Do you want me to explain what is Pneumonia?
In this condition bugs damage the layers of breathing channel and form a cavity full of
pus. This can cause pain, difficulty in breathing and from here pus enters the blood stream
to cause fever with rigors and chills.
INVESTIGATION
In order to confirm my diagnosis, I offer certain set of investigations like
- Full Blood Count (Increased WBC) > 15000
- ESR CRP (Increased ESR) > 100 mm
- Xray Chest (If symptoms not resolving or diagnostic uncertainty)
- Sputum for M C/S and Acid fast bacilli (If not responding to treatment)
- Pulse oxymetry (If oxygen less than 92 percent, require admission)
MANAGEMENT (Non pharmacological & Pharmacological)
Rest
Drink plenty of water
Stop smoking
Steam inhalation
Analgesia paracytamol 1gm four times/d
Clarithromycin 500mg twice a day for 7 to 10 days
FOLLOW UP
I would like to review and reassess your condition in less than 48 hrs.
SAFTY NETTING
If improving then continue with treatment otherwise we may consider chest X-ray or
admission in hospital.
CLOSING
Is there any thing else you like to ask me today? (No)
You can take leaflet about your condition from the reception desk.
Good bye. (Shakehand)
____________________
Hemoptysis (Blood in Sputum)
Hematemesis (Blood in vomiting)
52
PNEUMONIAS
Pneumonia may be defined as an inflammation of the lungs caused by acute infection
and is characterized by recently developed signs of consolidation both clinically and
radiologically.
COMMUNITY ACQUIRED AMMUNITY
It occurs in previously healthy individual. Normal pulmonary defense mechanisms
prevent the development of lower respiratory tract infection. Community – acquired
pneumonias occur when (i) There is defect in normal host defense mechanisms (ii) There is
a large infectious inoculums (iii) Highly virulent pathogen defeats immunity. Presentation may
be typical or atypical.
HOSPITAL ACQUIRED NOSOCOMIAL PNEUMONIA
Pneumonia developing more than 48 hours after admission in the hospital is called
hospital acquired pneumonia. Gram negative organisms are mainly responsible for
nosocomial pneumonia.
Gram negative bacilli e.g.
E.coli, Pseudomonas, Klebsiella (Gram negative organisms)
Strepto & Staphyllococcus (Gram Positive organisms)
ASPIRATION PNEUMONIA
Aspiration of large amount of material > 50 ml with a pH < 2.4 (such as gastric
secretion) produces classic aspiration pneumonia.
Organisms mixed aerobic and anaerobic organisms
Ecoli
Klebsiella
Pseudomonas
Staphylococcus
CLINICAL FEATRUES
Fever malaise and weight loss
Foul smelling purulent sputum suggest anaerobic infection
TREATMENT
Clindamycin or Augmentin
Duration of antibiotic continued until X-ray chest show improvement
That make take a month or more
Typical Atypical
1. Amoxil 1. Macrolide
2. Macrolide 2. Tetracycline
3. Septran 3. Fluroquinoline
(Fluroquinalone & tetracycline are
C/I in pregnancy)
Macrolide Fluroquinoline
Erythromycin Ofloxacin
Azithromycin Ciprofloxacin
Clarithromycin Levofloxacin
Moxifloxacin
53
COMPARISON OF TYPICAL AND ATYPICAL PNEUMONIA
Community acquired immunity can be divided into typical and atypical pneumonias. This
designation of typical and atypical is very helpful in providing clues to the possible causes.
Features Typical pneumonia Atypical pneumonia
Onset Streptococcus pneumoniare • Legionella pneuomophilia
(most common cause of • Mycoplasma pneumonia
pneumonia) • Chlamydia pneumonia
H. Influenzae • Viral pneumonia
Clinical features Fever, shaking chills and • Non-pulmonary features

predominant pulmonary features are predominant such as
such as productive cough with gradual onset of fever and
purulent sputum, chest pain, and dry cough. Myalgia,
signs of consolidation such as arthralgia, headache, sore
decreased chest movements, throat, nausea, vomiting
dullness on percussion, and diarrhea are
increased vocal fremitus, predominant.
egophony, bronchial breath • Respiratory symptoms
sounds and crepitations. (chest pain, productive
cough) are less marked as
compared to the typical
pneumonia.
• Abnormal chest x-ray
despite minimal signs of
pulmonary involvement on
physical examination.
Labs Leukocytosis No leukocytosis
WBC > 15000 WBC count not raised
Predominantly neutrophils in atypical pneumonia
ESR > 100mm
Chest X-ray Patchy or lobar opacity Patchy non lobar opacity
TYPICAL PNEUMONIA
Typical pneumonia is caused by streptococcal pneumonia and less commonly by H.
Influenza. Patient presents with fever and typical respiratory features such as cough with
rusty sputum and pleuritic chest pain.
PULMONARY SYMPTOMS
Dyspnea cough dry at first but one or two days later it becomes productive with rusty-
colored or blood-stained sputum.
EXAMINATION
Patient appears ill with rapid pulse rapid respiration, high fever, flushed dry skin and
herpes labialis (herpes develop 1-2 day after fever)
54
INVESTIGATION
1. SPUTUM EXAMINATION
GRAM STAINING
It may give an immediate indication of possible pathogen and thus aids in the selection
of initial antibiotic treatment.
2. SPUTUM CULTURE & SENSITIVY

3. CHEST X-RAY
Necessary for confirmation of diagnosis.
Early detection of complications e.g. Pleural effusion and empyema
X-ray changes maybe minimal at the start of illness.
Radiological changes appear 12-18 hours after the onset illness.
Consolidation may remain on the chest X-ray for several weeks after the patient is
clinically cure.
Chest X-ray should always return to normal by 4-6 weeks.
Chest X-ray may show patchy or homogenous opacity localized to the affected lobe
or segment.
4. Blood complete picture and ESR
WBC count Is greater than 15000 per cubic meter (> 90% Neutrophils)
ESR > 100 mm in first hour in streptococcal pneumonia.
WBC count is not raised in atypical pneumonia.
5. BLOOD CULTURE
It should be performed in patients with severe pneumonia before starting antibiotic.
6. SEROLLOGICAL TESTS
Pneumococcal antigen test. Serologic test of sputum, urine and serum for pneumoccal
antigen is 3-4 times more sensitive than sputum or blood cultures.
Serological tests (for atypical pneumonia) may be helpful in the diagnosis of
mycoplasma, Leginella, chalamydia and viral infection.
7. ARTERIAL BLOOD GAS MEASUREMENT
Measured in seriously ill patient.
_________________________
CBC WBC > 15000 , ESR > 100mm
Sputum C/S
Blood C/S Before starting Antibiotic
X-ray Lobar or pachy consolidation
Serological Test Pneumococal Antigen Test.
Blood gases < 92 Admission
_________________________
MACROLIDE: Erythromycin, Clarithromycin, Azithromycin
FLUROQUINOLONE: Ofloxacin, Ciprofloxacin, Levofloxacin, moxifloxacin.
55
TUBERCULOSIS
Scenario:
Mr. Tariq Butt 45 year recently migrated to UK from India, complains of cough
& Blood in Sputum.
Kindly gather relevant data, do focused examination & share a mutually
agreed management plan.
Proceed.
______________________
Hello
I am Dr. Raheel.
One of the family physicians in this surgery.
I am Tariq Butt 45 year.
Ok. Mr. Tariq Butt how can I help you today?
Doc. I developed cough a month ago but for the last one weeks I am coughing out blood in
sputum.
Doc. I feel feverish in the evening.
Any thing more.
I don’t feel like eating. It seems I have lost some weight.
Anything more?
No that’s all.
H/O PRESENT ILLNESS
You said you have cough for more than 3 weeks & now is coughing out blood. You
are feverish in the evening. Have you documenated grade of fever? D/D sore throat, Red
eyes, Running nose, along with cought.
Yes doctor its low grade 99oF & it occurs mostly in the evening.
How much weight you have lost?
I thing about 3 kg in one month.
PAST HISTORY
You have migrated to UK from India recently. Is there any past history of cough &
blood in sputum. (No)
HIV status tested.
Is there any past history of contact with some T.B. patient. (Travel to endemic areas
like India)
Yes my grand father was living with us in the same house and he was a diagnosed
case of T.B.
PERSONAL HISTORY
Do you smoke?
Yes about a pack per day.
Do you drink alcohol?
No I can not afford.
Any high blood pressure? (No)
Any heart trouble? (No)
Do you know your HIV status? (Its –ve, I got it tested recently)
What do you do for living? (I am labourer)
What kind of food you like?
I like meat & dairy products but cannot affored.
Do you like to exercise? (No)
Got a family? (Yes I am married)
Any kids? (yes 2 kids, 5 & 8 years old sons)
What about their health.
Doc they have also started coughing.
56
FAMILY HISTORY
You told me that your grand father was a diagnosed case of T.B. living with your family
before you migrated to UK. (Yes)
Is there anyother person you came to contact who is ill? (No)
SUMMARISE
So Mr. Tariq you have told me that you have cough for more than 3 week with blood
in sputum. You are feverish in the evening & has lost some weight.
You have a strong family history of contact with T.B. patient & you are a heavy smoker.
Is this all or you want to add something to it?
That’s all doc.
EXAMINATION
Well Mr. Tariq in order to reach my diagnosis, I need to examine you. Can I?
Yes.
Thanks for trusting me for examination. Please move on to the couch & take your shirt
off.
General physical examination and Full respiratory examination.
Finding are given in laminated paper by examiner.
Bronchial breathing at Apex of left lung.
INVESTIGATIONS
Mr. Tariq have you gone through any investigations so far?
Yes this is the X-ray.
WHO recommends new test namely Gene XPERT MTB/RIF ASSAY
Initial diagnostic test in all persons adults and children with signs and
symptoms of TB. XPERT MTB/RIF ASSAY simultateniosly detects
Mycobacterium tuberculosis and rifampicin resistence in less than two hours.
Initial diagnostic test in patients with suspected TB meningitis, instead of
conventional microcopy, phenotypic culture and DST, treatment should follow
immediately if the result is positive, additional testing is needed if the initial
Xpert MTB/RIF result is negative.
There is a suspicious shadow on x-ray. They say I have T.B.
Any other test done?
My montoux test shows disc of induration > 15mm.
Anyother test done? (No)
Doctor takes the X-ray & montoux test report. Confirm it name & age with the patient
name & age. Read them carefully. Put them in front of him instead of returning to patient till
the consultation is over.
Ok Mr. Tariq there is a suspicious shadow at the Apex of left lung which could be due
to Tuberculosis but we need to examine your sputum for the presence of AFB Bacilli (That is
T.B. Germ) in order to confirm T.B.
Your sputum will be tested for 3rd times if first two samples did not show presence of
AFB Bacilli.
If we found the AFB Bacilli in your sputum we will culture sputum AFB but we can start
the treatment of T.B. if AFB Bacilli are found in sputum. We will confirm the diagnosis with
AFB culture which takes 2 or 3 weeks. We will start TB treatment but will confirm it with AFB
culture which takes 2-3 weeks.
MANAGEMENT
The good news is that effective and curative treatment is available for tuberculosis and
person can become normal healthy in six months. Starting T.B. treatment is a big
responsibility both for doctor & patient as this treatment involves taking of 3-4 Antibiotics for
a period of 6 months. All these antibiotics have potential serious side effects.
I shall be referring you to chest clinic for start of treatment, If AFB culture is +ve.
SAFTY NETTING
57
If you develop red color urine. Rest assure it the color of medicine & not blood. If
develop any vision problem or joint pains, please report immediately to your family physician.
We may need to alter the medicines or stop the medicine.
Is it ok with you. (Yes)
Most importantly your wife & kids will be screened for T.B. infection with X-ray &
montonx test. (Sputum for AFB)
Do you understand so far. (Yes)
IMPORTANT NOTE
It is important to take medicines regularly on time. If you do not comply with taking of
regular anti-tuberculosis drugs, complications like resistence to these four medicines can
occur. As a result the treatment can become difficult and more expensive.
If not taking drug at time regularly, then DOT Direct observation Treatment will be started. In
this way drugs are dispensed & taken under direct observation of health worker.
LIFE STYLE CHANGES
Meanwhile there are certain life style changes which you need to adopt.
1. As you know this disease spread by air, so you need to wear mask for 2 weeks
after the start of medicines when you will no longer remain contagious. Can you do
it? (Yes)
2. Do not spit everytwhere. Please spit in a small pot with a cover lid. Wash it out in
flush. Can you do it? (Yes)
3. Take healthy diet which should include plenty of meat, fruits, vegetables & dairy
products. Can you manage it?
No (Doc I am poor labourer & can not afford such healthy diet)
Ok I will be referring you to social service who will ensure healthy diet for you &
your family.
4. Please keep the window curtains opens so the sunlight & fresh air can enter the
rooms. Can you do it. (Yes)
Is there anything else you want to discuss with me today? (No.)
Ok then see as soon as the reports of sputum AFB & culture arrive.
You can take leaflets about your T.B. condition from reception desk.
Further information from internet.
Good Bye (Smile Shakhand)
58
TUBERCULOSIS
SIDE EFFECTS OF ANTI-TB DRUGS AND TREATMENT
Rifampacin (R) • Red Color Urine • Reasure and CBC

• Thrombocytopenia
Isonizid (INH or H) • Neuropathy • Check Sensory

System
Ethmabutol (E) • Eye Involvement e.g. • Check Visual Acuity

Optic Neuritis and red and green
color discrimination
• Vision Problem
• Not given to Child
less then 3 year and
patient with renal
failure
Pyrazinamide (Z) • Hyperuricemia Gout • Check Uric Acid &

joint pain Monitor for Gout
Streptomycin (S) • Autotoxitiy and • Do Audiogram and

Nephrotoxicity Check renal function
hearing deafness periodically
• All Anti-TB drugs are Hepatotoxic (AST usually rise 3 times but Anti-TB drugs are
continued until AST is markedly raised i.e. Symptoms of Hepatitis appear then stop
ATT)
Refer chest clinic for initiation of T.B. Drugs.

P - Pyrazinamide 25 mg/kg body weight
E - Ethmabutol 20 mg/kg body weight
S - Streptomycin 15 mg/kg body weight
R - Rifampin 10 mg/kg body weight
I - Isonizid 5 mg/kg body weight
T.B. patient can do breast feeding.
Streptomycin contraindicated in pregnancy.
Other anti.T.B. Drugs can be given in pregnancy.
Vaccination of BCG contraindicated in pregnancy.
Vitamin B6 (Pyridoxine) 1.3mg/kg in children, 1.7 mg/kg in adults
59
OTHER SCENARIOS OF TB
1. Patient may present with joint pains. On taking drug history, he tells he has been taking
anti tubercolus treatment which included Pyrazinamide. Actually his joint pains are due
to Pyrazinamide causing hyperuricemia. Uric Acid is deposited in the joint and cause
pain.
2. Patient is on anti tuberculous drug for the last three months. Checking his sputum for
AFP shows that is sputum is still positive for AFP. In such situation try to check
compliance of the drugs and also if he has been in contact with any tuberclous patient
recently. He may not be taking his drugs regularly and forced dot therapy i.e., direct
observation therapy in which drugs are dispensed and taken in the presence of a
health professional.
Refer the patient back the chest clinic. He may be having multi drug resistence.
Kanamycin or other antibiotics may need to be added.
_______________________________
FOLLOW UP
TB patient follow up is done every 2 month in which
1. His X-ray chest, PA view is reviewed at 6 month.
2. His weight is checked whether is gaihning weight or not or still bellow BMI 25.
3. His blood is checked for ESR in the first hour
4. His sputum for AFB will be checked
____________________________________
Please do add Vitamin B6 Pyridoxine with anti tuberculous medicines.
60
SNORING & SLEEP APONEA
Scenario
Mr. Khalid Saeed 55 years has come to discuss his noisy breathing during night.
Please take relevant history & manage.
Proceed.
Doc. I have been sent to you by my wife.
She says I snore a lot at night which disturbs her sleep.
Anything more?
She say I sometimes stop breathing for brief time.
She is afraid I might die while sleep. Kindly help me & manage my problem.
I need to ask you few questions in order to reach a diagnosis. Can I ask? (Yes please)
Since when you are having noisy breathing? (For the last few months now)
Is it related to some special circumstances like when you are tired and under rest.
(Yes)
What is your position of lying while sleeping? (I sleep on my back)
How many pillows do you use? (2 thick pillows). Do you know your neck collar size?
(>16 cm) 43mm
Have you felt an episode of choking while sleep? (My wife noticed it)
Have you felt any headache in morning? (Yes)
Do you feel any lack of freshness in morning and tiredness. (Yes)
How likely it is for you to dose off or fall sleep while sitting & reading. (Yes)
Watching Tv? (Yes)
Sitting quietly after lunch without alcohol? (Yes)
Sitting & talking to some one? (No)
Sitting inactive in public? (Yes)
In a car, while stopped for few minutes on traffic signal? (No)
IN a car, as passanger for an hour without break? (Yes)
Do you feel excessive day time sleepiness. (Yes)
D/D
Change in voice? (No) change in weight (Hypo thyroid) (Obese BMI > 30)
Do you have difficulty in breathing through nose? (Yes) Adenodis
Do you feel difficulty in swallowing due to large tonsils? (I don’t have large tonsils)
PAST MEDICAL HISTORY
Is there any major medical problem in past like hypo thyroidism, high blood sugar, high
blood pressure. (No)
PERSONAL HISTORY
Do you smoke? (Yes, 2 packs /d)
61
Do you take Alcohol (Patient take excessive alcohol at evening) > 3 units
Do you take any recreational drug? (No)
How do you rate your weight? (Increase weight) I am obese. BMI > 30
Do you like to do exercise? (No)
What sort of food do you like? (Spicy and fried food)
What do you do for living? (Clerk in office)
Any stress at work? (No)
Have got a family?
Any stress at home? (No) but my wife has threatened to banish the bedroom.
FAMILY HISTORY
Is there any major medical problem in immediate family members. (No)
DRUG HISTORY
Are you taking any medicine regularly like sleeping pill at night. (Yes)
ILLNESS
Cannot concentrtate on work in the morning due to excessive sleepness in morning.
IDEA
I don’t know.
CONCERN
Might die due to choking during sleep.
EXPECTATION
You will find some solution for my problem.
SUMMARIZE
EXAMINATION – REASSURANCE & EXPLANATION IN LAYMAN’S LANGUAGE
Weight 100 kg
BMI – more than 30 obese
Neck circumference > 16cm (43mm) (Oxford page 308)
Thyroid gland inspection. (Normal)
INVESTIGATION
I offer you few tests in order to confirm my diagnosis.
TFT (Hypo Thyroid)
Refer to ENT for examination of Ear Nose and throat especially tonsils. Adenoids
Polylips.
MANAGEMENT
During sleep our throat air way become narrow. Snoring is the vibratory noise
generated as air passes through narrowed space.
Further narrowing produces louder snoring, labored inspiration & eventually choking
episode.
62
Increased effort to start breathing is sensed by the brain & transient arousal is
provoked.
During night hundreds of such transient arousals result in fragmented sleep &
consequent day time sleepiness.
Epworth sleep scale is useful assessment toll.
Life style changes for snoring without Apnoea.
If no Apnoea
Do not sleep on the back instead sleep on the side
Elevate head end of bed
Limit number of pillows to 1 thick or 2 thin pillows
Decreasing weight helps. Do brisk walk 30 min/d 5d/wk.
Stop smoking
Stop excessive evening alcohol
Stop sleeping pills in evening. Don’t drive if feel sleepy.
Suggest partner may use ear plugs to avoid snoring noise.
I offer to refer you to sleep unit where a doctor interested in sleep problem will do study
called Polysomnography.
PHARMCOLOGICAL TREATMENT
If nasal congestion then Biclometasone nasal spray twice a day ± Ipratropium Bromide
nasal spray at night.
If episodes of choking while sleeping then refer to sleep unit for C-PAP.
If C-PAP is not tolerated then referred to dentist or ENT specialist for mandibular
advancement devices.
If large tonsils then refer to ENT for surgery.
I offer you to Inform DVLA and other insurance companies.
C – PAP – (Continous Positive Airway Pressure)
OBSERVE SLEEP HYGINE THAT IS:
Don’t go to bed until you feel sleepy. Avoid day time naps.
Don’t eat work read or watch TV in bed room.
Bed should be confortable. Room should be warm or cool comfortably.
Avoid caffeine, Nicotene, Alcohol at bed time.
Have warm milk at bed time.
Avoid late night hard exercise but sex is ok.
Rise at the same time in morning regardless of how long you have slept.
63
HYPOTHYROID
(Oxford page ?? to be Rewritten)
SCENARIO
Mr. Hamid Saeed, 60 years old complains of lethargy and weakness of his
muscles of body for 4 months. Proceed.
Please tell me more (Let the patient talk for full one minute)
KNOWLEDGE BASE
Onset tends to be insidious and may go undiagnosed for years. Always consider
hypothyroidism when a patient has non-specific symptoms, depression, fatigue, lethargy, or
general malaise. Other symptons-weight ↑, constipation, hoarse voice, or dry skin/hair.
H/o Present illness
After listening ask about his weight. If weight is increasing then depression is ruled out
but mind it depression may co-exist with hypothyroid.
Then ask which weather do you like (Cold intolerance in case of hypothyroid)
What about your weight (Weight increased in hypothyroid)
What about your bowel habits (Constipation in case of hypothyroid)
Any change in quality of voice recently (Hoarseness in case of hypothyroid)
Any hair changes (Dry & thinning)
Any skin changes (Dry & Course)
What about your sleep (Over sleepiness, tired lethargic)
What about your period (Heavy period)
What about your mood (Depression) are you taking any medicines to decrease fats.
D/D Any morning stiffness for more than 45 minutes (PMR)
Any black stool / Anaemia.
PAST HISTORY
Any past history of similar condition
Have you ever recently received any treatment for your hyperactive neck glands e.g.
Any past radio active iodine uptake injection.
Any past history of operation on neck gland.(Thyroidectomy)
PERSONAL HISTORY (Bio Psychosocial History)
Do you smoke?
Do you drink?
What is the nature of your job? (Retired man)
Married for 25 years but no kids.
Any kids? No (infertility in case of hypo and hyperthyroid)
Any history of heart attack?
Any paralysis?
Any recent infection?
Any recent trauma?
FAMILY HISTORY
Any member of your family having problem with front neck gland? (Yes)
DRUG HISTORY
Are you taking any medicine regularly (Prescribed or OTC or herbal)
e.g. If yes which medicine you are taking? Amiodrone for your irregular heart beat or
lithium for mood problem.
Feel for texture of skin and hairs on dorsum of hand. (dry & course)
Feel pulse and count with watch (Preferably both hands) (Bradycardia)
Look from front and side for neck gland
Look from front as patient take a sip of water hold it and now swallow it. Thyroid gland
will move up. I need to feel your neck gland from behind while standing. Can I? Palpate
from behind as patient take a sip of water. Gland will move upward. Look for non
petting edema of feet hand and eye lids.
Check ankle jerk reflex ( Look at the Calf muscle to contract, its slow relaxing reflex)
64
INVESTIGATION
Have you undergone any investigation so far? Patient may show a three month old
report. Ask if he has been tested recently for TSH i.e. after three months. He wil show latest
report showing  TSH. Now at two reports you can diagnose hypothyroidism.
Based on history and examination I offer you to following tests:
Thyroid Function Test ( TSH,  free T4 T3)
Lipid Profile ( Triglacerides)
Fasting Blood Glucose
ECG (Low voltage, prolonged PR Interval, T wave alterations, cardiomegaly
MANAGEMENT
Based on your history, examination and investigations what I have gathered is that
you are having a condition what we called hypothyroidism. Do you know anything about
hypothyroidism? Do you want me to explain what is hypothyroidism?
REASSURANCE
Actually there is a gland in front of our neck called thyroid. This gland produces a
chemical. In your case this gland is producing less amount of this chemical because of which
you are having these symptoms. We will replace this deficient chemical with a medicine.
Patients taking thyroxine replacement entitled to apply for free prescriptions in
England.
<65y and healthy 50-100 mcg od levothyroxine. Re-check TFTs after 4-6 weeks.
Adjust dose to keep TSH in the normal range. Once dose is stable and TSH is within normal
range monitor annually and if symptomatic or worries about compliance.
If elderly or pre-existing heart disease Start 25mcg od levothyroxine and ↑ dose every
4-6 weeks according to TFTs. Consider adding propranolol if history of CHD as levothyroxine
can provoke angina.
Withdrawal of levothyroxine Usually needed lifelong. If diagnosis is in doubt stop
levothyroxine and re-measure TFTs after 4-6 weeks.
SAFETY NETTING & FOLLOW UP
Will you be able to take your medicines regularly? (Yes)
You will probably need Levo-thyroxine for life time but please come to me after every
4 – 6 weeks to re-measure TSH and to adjust dose of thyroxine .
Will it be possible for you (Is it convenient to you)
CLOSING
Is there anything else you wish to discuss with me today? (No)
You can collect leaflet about your condition from reception desk.
Good Bye (Smile & Shakehand)
IMPORTANT NOTE: Two reports of Hypothyroid ↑ TSH, ↓ free T4 & ↓ free T3, three
months apart. Only then diagnose Hypothyroid and then treat. No emergency.
Proximal muscle weakness (Positive). Go and get up test (Negative).
Bradycardia (Slow heart rate). Slow relaxing ankle jerk.
Healthy diet containing sufficient Iodene + exercise to decrease weight.
IMPORTANT NOTE
Family physician can treat hypothyroid but for hyperthyroid he must refer to
Endocrionology department for initiation of any of 3 treatments available i.e. carbemazole
tablet, radio active iodine injection or partial or total removal of thyroid gland.
65
HYPERTHYROID
Mrs. Abdullah 28 years 3 months pregnant presents with racing of the heart
sweating and tremor in hand. Gather relevant data, do focused examianation of neck
gland and do management. Proceed.
PRESENT HISTORY
Since when you are have palpitation (about 6 months) and sweating (about the same
period). My hands are always moist warm.
Does your Tremors occur suddenly in any particular situation (Anxiety panic disorder)
(No)
Do you feel any drumming in chest (increased heart beat) (Yes)
Which weather you like (Can not tolerate heat) (I like to stay in my AC room) (Its very
hot out side). (Hyper Heat HH)
What about your weight (Its decreasing) (my shirt have become loose)
What about your bowel habits (Sometimes diarrhoea)
What about your periods (Scanty periods) Now no periods as pregnancy.
PAST HISTORY
Any similar condition in the past. (No)
Any hospitalization recently. (No)
PERSONAL BIO-PSYCHO-SOCIAL
D/D
Do you excessively worry about minor things or fear of something bad happening in
near future? (Anxiety)
How are things at home? (No Stress) (Very peaceful)
How are things at work? (Stress) (Due to exam)
Do you smoke? No.
Do you drink? (No. I am avoiding as pregnant)
Job? (Student) Any post graduate exam coming in near future. (Yes)
Are you Married? Yes.
Any Kids? (Pregnant with 1st child)
Sleep? (Ok)
FAMILY HISTORY
Any Member of your family having problem with neck gland. (No)
Are you Asthematic any breathing problem. (No) (Beta Blocker Contra Indicator in
Asthma)
DRUG HISTORY
Illness (How this disease has affected your life). My exams are coming. My hands so
moist that paper becomes wet & I can not write.
ICE - Concern – what worries you most? (Exams)
Summarize and ask anything else to add.
EXAMINATION & INVESTIGATIONS
1. Examine hand for sweating and warmth
2. Check clubbing
Check pulse in both hands(It will be fast)
3. Please stretch your arms and spread fingers. Place a paper over dorsum of hand to see
tremors
Fine tremors present in case of hyperthyroid.
4. All eye signs are indicator of hyperthyroid.
(i) Exophthalmoses (From front)
(ii) Proptoses (from side & above)
(iii) Lid lag. Move finger abruptly from up wards to downwards. (Lid lags behind finger)
(iv) Double vision. Make H, patient feel diplopia in upward gaze.
Take sip of water and swallow (See from front)
66
Now I need to feel your neck gland from behind.
Now take a sip of water, hold & then swallow.
Palpate the movement of gland.
5. Percuss Sub sternal thyroid
6. PEN BURTEN SIGN
For retosternal thyroid confirmation ilicit pen burten sign i.e. raise both arms above
shoulder. Flushing of the face occur which is positive for retrosternal thyroid.
7. Auscultate heart for palpitation and then with bell of stethoscope ausculate for thyroid
bruie.
MANAGEMENT
I offer to refer you to the endocrinologist department for the initiation of treatment of
hyperthyroid. The specialist may give you a treatment with tablet or with radioactive iodine
injection or partial or complete removal of the thyroid gland with surgery.
Doctor can you explain what these three treatments are:
1. Specialist may offer you carbemazole 5mg thrice a day. Side effect include.
Agranulocytosis, aplastic anaemia, hepatitis. (Some problem with blood & liver)
Will repeat TSH (Free T3, Free T4) and adjust the dose accordingly till normal u-thyroid
state is achieved.
2. Specialist may offer Radio active iodine therapy. After this therapy thyroid gland will
produced lesser amount of thyroxine chemical, responsible for your symptom. Effects
takes 3 to 4 months to become apparent. Monitor TFT long term.
Allow me to inform you before hand that thyroxine chemical production can decreased
abnormally low and can cause sign symptoms of low chemical i.e. Hypothyroid.
Also you are suggested to avoid pregnancy for 4 months after Radio Active iodine
therapy.
4. If Specialist consider appropriate he may advise partial or complete removal of neck
gland to reduce abnormally high production of chemical thyroxine. Surgery has its own
complications like nerve responsible for voice box can be damage and Calcium levels
can be disturbed.
SAFETY NETTING
If while taking carbemazole, you develop sore throat, kindly immediately stop the
medicine and come to consult your family physician. If your condition deteriorate in any way
or you develop any new symptoms please. Seek immediate help.
FOLLOW UP
After every 4 to 6 weeks till U-thyroid state achieved. Then every 3 months.
Is there any thing else you would like to ask me today? (No)
Smile Shake Hand and say good bye. (Spmontaneously in one go)
IMPORTANT NOTE
In case of pregnancy offer propyl Thyouricil in the first trimasture and
methamezole in second trimasture instead of carbemazole.
67
DIABETES MELLITUS TYPE 1 COUNSELLING
SCENARIO
Mrs. David mother of 6 year old child Michael has come to discuss the insulin
injection problem with you. Kindly counsel her about insulin injections. Proceed.
Hello.
I am Dr. Raheel one of the family physician in this surgery.
May I know your good name please.
I am Mrs. David.
Ok Mrs. David what brings you to the surgery today?
Well Doc, I have a son 6 year old son, Michael. He became dizzy and fanted while
playing sports. He was taken to the nearest hospital where his blood sugar was found
to be very high. He was treated with insulin injections and he is advised insulin
injections for rest of his life to control his blood sugar as other adult take.
My questions to you is why my son can not take tablets as other adult Diabetic Patients
take.
Ok Mrs. David, let me explain why your child need insulin injections.
Actually Diabetes is of two types. Type 1 and type 2.
Type 1 Diabetes occurs in young children as your son is. In young children some times
one of our body organ called pancreas does not produce a chemical called insulin. Absolutely
The Insulin is not available in tablet form, so we have to replace that chemical insulin by
injections from outside.
Mrs. David are you following me? Can I proceed further?
In type 2 Diabetes that occurs in adults and their organ pancreas is able to produce
some amount of insulin and its functioning can be improved by taking certain tablets. So the
adults can take tablets but children need insulin injections for life long.
Mrs. David we are lucky that we are living in an era in which man made insulin is
available. Previously insulin was not available and type 1 children, with due apology, used to
die before adulthood in about six months time.
Question No.2. My son is afraid of injections will these injections be painful and bigger
needles will be needed to give the injection?
Well Mrs. David these injections are not painful because they are given by a very small
needle, the injection prick is nothing more than a bite by a mosquito. I can give this needle
injection to my self in front of your child to remove his fears before it is given to him.
Are you following me?
These days, very small needles are available. These needles are not only small but
very thin as well. Prick is only skin deep and not painful.
Question No.3. Will filling of the exact dose of insulin be difficult .
No Mrs. David these days we do not use syringe and bottels. Newer insulin pen are
available in which filling of the exact dose of the insulin is not difficult and very small thin
needle is there which can be replaced after very injection.
Questions No.4. I read it on internet that insulin can cause low sugar to the extreme
of endangering of the patients life.
Mrs. David with proper diet and proper dose of the insulin chances of low sugar attack
can be minimized. We can check the blood sugar frequently to prevent low sugar attacks e.g.
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just before the sports or after doing exercise . Also just before the diet is taken and two hours
after the diet is taken. Will my child need any special diet. No special kind of diet is
recommended. Your child can eat a normal healthy food as other people eat except he has
to avoid simple sugar & sweat things.
Question No.5. Can my child take part in sports?
Yes your child can play any game he likes the only precaution is to monitor his blood
sugar before and after the sports is played. Some sweet things can be taken before sport is
started and some sugary material like ordinary sugar, regular Coca Cola, Chocolate of some
sweet biscuits can be made available at hand.
Questions No.6. Will my child have a normal life expectancy.
Yes Mrs. David your child can have a normal life expectancy as any other child if he
keeps his sugar well controlled. The complications of Kidney, eye and nerves can be delayed
for decades if blood sugar is kept in normal range.
Let me share a good news to you that insulin producing pharmaceutical company few
years back gave medals to those type 1 diabetic vaterans who completed their 80 years of
lives while being on insulin injections.
Q.7. Can iInsulin injections cause obesity.
Yes insulin can cause increase in weight only if insulin is given in doses more than
required.
Q.8. May I know the sign symptoms of low sugar attacks. Sign of Hypoglycemia include
sudden desire of hunger, drenching sweats , tremors in hands gait become like than of a
drunken person. Fast heart beat drowsiness & headache can occur.
Q.9. What can be done if person becomes unconcious due to low sugar attack.
Glucagon injection can be given intramuscular in buttocks. Person regains
conciousness within five to fifteen minutes. One needs to learn how to give glucagon
injections before hand. All family members and colleagues at work should be taught. If
glucagon injection is not available 20cc of 25% glucose ampule can be given intravenously
(I/V).
Make sure that your child keep wearing medi alert bracelet or neckless describing your
child as diabetic. So that in emergency situations he can be taken to appropriate place to
help.
Mrs. David is there anything likes to ask me today?
No Doc that’s all for today.
You can collect leaflet about type 1 Diabetes from the reception desk.
Thank you for the cooperation.
Good bye.
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GLUCAGON INJECTION DOSE
In adult 1mg Intra muscular in bottuck

In children 0.5mg Intra Muscular (if weight is less than 25kg)
Glucagon injection works in 5 minutes and patient regains consciousness.
SYMPTOMS OF HYPOGLYCEMIA
Sudden desire for hunger

Sudden drenching sweats
Mood changes
Irritibility
Dizziness or Sleepiness
Headache
Vertigo
Bluring of vision or double vision
Tremors in hand
Drunken gate
Fast heart beat

Fast pulse
Fainting in extreme cases
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CALCULATION OF INSULIN DOSES
For Lantus
Body weight x0.3= dose of lantus
Suppose body weight is 80kg
80x0.3=24 units
This is the maximum doses calculation.
You can start with 10 unit at night and observe the fasting sugar level.
In morning
If you see the desired sugar level has not reached, you can increase the units by 2 units.
_____________________________________
To begin with good choice would be combination of regular insulin and NPH
This is humulin 70/30
It will take coverage of whole day by taking twice a day at morning and evening.
Its dosage will be body weight x 0.5 = dose
80kg x 0.5 = 40 units per day
2/3 in the morning and 1/3 at night.
25 units in morning and 15 units at night
This is the starting dose.
You can increase gradually by 2 units according to your post prandial sugar level.
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NORMAL VALUES DIABETES DIAGNOSIS
• You have to remember only 4 values i.e. 60 – 110 – 126 & 140
Also 180, 200 & 70
• Fasting Blood Sugar 60 – 110 mg
• 2 hrs post prandial 126 – 140mg
• Normal upto 199
• Normal value at which glucose spills in urine 180mg
• Declared Diabetic at Blood Sugar > 200mg (At 2 Occasion)
• Declared Diabetic at Fasting Blood Glucose >110(Even at 1 occasion)
_______________________
• Impaired Fasting Glucose 110 – 126mg
• Impaired Glucose Tolerance 140 – 200mg
_______________________
• Hypoglycemia common At 70mg (2.5mmol./L)
_______________________
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NORMAL LIPID LEVEL & METABOLIC SYNDROME
• Obtain complete lipoprotein profile after 9 to 14 hours fast.

• ATP III Classification of LDL, Total, and HDL Cholesterol (mg/dl)
LDL Cholesterol
• < 100 _______________ Optimal
• 100 to 129 ___________ Near optimal / above optimal
• 130 to 159 ___________ Border line high
• 160 to 189 ___________ High
• ≥ 190 _______________ Very high
Total Cholesterol
• < 200 _______________ Desirable
• 200 to 239 ___________ Border line high
• ≥ 240________________high
HDL Cholesterol
• < 40 ________________ Low
• ≥ 60 ________________ high
ATP III Classification of Serum Triglycerides (mg/dl)
• < 150 ________________ Normal
• 150 to 199_____________ Border line high
• 200 to 499 _____________ High
• ≥ 500 _________________ Very high
Clinical Identification of metabolic Syndrom – any 3 of the following:
Risk Factor Defining Level
Abdominal Obesity_________ Waist circumference
Men_____________________> 102 cm (>40 inches)
Women___________________> 88 cm (>35 inches)
Triglycerides _____________ ≥ 150 mg/dl
HDL Cholesterol __________
Men_____________________ <40 mg/dL
Women___________________ <50 mg/dL
Blood Pressure____________ ≥ 130/85 mmHg
Fasting Blood Glucose _____≥ 110 mg/dL
73
DIABETES MELLITUS TYPE 2
SCENARIO
Mrs. Abdullah 47 years known Type 2 Diabetic for the last 2 years has uncontrolled
blood sugar of 300 mg/dl. Take relevant history and manage.
Hello
I am Dr. Raheel.
May I know you good name please?
Abdullah 47 years.
Ok Mr. Abdullah what brings you to the surgery today?
Doctor I feel thirsty, drink a lot of water and pass a lot urine.
Anything else?
It disturbs my sleep and I don’t feel as energetic as I used to be.
Despite increased in appetite my weight is decreasing.
There are skin boils & I keeps scratch in my private parts. (pruritis)
What about your appetite? (My appetite is increased)
What about your weight? (My weight is decreasing)
Do you have boils frequently? (Frequent Infection) Yes.
Do you feel like scratching especially in your private parts? Yes.
________________________________________________________________________
COMPLICATIONS
MICROVASCULAR COMPLICATION
(1) What about your eye sight (↓ visual acuity early cataract) (Retinopathy)
(2) Do you feel any numbness in your arms & legs (Sensory neuropathy)(Motor
Neuropathy) especially tips of fingers & toes.
(3) Do you have any urinary problem? (Nephropathy)
MACROVASCULAR COMPLICATIONS
(1) Did you have any heart attack?
(2) Do you have any history of paralysis?
(3) Do you feel any weakness and wasting of your thigh muscles? (Proximal muscle
atrophy)
(4) Do you have any problem in performing sex? (Erectile Dysfunction) (Yes)
(5) Do you suffer from bloating and distension after eating? (Gastero Paresis) (No)
(6) Do you feel dizziness on standing from sitting position? (Postural Hypotension)
Autonomic neuropathy(No)
D/D
Are you a sort of person who worries excessively about minor things most of the time?
(Anxiety)
Do you feel pain when you pass urine. (UTI).
Do you feel you have to rush to toilet and have feeling of incomplete empting urge
incontinence?
74
RED FLAG
What about your mood.
For the past one month how often have you been bothered by low mood.
How often have you been bothered by loss of interest.
Any temperature?
PAST HISTORY
Did you suffer from any heart problem in past?
Did you had any episode of paralysis in the past.
PERSONAL HISTORY
Do you smoke? How much?
Do you drink? How much?
Any history of ↑ Blood Pressure? (Yes) Must ask every diabetic very important.
What do you do for living? (Public Bus driver)
Married? Yes.
Kids? Yes, 2
How are the things at home? (Psychological Problems & Stress) No.
How are the things at work? (Psychological Problems & Stress) No.
DRUG HISTORY
Are you taking any medicine regularly, prescribed or over the counter.
I am taking 500mg of Metformin thrice and Lisinopril for ↑ BP.
FAMILY HSITORY
Any major medical problems in immediate family members e.g. heart ↑ BS or ↑ BP.
(DM & heart problem runs in our family)
_____________________________________
ILLNESS ICE
SUMMARIZE and ask he has anything else to add
EXAMINATION
General Physical Examination
Foot
Skin
INVESTIGATION
I offer you the following investigations
blood sugar fasting
2 hours after meals
HbA1C
Urea Electrolyte Creatinin eGFR
ECG
NON PHARMACOLOGICAL MANAGEMENT
Mrs. Abdullah you have uncontrol type 2 DM.
75
DIET
First of all I offer certain changes in your life style like healthy eating habits and regular
exercise
Can you avoid simple carbohydrate and sweet things (Like Sugar, Honey Coca cola).
50% of calories should come from fiber rich complex carbo hydrate (Potato Brown
Rice, Whole Grain). Can you do it for me?
You food should have at least 5 portions of fruits and vegetable.
Reduce fats to minimum especially saturated fats. Can you do it.
No Red Meat, poultry Ok, Oily Fish good.
Reduce salt intake.
Can you bring Alcohol use in safe limits.
You need to stop smoking completely. Can you do it for me?
Spread the food evenly across the day.
You don’t need any separate diet from rest of the family.
No - expensive diabetic food products.
Diabetic diet is healthy diet.
EXERCISE
Try to do some regular exercise.
150 minutes per week.
You can divide it into 30 min/d 5 days a week. You can have 2 days holiday.
You can do exercise in the form of brisk walk, cycling, swimming or dancing jogging
or any other game.
Remember exercise ↓ weight,
↑ Insulin sensitivity, ↓ BP,
↓ Lipids and improves blood sugar control
Can you manage it? (Yes)
IMMUNIZATION
I offer you influenza and pneumococcal vaccination. (DM Immunocompromised state)
SMOKING
I offer you my assistance in quitting smoking. We will have a detailed session in the
next appointment.
DRIVING
Please inform DVLA and insurance about your type 2 DM diagnosis. Unless diabetes
mellitus controlled by diet alone. You can no longer drive public service vehicles or heavy
goods vehicles, because of possibility of low sugar attacks espcially if they occure frequently.
Check fasting blood sugar before driving and every two hour during a long journey.
Supply responsible member of family with glucagon injection.
EMPLOYMENT
If on insulin, certain job are not possible.
1. Working with dangerous machinery
2. Joining police or armed services
3. Driving a heavy goods or public service vehicle.
SELF MONITORING
Check your blood sugar at home pre-meals at least once a day at different times.
Keep a record.
Check HbA1c atleast 2 times a year.
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Your blood sugar is uncontrolled hence I offer you to increase the dose of metformin
to 1000mg twice a day and & add sitagliptin 50mg once daily.
Remember metformin can cause some tummy pain from bloating.
We will review your blood sugar every month and keep increasing the dose. Until
satisfactory control is achieved.
FOLLOW UP
I offer you a follow up visit after 1 month.
SAFTYNETTING
Kindly keep wearing medi-alert bracelets or necklet. Teach your family and colleagues
about what to do if you develop hypoglycemia. (Give glucagone injection)
HOPE
Although DM is a progressive disease but rest asure if you keep a good control of
Blood Sugar, you can delay complications by decades and live a very normal healthy long
life.
Is there anything else you like to ask me today?
(No)
Smile, shake hand and say good bye.
_______________________________
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HYPOGLYCEMIA
Mr. Zeeshan – 45 years known diabetic for 2 years has come to discuss his new
symptoms with you. Kindly take history and manage/proceed. Examination not
required.
MEET & GREET
Hello I am Dr. Raheel. One of the GP in surgery.
I am Zeeshan 45 year old.
Mr. Zeeshan please tell me how can I help you today?
Well Doc. previously my blood sugar was well controlled with diet and exercise
recently the other doctor prescribed me glimeperide 1mg once a day. Since then I am have
strange symptoms like profuse sweating & tremors in my hands at 3 am.
OK please tell me something more.
Doc. I checked my blood sugar at 3 a.m. it was below 70mg/dl. Same symptoms
occurred 7AM, after I returned from exercise. My legs were trembling, felt dizzy and my gait
became unsteady like that of drunken man. I felt dizzy.
Any thing else?
Well Doc. Although the symptoms resolved after taking some sweat thing like honey,
sugar or pepsi or a glass of milk and sandwitch I remained confused for a while and could
not concentrate on my business affairs. I am afraid some part of my brain is damaged.
Anything else you want to say?
No that’s all doctor.
_______________________________________________________
So you have told me that you are experiencing certain symptoms. After prescriptuion
of glimeperide 1mg once and you are afraid that your brain may be damaged. Your blood
sugar on two occations was less than 70mg/dl.
• Can I ask you a few more questions?
• Did you experienced any if such symptoms in the past?
No.
• Do you have high blood pressure as well?
Yes I am hypertensive as well and taking B-Blocker.
Atenolol 50mg a day. My B.P. is controlled.
• Are you a smoker?
Yes.
• How much? 20 cigarettes since 20 years.
Intend to quit. Yes.
As you know smoking is not good in a condition like diabetics. We will discuss this
issue in detail in next appointment. Lets first discuss your present symptoms.
• Do you drink?
Yes 4 unit / day. (Any intention to cut down to safe limit) (3 units per day)
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• Any heart problem?
FAMILY HISTORY
Any major medical problem in immediate family member.
Yes my mother is diabetic and my father was hypertensive and he died of heart attack
at the age of 60.(Oh I am sorry to hear that)
DRUG HISTORY
Are you taking any medicine regularly?
Yes Glimeperide 1mg once daily and Atenolol 50mg once a day.
Any other medicine? No.
Any drug allergies? No.
ILLNESS
How this problem has affected your life?
Doc. My Colleagues tell me that I behave strangely after such episodes. I can not
concentrate my business affairs properly.
IDEA
What do you think you are suffering from?
Doc. I think its this newly added medicine the other doctor at surgery prescribed me,
is causing these symptoms. Previously I was Ok.
CONCERN
What worries you most?
Doc. I believe some part of my brain is damaged.
EXPECTATION
What do you hope to gain from todays consultation?
Doc. I hope you will change my medicine to some safer medicine.
SUMMARIZE
Mr. Zeeshan you have told me that you have high blood sugar, high blood pressure
for which you are taking glimepride and Atenolol. You are a heavy smoker and drinker. You
have a strong family history of diabeties, hypertension and heart problem and you are having
some symptoms due to which you think your brain is damaged.
Is this all or you want to add something else?
No. That’s all doc.
In order to reach my diagnosis. I need to examine you. Can I examine you?
EXAMINATION
Examination not required.
INVESTIGATION
I offer you the following tests
HbA1C.
Blood sugar fasting and 2 hrs after meals.
Complete renal profile.
79
MANAGEMENT
Well Mr. Zeeshan what I have gathered from the information you have shared and
blood sugar reports is that you are having a condition what we call in our medical terms
“hypoglycemia”. Do you know anything about hypoglycemia. No Doctor.
Sometimes if a diabetic skip his meals or do excessive exercise or take more medicine
or insulin for his high blood sugar then his blood sugar can drop to dangerous levels and
cause certain symptoms like you are having.
It is my considered opinion that most probably glimeperide 1mg once a day is
responsible for your symptoms.
I offer you to change this medicine with metformin 500mg twice a day with every lunch
and dinner.
I also offer you to change your  B.P. betablocker medicine to ACE1 group like ramipril
2.5mg a day. B. Blocker decrease awareness of low sugar levels. It has to be tapered of in
one month’s time.
Please immediately take some sweet things like sugar, honey, sweet biscuits, regular
pepsi etc. if you experience any of such symptoms you described.
Please keep wearing a medi alert bracelet or neckless describing you as diabetic. So
that in emergency situations your family or colleagues at work could give you glucagon
injection which can be life saving. You will have to teach your family & colleagues at work
how to give this injection intramuscularly beforehand.
As far as your concern about brain damage is, let me assure you that brief low sugar
attacks do not damage brain but if person become unconscious and low sugar attack is
prolonged only then some brain damage is possible (Fuel for brain functioning is glucose
only).
I there anything else you will like to discuss with me today?
No. that’s all.
I offer you some written material about low sugar attack to read at home, you can get
further information from internet for which I will write authentic website address on your
prescription.
Good Bye (Smile & Shakehand)
____________________________
Did the other doctor prescribed wrong medicine. (Don’t Blame your colleague)
Glimeperide is a good medicine to lower  high blood sugar but its dose has be
titerated. In your case its dose was a little more than your requirement.
80
DIABETIC FOOT
Mr. Ramazan Ahmad 55 year type 2 diabetic since 4 years presents with
uncontrolled Blood Sugar and a planter foot ulcer since three weeks. Take relevant
history, do examination and management. Proceed.
MEET & GREET
Introduce your self smile shakehand. Built a rapport, put the patient at ease.
DATA GATHERING
Since when you are diabetic? (4 years)
Your Blood Glucose fasting is around? (180mg/dL)
Your 2 hour Post meals sugar is around? (225 mg/dL)
Your HbA1C is? (8%)
Since when you are having this ulcer on foot. (3 weeks)
PAST HISTORY
Any previous healed ulcers (No)
PERSONAL HISTORY
Do you smoke? How much? (I am a chain smoker)
Do you drink? How much. Intend to cut down?
What is the nature of your job? (Clerk in an office)
Married (Yes), kids (2 kids), exercise (No), diet, weight, BMI 28, how much do you
earn? (Belong to a low income group)
ILLNESS
How this foot ulcer has affected your life. (can not walk properly) (Cannot go to job,
likely to be unemployed)
ICE
FAMILY HISTORY
Is there any major medical problem running in your family like
High Blood Sugar, High Blood pressure or Heart problem. (Father was diabetic)
DRUG HISTORY
Are you using any medicine for your ulcer? (No)
Are you on any other regular prescribed medicines? (Metformin 500mg after meals
and Atenolol 50mg once a day for my high blood pressure)
SUMMARIZE
So Mr. Ramazan your Diabetes is uncontrolled and you are having foot ulcer since 3
week and you are a chain smoker. Is there anything else you like to add? (No that’s all)
EXAMINATION
In order to understand your problem I need to examine you. Can I examine you?
Yes you may proceed.
Kindly move on to the couch and expose your foot and leg up to shine.
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Remember rule…… look……. Feel…….move……..
LOOK
Observe tip of toes.
Look in between the toes
Look at dorsum of feet.
Look for presence of hairs on dorsal side of feet (Hairs absent indicate compromise
blood supply.)
Dry skin due to lack of sweat leading to cracks and fissures is an indicator of neuropathy.
Look for deformities like claw feet, Hallux valgus, Hammer toe, Flat feet, pes cavus.
Look at medial border.
Look at lateral border.
Feel back of heel by raising to see any heel pressure ulcer.
Observe nails
Look at sole of the feet
FEEL
Feel Bony prominences
Feel for the temperature of the foot on the dorsum of the foot and shin, using back of your
hand and comparing both sides at the same time.
Look at dorsum of feet and palpate for foot arteries (Dorsalis Paedis and Posterior Tibial)
Feel peripheral pulses i.e. dorsailis pedis and post tibial (Palpate on mid of dorsum of foot
just lateral to extensor hallucis longus tendon for dorsalis pedis. For posterior Tibial Artery
Palpate on medial and posterior side of medial malleolus)
Check vibration sense with 128 Hz tuning fork placed over bony area of big toe or ankle.
MOVE
Hold big toe between thumbs & index finger from sides Separate big toe from other 4 toes.
Ask the patient to close his/her eyes and move up and down big toe and then ask which way
the big toe is? (up or down). (Propreoception sense)
Cotton Wisp – touch tip of toes & ask which right or left foot you are touching.
Pin – for pain – Don’t press so hard that blood ooze.
Monofilament – For pressure sense. Touch at 9 areas of the foot Press monofilament till it is
bent. Bent monofilament puts 10gm of pressure on the foot.
Tunning fork 128 for vibration sense. Put big toe downward. Put tuning fork at bony
appearance at distal metarsal bone. Ask if he feels vibration & when stopped.
Check the ankle jerk.
MANAGEMENT
Mr. Ramazan there is a small ulcer on your foot. You might be perceiving it as a minor
problem but mind it God forbid, if it is not taken good care of, at this point, it can lead to series
of events which end with black dead foot which may need amputation.
In order to save you foot. You must control your sugar level in the first place and then
observe few do & don’t and be aware of some danger signs.
Do you under stand it?
Ok first Do’s
DO’S
Get your feet checked periodically by a doctor.
82
Use mirror to check under surface of your feet daily. If you have any problem with
mobility or vision, check with the help of some one.
Look for cuts and brusies and color of skin. Any swelling, ingrowing toe nail or open
sores.
Wash your feet daily with soap and water
No need for any fancy disinfectant
Wash inbetween your toes as well
Dry your feet carefully after washing especially in between the toes.
Keep skin soft by using moisturizing lotion but don’t use lotion in between your toes.
Cut toe nail straight and file the sharp ends. File in only one direction.
Protect your feet by appropriate foot wear
Check your shoes for stones and babbles before wearing.
Always wear cotton socks. They should be well fitting. No tight elastic, No holes
Buy new shoes at the end of day as feet swell in evening.
Wear new shoes for smaller periods at first and that too inside the house.
Should I continue with don’ts.(Yes)
DON’T
Don’t let you feet dry.
Don’t walk bear feet especially in the sun & sand.
Please don’t smoke. Try to quit smoking completely.
Don’t use corn medicine, or sharp blades if you have callus.
__________________________
Don’t use hot water to wash feet.
Don’t use hot water bottle to warm up your feet
Don’t warm your feet at fire
Don’t visit religious places in sun, You may burn your feet.
Make sure your feet don’t touch hot exhaust pipe of motor cycle.
Don’t use tight shoes with rough seen
Don’t use sandle with big toe hook
Don’t use tight socks.
83
SAFTY NETTING (Red Flag)
In the end few danger signs for which you must consult your doctor immediately
Foot become noticeably red.
Foot become painful tender,
Whole or part of foot become hotter than usual
There is open sore or blister
If any discharge (Pus or blood)
Feet smell bad
If you feel unwell e.g. fever, nausea, vomiting
If your blood sugar becomes uncontrolled for no obvious reason.
CHARACTERISTICS OF GOOD FOOT WEAR
Before you leave my surgery let me remind you few characteristic of good foot wear.
1. Correct shoe size
2. Roomy toe box to allow movements of toes
3. Fasting with either laces or valcro
4. Don’t use narrow toe box shoes.
5. Don’t use shoes which have straps only
6. Soft inner lining
7. Rigid outer sole
FOLLOW UP
Advise follow up for a diabetic foot according to following two charts and your findings
on history and examination.
CHART 1
No sensory neuropathy (Low current risk) Once every year
Sensory neuropathy +ve (Increased risk) Once every 6 month
Sensory neuropathy with peripheral vascular Once every 3 month
disease and or foot deformity (High risk)
History of previous ulcer Once every 1-3 month
=====================================================================
CHART 2
Neuropathetic ulcer Vascular Ulcer
Pulses present Pulses Absent
Normal ABI Decreased ABI
Warm feet Cold feet
Painless loss of sensation Pain ful
Ulcer Localized at pressure points Ulcer Localized at extremities between toes
Clearly defined or punched out ulcers also Less clearly defined ulcer
surrounded by callus
84
FOLLOW UP AND SAFETY NETTING
Mr. Ramazan your feet show loss of sensory feeling and I could not feel your feet pulses as
well so I think you are suffering from what we call in our medical terms is neuro vascular
planter ulcer foot. I would like to exam your feet every 3 months from now on wards.
Control blood sugar in the first place.
Stop Beta blockers as peripheral blood supply is decreased.
Can you manage it.
If you develope any new symptoms or problems with your feet please do not hesitate
to contact me immediately. We may need a multidisciplinary team work to take care
of your feet.
CLOSING
Is there any thing else you will like to discuss with me today?
I offer you some written material about your condition at reception desk.
You can learn a lot about diabetic foot from internet.
Good bye shaking hand with smile.
===================================================================
INDICATIONS OF NEUROPATHY
Dry skin due to lack of sweat leading to cracks and fissures.
Look for deformities like claw feet, Hallux valgus, Hammer toe, Flat feet, pes cavas
Other indicators are callus formation causing abnormal weight load and hence foot
ulcer development, abnormal shape of feet, planter neuropathic ulcer on bony prominences,
prominent veins on dorsum of foot, nail pathologies e.g. deformed nails, limited mobility (Hold
big toe from sides with thumbs & index finger and move up and down and note mobility)
INDICATORS OF VASCULAR DISEASE
Loss of peripheral pulsation (Dorsalis pedis, posterior tibial Artery)
Loss of hairs on dorsum of feet
Dark dusky skin
Feet turning Red in dependent position
Neuro ischaemic ulcers on tip of toes.
SIGNS OF INFECTION
Presence of discharge of pus or blood.
Presence of fever
Presence of maceration (a sign of fungal infection of skin)
If you observe red skin with swelling feet but no fever then think of charcot foot as
diffrencial diagnosis.
85
GESTATIONAL DIABETES
SCENARIO
Mrs. Abdullah 24 weeks pregnant has come to discuss a report.
Kindly take relevant history and manage. Proceed.
PRESENTING COMPLAINT AND LAB FINDINGS

Doctor I am pregnant for the second time, its my second trimester/
In my previous pregnancy I became diabetic but later on I became Ok.
Even this time my urine test had no sugar at the diagnosis of pregnancy.
OGTT at 16 weeks was normal.
I have come to discuss the second report in which my recently ordered OGTT at 24
weeks shows abnormal result of 250mg/dL at 2 hours.
Few days ago my blood pressure high so GP prescribed taking ACE inhibitor
Lecinopril 2.5mg for my high blood pressure. I forgot to tell him I was pregnant. (ACE
Inhibitors contraindicated in pregnancy)
Anything else. No Doctor. That’s all.
Before I jump to the management part I would like to ask you few questions.
1. You said there is a history of previous gestational diabetes in your first pregnancy
May I ask the size and weight of the born baby?
Doctor it was a big baby weighing more than 4.5kg.
May I ask how do you rate your weight?
Doctor my BMI is more than 30.
Is there any family history of gestational diabetes?
Yes Doctor. My mother had gestational diabetes when I was about to born.
REASSURANCE AND MANAGEMENT
Diabetes developed during pregnancy is called gestational diabetes.
2% of the pregnancies are affected.
In gestational diabetes no oral hypoglycemic can be given so I refer you for admission
to endocrinology department for start of Insulin.
We need to keep a fasting blood sugar less than 100mg/dl.
Purpose of such tight control is to decrease congenital anomalies to the minimum.
You are advised to keep tight control of your sugar with appropriate dose of insulin.
Avoiding episodes of low sugar attack.
Hope your second pregnancy remains uneventful.
Try to have a healthy diet comprising of 5 portions of fruits and vegetables.
Try to have a brisk walk 30 minutes per day for five days a week.
Immediately after the delivery of your child insulin will be stopped completely and your
oral GTT test will be done at six week after the delivery.
It is likely that gestational diabetes reoccur in future pregnancy as well.
30% of women developed permanent diabetes in less than 10 year.
Eye sight can worsen during pregnancy so check your visual acquity and change the
lense of your specticles if needed.
Can you do it for me.
Can you comply with my suggestion.
As mother was on insulin till delivery so the baby can have spells of hypoglycemia.
To check blood sugar of baby, blood from heel pad of baby is taken.
Serial blood sugar monitoring of baby for 48 to 72 hours is done till blood sugar level
is stable.
86
VIRAL HEPATITIS A, B AND C
SCENARIOS IN BRIEF
HEPATITIS A
SCENARIO
Mr. Abdullah 51 year was posted in rural areas, one month ago. He has been
diagnosed with Hepatitis A.
Mr. Abdullah will present with yellowness of eyes and skin with clay color stools and
dark yellow urine. He will have tenderness in the right upper tummy. He can also have fever.
Besides, these classical signs of Hepatitis he can complain of certain other symptoms like no
desired to eat, headache, extreme weakness, muscle and bone pain. He visited rural area
one month ago and drank tape water there. Probably the water was contaminated which has
given him Hepatitis A in about one month time.
Luckily a vaccine is available for Hepatitis A prevention the vaccine is called Havrix.
This vaccine can be used by travelers, health workers who are likely to go an area where
water is contaminated. House hold contacts of patient can also be given. This vaccine If
somebody in the house is diagnose with Hepatitis A. Besides vaccine readymade immediate
protection can be given by Hepatitis A immunoglobulins.
HEPATITIS B
Mr. Abdullah besides having classical symptoms of hepatitis like yellowness eyes and
skin clay color stools and dark yellow urine also fever. He will give history of travel to India
where he had an unprotected sexual encounter with a lady who turns out to be a patient of
Hepatitis B, six month ago (Hepatitis B incubation period six months).
Hepatitis B can be spread by sexual intercourse, human sliva and human bite also
from infected blood needles. Hepatitis B is mainly spread by sexual contact while Hepatitis C
is spread manily by blood transfusion. One has to be careful about hand wash after toilet.
Please check guide lines for breast feeding while haing Hepatitis C and semen deonation.
Unborn baby can be gien Hepatitis B if the patient is pregnant. Certain precautions has to be
taken. Besides avoiding alcohol and supportive treatment, Hepatitis treatment with interferon
and newer drug Tenofovir can be done. Tenofovir 300mg tablet is taken once a day. This
drug Tenofovir has replaced Lamivudine 100mg daily tablet. Now this drug Lamivudine is
considered second line drug.
Luckily a vaccine is available which can be prevent Hepatitis B with the name of
Twinrex. Three injections has to be given. Kindly check the schedule yourself. The other
name for twinrex vaccine is Engerex – B Vaccine.Passive immunity to non immunized
contacts of infected patients can be given. Vaccine if one found to be Hepatitis B confirmed.
For Hepatitis C sexual transmission is a little difficult not blood transmission.
HEPATITIS C
Mr. Abdullah gives history of travel to rural area of India where he met with an accident
and he was given unscreened blood transfusion two month ago (Incubation period of
Hepatitis C is 2 months). Please advise or counsel Mr. Abdullah to tell her life partner or wife
to get her tested for Hepatitis C also for syphilis of HIV. Advise Mr. Abdullah to practice safe
sex. There are list of certain other precaution which must by followed by Hepatitis C patient.
Use disposable I/V syringes and strict surgical instrument sterlizations before dental
87
procedure or gynae and obs minor surgical procedures. Tell Mr. Abdullah to keep his shaving
razor, comb and utensils separately from other family members. Please do not give blood
/semen or organ donation if you are Hepatitis C patient.
Although no preventive is available for Hepatitis C uptil now but we are luckily that we
are living in today’s care where a new curative medicine is available. This drug is available
with the name of Sofobuvir. This drug cures Hepatitis C in three months time.
Previously we used to give peg-interferor Injections and Ribavirine tabs and patient
use to linger on to 10-20 years with Hepatitis C and use to die of liver Cirhosis and liver
cancer.
Give Hepatitis A & B vaccine if any one found to be Hepatitis C confirmed.
88
DIFFERENTIAL DIAGNOSIS HEPATITIS A, B, C, D, E
Hepatitis Spread Incubati Risk Presentatio Investigation Complicati Treatment Prevention
on Factors n on
period
Hepatitis A Faeco 2 to 7 •Travel to • May be • LFT’s • No Carrier • Avoid alcohol • Immunization
Oral wks Endemic • HAV IgM State • Supportive • Active Havrix
Hepatitis A Route (One area asymptomati for acute • No Symptomatic for travelers,
patient along month) • c cases Chronic Treatment patients &
with the Homosexua • fever, • HAV IgG for Liver • Self limiting health
classical l pale stool, Chronic cases disease • Recover in workers
symptoms of • IV drug dark urine • Rare less then 2 • Passive
Hepatitis may Abuser jaundice Fulminent months Immunity for
present with • In • nausea Hepatitis Soft diet keep short term
headache, institutions vomiting Paracetamo yourself e.g. Travel,
extreme • Health Diarrhea l is liver hydrated take Household
weakness, no worker • Abdominal toxic you ornithine contacts of
desire to eat Pain can take aspartate and sufferer
also muscle • Tender Iboprofen gaviscon
and bone for pain and Metocloproami
pain. hepatomegal fever de for
y vomitting
Hepatitis B • Sexual • 6 to 23 • Travel to • • LFT’s • 10% • Avoid alcohol • Advise safe
• Sexually weeks endemic Presentation • HBsAg Carrier • Supportive sex
Transmitted Intercours area same as • Anti HBcAg in State Treatment • Blood
• 3 Antigents e (Average • infected Hepatitis A window period • 5 to 10% • Chronic Screening
HBsAg, • Vertical 6 sexual • May be • HBeAg shows Chronic Hepatitis • Vaccine
HBcAg partner high infectivity Hepatitis treatment is • Passive
HbeAg Transmis months) • Baby of Asymptomati (DNA Virus) leading to with Immunity to
sion infected c Cirrhosis interferon non
• Human mother • Serum leading to and immunized
bite & • IV drug Sickness & cancer First line drug contacts of
Saliva Abuser • is Tenofovir infected
• Infected • Health Immunologic Fulminating 300mg once patients
Blood Workers al Hepatitis dialy Angerex – B or
• Needle and Second line Twinrec
prick Complication Death drug is
s lamivudine
as 100mg once a
Arthralgia day
and
ulticarea
Hepatitis C • Infected • 2 to 25 • Multiple Presentation • LFT’s Do not • Avoid alcohol • 6 month

• Post blood weeks sexual same as • Anti HCV donate your • Treatment Follow up
Transfusion partners Hepatiti A & (3 or 4 months blood organ with • Regular
• Syringes Transfusi average • Babies of B post or simon Screening
• Dental on or 2 infected transfusion ) Now curative • Disposable IV
procedures surgery month mother • HCV RNA by treatment for syringes &
• Razer and • Vertical • PCR hepatitis C is strict surgical
instrument
combs Haemodyla AST, ALT available. The
sterilization
Transmis sis increased new drug
• Special
sion Patients name is Precautions at
• Not • IV drug sofobuvir Dental
easily abuser cures in 3 Procedure,
spread • Health months Obstetric &
by woker Safe sex Gynae & for
sexual • Travel to Minor Surgial
contact endemic Procedure
area • Use Separate
Razers,
Comb and
utensils
Hepatitis D • Same • Same • Same as • Same as • LFT’s
• It is an as HBV as HBV HBV HBV • HDV IgM
incomplete
virus
replicate
on HBV
Hepatitis E • Faeco • 2 to 9 • Travel to • Same as • LFT’s • 20% • Avoid Alcohol • No vaccine
Oral Weeks developing HAV • HEV mortality • Supportive & • Good
Route country • Mostly IgM & IgG in symptomatic sanitation &
(Average • Special risk Water • HEV RNA by pregnant treatment hygiene
40 for born PCR ladies
days) pregnant • It is more • No chronic
ladies sever than State
Hepatitis A
89
DYSPEPSIA
INFORMATION REVEALED FREELY
Mr. Fazal Ahmad Butt 51 year comes with pain in food bag area and burning
behind the chest. He also have fullness bloating and wind. Also complains of nausea
and vomiting. Please proceed and manage.
1. Since when
2. Is it first time
3. Any associated symptom
4. Any aggravating factor
5. Any releving factor
6. Any specific timing
7. Any relation with food
8. Any relation with lying down (Gastric Ulcer improved by lying down, Gerd and
pancreatic pain worsen)
D/D
1. Do you have sense of food coming up in your mouth? (GORD)
2. How long after taking food you feel pain in your food bag (Immediately in gastric ulcer)
(2 hrs later in duodenal ulcer).
3. Any change in your weight? (Loss of weight in gastric ulcer as patient avoid taking
food due to pain) (Weight gain in duodenal ulcer as pain is relieved by taking food so
he eats more)
4. Which foods ↑ burning (Coffee, Chocolate Spicy food)
5. Which ↓ burning? (Antacids)
RED FLAG
5. What is the color of stool? (Black in case of chronic GI Bleeding)
6. Do you persistently vomit food?
7. Do you have any swelling or mass in your food bag area. (Stomach Cancer)
8. Have you lost 5 – 10 % of your weight recently i.e. within 6 months? (Stomach cancer)
PAST HISTORY
Any previous confirmed diagnosis of stomach ulcer.
Any previous surgery of stomach or food bag.
Do you excessively worry about having cancer (Anxiety).
PERSONAL HISTORY
Do you smoke? How much? Are you willing to give up?
Do you drink? How much? Are you willing to cut down?
Are you fond of Coffee? Chocolate? Or Spicy fatty foods?
DRUG HISTORY
Are you taking any regular medicines e.g. some pain killer for any reason (Drugs like
Nsaid, Nitrates, Theophyllene Bisphosponate, Corticosteroids and Calcium Antagonist cause
dyspepsia)
FOCUS EXAMINATION
Look up (Anaemia)
Look down (Jaundice)
90
Look at nails (Clubbing)
GIT Inspection & palpation including Epigastric Mass Hepatomegaly Splenomegally
Ankle Edema
Lymph Node in neck
MANAGEMENT (Life style advice)
1. Give advice on healthy eating (Give full detail as described in Type 2 Diabetes.
2. Weight ↓ (Give full detail as usual)
3. Regular exercise (Give full detail as usual)
4. Cut down Alcohol to safe limits.
5. Stop smoking
6. Avoid Coffee Chocolate spicy & Fatty Foods
7. Raise head end of bed.
8. Have main meal, well before going to bed.
9. Continue to take antacid and alginates
MANAGEMENT (Drug Treatment)
If your heart burns and pain did not go with life style measures then I offer some tablets
(PPI or Omeprazole 20mg once a day for one month).
If still no response then I will perform a test called H Pylori Testing Endoscopy with the
help of this test we will try to detect some bugs (Called helicobacter pylori) in your food bag.
If bug is found then we will give a trial of combination of three drugs (Omeprazole,
Clarithromycin and metronidazole or Amoxicillin.
If still no response we will give some other medicines e.g. Ranitidine 150mg twice a
day or domperidone 10mg thrice a day for one month. Endoscopy if no response.
We will use these drugs in low dose i.e. in minimum amount to control symptoms or on as
needed basis. Review after one year.
Routine referrel for endoscopy if anxious about cancer and continuing need for NSAID for
joint problem.
Oxford Page 382 - 383
Diet
Exercise
Weight
Alcohol
Smoking
Avoid Coffee Chocolate Spicy food
Antacid Continue
Raise head end
Main meal time 2 hours before bed time
91
IRRITABLE BOWEL SYNDROMS (IBS)
Nusrat 24 years presents with loose motions and pain tummy for the last 4 years.
All investigations are normal, please gather data & manage. Proceed.
Duration of complaint is very important in this scenario.
I am Nusrat 24 year Dr. I have change in bowel habit to loose motions. I am
having three or four formed stools per day for the last four year. I have pain tummy
and blotting. My all investigations turn out to be normal. Kindly help me.
DATA GATHERING ABC
A - Abdominal or Tummy pain
B - Bloating
C - Change in bowel habit to diarrhoea or constipation
Do you have to strain while passing stool. (Yes)
Any change in bowel habit. (Yes) (Predominantly diarrhea)
Any urgency to pass stool (No)
Any tummy pain which is relieved by passing stool (Yes)
Any history of incomplete evacuation
Any pain or discomfort in tummy. (Yes)
Any bloating (Distenssion, tension and hardness) (Yes)
Symptoms made worse by eating (Yes)
Any passing of mucous (Yes)
RED FLAGS
Any blood in stool (No)
Any weight loss (No)
Any fever (No)
Any Diarrhea at night time (No)
Age Less than 40 and recent history of change in bowel habits. (4 years)
Family history of similar complaints. (Mother was anxious person). (Yes)
D/D (DIP – TIMS)
Any deterioration of symptoms on taking wheat (Coeliac Disease) (No)
D Any discharge from front passage (PID) (Pelvic Inflamatory Disease)
I Any painful intercourse (PID) (No)
P What about your periods. (Heavy pain full)
____________
T What kind of weather you like? (Hypothyroidism) I am comfortable in both hot & cold
weather.
EXAMINATION
Tender tummy +ve
Bloating positive on purcussion
INVESTIGATION
Its a diagnosis of exclusion. How far to investigate is clinical judgment, weighing risk
of investigation against possibility of serious disease.
Judgement is based on age of the patient, family history, length of history and
symptoms cluster.
92
Patient < 40 years check FBC, ESR, and endomycial antibody testing to exclude
coeliac disease.
Patient > 40 years colonic cancer must be excluded for any patient with a persistent
unexplained change in bowel habit – particularly towards looser stools.
Other Investigations to Consider
Stool samples to exclude GI infection if diarrhea.
Thyroid function tests if other symptoms / signs of thyroid disease.
Endocervical swabs for Chlamydia
Colonoscopy to exclude Colonic Cancer
Laparoscopy to exclude endometriosis.
MANAGEMENT
RE-ASSURANCE MISS NUSRAT
What I have gathered from discussing with you is that your gut is functioning at more
speed than usual. This speed of gut is disturbing you. This is a mind gut disease which is
affected by stress in life. Your all investigations are normal so you do not have to panic.
I offer you written information in the form of leaflets which will help you understand
your condition.
1. Just relax. (Most important advice)
Reduce stress in your life.
Take life easy
Take time out for leisure activities hobbies.
Spend time with friends and family
Listen to the relaxation taps
Do Yoga & Meditation
Don’t feel pressed by time.
2. Do regular exercise
3. Take regular meals. Avoid missing meals or leaving long gaps between meals.
Drink less than 8 cups of fluids per day.
Restrict tea coffee to 3 cupts per day.
Decreased Alcohol intake.
Decreased Fizzy drinks.
Limit fresh fruits to three times not more than 80gms / at a time.
Identify foods that provoke symptoms e.g. dairy products, citrus fruits, coffee, alcohol
tomatoes, gluten and eggs.
Recommended diet include Oragnes, Lemon, Carrots, Cucumbter, Whole Grain,
Wheat Whole grain pasta. Prohibited or C/I diet include Apricort, Apple. Peer,
Peaches, Milk, Yougurt, White Flour, Legumes, Chocolates.
I offer to refer you to dietician for exclusion diet.
4. PROBIOTICS
Probiotic recommended of IBS is called refoxamean (Specialist initiation)
93
Some evidence of effectiveness. Try 4 weeks trial.
5. IF CONSTIPATION
Ispaghula husk is better tolerated. If change in bowel habit is towards loose motion
then do not mention Ispagullah husk for constipation.
6. IF DIARRHOEA PREDOMINANT IBS
LOPERAMIDE
Avoid codeine phosphate for fear of addiction.
7. FOR PAIN TUMMY
Mebeverine, Peppermint oil, All effective
During the past one month, have you low mood down depressed hopeless loss of
interest.
8. ANTI-DEPRESSENT
Ask questions to stream dipression.
Only if overtly depressed. Low dose amitriptalene 10mg is effective. SSRI less
effective. Withdraw if no response after 4 – 6 weeks.
9. TALKING THERAPY & HYPNOSIS
Sometimes effective. Reserved for cases which don’t respond to conventional
treatment. Even after one year.
REFER
Dr. I am not happy with your diagnosis of irritable bowel syndrome. Can you please
refer me to some specialist? Ok as you are not happy to the diagnosis of IBS also you failed
to respond to treatment so I refer you to gastroentarologist spcialist for review of diagnosis
and further possible inestigations.
Refer to gasteroenterologist if patient not happy with the diagnosis of IBS.
If fail to respond to treatment then ref, for review of diagnosis and further
investigation.
Safty Netting
Relax
Diet
Exercise
Probiotic
Pepperamint oil for tummy pain
Loperamide for diarhoea (Ispagula husk for constipation)
Amitriptyline for low mood
& Talking therapy and hypnotherapy
94
CONSTIPATION
HEALTH BELIEF (CONCERN)
80% people believe that their bowel should open daily find out what patient means by
constipation. Any concern about underline disease.
DEFINITION
2 or more of the following for more than 3 months.
1. Less than 2 Bowel movements per week
2. Lumpy or hard stool (> ¼ of the time)
3. Straining at passing stool (> ¼ of the time)
4. A sense of incomplete evacuation (> ¼ of the time)
Most people consulting in general practice. Do not meet this criteria.
ORGANIC CAUSES OF CONSTIPATION
COLONIC DISEASE
Carcinoma, Chrons Disease, Divertical Disease, Stricture
ANORECTAL DISEASE
Anal fissure, Perianal abscess, Distal Proctitis
PELVIC DISEASE
Ovarian Tumor, Uterine Tumor, Endometriosis
ENDOCRINE DISORDER
Hypercalcemia
Hypothyrodism
Diabetes mellitus with Autonomic Neuropathy (Gasteroparesis)
DRUGS
Opoids, Antacids containing calcium or aluminium, Antidepressants, Iron
Antiparkinsonian drugs, Anticholinergics, Anticonvulsants, Antihistamines
Calcium antagonists
OTHER
Pregnancy, Immobility, Poor fluid intake
How many stools do you pass per week?
Your stools are hard or soft? What is the consistency of your stool (Hard & limpy or
soft)?
Any need for straining while passing stool?
Any feelings of incomplete evacuation after passing stool?
MANAGEMENT
1. Constipation in < 40 years
(i) Give life style advice
↑ fluid intake to > 2 liters per day
(ii) Add fiber to the diet (↑ fruits & vegetables eat whole grain foods.
(iii) ↑ exercise if possible
95
(iv) Avoid Alcohol
If life style advice alone fails and symptoms are causing distress start an osmotic
laxative e.g. Magnesium Hydro-oxide.
If osmotic laxative fail, try short course of stimulant laxative e.g. Senna 1 to 2 table
spoon at 5 to 7PM.
If still constipated specialist referral is warranted.
2- CONSTIPATION IN OVER 40
Any sustained change in bowel habit for > 6 weeks should be taken seriously and
investigated. Ask about
RED FLAG
(i) Blood in stool
(ii) pain Abdomin
(iii) Diarrhea (History of loose motion at night)
(iv) Tenesmus (Feeling of incomplete evacuation)
(v) Check current medication for example rate limiting calcium channel blocker for
example verapamil or ditiazem
EXAMINATION
(vi) Examine Abdomen for masses and liver enlargement
(vii) Rectal examination is essential to exclude low rectal carcinoma and to detect
fecal impaction.
Give life style advice as young people with constipation. Treat any reversible
underlying organic cause. Consider laxative e.g. magnesium Hydro-oxide and bulkforming
laxative e.g. Ispaghula ± stimulant laxative (e.g. Senna) Titrate dose to response.
Long term use of stimulant laxative including co-danthrusate is acceptable in very
elderly otherwise use only as per needed basis or intermittently (can casue ileus).
If oral laxative are ineffective consider adding rectal measures e.g. bisacodyl
suppositories for soft stools and glycerol suppositories for hard stools.
If still not clear / faecal impaction high phosphate enema can be done. Acts in 20
minutes.
High risk patient e.g. patient on Opoid, who are immobile or have medical conditions
which predisposed them to constipation put them on regular aperients pre-emptly.
Anal tear or fissure can cause constipation by a vicious cycle of pain and withholding
of stools. Give GTN Ointment which will relieve not only pain but also spasm of Anus. Local
anesthetic creams and Nsaids can also be given.
96
DIARRHOEA
DEFINITION
Acute diarrhea passage of abnormal or loose stools > 3 stools per day.
Chronic diarrhoea passage of > 3 stools per day for > 4 weeks.
Ask patient how many stools per day you are passing.
(More than 8 stool per day admit severe diarrohea)
(More than 3 stool per day moderate diarrhea. Treat the patient)
Since when you are having loose stools.
What is the color of the stool.
Consistency – is it well formed or loose watery stool.
Any blood in stool
Any mucous or lassy material in stool
Any one else in the family having similar complaints
Any travel to underdeveloped tropical country
Any associated symptoms e.g.
Vomiting
Fever
Abdominal pain
Weight loss
PAST HISTORY
Any history of surgery especially on lower tummy? (illiocecal disease)
Any history of increase blood sugar
Any problem with neck gland
D/D OR RED FLAG
Any weight loss.
Any blood in stool (Bowel Cancer)
Any allergy to wheat intake (Coeliac disease)
Any stress in life at home (or at work) (IBS)
DRUG HISTORY
Any excessive alcohol intake?
Intake of medicine like Antibiotics and Nsaids? (Pseudomembraneous colitis (Nsaid
C/I)
EXAMINATION (Sign of dehydration)
BP (Low)
Pulse (Fast)
Depression on Soft spot of head before 10 months (Fontenella)
Sunken eyes
Dry tongue
97
Low skin prick test
Epigastric mass
Bowel sounds (Fast)
INVESTIGATION
Stool for MC/S
Occult blood in stool (Rotavirus)
MANAGEMENT
If simple diarrhea with no fever, no blood, no dehydration then you can safely say its
because of food you have taken in the restaurant. Some restaurant do not take care of
hygiene
Remember BOB.
B 1. Some bugs may have entered in your foods and caused this problem.
O 2. Take ORS to complete your hydration.
B 3. Try to take bland diet e.g. Rice, Bread, Banana and yogurt. You can take any type of
food you like.
4. I offer you some pain killer for your tummy pain. Hyosine Tab. as per needed basis.
SAFETY NETTING
If you have any problem like
Dehydration
Fever
Blood in stool
Increase vomiting
Increase diarrhea
Increase thirst
Passing of urine after 6 hours. No urine for more than 6 hours.
Very low skin prick test
Please seek immediate medical help. You may need admission in hospital.
Follow up – within 24 hours to 48 hours.
98
TRAVELER’S DIARRHOEA (VIRAL GASTRO ENETRITIS)
STAPHAUREUS BACTERIAL FOOD POISONING
Mr. Zafar Kareem visiting Lahore from London has developed Diahorrea. Kindly
take relevant history and manage. Proceed.
Meet & Greet
Introduction of Doctor and patient.
On opening consultation SP says
I am passing loose stools
I have tummy pain as well.
On facilitation he says Doctor I have vomiting also.
I feel extremely weak and lethargic (Signs of dehydration)
Before we come to management part, may I ask you a few questions:
1. Since when you are have diarrhea? (Duration of Diarrhea) 1 day.
2. How many stool you are passing per day? (Severity) 3-4 stools /day.
3. Color (Brown)
4. Consistency (Solid, Semi solid or liquid) (Watery loose stools)
5. Stool float in pan? (No) (Foul smelling and difficult to flush)
6. Anything Increase stool? (Drinking tape water)
7. Anything decrease Stools? (No)
8. Associated symptom? Like vomiting, fever, tummy pain, weight loss.
Yes Yes Yes No
RED FLAG
1. Any Blood in stools? Formula for blood in stool CC – (SEE – C) Shegalla, Ecoli,
Entamoeba histolytica, compylobactor
2. Any Fever?
3. Weight loss?
4. Do you feel thirsty? (Signs of dehydration)
5. Is you mouth dry? (Signs of dehydration)
6. how much urine you have passed in last 6 hrs? (Signs of dehydration)
7. Any weakness or lethargy? (Signs of dehydration)
8. Any dizziness? (Signs of dehydration)
9. Any Headache?
D/D
– Do you pass lot of flatus while opening bowels? (Giardiasis) (No blood)
– After how much time of eating Bar-B-Q, your diarrhea started? (Staphaureus
incubation period 1-6 hours, caused by eating meat)
– Is any other member of family is also affected (contacts)
PAST HISTORY
– Any past history of similar complaints. (No)
99
PERSONAL BIO PSYCHO SOCIAL
– Do you smoke? How much? (2 packs per day)
– Do you drink? How much? (4 Units / day)
– Any ↑ blood sugar (No)
– Any ↑ blood pressure (No)
– May I know about nature of your job? (Chef in a restaurant)(Food handler can
go back work after 2 weeks of viral gastero enteritis. Patient may not have
symptom but virus is found in stool for 2 weeks).
FAMILY HISTORY
Any major medical problem in your immediate family members? (No)
DRUG HISTORY
Have you taken any medicine for your diarrhoea so far? (No)
Any allergies? (No)
ILLNESS
ICE
SUMMARIZE
EXAMINATION (General Physical Examination and Full Abdominal Examination + all Signs
of dehydration )
– Look for abdominal bloating and tenderness
– Signs of dehydration – all
INVESTIGATION
I offer you following investigation. Is it ok with you?
– Stool culture & stool for occult blood
– Rota virus can be rapidly detected in stool.
MANAGEMENT OF VIRAL GSTRO ENTERITS
EXPLANATION & REASSURANCE
Viruses cause inflammation of our gut and damage the cells lining of our gut. As a
result, fluid leaks from the cells into gut and produce watery diarrhoea.
Main symptoms of viral gastero enteritis are watery diarrhoea and vomiting.
Most cases of viral gastroenteritis resolve over time without specific treatment.
Antibiotics are not effective against viral infections.
Dehydration can be caused by diarrhoea, vomiting, excessive urination, or excessive
sweating, or by not drinking enough fluids.
NON PHARMACOLOGICAL LIFE STYLE ADVICE
You can take several steps to help relieve the symptoms of viral gastroenteritis.
– Allow your gut to settle by not eating for a few hours.
– Sip small amounts of clear liquids or suck on ice chips if vomiting is still a
problem.
– Give infants and children oral rehydration solutions to replace fluids and lost
electrolytes. (Salts and minerals)
– Gradually reintroduce food, starting with bland, easy to digest food, like toast,
broth, apples, bananas, and rice.
– Avoid dairy products, caffeine, and smoking alcohol until recovery is complete.
– Get plenty of rest.
– I offer you tablet Hyocine for your pain tummy.
– Also medicine for your vomiting Metocloproamide
100
– Ciprofloxacin Tablet for fever
– Lopramide Capsul as rescue therapy for urgent meeting
– ORS
PREVENTION
You can prevent viral gastro Enteritis in future by taking several steps e.g.
1. Prevention is the only way to avoid viral gastroenteritis. There is no vaccine
available.
2. Do not eating of foods or drinking liquids that might be contaminated.
3. Washing your hands thoroughly before eating.
4. Try to Wash your hands thoroughly after using the washroom or changing diapers.
5. Disinfecting contaminated surfaces
6. Longer cooking and re-warming time.
7. Prompt consumption of food.
MANAGEMENT OF DIARRHOEA DUE TO FOOD POISONING
Atia Allah 48 years old woman presents with diarrhea after eating Bar-B-Q in a
restaurant. Take relevant history and manage.
After how many hours of eating Bar B Q your diahorea started. (Staphaureus
Incubation period 1-6 hours, caused by eating meat.
Is any other member of family is also affected (contacts) (Yes)
In your case diarrhea is most likely due to ingestion of meat which contained a bug
called staphylococcus Aureus. There is evidence that other members of family who eat
B.B.Q. also has diarrhea.
You are passing 6 – 8 stools / d & you have weakness and lethargy. (8 stools/day)
You seem to have lost quite a lot of fluid and electrolytes in stools.
So I offer you admission in hospital for correction of your dehydration & electrolytes
balance.
________________________________________
If 3 or 4 stool/day then I offer you oral rehydration salt.
Do you know how to take it.
Explain (1 packet + 4 glass of boiled water) take sip by sip slowly.
Can you manage it?
As you have an important meeting to attend tomorrow and have fever . I also offer you
loperamide 1 cap. Now and then one capsule with every stool till your diarrhoea stops.
I also offer you Anti-biotic called ciprofloxacin 500mg BD for 7 days as having fever.
FOLLOW UP AND SAFTY NETTING
I would like to see you after 24 hours but if you develop fever, blood in stool or signs
of sever dehydration please seek immediate medical help.
Is there anything else you will like to ask me today?
No Doctor.
You can get leaflet about your condition from the reception desk.
Good bye (Smile Shake hand.)
101
DIFFERENCE BETWEEN ULCERATIVE COLLITIS & CROHN’S DISEASE
ULCERATIVE COLLITIS CROHN’S DISEASE
Age 40 – 50 years Age 40 – 60 years
Male = Female
Smoking protective Smoking is a risk factor
Diarrhea ± Blood / mucous Diarrhea ± Blood / mucous
Lower Abdomen Pain Abdominal Pain (Cramp)
Malabsorption
Mouth Ulcer
Bowel Obstruction due to stricture
Perianal Fistules & Abscesses Penduolous
Skin tags
Intra Abdominal Abscesses
Tiredness Malaise Weight ↓ Tiredness Malaise Weight ↓
Low grade fever Associated Condition Low grade fever Associated Conditions
Arthritis
Sacro ilitis, Ankylosing Spondylitis, Iritis, Same as UC
Uveitis
Erythema Nodosum > Common UC
Autoimune hepatitis > common in UC (Goa)
Same area of bowels affected on relapse. * Gall stones
Osteoporosis
Amloidosis
More Common crohn’s disease
* Skiplesion i.e. Normal areas in
between diseased area more
common in crohn.
Toxic Megacolon (Abd X-ray to exclude) * Toxic Maga colon rare
Risk ↑ if disease > 8 years * Intestinal stricture & Bowel
F/H of colon cancer age > 45 years obstruction
Onset in childhood More common in Crohn
* Malignancy of large and small bowel
cancer more common in 5% 10 years
after diagnosis
Sclerosing Cholangitis more common in UC
Proctoscopy - Inflammatures & Shallow
ulceration extending proximately from anal
margin suggest UC
Oxford Page 423 to 425
102
NEO-NATAL JAUNDICE
Mrs. Juna Patchy 55 years of age has come to discuss about her grand son who
has a problem. Take focus history and manage. Proceed.
I am Dr. Raheel one of the GP in this surgery.
I am Mrs. Juna Patchy 55 years old.
Mrs. Juna Patchy how can I help you today?
Doc. My grandson was born normal. He is now 6 days old, but he has developed
yellow discoloration of skin and eye. Yellow discoloration appeared later by the third
day.
Any thing more?
No Doc. That’s all I am just worried what treatment my son can get.
Ok Mrs. Juna Patchy, before I come to the treatment part may I ask you few questions?
When did you noticed discoloration? (Since last four days on the 3rd day of birth)
Was the baby born normal?)
What is the colour of urine? (Dark Yellow)
What is the colour of stool? (Brown)
Any throughing out (vomiting) (No)
Any temperature? (No)
Any fits? (No)
What is the blood group of mother? (Rheus –ve) (ABO in-compatibility)
What is the blood group of Baby? (Rheus +ve) (ABO in-compatibility)
Has Anti-D been given to mother? (Yes)
What is the hepatitis status of mother? If mother suffer from Hepatitis B (HBV +ve) the
baby may have congenital Hepatitis B from vertical transmission. Hence vaccination
of baby with Hepatitis B Vaccine and immuno globulin may have to be given)
What was the pregnancy like? (Uneventful)
Was the delivery normal? (Normal, C-Section, forceps, suction)
Has necessary all immunization for his age been given to baby? (BCG, Polio Hepatitis
B etc.)
Is baby being breast feed? (Yes)
Is he feeding adequately and properly? (Yes)
Was the ultrasound done to see development of baby? (Interauterine growth
retardation?) (Normal development on USS)
Did mother took any medication during pregnancy? (e.g. Drugs for high blood
pressure, high blood sugar or anti-tuberculosis medicines.
How many other kids mother have?
INVESTIGATION DONE
There are two reports
Do you have any report done on third day of birth showing. (Yes)
Total bilirubin (Normal level 0.5 to
Conjugated bilirubin
Unconjugated bilirubin
Any 2nd recent report done on 6th day of birth. (Yes) (The total bilirubin level is falling)
_____________________
Rule out congenital hypothyroidism by asking, Is mother taking any drug for neck gland
treatment e.g. thyroxine.
MANAGEMENT
Explanation and Reassurance
103
When a baby is born, its liver is immature and has not become fully functioning yet, so
a pigment accumulates in the baby’s body which cause this yellow discolouration.
We will do a blood test so see the level of this pigment. Jaundince between 2 – 6 days
is normal (Physiological). If it is below certain level, we can send the baby to home safely.
Yellow discoloration will become normal with in few days.
If level of pigment is high we will do phototherapy i.e. child is kept under special kind
of ultra violet light for 15 minutes thrice a day (All clothes are removed but eyes are covered
to prevent harmful effects of light to eyes. This light will convert harmful pigment into soluble
form which can be removed by the kidney through urine.
After phototherapy child will be handed over to you so that mother can breast feed,
the baby.
If even after phototherapy pigment levels are high, exchange blood transfusion
procedure will be done.
In this procedure we will replace blood containing harmful pigment, with blood which
does not contain pigment.
BREAST MILK JAUNDICE
Appear late in first week of life and peaks in 2 to 3 weeks time. Breast Milk Jaundice
is confirmed by suspending breast feeding for 24 to 48 hrs. Jaundice disappears.
Reassure parents, continue breast feeding, repeat estimation of serum bilirubin weekly
till levels become normal and jaundice subsides.
____________________
SAFETY NETTING
Jaundice at any time – If baby is unwell, has persistent pale stool or yellow urine which
stains nappy, baby should be ref to paediatrician.
If baby is unwell, not feeding properly or less active. Please seek immediate medical
help.
____________________
Is there anything else you would like to ask me today. (No)

You can get leaflet about your condition from the reception desk.
Good bye.
==================================================================
KNOWLEDGE BASE
Any Jaundice in the first 24 hrs is assumed to be pathological and need immediate
referral back to hospital to determine cause (hemolysis or infection) & for treatment
(Photography or exchange transfusion is rare and is done only in severe cases)
Jaundice from 2-6 days is physiological.
Jaundice at any time – If baby is unwell, has persistent pale stool or yellow urine which
stains nappy, baby should be ref to paediatrician.
Keep the child in sunlight for 3 times/d for 15 minutes after removing all cloths.
Keep monitoring service bilirubin certain limits bilirubin can cross blood brain barrier &
cause inflammation of brain called kersiecteres.
104
GALL BLADDER DISEASE
(Cholecystitis, Biliary Colic)
Mrs. Allah Ditta fatty fertile female of 50 persents with right sided upper tummy
pain. Take history. Do examination & management. Proceed.
S Where exactly does it hurt? (Site of pain) (Right Hypochondrium fossa) (Right side
upper tummy))
D Since when you have this pain? (½ hr)
R Does it go anywhere else? (Right shoulder)
P Is it constant or come goes in episode? (Constant since ½ hr but had similar attacks
of pain previously as well.
A What aggravates this pain? (Greesy food)
R What relieves it? (Pain killer) (Alcohol)
Any investigation done so far. (No)
Any medicine taken (No)
D/D
Any history of indigestion and flatulence? (yes)
May I know your weight or BMI? (Obese) 30 >
RED FLAG
Any investigation done? (Non)
Any fever? (Cholecystilis +ve) (Yes)
PAST HISTORY
You have told me that you had similar episodes previously as well?
PERSONAL HISTORY
Do you smoke? (No)
Do you take Alcohol? (Yes) (Alcohol seems to relieve my pain)
Are you Married? (Yes)
How many kids? (5 children) (fertile)
Any high blood sugar? No
Any high blood pressure? No
FAMILY HISTORY
Any similar complaint of gall stones in family. (Yes) Mother head gall stones)
Family history of heart problem (+ve) ( triglycerides)
DRUG HISTORY
What medicines you are taking regularly?
(Clofibrate Octreotide, Statin (Simvastatin 40mg at night Promote gall stone). Any
drug allergies. (No)
ILLNESS
How this disease has affected your life? I can not eat oily fried greesy food I like. It
provokes my pain.
CONCERN
What worries you most in particular.
A woman in neighbour had gall stones, she died of gall bladder cancer)
EXPECTATION
What do you hope to gain from todays consultation. Hope to get medicine to relieve
pain.
SUMMARIZE
So Mrs. Allah Ditta you have right upper tummy pain for the last ½ hr. It is aggravated
by greesy food relieved by alcohol. You have indigestion and flatulence. Your age is > 50 and
you have five children and you are taking statins. You have a positive family history of gall
stones and heart problem. Is there anything else you like to add. (No)
EXAMINATION AND INVESTIGATION
Inspect tummy auculate first for bowel sounds.
Palpated lightly - Palpate both kidneys
105
Palpate abdomen & press deeply while patient takes a deep breath (Patient will hold
breath due to pain) (Murph’s sign +ve)
I offer you Abdominal ultrasound test. (Righaway)
MANAGEMENT
Life style changes like avoiding fried foods.
I offer you pethidine injection 50mg I/M for your pain along with prochlorperizine
injection 12.5mg I/M for your nausea
I hope your pain will subside in few minute.
As you are having fever so I offer you a short course of antibiotic like ciprofloxacin
500mg twice a day for 7 day.
Kindly complete the course even if you don’t have any symptom. This act of your will
help in preventing drug resistance in future.
FOLLOW UP
I would like to review your condition as soon as results of ultrasound has come.
SAFETINETTING
If you develop pain again or fever become high or you develop yellowness of eyes &
skin, clay colour stool, dark yellow urine then seek immediately medical help.
Would you like to discuss anything else with me to day?
What happens next if i am confirmed to have gall stones?
1. If you don’t like operation and your stones are < 5 mm in size then they can be
dissolved by a drug called deursodeoxycholic acid.
2. Another option is lithotripsy. In this procedure sound waves are passed over
tummy repeatedly this crushes the stones No. Cut is given. Crushed stone pass
out through gut in gall bladder secretion.
3. We have a surgical option as well. Previously galls Bladder with Gall Stones
was removed through a large cut in the tummy and patient had to stay in bed
for 10 to 15 days but now a days gall stones are removed by few small holes in
the tummy and gall bladder is removed under camera. Although the procedure
required general Anesthesia but the patient can go home after over night stay
in Hospital.
Oxford Page 428 – 429.
Do not give even pain killer as this masks the signs for doctor or surgeon dealing in
emergency. Just call the ambulance alay the anxiety of patient. Do safety netting and if asked
let the patient know possible treatments.
NOTE:
Persistent digestive symptoms are common after removal of gall stones surgery &
difficult to treat. Digestive Enzymes has to given from outside in form of syrup or tablets.
106
APPENDICITIS
Hello.
I am Dr. Raheel one of the family physicians in this surgery.
I am Abdullah 25 year.
OK Mr. Abdullah how can I help you today?
Doc. I had developed pain around my umblicus about 2 hours ago. It was coliky in
nature. The pain has subsided around my umblicus but I have developed pain and
garding (Stiffness) over my right lower tummy.
I am feverish. Pain is severe on movement especially coughing and laughing. I have
no desire to eat and I have nausea, I have vomited also. My tongue is furred. I have
to walk in a stooped position which is very discomforting.
Ask all features of pain including:
On set suddenly
Duration 2 hours ago
Progression same
Aggravating factor movement coughing laughing
Releving factor (Non)
Associated symptoms (Nausea vomiting)
Medicine taken (No)
Any investigation already done (No)
Mr. Abdullah I would like to examine you. Can I examine you?
Mr. Abdullah I will be pressing in your lower tummy at a certain point (Macburney) i.e.
(2/3 of the distance between umblicus and Anterior superior iliac spine.
You have to tell me whather you felt more pain on pressing your tummy or on sudden
release of my hand (Patient will say I felt more pain on sudden released on hand)
Second test for confirmation of appendicitis of rovsing’s i.e. pain in right iliac fossa on
palpation in the left iliac fossa. Both rebound tenderness and positive rovsing’s
confirmed appendicitis.
Mr. Abdullah I offer you the following investigation.
1. Urine complete examination (Urine analysis is normal or positive for proteins and
leucocytes esterrase but negative for nitrites.
2. Full blood count which shows increased leucocytes mostly neutrophils.
3. Ultrasound Inflamed appendix can be seen with bigger ultrasound machine.
4. CT Abdomen can confirm appendicitis.
MANAGEMENT
Mr. Abdullah the information you have shared with me about your symptoms and on
examination clinically it appears that most likely you are having a condition called
appendicitis.
I am referring you to general surgery emergency right away. Would you like me to call
ambulance. Is any body accompanying you. Would you like me to inform your family
emergency department which is only 20 minuts away. I am not giving you any pain
killer as this will mask the sign symptoms for the doctor who will examine you in
emergency.
Appendix have to be removed immediately in emergency.
107
If inflamed appendix burst or perforation occurs the whole of the abdomen will be
infected and the treatment will become difficult.
Appendicitis affects one in thousand pregnancies. Due to pregnancy appendix is
displaced and pain is often felt in paraumbilical region or subcostally Admit immidiately
if suspected.
NOTE: As children localize pain poorly and sign to peritonitis can be difficult to ilicit. If
unsure of diagnosis and child is unwell admit.
If unsure of diagnosis and child is well arrange to review in a few hour or ask the carer
to contact you if there is any deteoration or change in symptoms.
In case the patient is a female kindly rule out the following three differential diagnosis:
1. Ask is it the mid day of your menstrual cycle?
On the mid day of menstrual cycle egg is release from the ovary and the patient feels
pain which can mimic the pain of appendicitis.
2. Ask do you feel difficulty in opening bowel or bladder? (Ectopic pregnancy)
Answer to this question if positive indicate ectopic pregnancy.
3. Ovarian tortion
Ask question about ovarian tortion.
108
HONEYMOON CYSTITIS
Mrs. Ghazala Fazal 22 year on honey moon, consults family physician for urinary
problem. Kidnly gather relevant data and share management plan examination not
required. proceed.
INFORMATION REVEALED FREELY
Doctor I am on my honeymoon in this hotel. I have develop burning or stinging pain
on passing urine for the last one day. My urine is cloudy. Some times its blood tinged & smells
strong urine odour.
Anything more you like to add?
I generally feel unwell, Probably I have fever.
Anything else?
I also have back pain and lower tummy pain.
Idea What do you think why you have these symptoms? (I do not know)
Concern What worries you most about these symptoms?
I think some bugs have entered my urine and causing these symptoms.
I think my husband is responsible for it. He is cheating on me. He might has
transferred some sexually transmitted diseases to me.
Expectation What are you hoping will happen from seeing me in surgery today?
Doctor as I told you this is my honeymoon period. Every moment is very precious. I
am very unhappy because these symptoms. They are ruining our pleasurable moments. I
have to go toilet several times at night. Please give me some medicine to fix it quickly.
Can I ask some personal questions. I assure you that whole conversation will remain
confidential between you and me. Nobody else will know about it.
1. Is there any chance you could be pregnant. (No)
2. When did you had your last menstrual period. (Few days ago)
3. Do you have pain while opening your bowel or bladder (Ectopic Pregnancy). (No)
Examination not required as not allowed.
D/D Red Flag
Do you have fever. (Yes)
Do you have blood in urine. (No)
Any discharge from front pssage. (No)
Any skin rash.
Do you have any history of trauma.
INVESTIGATIONS
Urine C/E CBC
Ultar Sound for abdomen and pelvis Blood Sugar
Pregnancy test
I offer you a test Urine complete, pregnancy test and ultrasound of abdomen and
pelvis.
Bring fresh specimen of urine, which you should collect after washing your private
parts with clean cotton wool and water.
109
MANAGEMENT (Counseling)
RE-ASSURANCE & EXPLANATION
What I have gathered from discussing with you is that you are having a condition in
which there is infection of water bag which can be called honeymoon cystitis as well. Do you
know what is cystitis.
Cystitis is inflammation of water bag (bladder). It is a common problem. Many women
suffer from it, at one stage of life or another. Most vulnerable times are starting of sexual
activity, pregnancy and after menopause.
Small bugs are normally present around the opening of front passage.
It is almost always caused by small bugs called Ecoli Bacteria, which travel from
urethra to bladder. It is often caused by intercourse which pushes the urethra and bacteria
towards bladder. Bacteria in bladder begin to replicate which leads to inflammation and
infection of water bag. Do you understand. (Yes)
PHARMACOLOGICAL TREATMENT
I offer pain killer like paracytamol for pain (2 Tablets 500mg 3 times a day).
I offer you a course of antibiotic. Drug of choice is Cefalexin 400mg twice a day. In
case of pregnancy drug of choice is Amoxacillin. Rule out pregnancy by pregnancy
test.
MANAGEMENT (I offer you few life style changes & few things to prevent it from happening
next time again)
1. Keep your self rested.
Warm in cold weather.
2. Drink lots of fluids. Try 2 cups at first, then one cup every 30 minutes. Increased fluids
in intake. Allows frequent urination to flush the bacteria from the bladder.
3. Sit in warm water tub. It will help relieve pain.
Don’t get constipation take plenty of vegetable and fruits to avoid constipation.
4. Try cranberry juice. It helps reduce symptoms by reducing multiplication of bacteria.
5. Don’t let urine build up. Refraining from urination for longer time, may allow bacteria
to multiply. Can you do it.
6. Try to empty your bladder completely each time. Is it OK with you?
7. Gently wash or wipe your bottom from front to back (i.e. vagina to Anus) after going to
toilet.
PREVENTION
How to prevent further attacks.
1. Get into habit of drinking plenty of fluids especially on hot days.
2. Pass urine often and do not let it build up.
3. Make sure you empty your bladder completely each time.
4. Wash your bottom gently after each bowel motion, using mild soap and soft tissue.
5. Empty your bladder immediately after intercourse. This helps flush out bacteria which
might have entered bladder through urethra. Double void after 5-10 minutes.
6. If your front passage is dry, use lubricants for intercourse (KY jelly for young women
& Estrogen Cream after menopause)
7. Can you wear cotton underwear,
8. Can you avoid tight jeans
9. Can you avoid vaginal deodourants.
10. Give prophalectically after intrercourse nitrofurintine 50mg Stat (Oxford Page 423)
SAFTY NETTING
If antibiotic do not work or if you have more attacks some special test [including X-rays
Kidney ureter bledder (KUB)] may be necessary to check your urinary tract.
FOLLOW UP (I would like to see you again in 24 hrs time)
Closing – All 5 sentences.
110
BENIGN PROSTATIC HYPERPLASIA (BPH)
Mr. Arif Irfan 72 years C/o urination problem. Take relevant history and manage.
Proceed.
FORMULA FUNWISE Frequency, Urgency nocturia. Weak stream, Interrupted Stream,
straning Incomplete empting of bladder.
IRRETATIVE SYMPTOMS
Mr. Arif Irfan do you have to pass urine more frequently these day (Freqency) (Yes)
Do you have to rush to toilet to pass urine (urgency) (Urge incontinence) (No)
Do you have to wake up at night to pass urine (Nocturia) (Yes)
OBSTRUCTIVE SYMPTOMS
Do feel hesitancy to start urination
Do you have to start and stop urinary stream
Do you have weak or double urinary stream
Do you have to strain to pass urine
Do you have feeling of incomplete empting of baldder after passing urine.
Do you have terminal dribbling
Just few more questions.
_______________________
IMPORTANT D/D
Are you bothered by these symptoms excessively (Yes)
Did you ever suffered from sudden blockage of urine (No)
Do you feel pain or burning while passing urine (UTI) (No)
Are you constipated. (No)
Are you taking any cough syrup containing Ephedrine.
SUMMARISE
RED FLAGS & D/D
Do you have high blood sugar (DM)
Do you have fever or pain or burning urine (UTI) (No)
Have you ever passed blood in urine (Stone) (No)
Have lost any significant weight recently (Malignancy) (No) (Any backache)
Do you have night sweats (TB) (No)
PERSONAL HISTORY
Do you smoke? (No)
Do you take alcohol? (How much) (4 units / day)
Any high blood pressure? (No)
PAST HISTORY
Have you undergone any surgical procedure through your front passage or on tummy?
Any post H/O hospitalization?
FAMILY HISTORY
Do you have any stone forming tendency in your family
111
DRUG HISTORY
Are you taking any medication regularly like Cough Syrup. Containing ephedrine? Or any
drug to lower blood pressure.
Are you constipated. When did you last pass your stool? (Yesterday)
Illness. What is the impact of your symptoms on your daily life. (Bothered excessively)
Idea: What do you think is the cause of your symptoms.
Concern: Are you worried about anything in particular. (Prostate Cancer)
Expectation: What do you hope to gain from todays consultation
Summarize & Ask
Is this all or you would like to add something?
EXAMINATION (NOT REQUIRED)
Abd Look for distended bladder, palpable kidney, examine external genetalia (No)
DRE Anal tone, size shape consistency of prostate (Normal size chestnut)
Smooth rubbery in consistency. Malignant gland is hard and lost its sulci.
PSA TEST VALUE IS INCREASED
(1) If prostate cancer
(2) Prostatitis
(3) Acute urinary retention
(4) Urinary catheterization or prostat biopsy
(5) After physical exercise
(6) increases in old age.
CONDITIONS FOR PERFORMING PROSTATE SPECIFIC ANTIGINE TEST
(1) Delay PSA test for one week if DRE examination done.
(2) If proven UTI, treat UTI & delay the PSA test for one month.
(3) If ejaculated within 48 hours
(4) Done vigorous exercise within 48 hours.
(5) Had prostate biopsy less than 6 weeks ago.
INVESTIGATION
I offer you few test like
1. MSU for blood glucose, Microscopy (Haemanturia) & Culture / sensitivity)
2. Urea, Cr and Electrolyte eGFR
3. Ultra Sound for size of prostate gland and for residual volume. (Normal residual
valume 30ml) 50 to 100ml residual volume is significant.
4. Serum PSA
Cut off value that should prompt referral to urology.
50 – 59 years ----- > 3ng/ml
60 – 69 years ----- > 4ng/ml
> 70 years ----- > 5ng/ml
Referral is not needed if the prostate is simply enlarged and the PSA is in the age-
specific reference range.
MANAGEMENT
EXPLANATION
Ok Mr. Arif Irfan what I have gathered from the information you shared with me
examination and investigation is that most likely you are having a condition what we called in
our medical terms benign prostatic hyperplasia.
Do you know any thing about Benign Prostatic Hyperplasia.
No. Can you explain a bit.
112
Actually there is a gland at the neck of water bag which get enlarged and cause
obstruction to urine flow. Since its normal pattern in aged more than 60 years. So nothing
sinister hence named benign Prostatic Hyperplasia.
REASSURANCE
As you have not lost weight, no back pain and examination and investigation finding
shows PSA report less than 4 so there is no sign of prostate cancer. Hence I can safely
reassure you that most likely your symptoms are due to simple enlargement of prostate gland
and not due to prostatic cancer. Benign Prostatic enlargement can be manage with medical
or surgical treatment.
(I) LIFE STYLE CHANGES
Before I offer you some medicine. I offer you to make some changes in your life style:
Try to decrease evening intake of fluids
Can you Decrease Coffee tea intake
Can you Cut down alcohol to safe limits
Can you learn some bladder retraining exercises from physiotherapist? I can refer you to
some physiotherapist.
Can you try to avoid constipation by taking adequate fluids, fiber and daily exercise.
Can you do it?
(II) ADVISE TEMSOLOSIN NEW MEDICINE 0.4 mg once daily
Previously drug treatment for BPH was drugs like prazocin & finestrides. These drugs
use to show their effect in 6 to 12 months time. If patient is excessively bothered by his
symptoms like frequency & urgency of urine and his sleep is disturbed, then now a days we
have a newer drug called Temsolocin 0.4mg, taken once daily. It shows its effects in days to
weeks time & patient is relieved his symptoms. This drug is worth giving a trial before resoting
to surgical option for which I will refer you to urologist.
(III) SURGICAL MANAGEMENT
If patient says I am excessively bothered by these symptoms. My sleep is disturbed.
Need quick fix cannot wait six month treatment of tablets is unacceptable table then I offer
surgical treatment.
Would you like to take tablet? (No) If you don’t like tablet, then we have a quick fix
surgical option. For this I will refer you to a urologist. He will pass an instrument through your
front passage and Remove part of gland which is obstructing urine flow. This procedure is
done under Lumber Anaesthesia i.e. your body below waist will be made numb to pain or you
can be put to sleep while operation is done. (General anaesthezia)
Is there any thing else you will like to share with me today?
No. You can collect some leaflets about your condition from reception desk
You can get further information from the Internet.
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URGE INCONTINENCE
Hello.
I am Dr. Raheel. One of the family physicians in this surgery.
I am Arif Irfan 72 years.
Ok Mr. Arif what brings you to the surgery today?
Well Doc, although its quite embarrassing but instead of suffering in silence.
I decided to contact you. Actually doctor I have involuntary loss of urine that is causing me
social and hygienic problems.
I have a strong urge to pass urine suddenly but before I reach the toilet large amount of urine
is passed in the clothes.
Anything more?
According to the information you have shared with me it is most likely that you are having a
condition called Urge Incontinence.
In this condition our urinary bladder contracts suddenly due to instability of detrusor muscle
of the bladder and large volume is passed involuntarily before the patient reaches the
washroom.
Mr. Arif Irfan before I try to manage your problem. I need to ask few question, can I ask?
Yes Doctor you may proceed.
Do you have to pass urine more frequently? (No)
Is it large volume or small volume of urine passed at a time? (Large)
Whether its occurs while standing, coughing, sneezing, during the exercise or laughing?
(Stress Incontintence) (No)
Do you have constant dribbling of urine all the time? (Over flow incontintence) (No)
Are you using any diuretic at night time? (No)
Do you have pain by passing urine? (No U.T.)
Do you have constipation? (No)
Is your washroom accessivable easily or there is unaccessability as occurs in market places?
(Yes accessible)
Do you have retention of urine? (No)
MANAGEMENT
Ok Mr. Arif Irfan, I offer you some lifestyle changes which will help you manage this
condition.
1. Do not drink large amount of fluids in the evening.
2. Avoid tea, coffee, nicotene, alcohol.
3. If you are using any diureting at night time use it in day time.
4. If you have any pain while passing urine. Talk to your urologist and get some
appropriate antibiotic.
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5. Avoid constipation. Take enough of fluids fibre and exercise daily.
6. If you have any cognitive deficit schedual your urine passing at every 2 to 4 hours.
7. Enuresis alarm can be worn.
I will be referring you to the physiotherapist. Who will teach you bladder training exercises.
Bladder training exercises means that you will resist the urge to pass urine for increasing
periods.
Start with an achievable interval based on diary evidence and increased the period slowly
over next six weeks.
If the bladder training exercise turn out to be ineffective I will be referring you to the urologist
who may start one of the drugs like oxybutynin or tolterodine or duloxetine.
FOLLOWUP
This condition spontaneously remit and relapse.
We will follow you up every 3 to 4 months.
Is there anything else to ask me today?
Yes doctor, are there any aids and appliances to deal with the social and hygienic problems
of incontinence.
Yes there are diapers available.
There are different pads are available.
Some bed covers which absorbed 1 to 3 litre of urine. Good laundary facilities are needed. If
the bed cover are left wet, they can cause skin problems.
Exernal catheter, sheaths and indwelling catheters are also available.
Some times patient is advised to do self catheterarization intermittently. Patient inserts
catheter into his bladder him/herself to drain urine.
Enurisis alarm can also be made use off.
Commodes urenal pots can be made available near the bed.
If urge incontinence is not settled with the lifestyle changes and the drugs we mentioned like
oxybutanin and tolterodine 2mg twice a day. Patient can be referred to the urologist.
Is anything else you want to ask me today?
No doctor, thank you.
Ok Mr. Arif Irfan, you can collect leaflet about urge incontinence from the reception desk.
Thank you for your cooperation and good bye.
____________________________________________
Types of incontinence: (1) Urge incontinence (2) Stress Incontinence (3) Overflow
incontinence.
STRESS INCONTINENCE
• Small amount of urine is passed on laughing coughing sneezing, lifting heavy weight.
• Bladder retraining exercises (Explain)
• Female also pelvic floor muscle exercises (Explain)
• Not related to Psychological stress.
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RENAL COLIC (RENAL STONE CALCIUM OXOLATE)
SCENARIO
Mr. Zafar Kareem 45 years presents with sever pain in right flank since 1 hours.
He is rolling round in pain on floor. Take relevant history and do management.
Meet & Greet
Introduction of patient and doctor
Patient is rolling in pain. First make him comfortable by asking if he needs pain killer.
Then start taking history. Show some urgency.
o As you are having severe pain would you like to have a pain killer shot?
No. You may proceed with your questions.
_________________________________________
Well Mr. Zafar kareem you have a right flank pain since 2 hours. Would you like to add
something to it.
I feel nauseous, Pain is going down to my private part (Testes in case of male & Labia
majora in case of female) (from loin to groin)
Anything else?
Some times my urine is blood tinged.
o Anything more.
No Doctor that’s all.
_________________________________________
Ok Mr. Zafar you have a sever pain from right loin to groin, going down to testes. You
also feel nausea & your urine is blood tinged.
o May I know how sever is your pain on scale, zero to ten if 0 is non and 10 max.
Doctor its around 7 on scale.
Any episode of similar complaint in the past? (This is the first time)
Do you have fever as well? (No)
D/D
D/D of Pain on right side of abdomen include cholecystitis, renal stone & appendicitis
Shingles Trauma intestinal obstraction)
Any history of trauma in to back? (Trauma) (No)
Any unilateral one sided rash on the body? (Herpes Zoster) (No)
Have you passed flatus recently? (Intestinal obstruction) (Yes)
Any tenderness on pressing on the lower right tummy? (Appendicitis) (No)
Any history discharge or pus from front passage? (STDs) (No)
What about your periods? (LMP) (Few days ago)
RED FLAGS
Any fever? (Infection) (UTI) (No)
Any Blood in Urine? (Renal Stone) (No)
Any Weight loss? (Malignancy) (No)
PAST HISTORY
Any past history of similar complaint.
Pain on passing urine since childhood? (Structural Abnomality) (No)
Any past history of pain on passing urine? (UTI) (No)
Any past history of stones? (No)
Do you have control on your urination? (neurogenic) (Yes)
PERSONAL HISTORY
What do you do for living? (Chef in a restaurant)
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How is environmental temperature where you work?
Any opportunity to drink water and pass urine at work?
Zafar I work as Chef in hot Kitchen of a hotel. Very busy, no time to drink water or to
go to toilet)
I have erretic life style due to working hours. Take lot of salted meat and coffee while
at home.
Do you smoke? How much? Intend to quite
Do you drink ? How much? Any intension to cut down?
FAMILY HISTORY
Any family history of kidney stones? (No)
DRUG HISTORY
Are you taking any medicine regularly ? (Yes Diuretic for ↑ BP)
Had an attack of Gout about since 6 months ago.
ILLNESS
How this disease has affected your life? Could not go to work in severe pain at the
moment.
IDEA
What do you think is wrong with you? (I don’t know)
CONCERN
Doctor will I continue have similar attacks of pain in future as well.
EXPECTATION
Some prescription to get rid of pain and stone for ever.
I need to examine you to confirm my diagnosis. Can I?
Inspect tummy
Palpate for kidneys
Any tenderness in right loin (flank)
Any palpable bladder also percuss for full bladder.
Any rebound tenderness in right iliac fossa (appendicitis & also rule out cholecystitis)
INVESTIGATION
Have you undergone any investigation so far.
I offer you urine complete examination
Abdominal ultrasound scan I will refer you to sonologist.
We might need to do some other tests later on e.g.
X-ray KUB
Serum Uric Acid
Urine Microalbumin uria
Urea electrolyte
Creatinin
Calcium phosphate
If necessary helical enhance CT Scan of tummy (Specialist initiation)
SUMMARIZE
MANAGEMENT
What I have gathered from the information you have shared with me and from
examination and previous investigation reports, most likely you have a condition what
we called in medical terms Renal colic. Do you know any thing about renal colic.
REASSURANCE
Most probably your problem is related to your kidney. There are channels caring urine
from kidney to water bag. There may be some obstruction in these channel causing
pain. May be due to some stone.
MANAGEMENT
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Refer for admission in emergency for investigations & treatment. Tell him you
will continue to take care of him once he is discharged from emergency.
Do not give even pain killer in your surgery. This will mask the signs for Doctor
in emergency. Call the Ambulance
If patient ask what will doctor in emergency give me treatment then tell him he can
offer you diclofenac sodium 75mg. injection I/M in buttock to relieve your pain. (Inj. Pethadine
50mg I/M If he had already taken pain killer injection and tablets and no relief then ref him to
urology for management and further investigations possible admission. Can also be given)
Stop diuretic start ACE1 for ↑ B.P.(Age 45 Enalapril)
I also offer you metoclopropamide for your nausea.
I hope your pain will be relieved in the next few minutes.
I offer you to take plenty of fluids offer few life style changes.
Sieve your urine for stone analysis
↓ salt intake
– ↓ Milk intake
Avoid Chocolate, tea, spinach, nuts, beans, beetroot, if stone is due to calcium oxalate
If urate stone, Alkalanise urine with potassium citrate (PH > 6.5)
If cystine stone, alklalinise urine with potassium citrate. D-Pencillamine may be
used as a chelating agent.
If Ca PO4 – Low Ca ++ diet, avoid vit D supplements Bendro flumi thiazide may
help.
SAFETY NETTING
I will like to review your condition as soon as reports of ultrasound has come.
You can contact me if you have any queries or pain does not subside or you develop
fever or any discharge down below. Seek medical help.
If anything else you would like to discuss with me.
Thanking you for your cooperation.
118
MANAGEMENT OF RENAL STONE (CALCIUM OXOLATE)
Food & life style changes.
1. Increase fluid intake upto >3L in 24 hrs
2. Decrease salt intake
3. Alkalinise your urine with Pot. Citrate.
4. Avoid tea coffee citrus fuit juice
5. Avoid chocolate and nuts
6. Avoid certain vegetable e.g. Rhubarb, Spenach, Beens, Beetroot
7. ↑ Milk in take (Avoid asking)
If there is hypper calci uria I will offer you Bendro flume thiazide 2.5mg once a day.
If there hyper oxal uria I will offer you tablet (Pyridoxine 5mg once a day (vit B6)
I hope to see you in 2 wks time. If you develop any fever, any blood in urine, or any
burning urine seek immediate medical help.
CLOSING
Is there anything else you like to share.
You can have reading material from information desk.
Thanking you for your cooperation.
Good Bye
NOTE: Please do not treat acute surgical emergencies at GP Clinic.
Refer all cases of:
1. Cholcystitis
2. Appendicitis
3. Pancreatitis
4. Acute Renal colic
Refer to general surgery in emergency.
Refer All cases of TB to the chest clinic.
Refer All cases of Epilepcy to the nurologist for the start of treatment.
Refer all cases of Rheumtoid Arthritis to Rheumotology Department for
initiation of disease modifying drugs.
Later on GP can followup side effect of medicines in his clinic.
119
URINARY TRACT INFECTION
IN AN ADULT
Hello,
I am Dr. Raheel one of the family physcians in this surgery.
My name Sajjad age 25 years.
What brings to the surgery today?
___________________________________________________
Doctor I am passing urine more frequently and there is pain while passing urine.
My urine is cloudy and offensive smelling.
Is there any else you want to add?
There is pain in my lower tummy as well and my urine appears to be blood tinged.
Mr. Sajjad before I come to the management part can I ask you few questions?
Is there any loin pain? (Yes.)
Do you have any fever? (Yes high grade)
Is fever accompanied by riger’s? (Yes.)
Do you have fatigue and malaise? (Yes.)
Do you have any associated vomiting? (Yes.)
Is there any past history of similar complaints? (No.)
Do you have diabetes? (Yes.)
Are you dehydrated? (No.)
Any instruementation through front passage? (No.)
Any cathederization? (No.)
Any unprotected sexual intercourse? (No.)
Any habit of delayed passing of urine due to long journey? (Yes.)
EXAMINATION
INVESTIGATIONS
I offer you the following investigations:
1. Midstream urine before starting of antibiotic.
Urine should reach laboratory fresh.
2. eGFR if more than 40 years and male.
3. PSA test if more than 40 years and male.
4. Renal tract ultrasound.
5. May I know the results of investigations. If you have already gone through any of
these test.
Mr. Sajjad the information you have shared with me and according to the investigations
done already you have shown me you are probably having a condition which is called in our
medical terminology as urinary tract infection.
This is a common condition almost 20% of women at any time in life suffer from UTI.
One case in every day surgery urinary tract infection.
Positive organism in 70% of the cases is a simple bug called Ecoli.
Other organizsm include protius or Psodomonas.
120
This is quite treatable with certain LIFE STYLE CHANGES and certain medicines.
I offer you few life style changes:
1. Increase the fluid intake upto 3 liters per day.
2. Urinate frequently.
3. Do not let urine build in bladder.
4. Double void (Go to toilet after 5 to 10 minutes again)
5. Void after intercourse.
6. Do not used nylon underwear.
7. Wear cotton underwear.
I offer you paracetamol for pain while passing in urine 500mg twice a day.
Ibuprofen 400mg thrice a day can by added.
I offer you Nitrofurantoin 100mg twice a day for 3 days.
Alternatavie would be Trimethoprim 200mg twice a day for 3 days.
If patient suffers from upper urinary tract infection involving kidney (Pylonephritis along with
the lower urinary tract infection.
If patient suffers from fever and you suspect pyelonephritis than according to the latest
guidelines give IVM antibiotic (Injection Cepharazone 2g IV 12 hourly for 7 days.
I offer you Ciprofloxacin 500mg twice a day for 7 days.
NOTE: This is a common scenario that post manupauses women keep reporting in
surgery about recurrent urinary tract infection. Infact their vagina is dry causing
recurrent UTI. We as a doctor on finding lucocytes and nitrates in urine
examination tends to write antibiotic frequently. Patient is usually reluctant to
have frequent course of antibiotic.
Infact post menpausual woman with recurrent UTI need topical estrogen lotion
apply to the vagina at night. This prevents the recurrent UTI.
Alternatively doxycycline 100mg twice a day for 14 days or
Azithromycin 500mg once a day for 6 days can be given.
If still not resolving patient should be referred to urology.
UTI IN A CHILD
Children usually do not complain classical signs of pain while passing urine or
frequency of urine.
They usually present with (1) fever (2) Low Tummy pain (3) Irritibility (4) Jaundis (5)
Failure to thrive (6) Noctornal Enuresis caused by UTI.
Investigation include (1) Urine C/E (2) M C/S (3) Ultrasound Abdomen and Pelvis.
TREATMENT Trimethoprin or Microfurintine
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DIFFERENTIAL DIAGNOSIS OF RF, RA, AS, OA ,GOUT
Rheumatic Rheumatoid Ankylosing Osteoarthritis Acute Gouty
Fever Arthritis spondylitis Arthritis
Predominently Children before Majority are Mostly Men Men & Women Mostly Men
Gender Pubirty of any women equally Affected
involved sex
Age of onset Usually before May start at any Starts early in Usually at Always after
pubirty but any age between 10 life Middle Age i.e. Middle Age
person affected to 70 years between 45 to i.e. between
usually
by Streptoccal 55 years 40 to 55
between the
Organism at years.
ages of
any age can
suffer 20 to 30 years
Probable Sore throat due Unknown; Unknown; Early wearing Due to
to Immunological Hereditary away of articular Deposit of
Cause
streptococcus Factors may be factor may be cartilage due to uric acid
involved involved bad genes, crystals in
joints.
or trauma
or after
operation
Clinical Sign & Migrating Pain, stiffness Pain & Pain and Extreme pain,
Symptoms Arthiritis with & swelling stiffness of stiffness of redness,
concommitent especially early back specially weight wearing
heat,
history of sore in the morning. causing joints.
throat Stiffness limitation of tenderness
Pain and
becomeless flexion
Stifness and swelling
Movement of
as day becomes worse of joints
Back. .
advances after full day specially big
activity toe
MP joints.
Laboratory (1) High ASOT (1) High ESR Presence of on X-ray (1) High
Titre HLA-27 Gene serum uric
Findings (2) Rheumotoid (1)osteophytes
on Blood Test
(Anti- +ve Acid level
factor +ve
streptalysin O HLA-B27
(2)reduced (2) Disturbed
Titre) (3) ANA Test
joints Renal
(2) High ESR (Anti Nuclear
space present Function
Anitbody +ive) (due to wearing
(4) Anti CCP+ve off cartilage.
Characteristic Migrating Mostly small Typically Mostly weight Most often big
Joint involved Arthiritis i.e. as joints of hands Starts at bearing joints toe but any
one joint gets are swollen & sacroilliac affected. other joints of
healed, the destroyed. Joint foot and hand
(knee, hip and
other joint Typically Ulnar can be
as evident on ankle joints
become painful Deviation of affected.
& swollen Hand Bones Lumbo- Sacral in sequence)
occur X-ray
Rheumotoid Bamboo
Nodule Thoraxsic
Spine causing
Swan Neck
difficulty in
deformiting
respiration
Botunneir’s
later on
deformity
122
NON SPECIFIC NECK PAIN
Moin Ahmad age 28 years come to discuss his problem and share his worry.
Take relevant history examine and share management plan. Proceed.
Enter.
Hand over the card to the examiner (Nod) & say Hello.
→ Doc – Hello shake hand with the patient (Nod) (Smile) I am Dr. Raheel one of the
GP’s. in this surgery Mr. Moin Ahmad how can I help you today.
* I feel pain in left side of my chest and it goes into my left arm and neck.
→ Doc – Anything else you want to share with me?
* Two weeks ago, my uncle died due to heart attack. I am worried that same might
happen to me.
→ Doc – very sad to hear about your uncle.
Mr. Moin Ahmad In order to get more detail about your condition. I need to ask few
questions if you allow me.
* Yes doctor you can ask.
→ Doc – Mr. Moin Ahmad can you exactly point out where the pain is?
* Patient points over left side chest, back of neck and left arm.
→ Doc – How did it started.
* I work in a factory as fore man and I use to check the machine in bending position.
→ Doc – Can you tell me the character of this pain.
* It’s a sort of Dull pain.
→ Doc – As you have said that this pain goes into your arm, does it goes any where
else like under arm or the other side of neck.
* No.
→ Doc – Do you feel any pins and needles, any weakness in your Arm.
* No.
→ Doc – Any weakness in your Arm.
* No.
→ Doc – Does this pain ever occurs on walking or running.
* No.
→ Doc – Any history trauma.
* No.
→ Doc – Have you noticed any rash over your neck and arm.
* No.
→ Doc – What about your digestion now a days.
* Its ok.
→ Doc – Is there any particular time when you feel more pain like at night or day.
* No but it increases when I bend to check the machines.
→ Doc – Anything which gives you relief?
* When I rest.
→ Doc – On a scale of pain when 0 is minimum and 10 is maximum, how will you rate
your pain?
* Its almost 5.
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→ Doc – Have you gone through any test for it.
* No.
→ Doc – Mr. Moin Ahmad few more question I need to ask if its ok with you.
* Yes Doc.
PERSONAL HISTORY
→ Doc – Have you ever been diagnosed of any major medical illness like high B.P.,
High Sugar any heart problem.
* No.
FAMILY HISTORY
→ Doc – Any major medical illness in your immediate family like High B.P., High Sugar
and heart problem?
* one of my uncle had this heart problem.
Drugs
→ Doc – Are you taking any medicine regularly or over the counter?
* No, occassionaly paracetamol for my pain.
→ Doc – Are you allergic to any medicine?
* No.
→ Doc – Do you smoke?
* No.
→ Doc – Do you take alcohol?
* No.
→ Doc – Do you Dope?
* No.
Ilness
→ Doc – How this condition is affecting your daily routine life?
* Most of the time I am thinking about it. It might be a heart problem.
Idea
→ Doc – What do you think about your condition.
* Might be a muscular pain of neck due to repeated bending to check machines.
Concern
→ Doc – What worries you most?
* May get a heart attack.
Expectation
→ Doc – What you want to gain from todays consultation?
* Kindly look into my condition and tell me it is not a heart problem.
→ Doc – Ok. Mr. Moin Ahmad, the information we have just shared with me, I would
like to summarize. If anything left, kindly add to it.
“You are feeling pain in your neck chest and left arm which increases by bending the
neck and you are worried that it may not be a heart problem as one of your uncle died due to
heart attack in recent past. You are here to clarify your concern.”
Is that all or you want to add to it?
That’s all.
124
Examination
→ Doc – Mr. Moin Ahmad in order to get more knowledge about your condition I need
to examine you. Is it ok with you.
* Yes. Doc you can.
→ Doc – Can you undo your shirt button and show me your neck upto your shoulder.
* Yes Doc.
→ Doc – Thank you
(Clean the hand with sanitizer, tell the patient that you will feel the neck, have some
movements of the neck, If you feel any pain or discomfort, kindly let me know) I will
stop there & then.
EXAMINE
* Look from side ways, look for any deformity, rash, loss of curve..
Feel the neck from behind by three fingers method starting from occiput upto mid
scapula asking the patient if there is any pain.
Would you please move your neck right & left side up & down. Try to touch your ear
on either shouder. Check the motor power of shoulders by shrugging of shoulder upwards
i.e. 11th accessory nerve test.
Finish the examination by saying thank you and ask the patient to tie the button.
Wash once again your hands with sanitizer.
→ Doc – Mr. Moin Ahmad the information we have just shared and the examination I
have gone through, it seems most probably you have a condition which we in our medical
terms call non-specific neck pain. Do you know what is non specific neck pain?
* No.
Explanation & Reassurance
Do you want to know about it?
Kindly explain it to me.
→ Doc – It is a condition in which due to inappropriate posture of the neck during
working sleeping, lifting out things gives rise to stiffness of neck muscles, due to which cord
like structures which we call as nerves,, they become irritated and causes pain in the neck.
Are you following me.
* Yes doc.
→ Doc – As you are not feeling pain while examination. No pain after walking or
running. No shortness of breath, we can safely say that it is not the heart pain.
* Thank you Doc you have made my mind clear.
→ Doc – Much can be done to improve this condition some are medicines, some are
life style measures, which way would you like me to go first?
* Some life style measures please.
Rest
Don’t Bend your neck repeatedly
→ Doc – I offer some reading material you can collect it from the reception counter,
which shows how to sit, work and lie down. Follow the guidelines. Can you do it?
* Yes.
→ Doc – I offer referral to a physiotherapist and occupational therapist who will teach
you some exercise techniques. Is it convenient to you.
* Thank you doc.
→ Doc – I offer you to take tablet paraceptamol 500mg thrice daily regularly (not on
as per needed basis) till your pain settles. can you take it?
125
* Yes thank you doc.
→ Doc – Anything else you want to ask about your condition today?
* No doc you have relaxed my tension about my heart problem.
→ Doc – Mr. Moin Ahmad we can arrange a follow up after two weeks time. Is it
convenient to you.
* yes doc. MRI on specialist initiation.
Safty Netting
→ Doc – If in between you feel that pain is increasing or you feel any pins needles or
weakness in arms seek immediate medical help.
* Ok.
You can use soft cervical collar but not more than 10 days.
Closing
→ Doc – Take some reading material from the reception desk. More information about
your condition can be taken from the internet. Thank you very much for your
cooperation (Nod, smile) Shake hand and say good Bye.
126
LOW BACK PAIN
TWO MINUTE SCENARIO OUTSIDE STATION
Mrs. Jones 46 years female computer teacher complains of backache. Take
relevant history examine and manage. Proceed.
MEET & GREET
FIRST SENTENCE SAID BY SIMULATED PATIENT
Doctor I have hurt my back and the pain has been terrible.
Go on Mrs. Jones.
One days ago I was trying to lift a heavy box at home in an awkward twisted position.
Suddenly my lower back seemed to seized up. It was very painful as I tried to move.
So I sat on the couch and since then I am taking rest. I heard rest is good for backache. I had
similar backache last time 8 years ago.
INFORMATION REVEALED WHEN SPECIFICALLY ASKED (OD-PARA) MI
(Open ended questions first, then closed ended questions + plus explore red flag signs
to role out serious pathology)
Where is the pain. Kindly locate (site) where does it hurt? (Point to lower back area)
Since when you have backache (Duration) 1 day
Is it constant or intermittent? (Pattern of pain) (Constent)
How severe is pain on a scale of 0 to 10 when zero being minimum and 10 being most
severe. (Severity) Its almost 6.
Does it radiate to any of your legs? (Radiation) (No)
Anything which relieves pain? (Relieving factor) (Rest) (Paracytamol)
Anything which makes pain worse? (Aggravating Factor) (Movement)
Have you notice any weakness in any of your legs? (No) (Motor Power) No weakness
in legs.
Any abnormal sensation such as numbness or pin and needles in your back or buttock
area? (Assocaited symptoms) No loss of sensation in leg.
RED FLAGS
Age < 20 and > 55
Any thoracic back pain.
Any pain in leg on coughing or sneezing (Slip disc)
Have you noticed any problem passing urine or opening your bowels.
S - Saddle anaesthesia (Any loss of sensation around back passage) (Anal Area)
S - Severe constant progressive backache.
S - Severe pain at night
S - Any history of steroids taking.
S - Any sleep disturbance
Gait problem
Any weight loss.
Any fever.
PAST HISTORY
Any history of similar problem in the past? (Had similar backache 8 years ago)
127
Any hospitalization
Any significant medical problem.
Any significant surgical problem.
Any past history of carcinoma or HIV?
Any previous fracture bones with minor trauma (Osteoporosis)
PERSONAL HISTORY
Do you smoke? How much?
Do you drink? How much?
How are the things at home? (not going to school, confined to home)
How are the things at work? (I am a computer teacher but on leave from school)
Your occupation? (Computer Operator involved in sitting most of day)
FAMILY HISTORY
Any serious medical problem in your immediate family members e.g. ↑ BS, ↑ BP or
Heart problem
DRUG HISTORY
Have you taken any medicine so far for pain?
Are you taking any medicine regularly prescribed or OTC? (Paracytamol from OTC)
Any drug allergies?
Are you taking any steroids? (No.)
BIO PSYCHO SOCIAL HISTORY
Are you Married?
May I ask you a personal question if you do not mind? It will remain confidential.
Are you Sexually active? (Backache started while having sex)
ILLNESS
How this backache has affected your life. (I can not go to work or do house hold work).
IDEA
How do you understand your problem?
I think it is the same simple backache which I had 8 years ago and which resolved
spontaneously with rest.
CONCERNS
What worries you most about your backache?
Doctor: I have three cats.
I am worried who is going to take care of them while I am resting.
EXPECTATION
What do you hope to gain from today’s consultation.
I hope you will prescribe some pain killer and backache will resolve with rest and time.
SUMMARIZE
128
Mrs. Jones you have told me that your hurt your back while lifting heavy box 1 day
ago. Rest seem to relieve the pain. There is no radiation to any leg and no disturbance of
passing urine or opening your bowels. No loss of sensation, around back passage. Is this all
or you want to add something. That’s all doctor.
EXAMINATION AND PRACTICAL SKILLS (Look feel move)
In order to reach my diagnosis, I need to examine you. Can I exam you? If I hurt you
anywhere please let me know, I will stop there and then. Would you please take your shirt off
for me.
1. LOOK
FROM SIDE
For any exaggeration or obliteration of lumber Curve (Lordosis or kyphosis)
(Scoleosis)
FROM BACK
For spinal curvature symmetry, stigmata of neuro fibromatosis.
2. FEEL
3. Palpate the spinous processes from Neck to sacrum. Then palpate para-spinal
muscles for any tenderness. (If you use three finger you can palpate processes and
paraspinal muscles simutaneously.
4. Check backward extension while standing. Would you please bend forward. Try to
touch your toes like I do. (Forward flexion)
Now bend Backwards as far as you can?
Make sure you are there to hold, If patient balance is poor. Don’t let patient fall. (While
backache extension testing)
Can you slip your hand on right side and then to left side.
5. To check for rotation of back, get the patient sit on couch with legs hanging down in
air to fix the pelvis.
6. Aways look at patient’s face. Make sure you are gentle and sensitive to patient.
Assess Power in Legs by checking Any Weakness in Knee Extension or Foot
Dorsiflexion while resistence.
Would you press your foot up & then down against the resistence of my hand.
SLR
Tell the patient to lie down supine.
May I know which leg hurts?
Check the normal side first.
Hold the heel and do passive elevation of leg with knee in extended position. Always
look at patient face. Then check abnormal side. Stop if pain.
Normally SLR is possible upto 80o in most people.
Test is considered positive if SLR is restricted in comparison with the opposite side
and cause pain on back of thigh, radiating upto toes.
If test is positive, lower the leg a little bit, dorsiflex the foot at ankle. Check if pain
becomes worse.
DEEP TENDON REFLEX

129
Check knee reflex.
Check Ankle reflex.
Would you please lie on your tummy or sit on couch. Palpate sacrolliac area.
Now lie the patient in prone position and palpate sacroiliac joint by direct palpation.
Femoral nerve stretch test if you have time.
MANAGEMENT (Acute Backache) (Life style changes and medicine)
What I have gathered from the information you have shared with me and examination
I have performed, most likely your backache is a simple mechanical backache due to lifting
of heavy box. Cause is probably strain of muscle. Let me assure you that full recovery is likely
in less than 4 weekly.
LIFE STYLE CHANGES
Avoid Bed rest.
Try to maintain normal actively as far as possible.
Stay mobile and return to work as soon as possible. This aids in recovery & prevent
backache from becoming chronic.
(i) 1. Observe proper lifting techniques i.e. bend your knees instead of your back while
lifting heavy objects from floor.
2. Improve your set up of chair & Table at computer work.
3. Do some regular exercise. It is a good idea to walk to work instead of taking bus.
4. Try to reduce your weight, if obese to optimum weight according to your height.
MEDICINES
4. Take pain killer regularly in proper dose instead of as per need
(Paracytamol 500mg four times a day)
5. If still in pain a tablet of ibuprofen 400mg can be added to it three times a day
unless contra indicated due to some stomach problem.
I offer Omeprazole if stomach problem.
_________________________
If pain is severe, muscle relaxant like diazepam can be considered.
I will ref you to physiotherapist for exercises if you could not return to work in 4-6
weeks time. Physiotherapist, osteopath and chiropractor are the options.
It is my considered opinion that X-rays are not required at the moment because there
won’t be any positive finding hence why expose to high radiation.
FOLLOW UP
See you in two weeks time. If symptoms aggravate you can come earlier.
MANAGEMENT (Nerve Root Pain)
If along with backache there is radiation of pain in leg with numbness with SLR reduced
and Ankle jerk absent. Management same as acute backache plus reassurance that
conservative treatment should be adequate. It may take 6-8 weeks for full recovery. Nerve
Root Pain is also likely to resolve with time hence no need for X-rays in first 4 weeks.
MANAGEMENT (Chronic Backache)
What I have gathered from your history is that you are suffering from chronic backache
of more than 3 months duration. Accordingly to history there are no serious problems which
could be treated by surgery. So you need to accept and cope with pain while leading a full
life as far as possible.
Exercise, Weight Reduction, proper lifting techniques help along with talking therapy.
If pain is severe I offer to ref you to pain clinic.
You see if you take pain killer for a long time then their effectiveness is reduced.
As you cannot sleep because of pain so I am offering you an antidepressant called
Amytriptalene. It is to be taken in 25mg dose at bed time. It will help your sleep. It has its side
effect like dry mouth, retention urine, blurring of vision, constipation etc.
I can offer you back support e.g. coursets, Belts)
130
Tens (Transcutaneous electrical nerve stimulation sometimes help some people.
Follow up and safety netting.
I am arranging a 2nd follow up visit in 4 weeks time. Is it OK and convenient with you
You can return sooner if you are not improving or things get worse. If you develops
any new symptoms or has any concerns.
If backache is not improving after 6 weeks then review reconsider your diagnosis and
do following investigations.
X-ray Lumbosacral spine AP & Lateral
X-ray Pelvis AP View MRI
FBC
ESR & C-R.P. (C reactive protein)
Alkaline Phosphatase
Serum Calcium
___________________________
Definition Acute backacahe < 3 weeks.

Definition chronic backache > 3 months
Acute mechanical backache (relieved in 4-6 weeks)
Nerve root pain (relieved in 6-8 week)
____________________________
Walk on their heels ___ L4 L5 (Motor power checked as foot in dorsiflexion)

Walk on toes ( - L5 - S1 - Planer flexion)
Pain upto thigh (check knee reflex)
Rediation upto foot (Check Ankle Reflex)
____________________________
SENSORY CHECK
Inner side of thigh L2
Anterior aspect of knee L3
Medial side shin or Tibia L4
Dorsum of foot – L5
Lateral side of foot – S1
131
RICKETS & OSTEOMALACIA
RICKETS
• Bone pain / tenderness: (Arms, legs, spine, pelvis)
SKELETAL DEFORMITY
• Bow legs, pigeon chest, rachitic rosary, odd-shaped spinal deformity.
PATHOLOGIC FRACTURE
DENTAL DEFORMITY
• Delayed formation of teeth, holes in enamel, increase cavities
MUSCULAR PROBLEMS
• Progressive weakeness, decreased muscle tone, cramps.
IMPAIRED GROWTH
• Short stature.
________________________________________________________________________
OSTEOMALACIA:
BONE PAIN
• Pain, particularly in hips
MUSCLE WEAKNESS
PATHOLOGIC FRACTURES
Low Ca+2
• Peri-oral numbness, hand & feet spasms, arrythymias.
_________________________________________________________________________
MANAGEMENT
DIETY DEFICIENCY
Vit-D and calcium supplements.
AGE RELATED DEFICIENCY
Vit-D 800 I/U per day to all elederly more than 80 years.
SECONDARY RICKETS & OSTEO MALACIA
Due to mal absorption, liver disease, CRF.
Treat the cause and supplement calcium and Vit-D.
=====================================================================
VIT-D FOODS
Egg, Margarin, Tinned Salmon
CALCIUM- FOODS
Whole milk, Yogurt, Sardin, Hard Cheese, Baked beans, Boiled Cabbage.
132
RICKETS
1. Injection indrop D
Signs
Bow Legs
(Vitamin D3 Injection)
Pigeon Chest
1 Inj. Every month for three months
Rhitic Rosary
Kyphosis
Inj. Can be given in muscle
Scoleosis
Inj. Can be drunk in a small amount of watter
Odd Shapped Skull
2. Calcium Sandos Syp.
Short Stature
1 Tea Spoon Morning Evening
Stunted Growth
Take a sun bath in winter and summer after
Tests Advised
removing at least half of the cloths
Serum Calcium Foods rich in Vit. D3 include Eggs, Milk, Yugurt,
Serum phosphate Butter, margarine, Cheese
Bread, Cabbage should be used in abundance
Serum Vitamin D 3 Level
Patient of rickets must consult his doctor after
Parathyroid Hormones every two months
Levels
Liver Function Tests
Renal Profile
Complains of bone pain,

Muscular Weekness and
muscle cramps, Delayed
teething, Holes in Enemal,
Increased cavities, Fracture
on minor Trauma, Peri Oral,
Numbness due to decreased
Calcium
133
FROZEN SHOULDER
FROZEN SHOULDER (Adhesive Capsulitis)

Mr. Aleem uddin 55 years presents with shoulder pain for the last 6 weeks. Take
history examine and manage. Proceed.
O- Where does it hurt? (Left shoulder)
D- Since when? (6 weeks)
P- How sever is the pain on scale of 0-10 (Its around 5 or 6) (Moderate to sever)
R- Does it go anywhere else up or down? (Down to elbow)
Is it constant or comes in episodes? (Constant)
A- At what time of day is it worse? (At night)
A- Is there anything associated with pain? (No)
M- What medicine you have taken so far? (Simple pain killer from over the counter)
I- Any investigation done so far? (No)
Any restriction of movement of shoulder joint? (Restricted in all direction)
Do you find – combing of hair difficult ? (Yes, External rotation specially restricted)
Any previous history of Gall Stones? (No) (Radiation to right shoulder)
Any chest pain (No)
D/D
Do you have high Blood Sugar? (Diabetes Mellitus) (Yes)
Do you suffer from indigestion after fatty foods. (Gall Bladder Disease) (No)
Do you have pain and stiffness in your neck? (Cervical spondylosis) (No)
Did you have any trauma to your shoulder joint? (Osteoarthritis) (No)
Any Fever. (Septic Arthritis) (No)
Did you had any heart problem recently. (No)
Referred pain from lung (Pancoast tumor)
Any rash (Herpes zoster)
Any morning stiffness particularly early morning > 1 hour? (Rheumatoid Arthritis)
PAST HISTORY
Any past history of similar complaint? (No)
PERSONAL HISTORY
Do you smoke? (No)
Do you drink? (No)
Do you dope? (No)
Any high blood sugar (Yes)
Any high blood pressure? (No.)
Married?
Kids?
134
What do you do for your living (carpenter)
Any stress at work (Likely to be unemployed. Cannot do my work any more)
Any stress at home (Has to feed 4 kids) worried about financies)
FAMILY HISTORY
Any family history of similar complaint? (No)
Any major medical problem in immediate family members? (No)
DRUG HISTORY
Are you taking any medicines regularly prescribed or OTC? (No)
Any Allergies? (No)
ILLNESS
How this pain has affected your life (Can not do my work any more)
For any financial problem, I will refer you to social services for change of profession
position on your work place or your duty.
ICE
How do you understand your problem.
SUMMARIZE
So Mr. Alim uddin you have moderate left shoulder pain for the last 6 weeks. Which is
not related to heart or Gall Stones. But you are diabetic. Pain is worse at night and all
movements at shoulder are restricted.
Would you like to add anything else to it?
No that’s it.
I would like to examine you. Can I? would you please take your shirt off for me?
I will be touching and try to move your shoulder.
If it hurts you let me know. I will stop there and then.
Never forget: the key rule “LOOK FEEL AND MOVE”!!!
1. LOOK FROM FRONT SIDE & BACK:

Look for any swelling, scar formation, shoulder alignment and muscle wasting.
Ask the patient to turn around and look for any swelling, scar formation, shoulder alignment
and muscle wasting.
135
2. FEEL FROM FRONT & BACK:
Feel the temperature with your hands , the shoulder and clavicular areas.
Feel sternoclavicular joint.
Feel the entire length of clavicular border upto acromioclavicular joint.
Feel/press gently coracoid process (2 cm inferior and medical to the clavicular tip).
Feel the humerus.
Come behind the patient
Feel the spine of scapula with finger tips
Move: Can you put your hands behind your head. Patient will not be able to raise the
effected hands upto the back of the head.
Finally don’t forget to ask the patient to dress up.
Do not start concluding until patient is seated.
Wash your hands with sanitizer before and after examination.
MANAGEMENT
Some time our shoulder joint become stiff and movements in all directions become
restricted without any known cause.
Many a times its viral in origin. Some times its in our genes which predispose to it.
Some times even minor trauma predispose to such pain. In medical terms it is called frozen
shoulder or adhesive capsulitis.
It is a common condition occurring in diabetics patients. It may take a year to recover.
The capsule around our joint become stiff and adhesive to bone underneath. Hence
movements are restricted and pain occurs.
Do you understand so far?
We have few options like:
1. Pain killer
2. Steroid injection into the joint
3. Physiotherapy exercises to restore movement
4. Surgical options
We will discuss all these options one by one?
1. Some times ordinary pain killer like paracytamol or Nsaids like Ibuprofen 400mg thrice
a day is sufficient to resolve pain.
2. If that does not help steroid injection e.g. Kenalog can be given with local anesthesia
into the shoulder joint. Some times this steroid injection helps in restoring the
movements also. Very small amount of steroid is given. Its safe.
3. Active physiotherapy exercise can help in gradually restoring movements. For
exercises I offer to refer you to physiotherapist. Active exercises are important to
restore function. Fifty percent of people with adhesive capsulitis do not regain full
normal movement if untreated. It may take a year or more to recover. (Do not tell
physiotherapy exercise yourself. Its not your domain refer to physiotherapist.)
4. If movements are slow to recover I will refer you to orthopeadic surgeon.
Last is surgical option. They will cut hard fibrotic adhesions under vision by
Arthroscopy or Instill special Saline fluid into the joint till a pop up sound is heard. This
hydrodilation is used where adhesions are soft.
Mobilization under anesthesia is another option.
End in the usual way. 5 sentences in 10 seconds.
136
CARPEL TUNNEL SYNDROME
SCENARIO
Mrs. Khursheed Pal 28 years old who consults you complaining of intermittent
pain, pins and needles sensation in her hands. Take history, examine and manage.
Proceed.
• Where does she experience the symptoms?
(I get tingling in the thumb, index finger, forefinger and vague ache in the hand
extending up to fore arm).
• For how long have you been experiencing these symptoms?
(I have been getting this for the past four months but it has got a lot worse in the past
one month).
• When do you feel pain and pins & needles?
I get this pain off and on during the day but it is particularly trouble some at night. I
have been woken up most nights.
• Asked all questions about pain (Formula OD – Para – MI)
• Onset on pain, How did the pain started (gradually).
• Duration of pain, since when you have pain (4 months)
• Progression–is it constant or comes and goes (Comes & goes).
• Is it increasing or decreasing in intensity. (Same) (Constant)
• Any associated features? (No)
• Any relieving factor? (Symptoms are improved by shaking of wrist)
• Any thing that aggravate pains?
(Doctor it is worse at night & in certain postures of hand)
• Have you taken any medication to relieve pain.
(Not yet specifically but paracytamol from OTC off & on as per needed basis)
Any investigation done so far? (None)
D/D
Ensure confidentiality and then ask
Is there any chance you could be pregnant. (Yes) I am four month pregnant at this
time.
Your BMI? (> 30) (Obesity risk factor)
Any neck gland problem. (Hypo Thyroid) (No)
Any fracture of the wrist in the past? (Carpel Arthritis)
Do you feel cold while others feel hot. (Hypothyroid)
(Carpel Tunnel is associated with pregnancy, obesity, hypothyroidism, carpel arthritis
and) Any fracture or trauma to wrist in the past
RED FLAG
Wasting of thenar muscles.
PAST HISTORY
I had fracture of the wrist which is mal-united (Carpel Arthritis)
137
PERSONAL HISTORY
Do you smoke? (No)
Do you drink? (No)
Do you dope? (No)
Any high blood pressure. (No) Any high blood fats? (No)
Married? (Yes)
Kids? (Yes I am pregnant at the moment)
(In pregnancy accomulation of fluid occurs which cause pressure over median nerve)
What is the nature of your job? (Computer Typist / Secretary)
How are the things at home? (Stress) Ok fine very peaceful
How are the things at work? (Stress) Ok fine
FAMILY HISOTORY
Any major medical problem in the immediate family members? (No)
DRUG HISTORY
Paracytamol give some relief but not complete.
ILLNESS
I cannot sleep properly. It is worst at night. It interfere with my daily activity. My hand
muscle are getting wasted and weak. (Thenar wasting) (Thing drop from my hand more
frequently). Can not do typing properly at work.
CONCERN Could it be something serious.
EXPECTATION She would like a diagnosis and some tablets to get rid of this problem. She
ready to undergo any investigation or referral.
SUMAMRIZE
You have told me that you have painful, numb, weak hand. Pain is worst at night and
that you are four month pregnant at the moment & previous fracture wrist & find difficulty in
performing daily activity.
Is there any thing else you will like to add? No.
Examination of the wrist (LOOK, FEEL, MOVE)
LOOK
Defomity due to mal-united colles fracture at wrist.
FEEL
Feel tenderness over lateral side of the wrist.
MOVE
Ask the patient to follow your movement of hands and perform:
Wrist extension
Wrist flexion
Lateral Movement at wrist
Medial Movement at wrist
And circumdection movements
Check her weight as obesity is associated with carpal tunnel syndrome.
138
Inspect her hands looking for any deformity, swellings, muscle wasting, skin changes
or scars. Check her finger and wrist movements and power in her hand – pincer grip
and power grip.
Check her thumb abduction against riesistence.
Check her palms for thenar muscle wasting.
Check ulnar and median nerve function
Check the sensation in her hands.
Normal sensation in medial 1½ finger are found indicating intact ulnar nerve & Numb
on thumb index & forefinger indicating median nerve compression.
SPECIAL TESTS (Phalen & Tinel)
(1) PHALEN TEST (Hold you hand in prayer sign up side down)
Hyper flexion of wrist for one min. produce pain and numbness in lateral 3½ fingers.
(2) TINEL TEST
Taping over wrist causes numbness pin and needle sensation
(3) Nerve conduction studies can be done if diagnosis is in doubt to confirm carpel tunnel
syndrome.
MANAGEMENT
EXPLANATION AND RE-ASSURANCE
What I have gathered from information you share with me and examination I performed
is that most probably you are having condition. Called carpel tunnel syndrome.
Do you know what is carpel tunnel syndrome? (No)
Actually there are cord or wire like structures in our fore arm and hand which move
our fingers. They pass through a narrow bridge at wrist. In pregnancy fluid accumulates in
our body causing pressure over nerves passing under this narrow bridge in wrist. This causes
pins and needle sensation in hand.
Do you understand now what carpel tunnel syndrome is.
Fortunately this is a common and simple problem which can be managed by simple
measures e.g. I offer you (Formula SSS)
(1) Pain killer paracytamol tab 500mg thrice / d.
(2) Night splint made by physiotherapy, may help. This splint is worn at night in wrist
extension position which is opposite flexion position which produces pins and needles
sensation.
(3) I offer steroid injection in carpel tunnel. It may relieve pain will be given by orthopedic
surgeon.
(4) If night splints and steroid injection did not help we have surgical option in which
memberane in front of wrist is divided under local anaesthesia to relieve your pain. For
this I offer to refer you to orthopaedic surgeon.
Usually things settles after pregnancy but in your case since there is wasting of
muscles of hand, I am referring you to orthopedic surgon for division of membrane
right a way.
Is there any thing else you would like to ask. (NO)
Doctor can I take Ibuprofen tablet? (No)
Only parcytamol during pregnancy is allowed. (No Nsaids)
You can take leaflet from the reception desk about your condition.
You can have further information from the internet.
Smile Shakehand and say good bye.
IMPORTANT NOTE
No Nsaid in case of pregnancy. Only paracytamol tablet can be given.
139
GOUTS
(Consult Oxford 5th edition Page 494 & 495)
Abdullah 40 years comes with pain in his right big toe. Please gather data &
Manage. proceed.
DATA GATHERING
Ask all features of pain
Site where exactly does it hurt? (Big toe)
Severe How severe is the pain. If on scale 0 to 10 zero is minimum & 10 being maximum
CONSTANT OR INTERMITTENT
Is the pain constant or comes & goes (in episodes)
RADIATION
Does the pain go anywhere else up or down? (No)
AGGRAVATING FACTOR
Any factor which increases the pain. (Meat)
RELIEVING FACTOR
Any thing which relieves the pain. (Pain Killer)
ASSOCIATED SYMPTOMS
Any symptoms which occur along with the pain e.g. Nausea Vomiting or sweating.
D/D RED FLAGS (Fati)
Any fever (Septic Arthritis) (Any red Hot Swollen joint with fever) (No)
Any travel abroad (having sex (Gonococcal Arthritis) (No)
Any trauma (No)
Infection Any diarrhea or genito – urinary problem, 2-6 weeks before joint problem e.g.
Reactive Arthritis or Reteir’s syndrome.
What about your weight? Are you over weight? (Yes)
What sort of diet you like? (Purine diet) (Meat)
PAST HISTORY
Is it for the first time you had such episodes of pain or had before as well. (Had it before
as well)
Any ↑ B.P. (↑ risk of HTN in Gout)
Any heart problem (↑ risk of CAD in Gout)
Any kidney problem
Any infection (Recurrent UTI)
Any surgery around the joint
Any H/O Hypo para thyroidism (Neck gland problem)
FAMILY HISTORY
Any F/H of such big toe pain? (HTN + Heart Problem in family.
PERSONAL HISTORY
Any excess of alcohol intake? (Yes. 5 units / d)
DRUG HISTORY
Are you taking any prescribed or over the counter medicines? (Aspirin, Thiazide
diuretic) (Taking thiazide diuretic for ↑ B.P.)
140
INVESTIGATION
(1) Serum Uric Acid
(2) CBC (increased TLC) Increase ESR (↑ blood urates but may be normal)
(2) Microscopy of Synovial Fluid, not usually required – reveal Sodium Monourate
Crystals (Negative bifringent) on polarized microscopy.
(3) X-ray not usually required. Only show soft tissue swelling unless severe disease when
erosive pattern is seen.
MANAGEMENT
RE-ASSURE
What I have gathered from discussing with you is that most likely you are having a
condition what we call in our medical terms Gout. These attacks of pain are due to deposition
of a chemical called uric acid in your joints.
I think your problem is due to excessive Alcohol & meat intake, Try to cut down & bring
alcohol intake to safe limits (i.e. 3u/d for M & 2 u/d for female)
CONCERN
It’s a common problem & usually resolves in < 2 weeks & after 2 – 7 days if properly
treated.
Its not septic arthritis. Your age, joints involved and lack of fever all goes in favour of
Gout. Hence infection is exclude.
For the management of GOUT including initiation of Urate lowering therapy
Treatment of acute attack
and review after 4 – 6 week
Please read from Oxford Page 495.
For prevention of further attacks (Life style changes)
W ↓ weight
A Avoid Alcohol
P ↓ Purine rich foods e.g. offal, red meat, yeast extracts, pulses & mussals
High Purine foods include oily fish, sardine trout, mackerel. Seafood like prawns, meat,
offal. Liver, kidney, heart.
Moderate purine include Beef pork, Lamb, chicken.
Low purine food include milk, cheez, butter, yougert, eggs.
D Avoid drugs like Aspirin & Thiazide diuretic
A Give allopurinol if recurrent attack 100 – 300 mg.
Rest, apply Ice packs, elevate joint (RICE)
I offer you a pain. Naproxen 500mg twice a day.
If he has GI problem then alternatively offer him colchicines 500 microgram twice a
day.
We can increase its frequency to four times a day until pain is relieved or side effects
appear (Side effects include Nausea vomiting diarrhea).
Steroid Injection (Methyl Prednisolone 80-120mg I/M or in the joint) are also effective)
Refer to Orthopaedic Specialist for injection.
Allopurinole 300mg once a day after one month when acute attack of pain and
inflammation has subsided. New drug alternative to Alopurinol is feboxostat.
Alternatively or in addition sulfin pyrazone can be given. (Uricosuric)
141
SUMMARY
(Rest, Elevate, apply ice, Dicophenac Sodium 75mg bd or cholchicine 500ugm bd is
it OK with you. Alloprunol 300mg once/d one month after pain has subsided check uric
acid one month later)
Check serum uric acid after two months. Aim for normal range.
Gout may be linked to increased risk of hypertension and coronary heart disease.
Chronic Gout (Recurrent attacks, Tofi in pina (Urate deposit in PIna and Tenden and
j oints and damaged joints) knee, wrist or shoulder joints) may also be involved.
Refer any patient with gout & kidney stones or recurrent UTI to urology.
Oxford Page 494, 495.
Please prescribe new drug Febuxostat 40mg once a day instead of Allopurenol.
Precautions should be observed in patient with schemic heart disease as
Febuxostat can cause sudden cardiac arrest.
Ramipril instead of thiazide diuretic.
142
OSTEO ARTHRITIS KNEE JOINT
Mr. Mustafa 55 years has come to discuss his problem of knees pain with you,
kindly gather data, examine and management. Proceed.
Meet & Greet
Introduction
H/O PRESENT ILLNESS
Doc. I have pain in my both knee joint, please help.
Where is the pain?
0 – 10 scale intensity? (Six)
How did it started? (Gradually)
What makes it better? (Rest)
What makes it worse? (Day activity)
Does it travel to any other area? (No)
Is there any other joint involved? (No)
D/D + RED FLAGS
Is there any H/o Trauma? (No)
Is there any H/O fever (Septic Arthritis) (No)
Any significant weight loss recently (malignancy) (No)
Is there any morning stiffness of > 1 hr (RA) (No)
Any discharge from front passage (Reactive Arthritis) (No)
Any eye discharge (Retiers syndrome) (No)
Any Night sweats (TB). Any change in Bowel habits (Enadtroled Reaction Arthritis)
PAST HISTORY
Any truma or fracture in past.
FAMILY HISTORY
Any major medical problem in immediate family members.
For example high B.P. or high blood sugar or heart problem. (No)
MEDICINE HISTORY
Are you using any Medicine regularly prescribe or over the counter.
Any drug allergies
Are you using any steroids
PERSONAL HISTORY
Weight? (Over weight rather obese BMI > 29
Exercise? (No)
Diet? (Oily fried food)
Smoking (2 packs per day)
Alcohol (5 units / d)
143
Recreational drug (Do you dope) (No stress at home or work)
Stress at home? Stress at work?
FAMILY HISTORY
Illness + ICE important (Can no longer go for morning walk I miss it)
SUMMARIZE
Examination (Look feel Move)
Look Skin for Erythema Redness – Effusion/Swelling
Echymosis due to trauma
Feel temperature and compare on both sides.
MOVE
(1) Passive – Flexion can you bend your knee check range of movement
Extension - Can you straighten your leg check range of movement
(2) Against Resistence – Flexion (Motor power)
Extension (Motor Power)
SPECIALIST TESTS
Medial & Lateral Ligaments (Stress test)
Anterior Posterior Cruciate ligaments (Drawer Test)
Medial & Lateral Menisci (Macmeray Test)
INVESTIGATION
In order to confirm my diagnosis and rule out other conditions, I offer you certain tests:
X-ray both knee joint AP and Lateral in standing position. (Doc I have already done
Xray and he produces the Xray to the Doctor)
FBC - ESR
LFT, TFT
Rheumatoid Factor anti CCP Test
Drain fluid for Microscopy if effusion present
MANAGEMENT
EXPLANATION OF WORKING DIAGNOSIS
Information you have shared with me & examination, I have performed, Most likely you
have a condition called Osteo Arthritis of both knees.
Do you know anything about Osteo Arthritis of the knee.
Do you want me to explain
It is an age related condition in which natural wear and tear takes place. Mostly in the
weight bearing joints like knee, hip, ankle.
It occurs mostly in the middle age. Both men & women equally affected.
I offer certain life style change.
Consider quit smoking (Cause osteoporosis and weak bones)
Reduce Alcohol to safer limits
Reduce excessive weight by exercise like swimming
144
Use stick or walker for walking as support
Do not climb stairs excessively
Don’t squat
I offer to refer you to physiotherapy for exercise. These exercises are meant to
strengthen muscles around knee joints and hence prevent friction of bones and decreased
pain. Moist heat is prefer that infrared or short wave diathermy.
PHARMOCOLOGICAL MANAGEMENT
Topical Ensaids like Ibuprofin cream can be prescribed.
(1) I offer paracytamol 1g 3 time/d
If pain not relieved we have an option of Ibuprofen 400mg thrice a day
Or Diclofenac Sodium 75mg twice a day.
(2) According to the new guidelines don’t offer glucosamine, chondriten or acupuncture
for OA management.
You can offer TENS by physiotherapist.
SAFTY NETTING
If your condition did not improve and you continue to have severe pain, I may refer
you to orthopaedic surgeon who may consider partial or total joint replacement. Life of
artificial joint is around 10 years.
FOLLOW UP
After one month.
Closing 5 sentences.
=========================
WALKING
Walking is good for OA knee.
SWIMMING
Swming is good to OA back and hip but may make neck OA worse.
CYCLING
Cycling for OA knee and hip but may worsen patello femoral OA.
___________________________
Murphy Test – For Gall Bladder (Catches breath)
Macburney Point – For Appendiutis (Rebound tenderness on removing the pressing
hand)
Macmary Test – For Knee Menesci tear Test
145
OSTEOPOROSIS
Mrs. Elisbeth 66 years of age comes with report of Bone Mineral Density (BMD)
of T-Score – 2.8. Take relevant history and do management. Proceed.
Meet & Greet
Introduction
I had a fall on out stretched hand & got wrist fracture. Fracture was taken care off.
Doctor asked BMD test. I wish to discuss of this BMD Test report with ou today.
Tell me more?
Any thing else?
Doc. I have a report. Please tell me if its OK. Doctor Confirm ID of patient by asking
name and age. Compare it with the report.
Before we go in to detail of this report I need to ask few questions, can I.
What prompted you to get this report done? (I just mentioned it doctor ordered it after
my fracture)
DATA GATHERING
Do you take plenty of dairy products in your diet (Low Calcium diet)
How do you rate your weight? (Under weight)
Do you like to take exercise? (No)
Do you know your BMI? 17 kg/m2
Do you smoke, How much? (Yes) 2 pack/day.
Do you drink Ahcohol, How much? (Yes) > 4 units/day
Change in height? (No) (Spinal compression)
Bone pains? (Yes)
(Consult clinical examinations with pictures and over 150 images book at Page 126)
=====================================================================
D/D
SHATTERED FAMILY (Formula for Osteoporosis)
S – Steroid use (Are you using steroids in any form?) Osteopenia starts with -2.5
H – Hyper thyroidism (Any neck gland problem If person is using steroid
Do you have tremors in hands? (No) and even his T-score is -1.5
Any drumming in chest? (No) Please treat as Osteoporosis
A – Alcohol & Tobacco use (4 U/d + 2 packs of cigarette)
T – Thin BMI < 17
– Testosterone low (Any change in beard hairs)
E – Early Menupause (I had menupause at the of 42) (Average age in UK 51)
R – Renal Failure (Any kidney problem?) (No)
Liver Failure (Any liver problem?) (No)
E – Erosive Bone disease (Rheumatoid Arthritis) (No) Any symmetrical hand joint pains
D – Low Calcium diet (Yes) Don’t like diary products.
DM type I
146
FAMILY HISTORY
Family history positive (No)
Low BMI < 17 BMI
Anorexia nervosa (Do you think you are fat while other say you are very thin)
(Are you deliberately trying to loose weight)
=====================================================================
Is there any change in your beared hairs? (Low Testosterone)
Do you mind if I ask any private question? (Confidentiality Ensured)
At what age did you start menstruating? (14 year)
Any swelling on your feet & eyes? (Renal Failure)
Is there any loss of appetite and yellow discoloration of eyes or skin? (Liver failure)
Any symmetrical joint pain in hands with morning stiffness of > one hours. (RA)
FAMILY HISTORY
Is there any similar complaints of bony pain in your immediate family members? (No)
DRUG HISTORY
Have you been using steroids > 5 mg/d (Asthmatic on regular steroid inhaler) (Yes)
RED FLAGS
Any significant loss of weight recently (malignancy) (No)
Any fracture of bone on minor trauma. (Yes)
Any fracture sustained on falling from < standing height. (Yes)
Any night sweats (TB) (No)
ILLNESS ICE
SUMMARIZE – EXPLANATION
INVESTIGATION
DEXA Scan (Dual Energy X-ray Absorbometry)
FSH/LH Ratio of Hormones (Yes)
Testosterone Hormones
Serum Prolactin Hormones
Urine for Bence Jone Protein (Multiple Myoma)
Bone Scan
______________________
FBC & ESR

Thyroid Profile
Renal Profile
______________________
TREATMENT
Maintain body weight so that BMI around 25.
Diet. Take skimmed milk, margarine, low fat yogurt, Sardine Salmon tuna fish, cottage
cheese, baked beans, boiled cabbage.
Regular exercise 30 min/d x 5d/wk. Gradually increase weight bearing exercises.
147
Stop smoking
Reduce Alcohol to safer limits
Keep yourself mobile, do regular execise, sit in the sun,
Remove loose carpets
Use stick for support.
Supporting handle in toilet
Replace slippery tiles of toilet with rough tiles.
As you are on steroids, please take calcium 1gm/d + Vit. D3 800 IU/d
Bisphosphonates
BISPHOSPHONATE
I offer you alendronate type of medicine. It has to be taken empty stomach in standing
position and do not lie down for one hour after taking medicine. Preferably keep walking.
Take medicine with full one glass of water. 70mg/ tablet every week or 10mg/d.
SAFTY NETTING
If you develp sever bone pains or high grade fever or pain tummy or hip fracture as a
side effect of bisphosphonate please seek immediate medical help, I may need to refer you
to rheumatologist.
FOLLOW UP
I hope to see you in one month’s time. Is it convenien to you. (Yes)
CLOSING
Is there anything else you want to discussed with me today?
You can take reading material from reception desk.
You can get further information from Internet.
I thank you for your cooperation & visit.
Good bye
__________________________
SAFTY NETTING
CALCITONIN & STRONTIUM
There are other treatments like calcitonin for pain relief and strontium but they are to
be initiated by the Rheumatologist specialist.
________________________
Currently only bisphosphonate and periparatide are recommended for Osteoporosis in men.
_______________________
DRUG HOLIDAY
To prevent femoral fractures in patient’s using bisphosphonate for more than 5 years,
a “drug holiday” of 1 – 5 year has been proposed for low risk patient after 5 years.
Oxford Page 508 also consult
148
RHEUMATOID ARTHRITIS
Hello
I am Dr. Raheel. One of the GP in this surgery.
I am Mrs. Zulfiqar 51 year.
Okay Mrs. Zulfiqar how can I help you today?
Doc Its been three months that I have pain & swelling in small joints of my both hands,
symmetrically. I have been taking paracytamol from over the counter but very little
relief.
Yes Doc both hands have stiffness early in the morning for more than one hour. As
the day progresses my stiffness decrease.
Anything more?
No Doc. That’s all.
___________________________________________________
Before I come to the management part, can I ask you few questions.
You live in UK which is a cold & humid environment. You had no joint pains before 3
months.
Doc. I migrated to UK 3 months ago from India.
Is there any other joints of feet also involved?
There is a claw like deformity in my toes & I have pain while walking.
Any other joint? (No)
Any Pain in Neck? (No)
Do you have any skin problem?
I have psoriasis. There is a psoriatic plague & a swelling at my elbows. My hands are
red (palmer Erythema)
Do you think you are getting paller? (Yes) (Normocytic Normochromic Anaemia)
What about your weight? (Its decreasing)
Any fever. (No)
Any malaise. (Yes)
Any eye changes. (They are dry)
Do you have any pins & Nedle sensations in your hands. (Yes in both hands) (Bilateral
carpel tunnel syndrome)
PERSONAL HISTORY
Do you smoke. (No)
Any Alcohol. (No)
Any recreational drug. (No)
Any high blood sugar. (No)
149
Any high blood pressure. (No)
What do you do for your living.
(I am computer typist at an office)
How are things at home?
I find difficulty in performing daily activities.
How are things at work?
I find difficulty in typing.
PAST HISTORY
Any past history of any joint pain? (No)
Any hospitalization previously for any reason? (No)
FAMILY HISTORY
Any similar complaints in immediate family members?
My grand mother had such joint pains. Her joints were destroyed in later life.
DRUG HISTORY
Are you taking any regular prescribe medicine or from over the counter?
No except paracytamol from over the counter.
_______________________________________________________
ILLNESS
How this disease has affected your life?
I am unable to continue my work as typist.
IDEA
What do you think is the cause of your symptom?
I think this cold & humid UK environment did not suit me.
CONCERN
Anything you are worried in particular?
I think I have the same joint disease as my grand mother which destroyed her joints &
made her bed ridden.
EXPECATION
Doc. Help me with my joint pain. I don’t want end up like my grand mother.
_______________________________________________________
EXAMINATION
In order to reach my diagnosis I need to examine you. Can I examine you?
Doctor washes his hands with senitizer & ask Mrs. Zulfiqar, can you roll up your
sleeves upto elbows & tuc your elbow in your chest at 90 o degrees. (Doctor has placed a
pillow over the knees of patient)
LOOK
With the patient’s palm down look for any swelling or muscle wasting or scars.
150
Look for obvious ulnar deformity.
Swan neck deformity of fingers or boutonniere deformity.
Or Z shape deformity of thumb.
Inspect the skin for thinning as may occur be in steroid use.
Look at the nails for any psoriatic changes such as pitting or onycolisis.
Now ask the patient turn his hands and face the palms. Look for the wasting of thenar and
hypothenar muscles.
FEEL
Assess the temperature of the hand at the wrist and metacarpal phalangeal joints.
Bimanually gently squeeze the MCP joints to see any tenderness.
Palpate any MCP joint for any swelling. If the swelling appear to be boggy it represents
synovitis, if it feels bony. It represents Osteoarthritis.
Run your hands at the both elbows to feel for any psoriatic plaque or rheumatoid nodule.
(Heburden Nod)
MOVE
Assess wrist flexion and extension by asking the patient to make a prayer sign and then
upside down.
Ask the patient to make a fist and see all fingers are tugged into the palm.
Ask the patient to touch his thumb to all the fingers one by one.
POWER GRIP
Ask the patient to squeeze your fingers to check the function of the hands.
PINCER GRIP
You can check pincer grip in two ways.
1. Doctor opposes his thumb and index finger and ask the patient to release it.
2. Ask the patient to pick up a thin coin. (Pincer grip)
TRIPOD GRIP
Ask the patient to hold a pen to check tripod grip.
You can rolled down your sleeves & come to back to chair.
I thank you for allowing & trusting me for examination.
Doctor washes his hands with senitizer again at the end of examination.
INVESTIGATIONS
In order to confirm my diagnosis. How it sounds to you if we arrange certain tests?
(Ok).
I offer you F B C, Haemoglobin & ESR
Rheumatoid Factor
Anti - C C P antibodies
It is my considered openion that X-ray of both hands is of no use at such my early
stage. They will only show soft tissue swelling hence why expose to radiation.
151
Doc. The other GP at the surgery ordered these tests. I have already got these tests
done. These are the reports.
Doctor takes the reports & confirmed name & age as Mrs. Zulfiqar 51 year.
Results of report are:
F.B.C. Increase platelets
Decrease W B C
Hb Decreased
ESR > 100 mm in first hour
Rheumatoid Factor (+ve) or (-ve)
Anti – CCP antibodies (+ve)
MANAGEMENT
Reassurance & Explanation.
From the information you have just shared with me & reports of investigations, I think
most probably you have a condition what we call in our medical terminology as
Rheumatoid Arthritis. It is a common & treatable condition. In this condition our body
defence system our genes & environment play a factor. At times this condition can go
better or worse.
Fortunately you & I are living in a era where newer drugs like Methotrexate &
inflixcemab are available. These drugs can significantly alter the progress of disease
hence called disease modifying drugs.
I offer you diclofenac sodium tab 100mg once daily besides disease modificying drug
for which I will refer you to Rheumatologist. He will start appropriate drug.
I as your GP will monitor dose & side effects of these drugs.
We will need a multidisciplinary team approach to treat your condition.
Team will involve medical & surgical specialists.
I will be referring you to physio therapist, a podiatrist & an occupational therapist who
will guide you certain exercises to help you keep walking & working.
We may involve a Rheumatoid specialist Nurse & social services as well.
Physiotherapist can help you with splints, appliances & strapping to keep your joints
mobile, decrease pain & preserve function.
Let me assure you that UK Govt. & community offer lot of support in the form of self
help group and carer help groups. Disable car parking badges & financial support is
also available.
SURGICAL MANAGEMENT
As the disease progresses tendon can be ruptured, joints can be destroyed but these
days orthopaedic surgeons can stitch back tendon to its place, transfer tendons from
one place to the other to help you keep walking & working. Even destroyed joints can
be replaced with artificial joints.
Is there anything else you will like to discuss with me today?
No Doctor.
You can get leaflets about your condition from reception desk.
Thank you for your cooperation & visit. Good Bye.
_________________
152
TEAM OF EXPERTS
Physio therapist
Podiatrist Occupational Therapist

Osteopath Orthopaedic surgeon
Chiropractor Rheumotogist
153
TENNIS ELBOW
Hello.
I am Doctor Raheel one of the family physicians in this suergery.
I am Mrs. Khalid 25 years old.
Well Mrs. Khalid what brings you to the surgery today?
_______________________________________________
Doctor I had large number of guests at my house last week.
I had to cook lot of food for the guests and also had to wash and rins lot of bed linnin
and clothes.
Due to this reptative movement I have develop pain on the outer side of my elbow.
Its ranges from minimal discomfort to excrutiating pain. Minor activities like lifting up a
glass or repetitive activity like hard manual work or playing tennis worsens my pain.
Doctor I am a tennis player. My tournament is coming and I need 100% level of
functioning in order to fight my title for the tournament.
NOTE:
Repetative occupations like brick laying or carpentary predispose to elbow pain
also playing recket sports like Tennis, Bedmintin, Squash also produce elbow pain.
EXAMINATION
Ok Mrs. Khalid in order to reach my diagnosis I need to examine you. Can I
examine you?
Can you extend you arm straight?
(Extention range in elbow is normal. No restriction of movement)
Can you touch right to the right shoulder and then repeate the same movement
to the left to the left shoulder.(Flexion range is elbow normal)
Mrs. Khalid put your elbow 90 degree of flexion and I will move your hand up
side down.
(Pronation and supination at elbow normal. No restriction of movement)
Mrs. Khalid would you please roll your sleeves up to the elbow.
Place the elbows at 90 degree at elbow joint.
Can you pointout where does it hurts.
Its hurts on the outer side of my elbow.
SPECIFIC TEST FOR TENNIS ELBOW (Resisted Extention of wrist)
154
Ok Mrs. Khalid try to lift your hand upwards while I will try to resist this
movement.
This resisted extension produces pain Mrs. Khalid where does it hurts.
She points out towards the lateral epi condile this make our diagnosis of Tennis
elbow.
Mrs. Khalid un roll the sleeves and come back to the chair. I thank you to
allowing me to examine you. (Doctor washes his hands with sanitize while patient
seated in her chair.)
MANAGEMENT
Stop the repetitive movement give your painful elbow some rest.
I offer you Neproxin 500mg twice a day.
Physiotherapy in the form of infra rays light may help.
I also offer to give a steroid injections in the outer side of your elbow inorder to
speed up the recovery.
Rarerly we used autologous blood injection to releive the pain.
Last of all if your pain persist I will be referring you to the orthropadic surgeon
who main release the pain ful tendon at the elbow by surgery.
Is there any thing else wants to discuss with me today.
Good bye.
155
GOLFER ELBOW
Hello.
I am Doctor Raheel one of the family physician in this surgery?
I am Mrs. Saeed 28 years old.
Well Mrs. Saeed what brings you to the suregery today.
_____________________________________________
Doctor I am a professional golf player.
My tournament is coming and I have been practicing golf for extended time but I have
develop excrutiating pain on the inner side of my elbow.
It is made worse on playing golf. I need 100% level of functioning as I have to win my
title in about 4 weeks. Kindly help me.
EXAMINATION
Ok Mrs. Saeed in order to reach my diagnosis. I need to examine you can I
examine you.
Can you extend you arm straight?
(Extention range in elbow is normal. No restriction of movement)
Can you touch right to the right shoulder and then repeat the same movement
to the left to the left shoulder.(Flexion range is elbow normal)
Kindly put your elbow at 90 degrees and move your hand from upside down at
elbow.
(Pronation and supination range normal. No restriction normal.)
Mrs. Saeed can you touch where does it hurts on the elbow.
She touches innerside of the elbow as doctor touches over the medial
epicondyle she complains of pain.
SPECIFIC TEST FOR GOLFER ELBOW (Resisted pronation at Elbow)
Ok Mrs. Saeed would you please put your elbow at 90 degrees at the pillow
over your knee and try to move your hand upside down at elbow.
I will try to resist this movement if you feel any pain please let my know where
does it hurts.
As the doctor does resisted pronation patient complains of pain on the inner
side of the elbow.
This makes our diagnosis of Golfer Elbow.
Mrs. Saeed please unroll your sleeves and come back to the chair.
I thank you for allowing me to examine you.
Doctor washed his hand to the sanitizer at the end of examination as the patient
seating in the chair.
Doctor starts with the management.
156
MANAGEMENT
Stop the repetitive movment which cause pain at the medial side of the elbow
i.e. you need to give rest to your elbow by not playing golf for a week or 10 days.
I offer you Naproxin tablet 500mg twice a day also omeprazole.
Physiotherapy of the form of infra red rays.
I also offer you steoid injection on the medial side of elbow in order to speed up
the recovery.
Last of all if you pain persist I will referring you to the orthopedic surgeon who
may released painful tendon at elbow surgically.
Follow up after one week.
Is there any thing else you want to discuss with me today? (No)
You can take leaflet about golfer’s elbow from the reception desk.
Thank you for your coopeation and good bye.
157
PLANTER FASCIITIS
SCENARIO
A Policeman complain of pain in inferior heel. Kindly gather data, examine and
manage. Proceed.
Hello.
I am Salman.
Ok Mr. Salman what brings your to the surgery today?
Doctor I have pain in the inferior part of my heel.
Pain is worst when I take first few steps after getting out of the bed.
Its only in my one foot.
Ok Mr. Salman, before I come to the management part, I would like to examine you.
Would you please move on to the Couch.
I would be pressing at certain point at the sole of your foot, you have to tell me, if it hurts you.
Doctor presses planter fasciia position and patient feels pain.
Ok Mr. Salman come back to the chair.
MANAGEMENT
Mr. Salman from the problem you shared with me and after examination, It is my considered
opinion that most probably you are having a condition called planter fasciitis.
It is a common condition occurring in runners, in police men and in solders who have to stand
for prolonged period of time as a part of their duty.
It is easily treatable and generally settles in less than 6 weeks.
You seems to be a little over weight, I offer you to reduce your weight.
Take paracytamol 500mg two tablets thrice a day. (Iboprofen can also be taken)
I can refer you to the orthopaedic surgeon who can give steroid injection at the painful side.
You can wear shoes with arch support soft heel and heel padding can also help.
I can refer you to prodiatry for fitting of, an insole.
I can also refer you to physiotherapist who can explain achilles tendon stretching exercises
which will help relieve your pain.
Is there any thing else to discuss with me today?
No doctor thank you very much.
Goog bye.
158
HEADACHE (Migraine)
ACUTE HEADACHE (Formula MESH – T8)
M Meningitis (Brain Covering Meninges Infection)

Is there any fever with headache.
Any vomiting
Or Neck stiffness
E Encephlopathy (Brain Tissue Infection)
Any fever, confusion with decreased conscious level beside headache.
S Sub Arachnoid Haemorrhage
Sudden onset severe headache in occiput area with Neck stiffness
H Head Injury
History of injury, Bruises. (First pin point pupils then dialated pupils)
↓ level of consciousness
Loss of memory
Period of lucidity
T–8
Any teeth or jaw pain.
Any history recent trauma or accident
Tempero-mandibular joint pain radiating to head.
Tonsil pain radiating to head,
Tempanic membrane pain radiating to head. (Ear)
Is your headache gradually increasing & vision gradually ↓ (Tumor)
Tropical Illness (Malaria, Dengue, Typhoid)
Any history of travel to South East Asia
Acute Recurrent Headache (GET-MC-S) (Get Medical Certificate)
G Glucoma
Do you see halos around bright light
E EXERTIONAL OR COITAL HEADACHE
Does headache occurs after love making.
T TRIGEMINAL NEURALGIA
Does this pain increase on Talking, Eating, Laughing, Touching e.g. shaving &
washing
M MIGRAINE & MENSTRUAL MIGRAINE
Do you have some strange warning sign feelings before headache occurs.
Is your headache unilateral thrombing in nature?
159
C CLUSTER HEADACHE
Is your pain focused around one eye & occurs 1 – 2 hrs after falling sleep or taking
Alcohol.
SINUSITIS
What happens to headache when you bend down.
SUB-ACUTE Headache (GCA)
Do you feel pain on side of your head while combing hairs.
CHRONIC HEADACHE (Formula) (IMP – TC)
I increased Intra Cranial Pressure.
Drowsiness decreased consciousness irritability VI nerve palsy peppilloedima,
drooping pulse, rising BP, Pupil changes first constriction then dilatation.
Headache worse on awaking with paralysis or numbness?
M Medication over use headache.
Does headache occurs on stopping medication?
P Pagets disease
Is there any bending of leg bones?
T Tension Type Headache
Is it like a band around the head & occurs when you are under stress?
C Cervicogenic Headache
Do you have pain & stiffness in Neck besides headache? (Due to OA of Cervical spine)
___________________
Formulas
Acute Headache (MESH-T8)
Acuter Recurrent (GET-MCS)
Sub Acute Headache (GCA)
Chronic Headache (IMP-TC)
NOTE IMPORTANT:
1. First of all acertain weather headach is acute, Acute recurrent, Sub acute or chronic
by asking duration of headache e.g. since when you are having headach (1 hr or six
months)
2. If it is acute then forget D/D of acute recurrent or sub acute and chronic type of
headache Do D/D of Acute type of headaches only.
3. Make a diagnosis. Ask specific question about that type of headache only and do
management accordingly.
160
MIGRAINE
Mr. Allah Rakha complains of sever headache for 1 day. Take relevant history &
manage. Proceed.
Hello.
I am Allah Rakha.
I have only right half headache for the last one day. Its started suddenly while I was
watching TV. Its very severe in intensity and throbbing a nature. It’s accompanied by
nausea.
History of PRESENT ILLNESS (Pain Formula)
When did your headache started? (Time) 1 day ago.
Can you show me where does it hurt? (Site) Its unilateral on right side)
How sever it is? If 0 is minimum & 10 maximum. (Its around 6 to 7)
Is it continuous or comes & goes. (Constant)
Did it started suddenly or gradually. (Suddenly)
Any factor which relieves pain (When I lie down in quiet dark place)
Any factor which worsen your pain. (Flickering lights & loud noise)
Does it go any where else up or down. (No)
Is there anything associated with headache like Nausea, Vomiting or sweating.
(Nausea)
Patient has said that it is a unilateral throbbing headache, very sever in intensity,
accompanied by nausea vomiting photophobia & phonophobia.
Do you have some strange feeling before headache occurs (Aura) (Yes) (Visual
disturbance)
D/D of acute recurrent headache
Do you see halos around the bright light? (Glaucoma) (No)
Did your headache started after love making? (Exertional or Coital headache) (No)
Does your pain start on talking, eating, laughing, touching like shaving and washing?
(Trigeminal Neuralgia) (TELT) (No)
Is you pain fucussed around one eye and occur 1 to 2 hour after falling sleep after
taking alcohol? (Cluster headache) (No)
PAST HISTORY
Any history similar complaint in the past? (Yes had it 6 months ago as well)
DRUG HISTORY
Are you taking any prescribed medicine regularly or over the counter or herbal
medicine. (No)
Are you allergic to any medicine. (No)
What medication did you use in the past to relieve your headache. ( I don’t remember)
161
FAMILY HISTORY
Any family history of similar complaints. (Yes) My father had it.
Any major medical problems in immediate family e.g. ↑ blood sugar, ↑ Blood pressure
or heart problem.
ILLNESS
While headache is there, I cannot continue my work or activity.
IDEA
What do you think what’s wrong with you?
I think some thing is seriously wrong with me like Brain Cancer or Brain Tumor.
CONCERN
What worries or bother’s you most?
One of my friends who had headache died of brain cancer later.
Expectation
What are you hoping will happen from seeing me in surgery today?
I expect you to investigate it thoroughly & give me some medicine to fix it permanently.
EXAMINATION MIGRAINE HEADACHE
I need to examine you in order to confirm my diagnosis. May I examine you. I will be
touching your face. If you feel any pain, please let me know, I will stop there & then.
1. Press over frontal sinuses over forehead.
2. Press over maxillary sinuses.
Ask the patient to open and close the mouth as you feel over both Temperomandible
joints and asked the patient to indicate if he feels any pain on any side.
3. Palpate over Cervical Spines from behind. Any tenderness?
4. Check pulse.
5. Check BP by Palpatory and Auscultatory method.
SUMMARIZATION
What you have told me is that you have severe unilateral right side throbbing headache
which prevents you from continuing daily activity.
It is brought by flashing of lights e.g. while working on computer or watching T.V. &
there is a strange feeling before it occurs.
Have I understood you correctly?
MIDAS (Migraine Disability Assessment Score)
A. On how many days in the last 3 month did you have a head-ache? (If a headache
lasted more than 1 day, count each day)
B. On a scale of 0-10, on average how painful were these headaches?
Where 0 = no pain at all,
10 = pain as bad as can it be
Question A & B measure frequency and severity of pain. This MIDAS score help in making
treatment decision.
INTERPRETING MIDAS SCORE
162
I Score 0 – 5 Minimal / infrequent Tend to have little or no treatment
disability needs. Can often manage with OTC
medication. If infrequent severe
attacks may require triptan.
II Score 6 – 10 Mild / infrequent disability May require medication for acute
attacks, e.g. NSAID ± antiemetic or
triptan.
III Score 11 – 20 Moderate disability Will need medication for acute
attacks. Consider prophylaxis.
Consider other causes for
headaches, e.g. tension-type
headache.
IV Score ≤ 21 Severe disability
May I know midas score – 15
MANAGEMENT
REASSURANCE
From the information you have shared with me, it seems most probably you are having
a condition called migraine.
I re-assure you that it is a Benign nature of headache. It is a common headache
controllable with drugs. Not any life threatening serious problem like Brain Cancer or Brain
Tumor.
(1) Give advice on Relaxation techniques and stress management.
Sort out the cause of stress.
Take enough of sleep without sleeping pills
_______________________
Look after your self
Don’t skip meals
Take time out to spend with family and friends
Take care of your weight
Avoid alcohol, nicotine and coffee
work hard
Physical Exercise ↓ level of adrenalene
Physical Exrecise ↑ level of endorphenes and bring sense of well being.
_____________________________
Avoid Inter personal conflicts.
Learn to accept what you cannot change.
Learn to say no.
Learn to manage accordingly to priorities.
163
Pharmacological Management of Migraine.
TREATMENT
1. Neproxin 500mg twice a day or Ibuprofin 400mg thrice a day or paracytamol 1g QID
+
2. Metochlopramide 10mg per oral.
3. Triptain (Somatriptain 50-100mg per oral or 6mg subcutaneously) +
4. We can repeat this treatment. Triptain are effective but repeating can cause rebound
headache.
5. Nara Triptan & eletriptan cause less reoccurrence rate.
PROPHYLAXSIS
Can be given if more than 4 attacks of Migrain in one month. Prophylaxis treatment
cause less frequency of migraine attacks. Prophalaxis decreased attack by 50% T ry a drug
for two months before deeming it ineffective. If effective continue for six months then
considered decreased in dose slowly and stopping.
First line
Propanalol 40mg twice a day.
Topiramate 25-50mg OD/BD
MENSTRUAL MIGRAIN
Menstrual migrain is defined as headache, Starting from two days before mensis to
three days after periods on at least two out of 3 consecutive months. Consider frovatriptan
2.5mg twice a day on the days when migraine is expected.
Frovatriptan 2.5mg twice a day
Zolmitriptan 2.5mg twice a day
Keep a diary of days in which you have menstrtual migration headache.
Treatment include Neproxin 500mg twice a day.
Metocloproamide for vomiting.
As you said that you are taking COC pills for the last three months. Stop COC pills if
they are causing menstrual migraine. You may have to resort to other contracepted methods
like a coil.
164
MANAGEMENT OF OTHER TYPES OF HEADACHE
M - 1. MANAGEMENT MENINGITIS
Give I/V or I/M penicillin – V in surgery or clinic and refer for admission in medical
ward.
E - 2. MANAGEMENT ENCEPHALITIS
Refer for immediate admission in medical ward.
S - 3. MANAGEMENT SUB-ARCHNOID HAEMORRHAGE
What I have gathered from your history and examination is that you are suffering from
what we call in our medical terms is sub-Archnoid Haemorrhage. I am issuing a referral letter
to Neurology Department for immediate admission.
H - 4. MANAGEMEND HEAD INJURY
Consider Admission in surgical ward.
5. MANAGEMENT SINUSITIS
Pain killer
Steam Inhalation
De-Congestent
No antibiotic unless feverish
Refer to ENT surgery to wash sinuses in chronic cases.
6. MANAGEMENT DENTAL CARIES
1. Oral Hygeine
2. Pain killer
3. Extraction
G - 7. MANAGEMENT GLUCOMA
Acetazolamide
E - 8. MANAGEMENT EXERTIONAL OR COITAL HEADACHE
1. Nsaid or Propanolol before attack
11. Management joint cell Arteritis
High dose steroids 40 – 60 Mg/Kg/D
12. MANAGEMENT RAISED INTRA CRANIAL PRESSURE
Refer.
13. MANAGEMENT OF MEDICINES FOR OVER USE HEADACHE
Aim to decrease consumption of pain killers until taken less than 15 days per month.
14. MANAGEMTN PAGET DISEASE
Refer. (Ortho)
15. MANAGEMENT CERVICOGENIC HEADACHE
1. Pain killer
2. Physiotherapy (Heat and Exercises)
3. Cervical collar.
IMPORTANT NOTE
1. Headache
2. Erectile Dysfunction
3. Contraception
Many choices are available for management. Cannot discuss all choices in 10 minutes in
detail so:
Give briefly choices available.
Discuss only that choice which patient prefer.
Discuss preferred choice in detail with pros & con, advantages & disadvatages side
effects etc.
165
MANAGEMENT TENSION TYPE HEADACHE
(Oxford 5th Edition Page 530)
In tension headache the person continues his/her daily house holding work. Mostly
women are involved.
1. Re-assure no serious underlying problem.
2. Try measures to allevate stress e.g. Relaxation Taps, Massage, Yoga,
Exercise.
3. Talking therapy can be tried (CBT)
4. Neck pain can be treated by Physiotherapist.
5. Pain killer has limited value. Might make matter worse.
6. Use Paracytamol or Ibuprofen and avoid codiene containing preparation for fear
of addiction.
MANAGEMENT CLUSTER HEADACHE

Treatment include
1. 100% Oxygen for 10-20 minutes.
2. Sumatriptan 6mg SC or 20mg nasal – stop 70% of headache in less than 15
minutes.
3. Consider prophylaxis (Velms), If attacks are frequent, last more than 3 weeks
and cannot be treated effectively. More effective if initiated early at the start of
new cluster. Refer to specialist if no response to verapamil. Refer for specialist
advice / neuro imaging for first bout of cluster headache.
MANAGEMENT TRIGEMINAL NEURALGIA

(Oxford 5th Edition page 531)
Carbamazapine 200 to 400mg tds per oral. Start with 100mg OD/BD and increase the
dose over weeks.
This will decreased the intensity & frequency of attack. But if treatment with
carbamazapine’s fail and patient less than 50 years old and there is neurological deficit in
between the attacks then refer to neurlogy. Pregabalin – start 75mg twice a day to a maximum
of 300mg BD. If ineffective consider continuity with Amitriptalin – start at 25mg at 5-7PM.
Increased dose by 10-25mg every 7 day to a maximum of 75mg.
_______________________________________________
Carbamazapine – Trigeminal Headache

Carbemazole – Hyper thyroid
166
MULTIPLE SCLEROSIS
SCENARIO
Patient present with MRI report. Impresion written on it of multiple sclerosis. Kindly
gather data and manage.Proceed.
Hello.
I am Dr. Raheel, one of the GP in this surgery.
I am Zubair 32 years.
I am sorry to waste your time doctor. Things have been a bit blurry in my left eye. __Just the
central bit__ for few weeks but it is back to normal now. I am sure it is nothing to worry about.
I just need to get my eyes checked by the optician.
I hope there is nothing seriously wrong or to worry about.
Eye is an important organ of our body. Your symptoms cannot be dismissed so easily.
Before I reassure you, I need to ask few question, can I ask?
When did you first notice problem with your vision? (About 3 weeks ago)
How did it progress? (My vision is back to normal now)
Was eye movements painful while your eye was blurred? (Yes)
Is there any injury to the eye? (No)
Any double vision? (No)
Any red inflamed eye? (No)
Any headache? (No)
Any weakness of limb or face? (No)
Any tingling or numbness in your limbs? (Yes) Tip of my fingers were a bit numb?
What about your speech? (It had become a scanning speech)
Any difficulty in swallowing? (No)
Any problem with opening your bladder? (No incontinence or urgency)
Any problem with opening your bowel? (No fecal incontinence or urgency)
Any problem with your balance or dizziness? (No)
Did you have any similar problem in the past? (No)
Do you have any other medical problem? (No)
FAMILY HISTORY
Is there any family history of any major medical problem? (Yes diabetes and heart problem
run in our family)
DRUG HISTORY
Are you taking any medicine currently? (No)
PERSONAL HISTORY
Do you smoke? (Two packs a day in my room with doors & windows closed) (Optic Neuritis)
167
Do you take alcohol? (Yes in safe limits)
Any of high sugar? (Yes my mother is diabetic)
Any history of heart problem? (Yes my father has Angina)
What do you do for your living? (I am a school bus driver and I nearly had an accident 3
weeks ago, because of this blurring of vision.
Any difficulty at home? (No)
ILLNESS
How this condition has affected your life?
Doctor I saw a program on television about multiple sclerosis. It showed that the problem
started with the blurring of eye.
I am a bus driver, I am frighten by the potential serious implecations of this disease.
IDEA
What do you think is the cause of your blurring eye.
My problem is resolve completely, I am otherwise a very healthy and fit person. So I do not
think I have multiple sclerosis?
CONCERN
Do you worry anything in particular?
Yes I am concerned about my job and future financial problems. I do not want to become a
burden on my family.
EXPECTATION
What do you expect from today’s consultation?
Doctor I want some reassurance that nothing is wrong, you can investigate or you can refer
me to some eye specialist or neurologist.
EXAMINATION
Blood pressure
Full neurological examination – assess the tone, power, sensation and reflexes in the upper
and lower limbs. Check his gait and balance also.
Examine his cranial nerves.
Check for Lhermitte’s phenomenon (i.e. flexion of the neck causes electrical sensation)
Fundoscopy – look for any optic disc atrophy.
THE FINDINGS GIVEN BY THE EXAMINER
Blood pressure 130/80
There is no foot drop or disturbance of gait.
No hypertonia, no hyperreflexia
No extensor planter response
No abscence of superficial abdominal reflex
No feeling of pins, tingling
No painful blurring or double vision
There was scanning speech
INVESTIGATIONS
Full blood count
168
Urea creatinin and electrolites
Blood sugar
Vitamin B12
Folate
MRI Scan
CSF fluid from the spine
Fundoscopy and further eye tests
FINDINGS GIVEN ARE
Complete blood picture, plain X-ray chest, ECG and urine analysis are unhelpful in diagnosis.
MRI
MRI is very sensitive to detect lesions of brain and spinal cord in MS. Multiple plaques are
visible.
CSF EXAMINATION
Exact cause is unknown. Immune mechanism against CNS myelin sheath is suggested due
to presence of increased levels of activated T-lymphocytes in the CSF and increased
immunoglobulin synthesis within the CNS. Myelin sheaths of peripheral neves are not
affected.
There are multiple areas of demylination within the brain and spinal cord.
Increased CSF lymphosytes but less than 50 cells/µL.
Total CSF protein is normal but the level of 1gG is increased.
CSF electrophoresis shows presence of oligoclonal bands of 1gG antibodies indicating the
production of antibody against unknown antigens within the CNS.
SAFTY NETTING
It would be premature to give a definite diagnosis without further investigations. It is my
responsibility as a doctor to suggest to refrain from driving until you see neurologist. You are
a bus driver and for the safety of passengers refrain from driving and inform the DVLA. I hope
you agree with it.
Yes Doctor I agree.
So I am referring you to the neurology department to be seen within one week.
Is there any thing else you want to discuss with me today?
No doctor.
You can get a leaflet about multiple sclerosis from the reception desk.
Good bye.
169
SEVENTH FACIAL NERVE PALSY
Hello.
I am Dr. Raheel.
I am Sabira Shakira.
Ok Miss Sabira Shakira. What brings you to the surgery today?
Doctor, Yesterday I went to sleep absolutely fine but I woke up in the morning, I noticed that
my lips was deviated to one side. When I took a glass of water to drink, water drolled out from
one side.
Ok miss Sabira Shakira is there any thing else you want to add?
Yes Doctor, I am going to be married in six weeks time and my face is now deviated.
I cannot frown my forehead, its very embarrassing. I have become very shy in going out.
Anything more?

Miss Sabira Shakira before I come to the management part. I would like to ask few questions.
Is it ok with you.
Did you bang you head recently? (No.)
Is there any weakness in arms? (No.)
Is there any weakness in legs? (No.)
Can you smile properly? (No.)
Can you frown your forehead? (No.)
Was there any ear pain preceding your facial paralysis? (Yes.)

Is there any past history of similar complaint? (No.)
HISTORY OF PERSONAL ILLNESS
Do you smoke? (Yes)
Do you drink? (Yes in excess of normal limit)
Do you have high blood pressure? (Yes I have moderate blood pressure for the last five
years.)
Is there any stress in life? (Yes I have financial troubles)
Is there any stress at home? (Yes I am worried my fiancy might leave me)
HISTORY OF FAMILY ILLNESS
Is there any history of high cholesterol in your family? (Yes)
170
Is there any history of heart problem? (Yes)
ILLNESS
How this condition has affected your life?
I have already told to I have become shy and histating to go out.
IDEA
What do you think is the cause of your illness?
I do not know.
CONCERN
My fiancy might leave me.
EXPECTATION
What do you hope to gain todays consultation?
I hope that you will find out the cause and give me some right medicine to fix it quickly.
EXAMINATION
Can I examine you?
Thank you for trusting me and allowing me to examine you.
1. Would you please look at the cealing without moving your head.
(Patient cannot wrinkle forehead equally on both side)
2. Would you please close your eyes firmly. I will try to open them. You do not let me
open your eyes.
(Patient is unable to resist on the affected side)
3. Would you please smile.
(Lips are deviated to the healthy side)
4. Can you show me your teeth?
(Lips are deviated to the healthy side)
5. Can you blow your cheeks for me. I will try to deflate them by touching the cheeks with
fingers?
(Cheeks are easily blown over on the affected side)
INVESTIGATION
Nerve conduction studies can be done.
171
Miss Sabira Shakira from the information you shared with me and the examination I
have performed. It is my considered openinon that most probably you have a condition what
we call in our medical terminology Facial Nerve Palsy.
Different nerve come out to the brain and spinal cord. Your seventh nerve which is
responsible on expression on face as well as taste sensation on the anterior two third of the
tongue is affected.
Rest assure that this condition is quite treatable by some medician andphysiotherapy.
Patient is alsmost completely recovered within six weeks to two months time and
nobody can even judge that you have Facial Palsy.
90% of the people recover completely but some times 10% of the people have some
residual deformity.
1. As you have reported to the surgery within 24 hours of occurrence of this condition so
I offer you Prednesolone Steroid tablets 30mg every day for 10 days. These Steroid
tablets will be tapered off gradually in one month.
2. I am referring you to the physiotherapy clinic who may give you a transcutaneous
nerve stimulation called Tens.
3. Physiotherapist may give you Heat Therapy in the form of infra red light. The only
precautions its cover you eyes while infra red light is being given.
4. Few other exercises and massage techniques will be advised by the physiotherapist.
5. There are few life style changes you can adopt:
(i) Wear black goggles when go out in the Market.
(ii) Use straw to drink water.
(iii) Chew a chewing Gum on their affected side.
(iv) Try to blow out balloons.
I hope with the above mentioned life style changes and medicines your condition will
improve in about six weeks time. Rest assure your fiancy will not leave you.
Is there anything else to discuss with me today?
No Doctor That’s all.
Ok Miss Sabira Shakira you can take the leaflet about facial nerve palsy from the
reception desk further information from the internet.
Good bye.
172
FEBRILE FITS
Mrs. Samantha is worried about her 2 year old Michel son who had his first fit 1
day ago. Kindly take history & mange. Please proceed.
DATA GATHERING
1. Are you an eye witness of fit?
2. Can you describe the fit for me?
3. Did he bit his tongue during the fit?
Did he pass urine during the fit?
Did he pass stool during the fit? (Poo)
4. What was the duration of fit? (Less than 5 mins (3 to 5 minutes)
5. How long did the child took to recover? About 10 mins, went to sleep
6. Did he had fever at the time of fit? (Yes)
What was the exact grade of fever? 103oF
D/D & RED FLAG
Febrile Fit, Epilepsy, Hypoglycemia Viral infection, post immunization meningitis,Brain
Tumor.
Any infection causing runny nose or red watery eyes. (No) viral
Any infection causing Cough and Flue like symptoms. (No) viral
Any neck stiffness with rash which does not blench with pressure. (No) Meningitis
Any recent immunization
Any family history of fits in the past. (Yes)
Is he a known diabetic (No) (No hypoglycemia)
Any History of raised BP and decreasd pulse (Raised Intra Cranial Pressure)
ASK ABOUT BINDS
1. Birth History
What was the mode of delivery
Was the delivery normal, C-Section or forceps?
2. IMMUNIZATION
Is all his vaccinations are done complete (according to schedule or Age).
3. NUTRITION
Is the child feeding properly and adequately. (Yes)
4. DEVELOPMENTAL MILE STONES
Ask specific question according to the age of child, in this case 18 month. Ask It is the
child running freely? (Yes)
PAST HISTORY
Any previous episodes of fits when child had high fever. (No)
173
FAMILY HISTORY
Did any first degree relative also suffered from similar fits while having high fever? (His
father had similar history)
DRUG HISTORY
Is the child taking any medicine regularly prescribed or OTC. (If yes then ask which
medicine)
Any drug allergy?
IDEA CONCERN EXPECTATION (ICE)
Patient’s mother may say
Is my child having epilepsy and will need life long medicines.
Will he need life long medicines?
Can he still become pilot?
Is my child having some brain tumor?
Address ICE in Management at first. There are no marks for asking ICE. If you have
not addressed ICE properly in Management.
SUMMARIZE & ASK
Is there any thing else you would like to add?
EXAMINATION
It would have been better, if the child was accompanying you. Please bring the child
with you in next appointment. I would like to examine him and have a little chat.
Level of consciousness by asking name or where are you now
INVESTIGATION
1. I offer you
2. Complete blood count with ESR
3. Mid-stream urine test for infection
4. Blood Glucose Test to exclude low sugar attack or DM, DI
MANAGEMENT From the information you have shared with me it is my considered opinion
that most likely your child is having from a condition what we call in our medical terms as
febrile fits. Do you know what are febrile fits? Do you want me to explain it to you. Are you
with me, Can I proceed.
In this condition child temperature regulating system is set at low level hence, child
has fits when he has high grade fever.
These febrile fits can re-occur in subsequent febrile illness (In 30% of children)
It is not a life threatening condition. Many children have fits with high grade fever.
Do you follow me?
You can prevent fit in future by the following steps:
(i) Whenever child have high temperature remove clothes
(ii) Start sponging with tapped water.
(iii) Open windows and start fan or AC.
(iv) If fever is high grade give paracytamol syrup before fit develops.
174
(v) If fit has developed, then give diazepam injection or suppository by back
passage.
Are you with me? Can I proceed?
REMEMBER PID
P Don’t panic
I Remove any injurious things around the child (e.g. electric wires) and turn the child to
the side position (Left lateral position).
I Don’t interfere with fit by restraining the child.
Fit will stop in < 5 minutes and Child will recover spontaneously completely in few
minutes.
SAFTY NETTING
Advise parent if child develop fit again or child deteriorate in any way, develop non-
blenching rash, kindly seek immediate medical help.
CLOSING
I will provide you some written information about your child’s condition. You can read
it at home and find further information on Internet. Is it OK with you.
FOLLOW UP
I am arranging a second follow up visit in less than 24 hrs. I would like the review your
child tomorrow morning.
ADMIT
If child was drowsy & irritable.
Systematically unwell or toxic.
Cause of fever unclear.
Sign Symptoms of Meningitis and age less than 18 months
Or cause of fever require hospital management
REFER TO PEDIATRIC EMERGENCY
If diagnosis is doubt,
If fits frequent and severe
If antiepileptic drugs indicated
Child is at ↑ risk of epilepsy
If history of epilepsy in first degree relative
Parents anxious despite re-assurance
Inadequate home circumstances, carer unable to cope.
NOTE
All immunization schedules should be completed.
There is only 1% chance that the child will develop epilepsy.
175
MANAGEMENT OF EPILEPSY IN ADULTS
Refer all patient with first suspectec seizure for urgent (Less than 2 week).
Assessment by a neurologist. 60% of adults who have one fit will never have another (90%
if EEG is normal).
Patient may present with scalp hair loss (Alopecia)
The child may be taking Sodium Valporate for absence seizures.
Advise every epilepsy child not to swim without supervization not to ride a bycicle on
main road or in dealt not be able to work as window cleaner on skyrize buildings e.g. work on
hights or work with dangerous machines.
Patient advised not to drive after initiation of medicine by nurology department till 6
months after drug have been withdrawn.
HISTORY
• Past head injury Also Read Oxford Pages 574 to 577
• Alcohol / drug abuse Also Read Oxford Page 1077
• Meaningitis/Encephalitis Also Read Oxford Pages 898
• Stroke
• Febrile convulsions
• FH of Epilepsy
• A cause is found in more than 2/3 of people with epiplepsy.
PROVOKING FACTORS
• Sleep deprivation
• Alcohol withdrawal
• Flushning lights
PRODROME
Precedes fit may be a change in mood or behavior.
AURA
Part of the seizure from example od sensations stranges smells flshining lights.
EYE WITNESS REPORT
Color movement of patient length of fit after effects.
MEMORY OF PATIENT
Momories of the event frequency of attack relationship to sleep nausea etc.
SYMPTOMS OF ATTACK
Bitton tongue incontinence of urine, confusion, headache, aching limbs or temporary
weakness of limbs (TODD’s Palsy).
TEST FOR FIRST FIT ONLY
• EEG, CBS, ESR/CRP, U/ECr, eGFR, LFT Ca+2
• Regular GP review, atleast annually is essential.
• Drug choice is specialist decision!
• Decision to stop drugs must be patient’s!
• Refer to specialist for superfitish of deny withdrawal.
• Advice patient not to drive during drug withdrawal of medications or for 6th months
afterwards.
• Surgery, vagus nerve stimulation, ketogenic diet are also the treatment option of
epilepsy.
176
TRANSIENT ISCHEMIC ATTACK (TIA)
SCENARIO
Mr. Rahman age 64 have come to the surgery because he felt few symptoms one
hour ago. Kindly take relevant data, examine and share a mutually agreed management
plan. Proceed.
Hello, I am Dr. Raheel one of the family physicians in this surgery?
I am Rahman 64 years.
Ok Mr. Rahman what bring you to the surgery today?
Doctor I was working on my computer about 3 hours ago, when I suddenly felt weakness in
my left arm and leg. I felt as if my legs have become numb.
I tried to call for help but my speech become slurred. However I manage to reach the bed.
My weakness and numbness in arm and legs gradually automatically became allright.
My speech also returned to normal.
Mr. Rahman I need to ask you few questions before we reach the diagnosis and start our
management.
May I know how did you manage to reach the surgery.
Doctor I was feeling ok so I drove my car my self to the surgery.
Mr. Rahman what do you understand why you felt weakness and numbness in your legs.
I am afraid it was like a termporary paralysis. Thank god it became ok within half an hour.
So your symptoms remain for half an hour
May I know did you loose consciousness or fell down. (No)
Is this the first time you were having this sort of problem? (Yes)
FAST
Face – Did your face fell on one side? (No)
Arms – Can he raise both arms and keep them there?
Speech – What about your speech? (It became slurred)
Time –For how longe your symptoms remained? (About half an hour)
Any difficulty in swallowing. (No)
PAST HISTORY
Any past episode of heart attack or paralysis or transient weakness of limbs? (No)
Any operation for artificial heart valves? (No)
PERSONAL HISTORY
Do you smoke? How much? Intend to quit? (Yes)
Do you take alcohol? How much? Intend to cut down? (Yes excess)
Do you have high blood pressure? (Hypertension) (Increased)
Do you have high blood sugar? (Diabetes Mellitus) (+ve)
What about your relations with rest of the family? (Stroke a family disease. Need carer
support) (Living alone) (Got a supporting wife but seemed hopeless & fedup.
177
What about your mood? (Depression) (Feel a bit low)
How do you rate your weight? (My BMI > 30 kg/m2)
D/D & RED FLAG
1. Did you had headache which could be called worst headache of your life?
(subarchnoid Hemorrhage) (No)
2. Did you had neck stiffness with temperature? (Meningitis) (No)
3. Have you ever had head trauma (Trauma)? (No)
4. Do you have headache which is worse in the early morning? (Tumor)? (No)
5. Do you have irregular heart beat? (Arrythmias due to AF) (No)
6. Any history of Fits (Epilepsy)
DRUG HISTORY
Are you using any blood thinning medicine (Anti coagulation therapy) (No)
FAMILY HISTORY
Any family history of increased blood pressure, blood sugar or any heart problem.
Yes high blood pressure, high sugar and heart problem exist in our family.
ILLNESS
ICE
Illness - This episode of paralysis has ruined all my future plans.
Idea - I think I have brain tumor.
Concern – Will I develop permanent stroke. Will I be able to walk again properly.
Expectation – I hope that such mini stroke do not happen again.
EXAMINATION (Brief Neurological Examination)
Brief neurological examination given in clinical examination book page 18.
1. Please walk for me few steps towards the wall. Now come back on your tip toes
and go back walking on your heels.
2. Romburg test to check the balance.
3. Alternate hand movements for coordination in upper limb.
4. Heel shin test for coordination in lower limb.
5. Straight leg raising.
6. All reflexes upper or lower limb including knee, ankle, biceps, triceps, babinske
sign.
7. One test for each of the 12 cranial nerves.
INVESTIGATION
In order to have more clear understanding of your condition, how about organizing few
test. Is it OK with you?
Blood Complete Examination with ESR
Lipid Profile
Renal Profile
Glucose Profile
______________________________________________________________
178
We may need few more tests like: which will be initiated by specialist
ECG
ECO
Carotid Artery Doppler Ultrasound
CT brain by specialist initiation
MANAGEMENT
EXPLANATION & REASSURANCE
The information I have gathered and examination I have performed most probably you
were having from a condition which we called in our medical terms TIA or transient Ischemic
attack (Or mini stroke). Clots block the blood vessels in brain, obstructing the blood supply to
an area of brain which control our limb movements.
We need CT scan in emergency to assess whether any blood vessel in the brain is
blocked by clot or it is busted. I am referring you to neurology emergency department where
they will do CT scan and if vessel is blocked then they will try to dissolve the clot with some
medicine. As early thrombolysis after ischemic stroke results in better out come. If the vessel
is busted then neuro surgeon can do some surgery to repair the busted vessel.
So without any delay I am referring you to neurology emergency department for
confirmation of ischemic or haemorrhagic stroke diagnosis.
Do you agree? Should I call ambulance?
Yes doctor I agree with you.
Well Mr. Abdullah thank you agreeing with my offer. Wish you best of luck.
While waiting for an ambulance can I offer you few life style changes which will help
prevent such mini stroke or stroke in future.
LIFE STYLE ADVICE WHILE WAITING FOR AMBULANCE
Please take low fat diet?
Reduce salt intake to < 3 g/d?
Take regular exercise, achieve satisfactory weight?
Stop smoking?
Avoid Alcohol in excess (predisposes to both ischemic and hemorrhagic stroke)?
AIDS & Appliances are available Physiotherapy exercises can do miracles.
As you might have memory loss and problem with opening container of medicines. So
neurologist will be giving you written prescription besides verbal instructions and you will
receive medicines in non-childproof tops.
Stroke is a long term problem and family illness. 40% of carer suffer Psycological stress < 6
week after discharge.
Let me assure you that there are support groups available for carer.
Patient and carer are entitled to benefits from UK Govt.
↓ stress by relexation exercises like Yoga and Medication.
Is there anything else you like to share with me today. (No)
Specialist investiagion include CT or MRI, caroted doppler, Echo. Refer to specialist
to be seen same day.
179
Good Bye, (shake hand & smile)
NOTE: Patient with TIA has a risk of stroke in the following month, with highest risk in
the first 72 hours.
In case of TIA patient recovers his initial symptoms in <24 hours.
In case of TIA neurologist may start Antihypertensive therapy from day one.
No need to defer.
You can give aspirin in your surgery if the patient have completely recovered
his TIA symtoms before referring to neurology department.
IMPORTANT NOTE:
How did you managed to reach surgery.
Doctor I drove my car myself because I was feeling OK.
Please do not send patient to emergency in his car again.
Make him sit in the reception till some friend or family member reach surgery.
If he develops stroke or TIA symptoms during driving he will be endangering his life
and at that of others at road.
If nobody is accompanying send him to emergency by ambulance.
Written Prescription besides verbal instructions will be given.
Medicines will be provided in non child proof tops bottles.
RISK FACTORS OF STROKE
Increasing age
Hypertension
Diabetes mellitus
Atrial fibrillation
Previous stroke or TIA
MI
Artificial valve of heart
Smoking, alcohol
Obesity
Low physical activity and
Hyperviscosity.
180
BRAIN TUMOR
SPACE OCCUPYING LESION
• Headaches
• Seizures
• Changes in personality
• Vision problems
• Memory loss
• Mood swings
• Tingling or stiffness on one side of the body
• Loss of Balance
• Nausea
• Difficulty concentrating
• Difficulty communicating as usual
• Feeling confused or disoriented
• Loss of coordination
• Muscle weakness
______________________________________
A Doctor will take a full medical history and perform a range of neurological tests to see
what is causing the symptoms. For example, they may:
• Run CT scans or MRI Scans, to provide an image of the brain.
• Conduct tests to check balance, vision and coordination Rhomber’s Sign finger
nose test.
Also, if they locate a tumor in the brain, they may take a tissue sample, or biopsy, to
find out what type it is.
A person should see their doctor if they experience severe or frequent headaches.
They will be able to rule out any underlying causes and suggest lifestyle changes or treatment
options.
181
INTERMITTENT CLAUDICATION (CALF PAIN)
SCENARIO
Mr. Abdul Haq 60 years old (chronic smoker) presents with complaint of sever
cramp like pain in calf for last 4 months. Take relevant history and manage – proceed.
Meet Greet
Introduction of doctor and patient
What brings you to the surgery today?
Information revealed on facilitation
I have got severe cramp like pain in my calf musles for the last four months. These
sever cramp like pain occurs after walking certain distance and is relieved on taking
rest.
Before I come to the management part can I ask you few questions?
You may proceed doctor.
1. Does the pain go anywhere elase?
1 SITE
Does the pain radiate down from back hip to toe? (Spinal Stenosis) (No.)
Does the pain radiate up from toe to calf muscles of leg? (Vascular claudication) (Yes)
2 NATURE
Is your cramp tightening or squeezing type (vascular claudication) (Yes)
Is your cramp pain burning, numbing or tingling type (neurogenic claudication) (No)
3 DISTANCE
Does the pain occur after walking a set distance each time (Vascular Claudication)
(Yes)
Does the pain occur after covering varied distance. (Neurogenic Claudication) (No)
What happens on walking up hill (Made worse) (n Vascular Claudication)
What happens on walking or using flat foot shoes? (Bare foot madeworse in Vascular
Claudication)
How is it relieved (By rest in Vascular Claudication)
Does the pain comes sooner on carrying heavy weight (Vascular Claudication) (Yes)
RED FLAG
Ensure confidentiality and ask:
Do you face difficulty in performing sex? (Impotence in Vascular Claudication) (Yes)
Do you have any bowel or bladder problem (Neurogenic Claudication) (No)
PAST HISTORY
Any past history of stroke?
Any past history of heart problem?
PERSONAL HISTORY
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Do you smoke? (heavy smoker) Any ↑ Blood Sugar (No)
Do you drink? (Heavy smoker) Any ↑ Blood Pressure (Yes, Taking B. Blocker
Atenolol 50mg once a day)
What do you do for living? (I am clerk in an office sitting job)
Married? (Yes)
Kids? (Yes)
How are thing at home? Ok
How are things at work? Ok
FAMILY HISTORY
Any major medical problem in immediate family members? (Heart problem in family)
DRUG HISTORY
Are you taking any medicines regularly? (B.Blocker worsen Peripheral circulation
Vascular Claudication)
Any allergies?
ILLNESS
How these cramps have affected your life? (Can not walk longer distance)
ICE
How do you understand your problem? (I don’t know)
What worries you most? (Amputation may be needed)
What do you hope to gain from today’s consultation) (Some medicine)
SUMMARIZE
Is there any thing else you will like to add.
Peripheral pulses (reduced or absent in Vascular Claudication) (Present in Neurogenic
Claudication)
Abdominal bruits heard after exercise in Vascular Claudication
Ankle jerk reduced after exercise (Neurogenic Claudication)
Skin may have atrophic changes pale cool hairless skin (Vascular Claudication)
Pulse – Absent (Vascular Claudication)
Parasthesia (Neurogenic Claudication)
Paralysis (Neurogenic Claudication)
Perishing cold (Vascular Claudication)
Blood Pressure (May be Hypertensive taking Beta blocker) (Vascular Claudication)
INVESTIGATION
Doppler Ultra Sound Ankle Brachial Index (ABI)
Less than 0.6 Severe Ischemia
Less than 0.9 Confirm Ischemia
183
BLOOD TEST
Lipid profile (Hyperlipidemia in Vascular Claudication)
Blood Glucose (DM in Vascular Claudication)
FBC - (Anaemia)
U&E Cr. Peripheral Artery Disease Assocaited with Renal Artery Stenosis
MANAGEMENT
EXPLANATION AND REASSURANCE
What I have gathered from information you share and examination is that you are
suffering from a condition called intermittent claudication in medical terms.
Due to smoking,  blood pressure,  cholesterol our blood vessel become narrow and
oxygen supply to our muscles decreased. During walking and exercise the demand for
oxygen is increased. When demand is not met with there occurs pain in our muscles which
is called in Medical Terms Intermittent Claudication.
There are a few life style changes that can increase pain free walking.
Stop smoking Control Diabetes Millitus
Loose weight Control Blood Pressure
Regular exercise Control Lipids
__________________________________
Drug like:
1. Aspirin and
2. Statin
3. Special drug (Naftidrofuryl Acetate) (NDF)
4. Stop beta blocker. Tapper it of in month as patient age is 60 that is more than 55, so
start Amlodopine 2.5mg once a day.
Stop smoking – single best thing you can do to yourself to decrease cramp pain is to
make a determined effort to stop smoking completely. Smoking speeds up hardening of blood
vessels. Smoking reduced the amount of blood and oxygen to the muscle causing pain. I can
help you in quitting smoking by helping you set a quit date. Also arrange nicotine gums and
patches and offer to refer to stop smoking clinic.
LOOSE WEIGHT
 weight put pressure on heart and  the more surface area for blood to be supplied.
It is important not to put on weight because the more the weight, the more blood and oxygen
will be required by muscles of legs and more the pain.
REGULAR EXERCISE
Improvement in pain free walking can be made by taking regular walk i.e. Training for
> 6 months. Formal exercise program can be very effective way to improve walking. Effect of
walking is greater than surgery (Angio plasty) Increase the distance walked gradually.
__________________________________________________________
ASPIRIN
184
Take low dose aspirin 75mg regularly. Clopidogrel is an alternative to those intolerant
to aspirin.
STATIN
Use low fat diet and take simva statin tablet 40mg once at night to reduce cholesterol.
Write Naftidrofuryl Acetate 100mg twice a day instead of Cilostazole which is an older
drug
Increase walking distance. It is best taken 100mg twice a day. Produce about 20%
improvement in maximum walking distance.
Naftidrofuryl increases walking distance. Consider only if exercise has fail or not suitable for
surgery / (bypass / angioplasty) reassess after 3-6 months. Discontinue if no improvement.
Specialist treament include
SURGERY
1. Angiography per cutaneous tansluminal Angioplasty + - (stenting or surgery)
Surgery is another last option. Risks and benefits will have to weighed before surgery.
If nothing worked and one is in danger of loosing his limb, various forms of surgery can done.
I will ref you to a team of vascular surgeons.
An X-ray of arteries called Arteriogram is done or doppler ultra sound scan is usually
performed first to provide information about the extent of disease.
Sometimes short blockage can be stretched open with balloon Angioplasty. Usually
done under local Anaesthesia and require an overnight stay in hospital.
Larger and longer blockages may need bypass surgery using plastic tube or vein from
leg. This is a major operation and done under general anaesthesia.
Some form of procedure is required to restore blood flow to the leg to avoid
amputation.
NOTE
Good +ve History + ABI < 0.95 Confirms Diagnosis of Vascular Claudication.
If good history but normal ABI (=1) Consider exercise testing and duplux US.
185
ACNE
Hello.
I am Miss Noor 22 years.
What brings you to the surgery today?
Doctor I am very unhappy. I do not want to go my university. My colleagues redicule me as
my boyfriend left me for a more beautiful girl.
Doctor actually I have developed pimples on my face. There are some pimples are filled with
pus. I have been taking certain medicine prescribed by the other doctor surgery but these
pimples are still their.
Ok Miss Noor.
Before I come to the management part I would like to ask you few questions.
Since when you are having these pimples on your face? (3 months now)
Do you have spots on your face only? (Yes only on face)
Do you have spots neck back or chest? (No)
Do you have pimples with pus? (Yes)
Do you have pimples with black heads? (Yes)
Is it related to your eating habit? (No)
Ensure confidentiality and ask:
Is it related to your periods? (Yes)
What about flow of your periods? Is it normal, scanty or heavy? (Flow is heavy)
What about your weight? (I am over weight)
Are you using any facial creams or cosmetics containing steroids? (Yes)
Are you sexually active? (No, If the answer is yes ask)
Are you using any contraceptive?
D/D
Do you have readness and swelling at the tip of the nose? (No acne rosacea)
Do you feel your symptoms incrase in sun light? (Yes Acne Rosacea)
Do you excessively worry about minor things? (Yes tenstion anxiety)
PAST HISTORY
Did you have such pimples in the past as well? (No)
FAMILY HISTORY
Is there any family history of such problem? (Yes)
PERSONAL HISTORY
Do you smoke? (No)
Do you take alcohol? (In safe limits) (Ok keep up the good habit)
186
Do you have high blood pressure? (No)
What do you do for living? (I am student at University)
How are the things at University?
I am not going to the University for the fear of being redicule by my colleagues, I am refraining
from social gatherings and dance parties for the last 3 months.
ILLNESS
How this problem is affected your life?
I am not going to the University. I am socially isolated. I am very much anxcious and tense. I
want my boyfriend back.
IDEA
What do you think is the cause of your pimples?
Doctor every since my period started, I am having this sort of problem off and on.
CONCERN
Do you worry anything specifically?
Yes I want my boyfriend back. I am feeling very low in mood. I wonder I might hurt myself.
EXPECTATION
What do you expect from today’s consultation?
I hope you will change the medicine and my pimples will go away.
EXAMINATION
The picture of your face show mild to moderate acne with papules and pustules i.e. pus filled
pimples.
Miss Noor our skin has certain glands which are called sebacious glands. They secretion a
fluid called sebum. Sometimes, these glands get blocked and the tip of the gland blocked
with the dirt appear as black head. Sometimes these pimples get infected and are filled with
pus.
Rest assure there is a treatment available for these pimples and pustules.
There are certain life style changes as well as some topical and oral medicine which can cure
these pimples.
DRUG HISTORY
What medicine you have taken?
I have taken topical retinoid adapalene alongwith benzoyil peroxide.
I started in low strenghth preparation 2 or 3 nights per week. Gradually increased frequency
and strength of application. This treatment make my skin dry and irritate the skin initially.
I am avoiding to go out in the sun. I had this treatment for one month. Then doctor prescribed
me fixed dose combination of adapalene + Benzoyl peroxide but of no use. My pimples are
still there.
Kindly prescribe me some other better medicine.
____________________________________________
Ok Miss Noor, I offer you antibiotic by mouth + topical benzoyl peroxide.
We may consider topical tetinoid if benzoyl peroxide is not tolerated.
Antiboitic of choice is lymecycline 408mg once daily. We will review after 6 weeks.
187
If inadequate response we will switch to doxycycline 100mg once a day (May cause
photosensitive reaction)
Antibiotic will be continued for a maximum of 12 weeks.
We will continue topitcal treatment once antibiotic course is finished.
Course of antibiotic can be repeated if acne recurse.
1. Aim is to decreased number of lesion till they stop appearing.
2. Prevent scaring
3. Decreased psychological impact of condition
This is not a disease of poor hygene.
Its not associated with diet.
________________________________________________
Picking on pimples does not help rather it leaves scars.
FOLLOW UP
Remember the treatment may take weeks & months to work fully and is usually continued for
few months and to years.
We will follow up every 2 – 3 months. Continue treatment until new lesions stop developing.
We will continue to take care of you.
LIFE STYLE CHANGES
Besides, the medicine I offer you certain life style changes which will help decreased your
pimples.
Washing of face twice daily with warm water and good soap.
Use fragrance free water based emollient if dry skin.
Apply moisturizer after washing.
Increased water intake.
Take healthy diet.
Do not squeeze the pimple.
Do not scrub excessively.
If you share your bed room do not share towels.
Reduce your stress in life.
Do not use cosmetics with steroids.
Exercise like walking and swimming detox the body.
Do not go in the sun without sun block.
Remember Acne is not contatious disease i.e. others cannot have it by touching you.
SAFETY NETTING
Miss Noor Acne not a trivial disease. It can cause both skin scars and emotional scars which
lasts life long.
As you have isolated yourself from social life and feeling low, I offer to refer you to the
psychologist for talking therapy. This might elevate your mood.
Remember there are now new technologies and other methods with which skin scars can be
completely removed.
188
CONCERN
I assure you that the person who left you because of these minor pimples is probably not
worth for a nice girl like you.
One day he will repent and come back to you.
With proper treatment these pimples will go away. These pimples are not your fault it because
of normal hormonal changes that occur at your age.
If treatment goals are not reached after 12 weeks we will review the treatment consider
alternative treatment or referral to the skin specialist.
___________________________________________
CLOSING
Is there any thing else you want to discuss with me today? (No)
You can collect the leaflet about acne from the reception desk.
Good bye.
189
IMPETIGO
Mrs. Parveen 30 years, has come to discuss the problem of his child Ali who has some
skin problem over his face.
Kindly diagnose and manage.
Proceed.
Hello.
May I know your name please?
I am Mrs. Parveen, 30 years.
Ok Mrs. Parveen, what brings you to the surgery today?
__________________________________________
Doctor, I am very much worried about my son Ali, six year old.
He has developed some thin walled blisters on his face. Wherever he touches new blisters
are formed.
Anything more?
Yes Doctor these blisters are easily broken and honey like yellow crusted lesion is left.
___________________________________________
Ok Mrs. Parveen, in order to reach my diagnosis I need to examine your child.
BIND
Is he accompanying you today?
No, but this is the picture of his face.
Ok Mrs. Parveen. I would prefer if you bring the child with you in next appointment, so that I
can examine him.
It appears from the picture you have shown me that your child having a condition what we
call in our medical terminology as Impetigo.
It is highly contageous disease. Your child might have got it in the school from his close friend.
Some schools and nurseries prevent the children from attending the school for the fear of
spread of infection.
It is advised the your child nails are cut properly. He wear some gloves.
As it causes itching so he should use cotton bud to scratch the lesion.
Mrs. Parveen let me assure you that with proper treatment this condition is curable in few
days and there are no scars left at the end.
Your child should not share his towels or face flannels with anybody else.
I offer fucidic acid cream to apply locally over the lesions.
Since your child is having wide spread lesions on his face. So I also offer an antibiotic called
flucloxacillin for a week.
Hopefully your child will be ok in 7 to 10 days. Prevent him from going to the school for this
period.
Is there anything else to discuss with me today?
No.
You can take leaflet about impetigo condition from the reception desk.
190
VITILIGO
Miss Noor 23 year has come to discuss some personal problem. Kindly gather
data and manage. Proceed.
Hello
I am Dr. Raheel, one of the GP in the surgery.
May I now your good name please?
I am Miss Noor 23 year.
Doc. I went to the beach in summer six months ago. I did not use sun screen. Later
on I developed a white patch over my hand. It has increased in size. Now I have similar white
patches around my mouth and eyes.
Any thing else you like to add?
Doc. I am a secretary in a private firm and these patches are the cause of annoyance
of my boss. I am likely to be unemployed. Kindly give me some medicine to fix this problem
quickly.
Ok, Miss Noor. Before I come to the management part, Can I ask you few questions.
Do you remember any injury or trauma besides sun burn. (No)
Is there stress in your life? (A lot of stress due to my job)
Are you a smoker? (Yes)
Yes Doc. I am a heavy smoker and my smoking seems to affect thes patches.
Do you drink? Yes Doc. I drink beyond safe limits and this alcohol seems to worsen
my white patches.
Do you dope or take any recreational drugs? (No Doc not at all.)
Is there any itching? (No Doc.)
Are these patches painful? (No Doc.)
Are these patches blenchable? (No Doc.)
Any history of receiving radiation? (No.)
Any history of receiving chemotherapy? (No.)
Is there any family history of such white patches? (Yes)
MANAGEMENT
REASSURANCE
Miss Noor this is a common condition which is not contagious. 18% have family history.
Skin loose coloring cells call melanin pigments. It is a permanent change. There is no cure
for it. Cause is not known. Can affect any part of skin in 10 to 30 year.
Patches join together to make bigger lesions. Usually skin is symmetrically affected.
Most common site are wrist, hands, around the mouth and eyes on face.
TREATMENT
1. As sun worsens the vitiligo. You are offered to use sun screen block.
2. Vitamin D can be taken 800IU daily.
3. Skin dyes do no harm.
191
4. Masking or camouflage make up hides the lesions very effectively. Never
underestimate the power of make up. Results are remarkable.
5. Wear hat and drinks lot of water.
6. Ultaviolet light phototherapy is also effective.
7. For topical steroid I will ref you to dermatologist.
8. Surgical treatments like skin grafting & melanocyte transfer procedures for
repigmentation is also available.
9. Some people have tried natural therapies like Gincobaloba.
10. Stress worsens vitiligo. Reduce stress. Question of why me? Its in our genes. 18% of
people have family history. These white patches affect our appearance but don’t let
them affect yur confidence. Don’t shy away keep your social activities as such.
11. Don’t over think. Don’t be embarrassed. Believe in your inner beauty & respect yur
skin. Many people loose confidence & become depressed (Suffer from low mood)
Insensitive people sometime hurtful words but never think of hurting your self. Other
people have bigger problems. Don’t believe in perfect skin. You can wear long dress
& long sockes if it affects your foot & legs.
12. Laser treatments are also available. These lesions are not contagious. i.e. others can
not have these by touching you.
ILLNESS & ICE
Impact of patches on job or social life.
EXAMINATION
Pulse
Paller
INVESTIGATION
Offer TFT
Blood C/E & Hb
For Pernicious Anaemia
MANAGEMENT
Ref to dermatologist for initiation of topical steroids and ultraviolet light therapy.
Ref to Psychologist if depressed. Talking therapy changes the way you think feel act
and behave.
Ref to social worker if jobless.
CLOSING
192
SCABIES
QUESTIONS FOR SKIN, ITCH OR RASH
SCENARIO
Mrs. Allah Rakhi 45 year has come to discussed severe itch of her 5 year
daughter Saima. Take history and manage.
Hello
I am Mrs. Allah Rakhi 45 years.
Ok Mr. Allah Rakhi what brings you to the surgery today.
Doctor I am here to discuss itching problem of my daughter Saima.
We have been to the other city to a relative. There my children had to sleep with the
children of my relatives. My relatives children were scratching already.
Probably my children got infection from there.
I am here to get some treatment for my children.
Ok Mrs. Allah Rakhi before I come to the management I would like to ask few
questions. Can I ask?
Is your daughter Seema accompanying you today?
No she not accompanying me today but I can bring her tomorrow in the next
appointment.
_____________________________________________
BIND
May I know what was the mode of delivery? (Normal)
Whether her all immunizations are done upto her age? (Yes)
Is she feeding adequately and properly? (Yes)
Has she achieved all her mild stones according to other contemporary children? (Yes)
Yes Mrs. Allah Rakhi I like to examine you daughter and have a chit chat with her.
Since when your child is having this itch? (2 weeks)
What areas are specially involved? (Hands, wrist, Ankle, Axilla and groin buttock
testes penis) (Private area)
At which time itch is more? (At Night Time) (Mite lay’s eggs at night)
Anybody else in the family having similar problem. (Family History positive) (Yes)
Does she have any rash with it? (Yes)
Does she have fever with it? (Might get infected) (Not yet)
Does she have any other medical condition with it e.g. Diabetes Mellitus?(may be
positive)
Have you tried any medication so far?
Any aggravating factor? More at night
Any relieving factor? No.
D/D
Did rash or itch started after taking some medicine. (No) (Drug Allergy)
Do you enjoy scratching over thickened skin. (Licun Planus) (No)
Is there any vesicular rash with itch (dermatitis herpetic formis)
Scabies is caused by a very tiny almost invisible insect which lives on skin. Some what like
head lice in our hairs.
Female insect called sarcoptis scabies lays eggs under the skin at night which cause itching
more at night.
Your symptoms are suggestive of a condition called scabies. Do you know any thing
about scabies. It is a not a serious condition but it is extremely contagious disease(Its spread
193
from one person to the other.) Can spread from direct contract with the person, his cloths and
bed lilin.
For this reason you have to keep yourself very neat and clean and at the same time
you will have to keep your bed sheets, your clothes and routine utensils very neat and clean.
Wash them your self daily at home. Put them under sun and iron from front & back both. Do
not send for laundry.
MANAGEMENT
I am offering you a medicine called permethrins 5%. Take bath, dry yourself and apply
lotion. You will apply this over your whole body below neck to the feet including scalp. Neck
face & ears. Ensure finger & toes webs are covered. Brush lotion under the ends of fingers
& toes nails. Then second application can be done after one week, if needed.
Reapply to whole body after one week. Reapply to hands alone if washed with soap
less than 8 hours after application.
This may need to be repeated a few times to complete treatment.
It is important for all family members to be treated at the same time. Leave the lotion
applied for over night and take bath again in morning. Use a diffrent set of properly washed
clothes and badlinin.
S/E Malathion can cause local skin irritation.
If you have severe itch then anti-allergic like chlorpromazine or loratadine to sooth
itching can be prescribed. Calamine lotion and chilled crotamiton lotion can also be applied
over the skin.
A new pill have been introduced called ivemactin pill but it is not used in children,
Pregnant ladies and breast feeding mothers.
Hospital staff should use gloves if treating a suspected case of scabies rash.
FOLLOW UP
I am arranging a second follow up visit after one week. Is it convenient to you?
SAFETY NETTING
Malathion can cause local skin irritation. Sometimes the rash get infected.
If you develop any pusy boil then come to me immediately you may need antibiotic as
well (Antibiotic can be systemic. Flucoloxacin or ceflexin systematically and fucidic
Acid or gentamycin or mucipirocin can be applied as topical antibiotic)
CLOSING
Is there is any thing else to discuss with me today.
You can take leaflets about your condition from the reception desk.
You can get further information from internet. Treatment include if infected
Thank you for your cooperation. Systemically flucloxacin or
Good bye Cefalexin tab. Locally apply
Do not handshake. (Smile & Node) Fucidic Acid Cream or
Gentamycin
KNOWLEDGE BASE
Scabies can affect all ages both sexes. C or S shape burrows are seen in typical sites
interdigital clefts, ulnar border of hand. Wrist, elbow, axilla, umbicus, buttocks, penis, breast
nipples
Palms soles, face are affected in infants but not in adults usually.
TREATMENT
There should be treatment of patient and all inmates of the house whether itching or
not.
Topical preparation should be applied on whole body. Entire body in infants.
Laundering of clothes should be done. No specific disinfectants required.
The following drugs can be applied to the skin: (Apart from Malathion & Permethrine)
25 % Banzyl Benzoite Emulsion
10% Sulfur Ointment (2.5% in infants)
10% Crotamiton cream.
5% Permethrin
194
Ivemectin tablet 200 micro ugm/kg/day taken orally as single dose. Repeated weekly
twice or thrice.
Permetherine 5% First line
Malathion Second line
Areas involved in children – axilla, trunk, abdomen not genital area usually.
Areas involved in Adults – Genital areas groin hands and toes.
Skin infestation
Scabies
Headlice
195
TINEA PEADIS (Athlete Foot)
SCENARIO
A sports man complain of white itchy maceration in between the toes for the last
2 weeks. Kindly gather data examine and do the management. Proceed.
Hello.
My name is Habib.
Ok Mr. Habib, what brings you to the surgery today?
Doctor I am a professional marathon race runner.
A tournament coming and I am preparing for it by doing some extra running.
But for the last two weeks I have developed whitish itchy maceration in between my toes.
Some pain is also there. Kindly help me heal my problem soon enough so that I can take part
in my tournament which is only three months away.
Ok Mr. Habib can I examine you.
Yes doctor (SP shows the picture of foot with whitish maceration in between the toes)
I will try to help & guide you to the best of my abilities.
Mr. Habib I have examined your feet but before I come to the management part can I ask you
few questions.
Do you use closed shoes while running? (Yes)
Are you fond of swimming? (Yes)
Does your feet sweat a lot when you do the running? (Yes)
Mr. Habib I offer you certain measures with which your problem will be solved.
First of all take some rest from your training.
Use two pair of shoes.
After using one pair of shoes, put it in the sun so that the sweat in the shoe become dry.
Use cotton socks in stead of nylon socks.
Stop swimming for a while.
Use open foot ware.
I also offer you to put miconazole powder (Cicatrin Powder) (Canestin) in between your toes.
Take terbinafen tablet 250mg once a day for two to six weeks.
Hope fully your problem will be solved and you will be able to take part in the tournament.
Wish you a winning trophy in marathon race.
Is there any thing else to discuss with me today?
No doctor thank you.
You can take leaflet about athlete foot from the reception desk.
NOTE:
Another scenario can be a Factory Labour who uses closed shoes for 8 hours in hot
humid climate C/o whitish itchy painful maceration in between the toes.
196
HAIR LICE
SCENARIO
Mrs. Sakina mother of Zainab 8 year old has come to discuss some problem of her
daughter. Kindly gather data and do the management. Proceed.
Hello.
I am Mrs. Sakina and I have come to discuss itchy scalp of my daughter Zainab.
Ok Mrs. Sakina, Is Zainab accompanying you today?
No doctor Zainab in her school at the moment but I can bring her tomorrow with me in next
appointment.
I have brought the picture of her hairs showing some white dots attached to her hairs.
School people say that your child is having head lice.
Doctor I thought that the head lice occurs in the dirty hairs only. I wash my daughter’s hairs
every alternate day myself. How can she has head lice.
Kindly guide me what can be done?
Mrs. Sakina the picture you have shown me, shows the egg shells or nits in her hair.
Let me clearify one myth, head lice can occur in clean hairs as much as in dirty hairs.
These head lice do not jump or fly and they can not remain viable away from the host.
Can I ask you one question?
Yes, please doctor.
Does Zainab has any closed friend with whom she joins head while studying?
Yes doctor she has a closed friend and they join heads while studying.
Doctor she sleeps with me at night and even I am having some itchy scalp.
Let me inform you doctor that I am pregnant at the moment.
MANAGEMENT
1. Mrs. Sakina wash the hairs of Zainab, apply a conditioner and then comb with fine
tooth detector comb. It is easily available from the pharmacy. Repeat washing, apply
hair conditioner and combing weekly. Lice are removed by the comb and are seen
trapped in its teeth.
2. Mrs. Sakina you can apply any one of the chemicals called Malathion or Phenothril or
Permethrin. All are available from over the counter. I offer you to apply Malathion to
Zainab hairs according to the instructions of manufacturer. Two times seven day apart.
Check wet conditioned hair with fine tooth detector comb before first application then
every second day until three day after second application.
3. Doctor can I also apply Malathion in my hairs as I am also having itch.
No Mrs. Sakina as you are pregnant Malathion is not advisable but you can apply
Dimeticone lotion or spray. Rub the lotion into the dry hair and scalp in the evening,
allow it to dry naturally, then shampoo off next day. Repeat after 7 days. Pregnant
Ladies and and breast feeding mothers can treat hair lice with wet combing or
dimeticone spray only.
197
4. Doctor is there any other treatment available besides Malathion and Dimeticone
spray? Yes Mrs. Sakina Electric combs, aromatherapy, herbal treatments are also
available but they lack scientific evidence of effectiveness. Choice is yours.
SAFTY NETTING
1. Mrs. Sakina all close contacts of Zainab and you over the past one month should be
trace and asked them to check these scalp for lice and treat as if needed.
2. After clearing of all the head lice if head lice occur again, check all close contacts again
and repeat treatment with different insecticide lotion. Shampoos are not effective.
Is there any thing else you want to discuss with me Mrs. Sakina.
No Doctor thank you, you have dealt my problem very well.
You can take leaflet about head lice from the reception desk.
Good bye.
198
PSORIASIS
SCENARIO
Miss Jullie has come to discuss some skin problem. Kindly gather data, examine and
do the management. Proceed.
Hello.
I am Miss Jullie.
Ok Miss Jullie what brings you to the surgery today?
Doctor you know it is summer, all my colleagues are wearing sleeveless and short skirts
Look at me I am wearing full sleeve shirt and Jeans.
Actually doctor I am hiding my skin lesions over my knee and elbows.
I have become shy because this skin problem and I am avoiding social gatherings.
Miss Jullie can I examine your elbows and knees?
Yes doctor (SP shows a picture of waxy shiny white silvery scales over the elbow and knee)
Ok Miss Jullie after examining your lesions, It is my considered opinion that you are having
a condition what we called in our medical terminology as plaques Psoriasis.
I will try to the best of my abilities to help and guide you, how to treat this psoriasis.
But before I jump to the management part, May I ask few questions?
Is there any family history of such similar condition?
Yes doctor my mother had Psoriasis.
Did you have any trauma? (No doctor)
Are you using any drug for your blood pressure? (Yes I am using beta blockers for my high
blood pressure)
Are you using any pain killer Nsaid? (Yes doctor I use Iboprofen for my knee pain)
Are you fond of Alcohol? (Yes doctor I drink alcohol in more than safe limit and Alcohol seems
to worsen my condition.
Is there any chance you could be pregnanat at the moment? (No doctor I am not pregnant)
Over the past one month do you feel down depress and hopeless? (Yes Doctor)
Have you loss interest in the daily routine works which you use to enjoy?
Yes doctor I cannot enjoy watching TV or reading books which I use to enjoy.
Can you concentrate? (No I have full poor concentration)
Do you have feeling of worthlessness? (Yes doctor)
Have you ever thought of hurting yourself?
No doctor I want to live. I hope you will find a solution and cure for my lesions at knee and
elbow.
MANAGEMENT
Ok Miss Jullie I will try to give you some medicine to clear these patches in the first instence
and secondly I can understand that these lesions have some psychological effects on you
making you shy and isolate you from social gathering.
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I offer you Betamethasone and Calcipotriol combination product available with the name of
Dovobet.
Discontinue when skin feels smooth even if it looking pink or red, after 8 weeks.
You can continue treatment with Emolient and Vitamin D Analogue (Calcipotriol as needed 8
weeks after discontinuation)
Please change betablocker medicine with Ramipril 2.5mg once a day as they worsen the
psoriasis.
Please use paracytamol tablet as a pain killer instead of Iboprofen.
Please avoid or take alcohol within the safe limit.
Sun light is usually beneficial but can worsen psoriasis in 10% patient.
The psychological impact of any chronic disease can be life long. As you are feeling shy and
avoiding social gatherings, I offer you talking therapy with a psychologist. This will boost up
your moral and will help you in continuing your social commitments.
Please do not let these minor lesions affect your confidence.
You should never think of hurting yourself as this disease although a chronic disease can
have remmissions and your skin become clear for months and years together.
Phototherapy and PUVA Therapy is available and help many people.
These days Immuno suppressive drugs like Methotraxsate and Monocolonal antibody can be
prescribed on specialist initiation.
SAFTY NETTING
All patient with Psoriasis should be assessed atleast one time every year.
If nails are involved or there is pain in the joints, patient should be rafered to Rheumatology
Department promptly.
Is there any thing else you want to discuss with me today?
No Doctor thank you, you have dealt my problem very well.
You can take leaflet about psoriasis from the reception desk.
Good bye.
200
D/D OF 4 RASH IN A CHILD
Chicken Pox Infectious from 2 days before rash appear till cropping crusting is over.
– Rash lasts 10-14 days
– Avoid pregnancy for 3 months after vaccinations.
– Vaccination 1-2 months apart. 2 doses
Rubella Infectious from 7 days before rash appears and 7 days after rash
disappeared.
– Rash lasts 3 days
– Avoid pregnancy for 3 months after vaccination
– S/S Fever, suboccipital lymphadenopathy, Macular pink
rash.
Measles First flue like symptoms. Rash appears first on face then on trunk and
legs.
Infectious from 4 days before rash appear and 4 days after rash has
disappeared.
Rash last for about 10 days.
vaccination 2,3,4 months, then 12-15 months, than 3-5 year (MMR)
___________________
D/D RASH
Chickenpox Macule papule vesicles (Pustules) Scab and crusting.

Different crops can be seen at the same time.
Rubella Macular – pappular pink rash
Measles Macular Pink Redish Rash.
Meningitis Rash purple in color – Tumbler test positive i.e. place a glass slide over
the rash and press, if the rash disappears its not meningitis but if the
rash Persist then meningitis is confirmed.
1. Chickenpox rash in pregnancy is more dangerous towards the end of the pregnancy
i.e. if rash appears during 8-9 months there is more danger to the unborn baby.(Foetal
Vericella Syndrome)
2. Rubella rash in pregnancy is more dangerous towards the beginning of pregnancy i.e.
if rash appears in early weeks of pregnancy there is more danger to the unborn child
like deafness and blindness.
201
HAND FOOT AND MOUTH DISEASE
OVERVIEW REASSURANCE
Hand foot and mouth disease – a mild, contagious viral infection common in young
children – is characterized by sores in the mouth and a rash on the hands and feet. Hand
foot and mouth disease is most commonly caused by a coxsackievirus.
There’s no specific treatment for hand foot and mouth disease. Frequent hand
washing and avoiding close contact with people who are infected with hand foot and mouth
disease may help reduce your child’s risk of infection.
SYMPTOMS HISTORY OF PRESENT ILLNESS
Hand foot and mouth disease may cause all of the following signs and symptoms or
just some of them. They include:
• Fever
• Sore Throat
• Feeling of being unwell (Malaise)
• Painful, red, blister-like lesions on the tongue, gums and inside of the cheeks
• A red rash, without itching but sometimes with blistering, on the palms, soles
and sometimes the buttocks
• Irritability In Infants And Toddlers
• Loss of appetite
The usual period from initial infection to the onset of signs and symptoms (incubation
period) is three to six days. A fever is often the first sign of hand foot and mouth disease,
followed by a sore throat and sometimes a poor appetite and malaise.
One or two days after the fever begins, painful sores may develop in the front of the
mouth or throat. A rash on the hands and feet and possibly on the buttocks can follow within
one or two days.
WHEN TO SEE A DOCTOR SOFTY NETTING
Hand foot and mouth disease is usually a minor illness causing only a few days of
fever and relatively mild signs and symptoms. Contact your doctor if mouth sores or a sore
throat keep your child from drinking fluids. And contact your doctor if after a few days, your
child’s signs and symptoms worsen.
CAUSES REASSURANCE & EXPLANATION
The most common cause of hand foot and mouth diseaseis infection with the
coxsackievirus A16. The coxsackievirus belongs to a group of viruses called nonpollo
enteroviruses. Other types of enteroviruses sometimes cause hand foot and mouth disease.
Oral ingestion is the main source of coxsackievirus infection and hand foot and mouth
disease. The illness spreads by person to person contact with an infected person’s.
• Nasal secretions or throat discharge
• Saliva
• Fluid from blisters
• Stool
• Respiratory droplets sprayed into the air after a cough or sneeze.
202
COMMON IN CHILD CARE SETTING
Hand foot and mouth disease is most common in children in child care settings
because of frequent diaper changes and potty training, and because little children often put
their hands in their mouths.
Although your child is most contagious with hand foot and mouth disease during the
first week of the illness, the virus can remain in his or her body for weeks after the signs and
symptoms are gone. That means your child still can infect others.
Some people, particularly adults, can pass the virus without showing any signs or
symptoms of the disease.
Outbreaks of the disease are more common in summer and autumn in temperate
climates. In tropical climates, outbreaks occur year round.
RISK FACTORS
Hand foot and mouth disease primarily affects children yournger than age 10, often
those under 5 years. Children in child care centers are especially susceptible to outbreaks of
Hand foot and mouth disease because the infection spreads by person to person contact,
and young children are the most susceptible.
Children usually develop immunity to Hand foot and mouth disease as they get older
by building antibodies after exposure to the virus that causes the disease. However, it’s
possible for adolescents and adults to get the disease.
TREATMENT
A doctor can usually diagnose HFMD diagnosis by conducting a physical examination.
They might look for sores or blisters on the feet, hands, and genitals. They may also
check for other common symptoms that occur alongside the sores.
Sometimes, a lab test may be needed to confirm a diagnosis. Doctors may look for
related antibodies or viral materials in the blood or collect throat and stool samples for
examination.
There is no cure and no specific treatment for HFMD.
Over the counter (OTC) medications can help to relieve pain and fever in some people.
Numbing mouthwashes or sprays may help reduce mouth pain. This can be helpful
for increasing fluid and food intake.
Soft foods, such as soup, can make eating less painful. Be sure to avoid hot or spicy
foods. If mouth ulcers become too painful, drinking cold water or sucking on ice cubes can
help to relieve discomfort.
A small number of patients may need to visit a hospital for I/V fluids if complications
develop.
PREVENTION
There is no vaccine to prevent HFMD.
It spreads through person to person contact, and good hygiene can lower the chance
of getting it.
Tips for reducing the risk of infection include:
• Disinfecting surfaces
• Frequently washing the hands with soap and hot water
• Not sharing utensils and drinking cups
203
Certain precautions can help to reduce the risk of infection with Hand foot and mouth
disease.
• Wash hands carefully: Be sure to wash your hands frequently and thoroughly,
especially after using the toilet or changing a diaper and before preparing food
and eating. When soap and water aren’t available, use hand wipes or gets
treated with germ killing alcohol.
• Disinfect common areas: Get in the habit of cleaning high traffic areas and
surfaces first with soap and water, then with a diluted solution of chlorine bleach
and water. Child centers should follow a strict schedule of cleaning and
disinfecting all common areas, including shared items such as toys., as the
virus can live on these objects for days. Clean your baby’s pacifiers often.
• Teach good hygiene: Show your children how to practice good hygiene and
how to keep themselves clean. Explain to them why it’s best not to put their
fingers, hands or any other objects in their mouths.
• Isolate contagious people: Because Hand foot and mouth disease is highly
contagious, people with the illness should limit their exposure to others while
they have active signs and symptoms. Keep children with Hand foot and mouth
disease out of child care or school until fever is gone and mouth sores have
healed. If you have the illness, stay home from work.
COMPLICATIONS
Complications are rare but can develop if HFMD is left untreated in certain individuals.
If the underlying cause is a virus known as enterovirus 71, it can affect the nervous
system.
This can lead to:
• Meningitis: An inflammation of the spinal cord.
• Encephalitis: An inflammation of the brain.
• Acute flaccid paralysis: In which weakness of respiratory muscles reduces
the ability to swallow.
Congenital deformities can occur if a woman contracts coxsackievirus during
pregnancy. This may be linked to the development of fetal heart problems. However, the risk
of this is very low, as it is rare that the virus can pass through the placenta.
Scratching at blisters or rashes can lead to a secondary infection.
If blisters develop in the throat, there may be a risk of dehydration.
In severe cases, cardiorespiratory failure can occur.
OUTLOOK
HFMD can sometimes result in hospitalization and even death, but most people
recover without compliations.
For those who are otherwise healthy, HFMD is not a life-threatening disease, and it
clears up without treatment within a week or two.
204
TYPHOID
SCENARIO
Mr. Kashif Ahad has come to discuss some problem, kindly gather data, do
examination and manage.
Hello
I am Doctor Raheel. One of the GP in this surgery.
I am Kashif Ahad 30 years.
Ok Mr. Kashif, how can I help you today?
Doctor I was posted in a slum village for 2 days ago I had to take my food, milk and
water from the street vendors. There were lot of house flies and excreta (Stools)
nearby passed by the villagers in the fields.
Anything more?
Doctor it has been 2 days now that I have returned to my city. I am having lot of fatique
and malase and high grade fever of 102oF. I also have headache.
To begin with I had constipation but now I have loose motions and tummy pain as well.
Anything more?
No That’s all doc.
What about your appetite? (I have no desire to eat)
Does your fever have any pattern? (Yes Doc. its low in the morning and gradually
increased in the night. (Step laddal pattern for 4 to 5 days)
Any black stool?
Any loose motion?
1. Any rash? (Yes, I have rose color spots on my upper tummy and back. Rash is
slightly raised and fades on pressure.
2. Do you feel any mass in your tummy? (Yes I can feel a Mass in my left upper
tummy which is soft and tender to touch) (Enlarged Spleen)
3. Is there any bleeding in their stools? (No Doc. not yet)
4. What about your tongue? (Doc its furred or coated white at the tip and edges,
making a V type shape)
Is there any similar complaint in the past? (No)
PERSONAL HISTORY
Do you smoke? (No)
Do you drink? (No)
Do you have any high blood pressure? (No)
Do you have any high bood sugar? (No)
What do you do for living? (I am an Environmental Engineer and rugby player)
How are the thing at work? (I am on leave for last 10 days)
205
How are the thing at home? (Very peaceful)
FAMILY HISTORY
Is any member of the family having a similar condition? (No, but my colleagues at the
rural area also have similar complaints of high grade fever and dirrhoea)
PAST HISTORY
Is there any previous history of hospitalization? (No)
DRUG HISTORY
Are you taking any medicine, either prescribed or from over the countr? (No)
ILLNESS
How this condition affected your life? (I am unable to continue my work I am on leave)
IDEA
What do you thing is the cause of your symptoms?
(I think the contaminated food, milk and water, I took at rural area is responsible for
my symptoms)
CONCERN
Anything you are worried in particular? (Doc. I heard that there is an epidemic of loose
motions in the community and it resistant to treatment. I wonder if I am going to die, If
I did’nt get proper treatment.
EXPECATION
What do you expect to gain from today’s consultation?
I hope you will thoroughly investigate and give me proper medicine.
EXAMINATION
In order to reach my diagnosis, I need to examine you. Can I examine you?
Yes Doc.
Would you please move on to the couch and lie down. Would you please lift your shirt
upto the chest?
Doctor washed his hands with the sanitizer.
Does general physical examination & full GIT examination.
The findings given by the examiner in a laminated paper are:
Temperature 102oF
Pulse 56 per minute (Relative Bradycardia) Pulse is slower in typhoid than would be
expected from the height of temprature. (In other fever each degree rise in temperature
increases the pulse rate by 10 beats per minute)
Tongue is coated white in V-shaped on tip and edges.
Red Rose color spot rash is there in upper tummy and back in crops, slightly raised
and fade on pressure.
Spleen in enlarged and is soft and tendor to touch.
INVESTIGATION
In order to reach my diagnosis how it sounds to you if we arrange certain blood and
stool tests. Blood culture positive in first week
I offer you Stoll culture positive in 2nd week
206
Typhi dot test IgM & igG 3rd week symptoms in diarrhoea and
bleeding.
Blood culture for salmonella typhi (Most important diagnostic test for typhoid, blood
culture is positive in about 80-% of the patient in the first week of illness)
Widal test is now consider obsolete but because it is cost effective, it is still being used
in backward countries as diagnostic tool for typhoid)
Stool Culture (Positive from secondary week)
Ultrasound for enlarged spleen
MANAGEMENT
From the information you have shared with me and the examination I have performed
and already done investigations you have shown me indicate that most probably you have a
condition which we call in our medical terminology as Typhoid Fever.
Do you know anything about typhoid fever? (No)
Do you want me to explain? (Yes Doc) (Boiled water and soft diet)
It is a type of fever in which there are symptoms of high grade fever, loose motion,
Pain tummy, headache, malaise, fatigue. Patient usually takes about 4 weeks to become
normal. There is return of appetite, fever subsides, tongue clears out, pulse become faster
with proper treatment. This condition is quite treatable.
Use clean boiled water
Use soft diet including Banana, Yougert, Broth or Soup and rice.
Life style changes include.
Wash your hands after going to toilet
Use lots of fluids and juices.
I offer paracytamol for fever. 500mg 6hrs.
I offer you ciprofloxacin tablet 500mg twice a day for 10 days (Due to resistence to
ciprofloxacin Azithromycin can be used for 14 days one capsul daily). I hope you will become
normal by the end of fourth week. If person is properly treated, there is less than one percent
chance that person may die of shock due to bleeding in the intestines or due to infection of
the brain.
IMPORTANT NOTE
As you are fond of contact sports like rugby and football, I offer you to refrain from
these sports which can rupture yours enlarge organ spleen in the tummy for few months.
If your condition does not improve, kindly seek immediate medical help. We may need
to admit you for further investigations and IV antibiotic.\
Typhoid vaccine is available one single injection.
CLOSING
Is there any thing like to discuss with me today? (No)
Good Bye.
207
MALARIA
SCENARIO
Mr. Shahzad Noor present with fever with severe headache. Kindly gather data
and manage. Proceed.
I have high grade fever and severe headache. Fever comes and goes every six hour.
I also have bodyache and muscle pain.
Question to be asked:
Since when you are having fever? (few days)
Have you documented the fever? (Yes its high grade 103F)
Any specific timing of the fever? (Every 6 hours comes and goes)
Any associated symptoms like rigors, drenching sweats etc. (Yes)
Any change colour of urine? (No)
Any severe headache? (Yes)
Do you have bodyaches and muscle pain? (Yes).
After what time fever and rigor episodes are repeating? (At every 6 to 8 hours)
Do you remain well in between these episodes of fever? (Yes).
Any impairment in consciousness? (Cerebral malaria) (No)
Have you been taking any prophylactic medicine? (No)
Any travel to malaria prevalent area? (Yes).
D/D (Differntial Diagnosis of Fever with Chills include Sore Throat, UTI, Malaria and
Amoebic Abscess. Ask
Do you have throat pain? (Tonsillitis)
Any pain while passing urine? (UTI)
Fever with Chills and severe headache which comes and goes every 6 hour.
Any pain right upper tummy? (Amoebic Abscess)
INVESTIGATION
1. Rapid Diagnostic Test
2. Geimsa stain Thick & thin film preferably during fever & Rigors.
3. Blood complete examination
4. Blood sugar level
5. Ultrasound tummy
TRAVEL HISTORY
Travel history to Africa where malaria and dengue are prevalent suggests strongly
malaria.
MANAGEMENT
PREVENTION
• Travellers should be advised that malaria may be prevented by following two simple
rules:
1. Avoid mosquito bites; and
2. Take anti-malarial medicines regularly Prophylactically
In order to avoid mosquito bites, travelers are advised to:
• Keep away from rural areas after dusk
208
• Sleep in air-conditioned or properly screened rooms
• Use insecticide sprays to kill any mosquitoes in the room or use mosquito coils at night
• Smear an insect repellent oil on exposed parts of the body. An effective repellent is
diethyl-m-toluamide (Muskol, Repellem, Rid)
• Use Mosquito nets (tuck under matteress; check for tears)
• Impregnate nets with permethrin (Ambush) or deltamethrin
• Wear sufficient light-colored clothing, long sleeves and long trousers, to protect whole
body and arms and legs when in the open after sunset.
• Avoid using perfumes, cologne and after-shave lotion (also attracts insects)
The risk of catching malaria is increased by:
• Being in a malaria area, especially during and after the wet season
• A prolonged stay in a malaria area, especially rural areas, small towns and city fringes
• Sleeping in unscreened rooms without mosquito nets over the bed
• Wearing dark color clothing with short sleeved shirts and shorts
• Taking inappropriate drug prophylaxis
MALARIA PREVENTION & PROPHYLEXIS
• Chemoprophylaxsis is not 100% effective. Advise all travelers to malaria region to
seek medical advice if unwell for upto 6 months after return.
DRUG TREATMENT
If plasmodium vivax and plasmodium ovail
Treatment would been choloquine course of 10 Tablets
If report show plasmodium falcipharum give combination of Artimether &
Lumiphentrin.
Adult tablet for adult 1 Tab. Twice a day for three days. 80/480
For child Pediatric tablet twice a day for 3 days
PROPHYLAXSIS
For all anti-malarial apart from mefloquine start one week prior to departure, during
and continue for 4 weeks after return.
For mafloquine – start 3 weeks before departure, during and for 4 weeks after return.
Mefloquine 250mg weekly
Choroquine 300mg 2 tablet same day each week
Chloroquin is safe in all trimesters of pregnancy
Doxycycline contra indicated in less than 12 years old children and pregnancy.
SCENARIO
SP says I have to travel tomorrow please give me some prophylaxis. My kid & pregnant
wife travelling with me. You can take doscycline 100mg 1 day before. Continue during & 4
weeks. After return also. Your pregnant wife can not have doxycycline (As contra Indicated
in pregnancy) So she have to stay back for 1 week & take 310mg chloroquine for 1 week
before entering malaria area or travel with you & observe precautions of cloths mosquito net
repelling oil coils etc.
Doxycycline cannot be given to a child less than 12 years. He can also take chloroquin in
suitable dose for 1 week & stay behind or observe precautions and go with you.
209
ANTI MALARIAL CHEMOPROPHYLAXIS
Drug Dose Start Stop
Choroquine 310mg weekly 1 week before 4 week after leaving
entering malaria malaria area
area
Mefloquine 250mg weekly 2.5 week before 4 week after leaving
entering
Proguanil Pregnancy 200g OD 1 week before 4 week after
Doxycycline 100mg OD 1-2 day before 4 week after
Malarone 1-2 day before 1 week after
(Proguanil+
Atovaquone) 1 tab.
OD
MALARIA & PREGNANCY
Chloroquin and proguanil can be used in usual doses in pregnancy. Give folic acid
5mg once a day with proguanil. Consider mefloquin for travel to chloroquin resistant areas.
Avoid malarone (Proguanil + Atovaquone) and doxycycline.
In case of pregnancy quinine is given 10mg/kg 8hr I/V for 7 days
Followed by clindamycine for 7 days
In pregnancy do not use fancidar or doxycycline
Avoid travel to malaria area during pregnancy
ANTI-MALARIAL USED IN PREGNANCY
Chloroquine, quinine
DIFFERENCE OF MALARIA & DENGUE
Feature Malaria Dengue Fever
Fever Intermittent comes & goes in Continuous
Episodes.
High grade with & headache Chills
In between Fever Well Persistently ill
Body aches Unwell when febrile Severe body aches
Spleen Enlarge Normal
WBC Normal Low
Platelets Low Very Low
Rash No Rash Reddish Macular Rash
Pain Bodyaches and Muscle Pain Pain behind the eyes and
severe bodyaches and
bone pains.
TREATMENT
Admit for treatment if
Malaria test positive
Persistent fever despite negative malaria test
Unable to check a malaria test e.g. at week ends
Very unwell
_____________________________________
SIDE EFFECTS
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Mefloquine Parenteral I/V Qunine Sulphate
Dizziness Hypoglycemia
Blurred vision Convulsions
CHLOROQUINE
Hepatitis
Alcohol (Chloriquin contra indicated in epilepsy
GI Disorder Can be given in pregnancy)
Neurological Disorder
Blood Disorder
1. For P.Vivax and P.ovale – Chloroquine course of 10 Tablets
4 Tablets stat (600mg)
2 Tablet after 6 hours (300mg)
1 BD for two days
• If intolerant to chloroquine then basoquine given (Amadoquine)
• To prevent relapse – primaquine for 2 – 3 weeks C/I in G6 PD deficiency
Give prima quine 1 tab. for 2 weeks if patient has relapsed after chloroquine course.
______________________________________________________________
For P. falciparum cholorquine resistant
Artimether – 2 Capsule daily for 7 days.
Quinine Sulphate – 10mg /kg 12 hourly I/V with dextrose for 7 days till orally possible
Most important side effect of I/V qunuine sulphate is hypoglycemia that is why it is
always given with glucose.
I/V fluids to prevent collapse
Blood transfusion with packed cells for severe anaemia
If oliguria – Manitol infusion.
Other group of anti-malarial, fancidar, Mafloquine and halfantrine
_________________________
ANTI-MALARIAL CONTRA-INDICATED IN PREGNANCY
Artem. Exafal, tetracycline, Halfan and Doxycyline.
________________________
(1) ADULTS
Lumifantrin + Artimether weight > 35kg 40mg Cap. 2 Cap daily for 7 days
Start with 4 Tab Inj. 80mg 2 injection I/M daily one
4 tab 8hr injection 80mg next day 4 days
4 tab 24hr I/M in buttock.
4 tab 36hr
4 tab 48hr
1 tab 60hr
(2) CHILDREN
In case of children, body weight 5 to 15kg 1 tab
15 to 25kg 2 tab
25 to 35kg 3 tab
Above 35kg 4 tab
______________________________________
211
Resistance to many drugs is increasing:
• The lethal plasmodium falciparum is developing resistance to chloroquine and
the antifolate malarials (Fansidar and maloprim)
• Chloroquine is still effective against P.Ovale and P.vivax (the most common
forms)
• Patients who have had spleenectomy are at grave risk from P. Falciparum
malaria
• People die from malaria even today in 21 st century because of delayed
diagnosis, and delayed therapy.
• Fever + Chills + headache = malaria
• Headache + Fever + Pain behind eyes + Bonepains= Dengue
• Headache + Fever + Violet rash + +ve tembler test = meningitis
• Fever with chills Headache + Loose motions = Typhoid
__________________________
In dengue fever there are severe bone pains and pain behind the eyes. It may become
hemorrhagic and tiny bleeding spots are seen under the skin.
CHLOROQUINE SENSITIVE MALARIA
Tab. Chloroquine Phosphate (Resochin) 250mg orally
4 tab. Once (stat)
2. tab. After 6 hours
1 tab twice daily for 2 days
CHLOROQUINE RESISTANT / FALCIPARUM MALARIA
PARENTERAL DRUGS:
Inj. Artemether (Artem) 80mg I/M
2 injections (160mg) once (stat)
One injection (80mg) daily for 4 days
ALTERNATIVE
Inj. Quinine sulphate 600mg IV
Dilute in 300-500ml of dextrose water given over a period of 4 hours every 8 hourly for
7-10 days.
ORAL DRUGS
Use one of the following:
• Cap. Artemether (Artem) 40mg orally
2 Cap. Daily for 7 days
• Tab. Fensidar (a combination of sulfonamide and diaminopyridine)
3 Tab. As a single dose orally
• Tab. Exafal (a combination of artemether and lumefantrine)
4 tab. at 0, 8, 24 and 48 hours
____________________________
Spleen is enlarged in malaria and typhoid.
High fever + Headache + Tummy Pain + Low pulse rate (Typhoid)
D/D of Fever with chills (Throat infection,U.T.I., Malaria Amoebic Abscess)
__________________________
Plasmodium Falciparum
Decreased consciousness
Capsule Artimether 2 cap. 7 day
212
Before starting primaquine always ask if patient has G6 PD deficiency. Malaria immunity in
G6 PD.
_____________________________________
SUMMARY OF CASE OF MALARIA
Presenting complaint
Data gathering + history of travel
Differential Diagnosis
Examination
Investigation
Management (Life Style Changes)
(Drug Management according to the repot.
Plasmodium vivax
Plasmodium ovale
Plasmodium Malariae
Plasmodium Falciparum (ICT) Test
213
DENGUE FEVER
Dengue Fever is sometimes called Fever – arthralgia – Rash syndrome
Dengue is the most important Arboviral infection worldwide because it is spread throughout
the tropics with great geographical range including
• America
• Africa
• Asia
• South Pacific
In terms of mosquito transmitted disease, it has the highest rates of morbidity and mortality.
It’s a flavi Virus like the viruses of yellow fever and Japanese encephalitis
Single stranded positive – sense RNA genome
_______________
Occurs as four different subtypes (Serotypes)
Den 1, Den 2, Den 3, Den 4
Vector is female
Aedes Aegypti
Aedes Albopictus
Aedes Polynesiens
_________________
Dengue Fever is acute viral disease. Always accompanied by fever or recent H/O Fever
Has range of manifestations from asymptomatic infection to life threatening disease.
Usually endemic
Can be epidemic
Often seasonal
Clinical feature of dengue fever, non shock Dengue Haemorrhagic fever and Dengue Shock
Syndrome are progressive. Patient is at risk of rapidly progressing on to more sever forms.
DHF is distinguished from dengue fever, by plasma leackage, not by degree of haemorrhage.
Leakage of plasma out of blood vessel is caused by acute ↑ in vascular permeability.
Ranges in clinical effect from mild circulatory disturbance to circulatory failure (Hypo
Voleamic Shock)
_______________________
Please differentiate between
1. Simpled dengue fever (Which resolves within 7 to 10 days at its own)
2. Dengue haemorrhagic fever (in which there is bleeding from gums, nose from
back passage.
3. Dengue shock syndrome. (in this scenario this is an emergency in this scenario
patient not only have bleeding condencies but plasma leaks out of the vessels in
the plural cavity or abdomen as ascites.
A patient suspected of having dengue should be assessed initially by
1. History taking
2. Physical examination including tourniquet test
3. Lab (i) WBC ↓ (ii) Platelet ↓
(iii) Haematocrit ↑ (iv) Monocyte ↑
4. Serology or other lab diagnosis
SCENARIO
Mr. Abbas Liaqat 25 year presents with few symptoms for the last two days.
Kindly gather relevant data. Examine investigate and do management. Proceed.
Hello
214
I am Dr. Raheel one of the GP in the surgery.
I am Abbas.
Ok Mr. Abbas, what brings you to the surgery today.
Doc. I have high fever with rigers and chills also severe headache.
I have pain behind my eyes. I also have severe muscle, bone and joint pain.
Is anything else you want to discuss with me today?
Do you have night sweats alongwith fever and chills and headache. (No)
Do you have any nausea or vomiting.(Yes Nausea)
Do you have any inability to swallow. (Refer him to emergency, If there are signs of
dehydration). (No)
Do you have any rash as well. (Yes Doc I have reddish macular rash which appeared
first on the trunk and then on my limbs.
HAEMORRHAGIC MANIFESTATIONS
There can be haemorrhagic manifestations like nose bleed (Epistaxsis), Bleeding from
gums, In vomiting or sputum fresh or altered blood in stool (Malena or Haematochezia)
EXAMINATION
Mr. Abbas in order to reach my diagnosis I need to examine you. Can I examine you?
OK Doc you may proceed.
PHYSICAL EXAMINATION
SIGNS
1. Rapid weak pulse
2. Narrow pulse pressure like 90/80, 80/70 (< 20mmHg) (Difference between systolic and
diastolic B.P. less than 20 mm hg)
3. TOURNEQUIT TEST
Included in diagnosis of both dengue fever and DHF. Is an indicator of capillary
fragility. Positive result is considered if haemorrhagic manifestations. Look for patectiae or
other forms of haemorrhage.
An area of 1 square inch (2.5 x 2.5cm) on flexor aspect of arm, just distal to the ante-
cubital fossa. The number of patchae within this area will then be counted.
Maintain BP cuff inflated for 5 minutes at 80mm/Hg (Between systolic and diastolic
pressure). There can be patechae under the cuff. Beaware of Ischaemia which is usually not
there.
➢ > 10 patechae per 1 inch Sq. (2.5 x 2.5cm) 1” x 1” (Diagnostic of Dengue Fever)
➢ > 3 patechae per 1cm Sq. (10 x 10mm) (Diagnostic of Dengue Fever)
Is diagnostic of dengue fever
215
4. ALL SIGNS OF DEHYDRATION
Hypotension Cold clammy skin
Prolonged capillery refill (> 2 Sec.)
Some ↓ Hb
Oligouria (No urine for >4 to 6 hrs)
Restlessness
Fatigue
Weakness
Pulse pressure (Difference in systolic and diastolic BP) in Dengue shock syndrome
(DSS) DSS is under 20mm Hg and is a better indicator of shock than hypotension, because
it generally develops earlier.
INVESTIGATIONS
Mr. Abbas in order to confirm my diagnosis. I need to peform certain tests. Have you
undergone any test already.
Yes Doc. I have gone through complete blood picture test also liver function test and
serology test. These are the reports. Doctor takes the reports and confirm it by asking name
and age written on the reports.
LAB REPORTS
Platelets count below 100,000 per mm is defined as thrombocytopenia Platelet count
decreased before homatocrit rises.
(1) CBC (two increased, two decreased)
WBC ↓
Platelet ↓
Monocytes ↑
Haematocrit ↑
2. LFT ↑
3. (Serology) Dengue specific IgM 1gG Antibodies (Positive)
SEROLOGY
Dengue is often diagnosed by detection of Dengue virus –specific anti bodies (IgM or IgG)
4. Dengue NS1 Antigen test positive in case of current infection in first two days.
DENGUE SPECIFIC IgM
Dengue IgM Shows or is consistent with current dengue infection (Acute) or dengue infection
within 3 months. IgM is detectable for 2-3 months after symptoms have ended.
Dengue Specific IgG
➢ Little significance
➢ Levels persist for years after infection
➢ is supportive of a diagnosis of current dengue infection only if titre are high
beause this is consistent with a secondary infection.
➢ Confirmed serological diagnosis is based on the change in antibody titre over
time. Hence the need for 2 samples from atleast 2 different time points to
compare.
216
REASSURENCE
Mr. Abbas the information you have just shared with me and the examination and lab
reports I have seen. It appears most probably you have a condition what we call Dengue
Fever.
Do you know about Dengue Fever. (No Doc)
Would you like me to explain what it is? (Yes Doc)
Mr. Abbas Dengue Fever is relatively is a mild disease characterized by the symptoms
you have described to me that lab reports confirm my diagnosis. This fever is a kind of viral
fever which resolves at its own in 7 to 10 days.
LIFE STYLE MANAGEMENT
WHO advise that a patient with a provisional diagnosis of dengue fever is cared for at
home.
The recommended case management
➢ Bed Rest
➢ Oral Paracytamol (Acetaminophen) (For fever & pains)
➢ Oral Rehydration with
ORS Solution
Fruit Juice
Plain water
➢ Normal food according to appetite. Apple Juice with Lemon and Water of Papitta
Leaves are suggested.
PHARMACOLOGICAL TREATMENT
➢ No Aspirin or Nsaids for fever or pain control is recommended as this knocks out
platelets which are already falling unpredictably
Oral paracytamol is given for pain relief (Analgesic Effect) and also to keep the
temperature down (Antipyretic effect)
Paracytamol should be given
➢ To try to keep the temp below 39oC ______ to reduce the risk of febrile seizures.
➢ Parcytamol is not recommended for children under 3 months.
➢ Chidlren ove 5 years can be given paracytamol syrup of higher concentration
(250mg per 10 ml)
Each tablet of paracytamol is 500mg
➢ More than six tablets in 24 hrs should not be given (3gm)
1 Tablet TDS (3 Tablets)
2 Tablet TDs (6 Tablets)
Never > 3 gm in 24 hours.
Excess of paracytamol can cause hepatitis
217
Paracytamol toxicity or poisoning _____ Antidode is N-Acetyl Cystine
_________________________
ORS initially but if signs of shock e.g. Narrow pulse pressure with hypotension
and cold clamy skin. There should be immediate resuscitation with rapid I/v fluids.
Followed by, initially higher rates of fluid administration.
More regular monitoring and additional lab tests.
SAFTY NETTING
At present you do not have any bleeding from the nose, gums or in sputum or in
vomiting or in stool so you are having only simple Dengue Fever, but if you develop any of
the following symptoms. Kindly seek immediate medical help in emergency.
➢ Cold hands and feet
➢ Rapid or weak pulse
➢ Low urine output
➢ Restlessness
➢ Persistent vomiting
➢ Lethargy
Mucosal bleeding (Including black stool) inability to take oral fluids.,
Severe Acute Abdominal pain.
Altered conciousness.
These are danger signs of deterioration.
Colloids such as plasma and dextran are currently reserved for refractory shock in
DSS. (Dengue shock syndrome)
RECOVERY AND CONVALESCENCE
Fever last 5-7 days (Max 10 days)
A recovery rash often described as Islands of whites in a sea of red. Weakness and
lethargy persist for 1-2 week. Some times depression.
Discharge criteria include platelets >100,000 per mm3 2nd serum sample for IgM IgG
titre level should be taken.
With regular CBC monitoring frank bleeding chances have lessened (Daily CBC or
Alternate date).
PREVENTION AND CONTROL
The mosquito Aedes Aegypte devels on clean house hold water.
➢ So keep store water utensils covered.
➢ Don’t let the water stand in flower pots, car tires.
➢ Remove water from Aircoolers when not in use
➢ Close the man made fountains, swimming pool in house.
➢ Don’t let the AC exhaust water stand. Wipe it out.
________________________________________________________________________
218
➢ Use impregnated mosquito nets.
➢ Use mosquito repellent oils on exposed areas such as hands feet and face. Use full
seleves shirts and avoid shorts.
➢ Use mosquito coils in side the rooms.
➢ Keep doors and windows closed during early morning and at sun set.
➢ Spray insecticide in gardens and don’t visit open spaces at time when Aedes
Aegypte mosquito bites i.e. early morning and sunset.
HELP LINE
➢ A helpline is established in Pakistan for patient information.
➢ Toll free number is 0800-99000
➢ Dengue Transmission is made worse by
➢ Unplanned urbanization is leading to this situation through
➢ Inappropriate waste disposal
➢ Inadequate water supply encourages people to store water. This creates mosquito
breeding sites.
➢ Over crowding
➢ Substandard Housing
➢ Rapid population growth
➢ Lack of adequate mosquito control
➢ Travel
PLATLET INFUSION IN MEGA UNITS

If patient reports blood in sputum or bleeding from nose or on sneezing patient is
referred to hospital for platelet infusions.
These day cell separator machines are available. 1 pint of donated blood gives 3 to 4
thousand of platelets. These 3-4 thousands of platelets are called 1 unit.
Patient usually need 6-8 units. These 6-8 units are called 1 mega unit.
So to have 1 mega unit ready, you need 6-8 pints of bood
Such cell separator machines are now available, by help of which only platelets are
removed and rest of plasma and cells are transfuse back into circulation. Doner recuperate
or regenerate his platelet count within 2-3 weeks.
1 Pint = 1 Unit = 3 to 4000 Platelets
1 Mega unit = 6 – 8 Units
219
RABIES (Dog Bite)
SCENARIO
Mrs. Khalid 35 years has an unprovoked dog bite on leg in the street after which
the dog ran away. She is afraid that she might contract Rabies. Take a relevant history
and manage.
How long ago did the dog bite you. (Time of Bite) (15 minutes ago)
Where were you when dog bit you. (location of Bite) (Was Strolling in street)
Was that a stray dog or a pet dog. (Stray dog)
Was the bite provoked or unprovoked. (Unprovokely)
Where did the dog bite you. (hand, leg, face etc.) (Leg location of bite)
What measures did you take before coming to Surgery. (None)
Do you smoke. (yes) (Immuno-compromised state)
Are you diabetic. (Yes) (Immuno-compromised state)
Do you have any circulation problem in your leg. (No.)
What is your HIV status. (+ve immunocomproised state) (If yes)
Did you receive primary tetanus vaccination. (At 2,3 & 4 mo of age)
Did you receive any booster dose in last 5 years. (No)
Are you vaccinated against Rabies. (No).
What is the nature of your job. (Veterinary doctor, Animal Handler, Rabies Lab worker,
international traveler) (Ordinary Citizen)
Any financial worries
Do you belong to high income group or low income Population. (Rabies Immuno
globulin are expensive). If you don’t mind, may I know your financial stateus? (I am
Affluent)
Do you have any of the following symptoms?
Is anybody accompanying you? (Reassurance and parental presence in case of
children.
EXAMINATION
I would like to exam your wound. Can I?
Examine skin muscle tendent, bone joint space, viscera, foreign bodies.
Major resuscitation rarely is required. Because patients typically are children,
reassurance and parental presence may facilitate examination. Where applicable, consider
the following:
• Distal neurovascular status (Pulses)
• Tendon or tendon sheath involvement
• Bone injury particularly of skull in infants and young children.
• Joint space violation
• Visceral injury
• Foreign bodies (e.g. teeth) in the wound
INVESTIGATION
In order to confirm my diagnosis and understand your condition more clearly, I would
like to organize certain test. Is it ok with you.
I offer to test your saliva, urine and spinal cord fluid (Fluid from spine) for negri bodies
for diagnosis of Rabies. Niger body appear on 7th day so perform the test on 7th day.
220
MANAGEMENT
REASSURANCE AND EXPLANATION
I offer you post exposure prophylaxis treatment Its very successful in preventing
disease.
Treatment after exposure known as post-exposure prophylaxsis (PEP) Treatment is
highly successful in preventing the disease, if administered promptly, generally within days
of infection.
MANAGEMENT
1. I offer to wash your wound with copious soap and water. Put saline water from a 20cc
syringe with 18 guage needle with high pressure jet to clean all dirt and foreign bodies. Leave
wound open.
2. You had your primary tetanus vaccination completed but did not receive any booster dose
in last 5 years so I will give you a tetanus toxoid injection I/M in your buttock.
3. But in your case it was a unprovoked bite and dog ran away after bite and is not traceable
so I will consider the dog as possible rabid dog and give you anti rabies Immunogloblin (ARIG)
and Anti-Rabies vaccine right away. (Do not wait for 10 days)
4. We will give you Anti-Rabies immuno-globulin (40 units/kg) in the right deltoid muscle
intradermally (Not intra muscularly)
Then we will start Anti-Rabis Vaccine immediately which will be given in the left deltoid
muscle I/M.
As you are expose to a possible rabid dog and who was most probably never been
vaccinated against rabies so you should get five injections of rabies vaccine.
You have presented in Emergency Department < 15 minutes after bite. Your wound is
clean, no dirt, not much bleeding, muscle tendons are intact, no bony injury but you are a
diabetic, smoker so that puts your wound in high risk, so I offer you an antibiotic containing
Amoxicillin and Clevunate (625mg twice a day for 3 days) (Augmentin)
VACCINE SCHEDULE POST EXPOSURE (5 Injection)
0, 3, 7, 14, 28 days 1ml I/M deltoid muscle 5 injections + one booster dose at 90 day.
Vaccine schedule (Pre Exposure) (4 Injection)
0, 7, 21, 28 days (For high risk individuals) 4 injections
SAFTY NETTING SIGN AND SYMPTOMS
If you develop any of the symptoms like Saliva drolling out of mouth. Hyperslivation,
Fear a water, Difficulty swallowing, Difficulty speech, Insomnia, Headache, Fever, Anxiety,
Confusion, Discomfort, Generalized weakness, Partial paralysis, Restlessness, and
agitation, Irritiability hallucinations. Please seek immediate medical help.
NOTE: NEGRI bodies appear on 7th day in saliva, urine and spinal cord fluid.
I offer you some written material about dog bite to read at home.
Is there anything else you would like to ask me today? (No)
Thank you for your cooperation
Good bye
Smile and don’t shake hand.
(If readers find this article insufficient, kindly consult internet on dog bite rabies)
Espcially latest vaccine schedule.
SUMMARY
1. Reassurance and Explanation
2. Wash with soap and water
3. Wash with saline water 20cc syringe and 18 guage needle
221
4. Give Tetanus Toxide injection
5. Antibiotic
6. Anti Rabies immunoglobulin
7. Anti Rabies Vaccine
NOTE:
Tetanus toxoid injection I/M in buttock
Immunoglobulin in right deltoid muscle intra dermally
Vaccine in left Deltoid muscle I/M.
NOTE: All though live vaccinations cannot be given in pregnancy but if dog bites a pregnant
woman then rabies vaccines can be given.
RABID ANIMALS INCLUDE

Bats, Cats, Dogs, Fox
NOT RABID INCLUDE
Rodents and Rabbits
Text Book of Medicine by Inam Danish Page 626
222
CHICKEN POX & PREGNANCY
SCENARIO 1
Mrs. Zarina Zahid is more than 28wk pregnant & is exposed to certain rash on
visit to neighbourhood. She is worried what will happen to her if she develops rash
and also worried about her unborn baby. Take relevant history and manage. (She has
photo of child with rash taken by mobile phone)
Hello
I am Zarina Zahid 25 years.
What brings you to the surgery today.
___________________________________
Doctor I am 28 week pregnant. My neighbor’s son has some kind of rash and I visited
their house unknowingly. I am worried whether I will develop similar rash. If I do what will
happen to my pregnancy and to my unborn child.
This is the picture of rash of my neighbor’s son.
Doctor look at the picture in the mobile and diagnose it as Chicken Pox Rash in
different stages of macule, papule and pustule also crusting of papules.
SCENARIO 1
Let me ask you one question.
Do you remember you had chicken pox rash in your childhood.
Yes, I definitely remember, I had chicken pox in my childhood.
Since you are sure that you had chicken pox in your childhood so I assure you that is
no danger to you or to your unborn baby due to immunity acquired from childhood
infection.
SCENARIO 2
As you do not remember whether you had chicken pox in your childhood, so in your
case before I offer any treatment, I need to ask you few questions. Can I ask you a few
questions?
1. Was your chicken pox antibody levels checked before pregnancy? (No)
2. Were you given chicken pox vaccine 2 doses 4-8 wks apart in childhood? (No)
3. How many weeks are you pregnant. (More than 28 weeks)
4. When were you exposed to chicken pox virus. (One day ago)
5. Have you developed any rash so far. (No)
6. Any pain on one side of body anywhere. (No)
7. Any vesicular rash in or around your ear or eye. (No)
8. Do you have any fever. (No)
9. PAST HISTORY
10. Any history of hospitalization previously.
PERSONAL HISTORY
Do you smoke. (No) (To assess if immunocompromised)
Do you know, what is your HIV status. (HIV –ve) (Immunosuperation)
Are you using any steroid. (No) (Not Immuno compromised)
How many children you have. (2 kids, 6 & 10 year of age)
223
How are the things at home? (Any stress) (Very peaceful)
How are the things at work? (Any stress) (No stress)
If there any financial difficulty? (No)
Will it be a problem if you have to buy some expensive medicine?
Me and my husband can affored any medicine you suggest.
DRUG HISTORY
Are you taking any medicines regularly or OTC? (No)
Are you allergic to any drug? (No)
FAMILY MEDICINE
Any major medical problem in the immediate family members e.g.  BP or  BS or
Any heart problem. (No)
SUMMARIZE
You are 28 weeks pregnant and you have been exposed to chicken pox virus one day
ago. Don’t remember if you had chicken pox in chidhood. You are smoker and you are HIV–
ve.
MANAGEMENT ( At Exposure)
1. Since you were exposed to chicken pox virus one day ago and you are 28 weeks
pregnant. so I would offer Vericella Zoster Immuno-globlalins (VZ-Ig) to you and to
your baby when born.
It will significantly  disease severity.
Duration of protection from VZ-Ig is limited. We will check antibody status again 3
weeks after first dose of VZ-Ig and shall give 2nd dose if still at risk of further exposure
> 3 weeks since first dose.
2. Vaccination is C/I if pregnancy or immunocompromised. So I offer acyclovir 800mg
five times every day by mouth for 1 week prophylactically.
SCENARIO 3
EXPOSURE IN PREGNANCY
If the mother has definitely had chickenpox there is no risk to herself or the baby. If
she does not recall having chickenpox, check her immunity-80% have antibodies from silent
infection.
In cases of `at risk’ exposure Arrange for VZ-Ig to be given to mother and/or baby.
This can be lifesaving and significantly decrease serverity if given ≤10d after exposre. Babies
are at risk if:
• The mother develops chickenpox from 7d befero to 7d after delivery.
• The mother is not immune and the baby is exposed to chickenpox <7d after birth.
• The baby has been exposed to chickenpox and has potentially inadequate transfer of
material antibodies (e.g.
preterm babies <28wk
Babies weighing <1000g at birth
Babies who have had blood transfusions
VZ-Ig can be given without antibody testing to these babies, but where possible, test
• Duration of protection from VZ-Ig is limited. Give a second dose if still at risk and further
exposreu occurs and ≥3wk since first dose. Check antibody status again before giving
second dose.
• Some advocate use of prophylactic acyclovir for women with significant additional risk
factors, e.g.,
224
Immunosuppression
Smokers
Women who did not receive early VZ-Ig or
Those in the second half of pregnancy.
Risk to the mother Chickenpox infection compliacates 2-3 in 1000 pregnancies.
Chickenpox Pneumonia is more common (10%) and can be severe (1 in 1000 mortality).
<20wk Causes miscarriage.
Risk to the baby rates of transmission are higher later in pregnancy (-50% >3wk; 5-
10% >28wk). Infection:
• Fetal varicella syndrome affects 1-2%- segmental skin defects /scarring, limb
hypoplasia ± paresis, low birth weight, microcephaly, neurological abnormalities (e.g.
hypotonia, eye defects). May occur up to 28wk gestation.
• 20-37wk intrauterine infection or death, shingles in childhood.
• 1wk before-1wk after delivery All babies should be given VZ-Ig. Onset 4d before
delivery-2d after delivery carries a 20% risk of overwhelming neonatal infection – these
babies should be given acyclovir in addition to VZ-Ig. Seek specialist advice.
PRE-CONCEPTIONAL PREVENTION
An effective chickenpox vaccine is available in the UK.
There is no UK policy to screen women for immunity to varicella infection, however it
is ossible to check immune status and vaccinate nonimmune women prior to pregnancy.
Pregnancy should be avoided for 3mo after immunization.
SCENARIO 4 (SEVERE PAIN BUT NO VESICLES)

Patient complains of pain only on one side of chest or back or tip of the nose or near
the eye in one or two adjacent dermatomes. The pain is very severe and there are no vesicles
or rash in this scenario person has not developed vesicles as yet. But this is a case of varicella
zoster infection.
Ask the patient to visit the surgery again in 24 or 48 hours time or when some vesicles
have appeared unilaterally in the area of pain.
SCENARIO 5 (Shingles)
Shingles are due to re-activation of latent chickenpox virus. Contact may develop
chickenpox but shingles cannot be acquired by exposure to chickenpox. Infectious until all
lesions have scabbed.
• Incidence: 1:25 Any age – more common if imunocompromised.
• Presentation: unilateral pain precedes a vesicular rash by 2-3d. Crops of vesicles
appear over 3-5d and are in the distribution of  1 adjacent dermatomes. The affected
area is usually hyper-aesthetic – pain may be severe. Lesions scab over and fall of in
< 14d.
• Management: disease is usually mild in children, so treat as for chickenpox. Oral
acyclovir (or similar) is only effective if initiated <48h after onset of the rash. If immuno-
compromised admit for IV antiviral.
Complications:
Post-herpetic neuralgia (rare in children): dissemination to other areas (occurs
immunosuppressed patients – admit for IV acyclovir); eye involvement – refer urgently to
ophthalmology. (Encephalitis, Pneumonia)
225
Contact with chickenpox in pregnancy is common. People with chickenpox are
infectious from 2d before the rash appears until the rash has finished cropping and crusted
over. Incubation period is 14-21 days.
OPHTHALMIC SHINGLES
Zoster in the ophthalmic branch of the oculomotor (3rd) nerve. Pain, tingling, or
numbness around the eye precedes a blistering rash and inflammation. In 50% the eye is
affected with conjunctivitis, scleritis, episcleritis, keratitis, iritis, visual loss, and/or oculomotor
nerve palsy. Nose tip involvement makes eye involvement more likely. Prescribe oral a
cyclovir (800mg 5x/d) and refer immediately to the eye specialist. The cornea may become
anaesthetic/scarred and require cornial grafting.
Specialist may give anti viral medicine by mouth.
He may start anti viral eye drops.
He may give anti viral cream to be applied over shingles.
SCENARIO 6
RAMSAY HUNT SYNDROME
Severe pain in the ear precedes facial nerve palsy. Herpes Zoster vesicles appear
around the ear, in the external ear canal, on the soft palate, and in the tonsillar fossa. Often
accompanied by deafness ± vertigo which are slow to resolve and may result in permanent
deficit. Pain usually abates after 48h but postherpetic neuralgia can be a problem. If detected
<24h after the rash appears, treatment with antivirals (e.g. acyclovir 800mg 5x/d for 1 wk)
may be effective.
SAFTY NETTING
Let be warn you that you should avoid contact with anyone, potentially at risk of
developing chicken pox specially pregnant women or neonates.
FOLLOW UP
CLOSING
_____________________
IMMEDIATE FAMILY MEMBERS IMMEDIATE FAMILY MEMBERS DOES
INCLUDE NOT INCLUDE
Parents, Father, Mother Uncle, Aunt,
Brother, Sister Neice & Nephews,
Son, Daughter Grand parents,
Grand childrens,
th
Chicken Pox & Pregnancy Oxford 5 Edition Page No. 628, 629, & 794, 795
226
RUBELLA & PREGNANCY
Me and my husband has been traying to conceive for the last two years. Finally I am
ten week pregnant. I went to my neighbor’s house. There lady was having a dence macular
pinkish rash. This is the picture of the rash. I am expose to this rash for more than 15 minutes
in a closed room (Significance exposure).
I am wondering if this exposure of rash will have any effect on my pregnancy or on my
unborn child. Kindly guide.
Ok Mrs. Rubina before I tell you about effects of exposure on your pregnancy and on
your unborn child, may I ask you one questions?
Were you tested for rubella antibodies at the time of pregnancy? (No)
Have you gone through any test now? (Yes)
INVESTIGATIONS
Doctor my blood for serology for rubella & parvovirus B19 was done and I was found to
be rubella IgM positive. I got myself tested again and it was still IgM positive.
Mrs. Rubina this is a serious condition in which if person is rubella IgM positive irrespective
of rubella IgG. Then statistics show that
TRANSMISSION RISK TO THE BABY
• Exposure upto 11 weeks → 90% chance of adverse out come.
• Exposure at 12 to 16 weeks → 20% chance of adverse outcome.
• Exposure at more that 16 week minimal risk of deafness only.
• If mother is infected with Rubella at > 20 week of gestation then infection does not
affect the baby.
You are ten week pregnant and you have been exposed to the rubella rash according to
the statistics there is a 90 percent chance that outcome will be adverse. Your child can be
• Deafness, blindness (Cataract), small eye, small head
• Cerebral palsy, Mental retardation. Cardiac abnormalities can be there.
There is 90 percent chance of giving birth to a handicapped child. You know very well
how difficult it is to raise a retarded child. Our experience tell that in such circumstance
termination of pregnancy should be advocated. I will be referring you to the gynae of specliast
for termination of pregnancy.
Go home Talk to your husband. Read the information leaflet about your condition and
come back. What ever you will decide, I will facilitate that. I will be with you.
If you have been exposed to the rubella rash after 20 weeks of gastation I would have
reassured you that you can continue with you pregnancy despite the exposure.
If IgG detected. igM not detected. This shows past infection but no evidence of recent
infection. I would have reassured you.
If Niether igM nor IgG detector. Person is suseptable for infection we will send the serum
again after one month.
VACCINATION AFTER TERMINATION OF PREGNANCY
Doctor If I decide to terminate my precious pregnancy this time what is the guarantee that
in the next pregnancy I will not the expose to rubella rash again. And if I am expose will I
have to terminate my pregnancy again.
No Mrs. Rubina If you decide to termination then I offer postnatal MMR vaccination.
Give postnatal MMR vaccination routinely to all women found not to be rubella immune
in pregnancy. Do not give rubella vaccination to women known to be pregnant.
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Avoid pregnancy for 3 month after vaccination. Recheck immunity after 3 months of
vaccination.
Do closing by five sentences in ten seconds.
NOTE:
Offer MMR to all women of child bearing age who are not immuneto Rubella (e.g. have
not had two doses of MMR or are seronegative.
MMR given at 12 month to 13 months first dose and second dose at 3 year four month
to 5 year.
I.e. offer MMR vaccine to all children AFTER their first birth day and then again at
preschool. Reimmunization is needed if given to children less than one year.
Ulterasound survillence is started 4 weeks after the onset of illness than every one to
two week until 30 weeks.
MUMPS & PREGNANCY (Mumps in male with Orchitis)
• If within 12 weeks of pregnancy, increased risk of miscarriage

• Do not cause malformation or defects in an unborn baby
• Complications of mumps are orchitis, encephalitis, hemolysis or pancreatitis
• If exposure is
• Within 20 weeks → 1:200 5%
• Within 13 – 20 weeks → 1:50 20%
• More than 20 weeks → very low
• More than 28 weeks → no risk
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ANAEMIA
SCENARIO
Mrs. Allah Rakhi presents with a report. Kindly gathered data and manage dietry
and drug treatment.
Proceed.
Hello.
I am Doctor Raheel one of the family physicians in this surgery.
I am Mrs. Allah Rakhi.
What brings you to the surgery today.
Doctor I have come to discuss this report with you.
Hb ↓
MCV _________ Normal 80 – 100
Hemtocrit
Serum ferritin ↓
Total Iron binding capacity ↑
Transferrin ↑
Doctor takes the report and confirmed with the name and age that these reports
belongs to Mrs. Allah Rakhi. Puts them infront of him instead of returning till the end of
consultation.
Mr. Allah Rakhi, before I come to the management part I would like few questions
Is it ok with you.
What prompted to have this report.
Doctor I was feeling breathless and some drumming in chest and I felt weakness,
tiredness and lethargy.
Ok Mrs. Allah Rakhi.
What about your tongue?
It appears to be large in size red and smooth.
My angle of the mouth are sore. (Angular Stomatitis)
Any blood loss in trauma, any blood loss in surgery?
Blood loss – Have you notice any bleeding from any of the external opening of your
body? (Nose – mouth or Anus)
What about flow of your periods – (heavy) after ensuring confidenciality.
Excessive donation – Repeated donation of blood before 3 months
Low intake – Are you taking normal diet?
Mal Absorption – Is there any change in bowel habit (Coeliac disease)
Does your stool float in the flush. (No)
Is there any chance you could be pregnant.(No)
RED FLAG
Weight loss
Any black stool or blood in vomiting
Pain in chest while climbing stairs, running or walking
Fever
DRUG HISTORY
Are you taking any pain killer like asprin or Nsaids
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Any antibiotic like chloramphenicol
Any immuno suppressant drug like Methotrexate
Any anti epileptic drug like Phenetoin
Any drug allergies
PERSONAL HISTORY
Do you smoke?
Do you drink?
How do you rate your weight?
Do you like to do some exercise?
What sort of diet do you usually take?
What do you do for living?
Any stress at work?
Got a family?
Any stress at home?
May I ask you a few personal questions? (Rest assure they will remain
confidential between you and me.
Ask 5 questions of menstrual history. (If she is having light or heavy menstrual
blood flow.)
Any history of similar complaint in the past.
Any history of similar complaint in the family.
Ask illness and ICE.
Summarize
EXAMINATION
General Appearance Pale Skin
Pulse weak and fast
Eyes – Look up (Pale Conjuntiva) (Anaemia)
Look down (Jaundice) (Yellow)
Nail
Pale
Capillery Refill
Kolinychia
Clubbing
Briefly Heart Sound any pansystolic functional murmur
INVESTIGATION
Full blood count with Hb & pheripheral film
Vit. B12, Folate level.
Iron study
Serum Ferritin (For confirmation of iron deficiency)
TIBC Total Iron Binding Capacity
Transferin (For confirmation of iron deficiency)
Haemoglbin electrophrosis for Alpha Thalacaemia and Sickle Cell Disease
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ttgA IgA antibody
Stool for Occult Blood
MANAGEMENT DIET & DRUG
NON PHARMACOLOGICAL (LIFE STYLE) CHANGES OFFERED
Take food rich in iron e.g. water cress, curley Kale, dark green leafy vegetable
Iron fortified cereals
Whole grain such as brown rice, bread, meat, liver.
Beans
Nuts and Resin (Meva)
Apricot (Khubani)
Purine (Allo Bukhara)
(1) I offer you ferrous sulphate 200 mg tablet twice a day.
This drug is not without side effect it may cause constipation or turn stool
black.
(2) If ferrous sulphate is not tolarated I may offer you ferrous fumarate
200mg twice a day.
I offer the vitamin C, (ascorbic acid) 500mg twice a day (It inhances iron absorption)
Take plenty of citrus juice to increase the absoption of iron
Pleae continue the treament for three months.
This treatment should raise Hb by 1gm/dL/Week
We will check haemoglobin every 3 weeks after the start of treatment.
FOLLOW UP
First follow up will be after one month then I offer a second follow up visit every three
months for one year. till your haemoglobin stays normal then annually.
CLOSING
Is there any thing else you would like to share with me today?
No thanks.
You can take written information in the form of leaflets from the reception desk.
Good bye.
_____________________
WARNING
Hb less than 13 for male
Hb less than 12 for female
Or less than 11 in first triamester

Or less than 10.5 in second / third triamester
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IRON DEFICIENCY ANAEMIA
SCENARIO
Mrs. Allah Rakhi 28 years mother of 3 year old son Fazal has come to discuss
reports. Kindly gather relevant data and share a management plan. proceed.
Hello, I am Dr. Raheel. One of the family physician in this surgery.

I am Mrs. Allah Rakhi 28 years.
What brings you to the surgery.
_________________________
Doc., I have come to discuss the reports of my Son Fazal 1 year old. Ever since he started
walking, he has become very fond of eating pica or soil. He keeps complaining tummy pain.
His appetite is decreased and he is becoming paler and paler every day.
Is there anything else you would like to add?
Doc., His tongue appears to be big, smooth red and angles of lips are sore.
Is there anything likes to add?
No, Doc., that’s all.
Doctor takes the report check it meticolately after confirming the reports belong to Fazal.
INVESTIGATION
Is there any investigation done so far? (Yes, I have these blood reports with me, which shows
hemoglobin____↓______)(Decreased)
Serum Ferritin ____↓_____ (Decreased)
Serum Iron ______↓______ (Decreased)
TIBC ________↑________ (Increased) Total iron binding capacity increased.
Is your son accompanying you?
No.
Mrs. Allah Rakhi, it would have been better, if your child was accompanying with you. I would
have examined him and given you more appropriate advice. Please bring the child alongwith
you next time.
In order to reach my diagnosis, I need to ask you few questions. Can I ask few questions?
B Was the birth of child normal? (Yes it was normal vaginal delivery but the child was of
low birth weight)
I Is all his immunizations are uptodate? (Yes his all vaccinations are done uptill now)
N Is the child feeding properly? (No, previously he was feeding adequately but now his
appetite has decreased)
D Did the child achieved his milestone in time? (Yes, the child achieved all the milestones
in time for his age)
PERSONAL HISTORY
Was the child breast fed? (Yes, the child was breast fed for six months initially)
Is this your first child? (Yes, this is my first child)
Is there any financial difficulty? (No, Me and my husband can provide milk & any another
things you suggest for our child adequatly)
Mrs. Allah Rakhi, may I know, what do you do for your living? (I am a teacher in Primary
School)
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Who takes care of your child when you go for your job? (I take my child with me to the school
day care centre)
DRUG HISTORY
Is the child taking any medicine regularly? (No)
_____________________
I What do you think is the cause of your child symptoms (I do not know Doctor)
C What worries you most about your child’s eating pica? (I am worried he might get
serious ill by eating soil or Pica)
E What do you hope to gain from today’s consultation? (I hope that you will prescribe
some medicine for his tummy pain and pale skin)
SUMMARIZATION
So, Mrs. Allah Rakhi, you have told me that your 1 year child Fazal eats pica, has tummy
pain and is getting paler and paler every day and his appetite is decreased?
Is there any else you would like to add? (No)
NON PHARMACOLOGICAL MANAGEMENT
Well Mrs. Allah Rakhi, what I have gathered from information you shared with me and
investigation done that your child is having a condition which we call in medical terms Iron
Deficiency Anaemia. Your child all symptoms are due to this problem. As the child eats soil,
certain germs have entered in the body which has decreased the red cells of the blood.
I suggest few life style changes:
Increased the meat, egg, green vegetables and apple in the child’s diet.
Can you do this? (Yes)
Kindly take care of the hygiene of the child, keep his hand clean as far as possible.
(Trim the nails of the child so that he does not eat pica. Can you do it?)
You may arrange some person to keep the child under supervision while you are away.So
that the child do not eat pica.
Anty helmenthics cannot be given to a child less than two year.
1. I offer you a deworming syrup called Mebandazole 1 tea spoon full once a day for 3
days only.
2. This syrup is quit safe to use but let me inform you that it can cause some loose
motions in your child or the child can become a little drowzy.
3. I offer you some iron syrup called ferrous sulphate 1 tea spoon full once a day for three
months.
4. This syrup can cause black color stool, you need not to worry. Hope fully his deficiency
will be fulfill and all parameters will become normal. We will repeat these tests in about
three weeks time.
FOLLOW UP
I offer second follow up visit after 1 month then every three monthly for one year till Hb
stable, then annually.
CLOSING
Please bring the child with you when you visit next time. I would like to examine his tummy.
Mrs. Allah Rakhi would you like to discuss anything else today? (No, thanks)
I offer you some leaflets which you can read at home.
You can get more information about your child’s condition from the internet.
Good bye.
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IRON RICH FOOD
Red Meat, Liver, Egg
Rasin Nuts (Wall nut)
Apricot, Prune, Citrus Juice, Apple
Water criss, Spinch, Curly Kale, Rubarb
Beans
Lentils
Green leafy vegetables
Fortified Cearials
FAILURE TO RESPOND TO IRON SUPPLEMENT

Consider H-pylore, Coeliac Disease, continuing bleeding, compliance with iron
supplement, anaemia is mixed or diagnosis is incorrect.
FOLATE RICH FOOD

Green Leafy vegetabels, brown rice, bread, fortified cerials.
___________________________
SUMMARY
Diet ___ Iron rich food
Hygeine ___ Keep hands clean Trim nails
___ arrange supervision
Deworm ___ Mebendazole 1 tea spoon once for 3 days
S/E loose motions + drowzziness
Iron Syp ___ Ferrous sulphate
1 tea spoon full once a day for 3 months.
S/E back stool.
Repeat blood test after every 3 weeks
1g hemoglobin should increased in one week
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ANAEMIA IN PREGNANCY
Hello
I am Dr. Raheel, one of the GP in surgery.
I am Mrs. Shagufta 25 year.
Doctor I am three month pregnant.
Gynacologist says that I have less blood in my body.
Anaemia in pregnancy can be an exaggeration of the previously existing anemia, or be of
dilutional nature (as pregnancy is a hyperdynamic condition)
Before we come to the management part can I ask you few questions?
May I know your Haemoglobin Level at the booking (11gm/dL)
How many live children do you have? (I have 5 children)
Have there been any multiple pregnancies? (Yes this time its twins)
What about your diet? (My diet is not healthy I belong to low siocio economic group)
Do you have shortness of breath? (Yes)
Do you have any drumming in chest? (Yes my heart seems to run fast)
Any chest tightness or chest pain? Yes I feel Anginal pain in chest while walking (Anaemia
can precipitate Angina in severe cases)
Do you feel fatigued?
Do you have headache?
Any leg cramps?
Do you have hair falls?
Any history of blood loss? (Previous or recent)
Any recent trauma?
Any recent surgery?
Any blood loss in stool, vomiting or Sputum?
What about flow of your periods? (I had heavy flow before becoming pregnant) (Ask this
question after ensuring confidentiality)
May I know your blood group?
What is your rhesus status? (Whether positive or negative)
History of pruritis Anai?
EXAMINATION
In order to reach my diagnosis I need to examine you. Can I examine you?
Yes you may proceed doctor.
Thank you for trusting me for examination.
Pulse (Low volume and fast)
Blood Pressure (Wide Pulse Pressure)
Look up (Check the lower conjunctiva for Pallor)
Look at the Nail Bed for Pallor and Kolinychia (Spoon Shapped Nail)
On Auscultation (Pansystolic functional murmur)
In order to confirm my diagnosis I need to offer you certain blood test like
235
Complete blood count and Hb
Peripheral smear
Stool for occult blood (Ova and cysts)
Urine complete examination (For Pus Cell and Blood and Glucose)
Blood group of both parents with rhesus status
MANAGEMENT
The information you have shared with me and the examination I have performed and the
already done investigation I have seen most probably you have Iron Deficiency Anaemia. Do
you know about Iron Deficiency Anamia.
No Doctor can you explain a bit.
Anamia is less amount of blood as comapred to our needs. Some decrease in Hb is normal,
in pregnancy as the fluid content of blood is increased.
In pregnancy Iron requirement is increased by 2 to 3 times and folate requirement is
increased by 10 to 20 times.
Anaemia is usually Iron deficiency Anaemia.
Complication is included excessive fatigue and poor foetal out come.
In order to increased Hb, I offer you certain lifestyle changes and certain medicines.
IRON RICH FOODS
Include liver, spinach, Apple, Red meat, Beat Root, Red beans, dark green leafy vegetables
etc.
I offer you a medicine called Farrous Sulphate 200mg twice a day for three months.
I also offer Folic Acid 5mg one tablet daily.
In case of megaloblastic anaemia add vitamin B12 one tablet daily.
SAFTY NETTING
If you have black stool or bloating or severe tummy pain seek immediate medical help.
FOLLOWUP
I would like to see you after one month.
Is it convenient to you. (Yes)
CLOSING
No.
Please collect leaflet about Anamia in pregnancy from the reception desk.
Good bye.
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SPIKES
Delivering difficult new to veteran is never easy especially in the matters of life and
death. Many providers may not have been talked to handle this dedicate conversation. This
training demonstrate how to deliver difficult information accurately with compassion. We
recommend using the approach that the follows the formula SPIKES. Which stands for
SETTING
PERCEPTION
INVITATION
KNOWLEDGE
EMPATHY
STRATEGY
__________________________________________________
1. SETTING
Secure a private sitting room ensuring the privacy and confidentiality. Room should be
comfortable there should be no interruption. There should be a tissue box. Doctors should
page is junior not to be disturb. Keep the pager and mobile phone off. There should be no
person other than the family member in the room. Doctor should go through the medical
record thoroughly before starting the meeting.
2. PERCEPTION
Question, what the family know about the condition of their loved one. Ask the family
members what is their perception or understanding of the medical situation of the veteran.
Ask the family members what the veteran would like to know that his health is failing. Ask
before you tell, what does the family know about the health of veteran condition. How much
they know about seriousness of their condition.
3. INVITATION
Although most like to know detail about condition but you cannot assume it. Asking
permission is respecting the right of veteran and family right to know.
4. KNOWLEDGE
Information is conveyed compassionately. Give warning that I have tell you about the
serious condition of the veteran. This prepare the family and veteran for the difficult news.
Make sure that you keep out the medical jargon, speak in layman’s language or in simple
English words. Give the information in small amount.
5. EMPATHY
Sharing with the emotional side is probably the most difficult, share facts with
understanding and compassion. Be good listener and provide support.
6. STRATEGY
Next step is establishing a future plan. Help the family and veteran comes to turn with news.
Allow time for questions. Indicate how the family can reach you next week. The
Knowledgeable the family member and veteran the better they will follow the
recommendations. Veteran patient can be given hospice care. Where he is comfortable till
the end of life. There his physical and spiritual needs can be met with.
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BREAKING BAD NEWS
Breaking bad news is one area where it is not difficult in real life but difficult in exams.
In real life patients do not come with the report of cancer and we have to break bad news to
an unknown person suddenly. In real life patients come with symptoms in first visit. If we
suspect serious disease we inform the patient about two to three possible causes including
cancer. We advise first line test. When patient comes back on second visit we inform the
patient about suspicion of cancer and order confirmatory tests or arrange any referral for
confirmation. Then the patient comes for the third visit with confirmatory test which shows
cancer.
By that time he is mentally prepared has discussed with other doctors and has good
idea about the diagnosis. On visit three we build on our previous discussion and inform that
our suspicion is now confirmed.
But in exams, an unrealistic situation is created, where you are given a report of cancer
and you have to tell an unknown person suddenly. This unrealistic situation causes problems
and not the breaking bad news itself. The catch lies here. Always ask the patient why did he
do the tests, what were the complaints on first visit. Then ask him about risk factors of cancer.
Anything told by others on visit 2 and 3. His own idea about the diagnosis. Ask him whether
he wants to know or not. If he wants to know about his condition then briefly tell him about
the diagnosis. This is called patient’s autonomy.
You keep ready for any sort of emotion like crying,
silence, anger, disappointment and deal accordingly.
Supposing you were not expecting a serious disease and during evaluation or
treatment you found something serious e.g., patient operated for gall stone, found to have
gall bladder cancer, patient during antenatal visit found to have fetal demise, patient
undergoing elective hernia surgery, dies on table due to cardiogenic shock, patient in the
ward admitted for gall bladder surgery dies due to MI.
These situations are different and difficult because no one is mentally prepared for
such “shocking” news. Such situations need carefully planned breaking bad news. Following
steps may help in breaking bad news in such unexpected bad outcome situations:
1. Identify a quiet and comfortable place for sitting.
2. Arrange for tissue, water etc.
3. Study the case in hand in detail so that you know the events.
4. Study the diagnosis, prognosis and general trend of such situations so that you can give
scientific answers.
5. Invite patient and/or attendants to that room and show respect and empathy.
6. Introduce yourself, your colleagues, patient’s attendants and their relationship with patient
so that all know each other.
7. Don’t entertain any irrelevant person in the room.
8. Stop all interruptions like phone calls, file work, nurse or staff dropping in.
9. Briefly summarize the events in chronology order and express the good intentions of team
and the best possible efforts of the team.
10. Mention the possibility of adverse outcomes based on evidence as warning shots.
11. Mention that you also met with unexpected adverse outcome and mention the adverse
outcome with concern and empathy.
12. Never get detached from patient or get rid of him by referring him to specialist. Be there
and be his advocate all along.
13. Show empathy by your words, by your expressions and your actions.
14. Always keep hope by saying: “We will do all that we can do in the best possible way.”
15. Never give false hopes or give him wrong information.
16. Provide your contact, ease in appointment and allow him to send you voice message if
he is in distress or in confusion.
17. Coordinate his care with oncologist and surgeons and be part of the team.
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Breaking bad news has a broad context and is rarely a one stage process.
1. CONFIRMING IDENTITY
A patient has come to discuss the reports, doctor has ordered previously.
Take the reports from the patient. Read them and put them in front of you.
Confirmed the identity of the patient by asking the name and age of patient and compare with
the name & age on reports.
Do not return the report to the patient even after reading the reports till the end of consultation.
2. BEGINNING OF BREAKING BAD NEWS WITH RECALL OF SYMPTOMS
I believe you came to the hospital because of feeling unwell and having lost some weight.
You have some test done and you have come to see me for the results. Can you recall your
presenting symptoms with which you came to me. (Patient may recall cough & sputum with
blood in sputum) In case of lung cancer.
Or in case lump in breast patient may recall her mother or sister had a lump in breast which
turned out to be breast cancer.
Ask his / her Idea, concern & expectation of what reports may be about before proceeding to
what actually reports say.
3. SUPPORT
Is anybody else accompanying you?
Would you like anyone else for example a friend or relative to be present while the reports
are explained or treatment options are discussed.
4. PATIENT AUTONOMY
Medical ethics now emphasize on patient autonomy and rights to be fully aware, to make
informed
choices about the diagnosis, prognosis and the treatment options
available.
Ask the patient
“Are you a sort of a person who wants to know everything about his condition.”
5. WARNING SHOTS
I am afraid the things are not looking as good as we were hoping If patient become alert and
ask the doctor. “Is anything wrong doc. Please tell me.
The result shows that you have a tumor or growth which could be malignant. Avoid the word
cancer.
Pause
Look for the reaction of the patient. Patient may become silent, violent or cry.
If patient become silent offer him a glass of water.
If patient starts crying offer him a tissue.
If patient is in denial, let it be his way of coping with bad news.
Just tape on the shoulder to show your empathy. Respond spontaneously & Naturally to show
your sympathy (empathy) to the patient genuinely. Not just to show examiner & certainly not
delayed reaction.
Respond Abruptly to all verbal & non-verbal clues genuinely.
6. HOPE
Although it is a terrible news but we can still do a lot of things to help you and feel better.
Pain can be controlled.
239
Certain medicines in the forms of drips can be given. (Chemotherapy)
Rays like X-rays can help in some situation. (Radiation)
There are self help groups where patients like you can sit and discuss their problems. This
will build your moral.
Certain social services are available who can help you at home.
COMMONLY ASKED QUESTIONS

Patient commonly asks how long I have got to live?
Tell the patient “It is a difficult questions to answer.
You will be given some medicines. Every patient responds differently.
I cannot predict how the disease will progress however we have found the growth in its early
stage probably it has not spread to other parts of body. It can be removed completely
surgically as well.
Patient may want to discuss his will with you. Tell him I am grateful for the confidence and
trust you have shown to me about your personal issues but would it be a better idea to leave
it to the next appointment with lawyer present.
Invite the patient to ask anything he wants to know.
Encourage and validate emotions.
Give bad news in small chunks and pauses.
7. FOLLOWUP PLAN
Do not end the consultation without giving precise follow up plan.
Patient would like to know what is going to happen to him in near future.
Do not give false hope. Be realistic and truthful. You may tell patient that death is not
necessarily the outcome of breast cancer. Many women after the treatment survive and live
a normal life. Even the removed breast can be reconstructed by plastic surgeon.
CONTINUITY OF CARE
If patient asks his GP doctor that “Is it the end of our long relationship as you are referring
me to a specialist. Assure him that you will continue to take care of him after he has been to
the specialist.”
You don’t have to ask everything now.
You can come back to see me any time you like. Show you availability for poor dying soul.
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BREAKING BAD NEWS (BREAST CANCER)
CASE No.1
Hello I am Dr. Raheel. One of family physician in this surgery.
My name is Mrs. xyz.
Well Mrs. xyz how can I help you today?
Doc. I have come to discuss results of my reports you ordered.
Well Mrs. Xyz can you recall your symptoms of pain and lump in the breast you felt.
Yes Doc.
HER IDEA
So what do you believe it could be?
I am afraid it could be cancer of breast.
HER CONCERN
What worries you most in particular?
Doc. It could be fatal in little time.
HER EXPECTATION
I need to know what are percisely the results of reports? And if it is cancer, is there
any thing that can be done to cure it?
SUMMARIZATION – CONFIRMATION OF ID OF PATIENT AND REPORTS
So your name is xyz? (Ask for name & age for confirmation of ID)
These reports belong to you. I am afraid that things are not looking good.
WARNING SHOT
Silence for a while
Would you like your spouse or some relative to be preset with you while these
reports are being read and explained to you.
SUPPORT
Is anybody accompanied by some body else today?
No Doc. My husband is on his way to the hospital but I am a strong women.
You can proceed with the results of reports.He will soon join us.
__________________________
Are you a sort of a person who would like to know each & every thing about her
condition?
Yes Doc. I want full frank disclosure.
Do not hide anything from me?
Its my right.
Well Mrs. xyz you came to me with a lump in your left breast and some bloodly
discharge from the nipple from left side only. You have undergone mamography and
FNB (Fine needle biopsy) and CT Scan. I am afraid the results show that you have
breast tumor or growth.
Shocked,
Oh silence, crying oh no doctor It can not be cancer (denile)
241
Allow patient some time to understand reports, offer tissue if crying or a glass of water
if silence. If appropriate a tap on shoulder to show your empathy towards patient
quickly promptly and genuinely.
Mrs. xyz would you like me to continue with the management options or you like to
come again or Should I book a 2nd appointment in near future.
No. Please continue what is going to happen to me in near future. (Give her hope)
Although it is a terrible news but we can still do a lot of things to help you feel better
and deal with the problem of pain.
I will be referring you urgently to one of my senior oncologist colleague who is expert
of such cancer.
MANAGEMENT OPTIONS OFFERED AND DISCUSSED
What will specialist do to me?
He can advise surgery to remove the lump and if necessary some medicines in the
form of drips can be given to kill cancerous cells. Later on some rays like Xrays can
be given.
Do you understand clearly about the options available or you have any questions
about them.
I understand.
Mrs. XYZ I don’t want to give you false hope but depending upon type of Breast
Cancer, death is not necessirily the final outcome. Many women survive after chemo
& Radio therapy & live a normal healthy life for years together.
Even removed Breast can be reconstructed by Plastic Surgeon for cosmetic purposes.
CONTINUITY OF CARE WITH FAMILY PHYSICIAN
I have been your patient for 20 years. Does that mean its an end of our long
relationship?
No. not all. Mrs. xyz.
After the surgery I will continue to take care of you.
MOST FREQUENTLY ASKED QUESTIONS
How much time do I have to live?
It is a difficult question to answer and no body can predict. Different patients responed
to medication differently. I can not predict how the things will progress.
WILL AND FINANCIAL ISSUE
I am worried what will happen to my near and dear loved ones after my death. Can I
discuss my will and financial issues with you?
Yes, you can, I am grateful for the confidence and trust you have shown to me about
your personal issue but would it be better if we leave it to the next appointment?
Arrange lawyer to be present in our next meeting.
Yes ok doctor.
SUPPORT AT HOME
May I know who else live with you at your home. My husband.
I can offer you self help group where persons with similar condition like your sit and
talk about there problems and fears.
I offer you certain social services which can help you at your home.
You get some reading material from reception desk and get further information from
internet.
Is there any thing else you like to share with me today?
No Doc.
Thankyou for your cooperation & visit.
Good bye (Smile and Shakhand)
VERY WELL WRITTEN
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BREAKING BAD NEWS (CEREBRAL PALSY CHILD)
CASE NO.2
SCENARIO: 30 years old Sofia comes to discuss the problem of her daughter Sana 2
year Sana. Kindly counsel her about her problem. Proceed.
Hello
I am Dr. Raheel.
One of the GP’s in this surgery – smile
May I know your good name please? (Mrs. Sofia 30 years)
Mrs. Sofia How can I help you today?
* Well Doc I went to a doctor for checkup of my daughter Sana, doctor gave me this
report showing that she is a case of cerebral palsy.
Doc. I have come to you to discuss this report and I wonder will she able to walk.
→ Doc – take the report from Mrs. Sofia confirm the name and age of her daughter
and Put the report in front of him and says:
Before going into the detail of this report, Mrs. Sofia, as you daughter is new in our
surgery I need to ask few questions if you allow me.
* yes Doc you can.
B → Doc – what was the mode of delivery of Sana
* delivery was normal but the child cried after few seconds.
I → Doc – Is her vaccination status up-to-date.
* yes.
N → Doc – Is Sana taking her meal regularly.
* Until few days back she was taking normal diet, but now she is reluctant to take her
meals.
D Has she achieve all mile stones of her age in time. (No)
CONCERN
→ Doc – You have said that Sana just keep lying in her bed.
* yes.
You are worried your daughter will be able to walk or not?
Well Mrs. Sofia – pause – I am afraid that she might not walk like her contemporaries.
* Oh – dry her eyes with tissues - (silence).
Now treat as BBN
→ Doc – Mrs. Sofia Is any body accompany you at the moment?
* No.
→ Doc – Are you feeling ok?
* Yes.
→ Doc – Mrs. Sofia do you think that you are a sort of person who wants to know each
and everything about the illness of your daughter.
* yes.
→ Doc – Are you feeling ok, or we can postpone our discussion to the next
appointment.
* No Doc you can continue.
_________________________________________________________________________
→ Doc – Mrs. Sofia what do you know about cerebral Palsy (Do you know anything
about C.P. Child).
* Well Doc I have heard that these children are physically and mentally behind normal
children.
→ Doc – Anything else you know.
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* No Doc, I am just worried that will my daughter walk like other children or not?
→ Doc – Mrs. Sofia as you have heard something about CP I am afraid that these
children have no cure for their illness but much can be done to improve their condition.
* Mrs. Sofia you can very well understand that being a female child how much I am
worried about my daughter.
→ Doc – Yes I can very well understand your thoughts about her future.
* Mrs. Sofia what can be done to improve her condition? Would some medicine help
her?
→ Doc – Mrs. Sofia as for as her limbs movements are concerned we can have the
facility of physiotherapist, who will teach how to improve her joint movement and to prevent
any contractures and deformities.
* Yes Doc.
→ Doc – Mrs. Sofia would it be a good idea if your daughter accompanies you in our
next meeting so that we can look into more detail about her general condition and if any test
be required we can offer her. How it sounds to you.
* Yes thank you Doc. I will bring her tomorrow. Will my daughter walk with this
physiotherapy.
→ Doc – Mrs. Sofia, every patients responds to such type of treatment differently. Few
children might need some surgical correction for the coming deformities of this limbs and few
children walk only with the help of braces.
We will try to make her as independent as possible regarding eating, washing, walking.
She will need special school with children of similar condition. I am afraid she will remain
behind the normal children of her age.
FOLLOW UP
We will continue to take care of her and follow up after regular intervals to check her
general health any complications regarding her present illness (C.P.). Is it ok with you.
* Yes Doc.
→ Doc – Anything else you want to ask me today.
* No thanks Doc.
→ Doc – If you have any queries about the condition of your daughter you can come
again any time.
Thank you very much for your cooperation and visit.
Good Bye. (Smile)
244
BREAST PAIN (MASTALGIA) PREMENSTRUAL SYNDROME
Miss Noor 25 years presents with breasts pain (Mastalgia). Gather data &
Manage Proceed.
Doctor I have breast pain.
Its in my both breasts and it seems to be related to my periods.
Is anything else you want to tell.
Yes doctor the symtoms seems to relieve after the periods are over.
This has been happening consecutively for last two months out of three months.
Miss Noor before I come to management part, can I ask you few questions?
Is there any tenderness and heaviness in both breasts during the periods.
Do you have any headache? (Yes)
Do you have any tummy blotting? (Yes)
Do you have any increased weight? (Yes)
Any mood swings and irritability? (Yes)
Is there any decreased ability to think? (Yes)
Are you prone to accident during the days following your periods? (Yes)
Do these symptoms interfere with your daily activities. (Yes)
So Miss Noor it appears that you have pain in both breasts related to you periods
along with the above said symptoms and all these symptoms are relieved after the priods are
over.
Most women of reproductive age notice symptoms / bodily changes in days / weeks
leading up to their periods.
These changes resolve or ↓ significantly during and after periods are over. They are
termed pre-menstrual tension (PMT).
If these symptoms / bodily changes, Occur on regular basis & are sever enough to
interfere with quality of life, they are termed premenstrual syndrome (PMS). Debilitating
symptoms occur in 5%.
In order to manage your symptoms I offer you certain life style chanes and some
medicines. Which way you would like me to go first. (Life style changes first please)
1. Keep symptoms diary & establish cyclical nature of
symptoms.
2. Wear loose cloths
3. Eat regularly
4. Small frequent meals
5. Complex carbohydrate, Bread, Rice, Potato, Pasta
6. Avoid Sweet snacks
7. Diet low in fat & salt
8. Decrease Coffee and alcohol
9. Plenty of fruits & vegetables.
10. Ensure Adequat Sleep
11. Decrease fluid intake
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12. Eat Diuretic foods like Strawbery and water melon
13. Consider cognitive behavior therapy. CBT changes how you
think, feel and
act.
If these life stayle changes did not relieve you symsptoms I offer your some medicine
as well.
DRUG TREATMENT OPTIONS
COC, Yasmin, Cilest
Anti depressants decreased physical & Psychological symptoms. I offer.
Fluoxetene 20mg once daily or Sertralene 50mg once daily can be given.
Diuretic decrease breast tenderness & bloating. Spironlatone ref. gynae.
Nsaids – Mefenemic Acid 500mg thrice a day. Decrease Premenstrual pain and
decreased menstrual bleeding as well.
Tranxamic acid if menorrhagia.
REFERAL
If your sympstoms continue to be severe enough and intefer your daily activity I may
refer you to the gynecologist or psychologist for cognitive behavior therapy and
evaluation CBT changes how you think, feel and act.
CLOSING
5 sentences in 10 seconds.
___________________________
SCENARIOS 2 (Only one breast pain) (Non Cyclical) (5 causes)

Mrs. XYZ complains of pain in only one breast and which has no relationship with the
onset of menstruation. Causes of non cyclical breast pain could be as follows:
Non Cyclical causes:
1. Mastitis (Is your one breast red hot swollen)
2. Breast Abscess (Is there any swinging fever)
3. Breast cyst (Is there any fluctuant or hard swelling without skin tethering)
4. Breast cancer (Is there any significant weight loss)
5. Cervical Nerve Root pain (Is there any pain in the neck which could radiate down to
the breast)
MASTITIS
The breast may be red hot swollen. Patient may have fever. Aereola may be cracked
and painful while feeding the child. Take care of hygiene, clean your breast before and after
feeding.
1. This inflamation of the breasts can be treated with antibiotic Flucloxacilen 500mg 4
times a day.
2. For pain Nsaid like Ibuprofen 400mg thrice a day or as per needed can be given.
3. Continue to breast feed or express milk to prevent milk stagnation, If too painful for
feeding. Topical remedies or nipple shields can be worn.
REFERAL
Advice from breast feeding advisor can also be sort. There may be a problem of
positioning of the child while feeding.
FOLLOW UP
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After one week.
BREAST ABSCESS
If there a breast abscess. A swelling with pus draining can be seen. Patient have
swinging fever. Some severe breast pain. Refer the patient to general surgery for incision
and drainage.
BREAST CYST
Benign and fluid-filled. Cysts may be of any size, single or multiple. Most common
>35y. Usually premenopausal women but may occur in postmenopausal women taking HRT.
Present as a firm, rounded lump which is not fixed and not associated with skin changes/skin
tethering.
First breast cyst Refer for exclusion of malignancy-urgently if ≥30y. Diagnosis is
confirmed with aspiration and/or USS and / or mammography.
Past history of breast cysts 30% of patients who have had a breast cyst develop
another at a later date. If the lump is accessible, it is reasonable to attempt aspiration. There
is no need to send aspirated fluid for cytology if the fluid is not bloodstained and lump
completely resolves. Refer if the fluid aspirated is bloodstained, the lump does not disappear
completely, the cyst refills; aspiration fails; or cytology reveals malignant or suspicious cells.
Do not attempt aspiration if you have not been trained to do so as there is a small but
significant risk of pneumothorax.
Refer to radiology for aspiration under ultrasound.
BREAST CANCER
Patient gives history of lump in the breast, on mamography, fine needle biopsy and
CT scan. Breast cancer is confrmed. Patient may have significant weight loss in small time.
Treat the patient as breaking bad news give treatment options like surgery, chemotherapy,
radiotherapy. Also give hope that death is not necessarily the final outcome. Many women
survive for years together after successful treatment with chemo and radiotherapy.
CERVICAL NERVE ROOT PAIN
A patient has Osteoarthritis of the neck vertebra. There may be pain in the neck which
can radiate to either breast and there may be numbness in the arm and hand.
Treat the patient by referring to physiotherapist.
Also give pain killer like Ibuprofen 400mg thrice a day.
Plus some muscle relaxant.
Refer to neuro surgery for MRI to rule out radiculopathy.
_______________________________
Refer to general surgeon if breast abscess for incision & drainage.

In case of Mastitis breast will be red, hot, tender, swollen. Usually in lactating mothers
due to creacks in skin of areola. Causative bacteria is called Staphylococus.
In case of breast cancer
1. Patient will complain of some lump in the breast.
2. There will be nipple retraction & bloody discharge from the nipple.
3. In case of breast cancer there will be history of significant weight loss which means
14 pounds or 7.5kg weight loss in three months.
TREAT THE CAUSE
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Do closing in 5 sentences in 10 seconds.
248
MENUPAUSE
SCENARIO
Mrs. Samantha William presents in your surgery with some symptoms. Kindly
take relevant history & manage.
Proceed.
______________
Meet, Greet & Introduction
Hello
I am Mrs. Samantha William. (48 years)
Ok Mrs. William. How can I help you today?
Doc. I have been feeling strange symptoms. As you know its winter but I sometimes get
drenching Sweats
My face become hot & then cold during the night. Its very uncomfortable.
Is there anything else you would like to add?
Doc. I have been diagnosed & treated with anti biotic for recurrent urinary infection recently.
My front passage is dry & my husband complains all the time.
Anything more?
Mrs. William before we start managing your symptoms, I would like to ask you few questions.
Some of the questions will be of personal & private nature. Let me assure you that whole
conversation will remain confidential between you & me & no body else will ever know about
it.
Is it ok with you.
Yes Doc. You can proceed. The symptom you have described are in conformity of
menupause.
Mrs. Willam you are 48 years old as you told me. In UK on average age of stoppage of periods
is 51 years.
May I know status of your menstruation.
When did you had your last periods.
Its been more than 1½ year that I did not have my periods.
When did you had your first period?
At about the age of 14 years.
Were they regular before they stopped?
No Doc. They first shortened by 10 days & then my period lengthened so much that I had
my periods after every 2 to 3 months.
I used to use 2 or 3 pads. Flows was normal but then it because scanty rather only spotting
occurred before they completely stopped.
_________________________________________________________________________
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1. Are you a person who worries a lot about minor things.
2. Do you have butter flies in stomach. (Yes) (Anxiety)
3. What about your mood (a bit low) (Depression)
4. What about your sleep. (disturbed due to hot flushes & sweating)
What about your desire to perform sex. (Its decreased)
PAST HISTORY & D/D
Any past history of removal of eggs producing organ (Ovaries). (No)
Any chest infection like TB in past. (No)
Did you had mumps. (Yes)
Did you had any Radio (or Chemo) therapy in past? (No)
Do you have any Neck gland problem.
Any kidney disease.
Do you know your blood Haemoglobin.
PERSONAL HISTORY
Do you smoke. (Yes about 1 pack a day)
Do you drink. (Yes mostly on week ends or parties but in safe limits)
(Good keep it up in 3 safe limits.)
Do you dope. (Any recreational drug) (No)
Do you have high Blood Sugar. (No)
What do you do for your living?
I am a School Teacher.
How are the things at school?
Just ok.
Do you have high Blood Pressure. (Yes. Mild Hypertension)
How are the things at home. (No stress, very peaceful)
FAMILY HISTORY
Is there any family history of early menupause running in your family. (Yes) (My mother also
had early manupause.
DRUG HISTORY
1. Are you taking any medicine regularly prescribed or over the counter. (No)
I used black cohosh to ease hot flushes. I also used evening primrose oil & ginseng but with
no or little relief.
2. Are you taking any (Ca++ Channal Blocker medicine) for high BP. (No)
Calcium Chennel blocker side effect is face flushing but I am taking ACE Inhibitor remipril
2.5mg onec a day.
ILLNESS IDEA – CONCERN - EXPECTATION
ILLNESS
How this condition has affected your life.
Its very uncomfortable.
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CONCERN
What worries you most in particular?
I read it on internet that with stoppage of periods my chances of having heart attack or
Fractures on minor trauma increase by 2 times.
INVESTIGATION
In order to confirm my diagnosis. I need to perform one blood test.
Its it ok with you.
Yes Doc.
I offer you Follical Stimulating hormone (FSH) level tested on 2 occations more than one
month apart.
FSH > 30 Ugm confirms Post Menstrual Women i.e. menupause.
Doctor I have done these tests on two occasion one month apart. My FSH reading is more
than 30 nenograms on both occasions.
MANAGEMENT
Mrs. William what I have gathered from your symptoms & FSH Report is that most probably
you are having a condition, what we call in our medical terms as early Menupause.
Do you know anything about Menupause.
Yes Doc. I know mensis stop in all women after certain age.
Mrs. William this condition occurs due to deficiency of female hormones called Oestrogen &
Progesterone. So logical treatment would be replacing deficient hormone from outside in the
form of medicines. This way of treatment is called Hormone Replacement Therapy.
This Hormone replacement therapy is not without side effects. These replaced hormone
increase the chances of breast & uterine cancer. This HRT can not be used for primary
prevention of thin bones or for prevention of heart attack. HRT is recommended until the
averge age of menupause that is 51 year.
So before resorting to HRT I offer you some life style changes & some simpler medicine. We
hope they will relieve your symptoms, which way you would like me to go first.
LIFE STYLE CHANGES
Avoid stress.
First try to some exercises like yoga or deep breathing.
Try to remain in cool ambient temperature.
Wear cotton cloths.
Avoid trigger food & drinks like spicy food, Alcohol or Caffeine. (Coffee & tea)
Please avoid smoking. Smoking forwards menupause by 2 years.
PHARMACOLOGICAL MEDICINE
1. I offer you a anti depressant medicine from SNRI group i.e. Venlafexin 37.5 mg twice
a day. This will help improve your mood beside hot flushes & sweating moderately. Is
it ok with you.
2. I also offer you vaginal lubricant i.e. topical oestrogen cream for local application. This
will help prevent vaginal dryness & recurrent episodes of UTI urinary infections.
3. I also offer you testosterone to improve your desire for sex.
Is it ok with you.
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SAFETY NETTING
If your symptoms did not improved, I may refer you to gynaecologist and psychologist for
CBT who may add some medicine.
FOLLOW UP
I offer you a 2nd follow up visit after one month.
Is it OK with you?
CLOSING & SEE OFF
Is there anything else you would like to share with me today?
No Doc.
Please don’t forgect to collect leaflets about your condition from reception desk.
I thank you for your cooperation & visit.
Good bye (smile & shakehand)
Oxfod – Page 710
Also read Menorhaegia from Oxford Page 708
__________________________________________________
PRIMARY DYSMENORRHOEA
No pelvic pathology. Starts 6-12 month after menache when an ovulary cycles are
established. Pain occurs during first 1 or 2 days of each periods.
Young women < 20 years with no other symptoms don’t require examination (unless
pathology is suspected)
In older women perform full abdominal & Pelvic examination.
SECONDARY DYMENORRHOEA
Secondry to some pathology – Pain starts just before the period & throughout the
periods. Associated with deep dyspareunia & vaginal discharge. Pelvic / Abdominal surgery
intro-ulterine Adhesions, cervical stenosis psychosexual problems.
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PRIMARY DYSMENORRHOEA (Painful Periods)
SCENARIO
Miss Julee Noor 16 years old presents with lower abdominal pain.
Take relevant history & do management. Examination not required.
Proceed:
MEET GREET & INTRODUCTION
Hello I am Dr. Raheel.
One of the GP in this surgery.
I am Julee Noor 16 years.
Ok Miss Julee how can I help you today?
Doc. I have cramp like pain in my lower tummy every month when my periods starts
& I have to skip my school due to pain. (Pain occurs during first one or 2 days only)
Is there any thing else you like to add?
Yes Doc sometimes I get vomiting & diarrhoea along with pain. This pain goes to my
back as well.
Anything more?
Before we start management of your pain I would like to ask you few questions. Some
of them might be very personal & private. Let me assure you that everything that we discuss
will remain confidential between you & me & no body else will ever know about it.
It is ok with you?
May I know your exact age?
I am 16 years old.
1. When did you had your first period?
I had it at the age of 15 years.
2. When did you had your last periods?
About 2 days ago.
3. Any bleeding in between the periods?
No.
4. Are they regular?
Yes 28 days.
5. How many days do they last?
3-4 days.
6. What about flow? Normal heavy or scanty.
Its normal. I use 2 or 3 pads per day.
Since when you are having painful period?
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When my periods started at the age of 15 years they were painless but now for the
last two months I have pain during first one or two days of my periods only.
Have you ever been to Gynaecologist.
No Doctor.
Any pervious investigations done.
No doctor I am healthy girl.
Are you sexually active? No Doc.
Are you using any form of contraception. (Only ask if sexually active)
PAST HISTORY
Do you have any mental or psychiatric problem? No Doc.
No Doc.
Any history of previous surgery on tummy like Appendisectomy.
Did you have any discharge from front passage in past. (STI) (No)
Any blood in stool (IBD)
FAMILY HISTORY
Is there any similar family history of painful periods.
Yes my mother used to have it.
PERSONAL HISTORY
Do you smoke. (No)
Do you drink – (No)
Do you dope (Any Recreational drugs) – No.
Do you have high Blood Sugar – (No)

Do you have high blood pressure – (No)
How are the thing at home.

No stress, very peaceful.
How are the things at University.
My exams are coming & I have to take leave due to pain. This causes little tension.
What about your mood – (Its normal fine)
What about your sleep – It’s a little disturbed
Do you like to exercise? – (No)
DRUG HISTORY
Are you taking any medicine at present prescribed or over the counter?
Yes I took paracytamol from over the counter but not much relief.
Are you allergic to any medicine? (No)
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IDEA – COUNCERN – EXPECTATION
IDEA: What do you think is the cause of your painful period.
I don’t know.
CONCERN: What worries you most in particular?
I am worried it could be something serious so I am consulting you.
EXPECTATION: What do you expect to gain from todays consultation?
You will find the cause & give me right medicine to fix it quickly.
EXAMINATION
Your age is less than 20 & you are not sexually active. You seems to be healthy
otherwise except pain during first 1 or 2 day of your period. So I am going to skip examination
except I would like to examine your back for any tenderness or obvious hump.
Would you please walk a few steps for me & back.
INVESTIGATIONS
Miss Julee in order to confirm my diagnosis I need to perform certain tests. How it
sounds to you if we arrange certain tests?
Is it ok with you? Yes doc.
I offer you abdominal & pelvic ultra sound.
Endo cervical swab for chlamydia & cervical smear. (No such test if not sexually active)
MANAGEMENT
Explanation & Reassurance
What I have gathered from the information you shared with me most probably you
have a condition what we call in our medical terminology as primary dysmenorrhea.
This is not a serious condition.
1. Pain occurs 6 months to one year after start of period when our ovaries start
producing eggs.
2. Pain occurs when our womb sequeses or contracts its blood supply is decreased
& pain occur.
3. Prostaglandis???
Life Style Changes
We can decrease your pain by certain life style changes & few medicines. Which way
would to like to go first.
Doc life style changes first.
1. Take planty of fluids.
2. Do regular exercise.
3. Avoid smoking.
4. When in pain, take warm bath. Sit in warm tub for a while. You can put hot water
bottle over lower tummy & squeeze it between legs & tummy. All these
changes help to decrease pain.
Medicines
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I offer you a tablet Mefenamic Acid 500mg thrice a day. Start taking medicine when
period starts. It not only decreases pain but also amount of blood loss. (If you were
sexually active then alternatively we have COC Pill.)
If you have any stomach problem I offer you omeprazole tablet 20mg once a day
alongwith Mefenamic acid.
Please visit me as soon as the reports of your ultrasound are available. I hope the
prescribed medicine will solve your problem but if your pain becomes severe or continues
beyond first one or two days of period, please seek immediate medical help.
CLOSING & SEE OFF
Is there any thing else you like to discuss with me today? (No doc)
You can get some leaflets about your condition from the reception desk.
Can get further information from internet.
Good bye. (Smile & shake hand)
256
POLYCYSTIC OVARIES (Hirsuitism)
Miss Sana age 22 comes to you with a problem.
Take relevant history and share management plan.
Proceed.
Polycystic Ovary syndrome case patient may present with infertility or hirsuitism
manage according to the cause.
Now a days polycystic ovary is known as polycystic syndrome.
This syndrome include acne, hirsuitism, weight gain, hair fall, infertility, oligomanorea
and anovolatory cycle.
Hello
I am Dr. Raheel
One of the GP in this surgery
May I know your name please? (Miss Sana 22 year)
Miss Sana how can I help you today?
* Doc I am very much worried, I have hairs on my face for the last 3 months. Have to
shave my hairs after every few days which looks very okward to me.
→ Doc – Miss Sana tell me more about your problem.
* Doc I am going to be married after 6 month time. It look very embarrassing for me to
have a face with beard on it. Kindly help me to getrid of these hairs.
→ Doc – anything else you want to share with me?
* No Doc that’s all.
→ Doc – Miss Sana In order to get more detail about your condition I need to ask few
questions. Our conversation may involve some personal and private questions. I
assure you all of our conversation will remain confidential. Is it ok with you.
* Yes its ok.
→ Doc – Shell we proceed.
* Yes.
Menstrual History
→ (1) Doc – thank you for trusting me. When did you have your first periods?
* At the age of 14.
→ (2) Doc – When did you have your last periods?
* About two weeks ago.
→ (3) Doc – Any bleeding in between the periods?
* No.
→ (4) Doc – Are your periods regular?
* No they are irregular.
→ (5) Doc – How is the flow?
* Normal.
→ (6) Doc – How many days they last?
* 3-4 days
→ (7) Doc – Have you noticed any such hairs any where else on your body besides
face? * No.
D/D
→ Doc – Any acute problems.
257
* No.
→ Doc –Which weather you like most?
* Not any in particular. Like both hot & cold weather.
→ Doc – Have you noticed any change in your voice.
* No.
→ Doc – Any change in your weight.
* I am obese. My BMI is > 30
PERSONAL HISTORY
→ Doc – What about your diet?
* Normal healthy diet.
→ Doc – What about your sleep?
* Normal.
→ Doc – Do you like to exercise?
* Yes occasionally.
→ Doc – Do you smoke.
* No.
→ Doc – Do you take alcohol.
* No.
→ Doc – Any Dope.
* No.
→ Doc – Have you ever been diagnosed of any major medical illness like high. B.P.,
high Sugar, any neck gland problem or any illness of the child producing organs.
FAMILY HISTORY
→ Doc – Any similar major medical illness runs in your immediate family members.
* No.
ILLNESS
→ Doc – How this condition is affecting your daily routine life.
* I need have to shave my beared frequently most of the time and I am now shy while
going to public places. Avoiding parties & social gathering.
IDEA
→ Doc – What you think about your condition.
* I think that I have eaten some wrong diet.
CONCERN
→ Doc –what worries you most in particular
* My fiancy might leave me.
EXPECTATION
→ Doc – What do you want to gain from to-days consultation.
* You will find out the reason and help me get rid of these hairs.
SUMMARIZE
Miss Sana the information you have just shared with me I would like to summarize if
anything left, kindly add to it.
258
For the last 3 month you have noticed some hairs on your face and you need to shave
them off & on. You are going to be married in six month time and you are worried that
your fiancy might leave you. So you want to get some solution soon.
Is that all or you want to add something to it?
* that’s all doctor.
INVESTIGATIONS
→ Doc – Miss Sana in order to reach my diagnosis & find cause of your symptom.
How it sounds to you if we arrange some tests for it.
* Yes its ok.
→ Doc – I am offer you some blood tests.
FSH on third day of your period
LH on third day of your period
Progesterone on 21st day of your period
Blood C/E
Neck gland test (TFT’s)
I am offering you an ulstrasound scan to look into the condition of child
producing organs of the body.
* yes.
→ Doc – Is it ok with you.
* Yes.
→ Doc – We will arrange a follow up visit soon after the report come.
* Yes.
→ Doc – We might need a referred to the specialist after the report.
* Ok.
_________________________________________________________________________
→ Doc – In the meantime much can be done to improve your condition some are life
style measures & some are medicines, which way one would you like to me to go first.
* Life style measures please.
→ Doc – Ok try to take healthy diet, fresh fruits & green vegetables at least five
portions a day.
Can you take.
* Yes.
→ Doc – Try to exercise atleast 30 minutes a day atleast 5 days a week.
Can you do it?
* Yes Doc I will try.
→ Doc – Take proper sleep 6-8 hours
Can you manage?
* Yes I can.
→ Doc – You are already shaving the hairs, I offer you some other option like
Beleching, electrolysis, laser therapy.
259
Coming to the medicine part of it
Apply eflonethene cream after waxing or bleeching or hairs.
I offer you eflornethene cream.
It will minimize the growth of excess hairs.
Topical eflornithine cream decreased growth of unwanted facial hairs. Continuous use
for > 2 months is required before benefit is seen.
Must be used indefinitely to prevent regrowth. Discontinue if no improvement in 4
months.
OTHER OPTIONS ARE
COC pill containing desogestel or co-cyprindiol, spiro nolactone help.
Is it ok.
* Yes Doc.
→ Doc – Anything else you want to ask about your condition today.
* No thank you Doc.
→ Doc – Ok. We will meet when the reports come. We might need referal to specialist.
Take some reading material from the reception desk. More information about your
condition can be taken from the internet.
Thank you very much for your cooperation and good Bye (nodding)
________________________________________________________________________
If patient produces report of Ultrasound showing string of pearl sign, diagnosis of PCO
is confirmed, > 12 cysts of 2 to 9 mm in diameter in each overy & or ovarian volume > 10 cm
3
cubic milimeter
Offer:
(1) Metformin 500mg twice a day.
(2) Clomifine if infertility (to induce ovulation).
(3) COC pill to regulate menstruation. COC pill with antiandrogen e.g.
Co-ciprindiol may decrease Acne & Hirsutism (hairs on face)
(4) I offer HbA1c check annually if obese (BMI > 30) & family history of DM
or age < 40 years.
SAFTY NETTING
Polycystic ovary syndrome is associated with increased risk of high blood sugar so
keep cheking fasting blood sugar also HbA1C annually. If you are pregnant with PCO you
will be tested for gestational diabetes with oral glucose tolerance test at less than 20 week of
gastation.
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MENORRHAGIA
Hello,
I am Dr. Raheel.
One of the family physicians in this surgery.
I am Mrs. Ashraf.
Ok Mrs. Ashraf what brings you to the surgery today?
___________________________________________________
Well doctor I think I am loosing excessive blood during my periods. I have to use more than
3 pads/day. There is flooding of blood & I pass clots. Sometimes I have to wake up at night
to change pads. Sometimes I have to use double protection in order to prevent leakage.
Would you like to add anything more. (No that’s all).
_____________________________________________________
Mrs. Ashraf before I come to the management part, I need to ask you few questions. Some
of the questions will be of some private & personal nature. I assure you that the whole
conversation will remain confidencial between you and me.
Ok doctor you may proceed.
So you have heavy flow & pass clots as well.
Are your periods regular? (Yes 28 days)
(Regular cycle suggests that ovalution is taking place.)
May I know how long do your periods lasts?
For 3 to 4 days but flow is heavy.
Are they painful as well? (Yes)
Is there any intermenstrual bleeding? (No)
Is there post-Coital bleeding? (No)
Are you using any contraception like IUCD? (No)
If using COC combined pill, have you stopped taking COC pills. (Not using COC)
What about your PAP Cervical smear? (Its upto date & normal).
Are you using any Anticoagulation medicine like aspirin. (No)
Any problem with neck gland like hypothyroidism? (No)
Is there any diagnosed pelvic inflammatory disease like endometriosis? (No)
RED FLAGS
Your exact age is over 40 years May I know if you have abdominal or tummy pain inbetween
your periods.
Any Abnormal pap smear?
Any sever pain during periods.
PAST HISTORY
Did you ever had treatment of excessive bleeding in past. (No)
ILLNESS
It affects my quality of life & daily routine. I feel fast heart beat & Maliase Fatigue.
IDEA
What do you think is the cause of your heavy bleeding. (I don’t know)
CONCERN
Is there any thing you are worried about specifically?
I am worried I might have uterine cancer or may need removal of uterus to stop excessive
bleeding.
261
EXPECTATIONS
Some symptomatic relief for excessive bleeding & pain.
1. Colour of skin. (Pale)
2. Pulse (Fast heart beat)
3. Blood pressure – Any dizziness on standing from sitting position. (No) (Postural
Hypotension)
4. Palpate tummy for any obvious masses. (Yes)
5. Enlarged uterus suggests fibroids. (Yes)
May I know examination findings?
INVESTIGATIONS
In order to confirm my diagnosis I need to perform certain tests.
Hb
FBC
Cervical Smear
Thyroid Function Tests
Coagulation Screen
Oestrogen & Progestrone hormone Level
Ultra Sound Abdomen & Pelvis.
Transvaginal ultra sound for any structural abdomality.
May I know results of tests if done already?
MANAGEMENT
From the information you have shared with me & from examination & investigations findings,
most probably cuase of your painful excessive bleeding are Multiple fibroids. Fibroids are
simple non-malignant muscle tumors of your uterus. Fibroids not only cause excessive
bleeding and pain but also make pregnancy to occur difficult. If pregnancy has occurred and
fibroids is near the opening of the womb, they can cause some difficulty in delivery and severe
bleeding.
1. For symptomatic relief I offer you Mefenamic acid tab 500mg thrice a day. Start on day
one & continue for days of heavy flow. Mefenamic Acid will not only decrese the
bleeding per cycle but also pain during the periods.
2. I also offer Transemic Acid 1 to 1.5gm thrice a day to reduce bleeding.
3. Some drugs like Ulerpistal Accetate can be used to shrink the fibroid size.
4. Hormonal treatment in the form of IUS may be effective in reducing menstrual
bleeding.
5. For definitive treatment I offer transvaginal removal of Fibroids. A procedure called
hysteroscopic resection of fibroids (also called myomectomy). For this I will refer you
to gynaecologist.
SAFTY NETTING
(If excessive bleeding please seek immediate medical help)
You may need to be referred to the gynaecology department.
FOLLOW UP Hope to see you next month
Is it convenient for you.
_____________________________________________________
Bleeding of more than 80ml per cycle (Per month) is called menorrhagia (Excessive bleeding)
DUB
Excessive menstrual blood loss in the asbsence of any detectable cause is called
Dysfunctional uterine bleeding.
262
PRIMARY AMENORRHOEA &
SECONDARY AMENORHOEA
PRIMARY AMENORRHOEA
No Mentruation by the age 16 years when growth & secondary sexual characteristic
development is normal.
CAUSES
1. May be Absent uterus as congenital abnormality in cousin marriage.
2. Imperforated Hymen
3. Transverse Vaginal Septum
4. Congenital chromosomal abnormality like turner’s syndrome.
5. Pitutary tumor prolactinoma
SECONDARY AMENORRHOEA
Absence of mensis for more than 3 months in a previously menstruating women.
Consider possibility of pregnancy.
Ask is there any chance you could be pregnant or If lactating or has menupause.
Other causes may include.
TB
Mump Infection
Weight decrease or increase may cause amenorrhoea.
Ask if she is deliberately trying to loose weight by vomiting, inducing purging, doing excessive
high intensity exercises
BMI < 19kg/m2 common cause
There may be family history of late menarche (Delayed puberty)
There may be family history of early menupause.
There may be uterine cervical stenosis or intrauterine syneche.
Any past history Chemo or Radio therapy.
Any gynaecology surgery e.g. removal of uterus.
Cyclical pain may suggest out flow obstruction.
Hirsuitism Acne may suggest P.C.O.
Life crisis or upsets like exams or berevements.
DRUG HISTORY
In case of injectable progesterone contraception, periods may not return more than one year
after stopping injections.
Drug history of heroin or methadone
Domperidone or metoclopramide or cimetazine or
Haloperidol or clozapine
EXAMINATION
Fine tremors
263
BMI < 19 kg/m2 (weight)
External genitalia Abnormality
Secondary sexual characteristics like breast growth, public Axillary hairs
Uterus mass
Ovarian masses on tummy palpation.
Web Neck
Short Stature
May I know examination findings.
NOTE
For young girls less than 20 year replace pelvic / vaginal speculum examination with per
abdomen pelvic ultrasound if not sexually active.
INVESTIGATIONS
Serum prolactin
TFT
LH / FSH
Serum testosterone if LH high
Transvaginal Pelvic Ulterasound
Karotype DNA for Tunner Syndrome
May I know results of tests if already done.
MANAGEMENT (Treat cause)
The information you have shared with me. I think most probably cause of your secondary
amenorrhoea is Anorexia Nervosa.
You are deliberately trying to reduce weight.
You think you are fat while others believe you are thin.
Your BMI is <17.5 kg/m2.
I offer to ref you to special eating disorders clinic.
Eat healthy diet. I refer you to dietician who will make you learn refeeding I/V or parternely
Doctors in eating disorder clinic may monitor your heart with ECG if they gave you any
antibiotic or Anti psychotic medicine.
I also reffer you to Psychologist for talking therapy called cognitive behavior therapy so that
you become aware of your problem. CBT will change the way you think, feel & Act or behave.
SAFTY NETTING
FOLLOW UP
After discharge from eating disorder clinic. I will continue to take care of your physical &
mental health annually.
Closing 5 sentences 10 secons.
264
SEXUALLY TRANSMITTED VAGINAL DISCHARGE
1. Chlamydia
2. Gonorhhoea
3. Tricomonas Vaginalis
CHLAMYDIA (Oxford 740) (5th Edition 716)
CLEAR DISCHARGE
Symptoms
In Infants:
If mother suffer from chlamydia Infection then 1 in 3 affected mothers have affected
babies symptom include ____ Conjunctivitis, Pneumonia, Otitis Media, Pharyngitis
Seek eye specialist advice. If suspected.
In Men:
Usually asymptomatic. May have urethritis (Pain while passing urine)
In Women:
> 70% asymptomatic
Symptoms could be
Vaginal discharge (30%)
Dysuria Read Chalamydia infection
Post – Coital Bleeding from 5th Edition Page 716
Intermenstrual bleeding
Pelvic Inflamatory disease.
On Examination:
Mucopurulent cervicitis
Hyperaemia & Odema of cervix
Contect Bleeding
Tender Adnexae
Cervical excitation
Investigations
In Men:
Urethral Swab for NAAT or First catch urine sample for NAAT
NAAT (Nuclic Acid Amplification Test)
In Women:
(i) If asymptomatic send self taken vulvovaginal swab for NAAT
(ii) If Symptomatic send Endo cervical swab for NAAT
Whether Male or Female if exposed to potential reinfection in less than 2 weeks time
then repeat NAAT test more than 2 weeks after exposure.
Pharmacological Management
(i) Doxycycline 100mg twice a day for 1 week.
(ii) Or Azithromycin 1gm once only by mouth.
(iii) Or Erythromycin 500mg 6 hourly for 2 weeks
During pregnancy & Breast feeding.
Erythromycin 500mg 6 hourly for 2 weeks.
Chlamydia is a major preventable cause of pelvic pain & Infertility. GP should supply
home-testing kits to patients who are at high risk of STI.
In UK self testing kits are available through GP surgeries, sexual health clinics &
contraception clinics & community venues e.g. schools.
265
YELLOWISH WHITE MUCOPRULENT DISCHARGE
GONORRHOEA
(5th Edition Page 717)
Hello.
I am Abdullah 45 year.
Ok Mr. Abdullah how can I help you today.
Dr. I am a business man. I was on a visit to India. I became intimated with a lady and
we had an unprotected inter course one week ago. Later I came to know the lady was
infected prostitude.
Now I am having yellowish white Mecuprulent discharge from the urethra and I also
have pain while passing urine. Also I have some anal discharge and perianal
discompfort.
Symptoms Presentation depend upon sight of infection.
In Men:
(i) Urethral Infection
Urethral discharge (80%) Yellowish white mucopurulent urethral discharge
Dysuria (50%) Pain while passing urine
Prostatitis & urethral stricture 2-5 days after exposure.
(ii) Rectal Infection:
Usually asymptomatic
Anal discharge (12%)
Anal / Perianal pain or discomfort
(iii) Throat Infection – More than 90% asymptomatic
In Women:
Asymptomatic (50%)
Vaginal discharge
Dysuria but Not frequency
Lower tummy pain
____________________
Abnormal vaginal bleeding - Miscarriage

Pelvic Inflamatory disease - Preterm labour
Abscess of Bartholin’s gland
(ii) Rectal Infection – Usually asymptomatic.
(iii) Throat Infection – Usually asymptomatic.
__________________________________________
Do you have any fever, (No) any body ache (Yes) and joint pain (no), any history of
homosexuality? (no)
Do you have high blood pressure? (No)
Do you smoke? (Yes) heavy smoker
Do you take alcohol? (Yes) Heavy drinker.
266
INVESTIGATION
In Men:
(i) Asymtomatic – Send first catch urine sample for NAAT (Nucleic Acid
Amplification Test)
(ii) Symtomatic – NAAT plus M, C/S with swab from Urethral, Rectal or Throat,
Swab as appropriate.
In Women:
(i) Asymptomatic – Send self taken vulvovaginal Swab for NAAT
(ii) Symptomatic – Send Endocervical Swab ± rectal ± Throat Swab for NAAT plus
M, C & S
Injection ceftriaxone 500mg IM as single dose plus Azithromycin 1gm once by mouth.
Paracytamol for body ache.
After treatment
(i) If persistent S/S after treatment test for cure with swab sent for M, C/S >72
hours after completin of therapy.
(ii) If asymptomatic following treatment, test for cure 2 weeks after treatment
completion with NAAT, followed by culture if NAAT positive.
(iii) If persistent infection seek specialist advice.
Please restrict yourself to your partner. Practice safe sex.
Doc. My wife is asking for sex. I am avoiding and hiding my secret.
Please tell your wife yourself about your venture and her confidence. You might have
transmitted the disease to her already. I can help in revealing the truth in couple counseling if
you like.
SAFE SEX
• Use condoms for all types of penetrative sex (vaginal, anal, oral sex)
• Have non-penetrative sex (e.g. body rubbing and mutual masturbation)
• Test for STIs before having sex with someone new, and suggest they are also tested
• Restrict number of partners to as few as possible.
• Get vaccinated against certain infection e.g. hepatitis A/B.
• Prophylactic antivirals to prevent HIV if in a high risk grou.
• Avoid sex when under the influence of alcohol / recreational drugs.
CONTACT TRACING
Best done by SH clinics. If a patient refuses to go, provide a letter to give to contacts
stating the disease involved, treatment given, and suggesting cotacts visit their local SH clinic
promptly.
267
TRICHOMONAS VAGINALIS (TV)
(Oxford page 716 & 717)
(Frothy Yellow Discharge, Offensive Odour)
Symptoms:
In Neonates
Purulent discharge from eyes of an infant less than 21 days.
In Men
50% may be asymptomatic
Dysuria
Urethral discharge
In Women
50% may be asymptomatic
Dysuria
Abdominal pain
Vaginal discharge (25%)
Frothy yellow discharge offensive odour discharge vulval itching or vulvil ulceration,
vulvitis and vaginitis. 2% have classic strawberry cervix.
Soreness_____Positive (vulvovaginal soreness)
Itch___Positive (vulvovaginal itch)
Examination__Strawberry cervix
On PH > 4.5 PH of secretions with narrow range pH paper.
Investigations
In Neonates
Send eye discharge swab for NAAT & M, C&S If confirmed, seek immediate specialist
advice.
In Men:
Urethral swab
First void urine for culture
In Women:
On examination – Strawberry cervix
High vaginal swab from posterior fornix at the time of speculum examination for M,
C&S and NAAT.
- If HV Swab is –ve. Consider Referal to Gum Clinic for wet microscopy & contact
tracing
- Rarely detected on cervical smear
1. First line treatment is with metronidazole 400mg twice a day for 5 to 7 daysor 2g once
only.
2. If treatment fail repeat 7 day course of Metranidazole.
3. If 2nd course fail give metronidazole 800mg thrice a day by mouth for 7 days.
Important Advice
Avoid sexual intercourse until patient & their partner have completed treatment &
cleared on follow up. Offer to refer to Gum clinic for contact tracing.
Side effects of metronidazole (Metalic Taste in mouth
_________________________________________
Bacterial Vaginosis (BV) & Trichomonas Vaginalis (TV)
Same treatment metronidazole.
268
NON-SEXUALLY TRANSMITTED VAGINAL DISCHARGE
(Grey white thin discharge, Fishy smelling)
1. Bacterial Vaginosis (BV)
2. Candidiosis
BACTERIAL VAGINOSIS (BV)
Symtoms Vaginal flora is changed from lactobacilis species to anaerobes.
10 to 40% of premenopausal women affected by BV about half of those women are
asymptomatic. ↑ risk of preterm delivery (Risk ↓ if treated)
Development of PID & Endometritis following Abortion or birth. post –infection after
Hysterectomy.
Vaginal Discharge
Color Grey – White
Consistency Thin
Smell Fishy – Smelling Offensive Discharge
Soreness No Vulval Soreness
Cervix on Examination Looks Normal
pH pH > 4.5 with Narrow-Range pH paper (BV or TV likely)
Investigation
High vaginal swab (HVS) for M, C&S confirm diagnosis.
Treatment
Treat without swab if:
(i) No examination is carried
(ii) pH is > 4.5
(iii) Clinical Picture typical of BV
(1) Metronidazole 400mg BD for 5-7 d or 2 gm single dose.
(2) Clindamycin 2% cream 5gm at night per vagina for one week
Recurrent Infection Treatment
Metronidazole 400mg BD for 6 days to cover each period or Metronidazole 0.75% gel
2 times/week per vagina for 4 to 6 month or Lactic Acid gel Alternate nights for one months.
PV Probiotics evidence of effectiveness lacking.
PH more than 4.5 in Bacterial Vaginosis and Tricomonas Vaginosis.
Bacterial Vaginosis Tricomonoas Vaginosis
Treatment Metranidazole tablet 400mg 5-7 days or 2g single dose.
Both bacterial vaginosis and trichomonas vaginosis have PH >4.5.
______________________________________________
Non Sexually Transmitted Sexually Transmitted

Vaginal Discharge Vaginal Discharge
1. Bacterial Vaginosis (BV) 1. Chalamydia
2. Candidiasis 2. Gonorrhea
3. Tricomonas
269
CANDIDIASIS (THRUSH) FUNGAL INFECTION)
(Oxford 5th Edition 713)
(Thick Creamy white, Cottage Cheeze Type Discharge)
(No odour)
Ask:
H.o Antibiotics Immuno compromise person
Steroids treatments Patient gives history of taking anti biotic for
Immunosuppression Sorethroat recently also he is on inhalor for
DM Asthma containing steroids.
Radio / Chemo Therapy Smoking positive
Pregnancy HIV Positive
Vaginal Trauma Diabetes Mellitus Positive
Cushings or Addisons disease Steroid Inhalor positive
Symptoms
(1) Vaginal discharge
(2) Consistency_______Thick creamy discharge
(3) Smell____________Non-Offensive
(4) Soreness_________Sore Vulva which may be cracked or fissured
(5) Color_____________Cottage cheese white
(6) Vulva Soreness positive
(7) Itch or pruritis

(8) Superficial dyspareunia (Pain during intercourse)
CANDIDIASIS VAGINAL DISCHARGE CHARACTERISTIC
Investigations
- Usually unnecessary
- If infection persist or recurs, Send swab from Anterior fornix for M, C&S
Non-Pharmacological Management
Wear loose cotton underwear.
Avoidance of soap, perfumes or disinfects in the bath.
Apply Emollient to treat vulvul dermatitis.
Pharamacological Management
- Treat only if symptomatic
- Clotrimazole pessaries (cure rate 90%)
- Alternate is Fluconazole tablet 150mg once only.
- If sever infection repeat once only after 3 days (83% cure rate)
- Fluconazole contraindicated in pregnancy & Breast feeding.
Recurrent Infection
4 or > 4 documented episodes in one year, with 2 or > 2 confirmed with microbiology
then Fluconazole tablet 150mg every 3 day for 3 times only, then 150mg weekly for 6 months.
Sexual Transmission
Can my partner get this infection from me?
No. Sexual Transmission is minimal.
Should my partner also be treated?
No need or benefit from treating partner unless overt infection.
270
HIV COUNSELING
Goal of HIV Counseling
To provide psychosocial support
To prevent HIV transmission
Objectives of HIV Counseling
To provide information
To help infected people handle possible emotional reactions
To facilitate individualized courses of action by patient / family
To facilitate behavior change
To assess risk of HIV infection
HIV Counseling Process
Introduction:
Greet the patient
Introduce yourself
Emphasize confidentiality
Explain the counseling process (What will be done today)
Assessment
Ask the patient:
Ideas, expectations, concerns
Who else knows
ILLNESS
How does it affect his/her life?
Listen, Allow Catharsis, `Ventilation’
Intervention
Working together:
Identify initial and later priorities
Identify options for immediate management
Identify `needs’ for later management
Emphasize prevention
Identify other appropriate support
Summary
Emphasize the “Open door”, “Ensure Continuity of Care”
271
PREVENTION & TESTING FOR HIV
This station may come as breaking bad news or as counseling. Patient may
present HIV report and is worried about having AIDS.
Hello, I am Dr. Raheel one of the family physician in this suregery. May I know your
good name please.
I am Abdullah 30 years.
Doc. I am a lab technition worker. I was drawing blood for a patient when I had an
accidental needle stick injury about one hour ago. Later I came to know that patient was a
known patient of Aids. I am worried that I might also contract Aids due to needle stick injury.
PLEASE UNDERSTAND THE DIFFERENCE BETWEEN HIV / AIDS
HIV – Human imuno-deficiency virus
AIDS – Acquired Immuno-deficiency syndrome
Remember the difference between HIV infection and AIDS disease.
Screening for HIV only tells that you have been exposed to this virus. You may never
develop full blown AIDS because of newer prophylactic treatments.
HIV infection may take 10-20 years to convert into AIDS.
You can have support from your family & friends.
There are many AID support organizations.
I can provide you written information literature about HIV and AIDS.
PERSONAL HISTORY
May I ask you few Personal Questions if you don’t mind? It will remain confidential
between you & me (Always take permission before personal confidential questions).
Are you married. (Yes)
Have you got any extra marital relations. (No)
What about your sexual practices (Vaginal, Oral, Anal).
Did you indulged in high risk sexual activity e.g. vaginal or anal sex without condom
with local residents in high prevalence area.
1. Do you have multiple sex partners.
2. Did you had any blood transfusion recently without testing for HIV virus.
3. Do you share needles for I/V drug abuse.
4. Do you remember any accidental needle stick injury.
5. Any travel to India or Africa or high prevalence area of HIV.
MANAGEMENT ACCIDENTAL EXPOSURE (Not curable but controlable)
If you had accidental exposure by needle stick injury then risk of HIV infection is 1 in
300 and risk is 1 in 3000 if blood is splashed over skin or in eye or mouth.
Exposure is significant if source is HIV +ve & the material is blood or semen or amniotic
fluid or genital secretions or CSF.
1. If accidental exposure has occurred, irrigate the site of exposure with running water.
272
2. Take blood sample from source and victim and establish potential risk of HIV.
3. Take blood for other STIs e.g. Hepatitis B&C, syphilis.
4. Refer to aid clinic for the start HAART treatment within one hour and continued for 4
weeks. If HIV subsequently confirmed?
5. Avoidence of breast feeding, anti-retro viral therapy and appropriate management of
delivery decrased risk of transmission to less than one percent. A detail fetal anomaly
scan is important if this is first trimester exposure.
Remember testing for HIV is entirely voluntary. I will need an informed written consent
before testing & you need to come back in person for for collection of results. Do you know
pros & Cons of testing for HIV e.g.
ADVANTAGES OF TESTING FOR HIV (PROS)
1. Anxiety due to uncertainty about HIV status, is ended.
2. Effective therapy is available, which improve the prognosis.
3. Knowing the result means that partner can be protected.
4. Can make a decision to move to safer sex.
5. Decision about pregnancy can be made.
6. Informed decision about medical issues, such as like live vaccines can be made.
(BCG Yellow Fever)
DISADVANTAGES OF TESTING FOR HIV (CONS)
1. If +ve, patient will need to cope with a devastating diagnosis.
2. A +ve result, may affect insurance and employment prospects.
3. HIV test is now offered to all pregnant women. Written information about the pros
and cons of test are available.
INVESTIGATION
As you have needle stick injury, I offer you a HIV screening test.
HIV antibodies can take 3 months to develop after HIV infection exposure. Test may
be –ve. If it is –ve, we will repeat the test in 3 months time.
If the test turns out to be +ve, then we will confirm the test with more specific test called
western blot test.
Choice of drugs is a specialist decision. A combination is usual (known as ‘highly active
anti-retroviral therapy’ or HAART). Adherence to therapy is essential to avoid
resistance. The aim is to decrease viral load to an undetectable level in <6 months.
Response to treatment is measured with viral load, CD4 count, and CD4 percentage.
Treatment failure requires switching or increased therapy. Do not stop/change dose
of ARDs without taking specialist advice.
CD4 COUNTS AND HIV RELATED PROBLEMS
CD4 Count Risk of opportunistic infection
(Cells /mm3
> 500 Minimal risk of opportunistic infections
200-500 Little risk of opportunistic infection unless falling reapidly, except TB
<200 Increased risk of serious opportunistic infection e.g. Pneumocystis
Pneumonia, Toxoplasmosis, Oesophageal candidiasis
<100 Fear over whelming infection
273
PREVENTION OF HIV INFECTION
Non pharmacological prevention:
1. Always have safe sex and use condoms.
2. Limit your self to your wife or partner.
3. Try to check blood for HIV infection before transfusion.
4. Do not share needles for I/V injection of drugs.
5. If got a needle prick injury, immediately wash it with running water.
6. If you are HIV +ve then it is better to tell your wife. Take her into confidence & try
to have her tested also. She might have contracted HIV already from you. If not
she can be protected by practice of safe sex.
7. You will need your wife support in the future management of HIV and AID disease.
So it is better to tell her yourself. If she comes to know about it from some other
source, her reaction can be worse than you can expect. If you tell her yourself she
will be more sympathetic and caring about your health.
8. Don’t eat uncooked meat or salads.
9. Don’t drink un-boiled tape water to avoid Toxo Plasmosis and Crypto Sporidial
diarrhea.
SIGN SYMPTOMS (SAFETY NETTING)
Tell the patient if he develops symptoms like:
Fever
Fatigue
Myalgia / Arthritis
Lymphadenopathy.
2. More specific symptoms include Blotchy violet rash affecting trunk
3. Oro genital / perianal ulcerations
4. Rarely aseptic meningitis or diarrhoea.
5. Oral condidiasis or shingles may occur due to immuno suppression.
6. Most patient are asymptomatic may include night sweats & Lymphadanopathy.
7. Advance HIV may present with opportunistic infections like pneumococcal
infection T.B., Toxoplasmosis, Pneumocystis pneumonia cryptosporidial
diarrhea and AIDS associated malignancies (e.g. Kaposi Sarcoma, Lymphoma.
Please seek immediate medical help if you develop any of the above symptoms.
FOLLOW UP (Talk about continuity and stigma)
I offer you a 2nd follow up visit afer one month. I will continue to take care of you though I
am referring you to a specialists AIDS clinic for treatment. They will give a combination of
3 anti retroviral drugs called HAART Therapy.
Adherence to therapy is essential to avoid resistance.
Treatment failure require switching or increasing therapy.
Do not worry about stigma attached to HIV infection. Community offer great support both
for victim and carer also.
Is there anything else you wish to discuss with me today? (No)
274
You can contact me if you have any queries any time. (Open door continuity of care)
I will follow up your care once you been to aids specialist clinic.
Good Bye (smile and shake hand)
You can shake hand with Aids patient but never with rabies or scabies patient.
HIV – Human Immunio Deficiency Virus

AIDS – Acquired Immunio Deficiency Syndrome
275
POST PARTUM CONTRACEPTIVE ADVICE (PARTICULARLY PILLS)
SCENARIO
Mrs. Smith 22 years gave birth to a baby girl 6 weeks ago. She wants some sort
of contraception. She does not want to feed her baby any more. Kindly manage
proceed.
Meet Greet
Introduction
How can I help you?
Doc. I gave birth to a baby girl 6 weeks ago. I do not want to breast feed her any more.
I need some sort of contraception, please guide me.
Congratulations on having a beautiful baby.
What do you know about contraception? (Some method of preventing pregnancy)
For how long you need contraception? (2 year)
Well we have many options like pills, injections, implants, coils, devices, condoms.
What you are interest in? (My husband told me to go for pills.)
Before I explain something about pills, in a order to find your suitability for pills I would
like to ask some questions.
(Ask permission first and ensure confidentiality) May I ask you few private question.
Let me assure you that all conversation will remain confridential between you and me. No
body else will ever know about it. (Ask only once in the beginning)
1.SEXUAL HISTORY
Purpose is find out suitability of pills, wheather pills are suitable for you or not.
(1) Are you sexually active? (Yes)
(2) Since when you are sexually active? (Since 18 year of age)
(3) Do you have a stable partner? (Married or limited to one person) (Yes I am Married)
(4) If multiple partners, ask what type of sex do you indulge into (Oral, vaginal or anal)
(What about your sexual practices) (Vaginal only)
(5) Are you using any form of contraception? (If yes then what type and for how long)
(Using regularly or occationally) (Husband uses condoms)
(6) Either you or your partner have ever been diagnosed or investigated for any discharge
from front passage.
(7) Have you and or your partner ever had a sexually transmitted disease such as
Chlamydia, gonorrhea, syphylis, HIV & was it treated successfully?
MENSTRUAL HISTORY
When did you had your first period? (At the age of 14)
When did you had your last period? (About 4 weeks ago)
Any bleeding in between periods? (No)
Are they regular? (Yes, 28 days)
How many days do they last? (3-4 days)
What about flow? Is it normal, heavy or scanty? (Normal 2-3 pads/d)
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How many pads do you have to use everyday (Normal, heavy or scanty) (2-3 pads /
day)
3. OBSTETRICAL HISTORY
How many times you have concieved so far. (2 times)
How many live children? (2 children)
Any mishap like miscarriage or abortion? (No)
Are you currently breast feeding? (No)
Is there any chance that you could be pregnant again? (No)
Any problem during pregnancy? (No)
Any complication during labour & delivery? (No)
Any complication after birth? (No)
SUITABILITY AND CONTRAINDICATION
Explain I need to ask you few more questions to find out whether pills are suitable for
you or you need any other form of contraception.
ASK ABC HILS FORMULA
A- Age more than 35 years and smoking (22 years Non-smoker)
B- Are you breast feeding currently. (No)
B- Blood pressure more than 140/90 (Its 120/80)
B- BMI more than 39 (25)
C Cervical Cancer or Breast cancer (No)
H- Headache, Paralysis. TIA Migraine (No)
I- Ischemic Heart Attack, PE, DVT
L- Any Liver Disease (No)
S- Smoking means more than 15 cigarettes per day + age more than 35 years
DRUG HISTORY
Are you taking any sort of antibiotic or any medicine for fits?
Combined contraception may interact with hepatic enzyme inducing drugs leading to
decreased efficacy e.g.
Rifampicin & griseofulvin
Anti convulcents like:
Phenytoin, Carbamyzepine, Phenobarbital, Topiramate
Anti viral e.g. Nelfinavir
St. John’s Wort
SO YOU ARE A SUITABLE CANDIDATE FOR PILLS
EXPLANATION
Combined Oral contraceptive pills contains two hormones Oestrogen and
progesterone which are similar to what our body produces.
COC pill works by changing the body’s hormone balance so that you don’t release an
egg from ovary. It also makes it difficult for sperms to enter womb.
Also making it difficult for fertilized egg to attach to uterus lining.
METHOD OF TAKING PILLS
Contraceptive effect starts immediately.
If started 1-5 day of cycle.
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If starting at another point in cycle, use additional contraception for first 7 days of use.
Take one pill once a day for 21 days then a break for 7 days for withdrawl bleeding.
MISSED COC PILL
1. If one pill is missed for more than 24 hours any where in the pack, Take missed pill as
soon as possible even if it means taking 2 pills in one day.
Continue take rest of the pack as usual.
No additional contraception needed .
Take 7 day break as normal.
2. If 2 pills missed in 1st week of the pack and unprotected sexual intercourse has
occurred in previous 7 days then emergency contraception is needed.
3. If 2 pills missed in last week of pack i.e. few active pills are remaining continue to finish
active pills start new pack without having a 7 day pill free period.
EFFICACY
99% efficacy.
To ensure 99% efficacy take pill on same time every day.
If you miss pill take the pill as soon as you remember, continue to take regular pill at
its time.
If you vomit within 3 hrs take another pill as soon as possible.
ADVANTAGES
Improves Acne
Decreased menstrual pain and bleeding
Decreased premenstrual syndrome symptoms
Decreased menupausal symptoms
No evidence weight gain
COS Pill reduces the risk of Ovarian Bowel and Endometrial Cancer
RISK OF COC PILLS
Venus thromboembolism
Ischemic Stroke
Breast and Cervical Cancer
Mood Changes but no increase in depression
SIDE EFFECTS
Nausea
Vomiting
Mood alteration
Increase B.P.
Increase B.S.
Pimples
Paralysis
SAFTY NETTING
Stop COC pill immediately if sudden sever chest pain, sudden breathlessness, pain in
calf of one leg, Acute tummy pain, Bad fainting attack or unexplained collapsed. Jaundice,
liver enlargement, yellowness of eyes, B.P>160/95mm Hg.
CLOSING
You are suitable candidate for COC and POP Pills. You can also take progesterone
hormone in the form of injections and implants. The option of having coil in the womb is also
valid for you if you want long term contraception.
Just take the information leaflet from the reception desk. Read them at home.
They are in much more detail than we have discussed. Go home and discuss with your
husband or partner and come back in about one or two weeks time with your decision.
I will facilitate whatever is your decision.
Is there anything else you would like to ask me today? (No)
Thank you for your cooperation and Good bye.
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DIFFERENCES OF COC & POP PILLS
COC Pill POP Pill
Contraindications of COC Pill Contraindications of POP Pill
Formula A, B, C, HILS • Weight > 70kg
A Age > 35 years & Smoker (Obesity Contraindicated)
B Breast Feeding not wanted has to take 2 Tab. Instead of 1
B Blood Pressure > 140/90 • Shift Worker (Strict time observation
B BMI > 39 not possible for shift workers.
C Cancer of breast & Cervical Cancer
H Severe Headache & Migraine Stroke
TIA
I IHD DVT PE
L Liver Problem
S Smoking
Starting COC Pill Starting POP Pill
Contraception begins immediately Contraception begins immediately
Starting taking pill on 1-3 day of cycle Start taking pill of 1st day of cycle
At the end of 3rd week of postpartum Start at 3rd week of postpartum
< 24 hr after miscarriage / TOP Changing from COC continue directly on
When changing COC to POP Variety start from the end of COC Packet (From day 21
the new pill omitting 7 day break and start omitting 7 day break)
new pill
Stop COC Pill immediately if
If sudden severe chest pain, sudden
breathlessness, pain in calf of one leg, Acute
tummy pain, unexplained collapse, BP more
than 160/95 mmHg.
Taking Pill Taking Pill
1 pill daily for 21 day then 7 day pill free 1 pill daily with no pill free break
break. Patient weighing > 70kg are often
prescribed 2 pills per day
POP pill must be taken at the same time
each day.
If delayed more than 3 hours (More than 12
hours for Desogestrel POP) treat as missed
pill. If pill is missed continue taking pill at
usual time and use condom for 2 days.
Diarrhoea & Vomiting Diarrhoea & Vomiting
Does no affect the contraceptivepatch or Continue taking the POP but use an
ring. If woman vomits less than 2 hours after additional barrier method during the episode
taking a COC pill or has very severe and for 2 days afterwards.
diarrhea, assume the COC pill has not been
absorbed and treat as a missed pill.
Antibiotic Antibiotic
Longer course of enzyme-inducing drug Efficacy of POPs is not affected by
Advise another unaffected method of antibacterials that do not induce liver
contraception, e.g., instrauterine device. enzymes. Efficacy is decreased by enzyme
Refer for specialist advice if other methods inducing drugs.
of contraception are unacceptable to the Advise women to use an additional barrier
patient. method or alternative contraceptive method
There is no evidence that broad-spectrum during treatment and for more than 4 week
antibiotics (e.g., amoxicillin) decreased afterwards.
efficacy of combined pill. Additional
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contraceptives. Additional contraceptive Advise an alternative method of
precautions are no longer recommended. contraception if taking long-term hepatic
Anticonvulsants that do not affect pill enzyme-inducing drugs.
efficacy
• Sodium Valproate
• Lamotrigine – but seizure frequency
may increased when combined
contraception and lamotrigine are
used together and side effects of
lamotrigine may be increased when
combined contraception is stopped.
Surgery Surgery
COC Pill should be discontinued and barrier
method used 4 week before elective
surgery, all surgaries to the leg or need long
immobilization.
Travel Travel
If traveling for more than 3 hours there is
increased risk of Deep Vein Thrombosis
(DVT). One can decrease the risk of DVT by
1. Drinking plenty of non alcoholic fluids.
2. Keep legs moving while sitting.
3. Walk up and down the aisle.
4. Graduated compression hosiery.
5. Taking prophylectically asprin 75mg daily.
FOLLOW UP FOLLOW UP
Three months starting or changing a Review 3 months after starting the POP or
combined contraceptive. Earlier if changing from CHC earlier if complications.
complications. Once established, review Once established, review every 6 to 12
every 6 to 12 months. At follow up, assess months. Assess risk factors and side effects;
risk factors and side effects; give health give health education, e.g., smoking
education, e.g., smoking cessation advice, cessaion advice, information about STIs.
benefits of long-acting reversible Information about long-acting reversible
contraception, information about STIs; contraception; check BP.
check BP.
BREAST FEEDING BREAST FEEDING
COC  Lactation and minor amounts are POP increase milk amount and allowed with
secreted in milk, hence, contra-indicated in breast feeding
breast feeding.
Sodium valporate and lomatrigine do not
affect pill efficacy.
___________________________________
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INJECTABLE PROGESTOGENS
Useful if oestrogen contraining preparations are contraindicated or poor compliance.
Failure rate is less than 4/1000 women over 2 year.
ADVANTAGES
• Can be used to age 50 year if no other risk factors for osteoporosis.
• Decreased ectopic pregnancy, functional ovarian cysts and sickle cell crises.
• Decreased risk of endometrial cancer.
• May alleviate premenstrual syndrome and decreased menorrhagia.
DISADVANTAGES
• Relatively contraindicated if DM with complications or multiple risk factors for CVD.
• May decreased bone density in first 2 to 3 year of use. Consider DEXA scan in older
women if result would influence choice.
• May be a delay in return of fertility of up to one year on stopping.
• Can cause menstrual disturbance if troublesome give next injection early (8 to 11 week
after the previous injection for DMPA) or add oestrogen if no contraindications.
• Other side effects, e.g., weight increased (up to 2 to 3kg), mood swings, acne.
RETURN OF FERTILITY
May be a delay in return of fertility of up to one year on stopping.
1. Starting injectible progestrogens give first injection upto 5 day of women cycle. If giving
for the first time after 5 day of cycle check the woman is not pregnant. Advise the
woman to use additional form of contraception for 7 days.
2. Post partum give first injection less than 21 day after delivery if possible. If breast
feeding and amenorrhoeic no additional contraception is needed.
REPEAT INJECTIONS
Depo Provera: Every 12 week (± 5 days).
Sayana Press: Every 13 weeks (± 7 days).
Noristerat: May be repeated once only after 8 weeks (± 14 days)
MISSED INJECTION AND NO RISK OF PREGNANCY
Give injection immediately if more than 14 weeks since last injection of DMPA (more
than 10 weeks if noristeratrone) advise no sex or additional barrier contraception for 7 days
after injection.
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PROGESTRONE IMPLANT (NEXPLANON)
Nexplanon is a radio opaque flexible rod (40mm x 2mm). It is inserted subdermally int
the lower surface of upper arm on day one to 5 of the cycle. If inserted after day 5 check not
pregnant and use an additional method for 7 days.
NEXPLANON LAST FOR 3 YEARS
Once removed, fertility returns immediately to normal.
ADVANTAGES
• Lasts three years and once inserted, no compliance required.
• Can be used for women at risk of ectopic pregnancy.
• No effect on bone density.
• Once removed, fertility returns immediately to normal.
DISADVANTAGES
• Special training is needed to insert/remove implants. Complications of minor surgery
can occur (e.g., infection, scarring)
• Decreased efficacy with liver enzyme-inducing drugs. Advise method of contraception
for the duration of treatment and 4 weeks afterwards or alternative contraception of
enzyme inducing drugs are being used long term.
• Cannot be used as part of a HRT regimen.
• May cause menstrual distrubances, exclude other causes. Treat with oestrogen,
additional progestrogen, or NSAID.
• Other side effects include acne, mood swings, breast tenderness, change in libido,
treat symtoms as needed.
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INTRA UTRINE CONTRACEPTIVE DEVICES
(Cu-IUD & IUS)
(Oxford 5th Edition Page ???)
There are two types of Intra Utrine Contraceptive Devices:

1. Copper IUCD
2. IUS Containing Progestrone
1. Copper IUCD
Acts by inhibiting fertilization, sperm penetration of cervical mucus and implantation.
Copper IUCD a suitable for:
• Older Parous Women
• In young nulliparous women as second line contraception and
• Emergency contraception
2. IUS
IUS release progestrogens (Levonorgestrel) directly into the utrine cavity.
Act by preventing endometrial proliferation, thickening of cervical mucus and
suppression of ovulation.
IUS can be used in women aged more than 18 years for:
• Contraception
• Menorrhagia (Menstrual bleeding is decreased significantly in 3 to 6 months)
• Prevent Endometrial Hyperplasia with estrogen therapy.
COPPER IUCD AND IUS
Long lasting and can be used until menpause.
Once fitted no compliance is needed.
Fertility returns immediately once removed.
Can be used for women who are breast feeding, obese, have concurrent illness like
migraine, venus thrombo embolism, diabetes mellitus, cardio vascular disease or taking long
term enzyme inducing drugs e.g., Anti convulsents, anti viral.
ADVANTAGES
Cu-IUD IUS
No systemic side effects. Decreased menorrhagia
Does not mask menopause Decreased Dysmenorrheoa
If fitted as emergency contraception can Decreased pelvic inflammatory disease
provide ongoing contraception Decreased risk of ectopic pregnancy
For women more than 40 years can remain If 45 years and amenorrhoeic can be left for
in uterus until menopause
7 years for contraception.
Change after 4 years if using IUS for
endometrial protection
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DISADVANTAGES AND PROBLEMS
Cu-IUD IUS
Risk of ectopic pregnancy is higher if using IUS not suitable for emergency
hormornal contraception. contraception may cause changing in
Consider ectopic pregnancy in any women duration of menstrual bleeding (Spotting or
who has copper IUD and develop tummy prolonged bleeding). Bleeding become light
or absent within 3 to 6 months of insertion.
pain.
Increase menorrhogia and dysmenorrhoea Mastalgia, mood changes, change in Libido
exclude infection in mal position. Treat with (usually resolved in less than 6 months)
NSAID with transemic acid consider
changing to IUS.
Suitable for emergency contraception
INSERTION OF COPPER IUD AND IUS

Special training is needed. Accreditation must be updated every five years. Device
may be inserted at the tail end of periods or immediately after miscarriage or termination of
pregnancy. Avoid during heaviest day of period. If not fitted in the first 7 day of cycle exclude
pregnancy before insertion for IUS advise additional method for 7 days. May be inserted
immediately after child birth or 4 weeks for postpartum exclude pregnancy need for additional
contraception depends on whether breast feeding. If breast feeding and amenorrhoic no
contraception is needed.
Utrine perforation may occur during insertion if suspected refer for urgent pelvic
ultrasound. Women may complain:
• Severe pelvic pain after insertion
• Pain during intercourse
• Increased bleeding or sudden changing in periods
• Unable to feel threads
• Increased risk of seizure at the time of cervical dilatation
• Ensure emergency drugs are available
• Rare complications include paller, sweating bradycardia
Immediately tip the women head down with legs raised
If bradycardia persist give 0.6mg atropine I/V
REMOVAL OF IUCD
If pregnancy is desired device can be removed at any time.
Remove after establishing hormonal method or used barrier method or abstinence for
7 days prior to removal.
If removing at the time of menopause:
1. Remove one year after period stopped if age more than 50 years.
2. Remove after two years of amenorrhoia if age less than 50 years.
NOTE: If difficulty removing device try again after five day course of topical estrogen.
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MISSING INTRA UTRINE DEVICE THREADS
1. Teach all women with IUCD to check IUCD threads after each period.
If threads founds that means IUCD is in place.
Advise to recheck again after next period.
2. If threads are not found advise the woman to use other contraception methods e.g.,
condom until checked by a doctor or nurse.
3. If threads are not found exclude pregnancy refer for ultrasound to confirm position of
IUCD.
4. If expelled, malpositioned or perforated uterus refer to gynecology for removal.
5. Try probing endocervical canal with a thread retriever or a pair of long handle forceps
before referring to gynecologist for removal.
FOLLOW UP
Perform routine check 6 week after insertion and annually thereafter.
Advise to return if women or her partner has any discomfort or she is concerned about
vaginal bleeding or discharge.
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CONTRACEPTION FOR TEENAGER UNDER 16 YEAR
Hello.
I am Miss Jully.
Miss Jully how old you are? (I am 16 year old)
Ok Miss Jully how can I help you today?
Doctor, I have a boy friend, I have become sexually active, I am afraid that I might get
pregnant or I might contract sexually transmitted disease, so please provide me
contraception.
Well Miss Jully before I provide your contraception I need to ask few personal and private
questions. Rest assure our whole conversation will remained confidential.
Is it ok with you?
Miss Jully have you informed your parents that you are sexually active or although you are
not legally adult.
Oh doctor I have not told my parents and I request you to maintain my confidentiality as your
ethical duty an do not tell my parents.
Miss Jully are you aware that in teen age, girls child producing organs are not mature enough
to bear the stress of pregnancy so it is better to delay sexual intercourse until older.
Please use condom as they not only prevent pregnancy but prevent sexually transmitted
diseases as well.
What do you say if I request you not to perform sexual intercourse until you are adult.
No doctor I cannot leave my boy friend. Our basis of friendship is sex. I will continue to have
sex even if it means getting pregnant or contracting any sexually transmitted disease.
Ok Miss Jully I respect you autonomy and promise to maintain confidentiality from your parent
about your sexuality. If you are determined to continue to have sex you are likely to suffer if
no contraceptive treatment is given. So I offer you.
To practice safe sex, use condom during sex it will provide protection from sexually
transmitted diseases also.
Condom has high failure rate as some times it get broken during the sex. IUS Intra Utrine
system can be fitted in a nulliparous to provide contraception on long time basis once fitted
there is no problem with compliance.
I can also offer you combined hormonal contraception in the form of pills, patches, vaginal
ring. With pills poor compliance can be a problem and leed to relatively high failure rate.
Remember we have the option of morning after pill if you want to prevent unwanted
pregnancy. This is one tablet levonorgestel to be taken if you are likely to get pragnent. The
drug is safe. Only some people have vomiting or spotting can occure. Beaware of morning
after pill and contact immediately to your family physician for the provision of morning after
pills if you are afraid to become pregnant.
What would you like to have?
COC Pills, patches or vaginal ring.
POP Pills
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IUS (Intra Utrine System)
Go home talk to you boy friend or partner, come back in a week or so I will provide you the
contraception of your choice. We will not wait until the first day of next cycle we will start the
contraception right away.
Is there anything else you wants to discuss with me today?
No doctor.
Thank you for you visit and cooperation.
Good bye.
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PRE-CONCEPTIONAL COUNSELING
Mrs. Sana Ahmad 25 years old is getting married next month and planning her
first baby soon. Take relevant history and counsel.
First of all congratulations you are going to be married soon. As you are planning to
have your first baby soon. I need to ask you few personal question. Let me assure you the
whole conversation will remain confidential. Purpose of these questions is ensure a healthy
baby, safe pregnancy & labour.
Are you and your partner related with each other? (First Cousin)
Are you aware that certain diseases run in families and can be detected before
pregnancy and during pregnancy through certain tests.
When was your last menstrual period?
Are you periods regular?
Are you using any contraceptive measures?
Have you ever been diagnosis with any sexually transmitted disease?
Have you and your partner undergone any test for your HIV status?
Have you and your partner undergone any test for your Hepatitis status?
Any test for syphilis?
Any test for rubella status?
When did you last have your pap smear?
Do you know your and your partner’s blood group?
Blood Group rhesus status?
Haemoglobin?
Any test for Haemoglobinopathies?
Do you smoke?
Do you take alcohol?
Any high Blood Pressure?
What sort of diet you take?
Do you take regular exercise?
Are you taking any regular medicines?
Any financial problems?
Any worries concerning pregnancy?
Are you aware of your social security and employment benefits, when you become
pregnant? e.g. maternity leaves.
MANAGEMENT & COUNSELING
Since you are going to be pregnant you should be physically fit to have a normal
healthy baby. For this reason I would suggest few things e.g.
Take plenty of rest?
(1) DIET
Have a good green vagetables, brown rice, fortified bread and cerials as healthy
nutritious diet?
Take plenty of fruits and vegetables.
Starchy food form for example breads, rice, pasta and potatoes.
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Protein rich foods for example leen meat, chicken, fish, eggs.
Fibre for example whole grain bread
Dairy foods e.g. milk & milk products
Iron rich food, red beans meals rental green vegetables fortified cerials
Red meat
Avoid alcohol and caffeine.
You can drink four cups of coffee, 6 cups of tea, 8 cans of cola daily.
Try to take folate rich foods prior to pregnancy and in the first 12 weeks.
Avoid large quantities of Vitamin A supplement and liver.
Avoid un-pasturized dairy products, uncooked eggs, pre-prepared salads?
When preparing food keep cooked and raw meat separately?
Only eat well cooked meat?
Wash all soil of fruits and vegetables before eating?
Wash hands after preparation of food.
FOLATE SUPPLEMENTATION
 risk of neural tube defect by 72%.
If no previous neural tube defects – 0.4mg od when pregnancy is being planned
and for 13 weeks after conception.
If 1 parent affected, on anti-epileptic mediation, or previous child affected –
Advise 5mg od from the time the pregnancy is being planned until 13 weeks after
conception.
(2) EXERCISE
Take regular exercise.
Try to maintain your BMI between 18 to 25.
(3) STOP SMOKING
Smoking  ovulation,  sperm count,  sperm motility. Once the woman is pregnant
smoking  miscarriage rate 2 times.  risk of pre-term delivery, and  birth weight (by
an average of = 200g). Smoking is associated with an  rate of cot death, chest
infections and otitis media in children. So it is better to stop smoking before you
become pregnant.
(4) STOP ALCOHOL
Alcohol does cross the placenta and thus may affect the developing brain. Miscarriage
rates are  in moderate drinkers. Current advice is to avoid alcohol in pregnancy.
(5) RUBELLA STATUS
If rubella status is unknown, please get it checked. Rubella infection in early pregnancy
carries a high chance of deafness, blindness, heart abnormalities and multiple foetal
abnormalities.
If you do not remember that you were given rubella vaccination in childhood, get it
checked, if its low, get yourself vaccinated, now before pregnancy. After vaccination
try not to become pregnant for three months.
Recheck Rubella status three months after immunization.
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(6) PAP SMEAR
If your pap smear is due, get it done.
(7) BLOOD GROUP
Get you and your’s partner blood group tested. If they are different then it can caused
problem for your baby.
(8) SEXUALLY TRANSMITTED DISEASES
It is better to know your HIV, Hepatitis, Syphilis, Genital Warts status before
pregnancy. There is a lot that can be done to prevent STD being transferred to your
new born baby like C-Section and certain drugs to treat these conditions.
(9) CONTRACEPTION
It is good to know different method of contraception e.g. COC Pill, POP Pill,
Progesterone injections and implants, IUCDs, Contraception methods not only prevent
pregnancy but also prevent sexually transmitted diseases.
If you are using inject-able progesterone as your contraception then fertility may return
after variable period. You should know when to stop and what to expect when you stop
contraception.
CHRONIC DISEASES
(i) DIABETES MELLITUS
If using oral hypoglycemic before pregnancy they are to be changed to Insulin.
It is important to have tight blood sugar control not only during pregnancy but also
before you start trying to conceive.
(ii) HYPERTENSION
If you are using any drugs for increase blood pressure, they should be changed to
medicine which are safer in pregnancy. (Labitolol, Methyldopa, Nephedipine)
ACE1 are contra indicated in pregnancy.
(iii) HEART DISEASES
Referal for specialist advice is indicated if situation not clear.
(iv) EPILEPSY
Safer medicines in pregnancy should be advised. For this, review of medicines by
neurologist should be made.
(v) GENITAL WARTS
C-Section can be planned.
GENERAL MEDICINE
Discontinue all medicines which are known to cause foetal abnormalities before
conception.
Avoid all unnecessary medications including over the counter and herbal medicines.
HYGIENE
Wear gloves when gardening and changing cat litter. Wash your hands afterwards.
TRAVEL
Travel by air before 32 weeks in pregnancy.
Travel to malaria area is not advisable in pregnancy.
When driving car, car seat belts should go above and below bumps and not across it.
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EMPLOYMENT BENEFITS
It is good to know employment benefits available during pregnancy so that you can
avoid possible hazard at work, attend antenatal care appointments and plan your maternity
leaves early in pregnancy.
You are entitled free prescription for dental care.
Antenatal and parental craft classes are available. Aquanatal classes and Yoga for
pregnancy classes can be attended.
You have a choice for place of delivery either at home or in hospital.
____________________
Please check the following new guidelines at following pages of Oxford:

Pre-pregnancy counseling Page 782 Oxford fourth edition
Antenatal Care Page 786
Screening in pregnancy Page 796
_____________________
Healthy Diet in pregnancy Oxford Page 783
Health promotion in pregnancy Oxford Page 792-793
Breast feeding advantages & problems Oxford Page 870-871
Drugs safe & contra indicated in pregnancy Oxford Page 792
______________________
HAEMOGLOBINOPATHY SCREENING
At first booking (Initial screening) for sickle cell disease
For thalasaemia → MCH in FBC if less than 27 consider diagnostic test.
DOWN SYNDROME SCREENING
1. Combined screening test – 10-14 weeks
2. HCG + PAPP + Nubal Nupcial Translucency test.
QUADRUPLE SCREENING TEST
14-20 week HCG + AFP + Inhibin – A + unconjugated esthiol.
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EMERGENCY CONTRACEPTION
SCENARIO
Mrs. Sabira Shakir 28 years reports to GP about rupture of condom during sex
24 hrs ago. She does not want pregnancy to occur. Take a focus history and managed.
MEET GREET
INTRODUCTION OF PATIENT & DOCTOR
DATA GATHERING
Mrs. Sabira Shakir I have been given information that condom rupture during sex 24
hours ago and you do not want pregnancy.
(1) May I know why you do not want pregnancy?
Doctor I have recently joined a new job. I am on probation at the moment. I cannot
afford to have pregnancy at this time. More over my family is complete. I already have two
kids a boy and a girl.
Any thing else you want to share with me now.
Doc. I am here for some morning after pills to prevent pregnancy.
How do you know you are pregnant? I am afraid of getting pregnant as intercourse
occurred in my fertile period of menstrual cycle i.e. on the 15 th day.
How does your husband feel about emergency contraception? (He agrees)
Have you considered other options like donating baby to issueless couples. (No way)
Have you been using any contraceptive method to prevent pregnancy? (No) My
husband uses condom.
I need to ask you few private and personal questions. I assure you they will remain
confidential between you and me. Can I ask? Yes doctor you may proceed.
SEXUAL AND MENSTRUAL HISTORY
I need to ask you few very personal questions. What about your sexual practices. (Oral
Vaginal Anal) don’t ask if in stable relationship like husband.
What about pap smear? (Normal)
We will discussed these matters in a short while but I need to ask certain questions if
you allow me, is it OK with you?
Ask about Last Menstrual Period & ascertain wheather condom ruptured in safe or
fertile phase of menses. (Between 11 & 18 days fertile phase) (15 days ago)
What was your age when you had your first period? (Menarche) 14 year
Are your periods regular? (Regular or irregular) (Length of Cycle) 28 days regular
How many days your menses last? (3 – 5 days normal) (Can be upto 8 days)
How many pads do you have to use in a day? (Light or heavy Mensis or normal (Flow)
2-3 pads daily.
Do you have any pain during menses? (Dysmenorrhoea) (No)
How many times you have conceived so far? (Normal fertility?) (Parity) (3 times)
How many live children do you have? (Gravida) 2 kids (family complete)
PAST HISTORY
Did you have any emergency contraception previously? (No)
How is your general health like? (Any problem which make medical or surgical
termination of pregnancy unsafe)
Did you ever had any fits?
Any recent infection requiring Anti-biotic?
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PERSONAL HISTORY (Bio-Psychosocial)
Do smoke?
Do Drink?
What is the nature of your job (receptionist in an office)
Any previous surgeries?
What are the home circumstances like at the moment, (Like any financial problem or
stress or relationship problems) (Financial stress , need job to meet both ends meet)
FAMILY HISTORY
Any major medical problem in immediate family member? (No)
DRUG HISTORY
Are you taking any medicines? (Acertain whether taking anti-convulsants or anti-biotic)
The dose of emergency contraception will have to be doubled
ILLNESS
Are you aware of consequences of emergency contraception?
Do you know what impact this emergency contraception will have on your work, home,
physical and psychologically health.
SUMMARIZE
So Mrs. Sabira Shakir you have told me condom raptured 24 hrs ago during sex and
you don’t want pregnancy because of your new job and financial constraints and you are not
taking any drug for epileptic fits or antibiotic currently. Condom rupture during fertile days of
mensis.
Is this all or you want to add something more. (No, that’s all)
MANAGEMENT
If you are determined to have emergency contraception I respect your autonomy. I
offer you one tablet of 1.5mg levonorgestril. (Double the dose if taking antifit tablet or have
been taking antibiotic recently)
Levonorgestrel
• Should be taken as soon as possible – efficacy decreases with time.
• Efffective within 24 hours 95%
• Must be taken within 72 hrs of unprotected sexual intercourse (UPSI)
• Single dose of lovenorgestrel 1.5mg (a progesterone)
• Mode of action not fully understood – acts both to stop ovulation and inhibit
implanatation. 95% effective if used within 24 hours, 85% effective if used within 48
hours and 58% effective within 72 hours.
• Levonorgestrel is safe and well tolerated. Disturbance of the current menstrual cycle
is seen in a significant minority of women.
• Vomiting occurs in around 1% of women
• If vomiting occurs within 3 hours then the dose should be repeated.
Can be repeated more then once in one menstrual cycle if clinically indicated
S/E
SIDE EFFECT
This drug is safe but you might expereice some nausea, vomiting or PV spotting.
293
If you vomit with in or less than 3 hrs after taking medicine, please come to me, I will
supply you some more pills.
SAFTTY NETTING
If you have any tummy pain or your periods are over due or are heavier or lighter than
usual, please seek immediate help.
NOTE:
Other option is copper IUCD if patient comes after five days.
You have told me that you have multiple partners so I would suggest to practice safe
sex. Use barrier method in addition to hormonal method of contraception.
KNOWLEDGE BASE DATA
Emergency contraception
There are now two methods currently available in the UK.
Emergency hormonal contraception
There are now two medical methods of emergency hormonal contraception
(emergency pill’, `morning-after pill’) levonorgestrel and ulipristal, (a progesterone receptor
modulator.)
• .
ULIPRISTAL ACCETATE (UPA)
• A progesterone receptor modulator currently marketed as EllaOne. The primary mode
of action is thought to be inhibition of ovulation.
• 30mg oral dose taken as soon as possible, no later than 5 days or 120 hours after
intercourse.
• Concomitant use with levonorgestrel is not recommended.
• May reduce the effectiveness of combined oral contraceptive pills and progesterone
only pills
• Caution should be exercised in patients with severe asthma
• Repeated dosing within the same menstrual cycle is not recommended.
INTRAUTERINE CONTRACEPTIVE DEVICE (Copper IUCD)
• Must be inserted within 5 days of UPSI (Unprotected sexual intercourse)
• If a women presents after more than 5 days then an IUCD may be fitted up to 5 days
after the likely ovulation date.
• IUCD should be copper IUCD and not progesterone containing IUS (Mirena)
• May inhibit fertilization or implantation
• Prophylactic antibiotics may be given if the patient is considered to be at high-risk of
sexually transmitted infection
• Is 99% effective regardless of where it is used in the cycle
• May be left in-situ to provide long-term contraception. If the client wishes for the IUCD
to be removed it should be at least kept in until the next period.
NOTE: Discuss the impact of Emergency Contracection on home work and physical health.
and psychological health. How does your husband feel about E.C discuss other option like
donating baby to issueless couples.
MODE OF ACTION
Levonorgestril stops ovulation and inhibits implantation.
Ulipristal inhibit ovulation
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IUCD Copper inhibits fertilization and implantation
__________________
Levonorgastril can be repeated more than once in same cycle.
Levonorgastril can be given within 72 hours or 3 days.
_________________
Uliprestril repeat dose within the cycle not recommended.
Uliprestril canbe given within 120 hours or five days.
__________________
Levonorgestril 1.5mg one tablet
Uliprestril 30mg
Copper IUCD not IUS or Mirena
Copper IUCD may be left in place to provide long term contraception IUCD should be
kept atleast until next period if patient wants to remove it.
___________________
Levonorgestril effectiveness
Within 24 hours – 95%
295
TERMINATION OF PREGNANCY (TOP) + ANGRY PATIENT
Scenario and questioning are almost same as in emergency contraception. So only
management is being discussed.
I became pregnant accidentaly. It’s a unwanted pregnancy. My family is complete with
two kids. Some relationship problem with my husband is also there. Some financial contraints
so I want to terminate this pregnancy. I am 13 week pregnant.
MANAGEMENT
Ok Mrs. Sabira Shakir. Would it be good idea to discuss with your husband about
termination of pregnancy. Take some time to think about it. And let me know what you think
is best for you. I will support you what ever your decision is.
TOP for social reasons is allowed in UK for less than 24 weeks gestation.
TOP has no upper limit if mother’s physical, mental or psychological health is at grave
risk.
TOP have no upper limit if baby is at serious risk of physical or mental handicap.
Medical TOP is done with Mifepristone followed by vaginal prostaglandins
(up till 9 week)
Surgical TOP suction termination uptill 15 weeks.
Dilatation and Evacuation from > 15 to 20 weeks.
FOLLOW UP
Follow up after the procedure done, is at GP surgery.
SAFETY NETTING
If patient has excessive bleeding, pain or high temperature and doctor suspects
infection, he may treat it with anti-biotics. If excessively worried then admit in emergency.
1. Make sure anti-D injection is given to mother, if mother child blood groups are
incompatible. Mother Rh –ve & child Rh +ve within 72 hrs of child birth.
2. Also before TOP, contraceptive method were discussed.
Choosen method of Contraception should be started immediately after TOP.
Complication like Heamorrhage, cervical trauma, Uterine perforation, fail procedure
and ongoing pregnancy, infection and psychological sequelae are common.
There is no association between TOP and subsequent infertility, miscarriage and
preterm delivery.
NOTE
Same scenario of TOP or EC may come as angry or difficult patient. Complaining that
you are not a good / safe doctor. I had asked you some contraception pills and look I have
become pregnant, despite of those pills.
Catch point in this scenario is first defuse the an anger. Make her sit in the chair.
Ask how does she know that she is pregnant. (Pregnancy test)
Ask if she is taking any other medicine e.g. Anti-Convulsants for epilepsy or anti-biotic
for recent flu infection which has decreased the efficacy of contraception pills and that is why
she has become pregnant. Probably she had anti-biotic from pharmacist without informing
doctor.
296
FEMALE INFERTILITY
Mrs. Abdullah, 28 yrs, comes to discuss her problem about infertility.

Knowledge base – Definition of Infertility – Inability to conceive for 1 year
despite regular unprotected intercourse 3 times/wk.
Meet
Greet
Introduce each other
Doc. How can I help you today.
Mrs. Abdullah – Doc. We been married for 5 yrs, but are unable to conceive baby I
feel very alone. All my cousins who got married have children. There is lot of pressure from
my in-law side to produce grand son for their family. I am very worried . My husband may
leave me. Please help me.
Mrs. Abdullah – Is your husband accompanying you today? (No Doc. I know its
important to counsel couple in a case of infertility. My husband is a very healthy athalete and
his semen report on two occations three months apart show normal sperm count, his genitalia
are normal. So he is not accompanying me today. Probably problem lies with me. (Private
parts)
Doc. Ok Mrs. Abdullah I need to ask you few question including some very private &
personal questions. (Ensure confidentiality) The whole conversation will remain confidential
between you and me and nobody else will ever know it.
Mrs. Abdullah – Its OK with me.
Is there any child from either partner from any previous relationship. (If any)
(No)
Doc. May I know how you are trying to conceive baby?
Mrs. Abdullah – We are having 3 to 4 times sexual intercourse per week
Doc. In which days of your cycle?
Mrs. Abdullah – A Gynaecologist friend of mine told us to perform intercourse during
11 to 18 days of menstrual cycle.
Is your menstrual cycle regular (Yes regular) cycle is of how many days? (28 days)
Mensis occur for how many day (3 or 4 day) what abut amount of bleeding? (I change
2-3 pads)
Is there any pain during mensis? (No)
Is there any bleeding in between the periods? (No).
D/D
Is intercourse painful? (No)
Any history of discharge from front passage (S.T.I. No)
Any history of surgery on lower tummy? (No).
Are you taking healthy food? (Yes)
What is the nature of your job? (I work for > 10 hours/day)
Is there any stress at work (yes)
Do you do any exercise? (yes I do heavy exercise)
Is there any milky discharge from your nipples (No. ↑ prolacting)
What about your weight (I have a BMI of 28) (PCO)
Do you have any excessive hairs on your body or face? (No) PCO
Do you have pimple problem on your face? (No) PCO
Do you smoke? (Yes two packs a day)
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Do you take alcohol? (Yes more than 4 Units per day)
ICE THEN SUMMARIZE

Well Mrs. Abdullah you have told me that you are performing sex for 3 or 4 times a
per/wk in right days of cycle to conceive. There is some stress at work and you are doing
strenous exercise to reduce your BMI of 28. Your husband sperm count is normal on 2
occations (3 wks apart approximately). Sample was taken after 2 days of abstinence.
Is this all or you want to add any thing to it (that’s all doc)
Investigations
Ok – Mrs. Abdullah every thing seems to be right and normal. I would like to ensure
that your ovaries are producing egg every month. For that matter I offer you two blood tests
1. FSH & LH hormone levels on 1 to 5 day of cycle.
2. Progesterone Hormone level on 21 day.
These test do not need any fasting or preparation.
Can you get them done for me?
3. I also offer you ultra sound scan of pelvis.
For this I will refer you to sinologist. Is it ok with you?
4. Serem Prolatctin can also be offered if there is any milky discharge from
nipples.
____________________
HISTORY OF RUBELLA
Do you have a record that you were vaccinated against Rubella (MMR Vaccination) in
childhood.
Do you know your current level of anti Rubella antibodies.
NON PHARMACOLOGICAL MEAUSRES
1. Stop smoking
2. Avoid Alcohol
3. Healthy diet
4. Light exercise
5. ↓ wt
6. ↓ stress
(Elaborate all these six points in detail if you have time)
7. PHARMACOLOGICAL MANAEMENT
Offer Folic Acid 5mg/d
FOLLOW UP
• Please come to see me as soon as the reports of tests are available. I might need to
refer you to Gynae & Obs specialist.
• GIVE HOPE: Lets hope that every thing is fine and you are able to conceive soon.
Please bring your husband with you next time you come.
• Is there any thing else you like to share with me today. (No)
− You can get further information from reception desk in the form of leaflets.
Thaknyou very much for your cooperation & visit
Good bye.
298
MALE INFERTILITY (A CASE OF UNETHICAL DEMAND)
Case No.1
Mr. Zafar Karim 30 years old has come to discuss his semen report with you.
Kindly proceed with consultation (Exam not required).
SEMEN REPORT
Quantity 2ml (1.5 to 7.5 ml normal)
Liquifying time 30 min. (Normal up to 20 minutes)
Consistency Turbid
(M) Total sperm count 15 Million (Normal 50 to 200 Million (Less than 40 million is
oligospermia)
(M) Motility Active 10% (Normally 75%)
Sluggush 20% (Normally %)
Dead 70% (Normally %)
(M) Morphology 40 to 80% Normal
(M) Microscopy 5 – 10 Epithelial Cells
3 – 5 Pus Cell (Indicate Infection)
Doctor I am very upset. I don’t want to live. I am happily married for the last 5 years
but I have not been able to produce a child.
Doctor my report is before you. Some body said it’s a very bad report. I will never be
able to produce a child.
Yes anything else?
Doctor. There is great pressure from my parents to marry 2 nd time. I love my wife & I
do not want to leave her. I wonder what will happen if I am unable to produce a child even
with 2nd wife.
SUMMARIZE & SAY
Now I would like to ask you few questions about your private life but before that let me
assure you that whole conversation will remain confidential between you and me. No body
else will ever know about it. (Confidentiality point very important). Is it OK with you. (Yes)
I thank you for trusting me.
First of all let me assure you that now a days there are certain newer technologies and
methods available by the help of which even people with very low sperm count can also
produce child (Gain trust and console).
• Have you got your wife checked by some Gynaecology?
Yes, Gynaecologist said that every thing is normal on her side.
Doctor I am very upset I don’t want to live. Help me. Find solution for my problem.
• Ask direct question about deliberate self harm like. Have you made any plan’s to end
finish your life.
No, not yet doctor.
Ok Good – (Other wise you have to admit him/her in emergency)
299
PRESENT HISTORY
• How frequently do you go to your wife?
About 2 or 3 times a week.
• Do you know the proper days of your wife menstrual cycle in which intercourse must
take place to produce child?
Yes Gynaecologist told us and we are following that. (11 – 18 days)
• Is your wife cooperative?
Yes she loves me.
• Was your marriage a arranged one or it was of your choice?
It was a love marriage.
• Do you have morning erections?
Yes.
• Do you have any problem achieving and maintaining sufficient erection required for
intercourse?
No problem with erection.
D/D & PAST HISTORY
• Did you had swellings over your face in childhood, I mean, did you have mumps in
your childhood?
Yes.
• Did you had any contact with any T.B. patient?
No (Genito-urinary T.B.)
• Did you had any discharge from the front passage? (STI)
No (No STD) (Gonococcal Infection)
• Any change in your beared or hair loss? (Decreased testosterone)
No (No Hormal abnormality)
PERSONAL HISTORY
• Your occupation & habbits?
I am a Chef at local restaurant. I have to work in very hot environment.
(Question about Testicular temperature is very important)
• What vehicle do you use, to go to your restaurant?
I use my bicycle.
• Are you into some sports?
Yes, I am fond of cycle racing.
Drug History
• Are you using any Medicine regularly?
Yes, Cimetadine for my stomach burning.
(Drugs responsible for impotence include cimetadine, B-Blocker (Propranalol),
Thiazide diuretics, some Antidepressants. Anti Psychotics etc. etc. ?????
300
• Are you a smoker?
Yes I smoke 20 cigarettes for last many years (smoking cause erectile dysfunction).
(Smoking cause oligospermia. With quit smoking one can increase sperm count)
• Do you drink?
Yes, I am heavy drinker (Alcohol cause E.D.)
• Do you use any recreational drug?
No (Some drugs can cause E.D.)
______________________________
• Any High Blood Sugar?
No (DM can cause E.D.)
• Any High Blood Pressure?
No certain (HTN medicine can cause E.D.)
_____________________________
• Do you do any exercise regularly?
No, I work 9 to 5 pm. I have no time for exercise.
• Do you have any children from your previous relationships?
No, Its my first marriage.
Family History
• Do you have any family history of such problem?
My brother has 3 kids
No. problem.
ILLNESS – IDEA - CONCERN - EXPECTATION
• How this problem has affected your life? (Ilness)
Doctor I am so upset that I don’t want to live.
• What do you think you are suffering from? (Idea)
How do you understand your problem (Idea).
I have low sperm count so I cannot produce child.
• What worries you most (Concern)?
I will never be able to produce a child and Doctor there is lot of pressure from parents
side to remarry. I worry what will happen if I am unable to produce even in 2 nd marriage.
• What do you hope to gain from today’s consultation?
Doctor: Either fix my problem or lie to my parents that my report is OK Tell them that I
will be able to produce a child in due course of time. I love my wife. I don’t want to divorce
her.
Summarize and ask. If he would like to add something?
EXAMINATION
Exam is normal and not required (Normal genitals, Normal secondary sexual
characteristics like beared, public and axilliary hairs, height) etc. (Growth of Breasts in case
of females)
_________________________
INVESTIGATIONS
301
Well Mr. Zafer Kareem I cannot commit any thing definitively on single semen report.
I offer you another semen report after about 5-7 days of abstinence and sample should reach
lab within 2 hours. Keep it warm in your pocket on the way.
I also offer you some Hormone tests like serum testosterone, LH, FSH and prolactin
levels. Please see me as soon as the reports of investigation has come, I may need to refer
you to one of my senior colleague or specialist gynaecologist or endocrinologist.
___________________________
MANAGEMENT
Mr. Zafer Kareem what I have gathered from your history, examination and
investigation is that most probably yours is a case of oligospermia that is low sperm count
but we need further investigation and there are new methods by the help of which even
people with low sperm count can preoduce child.
In your case most probable cause is mumps you had in your childhood but you need
to stop smoking completely and reduce your Alcohol intake to safe limits of less than 3
units/day. Can you do it?
Yes.
The drug cimetadine you are taking for burning stomach can also be contributory factor
we need to find Alternative methods to deal with your stomach burning.
Cycle racing can cause repeated trauma to your private parts. We need to find solution
for this also.
I offer you my help for quit smoking, for which we can have discussion in some other
separate session.
Will it be convenient to you?
As far as your concern is concerned.
As, a doctor & your family physician. I can not tell a lie to your parents. It will be
unethical on my part. I may loose my medical practicing licence. However we will find solution
to your problems as we discussed. We can find solution to your problem in other ways. Like
Invitro fertilization, Test tube baby, Adoption. Aksee method.
Is there anything else you would like to discuss with me?
No.
I thank you for your cooperation and for trusting me with your private life affairs.
Good Bye (Shake hand and smile).
A CASE OF UNETHICAL DEMAND
CASE NO.2 (Related Case)
Tell his wife or parents that abnormal report is normal.
Mr. XY I am your family Physician for the last many years. You are very dear and close
to me. I don’t want to loose you as my patient but I cannot tell a lie. It will be unethical on MY
part. I am bound by my oath. I may loose my medical licence to practice by such Malpractice.
So please don’t pressurize or force me to tell a lie. It creates a bad impression of your. We
can find solution to your problem in other ways (Give him alternate solutions).
Invitro fertilization
Test tube baby
Adoption.
Aksee method
302
PRE-MATURE EJACULATION
A newly married person comes with the compliant of pre-mature ejaculation.

Take complete history in the similar way as in case No.1 and find out physical,
psychological and social reasons for this patients todays attendance in Clinic. Find out if his
wife is desirable for him? Was it a arranged marriage or love marriage? Management is only
a small part of this case.
MANAGEMENT
Its a game we all need to learn with practice. You are a newly married person. You
have never been to anyother women before. So its natural to ejaculate earlier in the
beginning. You will learn this game with practice. Few solution are
• Divert attention for few seconds from enjoyment during intercourse (Not
recommended).
• Stop and start. Stop for a while when you are about to reach climax of your
pleasure and then start again. (According to oxford)
• Use anesthetic spray over your organ (Penis) and don’t forget to wear condom
afterwards other wise your wife’s private parts will also be anesthetised.
(According to oxford)
• Change position in which you usually do intercourse (Try new positions).
• Tell your wife to be more cooperative and make less movements and less noise during
sexual act.
• Tell your wife to gentally pull your testicles down when you are about to ejaculate.
• Withdraw your penis and tell your wife to press your glans penis between her thumb
and three middle fingers (With thumb being over the glans and three fingers on the
frenulum). This monover can give some more time for pleasure before tyou ejaculate.
303
ERECTILE DYSFUNCTION
Scenario
Mr. Asad Khan 62 year has come to discuss some personal problem. Take
detailed history & Management. (Examination not required). Proceed.
Hello, I am Dr. Raheel.
I am Asad Khan 62 years.
Ok. Mr. Asad Khan how can I help you today or what brings you to surgery today?
Doctor I am very embarrassed but I have to share this personal problem.
Doctor I am very sad & unhappy. I am unable to come upto the expectations of my
wife during sex.
I am unable to obtain & maintain sufficient rigidity of my organ to allow satisfactory
intercourse for the last 3 months.
Anything more you wish to share today? (No that’s all)
Mr. Asad there is nothing to be embarrassed about this problem. 50% of men aged 40
to 70 year experience this problem. The incidence increase with age. You have taken a bold
step to seek help about your private problem with me. People don’t seek help and suffer in
silence for a condition which is easily treatable.
First of all let me assure you that whatever you will discuss with me, will remain
confidential between you & me and nobody else will ever know it.
Is it ok with you
Yes
Thank you for trusting me with your private problem.
Before we come to managing your problem, I need to ask you few questions. Some of
the questions will be of private & personal nature. Purpose of these questions is to find out
cause of your erectile problem & appropriate treatment.
Is it ok with you?
Should I proceed?
Yes Doc.
1. May I know your exact Age?
I am 62 year young.
2. Did the problem started suddenly or gradually? (Gradually)
3. Is the erection problem consistent every time or you are successuful some time?
(There is consistant failure)
4. Do you have morning erections? (There is loss of early morning erections)
5. Do you want to have sexul intercourse?
(Yes I have normal desire but unable to obtain & maintain erection sufficient for
intercourse)
6. Is there any ongoing relationship problem with your wife?
No she is very cooperative & I love her.
304
Personal History
Ok Mr. Asad Khan.
I need to ask you few more questions before we come to management part.
Is it ok with you?
Do you have high Blood Sugar? (yes for the last 10 years.)
Do you have high Blood Pressure? (Yes uses Atenolol)
Any Heart problem? (Had heart attack 2 years ago)
Are you using any nitrate sort of drugs? (No)
Do you smoked? (Yes, 2 packs per day)
Do you take alcohol? (Yes 4 units per day)
Do you dope (Any recreational drugs)? (No)
Any milky discharge from nipples? (No) (Prolactin level increased)
Any decreased frequency of shaving? (No) (Testosterone level decreased)
Past History
Did you have any spinal back injury? (No)
Any operation on prostate gland? (No)
Drug History
Are you using any medicine prescribed or from OTC.
Yes I am using cimetidine for my stomach problem & sleeping pills for disturbed sleep
off & on. I am also taking beta blocker atenolol for my high blood pressure.
Summarise
So Mr. Asad Khan you have erectile problem for the last 3 months. You are diabetic &
had heart attack. You are heavy smoker & drinker. Using cimetidine, atenolol & sleeping pills.
Is this all or you want to add something to it?
That’s all Doc.
Examination
Not required.
Genetalia normal.
Investigation
In order to be on the safer side & document few parameters, I offer you few test.
Is it ok with you?
(1) Complete lipid profile
(2) Testosterone level to assess desired to perform sex (Libido)
(3) Prolactin hormone level
Is it ok with you?
Yes its ok with me.
Management
305
(NON-PHARMACOLOGICAL MANAGEMENT)
There are certain life style changes which you need to adopt. They will help improve
your sexual function.
(1) Diet: Try to take low fat, low salt food.
(2) Exersize: Try regular brisk walk 30 min/d for 5 d/week
(3) You need to stop smoking completely.
Are you willing to do so?
Yes Doc. If it improves my sexual function, Yes.
We will have a separate detail session about how to stop smoking in next appointment.
I will help you set quit date & will offer Nicotene Replacement Therapy (NRT)
Which will decrease your craving for smoking.
Is it ok with you. (Yes)
(4) Can you cut down your alcohol intake to safe limits i.e. 3 units/d (Yes) (Female 2 /
Male 3)
(5) Try to control your sugar within normal range. Can you do it. (Yes)
(6) We need to replace your cimetidine with safer antacids which does not cause ED
like Gaviscon syrup.
Pharmacological Management (Atenolol Causes ED so switch to ACE Inhibitor if < 55
and Calcium Chennel blocker if > 55) (Patient age 62)
There are certain tablets, Injections, devices & surgical procedures available for your
problem. What would you like to have?
Surgery is out of question. I am afraid of injections. Devices make me uncomfortable.
Tablets will be ok.
Well Mr. Asad Khan there is a tablet called Sildanafil. It is available in 25, 50, 100mg
strengths. We will start with lowest dose of 25mg at night one hour before the desired activity.
We will see the response. You may have to try 8 times before it works for you. It has to be
taken only one time in 24 hours. We can increase the dose to 50mg & then 100mg (maximum
dose)
SIDE EFFECTS OF SILDENAFIL
You are not using Nitrates for heart problem. This tablet is not contraindicated while
using Nitrates. Only precaution is not to use both within 24 hours. As both drugs cause
decreased blood pressure.
This drug is not without side effects.
It can cause headache, face flushing & acid reflex ↓ B.P.
Is it ok with you?
Yes its seems ok with me but are there any herbal remedies for my probem?
Yes. There is Apomorphine 2-3mg used 20 minutes before desired activity &
yohimbine 10-30 mg but their evidence of effectiveness is lacking. Choice is yours.
I think sildenafil will be ok.
Ok I will offer you sildenafil 25mg one hour before the desired activity to begin with.
NHS prescription are available for men with erectile dysfunction.
Is there anything else you like to discuss with me today?
No Doc.
Please come as couple in next appointment.
There are leaflets available about your condition at reception desk.
Thank you for your cooperation & visit
Good bye (Smile & shakehand)
306
Note: In this scenario patient has preferred pills. Some other patient may prefer intra
urethral/intra cavernosal injections or mechanical devices or surgical treatment. Please read
& remember detail of pros & cons of these treatments from oxford P-777.
Scenario No.2
Mr. Asad Khan 30 year has come to discuss some private problem.
Take detailed history & do management. Proceed.
Take detailed history as in previous case. First ask all 6 questions to acertain whether
cause is physical or psychological.
In this case.
1. Age 30.
2. Problem started suddenly instead of gradually.
3. Response in sex is inconsistent. Sometimes successful.
4. Patient wakes up with morning erections.
5. There is normal libido but there are relationship problem like performance anxiety, fear
of intimacy.
6. Patient may be using Antidepressants tablets.
He is a healthy person.
No High Blood Sugar.
No High Blood Pressure.
Not smoker.
Drink in safe limits.
No Dope ever.
Not using any medicine.
Normal beared. No ↓ in frequency of shaveing
No spinal injury.
Investigations
Include complete lipid profile, testosterone level. Prolactin.
Examinations
Normal (Not required)
Treatment
- Please come as couple in next appointment.
- What I have gathered from your history is you are having erection problem due to
relationship failure, performance anxiety & fear of intimacy. Not due to any physical
disease. I recommend a sexual manual (Book) for couple named “Treat your self
to sex”
I offer to refer you to psychologist. Psychotherapy is time consuming & expensive
but can avert the need for drugs. Give permanent resolution.
For the time being read manual at home. Stoking should progress slowly from non-
genital to genital – If anxiety occurs go back one step.
Progress until erection achieve.
Later you can proceed with intercourse.
If unsuccessful I may refer you as couple to psychosexual counselor.
Thanks for cooperate.
Bye.
PSYCHOLOGICAL ERECTILE DYSFUNCTION TREATMENT
307
According to the sexual book “Treat Yourself to Sex”.
I recommend sex book for couples named “Treat Yourself to Sex” Read the book
& stroking should progress slowly from Non-genital to genital. This means see if
there is erection only then start stroking. Do kissing hugging, breast fondling (non-
genital).
If there is erection proceed with stroking (step 2) but if on stroking erection not
sufficient erection due performance anxiety or fear of intimacy, go back to step 1,
of nongenital sex i.e. kissing hugging breast fonding male organ sucking or female
sensitive parts licking & see if there is erection only then progress to stroking.
308
SYPHILIS
• Primary syphilis chancre at the site of contact.
• Secondary syphilis 4-8 week after chancre – systemic symptoms: fever, malaise,
generalized lymphadenopathy, anal papules (condylomata lata), rash (trunk, palms,
soles), buccal snail track ulcers, alopecia.
• Tertiary syphilis 2-20 years after initial infection – gummas (granulomas) in connective
tissue, e.g. testicular gumma.
• Quaternary syphilis Cardiovascular or neurological complications.
TESTS FOR SYPHILIS

Blood for VDRL (Now considered old test)
Blood for TPHA (Now considered more sensitive)
INTERPRETATION
Advice given
1. Early syphilis (Primary, Secondary or Latent of less than 2 years duration)
Benzathine Penicillin 2.4 million IU intramuscularly once (Due to large volume it is
recommended that this dose be divided and given at 2 injection sites)
2. Alternative Regimen
Procaine Benzyl Penicillin 1.2 million IU intramuscularly once daily for 10 days
3. Alternative Regimen (For Penicillin allergic patients and non-pregnant patients)
Doxycycline 100mg orally twice a day for 14 days
OR
Tetracycline 500mg orally twice a day for 14 days
4. Alternative Regimen (for Penicillin allergic patients and pregnant patients)
Erythromycin 500mg orally 4 times a day for 14 days
This is the Management of Sexually Tarnsmitted Infections according to latest World
Health Organization guide lines
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ESTIMATED DATE OF DELIVERY
Calculation of estimated date of delivery is done as follow:

Date of first day of last menstrual period + 7 days minus 3 months
e.g. Last menstrual period (LMP) first day = 8 Sept. 2018.
EDD = Sept. 8 + 7 days minus 3 months
15 Sept. minus 3 months
EDD = 15 June 2019.
______________________________
Blue growth chart Boys,

Red growth chart Girls
0 to 2 year
2 to 12 year
________________________________
Expected height father height + Mother height ÷ 2
Plus 6cm for boys
Minus 6cm for girls
For example:
Expected height 180cm + 160 ÷ 2
340 ÷ 2 = 170cm
For boy height 170 + 6 = 176cm
For girl height 170 – 6 = 164cm
310
GROWTH CHART & FAILURE TO THRIVE
SCENARIO
Mrs. Smith has come to discuss growth chart of son age 3 months
weight 2.2 kg.
Meet greet
Introduction
How can I help you?
See this growth chart. Can you explain it to me.
What prompted you to have this growth chart done?
May I ask you some question about the birth of your son? (Ask bind)
B – What was the mode of delivery? Any complication before during or after birth?
I – Is his all vaccination done according to schecule? Any problem with immunization
(Important Question)
N – What type of feed he is taking. Is the child breast fed?
Are you following manufacturer instructions for preparing milk (if on fomula milk)
D – Has he achieved his development mile stones for his age in time?
Feeding problem / GIT
CVS problems (Paller)
Chest Problem
Bone Problem / Stature
Is he having any problem with sucking the milk?
Does he throw out milk soon after feeding?
Does he feel tired while taking feed? (Congenital Heart Disease)
Have you noticed any difficulty in breathing while he is feeding.
BREAST FEEDING
For a child of 2 months, breast milk is the best food or nutrition.
Exclusively breast feed if you can. There are day care centres for working woman.
Take your child with you.
Start solids at the age of 6-9 months.
IF FORMULA MILK IS GIVEN
Wash your hands thoroughly before preparing feed.
Sterilize bottle.
Sterlizers are freely available in market. Buy one
Prepare milk by add right amount of powder to right amount of water.
Usually one level scope of milk for every one ounce (30ml) of water.
Is he opening his bowels > 4 x/d
Is he inter acting with you with. (smile) (recognize the parents).
PAST HISTORY
Has the child ever been diagnosed with any medical condition like DM Asthma.
SOCIO ECONOMIC HISTORY
Illness – ICE – summarize.
311
ICE
IDEA
I know a number of things are going at the back of your mind. what do you think, is the
most likely cause of condition of your child?
CONCERN
Are you worried about anything in particular?
EXPECTATION
If Rickets suspected ask Bind & following questions
Is there any frontal bossing on his forehead?
Have you seen his chest what does it look like? (Poegeon Shaped Chest)
Is there widening of his wrist joints?
Is there any bowing of his legs?
SUMMARIZE
You are worried that your child not maintaining his weight according to his age.
DIAGNOSIS
Failure to thrive.
MANAGEMENT
Formula milk 1:1 dilution
1 ounce water = 1 level spoon of milk
1 ounce = (30ml) = 1 level spoon of milk
Sterlise feeder
There no feeding time for child. Should be feed on demand but should be given at 2
to 3 hours interval. Give child time to digest feed. Prop up the child after feed and Barp.
If fail to gain weight urgent refer to paeds specialist
DIFFERENT CHARTS FOR BOYS OR GIRLS
Growth chart is about health of child.
If child is on 90-95 centile scale. Then think of child hood obesity.
If instead of Age and weight (age and height) are given and age is in years instead of
months. Then think of Rickets.
If there are 100 children and your child is at number 3 per centile from bottom i.e. his
weight is not according to his age.
Advise about diet.
Difference of Marasmus & Kwashikor?
312
FAILURE TO THRIVE
Protein energy malnutrition (PEM) is the leading cause of death in children younger
than 5 years of age.
Protein & calorie deficiency occur due to social & economic factors. Increased calorie
requirement occurs in infection, trauma cancer. Increased calorie loss occurs in reduced
calorie intake (Anorexia), cancer. In developed countries like USA, factors that contribute to
poor growth are maladapted behavior & psychosocial factor. Feeding problems & poor growth
may be associated with minor acute illnesses.
MARASMUS KWASHIORKOR
1. Marasmus is the term used for sever 1. Kwashiorkor is caused by inadequate
protein energy malnutrition (PEM) & protein intake in the presence of fair
wasting (low wt/ht). to good calorie intake. (Food is
available but lacks in protein).
2. Cliniclal manifestation is emaciation 2. Clinical Manifestation is body weight
with a body weight less than 60% of of child ranges from 60 to 80% of
50th percentile for age expected weight for age.
3. There is loss of S/C fats stores & 3. Physical examination reveals
muscle mass. maintenance of subcutaneous fat &
marked atrophy of muscle mass.
4. Head appear large in proportional to 4. Enlarged parotid glands & facial
body length. edema result in moon facies, child is
apathetic disinterested in eating.
5. Odema Absent 5. Pitting odema varies from minor
pitting of dorsum of foot to
generalized edema with involvement
of eye lids & scrotum.
6. Hairs may be thin sparse & earily 6. Hair is sparse, easily plucked, appear
pulled out. dull Brown, Red, or yellow white.
7. Skin is dry & thin, Brady cardia & 7. Skin changes ranges from
Hypothermia signifies sever life hyperpigmentation to erythematous
threadening malnutrition. There may macular rash (pellagroid) on trunk &
be chronic diarrhea. Stunting growth extremies.
is more prevalent than wasting.
8. Chest infection may reveal basilar
rales. Abdomen is distented (with
enlarged soft liver. Bowel sounds are
hypoactive.
Treatment
Gasterointestinal tract may not tolerate a rapid increase in intake. Nutritional
rehabilitation should be intiated & advanced slowly. Interavenous fluids should be avoided.
Start nutritional rehabilitation with calories 20% above the child recent intake. Calorie intake
is increased slowly till catch up growth is initiated. Iron supplements are not recommended
for Kawashiorkor children for whom ferritin levels are often high. Other easily digested food,
appropriate for age may be introduced slowly. If feeding intolerance occurs lactose free
formula should be considered.
Malnutrished children are more susceptible to infection especially sepsis, pneumonia
& gastero enteritis. Hypoglycemia is common after periods of sever fasting. Hypothermia may
signify infection. Brodycardia may signify decreased metabolic rate to conserve enery vitamin
A & Zinc deficiencies are common. Social depreveation may result in impaired cognitive
function.
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PRIMARY NOCTURNAL ENURESIS
Scenario
Mrs. Samantha has come to discuss bed wetting of her five year old child Michal.
Kindly take relavant history and manage.
Proceed.
(Six year is the cut of age at which secondary causes of nocturnal enuresis will
be looked for)
Hello. I am Dr. Raheel, one of the family physician in this surgery.
I am Mrs. Samantha.
Ok Mrs. Samantha what brings you to surgery today?
Doc. I am very much worried about my son Micheal.
He is five years old but he is still wetting the bed at night.
I am tired of extra work washing his clothes and of bed linen)
Anything more? It hurts me when I punish and spank my own dear chlild.
But he still wets the bed.
Anything else you want to add?
Doc. We can not go out for vacations also. We have not been out of the city to our
relatives because of Micheal’s this embarrassing habit.
Anything more?
Ok.
Mrs. Samantha first of all let me assure you that it is not the fault of the child. His
involuntary bed wetting is not in his control. Its only a development delay which will be
corrected with time.
May I know the exact age of child?
He is five year old now.
Mrs. Samantha stastitics show that 8% of the children aged 4½ year in voluntarily void
urine during sleep on more than two nights per week. However there are certain life style
changes and certain medicines available. You will be able to go out of the city and for the
vacation.
Can I ask you few more question.
Is he dry during the day. (Yes)
Does your child have bowel control. (Yes).
Has your child been dry ever before? (No)
Is their any emotional problem due to your punitive measures. (No)
No he has not gained control ever since his birth.
_____________________
4 Has he complained of maltreatment & bulling at school by teacher or friends in the
last 2 months. (No)
5 Is there any family history of such problem?
Yes, his father had a similar problem of bed wetting when he was a child.
6 Did your child have any spinal injury? (No) (Mylomeningcoele)
7 Is there any tuft of hairs at the back of child?
Please bring your child with you on the next appointment . I would like to examine him
properly and have a chit chat with the child.
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INVESTIGATIONS
I offer urine C/E, (Rule out UTI & Diabetes)
Blood sugar fasting
2 hours after meals
HbA1c.
LIFE STYLE CHANGES
Ok Mrs. Samantha
I offer you certain life style changes which will help in having dry nights till the control
comes.
Please reassure the child that it is not his fault. Its only a development daily.
Do not take punitive measures.
Just limit the fluid intake to 1 to 1.4 literes per day.
Avoid tea or caffeine.
Train him to go to toilet 4 to 7 times during day and also before going to bed.
Offer a reward system like star chart in his room. He will get star on going to toilet
before bed time (Rather than a dry night).
Ask him to set an alarm clock for self awaking at the mid night.
ENURESIS ALARM
Mrs. Samantha if these measures did not work we have an option of enuresis alarm.
For this I will refer you to the school nurse or paediatric enurisis clinic. They will teach you
how to use this alarm.
Actually a sensor is put in the under garment and the alarm goes off when the urine
make contact with the sensor.
With the time, child wakes up in response to the bladder contraction rather than contact
of urine with the sensor, before alarm goes off.
This alarm become effective in less then 4 weeks time but may take months until child
is completely dry at night.
Continue until 2 weeks after achieving dry nights.
Restart if relaps occurs.
MEDICINE
As for your desire to go out of the city and for vacations, there is a medicine called
desmopressin which can be used for short time as rescue medicine.
This is a synthetic version of anti diuretic hormone taken at night . This drugs is not
without side effects. It side effects include headache, nose bleed, face flushing, mild tummy
cramps, nausea, nasal congestion and sore throat.
There is a precaution to be observed with the use of desmopressin because of fear of
water over load.
Advise the chliid not to take more than one mug of fluid from one hour before
desmopressin dose up 8 hours afterwards.
This drug is usually specialist initiated. There is another anti depressant drug
imipramine for children who do not responed to other treatment. This is also initiated by a
specialist psychiatrist for which I will refer you to a psychiatrist.
All five sentences of closing in ten sentences.
Refer to paediatric Enuresis clinic for enuresis alaram
Refer to psychiatrist for initiation of desmopressin
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MEASLES RASH
Mother of Miss Seemi Ghazal, 6 year old presents in GP surgery worried about
her daughter’s rash. Take relevant history & manage.
Meet & Greet
Introduction
Information freely revealed on facilitation
She has flu like symptoms 4 days ago. With runny nose and watering red eyes.
Did someone at school or home visited the child with similar rash (Spread by droplet
infection and direct contact)
Where exactly is the rash?
When did it appear?
What is the color of rash?
How does it appear / Is it raised on skin?
Does the rash blench on pressure?
Is there any associated symptoms?
What is the colour of rash? (Pink red)
From which part of body rash started? (Rash appeared first on face later on trunk
and limbs were involved)
Is it raise on skin? (Macular Rash Not raised)
Did you noticed any whitish spots inside her mouth (Koplic Spots) (White spots in red
background in front of first molar teeth)
Is there any associated feature with rash?
Like cough (Pneumonia)
Like Fever (Pneumonia or Meningitis)
Any headache? (Meningitis)
Any photophobia? (Meningitis)
Any Neck stiffness (Can not touch chin to chest) (Meningitis)
Any Nausea?
Does the rash blench on pressure? (tumbler test)
Put the glass slide over the edge of rash, if rash disappear then its not meningitis. If
rash persist then it is meningitis.
BIND
• What was the mode of delivery (Of Seemi)?
• How many other children you have?
• Is her all vaccination completed i.e.
2, 3, 4 months
12 – 15 months 1st dose (MMR)
3 – 5 year pre school (MMR) 2nd dose
• Is the child feeding adequately and properly (Not very unwell but not toxic)
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• Was all developmental mile stones were in time e.g. walked in 1 year.
Can child run jump climb stairs
Talk sentences grammatically.
SUMMARIZE
MANAGEMENT
So your daughter has pink rash after flu like symptoms. Rash disappear (blench) on
pressure. Child is not having cough or fever so most likely your daughter is suffering
from measles.
Although she received all the vaccinations in time, the Measles can still occur. It is
highly contagious so don’t send her to school till rash disappear. Child remains
contagious 4 days before and 4 days after the rash disappears. Also segregate other
small brother and sisters. Rash is self limiting and will disappear in about 10 days
time.
Fortunately child has no cough, no fever, No stiffness of neck so most probably there
is nothing serious like pneumonia or meningitis.
At present just let her enjoy school holiday. Segregate from other children.
Plenty of rest and fluids
Paracytamol if body aches or mild fever
SAFETY NETTING
However if child develops any high grade fever with cough, neck stiffness or
deteriorate in any way instead of improving, please bring the child back to me.
Please seek medical help urgently. She may need admission in hospital under child
specialist care.
Is there anything else you would like to discuss with me.
No
Good bye (Smile & Shake hand)
NOTE
You must take history of birth, immunization, nutrition and developmental mile stones,
in every paediatric case where child problem is discussed
NOTE 2
Rubella infection more dangerous in early pregnancy.
Chickenpox infection more dangerous late in pregnancy.
Dangers to mother and fetus and neonate child
Read Rubella from Inam Danish Book of Medicine.
Herpes Zoster – Shingles
Vericella Zoster – Chickepox
Herpes Simplex – Numbness and vesicles around lips
317
COELIAC DISEASE
SCENARIO
Mrs. Samantha has come to discuss some symtoms of her son Michel who is
ten months old. Mother is worried child is not thriving properly. Kindly gather relevant
data and manage. Examination not required. Proceed.
Hello.
I am Mrs. Samantha.
Ok Mrs. Samanatha. What bring you to the surgery today?
I am here to discuss the problem my son Michel 10 months old.
Dr. My son Michel is not growing properly.
Child was breastfed initially, trouble started after weaning or after introduction of solid
foods which contained glutin e.g. Barley, Rye, Oat and Wheat (BROW).
His anal area is red and his stool floats in flush.
Anything else Mrs. Samantha.
The child complains of pain tummy. His tummy is boated and distended.
There is a change in his bowl habits to chronic diarrhea and he is very irritable,
miserable, pale & has thin hairs.
Anything else.
Doc child not growing properly.
He is short statured as compared to his contemporary children.
Mrs. Samantha before we come to the management of the child, Can I ask few
questions.
(1) BIRTH HISTORY
Birth history. Was the birth of the child normal. (What was the mode of delivery)
Immunization Has the child received all vaccination according to his age.
Nutrition Is a child feeding properly and adequately.
Development Did the child reach his mile stones in time as other kids of his age?
(No)
Is there anything that increases diarrhoea? (Glutin or Wheat diet)
Is there any food which decreases his motions. (Glutin free diet)
How many stools does the child pass per day? (3 or 4 formed stools per day)
Does the stool float on the flush? (Yes)
(2) D/D
1.TB
Any constipation alternating with diarrhea (TB)
Any evening rise of temp (TB).
Any night sweats (TB)
318
2. MALIGNANCY
Any significant weight loss e.g. more than 5% of his previous weight in 6 months.
3. COLON CANCER
Any huge fresh blood loss in stool.
4. CHRON’S DISEASE
Mixed black stool (Chron’s disease)
Pain while passing stool (Chron’s disease)
FAMILY HISTORY
Any major medical problem in immediate family members. Like any diabetes, any neck
gland problem, any Asthma or Eczema. (No.)
DRUG HISTORY
Is your child taking any drug like thyroxin tablet or insulin injection. (No.)
EXAMINATION
In order to reach my diagnosis I would like to examine your child.
Is he accompanying you today. (No)
Can you bring him with you at the next appointment?
I would like to examine him and have a little chit chat?
I would like to examine any sign of dehydration like?
Capillery refill (More than 2 Seconds)
Dry Tongue (dehydration)
Dry Mucus Membrane (dehydration)
Skin Turgor lacks (dehydration)
Paller
Anaemia – No food absorbed
Hand for tremor (Thyroid)
Hepato spleeno Megaly
INVESTIGATION
In order to confirm my diagnosis, I need to perform certaint tests.
(1) I offer you Coeliac Disease specific screening test i.e. tTGA IgA for confirmation.
Tissue Trans Gluteminase Antigen IgA (tTGA IgA test) is done not after stopping
Gluten.
But test only if patient has eaten some Gluten in > 1 meal/d for ≥ 6 weeks.
(2) Anti endomycial Antibody Test.
(3) If the test came positive then we can further confirmed it by small Gut tissue
examination called Duodenal Biopsy. This is an invasive test for which I will refer
your child to the gastro entrologist.
Diagnosis is based on a small-bowel biopsy showing characteristic histological
findings of partial or complete villous atrophy.
Biopsies are usually taken endoscopically. Multiple biopsies should be taken, as
the lesion can be patchy.
319
TFT
HbA1C (To see status of comorbid condition like diabetes)
Hb
ESR – C-RP
FBC
Coeliac disease is caused by a permanent sensitively to gluten which is present in
wheat, barley and rye. It occurs in genetically susceptible children and adults. The classical
presentation is with chronic diarrhoea, tummy bloating and failure to thrive.
What I have gathered from symptoms you have shared with me and examination I
have performed, most likely your child is having a condition what we call in medical terms
Coeliac Disease.
Do you want me to explain what is Coeliac Disease
Basically it is a type of food allergy due to Gluten – Gluten is found in many foods e.g.
BROW. B – barley, R – Rye, O – Oat, W – Wheat.
Coeliac disease presents 6 months, after gluten has been introduced into the diet. The
classical presentation is with irritability, weight loss, pallor, loose motions and
abdominal distension in infants.
LIFE STYLE CHANGES
Life long Gluten free diet.
No BROW, No Barley, No Rye, No Oats, No Wheat.
Eat Rice, Potato, Corn, Soya, Flax seeds.
Take Adequate water to prevent dehydration.
Don’t take Fizzy or Caffenated drinks
Refer to a dietician for specialist diet advice.
Coeliac Society also publishes recipes.
Prescribe adequate amounts of gluten-free products.
Add supplements of deficient nutrients e.g. iron, folic acid, calcium until well
established on a gluten-free diet.
Women with coeliac disease contemplating pregnancy should take folic acid 5mg od
until 12 weeks of Gestation.
Permanent withdrawal of gluten from the diet leads to complete remission with symptom
resolution within weeks. Gluten-free diet will be needed for life.
Vaccination
All patients with coeliac disease have less immunity so coeliac patient are offered
pneumococcal vaccination once in life time and influenza vaccine every year.
Complications
Osteoporosis and malignancy (lymphoma or carcinoma of the small intestine). Both
are virtually eliminated by adherence to a strict gluten-free diet, but remain vigilant and refer
if suspected.
Consider bone densitometry to exclude osteoporosis.
SCREENING FOR FIRST DEGREE RELATIVES in families with a child who has coeliac
disease is also suggested.
320
Family members with gut symptoms should have coeliac disease excluded.
Screening of first-degree relatives should be offered.
SAFETY NETTING
If your child continue to have symptoms it may cause loss of weight failure to grow,
dental problem, bleeding from rectum mouth, or sever bony pain. Come immediately to the
surgery. Otherwise I would like to see you in 6 month time.
FOLLOW UP & SUPPORT
Coeliac patient should be followed up every 6-12 months, in a specialist coeliac clinic
or by a GP under a shared care arrangement with a paediatrician interested gastroentrology.
Families should be encouraged to join a parent support group such as Coeliac UK.
Failure to respond to gluten free diet then.
Most common reason is continued ingestion of gluten (Intentional or inadvertent). Re-
refer to dietician. If symptoms re-occur after a period of remission, rerefer to a specialist for
re-assessement of the diagnosis.
The diagnosis is confirmed by complete symptom resolution on a strict gluten-free
diet. Positive serology should revert to negative over time on a strict glulten-free diet.
& should be considered mark of conmpliance.
Is there any thing else you want to discuss with me today. (No.)
Please take leaflet about coeliac disease from the reception desk.
Thank you for you visit.
Good bye.
====================================================================
GLUTEN FREE DIETS

Gluten free diets should be looked for in a super market and through internet.
Consult dietician.
GP should prescribed gluten free diet on prescription.
Joining Coeliac Society UK is a good idea.
Few example of gluten free diet are:
Sugar Honey Jelly
Butter Margarine
Tea Coffee
Plain Meat Fish
Fruits and Vegetables, Pulses (Pea, Lentis and bean)
Egg, Cheeze, Milk, Yogurt, Rice and Potato
Diets Containing Gluten (Formula BROW)
Barlay
Rye
Oat
Wheat
GLUTEN FREE DIET INCLUDE
Rice Potato, Corn Soya, Flex Seeds.
Short stature is an important specific indication with a high diagnostic yield and good
catch-up growth once the condition is diagnosed.
Dietary compliance is difficult to establish in children.
NOTE: Coeliac disease is quite common in UK in children and in adults.
321
< 2 years Sign Symptoms > 2 years Sign Symptoms
Chronic diarrhea Loss of appetite
Failure to thrive Diarrhoea
Abdominal distension Constipation
Vomiting Anaemia
Typically pale and miserable irritable Short stature
Hair thinning
Associated disorders
Adults Sign Symptoms
General lassitude (80-90%) Dermatitis herpetiformis
Anaemia (85%) Pruritic Vesicular Rash.
Diarrhoea (75-80%) Type 1 DM
Weight loss Autoimmune thyroid disease
Constipation Primary biliary cirrhosis
Apthous mouth ulcers Sjogren’s syndrome
Sore tongue and mouth IgA deficiency
Dyspepsia Osteoporosis
Abdominal pain / bloating Epilepsy
Anxiety or depression
Bone pain due to osteoporosis
Muscle wasting
Neuropathies
Infertility
Non-gastrointestinal manifestations of coeliac disease
• Dermatitis herpetiformis (Pruritic vesicular rash)
• Osteoporosis
• Dental enamel hypoplasia
• Short stature
• Delayed puberty
• Iron-deficiency anaemia not responsive to iron supplements
• Infertility
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ATTENTION DEFICIT HYPER ACTIVITY DISORDER (ADHD)
Mrs. Najma, mother of Farhan five year old has come to discuss some problem.
Kindly gather relevant data and manage.
Proceed.
Hello.
I am Mrs. Najma.
Mrs. Najma what brings you to the surgery today?
Well Doc. There has been a complaint from the school that my child’s grades a falling.
He is not able to concentrate in the class. He lacks social awareness and shouts out answers
in the class.
He is unable to take turn or wait in a queue. He is excessively talkative in the class.
Ok Mrs. Najma, anything more?
No that’s all.
Mrs. Najma have you noticed anything like that in the house as well?
Yes Doctor, he is hyperactive in the home as well. He keeps running and climbing stairs
inappropreately in the home.
He is easily distracted and he is forgetful as well.
FAMILY HISTORY
Ok Mrs. Najma, Is there any family history of such problem among the parents?
Yes Doctor, his father says that he used to have such complaints when he was in the school,
that is why he has a low academic achievement and at the present unemployed.
ILLNESS
How this condition is affecting your child?
He grades are falling in class and both his teacher and the parent are worried.
IDEA
What do you think is the cause of this condition?
I do not know but my gynaecologist said that one of the cause could be that he was born
premature and I was doing substance abuse during pregnancy.
CONCERN
Is there anything that worries you particularly?
My child may also be a low academic achiever and have problem in future.
EXPECTATION
I hope you will prescribe some medicines, so that my child start behaving normally.
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MANAGEMENT
REASSURANCE
Mrs. Najma what I have gathered from the information you have shared with me that your
child having a condition what we call in our medical terminology as Attention Deficit
Hyperactivity Disorder.
Mrs. Najma 9 percent of the school going children in UK have this condition. It is said some
genetic factor may contribute to it and these children have learning difficulty.
There could be some emotional trauma like relationship problem of parents or some hearing
defect of child may contribute to this problem.
Since your child has persisting problem for the last six months and there is severe impairment
so instead of watchful waiting I am referring you to the community peadiatrics and also to
the psychologist directly. He will give some behavioral therapy to you child.
In this condition not only child is given behavioral therapy but at first some parent training and
education is also done.
Parents are instructed to use simple words while giving instructions. Speak softly, slowly and
patiently.
Make sure the child is well rested.
Avoid situations which are difficult for him such as sitting through long presentations or
shopping.
Try to remain patient and calm while dealing with your child. Your child will copy your
model and will become calm himself.
Do not force your child in the activities that are beyond his abilities.
You can offer your child yoga and meditation activities as well.
If parents are tired, they should give themselves some time out to rest and relax. Take help
from the babysitter or caretaker who is well knowledgable about attention deficit hyperactivity
disorder and mature enough to deal with the task.
Mother is advise to refrain from smoking and substance abuse and alcohol during next
pregnancy.
Reduce exposure to TV games till the second trimester.
Avoid environmental toxin.
To diagnose this condition I will be referring you to the psychiatrist. This condition must exist
in more than one situations like school and home.
Psychiatrist will start medicine called methylphenidate.
Is there anything else you want to discuss me today?
No that’s all.
You can collect the information leaflet about ADHD from the reception desk.
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MILE STONE & BIRTH HISTORY
In paeds special inquiry is made regarding following aspects. (BIND-SH):

1. Birth history
2. Immunizations (Vaccination) and Infections
3. Nutrition
4. Growth and development
5. Social history
6. Hereditary
(I) BIRTH HISTORY
It is divided into three headings:
1. Antenatal
2. Natal
3. Post Natal
ANTENATAL HISTORY
Enquiry about:
– Nutritional status of mother
1. Maternal Intake of Iron, Multi Vit., or drug
2. Maternal illness during pregnancy
3. Exposure to radiation
4. Any problem with previous pregnancies like abortion, still birth etc.
NATAL HISTORY
Enquiry about:
5. Place of delivery (Hospital, Clinic, Home)
6. Person who conducted the delivery (Trained or untrained e.g. Dai
7. Duration of pregnancy
8. Mode of delivery (Normal Vaginal delivery, lower segment caesarian section or
forceps)
9. Duration of labour
Any drug used during labour
POST NATAL HISTORY
Enquiry about:
10. Apgar score
11. Birth Weight
12. Did the child cry immediately
13. Was the child cyanosed or apnoeic
14. Any history of post natal illness
15. Any history of jaundice, phototherapy or exchange transufion.
16. Any medication during neonatal period
(II) IMMUNIZATION (Vaccination) THERAPY
(III) NUTIRITION
2. Is the baby feeding adequately and regularly or not and gaining weight or not.
3. Was the baby breast feed or bottle fed.
If the baby is breast fed then enquire about the following:
17. Dration of exclusive breast feeding
18. Age at which bottle was started.
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19. Dilution techniques
20. Amount of milk per feed
21. Frequency of feeding
22. Sterlization technique
23. Other fluids
When was weaning started and enquire about the following:
24. Type of weaning
25. Like or dislikes
26. Problem during weaning
27. Is the child gaining weight
28. Any food allergies
29. Amount of calories and protein content in diet
30. Any multivitamin or iron supplement.
WEANING
31. Advise parents to introduce `slids’ at any time from 4-6 months of age. The baby
is ready when he is always hungry, even soon after a feed.
32. It is not essential to use ready-made baby meals – often babies like home
prepared purees better, and they are chaper.
33. If making purees, advise parents not to add salt or excess sugar.
34. Sterilize feeding bowls and cutlery before use until the baby is > 6 months. Old.
35. Start with 1 flavour of finely pureed food e.g. baby rice. It is usual for most of
the food to ooze out of the baby’s mouth.
36. Babies often only take 2-3 teaspoonfuls per meal when they start taking solids.
37. It is usual for the baby’s stool to change consistency when waned.
38.
Add different foods 1 by 1. Avoid eggs and gluten until > 6 months of age.
39.
Introduce lumpy foods gradually after 6 months, and finger foods the baby can
feed itself (e.g. pieces of toast rusks biscuits) at 7-9 months.
40. Continue giving the baby at least 600ml of milk/d.
WORRIES ABOUT THE AMOUNT A CHILD IS EATING
– Common worry of most parents. Check the child is gaining weight along his
centile line. If so, reassure the parents often unrealistic expectations of the
amount a baby to toddler can eat or between meal snacks are the real
problem. If not gaining weight along centile line.
(IV) GROWTH AND DEVELOPMENT

A child may be brought for development delay. Beware of the great variation in
developmental achievement. It may be normal for a child to walk precociously at 10 month.
It is critical there fore that paediatrician detect the subtle abnormalities and normal variation
so that he can explain confidently to the anxious parents.
Developmental aspect of child is divided into four board categories
1. Gross Moter
2. Fine Moter
3. Social history
4. Language or speech
Few reliable developmental milestone most commonly seen are:
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Milestones Age
• Social Smile 1 Month
• Neck holding 3 Months
• Sit with Support 6 Months
• Sit without Support and Transfer object from one hand to another 7 Months
hand
• Hold object between thumb and finger (Pincer grasp) 8 Months
• Supported Stand 9 Months
• Walk with Support 10 Months
• Unsupported Stand 11 Months
• Attempt to walk alone 12 Months
• Run 18 Months
• Sphincter Control 24 Months
• Speech (1-2 Words) 12 Months
Up and down step, can kick ball 2 year.
Climb stairs himself, Walk on tip toe 3 years
Descend stairs, hopes on feet 4 years
3 And 4 Years Check
Climb and descend stairs
Run, jump and kick
Stand on one foot for one second
Walk heal to toe (4years)
Copies a circle but makes a square with difficulty
Threads beads
Built a tower of 8 bricks
Matches 2 colors
Recognizes colors
Uses plurals
Join words into sentences
Gives own name
Speaks grammatically (4 years)
Can eat well with fork & spoon
Developmental milestones: gross motor
The table below summarises the major gross motor developmental milestones.
Age Milestone
3 Months Little or no head lag on being pulled to sit
Lying on abdomen, good head control
Held sitting, lumbar curve
6 Months Lying on adbdomen, arms extended
Lying on back, lifts and grasps feet
Pulls self to sitting
Held sitting, back straight
Rolls front to back
7-8 Months Sits without support (Refer at 12 months)
9 Months Pulls to standing, Crawls
12 Months Cruises
Walks with one hand held
15 Months Walks unsupported (Refer at 18 months)
18 Months Squats to pick up a toy
2 Years Runs
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Walks upstairs and downstairs holding on to rail
3 Years Rides a tricycle using pedals
Walks up stairs without holding on to rail
4 Years Hops on one leg
Developmental milestones: Fine motor and vision

The table below summarises the major fine motor and vision developmental
milestones.
Age Milestone
3 Months Reaches for object
Holds rattle briefly if given to hand
Visually alert, particularly human faces
Fixes and follows to 180 degrees
6 Months Holds in palmar grasp
Pass objects from one hand to another
Visually insatiable, looking around in every direction
9 Months Points with finger
Early pincer
12 Months Good pincer grip
Bangs toys together
Bricks
15 Months Tower of 2
18 Months Tower of 3
2 Years Tower of 6
3 Years Tower of 9
Drawing
18 Months Circular scribble
2 Years Copies vertical line
3 Years Copies circle
4 Years Copies cross
5 Years Copies square and triangle
Books
15 Months Look at book, pats page
18 Months Turns pages, several at time
2 Years Turns pages, one at time
Developmental milestone: Social behviour and play

The table below summarises the major social behaviour and play milestones
Age Milestone
6 Weeks Smiles (Refer at 10 weeks)
3 Months Laughs
Enjoys friendly handling
6 Months Not shy
9 Months Shy
Takes everything to mouth
Feeding
May put hand on bottle when being fed 6 Months
Drinks from cup + uses spoon, develops over 3 months period 12-15
Months
Comptent with spoon, doesn’t spill with cup 2 years
Uses spoon and fork 3 years
Uses knife and fork 5 years
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Dressing
Helps getting dressed / undressed 12-15
months
Takes off shoes, hat but unable to replace 18 months
Puts on hat and shoes 2 years
Can dress and undress independently except for laces and buttons 4 years
Play
Plays `peek-a-boo’ 9 months
Waves `bye-bye’ 12 Months
Plays `pat-a-cake’
Plays contentedly alone 18 Months
Plays near others, not with them 2 years
Plays with other children 4 years
(V) SOCIO ECONOMIC HISTORY

Inquire about occupation and income of parents, living arrangements whether it is an
extended family, nuclear family or a single parent family.
Sources of support for mother, in physical, emotional and financial areas. Detail of
house particularly about number and size of rooms, ventilation, sewerage system,
availability of clean water and hygienic conditions of the surrounding are also important in
asscessing the socio-economic status of family.
(VI) HEREDITARY
Did you child achieved appropriate milestones for his/her age in time.
DEVELOPMENTAL MILE STONE

AGE DEVELOPMENTAL MILE STONE
1 month Social smile/recognize parents
4 months Roll over
6 months Sit up unsupported
9 months Crawing / crozzes over furniture
1 year Walk / Poncer grasp
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NORMAL PATTERN OF CRYING
Do you know normal patten of crying?
From birth upto 6 weeks – normal pattern of crying is 2 to 3 hours/day.
From 2nd month – 2 – 3 hr/d of crying but clustered around afternoon and evenings.
4 months onwards normal pattern of crying is 1 hr/d.
Treat the cause.
1. If hungry give feed of milk.
2. If wet change the nappy and apply nappy rash cream and maintain pamper free period.
3. If passing current jelly like stools refer to paediatric surgical emergency for air anaema.
4. Post immunization fever but otherwise well. Treat with paracytamol and plenty of fluids
apply ice cold sponges at the injection site.
5. Immunization reaction: Contraindication to vaccination. For specific
contraindication to individual vaccination consult the Green Book. General rules:
• Acute illness Delay until fully recovered. Minor ailments without fever or systemic
upset are ot reasons to postpone immunization.
• Severe local reaction to previous dose Extensive area of redness/swelling that
involvesmuch of the antero-lateral surface of the thigh or a major part of the
cirumfrence of the upper arm.
• Severe generalized rection to a previous dose Fever ≥39.5oC <48h after
vaccination; anaphylaxis, bronchospasm, laryngeal oedema, and/or generalized
collapse; proonged unresponsiveness; prolonged high-pitched or inconsolable
screaning for >4h; convulsions or encephalopathy <72 after vaccination.
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EXCESSIVE CRYING
Mrs. David has come to discuss excessive crying of her 5 months old child.
Meet & Greet
Introduction
Open question
How can I help you today.
My 5 months old child is crying excessively for the last whole night. I am very much
disturbed. We both parents could not sleep. Tell me more about it. Anything else.
When does the baby cry?
Can he be consold?
What do the parent do when baby is crying.
Any feeding problem, is feeding properly.
CNS - Any fever with neck stiffness and rash on the body
CVS – any paller
Is he feeling tirdness while taking feed (Congential heart disease)
EYE
Any eye discharge?
ENT
Is he having some nasal blockage?
Is he pulling his ear? Have you noticed any discharge from the ear?
RESPIRATION
Is he coughing? Or any breathing difficulty (Pneumonia)
Is there any H/o Trauma, injury or fall?
Is he vomiting?
G.I.T.
Is he passing his stools normally? Any Constipation or Diarrhoea? Any loose stool or
vomiting.
Is he passing current gelly like stool (Intersusception refer to emergency)
GENITALIA
Have you noticed any swelling on his Genitalia (Strangulated testicular tortion hernia)
refer.
SKIN
Have you noticed any rash on his nappy area.
CVS
B - What was the mode of delivery?
Any complication during pregnancy during labour or after birth?
I - Is his vaccination upto date according to schedule?
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Did he receive any immunization recently?
When was he given last vaccination (Important Question)
N - How he is being feed (Breast feeding or Formula Milk)
If on formula milk then what is the Ratio of dilution of milk.
Are you preparing formula milk according to said principles?
Over dilution Right way described
If under dilution – tell correct way of dilution.
D - Can he raise his head when lying on chest? (5 months) (developmental milestone)
Can he lift his leg and hold his foot (5 months)
PAST MEDICAL HISTORY
Is there any medical or surgical history of any illness?
Is he using any medicine currently
Any drug allergies?
FAMILY HISTORY
Any major medical problem in immediate family?
ICE
How this crying has affectd you?
What do you think is the casue of crying?
Are you worried about anything in particular?
SUMMARIZE
EXAMINATION
I would like to exam him. Please bring him along with you next time?
MANAGEMENT
(1) If passing current gelly like stools and drawing his legs towards abdomen then it is
the case of inter susception.
Refer immediately to paed surgical emergency unit for air enema. (Intersusception
rare in breast feed babies)
(2) (Post immunization fever) reassure this is common side effect of vaccination.
Advise syrup paracytamol 125mg/ml 3 times a day for 3 to 5 days.
ICE sponging at the site of injection.
(4) Testicular swelling refer to emergency
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DOWN SYNDROME
TRISOMY 21
Most common chromosomal abnormality
Life expectancy is decreased but half live up to 60 years.
Increased incident with mother more than 35 years
FEATURES
Development delay and learning difficulties
Flat occiput
Mongoloid face (Oval)
Low set eyes
Prominent inner canthus fold
Single palmar crease
Hypotonia
Congenital heart diseases (VSD and ASD)
Down’s Syndrome is an example of a genetic disorder that can be detected
antenatally. The aims of counseling are to give information on chromosomal / congenital
diseases, which may or may not present at birth but could potentially affect the child’s
quality of life. It is important to discuss how the condition will affect the child’s life (should it
occur). What the risk factors and calculated risks are for acquiring it and what treatment and
support is necessary. It is important to make sure all information is understood.
All information must be given in an unbiased way, and the parents must be given the
time and autonomy to make their own choice about how to proceed.
Screening for Down’s Syndrome is offered to all pregnant women at the booking
scan around the twelfth week of pregnancy.
The triple test measures levels of maternal serum alpha-fetoprotein, human chorionic
gonadotrophin and oestrio, and gives a risk of developing the condition. The ultrasound
scan measures muchal translucency (assessing the skin fold thickness at the back of the
neck). Both the triple test and nuchal translucency are screening tests at 10-14 weeks
gestation. The results of the triple test, ulterasound scan and the risk associated with
maternal age are combined to give an overall risk; but is still not a definintive diagnosis of
Down’s Syndrome.
Risk of having a Down’s Syndrome afected child with increasing maternal age.
Maternal age (years) Risk
20 1/1700
25 1/1400
30 1/1000
35 1/350
40 1/100
45 1/30
The chance of a 40 year old mother giving birth to a child with Down’s syndrome is
approximately:
A. 1 in 5
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B. 1 in 10
C. 1 in 30
D. 1 in 100
E. 1 in 500
Down’s syndrome risk – 1/1,000 at 30 years then divide by 3 for every 5 years.
Down’s syndrome epidemiology and genetics
Risk of Down’s syndrome with increasing maternal age
• Risk at 30 years = 1/1000
• 35 years = 1/350
• 40 years = 1/100
• 45 years = 1/30
Oneway of remembering this is by starting at 1/1,000 at 30 years and then dividing by 3 (i.e.
3 times more common) for every extra 5 years of age.
Women with high risk pregnancies are offered chorionic villous sampling (CVS) or
amniocentesis. Both these karyotyping techniques are very sensitive (They detect the
majority of affectd babies) Although the results of CVS are available in 24-48 h
(amniocentesis takes 2-3 weeks), the miscarriage rate following CVS is 40% while for
amino centesis is 1%. In some advanced centres a recent technique known as FISH
(Fluorescent ImmunoSorbent Hylondisation technique) can give a result within 5 days from
the amniocentesis.
DISCUSSING THE RESULTS WITH THE PARENTS
Be prepared for emotional responses from both parents when giving them potentially
bad news.
Are you the kind of person who like to know every thing about the condition he is
having
Would you like your partner or some relative present besides you, before we discuss
the results of reports.
Doctor is that a bad news.
Well, I am afraid the results of report are not that simple as we were hoping.
Most likely your child will be having an abnormality right from birth.
If possible, both parents should be present. It is important to be sensitive at all times,
allowing time for questions and stressing that antenatal care is ongoing and that they
can receive further advice and help at any time. Before explaining a high risk result it
is advisable to guage the parents’ understanding of the condition.
Before we discuss the results of report may I know what you understand by Down’s
Syndrome what abnormality or difficulties your would be child can have?
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DOCTOR-PATIENT SCENARIO
You may find the following role-play useful for OSCE situations:
Dr. M.: hello Mr. and Mrs. D., I’m Dr. M.
Mr. and Mrs D.: Hello
Dr. M. I understand you took a test recently to assess the risk of Down’s Syndrome
in your baby. Can I ask what you understand by the term Down’s Syndrome?
Mrs. D.: We know It’s a genetic thing that causes learning difficulties in children. Is
that right?
Dr. M.: Yes that’s right. It is genetic and it can cause developmental problem as well
as other problems in children. Do you understand what happens in the genes to
cause the condition?
Mrs. D.: Not really. I don’t really know at all – can you explain how it occurs?
Dr. M.: yes of coruse. Think of every cell in your body having information inside it,
coding for everything; One bit codes for the colour of your eyes, while another bit
may code for how curly your hair will be. All these codes are something we call DNA
and this DNA is arraned into long strings of information called chromosomes.
Every human usually has 23 pairs of chromomoes. When a mother has a baby, she
passes on one copy of her chromosomes to the baby and the father passes on one
copy of his chromosomes, so that the baby receives an equal amount of DNA from
each parent, and like them, ends up with 23 pairs of chromosomes. However, in
most cases of Down’s Syndrome, one parent passes on two copies of the 21st
chromosome and so the baby ends up with three copies of it. We can calculate if a
mother has a high risk of having a chld with Down’s Syndrome through the blood test
you had recently. However, the result of the test is only risk – so a person with a high
risk does not necessarily have a baby with Down’s Syndrome – in fact, a high risk is
considered to be a 1 in 200 chance. The risk gets higher as the mother gets older,
but a 20 years old mum with a risk of 1 in 1700 can still give birth to an affected child
– It’s only a risk – not a diagnosis – do you see what I mean?
Mrs. D.: Yes, Do you have my results?
Dr. M.: You have to remember it’s not a diagnosis, but the result showthat you are in
high-risk category.
(Silence)
Mrs. D.: But this doesn’t mean my child has Down’s does it?
Dr. M.: No, but we can give you a more definite result either way if we do some
further tests.
Mrs. D.: Okay. Wha tests?
Although terminations can occur up to 24 weeks (6 months) (and in some cases, any
time before birth), this may not always be the most desirable course of action. With
modern standards of medical care, Down’s children can lead very happy and loving
lives, well into their mid-forties. It is up to you to make sure the mother and family have
the information and support needed to make her own decision.
Always allow time for the family to ask questions either at the consultation or
afterwards. Also, stress the availability of information from support groups such as the
Down’s Syndrome Association.
Take your time before you make decision to terminate pregnancy or continue you
can get further information from internet.
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I offer you some written material about this condition to take home.
The ultimate decision is yours. The choice is yours but take time to make decision.
Having a handicapped child is not easy.
NOTE
SCRRENING TEST
• Triple Test
• Ultra Sound for Nuchal Translucency 10-14 wks gestation
__________________
CHRONIC VILLOUS SAMPLING OF PLACENTA (CVS)
1. CVS → Results in 24-48 hrs → Risk of Miscarriage 40%
2. Amniocentesis results in 2-3 wks → Risk of Miscarraige 1 %
3. FISH Tests Result in 5 days
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TINNITIS
Hello.
I am Doctor Raheel one of the GP in this surgery.
I am Mrs. Hameed.
Ok Mrs. Hameed. How can I help you today?
Doc. I did’nt want to bother you with this. I have ringing sound in my both ears. I thought it
will go away at its own. But now it is interferring with my life. The noise is loudess at night
when surroundings are quite. My sleep is disturbed and I am extremely frustrated.
Anything more?
Doctor, I have not had my ear wax cheked for years. I think this ringing sound is because of
it. I will try to help & guide you to the best of my abilities.
Before I come to the management part, Can I ask you few questions?
Is there ringing in both ears or just one? (Both ears)
Is it present all the time, or does it come and go? (Its constant all the time)
Since when has she noticed the ringing? (Since three weeks)
What makes it better? (Nothing)
What makes it worse? (At night its loudest)
Any associated symptoms with the ringing? (Like no deafness, no nausea, no vomiting, no
dizziness)
How intrusive you finds the noise? (It’s distressting. Cannot concentrate on my work)
Does it affect your sleep? (Yes, my sleep is disturb)
Does it stop her doing things? (No)
Any previous ear problem? (No)
How is her hearing? (My hearing is perfectly fine)
D/D
Any major life events recently? (No)
Have you banged your head anywhere recently? (No head injury)
Any ear discharge? (No)
Any pain in ear? (No)
Any dizziness? (No, my balance is quite ok)
Any history of cold recently? (No)
PERSONAL HISTORY
Do you smoke? (No)
Do you drink? (No)
Any high blood pressure? (Yes, taking ramipril daily)
How are things at home? (Fine but my sleep is disturb)
What do you do for your living? (I am a DJ at a Disco Music Club)
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How are the things at work?
Music is my passion and I enjoy loud music for 8 hours daily as my work. But this ringing in
the ear is ruining my pleasure.
PAST HISTORY
Past history of similar complains? (No)
Have you been near some explosion at any time? (No)
Have you heard any gun short at a near distance? (No)
Have you been hospitalized for any reason previously? (No)
FAMILY HISTORY
Is there any similar history in any family member? (My grand father use to complain of ringing
in the ear and he died of brain cancer)
DRUG HISTORY
What medicine have you taken over the last 6 months? (I am taking ramipril 2.5mg daily for
my blood pressure)
IDEA
What do you think is the cause of your symptoms? (I have no idea.)
CONCERN
Are you worried about anything in particular? (I might have brain cancer just like my grand
father who use to have ringing in the ear)
EXPECTATION
I hope that you will tell my It is not a serious thing and you will explain me what is going on.
EXAMINATION
Mrs. Hameed in order to reach my diagnosos, I would like to examine you, Can I?
1-TO TEST HEARING :
Whisper in each ear one by one and ask the patient to repeat what you have said.
RINNE & WEBER TESTS

REMEMBER: in normal hearing AIR CONDUCTION IS BETTER THAN A BONE
CONDUCTION
RINNE’s TEST : strike the tuning fork just above your own elbow then touch it on the mastoid
process behind one ear , ask the patient when he stops sensing the vibration then bring the
vibrating tuning fork anteriorly in front of same ear , now ask the patient if he can hear it .
Since normally aire conduction ie btter so patient will be able to hear vuibrating turning fork.
Repeat the same practice by testing the other ear.
IF THERE IS ANY ABNORMALITY NOTICED WHILE DOING RINNE’s TEST only then go
for WEBER TEST other wise omit it.
WEBER’s TEST : Place the tip of a vibrating tuning fork on the vertex or front of head , if the
patient says it is lateralizing towards one side then this means: the problem lies with the
lateralized side of ear.
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TRIGEMINAL NERVE (V)
SENSORY PART: Corneal reflex/ Ophthalmic, Maxillary and Mandibular) (Pain, touch
& temperature) Touch whisp of cotton to cornea. Touch maxillary mandibular rea with
pin.
MOTOR PART: All muscles of mastication
EXAMINATION:
1- Ask the patient to close his eyes .
2- Take a cotton wick / or use your hand finger , touch bilaterally regionally on face ( in
ophthalmic , maxillary and mandibular regions on face )
3- Ask the patient would you please clench your teeth/jaw, now feel the masseter muscle
.
4- To check corneal reflex: ask the patient to look up and away ::: then touch the cornea
with a cotton wick.
FACIAL NERVE (VII) Passes through ear
It’s a nerve that is responsible or expressions on face as well as taste. It also supplies
anterior 2/3rd of the tongue (to feel taste).
EXAMINATION:
1- Firstly, observe the patient’s expressions while talking. Drowing of saliva.
2- Ask the patient to raise his eyebrows ( a reasonable command would be : would you
please look at the ceiling without moving your head) Compare the wrinkles on both
side of fore head.
3- Ask the patient to firmly close his eyes, then you try to open it to show muscle power.
4- Ask the patient to show his teeth (Angle of the mouth will be deviated towards the
normal side)
5- Ask the patient to blow out his cheeks (Blow out the cheeks and press on both sides
with your fingers. Patient will be unable to maintain blow out cheek on the affected
side)
6- Ask the patient to smile (Angle of mouth deviated to the normal side)
MANAGEMENT
Mrs. Hameed you are experiencing some ringing noise in your both ears probably
because of damage to the ear nerves due to loud music which is your passion and profession.
You can hear the noise while there is no external stimulous. I assure you that
this is not a serious thing. It common and won’t end up in brain cancer.
Although the noise is distressing but there are number of ways to help you with this
condition.
1. General Sleep hygiene
Please follow the general rules of sleep hygiene i.e. bed room only for sleeping, no
laptop, no TV, avoid caffeine in the evening. Do some light exercise during the day. Winding
down before bed time.
2. Relaxation technique
You can do Yoga or meditation. You can buy some relaxation tapes.
3. Self Help Group
Joining a Local Self Help Group for support. Such as those run by British Tinnitis Association
4. Talking Therapy (Refer to Psychologist)

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Talking therapy in the form of cognitive behavior therapy in which psychologist will try to
change how you think, feel and act.
5. White Noise
Some background noise such as white noise generator can help. Hearing aids to decrease
background noise can be used.
Follow up & safty netting
I would like to review your condition in a month’s time or sooner if you have any new
concern or new symptom.
I can also offer to refer you to ENT specialist for his opinion, if the ringing noise
continues to be intrusive.
Is there anything else you would like to discuss with me today?
No.
Thank you for your cooperation and visit. (For coming in)
Good bye.
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OTITIS EXTERNA
SCENARIO
Mother has come to discuss ear discharge of his 12 years son Zohaib. Kindly gather
data, examine and do management. Proceed.
Hello.
I am doctor Raheel one of your phycisian in this surgery.
I am Mrs. Safia.
Ok Mrs. Safia what brings you to the surgery today?
Doctor, my son Zohaib has develop has a discharge from his right ear for the last 6 weeks.
His skin near the ear has developed some sort of skin problem as well.
Kindly guide what to do.
Mrs. Safia is Mr. Zohaib accompanying you.
No doctor he is not accompanying me today but I have brought the picture of the discharging
ear and skin problem.
Ok Mrs. Safia, it would have been better, if Mr. Zohaib is accompanying you, I would have
examined him and do the management in much better way.
Before I come to the management part, can I ask you few questions about your son habits.
Does your son complained of some pain as well.
Yes doctor he has severe pain in the ear.
Does he complain of some hearing loss.
Yes doctor, he can hear from that side very little.
Is there any offensive smell coming out from the discharge.
Yes its an offensive discharge.
From the picture it appears that the ear canal is red as well.
Is there any some swellings or nodes in front and behind the ears. (Yes doctor)
Is there any trauma to your sons ear. (No doctor)
Is your child diabetic. (No)
ILLNESS
How this condition is affected your child life?
His exams are coming but he is is refusing to go to school due to the pain and discharge.
IDEA
What do you thing is the cause of his illness?
Doctor he is very fond of swimming, I think the pool water is not clean. So some infection has
occurred.
Moreover, he keep using head phone in his ears.
EXPECTATION
What do you expect from todays consultation.
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I hope you will prescribed some medicine to cure this discharge.
REASSURANCE
Mrs. Safia this is a common condition in children, in humid environment and in children who
are fond of swimming and using hearing head phones.
It is quite easily treatable, first thing I would like to know wether the ear drum is in tact or not.
For that I may refer you the ENT department for aural toilet or gental syringing to clean the
offensive discharge.
I offer you a pain killer paracytamol one tea spoon 3 times a day.
If paracytamol is not sufficient to control the pain some ibuprofen tablets can also be
prescribed.
I am offering you aluminium acetate drops in the ear.
It is as effecting as any antibiotic.
At the moment I am avoiding steroid drops sofradex and some ototoxic gentamycin ear drops.
If the problem is not solved after one week, I may offer you an another ear drops called
otosporin (contains neomycin, Hydro cortison and polymixin B).
Adding some oral antibiotic like Flucloxacillin 4 times a day does not improve the outcome so
we will defer it unless the problem is not solved.
Keep the discharging ear covered with some cotton wisp.
Mrs. Safia please bring the child for examination as soon as possible.
Ok doctor I will bring him tomorrow.
Mrs. Safia is there any thing else you want to discuss with me today?
No doctor you have done the job very well.
Ok Mrs. Safia you can take the leaflet about discharging ear from the reception.
Thank you for your visit.
Good bye.
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ALLERGIC RHINITIS
Scenario
Mrs. Jamella Khan 28 years complains of runny nose, watery red eyes &
sneezing. Kindly take relevant history & manage.
Proceed.
Hello.
I am Mrs. Jamella Khan, 28 year.
Ok Mrs. Khan how can I help you today?
Doc. I have runny nose, red watery eyes frequent sneezing is for the last few days.
It happens every year during spring season but this is quite sever this time.
Any thing else you like to add?
Doc. I have an important business meeting to attend tomorrow morning. I have to
prepare lot of data for it but the symptoms are so intrusive that I am unable to complete my
important work.
Any thing else?
Ok. Mrs. Khan I understand your urgency to control these symptoms. Before we come
to management part, I need to ask you few questions in order to assess cause & severity of
your symptoms.
Is it ok with you?
Yes Doc you may proceed.
Mrs. Khan does your symptoms occur during spring season only. (Yes only during
spring season, when there are flowers & lots of pollen in air. What a pitty I can not enjoy
beautiful flowers & open spaces)
You said you have runny nose, red watery eye & frequent sneezing.
Any allergy to animal fur & fungi (yes ever since I brought a cat in the house, symptoms
are more.
Do you have any flour allergy (No)
Do you have any latex allergy (No)
Do you have any itching as well (Yes)
Do you smoke. (No)
Do you drink. (No)
Do you have any ↑ blood sugar (No)
Do you have any ↑ blood pressure (No)
History of Past Illness
Any past history Asthma (Breathing problem) (Yes)
Any skin problem (Eczema) (Yes)
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Family History
Any family history of Asthma
Or skin problem? (Yes)
Summarize
So Mrs. Khan you have sever runny nose, red watering eyes & frequent sneezing.
There is personal or family history of asthma.
Is there anything else you like to add? (No)
Examination (Not required)
However examination could include.
Runny nasal mucopurulent clear, discharge.
Allergic creases on the bridge of nose from persistent rubbing.
Red swollen inferior turbinates, inside nose.
On auscultation decreased air entry.
Management
Mrs. Khan what I have gathered from your symptoms you have shared with me, most
probably you are having a condition what we call in our medical term “Seasonal Allergy).
During spring season there are ↑pollen in the air.
To decrease the allergic exposure.
I offer you certain lifestyle changes & some medicine.
Which way do you want me to go first?
Life style changes first please
Non pharmacological Management (Life Style Changes)
Ok Mrs. Khan.
Try to avoid going to open grassy spaces during spring season.
Keep door & windows of the house closed.
Shut the car windows & use pollen filter for car while traveling.
Wear black sun goggles or glasses.
I know you like your pet cat very much but you need to be away from cat, which might
be giving you your symptoms. Donate your cat to friend.
Use nasal douching with saline nose drops.
Take steam inhalation twice a day.
1. As you have an important meeting to attend tomorrow morning, so I offer you Azelastin
anti allergic nasal drops, use as rescue therapy.
It acts fast (actually its onset of action is in less than 15 minutes)
Follow up & Safety Netting
2. Once your meeting is over. Please try visiting me again. I might offer you non sedating
loratidine tab 10mg once for long term use. It improves both eye & nose symptoms.
3. Lukotrine Receptor antagonist as concomitent asthma.
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4. If these measures did not work we have other options of steroid nasal drops & tablets
etc.
5. If your symptoms are sever & persistent, I may consider refering you to special allergic
clinic.
There they will find the allergen causing allergy & do desensitization treatment.
Risk of sudden fainting with allergic testing is high. So it can be done only at special
allergy clinics. Success rate is 50 – 70%.
Is there anything else you want to discuss with me today? (No)
You can take leaflets about your condition from the reception desks.
Good Bye (Smile & nod & Bow with respect)
If you don’t want to shakehand with a female patient)
Impotant Note
Please read oxford P.943 for other option of treatment available for runny nose only,
children & pregnant ladies, who don’t want steroid nasal drops or tablets.
Brief Treatment
1. If problem runny nose only then Ipratropium bromide nasal spray thrice a day.
(decreased nasal discharge but no effect on other nasal symptoms)
2. If concomitent Asthma leukotrine receptor antagonist can be used.
3. If nasal congestion is the only problem then ephedrine nasal drops thrice or four times
per day can be given. Discourage the use of ephedrine nasal drops for more than 10
days as may cause Rhinitis medicamentoza.
4. For children and pregnant women wishing to avoid steroid nasal spray and tablets.
Treatment would be topical sodium cromo glicate or nedo cromil sodium nasal spray.
5. Nasal steroids drops and steroids tablets are used as a last resort. Starting with high
dose and later tapering of to the minimal effective dose.
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VERTIGO
(Dizziness) (Blackouts) (Giddiness) (Feeling Faint)
KNOWLEDGE BASE
Vertigo episodes may last few second to minutes or hours or days.
Episode seconds to minute
Benign positional vertigo (Sudden onset) occurs with change in posture. Common
after head injury or viral infection.
Diagnosis is with halpike test. Treatment is with epley’s maneuver.
Episodes lasting Minutes to hours
Clusters of attack of vertigo and nausea, tinnitus and deafness and fullness in ear
which is progressive. Diagnosis is Meniere syndrome.
Prolong vertigo > 24 hrs
Peripheral - Viral labyrinthitis or trauma
Central – multiple sclerosis, stroke, tumor.
____________________
Mr. Saleem Tauseef presents in Surgery with complaint of vertigo. Take relevant
history and manage. Proceed.
Presenting complaint. I have feeling of dizziness or vertigo. It remains for few seconds
to few minutes occure with every change of posture.
Ask the patient what he understand from vertigo.
Is he spinning or surrounding are spinning? (Surroundings are spinning)
How often do you get vertigo? (With every time of posture)
What is duration of vertigo? (few second to few minutes)
Any associated symptoms e.g. nausea, deafness, tinnitus (No)
Any recent viral flu like infection (Yes)
D/D
Do you feel dizziness when you suddenly stand up? (Postural hypotension) (No)
Did you recently hit your head in any accident? (Post Head Injury) (No)
Do you get dizzy when you skip meal or take excessive exercise? (Hypoglycemia)
(No)
Do you have any neck pain and stiffness? (Cervical Spondylosis) (No)
Do you get dizzy after taking a lot of alcohol? (Alcohol Intoxication) (No)
Do you suddenly get dizzy and fall? (Sudden pre-syncope due to cardiac arrhythmia)
(No)
OTHER CAUSES OF DIZZINESS
Are you a kind of nervous person? (Anxiety & Panic Attacks)
Are you taking any medicines? (Anti-Hypertensive and Anti-Depressant)
Pre-Syncope with emotional stress or on urination? (Micturation syncopy)
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Are you taking any medicines like loop diuretic, TCA, Aspirin, Nsaid, Amino Glycoside
Did you suffer any viral infection recently?
Do you get dizzy when you sudden move your head? (Benign Positional Vertigo)
Do you have ringing in the ear + deafness + vertigo? (Meniere’disease)
EXAMINATION
Pulse
Blood Pressure (Sitting & Standing B.P.)
Cranial Nerves, (1) Pupil Reflex
(2) Mouth gag reflex say aah
(3) Make an H front of eyes
Ear whisper test
Carotid Bruei. Listen with the bell of stethoscope. Ask the patient to take a deep breath
and then hold the breath.
Cardiac
Listen to the heart murmurs and arithymias Listen with of stethoscope. Ask the patient
to take a deep breath and then hold the breath.
Cerebellar
Romberg Sign
Gait
Coordination tests
1. Finger nose test
2. Alternate hand movement for coordination.
INVESTIGATION
Urine for glucose (Diabetes, UTI)
Full blood count (Anaemia, MCV for Alcohol Abuse)
Liver function test (For systemic disease or Alcohol Abuse)
Renal function test and electrolyte
ECG and Ambulatory 24 hrs ECG with holter (For Arrhythmias)
Brain scan if required
HALL PIKE TEST

With head turned to one side, move patient from sitting to supine with neck extended
below plane of body over end of couch, repeat with head turned to other side (Positive
if causes nystagmus)
The test is positive for benign positional vertigo its symptoms of nystagmus occur after
a latent interval of approximately 10 seconds, and then settle after about 1 minute.
Immediate or persistent symptoms or nystagmus suggest a central rather than a
vestibular cause.
_______________________
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MANAGEMENT OF BENIGN POSITIONAL VERTIGO
Recurrent attacks of sudden-onset vertigo lasting for only a few seconds or minutes .
Occur due to sudden changes in posture. Common after head injury or viral illness. Diagnosis
is based on history and a positive Hallpike test.
MANAGEMENT
Paroxzizmal benign positional vertigo is episodic. Occurs only for few seconds or
minutes. Usually self-limiting (few weeks) – although may continue intermittently for years.
Reassure.
Labyrinthine sedative are not helpful.
Teach the patient to minimize the symptoms by sitting and lying in stages.
Try to maintain trigger position. Habituation may occur by maintaining the trigger
position until vertigo settles. If not setteling refer to ENT for Epley’s manoeuvre.
Refer to physiotherapy for exercises and rehabilitation.
VIRAL LABYRINTHITIS
Usually follows a viral URTI.
• Symptoms / signs Sudden onset of vertigo, prostration, nausea and vomiting
• Not associated loss of hearing
• Treatment Labyrinthine sedatives, e.g., cyclizine or prochlorperazine.
• Natural history Usually resolves in 2-3 weeks. If persists more than 6wk refer.
_____________________________________
MENIER’S SYNDROME
If patient says his vertigo lasts for few minutes to few hours. It is a complex of
symptoms including clustering of attacks of vertigo and nausea, tinnitus and sense of fullness
in ear. Deafness is also there and it is sensorineural type of deafness which may be
progressive.
MANAGEMENT
• Treat acute attacks with labyrinthine sedatives, e.g., cyclizing or prochlorperazine,
Consider buccal / rectal routes of administration if vomiting. Do not use long term.
• Encourage patients to mobilize after an acute attack.
• Prophalectically betahistine taken regularly may help in some patients, as may thiazide
diuretics, a low salt diet, vestibular rehabilitation, tinnitus maskers, and hearing aids.
• Provide information and advise about support organizations.
• Refer all suspected cases to ENT or neurology to confirm diagnosis.
• There is some indication that stress may precipitate attacks.
• Labyrinthectomy is a last resort and can help vertigo but results in permanent deafness
on that side.
• Look out for and treat concurrent anxiety and depression.
Ask question about Anxiety and Depression offer fluoxetine 20mg once a day.
Ask:
1. Are you a sort of person who worry a lot about minor things?
2. For past 2 months , have felt down depressed & low in mood?
3. For the past 2 months, have you lost interest in daily life activity?
4. Is there any stress at home or work?
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RED EYE (Viral Conjunctivitis)
My eyes are red since one day to began with my right eye became red but with the
passage of time both eyes are red and clear mucoid discharge is coming.
Anything more.
My eye rashes are struck would together when I wake up in the moning.
Since when you have red eye. (One day)
Is there any deep pain in eyes. (No.)
Is the pain only on surface like gretty sensation. (Yes.)
Is there any problem with the vision. (No.)
Is there any itching. (Yes, if allergic conjunctivitis)
Is there any irritation. (Yes.)
Is there any discharge from eyes. (Yes.)
Is the discharge clear mucoid. (Yes, in allergic & viral conjunctivitis)
Is the discharge purulent pus like. (Bacterial infective conjunctivitis)
What makes it better. (Cold compresses)
What makes it worse.
Any associated symptom. (No.)
_________________________________
D/D
Did you have any cold or runny nose recently. (Yes, URTI)
Do you wear contact lenses. (No.)
Have you been using any cosmetic containing steroid in or around the eyes.
Do you suffer from hay fever. (Yes if allergic conjunctivitis)
Can you recall any injury to the eye. (No.)
Did you noticed any hallows around the lights. (No Glucoma)
Have you been exposed to arc welding? (No.)
Any history of penetrating trauma to the eye? (Trauma). (No.)
PAST HISTORY
Any similar complaint in the past. (No.)
FAMILY HISTORY
Any body else in the family suffering from similar condition. (Yes family history of
Asthma)
DRUG HISTORY
Are you using any medicine regularly prescribed or from the over the counter. (No.)
Any known drug allergies.
(1) BACTERIAL OR VIRAL CONJUNCTIVITIS
Clinically difficult to differentiate. Doctors get it right only 50% of the time. Both present
with acute red eye. Usually starting in one eye and often spreading to involve both, together
with watery/purulent discharge. The eyes are often crusted ± stuck together on waking. Visual
acuity is not impaired. Both may occur in association with viral URTI.
MANAGEMENT OF ACUTE INFECTIVE CONJUNCTIVITIS
• Usually self-limiting condition; 65% settle in 2 – 5d without treating.
• I offer you to wash the affected eye(s) with boiled, cooled water morning and night.
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• Avoid contact lens use.
• Use simple hygiene measures (e.g. hand washing and not using shared towels)
• If symptoms are not improving in 3 – 5d, review the diagnosis and consider treatment
with topical chloramphenicol six hourly for 5d.
! Chloramphenicol is available OTC.
SAFTY NETTING
Advise patients to seek immediate medical help if
Decreased visual acuity,
Eye has deep pain rather than sore or gritty sensation,
Significant photophobia,
Eyelid swelling or
Symptoms are not improving in 5d.
______________________________________________
(2) ALLERGIC CONJUNCTIVITIS

Bilateral symptoms appear seasonally (e.g. hay fever) or on contact with an allergen (e.g.
animal fur).
Is both eyes are red. (Yes.)
Is there any watery discharge. (Yes.)
Is there any sensitivity to light. (Yes.)
Is there any personal history of asthma or hay fever. (Yes.)
Is there any family history of asthma and hay fever. (Yes.)
EXAMINATION
Follicles in the lower tarsal conjunctiva and ‘cobblestones’ under the upper lid.
MANAGEMENT OF ALLERGIC CONJUNCTIVITIS
Treat with topical or systemic anthistamines (e.g. sodium cromoglicate, nedocromil, or
olopatadine eye drops).
Avoid topical steroids due to long-term complications (cataract, glaucoma, fungal
infection).
Wash with cool boiled water. Can you manage frequent cold compresses?
To reduce discomfort use artificial tears 4-8 times/d for 7 days.
Povidine 1:10 solution may used to reduce adenovirus contagiousness.
Wash your hands with soap.
Wear black googles.
Do not pad
Take plenty of fluids
Paracytamol if pain and fever 500mg three times a day.
SAFTY NETTING
Refer to eye specialist if symptoms are persistent despite treatment or vision is
affected.
When epidemics of red eye.
Do not go to crowded places.
Do not Shake hand
Clean eye with tissues and dispose off this tissue properly.
If vision gets impaired due to Pseudomembrane then topical steroids can be given
Avoid corticosteroids, which reduce viral shedding and prolong the problem.
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THE KEY EYE SYMPTOMS (Formula Pili) UNILATERAL RED EYE (FORMULA GFC)
• Pain deep or surface grittiness Glucoma
• Any discharge watery or pusy Foreign Body
• Irritation Corneal Ulcer
• Itch
• Loss of visual activity
• Can you recall scratching or injuring your eye?
NOTE
ALLERGIC CONJUNCTIVITIS EYE – Sodium chromoglycate – Avoid topical steroid
BACTERIAL CONJUNCTIVITIS EYE – 0.5% chloramphenicol Eye drops OID
RED EYE
PAINFUL PAINLESS
Corneal Abrasion Subconjunctival Haemorrhage
Truma
Herpeszoster Infection Allergic Conjunctivitis
Corneal Foreign body
Arc Eye
Episcleritis and scleritis
Iritis
Acute Keratitis
Acute Glucoma
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GRADUAL LOSS OF VISION
MACULAR DEGENERATION
(Oxford Handbook 5th Edition Page 952)
Old patient presents with gradual loss of vision.
Meet & greet.
When did it start. How did it start.
What exactly is the problem with your vision? (Patient has distortion/ deteoration of
central vision)
Do you have problem with reconizing faces. (Yes)
Do you have problem in reading.Is this problem present in both eyes. (Always bilateral)
Have you ever noticed that on awaking up after sleep a shadow appeared and then
quickly faded away. (Yes)
Have you ever noticed stars infront of you. (Yes)
Have you ever noticed faces infront of you withopen eyes. (Last three symptoms are
very frightening)
PAST HISTORY / MEDICAL HISTORY (Increased BP is a risk factor)  age smoking
DRUG HISTORY
FAMILY HISTORY (Positive family history is a risk factor)
PERSONAL HISTORY (Smoking is a risk factor)
CONCERN (What worries you most about this problem)
EXAMINATION
INVESTIGATION
Amsler grid at normal reading distance with usual glasses on. Cover one eye & focus
at dot in the centre of grid.
If lines appear wavy distorted or broken suspect macular degeneration.
EXPLANATION
The inner layer of our eye ball is called retina, where an object or image are formed.
In macular Degeneration, some yellowish lipids are deposited they are called drusen) and
some blood vessels get disruptured forming scars result in irreversible loss of central vision.
Am I clear?
MANAGEMENT
I would like to offer your referral to ophthalmologist for confirmation of diagnosis and
early start of treatment. He could give you APPLIBERCEPT which is a monocolonal antibody
approved by NICE. It is given by injection into the eye once a month for three months. Eye
specialist will reassess for further injections.
There are some life style changes also. Most importantly smoking is making the
disease progress faster.
Some food supplements containing Omega 3, fattyacids, anti-oxidants and zinc
decrease progression by 25%.
352
ACUTE ANGLE CLOSURE GLAUCOMA
Normal Intra Ocular Pressure < 21mm Hg

Visual field deficit question:
1. When did it start
2. How did it started. Any halos around the light
3. Any history of trauma to eye.
4. Do you wear contact lenses
5. Do you wear specticles.
6. What makes it better.
7. What makes it worse.
RISK FACTORS
Family History
↑ with age
Abnormal ↑ blood pressure
Myopia
↑ Plasma Viscosity (Dehydration)
Diabetes Mellitus
Black Race
PRESENTATION
Incidental or Accidental finding during Routine exam of DM or patient of family history
of Glucoma otherwise patient presents late. Glucoma is asymptomatic and visual acvity
preserved but visual field are severly impared.
S/S
Optic Nerve damage (Glucomatous disc cupping)
Visual Field loss (Sausage shaped blind spot)
↑ IOP
Varients types Ocular HTN ↑ IOP + little field loss
Normal Tension Glucoma IOP Normal but visual field loss and disc cupping
MANAGEMENT
(1) Have regular eye sight check up 6 monthly
(2) F/H biannual check up of IOP (Tonometry and visual field check ups annually.
Refer patient with ↑IOP or on noticing disc cupping to ophthalmologist for
asscessment.
FOLLOWED UP
Life long follow up if patient has ↑ IOP
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MANAGEMENT PHARMACOLOGICAL
MEDICAL TREATMENT
(1) Topical Lantanoprost once daily in evening. (First line treatment)
It ↑ out flow of acquous flow.
(2) Topical B-Blocker e.g. Timolol BD ↓ acquous secretion.
Contra indication Asthma and Heart Failure
S/E Allergy and Dry eye.
(3) Topical Carbonic Anhydraze inhibitors e.g. Dorzolamide TDS
Or Twice daily if in combination with B-blocker ↓ acquous secretion
S/E Blured vision, Tiredness, Dyspepsia
(4) Topical alpha Agonist
e.g. Brimonidine BD
↓ Aquous secretion + ↑ out flow
S/E Local Irritation,
Headache,
Dry mouth,
Tiredness.
SURGERY
Trabeculoplasty
Consider if target not met with Medicine treatment.
Especially in patient < 50 years.
S/E surgical Failure and worsing cataract.
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ACUTE CLOSED ANGLE GLUCOMA
S/S
Hard Eye Ball
Cornea Looks Hazzy
Circum Corneal Redness
Fixed dilated Pupil
SIGN
Poor Fundal View
±
Cataract
Refer to ophthalmologist urgently
SUB ACUTE
(1) Latent (A symptomatic, IOP normal, anterior chamber shallow with narrow angle)
(2) Sub Acute (Episodic Halo’s arround light, Impaired vision, ± frontal headache, eye
pain.
(3) Acute
When the patient enter’s room or during the night attack precipated
Relieved by sleep
Entering brighter environment
ACUTE GLUCOMA
Blockage of acquous dranage
C/O
Eye pain
Acute loss of vision in 1 eye
Abdominal pain / nausea / vomiting
Refer acute and sub acute Glucoma to eye surgery as an emergency.
GLUCOMA TREATMENT BRIEFLY

1. Lanta no prost (↑ out flow)
2. Timolol (↓ acquous secretion)
3. Carbonic Anhydrase Inhibitor e.g. Dorzolamide (↓ acquous secretion)
4. Bri monidine (↓ acquous secretion + ↑ out flow)
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GENERALIZED ANXIETY
(Anxiety patient speaks fast & in high tone)
A young female Miss Noor presents in Surgery who appear to be very anxious
and concerned. Take a relevant history and counsel appropriately.
MEET & GREET

Introduce yourself and establish a rapport to put patient at easy. Ask how can you help
her?
Maintain eye contact. Pay special attention to verbal and nonverbal clues.
Be sympathetic and empathetic to patient distress. Listen attentively.
Miss Noor you appear to be a little upset. May I know your problem in detail. Facilitate
patient to say more and more till she become silent.
=======================================================
Doctor I fearfully anticipate that something bad might happen in near future.
I worry a lot about minor things.
Doctor I am feeling nervous, anxious or on edge most of the time.
Not being able to stop or control worrying.
I have trouble relaxing and I am easily annoyed or become irritable.
I have these symptoms for the last 6 months in most of the days.
Is this all or you want to share anything else.
That’s all.
_________________________________________
Can I ask few questions. (Physical symptoms)
Do you experience some racing of the heart. (Yes.)
Do you some time have difficulty in breathing. (Yes.)
Do you pass urine more frequently. (Yes.)
Is there any tremors in your hand. (Yes.)
Is your mouth dry. (Yes.)
Now I am going to ask you few more questions. (Psychological symptoms)
Are you restless. (Yes.)
Are you sensitive to noise. (Yes.)
Do you have poor concentration. (Yes.)
Do you suffer from trouble sleeping. (Yes.)
Do you fear loosing control or dying. (Yes.)
MANAGEMENT
Miss Noor you are experiencing certain sudden physical and psychological symtoms.
May I know since when you are having these symptoms.
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Doctor these symptoms have been occurring for the last six months, in most of the
days.
Most probably you have a condition what we call generalized anxiety.
D/D OF GENERALIZED ANXIETY

Which whether you like more. (I am comfortable in both cold and hot weather) (No.
Hyperthyroidism)
Do you get these symptoms when you skip your meals or do excessive exercise
(Hypoglycaemia) (No.)
Did you suddenly stop drinking alcohol in the past one or two weeks. (Withdrawal of
alcohol) (No.)
Any diagnosed growth of kidney.(Pheochromocytoma) (No.)
Any past history of low mood or depression.
Any past history of mental disease or admission in psychiatric hospital.
HISTORY OF PERSONAL ILLNESS
Do you smoke? How much? (Excessive Nicotine can cause anxiety) Yes 2 packs a
day.
Do you drink Alcohol? How much? (In excess of safe limits)
Do you take tea and coffee? How much? (Excessive caffeine cause anxiety)
How are the things at home? (Ok)
Has there been any significant life event? (No.)
Has she moved house or change job? (No.)
Has some one close to you has recently passed away? (No.)
Is any one ill at home? (No.)
Any Financial or legal problem? (No.)
Any marital discord? (No.)
Are you working under stress? (Yes.)
Any exam coming recently? (Yes.)
DRUG HISTORY
Are you on any regular medication or OTC medicine? (No.)
Are you taking any pills for sleeping? (No.)
(Withdrawal of Benzodiazpine may result in acute anxiety arising 1-2 week later.
Symptoms include (DIP) Depression, Irritability, insomnia and Panic Attack)
FAMILY HISTORY
Any one of the parent is a nervous or anxious person?(Mother was anxious person)
Any family history of depression? (Yes.)
EXAMINATION AND PRACTICAL SKILL
Thorough medical examinations & investigations are normal. Hence examination not
required.
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Briefly examine heart
Briefly examine lungs
Neck for thyroid swelling,
INVESTIGATION
I offer you
1. Fasting blood glucose
2. Thyroid function test
3. VMA test for catacolamin in urine
4. ECG
MANAGEMENT (Generalized Anxiety Disorder)
What I have gathered from the information you have shared with me most probably
you are having a common condition called generalized anxiety in medical terms. Each one
of us suffer from it at one time or another but yours is an excessive exaggerated One. I
would suggest few life style changes.
1. Avoid excessive smoking, Alcohol or caffeinated beverages in the evening.
2 Follow sleep Hygiene that is (No T.V. No reading or Lap Top in Bed Room)
3. Exercise in general to relieve stress.
(listen to relaxation tapes & music)
4. Do yoga and other forms meditation.
5. Do relaxation exercises at bed time.
6. I offer to refer you to psychologist for talking therapy and hypnotherapy
7. Real treatment of anxiety is anti depressants e.g. SSRI (Sertraline 50mg once a day).
This drug take 2-3 weeks to develop its effect. Continue anti depressant for 3 months
after recovery. Don’t consider treatment unsuccessful unless no improvement till 3
months.
8. What I have gathered your anxiety is quite severe and the anti depressents medicine
takes 2 – 3 weeks to develop it fully effect and under the anti depressant drugs patient
can become more anxious and agitated. So I am offering you short acting
benzodiazepine e.g. lorezipam one tab 2mg at night which is less addictive than long
acting benzodiazepine e.g. Diazepam or Alprazolam which are more addictive.
Please do not use lorezipam for more than 10 days to 2 weeks.
SAFTY NETTING
If you develop significant anxiety or agitation please stop the anti depressents and
contact your psychiatrist immediately.
FOLLOW UP
I would like to review your condition in about one weeks time after the start of
medication. As this medicine increase the risk of suicide. I would be following you weekly for
a month to monitor risk of self harm.
Then we will follow up you every 2 to 4 weeks in first three months and then every
three month.
Treatment will be continued for more than one year if drug is effective.
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CLOSING
Is there anything else you want to discuss with me today?
No.
You can collect information leaflet from the reception desk.
Good bye
SUMMARY
Life style changes
Talking Therapy CBT
Anti depressent sertraline 50mg once a day
Lorezepam short acting benzodiazepine which is less Addictive can be offered for two
weeks if severe anxiety interfering with daily functioning.
NOTE: Anxiety patient speaks fast and at a high volume.
Depressed patient talks slowly and in low volume.
Self neglect and tearfulness are obvious. Depressed patient avoids eye contact.
=================================================================
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POST TRAUMATIC STRESS (PTSD)
CASE NO.1
Rehman 30 year old man blames himself for the death of his close friend who
was traveling with him, which in fact is not true. You are the family physician, take a
relevant history and counsel the patient.
______________________________
Hello.
I am Rehman 30 years.
Well Mr. Rehman what brings you to the surgery today?
Doctor I was traveling with my close friend in my car, when we met an accident.
In which my friend died and I was saved.
I keep questioning myself. Why I was saved and feel guilty about the death of my friend.
As if I am responsible for his death.
Mr. Rehman I understand that you have been through terrible times.
Death of your close friend must be devastating to you.
Can you describe the incident in a little more detail.
Doctor it is very difficult and painful for me to recall the incident.
It causes flash backs of the incident as if it is happening now.
I sometimes have nightmares of about the incident also.
These flash backs and nightmares make me, restless, irritable and I cannot have a nice
decent sleep.
Ok Mr. Rehman can I ask few questions.
What do you do if you are unable to sleep.
Doctor I have been taking sleeping pills to get some sleep.
I have also been drinking excessively.
Just to foreget the incident I have been indulging in illicit drugs.
Mr. Rehman can I ask you, do you have support at home.
No doctor my wife left me few days ago and she took my 12 years old son with her.
I have no friends. Neighbours are unknown to me.
Do you have numbing of emotions.
Ok.
Are you avoiding similar situations.
Yes doctor, I am avoiding to go to the place of accident that reminds me of the incident.
Rather I am avoiding to drive a Car.
I am not going for my job.
Over the past one month, have you been down, depressed and hopeless. (Yes.)
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Over the past one month, have you lost interest in daily activities which you used to enjoy.
Yes Doctor I am not reading or enjoying watching TV which I used to do.
My feelings have become numb. I can not feel feelings.
Well Mr. Rehman what I have gathered from the information you have shared with me that
you are having a condition what we call in our medical terminology post traumatic stress
disorder.
If your symptoms had been mild then I would have followed the wait and watch policy. Many
a times some symptoms subside in four weeks. But in your case it has been more than one
month and you are having severe symptoms of post traumatic stress disorder.
So I am referring you to the psychologist for talking therapy, focused around the trauma.
I am also offering you an anti depressant drug namely paroxitene 20mg daily at night.
REASSURANCE
Mr. Rehman de briefing immediately after the trauma is usually unhelpful but let me assure
you that this accident was not your fault. It was just a mishap which could had happened
with anybody.
You should not feel guilty, I request you to start a normal life again.
You are a young man and have a bright future.
Go back to your job as soon as possible.
I offer you self help groups, you can join them. There people with similar condition sit and
talk about your problems. This will build your moral and help you get back to normal life.
Depression can co-exist with post traumatic stress disorder as is yours case.
So our diagnosis would be that you having a condition called post traumatic stress disorder
with co-morbid depression.
I can also offer you. Eye movement desensitization and reprocessing technique (EMDR).
Please try to reduce stress in life by the following tips:
• Ensure you get sleep and rest; avoid using sleeping tablets to achieve this.
• Look after yourself and your own health, e.g. don’t skip meals, sit down to eat, take
time out to spend time with family and friends, make time for hobbies and relaxation,
do not ignore health worries.
• Avoid using nicotine, alcohol, or caffeine as a means of stress relief .
• Work off stress with physical exercise. Exercise decrease levels of adrenaline and
increases natural endorphins which lead to a sense of well-being & happiness.
• Try relaxation techniques.
• Avoid interpsersonal conflicts. Try to agree more and be more tolerant.
• Learn to accept what you can’t change.
• Learn to say ‘no’.
Is there anything else you wish to discuss with me today. (No.)
Good bye.
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POST TRAUMATIC STRESS DISORDER
CASE NO.2
Can you describe the incidence in brief to me what actually happened.
Its very difficult & painful for me to recall the incidence. It causes flash backs of
incidence as if it is happening now.
I am Michel 35 years British soldier, deployed in Afghanistan where in a combat his
buddies died. He has night mares & flash backs of events even 3 months after the event.
Feels guilty about death of friends. Flash back make him restless, irritable & he can not have
nice decent sleep. Just to get some relaxing sleep, he took 6 to 8 paracytamol tablets with 6
to 8 cans of Bear & alcohol a month ago. The cooking of chicken meat in kitchen remainds
him of smell of his buddies bodies burning in combat & make flashbacks heappen again and
again. He has left the army back in UK wife left him & took the children with her but he is
unable to relax indulging in excessive alcohol drinking & drugs to get some sleep.
MANAGEMENT (POST TRAUMATIC STRESS DISORDER)
Tell the patient that treatment is talking therapy focused around your trauma rather
than drug therapy.
For Trauma base psychotherapy I will be referring you to the Psychologist directly or
through the psychiatric department.
If patient’s symptoms are mild then tell him I would like to wait and watch your
symptoms. Most of the times symptoms subside with in 4 weeks. Follow up in less than one
month. Debriefing immediately after trauma in unhelpful. Tell him it is not your fault and it was
just a mishap that happened with you. It can happen with anybody else. So you should not
feel guilty about yourself. (Refer if severe symptom)
Try to have a normal life, Can you manage it?
Try to go to your job
Go again at that place. You will see that things will not happen again. I think if you go
to that place it will boost up your moral.
You have a very good future is ahead of you. Ok, Do you agreed?
FOLLOW UP
You can visit me after one month.
If you feel that patient symptoms are sever and has persisted beyond 4 weeks then
refer him immediately to psychiatry department or psychologist directly for talking therapy.
Drug treatment can also be offered like Antidepressants SSRI namely paroxetene and
mirtazepine by family physician while amitriptyline and phenelzine type of drugs can be
prescribed by consultant psychiatrist for which you will refer him.
Do follow up and safty netting as usual.
PTSD includes
1. Flash backs and night mares
2. Avoident behavior
3. Numbing of emotions
Follow the basic steps for history taking,
• This station is similar to the depression station. It is important that you be
empathetic to the patient.
• You can built rapport by asking few general questions, which have importance
in the personal history like marital status, socioeconomic status. etc.)
_______________________________
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DEPRESSION
(Depressed patient speek slowly in low tone)
Mrs. Aysha 50 years old presents in your surgery with complaint of low mood.
She looks depressed and tired, her dress shows selfneglect as dress is over due to be
changed, she has smell of Alcohol, she avoids eye contact and she is tearful, feeling
distant. Take history and counsel her.
MEET GREET AND FACILITATE
Introduce yourself, address her by her name, establish a rapport to put her at ease.
Open consultation by saying.
Mrs. Aysha you seems to a bit upset or disturbed. May I know what is bothering you?
INFORMATIONG RECEIVED FREEELY
I am sorry doctor but I feel so low for last one month, I just cannot go on.
Ok tell me in a little detail what happened.
I came to see you last week for backache and wanted say all this but felt stupid, so
did not mention about my low mood & loss of interest. I can not get enjoyment out of the
things, I used to like such as watching TV or reading _______
OK go on.
I used to work part time but now I have to work 6 days a week 9 to 5pm. Since the
change of job I find it difficult to cope with demands of work & of running home and looking
after children. My appetite is poor and have lost some weight.
I am sleepless. I have Difficulty in falling sleep & wake up early in the morning at 4am
& then can not go to sleep.
INFORMATION REVEALED WHEN SPECIFICALLY ASKED
She has told you about low mood, loss of pleasure sleeplessness, decreased appetite
and weight loss. Now ask few other questions to confirm the diagnosis of depression.
Mrs. Aysha please tell me about your energy level (They are low).
Do feel fatigued or tired all the time? (Yes)
Do you have poor concentration or memory? (Yes)
Do you find difficulty in making decision? (Yes)
Do you feel hopeless and helpless? (Yes)
With any depressed patient, Risk of deliberate self harm should be access by direct
question about thoughts of suicide. You can ask the following few questions?
Have you ever thought of ending your life or hurting yourself?
Have you ever acted on such a thought? e.g. made plan, written last notes to loved ones,
arranged financial affairs to be taken care of when you are dead?
D/D
Questions about differential diagnosis of Hypothyridism (Hypothyroid associated
depression)
– Have you notice any change in voice recently?
(More horse or cranky indicate hypothyroid).
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– What kind of weather do you like?
_ I cannot tolerant cold weather. (Hypothyroid)
Any history of previous episodes of low mood requiring medication.
Any previous admission in any psychiatric hospital.
What did she do to help her with low mood previously.
PERSONAL HISTORY (Bio Psycho, social)
Do you smoke? (A lot)
Do you drink Alcohol? (in safe limit)
Any  Blood Sugar (No)
Any  B.P. Yes taking B-Blocker atenolol 50mg once daily. S/E B.Blocker depression.
Catch point in this case is change of attenolol to ACE inhibitor.
______________________________
Are you married? (Living alone divorsed)
Any Kids. (Yes.)
How old they are? They are Adult now & have flown out of nest.
May I ask you few private questions? It will remain confidential between you and me?
How is your sex drive? (No girl friend nobody to take care of me)
FAMILY HISTORY
Any other major medical Problem in your immediate family member?
Is any close members of family has history of any mental problem or depression. (Yes
mother had it)
Any financial or legal problem? (No) (likely to be unemployed)
IDEA What do you think you are suffering from?
I am afraid my low mood has something do with some mental illness. (Afraid of
stigmatization)
CONCERN What worries you most about your symptoms?
I am worried being labeled with mental illness and particularly do not want
employer to know about the diagnosis.
EXPECTATION What do you hope to gain from seeing me today?
I think if I need treatment for low mood. I think counseling with a stranger
would be a waste of time.
DRUG HISTORY
Are you taking any medicine regularly prescribed or OTC. (No)
Any drug Allergies (No)
(Drug causing symptoms of depression include Beta Blocker, Ca. Channel Blocker,
Oral contraceptive Pill, corticosteroids, Anti-psychotic drugs, drugs used for Parkinson
disease Diuretic like, thiazide and spiromide) Anti convulsants.
SUMMARIZE & ASK
If she/he has anything to add.
Examination not needed
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Through physical exam with full basic investigations are done & are normal
I offer you thyroid function test TFT which may show hypothyroid ↑ TSH ↓ free T3,
Free T4)
MANAGEMENT
Ideally show respect and empathy to patient what is difficult time for him / her rather
than focusing your energy on extensive check list of questions.
When negotiating a treatment plan, key is to find out what patient wants from coming
to see the doctor, so incorporate her preferences.
Explain in simple unambiguous terms the diagnosis by saying what I have gathered
from your symptoms is that you are have a condition Mild or Moderate or Major depressions
or depression with psychosis.
MANAGEMENT (Mild Depression)
1. Exercise help in relieving depression. Take care of your healthy diet and sleep. (6 – 9
hours)
2. Simple problem solving strategies can be tried in which after identifying different.
Cause of problem, we generate multiple solutions. Then we try out one solution
agreed. If it does not work we can modify solution in next meeting.
3. I can refer you for talking therapy to psychotherapist Brief psychological intervention
help.
You can get support from friends and family.
I can give you addresses of self help groups.
What I have gathered from your symptoms is you are having a condition called mild
depression.
I would not offer antidepressant pills for about 1-3 weeks because many a time
symptoms resolve with time. Meanwhile I would like you to take educational information
leaflet about depression with you. Read them at home also search on internet.
FOLLOW UP
Please visit surgery every 2 weeks so that I can evaluate development of any major
depression.
MANAGEMENT (Moderate Depression)
What I have gathered from your symptoms is that you are suffering from moderate to
severe depression.
Just like mild depression life style changes like healthy diet, exercise, sleep, support
from family and friends and self help groups will help to relief moderate depression as well.
You will also need talking therapy. We can try talking therapy as well. I can refer you
to psychologist for this.
You will be needing Antidepressants pills so I offer you fluoxetene 20mg at night.
Once a day.
Remember that their effect will not start immediately. They will take 2-3 weeks to show
their effects.
These drugs are not free of side effects. You may have mild symptoms like nausea
loss of appetite, vomiting, headache, dizziness or anxiety and aggression.
Do you understand?
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If you feel that you are more anxious or agitated then please seek immediate medical
help.
FOLLOWUP
I will arrange second follow up visit in 2 weeks or earlier if you prefers. Is it convenient
to you?
MANAGEMENT (Depression with Psychosis)
What I have gathered from your symptoms is that you are suffering from a condition
what we call in our medical terms depression with psychosis. Depression with risk to life and
severe self neglect need immediate admission in hospital. Talking therapy does not help.
ECT is required. Can you repeat what treatment plan we have agreed so far. Would you like
to have contact number of crisis mental health team. You can call them any time day or night,
if things get worse and you feel that you need immediate help.
If you agree to be admitted in Psychiatric hospital, its OK.
Otherwise I am compelled to call crisis team who will ensure admission.
MANAGEMENT OF DEPRESSION WITH SUICIDAL IDEATION
You have tried to finish your life so I am referring you for hospital admission
immediately.
You are a brave person and you will not try this again. What do you think, matters will
be resolved after your death? Have you ever thought what will happen to your family after
your death?
Use of anti-depressant has been associated with suicidal thoughts. Monitor for suicidal
risk especially at the start of treatment and after dose changes.
NOTE
• Allow the patient to speak uninterrupted and employ active listening skills respond to
non verbal communication, to demonstrate your interest and concern and empathy.
• Use silences to give the patient time to express her thoughts and feelings.
• Verbalize her distress – “I can see that you’re obviously upset”.
• Paraphrase and summarize to demonstrate active listening and to help confirm your
understanding.
• When a patient is upset, appropriate use of touch, e.g. tap on the shoulder can act as
a powerful show of support and empathy. However, this must be an authentic
response to the situation rather than a forced move. Whether you choose to use it will
depend on a number of factors, including the room set up, the rapport between yourself
and the patient, your judgment on how it will be received, and whether you feel
comfortable with such an act. If there is any doubt in your mind about appropriateness
of touch in any situation, then it is best not to use it.
• The new GP curriculum talks about finding a balance between emotional distance and
proximity to the patient – in other words, be caring but stay objective and professional.
____________________________
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IMPORTANT NOTE
MILD DEPRESSION TREATMENT

Wait and watch 1-3 weeks (2) Diet Rest Sleep (3) Exercise (4) Simple problem solving
Strategies (5) Talking Therapy.
MODERATE TO SEVERE DEPRESSION TREATMENT
Rest Diet Exercise Sleep Antidepressant Pills Talking Therapy
DEPRESSION WITH PSYCHOSIS
(1) Admission (2) Anti Psychotic Medicine (3) ECT (4) Call Crisis Team (5) Talking Therapy
and Anti Psychotic Medicines usually not helpful
____________________
Steroids in morning in single dose
Statins at night
_____________________
UNUSUAL DOSES
Chloroquin 310mg (Malaria)

Lemicycline 408mg (Acne)
Venlaflexin 37.5mg (Menupause)
Acyclovir 800 mg 5 times per day (Chickenpox)
Mebavarin (Colofac) 135mg
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POST NATAL DEPRESSION
Lubna 23 year old after giving birth to a female baby presents in surgery feeling
low. She is tearful and clearly distressed. Self neglect and baby neglect is also
obvious. Take a relevant history and counsel the patient.
Hello
I am Lubna 23 years.
Doc. I have been planning for baby but now that I have my baby, I feel unhappy. I am
suppose to be happy. It seems I don’t like my own baby. I wonder if I will be a good
mother.
Anything more?
I feel tired, sleepless, due to hassel of breast feeding. I don’t have much support from
my husband because he is on job most of the time.
These symptoms started at 6 week after delivery but symptoms are now at peak at
12 weeks. Congratulation having a beautiful baby.
Can I ask few questions.
A. PLACE IMPORTANCE ON MOTHER INITIALLY AND NOT JUST BABY
Since when you are experiencing these symptoms. (About 6week after delivery)
Have you often been bothered by feeling down depressed & hopeless. (In past one
month) (Yes, feeling low mood)
Have you often been bothered by loss of interest. (In past one month) (Yes)
• Are you eating & drinking well? (No)
• How is you sleep? (Disturbed) Wake up early in the morning at 3 or 4 am) &
then can not go to sleep afterwards.
• What about your weight? (Loosing weight)
• Ensure confidentiality then ask
• How is your sex drive? (Don’t feel like having sex) My husband is pushing me
for sex but I don’t feel like doing.
• When did you last go out with friends for shopping. (About 12 weeks ago)
B. FIND OUT ABOUT CIRCUMSTANCES SURROUNDING PREGNANCY
Was the pregnancy planned? (To ascertain If child is wanted) (Yes planned)
Was the pregnancy difficult? (No.) uneventful.
Any problem during labour or delivery ? (No) uneventful)
Any complication after delivery? (No.) uneventful)
C. (i) FIND OUT HOW SHE IS INTERACTING WITH HER NEW BABY
• How this baby has changed your life? (Completely change my life, I am not going to
my job)
• Is she breast feeding the baby or bottle feeding? (Breast feeding) (Yes)
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• Is her husband / partner helping in changing nappies? (Support available) (No)
• Husband busy in business. Does not help in changing nappies.
• Any other help or support available from friends or family or neigbours? (Support
available Sometimes)
C. (ii) PAST ILLNESS
Any past history of depression?
Any past history of suicide attempt?
D. FAMILY HISTORY
Any history of depression especially in your mother. (She was depressed in similar
condition as I am now.)
E. SOCIAL HISTORY
Any financial problems? (No)
F. RULE OUT ANY IDEA OF SELFHARM OR HARM TO BABY
Do you fear you will harm or neglect your baby? (No)
Have you ever felt like harming your self. (No)
Once you are happy that patient is not displaying ideas of self harm or harm to her
baby, proceed with management.
EXPLANATION
What I have gathered from the symptoms you have shared with me, it seems most
probably you are having a condition called moderate to severe post natal depression.
You are not the only women who is suffering from this problem. There are so many
other women who are having the same problem.
Many mothers find it incredibly difficult during this period after delivery and want to
give up everything.
We can treat it at this stage with some pills. You will have to take proper treatment.
Treatment will take 2-3 weeks to be effective and then shell be continued for 3 months after
recovery.
MANAGEMENT OF POST NATAL DESPRESSION
1. Rest You should ensure period of rest for yourself as well e.g. when baby is asleep.
2. Diet You should eat well, healthy diet at regular times.
3. Exercise Please do some brisk walking 30 minutes every day for 5 days a week.
You can take 2 days holiday.
Exercise releases happy hormones which elevate your low mood.
4. Support Should have regular contact with health visitor for guidance & support.
It is a good idea if your husband takes sometime off from work, over the next
couple of weeks, to provide you support at home. By that time drug will start
showing its beneficial effects or you can arrange some help among your friends
and family.
There are self help groups for support.
There are mother baby groups for support where women can meet other
mothers in similar circumstances. This helps build the moral.
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Talking Therapy Talking therapy like CBT can be helpful in to alleviate low mood. Talking
therapy changes the way you think, feel and act.
SAFTY NETTING
I am offering you a antidepressant medicine called sertraline tab 50mg once at night).
We can treat at this stage with some pills. You will have to take proper treatment. Treatment
will take 2 to 3 weeks to be effective and then shall be continued for 3 months after recovery.
You will have to take it once a day. You can continue breast feeding with this drug. Sertraline
tablet is safe in breast feeding.
(If not breast feeding fluoxatene 20mg once a day is most effective)
If breastfeeding and taking sertraline we will monitor baby for unwanted side effects of
medicine like drowziness and breathing difficulty.
FOLLOW UP
Is there anything else you will like to share with me today? (No)
You can visit me after 2 weeks. Is it convenient to you? You can come earlier if there
is any problem.
You can take (written material) leaflet from reception desk about your condition.
Good Bye.
===================================================================
KNOWLEDGE BASED INFORMATION

First keep in mind psychiatric problems relating to pregnancy include:
1. BABY BLUES
Start with depressive symptoms within first 2 to 3 days after delivery. They are mild in
nature, resolve in 2-3 weeks spontaneously with support, rest and good diet.
2. POST NATAL DEPRESSION
Start with depressive symptoms from 6 weeks after delivery upto 6 months. Mother
suffering from moderate to severe depression require antidepressants pills along with
support, rest and good diet.
3. PEUPERAL PSYCHOSIS
Most severe form involving hallucinations and violence (suicide and infanticide) Delt
with patient in hospital in mother – baby psychiatric unit requiring anti psychotic medicines
and electro convulsive therapy (ECT) Ensure 24 hours supervision.
As with all counseling stations, It is important to gain patient trust. Introduce your self.
Congratulate for having a beautiful baby. Be gentle, polite, smile if appropriate, make eye
contact. Try to empathysize with your patient.
=====================================================================
(I) MANAGEMENT (Baby Blues) (First 1-3 days)
If history suggests Baby Blues then first line treatment for such mild depression is:
Rest You should ensure period of rest for yourself (as well e.g.) when baby is
asleep).
Diet You should eat well, health diet at regular times.
Support Should have regular contact with health visitor for guidance.
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Should attend mother-baby group where women can meet other mothers in
similar circumstances.
(III) MANAGEMENT (Peurperal Psychosis)
If you gather from history that patient has suicide ideas or ideas of harming her baby
then advise immediate hospital admission in mother baby psychiatric unit.
If reluctant for admission use mental health act or atleast ensure 24 hours supervision.
Patient will require antipsychotic medicine along with Electro convulsive therapy.
Talking therapy does not work.
I offer you immediate admission in Hospital in mother- baby Psychiatric unit. We do
not want you to harm yourself or that of your baby. You yourself will not like to harm yourself
once your mental condition improves and certainly your baby is an important asset to your
family. I offer you admission in hospital in mother – baby Psychiatric Unit for safety of your
baby. There both of you will be supervise for 24 hours.
Do you agreed to be admitted.
Yes – then ok. Give follow up and proper closing.
If no then say I have to use my powers according to compulsory mental health act to
admit you in mother baby care Psychiatric Unit. I am compeled to call crisis team. I will be
obliged if you cooperate.
Thank you. Good bye.
===================================================================
Depression - Flouxatene 20mg
Post Natal Depression - Sertraline 50mg
Breast feeding - Sertraline is safe
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ANOREXIA NERVOSA
EATING DISORDER (WEIGHT LOSS)
SCENARIO
I have come to discuss some problem of weight loss of my daughter Seema 20
years. Kindly gather data and manage. Examination not required. Proceed.
=================================
Mother has come to discuss weight loss of problem to her daughter. She is deliberately
trying to reduce weight by inducing vomiting, purging using laxatives and diuretic and
excessive exercise. Her BMI is less than 17.5 she has not had her periods for more than
three months.
DATA GATHERING
1. When did you first notice her weight loss? (For the past one month)
2. What was her weight before? BMI 26
3. How much is her weight now? BMI 17.5
4. Is she deliberately trying to reduce her weight? (I think yes)
5. Does she has intense fear of gaining weight although underweight? (Yes.)
6. Formula SCOFF
S Does she make herself Sick because she feel uncomfortably full?
C Does she worry she will loos Control over how much she eat?
O Has she lost more than one stone weight in 3 months (1 stone = 14 pounds
7.5kg)
F Does she believe to be fat when others say she is thin?
F Would you say food dominate her life?
7. Is there any Scarcity of food like in femine? (No.)

8. Is she taking balanced healthy food regularly? (No.)
9. Have you noticed that her stool is difficult to flush away or floats in the pan?
(Malabsorption syndrome). (Yes.)
10. Any difficulty in swallowing? (No.)
11. Does she take food in the presence of other family members? (No.)
12. Any recent bereavement? (No.)
13. During the past one month has she felt down, depressed or hopeless? (Yes)
14. Has she lost interest in things she used to enjoy? (Yes a bit)
DIFFERENTIAL DIAGNOSIS
15. Is her periods regular? (No) (Did not have her periods for the last 3 months) (Anorexia
Nervosa)
16. Does she prefer to wear loose dangling clothes? (Anorexia Nervosa)
17. Does she has sweaty moist warm hands with tremors in them. (Hyperthyroid)
18 Does she has high blood sugar? (No)
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19. Has she been in contact with any known TB patient? (No)
20. Has she ever been tested to HIV and what was the result? (The result is negative)
21. Have you noticed any blood in her stools (Colon cancer)
22. Any mucous in stool. (IBS)
23. Has she ever treid to loose weight by inducing vomiting or using laxative? (Yes)
PAST HISTORY
Any major medical or mental problem in past.
PERSONAL HISTORY (Bio Psycho Social)
Does she smoke? (No.)
Does she drink? (No.)
Any recreational drug? (Never)
Do you know your BMI? < 17.5 kgm2
Do you like exercise? How much? What type? (Excessive exercise)
How are the things at home?
How are the things at work / school
Any financial / legal / marital / relationship problem?
Who else is living with you at home / Do you have good relationship with them? (No.)
FAMILY HISTORY
Is any member of your family suffering from some mental problem? (No)
Any hospitalization for any mental problem recently? (No)
DRUG HISTORY
Is she taking any medicines regularly, If yes, which medicine? (No)
ILLNESS
How this problem of weight loss affecting her life?
ICE
I What do you think what is wrong with you? (Idea)
C What worries you most? (Concern)
E What do you hope to gain from today’s consultation? (Expectation)
SUMMARIZE
Seema has intense fear of gaining weight. She is eating very little. Deliberately try to vomit
and purge. Does excessive exercise to loose weight.
She has not had her periods for more than 3 months.
Her BMI is less than 17.5 kgm2
EXAMINATION
In order to confirm my diagnosis. I need to her examine.
Can I examine you? (Yes.)
Findings given are:
(1) Ketone Breath (Fruity smell in breath)
(2) Lanugo hair (Yellow easy to pluck hairs)
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(3) As a reaction to acidic content vomited out deliberately there are acid burns and
oral ulcers in the mouth.
(4) You also have pitting in teeth due to loss of enamel of teeth.
MANAGEMENT
Ok Miss Seema what I have gathered from the information you shared with me and
the examination findings given to me she is most likely having a condition what we call in our
medical terminology Anorexia Nervosa.
Do you know any thing about anorexia nervosa?
EXPLANATION
It is a mental state in which person has intense fear of gaining weight and she tries to
loose weight by (inducing vomiting or diarrhoea + use diuretic and do exesseive exercise)
Do you understand?
I offer to refer Seema to a special eating disorder clinic or Psychiatric unit. They will
take care of her diet and teach her re-feeding (I/V or parental feed)
They may give her some talking therapy so that she becomes aware of her problem
and its solutions.
They may prescribe her some antidepressant drugs.
SAFTY NETTING
In her present state of excessive weight loss her heart must be compromised so if they
prescribed her any antidepressant, antipsychotic or Macrolide antibiotic or anti allergic drug
they will monitor it with ECG monitor.
Follow up
When she has recovered and taken full treatment from eating disorder clinic or
psychiatric department, I will continue to have her physical and mental check up every year.
Is it ok with you?
Is there anything else you would like to discuss with me today?
No.
Good bye, smile Shake hand.
___________________
KNOWLEDGE BASE
In Weight loss consider
Dieting (Deliberate effort to reduce weight)
Malnutrition (Not sufficient healthy food available)
Acute causes of Malabsorption (e.g. Coeliac disease, Pancreatitis)
CHRONIC DISEASE
Hyperthyroidism
DM
Chronic Infections e.g. TB, HIV
COPD
Heart failure
Renal diseases
MALIGNANCY
Breast prostate colon cancer etc.
PSYCHIATRIC CAUSES
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Depression
Dementia
Anorexia Nervosa
NOTE: Significant weight loss is defined as a loss of more than 5 – 10 % of body weight
over 6 months. 1 Stone in 3 months (1 Stone = 14 Pounds = 7.5kg)
(1) ANOREXIA NERVOSA

Deliberately trying to reduce weight.
Eat very little or small amount
BMI less than 17.5 kgm2
No periods for more than 3 months
(2) BULIMIA NERVOSA

Eats excessively then induced vomiting and purging.
BMI normal
Have periods normally
(3) Bing Eating
Pattern of consumption of large amounts of food, even when not hungry, Usually
associated with obsessive feelings about food and body image, feelings of guilt /
disgust about the amounts consumed, and / or a feeling of lack of control,
MANAGEMENT OF BINGE EATING
Give ongoing support and information.
Provide an evidence-based self-help programme as a first step and / or antidepressant
medication (SSRI is the drug group of choice)
If unsuccessful refer for specialist help. CBTmight be helpful
In all cases, provide concurrent advice and support to tackle any co-morbid obesity.
_______________________
MACROLIDE ANTIBIOTIC INCLUDE:

Erythromycin
Azithromycin
Clarithromycin
______________________
Give information
Check electro lites
Self help program
Fluoxetine 60mg once a day then refer.
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OBCESSIVE COMPULSIVE DISORCER (OCD)
Hello
May I know you good name please.
Zeshan 25 years.
Ok Mr. Zeshan what brings you to the surgery today.
I am embarrassed to talk about my thoughts & actions to anyone but now functioning
at home & office is so much affected that my wife has sent me to you.
I am used to wash my hands repetitively although they are clean.
I repeatedly check my doors for locks that disturbed my wife sleep.
Tell me more about it
I am always busy in these actions for most of the time. My important tasks are
left unfinished.
That’s all doc
H/O PRESENT ILLNESS
How did it started gradually or suddenly? (Gradually)
Durations - Since when you are having these symptoms. (Over a year)
How frequently do you get these symptoms. (All the time)
Anything that increases the problem? (Stress)
Anything that relieves the problem? (Having done the ritual)
What pushes you to perform repeated ritual? Is it some thoughts, images or
impulse or belief (Thoughts)
What type of repeated ritual do you perform e.g.Washing? Checking locks?
Counting all the time?
What do you do, when you get these thoughts? (Perform the ritual)
Do you try to keep them out of your mind? (Yes)
What happens when you try to keep them out? (Unable to do so)
Are you a sort of person who is excessively worried about orderliness or
symmetry. (Yes)
Does your daily activities take longer time to finish? (Yes they take my all time
& important things to do are left remaining)
Do these problem trouble you? (Yes very much)
PAST HISTORY
Is there any other mental or medical problem besides this in the past? (No)
PERSONAL HISTORY
Do you smoke, how much? (Yes) 2 packs per day
Do you drink how much? (Yes) in safe limits
How do you rate your weight? I am loosing weight
Do you like to do exercise? No
What do you do for living? Cashier
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Any stress at work? (Yes) Cannot finish counting till the end of day.
Do you have family? (Yes)
Any stress at home? Wifes sleep is disturbed due to my repeated checking of
doors & lock at nights.
FAMILY HISTORY
Is there any similar problem in your immediate family member. (Family History
very important which is usually positive). Mother had similar problem in her later days.
DRUG HISTORY
Are you using any medicine prescribed or OTC. (No)
ICE
How this illness (condition) is affecting your life? (Unable to complete my daily
work)
What do think is the cause of your symptom? (Don’t know)
Are you worried about any thing in particular? (Likely to be unemployed)
What do you hope to gain from today’s consultation? Some medicine to fix the
problem soon.
Summarize
MANAGEMENT
What I have gathered from the information you have shared with me.
It seems most likely you are having a condition what we call in our medical
terminology as obscessive compulsive disorder.
Do you know anything about OCD?
Do you want me to explain what is OCD?
This condition is not a serious. The cause is not known. Young female persons
with strong family history, are mostly affected. In this condition person performs
uncontrollably irrational acts due to some thoughts and belief or image or
impulse in his brain. It is treatable.
LIFE STYLE CHANGES
I offer you some life style changes like stress management. (Please consult page 82
of Green Book “An Introduction to MRCGP OSCE”)
Try to relax
Try to sort out the cause of your stress
Eat properly
Early morning walk etc.
Do some relaxation exercises like Yoga and meditation.
Have good sleep
Keep daily diary of your important work and perform your work according to your diary.
MEDICINES
Certain medicins are available for treatment
(1) I offer you fluoxetene 20mg once a day.
377
(2) I offer to refer you to Psychologist for self help, talking therapy like Cognitive
Behaviour Therapy for more than 10 hours including exposure response
prevention.
(3) I also offer to refer you for individual or group CBT and involving family and
friends for exposure response prevention if required.
I also offer you some addresses of self help group organizations.
I offer a follow up visit after one month. We will reassess the condition and if
necessary I will refer you for specialist care to psychiatry department)
CLOSING
No.
You can have reading material from the information desk.
Good bye. (Smile & Shakehand)
______________________________________________
EXPOSURE RESPONSE PREVENTION (ERP) (OCD)

Post Exposure Prophylaxsis (PEP) (Rabies)
378
ALZHEIMERE DISEASE (DEMENTIA)
SCENARIO
A young man comes to you about complaint of his father forgetfulness. Take
history and give management plan. Proceed.
Hello,
I am Michal.
Well Mr. Michal what brings to the surgery today?
I am here to consult you about my father Mr. William. He is 85 years old. He is
becoming increasingly forgetful. He is lost in familiar surroundings like neighbourhood.
Sometimes he has difficulty in recognizing familiar faces like me his son.
Is anything else you want to share with me?
Yes doctor he does not remember what took in dinner but can recall my & his childhood
memories in detail.
Any thing else?
Ok Mr. Michal I will try to help & guide you to the best of my abilities what is going
wrong with your father memory. But before that I would like to ask you few more
questions. Can I ask? Yes you may Proceed.
Does he has trouble knowing day, date and month?
Yes doctor he has trouble knowing the day, date and month.
He uses clues like newspaper or callender more than once in a day.
Can he manage his daily routine house hold work like:
• Managing money & shopping. (No)
• Preparing food for himself. (No)
• Maintaining hygiene like taking bath & changing cloths. (No)
Can he still drive his car?
He has decreased sense of direction.
He is lost in familiar surrounding like neighbourhood.
Does Mr. William has difficulty finding words to express himself?
Yes a literary person, writer of 2 novels. Now has scarcity of words to express
his feelings.
What about his mood? Mood is low. He is irritable most of the time.
Does he misplaces his objects & when he can nnot find them, he accuses other of
hiding or stealing his objects. (Yes)
What does he do for living?
He was a school teacher. He got early retirement due to his decreased performance
at work.
PERSONAL HISTORY
379
Does he smoke? (Yes 2 packs a day)
Does he drink alcohol? (only on week ends. I have control over his drinking)
FAMILY HISTORY
Any family history of similar problem?
Yes Grand father had similar memory loss problem in his later days.
DRUG HISTORY
Is he taking any medicine?
Yes sleeping pill in the evening.
SUMMARIZATION PLUS CONCERN & EXPECTATION

Ok Mr. Michal from the information you have shared with me now today it is obvious
that your father has short term memory loss, He is disorientated in time & space. He has
functional disabilities in managing daily routine house hold work & he has trouble finding
words to express himself.
You are very much concerned what is going on with your father which has badly
affected his life & you expect me to guide you what can be done for him.
INVESTIGATION
I offer you all routine tests to find out the cause of any treatable disease. I also offer
you one test called CT scan of the brain. I will be referring you to psychiatry department for
initiation or prescription of this CT scan test.
MANAGEMENT
The information you have shared with me, it appears most probably your father has a
condition what we call our medical terminology Alzhiemer disease.
It is an age related condition due to deficiency of a brain chemical called acetylcholine.
I offer to refer your father to a psychiatry specialist who is expert in such elderly people
problems.
He may prescribe your father some medicines like Donapizil, Rivastamine or
Galantamine for mild cognative deficit. If your father is found having severe cognitive deficit
drug like Mementin may be prescribed. These drugs slow down or delay the progress of
disease and cognitive decline.
There is an important role of carer in this disease.
If carer can not cope then there are respite services and social support by volunteers
to help carer.
Would you like to shift your father to shared sheltered home for elder people with
disease like alzheimer or dementia.
No, I would like to help him at his home where memories of his late wife are there.
Ok then take care of his chest infection, UTI and anaemia as they can cause confusion.
– Give him a note book to record “tasks must do” Prompts on mobile and medication
dispenser.
380
– Maintain a constant environment. (Do not change the arrangement of furniture and his
things)
– Arrange for door catches to prevent wandering.
– Consider fire and electricity safety alarms.
– Remove loose carpets to prevent fall.
– Replace smooth tiles of bath room with rough tiles to prevent slipping
_ Modify steep stairs.
– Arrange Rail Grabs for stairs
_ Arrange his bed room down stairs.
– Avoid sedatives if necessary give in low dose.
_ Ask him to stop driving. Inform the DVLA and confirmed it to me.
SAFETINETTING
There will be a time when he will not recognize even his close relatives or be able to
take decision, for that purpose you can legalize his will as a advance directive in the presence
of family lawyer.
Follow up
Psychiatric review by the psychiatrist will be done at home every month or earlier if
need arises.
CLOSING
Is there anything else to want share with me today? (No)
You can take leaflet about alzheimer from the reception desk.
Further information can be taken from the internet.
Thank you for your visit and cooperation.
Good bye.
HOSPICE CARE
Hospice Care is type of health care that focus on the palliation of terminally ill
patient. Pain and other symptoms can be managed and his emotional & spiritual
needs are also met with. Hospice care ensures comfort & quality of life till the end of
the life.
RESPITE CARE
Respite care provides short term relief of primary care givers. It can be arranged
for just an afternoon or several days & weeks. Care can be provided at home, in
healthcare facility or at an adult day care centre.
_____________________________________________
381
DOMESTIC VIOLENCE
Oxford Hand Book of General Practice
5th Edition Page 86
SCENARIO
Mrs. Rukhsana is facing domestic violence. Kindly gather data and counsel her.
Procced.
Hello.
I am Mrs. Rukhsana.
Ok Mrs. Rukhsana what brings to the surgery today?
Yesterday I visited you for the headache.
Today I have pain in my back.
Mrs. Rukhsana you have been visiting me almost daily with different complaints.
I can see that your hand is in plaster today, with a black eye and few cigarette burns marks
on your hand.
May I ask you a direct question, are you in some sort of a trouble like domestic violence.
Doctor I am an uneducated woman I do not understand what is domestic violence.
Can you explain it to me.
Yes Mrs. Rukhsana domestic violence can be in the form of physical abuse like beating of
the woman by the husband. It could be a psychological abuse like threatening behavior or
criticism on bringing less dowery or yelling in loud voice or calling bad names.
It could be in the form of sexual abuse where a husband forces his wife in sexual act without
her consent even if she is weak, tired or sick.
It could be in form of financial abuse where a husband does keep the controlled of money
with him and does not give any money to his wife for spending.
Ok doctor.
Is it a normal behavior.
No, this is not a normal behavior. This is against the law of human rights and you can report
to the police or some community social services.
Doctor you pick rightly, I am facing domestic violence. My husband beats me badly on minor
things e.g. by complaining not cooking food properly or not taking care of children properly.
He locks the door as he leaves the house. I am like a prisoner in my own house.
I think I deserve that kind of beating.
No Mr. Rukhsana you do not deserve of this kind of treatment, its against the human rights.
You can complain it to the police or to the community social services.
Doctor I am afraid if I complained he might harm me or my children, if he throws me out of
my house I will be home less. I am afraid of my husband.
Ok Mr. Rukhsana, I cannot pressurized you into any course of action. If you wish to return to
the place of violence its up to you. I hope one day you will gather confidence to break this
viscious cycle and run away from this violence situation.
382
I can suggest few things, if you allow me. Rest is up to you.
Devise a safety plan.
If you are afraid of being home less I can provide you the addresses of women refuge centres.
You just have to gather courage, keep some money in a safe place, your bank cheque book,
passport and legal documents of the house and run away from the violant situation to a place
of safety, if the need arise.
You can take into confidence your neighbours and get there help as well.
I will document your injuries like fractured arm, black eye and cigarette burns on you hand.
I can record these things in your file and give evidence in court for these injuries.
Thank you doctor you have guided me very well. I will try to break this viscious cycle of
violence and move to a place of safety with my children.
Mr. Rukhsana is there any thing else I can do for you today?
No thanks doctor.
Ok Mr. Rukhsana you can get further information about your human rights and domestic
violence from the internet.
Thank you for you visit and good bye.
383
CONVERSION DISORDER
OR HYSTERIA
SCENARIO
Mr. Fawad reports in your surgery with a paralyze hand. Kindly gather data,
examine and do the management. Proceed.
Hello.
I am Fawad.
Ok Mr. Fawad what brings you to the sugery today?
Doctor I was riding my motorbike when my wife hit me with her car from the back.
I fell down but fortunately did not got any injury or neither any other part of my body was
injured.
I am a rich business man but I had a big loss in business recently.
I and my wife had a fight. My wife has filed a divorce suit against me and she wants to take
half of my hard earned money and property.
But doctor my hand is paralyzed and I cannot write anything.
I will try to help & guide you to the best of my abilities.
Mr. Fawad I would like to do a brief nurological examination of your hand and body.
Mr. Fawad after examining your hand and whole body, I have come to the conclusion that
there is no physical problem with your hand.
Mr. Fawad please do not mind if I tell you that you have paralyzed your hand due to your
psychological stress of loss in business and your wife divorced suit.
I am not saying that you are faking that your hand is paralyzed.
You truly believe that your hand is paralyzed you can not move it.
Mr. Fawad allow me tell you that many a times our body converts our psychological stress
and emotional stress into physical response like your paralyzed hand.
This is a way of brain to deal with emotional stress.
We call this condition conversion reaction or conversion disorder.
Conversion disorder is always triggered by some upsetting situations like yours.
Statistics show that mostly such conversion disorder occur in young women who have history
of emotional stress and have hard time talking about their feelings.
TREATMENT
Conversion disorder symptoms usually come on suddenly. A person may have paralyzed
hand. May not be able to control some movement. May develop blindness or loss of smell or
loss of speech. But simply knowing that there is no serious physical cause for these
symptoms is enough to stop the symptoms. These symptoms will go away as quickly as they
came on.
384
We can treat it. After knowing that there is no physical cause and you are perfectly fine, but
if you still have problems I can offer you talking therapy in the form of counseling.
Hypnosis can also be offered.
Best way to prevent conversion disorder is to find good ways to manage life stresses like:
• Doing some exercise
• Calming activies like yoga and meditation may help
If any person have any mental health condition, he is advised anti depressant or anti
psychotic drugs and he is advised take this medication regularly as directed by the doctor.
Mr. Fawad is there any thing else to discuss with me today?
No doctor, you have explained me very well. I also agree with you that probably my symptoms
are related to my emotional stress, I am going through, I will take talking therapy & physio
therapy as a means to deal with my problem.
I thank you doctor for explaining me very well what is going wrong with me.
Mr. Fawad you can take a leaflet about conversion disorder from the reception desk.
Good bye.
385
COUNSELING
Counseling
It is midway between “advice” and “Psychotherapy”
Doctor facilitates patient to make changes himself according to his own
circumstances)
Patient must develop insight into problem
Useful in
Addressing specific issues
Coping with crisis
Working through feeling and inner conflicts
Improving relationships with others
How to counsel
Establish a good doctor-patient relationship
Explore patient’s insight into the problem and develop this insight.
Identify a range of possible options
Let the patient choose one out of few suggestions.
Encourage if patient is already taking positive measures
Make the patient recognize that they have to bring the change in their behavior.
Counseling Skills
Counseling skills are:
Empathizing
Active listening
Open ended questions and probing, closed-ended questions
Focusing, clarifying
Correcting misperceptions
Summarizing
Willingness of patient
Be sure to assess the patient’s willingness to adopt the new behavior.
Be reminded that what you think the patient should do and what the patient thinks
he/she should do, may be different.
There is no correct answer!
Correcting Misperceptions
Providing correct information to the patient in a sensitive way that does not put the
patient on the defensive.
Acknowledge misinformation and correct it.
386
STOP SMOKING COUNSELING
SCENARIO
Mr. David wish to quit smoking. Kindly gather relevant data and counsel him
how to quit smoking.
Hello.
My uncle was diagnosed as having Lung Cancer 6 months ago. He died a week ago.
He was a chain smoker. Doctors said cause of his Lung Cancer was heavy smoking for years
together. I wish to quit smoking. Kindly help me.
1. ASK
Before I come to managing your smoking can I ask few questions:
(1) Since when you are smoking? (For the last 20 years)
(2) How many? (2 Packs a day)
(3) Do you drink? (In safe limit)
(4) Any recreational drugs also? (Never)
(5) Have you ever tried to stop smoking in past? (Yes but could not succeed)
(6) What causes you to quit smoking now? (My uncle’s death a week ago)
(7) Does any body else in your family smokes? (No.)
(8) Do you have any medical problem? (Not yet)
2. ASSESS
Do you know hazards of smoking and benefits of quiting. (Not much)
May I offer you few hazards of smoking and few benefits of stopping.
HAZARDS OF SMOKING
It can cause heart attack, paralysis & breathing problems like asthma.
It can also cause blindness, impotance, infertility.
It can cause skin wrinkles, and stomach ulcer. It can cause certain cancers of mouth
lung, bladder & blood cancer.
Do you understand.
BENEFIT OF STOP SMOKING
One month after quiting, Your skin will be clearer, brighter and more hydrated.
Three months after quiting, You will not have cough and wheezing or your lung function
will improve by 10%.
By one years, your risk of heart attack will be half.
By ten years your risk of lung cancer will reduce to half.
You will no longer harm others by passive smoking e.g. particular to your children, no
asthma, no ear infection, no infant death.
Do you under stand. Can I proceed with craving for cigarette after quiting.
WITHDRAWAL EFFECTS OF QUITING
Do You know you can have craving for smoking after cessation (Yes)
You can become restless and irritatble & develop some symptoms of low mood
387
If you have craving you can decrease it.
• By distracting yourself by doing some gardening or reading book watching TV etc.
• You can drink water
• Do deep breathing
• Or discuss with friends and support groups, how they dealt with their craving.
3. Advice
It is my considered openion that:
1. The longer you smoke the more damage it does, so the sooner you stop the better.
2. It’s never too late to stop. Your health will start improving from the moment you quit.
3. Giving up tobacco will make you healthier and fitter – and save your money.
Do you understand.
4. ASSIST
I can help you in quit smoking.
I may involve your family members, friends and colleagues at work. They will also
help
I offer to refer you to stop smoking clinic.
I can help you set a quit date. You should stick to it. You should stop smoking on the
quit date, not even one puff after that.
5. ARRANGE
First of all we have to understand that nicotine in the cigarette which is highly addictive.
After stop smoking person can have craving for smoking due to nicotine addiction. Nicotine
replacement therapy replaces the nicotine but the tar and gases of cigarette are eliminated
which are very injurious to health.
Nicotine replacement therapy is available in the form of patches, gums, tablets and
lozenges, Nasal spray and inhaler. You can take NRT in which ever form you want to take,
its up to you.
I can offer Nicotine replacement therapy for 2 weeks. After 2 weeks if you
demonstrated continued commitment to stop smoking I will prescribe for further one
month. If you are unsuccessful then National Health Services will not fund another
attempt for more than six months.
Nicotine replacement therapy increases the chances of stop smoking by 1½ time. We
start with high doses for patients highly dependent. Treatment is continued for three months.
Dose is tapered of gradually over two weeks before stopping completely. However if nicotine
gums are used, they can be stopped abruptly. Nicotine replacement therapy can be used
in pregnancy. Contraindications to NRT are post MI, patient with arrhythmias, stroke
or TIA.
Before starting the management let me inform you that treatments are available in the
following form of
1. Nicotine replacement therapy
2. Tablets like buproprion & Varenicline (Champix)
3. Accupunture
4. Alternate therapies, Homeotherapy, hypnotherapy
5. Electronic Cigarrettes
388
If patient prefers nicotine replacement therapy tell him pros and cons of nicotine
replacement therapy only and do the follow up and closing.
If patient prefers tablets advise them while keeping in mind particular contraindications
of buproprion and varenicline.
If patient go for alternate therapies give detail of alternate therapy and tell him that
although these help some people but evidence of effectiveness is lacking. I wil respect
the autonomy of patient.
BUPROPION
It is not recommended age less than 18 years. It is contraindicated in pregnancy
and breast feeding, in eating disorder, epileptic fit and severe cirrhosis of liver.
Side effects of bupropion include dry mouth, upset stomach, drowsiness, dizziness,
headache. As it causes drowsiness hence no driving or operating machinery.
You are suppose to start Bupropion 1-2 weeks before your intended quit date (dose is
150mg once daily for three days then 150mg twice a day for 7-9 weeks)
Varenicline (Champix)
It is a new drug in addition to NRT and Bupropion. Depressed mood may be a
symptom of nicotine withdrawal. Thinking about committing suicide and suicidal attempt
has been reported in people trying to stop smoking. Suicidal ideation is reported with
Varenicline (Champix use).
Varniclene Tab start 1 week before the quit date in the following way:
0.5mg once a day on day 1
Day 1 to 3 0.5mg once a day in the morning
Day 4 to 7 0.5mg morning and evening one tab.
From second week onward 1mg one tab morning and evening.
Follow up after three week
Total three months consider prescribing for further three month to decrease chance of
relapce.
Do not take if pregnancy or mental illness (increases suicidal ideation)
Contrainficated in less than 18 year, shortness of breath, swelling of face, rash
or itching.
6. ALTERNATE THERAPIES
Homeopathy Hypnotherapy and Acupuncture are alternate therapies. Although they
help some people but lack scientific evidence. Electronic cigarettes are also available but
they are not without side effects.
7. FOLLOW UP
I will follow up your progress and offer you a second appointment free.
CLOSING OF CONSULTATION
Is anything else you want to discuss with me today? (No)
Thank you for you cooperation.
Good bye.
________________________
389
PATIENT NOT WILLING TO QUIT SMOKING
Mrs. Najma, Lawyer by profession, pregnant for 3 months. Not willing to quit smoking.
She says smoking is my life long habit of 25 years.
It relaxes me and the same time stimulates me to work.
My work as lawyer is very stressful and I cannot worked if I do not smoke.
Doctor tells her about the benefits of stopping and hazards of continuing smoking but
she is still reluctant to give up smoking.
Doctor then tells her about the hazards of smoking in pregnancy like low birth weight
of the baby and pre-term delivery.
Still not willing to quit.
Doctor tells her that she can save her other children from passive smoking and save
them from asthma, ear infections and sudden cot death.
The simulated patient who is an actor finally agrees to give up smoking.
Other wise if still not willing to quit doctor records his advise given in her file.
Give patient informative leaflet to take away with him to read at home.
Repeat advice to stop smoking whenever patient is seen in clinic.
Patient autonomy respected but patient never abandoned by doctor.
========================
Buproprion Contraindicated in Pregnant
Verenicline Contraindicated in Pregnant
NRT can be given pregnancy
_______________________
Contraindicated of NRT Contraindicated of Buproprion
(1) Recent MI (1) Pregnancy
(2) Cardiac Arrythmias (2) Breast feeding
(3) Stroke or TIA (3) Eating disorder
(4) Epileptic fits
(5) Cirrhosis of liver
390
ALCOHOLISM
(Oxford 5th Edition Page 159 & 1103)
Normal safe limit range is 3 units per day or (21 units per week) in male.
And 2 unit per day or 14 units per week in females.
An alcohol intake in excess of recommended levels is called heavy drinking.
Alcoholism – An actual dependence of alcohol without which patient has withdrawal
symptoms.
SCENARIO
Mr. David 37 years old has come to discuss his problem of alcoholism. Kindly
gather data & counsel him. Proceed.
Hello.
I am Dr. Raheel one of the GP in the surgery.
I am David, 37 years.
Ok Mr. David what brings you to the surgery today?
______________________________________________
PRESENTING COMPLAINTS
Doctor I need help with my drinking, I have been drinking excessively inorder to get
the same desired effect. I wish to cut down it to safe limits but is unable to do so
because of my frustrations.
More over my wife left me and has taken away my 12 years boy with her because of
my excessive alcohol intake. I have been drinking more alcohol inorder to cope with
this.
Doctor I have lost my job as security guard as I was found intocixated at my job.
Ok Mr. David. You want to cut down your alcohol to safe limits. I will try to help you to
the best of my abilities but before that may I ask you few questions?
Ask the following questions:
For how long you been drinking? (Ever since I got 18 years old)
How much daily? (6 cans of bear and a pint of Vodka)
What causes you to quit drinking now? (I have told you my problem at home & work)
Does anybody else in your family drink? (My father was a heavy drinker)
At what places you normally drink? (At home & at pub)
_________________________________________________________________________
Do you know the HAZARDS OF DRINKING?
I know a little bit but if you can exaplain me I will be grateful.
Alcohol can cause PHYSICAL PROBLEMS like ulcers of stomach, increased blood
pressure and stroke. It can also lead to obesity, high blood sugar, impotence, infertility
and certain cancers, like food pipe and breast cancer. Alcohol can lead to certain
nutricianal deficiencies, poor sleep and tiredness. You know its hazardous effect on
liver. Alcohol can cause recurrent accidents due to drunk driving.
Alcohol can cause certain PSYCHOLOGICAL PROBLEMS like Anxiety
(Restlessness and irritablility), depression and suiciadal ideation.
Acohol can cause SOCIAL PROBLEMS like you are facing breakup of marriage, loss
of work, social isolation and poverty.
_________________________________________________________________________
391
PERSONAL HISTORY
Have you ever tried to stop drinking in the past? (No.)
Do you have any other medical problem? (No.)
How is your performance at job? (I am jobless at the moment)
How is your marital life? (My wife left me)
Are you facing any financial difficulties? (Yes.)
Have you ever been convicted of assault, child neglect? (No.)
Have you ever been convicted of drunk driving? (Yes, I had been issued a ticket for
drunk driving once)
Any history of attempted suicide? (No thoughts of committing suicide I want to live
without excessive alcohol)
Any history of previous episode of depression? (No).
Have you notice that you drinking more and more alcohol to reach the same level of
satisfaction? (Yes.)
ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT)
I would like to ask you few questions regarding hazardous alcohol use:
1. How often do you have a drink containing alcohol?
2. How many drinks containing alcohol do you have on a typical day when you are
drinking? (Several)
Few more questions to assess your dependence on alcohol use:
1. How often during the last year have failed to do what was normally expected of you
because of drinking? (Many a times)
2. How often during the last year have you needed a first drink in the morning to get
yourself going after a heavy drinking session?
3. How often during the last year have you had a feeling of guilt or remorse after
drinking?
4. How often during the last year have you been unable to remember what happened
the night before of your drinking?
Just two more questions to assess harmful effects of alcohol on you:
1. Have you or someone else been injured because of your driking?
2. Has a relative, friend, doctor or other health care worker been concerned about
your driking or suggested that you can it down?
ACTION
Audit score 0-7 Alcohol education
Audit score 8-15 Alcohol education + simple advice
Audit score 16-19 Simple advice + brief counseling + continued monitoring
Audit score 20-40 Referal to specialist alcohol services for evaluation and
treatment
May I know the audit score. (Its 40)
_________________________
MANAGEMENT
Mr. David the information we have just shared from it appears that you are dependent
on alcohol and your willing to give up alcohol so I offer you certain life style changes as well
392
as some detoxification through community health team, so your depdence and craving to
reach same level of satisfaction could be managed.
I offer you detoxification with community health team with chlordiazepoxide
Dose of chlordiazepoxide is from 30mg to 10mg in tappering dose in one week.
Provide life style changes such as couple counselling.
Consume more nonalcohol beverages (Alcohol free bear).
Sometimes patient after detoxification relapse that is starting drinking again, in that
case, Acamprosate and diasulfiram is used on Specialist initiation.
Chronic alcoholic are defficient is vitamin B 12 I offer you vitanmin B12 (Thiamine)
200mg once a day for one week.
I also offer you to join alcohol anonymous group where people who has successfully
given up alcohol, sit together and share their achievement and problems.
LIFE STYLE CHANGES
Go to pub late.
Take rest days from alcohol
Learn to say no
Keep an alcohol consumption diary.
Suggest he involves his family and friends.
Agree targets to decrease consumption
INVESTIGATION
I offer you the following investigations.
Ultrasound for fatty liver and cirhosis
Full Blood Count (increased MCV)
LFT (Increased GGT), increased AST, increased Bilirubin
_________________________________________________________________
Please visit surgery as soon as the results of your reports are available and you have
contacted community alcohol team for detoxification. I would like to follow up you for
your progress.
Is there anything to want you to discuss today?
No.
Please collect leaflet about alcoholism from the information desk.
More informatoin from the internet
__________________________________________________________________
Ask the patient if he is aware of withdrawal symptoms if he decreased the alcohol
consumption abruptly e.g. DELIRIUM TREMENS
2 – 3 days after stopping alcohol intake withdrawal symptoms will occur including.
GENERAL SYMPTOMS:
(i) Fever
(ii) increased BP
(i) Increased heart rate
(ii) Increased breath rate
(iii) Insect crawling over the body or see small colored animals
NEUROLOGICAL SYMPTOMS
(iv) Tremors
(v) Fits
393
(vi) Fluctuated level of consciousness
Psychological symptoms, visual and Tectile hallucinations.
If patient is suffering from above mentioned symptoms this warrants emergency
admission to the hospital as delirium tremens are associated with 15%
mortality.
____________________________________________________
MANAGEMENT
As you are aware, that you are consuming too much of alcohol. Have you ever tried
to cut down in the past through community detoxification program or joined alcohol
anonymous or by visiting your GP for advice?
Assess the amount of alcohol patient is drinking on regular basis when they are seen
in surgery for other reasons.
Ask any patient’s presenting with symptoms / signs which could be associated with
excessive alcohol consumption about the amount of alcohol they drink. There are three
possibilities:
1. DRINKING WITH ACCEPTABLE LIMITS.
Reaffirm safe drinking limits. (Ok keep up the good habit)
2. DRINKING EXCESSIVELY BUT NOT WILLING TO QUIT
Record advice given to decreased alcohol consumption.
Give the patient an advice leaflet to take away.
Repeat advice to decreased Alcohol whenever patient seen in surgery.
3. DRINKING EXCESSIVELY AND WILLING TO QUIT
Patient may be an:
(vii) Non dependent drinker
(viii) Dependent drinker
(i) NON DEPENDENT DRINKER WILLING TO QUIT
(ii) DEPENDENT DRINKER WILLING TO QUIT
Dose of chlordiazipoxide for detoxification in one week will be as follows in tapering
dose:
30mg QID on day 1-2
15mg QID on day 3-4
10mg QID on day 5
10mg BD on day 6
10mg OD on day 7 then stop
Before detoxification asks the following questions:
Epilepsy
Vomiting
Diarrhea
History of previous withdrawal symptoms
Increased risk of suicide
Poor cooperation
Confusion
Malnarishment
Multiple substance abuse
Delirium Tremons
________________________________________________________
Page 1103
Alcohol Audit P - 159 Page 553
Pregnancy, Adolescent, fitness to drive Page 158 to 161
Questions addressing hazardus alcohol use
Alcohol Management Strategy
394
CHILDHOOD OBESITY
ONE MINUTE SCENARIO OUT SIDE STATION
Mrs. Rukhsana Saeed has come to see doctor about her youngest son Bilal’s
weight problem. (He is asthmatic and is on salbutamol & beclomethasone.)
First sentence – I am sorry to bother you doctor but I am worried about my son Bilal’s
weight.
DATA GATHERING
INFORMATION REVEALED FREELY WITH FACILITATION IN ONE MINUTE
Mrs. Rukhsana – I have learned from Bilal’s friends that Bilal is being teased at school
about his weight. He is a bit sensitive and refuses to go on the scale. I have treid to get him
play outside more but his brothers also like stay in and watch TV or play computer games.
INFORMATION REVEALED WHEN SPECIFICALLY ASKED
I glad you have made first step successfully by coming to see me to help your son
Bilal.
What is the age of your son? (5 year)
May I know the percentile of his age and weight according to his age and weight.
91 over weight.
98 obese.
99 Severe obesity.
Do you think Bilal have weight problem? (Yes)
When did you first noticed Bilal’s weight prblem?
A month ago when school friends complaint
What sort of food Bilal like to eat? (Fast food & Junk food)
Does he eat food with high sugar and fat content? (Yes)
Does he eat food rich in salt? (Yes)
How often does he eat fresh fruits and vegetables? (Occationally)
Where does he eat meals? (In his room)
Is he eating secretly? (Yes at nights open fridge)
How much exercise does Bilal do? (Very little)
Any sports he likes play? (No)
Does family ever do activities together such as swimming or walks? (No)
What is the whole family’s life style like? what does her husband think about family’s
life style?
What are other children’s views?
_____________________
How is Bilal getting on in school? (His grades are falling)

Has Bilal mentioned calling names? (No)
Does he has any educational or learning difficulties? (Yes)
395
What about Bilal Mood? (Low)
Has he mentioned any aches and pain? (No)
Headache or visual disturbances? (No)
FAMILY HISTORY
What is your husband’s job. (Businessman)
What’s your job. (Work at bakery 9am to 5pm.
How many more kids you have? (2 elder brothers)
Any problem with other kids? (No)
Do you guys like to exercise? (No)
What sort of food you guys like?
Is there any financial barrier in adopting healthier life style? (No)
Have you ever thought how these barriers might be overcome?
FAMILY HISTORY
Is there any family history of endocrine disorder e.g. ↑ blood sugar.
MANAGEMENT
In your case we need to think about the whole family needs.
When somebody’s intake is more than output over a long period of time, obesity
results. Management of obesity aims to reverse this trend on a long-term basis.
1. HEALTHY EATING
Try to have a healthy diet.
Use canola oil or olive oil one tea spoon per person for cooking.
Avoid oily, greasy and fried food
Try to have five portion of fruits and vegetables every day
Try to take all sorts of pulses, beans & legumes.
Try to have a low salt and low fat diet.
Avoid red meat
Poultry is ok, preferably if it is grilled.
Fish is good, it was omega 3 and omega 6 vitamins which are good for heart. Try to
take fish twice a week.
Try to take 2 table spoon of nuts daily.
Have at least 8 glass of water daily (3 liters)
Decrease hidden sugar calories in alcohol & prepared foods.
Increase fibre in food.
2. PHYSICAL EXERCISE
• For children aim for a total of 60 minutes of moderate activity each day.
• Encourage Bilal to take up sports which he enjoys.
• Aim to limit time spent on watching TV or playing computer games each day.
• Will you be able to enforce it?
396
• Regular aerobic exercise helps decreased weight and improve health. (Tailor advice
to the individual and local facilities).
• Increase aerobic exercise swimming or gardening till you sweat for minimum of 30
minutes per day for at least five days a week.
LIFE STYLE CHANGES FOR WHOLE FAMILY
DIETGiving Bilal and his brother’s packed lunches rather than money which they can spent
on unhealthy food. Ask how would children react to it?
EXERCISE
1. Walking to school rather than taking car. Ask whether this will be feasible or not?
FAMILY ACTIVITY
Organize regular family activities such as going swimming or walks with grand dad. Ask,
Are there any activities involving physical exertion that whole family enjoy?
Can whole family eat evening meal together at kitchen table instead TV lounge.
What would the family think about this?
Mrs. Rukhsana you will not bring home unsold cakes from her work at the bakery.
Mrs. Rukhsana can you agree to find time to cook proper food instead of bring prepared
meals from market.
GROUP THERAPY
Group activitivies with Weight Watchers, seem to have a higher success rate in
producing and maintaining weight loss.
BEHAVIOR THERAPY
Shown to be effective individually and in groups when combined with low-calorie diets.
In simplest form, involves advice to avoid situations that temp overeating.
FOLLOW UP
On a regular basis is essential to maintain motivation.
MAINTENANCE OF WEIGHT LOSS
Once a patient has lost weight, diet still needs to be monitored. On-going follow-up
has been shown to help sustain weight loss. Weight fluctuation (yo-yo dieting) may be
harmful.
In the end tell, Mrs. Rukhsana that you will like to talk to Bilal for proper assessment.
Can she ask him to see me for chat.
I will take his baseline weight and height and rule out any pathology causing his weight
gain.
I will refer Bilal to dietitian for further advice on meal planning.
I can refer him to some self help groups where obese people discuss their problems.
I don’t see any need for commercial weight management programs for excessive
weight loss in short span of time.
Thank you for coming to see me.
Good bye
__________________________________
Refer to Pediatrician, Dietition, Psychologist
397
PATIENT EDUCATION AND COUNSELING ABOUT OBESITY
DEFINITION
Obesity is when a person is carrying too much body fat for their height and sex when
BMI > 30. It happens when you eat more calories than you burn off over a period of time.
A laborer working on a building site may need as many as 4,000 – 5,000 calories a
day to keep an even weight. In contrast, an office worker who uses a car to get to work, and
does not exercise, may only need 1,500 calories a day. But most of us have more food than
we need, and much of it is higher in calories than the human body was originally designed to
cope with.
CLASSIFICATION
BMI (Weight in Kg  Height in M2):
18.5 – 24.9 = normal
25-29.9 = overweight
30-39.9 = obese
> 40 = morbid obesity
CAUSES
After child birth (Not breast feeding)
Lifestyle choices – Eating more calories, high fat, fast food and heavy drinkers Lack
of physical activity, Secondary causes – Cushing’s syndrome, Hypothyroidism,
antidepressants, anti-psychotic (Olenzipine), Contraceptions specially depo injection, Insulin
WAIST CIRCUMSFERENCE
An alternative indirect measurement of body fat that reflects the intra-abdominal fat
mass. Strongly correlated with CHD risk, DM, hyperlipdaemia, and increase BP.
Measured halfway between the anterior superior iliac crest and the rib cage at
umbilical level.
Extra fat is mainly around your waist (‘apple shaped’) is more dangerous than mainly
on your hips and thighs (‘pear shaped’) As a rule, a waist >102 cm for men and > 88 cm for
women is dangerous.
Childhood obesity is a strong indication that the child will be obese as an adult and is likely
to lead to serious health risks in later life.
SYMPTOMS
Being a little bit overweight tends not to cause too many noticeable symptoms but
once puts on more Wt, you can develop breathlessness, sweating a lot, snoring, inability to
cope with sudden physical activity, feeling very tired every day, and back and joint pains.
RISK / TRIGGER FACTORS
Obese person is far more likely to develop a range of health-related problems, high
cholesterol levels, diabetes, heart disease, stroke, osteoarthritis, high blood pressure,
gallstones, polycystic ovarian syndrome, infertility, GERD, and depression. It also contributes
to one third of cancers of the colon, breast, kidney and stomach.
PREVENTION
The best way to prevent becoming overweight, or obese, is by eating healthy food and
doing exercise regularly.
398
3. MEDICATION
Consider if a 3 month trial of diet / exercise has failed.
Medication is only used in extreme cases.
Drug specifically licensed for the treatment of obesity is orlistat (120mg tds with food)
(Orlistat reduces fat absorption form intestine and is excreated in faces.)
Anti obesity drugs should be offered if patient have previously made serious attempts
to lose weight by diet and exercise.
4. SURGERY
Only consider referral as a last resort if behavioral and dietary modification have failed
and BMI > 40. Gastroplasty (Adjustable gastric bending) is the most common procedure.
Mortality is high.
________________________________________________
COUNSELLING
Healthy eating tips for pregnant women.
Food recommended for pregnant 763.
Food to avoid in pregnancy.
___________________________________________________
Work, exercise & drugs safe & contra indicated in pregnancy 778
___________________________________________________
Breast feeding advantages for mother & baby 848-850
399
FALLS AMONG ELDERLY
SCENARIO
Michel 30 years has come to discuss some problem of his father William 70
years old who fell in the bathroom last night again. Take relevant history and manage
(examination not required). Proceed.
QUESTIONS TO FIND OUT THE CAUSE
When did it happen (One day ago)
How did it happen (He Slipped in bathroom)
How did he manage to get up (He could not get up from the floor himself until I reached
him in the morning.
Did he loose consciousness? (No)
Did he hurt himself? (Small Bruises)
Was it first time? (This was the second time he slip in the bathroom)
Is someone living with him? (No)
Is there any foot deformity or his shoes are of his proper size.
Did he had any stroke previously?
Is his bed or chair too low?
What about his eye sight? (Uses spectacles. Need to be checked again)
Any joint pain or deformity? (No)
What about his mood? (Depression) (No)
Does he suffer from Parkinson disease? (No)
D/D
Any history of fever recently? (No)
Any cough with phlegm recently? (No) (Pneumonia)
Any history of pain while passing urine recently? (No) (UTI)
Any history of ear problem recently? (No)
Any Increased thirst? (No diabetes or high blood sugar)
PERSONAL HISTORY
Does he smoke? How much? Any intention to quit?
Does he drink alcohol? (Yes in safe limit)
DRUG HISTORY
Is he taking any medicine e.g. sleeping pill, water pill, drug for ↑ BP & steroids.
(He is taking sleeping pill in the evening and atenolol 50mg for his blood pressure.
EXAMINATION (May not be required) (May I know examination findings)
Is your father accompanying you today? (No)
If your father was accompanying you I could have examined him for any bruises,
fractures, any irregular pulse or any difference in his sitting and standing blood
pressure.
400
I would have checked his temperature for hypothermia and his sacrum and heel for
any pressure source. I would have checked any sign of dehydration by checking skin
prick test or his tongue examination.
To check his muscle strength I would have asked him for go and get up test i.e. if he
can get up from the chair without using his arms.
People who have difficulty with go and get up test & present following a fall or have
recurrent fall, need to be referred to a fall assessment team.
INVESTIGATION
I offer you the following tests:
Blood complete,
Blood sugar
Eye testing
CT Scan for subdural haematoma
Ultrasound for Prostate enlargement
MANAGEMENT
If the cause of recurrent falls remains unclear and patient and carer is worried about
the possibility of further falls and there is doubt about weather patient can cope with it alone.
He should be shifted to shared shelter home. Would you like your father to be shifted to a
shared shelter home.
No I would like to take care him at his home.
Ok Mr. Michal try to remove hazards thing from the environment and take care of few
things like:
Removing loose rugs
Correcting Poor lightening or in accessible lights
Changing slippery tiles to rough tiles
Fitting foot wear
Moving bed down stairs.
Stairs grab rails
Steep stair modified
Special commode or urine bottle for night time use
Use of hip protectors to ↓ risk of hip fracture
Correct vision
(2) ALTER MEDICINES
I would like to reduce the dose of drug for blood pressure to 25mg atenolol instead of
50mg as patient blood pressure falls more than 20mm from sitting standing position.
I would also like to offer your father to refer to the neurologist who prescribed sleeping
pills to stop or decreased the dose of sleeping pill.
(3) PHYSIOTHERAPY
I offer you to refer physiotherapist for exercises to improve strength of muscles,
flexibility and balance and thus restore the confidence.
(4) Patient is advised to keep carer phone number or alarm system switch with him to
call for help if any further fall.
______________________________
(1) Refer to A&E if

Significant head injury.
Any other significant injury (e.g. Lacerations)
Any suspicion of fracture
(2) Admit to the acute medical team or elderly care team if
Cause of the fall was an acute medical problem (e.g. Stroke)
401
PALLIATIVE CARE
TERMINALLY ILL – TREAT AT HOME
SCANRIO:
Mrs. Aliya 44 year old has come to discuss some problem.
Kindly gather relevant data and discuss with her a mutually agreed plan of
treatment. Proceed.
Hello.
I am Mrs. Aliya 44 year old.
Ok Mrs. Aliya how can I help you today?
Doctor my oncologist has advised me to contact my family physician for my terminal
care. I have been diagnosed as having breast cancer which has spread to my liver
and bones.
Mrs. Aliya, I am extremely sorry to hear the sad news.
Anything more you like to share?
Doctor I know I am going to die but I don’t to know how it will end. Who will take care
of me in the end. I am a Widow and I have six year old son to take care of. I have lost
my job and I have financial restrains.
Anything more.
No that’s all.
INVESTIGATIONS
May I know what tests you have gone through.
Doctor I have gone through number of tests including:
1. Mamography
2. Fine Needle Biopsy
3. MRI
4. Ultrasound of liver to see spread of cancer.
5. Bone scan to see spread of cancer.
May I see the results of those reports.
Doctor takes the bundle of papers in his hand.
Ask the patient name and age again to confirm reports belong to Mr. Aliya.
DRUG HISTORY
My I know what medicine you are taken?
Oncologist gave me paracytamol and Ibuprofen for pain as he discharged me.
Also calcium vitamin D supplement
& Alprazolam 0.5mg for sleep deprivation
Does these medicines help?
402
Yes they do help but not completely.
May I know why you can’t go to sleep easily?
Doctor so many things are going on in my mind.
FAMILY HISTORY
Is there any member of the family like mother or sister ever had breast cancer?
Yes, my mother had breast cancer.
CONCERN
What worries you most in particular.
Doctor it is difficult for me to come to surgery to see the doctor. Sometimes because I
feel pain and too lethargic. I have nobody to help me.
Ok Mrs. Aliya. I have seen the reports which confirm your breast cancer in last stage
and it has spread to your liver and bones. It is difficult to predict how long a patient will
live depending upon the type of cancer and response of medicines but usually patient
has two or three months to live after the spread. I am sorry to give you this serious
information but it was necessary so that you can choose treatment options & make
your will as advance directive in the presence of family lawyer.
MANAGEMENT
Ok Mrs. Aliya I will help you in all the areas you need help including:
1. Somebody to help you at home like respite services.
2. Some NGO’s to help you financially and provide food vouchers for you and your
child.
3. Help you in preparing your will and adoption of your child to some needy childless
couples.
4. And finally to facilitate your admission to the terminally ill patient care ward to keep
you confortable and pain free till end.
We will deal all these issues one by one.
Is it ok with you? (Yes doctor please)
1. You are a brave woman. I can arrange some nurse who will help you when you
feel lethargic and some respite care services to facilitate your daily home chores.
2. Instead of admitting your child to the orphanage, some childless couple can be sort
who will be willing to adopt you child as their own child. You can select the future
parents of your child in your life.
Your child is certainly a great asset, not only to you but for the govt. of UK as well.
Rest asure that being a citizen of UK your son education and medical treatment
will always be free.
When your child will reach 18 year of age, he will have the legal right to know his
real parents. You can prepare and preserve a video record for your child when
he will reach 18 year of age.
3. If you do not want to leave your house where your husband memories are there.
You can stay in your own home as long as you can cope.
I will help you to arrange a helping hand in the form of nurse and a respite care.
Your physical, emotional & spiritual needs will be fulfilled.
Later you can be admitted to terminally ill patient care ward. (Hospice)
403
Better and strong pain killers like morphine and pethadine in form of injections &
patches can be given, so that you do not remain in pain till end.
Phantanil patches which are morphene pain killer patches can be given for relief
of pain for 24 hours. In UK there is a new concept of macmillan nurses. These are
specialist nurses for cancer patient. They work with GP for palliative care of patient & give
medicine and support.
You can make a will not to be resuscitated at the end of life.
________________
Have I dealt with all your worries and expectations? (Yes Doctor)
Is there any thing else you want to ask or share with me today?
No Doc. I am very thankful to you for solving all my problems very well.
FOLLOW UP AND SAFETY NETTING
Mrs. Aliya I would like to see you after every two weeks.
Yes Doc. I will see you after two weeks.
SAFETY NETTING
If you develop any severe pain or any bleeding from the wound of operation please
seek immediate medical help.
I as your family physician will always be there to help and guide you.
Good bye.
NOTE
Please listen to the patient attentatively. Be sympathetic and empathetic at the same
time.
React to verbal and non verbal clues promptly as your genuine concern and not just
superficial reaction to show the examiner and certainly not delayed reaction.
This is not a case of breaking bad news. Patient already have gone through number
of tests and she knows the definitive diagnosis already. In this case basically examiner
wants to see how you cater the patient, in time of need, specially when patient is dying.
________________________
HOSPICE CARE (House Worker)

Hospice Care is type of health care that focus on the palliation of terminally ill patient
pain and symptoms and attending to their emotional & spiritual needs at the end of life.
Hospice care priority comfort & quality of life by reducing pain & suffering.
RESPITE CARE (Volunteers for help for short term relief)
Respite care provides short term relief of primary care givers. It can be arranged for
just an afternoon or several days & weeks. Care can be provided at home, in healthcare
facility or at an adult day care centre.
END OF LIFE CARE FOR TERMINAL PATIENT
Hello.
I am Dr. Raheel.
404
I am Rasheed Ahmad 67 years old.
Ok Mr. Ahmad, what brings you to surgery today?
_________________________________________________________
Doctor, I am suffering from cancer of the stomach and doctor have told me that my cancer
has spread to my lungs, liver and bones.
I wish to know how much time I have to live also how and where my end of life will occur.
I am extremely sorry to hear sad news.
Ok Mr. Rasheed Ahmad is there anything else to discuss with me?
Yes, a lot of things are going on at the back of my mind which I wish to discuss.
Ok Mr. Rasheed Ahmad I would try to answer all your questions. But let me say I may not
have all the answers you need.
____________________________________________________________
As far as the life expectancy after disease have spread to the other organs is usually
about 2 to 3 months.
If your condition is deterioting day by day then death is likely to be soon.
I would like to ask you few question, Can I ask?
Ok doctor go ahead.
IDEA
What do you understand about the treatment options available for stomach cancer?
I do not know but a doctor told me that certain drugs can be given in the drip and rays like
xrays can be given to prevent the spread of disease.
Certain drugs can be given to alleviate the pain.
CONCERN
What is the most important issue for you right now?
Doctor I am living alone. Socially isolated. I need to be shifted to the old persons home.
What is your biggest worry? My life story book need to be published.
Is there any unfinish business that you would like to attend too?
Yes doctor I need to make my will in the presence of lawyer.
Are there any financial worries?
Yes I am a retired man and I have spent all my money on world tour.
I am broke financially at the moment.
405
Is there any sleep problem?
(Yes I cannot sleep due to pain)
Is there any severe pain?
(Yes there is severe pain in my whole body and bones)
EXPECTATION
Are there any particular expectations about future care and course of illness?
You have told me that I have about three months as disease has spread to the other
organs.
Is there any carer involved in your care?
Yes Methew is my carer at the moment and he is my nephew in relation.
Do you have other comorbilities for which other specialist doctors are involved?
Yes I have diabetes and heart problem alongwith the stomach cancer.
Is there any carer who communicate and coordinate between the health care
professionals?
Yes Methew communicate and coordinate.
Are you living alone?
(Yes I am living alone)
For the last one month have you felt down depressed and hopeless and low in mood?
(Yes)
Have you lost any significant weight?
(Yes I have lost 7.5kg in three months)
Is your over all activity significantly reduced? (Yes)
Are you breathless at rest? (Yes)
Is there any uncontrolled body pain and bone pains? (Yes)
Is there any severe constipation or nausea or vomiting? (Yes I have severe constipation
and nausea)
Do you need hospice care for your pain symptoms and emotional and spiritual needs at
the end of life? (Yes) also helping hand at home.
Do you want to ensure comfort and quality of life till the end? (Yes)
Does your carer need respite care i.e. short term relief for an evening or leave of several
days and weeks? (Yes he is tired of taking care of me day and night and he deserved a
nice holiday for few days)
INVESTIGATIONS
406
Full blood count (Blood transfusion may provide symptomatic relief for breathlessness
and tiredness due to anaemia)
Urea, Creatinin, Electrolites, eGFR
Liver function test
Xray chest to see evidence of spread of cancer
Abdominal ultrasound and CT / MRI Scans (May reveal intrabdominal spread of
malignancy and spread to bones)
MANAGEMENT
Make sure that you are not malnurished and adequate healthy food is supplied to you.
Be aware of dehydration.
Blueness of lips, tips of finger and toes may indicate need for oxygen therapy.
If alertness is affected and patient is drowsy, it may be due to high dose of pain killer
Opiods, dose opiods may need to be reduced.
As patient is in low mood as evident from the facial expressions, poor eye contact and
tearfulness, he should be provided therapy from the psychologist to boost his mood.
If there are scratch mark suggesting itching due to liver disease. Anti-allergics may be
given.
If under wear and bed clothes are stained which suggest loss of control for stool and urine.
This increases the risk of skin ulcers.
Pressure sore and bed sore should be prevented and treated.
For pain control paracytamol Nsaids and opiods may by given.
For terminal agitation (Benzodiazepine, Haloperidol may be given)
For nausea and vomiting, anti-ematic may be prescribed.
Identify and treat cause of nausea and vomiting like use of opiod, chemo therapy and
gestroesophegeal reflux or anxiety.
For increased secreations and pain tummy hyosine may be prescribed.
Steroids should be avoided. Steroid over used can cause fungal infection, muscle
wasting, bed sores.
Hypnotics may help to sleep at night peacefully and reduced day time fatigue.
Is there anything else you want to ask me today? (No.)
SAFTY NETTING
If your pain is not controlled and you are severely breathless or there any new symptom
or problem, please seek immediate medical help.
IMPORTANT SYMPATHETIC CLOSING
You do not need an appointment. My doors are open for you.
407
You may consult me on telephone anytime.
I will be happy to help you in any way.
__________________________________________________________
Is there any thing else you want to ask me today?
No.
You can come again if you have any quries.
Please take leaflet about stomach cancer from the reception desk.
Thanking you for your cooperation and visit.
Good bye.
408
SEXUAL ABUSE IN A CHILD
SCENARIO
Mother has come to discuss sexual abuse of her 12 years old daughter Miss Noor.
Kindly counsel her.
Hello.
I am Dr. Raheel.
I am Mrs. Martha.
Ok Mrs. Martha what brings you to the surgery today?
_________________________________________
Doctor it is a bit embarrassing but I am very much concerned about the safety, physical and
emotional health of my daughter. When I wash the clothes of my daughter there is vaginal
discharge on her clothes. I am afraid our driver is sexually abusing my daughter. I wonder it
is the punishment of any of my sins. I wonder whether I am a good mother or not.
Mrs. Martha starts crying.
Dr. Raheel offers her tissue and a glass of water placed near by. Dr. Raheel assures her that
it is not her fault. She is a good mother. Certain things are beyond our control.
Is anything else you want to share with me today?
Doctor this is my third visit to you for her recurrent Urinary Infection and vaginal discharge on
clothes. She is only twelve years old, which is very unusual.
____________________________________________________________
Ok Mrs. Martha.
May I know whether Miss Noor is accompanying you today?
Yes doctor she is in the waiting room.
______________________________________________________________
Mrs. Martha this is a serious allegation against your driver.
Has your daughter disclosed this to you that she is being sexually abused herself? (No.)
Doctor she is only 12 years old, she does not understand these things but I have noticed that
she has started playing with hers discarded dolls and toys, her childhood habit of thumb
sucking is back and she is bed wetting like a child.
Ok Mrs. Martha, before I come to the management or examination of your child, I would like
to ask you few questions. Rest assure that whatever we discuss will remain confidential
between you and me and nobody else will know it, is it ok with you?
Yes, you may proceed.
Mrs. Martha, are you real mother of your daughter Noor? (Yes.)
Is there any other male person in the house besides her father? (No.)
If she being bullied at school by some other male students or teachers. (I do not know)
What about your relationship with your husband? (Very happy)
Are you and your husband an alcoholic? (No.)
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Are you or your husband use some recreational drugs? (No.)
Are you facing any financial difficulty these days? (No.)
How many other children you have in the house? (Only one daughter)
I would like to ask few questions about your daughter Miss Noor.
Has she ever been acused of stealing money?
Is the child very tired or hungry all the time?
Is Miss Noor maintaining her hygiene and changing her dirty clothes regularly?
Is your child epileptic predisposing her to multiple injuries by falling?
Has your child ever tried to run away from the home?
CONCERN
May I know why you are consulting me now?
Is there any specific thing you are worried about?
Yes doctor although I am very much concerned and worried about the physical and emotional
health of my child but at the same time I am afraid that the my child may be taken into the
custody of state or police when social services are involved. I do not want to loose my control
and care over her.
_________________________________
Child abuse needs to be reported and further investigated. Miss Noor, both the parents and
the driver will be questioned and we try to reach the truth.
Your driver also has the right to be protected from wrongly being acused.
Formal assessment of child sexual abused will be done by team experienced in the
assessment of child abuse.
Child will be fully undressed for examination, we need to know if there are any suspicious
bruises around her genitalia
Any bruises on her cheek due to slapping.
Has there been any fracture previously?
Any teeth bitting impressions
Any burns suggestive of cigarette burns?
Do older injury coexist with the new ones?
_________________________________
I offer the following basic lab investigations:
1. Full blood count (To exclude thrombocytopenia in case of severe bruising)
2. Clotting screen (Extensive bruising may occur with abnormal blood clotting)
3. X-ray Skeletal Survey (To see past and present fractures suggestive of non accidental
injuries and multiple rib fractures)
4. We need to look inside her eyes by the eye specialist (Retinal Haemorrhages may
result from vigorous shaking or head injury)
_________________________________
I need other health professionals to be present while I examine your child today. If I found
suspicion of sexual abuse I will leave further examination to be done by a paediatrician with
experience in assessment of sexual abuse so that your child does not have to go through
multiple examinations.
Mrs. Martha do you agree that your child may be examine for sexual abuse? (Yes)
Reluctantly I am afraid I have to allow this inorder to save my child from physical, sexual or
emotional abuse. There is a constant ongoing risk of abuse, so I am going to fire my driver
but please put him under investigations even if it involves police or social services.
Mrs. Martha is there anything else to discuss with me today? (No.)
Thank you doctor for helping me.
Thank you for you cooperation and visit.
Good Bye.
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DISCUSS A REPORT
SCENARIO
Mr. William Henry 50 years is visiting surgery for the first time. He wants to
discuss his reports with you. Kindly do management accordingly to the reports of
tests. Proceed.
Please don’t start discussing report right away at this station. The words visiting your
surgery for the first time are very important. It implies that he is not one of your regular known
patients.
In this scenario you are supposed to take full relevant history before you start giving
your opinion about report and its management.
The report may be like this:
GLUCOSE PROFILE
Blood Glucose Fasting 150mg/dL (70-110 mg/dl)
Blood Glucose 2 hrs after meals 375mg/dL (126-140 mg/dl)
HbA1c 9% (Less than 6.5%)
RENAL PROFILE
Serum Creatinin 1.9 (Less than 0.5 to 1)
BUN 90 (Normal rnage 20-40 mg/dL)
eGFR 30 (Normal 30 – 90)
LIPID PROFILE
Triglycerides 250mg/dL (< 150)
Total cholesterol 340 mg/dL (< 200)
HDL 25 (25-35)
LDL 200 (< 100)
Key to this station is:
First look at the report and then take relevant history briefly & do management
accordingly.
Please don’t return the report to patient till management is done. Keep the report in
your hand. It shows that you are interested in patients well being & respect him.
Before we go into the details of these reports may I ask what prompted you to get
these reports done?
He may tell that regular doctor at surgery who prescribed them in his last visit is on
holidays, so he has come to you to discuss these reports.
Are you a known diabetic? (No)
Are you more thirsty than usual? (Yes)
Are you passing urine more frequently? (Yes)
What about your appetite? (My appetite has increased)
What about your weight? (My weight is decreasing despite of eating more)
Any Erectile Dysfunction? (No.) (Ask after ensuring confidentiality)
Any eye sight problem. (Yes I use specticles)
Any heart problem. (No.)
Any history of stroke or paralysis? (No.)
Any indigestion. (No) (Gastroparesis)
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PERSONAL HISTORY
Ask if he has high blood pressure also. What are the readings. During examination
take latest reading of blood pressure in clinic today. Ask what medicines he is taking for his
BP (Atenolol 50mg once a day).
Ask about nature of his job? (I am a school teacher)
How are things at work. (No stress)
How are things at home. (Very peaceful no stress)
Are you Married? (Yes)
Any Kids? (2 kids)
DRUG HISTORY
Are you taking any medicine regularly or from over the counter?
Yes I am taking Metformin 500mg twice a day for my high sugar.
I am also taking atenolol 50mg once a day for my high blood pressure.
FAMILY HISTORY
Is there any family history of:
High blood sugar or Heart Problem? (Yes diabetes and heart problem exist in our
family.
MANAGEMENT
Mr. William Henry from the information you have shared with me today it appears that
you have an uncontrolled high blood sugar as well as high blood pressure. You kidney
function are compromise and your blood fat level are also high.
You are taking Metformin for your high blood sugar but your kidney is not functioning
fully. So I offer you to stop Metformin altogether and refer you to the endocrionology
department for the start of insulin.When any complication of diabetes like you are having
kidney problem, no oral tablets can be taken for high blood sugar and we have to start insulin
injections.
You are taking atenolol for your high blood pressure but this medicine decreases the
low sugar awareness so I offer to change your atenolol with the medicine Ramipril 2.5mg
daily. We will tapper off your atenolol Beta Blocker Medicine over a period of one month.
Your total cholesterol is a bit high. Your bad cholesterol is also high while other type
of blood fat called triglyceride is also high. So I offer you atorvastatin 40mg once a day every
night. I also offer Ezitimide tablet for your high triglycerdes.
FOLLOW UP
I offer a follow up after every one month to see your blood sugar control. We will repeat
your cholesterol and triglycerides levels after every three months. Can you come after one
month for follow up.
Yes it is convenient to me.
SAFETY NETTING
Please comply with your dietry advice and exercise plan as given in the leaflet. Monitor
your blood sugar and blood pressure daily and keep a record. If you have uncontrolled high
blood sugar or high blood pressure you can consult me earlier than one month.
Is there any thing else you want to discussed with me today? (No)
Please take leaflet about diet and exercise from the reception desk. Further
information from the internet. Thank you very much for your cooperation and visit. Good Bye.
_______________________________________
Now you may return the reports to the patient which you had held in your hand uptil
now to show your interest and respect to the patient.
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n-Covid19
SYMPTOMS, INVESTIGATIONS
TREATMENT AND PREVENTION
Hello
I am Serwar.
Ok Mr. Serwar what brings you to the surgery today?
___________________________________________________________
I am here because I am suffering from high grade fever for the last 2 days.
I have taken paracytamol but not much relief.
I also have cough, some breathing difficulty.
I cannot feel the proper taste and my sense of smell is not that good.
Nurse has checked my vitals. They are as follows:
Blood pressure 110/70 Temperature 103oF
Pulse 98 per minute Respiration rate 20 per minute
Oxygen saturation 93%
Anything more you like to add.
No that’s all.
Before I comment on the information you have shared with me and the vitals you have given
me, I would like to ask few more questions.
1. Have you recently travelled?
Yes I have just return from China City Wuhan with my wife.
What about your wife symptoms?
Doctor she is having the same complaints as mine.
Well Mr. Serwar, the information you shared with me, it is most likely that you are having a
condition called Covid-19.
Do you know anything about it?
Oh yes Doctor I heared people die from it.
Am I going to die?
What will happen to my wife and kids?
Well Mr. Serwar its not like that.
I can see you are quite worried and concerned but let me assure you that 97% of the Covid-
19 patients are cured without any serious complication.
I did not know that.
Yes there are good chances that you will be cured.
Real time PCR (Polymerase Chain Reaction) done on a deep nasopharyngeal swab.
CBC
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D-Dimer
X-ray PA view
CT Chest on specialist initiation
Well Doctor, I have already done this deep nasopharyngeal swab test and it is positive
for Covit-19.
MANAGEMENT (LIFE STYLE CHANGES)
Well Mr. Serwar Covid-19 is a highly contageus disease it is spread or transmitted by
breathing or droplet infection.
Please isolate yourself in your home for 14 days.
Your room should have an attached bath room.
Wear mask N-95.
Keep 6 feet distance while talking to people, prefer open places to talk to visitors.
Avoid crowded places.
Meal to be served in the room in disposable utensils and spoon.
If anyone brings the meal or anyother required item both should be wearring gloves
and mask.
Wash the cloths inside the room.
Wash dishes inside the room.
Keep yourself busy with praying, reading, rest, yoga or meditation.
Lie in prone position while sleeping i.e. sleep on your belly.
______________________
1. As you have fever, take paracytamol or Ibuprofin if you feel uncomfortable. Take lots
of rest. Drink of plenty of fluids. Water is the best to avoid dehydration. Drink enough
of water so that your pee is like light yellow color.
2. As you have cough it is best to avoid lying on your back. Lie on your side or sit up right
on your seat. To help ease your cough try having tea spoon of honey. You pharmacist
can help about cough syrup. Try calling or contacting pharmacy online. Please stay at
home. Pharmacy can help with things like medicines at home.
Take steam inhalation.
Herbal tea 4 times a day.
Good light nutritionist food like chicken broast.
I offer you:
Some antiallergic like fenofaxadrine once a day.
Take antibiotic Azithromicine 500mg once daily.
Take some multivitamin containing Zink, Vitamin C and Vitamin D.
At hospital setting Anticoagulation like Rivaroxaban as Blood thinner can be
prescribed.
Injection remdesivir will be given in the form of drip 200mg IV on first day and 100mg
IV for the next 5 days.
Dexamethasone 4mg IV for 5 days.
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Chest physiotherapy can be started.
Try prone positioning that is sleep on your belly or tummy.
Monitor oxygen saturaton with pulse oximeter twice a day.
Monitor temperature with thermometer twice a day.
Monitor blood pressure and keep a record.
If you are FEELING BREATHLESS the following instructions can help you:
Keep your room cool.
Try turning the heating down or opening window.
Do not use fan as it may spread the virus.
Breath slowly in through your nose and breath out through your mouth with your lips
together like you are gently blowing out a candle.
Sit in up right position in a chair.
Relax your shoulder.
Lean a bit forward.
Support yourself by putting your hands on your knees.
Try not to panic if you are feeling breathless. This can make it worse.
Plesse arrange a PULSE OXIMETER at home.
A pulse oximeter is a device that clips on your finger to check the level of oxygen in
your blood.
OXYGEN LEVELS
Low levels of oxygen in your blood can be a sign you’re getting worse.
A pulse oximeter can help you spot this before you feel breathless or have any other
symptoms.
What to do at what oxygen level:
If your oxygen saturation is 95 to 100, stay at home and continue to check your blood
oxygen level regularly.
If your oxygen saturation is 94 to 93, Check your blood oxygen level again within an
hour – if it’s still 94 to 93, call your GP surgery for advice.
If your blood oxygen level is 92 or below check your blood oxygen level again straight
away if its still 92 or below go to A&E immediately.
In hospital setting high flow oxygen through nazal canula upto 6 litre per minute will be
given.
Positive pressure oxygen therapy can also be given.
If difficulty in breathing yourself mechanical ventilator may be needed.
___________________________________________________________
VACCINATION
Vaccination can be given 4 weeks after you have recovered Covit-19 infection.
Globally vaccination has been started.
Vaccination is approved for 18 year and over individuals.
Vaccination consider safe in pregnant females.
Usually required two doses 28 days apart.
Usually well tolerated but receiver can experience fever, fatigue malase, fast heart
beat or anyother symptom.
Vaccine is available with the name of Sinopharm, Sputnik and others.
Is there any thing you like to know today.
You can take information leaflet about Covid-19 from the reception desk.
Good bye.
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AUTISM SPECTRUM DISORDER (ASD)
Hello
I am Mrs. Sabira Shakir.
Ok Mrs. Sabira what brings you to the surgery today?
Doctor I gave birth to a premature baby less than 35 weeks of gestation.
While in pregnancy I was taking sodium velporate for my epilepsy.
Apparently at birth the child was normal.
Child did not do eye contact uptil the age of 3 years.
The child has not developed any speech.
Does not recognized or say Mama Papa.
Child keep rooming about in the room without eye contact and without comprehensive speech
aimlessly.
Mrs. Sabira I would like to ask few questions about your child, if you allow me.
Ok Doctor you may proceed.
Is he unaware of his surroundings. (Yes)
Is he uncomfortable in the presence of unfamiliar person. (No)
Has he difficulty in making friends and understanding relationship. (yes)
Does he respond to facial expressions and gestures. (No)
Does he has a rigid repetitive sterio type of movements. (Yes)
Decrease tolerance of others if somebody enters his personal space.
Plays alone, unaware of socially expected behavour. (Yes)
Apparently he is indifferent to pain temperature and adverse response to specific sounds.
(Yes)
MANAGEMENT
Mrs. Sabira Shakir what information you have shared with me, It is most likely that
your son is having a condition what we call in our medical terminology autism spectrum
disorder.
All the sign symptoms you have described depict the above said problem.
It is very sad that your child is severely disabled and nothing much can be done about
it. There is no cure for it. (Pause)
Oh no doctor Mrs. Sabira Shakir starts crying.
Doctor offers tissue and a sip of water.
Mrs. Sabira it is none of your fault that your child is disabled. Most probably its because
of sodium valproate you are taking during pregnancy and the child was born prematurely.
Other causes could be like:
Genetic Causes like down syndrome
Exposure to rubella rash in pregnancy
Miningitis
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Any birth injury or trauma
These children have learning disability, Attention deficit hyper activity disorder or
problems like anxiety may coexist.
It’s a life long condition requiring substantial support from community services. Most
interventions are behavioural and are delivered in educational setting.
Medication may be used for specific issues e.g. Melatonin for sleep problem.
Mrs. Sabira you will have to be very patient while dealing with your child and providing
support for life long.
I am available and willing to listen to your day to day problems.
If you like you may consult me whenever you need advice.
Is there anything like to share with me today?
No thanks.
You can take leaflet about autism from the reception desk.
Thank you for you cooperation.
Good bye.
417
WITHDRAWAL OF LONG ACTING SEDATIVE
ALPRAZOLAM DEPENDENCE TAPPERING OFF
Hello
I am Dr. Raheel
One of the GPs in this surgery
Shakehand
My Name is Ahmad. 55 years
Mr. Ahmad how can I help you today?
Doc six months back I was under great financial and mental stress and my sleep was
disturbed. So doctor prescribed me Alprazolam 0.5mg at night. I want to give it up
now.
Ok
Doctor I started with 0.5mg one Tab, At night but with the passage of time I had to take
two tablets i.e. 1mg Alprazolam in order to get sleep. I can not function normally if I
don’t take this medicine.
Anything more? (No, that’s all)
Ok so you are having dependence and tolerance to this medicine. Mr. Ahmad. Do you
know what is dependence and tolerance of drug. Do you want me to explain, these
two terms I used.
Yes Doc Please.
Dependence means that you are some sort of addicted to this medicine. Person can
not function normally if does not take that medicine. Some times he develops certain
withdrawal side effects also. If he does not take that medicine.
You got my point.
Yes Doctor.
Tolerance means that you have to increase the dose of medicine in order to have the
same desired effect i.e. sleep in your case. As you said you have to take 2 tab instead
of one tablet to get sleep.
If dose of medicine has to be increased, the effect can become toxic and dangerous
for health.
Do you understand what we have talked so far? Can I proceed further?
Mr. Ahmad I am glad that you have decided to quit this medicine. I will guide you how
to give it up successfully without getting side effects but first if you allow me I would
like to ask you few questions. Can I?
PAST HISTORY
Has there been any similar problem in the past.
Did you have any medical problem in the past like high blood sugar, high blood
pressure or heart problem.
Did you have any psychological problem in the past.
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FAMILY HISTORY
Any major medical problem in the immediate family members?
No.
DRUG HISTORY
Are you taking any other medicine these days prescribed or OTC. Other than
Alprazolan.
Are you allergic to any medicine?
MANAGEMENT
So Mr. Ahmad from the information you have shared with me, it seems that most
probably you have developed dependence and tolerance to Alprazolam and you want
to give it up. There is no Medical or Psychological problem in the past and you are not
using any other medicine currently.
Mr. Ahmad actually Alprazolam is a long acting drug i.e. it remains active in our
circulation of blood for longer time. I will first shift you to another drug then tapper it off
in steps. You are taking one mg Alprazolam at present which is equal to 10mg
Diazepam.
We will start with 10mg Diazepam and decrease the dose by 2 mg every week. In this
way we will tapper off your alprazolam in 5 weeks and then give it up completely.
Have you under stood. How we on going to tapper off the medicine.
Yes Doc.
Have I dealt with your problem properly? (Yes)
Is there anything else you want to discuss today?
No Doc.
You can collect some reading material fom reception desk.
Thank you very much for your cooperation.
Good Bye (Shakehand and Smile)

Do you know withdrawal. Effects of Benzodiazepines i.e. insomnia, irritability,
headache etc.
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PYREXIA OF UNKNOWN ORIGIN (PUO)
Scenario
Mr. Saleem has come to discuss his fever of more than 3 weeks duration. Take history
in detail and manage, kindly proceed.
KNOWLEDGE BASED DATA
– Fever of unknown origin (FUO) is defined as:
– A temperature greater than 38.3oC (101oF) on several occasions.
– More than 3 weeks duration of illness, and
– Failure to reach a diagnosis despite 1 week of inpatient investigation.
INITIAL QUESTIONS
How long have you noticed your fever?
Is there any pattern to it? (Can help in case of Malaria dengue typhoid)
Systemic enquiry
CVS & RESPIRATORY:
Any history of cough, cough with blood or sputum, SOB, chest pain or palpitations.
ABDOMINAL
Have you had problems swallowing food, tummy pain, jaundice, diarrhea, constipation,
mucoid or bloody diarrhea, masses or swelling in the abdomen?
CNS:
Did you sustain any head injuries or have noticed any weaknesses or pins and needles? How
is your eye sight?
Skin and Joints:
Have you noticed any rash on your body or nail beds. Aches and pains in the joints __ if so
which joints, what aggravating and relieving factors, morning stiffness, myalgia, etc.
(Ask specifically for temperature pain, jaw and tongue claudication and visual symptoms if
elderly)
Lymphoma and Leukemia:
Any unusual bruies, noticed glands swelling in the neck, axilla or the groin.
ENT
Toothache, dental history, facial pain of sinusitis, ear pain, repeated sore throats etc.
Past history
Have you been diagnosed with any medical condition in the past? Were you given treatment
for any medical problems in the past? Did you have rhematic fever in the past or have you
got any heart valve disease?
Have you undergone any operations in the past?
Contact history
Have you been in contact with anyone with TB, skin rash, diarrhea or fever.
When and where?
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Travel:
Have you ever lived abroad? Travel to tropics? Exposure to mosuquito, tick or other insect
bites? Did you take appropriate immunization and precautions before travel?
Sexual history
Have you got a regular sexual partner? Have you had any casual sexual partners? If abroad
such as Africa, consider HIV as a distinct possibility. Does it hurt when you wee or have you
noticed any discharge or ulcers in your private parts.
Occupation:
Vets and farmers may be exposed to brucella or other zoonotic diseases.
Drugs:
Prescribed medications, over the counter medications, recreational drugs,
immunosuppressants and corticosteroids, predispose to systemic fungal and viral infections.
ICE
What do you think is the cause of fever?
He may unveil his thigh & say I have an infected wound over thigh which
is the cause of my fever. Ha Ha Ha.
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GALACTORRHEA
What Causes galactorrhea?
Doctors do not always know what causes galactorrhea. The most common cause is a
pituitary tumor, a usually benign (not cancerous) growth on the pituitary gland. Other causes
include:
• Being pregnant
• Taking medications including birth control pills, blood pressure medicine, or

antidepressants like Amytriptalene.
• Over stimulating the breasts (through sexual activity or frequent self-exams)
• Thyroid disorders
• Chronic kidney disease
• Wearing clothing that rubs or scratches the breasts
What are the symptoms of galactorrhea
Milky nipple discharge when a person is not breastfeeding is the main symptom of
galactorrhea. Other signs of the condition may include:
• Amenorrhea (infrequent or stopped menstrual periods)
• Vaginal dryness
• Headache
• Reduced sex drive
• New hair growing on the chest or chin
• Acne
• Erectile dysfunction
INVESTIGATIONS
How is galactorrhea diagnosed?
Doctors usually diagnose galactorrhea with a physical exam and medical history. Your
doctor will ask about your lifestyle and any medicines you take.
If needed, two tests can confirm diagnoasis:
• Blood tests tell doctors if the levels of prolactin (milk-producing hormone) in the body
are abnormally high.
• Imaging tests called CT and MRI scans anable doctors to look for a tumor in or near
the pituitary gland.
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Underlying cause Possible treatment
Medication use Stop taking medication, change dose or
switch to another medication. Make
medication changes only if your doctor says
it’s ok to do so.
Underactive thyroid gland (Hypothyroidism) Take a medication, such as levothroxine to
counter insufficient hormone production by
your thyroid gland.
Pituitary tumor (prolactinoma) Use a medication to shrink the tumor or have
surgery to remove it.
Unknown cause Try a medication, such as bromocriptine
(Cycloset, Pariodel) or cabergoline, to lower
your prolactin level and minimize or stop
milky nipple discharge. Side effects of these
medications commonly include nausea,
dizziness and headaches.
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ANGRY OR DIFFICULT PATIENT
What is anger?
It is an intense emotion
Things which have a meaning for the person precipitates anger
Angry Patient
The patient may not be ready to move toward the medical problem until his grief is
adressed.
Anger about clinic staff
It is important to address these issues because they can interfer with your
effectiveness as a clinician if you do not effectively manage the situation.
Key
Remaining:
1. Be cool & calm Avoid saying yes or no
2. Attentive Start your sentence with words like
3. Empathetic look there is a system you have the
4. Professional right to complaint.
Listening to angry patient
Careful listening is a part of defusing the patient’s anger.
It also involves other skills such as repetitions, summaries, and empathetic
statements.
Step 1
• Express empathy for the patient and acknowledge the emotion.
“You seem upset about something, can you tell me. Tell me more about it in detail?
“Is every thing OK, you look upset”
• Acknowledge the difficulty / problem
“having to wait for 45 minutes is really a long time”
Step 2
Stay curious about the patient’s story
“Tell me about what is upsetting you”
Find out the specifics of the story-encourage the patient to give the details.
“Tell me what has actually happened”
“Tell me more about what the receptionist said to you”
Step 3
• Take an action on the patient’s behalf if possible. Be an advocate.
“I will see what cause the delay and will try to avoid it in future”
• When possible, link the patient with the resources that can help
“You have all the rights to complaint. Our Medical Director is the right person to talk
to”
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Step 4
• Transition to purpose for the visit
“Now tell me what can I do for you today” Now will you please tell me what brings you
to surgery today.
Arguing with patient
Arguing or expressing our opinions before letting patients finish their stories may
augment their anger.
Judgmental statements
• Judgmental statements are not helpful such as
“Sounds like the other doctor missed your diagnosis”
“the receptionist is stupid”
Patient may insist to fire the reception immediately.
Tell him we will investigate properly.
I am is not the only doctor in surgery.
If receptionist is found guilty, I assure you proper action will be taken.
SCENARIO
Mr. Irfan Queshi enters doctor’s room and demands to fire his receptionist
immediately. Kindly deal with such angry patient. Proceed.
Hello, Mr. Qureshi how can I help you today?
Doctor your receptionist made me wait for 45 minutes, please fire this receptionist
immediately.
Doctor remains cool and calm and acknowledges the anger by receptionist made him wait
for 45 minutes.
Mr. Quresthi you seem to be quite upset. May I know what actually happened?
Tell me a little detail.
Doctor I took an appointment yesterday myself and your receptionist forgot to enter my name
in your diary.
Ok Mr. Qureshi then what happened tell me in a little more detail.
Doctor when I reached here at my appointment time, she said I did not took any appointment.
In when I made her recall my phone call made yesterday, she remembered but still she make
me wait for 45 minutes.
Ok Mr. Qureshi having to wait for 45 minutes is quite a long time. I will look into the cause,
what caused the delay and will try to avoid in future.
No doctor I will not sit in my chair until you fire your receptionist.
Look Mrs. Samantha you have the right to complaint anything, but there is a system of the
surgery. I am not the only doctor in this surgery; our Medical Director is the right person to
talk to.
Doctor I do not know, you just fire your receptionist now.
Mrs. Samantha I will look what cause to the delay.
If the receptionist is found to be guilty or rude after the investigation I assure you proper
action will be taken.
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Ok doctor I understand now.
Ok Mrs. Samantha tell me what brought you to the surgery today.
Oh doctor I have cold, my nose is running, my eyes are watery and I have sneezing as well.
Ok Mrs. Samantha I offer you an anti-allergic by the name of loratadine. It is a non sedative
anti-allergy.
You can work while having this tablet.
I also offer you Vitamin C tablet. You can take vitamin C by taking lots of lemon and oranges.
Is there anything else you want to discuss with me today.
No doctor you solved my problem.
Don’t forget to investigate your receptionist fault and fire her if she is found guilty.
I assure you that proper action will be taken.
Good bye.
__________________________
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TIPS TO DEAL WITH
CONFIDENTIALITY AND ETHICAL ISSUES
5 RULES OF ETHICAL ISSUES

• Autonomy
• Confidentiality
• Do no harm
• Do good
• Justice
While dealing with the ethical issues please keep in mind above mentioned 5
rules. Always respect patient autonomy. Try to keep his confidentiality as for as
possible. Doctors and nurses are life savers. We do not intend to do any harm to
any of our patient that is why uthenesia death is against the law and punishable.
Uthensia happens when a nurse assist or enhance the death of a patient who is
an extreme pain and in misery out of her sympathy and empathy to the patient.
Doctors are always suppose to do good to their patients.
Doctors always try to do justice if a doctor writes state of the art expensive
medicines to a poor patient he will no do the justice as the patient won’t be able
to comply.
Similarly if a 80 years old man is put on ventilator for the last many weeks and
a young patient needing ventilator arrives in emergency and there is only one
ventilator. In such circumstances it may be justified if the ventilator facility is
denied to the old man and given to a young person.
RULE
Doctor should not disclose any personal information which he/she has
learnt during the course of his/her professional duties, unless the patient gives
permission.
PRINCIPLES
When patients give consent, make sure that they understand what will be
disclosed, the reason for disclosure and the likely consequences.
Release only as much information as is necessary for the purpose.
EXCEPTIONS
Necessary sharing of information with other persons concerned with the
clinical care of the patient.
Colleagues
Receptionist
Dietician
Protecting privacy of individual and preserving confidentiality of their health
record is essential for preservation of trust between patient and doctor.
The key to this station is not to break patient confidentiality, no matter what
the relative or patient says. No compromise on ethical issue. Keep privacy of
patient.
Patient may beg.
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Patient may threaten to severe his lifelong relations with the doctor.
Patient may try to bribe for wrong certificate.
Patient may offer you keys to a new car don’t accept.
Be strictly professional.
Never heed to patient’s tactics.
Do not compromise on ethical issues but do show sympathy and empathy for
human emotions.
Don’t be rude.
Don’t threat.
Try to maintain relationship with patient.
Doctors are bound by medical ethics not to disclose patient report without
patient’s consent.
You could loose your medial license for any unethical conduct you commit.
Failure to comply with standards can lead to disciplinary proceedings.
While dealing with confidentiality and ethical issues in a station keep the
following guidelines in mind while discussing with a patient.
SPECIAL CIRCUMSTANCES
Children
Disclosure can be authorized by a person with parental responsibility.
Young people mature enough to understand implications can make their own
decisions and have a right to refuse parental excess to their health record.
(Adolescence not adult 16 year girl asking for contraception and asks do not tell
my parents.)
MENTALLY INCAPACITATED ADULTS
Capacity must be judged in relation to the decision to be made. People with
a mental disability can authorized or prohibit sharing of information if they broadly
understand its implications.
THE DICEASED
Legislation covering records permits limited disclosure in order to satisfy a
claim arising from death. Where there is no claim, there is no legal right of access
to information.
SITUATION WHERE BREACH OF CONFIDENTIALITY MAY BE JUSTIFIED
Breach confidentiality only in exceptional cases and with a appropriate
justification.
This includes discussing a patient with another health professional not
currently involved with patient care. Wider disclosure to people loosely attached
with care require patient consent.
In emergencies where it is necessary to prevent eminent threat to life or
health of individual concerned or another person, confidentiality can be breach
(unless previously forbidden by the person).
INFORMATION REQUIRED BY DUE LEGAL PROCESS
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Confidentiality can be breached if required by the court or tribunal.
Understand and comply with the law.
Ask under which legislation it is sought. Check the legislation before
disclosing if unsure.
Statute requiring certain information to be given to a particular body e.g.
Hospital Management.
Order made by a court of law e.g. homicide, suicide. Refusal by the doctor
may be regarded as contempt of court.
Confidentiality can be breached in public interest e.g. danger of spread of
infection.
MENTAL CAPAICTY
If a person lack the ability to understand, decision must be based on an
evaluation of person’s best interest and reflect the individual expressed wishes
and values. A third party appointed by court may authorized disclosure.
DISCLOSUE IN PATIENT INTEREST
Patient is incapable of giving consent.
If the patient is the victim of neglect/physical sexual abuse
If it is considered undesirable for a patient to be told the full implication of
his condition a relative can be given the relevant information e.g. For home care
after amputation.
DISCLOSURE IN THE INTEREST OF SOCIETY
If patient reveals that he has committed or is about to commit a grave crime.
If police ask for access to personal medical information.
____________________
ETHICAL ISSUES IN BRIEF
Summarize what he has said
Ask his Idea Concern and Expectation.
Address his concern he will be satisfied
Ask why he wants unethical issue done.
In the end give a little sermon as
As a doctor I cannot do anything unethical.
There are legal aspect to it.
It can only give bad reputation to the doctor.
I can loose my license to practice
Mr. Tariq you are a good friend of mine.
And I would like to keep good relations as in the past. If you continued to
make unethical demands it creates a bad image of yours.
Don’t agree to unethical demands any way.
You will fail.
Don’t refuse straight away
Find out the why and his concern
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Solve his problem without agreeing to do unethical things
Don’t accept bribes or gifts.
Doctor can accept a gift upto 100 pounds in UK.
FEW EXAMPLES
(1) 16 YEAR GIRL ASKING FOR CONTRACEPTION

Doctor is supposed to keep the confidentiality of his patients as requested.
A 16 year old girl who is not an adult ask for contraception and demands that her
sexual activity be kept secret from her parental access.
Doctor will explain the girl that the child producing organs are not mature
enough to bear the stress of pregnancy at her age so it is better to delay sexual
intercourse until older. But if patient insist that she will continue her sexual activity
even it means getting accidently pregnant or contracting sexually transmitted
diseases.
Now it is the duty of the doctor to respect the autonomy of the patient and
promise to maintain confidentiality from her parent and provide her contraception
in the form of condom and practice safe sex. This will save her from getting
pregnant or contracting sexually transmitted diseases. Intra-utrine system can be
fitted in a nully parous woman as a long term contraception. There is no
compliance required once fitted.
The 16 year girls should also be told about the option of morning after pill
to prevent unwanted pregnancy.
In this scenario the ethical principles of autonomy confidentiality do no
harm do good are applied.
(2) EMERGENCY CONTRACEPTION

If a woman is likely to get pregnant due to unsafe sex in fertile period of
her menstruation.
Doctor should ask her whether she has told her husband and parents about
her decision of emergency contraception. She should also be asked if she is
aware of impact of emergency contraception on her work, home, physical and
psychological health.
Doctor should ensure that she is not asking for emergency contraception
just because of financial issues or some relationship problem.
She should be told about the option of donating her baby to the issueless
couples but if she is determined to have emergency contraception doctor will
respect the autonomy and provide emergency contraception.
In his scenario the ethical rules of autonomy confidentiality and do no harm
are applied.
(3) A PATIENT OF AZOSPERMIA MAKING

AN UNETHICAL DEMANDS
A patient of Azospermia asked doctor to tell her parents that he has
sufficient sperms to produce a child in due course of time and he is willing to bribe
him with the keys of a new latest model car or some hefty money.
In such unethical demands, doctor should tell the patient that he cannot tell
a lie to his parents. It will be unethical on his part. He may loose his medical
practicing license as he is bound by the hippocrate oath not to malpractice.
Doctor should not be rude with the patient instead he should by
sympathetic and empathetic and find a solution other than unethical demands like
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adoption of a child or latest invitro fertilization methods with which he might be
able to produce a child.
In this scenario the ethical rule of confidentiality and justice are applied.
(4) BREAKING BAD NEWS

If a son demands to be told about the results of report of her mother who
is having some cancer. Doctor is bound to keep the confidentiality of the woman
and refuse to the son to tell the contents of the reports, unless allowed by the
mother.
Doctor should respect the autonomy of patient and maintain her
confidentiality.
In this scenario the ethical rules of autonomy confidentiality and justice are
applied.
(5) HOMOCIDAL PATIENT

If a patient confides with the doctor about his intentions to kill somebody.
Doctor is not bound to keep this thing secret. Doctor should breach the
confidentiality and tell the intentions of the patient to the concerned authorities or
police to save the life of the person.
In this scenario ethical rule of justice is applied. Although the doctor is not
maintaining the confidentiality of the killer but he will be doing justice to the
community and likely victim.
(6) ASKED BY THE COURT OF LAW.

If a court asks about the medical record of a person doctor should breach
the confidentiality and give access to the medical record of the patient to the court
of law. He at the most doctor can demand under what legislation court is asking
him to breach the confidentiality.
If doctor does not comply with the order of the court of law with he can be
charge with contempt of court.
In this scenario the rule of confidentiality is breach but respect and justice
to the court is done.
(7) MENTALLY INCAPABLE CHILD

If a child is not mature enough or suffers from mental retardation and does
not understand the implication of his disease then parents should be asked about
the permission how to treat the child and breach the confidentiality of a child who
is unable to take a decision in his own best interest.
In this scenario doctor is trying the save the life of a person and he is
justified in doing so in the above mentioned circumstances.
(8) FOR RESEARCH PURPOSES

Do not use patient’s identifiable information unless it is absolutely
necessary.
It is not necessary to seek consent to use anonymous information.
Health information used for secondary purposes (e.g. planning, teaching,
audit) should whenever possible, be anonymous.
Use minimum necessary patient identifiable information.
Access to patient’s identifiable information should be on a strict “need to
know” basis.
In this scenario patient identifiable information is not used for research
purpose. So the doctor is practicing ethical rule of confidentiality.
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(9) JUSTIFY THE PURPOSE
Patient may voluntarily agree to identifiable information about themselves
being released to specific individual for known purposes.
Implied consent occurs when a patient is aware that their personal information
may be shared and of their right to refuse, but make no objection. Patient must
have had a realistic opportunity to refuse. If patient refuses, it should be clearly
documented and respected.
(10) CLAIM ARISING FROM DEATH
Legislation covering records permits limited disclosure in order to satisfy a
claim arising from death. Where there is no claim there is no legal rights of access
to the information.
Here the ethical rule of confidentiality is applied.
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TIPS TO DEAL WITH
SUICIDAL PATIENT
First thing to do with a patient who clearly state his intent to commit suicide is assess
the patient professionally his mental history and psychiatric assessment.
Ask the patient if he is hopeless. Hopelessness is a good predictor of subsequent and
immediate risk of suicide.
A young Schizophrenic patient who sees his ambitions being restricted due to disease.
He remains behind his colleagues who excel in their field.
Ask the patient if he thinks he has a bright future.
Patient who has shown his intents to kill himself. Ask him if he has made any plans to
kill himself.
Ask him if he has bought any weapon and does he know how to handle it.
Ask him if he has made any notes for his loved ones.
Ask him about his mood. For the last one month has he felt down depressed and
hopeless.
Ask him if for the last one month he has lost pleasure in the things he use to enjoy like
watching TV or reading a book.
Ask him if have made any arrangements for his financial affairs to be taken care of
after his death?
Does he want to kill himself just to hurt somebody who has hurt him.
Patient who has been discharged from psychiatric hospital recently is at risk of
committing suicide.
Patient who indulges in alcohol drinking excessively or is using illicit drugs is at risk of
committing suicide.
Patient who is living alone. Lack the support of his relatives, friend and is un known in
his neighborhood is likely to commit suicide.
MANAGEMENT
After proper psychiatric assessment by a psychiatrist or psychologist and evaluation of
risk factors he should be immediately admitted in psychiatric hospital for the treatment.
Usually patient somehow wants to live and agrees to get himself admitted but if the
mental patient does not have insight and refuses to get him admitted. He should be admitted
under compulsory mental health act.
Ensure patient physical safety and assess the risk of further self-harm. Suicidal risk is
not static it can change any time in any direction i.e., Impulsive attempted suicide or
postponement of idea of suicide temporarily or for good which was running in patient’s mind
for the last few weeks or months.
Physical self-injury involves cutting of wrist, burning of body with kerosene or petrol or
taking of an over dose of paracytamol or tricyclic anti-depressants or benzodiazepine
sedatives and pain killer opiates.
Suspected overdose of drugs will usually require urgent action.
Doctor should ensure your own personal safety during assessment.
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TIPS TO DEAL WITH
HOMICIDAL PATIENT
Many a times it happens during psychotherapy with psychiatrist and psychologist that
mental patient confides with his doctor that he intends to harm or kill or break the legs of
some person against whom he has grievances.
During the investigation by the police it comes out that somebody else has harmed,
kill or break the legs of that obnoxious person and the patient is blamed for that act.
Sometimes the patient who has threatened to harm, kill or break the legs of the person
actually does it.
1. It is the duty of doctor who is a psychiatrist to keep patient secret intent confidential. But now
due to the above mentioned example of homicidal harm it is now a law which permits the
doctor not keep patient’s secret confidential, rather inform the police or the authorities to save
the life of other person and detain the mental patient for psychiatric assessment and
investigation.
2. A woman after giving birth to a baby girl may want to kill herself and take life of her baby.
She does it because of lack of support.
Husband is a business man and remains on his tours outside the city most of the time.
Woman is breast feeding on demand of the baby but she cannot deal with the demand of
breast feeding and cannot takes adequate sleep due to lack of support. There are no other
relatives, close friend or familiar neighbor who could help the lady in such difficult time.
Woman has become suicidal and homicidal for the baby just because of lack of the support.
All is needed that husband take leave from his business or job for two or three weeks and
help her wife complete the chores of the house whenever find sometimes to rest and sleep
herself when the baby is asleep. Mother or mother in law or some married elder sisters can
be made available to the lady (Who has become suicidal and homicidal for the baby because
of lack of support). In such circumstances close friend and good neighbor can give some
time from her time to helper friend and neighbor.
If a woman who has given birth to a baby girl or a boy and has to become suicidal and
homicidal she should be immediately shifted to mother baby care unit where both of them
will be supervised 24 hours.
Woman is given some psychotherapy in order to change the way she think, feels and act.
She should be told that in such time of distress and due to lack of support she has become
suicidal. Her life is important and we are detaining you because you are in a state mind where
you cannot think clearly. Once this phase is over, you would not like to kill yourself.
Similarly you have become homicidal for your baby. You baby is also an asset to the
government of UK and you are being detained and supervise till your feelings goes away.
You yourself will not like to harm yourself or your baby once you become aware of your
mental condition due to cognitive behavior therapy.
MORAL
If a patient confides with his doctor about his sexually transmitted disease or a 16 year
girl tells his family doctor the she is sexually active while she is not adult and wants family
doctor not to tell his parents, it is supposed to be the ethical duty of doctor to keep the
confidentiality of patient.
In case mother is having cancer and son wants to know what is written in report, doctor
will keep the confidentiality of the lady and will refused to tell even his son the report of her
mother.
Doctor does not have to follow confidentiality. If the mental patient has become
homicidal. Rather it is the duty of doctor to inform the police or the concerned authorities in
order to save the life.
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TIPS TO DEAL WITH
PATIENT REFUSING ADMISSION
A patient of heart attack (suffering acute myocardial infarction) may refuse admission
in emergency.
Tell him.
I am a little concerned about your condition. I am worried it could be something
serious like heart attack.
1. I am offering you admission in hospital. It will be a wise decision on your part if you agree.
2. If I was in your position, I would have admitted myself.
3. If you were my brother, I would have given you the same advice.
4. Mr. Irfan it is my considered opinion as your family physician that you should get yourself
admitted in cardiology in emergency in order to save your life. Doctor need to be a little
assertive.
5. Life is more important than any other work. If life is there anything can be done later.
Look if you have life you can earn double the triple amount of money which you earn
from the present deal you are going to miss.
Or you can visit your granddaughter after you have recovered.
Respect patient autonomy. Doctor cannot force admission but do not abandon him.
Tell him few things to do in emergency including taking of some medicines & certain
preventive precautions like dispersible aspirin, do not climb stairs avoid unnecessary exertion
and then leave the rest to him/her.
_________________________________
CASE 2
A patient of puerperal psychosis may refuse admission.

Tell her:
“I offer you immediate admission in mother baby care unit.
We do not want you to harm yourself or that of your baby.
You yourself will not like to harm yourself, once your mental condition improves and
certainly your baby is an important asset to your family & country. Its safety is as important
to us as it is to you.
I offer you admission in hospital in mother baby care psychiatric unit for safety of you
and your baby.
There both of you will be supervise for 24 hours. Do you agree to be admitted?
Yes.
Patient willingness to get himself admitted is the success of doctor convincing
power.
(In case of yes do the closing as usual)
If no then tell her:

“I will have to use my powers according to compulsory mental health act to admit you
in psychiatric unit. I am compelled to call crisis team. I will be obliged if you cooperate.
Doctor can detain a person who have mental disease or is having psychotic delusion
by using compulsory mental act. But patient can still refuse the investigations and treatment
offered while being detained.
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ESSENTIAL PRESCRIPTION INGREDIENTS
Every prescription should have the following contents:
Name Age Date
Sex Weight
History (Main features) Examination (+ve –ve findings)
• •
• •
• •
Diagnosis
Rx
1. Drug Brand Name & Generic Name
Write clearly brand name of the drug and the generic name in the brackets because
certain drugs are similar in spelling. Patient may get wrong drug from the pharmacy.
Write only generic name, if asked to write prescription in exam
Write specific and symptomatic drugs e.g. Antibiotic for Pneomonia is specific
medicine and Paracytamol for fever and cough syrup is a symptomatic treatment.
2. FORM OF DRUG
Write Whether Drug Is In The Form Of Capsule, Tablet, Syrup Or Injection
3. STRENGTH OF THE DRUG
Write the strength of the drug such as 5mg, 10mg, 40mg or 80mg.
4. FREQUENCY OF MEDICATION
Write the frequency of medication such as once, twice, thrice daily.
5. ROOT OF ADMINISTRATION
Do not forget to mention root of administration e.g. By mouth, Sublingual or by
injection.
6. DURATION OF TREATMENT
Always specify duration of treatment e.g. Antibiotic for 7 to 10 days
7. RELATION TO FOOD
Relation with food should be mentioned such as ATT should be taken in fasting, before
breakfast.
8. INVESTIGATION ADVISED
Write down the non-invasive Investigations first & then invasive investigations late as
appropriate.
9. PREVENTION
Prevention is better then cure. Always mention non-pharmacological precautions to
alleviate patient’s problem.
10. FOLLOW UP
Give precise follow up period with date and time written on prescriptions.
Signature of the Doctor
Stamp of the Clinic
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MODEL PRESCRIPTION
Name: Mr. Saleem Akhtar Age: 55 years Date Jan. 15,

2011
Sex: Male Weight: 60kg
History: Poly Dypsia Examination findings:
Poly Urea Dry tongue
Poly Phagia Signs of dehydration +ve
Weight loss Cachexia
DIAGNOSIS
TYPE 2 DIABETES MELLITUS
Rx
1. Glucophage (Metformin)
• Tablet 850mg
• Thrice a day
• After the meals by mouth
2. Amaryl (Glymepiride)
• Tablet 2mg
• Once a day in the morning
• Half hour before breakfast by mouth
3. Piozer (Pioglitazone)
• Tablet 15mg
• Once a day
• With meals by mouth
INVESTIGATIONS ADVISED PREVENTION & PRECAUTIONS
Blood glucose fasting Adher to dietry plan as advised
Blood glucose 2 hrs after meals Do brisk walk 30/d for 5d/w regularly
HbA1C Take medicines as advised
Complete Lipid Profile Do Self monitoring of blood sugar
Serum Creatinin
Blood urea
FOLLOW UP
Review after one month i.e. Feb. 15th 2011 at 6:00p.m.
Signature of the Doctor
Stamp of the Clinic
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CREATE YOUR OWN QUESTIONS
WHICH CAN BE USED IN ALL 14 OSCE STATIONS
Read From
Dr. Raheel BOOK
AN INTRODUCTION TO MRCGP[INT] UK
PAGE ?????
438
TIPS IN RESPONSE TO RCGP FEEDBACK
1. RAPPORT
CANDIDATES FAILED TO BUILD A RAPPO WITH PATIENT
Hello (Say gently, politely with a smile)
Introduce yourself. I am Dr. Raheel one of the family physician in this surgery.
May I know your good name please? (Please do not ask age in this stage of opening
consultation. Please delete erase or cut age in opening consultation in all the articles of notes)
When you enter the OSCE Station greet both the examiner and patient as if you
were the incharge of the station. Have your seat near the patient and sit confidently and adjust
your position. Don’t look at the examiner, look at patient. When examine the patient do not
explain the findings to examiner, he/she is observing you. Always show respect to patient.
Always show empathy when the patient tells you something sad or about his suffering.
Do not forget to carry your email, role number card, original ID card or valid passport.
Please be punctual. Try to reach examination Centre well before the examination time
i.e. at least one hour before the exam time.
You might be caring your expensive mobile phone with you. You are not allowed to
carry your mobile phone in the examination hall. Your mobile phone will be taken away from
you and ticket number will be issued to you. Same ticket number will be pasted over the
plastic envelope in which your mobile will be saved. Keep the ticket number saved in your
pocket till the end of exam when you can receive your mobile back by showing ticket number.
Drink less amount of water before the exam. If you have the urged to pass urine during
the exam, use rest station time for that. This time you will be accompanied by the chaperon
till the wash room.
Keep your new clean matching dress ironed and shoes ready before the exam. You
should look like a professional.
Traditional country dress can be worn, but a tie and a suit would more appropriate.
A white Coat with name plate of the doctor can be added to the dress.
You can be successful. Keep your confidence high.
If you did not perform well at one station do not worry, complain or brood about that
station. Do not let your bad performance at one station affect your next station performance.
If you are a male Muslim & don’t want to shake hand with female SP, then decided
once for all whether you will shake hand with female SP or not.
This decision should be made during practice with your study partner, well before
entering the examination hall.
Just nod with your bent head or Bow like Chinese & Japanese citizens to show your
respect to SP. Female SP will withdraw her hand at once.
Just before entering the station, while standing outside the station reading scenario,
check, note and memorize time from your wrist watch. Again look at your wrist watch quickly
during consultation when you have reached the end of history taking i.e. Idea, concern and
expectation. This checking of time twice will help you complete the case in time. Be aware
and remember checking the time during consultation is a bad manner as if the doctor is in
hurry and examiner would give negative marks.
Throughout the consultation, you should never have rude attitude towards patient.
Always show respect toward patient and show empathy where appropriate.
Never be judgmental and do not use inappropriate remarks.
Your whole consultation should be according to evidence based medicine.
PHASES OF CONSULTATION
Fraser has very nicely described three phases of consultation i.e.,
439
The beginning,
The middle
And the end of consultation
These three phases of consultation need different ‘sets’ of communication skills. Learning
these three phases of consultation helps in keeping sequence and flow of consultation. This
sequence of three phases of consultation also helps in group practice for MRCGP [INT]
OSCE.
Beginning a consultation
BUILDING RAPPORT
You should always try to build a friendly rapport with the patients by giving him/her a
brief respectful smile. When you are greeting the patient with “hello”, “good morning” or
Asalam-o-alaikum”, there should be smile on your face.
If the name of patient is written outside the OSCE station, remember it and upon entering
the OSCE station, greet the patient by his/her name or surname. For example “Asalam-o-
alaikum Mr. Saleem” or “Good morning Mr. Qureshi”, both are good sentences. Then tell your
name in very simple words e.g., my name is Dr. Farah. There is no need to speak
unnecessary sentences like “I am your doctor today” or “I am one of the doctors in the
surgery”. These sentences are suitable in the UK context, while our exam is MRCGP [INT]
South Asia. Simple sentences work well.
Try to keep your voice loud and clear so that both the examiner and patient understand what
you are saying.
OPENING THE CONSULTATION with open ended question or invitation.
After building rapport ask the patient to tell his story by asking an open ended question or
invitation. For example:
“Mr. Saleem, how can I help you?”
“Mr. Saleem what can I do for you?”
“Mr. Saleem please tells me all about your
Problem?”
“Mr. Saleem, what brings you today?”
Once you ask the patient to tell his story, give him about one minute to tell in his own word,
in his own style and in his own sequence. This golden one minute has two benefits i.e., it
gives the focus of the case and also tells you what is affecting the patient the most. These
are the main clues for further questioning. Do not be afraid that patient will not stop and keep
talking for entire 10 minutes. This never happens, instead most patients stop talking before
completion of one minutes. This step is called facilitation.
Do not ask questions during the initial golden one minute.
When the patient completes this initial narrative, then simply ask “anything else” just to
make sure that you are not missing anything.
After patient has given his presenting complaints add one sentence to build rappor
i.e. I will try to the best of my abilities to help and guide you about the problem you have told
me.
2. DATA GATHERING
CANDIDATES ASKED TOO MANY UNNECESSARY QUESTIONS
Listen actively to the patient which means not only be content of problem but the feeling and
distress as well patient is having.
Be inquisitive. Explore like a detective what’s wrong with the patient.
Either explores the symptoms described in presenting complaint like all questions about pain
or motion and then asked few more questions open endedly in a patient oriented manner.
Do ask 3 to 5 differential diagnoses questions.
Also there has been an objection that candidates do not asked red flags.
You should be able to make your working diagnosis in the first one minute.
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Please avoid asking unnecessary detailed questions while in data gathering.
Ask few questions till your working diagnosis is made save time for initial 4 minutes of data
gathering to 3 minutes.
Use this time to give life style changes in a fast ratta fashion and do not forget to ask if he
can comply with these changes or is it ok with him.
Then ask past, personal, family, drug and travel history
Then comes the illness and ICE.
You should not have the need to ask 4 questions about illness and ICE separately.
Deduce or conclude illness and ICE of patient during data gathering.
At the end of data gathering summarize to show doctors understanding of patients problem.
Briefly sum up the most important things in history.
Not necessarily in the end. Can be done any time.
It signals your understanding of patients illness
It may bring up missing aspects
Tell briefly only positive finding in the history pointing towards your working diagnosis.
Incorporate illness and concern and expectation while summarizing.
Also do not forget to ask the patient if he has anything else to add.
EXAMINATION
Now is the turn of examination and investigations.
At the start of examination tell the patient why you need to examine him.
i.e. in order to reach my diagnosis I need to examine you. Can I examine you.
First take the permission.
Do minimum exposure for example instead of asking would you please remove your shirt.
Ask him to lift his shirt upto the chest for the examination of tummy.
Or open the buttons of his shirt so as to expose the neck.
Do not cause pain to the patient.
Take care of comfort of patient.
Leave the active examination all together, if it causes pain to the patient.
Ask the patient to do movement passively himself.
Use correct technique of examination. First explain. What you are going to do before touching
the patient e.g. I will be pressing at your tummy at a certain point you have to tell me whether
you feel more pain on pressing the tummy or on sudden release of the hand.
First explain and then do the rebound tenderness test at Macburney point.
You have only two minutes for the examination.
Do not forget to cover the patient at the end of the examination.
Thank the patient before moving on to investigation.
Ask SP or examiner in air, May I know the examination findings? (As the patient was a healthy
actor)
INVESTIGATIONS
THERE HAS BEEN AN OBJECTION THAT CANDIDATES OVER INVESTIGATE
Before offering investigation you must tell the why or reason for investigation e.g. in order to
confirm my diagnosis I offer you the following test.
Do not offer all the 10 to 20 investigations given in oxford.
Give only few investigations which point towards your diagnosis e.g. in case of typhoid offer
only blood culture in first week and ultrasound abdomen for spleeno magally.
In coeliac disease only offer tissue transglutaminaze IgA antibody and endomycial anti body
test.
441
Please do not over investigate.
After offering investigations again ask in the air to the SP or examiner.
May I know the result of investigations if any report are already done.
You should be aware of why you are referring someone so that you can
mention this in your referral letter.
• Where
• Whom
• When
• Why
• Referral letter
• Preparation for referral
If a patient suffers from heart attack, you will refer the patient to emergency or
cardiology department. If a patient suffers from stroke, you will refer him to
neurology department.
Whenever a family physician feels that the patient is not improving with his
medicine he has given or there is doubt about diagnosis, specialist opinion can be
sort and patient can be referred to proper department.
You should know where to refer e.g.
Gastroenterologist or general surgery
Neurologist or Neurosurgeon
Nephrologist or Urologist
Orthopedic or Rheumatologist
(1) Referral in Life Threatening Situation

You should also know when to refer life threatening situation. Refer immediately
with some life saving measures e.g., in MI put IV line, give oxygen, Aspirin, nitrates,
analgesic before referring.
For example putting a large bore cannula in 2 nd intercostal space in tension
pneumothorax.
For example putting IV line and giving Isotonic fluids in severe dehydration.
For example giving adrenaline steroid, anti-allergy, fluids, before referral in
Anaphylactic shock.
(2) In Urgent but not Life Threatening Situation

Refer within 24 hours e.g., acute appendicitis, acute cholecystitis, septic arthritis
etc.
(3) In Non-Urgent not Life Threatening Situations

Like Rheumatoid Arthritis, control of diabetes or hypertension epilepsy control refer within 2 weeks.
SECOND SUMMARIZATION
After examination and investigation again summarize to show doctors understanding of the
problem.
In lay man’s language. Do not use any medical jargon.
During this second summarization add the findings of examination and investigation results
as well.
During this summarization incorporate reassurance for minor problem or explanation in
serious problem.
Reassurance or explanation before life style and pharma management is necessary.
LAST TWO MINUTES
442
By now last two minutes are left do safety netting properly, give follow up and five closing
sentences.
Practice to finish consultation in 9 minutes while studying with studying partner instead of 10
minutes.
If you think there is not enough time to tell 5-6 life style changes, you can offer leaflet about
the life style changes from the reception desk.
PSYCHO SOCIAL IMPACT
Management not only include life style changes and pharmacological management but
psycho social impact of that condition on the patient’s life.
For example in Acne, Psoriasis and Vitiligo patient become shy, become socially isolated and
may have symptoms of low mood.
Also in case of lung cancer or stroke patient may cry on breaking the bad news, deal it
promptly by offering tissue or a glass of water.
May be a tap on the shoulder is required.
The non-verbal clues must be noticed and promptly responded.
Please deal with the social impact adequately with sympathy and empathy, using few
sensitive sentences for better communication of the feelings.
CLOSING
In the end do not forget to thank the patient for his cooperation and visit.
Before closing, ask is there anything else he wants to share or ask even if it is the last 9 th
minutes.
In case of breaking bad news say few extra sentences e.g.
In a case of cancer breaking bad news tell the patient that he does not need an appointment.
He does not have to ask all the questions now. He can come again if he has any queries.
You will be more than happy to help and guide him to the best of your ability.
Offer leaflet about his condition from the reception desk.
Always end by saying good bye again with the smile.
No hand shaking.
443
LOOK FOR NEW GUIDELINES
Look for new guidelines before attempting OSCE exam. e.g. latest Nice guidelines,
WHO guidelines and few changes in the fifth edition of Oxford hand book of general
practice.
1.: GOUT: Diet and Febuxostat New Medicine for Hyperuricemia
2-GONORRHOEA: Ceftriaxone Injection plus Azithromycin Tablet.
3-OA KNEE: Glucosamine chondriton sulpahte with Vitamin C is no more advisable

instead TENS & acupuncture advisable.
4-RENAL COLIC: Oxalate stone preventive food
5-MIGRAINE: MIDAS score for the treatment option
Menstrual Migraine Medicine zolmitriptan, Frovatriptan
6-SCABIES: Newer medicines like Ivemactin & newer guideline for application
7-HEAD LICE: Dimeticon spray in pregnancy
8-COELIAC DISEASE: With IGA anti-tissue transglutaminase anti-bodies
9-HEPATITIS C: New curative medicines, sofobuvir
10-PCO: Topical Eflornathine Cream for Hirsutism
11-PREMATURE EJACULATION: Treatment
12-CVD RISK: Framingham Scale Calculation
13-DIABETIC COMPLICATION: Diabetes Mellitus Type 1 Insulin Injection

Counselling, Cataract, Neuropathy, Nephropathy, Diabetic Foot,Gestational Diabetes,
Hypoglycemia
14-TYPHOID: Typhi-dot test, 1gM IgG blood culture, Stool culture.
15-EMERGENCY CONTRACEPTION: Ulipristal Levonorgestril Cu-IUD
16-CONTRACEPTIVE PILLS: New guidelines for missed pills
17-INTERMITTENT CLAUDICATION: Naftidrofuryl Accetate
18-FEVER: PUO Differential Diagnosis

444
19-POST-NATAL PROBLEMS: Pelvic Floor Exercises.
20- BENIGN PROSTATIC HYPERPLASIA: Bladder retaining Exercises
21-ALLERGIC RHINITIS: New Treatment according to situation or symptoms.

Azelastine, Loratadine, Sodium Chromoglacate.
22-ALCOHOL: New questions in history taking. (AUDIT)
23-ADHD: Methyphenidate.
24-ALZHEIMER: Rivastigmine, Donapizil, Galantamine
25- Acne: (Lemicycline 408mg) New guidelines for Mild Moderate Severe Acne
26- Anorexia Nervosa: (SCOFF)
27- Autism: (May be as experimental Case)
28- IBS: (Fod Food Map)
29- TB: (Gene Xpert MTB)
30- Covid 19: (Rash, Xray, CT Scan, Sign Symptoms, prevention and Treatment)
31- Hand Foot Mouth Disease: (Prevalent in Sri Lanka) Important for candidates
appearing in Sri Lanka.
32- Leprosy: (Prevalent in Sri Lanka)
33- Dengue Fever: (Prevalent in Sri Lanka)
34- Telephonic Consultation: Read from “Get Through book”.
35- Home Visit: Read from “Get Through Book and Oxford”
36- USE OF COILS AS CONTRACEPTION:
37- TIA (FAST):
38- ANOREXIA NERVOSA (SCOFF):
445
TIPS FOR SCORING HIGH IN OSCE
• Do not forget to carry your email, role number card, original ID card or valid passport.
• Do not forget to carry your stethoscope with you. Stethoscope will not be provided at
any station.
• Please be punctual.
Try to reach examination Centre well before the examination time i.e. at least one hour
before the exam time.
• You might be caring your expensive mobile phone with you. You are not allowed to
carry your mobile phone in the examination hall. Your mobile phone will be taken away
from you and ticket number will be issued to you. Same ticket number will be pasted
over the plastic envelope in which your mobile will be saved. Rest assure your mobile
will be safe. Keep the ticket number saved in your pocket till the end of exam when
you can receive your mobile back by showing ticket number.
• Take a light breakfast on the day of examination, if you get drowsy after a heavy
breakfast. Take only tea or coffee with some slice.
• Drink less amount of water before the exam. You will be given a short briefing how to
attempt consultation at every station. After the briefing you will be given the opportunity
to use the wash room before entering the examination hall. If you have the urged to
pass urine during the exam, use rest station time for that. This time you will be
accompanied by the chaperon till the wash room.
• Keep your new clean matching dress ready & ironed night before the exam. Get your
shoes shining by the cobbler at the hotel, night before the exam.
• You should look like an educated well dress doctor.
• Traditional country dress can be worn, but a tie and a suit would more appropriate.
• A white over all with name plate of the doctor can be added to the dress. Your overall
pocket should carry a pen torch and a parker pen. Stethoscope should be carried
around your neck at all the stations.
• May Allah accept you hard work and efforts and give you success. Most importantly
connect with your Allah by praying before the exam for your success. May Allah be on
your side.
• Relax. Have faith in Allah. Miracles do happen even today.
• You can be successful. Keep your confidence high.
• If you did not perform well at one station do not worry, complain or brood about that
station. Do not let your bad performance at one station affect your next station
performance.
• You should carry Dr. Raheel book “An Introduction to MRCGP [Int.] UK South Asia
OSCE” with you to hotel. Read and memorized. “create your own questions which can
be used in all 14 OSCE Station.” Also read General Rules of Examination & step by
step written techniques of examinations.
You should carry Oxford Hand Book of General Practitioners with you to the hotel for
last day readings of important cases.
DR. RAHEEL MRCGP OSCE MADE EASY NOTES can also be carried with you and
make use of these notes.
• If you have confusion about milligrams and milimoles please prepare one or two pages
of Normal Lab Values given in mg.
446
• Brain uses glucose as fuel for energy. Make use of toffee coffee with sugar available
during rest station. You can carry your own chocolate bar or sweet biscuits with you.
Don’t use chewing gum which can stick to your teeth.
• If you are a male Muslim & don’t want to shake hand with female SP, then decided
once for all whether you will shake hand with female SP or not.
This decision should be made during practice with your study partner, well before
entering the examination hall.
Just nod with your bent head or Bow like Chinese & Japanese citizens to show your
respect to SP. Female SP will with draw her hand at once.
• Just before entering the station, while standing outside the station reading scenario,
check, note and memorize time from your wrist watch. Again look at your wrist watch
quickly during consultation when you have reached the end of history taking i.e. Idea,
concern and expectation. This checking of time twice will help you complete the case
in time. Be aware and remember checking the time during consultation is a bad
manner as if the doctor is in hurry and examiner would give negative marks.
• Throughout the consultation, candidate should never have rude attitude towards
patient.
• Show respect toward patient.
• Show empathy where appropriate.
• Never be judgmental.
• Be tolerant.
• Do not use inappropriate remarks.
• Throughout the consultation, candidates should have appropriate ethical approach
according to the Hippocrates oath.
• Candidate’s whole consultation should be according to evidence based medicine.
• Clinician must master both scientific and humanitarian aspects to practice medicine.
Examiner likes to see that candidate has observed following points during all 4 domains
of consultation.
(1) MEET & GREET
1. Used appropriate greeting words.
2. Said it with smile & shake hand and Nodding of head all at the same time.
3. Maintained eye contact.
4. Did candidate put the patient at ease & established good rapport?
5. Sit leaning a bit forwards with hands on knees. Legs crossed or closed. Appropriate
body language.
6. Listen attentively & remember what SP said.
7. Facilitate patient to unfold his story in his own words, giving complete freedom of
choice to speak. While keeping an overall control of whole consultation.
8. Do not interrupt frequently. Frequently interruption is considered bad manners & rude
attitude. If you interrupt frequently SP may not be able to reveal his story completely
& you will be missing important data gathering information.
(2) DATA GATHERING
1. Prioritize from multiple symptoms or problems.
2. Ask relevant questions in appropriate sequence.
447
3. Do not repeat questions.
4. Do not take notes inappropriately in details. You might miss non verbal clues, where
you were supposed to show your empathy.
5. Doctor must try to discover the particular reason or reasons for patient’s decision to
consult today.
6. Overall data gathering should not be a hurried approached.
7. Please do not miss any important data.
8. Started with open ended questions.
9. Used closed ended questions appropriately.
10. Asked few differential diagnosis questions.
11. Ruled out Red Flags.
12. Take proper past history, personal & family history, Drug history, travel history, where
relevant contact history & Sexual history, Obs & Gynae history.
13. Identified verbal & non verbal clues and deal appropriately & genuinely. Reaction
should be prompt & not mechanical to show empathy to examiner.
14. Explore patient idea, concern and expectations.
15. Summarized in few sentences in patient’s layman language & asked if that’s all or
anything else he likes to add.
16. Summarized properly. You are supposed to summarize at least twice. Once at the end
of data gathering and secondly just before management.
(3) EXAMINATION & PRACTICAL SKILLS
• Take permission to examine & expose. Explain why examination is necessary.
• Ensured privacy.
• Do focused or minimum necessary examination around your working diagnosis.
• Examined with correct techniques.
• Moved with respect. Do not touch your body to the patient’s body.
• Was gentle in examination and it should not be a rough approach.
• Do not make the patient uncomfortable.
• Cover the patient as soon as the examination is over.
• Helped in dressing up and not in undressing.
• Thank the patient for allowing & trusting you for examination & for his cooperation.
INVESTIGATIONS
• Investigation should be performed only when their results will directly assist in the
diagnosis or have an effect on subsequent management.
• Appropriate, minimum, cost effective, non-invasive investigations should be
prescribed in the first instance and invasive investigations reserved for later time to be
initiated by specialist.
SUMMARIZATION
You are supposed to summarize at least twice. Once at the end of data gathering and
secondly just before management.
(4) MANAGEMENT
• Examiner would like to see that you have correctly solved the problem or made a right
working diagnosis.
• Appropriately reassured if minor problem & deal adequately if it was a serious matter.
448
• Explained the diagnosis to patient in layman language avoiding medical jargon. (Using
no medical terminology)
• Started with life style changes and precautions first.
• Prescribed right medicine with generic name & not brand name of medicine. Medicines
were prescribed in right strength, right dose with right time of day and for proper
duration, through right route.
• Opportunistic health promotion for smoking cessation or cutting down of Alcohol etc.
etc. should be done.
• Patient should be negotiated at every step if it was convenient or OK for him and
modify management accordingly if patient cannot comply with your plan of
management.
• Management should be patient centered approach and not doctor centered approach.
• Give proper follow up time according to the guide lines for the disease. Follow up date
and exact time should be written on prescription for patient’s convenience and that too
is negotiated with patient if that suits him.
• Examiner likes to see that candidate is a safe doctor. He did proper safety netting and
referred the patient to emergency or specialist in time. If things were complicated.
Safety netting is anticipatory care to avoid complications and treating in time.
• Before closing once again asks if there is anything else he would like to share with
you.
• It is important to close the consultation in a relaxed unhurried manner. Say good bye
with a smile and shake hand.
449
LIFE
“Life is an opportunity, benefit from it.
Life is beauty, admire it.
Life is a dream, realize it.
Life is a challenge, meet it.
Life is a duty, complete it.
Life is a game, play it.
Life is a promise, fulfill it.
Life is sorrow, overcome it.
Life is a song, sing it.
Life is a struggle, accept it.
Life is a tragedy, confront it.
Life is an adventure, dare it.
Life is luck, make it.
Life is too precious, do not destroy it.
Life is life, fight for it.”
MOTHER TERESA
450
QUOTES
1. YOUR KINDNESS MAY BE TREATED AS YOUR WEAKNESS

STILL BE KIND.
2. YOUR HELP TO OTHERS MAY GO UN-NEEDED & UN-NOTICED

STILL BE HELPFUL.
3. IF YOU ARE HONEST, PEOPLE MAY CHEAT YOU

STILL BE HONEST.
4. IF YOU FIND HAPPINESS, THEY MAY BE JEALOUS

STILL BE HAPPY.
5. THE GOOD YOU DO TODAY, PEOPLE WILL OFTEN FORGET TOMORROW.

DO GOOD ANYWAY
BECAUSE
ITS BETWEEN YOU AND ALLAH

ITS NEVER BETWEEN YOU AND PEOPLE
THINK ABOUT IT
STAY BLESSED
451
Dr. Raheel Akbar
M.B.B.S. (K.E.M.C)
Certificate in Diabetology
MRCGP1 (Int.) UK
Senior Family Physician
Mob: 0323-4521294
0332 -42 50 9 68
E-mail: akbar.raheel@yahoo.com
Raheelred9@gmail.com
452
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Clinical Notes For MRCGP (INT)

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OUTLINE FOR ALL OSCE STATIONS BRIEFLY

Explore details of symptoms described or Ask few more relevant symptoms.

HISTORY OF PAST ILLNESS

CLOSING & SEE OFF

3. GET THROUGH MRCGP

7. SHORT TEXT BOOK OF MEDICAL DIAGNOSIS & MANAGEMENT

(1) WEB SITES FOR PREPARATION OF OSCE

(2) WEB SITES FOR OSCE CONSULTATION VIDEOS

(3) WEB SITES FOR EXAMINATION VIDEOS

Ask all questions about pain (OD-PARA-MI) On set, Duration, Progression,

ACUTE CONGESTIVE CARDIAC FAILURE

MANAGEMENT Formula (Sven) + (Drug Treatment) + (Treatment for exacerbation)

CLOSING AND SEE OFF

H. Influenzae • Viral pneumonia

Clinical features Fever, shaking chills and • Non-pulmonary features

Chest X-ray Patchy or lobar opacity Patchy non lobar opacity

2. SPUTUM CULTURE & SENSITIVY

SIDE EFFECTS OF ANTI-TB DRUGS AND TREATMENT

Rifampacin (R) • Red Color Urine • Reasure and CBC

Isonizid (INH or H) • Neuropathy • Check Sensory

Ethmabutol (E) • Eye Involvement e.g. • Check Visual Acuity

Pyrazinamide (Z) • Hyperuricemia Gout • Check Uric Acid &

Streptomycin (S) • Autotoxitiy and • Do Audiogram and

Refer chest clinic for initiation of T.B. Drugs.

Please do add Vitamin B6 Pyridoxine with anti tuberculous medicines.

In adult 1mg Intra muscular in bottuck

Sudden desire for hunger

Fast heart beat

• 2 hrs post prandial 126 – 140mg

• Normal upto 199

• Normal value at which glucose spills in urine 180mg

• Declared Diabetic at Blood Sugar > 200mg (At 2 Occasion)

• Declared Diabetic at Fasting Blood Glucose >110(Even at 1 occasion)

• Impaired Fasting Glucose 110 – 126mg

• Impaired Glucose Tolerance 140 – 200mg

• Hypoglycemia common At 70mg (2.5mmol./L)

• Obtain complete lipoprotein profile after 9 to 14 hours fast.

PRESENTING COMPLAINT AND LAB FINDINGS

Give Hepatitis A & B vaccine if any one found to be Hepatitis C confirmed.

Hepatitis C • Infected • 2 to 25 • Multiple Presentation • LFT’s Do not • Avoid alcohol • 6 month

Is there anything else you would like to ask me today. (No)

DEEP TENDON REFLEX

Definition Acute backacahe < 3 weeks.

Walk on their heels ___ L4 L5 (Motor power checked as foot in dorsiflexion)

Complains of bone pain,

FROZEN SHOULDER (Adhesive Capsulitis)

1. LOOK FROM FRONT SIDE & BACK:

FBC & ESR

Podiatrist Occupational Therapist

SPECIFIC TEST FOR TENNIS ELBOW (Resisted Extention of wrist)

M Meningitis (Brain Covering Meninges Infection)

MANAGEMENT CLUSTER HEADACHE

MANAGEMENT TRIGEMINAL NEURALGIA

Carbamazapine – Trigeminal Headache

HISTORY OF PRESENT ILLNESS

HISTORY OF PAST ILLNESS

Chickenpox Macule papule vesicles (Pustules) Scab and crusting.

Rubella Macular – pappular pink rash

Measles Macular Pink Redish Rash.

PLATLET INFUSION IN MEGA UNITS

RABID ANIMALS INCLUDE

SCENARIO 4 (SEVERE PAIN BUT NO VESICLES)

MUMPS & PREGNANCY (Mumps in male with Orchitis)