Book Vol 2

DR MO SOBHY ACADEMY drmohamedplab2@gmail.
com (0044)7743137345
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DR MO SOBHY ACADEMY drmohamedplab2@gmail.com (0044)7743137345
VOLUME 2 CONTENTS
SURGERY 6
STRUCTURE 7
ANKLE-PIN REMOVAL 11
POST-OPERATIVE HEMIARTHROPLASTY 16
POST-OPERATIVE CYSTECTOMY WOUND INFECTION 22
POST HERNIORRHAPHY WOUND INFECTION 27
INGUINAL HERNIA PRE-OPERATIVE ASSESSMENT 33
OVARIAN CYSTECTOMY 44
LAPAROSCOPIC CHOLECYSTECTOMY (JEHOVAH’S WITNESS) 49
DELAYED PRE-OPERATIVE HIP REPLACEMENT ASSESSMENT 54
ACUTE PANCREATITIS 57
ACUTE CHOLECYSTITIS 62
BILIARY COLIC 69
ACUTE CHOLANGITIS 74
ACUTE DIVERTICULITIS 81
INTESTINAL OBSTRUCTION 88
VARICOSE VEINS 93
NECK LUMP 99
ACUTE APPENDICITIS 105
DEALING WITH PATIENT RELATIVES 107

STRUCTURE 108
POST-MORTEM EXAMINATION 108
“DON’T TELL MUM SHE ’S GOT CANCER” 111
MUM FRACTURED WRIST 114
EUTHANASIA 117
DEMENTIA- TALK TO DAUGHTER 118
OCP CONCERNED MOTHER 122
SURGEON SON ASKING ABOUT MUM ’S CT SCAN 124
LEVOTHYROXINE DOSE ADJUSTMENT 126
CHANGING COUNSELLOR 129
PREMATURE CHILD- TALK TO MUM 131
CP CHILD- TALK TO DAD 133
SICK NOTE- ANKLE SPRAIN 135
WHIPLASH INJURY 137
HEART FAILURE WITH HAEMATURIA- TALK TO SON 139
SEPSIS CALL FROM NURSING HOME 141
GENDER SELECTION PRE-CONCEPTION 144
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PATIENT REFUSAL 147

STRUCTURE 148
WARFARIN REFUSAL 149
INFECTIVE ENDOCARDITIS 152
PNEUMONIA PATIENT REFUSING TREATMENT 155
CANCER PATIENT REFUSING TREATMENT 158
BREAST CANCER PATIENT REFUSING TREATMENT 161
PATIENT REFUSING COLONOSCOPY 164
PROSTATE CANCER PATIENT REFUSING TREATMENT 166
GONORRHOEA IN A MAN 169
MEDICAL ERRORS 173

STRUCTURE 174
MISSED FOREIGN BODY 175
RASH AFTER AMOXICILLIN PRESCRIPTION 179
MIS-DIAGNOSED PNEUMONIA 183
MISSED HAIRLINE FRACTURE IN A CHILD 186
MISSED RENAL BIOPSY 189
MISLABELLED BLOOD SAMPLE 192
MISSED MI 194
PROBLEM COLLEAGUE 197

STRUCTURE 198
FACEBOOK POST 199
MEDICAL STUDENT ON COCAINE 202
ALCOHOL COLLEAGUE 205
BLOCKED IV CANNULA 207
DELAYED DISCHARGE LETTER 209
COLLEAGUE COMING LATE TO WORK 211
BREAKING BAD NEWS 213

STRUCTURE 214
INTRACEREBRAL BLEEDING 216
EXTRADURAL HAEMORRHAGE 220
PELVIC FRACTURE 224
POST-OPERATIVE BLEEDING 228
POST-OPERATIVE STROKE 233
BILATERAL STROKE 236
DCIS 240
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HIV TEST RESULT 243
NON-ACCIDENTAL INJURY 249

NAI INSOMNIA 250
INSOMNIA RHEUMATOID ARTHRITIS 254
INSOMNIA CANNABIS USER 257
DOMESTIC VIOLENCE/ ABUSE 260
INSOMNIA DUE TO DOMESTIC VIOLENCE 261
NAI IN CHILD 266
NAI PREGNANT LADY 270
NAI ELDERLY ABUSE 274
NAI SCALDED BURN 276
LGBTQ+ 280
STRUCTURE 281
LESBIAN CERVICAL SMEAR 282
LESBIAN BEING BULLIED 285
HOMOSEXUAL TEENAGER 289
TRANSGENDER 292
URINARY TRACT INFECTION IN TRANSGENDER 297
HEADACHE AND NOSEBLEED IN TRANSGENDER PERSON 301
LESBIAN CONCEPTION COUNSELLING 304
COUNSELLING 308
COUNSELLING STRUCTURE 309
DIABETES MELLITUS COUNSELLING STRUCTURE 316
DIABETIC REVIEW 317
DIABETIC FOOT 322
DIABETIC RETINOPATHY 325
HYPOGLYCAEMIA 330
HYPOGLYCAEMIC FITS 335
DKA 342
DIABETIC REVIEW (LEARNING DISABILITY) 348
MEDICATION COUNSELLING STRUCTURE 353
WARFARIN 355
STATIN 360
OSTEOPOROSIS (ALENDRONATE COUNSELLING) 364
CONTRACEPTION 370
EMERGENCY CONTRACEPTION 373
CONTRACEPTION COUNSELLING 378
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APIXABAN NOSEBLEEDS 381

BLOOD PRESSURE MANAGEMENT 385
POST-MI LIFESTYLE 391
POST-MI HEART FAILURE 396
POST-MI HEART FAILURE MEDICATIONS 401
POST-MI ERECTILE DYSFUNCTION 403
STROKE ASSESSMENT 410
OBESITY COUNSELLING 414
COPD SMOKING CESSATION 421
SMOKING CESSATION IN ANGIOPLASTY 427
SMOKING CESSATION IN BREAST FEEDING 432
CDAD CLOSTRIDIUM DIFFICILE 435
PROCEDURES 441
COELIAC DISEASE 442
BARRET’S OESOPHAGUS 448
COLORECTAL POLYP 451
COLONOSCOPY (FAINTING) 457
VASCULAR DEMENTIA 461
DERMOID CYST 466
MENINGITIS 471
MENINGITIS PROPHYLAXIS 477
MSRA COLONISATION 480
URTI REQUESTING ANTIBIOTICS 486
NEEDLE STICK INJURY (NURSE) 491
NEEDLE STICK INJURY (CHILD) 497
CHICKEN POX IN PREGNANCY 502
CYSTIC FIBROSIS PRENATAL COUNSELLING 509
CERVICAL SCREENING DYSKARYOSIS 516
LOW MOOD -MISCARRIAGE 520
MEASLES -COLLEGE BOY 525
CHILD WITH FEVER -TELEPHONE CONVERSATION 530
HERNIORRHAPHY 535
TWO PEOPLE ONLY POLICY 540
COVID POLICY 544
BREAST CANCER PAIN MANAGEMENT (BACK-PAIN) 548
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SURGERY
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Surgery
Structure for Surgery
The following are key points that should be considered in any pre-
operative assessment:
C → (Changes):
If the surgery is elective surgery that is planned, then ask: “Have there been
any changes in your health condition since the operation was planned?”
P1 → Any problems (system review) like: Head to toe QUICKLY
➢ Fever
➢ Headache – Problem with vision.
➢ Chest – Cough – SOB.
➢ Vomiting – Diarrhea - Constipation.
➢ Pain while passing urine.
P2 → Past Medical conditions and Surgeries?
→ Past medical conditions (5 conditions) DM - HTN - Thyroid - Cardiac – Renal

→ Past surgeries: Have you ever been hospitalised or had any surgeries
before? +/- Blood transfusions before?
1. What surgery?
2. Did you develop any complications (4 MAIN COMPLICATIONS ARE
INFECTION, BLEEDING, PAIN, PE)
3. Any problems with anesthesia?
P3 → D E S A + Recreational drugs
→ Have you been tested for HIV or HBV?

→ Smoking and alcohol are important here.
P4 → If female
→ Periods
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→ Pregnancy
→ Pill (v important)
→PAP smear
MAFT O S A
  
OCCUPATION SOCIAL ANESTHESIA
• What do you do • Who do you live with? • Were you put into sleep
for a living? • Can he/she stay with you for before for any previous
• Does it involve: the first 48 hours ? (day surgery?
Driving – case) • Do you have any:
Working with • How far away do you live − Loose tooth
heavy machines from the hospital? − Dentures
– lifting heavy • Do you have access to a − Neck problems
objects? phone? (If day-care surgery) − Back problems
➢ Very important questions:
✓ Changes since operation was planned?

✓ Social Hx, mainly for post–operative or day care surgery.
✓ Anaesthesia.
✓ Medications, must ask mainly blood thinners, DM medicine , OCP.
Note
1. If the patient is on warfarin → then
• Stop warfarin 5 days before.

• Start on S.C dateparin.
2. Lady on contraception:
• COCP (need to be stopped a month before).
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• POP (can be continued).
3. Diabetes medications
•If patient is on insulin → will be started on (GKI), glucose + k + insulin.
• If patient is on metformin → Will stop the night before the surgery i.e will
take the last dose at night and the next morning before surgery, FBG will be
measured and will be managed accordingly. After the surgery will continue
right away once he is able to eat and drink.
4. All patients must be started on L.M.W.H → SC deltaparin. Even if healthy,

except day surgeries.
5. If the question mentions, “ASSESS if he is fit for a Day Case Surgery” then
→ criteria:
You will have to assess using social questions:
> Age → less than 70 years old?
> BMI → not > than 30? When you verbalise examination
> Who do you live with? Can an adult to stay with him/her for the first
48 hours after surgery?
> Access to a phone?
> Live within an hour from the hospital?
In case of Joint (knee or hip) replacement surgery:
1. Where do you live?

2. What type of accommodation? 2 floored house with stairs or no stairs
and single floor?
3. Who do you live with?
4. Can they help you manage?
5. Body mass index?
6. How was your activity and mobility before? (E.g. Walks around
dependently)
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VERBALISE GENERAL EXAMINATION:
• If the question says “perioperative assessment,” then full previous hx

and verbalise examination.
• If only says “discuss postoperative complications” then no need to
verbalise examinations, follow the task.
• Don’t forget to take the BMI
MANAGEMENT:
Follow the same classic management of counselling structure but consider

giving priority for these points depending on each case.
1. Explain the procedure or surgery
2. Discuss advice before or any medications and any modifications if
needed.
3. Always follow patient concern and address:
- DRIVING AND SEX: 4-6 WEEKS

- WORK: 8-12 WEEKS
EXCEPTIONS:
Any KEYHOLE surgery: half the duration. i.e. D&S:2-3w ... W:4-6w
Any MI Procedure, Knee/Hip replacement: Double time D&S: 8- 12 w

... W:16-24w
4. In any perioperative assessment investigations required:

- Routine bloods
- Group and safe (Cross match)
- Urine dip stick
- ECG
- CXR
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5. Discuss the required treatment for the concern he/she has or the
complication he/she is worried about as Infection or PE.
6. Safety netting and post-operative advice. Clotting PE, infection,
bleeding.
If you develop any
− Fever infection
− Severe pain in the tummy
− Bleeding, dizziness, or drowsiness
− Shortness of breath and chest pain, feeling heat, redness or swelling in
your calf (CLOT), please come back to us.
Types of surgery stations and possible concerns:
1. Hx taking &/or perioperative assessment.

2. Social hx as in day case surgery or joint replacement.
3. Discussing and explaining about surgery.
4. Management of medications before and after surgery.
5. Concerns about driving, sex or work.
6. Concerns about prevention of complications as PE.
7. Angry patient with wound infection.
Ankle Pin removal

Who you are: You are F2 in Surgery.
Who the patient is: Mr. Ted Lasso, aged 51, presented to the hospital for his pre-operative
assessment. He has been arranged to have an operation under general anesthesia for the
removal of a screw in his ankle. His operation will be done in two weeks’ time.
Additional information: He had an ankle fracture twelve months ago and underwent surgery
because of it.
Special note:
What you should do: Please talk to the patient, assess his pre-operation fitness for day care
surgery and address his concerns.
Doctor: Hello, I'm dr (name), are you Ted?

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P: Yes.
D: Can you confirm your full name and date of birth please?
P: (Confirms details).
D: I can see from my notes that you had some pins fitted for an ankle fracture
about 12 months ago, am I right?
P: Yes, and I have come for my check-up now because I was scheduled for day
care surgery for pin removal from my ankle in two weeks’ time I believe.
D: Thank you for coming today, Ted, we booked this appointment to have a
small chat about your health before we go on with the surgery. That’s because
during the pin removal we might need to put you to sleep, and we want to
make sure that everything runs smoothly. Would that be okay?
P: Definitely doctor its fine.
Changes
D: How are you these days? Have you had any changes generally in your health
since the last appointment when the surgery was booked?
P: No, I’m fine.
Head to toe
D: Any fever, cough, SOB?
Any headache or flu-like Sx?
Any diarrhoea or constipation?
Any Pain while passing urine?
P: No.
P2
D: Do you have any longstanding medical conditions?
P: I am diabetic.
D: For how long?
P: 20 years now.
D: How is it managed?
P: I am taking insulin for it.
D: Which insulin do you take?
P: I am taking Lantus and Novarapid.
D: How do you take it?
P: I am taking Lantus once before going to bed. I am also taking Novarapid 3
times before each meal.
D: Do you take your Insulin regularly as prescribed?
P: Oh yes doctor.
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D: And your diabetes, is it well controlled?

P: Yes doctor.
D: Do you have any symptoms such as feeling thirsty or going to loo more
often?
P: No doctor.
D: By any chance any problems with your feet or eyes?
P: No.
D: Do you check your blood sugar regularly?
P: Yes, I check it regularly.
D: When was the last time you checked it?
P: I checked it this morning.
D: What was the reading?
P: 6.
D: Are you good with attending your GP follow ups?
P: Yes.
D: Are you going for annual diabetic check-up?
P: Yes.
D: Have you been diagnosed with any other medical conditions?
P: No.
D: Any high blood pressure or heart or kidney problem or blood disorders?
Previous surgery:
D: How was your experience in any previous operations?
P: It was ok.
D: Were you put to sleep? Anaesthesia
P: Yes.
D: Any problems after the surgery last time?
P: I vomited a lot last time. Doctor, will it be the same this time?
D: Oh, it was possibly because of the medications you had to put you to sleep
and also those to control your pain. We will take our precautions this time to
avoid that, don’t worry, I’ll make a note of it.
DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
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MAFTOSA:
D: Are you currently on any other medications apart from insulin?
P: No.
D: Do you have any allergies?
D: What do you do for a living?
D: Does it involve driving – working near heavy machines – lifting heavy
objects?
D: Who do you live with?
P: With my wife.
D: Can she stay with you first the first 48 hours? (day case)
P: Yes.
D: How far do you live away from the hospital?
P: 1 hour.
D: Do you have access to a phone? (If day-care surgery)
P: Yes.
D: Do you have any: loose tooth, dentures, neck problems, back problems ?
P: No.
Examination:
D: I would like to take your vitals, measure your blood sugar and take your BMI
if you don’t mind?
Management:
D: I would like to run some investigations including:
− All bloods mainly blood sugar.
− Urine dipstick.
− ECG.
− CXR.
D: From the information you have given me and according to my examination,

you seem fit to undergo this procedure and we can also do it as a day case
surgery. However, we need to give you some instructions:
1. You should have an empty stomach at least for 6 hours before we do the
operation. So, please, don't have breakfast or insulin the day of the surgery.
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2. We will put you on (GKI) which is glucose, k (an electrolyte) and insulin all
will be given through your veins. All good so far?
P: Yes doctor.
D: You mentioned that last surgery you had some problems with vomiting.
Well, it doesn't mean that it happened last time that it will happen again,
however we will give you anti–sickness medications and if you still vomit even
after medicine → Then , we will think of keeping you in the hospital until you
are stable.
Post – Operative management:
• After the operation once you recover from the anaesthesia and you can eat
and drink → Then , we will give you your normal dosage of insulin.
• We will send you home if everything is fine.
• 24 hours after procedure:
− Don't sign any important document.
− Don't work near heavy machinery.
− Don't work from heights.
− Don't drive until you are able to do an emergency stop without feeling
pain.
− Someone will have to stay with you for 24 -48 hours after the procedure
to look after you.
Safety netting → watch for any fever, redness, discharge, dizziness or SOB if
any of them happen please come back.
Follow up:
You will be seen by the GP over the next couple of weeks and you will be seen
by our surgical team sometime later to make sure that everything is fine.
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Post operative hemiarthroplasty
Who you are: You are F2 in Orthopaedics.

Who the patient is: Mrs. Margaret Fletcher, aged 74, presented to the hospital
after a fall with a fracture of neck of femur. She has been planned to have a
hemiarthroplasty.
Special note: Anaesthetist has explained pain management. The consultant has
explained the procedure.
What you should do: Please talk to the patient, discuss about post-operative
management and complications. Discuss about management once discharged
and address her concerns.
D: Hello I am one of the junior doctors here. I can see from my notes that you
had a fall. How are you doing so far? (Always try to use your notes)
P: It was a dreadful fall doctor I feel it was really painful around my hip.
Rapport
D: Sounds like an awful experience, I'm really sorry about what happened, how
are you feeling now?
P: I am fine.
D: Can you tell me how it happened?
D: How are you coping with the pain? Is your pain under control?
How is your hospital stay?
How is the care by doctors and nurses?
P: Thank you doctor, all is fine.
D: I think you had a chat with a few of my colleagues about what has
happened to you and what we are going to do for that, am I correct?
P: Yes they told me that I have a broken bone in my hip and you are going to
do an operation to fix it.
D: You are right. And I believe my consultant/colleague has explained to you
about the procedure of surgery and the pain management after surgery.
P: Yes doctor.
NO NEED TO TAKE MUCH TIME ON HX JUST FOLLOW THE PATIENT CONCERNS
AND IF YOU HAVE TIME TAKE HX AT THE END.
D: Have you got any concerns that need to be addressed before the surgery?
P: Yes I do.
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D: Alright don’t worry my dear I am here to answer all that you have on your
mind, please feel free to tell me your worries.
P: Can you tell me what happens after the surgery? CONCERN
D: After the surgery you will be shifted to a recovery room, where you will be
observed and monitored for a while.
P: When will I be able to walk?
D: We will try to make you mobile as quickly as possible after the operation.
We encourage our patients to walk the next day after the surgery, however
sometimes you will be made to walk on the same day of the operation. But you
will be needing some walking aids like crutches to walk in the beginning. We do
this to avoid any complications.
P: What are the complications of this surgery?
D: There can be some complications like:
− Infection or bleeding at the site of the surgery.
− Blood clot in the legs.
− Injuries to the blood vessels or nerves.
− Differences in leg length.
However, if any of these things happen we will manage them accordingly. How
do you feel so far?
P: Doctor, I am worried in case I have a blood clot in my heart or lungs.
Concern
D: EXPLORE May I ask you why are you worried about developing a blood clot
in your heart or lungs in particular?
P: (My friend had an operation and she had a blood clot after)
D: I'm really sorry about your friend, how is she doing now? reflect
P: She is fine now but after the surgery when she had the clot she was really
sick.
D: Oh I can understand why you look a bit worried about that then. Not
everyone who has this operation will end up having blood clots; however,
we'll take some precautions to prevent this from happening.
So, is it ok if we have a chat about your health in order to be able to address
your concern in a better way?
➢ Take hx at this point, Hx about symptoms and risk factors of blood clot.
P1 → Sx of P.E.
D: Do you have any chest pain ?
Do you have any SOB ?
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Have you ever had any weakness in any of your arms or legs?
P: No.
P2
D: Have you been diagnosed with any medical condition in the past like high
blood pressure, DM or any cholesterol problems?
P: No.
D: Any blood disorders or have you ever had any clots in the heart or the lungs
or legs?
P: No.
MAFTOSA
D: Are you currently taking any medications, OTC or supplements?
P: No.
D: Any blood thinners or COCP or any Hormone replacement therapies?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: Any blood disorders or blood clots in the family?
P: No.
DESA
D: How is your diet (Fast or fried food)?
D: Do you smoke?
Take social Qs:

D:
2. What type of accommodation? 2 floored house with stairs or no stairs
and single floor?
3. Who do you live with?
4. Can they help you manage?
5. How was your activity and mobility before ? (E.g. Walks around
dependently)
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D: Well, from the information you 've given me , the chance of you getting a
blood clot in your heart or lungs is low. However, we won't take any risk so, we
usually take some measures to prevent you from having any blood clots after
the surgery anyway.
Management:
1. Early mobilization is mandatory.

2. Exercise program by a physiotherapist
3. We will give you blood thinners injections from before your surgery every
day until few days after surgery (usually 28 days). Such as dalteparin S.C.
4. You will be given some special stockings (TED stocking) that will increase
blood supply in your leg and prevent you from having a blood clot.
5. There's a device called (intermittent pneumatic compression) which will
create some sort of pressure on your legs by charging air pressure → which
will improve circulation in your leg.
Some important advice, I would like to give you to follow after operation:
− Avoid bending your hip >90.
− Avoid twisting your hip.
− Don’t swivel on the balls of your feet.
− When turning around, take small steps, don't turn suddenly.
− When you enter a car sit first then move your legs inside slowly.
− Don’t cross your legs.
− Avoid sitting on a low chair or toilet seat.
D: Have you got any other concerns?

P: How will I get around in my home?
Take social Qs:

D: That’s a very valid concern can I ask you a few questions about your house
to answer you properly?
2. What type of accommodation? 2 floored house with stairs or a single floor
house with no stairs or a flat?
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P: I live in a house doctor.

3. Do you have all facilities on one floor?
P: No doctor my bathroom is upstairs.
D: Don't worry this is one of the areas we look into before discharging
you because climbing stairs can lead to a fall and cause dislocation, one
of the complications.
Our Occupational health therapist will assess your home condition and
do all the necessary adjustments before you get discharged. They make
sure all the facilities are on one floor as you can't go up and down stairs
until around 3 months. They will also change any low toilet seats to
higher seats, they will install rails in the bathroom and shower, they
may provide an electric chair for a while as well to help go up and down
stairs.
P: What about shower?
D: The bathroom can be slippery and pose risk of a fall, but don't worry
about it, an electrical chair can be fixed in the shower and also hand
railings can be arranged.
4. Who do you live with? Can they help you manage?
P: No doctor, that's one of the reasons why I am worried.
D: I can understand your concern, but don’t worry about it we can sort
that out for you by involving social services and arranging someone to
take care of you.
5. How was your activity and mobility before ? (E.g. Walks around
dependently).
Safety netting: After operation , at any time if you have:
− PE sx Let us know if you’re still hospital or ring 999 if you are at

home.
> Swelling in your legs and calf muscles.

> SOB or chest pain.
− Infection Sx: Contact GP if you feel

> Pain.
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> Redness.
> Heat.
> Bleeding.
> Discharge.
Questions you will be asked:
1. Walking with support (crutches) and with help of physiotherapist next day.
2. Will walk without support within 6 weeks, once operation site heals
properly and tissue becomes strong.
3. Discharge 3 – 5 days after operation. If you are fit and well without
complications. Occupational therapist to your home to make some
adjustments where everything will be on the same floor as you can't go up and
down stairs until around 3 months. Will install rails in the bathroom and
shower, will provide an electric chair for a while as well.
4. Driving / Sex → 6 weeks when you are able to do emergency stop without
pain.
5. If she asks about physical exercise:
Skiing → avoid.
Ball game → 4 months.
6. When can I come back to work → 12 weeks.
7. P: When can I have food and drinks after the operation?
D: You may be allowed to have a drink about an hour after you have been
to the ward and depending on your condition, you may be allowed to
have something to eat.
FOLLOW UP: You’ll be given an outpatient appointment to check on your

progress, usually six to 12 weeks after your hip replacement.
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Post–operative cystectomy wound infection
Who you are: FY2 in Surgery dep.
Who the patient is: 40 year old, Tanya Markovic: had an operation in her knee
last month. 10 days after, she had an infection at the site of the injury for which
she was treated. Now, she is ok, but she is very angry and wants to know why
she had infection.
Additional information: Post-surgical infection rate in this hospital is within the

national guidelines.
Special note: The nurse told you that the patient is angry. The patient has
booked a telephone consultation with your department.
What you should do: Talk to her address her concerns.
Note:
She is fine and no infection now, she only wants to know why she
had infection.
So, Hx → Past – Present – Future.→ Try to find risk factors like, DM
or wound care.
Always try to use your notes for at first.
Don’t blame anyone, you simply were not there. The question says the rates are
within the national guidelines.
The patient is angry so explore causes but be understanding and pay attention
to your language.
Telephone structure
D: Hello I am doctor (name) one of the doctors in the surgery department. Am I
talking to Tanya?
P: Yes.
D: Can you confirm your full name and date of birth please.
P: Tanya Markovich I am 40 years old.
D: How would you like me to call you?
P: Tanya is fine.
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D: Can you confirm the first line of your address?

P: …….
D: Is it a suitable time for me to talk to you Tanya?
P: Yes doctor.
D: If this line gets interrupted can I call you on the same line?
P: Yes doctor.
D: So Tanya, I was told that you had some concerns about the surgery you had
before, how can I help?
P: Yes doctor, I had an operation for my knee 4 weeks ago, after the
operation I had a very bad infection in my wound doctor. I got very
frustrated, it was supposed to be a simple surgery. I want to know why it
happened doctor? I am sure it might have been a mistake or poor hygiene by
the hospital. concern
D: I am extremely sorry about your experience Tanya, I want to make sure that
you are okay right now first. How do you feel now?
Present
P: I am fine doctor, I am just very disappointed with the whole thing, it is
unacceptable.
D: I can feel your frustration Tanya and I will do my best to understand what
happened. Can you tell me if you still have any (symptoms of infection) from
your wound? (Symptoms of infection)
- Pain?
- Fever/ Flu-like Sx?
- Discharge?
- Redness? Swelling?
- Are you able to walk?
P: No doctor.
D: Any cough? PE
P: Yes, sometimes.
D: Any reason for the cough?
P: Maybe because of my smoking.
D: How are your bowel habits? Any diarrhoea or constipation?
P: It is fine.
Rapport
D: What challenges did you have due to this infection? / How was the hospital
stay?
23 | P a g e
P: ………
PAST:
P2+MAFTOSA
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Are you taking any medications including OTC or supplements?
P: No.
D: May I know what do you do for a living?
P: I work in a building construction company.
D: Does your job involve any physical exercise or heavy lifting?
P: Oh yes doctor.
D: Did you start working after your operation?
P: I started working a week after I was discharged from the hospital. I went to
the office and they gave me office work.
Previous surgery
D: How did your operation go 4 weeks ago?
P: It went well.
D: How long did you stay in the hospital for ?
P: …….
D: What symptoms did you have before operation?
P: I had a cyst in my knee, and they got it removed because it was bothering
me when I move.
D: Did you have redness, swelling or discharge from the cyst before the
surgery? Sx of infection before.
P: No.
D: When the infection happened how were you managed?
P: They gave me antibiotics doctor, I wonder why they didn’t give antibiotics
before?
Wound Care:
D: About wound dressing in the hospital, how many times was it changed?
P: I’m not sure doctor, I don’t remember but quite a few times.
D: When you went home, were you given any advice about wound care or
were you told how to look after your wound?
24 | P a g e
P: Yes. They told me to remove the dressing after a few days and they told me
to clean and dry the wound with a towel after having a shower.
D: Did you go into the shower with the dressing?
P: Of course, not doctor.
D: Did you follow the instructions?
P: Oh yes doctor, as best I could, and still the infection happened. I was furious.
D: I understand Tanya you were doing your best and I appreciate that you were
following the advice.
DESA
D: You mentioned about smoking. How much do you smoke?
P: 1 packet a day.
P: No.
Examination:
No need for this but you can say “ideally if you were here, I would check your
vitals and examine your wound. I would be glad to book an appointment for
that later.”
Counselling:
Thank you for bearing with me so far Tanya, I understand that you want to
know how and why that infection happened. Well from the information you
gave me, I think that a handful of reasons might have contributed to its
occurrence, but may I ask you why you think it might a problem with the
hospital?
P: Because I have read online that infections can occur in hospitals all the time
and you are usually given antibiotics to prevent that, you only gave me
antibiotics when I already had the infection and the damage was done.
D: I see Tanya. Would you give me the chance to explain more about infections
and how things work in the hospital? Well, there are many reasons why a
patient can have a wound infection after surgery. It’s not always the hospital
which is the main cause. It could be reasons from inside the hospital or outside
as well.
Risk factors can be from outside the hospital such as not keeping the wound
clean , or not changing the dressing properly or having unclean dressing but I
25 | P a g e
understand that you were doing your best about that. (The patient here is
following the advice so praise her for that).
Other risk factors such as SMOKING or medical conditions as DM or on any
medications (please mention any positive RFs from the Hx), may contribute.
Smoking decreases the level of immunity, decreases healing power and this
can delay wound healing and cause infection.
With regards to the hospital we do take all measures to avoid that. We clean
the theatre and we do make sure we keep the wound clean and we change
dressing regularly. However, people can still get infections despite all
measures being taken. And we usually monitor the rates and do statistical
studies to make sure that the infections within the hospital are not getting
out of control.
On top of all that some people are just more prone to infections than others,
as when some people catch flu more frequently than others.
D: You mentioned something about timing of antibiotics am I correct?
P: Yes doctor.
D: Well, put simply, not all procedures require antibiotics as you read. Some
major surgeries do but not all of them. You know because antibiotics
themselves can have side effects like allergies N&V and in the long-term if
given needlessly they might reduce your immunity as they increase microbe
resistance and will no longer be effective if given later against same infections.
Therefore, we only gave you antibiotics when you had the infection Sx to spare
you the side effects and for the treatment to be effective. Does that make
sense?
P: Yes doctor.
If patient wants to complain → involve senior, PALS , RCAM.
D: I will be glad to book an appointment for you to come and have a your
wound examined and to walk you through proper wound care again.
D: Do you have any other concerns?
P: If she had work related challenges while having the infection offer sick note
or a report for the period back then but not now as she is no longer sick.
P: No.
26 | P a g e
Safety net: about infection Sx
Post herniorrhaphy wound infection

Who you are: Fy2 in Surgery department.
Who the patient is: Jack Ethan, a 35-year-old man, underwent herniorrhaphy
one week ago as a day case surgery. Now he presents with discharge, swelling,
oozing and redness at the site of the infection.
Additional information: The nurse told you that the patient is angry.
Special note: Post-surgical infection rate in this hospital is within the national
guidelines.
What you should do: Talk to the patient address his concerns.
Here, you will take full Hx. In these stations → Don't ever blame the patient and
calm him down. Divide the Hx you are taking into Pa st, Present and Future:
Past Present Future

• Why did he • Symptoms that • Examine
come in the first brought him • Investigations
place? (Hernia) now. • Management of
• What symptoms • Ask about wound wound infection:
did he have? (If care. -IV fluids
hernia was -IV antibiotics
complicated it -Paracetamol
could be the
cause of the
infection.)
• P2- Previous
surgery?
-Medical
conditions? (In
case of post
operative
complications
like DM.)
• P3= DESA (quick)
• MAFTOSA
(quick), mainly
medications.
D: Hi, are you Jack?

27 | P a g e
P: Jack Ethan.
D: Can you confirm your date of birth?
P: (Confirms) Are you a junior doctor? I don't want to speak to you, I
want your consultant to come can you call him please!!
D: Yes, I can call him for you, but it seems that you had a problem and
you’re upset about it and I am here to help you Jack. Can you try
sharing any of your concerns with me and I will do my best to help
solve any problems at least till my consultant arrives ?
P: I had an operation for my hernia one week ago. Now I have pain and
swelling here (Pointing to the site of operation)
❖ PRESENT:
P1 SOCRATES:
D: Oh, I am sorry about that. You mentioned pain and swelling (Always recap
briefly), does the pain go anywhere else? Radiation
P: No just around the surgery wound.
D: Did you have the pain before the surgery? Duration
P: No doctor only after the surgery.
D: How did it start, suddenly or gradually? Onset
P: I’m not sure doctor but maybe gradually.
D: Any change since it started? Is it getting worse or better? Course
P: Definitely worse, doctor.
D: Does anything make it better or worse?
P: No.
D: Can you score this pain for me on a scale from 1 to 10, with 1 being least
and 10 being the most severe pain ?
P: 7.
D: Have you tried anything for the pain ?
P: Tried PCM but it didn’t help.
D: How many tablets?
P: 2 or 3.
D: Do you have any other symptoms bothering you ? Open Qs
P: I have discharge from the wound.
D: When did you notice that?
P: A few days back.
D: What was the colour?
28 | P a g e
P: Yellow colour.
D: Any pus?
P: No.
D: Any bleeding?
P: No.
D: Any redness?
P: No.
D: Anything else?
P: No.
D: Any fever or flu-like symptoms?
P: No.
Other Surgery Complications:

D: Any nausea, vomiting?
P: No.
D: Any cough?
P: Yes, sometimes.
D: Any reason for the cough that you can think of?
P: Maybe because of my smoking.
D: How are your bowel habits? Any diarrhoea or constipation?
P: No. It is fine.
Wound Care
D: Have you been told how to look after your wound?
P: Yes. they told me to remove the dressing after a few days and they told me
to clean and dry the wound with a towel after having a shower.
D: Did you follow what you have been told?
P: Oh yes doctor.
❖ PAST:
Surgery:
D: How did your operation go three weeks ago?
P: Doctor, it went well.
D: What symptoms did you have before the surgery ?
(In case it was a complicated hernia that could be the reason why he had
infection)
29 | P a g e
D: You mentioned that you didn’t have any pain or swelling before the surgery
but did your hernia cause any sickness in any way?
P: It was a bit achy, and the doctors said it was irreducible, otherwise I was
fine.
Maftosa:
P: No.
P: No.
P: I work in a building construction company.
D: Does your job involve any physical exercise or heavy lifting?
P: Oh yes doctor.
D: Did you start working after your operation?
P: I started working a week after I was discharged from the hospital. I went to
the office and they gave me office work.
DESA
D: You mentioned about smoking. How much do you smoke?
P: 1 packet a day.
P: No.
D: Tell me about your diet?
P: It’s fine.
Examination:
If you don’t mind, I would like to check your vitals and examine your wound.
There is a picture showing swelling and discharge from the wound site.
Once the examiner gives you a picture, please → Describe it to the patient and
show sympathy and empathy.
Management:
Counselling
• Well, from the information you gave me and according to my examination, I
believe your wound is infected.
30 | P a g e
Q\ Dr why did I have this infection?

D: That’s a good question, James. Would you give me the chance to explain
more about infections and how things work in the hospital. Well, there are
many reasons why a patient can have a wound infection after surgery. It could
be reasons from inside the hospital or outside as well.
Risk factors can be from outside the hospital such as not keeping wound clean,
or not changing dressing properly or having dressing not clean but I know you
were doing your best about that (the patient here is following the advice so
praise him for that).
Other risk factors such as SMOKING or medical conditions such as DM or if the
patient is on any medications (please mention any positive RFs from the Hx),
may contribute. Smoking decreases the level of immunity, decreases healing
power and this can delay wound healing and cause infection.
With regard to the hospital we do take all measures to avoid that, we do
clean the theatre and we do make sure we keep the wound clean and we
change dressings regularly. However, people can still get infections despite
all measures being taken. And we usually monitor the rates and do statistical
studies to make sure that the infections within the hospital are not getting
out of control.
On top of all that, some people are just more prone to infections than others,
in the same way that some people catch flu more frequently than others.
1. Admit.
2. Senior.
3. Investigations:
− Blood (routine – infection markers).
− Culture and Sample from the wound.
4. TTT
We will clean the wound, put new dressing.
− Painkillers.
31 | P a g e
− Antibiotics → according to hospital protocol then will change it

according to swab result.
− I.V fluids.
5. Doctor I don't want to stay in hospital

− Why? (Concern → self-employed).
− Ultimate risk for not staying.
− Or address concern → you can go after to Citizen Advice Bureau and
take advice.
If you have time → you can safety net when he goes home.
6. Safety net:
Pain or symptoms getting worse, fever, dizzy, drowsy and signs of sepsis.
P: Doctor is it possible to catch this bug from the hospital?
D: It’s possible but it was day care surgery, so you didn’t stay overnight and
you developed the infection 1 week after the operation. If it was because of
surgery, you would have shown symptoms earlier.
P: Doctor is it happening a lot in your hospital?
D: Actually, the rate of infection after operations in our hospital is within the
national guidelines. This means it is not happening a lot in the hospital.
P: Doctor I want to complain. I am not happy.

D: I totally understand your frustration. Can I walk you through what we
usually do in the hospital when we face similar situations?
P: Doctor, I don’t want this to happen to anyone else.

D: I really appreciate your concern about other people. Like I said, wound
infection is one of the complications of any surgery. However, my colleagues in
the surgery department usually discuss everything about the surgery and its
possible complications and gain their consent before the surgery. And like I
mentioned we take every step to avoid every bad scenario.
32 | P a g e
We usually have monthly meetings in order to improve the quality of service

we provide to our patients and minimise the risk of such adverse events.
P: What is this meeting?

D: This is a monthly meeting, which is attended by our consultant surgeons
and other surgical staff. These meetings are held to discuss different clinical
dilemmas and scenarios with various patients, so we can learn why this
happened, how to avoid similar problems in the future, and implement what
we learn to drive improvement in our service delivery to the patients wherever
it is needed.
P: I am still not happy. I want to complain.

D: No problem at all. What I can do is I can get you in touch with PALS service
and it is a service where you can make formal complaints for them to
investigate.
Inguinal hernia pre-operative assessment
Who you are: You are an FY2 in surgical department

Who the patient is: Andrew Portland 45 years , been planned to have a right
inguinal hernia repair.
Additional information: Anaesthetist is due to have a chat and assess the
patient. The consultant will come later to take his consent and some Hx for
operation.
Special note: Nurse has found BP 155/88.
What you should do: Do operation assessment, describe operation, address
his concern.
D: Hello is it Andrew?
33 | P a g e
P: Yes.
D: Can you confirm your full name and age for me please?
P: Andrew Portland, 45 years old.
D: I can see from my notes that you have been planned for hernia surgery.
Well, I am here to have chat with you and discuss the surgery in detail, would
you like to know anything in particular? Concern
P: Yes, doctor I want to know more about the surgery.
D: OK, I will tell you about it, but firstly do you know
what a hernia is exactly? Sx of Complicated of hernia:
P: No. − Pain (Strangulation)
D: A hernia is a swelling that occurs when an − Irreducibility cannot push
internal part of the body like the intestine in your back
tummy pushes through weakness or a gap in your − Vomiting (obstruction)
tummy wall. Are you following me? − Constipation
It happens when the pressure inside your tummy is (Obstruction)
increased for example whilst coughing, sneezing or
− Redness / inflammation
constipation. (PAUSE) (You will have a pen and
over skin of hernia.
paper, you can draw a picture for him).
Risk factors
P: Ok.
− Cough
D: Has your pre-operative assessment been done?
P: Yes/No (Then do pre-assessment) − sneezing
D: I can see from the notes that one of the nurses has − Chronic Constipation
examined you am I correct? − Lifting heavy weight
P: Yes doctor she took my vitals.
D: Has anyone taken any blood from you?
P: Oh yes doctor. It has been done.
D: Have they talked to you about the results?
P: Nothing doctor.
D: No worries will check them later, can I ask you a few questions about your
health in general?
P: Yes.
P1 SWELLING
D: Could you please tell me how long have you had this hernia issue?
P: A few months.
D: How did you notice it first?
P: I just noticed some swelling in my groin area.
34 | P a g e
D: Which side do you have it? Site

P: The right side.
D: Can you describe its size, any change in size recently?
D: Can you push it back?
D: Do you have any (Sx of Complicated hernia) there?
P: Yes/No
D: Have you ever had any (risk factors) for hernia ?

P: Yes/No
P2
D: Have you had similar kind of problem in the past?
P: No.
P: No.
D: Any high blood pressure, diabetes, heart or kidney problems?
P: No.
D: Have you ever had any previous hospital stays or any surgeries before?
P: No.
MAFTOSA
D: Are you currently taking any medications, over-the-counter or
supplements?
P: No.
D: Any allergies to any food or medications?
P: No.
P: Yes. My father also had this problem when he was 60. EXPLORE
D: I’m so sorry to hear that. Did your father have an operation for his hernia?
P: No, He use to wear a truss. Concern
P: I work in a warehouse.
D: Does it involve lifting heavy weights?
P: Yes.
P: I live with my wife.
D: Can she stay with you first the first 48 hours? (Day case)
35 | P a g e
D: How far do you live away from the hospital?

D: Were you ever put to sleep before in any previous procedure?
DESAS
P: I eat everything.
D: Do you do physical exercise?
P: I am quite active at work.
D: Do you smoke?
P: Yes/ No
P: Yes/No
Examination:
I would like to take your vitals, and do a general physical examination including
your heart, lungs, tummy, nervous system and also your hernia. Is that OK with
you?
Management
Counselling
D: We checked your blood pressure, and it is on the higher side. This doesn’t
necessarily mean that you are diagnosed with high blood pressure. We need to
check at different times for us to come to a conclusion. We might have to
involve a heart specialist and the anaesthetist to have a say on this blood
pressure issue as it needs to be controlled before surgery.
P: Ok.
D: Has anyone explained to you what happens during surgery?

P: No.
D: Well, the only way to treat this condition is surgery → it could be open
surgery or a key hole operation, but since your blood pressure is on the higher
side, I believe you might have open surgery. However when you have the chat
with our consultant we will confirm which surgery.
36 | P a g e
− With regards to the open surgery → it will involve making an incision or a

cut on the skin, its usually about 6-8 c.m. After this, the surgeon will push
the tummy content back.
− After that a mesh will be placed which is a type of synthetic plastic support
patch in the weak spot in order to strengthen this spot.
− Your skin will be sealed with stitches that will dissolve on their own.
However, if you have keyhole surgery:

− Key whole surgery is far less invasive than open surgery. It usually takes
30-45 minutes and it only involves 3 small incisions in your tummy
through which a camera with a source of light, called a laparoscope, and
2 arms (or ports) are inserted into the tummy cavity to reach for the
defective weak spot and repair it. Then they put that mesh I told you
about shortly before.
− It is done under general anesthesia where you we will be put to sleep,
the incisions include a small cut which is usually near your belly button
and two others on the sides. Gas is injected through the cut to inflate
the tummy wall to make it easier to see internal organs.
− The camera is connected to a TV monitor and with the help of the ports,
the surgeon can see the instruments on the monitor and perform the
surgery.
D: Do you have any concern?

P: Doctor, why don’t you give me a truss to wear?
D: May I ask why you want a truss or what you know about it? (If he hadn’t
mentioned it before, then explore)
P: My father had a hernia and he had one.
D: Well, how is he doing now? (Same reflection as before).
D: Usually a truss is a temporary solution to those who are not fit for surgery
until they can have surgery, or those who have medical conditions and are of
an old age at which surgery could be life–threatening. Currently the TRUSS is
generally no longer recommended as it is now thought to have no or limited
benefit and they are also fairly uncomfortable.
P: Doctor, will I be in pain?
37 | P a g e
D: Unfortunately, all inguinal procedures are associated with pain ; however ,

we will try to manage this pain very well.
❖ During the operation:- Either you will be given:
− Local anesthesia, where we inject anesthetic medication into the
swelling.
− Spinal anesthesia where we will be injecting medications into your
back (here you will be awake).
− General anesthesia where you will be put to sleep, it’s the
anesthetist who will decide the best anesthesia for you.
❖ After the operation, you will be given painkillers, co-codamol or codeine
tab.
If the initial investigation has not been done, verbalise that some investigations
will be required before surgery:
- Routine bloods
- Group and safe (Cross match)
- Urine dip stick
- ECG
- CXR
DESA Management: Address the risk factors for hernia:
− Constipation → through diet advice.
− Cough → through smoking advice if he does.
− Heavy weight → If his job involves lifting heavy weight
> Why don’t you talk to your employer to change job
role?
> Find another job.
> Citizen Advice Bureau.
− Maintain healthy weight.
Safety net about Warning signs

1. Fever – tenderness – vomiting –constipation – SOB → Come back.
2. No driving.
38 | P a g e
3. No working near heavy objects or sign any important document for 48 hrs
(in case of general anaesthesia).
Patient might have other concerns as have questions to ask:

P: How long will operation last?
D: From 45 – 60 min.
P: When can I return to normal activity?
− Light activity (like shopping) → 2 wks.
− Normal or heavy activity → 4- 6 wks.
P: When can I start driving again?
D: 4- 6 wks. When you are able to perform SO,
SEX + LIGHT ACTIVITY → 2 WKS.
emergency stop without pain. DRIVE + HEAVY OR NORMAL ACTIVITY → 4 WKS.
P: When can I have sex?
D: 2 wks. When you are moving without pain.
PRE-OPERATIVE ASSESSMENT
Who you are: You are F2 in Surgery.
Who the patient is: Ms. Andrea Henderson aged 31, has come to the hospital
for a pre-operative assessment.
Additional information:
Special note:
What you should do: Talk to her, check her fitness for surgery and take verbal
consent for surgery.
D: Hello I am one of the doctors in the surgery department, is it Andrea ?

P: Yes.
D: Can you confirm your full name and age for me please?
P: Andrea Henderson, 25.
D: Nice to see you, I can see from my notes that you have scheduled surgery,
do you have any idea why you are here today?
P: Yes doctor, I have been told to come to the hospital for a check-up before my
surgery for the gallbladder removal.
39 | P a g e
D: Alright thank you for coming today, for this surgery we might need to put
you to sleep, so first let me ask you some questions about your health to make
sure you are okay to go, would that be fine ?
P: Yes sure.
D: How are you these days?
P: l am fine, thanks.
Changes
D: Have you had any changes generally in your health since the last
appointment when the surgery was booked?
P: Not really doctor.
P1+ head to toe briefly

Any fever, cough, SOB?
Any Pain while passing urine?
P: No/yes
P2
P: Migraine. EXPLORE
D: For how long?
D: How has it been managed?
P: I am taking sumatriptan.
D: Do you take your medicine regularly as prescribed?
P: Oh yes.
D: Is your migraine well managed?
P: Yes doctor.
D: Have you been diagnosed with any other medical conditions in the past?
P: Acute cholecystitis.
D: Can you tell me more about what happened exactly and how was it
managed?
P: Yes. I had an acute attack and I was hospitalised doctor, later they gave me
this appointment for a cholecystectomy.
40 | P a g e
D: Have you ever been hospitalised for any other reason or had any surgeries
before?
P: No.
D: Ever had any blood transfusion before?
P: No doctor.
MAFTOSA
D: Are you currently on any other medications apart from ….?
D: Does it involve driving – working near/with heavy machines – lifting heavy
objects?
P: I live alone doctor.
D: Can you have anyone stay with you for the first 48 hours after the surgery?
(day case)
D: Any operation may have some complications. We make sure that you are
fine and able to drink and eat before you go home. If you develop any
problems at home, we will need someone to be around you to look after you.
P: Okay doctor I can ask my younger sister to come and look after me.
D: How far away do you live from the hospital?
D: Were you put to sleep before in any previous surgery?
DESAS
D: How is your diet ?
P: Good.
D: How is your physical activity?
P: Good.
D: Do you smoke ?
P: No.
P: No.
P4:
41 | P a g e
D: How are your periods, any problems ?

D: Have you ever been pregnant before?
D: Are you currently taking any contraceptive pills? (v. important)
Examination:
D: If you are OK with it, I would like take your observations BP, temperature,
pulse and breathing rate. I will do a general physical examination including
your heart, lung and tummy. I will check your weight and height as well to
calculate your BMI.
I will also check your airway and your neck movements.
Management:
D: How much do you know about the surgery and are there any specific
concerns you have?
P: Not really, I want to know more about the surgery doctor?
Removal of the gallbladder (cholecystectomy) is considered a relatively safe
procedure, but like all operations, there is a small risk of complications. These
can include infections, bleeding, clotting problems, bile leakage, injury to the
surrounding organs, etc. You may also experience some side effects and
complications from the general anaesthesia. I will provide a leaflet of detailed
information on all of this and also about how we prevent these problems and
manage them if they happen. We always take our precautions for the surgery
to go smoothly.
There are two types of gallbladder removal surgeries, a laparoscopic (keyhole)
surgery or an open surgery.
An open procedure may be recommended if you can’t have keyhole surgery –
for example because you have a lot of scar tissue from previous surgery on
your tummy.
It is also sometimes necessary to turn a keyhole procedure into an open one
during the operation if your surgeon is unable to see your gallbladder clearly or
remove it safely.
42 | P a g e
Once you have had your surgery, you will usually be kept in the recovery room
for a while (maximally 24hs) just to make sure you’re okay to go home. Usually,
the cholecystectomy is done as day surgery, so you do not need to stay in the
hospital unless you feel sick after the surgery. Otherwise, you’re usually
discharged same day.
In any perioperative assessment we usually do some investigations to make
sure that you are fit and well:
− Routine bloods
− Group and safe (Cross match)
− Urine dip stick
− ECG
− CXR
We need to run some tests to make sure you are fit enough for the surgery.
I would like to send for some investigations including routine blood tests, your
blood group and your liver, kidney function. We will check your blood sugar
and bleeding and clotting time. And will do a urine test. In addition, we will
perform just a routine heart tracing and a chest scan.
Hopefully, all the examinations and investigations will be normal and you will
be able to have your operation.
Advice
Let me tell you what you need to take into consideration. You need to stop
eating and drinking 8 hours before the operation. You need an empty stomach
during the surgery, so you don’t vomit while we put you to sleep.
As you are taking sumatriptan, I would advise you to stop taking this medicine
24 hours before the surgery.
Please confirm that you are willing to undergo the procedure of gallbladder
removal?
PATIENT’S CONCERNS:
1. How big will the surgical incision be and will it leave a scar?
2. Will I be losing much blood?
3. I don’t want a blood transfusion as I am a Jehovah’s Witness.
4. Can it be open surgery?
43 | P a g e
Ask:
Is it okay to transfuse your own blood?
Is it okay to transfuse any blood products like platelets & RBCs?
Safety net:
If you develop any
− Fever
− Fever pain in the tummy
− Bleeding
− Shortness of breath and chest pain, hotness, redness or swelling in
your calf
Please come back to us.
Follow up:
We will arrange for follow up reviews after the surgery, you will be seen by
your GP in the next two weeks. You will also be seen by our surgery team in six
weeks to check how you are recovering after the surgery.
Ovarian Cystectomy
Who you are: You are an F2 in Surgery.
Who the patient is: Libby Addams, 23 years old, presents to the hospital with
abdominal pain. Ultrasound has been done and shows Dermoid Cyst in the
right ovary. Consultant has decided to do Open Ovarian Cystectomy with an
Pfannenstiel incision of 8.5 cm.
Additional information: Consultant has decided to keep the patient in the
hospital after the surgery for 2 days.
Special note:
What you should do: Talk to the patient and address her concerns.
D: Hi, are you Libby?

P: Yes.
D: Can you confirm your full name and date of birth ?
P: Libby Adams, 25/04/1999
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D: I can see from my notes that you had an ultrasound some time ago, has
anyone explained the results to you?
P: Yes doctor, after the ultrasound they said I have a cyst in my ovary, and I
have been planned for surgery and I have some concerns regarding the surgery.
OR:
(If nobody explained the results)
D: You have something in your ovary called Dermoid cyst, which is a fluid –
filled sac, which develops in your ovaries , usually it doesn't cause symptoms ;
However, if the cyst becomes enlarged or becomes painful or started causing
any symptoms then we have to remove it surgically.
D: I can see you have some concerns about the surgery I am here to address all
those concerns. But would it be ok if we have a chat about your health, to see
if you are fit for the operation first?
P1: Briefly (Quick, as condition is diagnosed).
D: Tell me more about your tummy pain?
P: I have had this pain for the last few days. Duration
D: How did it start suddenly or gradually? Onset
P: Suddenly.
D: Where exactly is it? Site
P: On the right side of my tummy
D: Does it go anywhere else? Radiation
P: No.
D: Since it started have you had any change for better or worse?
P: It’s getting worse doctor.
D: Can you score the pain for me 1 being least and 10 being the most severe
pain?
P: 7, doctor.
D: Have you noticed any thing that makes the pain better or worse?
D: I believe the pain you are having is being caused by the cyst that we are
going to remove. The cyst is in your right ovary and you said you feel the pain
on your right side also. Would you like me to give you painkillers now for the
pain or should I continue with the assessment for the surgery?
P: It’s OK carry on.
Head to toe very quickly
D: Any fever, cough, SOB
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Any pain while passing urine?
DDx: Ectopic (period)/ Peritonitis (Pain all over)
P: No Doctor.
P2
D: Do you have any long-standing medical conditions (HTN – DM – Bowel
problems)?
P: No.
Have you ever been hospitalised or had any surgeries before?
P: No.
D: Have you ever had any blood transfusions before?
P: No.
MAFTOSA
D: Are you on any medications including OTC or supplements?
P: No.
D: Any Allergies from food or medication?
P: No.
D: Any previous hospitalisations or surgeries in the past?
P: No.
D: Has anyone been diagnosed with any medical conditions in your family?
P: No.
D: What do you for a living?
P: I'm an accountant.
D: Can he/she/anyone stay with you first the first 48 hours after surgery ? (Day
case)
DESA:
D: Do you smoke?
P: Yes/No
D: Do you drink Alcohol?
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P: Yes/No
D: Are you physically active?
P: Yes. I’m quite active.
P4:
D: How are your periods any problems are they regular/ do have any unusual
discharge in between?
D: Are you currently taking any contraceptive Pills? (v. important)
Examination:
D: Thank you for answering these questions, is it alright if I examine you now?
I’d like to take your observations, BP, temperature, pulse and breathing rate, I
will do a general physical examination including heart, lung and tummy. I will
check your weight and height as well to calculate your BMI.
Management
(Counselling about surgery)
Has anyone explained about the surgery?

My consultant thinks that open surgery will be more suitable, incision will be
made on the bikini line.
Pfannenstiel incision, it’s also called a bikini line incision . This is an open
surgery that means that we will open the tummy and remove the cyst.
Note
If the question said open surgery → Talk about open surgery.
If the question said Keyhole surgery → Talk about keyhole
P: Doctor, do I have to have surgery ?

D: Well, this cyst could twist or rupture and bleed leading to serious
complications in the future. In that case we will have to do an emergency
operation. To avoid such a situation, it is best if we remove it now.
P: Will it be painful doctor?
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- During surgery → General anaesthesia.

- After surgery → Painkiller depending on severity of pain.

− Routine bloods
− Urine dip stick
− ECG
− CXR
D: Do you have any concern? May be concerned about surgery complications.
- Worried about pain → Painkillers.

- Worried about bleeding → Bleeding and damage to surrounding structures is
rare and if it happens, we will manage it accordingly. We will do blood
grouping; in case you need blood transfusion. Would you have any problems
with blood transfusions? (Jehovah’s witness?)
- Worried about infection → we will give antibiotics.
Safety netting:
When you go home, come back to hospital if you have:
- Severe pain.
- Redness at site of operation.
- Discharge at site of operation.
- Bleeding at site of operation.
- SOB/Chest pain
How long surgery will be ?

- 45 – 60 min.
How big is the scar ?
- 8 inches ; however , scar will be thin and on the bikini line so, will be covered
by underwear.
When will be able to go home?
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- The consultant decided for you to stay 2 days in the hospital after which you
can go home if no complications.
Is it cancerous?
- Mostly non-cancerous; however , we will send samples of it to the lab for
analysis.
P: Will I be able to become pregnant?
D: You have the cyst in only one of your ovaries for which we are doing the
operation. The other ovary is fine and so you should still be able to become
pregnant.
Lap Cholecystectomy (JEHOVAH'S WITNESS)

Who you are: You are FY2 in the surgical department.
Who the patient is: A 34-year-old lady, Ms. Ashley Ings, has been planned for
laparoscopic cholecystectomy by the consultant.
What you should do: Speak to her and address her concerns.
D: Hello I am one of the doctors in the surgery department, are you Ashley ?
P: Yes.
D: Can you confirm your full name and date of birth for me please.
P: Andrea Henderson 25/4/88
D: Nice to see you, I can see from my notes that you have scheduled surgery,
do you have any idea why we asked you to come here today?
P: Yes doctor, I have been told to come to the hospital for a check-up before my
surgery for the gallbladder removal.
D: Alright thank you for coming today. For this surgery we might need to put
you to sleep, so first let me ask you some questions about your health to make
sure you are okay to go, would that be fine ?
P: Yes sure.
D: How are you these days?
P: l am fine.
Changes
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P1+ head to toe briefly

Any fever, cough, SOB?
Any pain while passing urine?
P: No/yes
P2
P: No.
D: Have you ever been hospitalised or had any surgeries before?
P: No.
D: Ever had any blood transfusion before?
P: No doctor, I am a Jehovah witness.
D: Thanks for letting me know, I’ll inform the surgeon who will do your op.
MAFTOSA
D: Are you currently on any other medications apart from ….?
D: Does it involve driving – working near/with heavy machines – lifting heavy
objects?
P: I live with my husband doctor.
D: Can he stay with you for the first 48 hours ? (Day case)
P: Yes, sure doctor.
DESAS
D: Do you smoke?
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P: No.
P4:
D: Are currently taking any contraceptive Pills? (v. important)
Examination:
D: If you don’t mind I would like take your observations, BP, temperature,
pulse and breathing rate, I will do a general physical examination including
heart, lung and tummy. I will check your weight and height as well to calculate
your BMI.
Management:
Thank you for bearing with me so far Ashley.
− Routine bloods
− Urine dip stick
− ECG
− CXR
We need to run some tests to make sure you are fit enough for the surgery.
I would like to send for some investigations including routine blood test, your
blood group and your liver, kidney function. We will check your blood sugar
and bleeding and clotting time. And will do a urine test. In addition, we will
perform just a routine heart tracing and a chest scan.
Hopefully, all the examinations and investigations will be normal and you will
be able to have your operation.
D: Are you following me so far Ashley?

P: Yes doctor.
D: Do you have any specific concerns on your mind?
P: Yes doctor I want to understand more about the surgery, how it is done and
is there any chance of complications?
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D: Well I definitely understand your concerns, lets tackle them one by one. Till
now has anybody explained about your gall bladder condition?
P: Yes doctor I know I have an inflamed gall bladder that’s why I have the pain.
D: Yes correct. Well, for that inflammation the consultant has decided to do
keyhole surgery to remove the gall bladder. This surgery is a minor surgery and
… etc (discuss as above) everything clear so far?
P: Yes doctor.
D: As with any other procedure, there is always risk of possible complications

like:
− Pain after surgery—we give pain killers.
− Infections—we give antibiotics and monitor you.
− Clotting and PE- Precautions and blood thinners as above.
− Bleeding as well can occur, sometimes it may happen that during the
keyhole surgery if the surgeon is not able to visualise the organs
properly, it may be converted into an open surgery, which carries even a
higher risk of bleeding as the scar is bigger than a keyhole. But don’t
worry we are usually very cautious during the surgery and it’s not that
common for it to happen. Are you with me so far?
P: Yes doctor.
D: However, if this happens we usually prepare bloods to be transfused and it’s
very effective with bleeding. As you mentioned before, you are a Jehovah’s
witness and you don’t want to be given a blood transfusion, right?
P: Yes, Doctor I am a true believer, and I don't think I can take any blood
transfusion.
D: You need to know that blood is the most effective treatment in that case.
Although, I do respect your beliefs about your religion, I have to make sure
that you understand the consequences of refusing blood transfusions because
there are some other options, but blood is the most effective and without it,
the complications can get worse. Do you understand that Ashley?
P: Yes doctor I still don’t want a blood transfusion.
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D: There are other options such as other blood products (which do not have
the main RBC component, these are plasma, cryoprecipitate, albumin,
coagulation factors, immunoglobulins). How do you feel about receiving those?
P: I don’t want any blood products either.
D: Alright Ashley that’s fine we can involve Hospital Liaison Center for
Jehovah’s Witness, I will also have a discussion with my senior to see what
other options might be useful.
− Epidural patches
− Haemodialysis
− Epogen is a man-made form of the protein that stimulates your bone
marrow to produce more red blood cells.
P: I am not sure doctor if I would like these.

D: It’s okay Ashley you don’t have to decide now. How about you discuss this
with your family members and let us know as soon as you have a decision. You
have some time to think, but we wouldn’t want to delay your surgery too long.
Would that be alright?
If still refusing, tell her complications of delaying surgery as well, infection
can increase and spread to blood causing sepsis and shock.
P: Yes doctor, that would be fine.
If you require any more advice with regard to the surgery, or any questions on
religious matters we can help guide you to the relevant authorities in the
hospital. Do you have any other specific concerns that you would like me to
address today?
P: No doctor that's all, thank you.
D: Thank you Ashley.
D: Safety netting:
When you go home, come back to hospital if you have:
- Severe pain.
- Redness at site of operation.
- Discharge at site of operation.
- Bleeding at site of operation.
- SOB/Chest pain
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Delayed Pre-operative Hip Replacement assessment
Who you are: You are an FY2 in the Surgery department.

Who the patient is: Meryl Gatsby 55 years old came to the surgery department
for severe pain in her left knee.
Additional information: she was booked for knee replacement surgery 2 years
back but she never had it as she refused the surgery at that time.
Special note: she is requesting the surgery now.
What you should do: Talk to her address her concerns and discuss
management plan.
Exactly similar to the hx from the previous joint replacement surgery but with
special importance to whether she is fit now for the surgery or not.
Hx parts: 4 major parts; you should explore each to some extent.
− Past: Previous surgery appointment
I can see from my notes that you were scheduled for knee replacement
surgery 2 years back. Explore.
Can you tell me more?
Why did you refuse before?
Why do you want it now?
− Present: Condition now
Analysis of P1 SOCRATES: KNEE pain

D: Site: which knee? / What about the other knee? / Are you able to walk?
D: Onset: How did it start?
D: Character: Can you describe that pain for me?
D: Radiation: Does it go anywhere else?
D: Was it continuous or comes and goes?
D: Duration (time): when did it start exactly?
D: Alleviating factors: Does anything makes it better ?
D: Exacerbating Factors: Does anything makes it worse?
D: Severity: Can you score the pain for me on a scale from 1 to 10, 1 being the
least and 10 being the highest pain possible?
D: Have you tried anything for the pain?
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D: Anything else with the pain? Open Q before asking about DDx.
Changes
Head to toe briefly
Any fever, cough, SOB
Any headache or flu-like Sx
Any diarrhoea or constipation.
Any pain while passing urine
P2 Briefly
Do you have any long standing medical conditions?
Have you ever been hospitalised or had any surgeries before?
P3: DESA
D: How are you with physical activity ?
D: Do you smoke ?
P4:
D: Are you currently taking any contraceptive Pills? (v. important)
− SOCIAL HX
MAFTOSA
D: Do you have any medical conditions?
D: Are you currently on any medications?
D: Can he/she/anyone stay with you for the first 48 hours after surgery? (Day
case)
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D: How is your mood?
− CRITERIA FOR KNEE REPLACEMENT:
• Severe pain affecting her daily activities.

• Pain while resting or at night.
• BMI should be less than 30.
Examination:
As before.
Management:
Same counsel and address concern.
IF FIT:
As far as I am concerned you fit the criteria for the surgery. I am glad that you
have reconsidered and come back for the surgery, I will have to talk to my
senior and have a chat with him about your condition, at some point he will
talk to you and will assess you as well to see if anything else is needed.
IF NOT FIT: BMI is more than 30
− Apologise
− Offer painkillers
− Explain that the knee and the hip are weight bearing joints therefore
high BMI can exert a lot of pressure on the new joint prosthesis and may
cause the surgery to fail. ADVISE ABOUT DESA AND LIFESTYLE, BE
GENTLE AND INVOLVE YOUR SENIOR.
− Say the NHS provide criteria that one should satisfy before going for
surgery and unfortunately currently she is not meeting those criteria.
Offer the management option at this point and tell her you can book a
second follow up for reassessment for fitness to surgery.
Safety net
Same as before.
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Acute Pancreatitis
Key points: Consider these groups of questions to:
To reach Diagnosis To reach Causes To reach if there are

(Symptoms) (Risk Factors) any Complications
1. Pain in the abdomen 1. Gall stones (ask 1. Necrosis.

refers to back. about Hx of gall 2. Respiratory failure
2. Tenderness on stones or Hx of (ARDS)
abdomen procedure to remove (v. common).
3. Feeling or being sick stones).
(vomiting). 2. Alcohol.
4. Diarrhea.
3. Others: I GET
5. Fever.
SMASHED
6. Jaundice.
→ Side effects.
→ Virus mumps.
→Auto-immune.
❖ To reach diagnosis → Investigations

1. Blood tests:
− Bilirubin.
− ALT. Liver
− AST.
− ALP. Obstruction or bone
− Amylase.
Pancreas
− Lipase.
− GGT. Alcohol
2. USS → Picture of gall bladder (stone).
3. CT on abdomen.
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❖ At any case where there is Jaundice → you must ask about (Clinical picture
of Obstructive Jaundice).
1. Dark urine.
2. Pale stool.
3. Itching.
Who you are: You are an Fy2 in the emergency department
Who the patient is: 45 year old Rachel Fernandez came to A&E with severe
abdominal pain.
What you should do: Talk to her, take relevant history, discuss plan of
management and address her concerns.
D: Hello Rachel, I am one of the doctors in the emergency department. Can I

get your full name and age please.
P: Rachel Fernandez, I am 45 years old doctor.(The patient might be in pain
keeping a specific position so please don’t forget to acknowledge and reflect at
once)
D: I can see you’re holding your tummy Rachel , are you in any pain now? How
can I help you?
P: Yes, doctor I have severe pain in my upper tummy it’s very bad doctor.
P1: SOCRATES
D: Site: Where is the pain exactly? / Can you point with one finger?
P: Epigastrium (all over tummy if Peritonitis)
P: Started Suddenly
D: Character: Can you describe the pain for me?
P: Severe, agonising pain.
P: It’s going to my back doctor.
D: Is it continuous or comes and goes?
P: It is continuous doctor.
P: …… yesterday but got really bad today.
D: Alleviating factors: Does anything make it better ?
P: When I lean forward like this doctor (she might or might not be leaning
forward with her chest)
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D: Exacerbating Factors: Anything that makes it worse?

P: It’s always bad.
P: 10 its very severe doctor.
(You can reflect with one or two words here and show empathy with your facial
expressions “Oh it sounds very painful, just a few more questions and I will do
my best to help with the pain”)
REMEMBER TO ACT ☺
P: No doctor.
D: Anything else with the pain? Open Q before asking about DDx.
D: Have you got any nausea or vomiting, fever or diarrhoea?
D: Have you noticed any change in your skin colour lately?
P: No.
Remember any tummy pain means: Chest…Bowels…Urine…Genitals

(maximum 1 or 2 Qs each).
DDx
D: Any cough or chest pain with it that goes to your left side? (If old age you
must exclude MI.)
D: Any problems with your bowels recently like constipation?
D: Any pain while passing urine or change in its colour or smell ?
D: Any discharge from your front passage.
D: Any appetite change or weight loss lately? FLAWS
ICE:
D: Any idea what might be the cause? Were you doing anything specific before
the pain started?
D: Do you have any specific concerns regarding this pain?
D: Apart from the pain are you expecting anything in particular today?
P2:
D: Have you ever had this pain before?
D: Do you have any medical conditions? Like any stones?
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D: Have you ever been hospitalised or had any procedures like stone removal
before?
MAFTOSA:
D: Any similar tummy problems in your family?
DESA:
D: Do you smoke or drink alcohol? (It’s an emergency so only ask about
these)
Examination:
D: Thank you for bearing with me so far. If you can bear with me a bit longer, I
would like to take your observations BP, temperature, pulse and breathing
rate, examine your tummy and do a general physical examination, if you don’t
mind.
Provisional Diagnosis
From the information that you have given me, I suspect that you have
inflammation called Acute pancreatitis. It is an inflammation that causes one
of the major organs that shares in food digestion called the pancreas to
become painful and swollen.
Management:
Most people with this condition start to feel better within about a week and
have no further problems. But some people with severe acute pancreatitis can
go on to develop serious complications.
Therefore we will need to take some urgent steps right now to confirm the
diagnosis and start management as well.
1. We will need to Admit you to the hospital ( v. important).
2. I will involve my Senior as we will need to run some Investigations.
3. Investigations:
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− Blood → All blood + Special Pancreatic markers called Amylase + Lipase.

(Infection markers and blood sugar)
− X-ray → erect on chest and abdomen (must exclude perforation).
− US → to have a good visualisation of gall bladder to exclude stones and
AA Aneurysm.
− CT → Better picture of abdomen (and to exclude pancreatic necrosis).
By senior.
4. Mainly supportive + TTT Cause.

− Painkillers: immediately
− Fluids through your veins to prevent dehydration.
− Oxygen through face mask or nasal cannula to make sure your body
gets enough O2.
− You may need Antibiotics if you have infection on top like chest or
urine infection.
Nutrition:
− If not feeling too sick we can encourage you to eat and drink normally.
− But if the condition is more severe, better not to eat solid foods for a
few days or longer to avoid too much strain on your pancreas. You will
then be given a special liquid food mixture, with the nutrients you
need, through a tube to your nose that reaches your tummy called a
nasogastric tube (or NasoJejunal tube)
We will continue to monitor your observations, tummy symptoms, blood sugar

and pancreatic markers.
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5. Managing the cause:

− Advice against excessive alcohol consumption, discuss DESA advice at a
later appointment when you feel better. (May be with the GP)
− Discuss statins if high cholesterol.
− If stones: Refer to specialist who will do further investigations and will
give you options to remove the stones by a special camera test called
ERCP or removing the gall bladder by a surgery.
6. Safety net:
Please ring this bell if you feel you’re getting worse or persistent pain, or
if you feel drowsy, fever or not passing urine.
7. Follow up: it improves within a few days or a week in most situations unless
complications develop. Complications include:
− Pseudocyst (resolves on its own).
− Infection/necrosis which is treated by antibiotic according to
hospital protocol and surgery.
− Chronic pancreatitis.
IN A NUTSHELL :
1- ANALYSE PAIN VERY WELL (LEANING FORWARD )

2- STONES OR ALCOHOL AND FAMILY
3- PANCREATIC MARKERS (AMYLASE AND LIPASE)
4- MANAGEMENT ADMIT SUPPORTIVE
5- NUTRITION: EAT OR NG TUBE
ACUTE CHOLECYSTITIS
Who you are: You are an F2 in A&E.
Who the patient is: Martin Atkinson, 60 years old, came to the emergency
department with pain in his abdomen.
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What you should do: Please talk to him, assess and discuss your plan of
management with him and address his concerns.
D: Hello I am one of the doctors here in the emergency department, can I get
your full name and age please ?
P: I am Martin Atkinson I am 60 years old.
D: How can I help you? (Acknowledge if he is maintaining any specific posture)
P: I am having really bad pain in my right upper tummy doctor (right
hypochondrium)
D: Oh it seems like you are in real pain, I am sorry about that, can you tell more
about this pain Martin ?
P1 SOCRATES (recap whatever he mentions instead of asking again)

D: Site : You mentioned that the pain is in your right upper tummy / Can you
point with your finger to the pain?
P: (Patient will point to his right hypochondrium)
P: It started suddenly doctor.
P: It is a very sharp pain doctor.
P: Yes it goes to my right shoulder.
D: Was it continuous or comes and goes?
P: It has become continuous since it started doctor.
D: Duration (time): When did it start exactly?
P: It started this morning.
D: Alleviating factors: Does anything make it better?
P: No doctor it’s always bad.
P: Whenever I try to inhale the pain gets worse.
P: Around 8-9 doctor.
P: No.
D: Anything else with the pain? Open Q before asking about DDx
D: Any fever, N/V or sweating or feeling sick or dizzy? Infection and sepsis
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P: No (maybe fever)
D: Have you noticed any change in your skin colour lately? Jaundice
P: No.
D: Have you got any bowel problems lately? Diarrhoea or constipation? GUT
D: Do you have a cough or any chest pain that goes to your left side? Chest
D: Any problems with your waterworks? Urine
D: Have you sustained any trauma to this area?
P: No.
D: Have you noticed any lumps or bumps , weight loss , appetite changes
recently ? FLAWS
ICE
IDEA
D: Any idea what might be causing the pain? / Were you doing anything
specific before the pain started?
CONCERN
D: Do you have any specific concern regarding this pain?
EXPECTATION:
D: Are you expecting anything today in particular from us?
P2:
D: Have you had any similar problem in the past?
P: No (maybe yes if recurrent Calculi)
P: I have had hypertension for ten years now and I am on Amlodipine for it.
D: Any DM, heart disease or cholesterol problems?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
MAFTOSA
D: Are you taking any medications including OTC or supplements? (If female
ask about COCP)
P: No.
D: Any allergies from any food or medications?
P: No.
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D: Has anyone in your family been diagnosed with any medical conditions?
P: No.
DESAS (if very severe pain and an emergency don’t go in depth)
D: Do you smoke?
P: Yes/No
P: Yes.
P: I try to eat healthy. Or, eating a lot of fatty food fast food. Etc
P: I don't have much time.
D: Do you have any kind of stress?
P: No.
P: With my wife.
Examination:
D: Thank you for bearing with me so far. If you don’t mind, I would like take
your observations BP, temperature, pulse and breathing rate, I will examine
your tummy and especially your right upper tummy for a specific type of pain
called a Murphy sign. I will also do a general physical examination.
I would like to send for some initial investigations including Routine Blood Test,
kidney and liver function tests. I would also check for infection and
inflammatory markers called CRP.
Examiner may give you findings as Temperature: 38.5 or CRP high.
WATCH OUT ALWAYS SCAN THE ROOM IT MIGHT BE AN ABDOMINAL
EXAMINATION COMBINED STATION AND YOU WILL HAVE TO CUT THE HX
SHORT AND DO THE ABD EXAM
From the information that you have given me I suspect that you have an
inflamed Gall bladder. Sometimes it accumulates stones that causes blockage
and infection making the bladder swollen and painful. The condition is called
Acute cholecystitis.
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Types of Acute cholecystitis:

Calculous cholecystitis
Calculous cholecystitis (most common, and less serious) it develops when the
main opening to the gallbladder, (cystic duct), gets blocked by stones that are
formed from concentrated bile that is usually used to digest fat.
This bile builds up in the gallbladder, increasing the pressure inside it and
causing it to become inflamed or even infected (1 in every 5 cases)
Acalculous cholecystitis
Acalculous cholecystitis is less common, but a more serious type that develops
as a complication of a serious illness, infection or injury that damages the
gallbladder. (Major surgery, burns, sepsis, severe malnutrition or HIV/AIDS) no
stones are involved here.
Management
1- We need to Admit you for regular monitoring of your observations and

symptoms.
2- Senior: I will also need to involve my senior to run some further testing.
3- Investigations:
FBC, infection markers, LFT/KFT/U&E, S. cholesterol, S. Calcium, urine
dipstick.
ECG
Imaging: erect X-Ray, Abdominal US.
4- Symptomatic treatment:
− Supportive: NPO - O2- IV fluids- IV antibiotics (broad spectrum
according to hospital protocol)- Painkillers.
− Elective surgical removal following the specialist surgical advice.
− Long-term management of the cause: manage high cholesterol, Statins
if needed, if taking OCPs, it can be changed after consultation with the
patient.
− Advice about DESA: healthy lifestyle avoid too much fast food ,
exercise regularly, Alcohol and smoking.
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- Specialist referral for evaluation and further investigations and imaging such
as CT or MRI. Elective surgery may be required after resolution of infection to
prevent recurrence.
Surgical options depend on patient’s condition:
Laparoscopic cholecystectomy – a type of keyhole surgery where the
gallbladder is removed using special surgical instruments inserted through a
number of small cuts in your abdomen.
Single-incision laparoscopic cholecystectomy – where the gallbladder is
removed through a single cut, which is usually made near the bellybutton. It is
only done by more experienced surgeons.
Open cholecystectomy – where the gallbladder is removed through a single
larger cut in the tummy.
5- Safety net: Fever, jaundice, persistence of symptoms.
Keyhole surgery to remove the gallbladder

• Also known as a laparoscopic cholecystectomy.
• 2-3 small cuts are made in your right abdomen side (each 1cm or less)
and a larger one (about 2 to 3cm) by the belly button. Your abdomen is
temporarily inflated using harmless gas making it easier to see and
operate inside.
• A special thin video camera called laparoscope is inserted through one of
the cuts to help the surgeon see and remove your gallbladder using
special surgical instruments.
• X-ray or ultrasound scan of the bile duct for residual stones will be done
and if found will also be removed during the operation.
• Finally the gas in your tummy escapes through the laparoscope and the
cuts are closed with dissolvable stitches and covered with dressings.
• The operation is done under general anesthesia, which means you'll be
unconscious won't feel any pain while it's carried out.
67 | P a g e
• The operation takes 60 to 90 minutes, and you can usually go home the
same day.
• Full recovery typically takes around 10 days.
If the operation can't be done this way, or an unexpected complication occurs,

it may have to be converted to open surgery.
A laparoscopic cholecystectomy may not be recommended in these cases:
− Pregnancy third trimester
− Extremely overweight
− Unusual gallbladder or bile duct anatomical structure making the
procedure more difficult or dangerous.
Open surgery
• A 10 to 15cm incision is made in the abdomen, underneath the ribs, so
the gallbladder can be removed.

• Also under general anesthesia, so you won't feel a thing.
• It is as effective as Keyhole surgery, however it requires a longer
recovery time (up to 5 days in the hospital and 6 weeks to fully recover)
and causes more visible scarring.
Endoscopic retrograde cholangio-pancreatography (ERCP)

• It is a procedure in which a special long a thin flexible camera called an
endoscope is passed through your mouth down to where the bile duct
opens into the small intestine.
• It can diagnose and remove gallstones from the bile duct as it can widen
this opening by small heat induced incisions allowing the stones to be
removed or pass later to the intestine and come out with stools. A small
supporting piece called stent can then be permanently left in the duct to
keep it wider and prevent recurrence.
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• The gallbladder isn't removed, and further surgeries may be required to

remove the stones there depending on their size.
• Usually done under sedation, which means you'll be conscious but won't
experience any pain.
• It lasts from 15 minutes to over an hour with an average of 30 mins.
• You may need to stay in hospital overnight to be monitored and make
sure that you are recovering well.
Biliary Colic
Who you are: FY2 in the GP clinic.

Who the patient is: Rebecca Adams 42-year-old female presented to A&E with
abdominal pain under her ribs on right side.
What you should do: Talk to the patient, discuss a plan of management, and
address her concerns.
D: Hello I one of the doctors in the GP surgery here, can I get your full name
and date of birth please ?
P: Rebecca Adams, 5/5/1980.
D: How can I help you? (Acknowledge if she is maintaining any specific
posture)
P: I am having really bad pain in my tummy doctor.
D: Oh it sounds dreadful I am sorry about that. Can you tell more about this
pain Rebecca ?
P1 SOCRATES
D: Site : Can you tell me where the pain is exactly? / Can you point you’re your
finger?
P: It is in the middle and the right upper parts of my tummy doctor (Patient will
point to her epigastrium and right hypochondrium)
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P: It is a very sharp pain.
D: Radiation: Does go anywhere else?
P: Yes it goes to my right side and my right shoulder blade.
D: Is it continuous or comes and goes? Recap don’t ask again
P: It started few hours ago since this morning.
D: Alleviating factors: Is there anything that makes it better ?
P: Nothing doctor. (The pain is not relieved by going to the toilet or passing
wind)
P: When I breathe doctor.
P: Around 7-8 doctor.
P: No.
D: Anything else with the pain? Open Q before asking about DDx (Same as
before)
D: Any fever, N/V or sweating or feeling sick or dizzy? Infection and sepsis
P: No or yes may be N&V or sweeting but no FEVER
P: No.
D: Have you got any bowel problems lately diarrhoea or constipation? GUT
D: Any chest pain that goes to your left side? Chest (MI)
P: No.
D: Any problems with your waterworks or urine smell or colour? Urine
P: No.
P: No.
recently ? FLAWS
ICE
IDEA
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P: Yes, doctor I think it is triggered by eating heavy fatty foods (the pain may
happen at any time of day and may wake me up at night)
CONCERN
P: Yes doctor I have had this pain once before I am a bit worried now. I want to
know why I am having this. (EXPLORE what happened last time)
EXPECTATION:
P: I want something for the pain and some advice about how to prevent it in
the future doctor.
D: I appreciated your concerns Rebecca, I would like to ask you a few more
questions to get to the bottom of this, would that be alright?
P: Yes.
P2:
D: You mentioned you had similar pain in the past can you tell me more like
when exactly and what did you do then ? Recap instead of asking.
P: I had the same pain a few weeks ago after a heavy meal it woke me up at
night, it persisted for a few minutes and improved alone. (Usually lasts 1 to 5
hours, although it can sometimes last just a few minutes.)
D: Have you been diagnosed with any medical condition in the past or stones
or cholesterol problems?
P: No.
P: No.
MAFTOSA
D: Are you taking any medications including OTC or supplements? (If female
ask about COCP)
P: No.
P: No.
P: No.
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DESAS (Is a must here)

D: Do you smoke?
P: Yes/No
P: Occasionally.
P: I eat a lot of fast food.
P: I don't have much time.
P: Yes, I could say so, I am a lawyer.
Examination:
D: Thank you for bearing with me so far. If you don’t mind, I would like to take
your observations BP, temperature, pulse and breathing rate. I will examine
Murphy sign: The GP places their hand or fingers on the upper-right area of
your tummy and asks the patient to breathe in, if painful, then indicates an
inflamed gallbladder.
I would like to send for some initial investigations including Routine Blood Test,
kidney, and liver function tests. I would also like to check for infection and
inflammatory markers.
Provisional Diagnosis:
From what you said I'm suspecting that you have an inflamed Gall bladder. It
usually stores a green fluid that is secreted by the liver and helps digest fats
which is called bile. Sometimes the bile gets too thick forming stones that
accumulate and block the main outflow of the bladder. Gallstones don't
usually cause any symptoms but if the blockage is more severe it can cause
the bladder to be swollen and painful like what you described. This is called
biliary colic.
Are you following me so far?
Many factors can increase the risk of having gall stones such as:
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Remember the 5Fs

− Being a Female
− Fatty: Obesity high cholesterol levels, unbalanced meals, and fatty foods
− Fertile: pregnancy, COCPs and HRTS
− Forty: 40 years or older (the older you are, the more likely you are to
develop gallstones)
− Family hx
Most gall stones are simple however they might get complicated if they
obstruct the biliary out flow for longer time or at critical sites. They might
cause Serious infections with sever Sx as fever persistent pain dizziness (Acute
cholecystitis) or yellow skin discolouration chills and confusion (Acute
cholangitis) or Acute pancreatitis.
Management:
1- No admission needed
2- Involve Senior.
3- Investigations: as above especially in cholecystitis
− routine Bloods (LFTs/Inflammatory and infection markers)
− US scan
4- Symptomatic treatment depending on patient symptoms and impact on
life
− Mostly supportive Rest, plenty of fluids, and Painkillers
− DESA advice:
• Good Diet with moderate amounts of fat and having regular
meals with fruits and vegetables.
• Lose weight.
• Avoid food triggers like saturated fat (as fatty meats sausages
and hard cheeses) or spicy food and alcohol
• Exercise more
• Statins for high cholesterol
− Ursodeoxycholic acid tablets to dissolve the stones if small and
don't contain calcium.
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5- Refer to a specialist Gut surgeon who might request some further

investigations and imaging depending on the symptoms as:
− MRI (for bile duct stones)
− Camera test called ERCP (help diagnose and treat small bile duct
stones)
− CT (to assess pancreas)
➢ If symptoms are more severe and frequent, surgery to remove the

gallbladder might be recommended. The gallbladder isn't an essential organ
and you can lead a normal life without one.
Surgical options as mentioned above.
6- Safety netting.
• Come back to see a GP if you think you are having another attack.
• Contact your GP immediately for advice if you develop:
− Abdominal pain lasting longer than 8 hours
− Intense pain all over the tummy for which you can't find a
position to relieve it
− Jaundice
− High fever and chills
If it's not possible to contact your GP immediately, phone your local out-of-
hours service or call NHS 111.
PS: ONLY FOLLOW THE PATIENT CONCERNS, BE PATIENT CENTRED WITH YOUR CONSULTATION.
YOU DON’T HAVE TO MENTION EVERYTHING ONLY WHAT THE PATIENT NEEDS.
ACUTE CHOLANGITIS
Who you are: You are an FY2 in the Emergency department.

Who the patient is: Maria Gomez 45-year-old female came to the A&E with
severe pain in her right upper abdomen.
Additional information: Maria looks very sick, and she feels dizzy.
74 | P a g e
What you should do: Talk to Maria, take relevant history, discuss a proper plan
of management and address her concerns.
D: Hello I am Dr (name) one of the doctors here in the Emergency

department, can I get your full name and date of birth please ?
P: Maria Gomez, 6/5/78.
D: How can I help you ? Acknowledge if she is maintaining any specific posture
P: I’m having a very sharp pain.
D: Oh it sounds bad, I am sorry about that. Can you tell more about this pain
Maria ?
P: It’s in my right upper tummy doctor?
P1 SOCRATES recap what she said don’t ask again, show active listening
D: Site : You said the pain is in your right upper tummy. Can you point with
your finger to it?
P: (Patient will point to her right hypochondrium )
D: Character: You mentioned the pain is sharp can you describe it more?
P: It is very bad doctor.
D: Radiation: Does go anywhere else?
P: Yes it goes to my right shoulder.
D: Was it continuous or comes and goes? Recap don’t ask again
P: It started a few hours ago, since this morning.
P: Nothing doctor.
P: Its always bad.
P: Around 9 doctor.
P: No.
D: Anything else with the pain? Open Q before asking about DDx (Same as
before)
75 | P a g e
D: Do you feel sick or like you have fever or chills or sweating ? Infection and
biliary sepsis
P: Yes, doctor I feel very sick I am sweating heavily and I have chills all-over
D: You mentioned you are sweating do you have nausea or vomiting?
P: Yes doctor I vomited once and I am very nauseous.
P: Yes, I think my skin is a bit yellowish.
D: Do you have any itching?
P: Yes.
D: Have you got any problems with your bowels (colour or blood) ? GUT
(autoimmune IBD with Primary biliary cholangitis)
P: No or Pale stools (or blood in stools)
D: Do you have chest pain that goes to your left side? Chest (MI)
P: No.
D: Any problems with your waterworks or urine smell or colour? Urine
P: I think my urine is a bit darker than usual.
P: No.
recently ? FLAWS (PBC)
ICE
As before
P2:
D: Have you ever had similar attacks before?
P: No or yes as Colic pain.
D: Do you have any medical conditions such as stones or liver or cholesterol
problems?
P: No.
D: Any immune problems?
P: No.
P: No.
MAFTOSA
As before
76 | P a g e
Important (autoimmune profile)
P: No.
DESA- an emergency so don’t ask in depth

D: What about drinking and smoking?
P: Yes/No
Examination:
D: Thank you for bearing with me so far. If it’s OK with you I would like take
your observations BP, temperature, pulse and breathing rate. I will examine
I would like to send for some initial investigations including Routine Blood
Tests, kidney and liver function tests. I would also check for any infection and
inflammatory markers.
Findings handed may be

− High fever
− Enlarged liver or spleen
We have in our body something called a bile duct, which carries a special type
of greeny yellow liquid called bile, from the liver and gall bladder to our small
bowel to digest and absorb fats. Sometimes this bile becomes too thick and
develops stones that cause a block in that duct behind, and so inflammation
and infection occurs. From what you said so far, you mentioned (list some of
the +ve findings), and during my examination I found that (mention positive
signs ) . So, I suspect your bile duct may be inflamed and infected and this is
called acute cholangitis.
Management:
1- It’s an emergency condition so it is better that we Admit you to the
hospital for monitoring and proper treatment.
2- Senior.
3- Investigations (remember: –Bloods –Stool -Urine -image)
• Routine bloods
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− CBC high WBCs

− High Inflammatory markers (CRP)
− Liver functions probably high
− Kidney functions
− Auto immune markers (anti mitochondrial Antibodies) ??
• Blood Culture.
• Urine and stool analysis.
• Imaging:
− X-ray → cholangiogram dye.
− US.
4- Treatment
• Oxygen
• NPO
• Fluids → through your veins
• Painkillers
• Antibiotics → For 10 days according to hospital protocol for a week.
• Colestyramine or SSRIs for itching
• Ursodeoxy cholic acid → improve bile flow.
5- Specialist
May offer further investigations and suggest surgical treatment to open the
blocked duct.
− CT.
− ERCP or MRCP by specialist
(As above)
• Most patients with acute cholangitis respond to antibiotic therapy
but endoscopic biliary drainage of the infected bile is ultimately
required to treat the underlying obstruction.
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• Endoscopic therapy → Balloon dilatation may be used to open up

duct and increase flow of bile. You may need endoscopic therapy
several times, under local anesthesia.
• Surgery → to insert a stent or remove the blocked part.
6- Treatment of some of the complications of cholangitis:

− High BP → Your doctor may need to treat and monitor your ↑↑ BP in
liver (if there is portal hypertension).
− Weakening of bones (osteoporosis) → we may prescribe calcium and
some vitamins.
− Nutrition → You may be prescribed some vitamins (A / D /E/K) as
cholangitis can reduce absorption of some vitamins.
− Watch out for easing bruising or bleeding tendencies.
7- Safety netting as above
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IN A NUTSHELL :D
BILIARY COLIC ACUTE CHOLECYSTITIS ACUTE CHOLANGITIS
Only Biliary Colic Pain Same but more sever Colic CHARCOT TRIAD
otherwise patient is well Pain +
• Centre or Right • Very severe Colic
epigastrium of • Fever. pain (Rt epigastrium)
abdomen, spread • Feeling Sick. • High fever.
to RT shoulder • Labs • Jaundice
• Constant pain not Inflammatory Also may be
relieved by going markers raised • Sepsis
to toilet. CRP. • Confusion
• Recurrent attacks • LFT may be • Maybe autoimmune
a few Weeks to deranged. (IBD)
Months apart. • US Scan. • Labs:
• May be triggered • TTT: − WBC
by fatty food and − Admit elevated.
stress. − Oxygen − Infection and
• RFs: Female Fatty − Pain killers inflammatory
fertile Forty − Fluids markers.
Family − Antibiotics − LFTs probably
• Bloods normal, − NPO elevated.
LFTs normal − Refer to − US.
• US scan Gastro For − ERCP –MRCP
• TTT: surgical specialist
− Supportive options • TTT:
no Same as
admission Cholecystitis
− Painkillers +
− Rest ERCP and urgent
− Fluids drainage may be
− DESA advice required
− Elective
surgery
80 | P a g e
ACUTE DIVERTICULITIS
Who the patient is: Ambreen Morshed, 46-year-old female, came to you with
sever lower abdominal pain. She is extremely worried.
Additional information: the nurse has taken the patient’s vitals just a few
minutes ago.
Special note: Patient notes have been left by the nurse inside.
What you are supposed to do: Go talk to the patient, take relevant history,
(+/- Do relevant examination) and address her concerns.
(In these type of query combined cases, always scan the room for a
mannequin before you start taking history to prepare yourself and
notice if it is an examination station as early as possible)
D: Hello Ambreen, my name is doctor (name) I’m one of the doctors in the
emergency department. Can I get your full name and age please.
P: It’s Ambreen Morshed, I am 51 years old doctor. (The patient might be in
pain keeping a specific position so please don’t forget to acknowledge and
reflect at once)
D: I can see your holding your tummy Ambreen , are you in any pain now? How
can I help you?
P: Yes doctor I have pain in my lower tummy it’s very bad doctor.
D: Seems like you are having a difficult time. Rest assured I will be doing my
best to get the bottom of this.
P: Okay doctor.
D: Are you able to talk to me now?
P: Yes doctor.
P1: SOCRATES
D: Site : You mentioned the pain is in your lower tummy, can you point with
one finger where it is exactly?
P: It is all over my lower tummy right here to my left side doctor (patient may
point to the left Iliac fossa)
P: Started gradually doctor
P: it’s a very dull compressing pain.
81 | P a g e
P: No.
P: Initially it was on and off doctor but now it is continuously there.
P: 3 days ago.
P: Nothing or gets better after pooing or farting.
P: Not really it is always there or may say it tends to come and go and gets
worse during or shortly after eating.
P: 7/8 What to think about when there is
lower abdominal pain: (3 or 4 DDx
one or two questions each)
P: Yes doctor I have tried paracetamol but it did not
help. DDx:
• Female causes: PID,
D: Have you sustained any trauma to this area? Ectopic, Ovarian Torsion,
P: No doctor. miscarriage
D: Do you have anything else bothering you? • Cystitis (suprapubic pain)
P: I have been feeling hot lately doctor. • Urinary retention (in old
D: (Explore) for how long? male: look for prostate
P: About 2 days now. causes, including BPH and
D: Have you measured your temperature ? prostate cancer)
P: No. • UTI (upper and lower)
D: Anything else?
• Appendicitis
P: I also feel very sick.
• Diverticulitis (L iliac fossa)
D: Since when have you felt like that?
P: Since yesterday. • Trauma
D: Apart from the pain and the temperature what do • IBD
you mean by feeling sick?
P: I feel nauseous and I have had constipation for a while now.
D: Oh I see, have you vomited ?

P: No doctor.
D: You mentioned constipation, can you tell me more?
D: For how long have you had it?
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P: I have had it for two days now.

D: Are you passing wind?
P: Yes.
D: When did you pass last time?
P: This morning.
D: How did it start and how were your bowel habits before?
P: I am not sure doctor how it started but I’m fine with my bowels.
D: Anything else?
P: No.
D: Do you have any bloating or diarrhoea?
P: No.
D: Any bleeding from your back passage or have you noticed any blood or
mucus in you stool ? Cancer or IBD
P: No or maybe yes (blood and mucus can also be a sign of Diverticular disease)
D: Do you feel that pain increases after eating?
P: No.
D: Does emptying the bowel or passing urine ease your pain?
P: Yes/No
D: Any problems with your water works? (UTI)
P: No.
D: Any burning urination or smelly or cloudy urine?
P: No.
D: Any discharge from your front passage? (PID or Miscarriage)
P: No.
D: Any appetite changes or weight loss recently? FLAWS (Cancer or IBD)
P: No.
ICE
IDEA
P: Nothing specific doctor I was just lying down when it started.
CONCERN
D: Apart from everything you mentioned, are you worried about anything in
particular?
P: Might bring up the constipation or other Sx if you missed things above
(Concerns are important in every Plab 2 station) whatever she gives you
reflect and use it
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EXPECTATION:
D: Are you expecting anything specific today?
P: I want to know why I am having all of this and is it related?
P2
D: Have you had a similar kind of problem in the past?
P: I have had problems with constipation multiple times before but never pain.
P: No.
D: Any bowel disease such as IBD/Polyp?
P: No.
D: Any previous hospital stays or surgeries recently or in the past?
P: No.
MAFTOSA
D: Are you taking any medications including OTC or supplements or painkiller
other than PCM you took (Codeine can cause constipation, Ibuprofen and
Aspirin increase the risk)?
P: No.
D: Any family members ever complained of similar bowel problems?
P: No.
DESA
P: It is fine.
D: Do you eat enough fiber? Veggies and fruit?
D: Do you drink enough water?
P: I would say I drink frequently (or Yes I drink properly Doc)
D: How is your physical activity?
P: I don’t exercise much doctor.
D: Do you smoke or drink alcohol?
P: No.
P4 (careful the age of the female) (pregnancy – periods – Pills )

D: I am going to ask you a few more questions that may sound intrusive but it’s
all part of my consultation alright?
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P: Okay doctor.
D: Do you have any problems with your periods? Are they regular?
P: No they are fine and yes regular.
When was your Last Menstrual Period? (Ectopic pregnancy)
P: 3 weeks ago.
D: Are you sexually active?
P: Yes.
D: Do you practice safe sex?
P: Yes
D: Are you using any contraception?
P: We only use condoms, (IUD increase the risk of Ectopic Pregnancy)
Examination
D: Thank you for bearing with me so far, the nurse has just taken your
observations so I will have a look at them.
I would like to examine your tummy now and do a general physical. Would
that be okay?
Findings: Vitals: Temp: 38-39C ,,,, Pulse: 110/min ,,, BP: 130/80 ,,, RR:12-20 ,,,
O2 sat – 96%
Abdominal examination left iliac fossa pain with superficial and deep
palpation
Provisional diagnosis:
D: Well considering all you have mentioned about the constipation, the blood
and mucus in your stools and how you described the pain (basically whatever
she mentioned positive) and from my examination we found you have a fever
and pain in the lower left part of your tummy. I am suspecting you might be
having diverticulitis. In diverticular disease, small bulges or pockets
(diverticula) develop in the lining of the intestine. Diverticulitis is when these
pockets become inflamed or infected. Are you following so far?
P: Oh doctor so how did I get it?

D: One of the main risk factors is not eating enough Fiber which causes the
bowels to move much slower and constipation occurs. With recurrent
constipation the pressure in your large intestine increases leading to the bulges
85 | P a g e
of its wall. Later if they get inflamed or infected it will cause you pain and a
fever like what you have now. Are things a bit clearer now?
Management:
Acute diverticulitis can be serious and cause bad complications however luckily
we have a lot of treatment options to avoid that:
1. We would like to Admit you to the hospital to give you the best treatment,
until we make sure that is safe for you to go home.
2. I will involve my senior to have a look at you as well.
3. We will need to run some Investigations:
− Routine bloods and infection markers
− Stool analysis
− X-ray Imaging of your chest and tummy while standing and sitting
− Ultrasound of your tummy.
4. Treatment:
− Oxygen if needed
− Fluid only diet or NBM
− Fluids if unstable.
− Painkillers (higher dose of pcm or something else but I will have to
check with my senior)
− Antibiotics according to hospital protocol.
− Anti-sickness meds
− Laxative, to relieve the constipation.
5. Will involve a Gut specialist who may require some further imaging such as
CT, a special camera test called colonoscopy that will help him/her to see
the small the bulge in your large intestine.
The majority of attacks are treated sufficiently with this management.

However if things don’t improve sometimes surgery is needed to remove the
damaged part of the large intestine depending on the gut specialist’s advice.
6. After wards when you feel better we will have to discuss some lifestyle
advice to treat constipation and prevent further attacks.
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(DESA advice)
− Encourage high-fiber diet after the attack, aiming to eat about 30g of
fiber a day.
High fiber diets are vegetables, fruits, beans and pulses, nuts,
cereals, and starchy foods.
− Drink fluids and keep hydrated.
− Fiber supplements (powder sachets that you mix with water)
− Exercise and keep active
− May start laxatives regularly (as anti-spasmodics)
− Avoid smoking
(Mention only what is related to your case, don’t waste time).
7. Safety net: ring this bell or (if discharged come back immediately)
− Severe, constant pain all over or sharp, sudden pain
− High Fever
− Bleeding form your back passage or blood in stool
− Severe constipation or diarrhoea
− If you feel sick, dizzy or drowsy or about to faint,
If already diagnosed with Diverticular disease, management can depend on

patient’s condition:
− If Good can be treated at home with proper antibiotic, fluid-only diet
to relax the bowels and PCM while recovering. Start with very low
fiber diet not to strain the large lumen. After full recovery encourage
high fiber again.
− If Severe: then keep at hospital.
Risk Factors: Complications:

− Age (Most after 80 will have) 1- Rupture and
− Family hx Peritonitis
− Low fiber diet 2- Fistula
− Insufficient fluid intake 3- Abscess
− Smoking 4- Massive Per rectal
− Lack of physical Activity. Bleeding
5- Severe stenosis and
Constipation
87 | P a g e
Intestinal Obstruction
Who the patient is: Andrew Bright 50-year-old male came to the emergency
department with severe abdominal pain.
What you should do: Talk to him, take relevant history,(+/- Do the required
examination) , discuss an appropriate plan of management and address his
concerns.
Again, scan the room for the mannequin, it might be an examination station.
D: Hello Andrew, my name is doctor (name)I’m one of the doctors here in the
emergency department. Can I get your full name and age please?
P: I am Andrew Bright, 50 years old. (If keeping a specific position, please
don’t forget to acknowledge and reflect)
D: So, Andrew, what brings you here today I can see you’re holding your
tummy?
P: Yes doctor I have very bad pain in my tummy.
P1: SOCRATES (recap the points he mentioned don’t repeat them)
D: Can you tell me more about that bad pain? Open Qs then analyse.
P: I have had this colicky, bad, dull ache in my tummy for a few days now.
Maybe 3 days.
D: Site: Where is the pain exactly?/ Can you point with one finger?
P: It is all over my tummy and it’s very dull I can’t put it to just one area.
P: Started Suddenly
D: Character: You described the pain as a colicky, dull ache am I correct?
P: Yes.
P: No, only my tummy.
P: It is continuous.
D: Duration (time): You mentioned it started 3 days ago?
P: True
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P: No.
P: It’s always bad and it’s getting worse on its own.
P: 5-6 , it’s very severe doctor.
P: Yes I have tried some Ibuprofen but did not help.
P: Yes I have been vomiting and I feel nauseous.
(Explore with TRAC)
D: I see, for how long have you felt nauseous? (Timing)
P: Started 1 day after the pain.
D: How many times per day have you vomited?
P: 4 to 5 times per day
D: How much was the amount?
P:I don’t know doctor.
D: Any blood or mucus in vomit? (Content)
P: No.
D: Is it related to anything like anything that makes it better or worse?
P: Nothing doctor.
D: Anything else?
D: Have you got any fever or diarrhoea?
P: No.
Remember any tummy pain means : Bowels…Urine…Genitals (+/-chest)
(maximum 1 or 2 Qs each).
DDx
D: Any problems with your bowels recently like constipation?
P: P: I have been constipated in the last few days.
D: What do you mean by constipated? Do you mean that you don’t pass
anything at all or are you straining to pass?
P: No doctor I am not passing anything.
D: What about gas ?
P: Not even that doctor.
D: When did you last pass stool or gas? (Crucial question)
P: Yesterday.
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D: Any fullness or bloating in your tummy?

P: Yes.
D: Have you noticed any bleeding from your back passage?
D: Any recent change in the nature of your poo like colour or consistency?
D: How were your bowel habits before this problem? (IBD)
P: They were good Doctor.
+/- D: Any cough or chest pain? (MI, pneumonia)
D: Any pain while passing urine? (UTI)
+/- D: Any discharge from your front passage? ( STIs)
D: Any lumps or bumps or appetite change or weight change lately? FLAWS
D: Have you, by any chance, sustained any trauma to your tummy?
P: No.
D: Do you feel sick or dizzy or about to faint? (Complications and
dehydration)
P: No.
+/- D: Any weather preference? ( hypothyroidism )
ICE:
D: These last few days must have been difficult, have you got any idea what
might be the cause ?
D: Apart from all you have mentioned, do you have any specific concern?
D: I can see that the pain is troubling you I will do my best to help you with it,
But are you expecting anything in particular ?
P2:
D: Have you ever had this pain before?
D: Do you have any long-standing medical conditions or bowel disorders?
D: Have you ever been hospitalised or had any surgeries before? (Adhesions)
MAFTOSA:
D: Are you currently on any medications? TCA , ANTI DEPRESSANTS are risk
factors
D: Any similar tummy problems in your family?
DESA:
D: Can you walk me through your diet?
P: I eat a lot of meat and I am not really fond of vegetables and fruit.
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D: Are you physically active ?

P: Not really.
D: Do you smoke?
P: Yes about a pack per day for 10 years.
D: Drink alcohol ?
P: Yes 3 pints for 15 years now.
Examination:
(If there is a mannequin then it’s a combined station, cut the history much
shorter to make time for the examination.)
D: Thank you for being so patient, I have started to get the picture of what
might be happening but to complete it I would like to examine you.
I would like to take your observations, I will examine your tummy, I will also do
a general physical examination.
Possible Examination findings: Distended abdomen with generalised pain,
Resonant to percussion and exaggerated intestinal sounds.
D: Thank you, well you mentioned that you have tummy pain with constipation
and vomiting. From my examination your tummy was a bit distended with
increased intestinal movements and sounds, all of which are related to a
possible a bowel blockage, something that we call intestinal obstruction. The
blockage can be partial or total, and it prevents passage of fluids, gas and
digested food with gastric acids. That’s why you have not been able to pass
stool or gas. The build-up of these particles behind the block can cause that
pain you described.
Does that make sense to you?
It is an emergency situation which can cause serious complications, but luckily
you have come here before any of these happens, thank you for not delaying
getting the medical help you need. We have many treatment options available
at the moment.
Management:
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1- We would need to Admit you to monitor your vitals and symptoms.
2- I am going to involve my senior to have a look at you.
3- We will request some base line Investigations:
− FBC- infection marker.

− Blood group and crossmatch
− ABG- LFT/KFT/U&E
− Urine dipstick
− Abdominal X-ray erect and supine (imaging of your tummy and
chest while standing and sitting)
− US (Ultrasound scan)
4- Symptomatic Treatment:
− O2 (we will give you oxygen through your mouth or nose)

− NG tube (We will insert a small flexible tube through your nose to
your bowels and it will relieve the gas build up inside and will help
with the pain )
− NPO (Avoid eating with your mouth for now to relax your bowel)
− Painkiller
− IV fluids (through your veins)
− Antibiotics according to hospital protocol
5- Specialist: Surgery GUT specialist review for the cause, they might order
some other imaging as CT, MRI SCAN of the abdomen, or a special camera
test called colonoscopy to look inside the bowels and know the cause.
6- Sometimes this initial management can help resolve the condition, but if
things do not improve, surgery might be needed to treat the underlying
cause of obstruction.
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7- Options depend on the cause and the level of the block whether small or
large bowel:
− Keyhole surgery
− Endoscopic surgery (for Large Intestine obstruction)
− Open surgery
The aim is to remove adhesions (adhesiolysis) or bypass the obstructed part
or resect the obstructed bowel segment if severely damaged or put a stent
inside for rapid relief and keep the bowel opened.
8- Safety net:
• Persistent worsening of pain

• Sudden severe, sharp, pain
• Fever
• Feeling dizzy or about to faint (Dehydration).
Causes of Intestinal Obstruction:
P: What are the causes for this bowel obstruction ?

− Majority occur from previous surgeries and can cause adhesions.
− Some hernias when complicated- hernia strangulations
− May be malignancy or volvulus (Twisting of bowel).
Varicose Veins
Who you are: You are an FY2 in the GP surgery.
Who the patient is: Julia Marshal, a 45-year-old female, came to the GP with
pain and swelling in both of her legs.
What you should do: Go talk to her, discuss a plan of management and
D: D: Hello Julia, my name is doctor (name). I’m one of the doctors here in the
GP clinic. Can you confirm your full name and date of birth please.
P: My name is Julia Marshal, 5/2/77
D: How can I help you today?
P: I have painful swelling in both of my legs doctor.
D: Can you tell me more about it?
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P1: ODIPARA
D: When did you first notice it? Duration
P: I believe a few weeks ago.
D: How did it start? Onset
D: Any change in the swelling since it started? Is it getting better or worse?
Progression
P: Worse.
D: Have you noticed anything that makes the swelling better or worse?
P: No.
D: You mentioned that the swelling is painful as well?
P: Yes.
P1: SOCRATES Sx usually worse during warm

D: Can you tell me where it is exactly? Site
weather or after standing for
P: It is in both my legs.
long periods of time. They may
D: Does it go anywhere else? Radiation
improve with walking around or
P: No.
resting and raising your legs.
D: How did the pain start? Onset
P: It started gradually after the swelling.
D: Since it started has it increased or decreased? Course
P: It’s slowly getting worse
D: Anything that makes the pain better or worse?
P: Well, I think it gets worse whenever I’m at work.
D: What do you do for work?
P: I work as a hairstylist.
D: Does it involve you standing for long periods?
P: Yes, around 8 hours daily.
D: Has it affected your job?
P: Yes definitely doctor I am struggling more now.
D: Can you score the pain on a scale of 1 to 10, with 1 being the least painful
and 10 being the most painful?
P: It is about 5- 6.
D: Anything else that is worrying you?
P: No.
Associated Symptoms and DDx
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D: Any muscle cramps in your legs? (Peripheral Vascular dis)

P: No.
D: Do you have any fever?
P: No.
D: Any burning or throbbing sensation in your legs? (Thrombophlebitis)
P: No.
D: Any bluish discolouration? (DVT)
P: Yes/No
D: Do you have any pain in the calf? (DVT)
P: No.
D: Have you ever had any chest problems, pain or cough or difficulty
breathing? (PE)
P: No.
D: Have you ever felt your heart racing with chest-pain going to your left side ?
(MI)
P: No.
D: Have you felt weakness or unusual sensation anywhere in your arms or
legs? (Stroke)
P: No.
P2
D: Have you ever had any similar problems before?
P: Yes, I had swollen ankles during the third trimester of my pregnancy, along
with cramps in my leg muscles.
D: When was that?
P: About 4 months ago before I had my baby.
P: No.
P: No.
MAFTOSA
P: No.
P: No.
D: Has anyone else in your family been diagnosed with any medical condition?
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P: Yes, my older sister had the same condition after giving birth a few years
ago. She needed surgery to treat it.
D: Do you know what the name of her condition was?
P: I think she said it was Varicose Veins.
D: How is she now?
P: She is better now.
DESAS
D: How is your diet?
P: I try to eat healthy.
D: Do you do any physical exercise?
P: Yes/No
D: Do you smoke?
P: Yes/No
P: yes/No
P: No
D: You mentioned that you have just had a baby 4 months ago, how are you
coping and how is your mood?
P: I have been so drained lately, it’s a bit difficult doctor being a mother, with
work and all, But I am doing my best.
D: What about your partner, is he supportive ?
P: Yes doctor he is the best but we are just trying to cope with our new
circumstances.
ICE
D: Do you have any idea what might be going on with you?
P: I’m afraid it might be something similar to what my sister had, but I am not
sure what it is.
D: Do you have any particular concerns?
P: I think I might need surgery like my sister.
D: Were you expecting anything specific?
P: I don’t know what it is, I was hoping for you to explain it to me.
Examination:
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D: Thanks for answering my questions I will do my best to answer all your valid
concerns. But to do that properly I would need to examine you now would that
be alright?
I would like to check your Observations, do GPE and examine your legs while
standing.
Based on the type of pain and swelling you described and also considering your
sister’s problem, from my examination as well, I believe you also have Varicose
veins. Do you want me to explain a little more about them?
P: Yes please doctor.
D: So usually the veins in our legs push the blood back to our heart through a
set of special types of valves. These valves might become lax and weaken
sometimes , causing the veins to accumulate fluid, become swollen and
painful.
It’s a simple condition and quite common with jobs requiring long standing
hours as yours does and also after pregnancy. The bothersome symptoms can
be treated with surgery as you mentioned but there many simpler treatment
options also. Are you following me so far?
P: Yes doctor what are my options:
D: I’ll tell you about them now.
Management:
1. No need for admission.
2. I am going to involve my senior to have a look at you as well.
3. Investigations:
− I would also like to run some routine blood tests like kidney and liver
function tests,
We will need to exclude any clots in these veins which might be more serious,
we will do:
− Some blood tests called clotting profile and D-dimer.
− Special scan called duplex ultrasound to check the blood flow.
4. Symptomatic treatment:
• Pain killers PCM
• Lifestyle advice:
97 | P a g e
− Wear compression stockings daily (from early

morning till bedtime)
− Regular exercising and keeping active
− Losing weight and balanced meals
− Avoiding standing up for long periods of times
− Elevating the legs when resting
Wearing compression stockings can be very helpful and they come in different
colours, lengths and sizes. They should be pulled all the way up straight, they
will squeeze the veins pushing all the fluids and will help relief symptoms.
You can apply moisturizers if they are irritating the skin. You should have two
stockings for each leg so that you always have at least one pair washed and
ready to wear and they should be changed every 3-6 months.
5. We may refer you to a blood vessel specialist (Vascular surgeon) to
confirm the diagnosis, and also if you have:
− Very bad Sx like heaviness and itching as well
− Skin problems or colour change (indicate blood flow problem)
− Hard and painful varicose veins
− Leg ulcer below the knee (especially if has not
healed within 2 weeks) DDx of Varicose veins:
− Peripheral
➢ If this treatment does not help or symptoms progress or Arterial Disease
condition becomes complicated the vascular specialist − Cellulitis
can provide further more advanced treatment and − Thrombophlebitis
discuss the best options for your case depending on your − DVT
general health and the size, position and severity of your
veins, the aim is to seal or remove the veins:
➢ Nonsurgical simple Procedure: a special transducer wire is inserted into the

vein to deliver heat energy and seal the vein closed.
− Endothermal ablation
o Radiofrequency ablation (high-frequency radio waves heating)
o Endovenous laser (Laser heating)
− Sclerotherapy (Injecting special foam into your veins to close it)
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− Surgery (ligation and stripping of the affected vein if all others fail or
unsuitable)
“Worth mentioning that NHS only covers these invasive procedures when it is a
requirement, and not for cosmetic purposes.”
6. Safety net:
Come back immediately to the GP if you have:
− Worse Sx
− Fever with redness and inflammations in legs
− Skin changes
− Bleeding from the varicose veins
− Leg ulcers
− Pain while moving your legs (PAD)
− Chest pain or weakness anywhere in your body (Clots)
➢ Risk Factors for Varicose veins:

− Long duration standing
− Obesity (high BMI) and physical in activity
− Pregnancy
− Being a female
− Family Hx
− Previous leg surgeries, DVT
−
Neck Lump
Who you are: You are an FY2 in the GP practice.

Who the patient is: Allen Porter, 37-year-old male, came to the GP with a
complaint of neck swelling.
What you should do: Talk to the patient, take relevant history, discuss a plan
of management and address his concerns.
D: Hello my name is doctor (name) I am one of the doctors here in the GP

practice. Can I confirm your full name and date of birth please?
P: My name is Allen Porter, 8/10/85.
D: And may I call you Allen is that OK?
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P: Yes, doctor Allen is fine.

D: Thank you Allen, so what brings you here today?
P: I have recently noticed that I have some swelling.
P: It’s on my neck.
P1 Swelling analysis: (remember the derma structure very similar)
D: Do you have any idea how it started? Was it ever there before? Onset
P: I think it might have been there before but never that obvious doctor. OR I’m
not sure doctor I don’t know.
D: When did you notice it? Duration
P: This morning. (If it has always been there and he came only recently, ask why
he came now, what changed?)
D: Where exactly is it? Site
P: On the right side of my neck.
D: Have you noticed lumps or swelling anywhere else like in your neck or
armpit?
P: No.
D: Can you describe the size of the swelling?
P: Like a coin.
D: Any change in its size ,whether increased or decreased lately?
P: No.
D: Is it painful?
P: No.
D: Does it feel warm when you touch it?
P: No.
D: Does the swelling go away if you press it?
P: No.
D: Does it move when you swallow or stick your tongue out ?
P: Yes/No
D: Any change in the colour of the skin like getting red or dark ?
D: Any coughing up of blood or discharge from the skin on top?
P: No.
D: Any difficulty in breathing or swallowing?
D: Any change in your tone of voice?
P: No, (may say it feels like a lump in the back of my throat (red flag)* )
100 | P a g e
D: Anything else?
P: No.
DDx
D: Have you hurt yourself by any chance? (Trauma)
P: No.
D: Any fever or flu-like symptoms or cough? (infections)
P: No.
D: Any night sweats? (TB)
P: No.
FLAWS for CANCERS, TB and AIDS
D: Have you noticed any weight loss?
P: No.
D: How is your appetite these days?
P: Good.
D: Do you feel tired these days?
P: No.
D: Any dizziness or heart racing? (Heart failure with neck veins)
P: No.
D: Are you sexually active? (AIDS)
P: Yes.
P: Yes, my partner uses condoms. (No need to explore sexual hx further)
D: Do you feel hot when others feel the warm or the opposite with cold?
(Thyroid)
P: No.
ICE ----------- (Extremely Important can cut your history really short and help
you with management)
IDEA
D: Any idea what might be the cause of this swelling?
P: Not really doctor. (or might say: Yes doctor I might have cancer)
D: Explore: May I ask you why you think it’s cancer in particular?
P: My father had cancer when I was young.
D: Sorry to hear that. How is he now (show empathy and console him) ?
P: What cancer did your dad have?
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D: I can understand why you are thinking of cancer then. I will do my best to
get to the bottom of this.
CONCERN
D: Apart from the cancer concern you have, are you worried about anything
else?
P: No doctor or (may mention something else that you will have to address in
management)
EXPECTATION:
D: Are you expecting anything specific today?
P: I want to know if the swelling is something sinister. (or may say anything he
think he needs like biopsy or chemo treatment or radio therapy don’t forget
to mention whether needed or not in management and always reassure but
be realistic if he has red flags (way too early to say for sure—see the
provisional Dx) )
P2
D: Have you ever had similar swellings in the past?
P: No.
P: No.
P: No.
P: No.
D: Any previous hospital stays or surgeries or blood transfusions?
P: No.
D: Has anyone else in your family had cancer, other than your dad?
P: No.
DESA:
A few questions about your lifestyle now
D: Do you smoke?
P: Yes/No if yes explore (how many packs, for how long)
P: Yes/No (if yes explore how much for how long, ever tried to calculate the
units)
D: And can you talk to me about your diet?
102 | P a g e

D: Do you do any form of exercise?
P: Yes/No
Examination:
D: Thanks for being so patient with my questions. I would like to examine you
now to check your vitals, do a GPE and examine your neck. Is that OK?
If the Examiner doesn’t give you any findings, don’t pause start the
management right away and don’t waste your time!!
Examiner may hand you a note with the findings. If not, look for it around
and if you don’t find it, carry on and please don’t ask the examiner.☺
− Swelling is 1x1 cm, hard and fixed.
Provisional Diagnosis: (Best and worst case scenarios)

D: Well Allen I suspect that you may have swollen neck glands. While it can
be caused by simple conditions, best-case scenario it could just be a common
cold or ear or throat infection. Worst case scenario it could also be caused by
something worse and more sinister.
When we examined your swelling it was hard and fixed. Considering your
father’s history and your concern as well, we would need to do further
investigations to exclude the possibility of something as serious as cancer I
am afraid to say. However, it is still way too early to say for sure what is
going on. Thank you for coming at this stage you have done right thing.
(You can add any positive red flag sx from the hx as well but be brief and
simple)
Management:
1- I will refer you urgently to an ear nose throat specialist as a Fast track
referral within two weeks
2- Senior
3- Investigations:
We will send for some initial investigations like routine bloods and infection
markers.
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4- When you go to the specialist, they will do further investigations and

imaging as well like an ultrasound for the swelling, maybe an MRI or CT scan
as well to assess the area around the swelling more.
If it is very suspicious, the throat specialist might also take a sample from
the swelling for analysis depending on his decision.
How do you feel about that?
P: I’m trying to process it all doctor, I am even more worried now.
D: Let me apologise if I have got you more concerned but as I mentioned it is
still way too early and it could be anything so we will have to wait for the
results of the investigations. And rest assured that you will have a meeting
with a team of dedicated doctors called a multi-disciplinary team (MDT). They
will discuss your treatment options and start the required treatment at once
without any delays. In the meantime, don’t panic, like I said, it could be a cold.
Stay positive.
P: Yes doctor.
D: Would you like to know more about treatment options ?
P: Yes.
If it is cancer, then the treatment depends not only on the type, size, position
and stage of cancer but also your overall health.
− We have surgical options for resection of some tumors.
− Chemotherapy and Radiotherapy may be required as well to extend
the quality of life.
Indication for referral:

• Swollen glands are getting bigger, or they have not gone down within 2
weeks.
• They feel hard or fixed (as in this case here).
• Night sweats or high fever (feeling hot and shivery) for more than 3 or
4 days.
• Swollen glands with no other signs of illness or infection.
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• Swollen lymph glands just above or below the clavicle (aka collarbone:
the bone that runs from your breastbone to each of your shoulders) .
− Symptomatic treatment if needed depending on his Sx

− Painkillers
− Anti-sickness.. etc
− Safety net:
− Flaws
− Difficulty swallowing
− Difficulty breathing
− Hoarseness of voice
− Coughing bloods
ACUTE Appendicitis
• Appendicitis is a painful swelling of the small, thin pouch (about 5 to 10cm)

that is connected to the large bowel where stool comes out. Nobody knows
exactly what the appendix does, but removing it is not harmful.
• Usually affects young people aged between 10 and 20 years.
• Symptoms:
− Feeling sick nausea and loss of appetite
− Tummy pain:
> A characteristic pain migration that starts at the middle the
tummy and then migrates to the right lower abdominal
quadrant.
> It is a very severe pain that starts as on and off and then
becomes continuous to the extent that the pt doesn’t move at
all.
− Vomiting
− Diarrhea
− Constipation
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Management: Similar to Intestinal Obstruction:

1. Admit
2. Senior
3. Inv:
− Routine bloods, Infection markers and Inflammatory markers LFTs,
KFTs .. etc
− Ultrasound
− Xray Erect and supine
4. Treatment:
− NPO
− Oxygen
− IV fluids
− Painkillers
− Antibiotics
5. Refer to general surgery for assessment and Laparoscope surgery or open
surgery to remove the appendix according to patient condition.
Appendicectomy or Appendectomy.
It takes a couple of weeks to make a full recovery after surgery, but
strenuous activities may need to be avoided for up to 6 weeks after
having open surgery.
6. Safety net as Intestinal obstruction.
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DEALING WITH PATIENT

RELATIVES
107 | P a g e
Dealing with Patient Relatives

When talking to any relative, remember these C- words:
1. Consent
- The only situation, you are allowed to give information to the next of kin
without any consent is if (no mental capacity):
• Patient is unconscious
• Patient is in surgery
• Patient is diagnosed with dementia or psychosis
• Patient is a child
2. Confirm
You should confirm:
• Patient name and age
• Relative’s name
• Relationship of the relative to the patient
3. Concern
-In any station, you are speaking to relative, the relative always has a concern;
so, ask about it.
4. Coping
-While talking to a relative, it is important to ask about how he/she is coping?
-Is there any help that we can offer from our side?
POST – MORTEM EXAMINATION
Who you are:

You are a FY2 doctor in a Medical Department.
Who the patient is:
William Russell, 68 years old, was referred by the GP a week ago because he
had shortness of breath and pneumonia to be admitted in the hospital.
Unfortunately, He died yesterday, acute respiratory failure is the cause of
death.
Death certificate can be issued with acute respiratory failure.
What you should do:
Talk to his wife Mrs. Russell and address her concern.
108 | P a g e
Ask for concerns many times.

Expected concerns?
- What is a post-mortem?
- Will you disfigure his body?
- Will this delay the funeral or death certificate?
How are you coping?
Offer support and bereavement services
Encourage her to speak with other relatives about post-mortem decision.
Confirm data:
Doctor: Hi, I am Dr (name) one of the doctors here, may I confirm your name
and your husband’s name and age?
Patient’s Relative: My name is Mrs. Russell my husband is William Russell, 68
years old.
Sympathy:
D: I understand that your husband was admitted in the hospital and sadly he
died yesterday, I am really sorry for your loss, how are you doing?
PR: It’s difficult doctor to lose a loved one.
D: Please accept my condolences in this difficult time.
PR: Thank you.
D: How are you coping?
PR: It just happened so unexpectedly. He was fine, I don’t know what
happened.
D: Is there anyone with you?
PR: My nephew lives with me.
D: Has anyone explained to you what happened with him?
PR: I know that he had some infection, but I don’t know what happened after
that.
D: OK let me explain it to you. He had an infection which affected his lung,
something called respiratory failure, that means his lungs could not work
because of the infection.
PR: Oh, I see now…
D: Do you think that we can do anything from our side to help you cope with
this difficult time?
Concern: EXPLORE THE CONCERNS

D: I appreciate that you need to talk to me in this difficult time, I understand
you have some concerns, and I am here to address all of them.
PR: I want to do an autopsy doctor.
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D: OK we can help you with that, is there any specific reason for you wanting
an autopsy?
PR: It’s just that everything happened so quickly, I want to understand what
happened to him.
D: I can't imagine how you are feeling. Nobody expects their loved one to pass
away from a chest infection but it’s more common than people realise. What
do you know about what happens during an autopsy?
PR: Not much, one of my relatives is a nurse and she told me about it.
D: Did she explain the procedure for you?
PR: No, but I saw it in a documentary, and to be honest I am afraid that they
will disfigure his body.
D: Don’t worry we don’t do that; I will explain this procedure in detail?
The procedure:
- We do this procedure to find out the cause of death.
We need to take consent from you that you agree for us to go ahead with this
procedure. It is better that it’s done as early as possible.
- It is done in rooms resembling the operating room. First, we examine the

body on the outside to see any unusual signs such as wounds. Then we will
open the chest and tummy and we may need to examine his organs under
microscope. In this case we need to take further consent from you again that
you agree to do further examination on his organs and his organs will then be
returned back to his body.
- I am sorry to discuss these sensitive details with you but let me assure you
that we deal with any deceased body with dignity and respect. We do small
cuts on the body and it will be sutured again by neat stitches and we don’t cut
visible parts of his body like the face or arms.
D: Do you have any concerns so far?

PR: Doctor, how does this procedure benefit me other than me finding out the
cause of death?
D: That’s a good question. Apart from knowing the cause of death, it could
help us to know if there is a specific genetic condition in the family and if the
cause of death is a specific kind of infection. We would then be able to trace
the people he has been in contact with and treat them.
PR: How much time will it take?
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D: The examination may take 3 days and you can go ahead with funeral
arrangements as soon as the paperwork is released.
D: Will this delay funeral or issuing of the death certificate?
PR: No, don’t worry about that.
D: Have you thought about whether you want a burial or cremation?
PR: It will be a burial and I am not sure yet about the date?
D: Do you have family to help you with the funeral?
PR: Yes, I do thanks for asking.
D: I know this must be difficult for you, we have a department called
Bereavement support. There you can talk and share your feelings with
someone you can also help you. What do you think about that?
PR: I would like that, thank you.
D: OK, any other concerns?
PR: No.
D: I will discuss your request with my seniors, and I will give you some leaflets
about post-mortems. Please, take your time and we are here for you if you
need to discuss anything else.
DON’T TELL MUM SHE’S GOT CANCER

Who you are:
Who the patient is:
Mrs. Ali, a 77-year-old lady, presented with confusion due to a chest infection.
Investigations have been done which showed metastasis in her lung, liver
and kidneys. She had colon cancer 5 years ago for which she was treated
and declared cancer-free. Mrs. Ali was confused so the diagnosis was discussed
with her daughter.
Her son, Adam Ali was not present at that time. He told the
nurse today that he doesn't want anyone to tell his mother about her
cancer.
Additional information
Consent has been taken from Mrs. Ali to talk to her son. Diagnosis hasn’t
been disclosed to the patient yet. Patient has been assessed and has full
mental capacity now.
What you should do:

Talk to Mr. Adam Ali and address his concerns.
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Approach:
Doctor: Hi, I am Dr (name) one of the doctors here. May I confirm your name,
our patient’s name and age and your relation to her?
Patient’s Relative: I’m Adam Ali, my mum is Fatima Ali and she is 77 years old.
D: I understand you have some concerns regarding your mother’s condition
and I am here to address your concerns, how can I help you?
PR: I don’t want anyone to tell my mother that she has cancer.
D: I can see that you care a lot about your mother and I’m sorry for the
distressing news of her cancer. It must be a difficult time for you and for your
family. Before we deal with your concern it's important for me to know how
your mother was doing before she came to the hospital, if you don’t mind?
Check his understanding
D: How much you know about her condition?
PR: I know that she has cancer and it’s spread all over her body.
D: Yes, that’s right unfortunately. How did you hear about it?
PR: My sister updated me.
D: Any idea why she was admitted?
PR: She had a cough, shortness of breath, and she was confused.
D: I understand this must be difficult on you, how are you all coping with it?
PR: It’s so difficult but I am trying to do my best to be around her.
Check his mother’s reaction to bad news:

D: How did she handle the news of the first diagnosis of cancer?
PR: She was calm, but I still don’t want her to face that again.
D: Has your mum struggled to accept bad news in the past?
PR: No.
D: Has she expressed any wish not to know about something like that in the
past?
PR: No.
Exploring the concerns

D: Coming back to your concern, is there any specific reason that you do not
want us to tell your mother about her cancer diagnosis?
PR: My dad died of cancer and she went through a really tough time after that.
If she knows that she has cancer, her condition will be worse.
D: I’m sorry for your loss. Now I understand where you’re coming from, but I
would like to explain to you the situation here:
▪ We cannot hide any information from the patient as long as, they
have the mental capacity which means they are mentally capable
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of understanding and taking decisions. It’s our duty to be honest

with our patients.
▪ It’s her right to know about her condition and to make her own
choices.
▪ If we do not tell her about her condition, we will not be able to
take her consent to do further tests. Some of them, I am afraid,
might be invasive such as doing a camera test and taking a tissue
sample. She has the right to consent to these tests.
▪ And the same for treatment, we need to take her consent to go
through the appropriate treatment for her, as surgery or
chemotherapy, according to what is in her best interests.
▪ We should explain to her all-possible complications about the
tests and treatment.
PR: You can take my consent?

D: May I ask, has your mother declared any wish to appoint you to take
decisions related to her health on her behalf (power of attorney)? Or any
decisions about refusal of treatment?
PR: No.
D: In this circumstance then, I’m afraid, we need to tell her. If she finds out
about her condition later on, she will lose trust in us as medical professionals
and she might not accept her treatment.
PR: Can you please tell her it’s a small mass of cells?
D: No I’m sorry, we could not tell her only a fraction of the information, we
must tell her the exact diagnosis.
PR: Can I be with you when you tell her?
D: Let me assure you,
- we always ask our patients to bring a family member to be with us
whilst telling them an upsetting diagnosis, and if she wants anyone to be
with her it’s better as far as we are concerned.
- we break any bad news gently and we provide psychological support.
- As you are concerned, I will inform my senior and add your concern to
her notes.
- We will make sure that she is told about her diagnosis in a very
sensitive way. We have a team to support her in such situations.
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MUM FRACTURED WRIST

Who you are:
You are a FY2 doctor in an Orthopaedic Department.
Who the patient is:
Mrs. Emily Adams, 84 years old, had a simple fall and a sustained
fracture in her non- dominant hand. The fracture was fixed, and she has
been treated with MDT (Occupational therapist and physiotherapist).
They decided that she could go home. And she will be visited by
carers twice a day. She is also arranged for a follow-up every week.
She has mental capacity and wants to go home, and she will be given
a stalk.
Her son David has a concern
What you should do:

Talk to him and address his concern. Consent has been taken.
Approach:
D: Hi, I am Dr (name), one of the doctors here. May I confirm your name, our
patient’s name and age and your relation to her?
Patient’s Relative: I’m David Adams, my mum is Emily Adams and she’s 84
years old.
D: I understand you have some concerns regarding your mother and I am here
to address your concerns, how can I help you?
PR: How is my mother now?
D: She is fine right now and ready to go home.
PR: I don’t feel that she will be safe at home on her own, I believe a nursing
home would be better for her.
D: I appreciate your concern but before we discuss that, do you mind if I ask
you some questions regarding her condition to address your concern in a
better way?
Quick Hx
P1
D: How much do you know about her condition?
PR: I understand that she was admitted to the hospital after a fall and she had
a bone break in her wrist. She has been treated and you are discharging her.
D: How much do you know about what we have done for her?
PR: There was another doctor who explained things for me.
D: How was her health in general?
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PR: She is fine in general, she manages to do everything on her own,

sometimes she gets confused, but she is ok.
D: How was her mobility before she broke her hand? Was she moving
independently or was anyone helping her?
PR: She is independent.
P2
D: Any medical conditions?
PR: No.
D: Any hospital admission or surgery in the past?
PR: No.
D: Any bone breaks in the past? Or any previous falls?
PR: No.
D: Any use of walking aids?
PR: No.
D: Any problem with her eyesight?
PR: No.
MAFTOSA
D: Is she on any medications?
PR: No.
D: Is anyone living with her?
PR: She lives alone.
D: Is there anyone taking care of her?
PR: No, she lives alone.
Management (counselling)
D: I can see that your mother's condition is really concerning you? How are you
coping with that?
PR: I am worried about her that’s why a nursing home would be the perfect
choice for her.
D: Coming back to your concern, as you told me, your mother had a bone
break in her wrist. We fixed the break, so she is medically fit to go home. Also,
as we care about her safety at home, we arranged an occupational therapist
who examined the home and made sure that the environment is safe.
PR: Doctor, I think she is not fit enough, and she will not manage at home?
D: I can see that you are concerned about your mother, but may I ask why you
think that?
PR: She will not be able to wash her hands for example.
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D: I can see where you’re coming from, but we’ve already considered that she
will face some difficulties in her daily activities, so we arranged for carers who
will visit her at home twice a day to help her.
PR: When the carers leave, she would not be able to move freely at home?
D: I understand what you’re saying, but as your mother has broken her non-
dominant hand and she has been given a stick to support her while walking,
there’s no reason why she wouldn’t be able to move around. In addition to
that, the occupational therapist made sure that there is no risk at home.
PR: I think my mum had the fall when she was at home alone, so if she goes
home, she might have another fall?
D: Let me explain for you, whenever we have a patient with a fall, we always
assess the patient to know the reason behind the fall and we manage them
accordingly. The reason could be medical and non – medical; however, we
assessed your mother and fortunately we could not find any medical reasons
why she may have a fall again so she is actually fit to go home.
PR: Doctor, can you please keep my mother in the hospital?
D: I totally understand that you are worried and concerned about her. Your
opinion really matters to us but let me walk you through what is going on here.
Your mother has mental capacity that means that she could understand her
medical condition and decide for herself, and I can see that your mother wants
to go back home so our role as medical professionals is to respect her wishes,
how do you feel about that?
Patient: Doctor, can you please tell her that she needs a care home?
D: May I ask why she needs care home? Have you discussed this with her? As
far as she is concerned, she wants to go home. A nursing home may be an
option in the future, only if your mother can’t manage at home and needs
more than 4 carers to help her.
PR: Doctor, the problem is that I live in London and my sister lives in Oxford
and we can’t visit her daily?
D: I can see that you are a caring son but let me assure you, you don’t have to
visit her whenever you want as the carers are going to visit her twice daily. Do
you want to know what the carers do?
They will help her with cooking, feeding and personal care. They will be in the
house with her and before they leave, they will make sure that she does not
need anything.
I can talk to my seniors, and we can arrange meeting where you, the carers,
the physiotherapist and the occupational therapist will be there, which actually
happens in our hospital in order for you to tell them your concerns and also
your mother can be there if she agrees with that.
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PR: Can you take the responsibility if she has another fall?
D: I am really sorry, the risk of falling down can’t be eliminated completely but
we do our best to make sure that she would not have another fall in the future,
as we excluded the medical reasons for the fall, and we sent an occupational
therapist to check the home safety; however, we could not really promise that
she would not have a fall again.
- Also, we can arrange for the GP to visit her after 2 days from discharge
to see how she’s coping and if she is worried about anything.
- I appreciate that you care about your mother and I’m sorry that we
cannot agree on where she should go.
Euthanasia
Who you are:
A FY2 in Elderly care medicine
Who the patient is:
Elizabeth Alexander, 96-year-old lady, who was admitted to the hospital a few
days ago. She is terminally ill with metastatic cancer. She is on nasogastric tube
for feeding, subcutaneous morphine, midazolam and fluids.
Her son Charles, who is currently in Switzerland on holiday, would like an
update his mother’s condition. He is expecting a call from you.
What you should do:
Talk to the son and address his concerns.
BE SENSITIVE
Euthanasia is illegal in the UK.
Approach:
Doctor: Hi, I am Dr (name), one of the doctors here. May I confirm your name,
Patient’s Relative: I’m Charles Alexander, my mother is Elizabeth Alexander
and she is 96 years old.
D: I understand you have some concerns regarding your mother’s condition
and I am ringing to address your concerns, how can I help you?
PR: Doctor, I want something to end my mother’s suffering.
My mother is terminally ill and I know she is suffering and I know that she will
die soon.
D: I am really sorry about that, this must be difficult for you and your family.
Do you mind if I can ask you some questions regarding her condition to address
your concerns in a better way?
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Check for understanding:

D: How much do you know about her condition?
PR: I know that she has cancer which has spread all over her body and she is on
a feeding tube and other medications.
D: I understand that this must be an upsetting time for you, how are you
coping?
PR: It’s an awful time for us doctor, and I want her at peace.
D: Does your mum have any advance directive?
PR: No.
D: Are you the lasting power of attorney for your mum?
PR: No.
D: Has your mother discussed her last wishes with you, or how she would like
to spend her last days?
PR: No.
D: So how can you be sure what she wants to do?
PR: I am not sure, but she lived her life happily and all is she has right now is
just suffering.
D: Your mum is being looked after by a team of doctors and nurses who make
sure that she is comfortable and not suffering.
PR: Doctor, I need to end her suffering.
D: I am really sorry, but I can’t do anything that brings her life to an end as
euthanasia is illegal in the UK. We aren’t letting your mother suffer, we are
giving her medications to control her pain, anxiety and agitation.
PR: I want to bring her to Switzerland then, it’s legal here?
D: I really appreciate your concern; I will talk with my senior about that and he
will contact you about it.
Offer support to the patient
DEMENTIA- TALK TO DAUGHTER

Where you are:
You are a F2 working in the neurology department.
Who the patient is:
Mrs. Caroline Parker 88-year-old female has been admitted because of weight
loss.
Other Information:
She has been suffering from dementia in the last 3 years and has not been
taking food properly, recently. All the investigations including Blood tests, ECG,
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X-ray, Ultrasound and CT scan of the abdomen has been done and have come
back normal. Patient has been given some fluids and is able to tolerate a bit
now.
It has been decided that invasive and aggressive management is not
appropriate. Palliative care has been decided by the consultant. She was very
weak on admission, but she has been medically managed.
Special Note:
Patient is not available to talk. Consent was taken from the patient to talk to
her daughter. The weight loss is only due to dementia.
What you must do:
Please talk to her daughter Ms. Gwen Parker, take focused history, explain her
mother’s condition, address her concerns and discuss management plan with
her.
Dementia: chronic progressive disease that can affect patient’s appetite which
may lead to weight loss.
Introduction
Doctor: Hi, I am Dr (name), one of the doctors here. May I confirm your name,
Check understanding:
Doctor: I understand that your mum was admitted due to weight loss, I also
understand that she had some tests done, has anyone explained the situation
to you?
Paitient’s Relative: Yes, doctor my mum has dementia but I don’t know why
she is not eating any more.
D: Can you tell me more about your mum’s dementia?
PR: She has had dementia for the last 3 years and she has been taking
medication for it, but she is deteriorating. She has not been eating for the last
4 weeks. Sometimes she takes sips of water.
D: I appreciate you came today out of concern for your mother, thank you for
doing that. I understand that taking care of a patient with dementia is not easy
and we have many options for you. I would like to discuss them with you in a
minute, but I just want to ask you some questions to exclude other causes for
her confusion other than dementia, is that ok with you?
• Your P1 is weight loss (just quick hx, it’s counselling)
Confusion DDs:
- Any head injury?
- Any fever?
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- Any vomiting?
- Any diarrhoea?
- Any cough?
- Any burning sensation while passing urine?
- Any medications that you are aware of?
Questions of dementia:
- For how long has she been diagnosed with dementia?
- What treatment does she take for it?
- How is she at home, bed bound or able to move independently?
- Has she been in any dangerous situation due to dementia?
- Does eat and drink well?
- Does she do things independently or needs your help?
- Have you noticed any inflammation in her mouth?
- Have you tried to feed her yourself?
- Is there anyone else taking care of her besides you?
Questions for the relative:

PR: I am an office worker.
D: When you are at work, is there anyone is taking care of her?
PR: Yes.
D: Do you think the home is safe enough when she’s there alone?
PR: She’s bedbound, I don’t think she will come to any harm.
D: How are you coping?
PR: I am the only one who is taking care of her, I try to do my best.
D: Are you managing financially?
PR: Yes, I think I can support her.
PR: I am ok thanks for asking.
D: Are there any specific difficulties you are facing?
PR: No, I just want my mum to be OK.
• Management (counselling):
We have 2 parts of Management here
1st: Talking to her about the Palliative treatment

Explain to her that the cause of her mum’s poor feeding is dementia, and the
consultants think that palliative care is the best for her case right now.
Her concerns would be:
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PR: What is palliative care?

D: It’s supportive care that makes the patient as comfortable as possible by
managing the pain and other distressing symptoms. It also involves
psychological, social and spiritual support for you and your family or carers. It
is offered by a team of doctors and health care professionals.
PR: Why can’t you feed her through NGT or gastrostomy?
D: I appreciate your care about your mother, but her condition is terminal, and
this would put stress on her.
PR: Do you mean she is dying?
D: I am really sorry to tell you this, but we are not expecting her to improve.
PR: Will I be able to take her home?
D: Yes of course, I would give you some options to help you while taking care
of your mum on a daily basis.
2nd: Giving support:

1. Thank you for answering my questions and for your co-operation, before
I proceed, do you want me to explain anything regarding dementia or palliative
care?
2. I know that taking care of a patient with dementia is really
overwhelming, especially if you are the only person doing it. I would like to
discuss with you what we could do to help you and your mother.
3. We can arrange carers who can visit her daily while you are at work.
They would wash her and feed her, (if she wanted to eat anything, although I
know she is refusing food at the moment and that’s OK if she doesn’t want to
eat). And they also do housework to help you. How do you feel about that?
They will be there to help you and guide you also on how to care for her as she
deteriorates further.
4. We can also provide her with adequate pain relief to make her
comfortable.
5. We have also another option, which is a care home if you think you
would not be able to manage.
D: Do you have any concern so far?

PR: I’m not struggling financially right now, but I think I will be pretty soon. I
want to know about any support that is available to me?
D: Of course, I understand. There is financial support which is for patients who
have dementia and their relatives, it is called Dementia UK. I would speak to
my senior and do my best to arrange that for you as soon as possible.
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Safety netting:
At any time, if you feel your mother is suddenly confused or has a fever, cough,
vomiting, please, come to us immediately.
Special note if the scenario is about a patient whose appetite has decreased
only but not stopped completely.
There is a way of feeding dementia patients called “comfort feeding”:
• Try to give her any food she loves.
• Make sure it is liquidised and easy to digest.
• Use your clean hand to feed her and eat together as a form of bonding.
• Whilst eating you can put on her favourite show on TV to let her enjoy
her feeding time more.
OCP CONCERNED MOTHER

Who you are:
You are FY2 doctor in the GP clinic,
Who the patient is:
Mrs. Nicole Jolie, 48 years old, has come today after booking an urgent
appointment because she has a concern.
Family, including her husband and daughter have been registered at your
clinic for the last 10 years.
What you should do:
Talk to her and address her concerns.
This is a confidentiality station so, whatever happens you shouldn’t

disclose any information.
Introduction
Doctor: Hi, I am Dr (name), one of the doctors here, may I confirm your name?
Patient’s Relative: (Confirms her name)
D: I understand that you have booked an urgent appointment, is everything ok
with you?
Concern
PR: I have found these contraception pills in my daughter's room, and I want to
know who prescribed these pills for her?
D: I can see you are upset, sorry for the way you are feeling, but do you mind if
I confirm your daughter's name and age first?
PR: Her name is Diana; she is 15 years old.
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D: Do you mind if I ask you some questions to be in a better place to address

your concern?
Data gathering:
D: What has happened exactly?
PR: I found the contraceptive pills in her room today.
D: Have you talked to her?
PR: I tried to, but she told me they belong to her friend and slammed the door
behind her. Then we argued and she left the house.
D: Is she in a safe place right now?
PR: I don’t know.
D: Do you have any idea if she is in a relationship?
PR: I don’t know.
Management (counselling)
Thank you for answering my questions, I appreciate that you are concerned
about your daughter, but I am sorry I cannot give you any information
regarding that without her consent.
What I can do is explain to you what we always do when we have a girl in

Diana's age group come to us for contraception:
- When we see a patient under 16 years old coming for contraceptive pills,
we advise them to bring their parents. If they refuse, we still have to see them
and give them all the information they need.
- Before prescribing the pills, first of all, we make sure that she
understands the risk of being involved in a sexual relationship and taking
contraception.
- Then, we ask about the age of her partner and whether she is being
forced into sexual activity or not. If the partner is not in same age group as her
or if we suspect any kind of abuse, we inform a safeguarding officer
immediately.
PR: If you are giving them the pill aren’t you encouraging them to have sex?!
D: I understand that you are upset about this, but we know that if we didn’t
give young girls contraception, it wouldn’t prevent them having sex, it would
just put them at risk of becoming pregnant at such a young age.
PR: Doctor, can you please tell me if the GP gave her these pills?
D: I understand that you are concerned about your daughter, but I am really
sorry, we are obligated as medical professionals to keep the medical records of
our patients confidential, as long as they have mental capacity.
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PR: What if she got any STI?

D: I really appreciate your concern but let me reassure you that all doctors
always advise young people about safe sex and regular check-ups for any
STIs.
PR: We are religious, and we are against sex outside of wedlock.

D: I respect the fact that you have religious beliefs and they are important to
you in your family, but I’m sorry I still cannot betray a patient’s confidentiality.
PR: Just tell who prescribed the pills for her?!

D: I’m sorry, I could not give you any information, it would be unethical. How
would you feel if we gave information about you to anyone? You would lose
trust in us as medical professionals. We are happy for young people to be
responsible enough to come and speak to us about safe sex if they are going to
engage in it anyway.
If Diana comes to us, we could ask her if she would like to make an
appointment for you and her to see a doctor together to put your mind at
ease.
Or you could ask anyone who is close to her, to talk to her.
Or you could explain to her that you want to create a safe space environment
for her to speak to you without you getting angry at her and see how she
reacts. She might open up to you.
Sorry, I wish I could do more to help you, but I can’t.
SURGEON SON ASKING ABOUT MUM’S CT SCAN
Who you are:

You are a FY2 doctor in a Surgical Department.
Who the patient is:
Ms. Ellie Moon, 72 years old, was in the nursing home and brought
to the hospital as she lost some weight. CT scan was done on the
chest, abdomen and pelvis. Cancer in the ascending colon is
suspected. Diagnosis has not been mentioned to the mother.
What you should do:
Talk to her son, Dr Moon and address his concerns.
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NOTE
- When you enter the cubicle, the simulator will be standing so do not sit
down until he sits down.
- When you enter the cubicle, he will tell you “I am a consultant and I
want to know about the CT”.
- There is no consent from the mother so do not tell him any details about
the CT result.
Introduction
Patient Relative: I am Mr. Moon, a Surgery Consultant, and I have come a long
way from London to know about my mother's CT result.
Doctor: It is nice to meet you Mr. Moon, I appreciate that you came here to
talk about your mother's condition despite your busy schedule. I am Dr (name),
one of the doctors here, just some routine questions to make sure we are
talking about the right person, can you please tell me our patient’s name, age
and your relation to her?
PR: My mother is Ms Elli Moon and she is 72 years old.
D: How was your journey from London?
PR: It was good thank you but I don’t have much time. I want to know about
the CT result.
D: Definitely, I will talk to you about that in a minute, but do you mind taking a
seat?
PR: OK
D: I would like to ask you few questions about your mother's condition to be in
a better place to address your concern if you do not mind?
Data gathering:
D: Are you next of kin? So that I know I am talking to the right person?
PR: Yes, I am her eldest son.
D: Does your mother know that you are here today?
PR: I don’t know but I didn’t tell her.
D: I understand that she lives in a nursing home, is there any specific medical
reason for that?
PR: She had a stroke 5 years ago that’s why she lives there.
D: May I ask how do you know that Mrs. Moon underwent CT scan?
PR: The nurses in the caring home called me and updated me.
Then quick HX:

P1:
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- What do you know about your mother's condition so far?

- How is her health in general?
- Any other family member taking care of her?
- How are you coping with that?
P2
- Has she been diagnosed with any medical condition in the past?
- Any hospital admissions or surgeries in the past?
MAFTOSA
- Does she take any medications that you are aware of?
- Any family history of medical conditions?
Counselling:
- Thank you for answering my questions, I appreciate your cooperation.
- Unfortunately, I could not give you any information about your mother's
condition as
• I do not have any consent from her.
• I don’t have any information about whether she has mental capacity or
not.
PR: I am a consultant, just tell me the result.

D: Yes, I know that you are a consultant so you know the rules as well as me, I
cannot discuss a patient’s results without their consent.
I appreciate that you are very concerned about your mother but I’m afraid I
could not share any information, I am obligated to take her consent first.
Surely you understand it’s important that her confidentiality is protected.
PR: Can you go and ask for her consent then?
D: I can go and assess her mental capacity and take her permission to discuss
the results of the CT scan with you.
PR: Go and speak to your senior and tell him that I want to know my mum’s CT
result.
D: I totally appreciate your frustration with this and I don’t have a problem
speaking to my senior and asking them to come and talk to you, if you want - I
will also need to record this conversation in your mother's notes.
LEVOTHYROXINE DOSE ADJUSTMENT

Who you are:
You are a FY2 doctor in the GP clinic.
Who the patient is: Julia is the daughter of Mrs. Margert James, 75 years old.
Mrs. James has been diagnosed with dementia and lives in a care home and
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recently the dose of levothyroxine has been reduced for her as her thyroid
function
tests are normal. Julia has come today to understand why she has not been
informed about the change in the dose of her mother's medication.
Specific note
Thyroid function tests will be repeated after 6 weeks.
What you should do:

Talk to her and address her concern.
NOTE
This station is mixed (Angry + Medical Error).
Introduction:
Doctor: Hi, I am Dr (name) one of the doctors here, may I confirm your name,
Patient’s Relative: (Confirms information)
D: I understand that you have some concerns regarding your mother's
condition, and I am here to address your concerns.
PR: I went to visit my mother in the care home, and I found that the dose of
levothyroxine has been reduced without the doctor informing me. You know
that I have lasting power of attorney.
D: I can see that you are upset, I’m sorry about that, I will do my best to find
out why you have not been informed. Do you mind if I ask you some questions
to be in a better place to address your concern?
Focused history:
P1
D: How much do you know about your mother condition?
PR: She is in a nursing home because of dementia.
D: I am sorry about that, are you able to visit her frequently?
(Note: Asking the relative “how often do you visit her?” can sound judgmental.
But if you word it differently: “are you able to visit her frequently?” it takes
away any feeling for the relative of being judged, as it implies that if they don’t
visit often, it’s because they are unable to, it’s not out of choice.)
P: Every couple days.
D: That’s good. Is there any other family member who comes to see her?
PR: No, I am the only one.
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D: I can see you’re upset about her, how are you coping emotionally with her
having dementia?
P: It’s difficult to see my mum like this, but I am doing my best.
Take history about THE INCIDENT (Important)

• Did you make it clear to the doctors managing your mum’s condition
that you should be updated about any changes to her medication?
• Do they have your updated contact details?
• Have any of your contact details changed?
• Has this problem ever happened before?
P2
D: Has she been diagnosed with other medical conditions?
PR: In addition to dementia, she has problems with her thyroid, heart, kidney
and liver.
Counselling:
1- Apologise that she wasn’t informed of the change in medication.
I apologise that nobody seems to have contacted you. I will talk to my
colleague and try to find out why this happened and update you. Is that ok
with you?
2- Explain why the medication was changed:

- Regarding the dose of Levothyroxine, do you have any idea why we
reduced the dose?
- The reason is because your mother has an underactive thyroid gland.
This is a gland in front of our neck. Your mum’s is producing less amount of
thyroxin hormone, so we started her on levothyroxine to compensate for that.
- We did a thyroid function test for your mother and fortunately it is
normal, so we reduced the dose.
3- Update her about the new test.

- We will repeat the test again in 6 weeks and we may change the dose
again according to the results.
4- Solutions:
- We take these issues very seriously; I will escalate this to my senior and
fill out an incident form about it.
(If she is not satisfied and wants to complain, direct her to the PRACTICE
MANAGER as you are in a GP surgery or PALS in the hospital.)
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- Also, we will make sure that it does not happen again in the future, and
if there is any change in her medication, we will make sure that we contact you
about it. How would you like to be updated?
Give her options:
• Email
• Phone
• Arrange a meeting
5- Document this incident in her mother’s notes.
Changing counsellor
Who you are:
You are a FY2 in the GP clinic.
Who the patient is:
30-year-old lady has made an appointment to see you.
What you should do:
Talk to the patient and address her concerns.
Approach
• Assure her that she can change her counsellor
• Explore the depression history
• Offer confidentiality
• Explore the relationship
• Exclude abuse
• Impact on life
• Management

P: I want to change my counsellor.
D: OK, we can help you with that, it’s your right to choose who will treat you.
But first, do you mind me asking you why you were seeing a counsellor to
begin with?
P: I had depression.
Explore depression
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D: Can you tell me more about that?

P: It was 3 years ago after the death of my husband, I started to feel low then I
was diagnosed with depression. They gave me a medication called Sertraline
which I stopped taking a year ago because I was doing fine. Then I started the
counselling sessions.
D: How was your condition after starting the sessions?
P: I was getting better.
D: And how are you doing right now?
P: I am fine.
D: Any symptoms of depression?
P: No, I just want to change my counsellor.
D: Is there any specific reason for that?
P: I just want to change him and it’s my right to change him if I want to.
D: Of course, it’s your right and it’s not a problem. I just want to make sure
that you are aware that anything you say here will remain confidential
between you and the medical team?
P: I was in a relationship with him.
D: OK I understand now. Do you want to talk about it?
P: First, he started sitting next to me, then holding my hands and then kissing
me. Then we started dating and having sex together and everything was fine at
first. But then I saw him recently with a woman who I think is his wife. He lied
to me.
D: I am really sorry to hear about what you have been going through. This
should never have happened in the first place. I just need to ask you few
questions if that’s OK:
Exclude abuse
D: Was this relationship consensual?
P: Yes.
D: Was there any form of abuse during this relationship?
P: No.
D: You did the right thing by coming to us. It’s his responsibility to maintain
professional boundaries.
P: I just want to change to a female counsellor?
D: That’s not a problem at all.
IMPACT on her life

D: Going through all of that, has it affected your life?
p: No, I am OK.
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D: On a scale from 1 to 10, with 1 being the most unhappy and 10 being the
happiest, can you grade your mood for me?
P: 7.
D: Thank you again for opening up to me. Let me be clear that what happened
with you is unethical and wrong from the counsellor. Doctors shouldn’t engage
in any sexual relationship with their patients. You were vulnerable during this
period, and he took advantage of that.
P: Is he going to be disciplined for that?
D: Well, it’s a breach of trust in the practice to get into a personal relationship
with a patient and of course investigations will happen.
P: Please doctor I didn’t want to get him into trouble.
D: Look, you shouldn’t feel guilty about that at all. He should maintain
professional relationships with all patients, he knows that. If we didn’t report
him he might do it again to another patient.
Management:
1. Senior
2. Update her notes
3. Practice manager
4. Offer her help and support
Encourage her to make a formal complaint.

Investigations will be carried out.
You will get updated on the outcome of those investigations.
Ask her for the name of the doctor.
Premature child -Talk to mum

Who you are:
You are FY2 in PICU.
Who the patient is:
30-year-old lady who is here to visit her baby. She delivered her baby 5 days
ago. The baby was born at 27 weeks. The baby is being kept in an incubator.
What you should do:
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Talk to the mother and address her concerns.
Approach:
Explore the incident
Baby condition right now
Concerns
Management
Doctor: How can I help you?

Patient: My daughter is in the incubator because she was born at 27 weeks,
and I came to see my her today and I found her body covered with poo. I don’t
know why no one is taking care of her, why no one is changing her!
D: Really? I’m sorry about that. I can see that you are concerned about your
daughter, and I completely understand why you’re upset.
Incident hx:
D: Has this happened before?
P: This is the first time to visit her, I have no idea if this had happened before
or not.
D: Have you talked to the nurse there so she can clean her up?
P: Yes, I told her about it, and I cleaned my baby myself.
D: What did she say to you?
P: She just apologised.
D: I am really sorry about that; we will look into this issue and investigate what
happened.
Child condition:
D: When did you deliver your child?
P: 5 days ago.
D: Any problem with the delivery?
P: No.
D: How is your daughter right now?
P: I am worried in case she gets an infection from the poo being left on her.
D: Well, we don’t know how long the poo was left on her so don’t worry too
much, it may have only been a few minutes. But to put your mind at ease I will
examine her to make sure there is no sign of infection, and we can do a routine
blood test to make sure she’s OK.
D: Apart from that, do you have any other concern?
P: Can only one nurse take care of my child?
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D: Usually the nurses work on shifts every shift from 8 to 12 hours. It would be
difficult for only one nurse to take care of your baby. But we always make sure
that the nurse in charge is professional and we will inform her about your
daughter.
P: Can I take my baby to another hospital?
D: Well, you could, but it would be unnecessary as we have a great team here
and we always make sure that we are giving the best care. I’m sorry for the
incident and I will make sure it doesn’t happen again.
Management:
- Inform seniors
- Incident form
- Examine the baby and do routine blood tests to exclude infections.
- Offer PALS if the patient wants to complain.
- Document complaint in the baby’s notes.
- Talk to the head nurse.
CP Child – Talk to Dad

Who you are:
You are a FY2 in ED.
Who the patient is:
A 17-year-old fell down and sustained an ankle injury. He was brought to the
ED 1 week ago with an ankle injury which he had after falling from his
wheelchair.
When he came to the ED, he had an ankle bruise, but no bone tenderness was
found. He was assessed and discharged home without x-ray. He still has the
bruise, and his dad has brought him back to the hospital.
What you should do:
Speak to the dad, assess the situation and address his concerns.
APPROACH:
PREVIOUS VISIT
Doctor: I understand from my notes that you brought your son a week ago, can
you tell me more about that?
Patient: We came a week ago because he had an injury on his left ankle.
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D: Sorry to hear that, how did this happen?

P: He fell off the wheelchair, my son has CP.
D: What happened after that?
P: The doctor told me it’s just a sprain and he didn’t do X-ray. I felt he was in a
rush and didn’t give much care to my boy. He did this because my son has CP
and right now, my son’s ankle hasn’t improved.
D: I am sorry you feel like that, we do have anti-discrimination policies in all
hospitals. Did the doctor prescribe you any medications?
P: Just painkillers.
Current condition
D: You told me that your son condition is not improving, is he still in pain?
P: Yes.
D: What about the swelling?
P: That’s gone down slightly.
D: Is he able to walk at all or is he completely wheelchair bound?
P: He is not able to walk at all.
P: I want you to do an x-ray on my son, I think he has a broken ankle
D: I understand your concern, I will just ask you few questions.
MAFTOSA
Examination:
Observation of ankle: No tenderness.
Diagnosis:
Let me reassure you that when I examined your son, I didn’t find any
tenderness over his ankle. What he has is an ankle sprain which is an
overstretching of the ligament around his ankle.
P: Why you don’t want to do an X-ray?

D: I appreciate your concern but there’s no need for that as there’s no
tenderness, so we don’t suspect any fracture. An x-ray would expose him to
unnecessary radiation and this can lead to serious diseases.
Management:
- Continue PRICE
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Pain killers: exclude allergies

Rest: offer crutches
Ice packs: 15-30 mins
Compression: by bandages to support the sprain
Elevate legs: to reduce the swelling
- Offer leaflets
- Arrange follow up
- Offer support
- Safety netting
Sick note – Ankle sprain

Who you are:
You are a FY2 in the ED.
Who the patient is:
Mrs. Alice Jones has come to the hospital with an ankle injury. She fell over at
home after slipping on wet grass.
You have seen Alice 30 mins ago and examined her. She has bruising, swelling
and tenderness on the left malleoli. You have sent her for an x-ray.
What you should do:
Talk to her, discuss the x-ray findings, and address her concerns.
The x-ray will be normal
Approach:
Discuss the diagnosis

Doctor: Hello again, thank you for having the x-ray done. Let me reassure you
the x-ray is fine. I can’t see any form of fracture, but it will be reviewed by the
radiologist.
Patient: So, what do I have?
D: You have an ankle sprain, it’s an overstretching of the ligaments around
your ankle.
Management:
PRICE
Pain killers: exclude allergies
Rest: offer crutches
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Ice packs: 15-30 mins

Compression: by bandages to support the sprain
Elevate legs: to reduce the swelling
D: Is there anything concerning you?

P: Well, you have been so nice to me doctor and I’d like to ask you a favour, I
would like to change my notes?
D: May I know why?
P: Because I fell at work.
D: So why didn’t you say that when you came in?
p: I was in severe pain, and I got confused.
D: I am really sorry about that, but I can’t change your notes. I’m not allowed
to do that.
P: Come on doctor; you can’t help me with this?
D: I am really sorry, but I really can’t help you with that. However, I can add
extra notes on if you want but I can’t erase the older notes.
P: Can I talk to your senior, you are just a junior doctor aren’t you?
D: I have no problem with that, but my senior can’t do anything either as we
are all bound under the same regulations.
P: I want to see what you wrote in my notes?

D: Of course, I can guide you on how to get access to your notes: you need to
apply to the information department with written consent and they will
provide you with all your notes.
P: Look, I am a single mum with a 5-year-old boy, and I want to claim
compensation from my work?
D: What do you do for living?
P: I am a school cleaner.
D: Have you checked if you are entitled to any benefits from the government
to top-up your wages?
P: I am not doctor, that’s why I need you to change the notes.
D: I am really sorry I can’t do that, but I can:
- provide you with a letter to say that you were in the hospital and with
the findings of the examination and the x-ray.
- refer you to the citizens advisory bureau where they can find better
solutions that suite you.
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- advise you to talk to your manager and explain the situation to him and
he might help you.
- Offer her support with her child

- Refer to Citizen advisory bureau
- Arrange follow- up
Whiplash Injury
Who you are:
You are a FY2 in the GP surgery.
Who the is patient is:
A 35-year-old lady presented with some concerns.
She had RTA 2 weeks ago. The police and the ambulance brought her in, and
she was examined. Everything was normal.
What you should do:
Talk to patient and address her concerns.
Approach:
Accident Hx
D: How can I help you?
P: I want a note for the whiplash injury I had last week.
D: I see, can you tell me more about what happened?
P: After a night out with my friends on Friday night, I was driving a small
vehicle when the car drifted away and I hit a big tree.
D: Oh dear! I’m sorry to hear about that, then what happened?
P: The ambulance and the police came and brought me to the hospital. They
checked my breath and they found the alcohol content was high and they
banned me from driving for 3 years.
D: Oh dear, was there anyone else with you?
P: I was alone.
D: Before the accident what were you doing?
P: I was just having fun with my friends.
D: And how much alcohol did you have?
P: Just 3 glasses of wine.
D: Any recreational drugs?
P: No.
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Injury Hx
D: Did you sustain any injury or trauma?
P: Not really.
D: Any neck pain?
P: No.
D: Any confusion?
P: No.
D: Any bleeding?
P: N.
MAFTOSA
ICE
Examination:
Observation: Normal
Neck: Normal
Neurological: Normal
Diagnosis:
Well, the good news is that everything looks normal and I couldn’t find any
evidence of a whiplash injury.
P: Can’t you help me out and say I have it anyway? I pay all my taxes you
know…
D: I am really sorry, but I can’t document what is not true. I can’t write findings
that I haven’t observed, and you know that you don’t have any whiplash injury.
P: I work as a medical rep and my employer will fire me when I lose my license.
I will be struggling financially.
D: I am really sorry I’m afraid I can’t be of much help but to:
- Advise you to tell your employer the truth.
- You can apply for a job elsewhere, somewhere that doesn’t require a
driving licence.
- I can give you a letter that you were at the hospital.
P: I have 2 children; I don’t know how I will support them?

D: I’m sorry about that. If you lose your job you can apply for benefits whilst
looking for a new one. You can also go to the Citizens Advisory Bureau and see
if they can offer you better financial advice.
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HEART FAILURE WITH HEMATURIA TALK TO SON
Who you are:

Who the patient is:
Mrs. Sofia Smith, 77 years old, was admitted to hospital 2 weeks ago and she is
receiving treatment for heart failure. She is catheterized and has developed
haematuria.
What you should do:
Talk to her son and address his concern. Consent has been taken.
Approach
Doctor: I understand that you have concerns regarding your mother's
condition and I am here to address your concerns.
Patient’s Relative: There is blood in my mum's catheter and I asked the doctors
to look at it but no one was available.
D: I can see that you are upset, and I am sorry for the way you are feeling, l will
do my best to address your concern and know why that happened in the first
place. Can you please tell me what happened exactly?
PR: I tried to ask the doctors, but no one was available to see her.
D: I am sorry for what happened, I am afraid that I do not know what the
doctors were doing at that particular time, they may be on a busy ward round.
I will do my best to know about that and update you. Is there anything else
that is bothering you?
PR: Last time I spoke to a doctor, he was rude and told me that the consultant
will speak to me but no one came to speak to me.
D: I am sorry about that I will go and speak with him about that and he can
come and speak to you and provide you with any information you want. May I
ask you few questions?
Data Gathering:
D: Do you know the name of the doctor who was rude to you?
PR: No.
D: When did this happen?
PR: This morning
D: Have you spoken to anyone else after that?
PR: No, you are the first one.
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PR: Yes, my mother does not eat

D: I can see that you are very concerned about your mother and I totally
appreciate that. She may have lost her appetite because of the heart failure;
However, I will go and take a medical history from her to assess her condition
and treat her.
PR: Why is no-one feeding her?
D: If you think no-one is feeding her I will also document that in her notes and I
will speak to a senior nurse to understand what the problem is and try my best
to solve it as soon as possible. I will come back to update you.
You mentioned to me that you saw blood in her catheter, and you are
concerned about that. Right now, I do not know the reason for that I have to
examine her and take a medical history from her.
Do you mind if I ask you some questions to be in a better place to address your
concern?
Focused Hx:
P1
How much do you know about your mother's condition?
What brought her to the hospital?
Do you know what treatment we gave her?
You mentioned to me you saw blood in the catheter:
When?
How much blood?
How many times?
Is it the first time?
Any bleeding anywhere else?
Is she drowsy?
P2
- Any other medical conditions?
- Any previous hospital admissions?
MAFTOSA
- Apart from heart failure medications, does she take any other
medications?
- Any allergies that you are aware of?
- Who lives with her at home?
Relative:
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- I can see that you are a caring son, is there anyone else is visiting your
mother?
- How are you coping?
- What do you do for living?
- At any time, if you find it difficult to come to the hospital and see your
mother, you can call the department and we will update you with any
new information.
Management (counselling):
- Thank you for answering my questions,
- I can see that you are upset, sorry for what happened.
- Let me explain to you, your mother has heart failure, do you want me to
explain anything regarding her diagnosis or treatment?
- The catheter is a thin tube that drains the urine, it helps us to assess the
function of her kidneys, if they work properly or not.
- We usually take the urine and examine it.
- I will inform my senior to do some tests to know the reason for that.
- Any other concerns so far?
- Thank you for coming today.
SEPSIS CALL FROM NURSING HOME

Who you are:
You are FY2 doctor in the Emergency Department.
Who the patient is:
Mrs. Monica Thomson, 86 years old, was brought to the hospital from the
nursing home as the nursing staff noticed that she was unwell and confused.
She is not giving history because of the confusion.
On examination,
Temperature= 38
R.R= 26
Blood pressure= 90/60
Heart rate= 110
O2 saturation= 88%.
What you should do:
Take history over phone from nursing staff and discuss management with
examiner at the 6 minutes bell.
- In this station the nurse doesn’t know anything about the patient so tell her.
Can you please read from her notes.
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Approach
Doctor: Hello, I would like to have some information about Mrs. Thompson's
condition so is it ok if I ask you some questions?
Focused Hx:
P1
- How much do you know about her condition?
- What do you mean by confusion?
- Since when? How did it start?
- How is her health in general?
- How independent is she?
- Is she able to move and do personal staff independently?
DDs of confusion:
- Any trauma to her head or fall?
- Any fever?
- Any vomiting?
- Any cough? (If yes, explore…)
- Any burning sensation while passing urine?
- Any diarrhoea?
P2
- Is that the first time she’s been confused? (dementia)
- Any medical condition?
- Any hospital admission?
DESA
- Is she able to eat and drink well?
MAFTOSA
- Any medications?
- Any family history of a medical condition?
Social
- Who is coming to visit her?
- How often?
- Who is her next of kin?
- Could you send me their contact details?
Advanced care
- Any advanced care planning?
- Has she appointed lasting power of attorney?
- What is her DNAR status?
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Thank you for answering my questions, I would be grateful if you send us a

copy of her notes.
Talk to examiner
• I have called the nursing home regarding our patient Mrs. Thompson.
• On taking history, she has had confusion since…., and ….
• From the history and checking her observations, I suspect that she has
pneumonia, and I will use CURB-65 to assess its severity and there is a
possibility that it may be complicated by sepsis.
• I will use ABCDE protocol to assess her:
A • make sure the airways are patent.

B • high flow O2, 15 litre per minute, via non breathable bag.
• Chest examination
• Chest x ray
• sputum culture
• ECG
C • Attach IV line.
• FBC + LFTs + KFTs + FBS + blood culture + urea and electrolytes +
drug levels + ABG.
• Serum lactate • IV fluids
• Paracetamol
• Antibiotics
D • Check pupils
• GCS
E • Insert catheter to monitor urine output and do urine culture.
• Expose and check tummy and pelvis
• Review her notes and drugs
• Take collateral history from her GP
• Call her next of kin.
NOTE
- The patient may have allergy to amoxicillin so, you will give her
erythromycin.
- Do not give information to the nurse as she does not have a consent,
only take history from her.
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GENDER SELECTION PRE-CONCEPTION

Who you are:
You are a FY1 in the GP surgery.
Who the patient is:
Lydia, aged 33, came to the clinic to see you. She has 3 daughters aged 7, 4 and
1. She is taking contraceptives pills.
What you should do:
Approach:
D: Hi, how can I help you?

P: I want my next baby to be male.
Explore:
D: I see. May I know why?
P: I have 3 daughters and my husband wants a boy to carry on the family
name.
D: Do you feel that you are under pressure to do this?
P: No, it’s fine.
D: Apart from this, is there any other concern?
P: No.
Relationship with husband

Doctor: If you don’t mind me asking, how is your relationship with your
husband?
Patient: It’s fine.
D: You are not dealing with any form of abuse or neglect from him?
P: Not at all.
Previous delivery:
D: What about your relationship with your daughters?
P: It’s very good.
D: What about their health?
P: They are healthy.
D: Do they have any medical condition?
P: No.
D: How was their delivery?
P: Normal delivery.
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D: Any problems during delivery?

P: No.
Past history
D: Do you have any medical condition?
P: No.
D: Are you taking any medications?
P: No.
D: Do you have any family history of any genetic conditions?
P: No.
P4
D: When was your last menstrual period?
P: 4 weeks ago.
D: Is it regular?
P: Yes.
D: Any bleeding in between periods?
P: No.
D: Are you using any method of contraception?
P: Yes, I’m on contraceptive pills.
DESA:
P: No.
D: Do you smoke?
P: No.
Examination:
Observation.
Counselling:
D: Gender selection is illegal in the UK at the moment, but you can find it in
other countries. Such treatment is only permissible in cases where there is a
genuine medical reason for the procedure, for example in cases of sex-related
genetic defects. It can be used to avoid sex linked genetic disorders.
P: If I get pregnant, when can I find out the sex of the baby?
D: You can find out the gender between 18 and 21 weeks through ultrasound
scan.
P: If it’s a girl, can I terminate the pregnancy?
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D: No, abortion based solely on gender preference, where there are no health
implications for the baby or for the woman, is illegal in the UK.
P: My aunt has breast cancer. So, there are some chances that it may transmit
to my daughter. Can I give this as a reason to abort my child?
D: Breast cancer is not linked to any sex-related genetic defects, so it can’t be
used as a reason to terminate the pregnancy
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PATIENT REFUSAL
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Patient Refusal
REFUSAL STRUCTURE
• 7 Steps:
1. Why? (Patient will give you concern)
2. Address the concern:
- Start with the least costly solutions.
- Ex: If a patient refuses admission because he has kids at home and
no-one else takes care of them → start with their mum or dad,
relatives, friends and special services that look after them.
3. Caution him about consequences of refusal
- Give ultimate risk
- Consequences of refusal
4. Benefits of accepting (Management)
- Ex: Do you know why we need to keep you in the hospital?
5. Senior (Why + Consent)
- I will ask my senior to have a chat with you, would that be alright with
you?
6. Sign discharge against medical advice form
7. Safety netting
- We are still worried about you, please, if you have …… come back to us
immediately.
NOTE:
At any time if the patient agrees → start to take Hx + verbalize examination +
manage
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WARFARIN REFUSAL (RAT POISON)

Who you are:
You are an FY2 doctor in medical department.
Who the patient is:
Mr. Alex Wilson is 55 years old; he was admitted 4 days ago with palpitations and
he is diagnosed with AF. He is about to be discharged on warfarin. He has told the
nurse that he doesn’t want to take warfarin. He had MI and stroke 2 years ago.
What you should do:
Talk to him about it and address his concerns.
Approach
D: I can see from my notes that you have been admitted in the hospital for 3
days?
Build Rapport:
• How's your hospital stay been?
• How's the care by the doctors and nurses?
D: I can see from my notes that you are about to be discharged and I am here
to talk to you about your medications, before we start is there anything that I
can help you with?
P: I don’t want to take Warfarin.
D: OK. Well, no one can force you to take any medications if you don’t want
them. But before that can I ask you few questions?
Assess his knowledge

D: What have you been told so far about your condition?
P: I understand that my heartbeat is irregular and that carries risk of clots
forming at any time.
D: I’m glad that you know so much about your condition, you will be started on
warfarin, have you heard about it before?
It is a medication that makes your blood thin like water and prevents any clot
formation.
P: I do not want to take it.
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D: I understand that, can I ask you a few more questions before addressing
your concern?
P: OK.
QUICK MAFTOSA
Social history: to check who can remind him of the medication time and
convince him if he refuses.
P: I live alone after my wife died 2 months ago.
D: I am really sorry for your loss, how are you coping?
P: It’s difficult but I can manage alone.
D: What about your mood?
P: It’s fine, thank you for asking.
Refusal steps:
D: Going back to your concern. You have the right to refuse any medication,
but may I know why?
P: It’s a rat poison.

D: That's right technically, warfarin contains a substance called dicoumarol
which has been used as rat poison. However, we only use a very low amount of
it in Warfarin so that it cannot harm the human body. Also, it doesn’t have the
same reaction on our bodies as rats. But how did you hear about that anyway?
P: My dad was on warfarin and he died of severe bleeding in his brain?

“Check his MOOD here”
D: I am sorry about your dad, I understand where you’re coming from.
• Actually, bleeding is one of the complications of warfarin so we keep
monitoring the patient who is on warfarin by a special team called
anticoagulation clinic.
• If we found any warning sign, we would manage that accordingly.
• At the same time, many patients in the world are on warfarin and have
good health without complications.
P: Is there any other blood thinner?
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D: There are different types of blood thinner but warfarin is the medication of
choice for your condition.
3. Benefits
- We want the best for you.
- If you take warfarin, it decreases risks of developing complications.
- You will live a healthy life and we will keep monitoring you.
4. Scare
D: Do you know what will happen if you do not take it?
I am afraid that you may have a heart attack or stroke which are serious
conditions.
5. Senior
6. Offer to assign carer or home visitor from the GP.
7. Advise him to use an alarm to remind him about the medications
8. If he refuses. Ask him to sign Discharge against medical advice form.
9. Safety netting
- At any time, if you change your mind come back to us.
- If you develop any chest pain, leg pain, weakness in your body, come to us
immediately.
- Bleeding, bruise and headache.
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INFECTIVE ENDOCARDITIS – self discharge
Who you are:

You are FY2 in Acute Medical Department,
Who the patient is:
Ms. Nicole Harrison is 24 years old; she was admitted a week ago with infective
endocarditis. She is supposed to receive 3 weeks course of IV antibiotics. She is
IV drug user the nurse has been advising her to stay in the hospital. However,
she wants to leave the hospital. The nurse has asked you to talk to her.
What you should do:
Talk to her and address her concern.
N.B: The patient will be standing up and irritated, you need to stand as long as she is
doing so.
She will be anxious, agitated, shaking legs and rubbing her fingers.
Approach
Opening sentence: finally, a doctor is here, I need to go home, can I do that?
D: I can see from my notes that you have been admitted to the hospital for 3
weeks.
Rapport admission:
- How's your hospital stay been?
- How's the care by the doctors and nurses?

P: Dr, I want to go home
Refusal structure:
D: You have the right to leave the hospital if you want to, no one can force you
to stay, but may I know why?
P: Nurses are gossiping about me
D: I am really sorry about that, it shouldn’t happen at all, what did
they say?
P: They say I am addict.
D: I am really sorry for what happened with you, it should not happen to
anyone. Do you mind if I go and have a word with them to find out what
happened and then come back to you?
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D: Is there anything else is bothering you?
P: I want to smoke; they do not let me smoke.

Check Capacity
D: How many cigarettes do you normally have a day?
D: When was the last time you smoked?
D: I can see that makes you upset but do you know what condition you have?
P: I know that I have infection in my heart and I am receiving antibiotics for it.
D: Do you know the effect that smoking has on your condition?
P: It might have a negative effect on me, but I still want to smoke.
D: Of course, it’s up to you, if you need to smoke, we can give you a nicotine
patch how do you feel about that?
(If still refusing)
We can show you the smoking area in the hospital or the garden, I will discuss
this with my senior, is that ok?
D: If everything is sorted, would you consider staying in the hospital?
P: I still want to leave the hospital
Scare
D: Do you know why we want to keep you in the hospital?

- Because this kind of infection is treated with antibiotics through your veins
for 3 weeks and you have only had treatment for one week along with
monitoring you continuously.
P: Can’t I just take tablets instead?

D: I am afraid with this type of serious infection; we only use antibiotics
through veins as it is more effective.
NOTE:
The simulator is scratching her body.
Reflect: I can see that you are anxious, is everything ok with you?
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Do you mind if I ask you a few more questions to be in a better position to help
you?
Focused Hx:
• P1
- How are you feeling right now?
• P2
- Have you had any medical conditions?
• DESA
D: Do you drink alcohol at all?
P: Yes
P: I drink 5 glasses a day and if I stop drinking alcohol for a couple of days I
start to develop symptoms.
D: I understand this must be difficult on you, by any chance, do you take any
recreational drugs as well? (Yes)
D: What drug?
P: I inject myself with heroin.
D: When was the last dose?
P: Before I was admitted to the hospital.
D: Do you share needles?
P: Yes.
D: Have you heard about the needle exchange program?
P: No.
D: By any chance have you been tested for any STIs or HIV?
P: No.
D: It looks like you are experiencing Withdrawal Symptoms that affect any
person when he stops taking the dose of the recreational drug he is addicted
to. The withdrawal symptoms could also cause vomiting or tummy cramps,
have you had any of these symptoms?
- I will talk to my senior to give you medication for treating the withdrawal
symptoms, is that ok?
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• MAFTOSA
- Any other medications?
- Who do you live with?
Examination:
Ideally, I would like to examine your chest and listen to your heart and check
injection sites (if heroin). Is that OK?
Management:
- Explain she has the right to go home and no one can force her to
stay.
- Advise her to complete the treatment at the hospital, but if she
wants to leave, she must sign a discharge against medical advice
form.
- Give her the option to smoke in the garden or smoking area.
- Give her methadone to relieve withdrawal symptoms.
- Apologise for what happened with the nurses.
- Tell her about the needle exchange program.
- Offer her help and support if she wants to quit smoking and drugs.
Safety netting
PNEUMONIA PATIENT REFUSING TTT

Who you are:
You are FY2 in medical department,
Who the patient is:
Mr. Jack Smith is 78 years old and was admitted yesterday with a chest infection. He has
a history of COPD. 15 years ago, he had MI and 3 years ago he was diagnosed with heart
failure. He is receiving IV antibiotics for chest infection. He doesn’t want to take the
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medication.
What you should do
Talk to him and address his concern.
Approach
Doctor: I can see from my notes that you have been admitted with a chest
infection, how are you right now?
Patient: I am ok doctor thank you.
D: I understand that you have some concerns and I am here to address your
concerns, but before that can you walk me through your condition? Has anyone
explained your condition to you?
P: I know I have a condition called Pneumonia, which is a bug in my lung for which
I am taking antibiotics.
Quick Hx
- What brought you to the hospital in the first place?

P: I had a cough, fever and I haven’t been breathing well for the last 3 days.
• P2
D: I can see from my notes that you have heart failure, it’s a quite a challenging
condition, how are you coping?
P: The doctor gave me some medications for it.
D: Any other conditions?
Social history
P: I live alone, my wife died 5 years ago.
D: I am really sorry for your loss? Does any family member visit you?
P: Yes my daughter visits me every week, but she has rheumatoid arthritis.
D: I am really sorry to hear that, how is she doing?
P: She is fine.
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D: Do you have any concerns?
P: Doctor, I don't want to take my medications.
Refusal Structure:
D: Which medications don’t you want to take?

P: Heart failure medications.
D: May I know why you don’t want to take them? And do you know the name of
these medications?
P: They make me drowsy and tired all the time, I can’t remember the name right
now.
Address concern
D: OK, I totally appreciate your concern, but may I know why you think you are
tired due to medications?
P: I started to get tired only after taking these medications, before that I was
totally fine.
D: Tiredness may be due to many reasons, I would like to ask you some questions
and run some tests and if we are sure that you are tired due to the medications,
we can adjust the doses or replace them, how do you feel about that?
- Tiredness could be also due to heart failure; I am afraid if we stopped the

medications, it would be worse.
P: I don't want to take the medications and I want to spend quality time with my
daughter.
D: I appreciate how you are feeling, have you discussed your decision with her?
P: Not yet.
Warn him: Asses his capacity.
D: You have heart failure, that means your heart is unfortunately unable to
pump blood around your body properly. Do you know that?
D: Do you know why we are giving you these medications?
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To make it easier for your heart to work and bring your symptoms under control.
D: Do you know what could happen if you stop your medications?
I am afraid that your heart would not be able to pump your blood well, and that
makes blood and fluids accumulate in your body and in your lung which is a life-
threatening condition.
Benefit
D: If you take your medication, you will have a better quality of life as you are
concerned about your daughter, if your symptoms are controlled, you will be able
to enjoy the time you spend with her.
Senior
D: Do you mind If I speak to my senior, to have a chat with you about it?
• Examination
Ideally, I would like to take your vitals and examine your heart and your chest. Is
that OK with you?
• Management
I will inform my senior.
You can also discuss your decision with your GP and he can tell you about the
many options for end-of-life discussions.
• Safety netting:
At any time, if you change your mind, just let us know
CANCER PATIENT REFUSING CHEMOTHERAPY

Who you are:
You are FY2 doctor in the oncology department.
Who the patient is:
Mr. Michael Robert is 82 years old; He was admitted 2 days ago with
neutropenic sepsis. He was diagnosed with lung cancer 8 months ago and he is
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receiving chemotherapy for it. Cancer has shrunk after the chemotherapy.
What you should do:
Talk to him and address his concerns.
Approach
Doctor: I can see from my notes that you had been admitted 2 days ago, how
are you right now?
Patient: Much better right now.
concerns, but before that can you walk me through your condition?
D: Has anyone explained your condition to you?
P: No.
D: You have a condition called neutropenic sepsis, when you have a very low
number of neutrophils which are the cells that fight any infection and for that
we are giving you antibiotics through your veins. It’s a serious condition and it
needs admission.
Quick Hx
P1
What symptoms did you have?
Any fever?
Any SOB, Cough?
P2
D: I can see from my notes you have lung cancer, how is it managed?
P: I am taking chemotherapy for it.
MAFTOSA
D: Any other medications?
P: No.
D: Who lives with you at home?
P: I live alone.
D: Does any family member take care of you?
P: My daughter.
D: Is there anything you are hoping for from us?
P: Dr, I want to stop the chemotherapy

Refusal Structure:
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Well we can't force you to take anything against your will, but may I ask you,
why?
P: Every now and then I have this infection and it needs admission to the
hospital, and I am not OK with this anymore. I want to die in peace.
D: I totally appreciate that it’s frustrating for you to keep coming in, I can see it
is a challenging condition and chemotherapy is not comfortable. Can you just
bear with us a bit longer and complete your chemotherapy cycle? Because the
good news is the size of your cancer has shrunk after chemotherapy. Have you
discussed this with your daughter?
P: Not yet.
Scare
D: Do you know what could happen if you stop your medication?
• I am afraid the cancer could grow again and could spread to the
rest of your body.
• Your symptoms also would be worse, affecting your quality of life.
P: I am not taking the chemotherapy anymore; I hate coming to the hospital.
D: Is there any specific reason you hate the hospital, any bad experience?
P: No, I just want to spend my last days in my home.
D: What about the antibiotics?
P: I am ok with that.
D: What do you think about you taking the antibiotics at home?
P: That would be perfect.
D: Thank you for understanding, I will discuss this with my senior.
Benefit
- If you have your chemotherapy, we can keep your symptoms under
control and prevent cancer from spreading to the rest of your body.
Senior
- Do you mind if I ask my senior to have a chat with you about it?
- At some point, we can discuss with you your options of advance care
planning if you want.
Safety netting
At any time, if you change your mind please let us know.
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If you have any difficulty in breathing or bleeding anywhere in your body, come
back to us immediately.
BREAST CANCER REFUSING TTT

Who you are:
You are FY2 doctor in the GP clinic.
Who the patient is:
Mrs. Tanya Jones, 38 years old, has been diagnosed with breast cancer and she
is scheduled for breast surgery after 2 weeks. She is calling you because she
wants to discuss her management plan.
what you should do:
Approach
D: Hi, am I speaking to Mrs. Tanya Jones?
Could you please confirm your DOB?
Is this a suitable time to talk?
Could you please give me the best phone number to call you on in case the line
is disconnected?
I understand that you have some concerns regarding your treatment and I am
happy to address your concerns.
Doctor, I do not want to do my surgery.
Refusal Structure:
D: Well we can't force you to do anything against your will, but may I ask you, why?
P: I don’t feel that the surgery would help, I feel I’m going to die anyway.
Address concern
D: I totally appreciate how you are feeling, but many people around the world
have breast cancer and have successful surgery and live long and healthy lives.
May I know why you feel this way?
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Warn her of risks

D: Do you know what could happen if you do not have the surgery?
I am afraid the cancer will grow more and spread to your body and at that stage,
surgery would not be possible.
Benefit
If you do the surgery, we can improve the outcome of the disease, you will have a
good quality of life without any pain. Also if you have any concerns regarding the
shape of your breast after surgery, we have solutions for that, we can discuss
them if you are interested.
P: I am afraid of losing my hair?
D: Well surgery won’t make you lose your hair, but the chemotherapy after will.
However, let me reassure you this is only temporary. Your hair will grow back
again and in the meantime you could wear a wig or a hat?
P: Will you remove the whole breast?
D: It depends upon the stage and kind of cancer you have, but even if we remove
the whole breast, the surgeon can reconstruct a new one so this wouldn’t affect
your shape.
D: Any other concerns?
P: No.
3. Senior
- Do you mind if ask my senior to have a chat with you about this?
Quick Hx
• P1
- How is your health in general?
- Which breast?
- Any pain?
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- Any discharge or bleeding from your nipples?

- Any lumps elsewhere else on your body?
- You’re obviously going through a difficult time; how do you feel mood wise?
(Patient may say I feel low)
- By any chance is it affecting your sleep, or your appetite?
• P2
- Any other medical condition?
- Any surgeries in the past?
• MAFTOSA
- Are you on any medications?
- I can see it is a challenging condition, how are you coping?
- Who lives with you at home?
- Have you discussed this decision with them?
- Is there anything you are hoping for from us?
• Management:
1. Refer
- As you mentioned to you that you are feeling low, what would you think about
me referring you to a psychiatrist for talking therapy?
2. Safety netting
- At any time, if you change your mind just let us know.
- If you have any difficulty breathing or bleeding from anywhere on your body come
back to us immediately.
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PATIENT REFUSING COLONSCOPY

Who you are:
You are FY2 doctor in A&E.
Who the patient is:
Mr. Jack Green, 72 years old, he was brought by the ambulance because he
fainted. FBC was done which shows low HB, your consultant decided to do
urgent colonoscopy.
What you should do:
Approach
Doctor: I can see from my notes that you have been brought by ambulance
because you fainted, are you OK right now?
Patient: Yes, thank you.
D: I am here to talk to you about the further management that we will do for
you, but before that is it ok if you walk me through what happened?
P: I was just walking in the street and I can’t remember anything.
Focused Hx
P1
D: I can see from my notes that you fainted, have you injured yourself?
P: No.
D: Any tiredness?
P: Sometimes.
D: Any bleeding anywhere in your body?
P: Yes, I have rectal bleeding.
- FLAWS
• P2
- Any medical condition?
- Is it the first time you’ve fainted?
MAFTOSA
- Are you on any medications?
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D: We did some tests for you which show that you have anaemia and I
am here to talk to you about what we will do for you next. We would like to do
a colonoscopy, do you know what that is?
P: Doctor, I do not want to do it.
Refusal Structure:
D: Well, we can't force you to do anything against your will, it’s totally up to
you, but may I ask how much you know about what a colonoscopy is?
P: I do not know it
D: It is a flexible thin tube with a camera which is passed through your back
passage to help us to see the cause of your bleeding, May I ask why you do not
want to do it?
P: I am an old man, I am not keen on any procedures.
Address concern
D: I totally appreciate how you are feeling ,but even you are old , you still have
the right to live a good quality life and we are here for you to help you stay
healthy.
Warn him of risks

D: Do you know what could happen if you do not have the colonoscopy?
- I am afraid we may miss a serious cause of your bleeding and I
am afraid it could something sinister.
- Unfortunately, your tiredness may increase as we will not be
able to know the cause of bleeding and stop it.
Benefit
- If you do the colonoscopy, we will know the cause and treat it
accordingly and if it is something sinister, we will be able to
catch it early.
Senior
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- Do you mind if ask my senior to have a chat with you?
Safety netting
- At any time, if you change your mind just let us know
immediately.
- If your symptoms become worse come to the hospital
immediately.
PROSTATE CANCER REFUSING TTT

Who you are:
You are FY2 doctor in the urology department.
Who the patient is:
Mr. Robert Taylor, 74 years old, admitted in the morning with urine
retention. Catheter was inserted and he is well right now.
Mr. Taylor has history of prostate cancer. He wants to remove the catheter
and go home.
What you should do:
Approach
concerns, but before that can you walk me through your condition?
Quick history
He is already diagnosed with prostate cancer so no need for differentials.
• P1
Doctor: I can see from my notes that you were not able to pass urine, and a
catheter was inserted, can you tell me more about that?
Patient: I was not able to pass urine for the past 2 days.
- DDs of urine retention:
Any constipation?
Have you been told that you have bladder stones?
D: I understand that you have been diagnosed with prostate cancer, can you
tell me more about that?
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P: I was diagnosed with it 3 years ago.

P: They started me on chemotherapy.
D: Do you have any symptoms right now like back pain or problem with
urination + FLAWS?
P: No.
D: Any change in your condition since you have been started on the
chemotherapy?
P: No.
• P2
- Any other medical condition?
- Is it the first time to not be able to pass urine?
MAFTOSA
- Are you on any other medications apart from chemotherapy?
Thank you for answering my questions, do you have any concerns so far?
Counselling:
P: Dr, I want to remove the catheter.
Refusal Structure:
- Well, we can't force you to keep it in against your will, but may I ask why?
P: I feel I am ok I want to go home.
Address concern
- Yes, I am happy to hear that but do you know what condition you have?
- You have urine retention that means you are unable to pass urine, do you
know why you have this?
- It could be caused by anything that is obstructing the bladder and, in your
condition, it is most probably due to the cancer.
Warn him of risks
Do you know what could happen if we remove the catheter?
I am afraid that if we remove the catheter, you would not be able to pass
urine that could cause you pain and discomfort and finally your kidneys may
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be damaged.
Benefits
The catheter should remain for a couple of days longer and then it will
be removed, can you please stay in the hospital?
NOTE
In another scenario, patient may say:

P: I do not want to take chemotherapy anymore.
Refusal Structure:
D: Well, we can't force you to do anything against your will, but may I ask why?
P: I feel I am going to die anyway.
Address concern
D: I am sorry for the way you are feeling but may I know why you feel this
way?
P: My wife had cancer, she was on chemotherapy for a year and then she
died.
D: I am sorry for your loss, please accept my condolences. I understand now
where you’re coming from, but not all conditions are the same.
D: How are you coping with that?
P: It doesn’t matter doctor I know that I will die anyway
Warn of risks
D: Do you know what could happen if we stop the ttt?
I am afraid that cancer will grow more and affect your ability to pass urine, and
it will cause pain for you.
Cancer might spread to the rest of your body which is a fatal condition.
P: It’s ok doctor all of my friends died I think life isn’t worth living anymore.
D: I am really sorry that you feel like that, Robert. Who do you live with if you
don’t mind me asking?
P: I live alone.
D: Does any family member take care of you?
P: My daughter visits me every couple of days.
D: Have you discussed your wishes with her?
P: No.
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D: Do you think she would be happy with your decision?

P: It doesn’t matter it’s my decision at the end of the day.
Benefits
D: If you take chemotherapy, the cancer should shrink and the prognosis will
be better.
Senior
D: Do you mind if I ask my senior to have a chat with you about it?
P: No problem.
(If he continues to refuse, discharge against medical advice.)
Safety netting
At any time, if you change your mind just let us know immediately.
If your symptoms become worse come to the hospital immediately.
Gonorrhoea in a man
Who you are:
You are FY2 doctor in GUM clinic,
Who the patient is:
Mr. John Black, 34 years old, came with discharge from his penis a week ago.
Gonorrhoea was confirmed and he has been started on antibiotics 2 days ago.
Nurse talked to him about contact tracing, but he refused.
What you should do:
Talk to him, convince him and address his concerns.
Approach
D: I can see from my notes that you have been diagnosed with gonorrhoea and
you are receiving treatment for it, how are you right now?
P: I am fine, thanks.
D: I also understand that the nurse talked to you about contact tracing and I
am here to talk to you about your condition also. Before that do you have any
questions about gonorrhoea?
P: No.
D: Do you mind if you walk me through your condition from the beginning?
P: I started to have this discharge from my penis 2 weeks ago when I was in
Greece, after that it became more frequent and painful.
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D: How much do you know about gonorrhoea?

(This is a condition which is usually transmitted by having unprotected sex. It
is caused by a bug, it is not serious; however, if not treated it could be
serious. )
Quick Hx as it already diagnosed

P1
- What made you come to the clinic in the first place, was it the discharge?
(Unusual Discharge)
Tell me more about it.
- Anything else?
- Symptoms of gonorrhoea:
Pain while you are passing urine?
Pain in your testicles?
- Symptoms of Other STIs:
Ulcers in your private area?
Diarrhoea? Weight loss?
• P2
- Have you been tested for STIs before?
- Have you had this discharge before?
- Any medical conditions?
• Sexual so important
D: Sorry, I need to ask you some questions that are quite personal and in depth, but they are related
to your condition. If you feel uncomfortable and want me to stop just let me know. Are
you sexually active?
P: Yes.
D: Are you in a stable relationship?
P: Yes.
P: No.
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D: By any chance, have you had sex with another partner in the past 6 months?
P: I had sex with a girl while being in Greece.
D: Did you use any method of protection, like condoms?
P: No.
D: Have you had this unusual discharge after this?
P: Yes.
D: Have you had unprotected sex with your partner after this?
P: Yes.
D: By any chance, is your partner experiencing the same symptoms as you?
P: She hasn’t mentioned anything about it.
Examination:
• Observation
• Throat (check for signs of infection)
• Private parts
• Abdominal (if patient is female as they can get PID)
Patient concerns:
P: Why do you want to tell my wife?
D: May I know why you don’t want to tell her?
P: This could ruin our marriage, it was only one time and I promised myself I
wouldn’t do it again.
D: I really appreciate what are you feeling but you told me that you had
unprotected sex with her after having these symptoms and it’s highly likely
that you have transmitted the infection to her. So we need to check and treat
her because if only you get treated you will get the infection back again from
her after.
P: She will leave me if she knows what I did

D: I am really sorry about that, but have you heard about the anonymous
notification program?
P: No.
D: Your partner will receive a letter or an e-email saying that she might have
an STI and she needs to get tested without giving her any more details.
P: She doesn’t have any symptoms so why inform her?

D: Sometimes you have the infection without any symptoms, so we need to
test her to exclude that because this could have an effect on her health and
possibly her fertility.
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You:
- You might get infected again if she has the infection.
Your partner
- She might have long term complications like chronic infection, and
infertility.
P: If I don’t give you my permission will you tell her?
D: Well, we would need you to give us her contact details to inform her but as
I said we can do it anonymously and your name wouldn’t be mentioned.
Surely you love your wife, and you want to prevent any further harm to her
health?
P: Can we have children in the future?
D: Do you have any children right now?
P: No.
D: If both of you are treated early on, then you should be able to have
children like anyone else.
Advice
Stop sexual intercourse till both of you have been treated.
Use condoms.
Refer to gum clinic
Offer leaflets
Safety netting
• Persisting discharge
• Testicular pain and swelling
• Fever
Arrange follow up
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MEDICAL ERRORS
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Medical Error Stations
Key points:
1. Assess knowledge.
You should talk to the patient, or whoever you are discussing the error with,
and find out the latest information that he/she has been given. (v.v.v
important).
2. Check if any harm has occurred as a result of the error.
Here, you must do a relevant system review to make sure that patient is
stable.
3. Inform about the medical error (tell it in chronological order).
Never blame any particular person.
4. Apologise and reassure
If no harm has taken place.
5. Rectify the error (Management) (If harm has taken place).
Here, you must
→ Examine.
→ Investigations if needed.
→ Treatment.
→ Discuss how to prevent this from happening again.
6. Report the incident: Incident form.
7. Inform the patient and if they would like to complain refer them to:
P A L S
↓ ↓ ↓ ↓
Patient Advisory Liaison Service
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8. Root cause analysis meeting.

It’s a meeting where seniors and consultants meet and try to find out if
medical errors have occurred and how to solve them and prevent them from
happening again.
Note Beginning any telephone consultation:
1. Hi, I am Dr……., are you……...?
• Are you the mother of ……...?

• Can you confirm his age?
2. Are you busy now or can we talk?
Or, is it possible to talk now?
3. Can you please confirm your current address?

4. Can I call you on the same number we are speaking on now in
case the line is disconnected?
Missed Foreign body
Who you are:

You are an FY2 in the A&E.
Who the patient is:
A mother brought in her 2-year-old child, Milan, due to him swallowing a
foreign body. You examined the child and did an x-ray; you thought it was
normal and sent the child home. Later, the radiologist found that there's a
button in the oesophagus.
What you should do:
Talk to mother over the phone, tell her what happened and ask her to bring
the child back in again.
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Approach
D: Hi, I'm Dr (name) I am calling from the hospital. Are you Milan’s mother?
Can you confirm his age?
(Ask the questions noted on previous page on “Beginning any phone
consultation.”)
Assess knowledge
D: I understand that your daughter was here in the hospital because you
thought she swallowed a button?
P: Yes, he was playing with his older brother and I was in the kitchen when his
older brother called me saying that he swallowed a button, but the doctor told
me that the X-ray was fine.
General questions
D: Yes, the doctor you saw was me. Is it OK if I just ask you a few questions
about Milan. Is he in front of you right now?
P: Yes.
D: How is he now?
P: He is fine.
D: Is he active and playful?
P: Yes
Questions to check food pipe

D: Is he eating well?
P: Yes.
D: Have you fed him?
P: Yes.
D: Any vomiting?
P: No
D: Has he been to pass stool since you left the hospital?
P: Yes, no problem with that at all.
Questions to check windpipe (assess harm)
D: Is he breathing well?
P: Yes.
D: Any difficulty breathing?
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P: Yes,
D: Any drooling saliva?
P: Yes.
D: Any problems that you are concerned about?
P: You are worrying me, why are you asking all of these questions?
Inform about error
Well, when you came to the hospital today and we did the x-ray, I couldn’t see
anything unusual on the x-ray and sent you home. However, after our
radiologist double checked it, he spotted what appears to be a button in
Milan’s food pipe. Unfortunately, it seems I made a mistake in not spotting the
button and sent you home.
Apology
→ I'm really sorry that I 've missed this, please accept my apology,
P: How could you miss it?

D: It’s my mistake and there is no excuse for what happened, that’s why all
x rays get reviewed again by the radiologists.
→ I'm really sorry, now, my main concern is making sure Milan is OK. So,
please can you bring him back to the hospital?
Q. Doctor, is he in danger?
• Well, no, I don’t believe so, from the information you have given me he
sounds fine. The last thing I want is to frighten you, but we need you to
bring him back so we can see if the button is still in the food pipe or if it
has moved. Depending on the location of the button we can decide the
next course of action.
• However, a foreign body can get stuck sometimes in the food pipe or it
can be poisonous and cause damage to the food pipe.
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• So ↓
Rectify (manage)
1. Bring him.
2. Senior.
3. Examine him → General – Physical.
→ Chest – Abdomen.
4. Investigations → Repeat CXR and abdominal X-ray.
5. Management → If the foreign body is stuck, he might need
endoscopy to remove it.
However if it has passed the food pipe it can come out with his stool.
P: Doctor, I can’t bring him in. (Refusal approach)

May I ask you why?
• Address the concern.
P: I am about to go to work right now.
D: I totally understand that, but it’s really important that we see
Milan again. I can provide you with a letter saying that you needed
to come to the hospital for your employer.
(Offer her transport if she doesn’t have any way of coming in.)
• Risk or ultimate risk?
D: It might get stuck in his food pipe and this might cause
inflammation and other complications
• Benefits.
D: We will make sure that he is fine and we can follow up with him
after.
P: Doctor, how are you going to make sure that you don’t make this mistake
again in the future?
Well, I totally appreciate your concern:
• I will always go back to my senior before discharging any patient.
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• I will enroll myself in some courses to be able to read X-rays better.
• I will report this incident in the incident form.
• There’s also meeting called RCAM where seniors and consultants meet
and try to find solutions on how to prevent errors from happening.
• Don’t offer complaint procedure unless she mentions that she wants to
complain, then offer PALS.
Rash after Amoxicillin prescription

Who you are:
You are an FY2 in the Paediatrics unit.
Who the patient is:
An 8-year-old child, was given Amoxicillin last night after having a chest
infection. He developed a rash; his mother is concerned and wants to speak to
a doctor.
(Here, child developed rash and was given antibiotics).
What you should do:
In another similar scenario: Mum: Nurse was about to give him amoxicillin
even though, I told her that he has an allergy (Here, no symptoms and child
was not given antibiotics).
Approach:
Patient’s Relative: Where is the doctor who prescribed
amoxicillin to my child?
D: I can see that you are angry, but to make sure that I am taking
to the right person can you please confirm you son’s name and
D.O.B.?
Then introduce yourself.
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Explore:
D: Can you tell me what happened?
P: I brought my son yesterday to the hospital and he was discharged on
amoxicillin and when I gave him the dose this morning his body was full of a
rash.
D: Why do you think it’s the amoxicillin?
p: Because he is allergic to amoxicillin.
D: Did you tell the doctor about that? Or did anyone ask you if he has an
allergy?
P: No one asked me about it!
Here, make sure you take DDs and explore rash.
Any rash exclude THE RED FLAGS
• Anaphylaxis → difficulty with breathing and swollen lips.

• Meningitis → FEVER
P1 → Rash
D: Can you tell me more about this rash?
P: Like what doctor?
D: Is it itchy?
P: Yes.
D: Any bleeding?
P: No.
D: Is it getting bigger?
P: No, it’s the same since this morning.
DDs (v v important)
1. Meningitis → Vomiting?
P: No
→ Shy from light?
P: No
→ Pain on moving neck?
P: No
2. Anaphylaxis → Swollen tongue?
P: No
→ Swollen mouth?
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P: No
→ Swollen face?
P: No
→ SOB?
P: No
3. Trauma → Has he hurt himself by any chance?

4. Infectious mononucleosis → Any neck swelling?
• P2 →
D: Has he had an allergic reaction to Amoxycillin before? Can you tell me more
about what happened last time?
P: The same thing happened a year ago when he took amoxicillin and the
doctors told me that he has an allergy to it.
P: Apart from this, does he have any medical condition?
D: No.
Note
If the mother tells you, it's an allergic reaction (Explore) - May I ask, why you
think so?
- Explore any previous incidents?
• MAF
→ Any allergies to any other medications or food?
→ Is he on any medications?
→ Any family Hx of any medical conditions?

Quick hx about why he came to the hospital
D: Why did you came to the hospital in the first place?
P: He had SOB and cough and the doctor told me he had a chest infection.
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Examination
• Observations.
• Chest (for any chest infections).
• Rash.
• From the chat we had it does appear that the rash was most likely
caused by his allergy to the amoxicillin that he was given.
Management
1. Apology:
P: Why did you make such a silly mistake?
D: I am really sorry about what happened, it’s our we mistake we should

have asked you about the rash, but you did the right thing by bringing
him to the hospital.
2. Admit.
3. Senior.
4. Stop amoxicillin.
P: Will the rash clear if you stop the antibiotic?
D: It will get better and we will prescribe him another anti allergic
medication.
P: What about the chest infection?
5. Prescribe Erythromycin after doing allergy test.
6. Local anti-histaminic for rash.
7. Prevention of this from happening again.
• Incident form
• Will update our system (documentation).
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• Please, do tell any doctor that sees him in the future that he has
an allergy and I will give you a document to show to any doctor, to
explain what happened (Mum).
• We need to educate him to be aware as he grows up, that he has
an allergy to amoxicillin (Son).
8. Root cause analysis meeting.
9. PALS. Only if the patient wants to complain.
10. Safety netting: SOB & face and lips swelling.
11. Follow-up for the chest infection.
Mis–diagnosed Pneumonia
Who you are:

You are FY2 in the medicine department.
Who the patient is:
A 60-year-old man presented with cough. He had a CXR and was diagnosed
with pneumonia 4 weeks ago. Based on his CXR, he was discharged on
antibiotics.
On looking at his X-ray, we found that he was treated based on another
patient’s x-ray. Your consultant thinks that the patient was given antibiotics
unnecessarily for 4 weeks. Today, he is coming for a follow up.
What you should do:
Talk to the patient, explain the medical error and discuss the management
with him.
• Important here, the harm either:

- Short term of having antibiotics (so, ask about nausea, vomiting,
diarrhoea)
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- Long term which is decreased immunity and susceptibility of

infection, for that safety netting and follow up.
Approach
D: Hi, I'm Dr (name), are you (patient’s name)? Can you confirm your age? I can
see from my notes that you are here for your follow up.
Assess knowledge
D: Can you walk me through what happened?
P: I came 4 weeks ago with cough and the doctor did a CXR and he told me that
I have pneumonia and he started me on some antibiotics.
D: How are you right now?
P: I am much better, thank you
Symptoms + Side effects of antibiotics

D: Any SOB?
P: No.
D: Any fever?
P: No.
D: Any cough?
P: No.
D: Any vomiting?
P: No.
D: Any diarrhoea?
P: Yes, I had diarrhoea and I went to the GP and he told me it’s a side effect
from the antibiotics.
D: Do you still have it?
P: No.
D: Did you complete your treatment?
P: Yes.
Inform him about what happened
Unfortunately, a mistake has happened, you had been given antibiotics based
on an X-ray showing pneumonia, but we realise now that the x-ray was of
another patient, not you. Although you presented with chest infection
symptoms your x-ray was actually normal.
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Apology.
I am really sorry for what happened. Please accept my apologies.
• Is it ok if we examine you?
→ Observation.
→ Chest (You can mention or not)
P: What will you do to prevent this from happening again?

• Rectify
1. We can review you or if you develop any symptoms like fever, you
can come back.
2. Incident form.
3. RCAM.
4. PALS.
5. Prevention
• Educate staff to confirm identity of any patient and check

details written in the scans and make sure it belongs to the
patient.
• Provide better supervision for junior doctors.

We will instruct everyone to check identity properly on any test result.
CONCERNS:
P: How did this happen?
D: I am not sure about what happened, usually all x-rays are labelled. But we
are investigating to know exactly what happened.
P: So, why did I have this cough?

D: It might have been a viral infection.
P: What happened to the other patient?

D: I am not sure about what happened, but if any mistake happens, we contact
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the patient and start the treatment immediately.
P: So, is there any harm done?
D: Well, it’s never ideal to take antibiotics unnecessarily:
Short term effects Long term effects

•I have asked you about the • Which is ↓↓ immunity and
short term side effects of
susceptibility to infections for that →
antibiotics and you don’t
appear to be experiencing any Follow you up, if you have any signs of
of those symptoms.
infection, come back.
P: Will I have any long-term side effects from the antibiotic?

D: Well, it’s unlikely to happen. It may lead to antibiotic resistance but even
this happens when you take antibiotics long term and in your case, it was only
1 dose for 1 month.
Missed hairline fracture in a child
Who you are:

You are FY2 in orthopaedics.
Who the patient is:
A 4-year-old boy was brought by his father 3 days ago with a wrist injury. X-ray
was done, father was told that it's soft tissue injury and no bony injury.
Radiologist noticed that there is hair line fracture, the father was asked to
come back, he is on his way right now.
Special note
The orthopaedic consultant has advised you to put a plaster cast and arrange a
follow up in 2 weeks.
What you should do:
Explain the medical error, discuss the management with the father and
address his concerns.
Approach
D: Hi, I'm Dr X, are you…….? Are you the father of …….? Can you confirm his
age?
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D: I understand that one of us called you to come to the hospital.

P: Yes.
D: Has anyone explained why?
P: He told me that he needs to check on my son again.
D: I understand that your son came 2 days ago and had an x-ray?
P: Yes, that’s right.
Assess knowledge
• Past
D: Can you tell me exactly what happened?
P: He fell 2 days ago and he had pain around his wrist. He was holding
his hand all the time.
D: What did the doctors do?
P: They did an X-ray and said everything is fine and gave me some
painkillers and he has been taking the medication but there’s no
improvement.
• Present
D: How is he now?
P: He is still in pain, and he holds his wrist with the other hand.
D: Other symptoms?
P: No.
D: Any swelling?
P: There’s some swelling around his wrist.
• Inform about mistake.
D: I am really sorry but there’s been a mistake. You see, whenever we have an
x ray done, it gets reviewed a second time by the consultant radiologist. And
he found that there’s a small hairline fracture in your son’s x ray, that was
missed by the doctor who saw you 2 days ago.
• Apology.
I can see that you are upset and anyone in your place would feel the same.
It’s understandable.
Q. Doctor, how could this happen?
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• This fracture is called hairline fracture. It’s a very small fracture that can
be difficult to be detect sometimes but it can always be seen by a
radiologist. Of course, there’s no excuse for what happened, please
accept my apologies.
Note
Father will be very angry → Please be soft, nice and apologise.
Management
1. Senior.
2. Examine (wrist).
3. Investigations (repeat X-ray).
4. Treatment
- The consultant has advised me to put a plaster cast on your son’s wrist
and arrange a follow up in 2 weeks.
- Painkiller
P: How long will he have the cast?

D: Usually 3-4 weeks; however, he may need a longer time of 4-6 weeks.
P: Will he need an operation?

D: Let me reassure you it’s a small fracture, there’s no need for an operation
and it will heal on its own.
5. Incident form.
6. PALS: Only if the patient wants to complain.
7. RCAM.
8. Prevention
• Junior doctors will go for courses to read x-rays better.
• Advise seniors to supervise junior doctors and do not discharge unless
they go back to senior.
188 | P a g e
9. Follow up.
10. Safety netting.
Missed Renal Biopsy

Who you are:
You are FY2 in the renal unit.
Who the patient is:
A 21-year-old male, suspected post-streptococcal glomerulonephritis. You took
a renal biopsy from him 2 days ago and have been waiting for the results. Lab
said they didn't receive the specimen. A thorough search was conducted to
find the biopsy and it was not found.
What you should do:
Talk to the patient, explain what has happened and address his concerns.
Approach
D: Hi, I'm Dr (name), are you (patient’s name)? Can you confirm your age? How
are you doing?
Assess knowledge
D: I can see from my notes that you came 2 days ago for a biopsy?
P: Yes.
D: Why did you have the biopsy in the first place?
P: The doctor told me there is something wrong with my kidney.
D: What symptoms did you have?
P: I have blood in my urine.
D: Have your symptoms worsened or have you improved?
P: It’s the same doctor.
D: Apart from this, is there anything else?
P: No.
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• Challenges
D: How did the procedure go?
P: It went ok.
D: Any challenges?
P: It was painful.
D: How did you cope with it?
P: Nothing was done, but doctor I want to know the result of the biopsy.
• Inform about mistake.
D: Do you have any idea why I am talking to you?
P: No.
D: I am sorry, but a mistake has happened. When we took the biopsy
from you 2 days ago, we sent it to a lab and we have been waiting for
the result but there was no response from them. So, we contacted them
and they told us that they cannot find the biopsy. We did a meticulous
search and we couldn’t find it either. I am really sorry, but it seems we
misplaced the biopsy.
• I can't even imagine, how you are feeling now. I understand that you are
upset. It’s our completely our fault. I’m so sorry.
Q. How could this happen?
• Usually after doing the procedure → we label the specimen → someone

takes the specimen to the lab
So, The mistake could have happened either in labelling, or the courier
misplaced it, or it was lost at the lab.
Q. Who is responsible for this?
• At the moment we are not sure who is responsible; however, we have

reported the matter to the concerned department, and we will try to
get to the bottom of what happened.
• However, our main concern is you, so we would like to repeat the

biopsy to give you the correct diagnosis.
P: It was so painful and it’s your mistake and I am not going to do it
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again!
D: I know you’re understandably upset, but we want the best for you
and we can’t give you any treatment without the biopsy.
P: Why can’t you just treat me without the biopsy?

D: The biopsy was taken to know the cause of your disease and there are
multiple causes and we need to find the exact cause. Without the biopsy
it would be difficult to give you the right treatment.
We are also worried that if treatment is delayed your condition will get
worse.
So, Management
1. As you mentioned to me you had severe pain last time so I will

inform the relevant doctors to make sure that you are given
effective painkillers this time around. We can also give you a sick
note for your employer so you can rest off work till you’re better.
2. I’d like to examine you to make sure things are ok.
3. We will take the biopsy → is it ok if we go ahead with the

procedure?
4. Incident form.
5. RCAM
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6. PALS.
Mislabelled blood sample
(Patient for elective hernia procedure)
Who you are:

You are an FY2 in the general surgery department.
Who the patient is:
Adam smith, is a 40-year-old, who came yesterday for pre-operative assessment
for hernia. You took a blood sample from him. Today the lab called you to take
another sample because you didn’t label the sample properly. The patient has
been informed that he will receive a call from you.
What you should do:
Ring the patient and tell him over the phone and convince him that blood sample
needs to be taken.
Same approach
D: Hi, I'm Dr (name) I am calling from the surgery department, are you (name)?
Can you confirm your age?
(Questions from “Beginning a phone consultation” as before.)
D: I can see from my notes that you had some blood tests.
Assess knowledge
D: Do you know why we did these blood tests?
P: I am planned for elective surgery for my hernia, and they told me that
I need these tests.
D: Has anyone explained the surgery for you?
P: Yes.
D: Great, and do you have any concerns?
P: I just want to know the results of the tests.
Inform about error.

D: That’s actually why I am calling you. Unfortunately, a mistake has happened.
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P: What do you mean?

D: After your sample was collected, it seems I forgot to label it and the lab
discard any unlabelled samples. I am really sorry for my mistake.
P: How can you make such a silly mistake.
Apologise
D: I understand that you are upset, anyone in your situation would feel the
same. Please accept my apologies
• Rectify
By asking the patient to come to have blood taken.
D: I know this might be difficult, but I was wondering if you could come back so
that we can take another sample from you.
P: I can’t come.
Refusal approach
Why (concern)
P: I am an engineer and I have a busy schedule and the hospital is far
from me!
D: I understand you have a busy schedule, is it not possible for you to come
before or after you finish your work?
P: I can’t come I will be so tired.

D: What about going to your GP or another hospital nearer to you?
P: Doctor it’s your fault, you should take responsibility for it!
D: You’re right and I’m so sorry, but I am afraid we can’t go ahead with the
surgery without the blood.
• Address concern
One of the concerns is that he is away in another city → Then offer for
him to go to the nearest hospital. Or arrange a means of transportation.
• Risk of not having blood test taken → Delayed procedure.

2. Incident form.
3. RCAM.
4. PALS.
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Missed MI
Who you are:
You are a FY2 in the GP clinic.
Who the patient is:

Sam Murphy, 56-year-old man, was admitted to the hospital 3 weeks ago and was
diagnosed with MI.
3 days prior to his admission, he had come to ED with chest pain. He was seen by one
of the ED doctors who performed an ECG which was reported as normal. The blood
tests were done, but patient was discharged home on the basis of normal ECG,
before troponin was checked. He was also discharged home with a diagnosis of
muscle pain.
The cardiologist has reviewed d ECG and blood tests which were performed in the
ED-ECG shows T wave inversion and troponin is also positive.
What you should do:

Explain the medical error to the patient, assess for any complications, address his
concerns and discuss further management.
Assess knowledge
D: I understand that you came to the hospital 3 weeks ago, can you tell me more
about that?
P: Yes, it was a terrible experience. I had this chest pain and I was diagnosed with a
heart attack and I was admitted to the intensive care unit.
D: I am really sorry about that, how are you doing right now?
P: I am much better now doctor.
D: Any chest pain?
P: No.
D: Any SOB?
P: No.
The error:
D: I understand also that you came 3 days before this admission, can you tell me
what happened exactly?
P: I also had chest pain and they told me that it’s just muscle pain after my ECG was
normal.
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D: And you had some investigations done, right?

P: Yes, they took some blood from me.
D: Has anyone talked to you about the blood results?
P: No.
D: Was any treatment was given?
P: Painkillers.
D: I am really sorry but there was a mistake that happened. We shouldn’t have
discharged you before checking your heart attack markers. It seems that our
cardiologist reviewed your ECG and it was not normal.
Apologise
D: I am really sorry about that, I understand that you are upset, anyone in your
situation would feel the same. Please accept my apologies.
P: How did your colleagues miss this?
D: I can’t say for sure how this happened, some changes in ECG can be difficult
to be detected but I am not sure about what happened exactly.
P: Could this have been prevented?

D: I totally understand that what happened is upsetting, but the heart attack
couldn’t have been prevented because it’s already happened as shown in your
blood result.
Complication (heart failure)
D: I need to check for any complications that could have happened from this
delay. Can I ask you some further questions? Any heart racing?
P: No.
D: Any leg swelling?
P: No.
D: Any night cough?
P: No.
Examination
▪ Observation
▪ Chest
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Diagnosis
From the chat we have let me reassure you, there’s no complication due to the
delay. Let me tell you what I will do to ensure this doesn’t happen again:
Senior.
Investigations: CXR – Echo – ECG
Incident form.
RCAM.
PALS.
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PROBLEM COLLEAGUE
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PROBLEM COLLEAGUE
General approach:
SPIES
Seek information
Before you can do anything, you need to understand the nature of the
problem. This may involve discussing the matter with the individual concerned
or with other colleagues, if appropriate.
Patient safety
Once you have assessed the situation, you must make sure that patients are
protected. If the person is an immediate threat to patients (e.g. intoxicated or
about to do the wrong operation), then you must remove them from the
clinical area or tell them to stop doing whatever they are doing (this could be
done by having a quiet word with the individual in question, or in the worst-
case scenario calling for help to have them removed).
Initiative
Is there anything that you can do by yourself that will help resolve the
problem? In practice, this will only apply to minor issues, where there is no real
threat to patient safety. If the colleague is drunk, there is little that you can do
to help. However, if it is just an issue of a junior colleague being a bit slow,
then there are things that you could do to help in the first instance (e.g.,
individual coaching or a discussion).
Escalate
If the situation is too serious for you to deal with, then you must involve other
colleagues at appropriate levels of seniority. For a problem junior colleague,
this could be the Registrar, the education supervisor of the underperforming
colleague or another consultant.
For an underperforming consultant, this would need to be the clinical director.
If the situation is not resolved, you may need to escalate further to the medical
director, the chief executive or even the GMC. If you don’t know what to do,
you can seek advice from other organisations (e.g., the BMA, any medical
defence organisation, the GMC).
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Support
There could be a reason why the colleague is behaving in this way. As an
individual he may need support to deal with a problem(s). Your team will also
need support if it is one person down.
General tips for any station which involves talking to colleagues:

- Introduce yourself in a casual way; “I’m John, one of your colleagues here in
the department.” Don’t say “I am doctor…” or “I am your senior…”
- Don’t say “Can you please confirm your name and DOB;” He is your
colleague, don’t forget that.
- Take your time to build rapport.

• “How are you doing today?”
• “How is your rotation going here in the department?”
• “Have you seen any interesting cases recently?”
• “Have you decided on any specialty yet?”
- Be sensitive and not judgmental.
Facebook post (talk to colleague) scenario

Who you are:
You are an FY2 doctor.
Who the colleague is:
You were told to speak to your colleague, John, who is an FY1 doctor, as he has
put up a social media post about one of the patients who came into the
hospital and was pretending to be the queen. You saw the post and requested
to talk to him.
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What you should do

Talk to him.
Key issues arising from scenario:
- Breach of patient confidentiality and potential loss of patient trust in

doctors.
- This is unprofessional and unethical.
- FY1 doctor could be fired and lose medical license due to above reasons.
- Disrespectful to patient. May cause mental health harm to patient.
Key points when talking to your colleague:
- Approach colleague first before involving anybody else. This

demonstrates good communication skills and teamwork.
- Talk to your colleague on their own not in front of other colleagues or
patients. This ensures your colleague is not embarrassed and others
aren’t involved unnecessarily.
- Present a reasoned and balanced argument about why their behaviour is
an issue.
- Give your colleague a chance to explain themselves and listen without
interrupting.
- Try to come to a conclusion about how to solve this problem together
before involving others. For example, taking down the social media post
immediately and looking at the trust guidelines about social media and
confidentiality.
- If your colleague is not co-operating, you must escalate this problem to
your senior so that they can take action to discipline the doctor and
solve the problem.
- Patient safety and confidentiality are key issues and as a doctor you
should be advocating for your patient even if they don’t know about the
social media post.
Build Rapport
You: Hi John, my name is X, I’m one of the ward doctors, I think we’ve met
before?
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Colleague: Yes, we have, hello.

Y: How are you? Is work ok today? How do you find the rotation?
C: I’m well thank you; work is fine. How are you?
Introduce the topic

Y: Fine thanks. I was wondering if you had a minute to talk to me about
something privately, please? It’s to do with a patient on the ward.
C: Yes of course, what’s this about?
Y: I’m sorry to interrupt your work but I saw you posted something about a
patient on Facebook last night, am I right?
C: Yes, about Mrs. Jones, it was hilarious! She came into hospital pretending to
be the queen!
Y: Is that a patient you are looking after? What has she come into hospital
with?
C: Yes, she is on the ward. She came in with a chest infection and delirium. You
should have seen her; it was so funny!
Explore:
Y: Did you include any details about the patient on Facebook?
C: Just her name and obviously it says which hospital I work in but she’s so old
she won’t have Facebook; she won’t ever see the post.
Y: Did you take her permission before posting?
C: No
Y: Was the post public?
C: No, it’s only for my friends no one else can see it…
Y: You know that sometimes people can take screenshots and the post can
spread…
I know you think it is funny, but I think you should remove the post because it
contains personal details about the patient, do you realise you have breached
patient confidentiality?
C: I think it’s funny, I don’t want to remove it, she (the patient) won’t see it
anyway.
Deal with the issue

Y: Are you aware of the rules and regulations on posting patient information
on social media?
C: No, what is this?
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Y: It goes against the hospital social media policy and even if the patient
doesn’t see it herself, it breaches her confidentiality and it’s not professional or
ethical. You could also lose your job. Would you please delete the post?
C: Ok, I understand. Sorry I didn’t realise it was a big problem. I’ll remove it
now.
Y: Thank you. Did you post anything else about any other patients or on other
social media sites?
C: No just on Facebook, I haven’t done it before I just thought it was funny this
time. Sorry, I didn’t think properly about the consequences of posting it.
Do you think I should go and talk to her?
Y: Well, the patient may be still confused, but you can speak to your
consultant, he will further advise you on what to do.
• Advise him/her to read GMC guidelines for doctors on social media
issues.
• Make sure that he will delete the post.
• Safety-net at the end by advising him to refer to GMC guidelines next
time he wants to do something but is unsure if it is ethical.
If John refuses to take it down, you could say something like this:
Y: I’m sorry but I am going to have to inform Senior doctors so that they can
decide what should happen next. I’m not comfortable leaving the problem and
it appears that we disagree about what to do.
Medical student on cocaine

Who you are:
You are an FY2 doctor on the ward.
Adam Jones a 5th year medical student who is undergoing rotation in your
department. Last night you were at a dinner party with your fellow staff. Adam
was there sniffing cocaine and nurses have been discussing the incident this
morning. You noticed that he seems overly excited and hyperactive today.
What you should do:
You have requested to talk to him in private to assess his situation.
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-Patient safety
-Safety of the doctor in question.
-Safety of other colleagues.
-Senior escalation needed.
-Support for doctor in question.
-It is a sensitive situation.
Key points when talking to the student:

-Similarly, to the first scenario, approach the medical student away from other
nurses/patients.
-Recognise what your role as an FY2 doctor involves, including the limitations.
-Recognize when to ask for help.
-Patient safety should be your priority.
-Tone of speech is important-be polite, ask questions and reason with Adam,
don’t accuse/don’t be blunt. eg. Instead of saying “I saw you taking cocaine,
you were drunk,” you could say, “I’m worried that you don’t seem yourself this
morning, do you feel well enough to work?” before asking about drug/alcohol
use. Example conversation will follow below.
- Present a reasoned and balanced argument (but discuss calmly, don’t argue!)
Build rapport:
Introduce the topic:
You: You know, I saw you at the party yesterday, you looked like you were
having fun…
Colleague: It was so much fun, I really enjoyed it!
Y: I think I saw you sniffing something like white powder, but I could be wrong?
Are you ok? Do you want to talk about it?
C: I don’t need to talk about it.
D: Adam I am concerned that you don’t seem yourself this morning, do you
feel well enough to work?
C: Yes, I feel ok, thank you.
Y: I am afraid that this is not how you are normally, and even other staff are
talking about it, this can cause you problems…
C: What do you mean?
Y: I think you have been taking cocaine and it’s affecting you. I’m not trying to
annoy you, I’m here to help you.
C: Well yes, it was cocaine, but it wasn’t during working hours. It didn’t affect
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any patients…
Patient safety
Y: Well, it seems to be affecting you here today Adam, I feel awkward saying
this to you, but I’m worried about patient safety. You may make a mistake if
you are under the influence of cocaine whilst you are here working. You need
to realise that this is serious, and you could be asked to leave the medical
program if you act unprofessionally and are unsafe in work. I think you need to
be honest with yourself about this.
C: I understand, you’re right. I’ll go home. Just don’t tell anyone please.
Y: Did you see any patient today, so I can review them?
C: No
Y: I think it’s a good decision for you to go home. Do you want me to arrange a
taxi for you?
C: No, thanks.
History of cocaine abuse

Y: How long have you been taking it?
C: About a year
Y: Are you taking any other drugs apart from cocaine?
C: No.
Y: How frequently do you use it?
C: Twice a week.
Y: Is there a reason why you are taking it?
C: It just makes me feel good.
Impact:
- Medical students have the same obligations as doctors in terms of
behaviour and what they can and can’t do.
- It is unacceptable for any medical student or doctor to use any
recreational drugs as this will affect his performance at work and can be
reported to his dean or even to the GMC.
- It is important that any doctor or medical student who fears that they
may have grown dependent on any intoxicating substance to talk to their
GP or supervisor in order to get the help they need.
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Y: I’m sorry but I’m going to have to tell my senior the reason you are leaving
early today because they are responsible for overseeing medical students. I
won’t involve anybody else, ok?
C: Will they ask me to leave the medical placement?
Y: I’m not sure what their decision will be but if you are worried, I can come
with you to speak to the doctor tomorrow once I’ve had a chat with her and
you can explain what has happened yourself.
C: Ok thank you, see you tomorrow.
Key thoughts afterwards:
• Be compassionate and understanding.
• Offer support but don’t make any promises or give information that you
aren’t sure about.
• Check student is ok to get home and not a danger to themselves or
others.
• Don’t be afraid to escalate to a senior for support.
• Try to present the facts not just your opinion.
Alcohol colleague
Who you are:
You are an FY2 doctor in the medical department.
James Dean is FY1 in your unit. 2 days ago, you could smell alcohol on him and
today is the same. You have made an appointment with him to talk to him in a
private room.
What you should do:
Talk to him and assess his situation.

- Patient safety
- Safety of the doctor
- Senior escalation needed
- Support for doctor
- Sensitive situation
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Key points when talking to the doctor:

- Sensitivity and gentle approach
- Involvement of senior support
- Talk away from clinical area
- Build rapport
Build rapport:
You: James how are you doing? You don’t seem like yourself these days, is
everything ok with you?
Colleague: Yes, thank you for asking
Y: Do you have any idea why I arranged this meeting?.
C: No
Y: Well, I am a bit concerned about you… This is a bit awkward, but I noticed
that recently you have been coming in to work smelling of alcohol, and I
wanted to talk to you about it…
C: I don’t know what you’re talking about.
Y: Look I’m not here to judge you, I want to help you. Did you drink before you
came here today?
C: I am having some troubles.
Y: I am sorry to hear that James, do you want to talk about it?
C: Two weeks ago, I had a fight with my girlfriend, and we broke up. Since
then, I started to drink alcohol.
Y: Oh, I see why you’re upset James, but drinking and risking your career isn’t
going to make it better is it? It will only make things worse in the long run. I am
here to support you, thank you for opening up to me.
History of alcohol abuse

Y: How much do you drink a day?
C: 2 to 3 bottles of vodka per day.
Y: Have you always been a heavy drinker?
C: No, it started just recently.
Y: Apart from alcohol, are you taking any other substance to help you to cope
with the situation?
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C: No.
Patient safety
Y: Have you seen any patients today?
C: Yes.
Y: Can you give me their details, so I can review them?
C: OK.
Y: Why don’t you go home to relax, and I can cover you for today?
C: Thank you. I think it’s for the best that I go you’re right.
Y: Do you want me to arrange a taxi for you?
C: No thanks, I can handle it.
Offer support:
- Advise him to take some time off from work, and seek counselling for his
problem.
- Give him advice on how to cope with stress.
- Advise him to open up to any of his family members or close friends.
Y: Do you think you can stop alcohol by yourself, or do you think you may need
help?
C: I can do it myself.
Blocked IV Cannula
Who you are:
You are an FY2 doctor on the surgical ward.
Your junior colleague Sarah who is an FY1 doctor did not insert an IV cannula
into Mrs. Williams, a patient who was supposed to receive IV antibiotics for an
insect bite. The patient is upset and angry that the doctor didn’t do this as she
has missed her antibiotic dose.
What you should do:
Talk to the junior doctor about this.
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• Angry/upset patient
• Delayed abx
• Mistake made by colleague
Key points when talking to colleague:

• Talk to the colleague now rather than later so that the issue can be
resolved.
• Explore the reasons that caused this to happen.
• Don’t accuse/get angry/ bark orders at them.
• Be patient and understanding.
• Offer to help.
• Prompt junior doctor to apologise to patient and organize IV
cannula/abx, offer support.
SCENARIO:
Build rapport
Introduce the topic
You: Do you have any idea why I wanted to talk to you?
Colleague: No.
Y: Are you working alone today?
C: Yes, I am the only FY1 working today.
Y: I assume you are quite busy today then?
C: Yes.
Y: Is Mrs. Williams under your care?
C: Yes, I forgot to change her cannula but there was a CPR case and I
participated in it.
Y: I’m glad to see you are able to prioritise your patients. What was the result
of the CPR?
C: The patient is ok now.
Y: Great news, well done! But Mrs. Williams right now is quite upset as she
missed her antibiotics dose and unfortunately, she wants to complain.
C: I am really sorry about that. What do you think I should do?
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Advice you can give to your colleague:

- Apologize to patient, change the cannula immediately,
explain what happened, and if she still wants to complain after,
direct her to PALS.
- Always right down your tasks on your phone or notebook so
you don’t forget anything again.
- If you find yourself busy, don’t hesitate to ask for help from
other colleagues.
- Ask colleague if there is anything you can do to help
him/her.
- Encourage colleague to talk to the consultant and explain
the situation to him as all mistakes are an opportunity to learn
and develop yourself personally.
Delayed discharge letter
Who you are:

You are FY2 in acute medical unit
60-year-old Nando Manali who is supposed to be discharged today but Dr
Gupta has not prepared the discharge letter to be sent to the GP. The ward
manager has been asking the nurses for a bed for a new patient who is to be
admitted from the ED.
What you should do:
Talk to your colleague about the situation.
Approach
Build a rapport
Introduce the topic
You: Do you have any idea why I arranged this meeting?

Colleague: No.
Y: Is Mr. Manali under your care?
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C: Oh, I’m really sorry I forgot to write the discharge letter but it’s so busy here
today.
Y: The second thing is we need a place for a patient who is about to be
admitted, I wanted to talk to you about that?
C: My other FY1 colleague is sick today and I am covering him, there is too
much to do.
Y: Do you want any help?
C: No, thanks.
Y: I understand you are an FY1, how long have you been working?
C: This is my first job, I started working 2 days ago.
Y: Do you know how to write a discharge letter?
C: Yes, but I forgot to write it
Y: You seem overwhelmed with the work, how do you normally arrange your
work?
C: I try to memorize things in my mind.
Y: Have you tried to write it before?
C: No.
Effect:
Y: It seems like the patient is upset and wants to complain, so we should deal
with him promptly to reduce his distress.
C: Yes you’re right. What should I do?
Advise:
• Prioritise your tasks so you can write discharge letters earlier.

• You can write the tasks down on your phone or on paper so that you
don’t forget anything.
• If you feel there is too much to do, you can ask for help from other
colleagues.
• Go and talk to the patient and explain the situation to him.
• Talk to the consultant and explain the situation.
• If you have any other problems, you can ask for help from me; you can
get my bleep number and ring me if you need any help.
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Colleague coming late to work
Who you are:

You are an FY2 doctor
Your colleague John (FY1) keeps arriving late for work in the hospital.
What you should do:
Talk to him about this problem.

• Recognise own role, abilities/limitations.
• How does late arrival affect colleagues/patients?
• Is he ok?
Key points when talking to colleague:

• Sensitive approach, there may be a valid reason for arriving late.
• Don’t embarrass him in front of others.
• Talk to him quietly on your own, not in front of the whole team or on the
ward.
Approach
Build a rapport
You: John, can I talk to you alone for a minute? Recently, I started to notice
that you have been having trouble with coming into work on time, is there a
problem?
Colleague: It was just couple of minutes late and it only happened once.
Y: OK, well is there any specific reason you are coming in late? Maybe you can
tell me about it and we can try to come up with a solution together.
C: I slept late last night.
Y: Oh I see, may I know why?
C: I was playing PlayStation.
Y: Gaming can be a good way to relieve your stress, how many hours do you
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play a day?
C: It depends, but I enjoy playing it every day.
Y: But do you think it may have started to affect your studies?
C: Not at all.
Sometimes it will be different causes so you can ask:

How far do you live from hospital?
Any problems with the transportation?
Impact:
o You can miss the handover, and early morning teaching
sessions.
o This can give bad impression of you to others.
o It’s expected from you to show punctuality, even a few
seconds matter when it comes to a patient’s life.
Advice:
o Adjust your alarm so that you wake up earlier.

o Try to sleep earlier.
o Ask yourself whether you are spending too many hours
gaming and if so, limit the hours you spend on Playstation.
Escalate:
- Advise him to talk to his educational supervisor,
C: Will he punish me?

Y: Not at all, he tackles these types of issues all the time and he
will give you more advice.
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BREAKING BAD NEWS
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Breaking Bad News

Approach
Before breaking bad news to a patient or relative a few points are very
important to follow, read them once:
1. It’s important to break bad news in an appropriate setting. It should occur in

a comfortable, quiet and private room.
2. Other healthcare workers can provide support in breaking the diagnosis, for
example, a nurse specialist.
Ask the patient if they want anyone to be with them: “Would you prefer to
have a family member or a friend here?” Likewise, if there is someone else
already in the room, check to see if your patient would prefer to be told alone.
3. Begin by discussing the sequence of events leading up to this point (e.g.
scans, biopsies, etc) and assess the patient’s current emotional state. Ask
about any symptoms the patient may have been experiencing up to this point.
4. Establish what the patient already knows or is expecting, the patient may
or may not have been made aware of the possible diagnosis.
5. Check if the patient wants to receive their results today.
6. Ensure you deliver the information in sizeable chunks, and regularly check
the patient understands.
7. Use a warning shot to indicate that you have unfortunate news.
8. Provide the diagnosis using simple language.
9. Use the correct language. Cancer is cancer, death is death. There must be no
ambiguity about what the results show. Avoid using euphemisms or medical
jargon.
10. Deliver information in chunks, pausing between each piece of information.
After giving the diagnosis, it’s wise to wait for the patient to re-initiate the
conversation.
11. Make sure your tone is respectful, at a slow pace and clear.
12. Give the patient TIME to have their emotional reaction. People often find it
very uncomfortable watching patients like this but it is important to give the
patient space to react.
13. Recognise and respond to emotions with acceptance, empathy and
concern. Acknowledge and reflect their emotions and body language.
14. Do not lie when the patient asks questions about prognosis.
15. Make a plan together to meet the patient again and inform them of what
the next steps are.
16. Reassure the patient that they are going to be referred to the appropriate
team of specialists (if appropriate) or inform them of the follow-up
arrangements.
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17. Try not to rush the patient to make decisions about their treatment (if
possible), it is respectful and considerate to let them process what has been
told to them.
18. Check the patient understands the bad news you have delivered.
19. Summarize: respectfully and gently repeat any important points – patients
who are shocked or upset will not take in much information.
20. Ensure to answer any questions or concerns that can be addressed at this
stage (and listen out for any implicit ones).
21. Offer ongoing assistance to the patient should they think of any further
questions – this may involve giving them details of a clinical nurse specialist.
22. Offer assistance to tell others (e.g. other family members) the bad news.
23. Highlight where the patient can go to gather more information or gather
any support (support groups, websites).
24. Offer written materials if relevant and available.
General structure of BBN:

1. Always read the stations properly and never forget who you are, where you
are and your task.
“I am Dr XYZ, one of the junior doctors from the GP surgery.”
2. Firstly always confirm the identity which includes name and age of the
patient.
“Can you confirm your name and age please?”
3. Paraphrase from your notes, ALWAYS!
“I can see from my notes that you are here for your test results/ I am here to
update you regarding your son’s condition. Is it okay if we have a chat first to
understand the situation better?”
4. Check their understanding of their condition:
“Can you tell me how much you know about your/ his or her condition?”
5. Take focused history or relevant history that will lead you to the diagnosis
(P1)
“May I know why you had the test done in the first place? / May I know why
you came here in the first place?”
6. Take relevant past history:
“Has this ever happened before?”
7. Take relevant lifestyle history and other medical/ medication/ allergy history
(DESA+MAFTOSA)
8. Look for support system
“Is there anyone here with you? Do you want me to call someone for you
before disclosing the results or diagnosis?”
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9. Ask if anyone has explained to them the diagnosis or results before. Check
how much they already know.
“Has anyone explained to you the test results already?”
10. Break the news with layers, minimum of two.
“I’m afraid it’s not the news we were hoping for Mrs Brown.” (LAYER 1)
“Unfortunately, the lump is due to a serious underlying cause.” (LAYER 2)
“I’m so sorry to tell you, but you have breast cancer.” (BREAK THE NEWS)
11. Reflect on the emotions of the patient, if required offer tissue or water.
“I can see this is a huge shock for you”
“I can see that this is not the news that you expected, I’m so sorry”
12. Explain the diagnosis in simple language and in chunks.
13. Manage the patient with Advice, Risk factors, Medication,
Multidisciplinary review and Safety Netting the patient (ARMMS)
14. Address whatever concerns they are having and support them as much as
possible.
15. Referral/ provide leaflets and follow up. Summarize and recap/ Take
consent for surgery if required.
INTRACEREBRAL BLEEDING
Where you are: You are FY2 working in the A&E.
Who the patient is: Mr. Tony Greig, aged 70, has collapsed and was brought to
the hospital with loss of consciousness by an ambulance. The initial survey has
been done. The CT scan was done and shows massive intracerebral bleeding
due to ruptured berry's aneurysm. The neurology team has seen the patient
and evaluated his CT scan. They decided that surgery cannot be done.
Other information about the patient: He is breathing independently. Patient is
unconscious.
What you must do: Please talk to his wife, Mrs Greig, explain her husband's
condition and address her concerns.
Special Note: Patient is in terminal condition and only palliative care is
possible. Patient's wife does not know about her husband's condition.
Patient’s relative information: -

You are Mrs. Greig, a 60-year old lady;
You have come to the hospital to visit your husband who was brought to the
hospital by the
ambulance after collapsing at home.
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You and your husband were watching TV when he suddenly collapsed.

You called the ambulance and he was brought to hospital.
You have come on your own to hospital.
You have 2 children: Your daughter lives in Australia and your son lives in
London.
Concerns
1. How is my husband doctor?
2. What do you mean by terminal? (ask only if the doctor says it is terminal)
3. Can you take him to ITU?
4. How long will he live? / How long does he have remaining to live?
5. Why did it happen to him?
6. Are you doing anything for him while he is in hospital? Are you giving up on
him?
7. I have got two daughters who live in Australia. Do you think I need to call
them?
(Always keep normal facial expressions, avoid looking depressed and your task
is to break the news in layers and the treatment here is palliative care. If the
patient is about to expire, don’t be afraid, say it in a nice and expressive
manner and look for support system)
Doctor: Hello Mrs. Greig I am Dr (name) one of the junior doctors in the
department. Could you confirm your husband’s name and age for me please?
(Confirm identity)
P: Tony Greig, aged 70. Doctor, can you please tell me how my husband is?
(Never say I will tell you later)
D: I can see (always acknowledge) you are worried. I am here to answer all
your questions. Before we start, Mrs. Greig, is there anyone you’d like to join
us to support you for this discussion? (Look for support system)
P: No. Doctor can you tell me how my husband is?
D: Well, your husband is being looked after by an expert team of doctors. I can
see that you are very concerned. Would it be all right if I ask you a few
questions before I go on? (Try to know what happened to explain concerns
later easily.)
P: Okay doctor.
P1- focused hx
D: Can you tell me what happened? (We need to know how much the other
person knows, so ask)
P: Well, we were just sitting and all of a sudden he lost his consciousness.
D: Okay, so what did you do?
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P: I called an ambulance and then brought him to the hospital immediately.

D: You did the right thing. I cannot imagine how you must have felt at that
time.
(Appreciate what she did and reflect emotions)
Ask related questions: (Before, During, After)
1. Did he have a fever or a headache or vomiting before he fainted?
2. Was he unwell in any other way before he fainted?
3. Did he experience any warning before the collapse?
4. Was he conscious at that time?
5. Did you notice any fits or any other problems?
6. Did he lose consciousness when you collapsed?
7. How did he feel after the collapse? Confused? Hallucinating? Amnesia?
P2- Past hx
D: Is it the first time that this has happened?
P: Yes/No
P3- Maftosa + desa
D: Has he been diagnosed with any medical conditions in the past?
P: High blood pressure (Pt may say hypertension/ kidney related problems,
strokes, etc)
D: Was he under any medication? Blood thinners? Allergy?
D: Family hx of any sudden death? Kidney related problems?
Always check knowledge and idea before breaking the bad news-
(2 layers then break the news)
D: How much do you know about your husband’s condition? Do you have any
idea what’s going on? Has anyone spoken to you before me?
P: No doctor I have no idea and you are the first one talking to me. Is he okay?
D: As you know your husband was brought to the hospital by the ambulance.
When he came to the hospital, we performed some examinations and also a CT
scan of the brain very quickly to find out why he collapsed.
P: Okay, what happened?
D: Do you have anybody with you today, or do you want anybody to be with
you?
P: Please tell me?
D: So we assessed him, we did a CT scan on him. Unfortunately, it’s not what
we were hoping for. PAUSE (just 1 to 2 seconds) 1st layer
P: What?
D: I’m afraid, we don’t have good news for you Mrs. Greig. PAUSE- 2nd layer
P: What? I don’t understand.
So break the news.
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D: Unfortunately, the CT scan shows he has massive bleeding inside his brain.
PAUSE
(See the response of the patient. The patients can respond in different ways.
The patients can be shocked; they can be loud and start crying. They might just
go into a quiet mode. So anything can happen. Whatever happens, give your
response accordingly.)
D: I can see that you are really shocked by all this. You were not expecting
news like that.
(EVE protocol)
(So, just explain these things to the patient. Wait for 4 or 5 seconds till the
patient is calm, looking at you again. If you think you need to offer a tissue,
offer a tissue, offer a glass of water etc. Then ask her:
D: Do you want me to tell you more or do you want anyone to be with you?
(Offer support once again)
P: It is fine doctor.
D: I understand it would be really hard to talk at this moment, but do you have
any questions at this point? (Ask concern and how much they want to know)
P: Why did it happen to him?
D: Most likely this could have happened because of his high blood pressure.
P: What are you going to do for him? Any surgery?
D: Usually if someone has suffered a bleed, the brain specialist would try to
remove the clot in the brain but in your husband case, I’m sorry the expert
team of doctors has assessed him and they feel surgery is not going to be
helpful for him.
P: Why?
D: It is not a good option for him; it can in fact become more dangerous or
fatal for him.
P: Can you take him to ICU?
D: Well, we keep patients in the ICU if they can’t breathe on their own or if we
are expecting them to recover. But Mr Greig is unconscious but breathing on
his own.
P: Are you going to keep him just like that?
D: Well, the experts think that palliative care is the best care that we can
provide him now.
P: What is palliative care?
D: It is care that is given to patients when they are in a terminal condition. It is
giving social, psychological and spiritual support to the patient and his family
and we will try to relieve his pain and make him as comfortable as we can.
P: Did you say terminal condition? Is he going to die?
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D: I am sorry to say it but I am afraid given the situation, it’s less likely that he
is going to make it. (Don’t be afraid to say he is going to die, but wrap it in a
nice manner.)
P: How long does he have?
D: It is really difficult to say how long he will last, it varies from patient to
patient. As we monitor him more we will get a better idea of how long he has
left.
P: Should I call my children?
D: Yes you should definitely inform them. Your husband’s condition is quite
serious so it’s better that your children know about his condition so if they
want to visit, they can visit him and also support you.
P: Can I take him home?
D: I need to speak to my seniors to see how that can be arranged.
Few other questions you can ask: (Talk about end of life care)
D: Do you feel that this is what he would want at this stage?
D: Do you know if he has ever expressed his wishes regarding where he would
like to be if things come to this point?
D: Do things he would like to be done at this stage of his life.
D: I know this is very devastating news. If you need any kind of support please
do let me know. I can be there or I will arrange any of my colleagues to be
there to help you with whatever you need.
Extradural haemorrhage
Where you are: You are FY2 working in paediatric emergency.
Who the patient is: Joshua, aged 9, had a road traffic accident an hour ago.
Other information about the patient: Initial surgery has been done and there is
a head injury. No other injury has been found. CT scan has been done and
shows extradural haemorrhage. You have not seen the patient. A team of
doctors is resuscitating the child and planning to take him to the theatre.
What you must do: Please talk to the mother, Mrs. Parker and address her
concerns.
Patient’s relative information (Positive findings for candidates to simulate)

You are the mother of Joshua
You and your husband with the kid went to a park for a picnic
Your child was out of your sight, you did not hold your child hand.
Joshua saw dad approaching and ran towards his dad and unfortunately was
hit by a car.
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You feel guilty and think it’s your fault.

Don’t let the doctor greet, ask questions like ‘how is my child doing?’
Your husband is in the waiting area.
Concerns:
1. Is my child okay? Doctor will he die??
2. What type of surgery?
3. Are there any complications for this surgery
4. Can we see him?
5. Will he suffer any permanent damage?
Emotions: Very stressed.
Before beginning the station always remember what the station is about and
what your task here is, child has EDH and child is bleeding as you can see, he is
unstable so you will mention that (Blood transfusion) and fluids. It’s a case of
hope, he is going to recover, going to become conscious, going to get better
once surgery is done so, reassure the relative in the end.
Doctor: Hello Mrs Parker. I'm Dr (name). Let me just confirm, are you the
mother of Joshua?
P: Yes, please tell me how is my child doctor? Is he okay?
D: I understand how worried you must be, I am here to talk to you about him.
Before that could you please confirm for me your child’s name and age?
(Always check identity)
P: Joshua, 9 years old. Please tell me how he is?
D: I understand you are really worried about your son. He is in good hands. He
is being looked after by an expert team of doctors and they are doing their
best for him to get better.
(This is a case of hope, hope he is going to recover, hope he is going to become
conscious and get better once surgery is done).
D: Would it be all right if I ask you a few questions to understand the situation
better? I know it might be difficult for you to go through this again, but could
you please tell me what happened? How this happened?
P: Doctor we were out for a picnic, Joshua saw his dad and got excited and ran
out to his dad across the road. A car was coming from the opposite side and it
hit him and he was on the floor and he fell unconscious. Ah! It was my fault; I
will never forgive myself! I should have been holding his hand!
D: I cannot imagine how difficult this must be for you, but please do not blame
yourself. It was not your fault. It was an accident.
P1 focused hx only related questions (Before, during and after the situation)
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Did you witness the accident?

Did you notice any fluid or blood coming out of his ears, nose, and mouth etc?
Did you notice any bleeding externally on his head?
Was he making any jerky movements with his body?
Did he lose consciousness? If yes, how long? Did he regain conscious
afterwards?
Did he have any other problem?
D: What did you do then?
P: We just called the ambulance and came to the hospital.
D: You did the best thing bringing him to the hospital. Just a few more
questions before I go on to explain his condition. (Appreciate her for calling
the ambulance)
P2 past hx
D: Can you tell me is it the first time this has happened that he lost his
consciousness?
AMPLE (Hx for surgery) check if he’s eligible for surgery. - Allergy, Medication
Hx, Past medical
Hx, Last meal and Events leading to the incident.
D: Any blood disorders or any blood thinning medications at all?
D: When did he take his last meal?
D: Does he have any allergies?
D: Any events leading to the injury?
D: Do you have any idea what could be the cause of the loss of
consciousness/drowsiness (based on presentation)? (Ask idea)
P: I don’t know doctor, will he die?
D: We are doing our best to help him; he is with a team of expert doctors.
D: Has anyone explained anything to you regarding your son so far?
P: No doctor, will he be okay?
D: Alright, so before I go on to explaining, do you want anyone to be with you
for support? (Check support system)
Break the news + 2 layers
D: As you told me, you brought him to the hospital, he was unconscious, we
also found him unconscious, and did an examination on him, and then the
specialist send for a CT scan of the head.
Unfortunately, I do not have good news for you. PAUSE, 1st layer
(Wait for her reaction.)
P: What do you mean?
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D: I am afraid; it’s not what we were hoping for. Would you like me to call
your husband? (Call for support system again) PAUSE 2nd layer
P: No, please tell me what happened?
Now break the news
D: The CT scan shows, there is bleeding on the outer part of the brain. There
is a collection of blood, which is compressing on the brain and this is the
reason for his loss of consciousness.
PAUSE (Wait for her reaction.)
If she is reacting/crying a lot, you can see the tears, offer a tissue or offer her
water. Ask her again,
D: I know you are really distressed after that, I am sorry to be the bearer of bad
news.
P: Is he going to die? What are you going to do for him?
D: Our expert team of doctors thinks that he will benefit from surgery, and we
need to do surgery, as we need to remove that blood from the outer part of
the brain so that his symptoms can be resolved and he regains his
consciousness.
P: Are you putting him in surgery now? He is such a small child to have a
surgery.
(She will be distressed, whatever she is reacting like, keep acknowledging,
keep reflecting.)
D: I know it’s upsetting. It is very natural for you to be worried. But, the surgery
is his best hope of making a recovery. It will be done by an expert team of
doctors, surgeons, paediatric surgeons in the hospital.
P: Are there any complications from the surgery or permanent damage to his
brain?
(Say in a good and hopeful way).
D: Well, there are some complications that are associated with every surgery.
Some short term complications and some long-term complications. Mild to
moderate bleeds do not suffer any damage.
The short-term complications:
1. Bleeding.
2. Infection.
3. Blood clots in his leg.
The Long term complications:

1. Weakness in arms legs face, loss of sensation.
2. Persistent pain or difficulty in walking.
3. Developmental problems---he might be slower than other kids.
4. Difficulty with speaking.
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(Keep giving her hope, so that she will be happy and consent to surgery)
D: Are you okay with the surgery?
P: What type of surgery is going to be done?
D: The surgeons are planning to do an operation on his brain. They will make a
hole in the skull.
Through this hole, the blood clot will be removed.
P: Will he be okay?
D: We are preparing him for the operation. Surgeons believe he has a higher
chance of getting better with this operation.
P: Can we see him doctor?
D: Well, you can surely see him, but at the moment he is being resuscitated.
We are planning to take him to the theatre, so let me check with the seniors
and get back to you. But don’t worry I will definitely get back to you.
(Don’t ever say no to a patient, especially to the relative whose child or
father or mother is going to surgery).
D: Is it okay for us to go ahead with the operation? (Consent)
P: Ok doctor.
D: We might need to give him a blood transfusion. Is it okay with you? (Check
if Jehovah witness)
Take consent for the surgery.
D: Any concerns?
D: I understand this is a really difficult situation for you, if you have any
concerns or need any help or any support, please let me know and I, or one of
my colleagues, will be there with you,
P: Thank you doctor.
D: Stay strong and positive. We are doing our best.
PELVIC FRACTURE
Who you are: You are an FY2 in A&E.
Who the patient is: Reggie Adams, 8 years old.
Other information: Reggie Adams, an 8 year old boy, was brought in by his
father, Ronald Adams, following a road traffic accident. Initial survey was done,
and revealed that he had an unstable pelvic injury. He has lost a lot of blood
and is hypotensive. Initial management was done and the patient was
resuscitated. He is being prepared to go in for Surgery.
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What your task is: Talk to his father, explain about further management, and
Patient information: (This is for candidates to simulate well)

You are Ronald Adams, father of Reggie Adams.
You had taken Reggie out to the park, along with your wife. Just when you
bent down to pick something up, Reggie ran into the middle of the road and
was hit by a truck.
You noticed Reggie’s pants were soaked in blood, and he looked pale at the
time.
You are very anxious, and you feel guilty that this could be your fault.
Reggie has not had anything but a glass of milk at 7 am this morning. He does
not have any loose teeth, and no previous surgery, and has no diagnosed
medical condition.
Concerns
Is Reggie going to die?
What can you do for him?
Can I see him?
Emotions: Anxious
D: Hello, I am Dr (name), one of the doctors working here in A&E. Are you
Reggie’ father?
P: Yes Doctor.
D: Can I confirm Reggie’s age please?
P: He is 8 years old, doctor.
D: Thank you. And may I know your name please?
P: I am Ronald Adams.
D: Alright Ronald, has anyone else been here to talk to you about your son?
P: No doctor. Is he okay? He seemed very sick when I got him here. I am really
scared that he is seriously hurt.
D: I can see that you are really concerned about Reggie and understandably so.
I am here to talk to you about him and to answer your questions to the best of
my abilities. However, I do need to ask a few questions in order to have a full
understanding of what happened and of Reggie’s health in general. Is that
okay?
P: Yes Doctor.
P1- Always take focused hx of what happened
D: Ronald, I know that it must be hard for you to have to keep going over what
happened, but if you don’t mind could you please walk me through it again?
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P: Doctor, I was taking Reggie to the park today morning, along with my wife.
On the way there, I bent down to pick something up that my wife dropped.
Meanwhile, Reggie ran to the middle of the road and got hit by a truck.
Ask related questions (Before, during and after the situation)
Did you witness the accident?
Did you notice any fluid or blood coming out of his ears, nose, and mouth etc?
Did you notice any bleeding externally on his head?
Was he making any jerky movements with his body?
Did he lose consciousness? If yes, how long? Did he regain consciousness
afterwards?
Did he have any other problem? Pale?
D: What did you do then?
P: We just called the ambulance and came to the hospital.
D: It must have been so shocking for you. Just a few more questions before I go
on to explain his condition.
P2 past hx
D: Can you tell me if this is the first time that he has ever lost consciousness/
become pale?
AMPLE (Hx for surgery) Check if he’s eligible for surgery. - Allergy, Medication
Hx, Past medical Hx, Last meal and Events leading to the incident.
D: Any blood disorders or any blood thinning medications at all?
D: When did he take his last meal?
D: Does he have any allergies?
D: Any other events leading to the injury?
D: Do you have any idea about how badly he was injured when he came in?
(Based on presentation)? (Ask idea)
D: Alright Ronald. Thank you for the information. I will now explain about
Reggie’s condition.
P: Yes doctor.
D: Is there anyone else you’d like to have here with you? (Look for support
system)
P: No doctor, I am fine.
Breaking news + 2 layers

D: So, Ronald, when Reggie came in, our team of emergency doctors examined
him, and we don’t have good news I’m afraid. PAUSE 1st layer
D: I’m afraid that the findings were not what we were hoping for. PAUSE 2nd
layer
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P: What is it doctor?
Now break the news
D: We are of the opinion that he has an unstable hip fracture. PAUSE
P: Oh no. (Reflect emotions)
D: I’m sorry to tell you, he has also lost a lot of blood from the fracture site,
and so he also has a low blood pressure.
P: What can you do for him doctor?
D: We have given him some fluids, and stabilised his fracture, and we have
managed to bring his blood pressure back up. However, the team is of the
opinion that surgery might be the best option for him. We are presently
preparing him for surgery.
P: Doctor, will he die?
D: Ronald, we have the best team working on him and we will do everything in
our power to treat him. Please try to stay positive. (Reassurance)
P: Okay doctor.
D: Ronald, do you consent to us giving him a blood transfusion or blood
products if required? (Checking if they Jehovah witnesses)
P: No doctor. Can you tell me more about the surgery?
D: So as for the surgery, It will be done under general anaesthesia so that he
won’t feel any pain. The orthopaedic surgeons will fix his pelvic bone back in
place. I will make sure the surgeon comes in to have a chat with you in order to
explain it better.
P: Okay doctor. Can I see him?
D: Ronald, of course, you can see your son. However, at the moment, he
is being prepared for surgery. I will talk to my team and let you know if you can
see him before he is shifted to the operating room. Would that be, okay?
P: Yes doctor.
D: Is there anything else you want to ask me?
P: What are the complications of the surgery?
D: The complications:
1. Bleeding,
2. Infection.
3. Blood clots in his leg.
P: Can we see him together doctor?
D: Well yes, but at the moment he is being resuscitated. We are planning to
take him to the theatre, so let me check with the seniors and get back to you.
But don’t worry I will definitely get back to you. (Don’t ever say no to a
patient, especially to the relative whose child or father or mother is going to
surgery).
D: If there is anything that you need, just ask for me and I will be right back
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to talk to you.
D: I understand this is a really difficult situation for you, if you have any
concerns or need any help or any support, please let me know and I, or one of
my colleagues, will try our best to accommodate you.
D: Stay strong, we are doing our best.
POST-OP BLEEDING- AORTOBIFEMORAL BYPASS SURGERY

Who you are: You are an F2 in Vascular Surgery.
Who the patient is: Mrs. Sarah Khan, a 60 year old woman.
Other information you have: She has undergone an Aorta-femoral bypass graft
in her lower limb due to vascular insufficiency that caused calf pain. She was
shifted to the recovery room, after the operation. Your nurse colleague noticed
that she was bleeding heavily into the drain, a few hours after the operation.
She was given six units of blood products. Your colleagues all scrubbed in to
the theatre. She was taken to the theatre for re-exploration. Her husband has
come to the hospital to see his wife.
What you must do: Talk to her husband and explain what has happened and
Special Note: There was no error in surgery. This is a known complication of
the surgery. Consent from Mrs. Khan has been taken to talk to her husband.
Patient information: (The positive findings for candidates to simulate)

You are Mr Khan, 66-year-old man, husband of Mrs Sarah Khan.
You have come to the hospital to see your wife.
Your wife had undergone aorta femoral bypass surgery because she had some
circulation problem in her legs.
You don’t know she has suffered a bleed during the procedure.
You feel like the doctors have made mistakes.
You have two kids who live in Australia.
Concerns:
1. You have given 6 units of blood, Is that serious?
2. If doctor says it’s a complication, ask how often people develop
complications like this?
3. How long will the operation last?
4. Why did you do the surgery in the first place if there was a risk of
complications?
5. I think you made a mistake?
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6. Is she going to die?

7. Should I call my kids and tell them their mother is dying?
Always remember about BBN stations:

1. Always take HX about what happened?
2. Always assess knowledge about what they know, so you avoid telling them
things they already know, whilst patient’s relatives are devastated and want
news of their loved one.
3. Always ask about support system.
4. Who is here with you now? Who do you live with? Do you have any family
living near to support you?
5. Then, break the bad news. (2 warning shots + bad news)
6. Acknowledge the emotion and give support.
7. Address the concerns accordingly.
D: Hello I am Dr (name), I am one of the junior doctors here, are you the
husband of Mrs. Khan?
P: Yes doctor.
D: Can you confirm for me your wife’s name and age?
P: Sara Khan, 60 years old.
D: Thank you, I am here to update you regarding your wife’s condition. But
before that I want to know how much you know about her condition. (Assess
knowledge of her husband about her condition.)
P: She had a problem with blood flow in her legs for which doctors had decided
to perform surgery and she underwent the surgery this morning.
D: Yes, your wife had surgery this morning. Has anyone explained anything to
you regarding the surgery?
(Always ask if anyone has explained before you)
P: Yes/No
D: The operation is called Aortobifemoral bypass. As you said she had a
problem with blood flow in her legs and this bypass surgery is done to redirect
blood around narrowed or blocked blood vessels in your belly or groin. The
surgery is done to increase blood flow to the legs.
P1 focused hx about dx (V. Focused, don’t waste time asking too many
questions as your task is not making dx)
D: Is it okay if I ask you a few more questions? What made her come for
surgery in the first place?
P: She had calf pain and later a doctor explained it was due to vascular
insufficiency.
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Focused hx about bleeding (Bleeding is current complaint)

D: Has she ever mentioned to you about having bleeding from anywhere?
(Gum bleed/ nosebleed/ urine/back passage?
P2 past hx
D: Has this ever happened before?
P: Yes/No
P3 maftosa + desa
D: Does she have any medical condition? Any bleeding disorders? Any
medications like blood thinners? Allergy? Any family hx of similar condition or
any bleeding disorder?
D: Does she have any hx of smoking or alcohol?
P: Yes/No
D: Has anyone spoken to you about your wife's current condition? (Assess
knowledge)
P: No, I just know that she had an operation this morning. I came to see her
but she was not in the recovery room.
Breaking the bad news into layers.

D: Okay, before I discuss your wife’s current condition with you, do you want
me to call anyone else here at the moment to support you? (Ask support
system)
P: Yes/No
D: Have you and you wife been told about the possible complications of the
surgery?
P: Yes/No
D: Alright, so what happened is she had an operation this morning. The
operation went well and she was doing fine after the surgery in the recovery
room. Then something happened that we didn’t expect. PAUSE 1st layer
P: What happened?
D: In the recovery room, unfortunately there was a complication. PAUSE 2nd
layer
P: What do you mean by complication?
Break the news
D: The surgery went well but in the recovery room she started to bleed
severely in her drain tube.
P: What? Bleeding? (They will react in different ways- If pt. cries, let them)
DON’T INTERRUPT
Offer tissue or a glass of water, acknowledge it, EVE protocol
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D: I can imagine how worried you must be right now. Anyone in your shoes
would react the same way.
P: What are you going to do for her?
D: We have given her six units of blood to make up for the loss.
P: What? 6 units? Isn’t it too much? Is her condition serious?
D: It is quite a lot of blood, but we need to compensate for the loss of blood
and you wife is in a serious condition. Now we have taken her back to theatre
immediately to stop the bleeding.
P: Will she be okay doctor? Is she going to die?
D: It is difficult to say but we will do our best to help her. At the moment, she’s
in the operating room. The surgeons are trying best to stop the bleeding. We
hope that they’ll be able to stop the bleeding and she’ll recover from it. I can
also assure you that she is in good hands and we are trying our best. (You can
do nothing but reassure)
P: Have you guys done a mistake during the surgery?
D: Not at all, I’m afraid this is one of the complications of this surgery.
P: How can she lose so much blood? I am sure something might have gone
wrong?
D: I can assure you that the surgery was uneventful, which is a good thing. This
is one of the complications of this surgery.
P: I wasn't aware of this. No one had told me about it.
D: Usually we explain the procedure and all the possible complications to the
patient and then take their consent. And I am sure that your wife was aware of
all of it before going for the procedure.
Management (Explain the procedure/ Complications/ Advice/ Safety net)

P: What is the exact cause? How could this happen to my wife? (If they give
you a paper and pen, draw and show the patient’s relative for better
understanding, below there’s a picture)
D: Let me explain about the nature of this operation to you. In this operation
we insert an artificial vessel between the main artery in the tummy (aorta) and
two main arteries in both groins (femoral arteries) that supply blood to the
legs. This involves major blood vessels and is major surgery and that's why
there is always a risk of complication. Now you can imagine why there is a
chance of bleeding after this operation. (Explain clearly what and how this
might have happened).
P: Why did you do the operation if you knew there would be complications?
D: Your wife needed an operation because she had problems with circulation
in her leg. If she hadn’t had the surgery, there could be severe complications
anyway like maybe even losing her leg. The aim of this operation was to
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improve the blood supply to her legs and to relieve her symptoms. In her case
the advantages outweighed the disadvantages and that's why she went for it.
(To tackle this kind of question always say benefit over risk.)
P: How often do these complications happen in this hospital?

D: It’s a very unfortunate situation that your wife had it. I assure you that this
is a very rare complication occurring.
P: What is the success rate of this operation?
D: It differs from patient to patient. It depends on their age, general fitness and
whether they have any medical problems. Unfortunately, your wife has
developed one of the serious complications of this operation, which makes it
difficult to say what will happen exactly.
P: Doctor, shall I call my children to come?
D: I think you can call to inform them. Your wife’s condition is quite serious so
it’s better that your children know about it so if they want to visit, they can
visit her and also support you.
P: How long will the operation last?
D: I’m not sure but we will try to control the bleeding as soon as we can. It
should last a few hours at least. However, I will be updating you at regular
intervals.
P: Doctor, are there any other complications?
D: Another complication could be infection at the site of operation. To
prevent this happening she has been given antibiotics during the operation.
Also blockage of the bypass graft, this is a specific complication of this
operation where the blood clots within the bypass graft causing it to block.
Limb loss (amputation) happens sometimes when the bypass blocks and the
circulation cannot be restored. The circulation to the foot may be so badly
affected that amputation is then required.
Chest infections can occur following this type of surgery, particularly in
smokers, and may require treatment with antibiotics and physiotherapy.
Occasionally the bowel is slow to start working again, this requires patience
and fluids will be provided in a drip until your bowels get back to normal.
Advice:
1. She needs to have rest more than usual. After that she can gradually return
to her normal activities.
2. She should not put too much strain on her operative wound.
3. She can gradually increase the amount of exercise and increasing the
distance that she walks.
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4. She should keep the wound area clean by daily bath or shower and dry the
area gently with a clean towel.
Safety netting
If she has redness or discharge from her wound, please seek advice from her
GP. If she develops sudden pain or numbness in her leg, which doesn’t get
better within a few hours, please contact the hospital immediately. If she
experiences any pain or swelling in her calves or any shortness of
breath and chest pain, please immediately come to the A&E
(Whenever they give you a paper and pen, draw picture for them for better
understanding.)
Post-Operative Stroke
Who you are: You are an FY2 in a Neurosurgery Department.
Who the patient is: Mrs Stella Walker, an 80-year-old lady who had brain
operation for a space occupying lesion. While in the recovery room, they
noticed that she is not able to move one part of her body. CT scan of the brain
was done which showed ischemic stroke. She is now at the intensive care unit.
Other information: She is waiting to be reviewed by the stroke specialist.
What you must do: Talk to the son and address his concerns.
Patient Information: (Positive findings for candidates to simulate)

You are Dan Walker.
Your mother had brain surgery for brain tumour.
Your mother had some behavioural changes, her personality had changed.
During the surgery she developed a stroke.
The doctor is coming to explain the situation.
You live with your mum. You are the next of kin.
Concerns
Is she going to die?
Will she be able to use the right part of her body? –
Do you think she is going to recover from this? –
What are you going to do for her?
Emotions: Anxious
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D: Hello I am Dr (name), I am one of the junior doctors here, are you the son of
Mrs Walker?
P: Yes doctor.
D: Can you confirm her name and age for me?
P: Mrs. Stella Walker, 80 years old.
D: Thank you, I am here to update regarding your mother’s condition. Before
that I want to know how much you know about her condition? (Assess
knowledge about her condition)
P: My mother had brain surgery for a brain tumour.
D: Yes, your mother had surgery. Has anyone explained to you anything
regarding her current condition? (Always ask if anyone has explained before
you)
P: Yes/No
D: Before we move forward can we have a chat to understand the situation a
bit better?
P: Yes/No
P1 Data gathering- Take History always
D: Why did she have the surgery done in the first place? What did you notice
first?
P: She had some behavioural changes, her personality had changed, we were
worried so we brought her to here and later she was diagnosed with a brain
tumour.
D: I am so sorry to hear that. Who does your mum live with?
D: Are you the next of kin?
D: Any siblings?
D: Who looks after your mother? (Psychosocial and support system)
D: What have you been told so far?
P2 -Past hx
D: Were the symptoms happening for the first time?
P3- Desa + Maftosa
D: Any medical condition/ medication/bleeding disorders? Blood thinners?
Smoking/ Alcohol hx?
Family hx of stroke? Previous brain tumour?
D: Are you alone here or do you want me to call anyone here now for support?
(Check support system)
Let’s start breaking bad news (2 Layers + break the news)
D: Okay don’t worry I am going to explain everything to you. Your mother had
an operation and it went uneventful, which is a good thing in operations. Later
we shifted her to the recovery room. However something happened that we
didn’t expect. PAUSE (1ST layer)
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P: What happened doctor?

D: While in the recovery room, she was noticed to have weakness on one side
of the body. We then requested a scan of the brain and unfortunately the
results include bad news. PAUSE (2nd layer)
P: What doctor?
Now break the news:
D: I’m sorry to say the scan showed that she has suffered a stroke. PAUSE
(Allow the news to sink in and respond according to his emotions. Offer
tissue if required.)
P: How could this happen? I thought she would recover well. Is this your
mistake?
D: No, not at all. Actually, It is one of the complications of the operation. Every
surgery has some complications; during the operation she developed reduced
blood supply to the brain which has caused the stroke and damage to the
brain. It’s quite natural to be upset about it, I understand.
P: What are you going to do for her?
D: She has been transferred to the ITU for close monitoring and support.
P: Is she going to die?
D: I am afraid; she is in quite a serious condition but it’s really difficult to say at
the moment as to how her body will react. She had brain surgery and then she
suffered a stroke.
Unfortunately, it’s difficult to predict. Hopefully, when she has had a review by
the specialist, we will be able to give you more information.
P: Do you think she is going to recover from this?
D: She has been taken to the ITU so she is receiving the best treatment
possible so there is a possibility that she may show signs of recovery but we
are waiting for the specialist to review your mother and give us an opinion and
assessment on the effect of the stroke on her brain and the chances of her
recovery.
P: Will she be able to use the right side of her body?
D: It is difficult to say but the stroke specialist will come and assess. Then they
can give us information in terms of the prognosis of whether she’ll be able to
use the right side of her body. Sometimes people are able to use the side of
the body that has been affected but I can get some information and get back
to you on this after the specialist has completed their assessment.
D: Is there any way we can support you?
D: Is there anyone else that needs to be informed about your mum’s
condition?
D: Do you have any siblings?
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D: We would like to have your telephone number so that we can contact you if
necessary- Always look for support system in BBN stations.
P: It’s just me. Yes/No
P: What should I do now?
D You can wait in the waiting area. When the specialist has reviewed your
mother we will ask him/her to talk to you.
P: Can I see her now?
D: After talking to my seniors, we will arrange for you to see your mother in
the ITU.
P: Okay doctor.
D: If she develops worsening symptoms, if you need any help or have
questions, always ask me.
(Safety net)
P: Thank you.
Bilateral stroke
Who you are: You are an F2 in Surgery.

Who the patient is: Mr. David aged 65, had an Ischemic Stroke last week which
affected his left side. He was recovering well and doing fine. He developed
another stroke yesterday and his GCS is 3 now. They did CT scan and it showed
massive clot in both the hemisphere. Only Analgesics and IV Fluids can be given
to the patient.
Other information: If patient deteriorates then Do Not Resuscitate the patient.
His daughter came to you to discuss her father’s condition.
What you must do: Please talk to the daughter, explain her father’s condition
Special note: Daughter is pregnant. MDT has decided that surgery cannot be
done and they have decided only palliative care is possible.
Patient Information:
You are Maria Williams.
Your dad had a stroke, After the first stroke, he was able to speak to you and
move his hand.
He had another stroke 4 days ago and is now in a coma.
You’re expecting improvement and think he’s going to be okay.
The problem is you are 36 weeks pregnant and you’re going to deliver your
son.
Your father wanted to see your son.
You want the doctors to delay his death until you give birth.
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You are his only family.

You want to delay his death so he can meet his grandchild.
Concerns
1. Are you going to give up on him?
2. Can you please talk to your seniors to change the management plan?
3. Will he be okay?
4. Can you delay his death until I give birth?
5. Can we give NG tube to my father?
Doctor: Hello Miss Jane, my name is Dr (name), one of the junior doctor here,
May I confirm how you are related to Mr. David Jones? (Confirm identity)
Patient: I am his daughter. How is my father doing doctor?
D: I’m here to talk to you about your father’s condition. What do you know
about your father’s condition? (Assess knowledge)
P: He had a stroke, but he was doing fine after that. He was recovering well.
D: I’m so sorry to hear about his stroke. You mentioned that he had a stroke;
can you tell me a bit more about it? P1- Focused hx
P: My dad had a stroke, after that, he was able to speak to me and move his
hand.
D: Yes, you are right. I would like to discuss his present condition with you. But
first, is it OK if I ask you some questions about his health?
P: What do you want to know?
D: Has this ever happened before? Any blood thinners, bleeding disorders?
D: Would you like me to call someone to be with you for support before I
continue?
P: No, it’s OK.
P2+ P3
Break the news with layers
D: I don’t have good news PAUSE (1st layer)
P: What do you mean by not having good news?
D: I am sorry, after the first stroke you father’s condition started to
deteriorate. We examined him and did a CT scan of his head. Has anyone told
you about CT scan result?
P: No, tell me about it?
D: I’m sorry to say that it’s not what we were hoping for. PAUSE. (2nd layer)
Would you like anyone to be with you whilst I discuss your father’s condition?
(Check for support system again)
P: No, I came to the hospital alone; please tell me what has happened?
Break the news
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D: Unfortunately, you father had another stroke yesterday which has affected
both sides of his brain and he is unconscious now. He went into a comatose
state. Are you aware of that? (Pause, let the patient sink in, reflect emotions)-
Don’t interrupt.
D: I can see that this isn’t something you were expecting. I’m really sorry to be
the bearer of bad news. EVE Protocol
P: Are you going to give up on him? Can you operate on him?
D: Unfortunately, we cannot do an operation as this is his second stroke. With
a massive stroke affecting both sides of his brain, our team of experts believe
that at this stage an operation is not possible. It’s called a bilateral stroke.
PAUSE
D: I’m really sorry to say that his condition is terminal at this stage.
P: Will he survive from here?
D: I am afraid, we are not expecting him to get better and the specialists (
MDT) have decided that if his heart stops, we will not do chest compressions
(CPR) as it will not be in his best interests.
P: Doctor, does this mean that you cannot do anything for him?
D: No, we will give your father supportive treatment. We will take measures to
make sure your father is as comfortable as he can be. It has been discussed by
a team of specialists – a multidisciplinary team. And it has been decided that
the best treatment for your father is palliative treatment. He will be given
fluids and painkillers.
P: What is palliative care?
D: Giving social, psychological and spiritual support to the patient and his
family and we will try to relieve his pain and make sure he has round the clock
care.
Note: if they want more description about palliative care
(We will keep his eyes and mouth moist and also we will keep moving him
from side to side to avoid any bedsores and keep moving his joints to avoid any
joint stiffness. It is supportive therapy which is designed individually for every
patient to help them according to their needs).
P: So, what are you going to do for him?

D: We will keep him in the hospital.
1) We will give him IV Fluids and pain medication so he will not be in pain.
2) We will take all the necessary measures to prevent bed sores and we will
give palliative care.
3) We will provide mouth care whilst maintaining good hygiene.
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4) We will gently exercise his joints to stop them from becoming stiff and we
may also use compression stockings to prevent blood clot formation in his legs.
5) We will basically make him as comfortable as possible.
P: How much time does he have doctor?

D: It is very difficult to say how much time he has. I’m afraid he could develop
complications such as an infection. However, there are a few complications
with such bleeding in his brain or another stroke that could happen at any time
and could be fatal.
P: Are you giving up on him?
D: I’m really sorry I’ve given you that impression. We are not giving up on him.
We are trying to do what is best for him. Palliative treatment is the best
management for him at the moment.
P: Can you please talk to your seniors to change the management plan?
D: I can arrange for you to meet with my seniors. They may also explain it to
you.
P: Dr can you put him on ventilator as I’m due for my delivery in the next 2
weeks.
D: I wish I could say yes but unfortunately the condition is such that it is
terminal and we are not expecting him to get better and as I have mentioned
our team of doctors has decided not to resuscitate him if his heart stops
beating.
P: Can I see my dad?
D: Your dad is in a critical situation now, but of course I will talk to my seniors
about you going in to see him as soon as possible. Bear in mind he is in a coma.
P: Can you please delay his death until I give birth? I am 36 weeks pregnant
currently.
D: I understand your situation. I’m really sorry about what you’re going
through, however, there’s very little that can be done. We do not have any
control over someone’s death in such situations. We can’t quicken or delay
someone’s death. It has to happen naturally.
P: Doctor, we have some financial issues, is there any help?
D: We can help you with some social help such as care givers at home. You can
also think of a care home he could go in.
P: Can we give an NG tube to my father?
D: I am afraid an NG tube will only cause your father to suffer and he would
not benefit from it.
D: Do you have any other concerns? (Safety Net and Advice).
P: Can I take him home?
D: I need to speak to my seniors to see how that can be arranged.
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A few other questions you can ask: (Talk about end of life care)
D: Do you feel that this is what he would want at this stage?
D: Do you know if he has ever expressed his wishes regarding where he would
like to be if things came to this point?
D: Do things he would like to be done at this stage of his life.
D: I know this is very devastating news. If you need any kind of support please
do let me know, I can be there or I will arrange any of my colleagues to be
there for support.
DCIS
Who you are: You are an FY2 in the Surgery department.

Who the patient is: Remy Adams, 32 years old.
Other information: She had a FNAC following an abnormal mammogram result
done as part of her routine breast screening. The FNAC was done in an outdoor
clinic a few days ago. The test shows that she has low grade DCIS.
What your task is: Talk to the patient and address her concerns.
Patient information:
You are Remy Adams, 35 years old
You had a test done few days ago. The nurse at the outdoor clinic explained to
you that there is a possibility of breast cancer being detected in this test.
You are very anxious about the results.
You regularly self-examine for breast lumps.
You do not smoke, or drink. You get regular periods. Your first period was
when you were 14.
You have read on the Internet that your breast can be removed.
You do not understand how you could’ve got this.
QUESTIONS:
What will you do for me?
Why do I have this?
Will you remove my entire breast? I read on the internet about lumpectomy.
Doctor: Hello, I am Dr (name), one of the junior doctors working in the Surgery
department. Can I confirm your name and age please?
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Patient: Hello doctor, I am Remy Adams, and I am 35.

D: Is it okay if I call you Remy?
P: Yes that’s fine.
D: Nice to meet you Remy, I can see from my notes that you have come for
your FNAC results. Is it okay if I ask you a few questions before I explain your
results to you?
P: Yes doctor, go ahead.
D: Thank you. So can you walk me through what happened and why you had
the FNAC done in the first place?
P: Yes doctor. I underwent my Mammogram a few weeks ago as a part of a
routine breast screening program. The results came out abnormal. The FNAC
was taken in the clinic. Honestly, I don’t even see why I would have an
abnormal mammogram result as I have a very healthy lifestyle. I even examine
myself regularly for any lumps. I am really scared about this result doctor.
D: Firstly Remy, I think it is great that you put in the effort to stay healthy, and I
applaud that you self-examine on a regular basis. I can see you are really
concerned about the results, but in order to answer your queries in a better
way, I will need to ask just a few more questions.
Is that ok?
P: Yes doctor.
D: Do you have any pain at the site of the procedure?
P: No doctor.
D: Remy, you did say that you regularly examined your breasts. Did you by any
chance feel any lumps?
P: No doctor.
D: Any discharge from your nipples?
P: No doctor.
D: Any changes in the skin of your breast or nipples?
P: No doctor.
D: Have you noticed that you have been eating less than usual by any chance?
P: No doctor.
D: That’s good. Have you been noticing any unintentional weight loss?
P: No doctor.
D: Any fever at all in the past few days?
P: No doctor.
D: Any night sweats?
P: No doctor.
D: Any lumps and bumps elsewhere on your body?
P: No doctor.
D: Remy, can you tell me if your period is regular?
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P: Yes doctor. My last period was last week.

D: And can you tell me when you first got your period?
P: It was when I was 14, doctor.
D: Do you smoke or drink?
P: No doctor.
D: Does anyone in your family have a history of cancer?
P: No doctor.
D: Were you diagnosed with any medical conditions in the past?
P: No doctor.
(BBN- Assess knowledge, Warning shots and give the diagnosis. Pick on any
non-verbal cues on revealing diagnosis, and acknowledge them. For example,
being taken aback, disappointed.)
D: Alright Remy, thank you for being patient with me. Let us discuss your test
results now.
D: Do you have any idea of what the result might be?
P: Yes doctor. The nurse at the clinic did explain to me that there is a possibility
of cancer.
D: Remy, before I talk to you about the result, is there anyone else you would
like with you here today?
P: No doctor. That’s okay.
D: Alright Remy, I’m afraid the results of your FNAC do show some abnormal
cells in it. In medical terms, we call it ductal carcinoma in situ. Have you heard
of it?
P: No doctor. Is it cancer?
D: Ductal carcinoma in situ is a very low grade of breast cancer, which means
that it has not spread to the nearby tissue. The good news is that since we
caught it early, it is a very treatable condition.
P: Why did I get it doctor?
D: There are various risk factors that might cause this but in your case, it’s not
clear why you got it.
P: What can you do for me doctor?
D: We have various options to treat you at this point. The first option is
Surgery.
P: Are you going to remove my whole breast doctor? I read on the internet
about options like lumpectomy.
D: That’s great that you have been reading about it. You are right. There are
two options when it comes to removing the cancerous cells. We could either
remove your entire breast, also called a mastectomy, or remove only a part of
the breast that has cancerous cells in it, also called a lumpectomy. Is there
anything that particularly concerns you about these options?
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P: Yes doctor. I would rather not have my breast completely removed, as it

affects the way I look, and I feel like I will really lose my confidence after that.
D: Remy, your concern is valid. I will make sure I discuss with the senior
surgeon about the best option in your case, and request him to have a chat
with you about it as well.
Apart from the surgical options, the specialist may also offer you with the
option of hormonal therapy. Your breast can be reconstructed following the
surgery, and we can make sure the way you look isn’t affected.
P: Okay.
D: Is there any other concern that you would like me to address?
P: No doctor.
D: We will be arranging for you to see the breast surgeon urgently, within two
weeks.
P: Ok.
Safety net for FLAWS and metastasis. Offer leaflets.
HIV Test Result

Where you are: FY2 in GP surgery.
Who the patient is: George White, 25-year-old man, who has come for his
reports.
Other information you have: Presented with generalised lymphadenopathy 2
weeks ago. Blood test was done, FBC, LFT, U&Es, Urine chlamydia screen was
normal. HIV antibody and p24 antigen test are positive. He is diagnosed with
HIV infection and has been referred to GUM clinic.
What you must do: Talk to the patient, discuss results, address his concerns,
and manage the patient.
Patient information: (The positive findings for candidates to simulate)

Your name is Gorge White; you are a 25-year-old gentleman.
Last week you came to the GP to be tested for HIV because you had casual sex
when you visited Thailand 3-4 weeks ago.
You have noticed that you have swellings/lumps in your neck, armpit, and
groin 2 weeks ago.
You had unprotected sexual intercourse with a male partner.
You are married.
After returning from Thailand, you had unprotected sexual intercourse
multiple times with your wife.
You had gone for a business trip to Thailand.
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You work as an IT engineer.

You are otherwise fit and well.
You are not on any other medication.
You are scared to tell your wife that you have been diagnosed with HIV.
You feel like your wife will divorce you if you tell her you have a HIV infection.
You have been married for 3 years.
You live only with your wife.
You have got no known allergies.
Questions:
1. Should I inform my wife?
2. Can you help me tell my wife?
3. Can I have children with HIV?
4. Is there any chance I could have transmitted the HIV to my wife?
5. Can we repeat the test?
6. Should I inform my employers?
Emotions and attitude:

Very worried
Afraid that your wife will leave you if she finds out that you contracted HIV.
GREET
Dr: Hello, I am Dr (name), one of the foundation doctors in this GP surgery. Can
you please confirm your name and age for me?
Pt: Hello Dr, I am George White, 25 years old.
Dr: Nice meeting you George. I have been asked to come and talk to you about
your test results. Has anyone explained the test results to you at all?
Pt: No.
Dr: Okay, don’t worry. Would it be alright if I ask you a few questions before I
go on to disclose the report?
Pt: Sure doctor. That’s fine.
P1- FOCUSED HX
Dr: Was there any particular reason you wanted to get tested in the first place?
Pt: I noticed some lumps and bumps.
Dr: Alright, can you tell me more about it?
Pt: They are in my neck, groin, and armpits.
Dr: When did you notice them?
Pt: A couple of weeks ago.
Dr: Has it changed?
Pt: No.
Dr: Is it painful?
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Pt: No.
Dr: Have you done anything about it?
Pt: I came to my GP, and he ordered some tests for STIs.
Dr: Alright, so apart from lumps, any other symptoms at all?
Pt: I’m not sure.
Dr: Any fever or flu-like symptoms?
Pt: No.
Dr: Any sore throat or cough?
Pt: No.
Dr: Any night sweats? Did you notice any weight loss? Any loss of appetite?
(FLAWS)
P: No.
Dr: Do you feel tired recently?
Pt: No.
Dr: Any Joint pain? Muscle pain?
Pt: No.
P2- PAST HX
Dr: Have you had a similar kind of problem in the past?
Pt: No.
Dr: Have you been diagnosed with any long-standing health problems in the
past?
Pt: No
MAFTOSA + DESA
Dr: Are you on any medications currently?
Pt: No.
Dr: Any allergies from any food or medications?
Pt: No.
Dr: Has anyone in the family been diagnosed with any medical condition?
Pt: Yes/No
Dr: Have you travelled outside UK recently?
Pt: Yes, I have been to Thailand about 3-4 weeks ago.
Dr: What do you do for living?
Pt: IT engineer.
Dr: If you don’t mind, I need to ask you some personal questions. Can you tell
me if you are sexually active?
Pt: Yes.
Dr: Do you have a stable partner?
Pt: Yes, I am married.
Dr: Do you have any other partner?
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Pt: Yes doctor last time when I went to Thailand I had casual sex with someone
there.
Dr: Do you practice safe sex, like using condoms?
Pt: No, I don’t like how they feel.
Dr: Did you practice unprotected sex with your wife after trip?
Pt: Yes, multiple times.
Dr: What’s your sexual preference?
Pt: I am bisexual.
Dr. Okay. A few more things regarding your lifestyle, do you smoke?
Pt: Yes/No
Dr: Do you drink alcohol?
Pt: Yes/ No
Dr: By any chance, do you take any recreational drugs?
Pt: No.
Dr: I would like to do a GPE, take your vitals, and examine your lumps and
bumps. Is that OK with you?
Pt: Okay doctor.
Dr: Are you happy for me to explain the results to you now?
Pt: Yes.
Dr: Do you want anyone to be by your side now whilst we discuss the results?
(Support)
Pt: No.
Dr: Do you have any idea why are you having these lumps and bumps? (IDEA)
Pt: No.
Explaining / disclosing the results:
Dr: So we screened you for STIs and most of the tests came back normal.
However, there are some bad news as well. PAUSE
Pt: What happened doctor?
Dr: I am sorry to say, that the HIV test came back positive, which means that
you’ve got HIV.
*PAUSE* (Patient might be quiet, might be shocked)
EVE Protocol (Acknowledge emotion/ Reflect/ Show empathy)
Dr: I can see that you are really shocked by this news./ You were not expecting
this news./ I am so sorry to tell you all this. (Acknowledge the emotion)
Explain the diagnosis

Dr: Are you aware of what HIV means?
Pt: Yes/ No
Dr: HIV (Human Immunodeficiency Virus). It’s a virus that damages the cells in
the immune system and weakens your ability to fight infections.
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Pt: Is HIV and AIDS same thing?

Dr: No, AIDs (Acquired Immunodeficiency Syndrome) is a state of very low
immunity when you become susceptible to threatening infections. This state
develops after the HIV virus has destroyed the immune cells.
Pt: Why do I have HIV?
Dr: It is transmitted through unprotected sex or infected needles. In your
situation, it’s likely you got it from the person you had sexual intercourse with
in Thailand.
Pt: Could it be a false report? Can we do the test again?
Dr: Well you are right. Sometimes the report can be false, but we have already
confirmed by testing your sample again. We always check it twice before
telling the patient.
MANAGEMENT: ARMMS
1. ADVICE:
Pt: Should I inform my wife?
Dr: Yes, I would advise you to inform your wife that you are HIV positive so
that she may come and get tested. You should also inform any sexual partners
you may have been in contact with recently about your current condition and
encourage them to get tested.
Pt: I am afraid she might leave me. Can you help me tell my wife?
Dr: I understand it’s difficult. We can inform her through a partner notification
program, by which we invite partners anonymously to come and get tested.
Please note: If patient refuses, please gently encourage them to tell their
partner. Explain that whilst nobody can force him to tell her, he could be
criminally liable of reckless transmission of HIV if he continues to have
unprotected sex with his partner whilst knowing he has HIV. Nevertheless,
we will not inform her without letting him know first. (Do it in a very nice
manner, don't threat, try to convince. Here it is your moral duty to convince
the patient to do the right thing.)
Don't talk in a judgmental way, don’t threaten.
2. RISK FACTORS:
Pt: Is there any chance I can transmit the HIV to my wife?
Dr: Yes. If you have unprotected sex. So, we always advise HIV patients to
avoid sex for the first 6 months of treatment whilst the virus is still detectable,
or if you have sex it’s better to use condom. (Avoid sharing needles if he gives
you Hx of iv drug abuse and avoid blood transfusion).
Pt: Can I have children with HIV?
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Dr: Yes you can, but we would need to take measures to prevent mother to
child HIV transmission. Transmission from mother to baby during pregnancy,
birth or breastfeeding is possible.
3. MEDICATIONS
Dr: Do you have any concerns at this point?
Pt: What are you going to do for me?
Dr: We will refer you to the GUM Clinic. In the GUM clinic, once you are there,
they are going to start you on some medications for HIV to lower the viral load
in your blood. You will be given antiretroviral medication- one or two tablets to
be taken throughout your life. You'll have regular blood tests to monitor the
progress of the HIV infection before starting treatment. (HIV viral load test and
CD4 cell count)
Note: Most people taking daily HIV treatment reach an undetectable viral load
within 6 months of starting treatment.
Pt: Can I have a normal life?
Dr: If you manage your condition properly by taking your medicine correctly
and avoiding illness, you should be able to live a near-normal life.
Pt: Should I inform my employers?
Dr: There's no legal obligation to tell your employer you have HIV, unless you
have a frontline job in the armed forces or work in a healthcare role where you
perform invasive procedures.
4. Multidisciplinary
Being diagnosed with HIV can be extremely distressing, We can provide you
with counselling so you can fully discuss your condition and concerns.
5. Safety netting
Dr: Alright, if you are feeling unwell, please come back to us immediately.
Follow up appointment within 2 days specific for HIV.
Leaflets and information on where patient can get support from.
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NON-ACCIDENTAL INJURY
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Non-Accidental Injury
Insomnia
Approach:
Sleep stages
• 1st stage: difficulty falling asleep
• 2nd stage: wakes up in the middle of the sleep
• 3rd stage: wakes up early in the morning not refreshed
P1: (ODIPARA)
Tiredness or difficulty or sleeping problems. Can you please tell
me more about it?
Don’t forget to ask if anything specific happened
EXAMPLE:
P: I have had this insomnia for 5 weeks?
D: Did anything specific happen 5 weeks ago?
Elaboration of P1
● When do you go to bed?
● When do you fall asleep?
● But by the time you get to sleep, is it after midnight?
● Wakes up in the middle of the night.
● When do you wake up?
● Do you take naps during the day?
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● Any idea about what is causing your difficulty in sleeping?
- Duration of P1
(How long have you had this problem?)
● Did you do anything to resolve it?
● Did you take any medication for it? Have you had this problem before?
If suffering for a long time involve psychosocial:
The impact of insomnia on patient’s life. Three months you’re not able to
sleep? Sounds quite distressing.
● How is this problem affecting your life?

● How is this problem affecting your daily activity?
● What do you do for a living?
● How's your mood?
Sleep environment
1. Bedroom:
● How's your sleeping environment?
● Sleep hygiene and room atmosphere.
● Do you sleep in your bedroom?
● Noisy, uncomfortable environment. With whom do you live? (Snoring)
2. Before (Bedroom), person goes to bed (DESA + Recreational Drugs,)

• Do you play games before you try to sleep? Computer, tv.
• Heavy meals before bed / body weight.
• Exercise before bed.
• Smoking before bed. / Recreational drugs?
• Alcohol before bed.
• With whom do you live? / Where's the partner?
• Energy drinks, caffeine, tea or any caffeinated drinks?
3. Before bedroom
• Work and Daily life.
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• Stress at work / change of work shift / jet lag

4. Physical health + PMH
● Obstructive sleep apnea (Difficulty in breathing through the nose)
● Pain, Headache, Chest pain, Joint pain
● Thyroid problem
● Tummy or bowel problems like constipation or diarrhoea
● Urine problems, incontinence, do you go to toilet more often than
normal?
5. Mental health
● Mood
● Stress
6. (NAI) non accidental injury (V. important)
● Is something bothering you recently? Offer confidentiality.
● Anything else? Apart from insomnia?
-ICE (Idea, Concern, Expectation)

• What's your main worry?
• What's your main concern?
• What worries you the most?
• Apart from insomnia? What is your main worry?
• Or do you have any concerns before I proceed?
• Are you expecting anything in particular from me today?
- EXAMINATION
- PROVISIONAL DIAGNOSIS
Management
How you can treat insomnia yourself

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Insomnia usually gets better by changing your sleeping habits. Identify

factors and address them.
- Do
• Go to bed and wake up at the same time every day.
• Relax at least 1 hour before bed, for example, take a bath or read a
book.
• Make sure your bedroom is dark and quiet; use curtains, blinds, an eye
mask, or ear plugs if needed.
• Exercise regularly during the day
• Make sure your mattress, pillows and covers are comfortable
- Don’t
• Do not smoke or drink alcohol, tea or coffee at least 6 hours before

going to bed.
• Do not eat a big meal late at night.
• Do not exercise at least 4 hours before bed.
• Do not watch television or use devices, like smartphones, right before
going to bed, because the bright light keep you more awake.
• Do not nap during the day.
- Maintain a sleep diary
- Sleeping Diary
SAFETY NET
● Finally driving advice DVLA/ I think you must inform DVLA & stop driving?
If the patient refuses / Why? Address concern? Ultimate risk to his
safety? Family if he has accident.
Sleep apnoea can cause other problems

(Come to us if you do not improve or have new symptoms)
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Without treatment, sleep apnoea can lead to:

• High blood pressure
• Higher chance of having a stroke
• Depression or changes in your mood
• Higher chance of having a serious accident caused by tiredness, such as
a car accident
• Difficulty concentrating at work or school
Insomnia in Rheumatoid Arthritis

Who you are: You are Fy2 in GP clinic.
Who the patient is: Mrs. Ashley Adams, 65, presented to the clinic for
assessment. Patient has been diagnosed with Rheumatoid Arthritis.
Patient is on the following medication:
• Methotrexate PO 7.5 mg per week.
• Paracetamol PO up to 8 tablets.
• Folic acid.
Her arthritis is under control and blood levels of Methotrexate is normal
What you should do:
Please talk to the patient, take history, management with the patient and
P1:
P: I have insomnia (ODIPARA)
P: I go to bed at 10 pm but I don’t fall asleep until 3 am and I wake up at 9 am.
D: How long have you been having this?
P: About 3 months.
D: Did anything specific happen 3 months ago?
P: My husband died, I think I can’t sleep alone.
D: I am really sorry, please accept my condolences. How is your mood?
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P: it’s ok.
D: On scale from 1 to 10, can you grade your mood?
P: 7.
D: Apart from this, anything else?
P: No.
D: What’s your main concern?
P: I just want to sleep.
Psychosocial:
D: You told me you have had insomnia for 3 months, it’s a long period, how is it
affecting your life?
P: It’s ok doctor.
D: Is it affecting your concentration?
P: No, I just want to know why I am unable to sleep.
P: I live alone after my husband’s death.
D: Any family member or friend visiting you?
P: I have 2 daughters but they live away from me.
Insomnia qs (like the structure)

D: Do you take naps during the day?
P: No.
D: How many hours do you sleep continuously?
P: 5 hours.
D: Have you tried anything to help you to sleep?
P: I tried reading books and listening to music but nothing helped.
P2:
D: Have you ever had problem before, in the past?
P: No.
D: Apart from RA, do you have any medical condition?
P: No.
D: Can you tell me about your RA?
P: I was diagnosed with it 15 years ago, but I am taking medication for it. I am
able to help myself at home and I don’t have any pain.
DESA:
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D: Do you smoke?
P: No.
D: What about alcohol?
P: I don’t drink alcohol.
D: Do you drink coffee or tea?
P: Just once daily at 1pm.
MAFTOSA:
ICE:
D: Do you have any expectations for today?
P: I want sleeping pills.
D: Any idea why you are having this?
P: No.
Examination:
- Observation
- General physical
From what you have told me, you are having a problem called insomnia, it’s
probably due to your husband passing away. It’s a big change in your life and it
will take some getting used to. In the meantime, I’ll try and help you.
Management:
- Reassure her: there are a few things which we can do together to help with
your sleeping problem:
- We can start with a few changes in your sleeping habits.
Do/Don't
● Write a list of your worries and any ideas to solve them before going to
bed and this may help you forget about them until the morning
● You mentioned that your husband passed away recently and it could be
one of the reasons you are having difficulty sleeping, if changing your
sleeping habit does not help, we may refer you to cognitive behavioral
therapy.
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- Sleeping pills, we would prefer if you start with lifestyle changes and then
if it does not improve your sleep, we will try the sleeping pills.
● Sleeping pills have their own side effects and you can develop
dependence on them. More importantly, sleeping pills may not work
without lifestyle modifications as I mentioned earlier.
● We will try with these simple measures first and then if you still need
sleeping pills after, I will discuss it with my senior and hopefully we can
prescribe them to you.
● Offer CBT
● Offer leaflets
● Safety netting: Persisting of the symptoms memory problems and falls
INSOMNIA (CANNABIS USER)

Who you are: You are an F2 in GP Clinic.
Who the patient is: A 45-year-old man came in with sleep disturbance.
What you should do: Please talk to him, assess him and address his concerns.
P1:
P: I have insomnia (ODIPARA)
P: I take too much time to sleep, I stay in bed till 6 am .
D: When do you go to bed?
P: 2 am.
D: Why so late?
P: I just hang out with my friends.
D: How long have you been like this?
P: 4 weeks.
D: Did anything specific happen 4 weeks ago?
P: Nothing specific.
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D: Apart from this, anything else?

P: No.
P: I just want to sleep.
Psychosocial:
D: You told me you have had this sleeping disturbance for 4 weeks now, it’s a
long time, how is it affecting your life?
P: It’s ok doctor.
D: Is it affecting your concentration?
P: No, I just want to know why I am unable to sleep.
P: I am unemployed at the moment.
Insomnia qs (like the structure)

D: Do you take naps during the day?
P: No.
D: How many hours you sleep continuously?
P: 5 hours.
D: Have you tried anything to help you to sleep?
P: No.
P2:
D: Have you ever had this problem before?
P: No.
P: No.
DESA:
D: Do you smoke?
P: I smoke marijuana.
P: I started smoking it 6 weeks ago, I smoke 2 joints (cannabis cigarette) a day.
D: Did the sleep disturbance start after that?
P: I think so.
P: I don’t drink alcohol.
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D: Do you drink coffee or tea?

P: No.
P: No.
MAFTOSA:
ICE:
D: Do you have any expectations for today?
P: I want sleeping pills.
D: Any idea why you are having this sleep issue?
P: No.
Examination:
- Observation
From what you have told me, you are having a problem called insomnia, I
suspect the marijuana is the cause for that.
Management:
There are a few things which we can do together to help with your sleeping
problem:
● You mentioned that you go to bed late it's very important that you go to
bed early and wake up early to regulate your sleep cycle.
● It is better you set a time to go to bed and to wake up in the morning

We can start with a few changes in your sleeping habits.
● You said you are anxious, and you are smoking marijuana for it. However,
unfortunately marijuana may have a few side effects on your sleep, it can
disturb your sleep and it can make you anxious, it is very advisable for you to
stop smoking marijuana we have many services for you and it may help you
stop.
● Maintain a sleeping diary
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As for sleeping pills, we would prefer it if you start with the lifestyle changes
and then if they do not improve your sleep, we will try the sleeping pills.
● Sleeping pills have their own side effects and you can develop dependence
on them, more importantly, sleeping pills may not work without lifestyle
modifications as I mentioned earlier.
● We will try with these simple measures first and then in the future if you
still need sleeping pills, I will discuss it with my senior and hopefully we can
prescribe them to you.
Domestic Violence / Abuse
- FACTORS SUGGESTIVE OF CHILD ABUSE

● Patient looks worried & anxious & scared
● Signs of burns
● Findings not matching the history
● Delayed presentation; Find out how far they live from the hospital, find out
why they delayed bringing child
● Unexplained bruises or bruises of different ages
● Nature of the injury
- If Suspecting Abuse / Domestic Violence:

Relationship Questions
• Who do you live with?
• How long have you been together?
• Is everything all right at home?
• How is your relationship with your partner? (Usually, patient talks after
comforting and confidentiality)
- If she is not talking at all

● Humiliation: Does your partner make you feel bad about yourself?
● Fear: are you afraid of your partner?
● Rape; has your partner ever forced you to have sex with him?
● Violence: have you ever been physically hurt by your partner?
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- Problem Questions
● Has he done anything like that before?
● Have you ever done anything to try to solve this problem?
- Partner questions
● Does he have any mental health problems?
● Was he under the influence of alcohol or drugs when he did this?
● Does he have any criminal record?
- Children questions
● Do you have any children?
● Is your partner the biological father of your child?
● Has your partner ever hit your child?
● How is the relationship between your partner and your child?
● Has your partner ever hurt you in front of your child?
- Family, Friends and Finances

● Do you have any family member living nearby?
● How is your relationship with them?
● What do you do for a living?
● Do you have any friends nearby?
Insomnia due to Domestic Violence
Who you are:

You are an FY2 doctor in medicine.
Who your patient is:
Mrs. Elissa Banks, aged 32, came to the hospital with insomnia.
What your task is:
Please talk to patient and address her concerns.
P1
D: What brought you to the hospital?
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P: I have trouble sleeping.

D: Please tell me more about it.
P: (Let her speak)
D: When did this problem start?
P: It started a few months ago.
D: Do you have trouble getting to sleep or do you wake up in the middle of the
night?
P: I have trouble in going to sleep.
D: What time you go to bed?
P: I go to bed around 10pm.
D: What time you usually go to sleep?
P: I go to sleep around 2 am. Sometimes I don’t sleep all night.
D: What time do you usually wake up?
P: I wake up around 8am.
D: Do you wake up during your sleep?
P: No.
D: How was your sleep before this problem started?
P: It was fine.
D: Do you take any naps during the day?
P: No.
D: Anything else?
P: No.
D: Can you think of anything which might be the cause of your problem?
P: No.
D: Tell me what you do before you go to bed?
(Patient is anxious and shaking too much in the station. We need to make her
comfortable. After that she will open up)
D: Are you comfortable? Or is anything bothering you?
P: Is this conversation confidential?
D: Yes, it is confidential.
P: I am having problems with my husband.
D: Could you please tell me more about it?
P: He got violent with me.
D: When did that happen?
P: It happened few days ago.
D: Has it happened before?
P: Yes it has happened many times.
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D: How long have you been together?

P: 1 year.
D: Does he have any mental health problems?
P: No.
D: Was he under the influence of alcohol or drugs when he hit you?
P: No.
D: Does he have any criminal record?
P: No.
D: Do you have any injuries from him that you would like me to look at?
P: No it’s OK.
D: Is there anyone else living with you? Any children?
P: No.
D: Any relative nearby?
P: No.
You want to complete your history, but halfway through she has just made a
shocking revelation about her husband. What about your history? You can
say this:
D: What you are saying about your husband is probably linked to your
insomnia. But just so that I can get a complete medical picture about you,
without jumping to a diagnosis prematurely, is it OK if I finish asking you
these health questions and then we can address this issue better? (You can
say this, so she doesn’t think you have just casually dismissed her revelation
to you by moving on to other questions that have nothing to do with her
husband.)
P: Yes OK.
MOOD
P: It is okay.
D: Could you please score the mood on a scale of 1 to 10, where 1 is lowest
and 10 being the highest.
P: It’s low doctor like 3-4.
Suicide
D: Do you feel suicidal/Like hurting yourself? (Signpost first)
P: No.
F (Friend, Family, Finance)
P: I work in landscape gardening.
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D: Do you have any friends?

P: I have a few friends around.
D: Did you discuss it with them?
P: No.
P2 (Medical and Mental History)
D: Any fever, flu, or cough?
P: No.
D: Any problem with urine or bowels?
P: No.
P: No.
D: Any asthma?
P: No.
D: Are you taking any other medications including OTC or supplements?
P: No.
P3 (DESA)
Ask about tea or coffee? How much? When you take last cup? Smoking.
Alcohol. Recreational drug, stress. Watching TV etc. Noisy environment
Impact and Insight
D: Do you think your sleeping problems are because of this ongoing issue with
your husband?
P: Yes. I think so.
Examination:
Is it OK if I check your vitals and do a general physical examination to see if
everything is alright? —Normal
Management:
*NAI and depression are the most common causes for insomnia.
- Admit for NAI in elderly and children, or depression with

suicidal thoughts.
- If a child is involved, do not forget to raise concerns with
your senior, so social services can interfere to assess the
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situation.
- If in adult, like in this case, offer social services referral for
support with an accommodation, financial support, support
for job search to achieve independence.
D: The incident you told me about with your husband is illegal. You don’t need
to put up with this. There are some ways that we can help and support you.
There is a designated person in the hospital who deals with these issues. We
can arrange a meeting with that person. He will explain about the services that
are available to help people in your situation. Don’t worry. My colleague will
refer you to an organisation - MARAC (A Multi Agency Risk Assessment
Conference) and they will support you.
P: I am afraid to go home.
D: The police and social services will be involved, you don’t have to worry
about anything.
- Talk to my senior.
- Investigations:
o Basic bloods for physical cause (FBC, FBS, TFT, LFT,

KFT, TFT, vitamin levels) *urine screen/dip for
infection/drug screen.
o If NAI/injury, investigate it by doing an X-ray, clotting
factors- skeletal survey- fundoscopy- CT head.
o
- Symptomatic & lifestyle management:
Sleep hygiene: avoid caffeinated drinks, recreational
drugs, avoid heavy meals, alcohol, smoking and exercise
before bedtime. Avoid taking naps in daytime. If shift
worker, think about changing the job or speaking to your
supervisor to organize your rota so you can be consistent
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in consecutive shifts without major fluctuations in sleep

schedule
- Specialist: according to the cause (NAI, raise concern with
your senior so he/she can contact the social services, if
depression, manage with CBT, anti-depressants and/or
psychiatrist referral, etc.)
- Safety netting for persistent insomnia that is not managed by
the above measures and for complications (for example, if
depressed or NAI, for low mood and suicidal thoughts).
- Follow up.
If patient asks for sleeping pill

- Ask why?
- Address the concerns.
- Offer other solutions.
- Say it is addictive and it may cause rebound insomnia when
stopped, so it is not a long-term solution.
- It could be an option only if these solutions fail, only for
short-term after consulting with your senior.
Non accidental injury in child

Who you are:
You are an FY2 in paediatrics.
Who the patient is:
Miss Tanya bought her 4-month-old son, Adam, with swelling on his left arm.
X-ray was done and spiral fracture has been diagnosed.
What you should do:
Talk to the mother and address the initial management plan with her.
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NAI history: environment + delayed presentation
For everyone at home ask (job/ finances/ alcohol/ drugs)
Important: (Any other children at home?)
Presentation: Delayed presentation shows NAI
• So, when did you notice it?

• What did you do immediately?
Environment: Who is at home?? (Me and my sister & partner)

Her:
➢ How do you get on with her?

➢ Was it a planned pregnancy?
➢ What do you do fora living?
➢ Do you manage financially?
➢ Do you drink any alcohol or take any recreational drugs?
Sister, Partner: Same questions
Please don’t be harsh with the mother and praise her for
bringing the child early.
P1 (ODIPARA)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: I can see from my notes that your son has some swelling in his arm,
can you tell me more about that?
Patient’s Relative: I came home from my night shift, as I work as a nurse, he
was crying a lot and I noticed this swelling, I brought him immediately to the
hospital.
D: You did the right thing by bringing him here, you are a caring mother.
How long did it take you to bring him here?
P: The bus took about 30 minutes to bring us here.
D: Have you noticed any other swelling in his body?
P: No.
D: Any bluish discoloration or injuries?
P: No.
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Concern
D: Other than this, do you have any other concern?
P: I just want to know how he is doing right now.
D: Don’t worry he’s in safe hands; the nurses are caring for him.
DDs:
Head to toe
D: Any fever?
P: No.
D: Any discharge from ears?
P: No.
P2
D: Has he ever had this before?
P: No.
D: Has your baby been diagnosed with any medical condition?
P: No.
BIRD DDD
Don’t forget NAI
NAI
D: Who do you live with other than Adam?
P: My boyfriend, Tom.
D: Is he Adam’s biological father?
P: No.
D: How does he get on with Adam?
P: I think they get on OK.
D: What does Tom do for a living?
P: He doesn’t have work at the moment.
D: How are you managing financially?
P: I am the one who is providing everything.
D: Does he drink alcohol?
P: Yes, like 3 beers a day.
D: Any drugs?
P: No.
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Dehydration
D: Is Adam active and playful?
P: Yes
D: Does he wet his nappies as usual?
P: Yes.
DIET:
D: What do you feed him?
P: He is on bottled milk.
D: Any changes to your diet?
P: No.
D: Is he feeding well?
P: Yes, he is feeding well.
MAF
D: Any medication including OTC medicines?
P: No.
D: Any allergies?
P: No.
D: Any family history of a similar problem?
P: No.
Examination:
➢ General physical examination
➢ Head to toe
Provisional Dx:
From the chat we had and after examination, we found that your son has a
fracture. I must inform you that this type of fracture only occurs when the
hand is twisted deliberately by someone.
P: Do you mean that my boyfriend did this?

D: We are not accusing anyone in particular, but the injury looks suspicious.
Therefore, I am going to have to involve my seniors.
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Management of NAI:
1- Admit
2- Senior
3- Investigations
➢ Blood
➢ X-ray on arm (only if it’s not mentioned in the question)
➢ Skeletal survey
➢ CT head
➢ Examine check eye (shaking baby syndrome)
4- Paracetamol as painkiller
5- Specialist:
➢ Orthopaedic to fix the fracture
➢ Social services
D: Adam has a type of fracture that doesn’t occur accidentally, it usually

happens if someone twisted his arm deliberately.
P: Are they going to take my son away from me?
D: Well, it certainly doesn’t mean that they will take him away. After all, you
did the right thing bringing him in, which shows that you love and care about
him. What they will do is investigate what happened to him and make sure it
doesn’t happen to him again.
NAI – Pregnant lady
Who you are: You are an FY 2 in OBG.

Who the patient is: Alicia Peterson, aged 28, is 12 weeks pregnant and
presented to the hospital complaining of vaginal bleeding. She is here for her
antenatal check-up. Your nurse colleague examined her and found no visible
bleeding in her vagina.
Ultrasound showed a viable 12-week pregnancy examination result was
normal. Your nurse colleague noticed burn marks and a fingerprint-like bruise
on her right wrist, but she did not disclose it to the patient.
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What you should do: Please talk to the patient, review the patient, discuss
necessary management and address her concerns.
- POSITIVE FINDING
● Her voice will be quiet, don’t ask her to speak up.
● Pregnancy is uncomplicated, NAD.
● Keep offering confidentiality, give pauses, show sympathy.
● If she says, she wants to go home: YOU CAN GO HOME. Ask “why are
you so anxious to go home?”
● She will open up (sometimes at 2 min bell)
Approach:
D: I understand that you came with bleeding from your front passage, and a
scan was done, has anyone explained the findings to you?
P: Is my baby fine?
D: Let me reassure you, the scan came back normal and your baby is fine.
P: Thank you doctor, the nurse asked me to talk to you, can I go home now?
D: Yes you can go home, but before that can we have chat to make sure
everything is ok with you?
P: OK.
D: I can see that you are uncomfortable, are you ok? I understand that you had
some bleeding, do you have any idea what may have caused it?
P: It happened spontaneously; I don’t know.
Offer confidentiality
D: I want to make sure you know that anything you tell is confidential between
you and the medical team. We just want to make sure you are ok.
P: OK doctor.
D: One of the nurses told me that she found some bruises and burn marks on
your body, can I have a look at them? May I know how you got them?
Don’t keep telling her about confidentiality, once is enough, give the patient
time to speak, be sensitive.
P: I don’t want to talk about it.

D: What might happen if you talk about it?
P: He might kill me.
D: Who might? This is a safe place here. No one can harm you.
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P: My husband.
D: You seem frightened of him; Can you tell me what is happening with him?
P: He has been abusing me verbally and physically for the past 2 years. He
always threatens me if I ever speak about it.
D: I am really sorry about that. He can’t hurt you here. Was he the one
responsible for the bleeding?
P: Yes, he kicked me in the tummy.
D: This must be difficult for you, who do you live with?
P: We have a 3-year-old boy called Sam.
D: Has he ever been abusive to him?
P: No.
D: Has he ever abused you in front of him?
P: Yes.
Support
D: Have you tried to discuss this to anyone?
P: No.
D: What about any family or friends?
P: He prevents me from visiting anyone.
IMPACT
P: It’s ok.
D: On a scale from 1 to 10, with being the lowest and 10 being highest, can you
grade your mood?
P: 4.
D: Sometimes when someone is going through a difficult time, they may have
thoughts of hurting themselves, is that the case with you?
P: No.
D: How do you cope with all of this stress?
P: I just try to take care of my child.
D: I really appreciate that, you are a lovely and caring mother.
Husband:
D: What does your husband do for a living?
P: He is an accountant.
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P: 5 years.
P: Yes, 4 glasses of whiskey a day for the last 3 years.
D: What about smoking?
P: No.
P: No.
D: Does he has any financial problems?
P: No.
D: Does he have a criminal record?
P: No.
- EXAMINATION:
● My nurse colleague examines you and found a bruise on your wrist, may
I examine you too please?
● I would like to check your observations, do a general physical
examination and check your wrist: fingerprint bruise on the wrist.
- Explain
I am really sorry to hear about what you are going through. Domestic violence
is something taken quite seriously by the police. It’s a criminal offence and you
don’t deserve this, and you are being very brave by talking about it, I know it
wasn’t easy for you.
MANAGEMENT
- Offer support This is completely illegal you do not need to put up with
this.
- Offer talking therapy
- We would like to keep you in the hospital for a while to make sure
everything is fine with you.
- Call my senior to review your case, he has better experience with these
kinds of situations.
- Involve social services
There is a designated person in the hospital who deals with these issues we
can arrange a meeting with that person he will explain about the services
available to support you and your child. I know that your husband is not
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aggressive to Sam but witnessing what is happening to you can affect him
emotionally and psychologically also.
- Involve the police.

- Tell her about the national Domestic helpline number
- Direct her to someone who can offer her financial support
- Support by woman's aid group
- Refer to a sexual assault centre (SARCs)
NAI – Elderly abuse
Who you are: You are an FY2 in A&E.

Who the patient is: Mrs. Blake, aged 85, was brought to the hospital by her
daughter after having a fall. On examination there are multiple bruises of
different ages on her body. She has tenderness in her chest.
Additional notes: Patient is not available to talk, she has been sent for X-rays,
consent has been taken from the patient to talk to her daughter.
What you should do: Please talk to her daughter, Angela, and discuss your
further management plan with her.
- POSITIVE FINDING
● Daughter did not witness the injury. She was getting ready to go to work
changing clothes.
● PMH Mother has dementia, mother becoming forgetful, able to eat.
The condition is getting worse.
● {Find out who the usual caregiver is}. Daughter is the main caregiver.
● Daughter works in an office job, works long shifts, night shifts.
● Anyone else at home with them, has two children aged xx, xx
● Not receiving financial support or dementia nurse for mother.
● When it was noticed, rushed her to hospital straight away.
● No other problem causing fall, no other medical condition, heart
disease, blood pressure, DM, no problems with the eyes, no alcohol use,
no slippery floors, Inadequate lighting, unsecured mats, or rugs,
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Approach:
D: I understand from my notes that your mum had a fall, can you tell me more
about it?
P: I didn’t witness the fall itself, but I think she fell with the Zimmer frame.
When I realised it, I brought her immediately.
D: You did the right thing by bringing her, where were you at that moment?
P: I was watching TV.
D: What was she doing?
P: She was walking to her room.
Quick FALL QS (BEFORE – DURING – AFTER) + MAFTOSA
SOCIAL HX
D: Who normally takes care of your mother?
P: I am the only one who takes care of her. I help her with cleaning and eating
and support her financially.
D: You are a lovely daughter, your mum must be proud of you. Who else is at
home?
P: I live with my mum and my 2 children.
D: Does your mum walk independently?
P: She uses aids.
D: Does she need any help with bathing and dressing?
P: Yes, I always help her.
D: Who stays with her when you are away?
P: Just my children.
P: Sometimes I work as a cashier.
D: Do you feel you need any help with being the only carer?
P: It’s overwhelming especially when you are struggling financially.
D: I understand this must be difficult for you, do you smoke?
P: No.
P: No.
Elderly abuse questions:

D: I need to ask you some questions to understand what happened to your
mum exactly. We ask these questions in every elderly injury situation.
Has your mum had similar falls in the past?
P: No.
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D: I understand that taking care of an elderly person can be exhausting and

frustrating, and this can make people do things that are out of character. Has
such thing happened with you would you say?
p: I pushed my mum doctor.
D: OK I see. I am sorry about what you and your mum are going through. How
many times has this happened?
P: I can’t remember.
D: Other than pushing her, is there anything else you want to tell me? (Open
Q)
P: Sometimes I shout at her too.
EXAMINATION:
● A full examination was done of your mother and multiple bruises of
different ages have been identified.
● Ask the daughter if she has any idea why her mother has more than one
bruise of different ages on her body.
MANAGEMENT
- Admission
We would like to keep your mother to do some further testing like skeletal
survey to identify the reason for her multiple bruises
- Social services:
presence of multiple bruises on her body points toward the elderly abuse
- Tell her about the possibility of carers or referring to nursing home.
NAI – Scalded burn
Who you are: You are an FY2 in the GP clinic.

Who the patient is: Alicia, a 20-year old girl, came complaining of a scalded
burn on her tummy.
A nurse has seen the patient and has done the dressing.
What you should do: Talk to her and address her concerns.
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Approach:
D: I can see from my notes that you have burn on your tummy, how are you
right now?
P: I am ok.
D: I understand that this kind of burn must be very painful, do you want me to
give you some painkillers?
P: I am not in pain right now, thank you.
D: May I know what happened?
P: A kettle with hot water fell on my tummy.
D: I am really sorry about that, when did this happen?
p: 2 hours ago and I came immediately to the hospital. I am ok right now I want
to go home.
D: You can go home, but I’d like to ask you few questions before that if you
don’t mind?
P: OK
Offer confidentiality:
D: I can see that you are looking down. You do know that anything you tell me
will stay confidential between you and the medical team, don’t you?
P: I don’t want to go with this man.
Explore:
D: Which man?
P: He is outside. He is my boss.
D: What does he make you do?
P: He forces me to do bad things.
D: What do you mean by bad things?
P: He forces me to have sex with different men.
D: Who is he to you? Are you related?
P: No he’s just someone who has controlled me since I was young.
P: I live with other girls who are like me.
D: How many girls are there?
P: 3.
D: Are they in the same situation as you?
P: Yes.
D: Where are your parents?
P: They are not here, they are in Romania. That’s where I’m from.
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D: Do you have any relatives here?

P: No.
D: Have you tried to leave this man?
P: No, I’m scared, he will not allow me to leave. He’s dangerous.
D: Does he threaten you?
P: Always.
D: Did he throw the kettle water on you?
P: Yes.
- EXAMINATION:
● Is it OK with you if I do a physical examination and examine your tummy?
- Explain:
I want you to know that you are in a safe place right now, no one can harm you
here. What’s happening to you is illegal and we can help you to get out of this
if you let us.
- Management:
- Offer support:
This is illegal you do not need to put up with this.
- Admission:
We would like to keep you in the hospital for a while to make sure everything
is fine with you.
Senior
I will call my senior to review your case, he has better experience with these
kinds of situations.
- Call the Police: tell her about the national Domestic helpline number -
support by woman's aid group - refer to a sexual assault centre (SARCs)
- My colleague can also refer you to an organisation, (MARAC) a multi-agency

risk assessment conference, and they can support you financially by providing
you with housing and making a plan with you to make sure that you are safe.
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- You mentioned that you live with other girls we would like also to help them.
Can you tell us your home address?
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LGBTQ+
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LGBTQ+ CASES
Lesbian – Gay – Bisexual – Trans - Questioning/Queer +(more)
In all LGBTQ+ cases there are a few things you need to be aware of:
1) Understand that most of the LGBTQ community have had difficulties in

coming out to the world. They can feel lonely, isolated, and scared. This
can make them more prone to depression and they have higher suicide
rates than the rest of the population.
2) Never make them feel like you are being judgmental. Make them feel
safe when they are talking to you.
3) Always offer them support: LGBTQ+ groups and counselling sessions.
Always check the impact of being LGBTQ+ on their life:
• You must always ask about their mood, then score it, then depression,
then suicide.
• Drugs, alcohol abuse, recreational drugs and please ask about their main
concern early on.
• Ask if they are stressed and how they are coping?
• Sexual history and safe sex.
Some of these stations do not require a lot of medical intervention but you
need to offer support and empathy, then safety net them for abuse,
depression, and suicide.
Be friendly and make the patients feel that they are not alone and you are here
to help them.
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Lesbian Cervical Smear

Who you are:
You are an FY2 in the GP clinic.
Who the patient is:
Sally, aged 25 years old, has come to you with some concerns. She has been
invited for cervical screening.
What you should do:
Approach
In this station there are a few things you need to keep in mind:
1) What is her main concern? Does she not want the cervical smear? Or is
she asking why she received an invitation through the mail?
2) If she is refusing it, then why? Has she had it before? Was it painful? Any
problems with the previous smear?
3) What does she know about the smear? Why do we do it? She could have
a misconception about it like a lot of people do.
Pap smear is a test done to screen for early changes or abnormalities in the
cervix that can later lead to cancer. It also screens for HPV which is the main
risk factor for cervical cancer. Here comes the conflict as she believes being a
lesbian means you are not prone to get HPV, which is more commonly
transferred via having penetrative sex with a male. This however is not true, as
with other sexually transmitted infections, HPV is passed on through body
fluids and therefore can also be transmitted through lesbian intercourse
History:
1) Period
2) Abnormal vaginal bleeding
3) FLAWS
4) Smoking
5) Family history of cervical cancer
Then you need to convince her that despite being lesbian, she is still prone to
sexually transmitted infections. HPV may be passed on from woman to woman
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through kissing, oral sex, fingering, sharing sex toys or genital-to-genital

contact.
Remember: You can’t force her to take the test. You are just offering.
Contraindication of speculum:
- Patient refusal
- Forensic investigations
Contraindication of cervical smear:
- Same as speculum +
- Active vaginal bleeding
- Active menstruation
- Pregnancy
- Recent sexual intercourse
- Recent use of spermicidal gel
Scenario
Doctor: How can I help you today?
Patient: I am very angry and wondering why you invited me for a cervical
smear, I think you sent me the letter by mistake.
D: I can see that you are upset about that, may I know why?
P: Because I told the last doctor I saw that I am a lesbian and I don’t need this.
D: OK can I ask you few questions to understand why you were invited for the
smear?
P: OK.
D: Have you had a cervical smear before?
P: No.
D: How old are you?
P: 25.
D: I see, all 25-year-olds get asked to begin having smear tests by their GP,
that’s why you received the letter. How much do you know about it?
P: I just know that lesbians don’t need to do it.
D: OK, why do you think that?
P: Because you can only get Human Papilloma Virus from a man.
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D: I’m afraid you are mistaken, that’s not true. HPV, like any sexually
transmitted infection is passed through an exchange of bodily fluids, therefore
it can be passed on in lesbian sexual relationships also.
SEXUAL history:
D: Is it OK if I ask you a few private questions to see how much you are at risk?
P: OK.
D: Are you in a sexual relationship at the moment?
P: Yes, I have a girlfriend.
D: Have you had previous sexual relationships from before you were with her?
P: Yes.
D: Has she had previous sexual relationships from before she was with you?
P: Yes. But we have both only been with women.
D: I’m afraid that doesn’t matter. Just the fact that you have both been with
other people, regardless of their gender, it is enough to put you both at risk of
HPV. Have you been tested for any STIs before?
P: No.
D: What about your partner?
P: I don’t know.
D: Have you ever had the HPV vaccine?
P: No.
P4
D: Any abnormality with your periods?
P: No.
D: Any abnormal or irregular bleeding?
P: No.
Risk factors:
D: Do you smoke?
P: No.
D: Any family history of any conditions to do with the cervix or breasts?
P: No.
MAFTOSA
Explaining cervical smear:

Let me explain to you what a cervical smear is. It’s a test done to screen for
early changes in the cervix (neck of your womb) that can later on lead to
cervical cancer. As you know, it also screens for an infection called HPV which
is the main risk factor for cervical cancer.
It's offered to all women who are sexually active or have been sexually active:
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-from 25 to 49 years old every 3 years.

-from 50 to 64 years old every 5 years.
Anyone can have cancer without symptoms.
You were sent the invitation because of your age.
During cervical smear:

They'll gently put a smooth, tube-shaped tool (a speculum) into your vagina. A
small amount of lubricant may be used. The nurse will open the speculum so
they can see your cervix. Using a soft brush, they'll take a small sample of cells
from your cervix. It’ll all be over within a couple of minutes and you can bring
your girlfriend with you if you prefer.
P: What will happen if you find any abnormality?

D: We will use a special microscope to take a look at the abnormal cells in a
better way. This is called a Colposcopy.
P: My girlfriend is 24.5 can she get tested?
D: She can get tested in 6 months when she is 25. We don’t advise women
under 25 to get tested yet as sometimes under 25s can have cervical cell
changes that may flag up as abnormalities in a smear test. However, we have
found that if left without treatment, these changes can go away on their own
in that age group. So, if we tested under 25s we would end up treating a lot of
them unnecessarily. But please, do advise her to come as soon as she is 25.
Offer leaflets.
Practice safe sex: Always wash and put condoms on sex toys. Visit sexual
health clinic on a regular basis to be tested for STIs.
Safety netting: Please come back to us or visit a sexual health clinic if

experiencing abnormal discharge, bleeding in between periods or pain in your
abdomen when having sex.
Lesbian being bullied

Who you are:
Who the patient is:
Alice Bonar has come to the GP clinic with some concerns.
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What you should do:

Talk to the patient, take history and address her concerns.
Presentation:
I. “I have been having panic attacks recently.”
Please, do not just take her words as an accurate diagnosis, you are a
doctor, you need to diagnose what she has by asking her questions.
Tell me more about these panic attacks? What happens? What do you
feel when you have them?
SOB? Heart racing? Chest pain?
All of this can be an actual cardiac problem you must first exclude
that.
II. “I want to leave my work.”
DON’T FORGET TO CHECK:

- Mood?
- Suicidal thoughts?
- Drugs and alcohol?
Remember, panic attack is a diagnosis by exclusion, which means you need to

exclude all other causes through history, examination and investigation.
• Explore the pain (SOCRATES)

• Check for risk factor
• Exclude PE
• Trauma
• Order an ECG, serum cholesterol and FBC.
If everything comes back normal, then we are suspecting it is a panic attack.

This is how you can be a safe doctor.
The panic attack:
- Is there anything specific that comes to your mind that triggers it?
- When do you usually have them? Where? How often? When was the last
one?
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- At work, what happens there?

Her colleagues are talking about her after they found out that she is a
lesbian and it makes her uncomfortable.
- Show empathy and reflect on it. Ask her how has it affected her life? Her
relationship with her colleagues and partner?
- Tell her that it is completely unacceptable and even illegal to
discriminate or bully anyone based on their sexual preference and that
you are sorry this is happening to her.
- Advise her to talk to her HR department and her supervisor to take
actions against whoever is bullying/harassing her.
Scenario:
P: Well doctor I have been working in a company as a part of the IT team and I
really enjoy and love my work, but recently there are two new employees who
annoy me and comment on my sexuality because I am lesbian.
D: I am really sorry to hear that. You shouldn’t be treated like that by anyone
for any reason.
ABUSE:
D: What kind of things they say about you?
P: Just bad things about being a lesbian and making fun of me..
D: Have they hurt you physically?
P: No.
D: Have they insulted you?
P: Not directly to my face.
D: Have you tried talking to them about how it makes you feel when they
gossip about you?
P: No, I’m worried about causing an atmosphere.
D: Have you talked to anyone about it?
P: No.
D: Have you thought of talking to your manager about it?
P: No.
D: What prevents you from talking to your manager?
P: I am not a kid to ask for help I can handle it myself.
D: I can understand that but asking for help doesn’t mean that you are a kid.
This is obviously affecting you and your manager should care about that.
Relationship
D: Do you mind telling me if you are in a relationship at the moment.
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P: Yes, I have a girlfriend.

D: And how is everything between you and your partner?
P: Everything is fine.
D: Have you talked to her about what are you facing?
P: No, I don’t want to upset her.
D: Is your family supporting you?
P: Yes.
IMPACT:
D: How has your mood been?
P: I feel depressed.
D: Can you score your mood on a scale of 1-10 for me, with 1 being very low
and 10 being very happy?
P: 4.
D: When a person is under stress or depressed, they might drink or smoke
more than usual, has that been the case with you?
P: I started to drink wine more, I feel it helps me.
P: No.
D: How is this affecting your life?
P: It made me hate going to work.
D: Do you sleep well?
P: Yes.
D: What about your appetite?
P: It’s fine.
D: Are you missing work days because of it?
P: No, I still go in despite how I feel.
P: It’s ok.
D: Have you had thoughts of hurting yourself or others?
P: No.
D: Is there anything else concerning you?
P: No.
Management
- Tell her to inform her manager about this as bullying in the workplace is
illegal. She has the right to complain about that.
- Offer support groups for example, LGBTQ foundation, Mindout, Stonewall.
- Offer to refer her for counselling sessions.
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- Advise her to reduce the amount of wine she is drinking as it will not help her.
Safety-net about mood and suicidal thoughts.
Manage the panic attack:
- Find a calm place, close your eyes and breathe deeply and slowly maybe
through a bag.
- Try to think of a calm, nice place and imagine yourself there.
- Remind yourself that this feeling is only temporary, and it will pass.
- Talk to your friends or partner about it.
- Meditation and exercise.
- CBT if she needs it.
- If all doesn’t work then antidepressant medication may be considered.
Homosexual teenager
Who you are:
Who the patient is:
Jake, aged 15, has come to the clinic with some concerns.
What you should do
Talk to the patient, take relevant history and address his concerns.
There’s a difference between homosexuality and transgender:

- Homosexuality is a sexual preference which refers to the type of person you
are attracted to. It’s normal to be attracted to people of the same gender as you.
So DON’T SAY it is ‘a condition’ or ‘a problem.’
- Transgender means the patient feels that they were born in the wrong gender.
For example, a male who feels like he is a female on the inside, or vice versa.
- A lot of transgender teenagers/adults may or may not have had gender
dysphoria when they were young children.
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- Gender dysphoria is when a person, usually a child, may have a sense of

unease because of a perceived mismatch between their biological sex and their
gender identity.
- However, not all children who have gender dysphoria will grow up to be
transgender people. The NHS website explains:
“A diagnosis of gender dysphoria in childhood is rare.
Most children who seem confused about their gender identity when young will
not continue to feel the same way beyond puberty.” NHS website.
Approach:
This is a talking station so listen to the patient, adjust your posture and tone of
voice;
a. Be supportive.
b. Explore his feelings.
c. Exclude abuse and suicidal thoughts.
d. No need for medical assessment at all.
e. Safety net, safeguard and advise the teenager.
Scenario
Patient: It’s embarrassing doctor.
D: Don’t feel embarrassed please, I am here to help and anything you say to
me is confidential.
EXPLORE:
P: I have feelings for one of my male classmates.
D: Thank you for opening up to me. I will do my best to help you. Can you tell
me more about it?
P: I have been having these feelings for the past 6 months.
D: What kind of feelings?
P: Feelings of love.
D: How old is he?
P: He is 16.
D: OK so what is the problem?
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P: I want to speak to him but I’m afraid because one of the boys in school came
out as gay and he was bullied after that, and I don’t want that to happen to
me.
D: I am sorry to hear that.
MCFAMISH
D: Have you talked to anyone else about how you feel? (SUPPPORT)
P: No.
D: What about your family?
P: I haven’t told them. They will not accept it, they are religious.
D: Would you feel in danger if they found out?
P: No, but they just wouldn’t be happy.
P: It’s fine.
D: On a scale from 1 to 10, with one being the lowest mood and 10 being the
happiest, can you score it for me?
P: 6.
D: Sometimes, when a person feels upset they might have thoughts of hurting
themselves or others, has this been the case with you?
P: No.
P: Nothing like that
P: No.
D: How is your studying going?
P: It’s fine.
D: Is this affecting your sleep or appetite?
P: No doctor but I am just stressed.
SEXUAL Hx
D: Do you mind telling me if you are sexually active?
P: No.
Concern:
P: I just want to know what’s wrong with me?
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D: Let me assure you, there’s nothing wrong with you, you are just having a
crush on someone. It’s totally normal. There is no wrong or right when it
comes to sexuality. It’s like a journey of self-discovery. With time you will learn
more about yourself and what makes you happy.
D: Do you think I should tell him about my feelings?

P: Well, coming out is a big decision so take your time. You are still young and
have plenty of time for that so what’s the rush? Try to focus on yourself and
your studies and have positive people around you that you can talk to. You
could become friends with your crush and then in time, if he feels the same
way it will become clear to you.
Management:
- Offer support groups.
- Offer counselling sessions.
- Don’t be pressurised into any sexual activity.
- If sexually active already advise on safe sex.
Safety-net about mood and suicide.
Transgender
Who you are:
Who the patient is:
Gary, aged 16, has come to you with some concerns.
What you should do:
Talk to the patient, take relevant history and address her concerns.
Again, transgender is completely different from sexual preference.

A transgender person is confused about his/her gender identity. They feel
trapped inside the body of a man while being a woman or vice versa.
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➢ The NHS definition: a term that describes a sense of unease that a person
may have because of a mismatch between their biological sex and their gender
identity. This sense of unease or dissatisfaction may be so intense it can lead to
depression and anxiety and have a harmful impact on daily life.
➢ They can still be straight, gay, or bisexual despite being a transperson.
➢ The transperson is someone who is having severe stress and discomfort all the
time as they feel trapped inside the wrong body so they are more prone to
depression, suicide and drug abuse. By drug abuse I mean taking non-prescribed
hormones (usually purchased online) which can endanger their lives. Please be
very compassionate and careful to safety-net them and help them to avoid
making any decisions that can eventually harm them.
➢ How will you know that the person in front of you is transgender in the exam:
-He/she will tell you a name that doesn’t appear to match their gender.
-Or it will be a person who will tell you when you ask “how can I help you” that
he/she has been feeling trapped in the wrong body all their life and wants to
change to the opposite sex.
Scenario
Patient: Doctor I want to change my sex I want to be a female.
D: I really appreciate how difficult it must be to share that with someone who
is a stranger, so you are very brave in doing that. I will do everything I can to
help you. How long have you felt this way?
P: For the past 6 months.
D: So you are biologically a boy but you consider yourself a girl on the inside?
P: Yes.
Family and support groups:

D: Have you talked to anyone about your feelings?
P: No.
D: What about any close family member or friend?
P: I haven’t told anyone.
D: Do you feel that you won’t be supported?
P: I don’t know, I just don’t feel ready?
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D: Are you a part of any LGBTQ support groups?

P: Yes there are some Twitter groups online.
D: So, do you have any transgender friends?
P: I have some yes.
Impact:
D: How is your mood recently?
P: it’s OK.
D: On a scale from 1 to 10, with 1 being the lowest and 10 being the happiest,
can you score it for me?
P: 7.
D: Do you smoke?
P: No.
P: No, I don’t drink alcohol.
D: Sometimes, when a person feels upset they might have thoughts of hurting
themselves or others, has this been the case with you?
P: No.
D: Have you thought of hurting yourself or others?
P: No.
D: Have you faced any type of discrimination or abuse?
P: No.
D: Have you started living as a female?
P: Not yet.
D: Are you studying at the moment?
P: Yes.
D: How are your studies going?
P: Fine.
Sexual history:
D: Do you mind telling me if you are sexually active?
P: No, I’m not.
MAFTOSA
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P: No.
P: No.
ICE
From the chat we had it appears that you may be experiencing gender
dysphoria. This is when a person feels like they are born in the wrong gender.
However, you haven’t always felt like this, you said you have only felt this for
the last 6 months so I can’t be sure. And I would not be able to diagnose you
after just one short conversation with me.
The best thing is for me to do is to refer you to a specialist in a Gender Identity
clinic who will go into more depth and detail with you about your feelings and
get to the bottom of why you feel like this. After they analyse you if they find
that you do have gender dysphoria, they will discuss your options with you.
Management:
- Refer to gender dysphoria clinic (above 18) or Gender identity development
service (below 18)
• Where they have a team of doctors in multiple specialties
(psychologists, endocrinologist, surgeons and therapists) who will assess
you and develop a plan with you to help you in the best way suitable to
you in order to make you feel more comfortable and at ease with your
identity. You are not alone, we are with you and will help you.
• Treatment will include:

a- medications
b- surgery
c- speech &language therapy: to help you develop an appropriate
sounding voice for your gender.
• The time till the referral can take some time which is because there are
a lot of people going through what you are going through, that is why
there is a big waiting list.
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If below 18:
In the meantime, till you get your first appointment, how about I refer you to
children and young people mental health service (CYPMHC) where they will
support you and give you all the psychological support you need to feel at ease
until your appointment.
If 18 and above:
How about I refer you to one of our specialised counsellors who can help you
and support you to be more at ease till your appointment so you do not have
to go through this alone?
- Advice:
- Stop smoking if you smoke.
- Lose weight if you are overweight as it can cause some hormonal
disturbances.
- Please do not self-medicate, you do not know what you're being sold,
and you could harm yourself without regular monitoring. Hormones
may also affect your future fertility.
- Practice safe sex if you are sexually active.
- Talk to your parents.
- Social transitioning (Live in your preferred gender):

This is an important part of managing gender dysphoria at home, work and
socially.
- You would need to do this before you can have gender surgery. Gender
dysphoria clinics need to know the changes you want to make in your
social role will improve your life and be sustainable over time, so that
they can help you with this process. You might want to start wearing
clothes of the opposite sex or unisex clothes.
- You can also change your name by deed poll which you can do for free
then use that to change your name in your passport, ID and official
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documents. Your GP can change your name on your medical records, as

well as noting your preferred pronouns on the system.
Safety netting:
- Be careful of taking un-prescribed hormones because even with the

prescribed hormones there are multiple risks of blood clots, weight gain, acne,
increased liver enzymes and hair loss. It needs tight lifelong monitoring so if
you do take it on your own, you will be endangering your life.
- If you ever feel lonely or depressed or the want to harm yourself, please call
us or come to the clinic. We are always more than happy to help you and
support you.
UTI in a Transgender
Who are you:
Who the patient is:
28 year old transman with the birth name of Samantha Mason who now goes
by Peter Mason has come to see you with some urinary symptoms.
What you should do:
Talk to the patient, take relevant history and address his concerns.
Approach
From the beginning of the station, the patient tells you to call he/him with a
name different than their apparent gender or their name in the scenario then
you will understand that he/she is a transgender. In this case, you can add a
question here:
I understand you are transitioning, but do you still have your periods?
(If a female transitioning to a male) by any chance, can you be pregnant?
Do you practice safe sex?
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If the patient did not give you any clues from the beginning that he/she is
transitioning then continue normally as a UTI case then in the past medical
history do the following:
• Medical conditions?
• Medications including over the counter or supplements?
Here he/she can tell you ‘’ I am taking testosterone or estrogen’’ may
I ask you why? ‘’ I am transitioning ‘’ and how far are you in the
transition process? And were these medications prescribed or
did you have your gender identity clinic yet?
• Afterwards, check mood.
how are you coping?
any stresses? Any abuse? Are you satisfied with the transitioning
Risk factors for UTI in transgender:
You do not necessarily have to ask these, but know them for your own
knowledge.
1) Transgender women (biologically male) tend to tuck in their penises in

female underwear which makes them more prone to infection.
2) Transgender men (biologically female) use testosterone which causes

vaginal dryness and can predispose them to all kinds of infection.
3) Both of them tend to hold their urine because they cannot easily find a
suitable bathroom (unisex or mixed bathroom) which also increases
likelihood of UTI.
History:
• Pain? Frequency? Change in the colour or smell or urine?
• Fever?
• Blood in urine?
• Tummy pain?
• When was the last time you passed urine?
• Concern?
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P1: (ODIPARA)
Doctor: how can I help you?
Patient: I have a burning sensation.
D: Tell me more about that?
P: It burns when I pee.
D: Is it all the time or it comes and goes?
P: All the time.
D: Is there anything that makes it better or worse?
P: No.
D: Anything else?
P: I don’t think so.
D: Any pain anywhere else?
P: No.
D: Any fever?
P: I haven’t measure it but I feel warm.
D: Any change in colour of your urine?
P: No.
D: Any blood in your urine?
P: No.
D: Any tummy pain?
P: No.
D: When was the last time you passed urine?
P: This morning.
D: Anything else concerning you?
P: No.
P2:
D: Have you had this condition before?
P: No.
P: No.
MAFTOSA+ Sexual Hx:

P: I am taking testosterone.
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P: I have been taking it for the past 3 months as I am transitioning.
D: Who prescribed it to you?
P: The doctor, and I am taking it as prescribed.
D: Are you happy with the transitioning process?
P: Yes.
D: Have you had any top or bottom surgery for it?
P: Not yet.
D: Are you facing any problems with transitioning?
P: it’s just embarrassing to go to a public toilet so I hold my urine in when I am
not home.
D: Do you feel supported by your loved ones?
P: Yes
P: No.
P: It’s fine.
ICE
Examination:
• Observations: Temp 38
• Tummy
• Urine dipstick test- to be done straight away and preferably sample
should be taken midstream.
Diagnosis:
From the chat we had, you told me you have a burning sensation while passing
urine and your urine dipstick test has come back positive, so it looks like you
have a urinary tract infection, possibly from holding in your urine when you
are out.
It is not dangerous, but we need to treat it before it gets worse or potentially
spreads to your kidneys.
Treatment:
• Investigations:
- urine sample+/- culture
- FBC
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- RFT
• Medications:
Nitrofurantoin 100 mg BD or 50mh QD
• Advice:
Drink plenty of water, do not hold in your urine.
• Support:
Give lots of emotional support.
• Safety net
Persistence of the symptoms and mood
Headache and nosebleed in a transgender person

Who you are:
You are fy2 in the GP clinic.
Who the patient is:
Criss Smalling is a 21-year-old male who made an appointment to see you.
What you should do:
- This is a female transitioning to a male using testosterone which

increased his/her blood pressure and causes headache and epistaxis.
- If you find in the examination that his BP is high, please refer him
immediately to the hospital. And if you are in the hospital, keep him under
observation for a while.
History:
- Headache, blurring of vision (increased blood pressure)

- Hx of epistaxis
- When you ask about medications (explore) “I am taking testosterone”.
Why? “I am transitioning”. Was it prescribed? “No”.
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Please in the examination do not forget to examine the nose, measure blood
pressure, and listen to the heart and lungs.
P1: (ODIPARA)
P: I keep having nosebleeds.
D: Tell me more about it?
P: It happened 5 times in the last week.
P: No.
D: Anything else?
P: Yes, I have a headache all the time.
D: Can you describe your headache for me?
P: It started 3 weeks ago and it’s all over my head and I took paracetamol for it
but it didn’t improve.
D: Anything else?
p: No.
D: Anything concerning you?
P: No.
Differentials:
D: Any bleeding from anywhere else?
P: No.
D: Have you sustained any trauma to your nose?
P: No.
D: Any nose picking?
P: No.
D: Would you describe this headache as the worst headache of your life?
P: No.
D: Any fever?
P: No.
P2:
D: Have you had this condition before?
P: No.
P: No.
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MAFTOSA+ Sexual Hx:

P: I am taking testosterone.
P: I have been taking it for the past 4 months as I want to be a male.
D: Who prescribed it to you?
P: I wanted to go to the gender identity clinic but it takes a lot of time so I
bought it online and started taking it.
D: And how long have you been taking it?
P: For the past 10 days.
D: Have you noticed any changes ?
P: Yes, my voice started to be deeper and I am really happy with that.
D: Are you facing any problems while transitioning?
P: No I am OK.
D: Any other problems?
D: Do you feel supported by your loved ones?
P: Yes.
P: No.
P: It’s fine.
ICE
Examination:
• Observations: BP 170/100
• Nose
• Neurological
Diagnosis:
From the chat we had, you told me that you have bleeding from your nose, a
headache and you are taking testosterone also, I believe this must be a side
effect from the medication.
Management:
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- We will refer you immediately to the hospital to monitor your blood

pressure and according to the level of your blood pressure we might
need to give you some antihypertensive medications.
- Painkillers for the headache.
- Advice regarding how to stop a nose bleed: lean forward, close one
nostril with your finger for 30 seconds then shift. If the bleeding does
not stop in 15 minutes, go to the nearest hospital.
D: Can you please consider stopping the testosterone for now?
P: No doctor this will postpone my transitioning?

D: I appreciate that, but this can cause you to have a heart attack, stroke or
even death. Surely it’s not worth risking your life.
P: Can you help me to get an appointment faster in the gender identity clinic?
D: I will do my best to speed up your appointment.
- Arrange a follow-up
- Safety-net
Lesbian conception counselling

Who you are:
Who the patient is:
Samantha, aged 25, has come to you with some concerns regarding her wishes
to have a baby.
What you should do:
Talk to the patient, take history and address her concerns.
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Firstly, this is a happy station, one of a very few in PLAB2, so you need to look
happy and to congratulate your patient on taking such an exciting step forward
in building her/his family.
Second, you need to be aware that there are many options for a lesbian/gay
person to have a child and the station is only 8 minutes so you need to find out
which category of options suits your patient more and start addressing it.
There are two main categories:
▪ Do you want the baby to be related to you or your partner genetically

or not?
▪ Do you or your partner want to be pregnant or not?
1) Having a baby genetically related to you:
- Donor insemination:
It involves having a donated sperm from a male to fertilise an ovum from you.
Then:
- Artificial insemination:
Intrauterine Insemination (IUI)- It involves injecting the donated sperm
directly into the womb. The source of the sperm can be a friend you choose
or via anonymous donors from a fertility clinic.
It can be done at home (using a friend’s sperm) or in the fertility clinic “see
legal parenthood regulations below”.
It is best recommended to be done in a fertility clinic as the sperm will be

‘washed’, concentrated and screened for any STI with higher chances of
success, but it will not be covered by the NHS (a same sex couple need to try 6
times via private fertility clinic till they are eligible for an NHS covered IUI)
2) Having the baby genetically related to you, but you or your partner does not
want to become pregnant:
Surrogacy- Having your fertilised ovum injected into the womb of another
woman who will be pregnant with your baby but won’t have parental right to
the baby.
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It should be done via Surrogacy UK who will arrange a proper match and
arrange the whole journey and supervise it.
3) Having a baby not genetically related to you:

1) Adoption: you and your partner can apply to adopt a child who will take
your name and you will be his legal parents permanently.
2) Fostering: you will take care of a child temporarily and will not be his
permanent legal parents.
4) Co-parenting:
Two persons or two couples work together to raise a child and all share
parental rights and custody of the child.
Legal aspects of parenthood in case of IUI:
1) For couples who are married or in a civil relationship:

If a baby is conceived in a UK licensed fertility clinic or at home then
the non-birth mother will automatically be the second legal parent
and will be named as such on the birth certificate. The donor will have
no legal parental rights.
2) For couples who are not married or in a civil relationship:
If IUI is done in a UK-licensed fertility clinic, they will need to complete
a form in the clinic for the non-birth mother to be the second legal
parent.
If not done in a UK-licensed clinic, the non-birth mother will need to
apply to adopt the child to be the second legal parent.
Now, back to the station, after you have figured out which way, she wants to
have the baby. Genetically related or not? Get pregnant or not?
Take history of both partners or of the present partner and ask her to invite
the other partner to another appointment:
Past medical history
• Any medical conditions?
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• Any problems related to your womb?

• Ever been pregnant before?
• Have you tried in any way to get pregnant?
• Is there any specific reason you want to get pregnant now?
• Any children?
• Have you ever been diagnosed with any STI?
• Have you ever been screened for STI?
P4
• Period
• Pills
• Pap smear
MAFTOSA + DESA
• Medications?
• Family history of any medical conditions (very important especially if the
child will be genetically related to her)?
• Occupation?
• How are you managing financially?
• How are things at home?
• Smoking?
• Alcohol?
Then continue the normal structure:

Examination: observations, tummy and speculum.
Investigations: US, STI screening, FBC, LFT etc.
Afterwards, tell her the options that suit her preferences and her situation as
mentioned above.
See also: -
P.E in a Transgender person: Cardiovascular chapter
Lesbian-Depressed: Psychiatry chapter
UTI in transgender: Urology chapter
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COUNSELLING
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Counselling
Counselling structure
Remember this piece of advice before starting counselling stations ☺ :

• You don’t need to take a very long hx depending on the case. Sometimes
it’s already diagnosed.
• When you think about hx remember these three things:
− Analyse the main complaint.
− Explore complications Sx.
− Explore Risk factors.
− DESAS (Diet—Exercise – Smoking – Alcohol -- Stress) V. Important
• Always Always Always explore ICE : (Ideas ---- Concerns ---

expectations of the patient) in depth and more than once. V. Important
− If you miss or forget to address the patient’s main concern or
expectation, that’s a lot of marks gone with the wind, really
simple and helpful Qs yet you forget them.
What a shame !! .
• Management
− Counselling stations are (2/3) management and (1/3) history, you
will not lose much by cutting hx a bit short but BAD
MANAGEMENT is definitely a huge loss, so be smart.
− Follow a structure.
− Don’t force the patient and advise about lifestyle modifications as
suggestions and options rather than making it sound as
obligations or orders.
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− Involve the patient and check understanding; ask about his

preferences and whether he can or cannot do this and that, and
how he feels about all of it.
− Be empathetic with body language and tone of voice.
− You can show a lot of IPS with good management presentation
and these are valuable marks that you will definitely need.
History taking:
Follow our usual structure with some considerations.

❖ Introducing yourself and starting the station:
Counselling stations may be a first presentation or follow up of a patient with

some concerns, so always read the case notes thoroughly and use them. Be
aware of whether it’s a phone/video consultation or a GP appointment. Do
not start all with the same “How can I help you?!” it’s not always the best
start. USE YOUR CASE NOTES.
However, phone and video consultations more or less have the same start,
you will need to confirm 5 things:
1. Full name.
2. date of birth.
3. First line of your address.
4. Whether it’s a suitable time to talk now or you should call later.
5. If the line gets interrupted how to approach them again. (eg, If this line
fails can I call you back on the same line?)
❖ P1: Depending on the complaint and the case notes

− Open Qs, then the current complain by ODIPARA or SOCRATES.
− Associated Symptoms: will need to exclude red flags and
complications.
❖ DDx:
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− No need to go in depth if follow up and diagnosis is already given.

Otherwise, two or three Qs maximum.
❖ ICE
• Very important to ask in every case, it’s guaranteed that you will
find something.
❖ P2 (Past Hx )
− Medical Conditions: One of the core concepts of any counselling
station is to ANALYSE THE CONDITION he has VERY THOROUGHLY.
(Will be discussed with each case)
• The main common points to explore are:

o What is it?
o For how long?
o How is it controlled? +/- the last time measured it?
(blood pressure or RBG)
o Medications:
- What type of meds?
- What dose?
- Are they taken regularly as prescribed?
- When was the last time?
- Any problems with them?
o Compliance with follow ups +/- if not compliant then
explore why?
o Complications red flags (may ask earlier)
• Remember the PAN of medical conditions, 5 main medical

conditions that can be controlled by DESAS
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− Previous similar complaints

− Previous Hospitalisations ( or surgeries; if relevant)
(DESA & MAFTOSA are very important in counselling stations, you
need to advise regarding this in the management part)
❖ MAFTOSA
(Medications – Allergies – Family Hx—Travel—Occupation—Social
and Mood—anything else)
− Same as in previous structures
− Remember you asked about the medications once before
and there might still be a chance that the patient is
taking other medications too, so ask about “Any
(OTHER) meds apart from those mentioned!”
− Always use the term Medications don’t use the term
Drugs
− Occupation and psychosocial may be integral in your
structure here.
❖ DESAS: (Diet—Exercise – Smoking – Alcohol – Stress)

− Sometimes you will have to explore with one or two more Qs about
types of food and degree of physical activity , be smart don’t
overdo it so you don’t waste too much time, but yet again don’t
miss the important points.
− Use open Qs such as, “Can you tell me about your diet?”, “Does it
include a lot of microwavable food/fast-food?” , “ Do you eat
enough vegetables and fruit ?
− In these particular stations, you can ask DESAS here as a whole,
then start managing them later or delay and ask one by one in
management while addressing each as you go. It depends on how
the station is going and how much time is left. (Through practice
you will adopt your best approach)
− Smoking and Alcohol Qs: What type? How much? For how long?
Examination: as previous structures with special concern over the organs

affected.
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Management:
For counselling In all these stations, your management is talking about (DESA)
or Lifestyle modifications, and what other steps in terms of investigations or
treatment options may be needed.
Follow the ARMMS structure for counselling.
A: general Advice
R: Risk Factors management
M: Management (Investigations and Medications) u can involve senior
here
M: Multi-disciplinary team (or and referral needed)
S: Safety netting
An example of how management in any counselling station should go:
❖ Advice and risk factors:
Is it ok , if we discuss some lifestyle modifications , things that you should

do in order to decrease the risk of having ………….?
❖ One important factor is DIET , can you tell me what type of food you eat?
> Well, the kind of food that you are eating is very high in fat content
which contributes to …….
1. Eat more white meat like chicken and fish and cut down on red
meat. 2 portions of fish a week.
2. Use olive oil instead of butter.
3. Plenty of fruit and vegetables.
4. Eat 2 out of 5 portions a day (2 portions of fruit a day).
5. Drink plenty of fluids.
6. Reduce the amount of salt in your food as it ↑↑ your blood pressure.
> How does that sound? Am I making sense so far? (Remember to
assess patient’s understanding, involve him in a wonderful
patient-centered discussion)
> I can also refer you to a dietitian who can help you with that if you
would like.
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❖ Another important risk factor is EXERCISE, do you do any form of

exercise?
I totally understand how difficult it to stick to doing some kind of exercise;
however, it’s very important to improve your condition, so I highly advise
you to:
1. At least start by walking inside your house.
2. Then, start doing some exercise like brisk walking for 30 minutes a
day for 5 days a week.
Would that be ok with you ? Patient might say he doesn’t have time
for it.
➢ Well , I totally see where you are coming from, but:
3. You could invest in a treadmill (maybe a secondhand one) and use it
for at least 30 minutes a day while you are watching your favourite
program or listening to your favorite music . How does that sound?
4. You can also try parking a few blocks further from your workplace
and walk the remaining distance? Would you consider that?
❖ You mentioned that you smoke?
Well, SMOKING is not good for your health as I’m sure you know; it
damages the blood vessels and can increase your BP, causes cancer and
other health problems. I strongly advise you to stop smoking and we can
help you with that whenever you are ready to do so.
1. There are nicotine replacement products - including patches, gum.
lozenges and mouth and nasal sprays.
2. We can also provide you with some tablets (varenicline and
(bupropion) that can help you with bothering Sx.
3. We can refer you to a smoking cessation clinic as well. There some
support groups that can help encourage you as well.
❖ Patient might say I have a lot of stress in my life that’s why I smoke.
I can understand how stressful life can get; however, we can suggest other
ways to blow off some steam.
1. Why don’t you take some Yoga classes or relaxation classes, CBT?
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2. When you are ready to quit, we can refer you to smoking cessation
clinics where you can be offered medications to help you.
3. We can suggest some support groups where you can talk to people
who are on the same journey as you for advice and support.
❖ You also mentioned you drink ALCOHOL ?

Too much Alcohol can be bad for your liver and health in general, so I
strongly recommend that you should drink within the recommended limit
which is 14 units a week with a maximum of 2-3 units a day.
Am I making sense? How does that sound? Do you agree with me?
The reason I have been giving you a lot of instructions , is because we care
about you and if we manage to co-operate together and if you can follow
the advice , the risk of you having ……… will significantly decrease. Are you
following me?
NB: Always reflect upon what the patient has to say, show empathy, and offer
solutions in the form of options to help. Address what the patient has as risk
factors don’t discuss everything otherwise you will sound robotic and scripted.
❖ M: Investigations & Medications: based on each case.
❖ M: MDT and other referrals if needed.
❖ Safety net: Whenever needed depending on each station. Maybe stroke,
angina, DM renal, eye, heart, and foot complications, seizures … etc
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DIABETES MELLITUS COUNSELLING STATIONS

Key points:
1- You must take diabetic history:
• Since when have you been diagnosed?
• How is your diabetes managed?
• Do you take any medication for it? If yes (what medication? /what
dosage? /do you take it as prescribed?)
• Is it well controlled or not?
• Do you measure it, when was the last time? What was the reading.
• Do you go for your regular follow-ups? / do you review your medication
with your GP?
• Do you have any complications
− problem with your vision
− pain while passing urine (UTI)
− chest pain or problems with your heart
− numbness or tingling in your hands or feet (Neuropathy)
2- In all cases of DM you must mention the PAN (cholesterol/ DM/ HTN/
thyroid problem/ strokes or mini strokes)
3- Management of DM : ARMMS
− Advice
− Risk factors (DESA) as above
− Medication + investigations ( blood : FBC/ RBS/ hb A1c/ LFT/ KFT/
cholesterol level)
− MDT : multidisciplinary team : Diabetic clinic referral ( where podiatrist/
heart specialist/ kidney specialist/ eye specialist)
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DIABETIC REVIEW
Who you are: You are an F2 in GP Surgery.

Who the patient is: Jon Mendes, a 52 year old male, has been diagnosed with
type 1 DM since 14 years of age, he came to GP 4 months ago and he was
given insulin for a month and he never came back again.
Additional information: Urine test has been done and shows ++ glucose and +
protein. The patient has been seen by an optician. Fundoscopy has been done
and showed dots and blots. The plan is to refer the patient to ophthalmologist.
His prescription was one month old.
Special note: Examination has been done by nurse. He has loss of fine
sensation and pain below ankle bilaterally.
What you should do: Talk to the patient about diabetes control and discuss
initial management plan. Please don’t examine the patient.

clinic. Am I talking to Jon?
P: Yes.
D: Can I get your full name and date of birth please.
P: Jon Mendes, 3/6/1970.
D: Thank you, may I ask you what brought you here today? Or I can see from
my records that you haven’t come to your follow-ups for a while now, how can
I help you today?
P: I believe it is about time doctor that I control my DM and look after myself.
P1 Explore DM:
D: Oh I am very glad that you have come to this decision, I can see that you
have been diagnosed with DM since you were a teen am I correct?
P: Yes doctor.
D: May I ask how you have been managing it so far?
P: With Insulin doctor.
D: Which insulin?
P: I am using Glargine once a day.
D: Do you take it as prescribed?
P: Not always, but I am trying my best doctor.
D: Is it well controlled?
P: I am not sure, but I think so.
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P: No.
D: As I mentioned It seems like you have not been attending the last few GP
follow-ups is there any reason why? (Use your notes whenever possible)
P: No, I just don't get the time.
D: Have you had any bothering symptoms lately? Open Q
DM Sx
D: Feeling thirsty?
P: No.
D: Do you go to loo more often than usual?
P: No/ I might say so
D: Have you lost any weight recently?
P: Yes.
DM complications:
D: Any problem with vision?
P: I have been having some blurry vision for the last 2 months yes, that is why I
went to my optician and he sent me here.
D: Thank you for coming. Have you had problems with any of your feet?
P: My left foot is always sore and both of them have like a burning sensation.
Briefly explore SOCRATES

D: Oh, you mentioned it’s a burning sensation, do you have pain or any other
unusual sensation anywhere else? Like your hands or your chest?
P: No.
D: For how long have you had it?
P: For the last 2 months.
D: Any change since it started?
P: It is getting worse.
P: Not really.
D; Have you tried anything for it?
P: No.
D: Do you have any wounds or ulcers on your feet?
P: …
ICE
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IDEA
D: Do you have any idea what might be going on with your vision and feet?
P: No/ or Yes it might be my DM.
CONCERN
D: Do you have any specific concern for us today?
P: I want to know why I am having all of this and is it related to my DM?
EXPECTATION:
P: I want you to help me feel better doctor.
P2
D: Have you been diagnosed with any other medical conditions? (Remember
the PAN)
P: I have had high blood pressure for the last 5 years. (explore)
D: How has it been managed?
P: I take Amlodipine once a day.
D: Do you take it regularly?
P: Yes.
HTN Sx
D: By any chance any headache or dizziness?
P: No.
D: Any problem with your kidney or high cholesterol levels ?
P: No.
MAFTOSA:
D: Are you currently on any OTHER medications apart from those for BP and
DM?
P: No / vitamins
P: …
D: Any family Hx of similar problems with DM ?
P: I am not sure.
P: I work in an office.
D: Has it been stressful lately?
P: Yes/No
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DESAS
P: Good/bad (explore if bad as above)?
P: Yes/No
D: Do you smoke?
P: Yes/no
D: Do you drink?
P: Yes occasionally.
Examination: has already been done so no need to mention or say will

examine again.
The nurse has just examined you a while ago but I will have a look myself
would that be okay?
I will take your observations, will also examine your chest, your hands and
your feet.
We will measure your blood sugar level as well.
Thank your bearing with me Jon.
When we examined your legs there was loss of sensation below the ankles in
both of them. Also regarding the optician he found some abnormalities in the
back of your eyes. Given the fact that you currently have (any positive Sx) , you
also have had DM for a long time now and the urine test we have done, shows
some abnormal markers of the kidneys. I am sorry to say that it seems your DM
is not well controlled and has started to affect other organs. Are you following
so far?
P: Yes. How are other organs affected?

D: DM can cause damage to large blood vessels affecting the kidneys and the
heart, also the small ones at the back of your eyes causing vision problems. It
can affect the nerves of your feet as well and that’s why you have pain.
Management:
P: What can I do now then?
D: One very important thing is to take your insulin regularly as prescribed.
Because it will help control the blood sugar levels, therefore preventing any
further organ damage.
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❖ Advice and Risk Factors as above:

• Eating a healthy DIET can help control blood sugar and improve your health
as well, I would encourage you to:
1- Decrease fat and sugary food
2- Plenty of fruit, veg and fluids
3- Olive oil instead of butter
4- White meat instead of red (chicken + fish)
5- If you struggle with that we might refer you to a dietician.
6- It may be difficult to cook every day, but you can cook once or twice per
week and use that food for the whole week. So, you don’t eat fast food
daily.
• EXERCISE: Running for at least 30 minutes a day for 5 days a week
• SMOKING and ALCOHOL: have an extreme bad impact on your health, so
would you consider quitting smoking and drinking? Or at least cutting down
gradually on both and if you are ready we would be more than happy to
help you with that. (Smoking cessation clinic?)
❖ Medications:
− I will have to review your medication with my senior after doing some
investigations to assess your condition properly. These include (blood:
RBS/ FBC/ cholesterol/ ESR/ CRP/ HBA1c/ KFT/LFT), ECG
− You mentioned you have pain so we might give you some painkillers.
NB: If patient is not on medications, then talk to senior to prescribe some

insulin.
❖ Multidisciplinary team:
Later we will refer you to something called a Diabetic clinic that consists of a
group of doctors who will work together to assess you and formulate the best
management plan for your case. These doctors are kidney specialists, eye
specialists, heart specialists and psychiatrists? How do you feel about that?
It’s crucial that you attend your follow-ups because we will only detect any
further complications and know how you are responding to the treatment
when we examine you again later and do some further testing on your follow
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ups to make sure that you’re well and that you’re DM is not getting worse.
How does that sound? Will you be able to attend them?
❖ Safety netting- About complications:
If you have any of these please don’t hesitate to come back to the GP:
− pain in eye or vision problems
− chest pain
− pain in hand or feet
And if you suddenly feel dizzy after any insulin injections, please eat something
sugary and if you don’t improve call 999.
Diabetic Foot
Who you are: You are FY2 working in the diabetic clinic.
Who the patient is: Brian White, aged 49, presented to the clinic for his
diabetic annual review. He has been diagnosed with diabetes for 5 years years
now and not on any medication. His condition has been controlled only with
diet.
What you should do: Please talk to the patient, take focused history, do
relevant examination and discuss management with the patient.
(This is a historical combined station that is very rare now)
D: Hello my name is doctor (name) I am one of the doctors here in the diabetic
clinic. Am I talking to Brian?
P: Yes.
P: Brian White, 9/8/1971.
D: I understand that you are here for your annual diabetic follow-up is that
correct?
P: Yes doctor.
D: Thank you for coming today, Brian. Well, we are going to have a small chat
about your health, but before we start do you have any specific concerns?
P: Not really doc.
D: I understand you have diabetes, and you came for your annual review.
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P: Yes.
P1 Explore DM:
D: For how long have you been diagnosed with DM?
P: For the last 5 years.
D: May I ask how you are managing it or how it is controlled?
P: I am managing it with my diet.
D: I can see in my records here that you have not been started on any
medication, right ?
P: That’s right doc.
D: And is your diabetes well controlled?
P: Yes I think so.
P: Yes doc.
D: When was the last time you measured it?
P: Yesterda.
D: What was the reading?
P: It was 6.
D: Was that before or after the meal?
P: Before my meal.
D: Have you been regularly following up with your GP?
P: Yes doc.
P: No.
DM Sx
D: Any excessive thirst or weight loss?
P: No.
D: Any problems with your water works?
P: No, all fine.
DM complications:
P: No.
D: Any unusual sensation in any of your hands or feet?
P: No.
ICE
P: …
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P: …
P: …
P2
D: Have you been diagnosed with any other medical conditions? Remember
the PAN
D: Have you ever been hospitalised for any reason?
MAFTOSA:
P: No.
P: Not that I know of.
D: Any Family Hx of problems with DM ?
P: I am not sure.
P: I am living alone at the moment doctor.
DESAS
P: Currently, I eat everything. I was living with my wife initially for 4 years, then
she left me, and now I am eating anything I want and whatever I find. Mainly I
eat burgers and chips.
P: No.
D: Do you smoke?
P: Yes/no
D: I am sorry about what happened with your wife, how are you coping after
the break-up? Has it been stressful lately?
P: I am not living my best days to be honest but I’m fine, it’s no longer a big
deal.
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Examination:
D: To complete my consultation is it OK if I examine you now; I will take your
observations. I will do a general physical examination including checking your
heart, lung and tummy as well. I will check your weight and height to calculate
your BMI and will also have a look at your feet.
You will probably be handed the Examination findings: if there are any signs
of diabetic foot problems verbalise.
As the previous case.
Management:
As the previous case, stressing on podiatrist and Diabetic foot clinic.
Diabetic Retinopathy
Who you are: You are FY2 in the GP Surgery.

Who the patient is: Mr. Christian Moore, aged 46, came to the clinic with a
new problem. He is diagnosed with noninsulin dependent diabetes mellitus,
which is controlled with diet.
Additional information: none / Or the patient has been referred by an
optometrist.
Special note: Please do not examine this patient.
What you should do: Please talk to the patient and discuss plan of
management with the patient.
(May come as a combined station so be cautious and scan the
cubicle once inside)

clinic. Am I talking to Christian?
P: Yes
P: Christian Moore, 12/12/1972.
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D: May I ask you what brought you to the GP clinic today? Or how can I help
you today?
P: Doctor I went to optician to check my eyes. He gave me this note.
LETTER:
WE EXAMINED THE EYES OF MR. CHRISTIAN MOORE, A 46 YEAR- OLD GENTLEMAN. HE HAS
BEEN DIAGNOSED WITH DIABETES .
HE COMPLAINED OF HIS EYESIGHT BUT HIS VISUAL ACUITY IS NORMAL BUT ON
EXAMINATION THE RETINA SEEMS TO HAVE SOME DIABETIC CHANGES .
CARRY THIS LETTER WHEN YOU SEE YOUR GP. FOLLOW UP IS REQUIRED .
D: May I ask you what made you go to the optician?

P: I just went to check my eyes to see if I need glasses, I am a painter and I'm
having trouble seeing fine lines while working.
All scripted people will dive into DM as a straight forward cause which is
wrong, please explore the vision problem: ODIPARA briefly before that:
− Since when?
− Which eye? What about the other eye? have you noticed if it happens
at specific times?
− Have you sustained any trauma (both)
− Any pain? Double vision?
− Itchy? Bleeding? Discharge?
− Any floaters?
− Coloured haloes around light?
D: I understand how frustrating it must be, especially for a painter, I will do
everything I can to help you with this, can you tell me when this started?
P: A few days ago.
D: And how did it start?
P: It started gradually and kept getting worse.
D: Have you noticed anything that makes this problem better or worse?
P: No.
D: Has anyone told you what is going on? (Idea)
P: No doctor, the optician gave me this letter and asked me to see you.
P1 Explore DM:
D: I can see from the letter that you have been diagnosed with DM. For how
long have you had it?
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P: For 2 years now.

D: May I ask how you are managing it / how it is controlled?
P: With some changes to my diet doctor as I was advised before.
D: Do you take any medications for it?
P: No.
P: I think so doctor
P: No.
D: When was the last time you measured it?
P: 2 years ago.
P: No doctor I haven’t had any symptoms to go to the GP about, until now.
D: Have you had any other bothering symptoms lately? Open Q
P: Only my vision.
DM Sx
D: Any excessive feeling of thirst or going to loo more often than usual?
DM complications:
D: Any pain while passing urine?
D: Any chest pain or feeling that your heart’s racing?
ICE
D: Are you expecting anything in particular from us today?
P2
D: Have you been diagnosed with any other medical conditions? (Remember
the PAN)
P: No.
P: No.
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MAFTOSA:
D: Are you currently on any OTHER medications apart from those you
mentioned?
P: No doctor.
P: No.
D: Any Family Hx of similar problems with DM ?
P: I am not sure.
DESAS
P: I eat everything doctor.
P: Not really, I don’t have much time.
D: Do you smoke?
P: Yes/no
P: Yes sometimes.
D: Have things been stressful lately?
P: Yes definitely doctor I have had some difficulties at work.
Examination
D: Is it OK if I take your observations? I will do a general physical examination
including heart, lung and tummy. I will check your weight and height as well to
calculate your BMI.
I will also have a look at your feet and the back of your eyes.
Diabetic retinopathy
I suspect that you have a condition in your eyes called Diabetic Retinopathy,
where the high blood sugar has affected your eyes.
If the blood sugar increases in your body, it causes the blood vessels that
supply the back of eyes (retina) to bulge out and start leaking. Also new blood
vessels are formed that are also tiny and start leaking too.
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P: Oh no, I don’t want to lose my vision...

No of course you don’t. We can try to help you to decrease the risk of you
losing your vision, by following up with the advice we give you. However what
is worth mentioning is that whatever damage has already happened, can’t
always be corrected, but we can avoid any further damage. Are following me?
Management:
Follow the same as previous approach and advice.
Advice:
− Advice about diet (dietitian)
− Exercise
− Smoking (Smoking cessation clinic)
− Alcohol (Alcohol cessation clinic & support worker)
− (Advice about informing DVLA & not driving)
Risk factor: Of increased blood sugar.
Medication:
Speak to senior to review your diabetic medication and monitor your blood
sugar.
Multidisciplinary team:
− Refer to ophthalmologist (eye specialist)
− If early diabetic changes, (nothing but control DM) & follow up.
− If getting worse, then laser the back of eyes to burn new vessels & seal
the leaking ones.
− Or surgery (vitro retinal) to remove part of jelly substance behind lens.
Safety netting: as before.
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Hypoglycaemia
Who you are: You are an FY2 in GP clinic
Who the patient is: 35-year-old Eddie Brown, is known to have diabetes of the
insulin dependent type. Two weeks ago, he collapsed after injecting himself
with too much insulin. Now he came for a diabetic review.
Special note: His HbAlc is 61.
What you should do: Talk to him and address his concerns.
NB: Note that the station is about DM complications (hypoglycaemia) but not
an emergency as patient developed dizziness or felt he was about to faint a
week ago, now he is stable (GP clinic).
clinic. Am I talking to Eddie?
P: Yes.
D: Can I confirm your full name and date of birth please.
P: I am Eddie Brown, 17/07/1987.
D: I can see from my notes that you had an incident two weeks ago? How do
you feel now?
P: It was dreadful doctor I am fine now, but I really don’t want it to happen
again.
Here, the presenting complaint is collapse. At least ask 2 questions to exclude

other causes of collapse, as a diabetic patient collapsing could be due to
other causes. Also show you are considering any post collapse consequences
(E.g. if he had any injuries…)
To explore any collapse: before, during, after.
D: I am sorry about what happened to you, it sounds awful. Well, we can have
a small chat to explore what happened exactly and I will be happy to help
prevent it in the future. Would that be alright?
Explore P1 the collapse:

D: Can you tell me more about what happened last week then?
P: Nothing interesting doc, I had my injection as usual then I felt very dizzy and I
collapsed.
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During:
− When did it happen? (You already know this from the note so don’t
ask)
− Where were you? P: At home.
− How did it happen?
The patient already mentioned that he took injection don’t repeat
yourself, but you can explore what injection he took? And the Dose.
P: It was my insulin injection doctor.
D: Was it your regular dose as prescribed?
P: He might say: I don’t recall doctor (or) Maybe it was a bit more than usual
(or) Yes, as I was advised doctor.
D: What do you mean when you say you collapsed?
P: I was about to faint.
D: Did you lose consciousness?
P: No I wouldn’t say so but I felt I was about to.
D: Did you have a fit?
P: No.
Before:
D: Did you have your meals as usual before your injection?
P: He might say: yes (or) No doctor I was too busy I had an urgent call from
work I had to drive there very quickly and I skipped the meal after my insulin
(or) Or I had too much food at dinner when I was at a party last night that’s
why I took an extra dose.
D: Did you sustain any trauma before you felt faint?
P: No.
D: What did you feel just before the collapse?
Symptoms of hypoglycemia:
− Shakiness
− Dizziness
− Sweating
− Hunger
− Irritability
− Heart racing
P: I was shaking, sweating and very dizzy.
After:
D: What did you do after the collapse?
P: When I felt dizzy I took something sugary as I always keep sweets on me.
(Praise him)
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P1 Explore DM:
D: That was very clever thinking, well done. Now about your DM, for how long
have you been diagnosed with it?
P: 15 years now.
D: May I ask how you are managing it or how it is controlled?
P: I used to take Metformin and Glimipride initially. 6 months back I started
taking insulin.
D: May I know what type of insulin you’re taking and how you take it? (And
what dose) ?
P: I don’t recall the name of the insulin, but I take 10 units in the morning and
10 units in the evening.
D: Are you taking your insulin regularly as prescribed?
P: Yes.
D: Is you DM well controlled?
P: I am not sure but mostly yes.
P: I have a glucometer, but I don't use it.
P: Yes, that’s why I am here today.
D: Any vision problems or pain in your feet?
P: No.
P: …
DM Sx
As before
DM complications:
As before
ICE
D: Do you have any idea of what might have caused you to nearly faint?
P: A few days back I had a conversation with my sister about what happened.
She is a nurse, and she told me it might be a hypoglycaemia attack.
D: She is probably right. Do you have any specific concern for us today?
P: I want to know how to avoid that in the future.
P: …
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P2
D: Have you had similar episodes in the past?
P: No.
D: Have you been diagnosed with any other medical conditions? Remember
the PAN
P: No.
P: No.
MAFTOSA:
D: Are you currently on any OTHER medications apart from those you
mentioned?
P: No.
P: No.
D: Any Family Hx of similar problems with DM ?
P: No.
P: … (A Taxi Driver? You should never skip driving advice in this case.)
DESAS
P: I eat everything, I love all sweet desserts, especially cheescake.
P: Not much.
D: Do you smoke?
P: No.
Examination:
D: Is it OK if I take your observations? (Pause for consent) I will also do a
general physical examination including heart and tummy. I will check your
weight and height as well to calculate your BMI. I will also have a look at your
feet and the back of your eyes. We will check your blood sugar as well.
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Thanks for your patience, Eddie. Well based on everything you told me (you
can recap quickly) I suspect your sister was right and that what you have is
hypoglycaemia. It is a complication of diabetes that can happen when your
blood sugar is low. It can be caused by too much insulin like your case/
skipping meals/ less meals/ vomiting). Are you following so far?
I am afraid this condition is very serious as it can be life-threatening and lead
to sudden death if not treated properly. But luckily you did the right thing by
eating some sweets when you felt unwell. However you should know how to
prevent it in future so I will explain a bit more about what hypoglycaemic
symptoms are and how to deal with it in the future ? How do you feel about
that?
P: Please do so I will be glad doctor.
Management:
Advice and risk factors:
− Make sure you don’t inject yourself with too much insulin.
− Make sure you don’t fast while taking insulin.
− Always continue to keep some sweets in your pocket.
− Measure your blood sugar regularly and after each meal.
− You should wear a diabetic bracelet.
− If necessary, give DESA advice.
You can suspect you are going to have an episode if you feel you’re
shaking/ dizzy/ sweating/ hungry/ irritable.
− If you feel any of these please eat or drink anything sugary at once.
(Small glass of non-diet fizzy drink or fruit juice, a small handful of
sweets, or four or five dextrose tablets).
− Measure your blood sugar 10-15 minutes afterwards.
If it's still below 4mmCit, treat again with a sugary drink or snack and
take another reading after 10-15 minutes.
If it's 4mmol or above and you feel better then you can eat a full meal.
− If you feel worse or are about to faint, call 999.
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− Call someone for help if you are alone.

− DON’T DRIVE
Investigations and Senior

− RBS
− HBA1C already checked?
− LFT / KFT/ cholesterol
− ECG
Management:
No management here the patient is okay he had the attack 2 weeks back.
MDT
We measured your blood sugar with something called a HbA1c and it came a
bit higher than usual. It means that your blood sugar has been high for the last
couple of months. To control your diabetes better and avoid any bad impact on
your health, we can refer you to a diabetic clinic where an ophthalmologist/
kidney specialist/ heart specialist/ foot specialist can help develop a better and
more suitable plan.
Safety netting:
About driving it is better to consult DVLA as they have some guidance about it.
If you keep having frequent hypoglycaemic episodes it can be very dangerous
as one day you might develop the attack without any alarming symptoms, so
make sure you inform us or your diabetic clinic doctors.
Hypoglycaemic Fits
Who you are: You are an Fy2 in A&E.

Who the patient is: Adam Smith, a 25-year-old, is a known case of type 1 DM
which is controlled by insulin. He was brought to A&E by the ambulance after
he collapsed while he was shopping.
Additional information: Patient doesn’t want to stay in the hospital.
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Special note: Vitals: B.P. 100/60, P.R. 105, R.R. 20, Sats. 95%, Blood sugar 2.1,
insulin:c peptide:2:1
What you should do: Please talk to the patient, take history, convince him to
get admitted and discuss your initial plan of management with the patient.
Revise:
REFUSAL STRUCTURE
7 Steps:
1. Why? (Patient will give you concern)
2. Address the concern: Start with the least costly solutions- Example: If a
patient refuses admission because he has kids at home and no one takes
care of them → start with their mum or dad or other relatives, friends and
special services that can look after them.
3. Warn him of risks
• Give ultimate risk
• Consequences of refusal--- DEATH
4. Benefits of accepting (= Management ): Do you know why we need to keep
you in the hospital ?
5. Senior (Why + Consent ): I will ask my senior to talk to you about it, would
that be alright with you ?
6. Sign ‘Discharge against medical advice form’
7. Safety netting: We are still worried about you, please , if you have ......
come back to us immediately.
NOTE: At any time if the patient agrees → start to take Hx + verbalise

examination + manage
If the patient still refuses after following the structure and addressing all his
concerns DON’T PANIC, it doesn’t mean that you will fail the station. Be
empathetic and smart and follow the patient. That’s how you pass.
D: Hello Adam, I am Dr (name) one of the doctors here in the emergency

department.
P: Yes.
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P: Adam Smith, 2/1/1997

D: I can see from my records that you were brought here by the ambulance
earlier today. Can you tell me what happened?
P: I want to go home.
Start PT REFUSAL
D: May I know if there is any particular reason that you want to leave? WHY
P: I have many things to do at home that is why I want to go home.
D: Of course, it’s your right to go home if you want to, but it is our duty also to
assess your condition and make sure that you are safe to be discharged, and if
all is well we can definitely discharge you. So could you bear with me just a few
minutes to explore more about what happened and exclude any sinister
causes?
P: Okay. I don’t know, I collapsed while I was out, then I woke up here.
Collapse HX BEFORE DURING after:
BEFORE:
D: Do you remember what happened before you collapsed? Risk factors:
Were you doing anything specific?
• Excessive
P: Shopping.
D: Any dizziness or sickness, vomiting, sweating, shivering, or exercise
feeling that your heart is racing? • Alcohol
P: Yes I had sweating and shivering. (Party)
D: Did you sustain any trauma? • Missed meal
P: No. • Extra insulin
D: Did you have any fever?
P: No.
D: Did you have your meals as usual?
P: I was busy and skipped my breakfast and I took my insulin.
DURING
D: Anything you remember during the collapse?
P: No.
D: Did you lose your consciousness?
P: Yes.
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D: Any jerky movements? Bit your tongue / wet yourself?

P: I don’t know about jerky movements, but I didn’t bite my tongue or wet
myself.
D: Was there anyone around when it happened?
P: Yes/No
D: Who brought you to the hospital?
P: I don’t know who called the ambulance.
AFTER:
D: Could you tell me what happened after the collapse?
P: I don’t know, the next thing I knew, I was here.
D: Any head pain or vision problems?
P: No.
D: Did you vomit?
P: No.
D: How are you feeling now? Any pain anywhere?
P: I am fine.
P2
D: Has anything similar happened before?
P: No.
D: Thank you for your patience so far Adam. I understand that you have been
diagnosed with DM.
P: Yes, I have DM---------EXPLORE
P: Since I was 11.
P: I am taking insulin.
D: Which insulin?
P: I am taking it two times a day. I don't remember the name.
D: How many units?
P: 16 in morning and 16 in the evening.
P: I think so.
P: Yes. (In the interest of timekeeping, you can move on, but if you have time-
explore as before)
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D: Are you regular with your GP appointments and annual check-ups?

P: Yes.
DM sx
As before, briefly.
DM Complication
As before, briefly.
D: Any previous hospital stays or surgery?
P: No.
MAFTOSA:
D: Have you been diagnosed with any other medical condition like kidney
disease, heart disease or high cholesterol?
P: No.
D: Any other medications apart from insulin?
P: No.
P: No.
D: Any family history of any medical condition?
P: No.
DESAS:
Acute setting, no DESA, only ask about diet, exercise and alcohol.
D: Do you drive?
P: No.
ICE
D: Do you have any idea what might have happened when you collapsed?
P: Doctor I don’t know, I don’t care, I just want to go home.
D: I apologise if I am taking too long Adam. Just a couple of minutes and we
will be done. Do you have any specific concerns or expectations from us?
P: No.
Examinations:
D: thank you for bearing with me Adam. Is it OK if I check your vitals? I will do a
general physical examination including checking your heart and tummy also.
We sent for some basic lab tests and I am afraid to say your blood sugar
came back extremely low. I suspect you had a hypoglycaemia attack, and it
could be a very serious condition Adam. Are you following me?
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P: Yes.
D: I understand how much you want to be discharged, but it could be

dangerous to send you home in this state. It would be much safer if we
admitted you for now, and started treating you before the condition gets
worse. How do you feel about that?
P: No. I will go home.
1. D: Ok well, we can't force you to stay against your will , but may I ask you
why you won’t stay?
P: My kids are at home, and no-one is looking after them, and I was
shopping for my eldest’s birthday when all this happened.
2. Address concern I can see that you are concerned about them. Do you have
a partner who could look after them? What about your friends or
neighbours? We may be able to arrange childcare by social services, is that
ok ?
3. Warn him of risks: Do you know what condition you have? (If he is still
persistent, explain again.) You have hypoglycemia, which means your blood
sugar is on the lower side and I am afraid it’s a potentially fatal condition
because sugar is the main food for your brain. That’s why you passed out
earlier today. If your blood sugar remains low, you might go into a
permanent coma or even worse, it might cost you your life? Then you won’t
be much good to your children will you, when you’re gone?
4. Benefit
Do you know why we want to keep you in the hospital? To keep monitoring
you and start you on proper medication. To give you fluids, glucose, which is
sugar, to make sure your condition is improving until it’s safe for you to go
home.
So what do you think now about what I’m saying to you Adam?
P: Okay doctor, I will stay.
D: I am glad you came to this decision would like me to explain more about
anything?
P: Yes, why did this happen to me?
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D: Well, we did a test called insulin c peptide ratio and it shows the reason for
your hypoglycaemia is that insulin you took. From the information you have
given me, the reason may be due to your missed meal , extra insulin and
excessive exercise.
Management: Patient is in A&E, so you can follow the classic structure or

ARMMS
1- Admit
2- Senior
3- Investigations:
− Blood: CBC/ RBS/ HbA1C/ LFT/KFT/ Cholesterol
− Urine: protein/ sugar/ dipstick
− ECG
4- Symptomatic:
Fluids that contain sugar through your veins + insulin through your veins +
monitor sugar level continuously.
5- Refer to diabetic clinic:
We will refer you to Diabetic Clinic (Eye/ kidney/ heart / feet specialist
(vvimp) to adjust the dose of insulin and give advice about your diet.
Hypoglycaemia: same as before
− Causes
− Symptoms
− What to do if you develop symptoms
Safety net DVLA if driving
N.B: If you don’t have time, mention that we can arrange an appointment to
discuss (DESA).
Advice and Risk Factors Same advice as before:
− Make sure to eat your meal after taking insulin.

− Measure your blood sugar before taking the dose of insulin.
− We will give you hypoglycemia bracelet.
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− It is important to keep something sugary on you all the time and be

aware of symptoms of hypoglycemia and once you feel any of them
immediately take it and come the hospital.
− Some factors can make you have hypoglycemia, such as excessive
exercise, or alcohol ,missed meal or extra insulin it is better to avoid
them , how do you feel about that ?
NB: the patient may keep refusing even to give any hx so keep
following the refusal structure and be smart with your language until
he agrees to carry on.
DKA
Who you are: You are an FY2 in emergency department.

Who the patient is: 30-year-old Pauline Lynn has been brought by an
ambulance to the A&E with history of abdominal pain. She has been diagnosed
with Type 1 diabetes. She is Insulin dependent. The blood test has been done
and she has been diagnosed with DKA. She is not willing to stay in the hospital
Additional information: Vitals:- BP: 90/60 mmHg, Pulse: 110,02 Sat: 95, RR: 17,
TEMP: 37
Special note: Patient is refusing admission
What you should do: Take focused history, discuss the appropriate plan of
management.
D: Hello I’m one of the doctors here in the emergency department. Is it

Pauline?
P: Yes.
P: (She confirms details)
D: I can see you are in distress Pauline, what is going on? /What brought you
here today?
P: I just want to go home; I don’t want to stay here.
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D: Well it is your right to go if you want, but how about I ask you some
questions first and if everything is fine, then we can send you home.?
P: No doctor it is just some tummy ache. Don’t bother, I need to go home.
D: Pauline it’s our duty to make sure you’re safe and we wouldn’t want to miss
anything serious before we are able to discharge you, right? Can you please
describe more about this ache?
P: Okay doctor. (OR) Doctor I am fine please send me home !!
Start Refusal structure

(It is unlikely that the patient will be that stubborn with the Hx so she will
probably answer but will strongly refuse admission later in management.
Depending on the patient you can start your refusal structure here or later)
Why ---- Address --- Benefit --- Warn
P: Like I said doctor I felt sick, and I had tummy pain. Explore pain
(SCOCRATES) and sickness briefly as it is already diagnosed DKA.
D: Can you tell me more?
P: I have had pain all over my tummy, (points towards her abdomen) for the
last few hours and it is getting worse.
D: How did it start?
P: Suddenly.
D: What about the sickness?
P: It started at the same time with my belly discomfort.
D: Is there anything that makes you feel better or worse?
P: No.
D: Can you grade the pain for me from 1 to 10 with one being the least and ten
being the most severe pain?
P: 7.
D: Have you had anything else apart from these?
P: No.
DDx (1 or 2 tops) (Make sure don’t spend a lot of time on DDs of tummy pain
as it is DM station)
D: How are your bowels?
P: Nothing new.
D: Any vomiting?
P: No.
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P4: D: How are your periods? When was the last? Are you on any
contraception?
Don’t forget Ectopic pregnancy (Important)
DM Sx
D: Any problems with your water works, like going to the loo more often?
P: Yes/No
D: Have you been feeling excessively thirsty?
P: Yes/No.
DKA Sx (dehydration Sx)
D: Is your mouth dry? Not going to the toilet?
P: No.
D: Have you been breathing faster or deeper than usual?
P: Yes/No
D: Have you noticed or been told that your breath smells funny or maybe
fruity?
P: Yes/No.
D: Do you feel like you are a bit confused or dizzy and about to faint?
P: No.
D: Do you feel tired or drowsy?
P: No.
D: Any fever, flu-like symptoms recently? (Viral infection most common
exacerbating factor)
P: No.
P2
D: Have you had similar problems in the past?
P: No.
D: I understand that you have diabetes, can you tell me more about it? Explore
like before:
P: I have had diabetes for the last 10 years, since I was a teenager.
D: How is it controlled?
P: I take insulin Actrapid and some other one I can’t really recall.
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D: How many times a day are you taking it? Risk factors & DKA
P: I take it once at night and 2-3 times during the day. • Infection (chest &
D: Do you take it regularly? urine) v. important
P: Usually I do. But I didn't take it for the past 5 days.
• Not taking
D: May I ask why?
medications?
P: I have a wedding in 4 weeks time and I want to look
beautiful in the dress I bought. I stopped my insulin as I Complications of DM (DKA):
didn't eat much in the last 5 days trying to lose some (dehydration questions)
weight so I can fit into my dress. − Dry mouth
D: I understand. I just want to ask a few more questions − Feeling thirsty
to assess if it’s safe to send you home. − Not passing enough
P: Okay.
urine
D: Have you ever skipped your dose of insulin before?
− Drowsy
P: Yes. I did it when I was 16 and there was no problem.
D: Do you check your blood sugar regularly? − Dizzy
P: Not really. In any case of DKA you must
D: When was the last time you checked it? remember:
P: When I came to the hospital. − DM hx
D: And what was the reading?
− Infection as a cause
P: 22.
− Dehydration as a
D: Do you attend your GP and annual review regularly?
complication
P: Yes.
D: When was the last time you went to the GP?
P: A year ago.
D: Have you been diagnosed with any other medical conditions?
P: No.
MAFTOSA
As before, especially MAF
DESAS:
Acute setting so no need (you can say we will book another appointment to
discuss lifestyle modifications.)
Examination:
Thank you, Pauline, for being so cooperative. I would like to check your vitals
and examine your heart, chest and tummy now, would that be okay?
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I would also like to send for some initial investigations including routine blood
tests and your blood sugar level.
The examiner or the role player will say: All the investigations are on the
table.
I am well aware that you really want to go home, but how about you give me
the chance to explain what might be going on here, and then I will let you
decide because it could be serious.
P: Please let me go home doctor. I feel fine and I have got so much to do. And I
swear I will start eating and taking my medications regularly.
D: I understand your frustration, Pauline. I am afraid your condition might be
very serious now. What you have is called Diabetic Keto Acidosis, where blood
sugar goes very high along with other bad chemicals called Ketone bodies. It’s
a serious diabetic complication and life threatening if we don’t treat
immediately, so it is better to admit you. I’m sorry to say it!
P: Oh doctor I want to go home please don’t admit me I am fine.

1. D: May I ask why you want to go home Pauline?
2. P: Because I have so many arrangements to do before the wedding.
3. Address the concern: How about you get some help from any of your
family or friends?
P: They are doing so much already doctor.
D: Why don’t you hire a wedding planner and she can help you with all the
arrangements, at least until you’re well enough to carry on.
4. Benefits If you stay in the hospital we can provide the suitable management
that will help you with the pain, run some tests and make sure that you are
recovering and then after that we can send you home.
5. Warn her of risks Ultimate risk --- DEATH
P: Okay doctor It seems really dangerous, I will stay and will talk to my family
about the preparations.
Management:
Admit
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Senior
Investigations
(DM/infection/ dehydration) Verbalise what has not been requested yet to
help you exclude any DDx that you may have missed with your history. Always
a good strategy to mention the investigations if you are cutting the history
short.
− Blood (RBS/ ESR- CRP/ cholesterol/ ABG/ KFT)
− Urine (dipstick culture + ketone bodies)
− CXR: chest infection
− Erect abdominal x ray to exclude perforation
Findings will be on the table: RBG (30 mmol), ABG (metabolic acidosis),
ketonemia and ketonuria.
Treatment:
Symptomatic:
− For DM (insulin injections into your veins on a drip to decrease sugar
levels)
− For dehydration (fluids through your veins)
− For infections (antibiotic) / paracetamol for fever.
Lifestyle: if there is a problem in DESA or (advise about the cause of DKA)

Verbalize booking follow up appointments to discuss it.
− Even if you’re busy, you must still take your insulin.
− You must go for your regular follow-ups.
− If you have fever or signs of infection you must see your GP
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Safety netting: About Driving and Hypoglycaemia and DKA.
(Another scenario of DKA)

You are an FY2 in emergency department. Alicia, 16 yrs old, with abdominal pain &
weight loss. She has come with her mum (ask the patient if it’s OK for her mum to
stay)
Make sure it’s not anorexia nervosa station, it’s a case of undiagnosed DM with DKA
first presentation, so ask her about (polydipsia/ polyuria/ weight loss)
Diabetic review (with learning disability)

Who you are: You are an FY2 in GP clinic.
Who the patient is: Matt Albertson, aged 24, was diagnosed with Type 1
diabetes two months ago after he had an episode of DKA. He was admitted
and managed in the hospital. He was started on a short-acting insulin three
times with meal and long-acting insulin before going to the bed.
Additional information: The diabetic nurse has been going to his house to
check the blood glucose and on 2 occasions they were on the higher side.
This is a very basic counselling station but what you need to consider is the
following:
− The patient may be slow of understanding, don’t rush the
patient, go at his own pace.
− Use easy terminology, repeat and make sure he understands.
− Explore what difficulties he has.
− Explore the social support around him.
− Watch your language and don’t offend the patient.
D: Hello I am one of the doctors here in the GP clinic. Am I talking to Matt?

P: Yes.
P: (Confirms details)
P: I am here for my diabetic review.
Explore DM as before
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P1 Explore DM:
P: For 2 months.
D: Do you take any treatment for it?
P: Yes I take insulin.
D: Do you follow the doctor’s advice about how to take it?
P: Yes doctor I take it after sugary things and sweets, to keep my blood sugar
low as my doctor told me last time.
D: Is that what the doctor told you last time you were here?
P: Yes doctor.
D: Do you remember the dose?
P: Sometimes I get confused with it doctor.
D: Is your blood sugar well controlled?
P: I don’t know doctor.
P: The nurse checked it for me twice.
D: When was the last time you measured it yourself?
P: When she came 4 days back.
P: Yes.
P: …
DM Sx
D: Any excessive feeling of thirst?
P: Yes most of the time.
D: Do you go to loo more often than usual?
P: Yes a lot doctor I hate it.
P: I don’t know.
DM complications:
P: No.
P: No.
P: No.
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D: Any chest pain or feeling like your heart is racing?

P: No.
D: Do you sometimes feel dizzy or about to pass out after your insulin?
P2:
D: I can see from my records that you were here 2 months back do you
remember what happened?
P: Yes doctor I had very bad tummy pain, they told me I have high blood sugar
and that I have to take these injections.
D: Do you have any other medical conditions?
P: No.
P: No.
MAFTOSA
D: Do you take any medications ?
P: No.
P: No.
D: Do you have any similar health problems in your family?
P: No.
P: I live alone.
D: Do you have any family nearby? (Watch out when you ask this Q do not say
who take cares of you, he is a grown man).
P: Yes my parents, they check up on me every now and then.
P: I work from home.
D: How have you been feeling lately? Do you feel stressed by any chance ?
P: Yes, I am a bit stressed because I don’t want to get sick again like what
happened before.
D: That’s wise of you to care about your health.
Explore the disability: You will have to exercise very good active listening
and a decent choice of words.
D: You mentioned that sometimes you get confused with the dose of your
medications right? Can you tell me more about that?
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P: (…) (Whatever he says you consider in management.)
Possible difficulties:
“Sometimes people taking the same medicine may struggle a bit in the
beginning because they do not..”
− Remember to take it (Forgetful of the time)
− Remember or understand the doctor’s advice because he might be
talking quickly and it’s a lot to take in when explained for the first time.
− Understand when reading instructions … or cannot write notes to
remind themselves..etc
Other difficulties:
• It might be painful injecting so many times.
D: Do you have any concerns you want to talk to us about ?
DESAS:
P: Good/Bad
P: Good/Bad
D: Do you smoke?
P: Yes/No
P: Yes/No
Examination:
Thank you for attending your follow up today. To complete it I would like to
check your observations. I will do a general physical examination including
checking your heart and tummy and I will take a look at your feet as well. I will
check your weight and height (to calculate your BMI).
We will also measure your blood sugar level now. Would that be okay?
Thank you Matt for bearing with me. Now let me try and explain alright?
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Our nurse has visited you twice over the last month, and she found out that
your blood sugar is still higher than usual when she measured it. Do you
remember her visits?
P: Yes.
Well From our chat as well you mentioned you are always thirsty and that you
go to loo often, right?
We suspect that your blood sugar is not well-controlled, especially when you
take your insulin only after sugary food. And that will make the condition you
have, which is called Diabetes, get worse. Am I going to fast?
P: No doctor, so what are you going to do?
Management:
Advice and Risk factors:
D: I appreciate that you were doing your best to take the insulin, but you
were still struggling a bit. How about I revise with you when and how to take
it to control your blood sugar better? Would you like that?
It is very important to take your insulin regularly not only after sugary food. You
have to take the insulin 3 times a day, every day, before breakfast, before lunch
and before dinner. You have to take one insulin before going to sleep. Make
sure that you do not miss any of your meals or your insulin, otherwise your
Diabetes will not be controlled and you will feel sick again.
Always keep something sugary with you and if you feel dizzy after insulin, eat
it.
We will give a bracelet to let doctors know that you are on insulin just in case
you feel sick suddenly.
P: But I sometimes forget my doses doctor:
D: Options:
− You can remind yourself by writing a note or putting an alarm on your
phone(ask if he can use a mobile).
− Take it just before each meal as I mentioned.
− Your family members can help remind you.
− A GP reminder call.
− We can send the Diabetic nurse every now and then to remind you how
and when to take it.
− You can call the GP the any time if you have any queries.
How do you feel about all that?
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Management: (Inv + senior)

We will do a routine blood test (cholesterol level/sugar level/kidney/liver
function/HbA1c/ urine test)
DESAs ADVICE
Exactly as before.
You mentioned you feel stressed more than usual and it can have a bad effect
on DM. We are here to help you at every step. Try talking to your family and
friends. Try doing some physical activities such as walking, jogging or
swimming. In this way you can relive your stress and relax yourself. You may
also try taking yoga classes.
P: How dangerous is DM doctor?
D: DM can cause damage to large blood vessels and can cause kidney and
heart disease and high blood pressure. It can cause damage to small blood
vessels at the back of your eyes and can cause vision problems. It also affects
the nerves of your feet. Missing an insulin dose is one of the most common
causes of DKA which you had in the first place.
MDT and Diabetic clinic:

As before.
Safety net: Hypoglycemia and DM complications.
Medication Counselling structure:

It may show up as a counselling station like before with special concern about
the medicine OR, a patient being discharged from hospital, and you were
requested to council the patient about the medicine.
❖ What you should remember for this station
➢ Use your notes to start and build rapport before discussing the meds. You
can build rapport by asking Admission questions; For any patient being
discharged ask these:-
1. What brought you to the hospital? (What symptoms did you

have)?
2. When were you admitted?
3. How much do you know about your condition? (If anything
was explained before).
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4. How was the hospital stay? (Doctor and nurses been

heldful?)
5. What was done for you in the hospital? How were you
managed in the hospital?
− Any medications given?
− Any investigations done?
− Any advice given?
6. How do you feel now? Do you think you are ready to go
home ? (Complications of surgeries if had one)
➢ Take brief focused Hx as any station (concentrate on contraindication for
the med and allergies)
➢ Points you need to explain about each medicine: (Go slowly making sure he
is following and check understanding every now and then)
1) Name.
2) Form.
3) How to take it.
4) Dose.
5) Mechanism (why the patient needs to take it).
6) Contraindications (you need to ask while taking brief Hx
before discussing the med)
7) Side effects, what to do if you develop any symptoms?
8) Important safety information about the medicine
9) Drug interaction (if the patient is on any medication).
➢ Advice about DESAS if required and you have time.

➢ Give some leaflets about the medicine. Please note: Leaflets do not cover
all the topic and diseases of medicine ☺
IN SHORT: How the station should FLOW:

• PAST: Rapport(Admission Qs) –Very Focused HX - P2(medical conditions
and contraindications of medicine) – MAFTOSA(Medications and
Allergies) -DESAS(always should advice if u have time)
• PRESENT: How do you feel now?
• FUTURE: Medication counselling (Core of the station) and DESAS advice
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Warfarin
Who you are: You are FY2 in medicine.
Who the patient is: Alicia Sanderson (39) was admitted to the hospital for a
week because she had leg pain. She was diagnosed with DVT and was
managed. Now, she is being discharged. Your consultant is sending her home
on warfarin.
What you should do: Please talk to the patient, explain about her medication
D: Hello I am one of the doctors here in the Medicine department. Am I talking

to Alicia?
P: Yes
D: Can I have your full name and date of birth please?
D: I can see from my notes that you have been admitted in the hospital.
Rapport Qs
D: What brought you to the hospital?
P: I came to the hospital because of my calf pain. I was told someone is going to
talk to me about my tablets and discharge me, (pointing towards medications).
D: Well yes that’s exactly why I am here, but before I get to these Meds may I
ask you if you have any idea why you had this leg pain and has anybody
explained anything to you about it?
P: Quite frankly they did doctor but I panicked when they said clots and I didn’t
concentrate much?
D: I am sorry you felt that way. Don’t worry I will explain everything in just a
few mins, have you had any investigations done?
P: They said some routine investigations and something about clotting!
D: No worries, how was your hospital stay? How did you find the doctors and
nurses here?
P: All was fine doctor.
D: How is your leg pain, do you feel ready to go home?
P: It is much better and I can’t wait to go yes.
D: I am glad that you’re better.
Well let me explain now, you had a clot which is thickening in your blood.
Blood clots are very common and can be controlled by some meds, however it
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can get risky as a blood clot can travel to your lungs or heart. That's why my
consultant has prescribed you these meds to take home, they make your blood
thin and decrease the risk of this happening , are you following ?
P: Yes.
D: Is it ok if we have a chat about your health in order to make sure that it's
safe to give you this medication.
P: Yes doctor it’s fine.
P2:
D: Any similar pain before?
P: No.
D: Any SOB – chest pain – pain anywhere in your body? (PE).
P: No.
D: Have you ever been diagnosed with any medical conditions? (HTN – Peptic
ulcer – Bleeding anywhere – Liver condition.) (Contraindications for warfarin)
P: No.
P: No.
MAFTOSA:
D: Are you currently on any medications apart from those you mentioned?
P: No.
P: No.
D: Any family hx of clots?
P: No.
D: What do you do for a living? (Long standing and desk jobs increase the risk
of VV and DVT)
P: …
DESAS:
D: Tell me about your diet? (Green vegetables rich in vit K contradict warfarin,
CRANBERRIES)
P: I eat everything.
P: Good/bad
D: Do you smoke?
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P: Yes/No
D: Do you drink alcohol? (Binge drinking to be avoided while on warfarin).
P: Yes.
P4:
D: By any chance could you be pregnant? (Breast-feeding)
P: No.
D: Are you currently taking any contraceptive pills? (V. important) (Interact
with Warfarin and increase Clotting risks)
P: No.
Examination:
As usual.
Medicine Counselling:
Management (counselling medicine)
• We will be prescribing some medicine called warfarin, it is what is going to
keep your blood a bit thin to prevent any serious clotting, alright?
• Form : It’s a tablet taken daily at a fixed time with water (would you be
able to do that?)
• Dose : You will take it once a day for a start and better taken in the
evening, starting from today.
• How it works : Already mentioned.
• Contraindications: Already asked.
• Side effects (bleeding) , you can be at risk of bleeding ; however , we
usually do multiple blood tests and specifically one to check how thin
your blood gets, it’s called an INR. We do it frequently at the beginning
of each course till we decide the most suitable dose for you to achieve
the level we need.
Symptoms:
− Any bleeding from your body.
− Dark stool.
− Heavy periods.
− Headache or blurring of vision
• What to watch out for:
1) Falls
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2) Avoid Contact sports (like rugby) but can play non-contact

sports. However be cautious and wear protective clothing.
3) When you go to dentist, tell him that you are on it.
4) If you buy OTC meds make sure you let the pharmacist know.
5) Don’t take any antibiotics or pain killers without asking your
GP.
6) While shaving (if a male).
7) While using sharp objects.
8) Avoid: Cranberry juice—also green, leafy veggies
• General Safety advice:

− We will give you a bracelet that you will have to wear which
signifies that you are on warfarin which will be very important if
you ever become critically ill.
− You will keep a record book which indicates your treatment record,
dose of your medication and date of your blood tests with you,
called the yellow book.
− Will give an alert card to keep in your wallet as well, it has your
details, medicine name, reason for the treatment, target INR, date
treatment started, the name of warfarin clinic and telephone
number of warfarin clinic. You can show it to your doctors, dentist
pharmacist…etc
P: What if I forget to take the medications?

D: Well, Alicia , it's extremely important not to forget it. But if you think you
might forget we can seek some solutions to stop that happening. May I ask
you, who you live with ?
P: I live with my partner.
D: Is your partner at home in the evening.
P: (If yes, tell her to ask partner to remind her.)
If No
Other options:
D: You can write a note and put it where you can see it every day in front of
you, like on the fridge for example. Write it down as a schedule.
Do you have a phone ? →You can put alarm on your phone.
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Do you do any specific activities at night like watching TV or reading

something? You can link it mentally with these activities.
Well, if you do forget to take it:

> If you remember after 12pm → then , don't take it , wait till next day and
take regular dose.
> If you remember before 12pm → then take it.
• Any other concerns?
PATIENT’S CONCERNS
P: Doctor, if I have a headache what should I do?
D: If you have a mild and simple headache, you can have Paracetamol. Please
do not take medicine such as Ibuprofen or Diclofenac. But if you have any
unusual bad headache with vision problems, you will need to see a doctor
urgently.
P: If I cut myself then?
D: Apply firm pressure to the site for at least five minutes using a dry and clean
dressing. If blood doesn’t stop then please come to the hospital.
P: If I have a nosebleed (same: apply pressure and come to hospital if bleeding
persists more than 10 mins)
Safety net:
Safety net about bleeding symptoms and red flags.
Follow up:
Book appointments for INR and to make sure she is coping with medicine.
NB: Sometimes the patient will have some sort of a learning disability and
you observe that when you enter the cubicle the patient will be slow of
understanding. it will be the same structure as this consultation but with the
same approach we discussed in the previous diabetes station.
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Statin
Who you are: You are FY2 in GP surgery.
Who the patient is: Mrs. Louisa Muriel, aged 61, came to the clinic for health
checkup. All the blood tests including blood sugar, LFTs and U&Es came back
normal. Only cholesterol was found high and her ORISK score is 16%. She is
due to be started on statins.
Special note: BMI=28 , BP =160/90 ,Cholesterol = 6.9
What you should do: Please talk to the patient discuss your initial plan of
management with the patient and address her concern.
NB: This is a counselling based on test results station so watch out, be wise with
your intro. Don’t say “how can I help you?” better to use your notes. Remember
the test results structure:
1. Use your notes
2. Always give him/her the option of what he/she wants first “Chat history?
Or to start with the results?”
3. Explore why he/she had the tests done in first place.
4. What Sx he/she had.
5. Then take focused Hx concentrating on: Risk factors --- medical
conditions – Medicine Contraindications—MAF – DESAS. =+/- P4
D: Hello my name is doctor (name) I am one of the doctors here in the GP clinic
Am I talking to Louisa?
P: Yes.
D: Can I have your full name and date of birth please.
D: I can see from my notes that you are coming for your blood results and I
have your test results here with me right now. Would you prefer it if we had a
chat about your health first to put me in a better position to explain the
results?
P: Whatever suits you doctor. It’s fine by me.
D: Thank you very much. Could you please tell me why you had these blood
tests done in the first place?
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P: Because one of my friend’s had a TIA and I was worried I thought I should go
for a check-up.
D: Do you know what these tests are for?
P: I don’t exactly know but I asked for a general check-up.
D: Is anything bothering you recently?
P: No.
Clotting Sx:
Symptoms of (MI – Stroke – TIA) which are consequences of high cholesterol.
Have you had any chest-pain –SOB—heart-racing? MI and PE
Any weakness or unusual sensations anywhere in your body, legs or arms?
Stroke
Any facial weakness or slurred speech? Stroke
Any vision problems? TIA
Any pain or swelling in your legs? DVT
Any headache? HTN
P: No, but I am getting worried now doctor.
D: I am sorry if I’ve alarmed you Louisa, all the questions I am asking are part of
my consultation to explore your health in general. Alright?
P: Okay.
D: Would like to carry on?
P: Yes.
P2
P: No.
Contraindications of statin
D: Any liver problems?
P: No.
D: Any high blood pressure or Diabetes? The pan
P: No.
D: Any heart disease or kidney disease?
P: No.
P: No.
MAFTOSA
D: Are you currently taking any medications?
P: No.
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P: No.
D: Has anyone in your family ever been diagnosed with any stroke, high blood
pressure or any other medical conditions?
P: No.
DESAS
P: I eat everything; I love fast-food and pastries.
P: Not much to be honest.
D: Do you smoke?
P: No/Yes
P: No.
P: No.
Examination:
As before.
Management:
Explain Results
Thank you for being so patient. Now about your test results. It was really smart
of you to have this check-up done. We have checked for your blood sugar,
some liver and kidney markers, all of which came back normal except
cholesterol which was a bit higher than usual (6.9), and normally its less than 5.
Do you know what cholesterol is?
Cholesterol is a fatty substance known as a lipid and is essential for the normal
functioning of the body when it’s within the normal range. It's also called the
bad fat, because if found in higher levels then it causes health issues as it starts
accumulating in different blood vessels. For example, in your heart leading to a
heart attack or in your brain leading to a stroke.
Explain Q – risk and investigations

There is something called a Qrisk assessment which is a Prediction of having
cardio-vascular disease using various input and data from your history,
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regarding different lifestyle risk factors you have, family health status and your
blood test results. Q- risk >10 means 10% chance having CVD.
Do you have any idea of what can cause high cholesterol ?

It's either secreted by the liver or you get it from your diet. So, there are 2
ways to handle this issue:
− Having a healthy diet (then advise about diet ).
− Some medications called statins, that work by decreasing the formation
of cholesterol by the liver. And that is the medicine we are going to send
you home with.
Then explain about statin

• Many names such as atorvastatin , simvastatin , pravastatin.
• Forms: They come in the form of tablets.
• Dose: You will take it with water once a day for the rest of your life, usually
at night.
• Mechanism : as I told you it works by ↓↓ cholesterol formation by your
liver.
• Side Effects : like any medications have some side effects:
− Severe muscle pain.
− Can damage liver.
− Can damage kidneys.
• General Safety advice:
− It's important to always monitor liver and kidney functions (at 1 – 3 – 6
–12 months) after taking medications. (v. important)
− Contraindicated in pregnancy, also in young.
− Consult the doctor before taking any antibiotics as some of them can
increase the risk of statin harming your muscles.
High blood pressure reading:

Another thing is that we when we examined you, your blood pressure was on
the higher side, so I’m going to involve my senior and we will probably repeat
your BP and vitals today to make sure it’s not just high because you are in the
clinic as sometimes people get really stressed out in these settings (known as
white coat hypertension).
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In your next follow up we are going to decide if it was confirmed that you
have HYPERTENSION, which is high blood pressure, in which case it would be
very important to bring it down. Having high blood pressure can cause a lot
of damage to your blood vessels supplying the brain and heart. With high
cholesterol it can cause clots and narrowing of these blood vessels. It can
cause a lot of strain on the heart as well. Unfortunately, high blood pressure
and cholesterol are a perfect combination for causing heart-attacks and
strokes.
It can be managed with some advice about stress management, lifestyle
modification, especially exercise and diet (less salts), and some medications
that we might have to start you on in the future. How would you feel about
that?
Advise about rest of DESAS.
As before
Safety netting:
If you feel chest pain going to the left side of your body.(MI) Arm or facial
weakness or slurred speech.(stroke) Severe headache or blurring of
vision.(HTN ) Muscle pain and weakness (Statin induced myopathy). You can
come back to the GP at once.
Follow up:
We are going to set up some appointments deal with your blood pressure
and see how you are coping with the medicine and advice we gave so far.
We can give you leaflets about statins and high blood pressure, it will help
remind you of the advice we gave you about your lifestyle. And at any point if
you have any other question, please do not hesitate to contact us again.
Osteoporosis: Alendronate Counselling
Who you are: You are an FY2 in the GP surgery.

Who the patient is: Malaz Mokhtar, 65 years old. She had a fall and fractured
her hip 3 months ago. She had an operation at the time and she is recovering
well now. DEXA Scan has been done 2 weeks ago, which showed Osteoporosis.
She is here for her results.
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What you should do: Please talk to the patient, discuss the result and plan of
management. Explain the medication (in the cubicle, you will have a paper
with some medications and doses).
Please note that she had the operation some time ago and she is here today for
the results of DEXA scan. The station is about alendronate and osteoporosis not
the fracture or the surgery.
D: Hello I am one of the doctors here in the GP surgery am I talking to Malaz?
P: Yes.
D: Can I have your full name and date of birth please.
D: I can see from my notes that you were admitted to the hospital for fall that
unfortunately injured your hip, am I correct?
P: Yes doctor it was a difficult a time !
Rapport Qs
D: Must have been a dreadful experience, how are you doing now?
P: I am much better doctor.
D: I’m happy to hear that. May I ask you how it happened? (Explore the cause
of the fall, her house might need some modifications)
P: I was walking around the house and there was some loose carpet, I just
tripped and fell.
D: Are you in any pain now? Or Any problems with movement?
P: No or Well the painkillers are working just fine (explore here or later by 2
questions tops)
D: What type of painkillers are you taking?
D: Are you taking them as prescribed?
D: Do you have any problem with them?
P: Not really, all is well.
+/- How was your hospital stay and the care by doctors and nurses? (don’t
overdo rapport if you don’t have time)
D: Do you remember what happened in the hospital? How were you
managed?
P: When I went to the hospital, they gave me some painkillers and did an X-Ray
of my hip after which I was booked for the surgery.
D: I understand that you had some special scan recently, right?
P: Yes doctor I am here for my scan results.
D: Do you know what these tests are for? (Explore knowledge)
P: Not really.
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D: Has anyone told you about the results so far?

P: No.
D: I have the results right here with me, but I would prefer it if we had a chat
about your health first to put me in a better position to explain things, would
it be fine with you or would you like me to explain them now?
P: Whatever suits you doctor is fine by me.
P2
P: No.
P: HTN.
D: Since when? Explore briefly
P: For last few years.
D: Do you take any medication for it?
P: I am taking Amlodipine.
P: Yes.
D: Any other medical illness? Kidney diseases, or gut problems or gut ulcers or
heartburn.
P: No.
D: Any previous hospitalisations for any reason?
P: When I was 35, I had a surgery to remove my ovary and womb. (no
oestrogen- weak bones)
MAFTOSA
D: Are you taking any medications including OTC or supplements? Steroids,
vitamin D, Calcium
P: No.
P: No.
D: Have there ever been any bone disease or unusual fractures in the family?
P: My mother and grandmother both of them had the same fracture about my
age, they fractured their hips.
D: Who do you live with? (Social Care and support)
P: I live with my husband.
D: Was he able to help you around?
P: Yes doctor.
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P4
D: Sorry for asking this question, it may sound intrusive , I know you are 65 ,
but its related to your condition , how long ago was your Last Menstrual
Period? (You don’t have to repeat if she mentioned about oophorectomy but
never forget to ask this question otherwise, Early menopause)
P: When I was 35 when my womb and ovary were removed.
D: Have you been pregnant before?
P: Yes I have 2 children when I was 25 and 29.
D: Have you received any Hormone Replacement Therapy after your
menopause?
P: I was offered it but I didn't take it.
DESAS
D: Can you tell me about your diet?
P: It’s healthy.
D: Do you eat greens, cheese, fish or eggs? (calcium/ vit D)
P: No.
P: Used to be quite active, until I got the fracture. But I am recovering.
D: Do you smoke?
P: Yes/no
P: Yes/no
Examination:
I would like to take your vitals your blood pressure and I will do a general
physical and examine your hip as well. Also check your height and weight (BMI)
would that be fine?
Management:
D: Thank you for bearing with me, I’ll explain everything now. The scan you had
is called DEXA scan it is basically to assess how strong your bones are especially
after that fracture you had. The results show your bones are in some sense
porous and therefore weaker than normal because of a slight reduction in its
density and quality.
This condition is called Osteoporosis and it develops slowly over the years.
Without treatment the more porous and fragile your bones will become, the
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higher the risk of a similar fracture happening again in the future. Are you
following so far?
P: Yes doctor but why do I have this osteoporosis?

D: In your case you might have a handful of causes:
− Age
− Having your ovaries removed at an early age cause, so a decrease in
oestrogen hormone, which normally helps maintain bones.
− Not eating enough dairy products rich in calcium and vitamin D which
are the main maintainers of strong bones.
− Having a family member with similar problems so it might be genetic as
well.
P: So what happens now doctor?
ARMMS
1. Advice
− It is highly advisable for you to increase the calcium in your diet which is
important for your bones by eating lots of greens and dairy products.
− It is important to expose your skin to sunlight daily as it is a source of
vitamin D, which is important for your bones too, or take vitamin D
supplements.
−
2. Risk factors
We would like to prevent future falls and bone breaks, so :
a. We can arrange with the occupational therapist to do simple
changes in your home to decrease risks. They check your home for
any hazards that may cause you to trip over, would you be happy
with that?
b. Also, it’s better to have regular hearing and sight tests.
3. Medication and investigations

Medicine counselling:
- I will inform my senior as we would like to start you on a special medicine
called Alendronate which helps strengthen your bones. Would you like me to
discuss it with you?
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P: Please doctor.
❖ Bisphosphonate******
− It should be taken on empty stomach with a big glass of water in
upright sitting or standing position and for 30 mins do not lie down.
− You can eat 30 min after taking it.
− Some side effects related to it such as irritation or pain in your stomach
or Jaw pain(necrosis) , if you have any of them please let us know,
mostly they will improve gradually with continued use.
− You may need it for 5 years.
Other supplements and ttt that will prove useful:

• Calcium: Important mineral in your body to have healthy bones -2
tablets every day
• Vitamin D: to enhance Ca absorption
• Hormonal ttt: (If she is not already on this)
4. Multidisciplinary team:
We can refer you to a dietitian if you are interested to give you advice about
your diet.
Exercise is good for you as it increases strength of your muscles, gym instructor
can guide for the best exercise for you.
5. Safety netting
If you experience any side effects after you start your medications such as jaw
pain or tummy pain , come back to us immediately.
NOTE
The patient may ask about swimming ? You can swim , but take extra care not
to fall.
What about dancing ? You can dance , actually it’s good for you.
❖ Other medications that may be mentioned in the stem and may require
explanation:
Aspirin:
− Taken orally dose will be mentioned 75 mg
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− Every day with water

Codeine:
− Dose: 30 mg QDS (4 times per day)
− Taken orally
− Used for pain relief
− Might cause some constipation
Laxatives:
− To be taken twice daily to help with the pain killer induced constipation.
Paracetamol:
− To be taken when needed for pain relief.
− Orally with water.
− Maximum dose 1 or 2 tablets every 6 hours but only take it when
needed.
BP Medication:
In another scenario postural hypotension will be the cause of the fall so the
dose will be reduced after revising with senior.
Lisinopril: 10 mg reduced to 5 mg and then review with cardiologist at your
next appointment.
Contraception
Take these crucial basic concepts for contraception and apply to any case:
1. In most cases you will give COCP or pills unless there is a strong
contraindication.
2. The age of sexual consent in England and Wales is 16, however when it
comes to contraception and STI advice, it’s always better to counsel and
provide because they are likely to have sex with or without the
contraception.
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3. You can always provide counselling about contraception/ abortion/ STI

advice/ STI treatment without parental consent to young people less
than 16 IF they have mental capacity.
4. You can encourage the teenager to tell her parents but never force her
and make sure that the conversation will be safe and will not pose any
threats on the patient’s wellbeing, otherwise don’t involve parents
Eg: explore how her parents are? How are things at home? Does she feel
safe there? How is the relationship with her parents? The same
questions apply to teenage males.
NB: Mental capacity means that the individual can

1. Understand information
2. Retain information
3. Repeat it when asked
4. Weigh the pros and cons of each option
and choice when explained.
So simply if the patient can think, respond, understand and engage in a
conversation then he/she has mental capacity.
Confidentiality
When to disclose:
1. If lacking mental capacity.
2. Child in an abusive relationship.
3. Underage: less than 13 of age whatever the circumstances (AGE OF
CONSENT IS 16)
4. If there is big age difference (If one’s age 13-16 and other is more than
16).
5. Partner is in a position of trust I.E (teacher, GP, coach, religious leader)
(AGE OF CONSENT BECOMES 18 IN THIS CASE)
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6. If the relationship involves Drugs/ Alcohol/ Bribery/ or being forced

into intercourse.
7. Explore the nature of the relationship and raise concerns if you are
suspicious but you can’t judge the situation, or the patient is not
sharing much info; weigh risk vs benefit and act in patient’s best
interest.
Remember this timeline:
➢ Less than 13: always disclose to
Key for Emergency Contraception station:
SS and parents.
1. Presenting complaint is unprotected sex (2
➢ 13-16: no need to disclose as
words)
long as both are within the
So,
same age group and no red
➢ First word (unprotected)
flags as mentioned above.
− When did you last have unprotected
(Drugs etc)
sex?
➢ More than 16: no need to − Was it the first time ?
disclose as long as partner is not ➢ Second word (Sex) take full sexual hx.
in a position of trust (18) ➢ 14 years old?
So,
Sexual Hx:
• Explore partner (age and relationship)
1) Are you currently Sexually active?
− Age?
2) Do you have a Stable partner?
− How do you know him?
3) For How long?
− How is your relationship with
4) Any other partners?
him?
5) Do practice safe sex?
• Assess mental capacity.
6) Does your partner have similar Sx?
7) Ever had STI screening? ➢ Exclude Contraindications
➢ Discuss Medications (morning after pill)
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Emergency contraception
Who you are: You are FY2 in GP clinic.
Who the patient is: 14 year old Alberta came to the clinic. She had unprotected
sex and she has some concerns.
What you should do: Please talk to the patient, assess the situation and

clinic. Am I talking to Alberta?
P: Yes.
P: (Confirms details).
P: I am here for the morning after pill/I need emergency contraception.
D: OK we can discuss the different options available to you regarding
emergency contraception. But may I ask you why you need it to make sure you
understand what it’s for?
P: I had unprotected sex with my boyfriend last night.
D: Alright well you’ve done the sensible thing by coming here today. You look
distressed, are you ok?
P: I am scared doctor, I don’t want to get pregnant at this age.
D: Don’t worry I will see what we can offer you regarding the contraception
but I would need to ask you a few questions that may sound a bit intrusive
but they are important to decide which option would be safest and most
effective for you.
P: Ok.
She will be really nervous and at some point she gets too anxious to open up.
Get her to calm down and explain this a safe place and offer confidentiality.
P1 → Unprotected Sex so take sexual hx.
You mentioned that the incident happened last night, correct?
P: Yes.
D: Before this incident, had you been sexually active?
P: Yes.
D: May I know for how long?
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P: Just a few weeks.

D: Was it the first time you’ve had unprotected intercourse? Or has it
happened before last night as well?
P: First time doctor.
D: Do you usually use any form of contraception?
P: Yes, doctor we always use condoms.
D: So it was just last night that you didn’t.
P: Yes.
D: Okay, so you said you have a boyfriend right?
P: Yes.
D: For how long have you been together?
P: For about a month and half now.
D: Do you have any other partners or just him?
P: No.
D: Do you mind telling me the age of your partner?
P: I won’t answer it doctor what has that got to do with anything? I am only
here for the morning after pill are you going to give it to me or not?
D: Alberta, please don’t worry, this is a safe space where you can speak freely
and not worry about anybody hearing about it. I am here to help you. But
before giving you the emergency contraception, I want to make sure that you
are safe and you’re not in any danger or being forced to do anything you aren’t
comfortable with. So I need to ask some questions about him, is that OK?
P: OK.
D: So how old is he?
P: 15.
D: OK thank you for telling me that. Has anybody threatened you or forced you
into having intercourse when you didn’t want to? (You can use the word
‘anybody’ instead of ‘your boyfriend’ as it sounds less accusatory towards
someone she probably cares about. It also covers the possibility of any
separate third party abusing or trafficking her at the same time.)
P: No nothing like that.
D: OK, and how did you meet him?
P: He is one of my friends at school.
D: Is he the only person you have ever had intercourse with?
P: Yes.
D: OK. Thank you for trusting me with those answers.
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IF she had many partners before ask “Have you ever had any sexual
intercourse with any adult, by that I mean anyone over 18?”
P4
P: 2 weeks ago.
D: Are your periods regular?
P: Yes.
D: Any bleeding or discharge between periods?
P: No.
D: Do you have any tummy pain? (ectopic)
P: No.
Assess MENTAL CAPACITY BY ASKING Qs, CHECK UNDERSTANIDING AND
OBSERVE HOW SHE RESPONDS. (If she answers → so she has mental capacity)
D: How did you come to know about the morning after pill?
P: They told us about it in school.
D: Do you know what it is used for? (If you already covered this Q you don’t
need to ask again.)
P: Yes. It prevents pregnancy after unprotected sex.
D: Do you know what will happen if you don’t take it after unprotected sexual
activity?
P: Yes, I might get pregnant and that is what I fear.
D: Do you know that it doesn’t protect you against sexually transmitted
infections.
P: I know they told us that in school.
➢ If she doesn’t know explain, then see and if she understands then she still
has mental capacity
Social support
P: My parents.
D: How is your relationship with them?
P: It’s very good doctor, I love them.
D: So have you tried talking to them about this relationship?
P: No!
D: May I know why?
P: I don't want them to know.
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D: OK, whatever we discuss here is confidential as I said, but we do advise you

to discuss this with your parents as you can get some support from them.
P: That is ok. I don't want them to know.
P2+MAFTOSA+ DESA (to exclude CI)

D: Have you ever had this pill before?
P: No.
D: Have you been diagnosed with any medical condition in the past? (Liver
problems, Asthma, epilepsy)
P: No.
D: Are you currently taking any medications, over-the-counter drugs or
supplements?
P: No.
D: Any allergies?
P: No.
P: No.
D: Have you ever taken any recreational drugs? (Signpost before this Q if you
have not already)
P: No.
Management:
D: There are two types of emergency contraception: Morning after pill or
Intrauterine device/ coil which can be inserted into your uterus at a sexual
health centre. These can be given within 72hrs and 120hrs after having
unprotected sex. Which one would you prefer?
P: The morning after pill.
Discuss about the morning after pill following the medication points as we said.
↓
1) Form : two types of emergency contraception
− Levonelle tab (which is taken within 3 days ).
− Ellaone tab (Taken within 5 days of unprotected sex).
2) Mechanism (how does it work) ) It works by preventing or delaying release

of an egg.
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3) When should it be taken ?

➢ You will take one now ASAP in front of me with water because the earlier
you take it , the more effective it is.
4) Are there any side effects ?

➢ Usually side effects are uncommon ; however , feeling sick , diarrhea ,
dizziness , breast tenderness are common side effects.
If you do feel sick and vomit within two hours of taking the pill , make sure you
take another one (v. important).
Safety netting and general advice:

Here are some things that you need to be aware of and things that you need to
watch out for:
➢ NOW:
1. There is still chance that you might get pregnant So→ if your period is
overdue , make sure you do a pregnancy test or come back to us for a
checkup.
2. There is also a serious condition that can rarely happen (ectopic pregnancy).
It's pregnancy outside the womb. It's usually in the ovarian tube, so if your
period is late and you have pain and bleeding , come right away.
➢ Future
3. This pill does not protect you against sexually transmitted diseases. So you
will need to keep using condoms because it is the only effective way for
preventing STIs.
4. The pill will not protect you against future unprotected sex so if you are
going to continue having intercourse you can come back to us to discuss
long-term contraception.
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Contraception Counselling
Case:
22 year old, Daisy Sampson , came to GP clinic with a concern. Talk to her.
Revise OBG chapter this is a summary of Contraception options

Approach:
D: Hi , I am dr (name) , are you Daisy?
Can you confirm your full name and D.O.B.?
How can I help you today?
P: Dr, I want a method of contraception
D: OK, I can help you with that. Are you using any form of contraception at the
moment?
P: Yes
D: What are you using ?
P: Condoms.
D: Is there any reason why you want to change contraception? You want
something more long-term maybe?
P: I’m worried about them breaking, I want something better.
Well, we have 2 different methods: pills and devices. What would you like
me to discuss first?
P: (Any).
So, before we go ahead can I have a short chat with you first about your
health?
(Make it a patient centred approach, discuss what she needs to be discussed
first)
Quick history to exclude contraindications:
1) Do you have a stable partner?
2) Do you have children?
3) Have you taken any contraceptive pills before?
4) Do you have any medical conditions?
5) Are you on any medications?
6) Are you allergic to anything?
❖ Combined oral contraceptive pills

• Tablet.
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• Once a day with water.

• It has 2 components oestrogen and progesterone.
• Mechanism: Prevents ovaries from releasing eggs, thins the
endometrium lining, thickens cervical mucosa.
• In some situations we don't give this pill:
So:
− Do you have any chest pain or SOB?
− Have you ever had any blood clot in your heart or lung?
− Are you on any blood thinners?
− Any of your blood relatives had blood clot in heart or lung ?
− Do you have any liver diseases?
− Do you get migraines ?
− Do you smoke ?
− Any family members diagnosed with breast cancer?
❖ Another medication called Progesterone Only Pill

• It does not contain oestrogen.
• So, there are none of the side effects that usually happen with COCPs.
• Tablet to be taken with water by mouth.
• It works by → Preventing ovaries from releasing eggs, thins the
endometrium lining, thickens cervical mucosa.
• Advantages:
− 99% success rate.
− Reversible method.
− Does not cause clots.
• Side effects:
− Irregular periods, vaginal blood spotting.
− Headaches.
− Mood swings.
− Weight gain.
− You do need to remember taking it.
❖ Contraceptive implants
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• Small flexible tube that is inserted under skin of upper arm releasing
progesterone.
• It lasts 3 years.
• 99% effective.
• It works by → (same as progesterone)
• One of the advantages
− You don't need to remember
− Reversible.
❖ Intra – uterine devices
• A plastic or copper device put in uterus.
• Mechanical barrier works by preventing egg and sperm from meeting.
• The copper also has spermicidal effect.
• Advantages
− You don't need to remember.
− 99% effective.
− 5 years or more.
• Disadvantages
− Damage to uterus.
− Pelvic inflammation.
− Heavy or painful periods.
− Ectopic pregnancy.
❖ Hormone–releasing intra-uterine device.

• Plastic device that contains progesterone hormone.
• It works by:
− Mechanically by preventing sperm and egg from meeting.
− Hormonally: Secrets hormone that works only locally on the
uterus (progesterone), Prevent release of egg, Forms mucous
plug.
Advantages → Remain in place for 5 years.

− 99% effective.
− Do not need to remember.
− Does not have systemic side effects.
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❖ Female Sterilisation
• Permanent method.
• By blocking the part of fallopian tube that connects ovary to uterus.
− 99% effective.
− Difficult to reverse it and NHS does not fund it.
• However, we highly recommend condoms as it's the only method to protect

against STIs especially if patient is not in a stable, exclusive relationship.
Apixaban Nosebleeds
Who you are: You are FY2 in the GP surgery.
Who the patient is: John Lennon has had a nosebleed. He is on Apixaban.
Dr: Hello, my name is dr (name), I am one of the doctors in this GP clinic. Can I
get your full name and date of birth please?
Dr: How can I help you today John?
P: I had a nosebleed doctor about 2 hours ago.
Dr: I can see you’re pretty anxious about it. How are you now?
P: I am fine. But to be honest I panicked, and I came to GP right away.
P1 epistaxis ODIPARA+TRAC
Dr: If you were worried it’s good that you came in about it. You mentioned it
happened two hours ago(Timing), can you say how much blood there was?
(Amount)
P: Around a quarter of a cup doc.
Dr: Any idea how the bleeding started? Were you doing anything specific
before? (Relation)
P: I picked my nose, then bleeding started.
D: Did you notice what the blood was like? Was it bright red (frank) blood or
was it mixed with mucus? Character
P: Bright red blood doctor.
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Dr: For how long did you bleed? (Duration)

P: I think for around 10 minutes.
Dr: Did you try anything to stop it?
P: I just put a towel on my nose.
Dr: Is it still bleeding?
P: No doctor it stopped by itself.
Associated Sx
Bleeding tendency:
Dr: Have you had any bleeding from anywhere else in the body?
P: No.
D: Any rash like red or purple spots on your skin?
P: No.
D: Do you tend to bruise easily?
Anaemia:
Dr: Do you feel you’re tired more than usual? (ITP)
P: No.
Dr: Any fever/ or repeated infections? (Blood malignancies)
P: No.
FLAWS
Dr: Have you noticed any weight loss or lumps or bumps in your body?
Pt: No.
Complication Sx:
D: Do you feel dizzy, drowsy, or about to faint? (Shock)
P: No, doctor I am fine.
Dr: Any headaches or vision problems? (HTN) and (ICH)
P: No.
P2
Dr: Is it the first time it’s happened?
Pt: Yes.
Dr: Have you ever been diagnosed with any bleeding disorders?
P: No.
Dr: Do you have any long-standing medical conditions?
P: I have had a clot in my leg for the last 3 years.
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MAFTOSA+DESA
Dr: Are you taking any medications for it?
P: I am taking Apixaban.
(explore)
Dr: For how long?
P: The last 3 years.
Dr: Are you taking it as prescribed?
P: Yes.
Dr: Are you going for your regular blood check-ups?
P: Yes.
Dr: Are you taking any other medicine (blood thinners)?
P: No.
Dr: Do you have any allergies?
P: No.
Dr: Have any of your family members ever had similar problems?
P: No doctor.
Dr: What you do for living?
P: I am a student.
Dr: Do you do any form of exercise? (Contact sports)
P: No.
CONCERN
D: Do you have any specific concern regarding this bleeding?
P……….
EXPECTATION:
P:…….
Examination:
I would like to take your vitals now if you don’t mind? Especially your blood
pressure, and pulse. I would also check your nose, mouth and some glands in
your body.
Dr: From what we have discussed so I suspect that you had this bleed because
you picked your nose. What you need to understand is that it’s a common side
effect for people who are taking Apixaban. In most cases it is not that serious
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and can be avoided by simple advice. Shall I give you some advice on how to
avoid it in future?
P: Yes doctor but I have a question, why don’t I stop taking the medicine then,
if it is the cause, I mean it’s not normal to have a nosebleed whenever you pick
your nose?
Dr: I completely understand what you are saying, it’s not pleasant to keep
having nosebleeds, but what you need to continue taking Apixaban as it is
necessary to keep your blood thin in order to prevent it clotting. Stopping the
medicine would increase the risk of clot complications that may cause heart
attacks or a stroke, which by far are much more serious than just a few
nosebleeds that can be avoided? Are you following so far?
P: I read on the internet that having your blood too thin can cause serious
bleeding like what I had, I am worried doctor…
Dr: I am glad that you are keen on understanding more about your meds and
their risks. Well usually we have frequent follow ups and regular blood testing
to make sure that your blood is not too thin. We also give advice about how to
protect yourself to avoid bleeding and how to deal with any bleeding if it does
occur. How would you feel about that?
P: OK tell me your advice then.
Management:
Senior: For now I would like to review your medications with my senior to
make sure that everything is ok.
Investigations
We are going to run some routine blood tests and bleeding profile including
INR, to make sure that your blood is not too thin.
Symptomatic ttt
To stop a nosebleed yourself
A. Sit down and lean forward, with your head tilted forward.
B. Pinch your nose just above your nostrils for 10 to 15 minutes.
C. Breathe through your mouth.
Hospital treatment for nosebleeds

− If we can see where the blood is coming from, they may seal it by
pressing a stick with a chemical on it to stop the bleeding.
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− If this is not possible, we might pack your nose with sponges to stop the
bleeding. You may need to stay in hospital for a day or two.
When a nosebleed stops

− After a nosebleed, for 24 hours try not to ( blow your nose - pick your
nose - drink hot drinks or alcohol - do any heavy lifting or strenuous
exercise - pick any scabs )
Safety netting
Come to A & E immediately if :
− Nosebleed lasts longer than 10 – 15 minutes.
− Excessive bleeding.
− If you swallow a large amount of blood that makes you vomit.
− If bleeding started after a blow to your head.
− If you are weak or dizzy.
− If you have any difficulty in breathing.
Follow up
Dr: We will arrange your follow up in a month, to see how you’re are doing.
I will also give you a leaflet about Apixaban so you know more about it from
the NHS rather than the internet.
Blood pressure management

Who you are: You are an F2 working in GP clinic.
Who the patient is: Angel Di Maria aged, 55, presented to you for his first
follow-up. Patient has diabetes mellitus. Patient has been admitted to the
hospital due to cellulitis four weeks ago and was treated for it with antibiotics.
During the admission, patient was newly diagnosed with hypertension. On
discharge, patient was prescribed with some medications.
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What you should do: Please talk to the patient, take focused history, check
his/her blood pressure and discuss further management with the patient. This
is patient’s first review after being diagnosed with high blood pressure.

clinic, am I talking to Angel?
P: Yes.
D: Can I have your full name and date of birth please?
P: (Confirms name)
D: I can see from my notes that you had been admitted to the hospital 4 weeks
for an infection. How did that go?/ Can you tell me what happened?
P: Yes, doctor it was four weeks ago when I was diagnosed with cellulitis, and I
was admitted to the hospital. I was treated with antibiotics, I recovered later
well. During that period, I was diagnosed with high blood pressure and I have
come here for my review today.
Rapport Admission.
D: Thank you for coming, may I ask you how you’re feeling today? How is your
leg?
P: Much better.
D: Are you in any pain or fever now?
P: No not really doctor.
D: I’m glad to hear that. How was hospital stay back then?
P: Aah doctor it was dreadful…
D: I am sorry to hear that. How was the care by the doctors and the nurses?
Did anything in particular happen?
P: No not like that I am just not really fond of being hospitalised.
D: Well, I can understand that, if I am not mistaken you have been prescribed
some medication for your high blood pressure?
P: Yes doctor (points towards Enalapril).
D: I am here today to discuss your medications with you. and I would like to
explore a bit about your health generally to check how you’re recovering.
Would that be alright?
P: Sure doctor.
Note
• In this station, dose will be written already, the purpose is actually making
the patient understand. Taking focused Hx and addressing his concerns.
• Talk slowly and always ask the patient
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> Are you following me ?

> How does that sound ?
D: Do you have any specific concerns that you would like me to tackle with you
today?
P: I don’t like the medication This blood pressure medication gave me a
cough.
D: May I ask why you think it’s the medication that’s giving you a cough?
P: I have been taking these (point towards Aspirin and Statin) for a long time
and I never had any problems. I am sure it is because of my blood pressure
medication. I don't want to take this medication.
D: We do have other medicine options that we can discuss but if you don’t
mind, I would like to know more about the cough?
P: Okay.
P1 Cough ODIPARA:
D: When did you start having this cough? Onset and duration
P: Few weeks ago since I started taking the medicine.
D: So you didn’t have any cough before you started your medications?
P: No.
P: Nothing.
D: Any change since it started? Getting worse? Getting better? Course
P: No.
D: Any discharge, phlegm or blood with this coughing?
P: No, its dry.
Associated Sx and DDX
D: Any fever, flu-like symptoms ? (Pneumonia)
P: No.
D: Any headache? Any dizziness? Any visual problem? (HTN Sx)
D: Any chest pain. SOB or heart racing? (Heart Failure Sx)
P: No.
Explore Medication:
D: How about the medicine, are you taking it as prescribed?
P: I was but I stopped taking it 3 weeks ago after I had the cough.
D: Any symptoms after you stopped taking your blood pressure medication?
P: No.
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P2
D: Any similar cough in the past?
P: No.
D: Do you have any other longstanding medical conditions?
P: Yes I have DM.
Explore briefly
D: For how long?
P: 10 Years.
D: How do you manage it?
P: My diabetes is controlled by diet.
D: Are you taking any medications for it?
P: No doctor.
P: Yes.
D: Do you go for your GP appointments and annual check-ups regularly?
P: Yes I frequently come to my GP here and he says my diabetes is well-
controlled.
D: That’s great.
DM Sx
D: Any problems with going to the toilet or your weight recently?
DM complications:
D: Have u ever been hospitalised for any reason, other than this last
admission?
P: No.
MAFTOSA:
D: Since when have you been taking these Aspirin and statin?
P: 10 years.
D: Do you take them regularly?
P: Yes doctor.
D: Are you currently on any other medications apart from those you
mentioned?
P: No.
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P: No.
D: Any Family Hx of similar cough problems?
P: I am not sure.
P: I’m an architect.
DESAS
P: It’s quite healthy I think.
P: No.
D: Do you smoke?
P: Yes/no
D: Have you been stressed about anything lately?
P: Yes/No
Examination
D: Is it OK if I take your vitals and your blood pressure now and also examine
and listen to your chest as well?
EX: 170/100.
Thank you for bearing with me Angel. From you have told me so far (Mention
postives), I agree with you that you probably have the cough as a side effect of
the BP medication you were prescribed which actually does cause a persistent
dry cough.
From the examination I have done, your blood pressure is pretty high at the
moment and it is probably because you haven't taken your blood pressure
medication in the last few weeks. This can be serious as well of we don’t
manage it properly. Is everything making sense to you Angel?
Management:
Seniors:
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I will discuss this with my seniors. We will probably change your medication to
another one that hopefully you can take without any problems this time.
Investigation: Routine and CXR
Treatment:
We will change your medication to another group of medication (ARBs). I will
double check your new medication with my book as well.
Please don’t stop your medication without consulting one of the doctors here
first and take them regularly as we prescribed, otherwise you may face many
problems in the future if your blood pressure remains high. It can damage your
blood vessels, heart and brain. If you at any time develop any side effects,
please feel free to come back to us.
S/E of ARBs: Dizziness, headache, drowsiness, nausea, vomiting, diarrhoea,
elevated potassium levels.
Advice About DESAS as before
Safety net:
− HTN complications: Chest pain, SOB, cough, vision, weakness anywhere
in your body.
− DM complication and Sx: Frequent trips to toilet, weight loss.
NOTE:
Sometimes the patient is on Amlodipine complaining of Ankle oedema (a
common side-effect of CCBs). Same approach and change to other medicine
after revising with your senior, and confirm with your BNF book.
If the patient is insisting to know the substitute, then say ACE inhibitors
(Ramipril)
Always remember that you don’t have to mention drug name or dose
yourself unless the patient asks you specifically and if it happens try to give a
smart answer like ‘I’ll check with senior and BNF’.
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Post MI Lifestyle
Who you are: You are an FY2 in Medicine.

Who the patient is: Morten Peterson had MI 4 days ago. He was admitted to
the hospital. He has been medically managed. He is going to be discharged.
Additional information: Patient has been prescribed the following medication:
Aspirin, Bisoprolol, Simvastatin, Clopidogerol, and Ramipril.
What you should do: Please talk to the patient, discuss about lifestyle
modifications and address patient’s concern.
(Remember this a tricky station because you can easily lapse into a long
needless history. What you need to explore in hx are (Complications and red
flag Sx , risk factors, and DESA) then then follow the usual structure in
counselling and focus on the risk factors he has first. Then mention the rest
later, safety net about red flag Sx and what to do if he experiences a similar
attack)
D: Hello, I am one of the doctors here in the medicine department. Am I talking

to Morten
P: Yes.
D: Can I get your full name and date of birth please?
Rapport of Admission and Discharge Qs
D: So Morten I understand that you had been admitted 4 days ago with a
heart problem, may I ask you how much you know about your condition ?
P: I was told that I had a heart attack.
D: Yes you are right. So can you tell me what happened? /What Sx did you
have?
P: I had the worst chest tightness ever about 4 days ago. I came to the hospital
and they told me it’s a heart attack. I was kept here, and I was given some
medication.
D: It must have been a dreadful experience, sorry about that. Are you having
any chest pain now? Do you feel tired or dizzy? Any chest tightness? Any
SOB? Any heart racing? Any ankle swelling?
P: No.
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D: How do you feel today?

P: A few days back it was a real nightmare. Thankfully it I am better now and
ready to go home now.
D: Glad to see you well and energetic. How about your hospital stay ? How was
the care by the doctors and nurses?
P: Really good.
D: Great, do you know what investigations were or what medication was
given?
P: I am not quite sure I remember, but I know I was treated for a heart attack.
D: Well I am glad you are feeling well and ready to go. That’s basically why I am
here, my consultants have decided to send you home with some medications
to take, and we wanted to discuss a few things about your health and the
medications before you go. Would that be okay?
P: Yes sure, I was told that someone is going to talk to me.
D: Sorry if I have kept you waiting. About this pain have you ever had similar
attacks in the past?
P: No.
MAFTOSA
D: Have you been diagnosed with any medical condition in the past? DM?
HTN? High cholesterol?
P: No.
D: Do you know about the medications we have prescribed for you to take at
home? Do you know how to take those medications?
P: Yes.
P: No.
P: I am a businessman OR Bus driver.
D: Would you say that you are usually stressed?
P: Definitely doctor yes.
DESAS
P: Wouldn’t say healthy, mostly fast-food and microwaveable things, I don’t
get enough time to cook.
D: Do you do any form of physical activity?
P: No.
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D: Do you smoke?
P: Yes.
D: How many packs per day?
P: About 20 cigarettes a day.
P: Yes.
D: Do you have any specific concerns on your mind?

P: Well, I do have to travel a lot for different conferences? I have one in 3 days
and I have to be there. When, can I go back to work?
D: Okay I see, that’s a very valid concern. What about your expectation, what
are you hoping to achieve from our discussion today?
P: I was hoping to have some advice about my lifestyle and what changes I
have to make.
D: Well that’s exactly what I was going to discuss with you, but before that I
would like to explain more to you about what you had, why you had it and how
to prevent it in the future.
P: OK doctor.
Examinations: Mostly vitals and general physical as before.
Diagnosis:
The heart needs its own blood supply for the heart muscle to survive. During a
heart attack, the blood flow to the heart stops because of a narrowing or clot
in the blood vessels. It can be life-threatening if it is not treated. Fortunately,
you were treated and are recovering well now. Further attacks can be avoided
by adopting some lifestyle modifications, as you mentioned, along with the
medication we started you on.
Now, many factors can cause a heart-attack to take place. Some of them are
called non-modifiable factors because they cannot be avoided, like age , family
Hx. However, some factors can be modifiable, like diet and other lifestyle
factors. So if we manage to improve these factors then the chance of you
having heart attack will decrease.
Shall I continue? Are you following so far?
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P: Yes, please!
DESA advice as before: Counsel about diet, physical activity, smoking, alcohol
as before.
Then, ask about driving:
D: You mentioned that you travel frequently OR you mentioned you are a bus
driver:
− Many people can now return to driving 1 week after a heart attack,
as long they do not have any other condition or complication that
would disqualify them from driving and they are able to perform an
emergency stop without any pain.
− But in more severe cases, at least 4 weeks after a heart attack may
be needed depending on patient recovery.
− DVLA recommends that patient who drive a bus or coach should stop
driving for at least 6 weeks after a heart attack.
− Might be better to inform the DVLA especially if working as a driver,
the DVLA have special guidance about driving again and they might
need the driver to take an exercise tolerance test.
D: You also mentioned you want to go back to work: Most people can return
to work after a heart-attack , but I am afraid to say early work return can
cause another attack because of all the stress and effort you go through there.
− If your job involves light duties, such as working in an office, you may
be able to return to work in 2 weeks.
− If your job involves heavy manual tasks or your heart was extensively
damaged, it may be several months before you are fit enough to go
back. It’s better to rest for 4-6 weeks. (Or 2-3 months depending on
your recovery).
D: How do you feel about that? Do you have any other concerns? (Keep asking
about concerns as new ones can always come up along with your
consultation)
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P: When can I have sex again?

D: Patients are usually able to have sex again once they feel well, usually in 4 to
6 weeks after a heart attack. (As long as you can walk without any discomfort
such as shortness of breath.) If you are taking Viagra (Sildinafil), then don’t
take GTN 24 hr before and after taking sildenafil.
P: Sometimes I will have to travel by plane, is it safe?
D: You can fly after 2 – 3 weeks. (If it’s the first time he has had a heart attack
and has no other risk factors.)
Management: Ask about the medications, whether they were explained, or
not so don’t discuss much about them unless the patient asks or the task
mentions clearly to explain medications. If any medication are not explained,
then explain it.
Explain what GTN is, when to take it and what it does (improves blood flow
to your heart)
MDT: Refer to Cardiac rehabilitation for follow up and better recovery.
Safety net: If you ever have heart attack Sx:
− SOB
− Chest pain going to left side with jaw pain
− Heart racing
− Sweating, etc.,
➢ Take GTN spray & wait 5 min watch out if you feel too dizzy or drowsy
this might be your blood pressure dropping.
➢ If not relieved, take 2nd time & wait 5 min.
➢ If not relieved, take 3rd time & call ambulance urgently and make sure
to mention “I feel I am having a heart attack” to trigger a quick
response. Please don’t drive yourself to the hospital. If possible ask
someone around you to do so or call the ambulance.
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Post MI Heart failure
Who you are: You are an FY2 in GP.

Who the patient is: David Fisherman aged, 68 has come the clinic for his heart
failure medications follow up. He had a heart attack 6 weeks ago for which he
was admitted. Later was discharged on these medications. Clopidogrel,
Ramipril, Atorvastatin, Bisoprolol
Special note: He was advised follow up every 3 weeks with cardiologist and
every week with the GP.
What you should do: Please talk to the patient and address his concerns.
D: Hello, my name is Dr(name) I am one the junior doctors in this GP surgery.
Can you confirm your name and age for me please?
P: My name is David Fisherman, I am 68 years old.
P: David is fine.
D: OK David, I can see you are here for your follow up, am I correct?
P: Yes, doctor I was advised to come every week to my GP.
Explore the previous attack (PAST)

D: Can you please give me a brief recap of what happened before and how
you’re coping so far?
P: I had a heart attack 6 weeks ago and I was admitted for 4 days after which I
was discharged on some medication.
D: I am sorry to hear that David. How are doing now?
P: I am better now I don’t have any pain. However I keep having shortness of
breath and I get tired a lot quicker than before.
Present
D: I see. So, you are having SOB and tiredness. Are they your main concerns or
is there anything else?
P: Yes doctor I want to know about the medications’ side effects, I am afraid
they may be the cause of these problems.
D: Yes I can see where you are coming from. Is it okay if I ask you a few
questions just to understand your symptoms better?
P1: ODIPARA
D: For how long have you had this shortness of breath?
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P: For a few weeks now after I was discharged from the hospital.
D: How did it start and is it changing for the better or worse?
P: It started gradually and keeps getting worse.
D: Have you noticed anything that makes it worse or anything you do that
relieves it?
P: I live on the third floor and whenever I am going upstairs it gets really bad, I
become so tired that I have to rest for a few minutes halfway before I am able
to carry on. (Factors: Exercise, Lying down, Weather)
D: Is there anything else you noticed that is bothering you? Heart failure
symptoms
P: Yes I believe my ankles are a bit swollen, and it’s going up to my knees.
D: When did you notice that?
P: About 3 weeks back.
D: Is it always there?
P: Yes doctor but it gets worse in the evening and I have to raise my legs up for
a while before it starts improving.
Heart failure and MI sx (5 chest Sx)

D: Any breathing difficulty when you lie down?
P: Yes doctor I have to sleep on a pillow until this breathing difficulty gets
better. Recently I started sleeping on the couch, I can no longer sleep on my
flat bed.
D: Any problems with your urination? (Change in quantity or frequency?)
P: I am not sure.
D: Have you noticed your heart racing?
P: Yes with most of my activities.
D- Any sweating?
P: Yes sometimes.
D: Have you faced any chest pain since you were discharged ?
D: Any nausea or vomiting?
D- Any tremours?
D- Light-headedness?
P: No.
D: Any cough perhaps? (Major Side effect of Ramipril)

P: Sometime I do cough.
D: Any specific time? Is it dry or with discharge?
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P: When I am lying down or with exertion. And it’s usually dry.

D: Any bleeding that you have noticed recently? (Anti platelets-clopidogrel)
D: Any Fever?
D: Any recent chest trauma?
D: Any change in your weight recently?
P: Yes I am gaining weight. Or No.
(These previous questions above cover PASHA DDs for chest Sx.)
P2
D: Have you had any of these or similar problems in the past?
P: No.
D Have you been diagnosed with any medical condition in the past?
P: No only this heart attack.
D: Any past surgeries?
P: No.
MAFTOSA
D: Are you currently on any medication besides the ones you are taking for the
recent illness?
P: No.
D: Are you taking your medications regularly as advised?
P: No doctor.
D: Are you confused about how to take your medications?
P: No (Compliance), I just don’t like them.
D: May I ask why?
P: I don’t think they are helping me and I read they cause a lot of side effects.
D: Had you noticed any of these symptoms before or all after starting your
medications?
P: After I got discharged doctor.
D: Have you attended your GP and heart specialist follow ups?
P: No.
D: Are you allergic to any medication?
P: No.
D: Any family history of any significant health issues or any heart problems?
P: Yes, my father died of a heart attack last year.
D: I am sorry to hear about your loss David. It must have been a hard time for
you and your family.
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P: I am retired.
D: How is all of this affecting your life and daily activities?
P: I don’t like it doctor I have to rest a lot and I used to be active and go for
walks.
DESAS:
P: Balanced and good.
D: Do you smoke?
P: Yes.
D: How much do you smoke? And since when?
(If patient gives a long history and excessive smoking please include smoking
cessation in management as it is major risk factor for MI)
P: About 15 cigarettes a day, since my teenage years.
P: No
EXAMINATION
I would like to do a GPE, check your BP, pulse , breathing rate and temperature
and examine your chest, including your heart. Would that be OK with you?
I would also like to perform a heart tracing ECG and CHEST X RAY scan.
I would like to order initial investigations like routine blood tests. Renal
function test, liver function test and Urine dip. We’ll also check for heart attack
and heart failure markers.
Findings may be given: Bilateral course crackles.

From what you have told me and based on my examination. I am suspecting
you have a condition that affects the heart making it very weak & not pumping
out blood properly to other body parts of your body. That’s why you feel tired.
Blood and fluids also start to accumulate in your lungs causing SOB and in your
ankle causing ankle swelling. This condition is called heart failure. Do you
understand me David?
P: Why do I have this?
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Well, this happened as a complication of the heart attack. During a heart

attack, a part of the heart muscle is changed and becomes too weak to pump
enough blood. Many factors can contribute to this, the fact that you were not
following up or taking the medicine as you were advised might also be factors.
Smoking in itself can have a very bad impact on the heart.
Management:
1. Send to the hospital for care under Cardiology unit.
2. Senior.
3. Investigations → If you have not mentioned, then mention as before.
4. Symptomatic + Lifestyle
o O2
o Diuretics (to get rid of some fluids in your body) 40mg Furosemide.
o D E S A (v. important ) for risk factors (as before)
o Smoke cessation (as before)
5. Heart Specialist → for further investigations and some scans (Echo-

cardiograghy) to show your heart walls. Also we may need to check if you have
significant narrowing of your blood vessels .
Refer to cardiac rehabilitation: for education, support, exercise, and relaxation

techniques.
6. Long term: stress on the importance of medications and being compliant.

− ACE inhibitors.
− B blockers.
− Statins.
7. Safety netting → MI (v. important).
8. Follow up regularly → Once we discharge you.
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Post MI Heart failure medications
➢ If the patient is well with no Sx whatsoever and the stem says that he has
been diagnosed with heart failure and was started on the medications,
explore the patient’s concerns. If all he wants is to understand about the
meds then that is the core of the station.
➢ Follow the same hx (all will be fine). Examine, then manage by DESA advice
and discuss medications.
➢ Make sure to ask CONCERNS, EXPECTATIONS AND IDEAS HERE.

Who the patient is: Daniel Lampson, aged 65, has come the clinic for his heart
failure medications follow up . He had a heart attack 2 weeks ago and was
diagnosed with heart failure. He was discharged on these medications.
Clopidogrel, Ramipril, Atorvastatin, Bisoprolol
He was advised follow up every 3 weeks with cardiologist and every week with
the GP.
What you should do: Please talk to the patient and address his concerns.
Medicine discussion:
Most of the medications you were prescribed are absolutely necessary for your
condition at the moment to protect your heart, improve its functions and
prevent you from having further heart attacks.
As any other medications, they may have some side effects: such as nausea,
vomiting, headache, tummy pain. But they can settle after some time. If they
persist for more than a few days (3-4) come back and we will seek different
options for you but please don’t stop the medications yourself without
consulting a doctor.
Now let’s discuss a bit more about each one:
CLOPIDOGREL:
− Makes blood thinner to prevent formation of clots in your blood.
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− Has a bleeding risk so watch out for falls or any unusual bleeding from
your nose, in your urine, in your stool (darker poo) or easy bruising, any
headache or dizziness call 999 immediately.
RAMIPRIL/ Lisinopril
− Controls your blood pressure as well as prevents further damage to your
heart (remodeling of the heart).
− Can cause side effect of excessively lowered blood pressure like feeling
dizzy, lightheaded, blurred vision, headaches. If they don’t subside come
back so as we review the medications.
− Can induce persistent dry cough, if it does not settle with any OTC cough
medication, come back and we will discuss different options like ARBs.
ATORVASTATIN:
− Important to control the levels of harmful fats aka cholesterol in your
blood. Cholesterol plays a major role as a risk factor for heart attacks, as
it accumulates in blood vessels making their lumen narrower and their
surface more rougher, and both changes together can induce clotting.
− Can cause side effects like n/v/d but also joint and muscle aches,
sleeping problems, runny or stuffy nose and burning in your urine. In
case of such persistent symptoms, come back.
− Consult your doctor before taking any antibiotics as some specific types
can increase statin complications.
− May affect liver and regular follow up is needed.
BISOPROLOL
− Controls your heart rate and blood pressure to some extent as well.
− Can cause sleeping problems, joint pain, cough nausea/diarrhea and
irregular slow heart rate- in case you feel dizzy or unwell call 999
immediately.
I know that all these side effects may sound overwhelming. But realistically
they don’t happen to every individual, as everybody is different. Many may or
may not develop these side effects. We aim to educate and warn patients
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about them in case they feel anything unusual or unwell so they can come back
and we will review the medications. It’s worth mentioning that it’s very
important for you to take these medications as they will prevent you from
further complications and help control your heart condition.
Other discharge medications that might need explanation in various
situations:
CODEINE:
− This is for severe pain. It has not been prescribed for you to take it
regularly, but you can take it when you have severe pain.
− Certain side effects may occur occasionally, like constipation, feeling
sick, vomiting, feeling sleepy, dizziness or dry mouth. If you experience
any of these please stop taking the medication & come back to us.
CALCETRIOL:
− It is type of vitamin D that will help your body to absorb the minerals
required to strengthen your bones. This has been prescribed twice daily,
you take it in morning & evening every day.
PARACETAMOL:
− It is for pain and fever. If you feel pain, you can take it twice daily.
LAXIDO Sachet:
− This is for constipation. I understand that you do not have constipation
right now. But if you develop constipation, do take it once daily.
Post MI Erectile dysfunction

Who the patient is: Mr Harry King, aged 56, had an MI 3 months ago. A follow-
up was arranged 6 weeks ago. During his follow up, he was diagnosed with LVD
and was prescribed Aspirin, Ticagrelor, Bisoprolol, Ramipril and Statin.
Special note:
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What you should do: Please talk to the patient, assess him and address his
concerns.
D: Hello my name is Dr (name),one of the junior doctors in this GP clinic can I

have your full name and date of birth please?
P: I feel tired doctor.
D: Can you tell me more about your tiredness? (open question)
P1 (ODIPARA)
P: I am always tired all the time since my follow up 6 weeks ago.
D: Yes, I can see from my records that you have been diagnosed with a heart
condition are you aware of what happened exactly at that time?
P: Yes, doctor they said I have some left sided heart weakness and I was
started on some medications.
D: About that tiredness, can you tell me how it started and if there’s been any
change since it started?
P: I started gradually and I am getting more tired as time goes on.
D: Is there any specific time of day you feel more tired?
P: Not really.
P: No.
D: Anything else?
P: I am embarrassed to talk about it.
D: Please don’t be, I am your GP and you can discuss anything with me. This is a
safe place and we are here to help and support you.
P: I am not able to maintain an erection.
D: Tell me more about it? Open Q
ODIPARA
P: After the heart attack.
D: Any change since it started ?
P: Yes doctor but it hasn’t changed much since it started.
Explore ED
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D: I am going to ask you few questions that may sound a bit intrusive, but they
are very important for me to understand what is causing the problem.
Do you have difficulty obtaining an erection or maintaining one?
P: I can get one, but I can’t maintain it doctor.
D: When it happens is it suitable for penetration?
P: Yes.
D: And how long does the erection last?
P: Not long.
D: So are you able to ejaculate at all?
P: No.
D: Any pain or discomfort with erection?
P: No.
D: Is there an unusual shape or curvature of your penis with erection?
(Peyronie disease)
P: No.
D: Do you get a morning erection?
P: Yes.
D: OK just a few more questions about your health and we will come back to
this.
DDx
D: Anything else with tiredness?
D: Do you sometimes feel dizzy or drowsy or that your hands and feet are cold.
(Heart problems)
P: Yes doctor my hands feel cold sometimes.
D: When did you notice it?
P: After my follow up.
D: Any chest pain or heart racing or SOB ? (heart)
P: No.
FLAWS
D: Do you have any lumps or bumps anywhere in your body? (Cancers)
Any swelling in legs or puffiness in your eyelids? (CKD)
D: Have you had any change in your weight or appetite lately? (Thyroid and
cancers)
P: No.
D: Do you feel cold when others feel normal? (Thyroid)
P: No.
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D: Any problems with your water works like going to toilet more often or
feeling thirsty a lot? (DM)
P: No.
D: Any bowel problems like constipation, diarrhoea or tummy pain? (IBD)
P: No.
D: How has your mood been recently? Could you score it from 1-10, 1 being
the lowest and 10 being the highest.
P: Fine, 7.
D: Sleep disturbance or lack of concentration?
P: No.
D: Have you sustained any trauma to your back? (Spinal injury)
D: Have you had a similar problem in the past?
P: No.
P2:
P: Only the MI 3 months ago and I attended my follow up 6 weeks ago.
D: What was done for you in the follow up?
P: I was started on Aspirin, Ticagrelor, Bisoprolol, Ramipril and Statin.
D: Are you taking them regularly as prescribed?
P: Yes.
D: Any bothering side effect after these meds?
P: I asked for any side effects during my follow up but the cardiologist
dismissed my concern completely.
D: Sorry about that. Well we can discuss the medication with you later if you
want.
Have you noticed this problem with erection before or after the medications
were started?
P: After the meds were started.
D: Okay, any other medical conditions?
P: No.
D: Have you ever had any surgeries before?
P: No.
MAFTOSA
P: No.
P: No.
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D: Any family history with similar conditions?

P: No.
D: Who do you live with and how are things at home?
P: I live with my husband doctor.
D: How is your relationship with him?
P: It was fine doctor but I am afraid this problem might affect us as a couple.
D: I am sorry to ask this but have you had any other occasional partners?
P: No doctor I am committed to him? (If he has multiple partners explore,
does this erectile problem happen with all of them?)
DESAS Possible Causes for erectile

D: Do you drink alcohol? dysfunction:
P: Yes/No
D: Do you smoke? 1) Cardiac (Heart failure or Angina)
P: Yes/No 2) Endocrine DM or thyroid
D: What about your diet? 3) Cancers
P: My diet is very good. 4) Renal
D: What do you do for living? 5) Trauma spinal injury
P: I have my own business. 6) Mood
D: Is it stressful? 7) Stress
P: Yes or no 8) Medications
9) Smoking
Examination:
If it’s OK with you, I would like to take your vitals and do a general physical
examination. I would like to examine your chest, heart, tummy, and your
private area and also examine your legs and do muscle and nerve examination.
I will also send for some initial investigations including routine blood tests.
From what you have told me so far and from my assessment, you mentioned
you have tiredness, cold hands and erectile dysfunction. I am guessing it might
be due to the medications (beta blocker) that you are taking for your heart
condition. But before we say for sure we will run some investigations, I will
check my book and have a discussion with my senior.
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Every medication has side effects but they have benefits too. People are
different from each other when it comes to how the body responds to
medications and they do not always develop side effects. However, since you
are experiencing the side effects, we will have to make some changes in your
medications and for that we will have to refer you to the specialist who will be
able to help you.
Please do not stop the medications until advised by the specialist, because it’s
much more important to control your heart condition.
And please bear with us once we change the medicine things should get better.
Bear in mind: Multiple factors can intervene along with the medicine to cause
erectile dysfunction, stress, mood, smoking and even your heart problem itself,
if not controlled. Therefore, I would like to have a discussion with you about
some lifestyle tips that might help you feel better and in good health and
prevent further problems like these in the future.
DESA ADVICE as before.
Management:
1. No admission
2. Senior.
3. Investigations:
We will do some routine blood tests as CBCs for anaemia, liver and kidney
function, vitamin levels and thyroid hormone. We will also check blood sugar
and do some urine tests.
4. Treatment:
• Medications ( sildenafil )
− No need for prescription
− Pharmacist consultation
− A form needs to be filled
• Vitamin supplements
• DESA Advice
• Good rest and good sleep habits
• Relaxing techniques
5. Specialist
− Heart specialist
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− Psychologist CBT and couples therapy for relationship with partner if

problem persists.
− Andrologist a doctor who deals specifically with erection problem if
persists.
ASK ICE Ideas concerns and expectations

PATIENT'S CONCERNS
− Will my erectile problem resolve?
• After excluding all other causes by our investigations, if you follow the
advice after changing medicine, things will get better.
− Will I get back to my normal self without feeling tired?
• Having a weak heart is a longstanding condition but manageable by being
compliant with the medications and follow ups, keeping a healthy lifestyle
and avoiding smoking and alcohol and eating a balanced diet, things will
start to improve slowly.
− Will there be lifelong effects?
• Regarding the erection problem it can improve after a while, however
following the advice and maintaining a healthy life style is crucial to
prevent further damage to the heart and avoid any lifelong problems.
− Will the new medications have the same side effects?
• Every medication has its own side effect, but as I mentioned it’s not a rule
that they must happen because people respond differently. What we do is
that we follow up and if you have any problems we can discuss other
options.
❖ Side Effects of Beta Blockers

− Feeling tired, dizzy or lightheaded (bradycardia)
− Cold fingers or toes
− Inability to achieve a proper erection (impotence), vivid dreams,
difficulties sleeping or nightmares.
− Feeling sick
− Hypoglycaemia
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6. Safety net:
As before in MI, don’t take GTN 24 hr before and after taking sildenafil.
7. Follow up
Stroke Assessment

Who the patient is: Mr Arthur Shaw, aged 60, has booked this video
consultation. He is very worried and has some concerns about having a stroke.
Additional information: he has checked his blood pressure earlier today and it
was 150/100 mmHg
What you should do: Please talk to the patient, take history, and address any
issues that may arise with the patient. Please do not examine this patient.
(ICE is extremely important in this case, the patient will be worried and came
here looking for advice. Exercise good IPS and be patient centered. Follow his
concerns). Please note it might come as a video or telephone consultation.
Video/Phone call approach

D: Hi, I'm dr (name), am I talking to Arthur?
P: Yes.
D: Is this a suitable time to talk?
P: Yes.
D: If this connection gets interrupted can I call you again on this number?
P: Yes doctor.
D: I understand that you have booked this video call due to some concerns you
have, how can I help you?
P: I'm very worried. I'm worried about having a stroke.
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D: May I ask you why you are worried about getting a stroke?
P: Yes doctor you see because my dad died of a stroke and my brother had one
about a year ago and he is handicapped now, he can only move his right side.
They both had high BP and I recently found out that my BP is high (V.
important).
D: Well, I'm so sorry about what happened to your dad and your brother. May I
ask how your brother is coping now?
P: He gets the help he needs but he is struggling a bit.
D: It must be dreadful, I understand why you are worried now. So would it be
OK if we have a chat about your health in order to be able to address your
concerns?
P: Yes.
P1:
Stroke Sx
D: Have you ever had any facial weakness?
Arm or leg weakness?
Slurred speech?
P: No.
High Blood pressure:

D: Have you ever had any headaches / blurring of vision/ nosebleeds?
P: Yes I get headaches sometimes.
Explore:
D: Can you describe these headaches?
P: It’s in the back of my head and it comes and goes.
D: For how long have you been getting them?
P: Maybe a month now.
P: Gradually.
P: Not really.
P: No.
D: Anything else?
P: No.
D: Have you ever had any chest pain that goes to the left or felt your heart
racing or SOB?
P: No.
P2
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D: Have you suffered from any similar headaches in the past?

P: No.
D: Have you ever been diagnosed with any medical conditions?
P: No.
D: You mentioned that you found out that your blood pressure is high, may I
ask how found this out?
P: Because of this headache doctor, only this morning I asked one of my
neighbours who is a pharmacist to measure my blood pressure and he told me
it was high and I should go and get it checked. That’s why I am calling.
D: I see. Have you ever had your blood pressure measured before this
morning?
P: No.
D: Well I’m glad you are seeking advice quickly. Have you ever been
hospitalised for any reason?
P: No.
MAFTOSA:
P: No.
P: No.
D: Any Family Hx ? If already mentioned don’t repeat
P: No.
P: Businessman.
DESAS
P: Not so good doctor I am eating a lot of fast-food, mostly burgers and chips.
P: No I don’t have time.
D: Do you smoke?
P: Yes/no
P: Yes I do doctor
D: How much are you drinking?
P: Probably more than I should to be honest.
D: Has it been stressful lately?
P: My job is always stressful doctor.
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ICE
D: Do you have any idea what might be going on with you?
P: I think it’s the high blood pressure doctor.
D: Do you have any other concerns for us today apart from the fear you have
of a stroke? (Already mentioned stroke)
P: …
P: Some guidance and advice about preventing a stroke.
Examination:
Ideally, I would like to book you an appointment to come in for a check-up, I
would take your vitals and your BP, I will also do a general physical and check
the nerves around your head as well as the nerves and muscles of your hands
and feet. I will also check your chest and heart.
Do you know what a stroke is?
It’s a condition of the brain, where there is a complete blockage of the blood
supply of the brain . This condition can cause paralysis unfortunately, some
people can improve completely with time, others can have the paralysis last
forever and it can, of course, be life-threatening.
Do you have any IDEA of what causes this problem?
P: No.
Some factors are non–modifiable like age or family hx, whilst others are
modifiable like diet, exercise , cholesterol , DM or high BP. So, if we work on
these modifiable factors, we 'll decrease the risk of you having stroke.
Management:
1. I'll talk to my senior.
2. We’ll run some investigations when you come:
➢ Blood → FBC – FBS – CHL – TFTs – Clotting.
3. Advice: DESA ( v. important) In details as before. Address the RFs he had
(exercise, stress, diet, alcohol, and high blood pressure)
4. It takes more than one reading to diagnose high blood pressure. Having a
high blood pressure can increase the risk of stroke and it might be the cause
413 | P a g e
of your headaches as well. You mentioned that you have had one high BP
reading already → So when you come we will measure it again and we
might need to refer you to a heart specialist who will investigate this issue
further and might start you on some BP medication. How would you feel
about all of that?
5. Safety netting → At any time if you develop any facial weakness or slurred
speech , ring 999.
6. We'll give you a few follow – up appointments to make sure things are in
place.
o Here, patient has never developed stroke, so no need to talk
about DVLA.
o But, if the patient has developed stroke before, advise him to
inform DVLA.
Obesity counselling
Who you are: You are F2 in GP clinic.
Who the patient is: Jessica Louvers, aged 48 years old, presented to the clinic
with a complaint of being overweight.
What you should do: Please talk to her and address her concerns.
(Might come as a telephone consultation so follow the phone structure then
same Hx and counselling structure)
> In this station you need to show that you are not scripted,
don’t jump into obesity counselling, Explore some possible
causes of obesity first then take the rest of hx especially DESAS
and then management.
> Management here should be discussed as options and follow
the patient.
> The patient can get really talkative don’t interrupt her .
> Don’t forget BMI
D: Hello I am one of the doctors here in the GP clinic. Am I talking to Jessica?

P: Yes.
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D: Alrighty then, how can I help you today?

P: I am obese doctor, I am fed up with my body. I really want to lose weight I
cannot stand it anymore.
D: I understand people can sometimes struggle with their weight, don’t worry
we are here for you and we can help you with this problem. In order to do that I
would like to ask you a few Qs about your health in general would that be fine?
P: Yes of course doctor.
P1 obesity: ODIPARA
D: How long have you been overweight?
P: For a really long time doctor and my weight problem got even worse after
the pregnancy. (Duration and course)
D: Have you had this weight change suddenly or did it happen over a period of
time?
P: Over a long period definitely, I have always been leaning on the overweight
side doctor.
D: Can you think of times were it got a bit worse or better, apart from what
happened after pregnancy?
P: No I was always like this.
D: How much weight have you gained after pregnancy?
P: A lot doctor, it as very obvious.
D: Do you know your weight at the moment?
P: Yes doctor I am 100 kg?
D: We usually plot weight against height as an indicator for obesity, Body Mass
Index aka BMI? Have you ever tried to calculate that?
P: Yes doctor I read about it online, I did that and turns out I have a BMI of
40.
ICE:
D: Is there any specific reason you decided to come especially today for this
problem?
P: My family is struggling with this problem now, I don’t like how people are
looking at me now doctor. I don’t even like looking at myself, I feel lost and I
need options, because I am always hungry and I love food to be honest.
D: Don’t worry I will try to help you as much as I can.
P: Okay doctor.
415 | P a g e
P: No.
D: Are you expecting anything in particular to happen?
P: Yes doctor I think I would prefer surgical treatment? Or Are you going to
give me any meds?
D: What makes you want the surgery?
P: After I measured my BMI online, I read somewhere that I might need
surgery.
D: Ok we will get to that option in a minute, just a few more Qs about your
health?
P: Okay.
DDx
D: Do you get breathless while sleeping? (OSA)
P: Yes/ No
D: Do you feel cold when others are feeling fine? (Thyroid)
P: No.
D: Any bowel problems lately like constipation?
P: No.
D: Do you feel tired these days?
P: Yes.
D: Have you noticed any unusual hair growth or a rash anywhere on your skin
? (PCOS)
D: Any problems with acne?
D: Any problems with your water works? Or feeling excessively thirsty? (DM)
P: No.
P: Not in the best of moods doctor.
D: Can you grade your mood for me on a scale from 1-10, 1 being the lowest
and 10 being the happiest?
P: 5-6
D: How is your diet? Can you walk me through what you eat?
P: I love food, especially fast-food doctor, I don’t like cooking much and I eat a
lot of microwaveable things.
D: Do you sometimes eat when you are stressed or angry ? (Eating disorders)
P: When I am stressed, a good meal can help a bit doctor.
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P4
D: How are your periods? (PCOS)
P: I don’t get them any more doctor
D: May I ask when they stopped?
P: At the age of 35 they told me my ovaries failed early.
D: Are you taking any hormonal treatment now?
P: No.
P2:
D: Have you always had this problem?
P: Yes doctor.
D: Have you ever tried losing weight before?
P: Yes doctor.
D: How did you do it and what happened? Can you tell me more?
P: Yes doctor I went to the gym but I stopped later because I could see people
were making fun of me.
D: That must have been dreadful. Did you seek any medical help from a doctor
about this before?
P: No.
D: Have you been diagnosed with any medical conditions?
P: No.
P: No.
MAFTOSA
D: Are you currently taking any medications (like steroids), over-the-counter
drugs or supplements?
P: No.
D: Any allergies from food or medication?
P: No.
P: My family have always struggled with weight. My father and mother died of
a heart attack. They were also obese.
D: Any other medical condition in the family?
P: No.
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P: Unemployed.
P: Yes/No
DESAS
D: Do you smoke?
P: Yes/ No
P: Yes/No
D: After you stopped the gym do you still do any form physical activity?
P: Yes/ No
Examination
If you don’t mind, I would like to examine you. Check your vitals, do a general
physical examination and check your height and weight, to calculate your BMI
again.
I would like to send for some blood tests for routine tests, to check the
functions of your liver and kidneys and to check the level of cholesterol in your
blood , your blood sugar level, your hormonal and thyroid profile as well.
Findings note: Everything is normal. BMI is 40.

Obesity Counselling:
ARMSS
Advice and risk factors
Thank you for bearing with me so far. We have checked for a couple of things
and everything seems normal but the BMI came back 40 which is very high like
you mentioned.
Many factors can cause obesity like eating a lot of calories from greasy or fast
food and not doing much exercise. It can be genetically related as well and runs
in family like in your case. It can be from certain diseases too but fortunately
you don’t have any red flags for those.
Being obese can have a bad impact on your heart, brain and increase clotting
risks, it affects your breathing and your health in general, physically and
mentally. So it’s crucial to lose weight and I am glad that you came to this
decision. It is a bit of a difficult road but we will help, support and guide you at
each step, and will provide different options.
To lose weight it’s very essential to adopt a healthy lifestyle. You also wanted
to know about surgery/medicine which I will also discuss with you.
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What would you like me to discuss first?
DESA Advice as before:

Diet
− Download the free NHS weight loss plan app
− Try to eat healthy homecooked food, not takeaway.
− Reduce salt and oil in your food by choosing to bake food instead of fry it.
− Plenty of fruit and vegetables (may say I don’t like veggies so say fruit
and fish)
− Make sure you are drinking plenty of water.
− White meat and fish is better than red meat.
− Eggs, beans and other non-dairy sources of protein are good.
− Avoid salty food as it raises your blood pressure.
− Eat slowly and avoid situations where you know you could be tempted to
overeat.
− We can refer you to a dietitian who can advise you on that.
Exercise:
− Firstly, I know what you experienced at the gym was unacceptable, must
have been painful but being active is necessary to lose weight and to give
you a good sense of well being and a happy mood.
− You don’t necessarily have to go to the gym. You can go for walks or
cycling , exercise at your home following videos of trained instructors
that you can consult first about the type of training you can do.
− Ideally 30 mins 5 days a week. It could be split into two sessions of fifteen
minutes or three sessions of ten minutes.
− Don’t fall into a sedentary life. Find a hobby that you love and keep doing
it. You can try activities such as fast walking, jogging, swimming or
tennis.
− We can refer you to weight loss support groups, they can give you advice
and support you as well.
Smoking and alcohol: same as before
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Management/Investigation/Involve senior
MEDICATIONS:
If lifestyle advice is not effective alone. We can prescribe a medication called
Orlistat.
− Reduces the amount of fat you absorb during digestion and decrease
your appetite.
− Might cause some diarrhea or gastric upset.
− Must be combined with a balanced low-fat diet and other weight loss
strategies.
− Only prescribed if you have a body mass index (BMI) of 28 or more, and
other weight-related conditions, such as high blood pressure or type 2
diabetes or BMI of 30 or more.
Surgery
Sometimes surgery is used as a treatment for people whose BMI is 40 or more
which is very high. They are called bariatric or weight loss surgeries,
Types of weight loss surgery:
There are several types of weight loss surgery.
− Gastric band - a band is placed around the stomach, so you don't need to
eat as much to feel full.
− Gastric bypass - the top part of the stomach is joined to the small
intestine, so you feel fuller sooner and don't absorb as many calories
from food.
− Sleeve gastrectomy - some of the stomach is removed, so you can't eat
as much as you could before and you'll feel full sooner.
MOOD:
− You mentioned that your mood is not so good so we can refer to a
Psychologist who can offer a form of talking therapy called CBT.
MDT and referrals:

Mentioned above with each. Also, surgeon for surgery if needed.
Safety net:
About mood feeling low and clotting Sx stroke (weakness and slurred
speech) MI(SOB , heart racing Chest pain) or DVT(leg pain and swelling)
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Follow up later to see how u are coping and we can give u a leaflet about the
advice we discussed for obesity.
❖ For most adults a BMI of:

DDs:
− Hypothyroidism
− Diet
− PCOS
− Physical activity
− Long term usage of
steroids (Cushing’s
Syndrome Family
history)
COPD Smoking Cessation

Who you are: You are F2 in Medicine.
Who the patient is: Mr. Winston Zelhniski, aged 61, has come for annual
check-up. He is diagnosed with COPD and is using inhalers. From time to time
he gets recurrent chest infections, and he is taking antibiotics for a recent
infection that he is recovering from now.
Special note: Your nurse colleague has examined the patient. She has been
talking to him about smoking and he has been reluctant to stop. She asked you
to go and advise him.
What you should do: Please talk to him, take focused history and discuss the
proper management and advice about smoking.
D: Hello my name is doctor(name) I am one of the doctors here in the medicine

department. Am I talking to Winston?
P: Yes
P: Winston is fine.
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D: I understand from my records that have been diagnosed with COPD and you
are here for your annual check- up. Is that right?
P: Yes doctor, the nurse colleague told me that you are going to talk to me.
D: Well for a start thank you for coming to your check-up today. Why don’t we
have a chat about your COPD and how you’re coping and if you have any
problems with your health in general.
P: Okay doctor.
COPD
D: Has anybody explained thoroughly what COPD is Winston?
P: Yes but I don’t pay much attention.
D: Chronic obstructive pulmonary disease describes a group of lung conditions
that affect airways making them narrower and therefore more difficult to
empty air out of the lungs. Air remains trapped inside and along with some
degree of inflammation that occurs in the small airspaces called alveoli this
damages your lungs that start to function poorly, are you following?
P: I see.
D: When were you diagnosed?
P: 10 years ago.
D: How is your condition controlled now? Do you still have any bothering Sx?
P: Not very well, I am coughing more, I still have shortness of breath and I
cannot climb the stairs now.
D: How long have you been like this?
P: A few weeks doctor.
D: Do you take any medication?
P: I am using Blue and brown inhalers.
D: Do you take them regularly as prescribed?
P: Yes, as best I can.
D: How do you take the blue inhaler?
P: Whenever I’m really short of breath.
D: How often do you use your blue inhaler?
P: 3-4 times a week.
D: How long have you been using it like this?
P: A few weeks now (a sign of uncontrolled COPD)
Chest infections:
D: I can see from my notes that you have repeated chest infections, correct?
P: Yes, I am taking antibiotics for my most recent one.
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D: How are you feeling now?

P: I’m better, I am recovering well thankfully.
D: How did you feel before?
P: It wasn’t so good I had chest pain and fever and I was coughing up phlegm.
P: When I get an infection I cough more and have yellowish phlegm.
D: How much is the amount of phlegm?
P: Patient shows handful.
D: Any blood in your phlegm?
P: No.
D: How frequently do you get these infections?
P: Very frequently about five times a year.
D: How do you manage them?
P: I go to my GP and he gives me antibiotics.
D: Have you ever been hospitalised for a critical chest and lung problem you
had?
P: Yes doctor, sometimes my COPD gets really worse and other times I get
really bad infections.
D: Any other symptoms?

P: No.
D: Any wheezing (unusual breathing sounds)?
P: No.
P2
D: Have you been diagnosed with any other medical conditions in the past?
P: No.
MAFTOSA
P: No.
D: Any allergies from any food or medicines?
P: No.
P: I am an NHS Manager.
P: I live with my wife and my two children.
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DESA
D: Do you smoke? Important to explore thoroughly
P: Yes.
D: How much do you smoke and for how long ?
P: 30 cigarettes since I was a teenager.
D: Has anybody ever told you about the impact of smoking on your health and
lungs?
P: Yes I know it can cause death. One of my friends was smoking and I believe
he died of lung cancer.
D: I am sorry about your friend. Have you ever thought of or tried to stop
smoking?
P: No (if yes explore how was it managed and why it failed.)

P: I can’t do much because of SOB.
Examination:
I believe the nurse has examined you already but I would like to have a listen
of your chest and heart and I will check your vitals as well. We also have a
device called PEFR that can assess your airway capacity when you blow in. Is
that OK?
Smoking counselling:
Advice and risk factors
Based on what you have been experiencing lately from repeated infections,
increased coughing and SOB with little exertion. I am suspecting that your
COPD is getting worse.
Has anybody told you what might cause COPD and what factors can aggravate
it?
P: Probably but it all goes over my head. (He means he doesn’t really
understand it all).
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COPD can have many causes it can be genetic and runs in families or it can be
caused and worsened by exposure to air pollution. However one of the main
causes of COPD is smoking.
Smoking in itself can have a catastrophic effect on your lungs and heart as it
damages the blood vessels increasing risk of clotting, and finally can cause lung
cancer like what might have happened to your friend. Are you following all of
that Winston?
P: I don’t like the sound of it doctor, I understand what you are saying but, I
really love smoking doctor.
D: I know that it is difficult to think about quitting and I am not here to nag
you, I just want to make sure that you understand how bad smoking is and
that you know that you have options to quit. So can I just ask you, what
exactly is it about smoking that you love so much? (You need to understand
why he is smoking to give him solutions).
P: I enjoy smoking because it makes me relaxed and less stressed, it gives me
this good feeling about myself.
D: I am sure it’s not easy to handle stress, but can’t you find other ways to
relieve it? Maybe:
− yoga
− relaxation techniques and meditation.
− Talking therapy by a specialist called CBT.
− Going for walks or meeting up with your friends and family. How would
you feel about trying these out?
P: Yoga! No way. It is still too difficult to quit.
D: Well, let me explain why, while many claim that smoking relieves stress.
After a long time smoking you become dependent on nicotine. Then when you
don’t smoke for some time you start getting the withdrawal Sx of nicotine such
as bad moods and cravings for cigarettes and it makes you very stressed. It can
seem like smoking is reducing your stress but in fact it’s not. Studies show
stress levels can go lower after people have stopped smoking.
I am sure that it’s not easy! But there are other benefits of quitting:
− Financial gain: You can save money to spend on activities like travelling.
− Social gain: Let’s be honest Winston, smoking stopped being cool in the
90s! You will smell better and you won’t have to leave your family on
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outings so you can go and smoke. And your house will feel fresher too
for visitors.
− Most importantly: The greatest benefit of quitting is to your health. You
will suffer less with your chest Sx because if you keep smoking your
lungs can eventually fail, is that what you want?
Management and senior

We will request some investigations to make sure that all is well. Routine
bloods/ heart tracing.
P: How can you help me with this doctor?

D: Provide options:
− At your own pace if you do decide to quit we are going to help and
support you at every step, but you need to know that the sooner the
better and easier it will be for your lungs to improve.
− There are medical and non-medical ways to help you stop smoking.
Medical Management:
Regarding the unpleasant withdrawal Sx. It all happens because of the
nicotine, which is very addictive.
− We can offer you nicotine replacement therapy, that provides you with
a low level of nicotine without the poisonous chemicals present in
tobacco smoke. This is available in the form of patch, spray or chewing
gum.
− Stop smoking tablets Champix (varenicline) and Zyban (bupropion).
They are started 1-2 weeks before quitting and can reduce craving.
Non-medical approach:
− We can refer you to a smoking cessation clinic where they will offer
different options for quitting.
− Support groups where you can meet people who have stopped smoking.
They can share their experience with you and motivate you.
− Helplines (the free Smokefree National Helpline), which can help you
and advise you how to deal with your cravings.
− Online support such as NHS Smoke free Website, which can boost your
chance of success.
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− Specialist psychologist can offer CBT sessions to control stress and help
you quit as well.
− E cigarette not the best option as it’s not-risk free, but some people
believe they are still safer than cigarettes and can help people stop
smoking.
If you do relapse, we won’t judge or nag you or take it personally. We’re a

friendly face that understands how difficult it is to quit, and we’ll help you get
back on track to becoming a nonsmoker.
MDT and referral:

− Chest for spirometry.
− Psychologist for CBT
− Smoke cessation clinic
Give leaflet and don’t force him.

Safety net:
COPD sx (SOB sever breathlessness, wheezing), PE sx, MI sx, FLWAS of cancer
Follow up: GP after 2 weeks, and medicine after 4 weeks.

The outcome is that if you manage to counsel in a decent way he will accept
(and if he says I am ready, you should set a date then) or he will tell you “I
will consider it”.
Smoking cessation in angioplasty

Who you are: You are F2 in General Medicine.
Who the patient is: Mrs. Helen Tillmans, aged 56, presented to the hospital.
She has been diagnosed with unstable angina and has been planned to have an
angioplasty. Patient has high cholesterol, and she is on statin and aspirin. Her
condition is well controlled.
Additional information: Patient has smokes 20 cigarettes per day in the last 35
years. She is not willing to quit smoking.
What you should do: Please talk to the patient about vascular risk, lifestyle
modification and smoking cessation.
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D: Hello I am one of the doctors here in the medicine department. Are you
Helen?
P: Hello doctor, yes I am.
D: I understand that you are being prepared for a heart procedure, has
anybody talked to you about what is going on?
P: Not much doctor.
D: How much do you know?
P: I had this chest pain and they did some management of it and then they told
me someone is going to talk to me.
D: Well I’m here to discuss with you about what happened and explain
everything you want. Do you know why you had this chest pain and what
procedure you need to have?
P: No doctor.
Explain what is going on

D: You had chest pain because of a condition called Angina.
Like any organ in our body, the heart needs a constant supply of blood through
a network of blood vessels. Sometimes these vessels become narrow and the
blood flow to the heart is reduced. Causing a similar chest pain which is called
angina.
Angina can be treated with medications. However, sometimes we need to
perform an urgent procedure called an angioplasty, in which we try to widen
and remove the block from the vessel supplying blood to your heart. It involves
putting a short wire mesh tube in there. Therefore, the blood can flow through
the vessels and the pain is relieved. Is that clear so far?
P: Yes.
P1 Chest pain (not In depth she is already diagnosed)

D: Would it be okay if I asked you a few questions about your health to assess
you better?
P: OK.
D: Tell me more about your chest pain? (Open Q)
P: I used to get this chest pain but not as frequent. It’s very bad, crushing and
more to the left side of my body. Previously I had it while doing physical
activity but now it sometimes happens even at rest.
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Site mentioned
Onset and course mentioned
Radiation mentioned
D: For how long have you had this pain and when it comes, how long does it
last? (Duration)
P: One and a half years now, every attack is getting worse. It used to last
seconds but now maybe 20 mins.
D: Is there anything that makes it better or worse apart from exercise?
P: Like I mentioned, it used to improve when I rested, but not anymore.
D: Have you tried anything for the pain before.
P: No.
D: Any other symptoms that bother you?
P: Sometimes I have difficulty in breathing/ heart racing/coughing
Explore briefly? ODIPARA
For how long have you had that?
Any change since it started?
Is there anything that makes it better or worse?
D: Any other symptoms?
P: No.
P2:
Similar attack before already mentioned show active listening don’t repeat
questions.
D: I can see from my records that you have had problems with cholesterol.
How long have you had that?
P: The past few years.
D: Are you taking any medications for it?
P: I’m taking aspirin and statin.
D: Do you take it regularly?
P: Yes. I never miss any medicine.
D: Do you see your GP regularly?
P: Yes.
D: Any other medical conditions? DM or HTN?
P: No.
D: Have you ever been hospitalized for any reason before?
P: No.
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MAFTOSA
P: No.
D: Any allergies?
P: No.
D: Do you have any family history of heart problems?
P: No.
DESAS
D: Do you smoke? Important to explore thoroughly
P: Yes.
D: How much do you smoke?
P: I smoke a lot, 35 cigarettes per day.
D: For how long have you been smoking ?
P: Since I was young.
D: Has anybody ever told you about the impact of smoking on your health and
lungs?
P: My GP tried to tell me but I don’t want to quit.
D: I see. And in the past have you ever thought of or tried to stop smoking?
P: Well I tried to to cut down a bit doctor but I couldn’t. (If yes explore how
was it managed and why she relapsed)
D: Can you tell me what happened back then?
P: It was too difficult, I was agitated and grumpy all the time, it felt really
unpleasant. In addition I don’t want to stop it completely I still want to enjoy it
every now and then.

P: Occasionally.
P: Good.
P: I try to be active.
P: Everyone has stress in their life.
Examination:
I would like to check your vitals if you don’t mind.
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(She is admitted so no need to verbalise a lot of examinations or to discuss

many investigations, she has already been diagnosed)
Smoking Counselling:
Exactly like the previous case, offer same options one by one and address
patient concerns.

I know you mentioned that you fancy a cigarette every now and then and that
you love it, but I need to tell you that smoking can have a very bad effect on
your heart, especially after this angina attack you had. Would you give me the
chance to tell you how dangerous can a cigarette be?
Smoking can have a catastrophic effect on your lungs causing cancers and
other lung diseases. It can affect your heart as it damages the blood vessels,
increasing your risk of clotting and more angina attacks or even something
worse called Infarction. That is when the heart muscle starts to fail because of
too little blood supply. It can eventually cause death. Are you following Helen?
P: Doctor I am not buying it sorry. My grandfather used to smoke and he is 90
years old now, he never complained of anything and he is in good health. Can
I just reduce the amount I smoke rather than stop completely?
D: Well, I’m happy that your grandpa is fit and well, but let me tell you smoking
affects people differently and at variable rates, it doesn’t mean that because
your grandad is OK, that you will be ok too. In your case from the looks of it,
you mentioned that the pain started to happen when you are at rest and for a
longer time than before, these are very bad signs of progressive heart disease.
Does that make sense?
P: Are you going to cancel the procedure if I don’t stop?

D: No of course not, this procedure is a life-saving one, but if you don’t stop
smoking afterwards it can markedly reduce recovery and predispose you to
further attacks.
P: I’m afraid I might gain weight after if I stop smoking?

D: I understand why you might think like that, smoking destroys our taste buds
and it alters how we taste and smell food. When you stop, they can recover and
you will start enjoying food more. Smoking also blocks the appetite so you
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might feel slightly hungrier but you don’t have to worry, if you put on weight,
come back and we will help you lose it again.
P: I am worried I will craver cigarettes a lot and I will be too stressed or even
depressed?
D: CBT-Talking therapy -- YOGA – smoke cessation clinic -- support groups –
helplines -- Medical and non medical treatment as before.
Rest of ARMMS and smoke cessation advice as the previous station.
Smoking cessation in breast feeding
Who you are: Fy2 in the postpartum clinic.

Who the patient is: Bianca Adams, 34 years old, has delivered a baby 6 weeks
ago. She has presented for post-natal follow-up. She is currently breast
feeding.
What you should do: Please talk to the patient address her concerns.
D: Hello my I am one of the doctors here in the OBG/Post-partum care. How

are you today, Bianca?
P: Very well.
D: Can I confirm your full name and date of birth please?
D: I understand from my records that you had a baby 6 weeks ago,
congratulations! And you are here check- up, is that right?
P: Yes doctor.
D: Well for a start thank you for coming to your check-up today. Why don’t we
have a chat about your little one’s health in general, and explore any
challenges that we can help you with?
P: Okay doctor.
Mother’s status:
D: How have you been feeling after delivery?
P: Fine doctor.
D: Did you have any problems with pregnancy?
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P: No thankfully it was smooth.

D: Do you have any PAIN/ BLEEDING FROM FRONT PASSAGE/ FEVER/SOB/
Complications?
P: No.
D: How is your mood/ How does It feel to be a new mother?
P: It’s difficult doctor, I feel more responsible now and I am doing best to
manage.
Baby’s health:
Don’t take BIRD hx in depth just a few questions to make sure all is well with
him/her.
D: So did you have a boy or girl?
P: A boy.
D: Lovely! How is his health so far? Does he have any problems?
P: No.
D: Any change in his skin colour?
P: No.
D: How are you feeding him? / is he feeding well?
P: I’m breast feeding him and he is feeding well.
D: Sounds great, just to make sure, are there any problems with his wee or
poo?
P: No, all good.
D: Is he sleeping well? Does he look calm and comfortable to you?
P: Yes.
D: Are you satisfied with his development and growth so far?
P: Yes doctor.
ICE:
D: Do you have any concerns that you want to share with us today?
P: Yes Doctor, I have been smoker for a long time. I stopped smoking the whole
time that I was pregnant, but I have recently started again doctor. Being a
mother with a newborn baby and all, I want to stop again doctor. Can you help
me?
D: I think you are great mum already, Bianca. That is a good and wise decision,
and we can definitely help you with it! But before that can you tell me more
about your smoking habits?
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Explore smoking like before

D: How much do you smoke?
For how long?
What type have you been smoking?
Have you ever tried to stop before pregnancy?
How did you do it?
Did you follow specialist advice? Did you face any challenges?
Are there any circumstances where you are more tempted to smoke? Who do
you smoke with? When do you smoke?
D: What motivated you to stop smoking?
(She does not want the baby to be a passive smoker.)
D: How does smoking make you feel? What made you relapse last time?
(She will say she tried to stop before but she relapsed it was difficult because
she is always tempted to smoke again. Sometimes she gets too agitated or
annoyed when she stops, but she is too determined now to stop.)
Ask about other withdrawal Sx
D: When you stop do you feel restless, grumpy , any itching, any poor
concentration.
D: Any FLAWS/ Coughing / Breathing problems?
MAFTOSA+DESA
D: Have you ever been diagnosed with any medical conditions? Are you taking
any other medications including OTC or supplements?
P: No.
D: Any allergies from any food or medicines?
P: No.
Examination:
Mother and baby routine.
Management:
ARMMS exactly as before but tailor the management to her, know her
motives to stop and use them to encourage her.
Offer treatment as before: look above
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Pt concerns:
➢ P: are you going to give me any medicine?
Yes NRT nicotine replacement therapy also meds for withdrawal Sx but
bropiupion is not safe in breast feeding mums so avoid.
➢ P: Will they affect my baby if I’m breast feeding?

We will avoid any meds that can affect the baby, also NRT only contains the
nicotine. Any harmful cigarette components like tar and coal are not present.
➢ P: What about the E-Cig is it safe?

Still safer than the actual cigarette but NRT is much safer. Besides E-cig is
costly and is not the NHS desired option.
Otherwise the remaining management is the same as before.
CDAD Clostridium Difficile
Who you are: You are F2 in General Medicine.

Who the patient is: Michael Wayne, 79 years old, presented to the hospital 10
days ago. A diagnosis of pneumonia has been made. Patient has been admitted
in the hospital and treated with antibiotics and had been recovering well. He
developed diarrhoea 2 days ago before getting discharged. Investigations were
done. On the basis of a stool sample the diagnosis of Clostridium Difficile
Associated Diarrhoea has been made.
Additional information: He has been moved to another ward with patients with
similar conditions. He is now receiving IV fluids and antibiotics. Larry, his son is
really concerned about his father’s condition and wants to talk with you.
Special note: Consent has been taken from the father to talk to the son.
What you should do: Please talk to the patient’s son and address his concerns.
(Remember this is a test results with a talking to a relative (4Cs – Consent/

Confirm ID/ Concerns/ COPING) structure. You will assess knowledge, you can
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build rapport by admission questions. Ask about ICE and address the sons
concerns and explain everything)
Hi , I am one of the doctors here in the medicine department, am I talking to
Larry the son of Michael?
P: Yes.
D: Can you please confirm your father’s full name and date of birth for me?
D: I am here to talk to you about your father’s condition at the moment but
before that do you have any concerns you want to share with me ?
P: I came to see him today and I found him shifted to another ward and
everyone who goes into his room is wearing an apron and mask. It seems like
quarantine I am very worried, what happened?
D: I can see that you are worried and I’m sorry if we made you feel alarmed. I
will explain everything to you in a couple of minutes but let me assure you that
the way we are treating him is in his best interests. Do you mind if I ask you
some questions about his condition?
P1
D: How much do you know about his condition? / What brought you to the
hospital?
P: My father was unwell 10 days ago, we brought him to the hospital and he
was admitted when they discovered a chest infection. He has been recovering
as far as I know.
D: What Symptoms did he have?
P: He had shortness of breath and cough for a few days.
D: Has anyone explained to you how he was being treated?
P: Yes he was receiving antibiotics.
D: Do you have any questions regarding the chest infection?
P: I want to know why he was shifted to another ward and how he is now?
Hx of Clostridium difficile:
D: I understand you’re worried and I will explain everything to you but I would
like to know if he mentioned to you that he had any bowel problems like
diarrhoea?
P: Yes doctor he had did say he had diarrhoea 2 days ago.
ODIPARA
D: Was it only 2 days ago or did he have it before coming to the hospital?
P: No only 2 days ago not before.
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D: Have you noticed any blood or mucus in his stool?

P: I am not sure but he didn’t mention anything.
D: When was the last time you saw him?
P: Yesterday in the morning.
P2
D: Has he ever been diagnosed with any medical conditions ?
( DM – kidney disease )
D: Has he ever had a chest infection before ?
D: Previous surgeries or hospital admissions?
MAFTOSA and DESAS

not in depth
D: Is he on any medications?
P: No.
D: Any allergy that you are aware of ?
P: No.
D: Any family Hx of gut or bowel problems?
P: Not really.
D: Does he work at all ?
P: He was a carpenter, but now he’s retired.
D: Has he travelled abroad recently?
P: No.
D: Is anyone living with him at home?
P: He can manage by himself doctor he was living alone.
D: Can you please tell me about his diet? Does he eat out a lot?
D: Does he smoke or drink alcohol?
Examination:
Watch out you are talking to the son no examination needed.
Provisional Dx:
Thank you for answering my questions. Mr Wayne was admitted with a chest
infection like you said and according to our hospital protocol, we gave him
specific antibiotics to manage this infection. Two days ago, he started having
diarrhoea and we did a stool test for him, have you been made aware about
any of that ?
P: No doctor.
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D: Well the stool test came back positive for clostridium difficile , have you
heard about it ?
P: No, what is that doctor? Is it serious?
D: The antibiotics we give are strong and can cure chest infections however,
one of the downsides is that they are so strong that they sometimes kill the
good bacteria that are normally present in our gut to protect us. This gives the
chance for harmful bacteria to grow and causes infection and this kind of
bacteria is called clostridium difficile. This bacterium is also contagious so
that’s why we moved him to another ward to avoid it spreading to others. That
is why you saw everyone wearing masks and aprons around him. Keeping him
in that ward tells all hospital employees that they should be extra vigilant
when it comes to hygiene with him and with themselves as that ward is for
illnesses that can be passed on easily.
Any concern so far ?
P: But why is he in the ward with food poisoning patients?

D: That bacteria can cause diarrhoea and it can easily pass from person to
person if left in the main ward. That's why with all diarrhoea cases we shift the
patients to a separate room or another ward to look after them more closely
and to prevent this bug from spreading.
P: Could that be food poisoning from hospital food ?

D: No it is highly unlikely. If there was food poisoning here then more than one
patient would have it and I’m sure you know that hospitals are extremely
sterile environments. We deal with many immunocompromised patients and
so we are extra vigilant with these things. As I said this can be a side-effect of
the strong antibiotics your dad has been on.
P: When can I take him home ?

D: At the moment, I cannot not determine when it will be safe for him to go
home. we are giving him treatment and we will repeat the stool test again ,
once it is cleared, and if the chest infection is cleared as well, he can go home
then. I will check with my consultant and will tell you when he decides. (It may
take 10 to 14 days)
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P: Can I see him ?

Yes , definitely you can see him , but first I would like to show you the
protective equipment as the apron, gloves and mask we wear and teach you
how to use them before we go into his room. Would that be okay?
P: Can I bring my children to see him ?
D: May I ask how old they are?
- If <12 → I believe that they are too young and their immunity is not fully
developed, I am afraid it wouldn’t be wise.
What do you think about doing a video conference call , so they can see and
talk to him?
D: Can I bring him books so that he doesn’t feel bored ?

Of course you can bring him books but I am afraid when he leaves , you should
throw them away as this kind of bug can stay alive on non-living objects for
long period of time.
P: Doctor, did you give him the wrong medication?

D: I do understand your concern, but your dad had chest infection and the
treatment for that is antibiotics.
We did not give him any wrong antibiotic, this is just one of the side effects of
the medication that your dad needed to take.
P: What are you going to do for my dad?
Management:
❖ Keep in the hospital under proper monitoring.
❖ Will always consult with my senior
❖ Investigations
− We will do some further investigations like routine blood to see the
amount of blood cells and infection markers.
− We may need to have a look at your father's bowels by doing a
procedure called colonoscopy. We may need to take some samples.
− We may also need to do some imaging such as X-Ray or CT Scan for
his chest infection.
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❖ Medication
− We should stop the antibiotic that caused this infection.

− We will start him on another antibiotic according to hospital protocol
(vancomycin – metronidazole for 10-14 days )
− We will give him fluids through his veins.
Then repeat the swab again.
P: Doctor, are you giving him antibiotics again?

D: Yes we must prescribe antibiotics. If this condition is left untreated it may
cause some complications such as bowel perforation, which needs surgery. We
don't want this to happen to your dad.
❖ Safety netting
There are some measures, highly recommended to do to prevent you from
catching the infection:
> It is better not to share towels.
> Wash your hands before and after going into his room.
> Please, try not to touch anything inside the room such as pillows or
blankets.
> After you come home first thing , take off your clothes and wash your
clothes with high temperature.
> If you experience any cramps or diarrhea, come to us immediately
NB: Pseudomembranous colitis is a notifiable disease to public health England/

local health monitoring team.
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PROCEDURES
Structure for all procedures:
Procedure stations include:
• Endoscopy
• Colonoscopy
1. PAST
Why did you come ?
P1
Explore
D.Ds → not much only 2 or 3
P2
− Any previous procedures ?
− How did it go ?
− How was your experience when you had it? / How did it go? / Did you
have any problems?
− Any heart conditions ? ( contraindication )
P3 + MAFTOSA
• Ask about contraindications of procedure
• Medications :
> Clopidogrel → stop 1 wk before
> Iron , ACE , Warfarin → stop 5 days before
> NSAIDS , Diuretics → stop 48 hrs before
> Insulin → Stop in morning in day of procedure + Do not eat
> You will be given gki ( glucose + k + insulin )
> Metformin → Not to take evening dose
Bleeding Qs
− TRAC + ODIPARA
− Dizziness – Fainting
− Bleeding any where
− Blood disorders
− Blood thinners
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2. PRESENT : How are you now ?

3. FUTURE
PROCEDURE
BEFORE DURING AFTER
= complications
• Bowel will be • Sedation • Bleeding
empty • Pain killers • Severe pain
• Fasting for few (perforation)
hours • Do not drive
• Fluids • Do not sign any
• Laxatives important
documents ( due
to sedatives)
4. CONSENT
Are you ok to go through the procedure?
Coeliac DISEASE
Who you are: You are FY2 doctor in GP clinic.
Who the patient is: Adam Smith, 30 years old , came with tiredness 2 months
ago, blood tests showed that he has anaemia. He was given iron tablets but no
improvements. A week ago transglutaminase test was ordered and it came
back positive. He is scheduled for endoscopy and duodenal biopsy as coeliac
disease is suspected.
What you should do: Talk to him and address his concern.
(You don’t have to ask every single question in the Sx and complications, the
patient is leaning towards a diagnosis and the main aim is to follow the
patient’s concerns, explain the procedure and prepare him for it, after taking
only the right amount of Focused Hx)
D: Hello , I am one of the doctors here in the GP clinic. May I confirm your full
name and your date of birth.
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D: I can see from my notes that you are here for your test results , I have them
here with me. If you do not mind, can we have a chat about your health first
before we discuss these results to be able to explain things in a better way?
P: No problem doc.
❖ PAST:
D: Why did you have this test done in the first place ?
P: I was feeling tired in the last few weeks and I have been having tummy
discomfort.
P1:
Tiredness ODIPARA:
D: Can you tell me more about your tiredness? (Open Q)
P: I have been feeling tired for the last few weeks, I went to my GP and there I
had some tests done and he told me I have Iron Deficiency Anaemia. He gave
me Iron Tablets.
D: Has it changed since it started?
P: It’s getting worse.
D: Have you noticed anything that makes it better or worse?
P: No.
D: After the Iron tablets did you feel any improvement?
D: Did you take those tablets regularly?
P: Yes.
Tummy discomfort
(SOCRATES very briefly)
D; What about this tummy discomfort, can you tell me more about it? (open
Q)
P: It’s like a dull tummy pain or bloating and has been all around my tummy for
a few weeks now!
D: Have you noticed anything that makes it better or worse?
P: I’m not sure.
D: Do you have anything else with it?
Coeliac disease Sx:

D: Any bowel changes like diarrhoea or constipation?
P: I have had diarrhoea the last few weeks.
ODIPARA
P: Gradually?
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D: Has it changed since it started?

P: It is getting worse.
D: How frequently do you have to go?
P: 3 to 4 times a day.
D: How were your bowel habits before?
P: I used to go once in a day.
P: No.
TRAC
D: What is the consistency?
P: It is watery.
D: Does it seem like stool that’s difficult to flush? (malabsorption)
D: Any blood or mucus?
P: No.
D: Any change in bowel habits?
P: No.
Any Skin changes? Dermatitis herpetiformis (DH)
P: No.
Red flags :
D: Any problems with your water works? Do you feel thirsty? (Dehydration)
P: No.
FLAWS: (GIT Lymphoma)
D: Any weight loss?
P: Yes. I lost half a stone in the last few weeks.
D: Was it intentional?
P: No.
D: Any loss of appetite?
P: No.
D: Any problem with your balance? Or unusual tingling sensation in your
hands or feet? (Vit B Deficiency)
P: No.
D: Any bone pains? (Vit D deficiency and osteoporosis)
ICE:
D: Do you have any idea what might be going on?
P: I was told I have Iron Deficiency Anaemia and my GP sent me here for
Endoscopy, because he is suspecting I might have something with my bowels.
And I think it might be coeliac disease?
D: May I ask you how much you know about this condition?
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P: My sister was diagnosed with coeliac disease when she was young.
D: Do you have any other specific concerns?
P: I would like to know more about endoscopy and how it is done? Do I have to
prepare myself in anyway?
D: Thank you for bringing it up, I will explain everything you need to know in
just a few moments. Just a few more questions about your health.
P2
D: Has it ever happened to you before?
P: No.
D: Have you ever been diagnosed with any medical condition in the past? (DM,
thyroid or skin problems)
P: No.
P: No.
MAFTOSA
D: Are you taking any other medications apart from the iron tablets you told
me about, including OTC or supplements?
P: No.
P: No.
(Family Hx: already mentioned, don’t repeat yourself, show active listening)
D: What do you do for a living? (Not important but can hint to IBS and since
coeliac is the most possible Dx you can skip.)
D: Is your job stressful?
DESA Quickly
D: Do you smoke?
P: Yes/No
P: Occasionally.
P: Good/Bad
Examination
− Observation
− Tummy
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❖ PRESENT
D: Do you know what test we did for you? Do you know what we are looking
for?
P: I believe some markers for coeliac disease.
D: That’s right, your blood tests were screening for specific coeliac disease
markers called (TTG) , and it came back positive. As your sister has it, do you
know much about it?
P: From what I have seen with my sister I believe it’s an allergy to gluten. Am I
correct? and I will have to stop eating it to feel better?
D: Yes, you are right. You seem like you are well informed. It is a condition
where your immune system attacks your own tissue when you eat gluten so
yes it’s a form of allergy in simple words. It causes damage to your gut so it
becomes unable to take nutrients and that might be the cause of your
tiredness, anaemia and diarrhoea as well like what you described.
− Gluten is present in wheat , barley , rye, etc.
➢ To confirm the diagnosis , we need to perform a special camera test
called an endoscopy.
❖ FUTURE
Management:
1. Refer you to gut specialist

- To do an endoscopy , which is thin flexible tube with light and camera will be
attached to your mouth and pass down to your gut. Especially to an area called
duodenum and jejunum. We will need to take samples for analysis to check for
specific inflammation markers of coeliac disease.
In the meantime you will need to continue eating food containing gluten for
about 6 weeks before performing the procedure otherwise the specific gut
changes will not be there if you stopped gluten and that will result in false
results. So may I request that you keep eating a gluten rich diet until the
diagnosis is completed. I know it might be distressing but it’s essential at this
step. Would that be OK?
Before the procedure we will need to prepare you. (similar to colonoscopy)

− You will need to fast for 6 hours before the procedure
− Then the following:
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Before During After

• You need to eat • We will take a Complications like
food that sample to nausea or vomiting or
contains gluten examine it under cramps are rare,
for the test to be microscopy to however we will still do
accurate. check it for signs our best to prevent
• You will be given of coeliac disease. them.
local anaesthetic • Procedure takes
to numb your around 15-30
throat and minutes
medication to
help you relax
during the
procedure.
2. Involve senior.
3. Further tests and investigations:

− to check level of vitamins and minerals especially iron profile, as they
might be deficient due to coeliac disease.
− bone scans (DEXA scan) to check bone strength.
4.Management
If diagnosis with coeliac disease is confirmed, the only treatment to follow is:
− Gluten–free diet: Your symptoms should improve considerably within
weeks of starting a gluten-free diet. However, it may take up to two
years for your digestive system to heal completely.
− We can refer you to dietician to adjust your diet without gluten.
5. Safety netting:
- If you have severe diarrhoea, dry mouth or do not urinating as usual, come to
the hospital immediately, because that might need special attention. Or if you
have FLAWS (Lymphoma) please report it to your GP.
6. Leaflets: for Coeliac and gluten free diet and also about colonoscopy (What
to expect and how to get ready.)
Do you have any other concerns?

P: Do I have to take time of work?
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D: Yes you can take a few days off work until the effect of sedation wears
away and you feel better and ready to work.
P: Can it be cancer?
D: Why you think it is cancer?
P: I am worried because I am losing weight and feeling tired.
D: Your blood test shows that coeliac disease is the most probable diagnosis,
and all these symptoms that you are having indicate that too. However, as I
have already mentioned we will have to do the endoscopy to confirm the
diagnosis.
P: Can coeliac disease cause any complications:

D: Unfortunately, yes but with proper treatment we can avoid or at least delay
these complications. These complications include:
- Anaemia
- Bone diseases and osteoporosis
- DM (as part of auto immune profile)
- GIT Lymphoma (watch out for FLAWS we can avoid that
by proper management)
Barret’s Oesophagus
Who the patient is: Mr David Smith is 55 years old, he had endoscopy a week
ago which showed Barrett’s oesophagus.
What you should do: Explain the results to him and talk to him about the
survilliance ( each 3 years)
(Very similar to the above station, follow the same structure)
Hello, I am one of the doctors here. May I confirm your full name and your
date of birth?
I can see from my notes that you are here for your result, I have your results
but if you do not mind , can we have a chat about your health ?
❖ PAST: Why did you have this camera test?
P1 → heart burn (ODIPARA)

− Explore
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− Any change in your symptoms since you did the test ?

− Anything else ?
DDs :
− Difficulty swallowing ?
− Change in your voice ?
− Nausea or vomiting ?
FLAWS: Very important (it’s Barrett’s- a pre- cancerous disease)

P2
− How was the test ?
− Did you experience any challenges? Any problems afterwards?
− Any pain or vomiting blood after the test ?
− Any medical conditions ? ( stomach ulcer )
DESA: Smoking/ alcohol increase risk of cancerous transformation so you will

have to counsel about them. Spicy food, chocolate, coffee, fried food, fizzy
drinks and being overweight can make symptoms worse.
MAFTOSA: stress can make symptoms worse, so advise and offer options.
Examination:
− Observation
− BMI
− Tummy
❖ PRESENT
(Explain the results)
Unfortunately, the result shows that you have a condition called Barrett’s
oesophagus. The Oesophagus is your food pipe and due to a long time reflux of
acid from the stomach to its lower part, it causes a change in the shape of its
cells. Let me assure you this change in itself is not malignant or cancerous and
could remain constant in many people; However, it has a higher potential to
become a cancer compared to other normal cells. So we will need to perform
a similar endoscopy to monitor it every 3 years to pick up any serious
changes as early as possible and manage them properly.
❖ FUTURE
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Management: A R M M S
Advice:
− Reduce weight to improve symptoms.
− Avoid eating or drinking couple of hours before bedtime.
Risk factors
• Smoking → has chemical that can damage your food pipe → We can
refer you to smoking cessation clinic.
• Alcohol → better to cut down or follow the recommended weekly
amount (14 units per week and not more than 2-3 units per day) to
improve your symptoms.
• Food → Avoid certain food can increase the heartburn such as : (spicy –
fats – coffee)
− Small frequent meals
− 5 potions of fruits and vegetables
Management and investigations:

• I will inform my senior because, you might need medication for your
heartburn ( PPI )
• H – pylori test
Multidisciplinary: We need to keep monitoring it by performing a camera test

at regular intervals and we might take a sample for further examination under
microscope.
Safety netting:
− Worsening of your symptoms
− Difficulty swallowing
− Losing weight
P: Why you do not remove them?

That’s a good question. The food pipe is an important structure in our body
and surgery is not recommended at this stage as it has a low risk of turning
into cancer. We will keep monitoring you and if, at any time, we found any
abnormality, we can deal with it in its early stages.
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COLORECTAL POLYP
Where are you: FY2 in GP surgery. Patient information: You presented
Who the patient is: Lucy Clark, 55-year-old to your GP a few weeks ago with 2
woman, has made an appointment to see you. episodes of blood in your stool. Your
Other information you have: You had referred her GP referred you to the specialist
to the hospital for per rectal bleeding. She had who performed sigmoidoscopy.
sigmoidoscopy done which showed bleeding They found some polyps, which they
polyp. Histology was done which confirmed benign removed and sent to lab for
adenoma and some dysplastic changes. The histology. Results showed benign
specialist would like to perform a colonoscopy. The polyps. You were quite happy
patient would like to talk to you about it. everything was going well.
What you must do: Talk to her & address her While having sigmoidoscopy done,
concerns. you had discomfort and you’re not
keen about having this procedure
Concerns: again. Since polyp removal; no
1. Why do I need another camera test when the bleeding.
biopsy showed benign? You are not happy doctor asked to
2. Is sigmoidoscopy not enough? do another camera test.
3. Do you think it could be cancer? You live with your husband, and he
4. How long will the procedure last? can come and get you. It is not a
5. Are there any complications? problem.
6. Will you put me to sleep, doctor? You are normally fit and well and
7. Will I be in pain? not under any regular medications.
8. Do I need any preparation? None of your family member has
such problems.
Note that you should explain the procedure to the Last time you had colonoscopy, it
patient in a simple and understandable manner. was very embarrassing for you, this
This particular patient is anxious about the is why you do not want to go
procedure. through it again. You also had
The candidate should provide information to severe discomfort. They did not
reassure the patient and allow the patient to make offer sedatives initially until halfway
an informed decision about the procedure. through the procedure.
(Analyse the main complaint, not too many
questions as you need to have more time to
address the concerns the patient will have. Don’t waste time asking too many
DDs.)
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D: Hello Mrs Clark, my name is Dr (name), I am one of the junior doctors in this
department. Could you confirm your name for me, please?
P: Hello doctor, I am Lucy Clark.
D: Nice meeting you Mrs Clark, I can see from my notes that you had a camera
test done 2 weeks ago.
P1 FOCUSED HX
D: May I know why you did the test in the first place?
P: Well I had this problem of bleeding from my back passage 4 weeks ago. I
went to the GP he sent me for this test.
D: Okay, can you tell me more about this bleeding? (Open Q)
P: I noticed blood in my stool 2-3 times since then.
D: I see. I just need to ask you some questions regarding your general health.
(Acknowledge if she is showing emotion, blood in stool can be scary)
D: How are you doing now? ALWAYS CHECK CURRENT CONDITION
Associated symptoms
D: Do you have any tummy pain? Diarrhoea? Constipation? Nausea/vomiting?
D: Fever? Loss of appetite? Weight loss? Tired? Weakness? (FLAWS) Check
red flags
P2 PAST HX
P: No.
D: Have you ever been diagnosed with any medical conditions in the past or
any bleeding disorders? Or any heart problems?
P: No.
D: About the previous camera test how did it go?
D: Did you have any problems or challenges while having it done?
D: Did you have any bothering Sx afterwards, like pain or bleeding from back
passage?
P: It was very embarrassing for me, I also had severe discomfort and they did
not offer sedatives initially until halfway through the procedure.
D: I am sorry about the experience u had.
MAFTOSA + DESA
D: Few questions regarding your lifestyle now, do you smoke? Alcohol? Diet?
D: Mrs Clark, are you under any medication like blood thinners or anything
else?
D: Any allergies? Any family hx of a similar condition?
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D: What do you do for a living? Who do you live with? How has this been
affecting your social life? (V. important to ask about Mood and Psychosocial)
D: Thank you for answering the questions. (Appreciate the patient wherever
possible)
Let’s talk about your procedure and test results. So as you mentioned you
went through a camera test earlier. Did anyone explain to you the test reports?
P: Yes, the doctor explained I have colon polyp and the biopsy confirmed it as
adenoma (benign).
D: Do you know what polyp is?
P: Yes/No
D: A polyp is actually a non-cancerous/benign growth in the lining of the gut.
P: Do you think it could be cancer?

D: No, like I said, it’s non-cancerous. I understand this might be scary but these
are benign growths. But if we do not remove them, over time they can
become cancerous. (Acknowledge emotion)
ICE
D: Do you have any idea why you have been sent here? (Do ICE, always assess
her knowledge to save time. If they know, don’t explain, if they don’t know,
then explain)
P: I have been told I will be having a colonoscopy.
D: Yes, do you have any concerns at this point? (Always ask concern every now
and then)
P: Why do I need another camera test?

D: May I know why you don’t want to do it?
Any challenges you faced last time? (Try to explore the reason of refusing and
always ask how the procedure went last time?)
P: Last time it was really uncomfortable and I also had to wait for the results
for too long.
D: Now I see where your concerns are coming from. I am sorry you had to go
through such a bad experience last time; we will make sure you are as
comfortable as possible. We will give some sedatives to relax.
I’m so sorry that you had to wait that long for the results, it was a special type
of test and it can sometimes take a little more time to get the results.
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P: Is sigmoidoscopy not enough as the biopsy showed it was benign?

D: I am afraid not, as there is a chance you may have polyps further up the
bowel which might turn into bowel cancer if they are not removed. So we
need to check that there are no more polyps further up the bowel and that
there is nothing else going on. Unfortunately, having a polyp is one of the risk
factors of developing cancer so we need to check the whole colon and remove
any we find. (Deal with the concern clearly)
P: Alright, can you explain the procedure to me?

D: A colonoscopy is a simple camera test where we will be passing a lubricated,
flexible tube, which has a camera on the tip, up through your back passage and
into your bowels to visualise your bowels from the inside. The camera will help
us see what is going on inside. We will pass gas into your bowels to inflate
them so that we can see things more clearly. We may need to take pieces of
tissue from any abnormal areas to be examined in the lab.
P: How long will the procedure last?
D: The procedure usually lasts about 30-45 minutes, but it can vary.
P: Will you put me to sleep, doctor?
D: For this procedure you will not be put to sleep, but we will give you some
sedatives through your veins to help you relax.
P: Will I be in pain?
D: You may feel the camera go in, but it should not hurt.
P: Do I need any preparation?
D: Well,
− before the procedure you will need to empty your bowels for a better
view.
− You will need to have a special diet a couple of days before the
procedure.
− We will also give you laxatives to take a day before the procedure, which
will help you clear your bowels.
P: What happens after a colonoscopy?
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D: You'll then be moved to the recovery room. The nurses will monitor you
until you're ready go home. You might be at the hospital for around 2 hours
from getting there, to going home.
P: Are there any complications?
D: Most colonoscopies are done without any problems. However, like any
procedure, there are a few complications that might occur:
− The sedative may make you feel drowsy and tired for several hours
afterwards.
− There is a risk of damage to the bowels. (Perforation/puncture of the
bowel)
− You might experience fever after the procedure. (infection)
− Abdominal discomfort (bloating).
− You may also have some blood in your poo or bleeding from your
bottom.
If any of the above occur, we will manage you accordingly.
P: Dr why did you not do a colonoscopy from the beginning ?

I can appreciate it is not easy to go for another procedure again, but we usually
start with the non-invasive one and if there is anything abnormal found, then
we do the more invasive procedure. I know you are saying you had a bad
experience last time, I really apologise for that. (Address the concern about
the previous one as pain or sick leave )
Management
(For counselling in all these stations, your management is talking about (DESA)
or lifestyle modifications, and what other steps in terms of investigations or
treatment options may be needed).
ARMMS:-
Advice:
− A few hours of monitoring are required until sedation wears off.
− Needs someone to pick her up.
− The effects of the sedative may last up to 24 hours, we therefore advise you
not to:
1. Drive or ride any type of bicycle for at least 24 hours.
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2. Operate any type of electrical or mechanical equipment/ machinery

for at least 24 hours.
3. Sign any legally binding documents for at least 48 hours.
4. Drink any alcohol for at least 24 hours.
5. Not be responsible for young children, disabled or dependent
relatives for at least 24 hours.
− You can eat as you normally would.

− Rest quietly for the remainder of the day and if possible have someone stay
with you overnight.
Risk factors:
− Smoking
− Family history of lung cancer
− Family history of polyps
− Does she have brothers and sisters/Do any of the brothers and sisters
have any bowel problems of polyps.
Safety Netting:
− If any of the following happen, you will need to come back.
• Abdominal pain
• Rectal bleeding
• Fever
Consent:
Before During After
Bowels have to be clear You will usually be As you will be given a
to see properly: awake but you will be sedative, please avoid:
• 3 DAYS BEFORE offered medications to • Driving for 24hrs.
avoid food that make you comfortable • Signing important
contains wheat, • We may need to documents.
bran, green take a biopsy to It’s a day case so you can
vegetables. examine later in a go home the same day.
• 1 DAY BEFORE lab. Complications may be
only clear fluids, • Procedure takes bleeding or tear of the
water, soup. around 30-45 bowel, but they are very
• 4 HOURS BEFORE minutes. rare.
NPO • You may feel
bloating or cramps.
How do you feel about everything we have discussed and the procedure now?
Would you agree to consent to the procedure now?
Follow up: You should get a letter or a call with your results 2 to 3 weeks after
a colonoscopy.
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➢ Regarding colonoscopy preparation:
Colonoscopy (Fainting)
Who you are: You are FY2 doctor in A&E.
Who the patient is: Mr Alex Johnson complains of per rectal bleeding. He came
to A&E today after he fainted, bloods were taken and you can find them in the
cubicle. The consultant decided to schedule him for colonoscopy.
What you should do: Talk to him and address his concern, discuss the plan of
management.
D: Hello, I am one of the doctors here in A&E . May I confirm your full name
and your date of birth?
D: I can see from my notes that you have some sort of bleeding and you
fainted, may I know what happened exactly?
P: I don’t know what happened doctor. I am here because I fainted.
P1
D: Oh I see can you tell me more about it? Open Qs
P: I don’t know exactly what happened to me. My wife witnessed the episode.
(Any fainting station BEFORE/DURING/AFTER)
BEFORE
D: How were you feeling before you fainted?
P: Fine.
D: Were you doing anything specific?
P: No doctor I was reading the newspaper at home?
D: Did you eat and drink well and had all your meals ?
P: Yes doctor I ate well.
D: Did you sustain any trauma to your head?
P: No.
During:
D: Did your wife tell you that when you fainted you were making jerky
movements?
P: Yes/No
D: Did she say you wet yourself or bit your tongue?
D: Did you hurt yourself when you fainted?
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P: No.
D: How long did this episode last?
P: She said 2-3 minutes.
After:
D: Were you drowsy when you woke up?
P: Yes very.
D: My reports say that you have some sort of bleeding problem, please tell me
more about it?
P: What do you want to know?
ODIPARA-TRAC
D: When did it start?
P: I noticed it 8 months ago for the first time.
D: Can you describe what exactly you noticed?
P: I noticed some blood in my stool.
D: How many times did it happen? Times
P: I’ve noticed it some 2-3 times since then.
D: Is it related to anything you noticed? Anything that increases or decreases
it.
P: No not really.
D: How much is the amount?
D: You mentioned it is red, is it bright red or brown? colour
P: It’s red like fresh blood.
Associated Sx and DDs

D: Anything else with it? Open Q
P: …
D: Any pain while passing stool? Or any pain in the tummy?
P: No.
D: Any problems with bowel habits recently? Constipation/diarrhoea?
P: No.
D: Any nausea/vomiting?
P: No.
FLAWS
D: How is your appetite these days?
P: Fine.
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D: Have you noticed any weight loss?

P: No.
P2:
D: Have you ever had similar bleeding or fainting before in the past?
P: No.
P: No.
D: Any hospitalisations or surgeries?
P: No.
MAFTOSA
P: No.
D: Do you have any allergies from food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition or
similar bowel bleeding?
P: No.
D: May I ask you what you do for a living?
P: I am a carpenter.
P: No.
DESA
D: Do you smoke?
P: Yes/No
P: Yes/No
P: I don’t have much time.
ICE very important to address the patient’s concerns.
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Examination
Thank you for bearing with me, If you don’t mind, I would like to examine you,
take your observations and your blood pressure, do a GPE and check your
back passage, I will also check your Lab reports:
Results in paper:
LFT/KFT/TFT-normal
HB: low
While most of your tests are normal, your haemoglobin levels which may
correspond to the function of red blood cells are on the lower side. It means
that you may have a form of anaemia and when severe enough it may result in
similar fainting episodes. So far are you following me?
P: Yes doctor, so what now?

We are thinking that this anaemia might be related to the blood loss you have
from your back passage. That is why my consultant wants to discuss you having
a colonoscopy, to find out any possible causes for the bleeding in your bowels.
How would you feel about that?
P: I have already had so many tests, I don’t want to it doctor.

D: May I ask you why?
P: I have had enough of testing I don’t want any more.
D: I understand that a procedure like this can be intimidating but it’s crucial to
find out the cause, most of the time it is nothing serious but sometimes it can
be as severe as cancer. If there is anything sinister going on we want to detect
that as early as possible to provide better and more effective treatment
options before it’s too late. Does that make sense to you?
D: Oh my god doctor is it cancer?!

P: I am sorry if I have alarmed you. At the moment what is reassuring is that
you don’t have any red flag complaints apart from the bleeding, and it’s still
way too soon to say. That is why we recommend you having the colonoscopy?
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P: How would a colonoscopy help?

A colonoscopy is a camera test that passes a thin long flexible tube through
your back passage to allow us to see inside your bowels. It is an investigative
and therapeutic tool for any bowel symptoms. It can help detect the cause and
treat it in some circumstances. It can also take samples to analyse if a
malignancy or a sinister cause is suspected.
Most of the time, it will not find anything worrying. But sometimes it might
find something that needs a closer look or further testing.
D: Do you agree to go through the procedure? CONSENT

P: Okay doctor.
D: So we will keep you in the hospital for now till we do the colonoscopy. There
are a few preparations that I would like to discuss with you before the
procedure, if you want?
Discuss as mentioned in the previous cases.
Be patient centered and follow his concerns
Safety netting: If you have severe pain, bleeding or high temperature after the
procedure come to the hospital immediately.
If you feel dizzy, drowsy or about to faint please ring this bell because it might
be that you are bleeding severely. We will come at once.
Vascular Dementia
Who you are: You are an F2 in GP.
Who the patient is: Tracy Williams, aged 58, is diagnosed with psoriasis and is
using skin emollients. Her psoriasis is well controlled. Recently she booked an
appointment with her GP to discuss a few concerns.
Special note: The nurse has found her BMI to be 32.
What you should do: Talk to the patient and address her concerns.

clinic. Are you Tracy ?
P: Yes.
D: Can you confirm your full name and date of birth please?
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D: Thank you Tracy. Well how can I help you today? I understand you have
some concerns for me?
P: Doctor can you tell me what dementia is?

(Whenever the patient brings up a medical term or a specific disease
please explore WHAT they know about it and WHY they are worried
about it).
D: Yes definitely, but may I know why you want to know about dementia
specifically?
Explore Concern:
P: I am worried I might have it doctor.
D: Why do you think you have it?
P: Because my mother has it, and my sister has recently been diagnosed with
vascular dementia. That is why I am worried now doctor, I am thinking I
might be at risk.
D: Oh I see where you are coming from now. Sorry about your mother and
sister, may I ask how are they doing now?
P: My mum was struggling doctor and her condition has worsened as she has
gotten older, but we are managing with her now. My sister on the other hand
was recently diagnosed, and I will try to be there for both of them as much as I
can.
D: That’s very good of you. Rest assured we will do all we can to support you
and answer all your concerns. Could you please tell me how old your mother
and sister when they were first diagnosed?
P: I am not sure about my mother, but my sister was about 65 years old. She is
my older sister.
D: Let me ask you a few questions to have better insight into your problem.
Would it be alright?
P: Yes doctor.
D: How much do you know about dementia?
P: I know about dementia enough doctor, but I am just worried about getting it
myself.
Dementia Questions:
D: Are you forgetful of things more than usual these days? Like forgetting food
in the oven or keys in the door or misplacing things?
P: No.
D: Do you sometimes find it difficult to remember familiar faces?
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P: No.
D: Do you feel a bit confused sometimes about time or place? Like losing your
way around when you are going home?
P: No.
D: Do you feel it is difficult to concentrate on your work?
P: No.
D: Do you find it hard to carry out your daily tasks?
P: No.
D: Have you ever struggled to find the right words in a conversation?
P: No.
D: How is your mood? Any mood changes?
P: No.
Cardiovascular Sx:
D: How is your health in general?
P: It is fine.
D: Have you ever had any heart problems/ Heart attacks? Chest pain going to
the left side? Heart racing?
D: Have you ever had any strokes or any weakness anywhere in your arms or
legs?
D: Any headache or light headedness?
P2
D: Have you ever been diagnosed with any medical conditions in the past?
P: Yes, I have psoriasis.
Explore briefly
D: How are you managing it?
P: I am using emollients and steroid creams for that.
D: Is it under control?
P: Yes.
D: Are you using them as prescribed?
P: Yes.
D: For how long have you been using steroid creams?
P: for a very long time since I was diagnosed about 30 years ago.
D: Any other medical conditions?
P: No.
D: Any DM, HTN, high cholesterol? (Ask specifically very important here.)
P: No.
MAFTOSA
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P: No.
D: Has anyone in the family ever been diagnosed with any medical condition
apart from dementia that your sister and your mother had?
P: No.
P: I work in an office.
D: Is it a stressful job?
P: I would say so yes doctor.
P: I live with my husband. We take care of each other, but I take care of him
more.
DESA
P: I eat everything like burgers, chips, I mostly eat outside because I don’t have
time to cook.
P: I don’t do much of it.
D: Do you smoke?
P: Yes.
D: How much have you been smoking per day and for how long?
P: About 15 a day for 15 years now.
P: Yes.
D: How much have you been drinking a day and for how long? Have you tried
calculating the units you drink each day?
P: For 40 years now, I don’t calculate it doctor.
ICE:
D: Are you worried about anything else ?
D: Were you expecting anything specific from us today?
Examination:
Thank you for bearing with me so far, I would like to examine you now to take
your vitals, your blood pressure and heart rate, I would also check your body
mass index. Is that OK?
(If the stem doesn’t mention BMI you will need to verbalise it. In the
examination there will be a result, so be safe and mention it anyway).
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From our assessment and from what you have told me, you don’t have any
suspicious signs or symptoms for Dementia. But to be fair there are some risk
factors that I picked up from our chat which might increase your risk of having
it. Would you like to hear more about the risk factors and how to avoid
dementia?
Vascular dementia can have many causes and risk factors. It happens when the
blood supply to the brain is affected somehow and this is called a stroke.
Dementia can happen after one major stroke or many repeated strokes that
may affect your brain functions such as memory.
Many factors can increase stroke risk. Some of them are called non-modifiable
factors like age , family Hx, which we can’ t do anything about. On the other
hand some factors can be modifiable, like diet and other lifestyle factors. So
we calculated your BMI and it turned out to be on the higher side, which
means that you are at higher risk of getting dementia, but if we can help you
achieve a healthier weight/BMI then that risk would decrease.
Are you following so far?
P: Yes doctor but what is BMI?

D: BMI is your BODY MASS INDEX, and it simply means we are plotting your
weight in relation to your height to see if it is higher or lower than it should be.
A high BMI means that your weight is above the healthy level for your height
and that might carry some risks and affects your general health in a bad way.
Does that make sense to you?
P: Yes doctor so what do suggest?
Counselling:
> Discuss DESA and ADVICE as before.
> DEMENTIA ADVICE: to strengthen your memory we can recommend
some things:
− Try to read books more.
− Engage in discussions and conversations with your family members
and friends.
− We can recommend some memory exercises like word games and
SUDOKU.
− Try to keep active and sociable as much as you can.
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> Psoriasis ADVICE:

− Psoriasis and long-term use of steroids can also carry some risk of
developing DM, HTN and heart problems which in turn increase
vascular dementia risk.
− Since you are also using steroids, it’s crucial to attend regular
follow ups for proper monitoring of any side effects, and to take
your medicine as prescribed.
Management treatment and INVs + Senior:

We will order some routine blood tests: like
− RBG
− FBC/CBC
− RFTS and LFTS
− Cholesterol and lipid profile to calculate your Qrisk
− ECG
MDT:
Dietitian, CBT and Psychologist, Revise steroid use with Dermatologist (skin
specialist).
Safety net:
As before (MI/Stroke/Forgetfulness/) + steroid SE (DM/HTN/ Weight
gain/vision problems)
Offer leaflets.
Follow up:
Set another appointment after a few weeks, to see how she is coping.
Dermoid cyst
Where you are: FY2 in GP surgery.
Who the patient is: Anna Parker, 26 years old, presents to the hospital with
abdominal pain. Ultrasound has been done and shows dermoid Cyst in the right
ovary. The consultant has decided to perform an open ovarian cystectomy via
Pfannenstiel incision (8cm). The wound will be closed using absorbable sutures.
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Consultant has decided to keep the patient in the hospital after the surgery for
2 days.
Additional information: none
Special note: Consent has been taken from the consultant.
What you must do: Talk to the patient and address her concerns.
Please note plab2 stations have no right or wrong scheme of approach. It’s all
about addressing the concerns and fulfilling the Qs task, while taking just the
sufficient amount of history. So, in this particular case you can use the
Surgery structure, combined with test results and counselling structure. BE
FLEXIBLE.
D: Hello Miss Parker, I am one of the doctors in this surgery department. Could
you please confirm for me your full name and age?
P: Anna Parker, 26 years old.
D: Nice meeting you Miss Parker. I gather from my notes that you have been
scheduled for surgery. Are you aware of that?
Patient: Yes doctor and I have some concerns regarding the surgery.
D: Yes, I am here to address all your concerns. Is it okay if we have a chat about
your health before that?
P: Okay doctor.
P1- Focused hx
D: Thank you. Can you tell me why you came to the surgery in the first place?
P: I came to the surgery because of pain in my tummy.
P: I have had this pain for the last few days in the right side of my tummy.
D: Has the pain increased from before? (Changes/ Complication)
D: Do you feel dizzy? Heart racing? (Complication/ Torsion/ rupture)
P: Yes/No
D: Anything else apart from this? Vomiting? Fever? Bowel or Bladder
problems?
P: Yes/No
P2- past hx
P: No.
D: Have you undergone any surgery in the past?
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P: Yes/No
MAFTOSA
D: Do you have any long-term medical condition?
D: Are you taking any medication at the moment?
P: Yes/No
D: Has anyone in the family been diagnosed with any medical condition?
P: Yes/No
P: I'm an accountant.
D: Who do you live with? / Is there anyone to look after you once you are
discharged?
P: Yes/No
D: Do you drive?
P: Yes or no.
DESA
D: Tell me about your lifestyle, do you smoke? Alcohol?
P: Yes/No
D: Thank you for answering these questions.
Counselling:
Explain the results/ diagnosis/ procedure/ complication
D: Has anyone explained to you the results of your ultrasound scan?

P: Yes/No. She might say “I have been told I have a cyst in my ovary but I am
not aware of any specifics can you please tell me more doctor?”
If no, then explain. (Always ask patient what they know and how much they
want to know)
D: As you told me, you came to the hospital with tummy pain, we did a scan
and we found there was a fluid-filled sac in your right ovary which we call an
Ovarian Cyst. Are you following?
P: Why do I have this?

D: Ovarian cysts often develop naturally if you have monthly periods. They can
also affect people who have been through the menopause.
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I am here to help as much as possible so please share with me any concerns

you have? (ALWAYS do ICE)
P: What is going to happen now?

D: We have run all the tests and as results show an ovarian cyst. Our
consultants are of the opinion that performing surgery would be the best
approach.
P: Why do you have to operate?

D: Even though it’s not serious at the moment, the reason we need to operate
is because if it is not removed now, it can create further complications. (IF you
pause while speaking, its an invitation for the patient to ask questions so be
aware this a good communication tip but don’t overdo it)
P: What complications doctor?

D: It can continue to grow and has a high chance of rupture, bleeding or
twisting.
P: What kind of operation will you do?

D: We will be performing an open surgery that we call an ovarian cystectomy,
which is removal of the ovarian cyst. In this operation the surgeon will make a
cut three to four inches in size in the lower part of your tummy just above your
bikini line (Pfannenstiel incision). He will then remove the cyst and close the
tummy back up again.
P: Any preparation for the surgery?

D: For this operation, you will need to be admitted the day before and you also
need to fast for eight hours before the operation.
P: How big will the scars be? Will it be visible?

D: About 8 cm. The scar will be very thin and would be covered by a bikini so it
wouldn't be visible on a beach.
P: Will you be removing my ovary as well?
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D: That’s a good question. So far we are only planning to remove the cyst,
however if the surgeon sees that the cyst is occupying a large portion of the
ovary, he may suggest removing the ovary as well.
P: Will I still be able to have children?

D: As long as the other ovary is working fine, you should be able to get
pregnant and have children like everyone else.
P: How long is the operation?

D: It will take about 45 minutes to an hour.
P: How long will I stay in hospital?

D: After the operation you will be taken to the recovery room and then to the
ward. You might need to stay in the hospital for 2 days, depending on how you
feel after the operation.
P: Are there any complications following surgery?

D: As with all surgery there are certain complications such as bleeding,
infection or damage to the surrounding structures. However, these are quite
rare and we will take due care of this.
P: When can I return to work?

D: Initially it is important to rest for at least for four weeks and thereafter it all
depends on how you feel. If heavy work, may need about six weeks to rest.
P: When can I have sex again?

D: Well, it is advisable to avoid intercourse for two to four weeks after surgery.
P: When can I drive after the surgery?

D: It is advisable to avoid driving until you are able to perform an emergency
brake without feeling any discomfort. It will usually take 4-6 weeks.
P: What about stitches?

D: We will be using absorbable stitches, so you don’t have to worry about
getting the stitches removed.
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P: Is it cancerous?
D: Ovarian cysts are mostly not, however we will send the sample to the lab to
be analysed to be sure.
Safety net for rupture, torsion, bleeding and any discomfort. Also you can
safety net for post-operative complications
Please Note: If the station asks about laparoscopic cystectomy, then mention
what’s below:
The operation is called a “laparoscopic cystectomy” which is keyhole surgery.

The surgeon will make a small incision below your belly button and insert a
small amount of harmless gas to distend your tummy and make it easier to
operate inside. This gas will be removed after the operation. We will also make
two small incisions on either side of your lower tummy to insert a camera and
instruments.
For laparoscopic surgery: Provided that everything goes smoothly you may be
able to go back home on the same day or next day.
Work/sex/driving: Can resume after approximately two weeks depending on

the patient’s recovery.
Meningitis:
Where you are: FY2 in A&E.

Who the patient is: Max Carson, 20 years old. Max was sitting with his dad and
watching TV when he suddenly felt drowsy and had a fit. Then, he was
confused and was brought to the hospital by his father.
What you must do: Talk to the father, Mr. William Carson, take focused
history, explain investigations, address concerns and discuss initial
management plan.
Dr: Hello, I am one of the FY2s here in A&E. Am I talking to William?
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P: Yes doctor.
Dr: Can you please confirm your son’s full name and date of birth for me?
P: His name is Max Carson and he is 20-year-old.
D: Thank you. How may I address you?
P: Mr. William Carson.
P1- FOCUSED HX
D: I understand your son was brought to the hospital because he was feeling
unwell and had a fit. Could you please tell me more about it?
(Remember before- during - after)
P: Well, we were watching a football match on the sofa when suddenly he
became drowsy and confused.
He was acting funny and weird. Then his entire body started shaking.
(Always try to use the patient’s own words. He said ‘shaking’ not ‘fit’ so use
‘shaking’. It will show you as a more active listener. Also try to summarise
and recap better than asking about what he already mentioned in his P1).
D: I am sorry to hear that. What did you do then?

P: I got really afraid and called an ambulance.
D: Well you did the best thing calling the ambulance. Could you tell me a bit
more about this shaking?
(ODIPARA)
When did it happen?
P: About an hour ago.
D: How long did it last?
P: Around 2 minutes.
D: What happened before that? (Before)
P: He was drowsy.
D: Was he making jerky movements with his limbs? (During)
P: Yes, he was shaking all over.
D: You mentioned he was drowsy, did he lose consciousness?
P: Yes, for around 2-3 minutes.
D: Did he wet himself? Or bite his tongue?
P: No.
D: What did you mean when you said he was acting funny?
P: He was mumbling inappropriate words and he was hearing sounds which I
could not hear. I felt like he was hallucinating.
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D: What happened afterwards? (After)

P: He was confused and drowsy.
P2- PAST history

P: No.
D Was he sick recently?
P: Yes, he had flu like illness couple of days ago.
D: Did he have a fever?
P: He was mildly feverish.
D: Anything else?
P: He had a mild headache.
DDs:
D: Did he have early morning headache or vomiting? (SOL/Tumour)
P: Headache like I said, but not early morning.
D: Did he have any rash anywhere on his body? Or neck stiffness?
P: I am sorry, I didn’t notice.
D: Did he have runny nose? (Sinusitis)
P: No.
D: Was he more tired than usual? Was he losing weight? Any lumps or swelling
anywhere in his body? (FLAWS of Malignant)
P: No.
D: Did he have any trauma to his head?
P: No.
D: Weakness in any part of the body? (Stroke)
P: No.
D: Has Max been in contact with anyone with similar symptoms? (Contact Hx
very important)
P: I don’t know.
D: Other than Max and yourself, who else is at home? (Psychosocial)
P: Just him and me.
P2
D: Has he been diagnosed with any medical conditions?
P: No.
MAFTOSA
473 | P a g e
D: Does he take any medications?

D: Did he take a vaccine for meningitis any time in the past?
D: Any allergies?
P: No.
D: Any family history of epilepsy or similar condition?
P: No.
D: Has he travelled outside UK recently?
P: No.
D: Do you know if he takes any recreational drugs?
D: Is he sexually active?
P: I don’t know.
D: What does he do for a living?
P: He is a student at Liverpool University.
DESA:
No room for DESAs this is an emergency situation.
D: Does Max smoke cigarettes or drink alcohol?
D: Thank you for bearing with me so far.
Examination:
D: We are going to take his observations and do GPE, check for a rash,
neurological examination, reflexes and special test to see any brain infections
and Fundoscopy. We will send for some routine blood tests.
CSF and scans of the brain.
(Please explain the tests results to the patient or patient’s relative showing
them on the test results paper)
> Observation: Pulse- 100 BP-110/70 Temperature- 38 Sp02- 96% GCS-
11/15
> Patient condition: Drowsy, confused
> Findings: Red, non-blanching rash all over the body.
> Examination: Kernig’s sign and Brudzinki sign positive
> CT scan- Normal
> CSF- glucose low, cells increased, mostly Neutrophils
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(Please note: Always ask idea before saying diagnosis)
D: Do you have any idea what’s going on?
P: No.
D: Given the situation and examinations, we believe it’s an infection of the
covering of the spinal cord and brain, called Bacterial Meningitis. (If you have
time, tell the positive findings to support the dx)
P: Meningitis is serious, isn’t it?

D: Meningitis can be very serious if not treated quickly. It can cause life-
threatening blood poisoning (septicaemia) and result in permanent damage to
the brain or nerves.
MANAGEMENT: You can use ARMMS or the 7-step management
P. What will you do for him? (Advice and Management)

D: We need to admit him to the hospital immediately.
D: I will involve my seniors to reassess Max’s condition and order some

investigations.
Investigations:
We will send for some further tests and we will take a small sample of the
CSF which is the fluid around your son’s spine to analyse it for any infections.
We will do some special scans of the brain as well called CT and MRI scans.
> CT scan- Normal
> CSF- glucose low, cells increased, mostly Neutrophils
Symptomatic Treatment:
Bacterial meningitis usually needs to be treated in hospital for at least a week.
Treatments include:
− Antibiotics given directly into a vein according to hospital protocol. (IV
Ceftriaxone).
− Fluids given directly into a vein.
− Oxygen through a face mask.
− Steroids to prevent swelling around his spine and brain.
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P: Will he be ok after treatment?

D: Most people with bacterial meningitis who are treated quickly make a full
recovery.
P: Is he going to die?
D: If treated early, there is a good prognosis. However, it's estimated that up to
1 in every 10 cases of bacterial meningitis are fatal.
P: Any complication?
D: Since you brought Max in early we can start treating him quickly and
hopefully he will recover completely, although some are left with serious long-
term problems. Hearing loss or vision loss, problems with memory and
concentration, epilepsy, co-ordination, movement and balance problems, and
also unfortunately loss of limbs.
P: Is there any vaccination for this infection?

D: A number of vaccinations are available that offer some protection against
meningitis.
D: Please note, we need to give Ciprofloxacin to any close contact with him in
the last few days.
It is also a notifiable disease to public health team, because we would need to
trace all contacts and treat them properly to protect them from developing the
same.
Multidisciplinary team/ specialist.

Involve a nerve specialist, they will do further assessment and more specific
investigations like EEG which is a special tracing of the brain electrical activity.
Safety netting.
Worsening symptoms to be informed.
Follow up:
We will make sure that he will follow up later with his GP and the nerve
specialist after he is discharged.
Leaflets.
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Meningitis prophylaxis
Where you are: You are FY2 working in GP Clinic.

Who the patient is: Olivia, aged 50, came to the GP clinic with some concerns.
What you must do: Talk to the patient and address her concerns.
D: Hello, I am one of the FY2 in the GP surgery. Can you please confirm your
name and date of birth for me?
D: Nice meeting you Olivia. I can see you are quite worried about something,
how can I help you today?
P: I am concerned that I could have meningitis.
D: Alright, I can see that you are concerned about meningitis. In order to
answer your questions in a better way, I would like to ask you a few questions
first about your health. Is that okay?
P: Yes doctor.
D: Can you tell me why you are concerned about meningitis?

P: My niece was diagnosed with meningitis one week ago.
P1 Explore Niece
D: Alright, I am really sorry to hear about it. How is she now? (Showing
concern about niece, building rapport)
P: She has been in the hospital for the past 5 days.
D: What symptoms did she have?
P: She had a fever, some jerky movements, and a rash on her body.
D: Alright and how is she doing now?
P: She is doing fine now.
D: Alright, I am really glad that she is improving now. Okay, as you are
concerned about yourself having meningitis, I would like to ask you a few more
questions regarding your health.
P: Okay.
Focused hx
Meningitis Sx
D: Can you tell me have if you had any symptoms of fever?
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P: No.
D: Any rash anywhere in your body?
P: No.
D: Any flu-like illnesses or any cough at all?
P: No.
D: Any headaches or neck pain or any fits or vomiting?
P: No.
D: Great. Can you tell me when was the last time that you came into contact
with your niece?
P: 2 months ago.
D: Did you come into contact with anyone else who had similar symptoms or
anyone who had come in contact with your niece recently ?
P: No.
MAFTOSA + DESAs
D: Please tell me, have you been diagnosed with any other medical condition
in the past?
P: No.
D: Do you take any regular medication? Allergies?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: Who do you live with? (Psychosocial)
P: With my husband.
D: How is he? Is he doing well? (Contact hx)
P: Yes.
P: Bank manager.
P: No.
Examination:
D: Now if it’s OK with you I will just do a quick general and neurological
examination on you. Will check for special signs as well like Kernig’s sign and
Brudzinki sign, we will send for some routine blood tests, and infection
markers.
Examination and investigation findings: (All reports normal)
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Counselling (Just reassure the patient)

P: Okay. Are there any possibilities that I might have contracted meningitis
from my niece?
D: Alright, I can see where your concerns are coming from, however Olivia,
your history and examination shows no sign of meningitis, you seem to be
completely fine. The chances of transmission are high if the contact is in the
past 7 days for a number of hours and involved close activities, like kissing on
the face. (Please note: The risk is highest in the first 7 days after a case is
diagnosed and falls sharply thereafter. Prophylaxis or vaccination for close
contacts is usually arranged by secondary care. NICE>CKS)
P: Is there any medication for prevention?

D: Yes, we give antibiotic prophylaxis Ciprofloxacin in adults, and it should be
given as soon as possible (ideally within 24 hours) after the diagnosis. It’s made
by the Consultant in Public Health Medicine (CPHM).
P: Are there any vaccinations?
D: Yes there are some vaccinations for Meningitis and I will give you a leaflet
about them:
Meningitis B: 8 weeks, 16 weeks, and booster in 1 year
Teenagers and University students: Meningitis ACWY (from 14 till 25 years)
Hib vaccination: 8 weeks, 12 weeks, 16 weeks
MMR: 12-13 months and 40-60 months
Pneumococcal vaccine: 2 injections at 12 and booster in 1 year
D: Thank you for coming in today to learn more about meningitis and
prevention. Any other concerns?
P: I got meningitis vaccination 3 years ago so do I need to take it again or I

will still be protected?
D: Sometimes meningitis booster doses are given every three years only to
those who are at high risk of developing meningitis. Hopefully, you will not
need one now as you are not at risk. However, you may be given a dose of
antibiotics as a precautionary measure if the risk is high. Does everything make
sense now?
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P: Well doctor my brother and his wife had a call from someone telling them
to go for specific treatment, why didn’t I get the call?
D: Meningitis is a notifiable disease because it can cause some serious
complications. So Public Health usually traces any contacts who are at risk and
gives them the precautionary Antibiotic I told you about before. At the
moment, you are not at risk and that’s why you were not approached by the
office. Clear now?
P: What are the symptoms I should watch out for?

(Safety netting)
D: If after going back from here, you feel you are developing a fever or you are
developing a rash or any headaches or fits, please come back to us
immediately, we might need to reassess you.
If the patient doesn’t ask questions don’t be stunned, start explaining that she
is not at high risk and why she is not at high risk. Safety net. And ask about
concerns again before finishing.
MSRA Colonisation
Who you are: You are an F2 in Respiratory Dept.
Who the patient is: Mr David Harrison, 55 years old, was admitted to the
hospital a few days ago. Patient has been diagnosed with COPD. Nasal swab
has been taken. The result shows MRSA. Patient has been isolated and all
necessary precautions have been taken.
What you should do: Please talk to the wife and address her concerns. Consent
from husband has been taken.
D: Hi , I am one of the doctors here in the respiratory department. Am I talking

to Mrs Harrison. David’s wife?
P: Yes doctor, I am Debra. Debra Harrison.
D: Can you please confirm the name and age of your husband?
P: He is David Harrison and he is 55 years old.
D: Thank you for coming today, I am here to talk about your husband’s
condition but before that do you have any specific concerns ?
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P: I came to see him today and I was surprised when I found out that he was
isolated in a separate room. Everyone goes into his room wearing an apron and
mask and I'm not being allowed inside. What happened doctor?
D: I can see that you are worried, sorry we made you feel that way. I will
explain everything to you, but do you mind if I ask you some questions about
his condition first, so I am able to answer all your queries better?
P: Yes doctor.
Focused Hx
P1
D: How much do you know about your husband’s condition?
P: He has a smoker’s cough and suddenly 2 days ago he became breathless, so I
brought him to the hospital and he was admitted. My husband was doing well
until today. I don’t know what happened.
D: Do you know how he was treated in the hospital ?
P: Yes he was given some antibiotics and was recovering well so far.
Hx of COPD :
D: For how long has he been diagnosed with smoker's cough?
P: It's more than 10 years now.
D: How is it managed ?
P: He is using blue and brown inhalers.
D: Is he compliant with medications?
P: Yes doctor.
D: Is his condition well controlled?
P: Mostly yes.
D: How is his cough now?
P: I believe it’s better doctor.
D: Do you have any questions regarding smoker’s cough?
P: Not really doctor what I want to know is why has he been isolated despite
recovering well in the hospital? It doesn’t make any sense to me. I am a bit
worried. You’re treating him now as if he has leprosy.
D: My apologies Mrs Harrison, I can see you are caring wife rest assured we
are doing the best for your husband and I am going to explain everything but
I need to ask just a few more questions is it okay to carry on.
P: Ok be brief doctor I want some explanation.
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D: Thank you for cooperating Mrs Harrison your answers will help us
massively.
Hx of MRSA:
D: Has your husband ever had any skin lesions ? swelling ? pain ?
D: How is he in general?
P2
D: Has he been diagnosed with any medical conditions away from smoker's
cough?
P: No.
D: Has he experienced the same symptoms before?
P: His COPD was never that bad doctor.
D: Previous surgeries/ admissions?
MAFTOSA
D: Is he on any medications apart from smokers cough medications?
P: No.
D: Any allergies that you are aware of ?
P: No.
D: What does he do for a living ?
P: He is a retired business man.
D: Is anyone living with you and your husband at the moment? (Anybody else
at home feeling unwell)
P: No, it’s just us.
D: How do you feel?
P: I am fine doctor.
D: Have you travelled abroad recently?
DESA
D: Can you please tell me about his diet ?
P: We eat as healthy as possible.
D: That’s good to hear, how about his physical activity?
P: He is not quite active but he can manage on his own.
D: Does he smoke?
P: Yes he still smokes.
D: How much and for how long?
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P: I am not sure doctor.

P: Only occasionally.
Provisional Dx:
D: Thank you for being so patient and answering all my questions,

D: You told me your husband has COPD and was admitted because he had SOB.
Are you aware that he had a swab taken from his nose as a screening for some
infections too?
D: We tested him for some bacteria called MRSA , Have you heard about it?
P: Oh my god, I saw about it on TV. It is a superbug and its infection has no
treatment and it is very dangerous. Is he infected with it doctor?
D: No you don’t have to worry, its currently not an infection, let me elaborate
more. When we did the nose swab for Mr. Harrison it came back positive for
MRSA, but all that means that at the moment is that he is carrying the bug on
his skin and it is not making him ill or anything. We call this MRSA colonisation.
A lot of people can have these bacteria on their skin especially on the arm pits,
groin and nose, and it does not necessarily mean that they are infected as well.
Am I clear so far?
(The wife will have concern about the difference between colonisation and
infection so you need to explain)
P: So why are you isolating him if he is not infected doctor?

D: As you are concerned with the way we are treating him, I would like to
explain what we usually do this with any patient who have MRSA. As I
mentioned it’s a serious infection so we try to prevent the spread of the
infection in the hospital. We usually shift MRSA carriers to special rooms
because even if they are only carriers, they can still pass the bacteria on to
others. We also make sure that anyone coming in contact with them, will take
specific precautions not to spread bacteria around.
Any others concern so far?
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P: Could he get it from hospital, I heard it spreads due to dirty hands because
people don't wash hands properly. Is that correct?
D: MRSA spreads from person to person, usually through direct skin-to-skin
contact. I am not sure about the source, it could be from outside as we do
routine screening for all our patients for MRSA before admission. Also for the
medical staff on a regular basis. Anyone could have MRSA on their skin without
it causing any symptoms unless the person has low immunity or has any
broken skin.
P: Could this bug kill him ?

D: it does not necessarily kill, let me explain more about MRSA. MRSA stands
for Methicillin Resistant Staphylococcus Aureus. It is not more aggressive or
infectious than other subtypes of Staph bacteria but its infection is very
resistant. Although a strong antibiotic option can work against this bug, it
remains resistant to most of the common antibiotics we use ,making it an
infection that is much harder to treat than other bugs if it goes deeper into the
body.
If a person is healthy, MRSA usually won’t cause an infection and we call this
person an MRSA carrier. However; when we have a poor immune system this
bug can be very infectious, as in your husband’s case I am afraid to say. Mr
Harrison has COPD and is using steroid inhalers which can make his immunity a
bit weaker than usual. We do these routine swabs to any admitted patient in
order to protect people like your husband. (Pause)
At the moment, Mr Harrison is only a carrier and hopefully we can clear the
bug with the help of some medication. And even if he develops an MRSA
infection we can use the strong antibiotic I told you about and most patients
will respond to it. But it’s much better to eradicate this colonisation before it
causes any infection. Does that make sense to you?
P: To some extent yes doctor. I would like to see him, is it possible ?

D: Yes , definitely you can see him , I could come with you if you like and show
you the protective equipment we wear before we go into his room as the
apron, gloves and mask, and I will teach you how to use them. I will also give
you some instructions to follow after which you are good to go.
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D: Do you mind if I discuss with you how we are managing him ?
Management:
ARMMS
1. Advice
If you would like, we can screen you for MRSA ? It’s just a swab we take
because you are living with him and anyone else living with him at home can
get the same swab too.
2. Risk factors
− There are some measures which are highly recommended to prevent
you from catching the infection.
− It is better not to share towels and wash your hands before and after
going into his room.
− Please, try not to touch anything inside the room such as pillows or
blankets.
− After you come home, wash your clothes on a high temperature.
3. Medication and investigations

− We will put a special antiseptic cream/paint (Mupirocin Nasal ointment
2%) up his nose up to 3 times a day for 5 days and apply antiseptic lotion
(Chlorhexidine) to his body.
− Then, we will repeat the swab again to make sure that the MRSA
colonisation is eradicated.
4. Safety netting
− If you feel unwell, swelling, or pain in your body, come to us
immediately.
− If you have any open wounds or broken/ cracked skin please let us know
to take care of it as it is a way for the bug to get into the body.
P: Can I take him home with me doctor if he has recovered from the COPD
thing?
D: MRSA colonisation doesn’t prevent him from returning home, however I will
have to check with my seniors to see about that. My advice for now is that it
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would be much better and safer for Mr Harrison and you as well if he
continued his treatment course in the hospital and rest assured that we are
taking the utmost care for your husband.
URTI Requesting antibiotics
Who you are: You are F2 in GP surgery.

Who the patient is: Sara Nunez, 29 years old, presented to the clinic 2 days
ago because of a throat problem.
For the last 3 days she had runny nose, sore throat, sneezing, blocked nose and
cough. Patient has been seen by nurse practitioner.
Additional information: Nasal and throat Swabs were taken, and no bacterial
growth has been found. She was diagnosed with viral URTI. Mild analgesics
were prescribed. Steam inhalation has been advised.
What you should do: Talk to the patient, assess her and address her concern.
D: Hello I am one of the doctors here in this GP clinic. Can I get your full name
and date of birth please?
P: (Confirms name)
D: I understand from my records that you came here a couple of days ago. May
I ask how I can help you today?
P: I came to the clinic 2 days ago because of my throat problem. I still have it
all the same doctor. Please give me antibiotics I think they will help me
recover faster.
D: I can see that you are really bothered about being sick and that’s
understandable. Will you give me the chance to ask you some questions about
your throat problem and then I will definitely see what I can do about the
antibiotics you want. Would that be okay?
P: Okay doctor.
D: Could you tell me what type of throat problem you had when you came 2
days back?
P: I had a sore throat and a cough. I was sneezing, I also had a runny nose and
it was blocked.
P1 ODIPARA
D: Since when have you had this?
P: For about 3-4 days now.
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P: I just woke up sick one day.
D: Have you noticed anything that makes these symptoms better or worse?
P: No doctor.
D: Any change since you came here two days ago?
P: No it’s the same I am not getting better.
Previous visit:
D: When you came here before, what happened exactly? Did anybody explain
what was wrong with you?
P: Your nurse colleague saw me and she took a swab, and then I met a doctor
who told me that its only a cold/flu.
D: Did anybody explain the swab results.
P: I don’t think so doctor.
D: Where you given any advice?
P: They recommended steam inhalation and told me to take Paracetamol.
D: Did you take PCM and steam inhalation as prescribed?
P: Yes. I took 2 tablets only and I was drinking lots of fluids, I took steam only
once. It wasn't working that is why I came for antibiotics.
D: How do you feel now?
P: It is the same, I still have a sore throat and cough.
➢ Centor Criteria:
D: Is there anything else that is bothering you?
− Exudates or swelling
P: No.
of the tonsils.
− Tender/swollen
DDx and red flags anterior Cervical LNs
D: Any headache or body ache, any tiredness? − Fever more than 38
P: I am tired doctor, otherwise no. − Absence of cough
D: Any rash, neck stiffness? (Meningitis)
P: No.
D: Have you noticed any pus in your throat or phlegm with the cough or any
high fever or difficulty swallowing? (Bacterial infection; remember Centor
criteria)
P: No.
D: Any swollen gland in your neck or armpits? (Inf. Mononucleosis)
P: No.
D: Any ear problems as pain/ discharge/ or hearing difficulty? (Otitis media)
P: No.
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P2:
P: Yes a few months ago.
D: What was done for that?
P: I was given antibiotics that time.
P: No.
MAFTOSA
D: Are you taking any medications including over the counter and
supplements?
P: No.
P: No.
P: No.
DESA
D: Do you smoke'?
P: Yes/No
P: Just occasionally doctor.
D: I am going to ask you a question that may sound intrusive, but it’s part of
my consultation. Are you currently sexually active?
P: Yes doctor, I live with my girlfriend.
D: Do you practise safe sex? (don’t go in depth)
P: Yes.
ICE
D: Do you have any idea what you might have?
P: Yes doctor I believe I have a bacterial infection.
D: Are you worried about anything else apart from the throat problem?
P: I just want to improve quickly doctor. Please can you prescribe the
antibiotic for me?
D: May I ask why you want antibiotics or what makes it so important to recover
fast?
P: Yes doctor to be honest I want to get well as soon as possible to be able to
attend my grandma’s birthday, its in 5 days time. She is 97 years old and we
are very close that’s why I wouldn’t want to miss it.
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D: Happy birthday to your grandmother, I wish her good health and long life. I
can see where you are coming from.
Examination
D: Thank you for answering my questions, I would like to check your
observations, have a look at your throat and the glands in your neck, I will also
examine your chest. Is that OK?
Findings: T: 38C
From what you described so far and from our assessment as well, I believe you
probably have a condition called an Upper respiratory tract infection URTI or a
common cold. It is an infection of the nose, throat and other parts of your
upper airway. It is usually caused by viruses. I know that you are worried about
bacterial infections, but we have taken some swabs from your throat and nose,
checking for bacterial growths and none were found. From the symptoms you
mentioned as well, you don’t have any red flags for bacterial infection. Are
you following so far?
P: What do you mean doctor? Why don’t you just give me antibiotics I’m sure
it will help?
D: Antibiotics work against bacteria, but they are not effective against viruses.
Giving you antibiotics unnecessarily can produce short and long term side
effects.
− Shortly after taking Abs you can develop nausea/diarrhoea/stomach
upset/some can cause severe allergies as well.
− In the long term you can develop what is called antibiotic resistance.
This means that when you are given antibiotics for other infections in
the future, they might not be as effective and won’t work, therefore it
will be more difficult to treat you.
P: I see doctor, so why was I given antibiotics for my last cold?
D: I am not sure what happened then but probably because you had signs of a
bacterial infection that were confirmed by swabs. Does that make sense now?
P: Doctor I really need to improve before the birthday.

D: This infection will settle down on its own. It may take up to 1-2 weeks. You
feel the worst in the first 3-4 days but afterwards you start feeling better
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because the body can actually fight this viral infection. I can only give you some
medications for pain and fever and some advice to follow. Would you be
interested to hear it?
P: Please doctor.
Management:
7 step approach:
1. No admission.
2. Senior
3. Investigations:
> Will do some routine bloods (swabs already done)
4. Treatment
> We will give you PCM to reduce your temperature.
> Take steam inhalation to lose mucous so that you can breathe
properly.
> Drink plenty of fluids; you can also drink warm water with honey
and lemon.
> Salt gargles and lozenges are also helpful.
> It is advisable to wash your hands often with soap and water.
> Please don't get too close to others.
> Avoid sharing towels because you can easily pass this infection in
the first few days to other people.
Usually this advice is very sufficient and will probably help you recover by the
time of your grandma’s birthday.
5. Specialist:
> No need for now but if things do not improve we can refer you to
a chest specialist.
6. Safety netting:
> If you develop headache, rash or vision problems (meningitis)
> Ear pain or discharge (OM)
> Rusty coloured phlegm (Bacteria)
> Your symptoms don’t subside in 2 weeks.
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Come back to us because in this case you might need further

investigations and maybe antibiotics to recover.
7. Follow up in 1- 2 weeks’ time
Other possible CONCERNS:

> When are you going to give me antibiotics?
> If it turns into a bacterial infection, what then?
> The patient might have another circumstance as a party in the near
future or might have a friend that had the same Sx and was prescribed
antibiotics and got better. Don’t be tempted to give in to his demands.
Keep explaining until he fully understands.
Needle stick injury NURSE

Who you are: You are F2 in A&E.
Who the patient is: Your nurse colleague, Mrs Rosanne Vargara, aged 25, has
come to you rushing and extremely worried because she has pricked herself
while taking blood from a patient.
Special note: you are the first she talks to.
What you should do: Please talk to the patient, take relevant history, discuss
your plan of management with your patient and address her concerns. She is
very worried. You are the first person seeing her.
(Remember some key points in this station: Try to reassure the nurse, praise if
she has done something right, explore her concerns and give her some
guidance)
After any needle stick injury:

1. Dispose of the needle in sharps bin.
2. Do not squeeze the bleeding point.
3. Wash the hand under running water with soap.
4. You can wash it with alcohol afterwards.
5. Inform senior.
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6. Go to occupational health to seek medical advice. If the incident

happened afterhours go to A/E).
7. Fill in the incident form.
8. Make sure you call someone else to collect the bloods from the patient if
you failed to collect it.
D: Hello I am (name, no need to say doctor) I am one of the FY2s here in the
hospital, its Rosanne right? Do you need any help? You seem really worried!!
(Don’t start with what brought you here/name/DOB, she is your colleague,
and she is a nurse with a name ID anyway. Be smart, don’t be robotic)
N: I was taking bloods from a patient and he moved his hand out of nowhere
and I pricked my finger accidentally. I am very afraid doctor … what should I
do?
Your history will have four parts

- The needle stick injury itself
- The needle
- The patient
- The nurse.
1. The needle stick

D: Well you have done the right thing coming to me now, can you help me
understand what happened so that I can help you?
N: Yes doctor.
D: When did this happen?
P: An hour ago doctor.
D: How deep was the injury or was it superficial?
N: It was superficial.
D: Did you bleed at all?
N: No/ yes
D: The area around the injury, is it hot/ red/ tender/swollen?
N: No.
D: Were you gloved?
N: Yes.
D: Good, may I ask what you did afterwards?
N: I washed my hand with water and alcohol after that.
D: Did you wash it with soap?
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N: I washed it with plenty of soap.

D: You did the right thing. Did you squeeze the area?
N: Yes doctor.
D: Did you notify the occupational health or tell anybody else before me?
N: No, you are the first one I have seen doctor.
2. Explore the Needle:

D: What kind of needle was it?
N: It was just the normal butterfly needle we use for taking bloods.
D: Was there any visible blood on the needle?
N: I don’t know doctor.
D: Did you dispose of the needle into the sharps bin?
N: Yes.
3. Explore the patient

D: Well done. Now, can you tell me about your patient? What was he admitted
for?
N: He is 20 years old, a suspected case of meningitis.
D: How is his condition now?
N: He was unconscious doctor.
D: Have you checked his records for any blood borne infections?
N: It does not say anything.
D: Have you taken his blood?
N: No I could not but I have asked my colleague to do it.
NB: you can check the patient records but you can never test him for
bloodborne infection without him consenting if he is unconscious.
4. The Nurse General Health:

P2
D: OK good. Do you have any chronic medical conditions?
N: No.
D: Have you ever had any surgeries before?
N: No.
MAF
D: Do you take any regular medications?
N: No.
N: No.
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D: Do you have any family hx of blood borne infections?

D: Are you up to date with your vaccinations, especially HBV?
N: Yes doctor I am vaccinated.
D: When did you receive your last dose?
N: 2 years ago.
D: Have you received any booster?
N: No.
ICE:
D: Do you have any specific concerns?
N: I am worried about any infections I might get.
D: It’s understandable. May I know which infection is your biggest concern?
Address any concern she has, depending on her response and then start the
advice.
N: Meningitis.
D: You told me that you were gloved and you took all universal precautions
(Gloves or gown) and kept the appropriate distance from the patient’s face?
N: Yes.
D: Let me reassure you that Meningitis is not a blood borne disease but an air
borne one and you had your PPE on, so it’s unlikely that you will get it.
When the bloods come out, we will know whether he has meningitis or not.
We will also seek advice from our microbiology team or occupational health
to see if you need any specific antibiotics.
N: HIV.
D:
− The risk of catching HIV after any needle stick injury is very low, only
0.3% risk.
− The patient would also need to be HIV positive in an active detectable
phase. We will check his records again but if it’s not there we can ask for
his permission to be tested when becomes conscious again.
− You said you were gloved and the injury was superficial. You also reacted
very well afterwards, you washed your finger with soap and water, so
you should not be that worried.
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N: Can we get blood from my patient to know if he is HIV positive or not?

D: As I mentioned we will have to take his consent first, but as he is
unconscious we will have to wait once he’s conscious again to get his
permission. However, we can check his medical records to find out if he has
been diagnosed before or not. (Note: if she already mentioned the records
don’t repeat it)
Management and Investigations/ MDT:
− We will seek advice from our microbiology team or occupational health.
− We can offer you post-exposure prophylaxis medications (PEP),
following their advice.
− PEP: should be taken within 1-72 hours and for 28 days. Can have side
effects such as nausea and vomiting but it is very important to complete
the course once started.
− Some blood tests including your liver and kidney function test are
required for follow up.
− A blood sample from you will be sent to our virology or microbiology
laboratory to be stored for medico-legality.
− There is no point in testing this sample at this stage it won’t show
anything.
− HIV status will be checked three months later.
− It is advisable to practice safe sex for a period of three months. Please
do not donate blood until all your screening tests are clear.
N: Hepatitis?
D: Which hepatitis B or C?
P: Doctor, I am worried about both
D:
− The chances of catching hepatitis are also low.
− The patient should be hepatitis B positive. We are not sure yet …
continue as before.
− You took all your safety precautions and you had the PPE on… etc
− Even after all that the risk is 30% for HBV and only 3% for HCV.
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− It is advisable to practice safe sex for a period of three months. Please

do not donate blood until all your screening tests are clear.
Management and investigations / MDT:

− You mentioned you have been vaccinated against hepatitis B so that is
somehow reassuring.
− We will check with microbiology and occupational health anyway to
check your HBV antibody levels (HBsAb) after the vaccine and whether
you will need an HBV booster (you can have it now before getting the
results).
− We will take a sample of your blood now (medico legality), and in the
next three and six months, to see your liver functions and HBV serology
markers. Are you following so far?
− We will also do HCV antibody tests (but not at the moment because the
body takes some time to start the immune reaction and produce
antibodies. If positive it does not mean that you are currently infected
now, it simply means that you have had HCV at some point in your life).
− We can also do HCV PCR test to confirm whether the HCV is active and
reproducing inside your body or not.
How do you feel about that?
N: Wound Infection: Are you going to prescribe me antibiotics?

D: The risk is low but we will examine the wound for any redness, swelling,
heat, tenderness, pus or any discharge. If needed, we will give you antibiotics
after ruling out allergies and contraindications.
D: All clear so far? I would like to take the matters further now? Would that be
alright?
D: Have you filled an incident form?
N: Yes doctor.
D: Very well and did you inform your senior?
N: I will do now doctor.
D: Excellent.
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Safety net:
• If by any chance you noticed tummy pain, yellowish discolouration of
your skin and eyes, nausea or fever. (hepatitis)
• Fever or rash or severe headache or neck stiffness and photophobia.
(Meningitis)
• The wound becomes swollen/ painful/tender/ red / discharge pus.
(infection)
Please come back to us.
You have had good judgment at almost every step and accidents like that can
happen sometimes. Please in the future be very cautious and if something
similar happens to you again or to someone in front of you advise them to
clean the wound with plenty of soap and water maybe alcohol as well but
never squeeze because it can increase the risk of infection.
Needle stick injury in a Child

Who you are: You are F2 in A&E
Who the patient is: 4 year old Emma was brought to the hospital by her
nanny. The nanny rushed with her to the A&E after Emma had a needle stick
injury while playing at the park. You are talking to the nanny, her name is
Nabilah and she is extremely anxious.
Special note: The child is in the next room, your nurse colleague is looking after
her. She has called the parents and they have given consent to start treatment.
What you should do: Talk to the nanny, take history and address her concerns.
Doctor: Hello I am one of the FY2 here in the A&E, am I talking to Nabilah?
Patient’s Relative: I am worried about Emma doctor, I don’t know what to do I
was supposed to take care of her. How is she now? I want to see her.
D: Don’t worry Nabilah rest assured, she is in the next room with my nurse
colleague and we are taking the best care of her. Can you please for now tell
me her full name and date of birth to be able to help you both.
PR: (Confirms details)
D: May I know what your relation is to her?
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PR: I am her nanny.

D: Can you tell me what happened exactly?
P: She was playing in the park. She was going down the slide and I heard her
scream. I went there to find out what had happened. I saw a needle stuck in
her hand and she was crying.
Your history will have 3 parts

- The needle stick injury itself
- The needle
- The child.
1. The needle stick:

D: Well you have done very right coming to the A&E. May I ask you,
when this happened? (also where and how this happened if she hasn’t already
mentioned)
N: 3 hours ago, doctor.
D: How deep was the injury or was it superficial?
N: I am not sure doctor but was not that deep.
D: Did she bleed?
N: Yes she did.
D: Was it stuck in her skin for a while?
N: Not sure doctor but I don’t think so.
D: The area around it, is it hot/ red/ tender/swollen?
N: No.
D: May I ask what you did afterwards?
N: She was bleeding so I washed and squeezed her hand and then called the
ambulance.
D: Did you wash it with soap?
N: I washed it with plenty of soap. Oh my god doctor Emma was my
responsibility I am such a bad nanny.
D: You have done the right thing bringing her in. Did you call her parents ?
N: Yes doctor her mother is on her way, she said she will be here in around 45
mins.
2. Explore the Needle:

D: Good. Now, about the needle , can you remember what kind of needle it
was?
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N: It was hollow-bore needle.

D: Was it attached to a syringe?
P: Yes doctor.
D: Was the needle rusty?
P: I don’t know. It seemed old.
D: Was there any visible blood on the needle or in the syringe?
N: No.
D: Did you dispose of the needle?
N: I brought it with me doctor/ I don’t remember I was so afraid.
N: Doctor I am really sorry but I’m going to write down what you are asking
and telling me, because I want to show it to Emma’s mum. Emma was my
responsibility, and I am afraid I might forget something”
D: Don’t worry, you can write down anything you want, but let me assure you
that we will note everything on her hospital record as well and will talk to
Emma’s mum and explain everything to her when she comes.
The Nanny looks very worried. Please reassure her. She might say that she is
afraid she will lose her job.
(If she brought the needle with her, you can say that we can check the needle
later and examine her)
Explore the patient

D: Well done, we can check the needle if you have it, can you tell me about
Emma?
P2
D: Does she have any chronic medical conditions?
N: No.
D: Have she ever had any surgeries before?
N: No.
D: Is she up to date with her vaccinations, especially tetanus and hepatitis
jabs?
N: I am not sure, but I think so. Oh my god what have I done I swear I wasn’t
careless.
MAF
D: Don’t worry. These things happen, you didn’t know there would be a needle
in the park. I will confirm with her mother and check her GP records. You are
doing well so far. Does she take any regular medications?
N: No.
D: Does she have any allergies?
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N: No.
D: Does she have any family hx of blood borne infections or tetanus?
N: No.
D: Who normally looks after her?
N: I have been her nanny for 3 years now, I usually look after her along with
her parents.
Examination:
I would like to check her vitals and take a look at her hand. (Also check the
needle, if you have it?
Counselling:
ICE:
D: Do you have any specific concerns?
N: I am worried about infections.
D: May I know which infection is your main concern?
P: Please tell me about all of them.
(Address any concern she has, depending on her response and then start the
advice.)
I can see that you are a caring nanny, well let me tell you about them one by
one…
Q. I am worried about Wound Infection will you give her antibiotics?

We will only prescribe antibiotics if Emma develops symptoms or signs of
wound infection such as pain, discharge, redness, heat or swelling. So, keep an
eye on her and if she develops any of these let us know straight away.
Q. What about Tetanus?

There is a possibility of catching a tetanus infection, especially if the needle was
rusty:
− I will talk to my senior and check with microbiology as well to see if she
requires any special treatment.
− We will check her records for vaccination history for tetanus and will test
her for tetanus antibodies.
− Accordingly, we might give Emma a tetanus jab, tetanus immunoglobulins
(provide rapid but short term protection) or antibiotics. But I will have to
discuss with my seniors and her parents when they arrive.
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− Tetanus vaccine schedule:

• the first 3 doses are given as part of the 6-in-1 vaccine at age 8, 12
and 16 weeks (2m/3m/4m)
• a booster dose is given as part of the 4-in-1 pre-school booster at
age 3 years and 4 months.
• a final dose is given as part of the 3-in-1 teenage booster at age 14
(13-16)
• This course of 5 injections should provide long-lasting protection
against tetanus.
Hepatitis (B or C)
− Usually, these viruses cannot survive outside the body for long. You
mentioned that the needle was a bit rusty and old, assuming that it has
been there for a long while now it is very unlikely that transition of
similar viruses will occur from a similar needle injury.
− You told me her finger was washed immediately after the injury and
this decreases the odds of acquiring this infection as well. But please if it
ever happens again, avoid squeezing the injury.
− If she was found not to be vaccinated against HBV, she will be then be
given a Hepatitis B jab today and later two more shots, one in 4 weeks
and the other in 8 weeks’ time.
− We are also going to take routine blood tests, including a blood sample
to see how her liver is working. The blood test will be repeated in the
next 3 and 6 months to make sure everything is fine.
− To check for HCV we will do antibody check and PCR as well … etc (as
previous case)
HIV
− HIV is a virus which also cannot survive long outside the body.
− You told me her finger was washed immediately after the injury and this
decreases the odds of acquiring a similar infection.
− We can arrange for a reliable test at 3 months from the incident.
− TTT – Post exposure prophylaxis as discussed in previous case, only if
needed, not routinely given.
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Management in short:
1. Will keep her for now
2. Senior
3. Investigations as above
• routine bloods
• LFTs and KFTs
• Tetanus antibody titre
• HIV in 3 months and will keep a blood sample for now.
• HBV and HCV in 3 and 6 months
4. Treatment:
− Tetanus jab/ IGs/ antibiotics
− PEP
5. Involve microbiology
6. Offer leaflet about all that you said because she was worried she will forget.
(NSI and Blood borne infection)
7. Safety net:
− Tetanus Sx fever, unusual movement and muscle stiffness or
paralysis.
− Yellowish discolouration, tummy pain.
The patient might be worried about consent to start treatment. Tell her that
you will call the parents right away and reassure her.
The patient will say she might lose her job, so reassure her that these things
can happen and that the nanny showed a lot of care and reacted well by
bringing her to hospital and then calling the parents. When she arrived at A&E
she started taking notes at once not to forget anything, showing how seriously
she is taking the incident. Tell her the parents might understand.
Chickenpox in pregnancy
Who the patient is: Clare Clarkson aged 32 is a pregnant lady coming to you
with some concerns.
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D: Hello I am one of the doctors here in the GP clinic. Can I get your full name
and date of birth please.
D: How can I help today?
P: My son was diagnosed with chickenpox recently, and I’m pregnant doctor,
I fear that it might affect my unborn child.
P1 What is significant exposure:

Explore about the exposure:
A person with chickenpox is very infectious. The
D: When was he diagnosed?
virus spreads in the air from person to person.
P: He got it 2 days ago.
Without past chickenpox exposure, there is a good
D: How was he diagnosed? chance of catching it if:
P: My husband took him to the GP
and he was diagnosed there? − Person is in the same room as someone with
D: Was he started on any treatment. chickenpox for more than 15 minutes; or
P: Just some PCM and advice to keep − You have any face-to-face contact with
hydrated. someone with chickenpox, such as having a
D: And how is he now? conversation.
P: He has some spots and it’s still
itchy all over but he is fine.
(Her son can usually spread the infection 2 days before the spots appear until
they have all formed scabs – usually 5 days after your spots appeared).
D: Do you still come into close contact with him since he was diagnosed?
P: Yes but I try not to touch him so I don’t get it.
D: Do you have any symptoms like your son had? (May take 1-3 weeks for
chickenpox to appear)
Chickenpox Sx
D: Any fever?
P: No.
D: Any body aches?
P: No.
D: Any rash of red bumps or blisters?
P: No.
D: Do you feel itchy?
P: No.
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D: Have you ever had chicken pox before or as a child?

P: No.
D: Have you ever been immunised against chickenpox?
P: Not sure doctor.
Antenatal history:
D: How many times have you been pregnant?
P: Only twice.
D: How many weeks are you in?
P: 32 weeks.
D: What is your estimated date of delivery (EDD)?
P: (gives date)
D: Planned method of delivery?
P: Normal.
D: Was it a planned pregnancy?
P: Yes doctor.
D: Do you feel the baby kicking and moving a lot? (Baby kicks starts from 16-24
weeks)
P: Yes, apart from this chickenpox thing, all has been well doctor.
D: I understand you are worried, we will see what we can do about that.
D: Do you have any tummy pain, any bleeding or unusual discharge from your
front passage, any headaches or vision problems?
(Dangerous Sx of pregnancy) Important brief antenatal Hx
P: No. questions:
D: Do you have any other concerns apart from the − Weeks of pregnancy
chickenpox? − Delivery date
P: No. − Planned or not, then rapport
− Baby kicks
P2 − Dangerous Sx
D: Do you have any long-standing medical − Concerns
conditions?
P: No.
D: Have you been diagnosed with any conditions during pregnancy like blood
pressure or blood sugar problems?
P: No.
D: Any previous hospitalisations or surgeries?
P: No.
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D: Have you attended all your antenatal check-ups?

P: Yes.
MAFTOSA & DESA:
D: Are you taking any regular medications or supplements? OR have you
started anything new during pregnancy?
P: Only folic acid
P: No.
D: Any of your family ever had problems with pregnancy?
P: No.
D: Do you smoke?
P: No.
P: I stopped when became pregnant.
D: Are you eating well?
P: Yes doctor.
D: Great, may I know who you live with?
P: My partner, my father and my son.
D: Are they supportive of you?
P: Yes very much doctor
D: How are they doing? Anyone developed itchiness or a rash lately other
than your son?
P: No, but my father is on chemotherapy.
D: Oh I am sorry about that and how is he doing?
P: He is fine.
Examinations:
Thank you for bearing with me, I would like to take your observations now, do
a GPE and also why don’t we just check your belly for the baby parts after that,
just to make sure that everything is fine with your pregnancy? Is that OK?
Counselling:
As you’re worried about acquiring chicken pox after this exposure, let me give
you some facts based on what you have told me so far:
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• You don’t have any red flag symptoms so far so that’s a bit reassuring. But
your child can still be infectious. So you might have to cut down contact
with him as much as you can, like touching him or staying with him in the
same room, until his lesions are crusted over (after about 5 days from rash
onset).
• We will check your records if you have had chickenpox in the past or
received the immunisation, you are likely to be immune. You do not have to
worry or do anything, but better to discuss this with your antenatal doctor
or midwife.
• If you have not had chickenpox or are not sure, a chickenpox antibody
blood test may be advised to see if you are immune.
P: What is the blood test?

The blood test checks for antibodies to the chickenpox virus in your blood:
− If you have them it means you have had it before, or you have been
immunised. No further action is then needed.
− If you do not have any antibodies then you are at risk.
o You can be given an injection called immunoglobulin which
contains chickenpox antibodies that may prevent or make it less
serious if it does develop.
o It is best to have the immunoglobulin injection within four days
(can still be effective if given up to 10) days) after coming into
contact with the virus.
P: Why is it important to avoid chickenpox during pregnancy?

❖ For the mother
Chickenpox is typically an unpleasant illness when you are pregnant and tends
to be more severe than the illness children get. It can cause:
1. Inflamed lungs (pneumonia).
2. Brain inflammation (encephalitis) and problems with co-ordination of
movements.
3. Vary rarely, it may affect the heart and kidneys.
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❖ For the unborn baby
Although rare but a very severe condition called foetal varicella syndrome (FVS)
can happen. It may result in serious abnormalities to your baby. These include:
− Skin scarring.
− Problems with the eyes.
− Abnormal arm and leg growth.
− Problems with brain development.
It’s rare, but the chances of you developing chickenpox in pregnancy are as
follows:
▪ The risk is 1% if in the first 12 weeks of pregnancy
▪ Between 13 and 20 weeks is a bit higher about 2%.
▪ After 20 weeks, the risk very low, with no reported cases after 28 weeks
of pregnancy.
▪ If within seven days before or after giving birth, your newborn baby may
develop a severe form of chickenpox but not FVS. This is the most
dangerous time for babies and it can cause death, but there is an
immunisation to help prevent this. (If this happens the baby can develop
shingles later in his life)
P: What about me doctor because you mentioned it can be severe as well?

Most pregnant women who have chickenpox recover fully and their babies are
fine. However, as I mentioned the illness tends to be unpleasant and there is
some risk of complications. Are you following so far?
Management/Investigations/senior:
D: If you do develop chickenpox let me tell you how we can deal with that:
1. You and your baby will be reviewed daily but we might keep you in the
hospital if you have:
• Severe spots (a severe rash).
• A bleeding rash or bleeding from your vagina.
• Chest/breathing problems.
• Drowsiness or being sick (vomiting).
• if you have lung disease or you’re a smoker, or taking steroids
or other immune suppressive treatment.
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2. Senior
3. Will run some investigations
• For you (CBC, LFT, KFT, infection markers)
• Your baby (detailed ultrasound scan at 16-20 weeks of the
pregnancy, or five weeks after the infection has cleared if the
infection was later on in the pregnancy. The aim of this is to look
for signs of fetal varicella syndrome (FVS).
4. Treatment:
➢ Antiviral medication (acyclovir), must be within 24 hours of the rash first
appearing. It does not cure the illness but tends to make it less severe and
helps to prevent complications in mother and baby. This would be advised
by a specialist in hospital.
If you develop chickenpox within seven days before or after the birth of your
baby:
− You should see a doctor immediately.
− immunoglobulin treatment to the baby to prevent chickenpox
developing
− Antiviral medicines by specialists in hospital in newborn babies who still
develop chickenpox after IGs.
− Avoid other pregnant women and newborn babies until all the spots
have crusted over (commonly about 5-6 days after onset of the rash).
P: Can I be immunised against chickenpox?

− If you have had chicken pox as a child then you are immunised but if your
are not sure, there is an effective vaccine that protects against it.
− It is recommended by the RCOG and NHS that immunisation against
chickenpox should be considered by all non-immune women before they
become pregnant, or soon after they give birth.
5. Referral: we would like you to discuss this as well with your antenatal
clinic.
6. Safety net: please seek advice if
− If you come into contact with chickenpox and you are sure you are
not immunised.
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− If you develop chicken pox Sx within 7 days before or after

delivery or before 20 weeks
− Dangerous Sx of pregnancy as above
− Dangerous Sx of chickenpox as above
7. Follow up
8. Leaflets about chickenpox in pregnancy

P: No thank you doctor.
Cystic Fibrosis Prenatal Counselling

Who you are: You are FY2 in General practice.
Who the patient is: Adriana Ferreira, a 28 year old lady, has booked this phone
consultation appointment to discuss some concerns she has. (OR might say has
booked a prenatal counselling appointment)
What you should do: Talk to her and address concerns.
D: Hello, am I talking to Adrianna?

P: Yes.
D: Hi, I am one of the doctors in the GP clinic, I am calling today because of the
consultation you booked, but before we carry on can you confirm your full
name and date of birth.
D: Can you confirm the first line of your address.
D: Is it a suitable time for you to talk.
P: Yes doctor it’s fine I have been waiting for this call.
D: If this line gets disconnected can I call you on the same line?
P: Yes doctor.
P: I am thinking of becoming pregnant and I am concerned about it?
D: May I know why?
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P: My half-brother is suffering from cystic fibrosis, and I am afraid if I have a

baby, the baby will get it too.
CONCERN and Knowledge

D: May I ask you what makes you so worried about CF? How much do you
know about it?
P: I don’t know much doctor but I know that it’s a serious condition and it’s
hereditary.
P1:
Explore the Half-brother with CF
D: I see. So about your half-brother, how is he now? What kind of symptoms is
he experiencing?
P: I’m not sure because we don’t live together.
D: So, as he is your half-brother, do you have a common parent?
P: Yes, we have the same mum, but he has a different dad to me.
(Half-brother or half-sister means you have 1 common parent.
Stepbrother or stepsister means you have no common parent, i.e. no blood
relation.)
CF Symptoms in the patient risk in the patient:

D: Have you ever had any persistent bothersome symptoms?
P: No.
D: Recurrent chest infections?
D: Do you have any cough or sputum?
D: Any breathing problems as SOB or wheezing?
D: Any recurrent fevers?
D: Any tummy pain or change in skin colour as jaundice? (LCF)
D: Any bowel problems such as diarrhoea or stool that’s really smelly or
difficult to flush?
P: No.
P2:
D: How is your general health? Have you ever been diagnosed with any long-
standing medical conditions.
P: No, I’m fine.
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D: Ever been hospitalised or had any surgeries or procedures done around

your private parts or for any other reason ?
P: No.
MAFTOSA: (Family*****)
D: Anyone else in your family been diagnosed with CF or had similar
symptoms?
P: No.
D: How is your partner? Does he have any similar Sx like I have just asked or
any long standing medical conditions like CF?
P: No, my partner is fine.
D: How about your partner’s family, any similar Sx like I have just asked or
any long standing medical conditions like CF?
P: No.
D: Are you currently taking any medications, over-the-counter drugs or
supplements?
P: No.
P: No.
P4
P: 2 or 3 weeks ago.
D: Are they regular?
P: Yes.
D: Any problems with your periods?
D: Any bleeding or unusual discharge or spotting between your periods?
P: No.
D: Any painful or heavy periods?
P: No.
D: Have you been pregnant before?
P: No.
D: Are you on any methods of contraception?
P: No, we have been trying for a baby for 3 months now.
DESA: (you will counsel about them later)

D: Do you smoke?
P: No.
511 | P a g e

P: No
P: Good/bad
P: Yes/No
Examinations:
Ideally if you were here I would take your vitals to see if you have any issues
with BP… etc.
Counselling:
Advice and Risk factors:
Considering what you have told me so far, it seems that the chances of you
having a child with cystic fibrosis are pretty low. To be at risk you need both
parents to be carriers of CF. You said your brother has it, but he is only a half-
brother which means your mum and his dad must both be carriers. But you
have a different dad, which means you may or may not be a carrier. But you
would also need your partner to be a carrier for your baby to have CF and from
what you said, you and your partner along with your extended families have no
symptoms or history of CF. Therefore, the chances of your baby having it are
pretty low.
D: But would like me to explain more about CF:
➢ Cystic fibrosis is an inherited condition that causes sticky mucus to build up
in the lungs and the gut. This causes repeated lung infections and problems
with food digestion.
• Cause of cystic fibrosis

It is a genetic condition. It’s caused by a defect in the gene controlling the
movement of salt and water in and out of cells.
It can result in build-up of thick, sticky mucus in the body’s tubes and passage
ways, particularly the lungs and the gut. Therefore, it can cause the following
Sx:
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− Recurring chest infections

− Wheezing, coughing, shortness of breath and damage to the airways
(bronchiectasis)
− Difficulty putting on weight and growing
− Jaundice
− Diarrhoea, constipation, or large, smelly stool (Malabsorption)
− A bowel obstruction in new-born babies (meconium ileus) – surgery may
be needed.
D: Are you following so far. Do you have any queries?
P: Yes doctor I never see my brother but I would like to know if it’s possible to
catch this disease from my brother?
No, it’s not possible to “catch” it from someone else who has it. You are born
with it. Does that make sense?
P: Yes, so how is cystic fibrosis inherited doctor?

I am glad you asked this question, we usually have two copies of each gene
that are responsible for a specific trait for instance like hair colour.
CF is inherited in the form of Autosomal recessive mode,
• If you have only one copy defective then the person will only be a carrier
and will not have the disease but can pass it later on.
• If the person gets Two defective copies then the person will be affected, he
will have the disease and can pass it later to his offsprings.
• For the newborn to be affected he has to inherit two faulty genes, one
form each of his parents. And we have different scenarios for that:
− If none of the parents are affected, then there is no risk.

− If one is affected and the other is healthy, then all the babies will be
carriers, but not affected.
− If one of the parents is carrier and the other is healthy. Then babies will
be 50% carriers and 50% healthy.
− If both parents are carriers, then babies will be 50% carriers, 25%
affected, and 25% normal.
Please note it’s better to draw whenever possible as it will make the patient
understand and follow more.
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Management/ Investigations/ and Senior

Diagnosing cystic fibrosis after delivery:
− Blood spot test (heel prick test) is a screening test carried out routinely in
UK for all newborn babies shortly after they are born.
If the results suggest that the newborn may have cystic fibrosis, some
additional tests will be done to confirm they have the condition.
− A sweat test – to measure the amount of salt in sweat, will be abnormally
high in CF.
− A genetic test – where a sample of blood or saliva is checked for the faulty
gene that causes CF.
These tests can also be used to diagnose cystic fibrosis in older children and
adults who didn’t have the newborn test.
Diagnosing CF before delivery:

− Amniocentesis: part of the fluid around the baby is collected for analysis.
Done at 11-14 weeks.
− Chorionic villus sampling CVS: Sample tissue from placenta, done at 15-22
weeks.
• Both carry a slight risk of miscarriage.
Diagnosis prenatally before getting pregnant:

Gene study and karyotyping: If both members of a couple are suspected CF
carriers.
TREATMENTS:
• Medicines for lung problems
− Antibiotics: for repeated infections
− Steroids: for inflammation and bronchiectasis
− Bronchodilators: for breathing problems
− Mucolytic: medicine to reduce the level of mucus and to make the
mucus in the lungs thinner.
• Exercise: physical activity, like running, swimming or football, can help clear
mucus from the lugs and improve physical strength and overall health.
514 | P a g e
MDT and Referral:

− Physiotherapist can advise on the right exercise and activities for each
individual (chest physiotherapy and breathing techniques).
− Dietitian and nutritionists: for Dietary and Nutritional Advice
(high-calorie diet, vitamin, mineral supplements and taking digestive enzyme
capsules with food to help with digestion).
− referral to local genetics services (genetic clinic): for advice if both parents
are confirmed (or suspected) Carriers.
• Lung transplants: if all measures fail.
P: Does it have any serious complications?

It can cause on the long term, Osteoporosis, DM, nasal polyps and sinus
infections, liver problems, fertility problems. In the long-run can be fatal if it
leads to a serious infection or the lungs stop working properly.
P: how is its prognosis?

Unfortunately, it’s a long-standing chronic condition that tends to get worse
over time. It has no definitive treatment, but its symptoms can be controlled
by meds to delay the complication as much as possible. However, it can be
fatal if complications develop when the condition is neglected and not treated
properly.
Safety net:
CF symptoms/ CF complications/ support groups: British lung foundation
trust, CF trust/care.
Another possible scenario: A female with a partner

who is a carrier or another with a partner who is
affected with CF.
Please follow the same structure and DRAW
DIAGRAM IF YOU CAN.
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Cervical Screening (Dyskaryosis)

Who the patient is: Miss Julia Carrick, aged 26, has come to you with some
concerns. She has had regular cervical screening. The results showed mild
dyskaryosis and HPV was found negative.
Additional information: She was advised to have regular follow up after 3
years.
What you should do: Talk to her, assess her and address her concerns.
D: Hello, I'm one of the doctors working in this GP surgery; I think it’s Julia
right?
P: Yes doctor.
D: Can I please confirm your full name and date of birth?
(Follow Test results structure)
D: I can see from my notes that you have come today for the results of the pap
smear you had a couple of weeks ago, right?
P: Yes doctor.
D: Well I have them here with me I could explain them right away but I would
prefer it if we had a chat first about your health generally to be able to explain
the results better, so what would you prefer?
P: Whatever suits you, doctor.
Cervical Cancer Sx
D: How would you describe your health at present?
P: I'd say I'm healthy doctor.
D: That sounds great. Have you experienced any symptoms in particular
recently that you'd want to talk to me about? (Open Q)
P: I don’t think so…
D: Have you experienced any bleeding or unusual discharge from your front
passage?
P: No.
D: Have you had any pain or bleeding during or after sex?
P: No.
D: Any lower back pain at all? (Metastasis)
P: No.
FLAWS
D: Have you recently noticed any weight loss or appetite change?
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P: No.
D: Any lumps or bumps anywhere in your body?
P: No.
D: Have you had any fever or night sweats recently?
P: No.
UTI Sx:
D: Any problems with your waterworks?
D: Any change in urine colour/smell?
D: Any frequency?
P: No.
Sexual Hx (Signpost)
D: I will now be asking you a few questions about your sexual health, they
might sound intrusive, but they are a part of my consultation, is that OK?
P: Fine.
D: Are you currently sexually active?
P: Yes.
D: May I know if you are in a stable relationship?
D: Do you practice safe sex? By that I mean, do you use condoms?
P: Yes doctor, I am very keen on that.
D: That’s brilliant. By any chance do you use any toys during sex?
P: No.
D: (If yes) Do you share sex toys with your partner?
P: No.
D: Have you been tested or treated for any STI before?
P: No.
P4
D: Have you been getting your periods regularly?
P: Yes.
D: Can you tell me when you got your last period?
P: It was two weeks ago.
D: Have you experienced bleeding or unusual discharge in-between your
periods?
P: No.
D: Have you ever experienced any pain with period or unusually heavy
periods?
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P: No.
D: Have you ever had a pap smear done before? (She might have had it before
and has a bad experience)
P: No.
D: How was your last PAP smear, any problems or difficulties?
D: Have you ever had the HPV vaccine?
P: No.
P2/MAFTOSA/DESA
D: Have you undergone any surgeries before?
P: No.
P: No.
D: Are you on any medication?
P: No.
D: Any allergies?
P: No.
D: Any family history of significant health conditions, specifically cancer?
P: No.
D: Do you by any chance smoke or drink?
P: No.
Examination:
I would like to take your observations and do a general physical if that’s OK
with you.
ICE
IDEA
D: Any idea what was this test is for?
P: No doctor.
CONCERN
D: Do you have any specific concern regarding this test?
P: I have read online that it’s a test for cancer and I was stressed about it.
EXPECTATION:
D: Sorry about that, don’t worry I will explain everything, Are you expecting
anything today in particular from us?
P: Just the results and what I should be expecting afterwards.
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Counselling:
Thank you for your patience, I would like to explain what this test is for and
then discuss the results with you now alright?
P: Is it cancer?
A Pap smear is a test done to screen for early changes in the cervix that can
later on lead to cancer so it’s mostly a screening test. It’s done every 3 years
for women between 25-49 years old and every 5 years for women between 50-
64 years old. It doesn’t mean you have cancer but the aim is to prevent cancer
in the future. It also screens for HPV which is a type of STI and is the main risk
factor for cervical cancer.
From our assessment, your report says you have mild dyskaryosis, which
means mild changes in your cervical cells, that are not cancerous yet, but can
have a low potential in the future to become cancer.
A small sample of cells were also tested for HPV infection. Fortunately, HPV
testing came back negative and for now it means that the risk of having
cervical cancer is even less. Does all of that make sense to you now?
What is even more reassuring is that you don’t have any risk factor for cancer
based on what you have told me so far. So you don’t have to worry okay!
P: What are you going to do?
So I have checked with my senior and we have looked up the guide lines and
the best plan is as follows: It is advisable to come for your next cervical
screening after 3 years following your regular screening schedule as I
mentioned before.
Safety net:
• If you develop any weight loss, lumps and bumps, pain during sex or any
other unusual symptoms, please come to the hospital. (FLAWS) + blood or
discharge from your front passage.
• Condoms can help you protect from HPV so please keep practicing safe sex.
• The HPV vaccine protects you against the types of HPV that causes the
most cases of genital warts and cervical cancer, so we might consider it
later.
D: Do you have any other concerns.

P: No thank you doctor.
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Low mood miscarriage

Who the patient is: Ester Addams, aged 30, has come to you with a low mood.
(Remember the MC FAMISH)
D: Hello I am one of the doctors here in the GP clinic. Can I get your full name
and DOB please?
P: I'm not feeling myself lately.
P1
D: I am sorry that you feel like that can you tell me more about it? (Open Q)
P: I don’t know how to describe it.
D: What do you mean by ‘not feeling myself’?
P: I feel very low.
D: Since when have you been feeling like this?
P: For the past 2 weeks.
D: Did something significant happen 2 weeks ago?
P: I had a miscarriage 2 weeks ago (sometimes says partner had miscarriage)
D: Please accept my condolences, I can sense that you are struggling. How are
you coping?
P: Not very well doctor.
Depression Sx: (MOOD)
D: Can you score your mood on a scale of 1-10?
P: 3 or 4.
D: Do you feel sad, hopeless or irritable most of the time?
P: Yes.
D: Do you have a loss of interest in activities that you used to enjoy?
P: Yes.
D: Do you have feelings of emptiness or worthlessness?
P: I don’t know.
D: Tell me about your appetite and diet?
P: It’s bad, I don’t feel like eating most of the time.
D: How is your sleep?
P: I can’t sleep very well.
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D: Sometimes people experiencing difficult times like these can have recurrent
thoughts about dying or harming themselves, by any change do feel the same?
P: Yes/No
D: Anything else?
P: No.
D: Do you sometimes see/ hear or feel things that are not actually there or felt
by others around you? (Psychosis)
P: No.
D: Do you have episodes of feeling very happy, elated or overjoyed? (Bipolar
mania)
P: No.
D: Any history of depression or comorbid mental health problems before ?
P: No.
D: Any family history of mental illness?
P: No.
DDx
D: Do you feel cold even in a warm environment? (Hypothyroidism)
P: No.
D: Do you have the same mood and feeling around your periods? (PMS)
P: I don’t know.
Impact:
D: You mentioned that this mood is affecting your sleep and daily activities,
may I ask you what you do for a living?
P: I’m on leave, I don’t think I am able to work.
P: No.
D: Are you currently taking any medications, OTC drugs or supplements?
P: No.
D: Any allergies from any food or medication?
P: No.
D: Do you smoke?
P: No.
P: No.
D: Sometimes when a person is struggling that much he might take
recreational drugs? Have you taken any?
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P: No.
Support: Family and friends

P: With my partner.
D: How is your relationship with your partner? Is your partner supportive?
P: It is good, she is really supportive.
P: 2 years.
D: Are you close to your family members? Are they supportive?
P: Yes.
D: Do you have any supportive friends around?
P: I have many supportive friends.
D: Are you financially stable?
P: Yes
D: Do you have any concerns?
P: 1. Will I ever feel better again?
2. Is it depression?
Examination:
I would like to take your vitals if that’s OK.
I believe what you are going through is a form of depression which is simply
feeling unhappy, low and fed up for a few days. Most people go through
periods of feeling down, but when you’re depressed you feel persistently sad for
a long period of time, maybe weeks or months, rather than just a few days.
Management:
In short: treatment of depression depends on the severity and the
environment around you.
GRADES of depressions:
• Mild: persistently low mood without impact on social life.
• Moderate: Persistently low mood severe enough to affect life (appetite/
weight/ daily activities/ job/ sleep inability to concentrate on tasks...etc)
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• Severe depression: Moderate plus suicidal ideation

• Psychotic depression: Severe plus hallucination or delusions.
7 steps approach:
1. Discharge if mild or moderate, or Admit if severe or psychotic.
2. Senior
3. Investigations
− Routine bloods
− Thyroid function levels
− LFT and KFT
− Drug and toxin levels.
4. Treatment
If mild:
• CBT:
Talking therapy. It helps to change the way we think about life challenges, and
thus affects that way we feel. It can be offered in forms of:
− self- help such as websites/app on the phone such as Mood Gym app.
− One-on-one counseling sessions can be done in case of some challenges
in relationships.
• Family therapy can help in case of family related disagreements and
conflicts.
• Rehabilitation or community service access. If drug and alcohol are
involved, avoid their use as they can increase the symptoms and
complications.
If Moderate depression or failed CBT:

• Add anti-depressants such as SSRIs and TCA. They are used for a minimum
of 6 months until remission is achieved and at least another 3 months to
prevent relapse.
SSRIs are most commonly used nowadays as they have less side effects as
compared to TCA.
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− Medication is started slowly, and the dose is increased gradually to achieve

the lowest effective dose that achieves maximum benefits with lowest side
effects.
− If used correctly it does not cause withdrawal symptoms.
− Side effects are nausea, tiredness and tummy discomfort. These wear off
after few days. Another side effect is loss of libido, but it does not happen
to everyone, and there are options for it to be managed if it happens
including other medications, adjusting the dosage and changing the
medication. Other side effects that are more common with TCA include
weight gain, flushing, blurring of vision, tiredness and flu-like symptoms.
Stop CBT if the patient does not experience any improvement and not happy to
continue with it. However, advise that maximum benefit is achieved using a
combination of both.
Raise concerns with your senior (who can involve social services, until the
patient recovers): If children are involved with the patient who has depression,
if the depression affects their functioning abilities/suicidal and he/she is the
only carer/parent, such as a single parent, or there is another parent but with
compromised mental health/drug and alcohol use problems.
Avoid taking sleeping pills, as they make it difficult for you to sleep and you
need higher doses for them to be effective (dependence). They are not the first
line of management for insomnia in depression, but they can be used briefly in
special circumstances and with senior approval.
Better treatment for insomnia:
− sleep hygiene
− relaxation techniques
− breathing techniques
• Support:
− Partner
− Family and friends
− GP
− Good Samaritan group- who are going through similar situation to
support each other.
− Helpline
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5. Refer to Psychiatrist/ Psychotherapist/ Counsellors.
6. Safety netting
Helpline for any: suicidal thoughts if you ever feel the need to hurt yourself.
For psychosis, if you think you see, hear or feel things that are not there.
7. Follow up: after a couple of weeks
Measles College Boy

Who the patient is: Mr. Jared Lolland, aged 18, has booked a telephone
appointment because of some concerns he has. He noticed he had rash, and he
was worried.
Special note: he has sent a picture of the rash by email.
What you should do: Please talk to him, take history, discuss your plan of
management and address his concerns.
D: Hello, am I talking to Jared.

P: Yes who is this?!
D: Hi, I am doctor (name), one of the doctors in the GP clinic. You have booked
a phone appointment with me. Before we carry on can you confirm your full
name and date of birth?
P: Finally, I was waiting for this call, I am Jared Lolland, I am 18 years or (DOB
is 25/8/2001) (you will find it in front of you in the patient notes).
P: 24 Albertson Ave Chatham St.
D: Is it a suitable time for us to talk?
P: Yes doctor it’s fine I have been waiting for this call.
D: OK, if this line gets disconnected can I call you on the same line again?
P: Fine doctor.
P: I have got rash all over my body.
(If his complaint is long try not to repeat the same points he mentioned while
asking, better to recap AND show active listening.)
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P1
ODIPARA then derma structure.
D: Tell me more about it? Do you have any picture of it that you can send us?
P: Yes doctor here you are. I have sent it through email, it started two days
ago doctor, and kept spreading all over my body. Duration
D: How did it start? Onset
P: It started on its own.
D: Does the rash come and go?
P: No.
P: No.
D: Where exactly did it start? Site
P: It started on my face doctor maybe behind my Skin lesion:
ears and on my forehead. (Measles starts on the Since when? What made you
face around the hairline then spreads to the rest of come now?
the downwards body).D: You mentioned it’s all Site? Anywhere else?
over your body so to where exactly did it spread Size? Any change in size?
later? RadiationP: Downwards to my body, neck, Colour? Any change colour?
chest and legs. Shape? Any change in shape?
D: Does it have a specific shape? Is it bleeding?
P: Like red, raised spots doctor. Is it itchy? Painful?
Any Discharge?
D: Any change in shape since it started?
Related symptoms:
P: Not really but the rash is spreading.
Any other Sx? Fever?
D: How about their size? Any joint pain? Eye problem?
P: They are pretty small doctor. Have you used anything on it?
D: You mentioned they are spreading but has their In any rash exclude:
size changed? Meningitis
P: No. Anaphylaxis
D: What about the colour? Any change since it
started spreading? The person is infectious from
P: Its red and all the same doctor. when symptoms first appear
D: Does it itch? (around four days before the
P: Yes /No rash appears) to four days after
D: Is it painful? the onset of the rash. Measles is
an airborne infection that is
P: Yes.
spread by droplets from
D: Any bleeding or discharge?
coughing or sneezing, close
P: No or Yes (Some have ruptured and discharging personal contact, or direct
clear fluid) contact with nasal or throat
D: Any other symptoms? Open Qs secretions.
P: I believe I have been feverish for the last 3 days.
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D: Have you measured your temperature or tried anything for it?

P: I did not measure but I took Paracetamol and it helped.
D: Anything else?
P: I have runny nose, and cough doctor.
D: Since when and for how long have you had it?
P: For about 5 days now.
DDx
Measles comes with Conjunctivitis and Koplik spots in the mouth
D: Any redness or soreness in your eyes?
P: No.
D: Any ulcers in the mouth?
P: Yes/No (Might say I have noticed white spots in my mouth)
D: Do you feel tired? Do you have any muscle or joint pain?
D: Any neck stiffness/headache/ shyness from light? Meningitis
D: Any swelling in your lips or mouth or breathing problems? Anaphylaxis
P: Yes/No
D: Have you come into contact with anyone who had any type of skin lesions?
P: No.
P2+MAFTOSA
D: Have you ever had any similar skin lesions before like chicken pox or
measles? Very important, ask directly
P: Yes / No
D: Are you up to date with your vaccinations specifically MMR vaccine?
P: No.
D: Do you have any longstanding medical conditions?
P: No.
P: No.
P: No.
P: No.
D: Has anyone in your family ever had similar problems?
P: No.
Psychosocial:
D: Who do you live with at home?
P: I live with my roommate doctor I am in university accommodation.
D: Okay and may I ask do you do anything for a living? Occupation
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P: No I am just a student.
D: Have you come into contact with anyone who had similar Sx?
P: No.
DESA (not necessarily important here if you have time and still confused
about Dx ask)
P: I don’t eat healthy.
P: I don’t have much time
D: Do you smoke?
P: Yes/No
P: Yes/No
ICE
D: Do you have any idea what might be going on?
P: No doctor.
P: I have exams in just a few days, I am really stressed, when the rash
appeared I became really sick and feverish (Fever spikes after the rash in
measles).
P: What should I do to make it go away? It looks nasty.
Examination:
Ideally I would like to book an appointment for you to come to the GP to do a
GPE, take your vitals and to examine your skin lesions.
If the patient is in the GP clinic then you might be handed the results with all
normal, but fever.
From what you have told me so far and based on the image you sent me, I am
suspecting you have measles. It is a viral infection that anyone can get, if they
are not vaccinated or have not had it before.
The measles rash appears around 2 to 4 days after the initial symptoms and
normally fades away in a week’s time. You will usually feel most ill on the first
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day or second day after the rash develops that’s why you are feeling worse
now.
I understand it’s very unpleasant because of its symptoms, but let me reassure
you that the body can fight the infection and clear it on its own. It usually takes
7 to 10 days to improve.
Management:
7 steps approach:
1. It doesn’t need an admission or anything but we will invite you to you come
for an assessment, to make sure you are coping with this infection. And then
will send you back with some advice.
2. I will involve my senior
3. We will run some routine investigations (CBC, infection markers, LFTs and
KFTs, culture for any discharge)
4. Symptomatic treatment: We will start you some medications
− Painkillers as Paracetamol/ibuprofen (keep using PCM as you mentioned

it helped but we might increase the dose a bit for a while)
− Drink plenty of water and rest.
− No need for Antibiotics, it’s viral.
I know that you have exams ahead but it’s very important that you rest very
well and stay away from university for at least 4 days from when the measles
rash first appeared. This is because the infection is very contagious and if you
don’t recover well it might have some complications that we would not want to
happen. Will you be able to do that?
P: What about the exams doctor?

D: Don’t worry because when you come for your assessment we will be able to
write you a sick note that you can show to your tutors and they might able to
reschedule your exam. Would that help?
P: Yes doctor.
5. No need for referral unless he is getting worse.
6. Safety net:
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• Avoid contact with people who are vulnerable such as young children
and pregnant women, as can be very dangerous if they contract it.
• If you develop any:
− chest pain, SOB, cough with discharge (pneumonia),
− drowsiness, confusion or fits (meningitis/encephalitis)
please come back to us.
• We might have to notify the local public health office for contact tracing.
• As you mentioned you never had the vaccine MMR After recovery we can
offer it for you.
7. Although not necessary but we can arrange for a follow up later to make
sure that you are recovering well.
CHILD WITH FEVER TELEPHONE CONVERSATION

Who you are: You are an F2 in Paediatrics
Who the patient is: Martin, a 9-month-old baby, has been sick for 2 days and is
on triage care call. His mother, Andrea is concerned.
Special note: Mother is very worried and concerned.
What you should do: Talk to the mother, discuss the initial plan and address
her concerns.
(A good way to think about this station is an ABCD approach, then Paediatrics
structure and please note that it’s a phone consultation and the patient may be
too nervous rushing asking questions. Follow the patient but at some point you
will have to confirm the ID and address if you are going to send an ambulance).
D: Hi, I am doctor (name), one of the doctors in paediatrics, is it Andrea?
P: Yes doctor my son my son, he is too sick, I don’t know what I should do, can
you please come and see my baby immediately?
D: It’s okay Andrea you have done right calling us I will do my best, can you just
confirm your full name , your son’s full name and date of birth?
P: Andrea Addams, my son is Martin Addams, he was born 7/7/22.
P: 31 Derby road Chatham.
D: Are you home now?
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P: Yes doctor I am home.

D: if this line gets disconnected can I call you on the same line?
P: Yes doctor.
P1 (ODIPARA)
D: You mentioned your son is having a problem, can you elaborate
more?
P: He has had fever for 2 days now and he doesn’t seem well.
D: Have you measured the temperature?
M: Yes doctor. I have measured it with my home thermometer,
and it was 39C.
D: Have you done anything for it?
M: I gave him paracetamol, but it has not improved.
D: Is there anything making it better or worse?
P: No.
D: Have you noticed any other symptoms? Open Q
M: I don’t know.
(Even on the phone you can ask ABCDE approach to assess

severity of the situation)
ABCDE
Airway and Breathing:
D: How is his breathing? Any wheezing or unusual sounds?
P: He is breathing funny and it’s a bit wheezy.
D: Does he seem to you like he is struggling to breathe or bluish in colour.
P: No doctor.
D: Did you notice any cough?
p: Yes, since yesterday.
D: Does he have any phlegm with it?
P: No doctor.
Circulation:
D: Does he seem pale to you?
P: A bit yes doctor.
D: Is he passing urine normally?
P: No, I haven’t changed his diaper since yesterday.
D: Any diarrhoea or loose stool?
P: No.
D: Does he seem dehydrated to you? Is he crying without tears?
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P: I am not sure doctor.

Disability:
D: Is he active, conscious and responsive to you?
P: Not really doctor he is very drowsy and lethargic, he opens his eyes but he is
not responsive.
D: For how long has he been like that?
P: He has not been himself for the last 2 days but he suddenly got really worse
now (+ve finding)
D: Did you seek any medical advice?
P: Only now.
ICE
D: Apart from this are there any other concerns?
P: I just want to know what’s wrong with my baby
ASK ABOUT THE REST OF THE SYMPTOMS

DDS:
D: Did you notice any rash? Meningitis
P: No.
D: D: Any difficulty in moving his neck?
P: No.
D: Does he shy away from light?
P: No.
D: Any known allergies or any swelling in his lips or gums or face? Anaphylaxis
P: No.
D: By any chance, any trauma to his head?
P: No
D: Does he cry when he pees?
P: No.
D: Any offensive smell from his urine?
P: No.
D: Are his ears in pain or discharge?
P: No.
D: Any vomiting?
P: No.
D: Was he pulling his legs towards his tummy?
P: No.
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P2
D: Did he have this problem before?
P: No.
D: Has your baby been diagnosed with any medical condition?
P: No.
BIRD DDD
D: How was the birth of your baby?
P: Fine.
D: Are you happy with the red book?
P: Yes.
D: Is he up-to-date with all his jabs?
P: No.
D: Did he receive any recent jab?
P: No.
DIET
D: You are very cooperative Andrea thank you. May I ask what
you feed him?
P: He is mostly breastfed but he has some of the food I cook for
myself at home.
D: Any changes to your diet?
P: No.
D: Is he feeding well?
P: He is not feeding well in the last two days.
NAI
D: Who do you live with apart from your baby?
P: My husband.
D: Any other kids?
P: No.
D: Is everything ok at home?
P: Yes, we are a happy family.
D: Have you travelled anywhere with your child recently?
P: No.
MAF
D: Any medication including OTC medicines?
P: No.
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D: Any allergies? Very important

P: No.
D: Any family history of a similar problem?
P: No.
Examination:
When he comes to the hospital: Observations (dehydration) / Chest: (fever/
crackles or wheeze / spO2 92%)
Provisional DX:
Thank you for answering all my questions, you have been a great help to your
son and you are doing really well. You mentioned that your son has not been
well in himself, he was coughing and (recap positive Sx)
I suspect your baby might have a serious chest infection that is causing him to
be severely dehydrated and may be shocked. He needs immediate admission.
P: Oh my god what should I do doctor?

D: Don’t worry I will be contacting and sending the ambulance right now to
get your baby to the hospital. Please bear with me over the phone. I am not
going to hang up until it arrives. Do you want to know how we are going to
treat him?
We will have to examine him, do some blood tests and a chest x-ray. If we
find it is an infection, we will give him antibiotics.
D: Ok Dr. When will the ambulance arrive?
D: I have just contacted them, and they will send one immediately.
Hopefully, it should reach you soon.
P: No.
Safety net: please make sure that you son is breathing as much as you can,
elevate his legs and stay next to him. If he develops any rash or fits please tell
me right away I’m here on the phone still.
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HERNIORRHAPHY
Where you are: You are FY2 working in surgery.

Who the Patient is: Mr. Jamie Anderson aged 40.
Other information about the patient: He is due for a right inguinal hernia
repair. He has come for pre-operative assessment. Anaesthetist has done the
assessment. The nurse measured his blood pressure as 160/90 mmHg. Please
explain the procedure and address his concerns. The consultant will come later
to take consent.
What you must do: Talk to the patient and address his concerns.
Patient info:
You have been scheduled for hernia repair.
You work in a warehouse and your job requires lifting heaving objects.
You smoke 15-20 cigarettes every day since young.
You have been told your blood pressure is high.
You father had a hernia operation and wears a truss.
Concerns:
1. Do I have to wear the same thing (truss) as my dad used to wear?
2. When can I go back to work?
3. When can I have sex again?
4. When can I start driving?
5. When can I go back home after surgery?
6. Nurse said my BP is high, are you going to stop my surgery?
7. What will you do during operation?
8. Will the surgery be painful?
D: Hello, I am one of the FY2 in surgery. Can you please confirm your name and
age for me?
D: Nice meeting you. I believe you were diagnosed with inguinal hernia and is
being scheduled for surgery, am I right?
P: Yes.
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D: Alright, I have been sent by my consultant to address your concerns. How

may I help you?
P: I have got some concerns regarding the surgery.
D: Okay. I am here to talk to you, but before that let me ask you few questions
about your health so that I can address your concerns better. Is that okay?
P: Okay.
Changes:
D: How are you doing now? Any changes in your health since the day your
surgery was planned until now?
P: No.
D: That’s great. How much do you know about your condition? Did anyone
explain what a hernia is?
P: Yes/No
D: A hernia occurs when an internal part of the body pushes through a
weakness in the muscle or surrounding tissue wall. An inguinal hernia is the
most common type of hernia, and it mainly affects men.
P: Okay.
P1 Focused hx
D: Could you please tell me since when have you been having this problem?
P: Few months now.
D: Which side do you have it on?
P: The right side.
D: How did you notice it at first?
P: I just noticed some swelling in my groin area.
D: Do you have any pain there?
P: Yes/No.
D: Do you have any persistent or heavy cough?
P: No.
D: Do you have any vomiting? Constipation? Redness or tenderness over the
hernia? (Complication/ strangulation)
P: Yes/No
D: Has your pre-operative assessment been done?
P: Yes/No (If yes then don’t do. If no, then do pre-assessment)
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D: I will ask you a few questions regarding your general health. Do you have
any headaches? Vision problem? Cough? Chest pain? Bowel or bladder
problem?
P: Yes/No
P2 past hx
D: Have you undergone any surgery in the past?
P: Yes/No
DESA+ MAFTOSA
D: Do you have any long term medical condition? Taking any medication?
Allergy?
P: Yes. My father also had this problem when he was 60.
D: I’m so sorry to hear that. Did your father have an operation for his hernia?
P: No, he used to wear a truss. Do I have to wear the same thing (truss) as my
dad used to wear?
D: No, we only recommend a truss to the patients who can’t undergo surgery.
P: Okay.
D: Tell me about your lifestyle, do you smoke? Alcohol?
P: Yes/No
D: Have you ever been tested for any STIs? Like HIV or HBV?
P: Yes/No
P: I work in a warehouse.
D: Does your job involve lifting heavy weights or driving?
P: Yes, it does.
Same day discharge criteria:

D: How far do you live from hospital?
D: Do you have access to a phone?
D: Is there anyone to look after you after the surgery for the next 2 days?
Examination:
D: Great. Has anyone examined you so far?
P: Yes/No
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D: If no- I would like to check your vitals and do a general physical

examination, and your hernia. Is that OK? I would like to send for some routine
blood tests as well including your blood group.
D: We checked your vitals, and your blood pressure is on the higher side.
P: Yes, the nurse said my BP is high, are you going to stop my surgery?
D: Well, there are two types of operations for hernia, key-hole surgery under
general anaesthesia and open surgery under spinal anaesthesia. But as your
blood pressure is high, we will be doing open surgery under spinal anaesthesia
or else we will have to wait and postpone your surgery until your BP is
controlled.
However, I will inform the surgeon and anaesthesiologist about it, and if they
can give any BP lowering drugs to control it and proceed with the surgery.
Explain the surgery:

D: Has anyone explained to you the procedure and how we do this surgery?
P: No. Please explain.
D: Don’t worry I will explain it to you. In open surgery, the surgery is carried
out under spinal anaesthesia. You will be awake during the procedure, but the
area being operated on will be numbed so you won't feel any pain. The
surgeon makes a single incision about 6-8 cm, over the hernia. The surgeon
then places the tummy content back. A synthetic mesh is then placed in your
tummy wall, over the weak spot to strengthen it. When the repair is complete,
your skin will be sealed with fine stitches.
P: Do I have to take the stitches out later?
D: No, these usually dissolve on their own over the course of a few days after
the operation.
P: How long the surgery will last?
D: It usually takes between 30 to 60 minutes.
P: For how long do I have to stay in the hospital?
D: This operation can be done as a day care. Sometimes there might be some
complications after the operation and you may have to stay in the hospital
overnight in that case.
538 | P a g e
Management
(Post-operative care/ complication and advice)
P: What complications do you mean?

D: Like any other operation, this may have some complications. You may have
some pain on the site of incision; but, we will give you painkillers to ease your
pain. Infection can happen after the operation. Fortunately, this is uncommon
but if this happens, we can prescribe you antibiotics. Bleeding and damage to
surrounding structures may also be possible. If it happens we will manage it
accordingly. You may experience hematoma. Formation of blood clots in the
legs or lungs is also possible. We will advise you on gentle physical activity to
improve the circulation of blood in your legs. If you are at risk you will be given
special compression stockings and blood thinners to reduce the risk.
P: Is there any long-term complications?

D: In some patients, the hernia may come back. Sometimes, patients may
experience mesh infection. If this happens, the mesh will be removed.
P: How should I take care of my wound?

D: We will advise you on wound care and how to maintain hygiene. A plastic
dressing will cover the wound and can be peeled off after 3-5 days. Wounds
should appear clean, dry and healing. If you are worried about anything or you
notice it’s bleeding, please come back to us.
P: Will I be able to take a shower?

D: Yes, you can take shower rather than a bath for the first 10 days. But cover
the dressing.
P: When can I drive after the surgery?

D: It is advisable to avoid driving until you are able to perform an emergency
brake without feeling any discomfort. It will usually take 4-6 weeks.
P: When can I resume my sexual activity?

D: When you feel comfortable, usually 2 weeks.
P: When can I go to my work?

D: As your job involves heavy lifting it may take up to take 4-6 weeks before
you can return to work.
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Advice:
1. Drink plenty of water for two days before the operation.
2. Eat plenty of fruits and vegetables during this period as this helps
avoid constipation and pain after operation.
3. It is advisable to continue such diet after the operation.
4. You may take laxatives for the first two days after the operation if
needed. This also helps reduce pain and constipation.
Safety netting:
If you have sudden, severe pain, vomiting, calf pain or short of breath,
excessive bleeding, difficulty in passing stool or wind (Obstructive or
strangulated hernia), please come back to the hospital immediately.
Two People Only Policy
Who you are: You are an Fy2 in medicine.

Who the patient is: Maria Khalil an 86 year old patient who is terminally ill, she
has been admitted in the hospital due to respiratory failure. She is unconscious
now. All family members are coming here repetitively praying and making loud
noises. Other patients have started complaining.
What you should do: Talk to Murhaf Khalil the grandson and tell him about
hospital policy and explain the situation gently.
The hospital policy:

According to the hospital’s policies, only 2 relatives can visit a patient at the
same time. And 2-5 pm is silent time and no visitors are allowed.
D: Hello, I am one of the doctors here in the hospital, are you Murhaf?
P: Yes doctor.
D: Just to make sure, are you Maria’s grandson?
P: Yes doctor.
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D: Can you please confirm her full name and date of birth for me?
Build Rapport:
D: I see you here every day, you seem like a caring grandson. May I ask you
how much you know about your grandma’s condition?
P: I know that she has been admitted with respiratory failure, and that she is
terminally ill that’s why we are showing our support to her.
D: It must be a difficult time for you and your family. May I ask how you are all
coping?
P: As long as she is at peace and not in pain, we can tolerate it.
D: You are really a supportive family I can see that. How is her hospital stay so
far?
P: All is fine doctor.
D: What about the care by our staff ? All good?
P: Yes doctor they are really friendly.
D: Do you have any concerns or questions regarding her situation?
P: No.
Explore about the visiting:

D: I understand that the whole of your family has been showing a lot of
support lately. May I ask you how often you all visit her?
P: Every day doctor.
D: How many people visit her daily?
P: it is hard to say doctor, all the family has been visiting.
D: How many people at the same time?
P: I am not sure, maybe around five or six.
D: For how long do you stay?
P: I don’t know.
D: At what time do you usually visit?
P: No specific time doctor, some visit in the early morning others visit at night,
it depends on our working hours.
D: I know that you also pray next to her that’s really nice of you. Do your
prayers involve singing or talking loudly?
P: Yes doctor sometimes.
541 | P a g e
D: I can see it is a very tough time for you all, but I am here to talk to you about
an issue that’s come up. Do you have any idea what I might be here to talk
about? IDEA
P: No.
D: Are you aware of the visiting policy in the hospital?
P: I know about this policy but we are huge family and a lot of them want to
see and pray for her.
D: I understand this concern, but at the moment we have this 2 person policy
in the hospital, so I am afraid to say only two people are allowed to visit at the
same time, would that be possible?
P: No I am sorry doctor we want to see her and we a big family.
D: Will give you me the chance to explain why we have this policy?
P: Go on.
D: Any hospital is a place where treatment and therapy are provided so it is
important that all patients are very well rested to help them to recover. Or at
least we want them to be at peace and as comfortable as possible, like what
we are trying to achieve for your grandma too. Does that make sense to you?
There are also other patients in the ward and we treat all patient with the
same level of care so we wouldn’t want to disturb them by allowing a huge
number of visitors, which will naturally create a lot of noise and that might
affect the sleep of all patients in the ward. Wouldn’t you agree? And good
sleep is crucial for a fast recovery.
P: This is our religion, these are the norms that we have to follow in our
religion.
D: We respect your religion, we wouldn’t prohibit prayers provided that they
are carried out at a reasonable level of noise with only 2 family members
there and during the hospital visiting hours from 2pm to 5pm.
By following this we will make sure it is fair for every patient in the ward.
P: Doctors do not respect their religion and they don’t understand the
importance of these rituals.
D: We respect all the religions, but we have to think about the needs for other
patients too. They are sick and we need to look after each and every single
patient and make sure that all their needs are met.
542 | P a g e
P: Nobody complained doctor.

D: Well I am afraid to say a handful of nearby patients have started to raise
concerns.
P: Oh doctor they don’t understand, that’s really frustrating. You mentioned
visiting is only allowed from 2-5pm, what about those who are working and
cannot come within this period?
D: I really do understand how frustrating this might be but can I suggest
something? Why don’t you try a video call ? Since covid that has been the main
recommendation by the hospital whenever possible now, to avoid catching any
infections.
P: No doctor This is the only way we can perform the last rituals by praying
together in front of her.
D: There is a praying area where you can go and pray for your grandmother
without causing any inconvenience to other patients, would that be a
reasonable option for you.
P: No doctor, we have to be there beside her. Our priest is also coming and all
the members of our family should be there.
D: As I have already mentioned that we respect all the religion, what we can do
here is I will talk to my seniors, ward manager and head nurse and we may be
able to shift your grandmother to a private room where you can perform the
last rites and rituals.
Do you have any other concerns?
P: We will be keeping the Bible beside her?

D: I don’t think it should be a problem but I will have to check with the senior
nurse first to see if it possible.
If there is anything else you need help with please don’t hesitate to call.
P: Okay.
543 | P a g e
Covid policy
Who you are: You are FY2 in Medicine.
Who the patient is: Mr Albert MacBride, a 95 year old man, whose wife has
been admitted in the hospital for a respiratory illness. Mr. Albert is calling to
discuss certain hospital visiting policies.
Additional information: The condition of Mrs Martha MacBride 84 years has
progressed to an end stage level and the consultants have recently decided to
start her end of life care.
What you should do: talk to the patient over the phone and address his
concerns.
PS: Each hospital has its own guidance so take a few seconds and read the
guidance before you start answering the patient questions or read it while
chatting with patient but you will have to be multi-tasking and very attentive to
what he says.
Hospital Covid Policy:

o All visitors must now be registered with a relevant department.
o Only one visitor can be registered and only the named person can visit.
o Patients who have been admitted to a ward for less than ten days cannot be visited.
o When they intend to visit, the visitors must make arrangements in advance with the
department they are registered to before visiting.
o Visitors must wait in a secured waiting area.
o All visitors must be provided with personal protective equipment, and the must be
given the proper instructions about donning and doffing the equipment.
o People who are seventy and more are not allowed to visit the hospital for the
possibility of contracting high risk infections.
o Exception to this guidance can be made based on special circumstances considering
the consultants and senior nurse judgment.
o Visitors are expected to wear surgical masks, mind the 2m safety distance and follow
the adopted instructions for hand hygiene at all times.
o Hospital is strongly encouraging virtual contact and video calling instead of in
hospital visits.
D- Hello, I am one of the doctors in the medicine department. Am I talking to

Mr Macbride?
H: Yes, yes doctor. (a frail old voice through the telephone)
D: Can I get your full name please?
544 | P a g e
H: Albert MacBride.
D: And how may I call you?
H: Just Albert is fine doctor.
D: I understand that your wife has been admitted here the department ?
H: Yes doctor.
D: May I confirm her full name and date of birth?
H: (Confirms details).
P: 18 Oxford Road
D: Is it a suitable time for you to talk.
P: Yes doctor it’s fine.
D: If this line gets disconnected can I call you on the same line?
P: Fine doctor.
D: Thank you Albert. From what I understand you have some inquiries about
the visiting policies in the hospital. Can you tell me what seems to be the
issue?
H: You see doctor my beloved wife was diagnosed with a serious “lung
illness/massive stroke/heart failure”, and the doctors have now decided that
there is no point in any active treatment. They said they will keep her on a
palliative plan.
D: Sorry to hear that Albert, such heavy news, may I ask how you are coping?
H: I have been better doctor I just really miss her.
D: I know it must be a difficult time for you, how exactly would you like me to
help you today?
H: My son’s name is on the visitors register as he is the one who was visiting
my wife. However, given the fact that she has no hope to recover now, I
would want my son’s name to be taken off the register and replaced with my
name instead so that I can be with her.
D: Well Albert, I can see how much you care about your wife and you want to
share these last valuable moments with her. At the moment there are a
number of factor that we need to consider because the COVID situation as you
know still prevails. We might consider things like your general health, your
wife’s condition, social bubble with your son as well. So may I ask you a few
questions to see if we can add you instead your son on the visitor register? Will
that be fine?
P: Yes doctor
P2+MAFTOSA
D: How old are you Albert?
H: I am 95.
D: And how is your general health?
545 | P a g e
H: It’s fine doctor, I am just too old with pains and aches, but I am fine in
general.
D: Have you had any recent fever or flu like illness?
H: No doctor.
D: Have you been diagnosed with any medical conditions (lung problems, heart
problems, blood disorders, cancer)?
D: Are you on any kind of medications (Steroids, radio or chemotherapy)?
P: No.
D: That is good to hear. Hope you are taking care of yourself Albert, at any
point if you think you need any medical advice please don’t hesitate to call us.
(Medical conditions/medications/any fever or flu Sx are all points for you to use
while convincing him not to visit)
SOCIAL BUBBLE:
D: Do you and your son live together?
H: Yes doctor (Same social bubble)
D: Have you come into contact with a person who has been confirmed to have
COVID 19?
H: No doctor.
D: Do you know if the area you live in is a high alert zone for COVID infections?
H: I don’t know doctor.
D: Don’t worry I have confirmed your address, I will look it up.
H: Okay.
D: Thank you for answering all my questions Albert. Regarding your request we
are here to help. I really appreciate that you want to visit your wife. I will have
to check with the authorised people in the hospital if we are able to make this
swap between your name and your son’s on the register.
But I will have to be frank with you: you visiting the hospital at the moment
might be very risky for you, and it’s actually not advised by the current visiting
policy, so it might be difficult to make this change allowing you to visit in
person I am sorry to say. But we have some other options if your are
interested?
H: What do you mean doctor? I want to see my wife.

D- Well Albert, as doctors we should consider a lot things including your health
as well.
As you said you are 95, you also mentioned you have (what you got from Hx),
I am very concerned that at this age and vulnerability, a hospital might be a
very hazardous environment for you. you could catch an infection especially
546 | P a g e
covid and it can easily impact your health very badly and I wouldn’t want to
risk that. Are you following me Albert?
H: Yes I do doctor, but to be honest I have lived my life and I would not have
it again without Martha, I just want to be with my wife in her last days and I
don’t care what happens next.
D: Albert I am afraid if you are risking your health as well as other peoples’
health I can’t let you do that. Covid infections at your age are really serious and
may cause death, does that makes sense?
H: Yes doctor but I still insist.
D: Well, we have another option where you can be with your wife through
virtual contact.
H: No doctor.
D: It is basically a video call through which you can see her and chat with her as
well within a safe environment and without jeopardizing your health. Will you
be interested?
H: Doctor, she is dying. What do I make of all of that if I can’t hold her hands?
We made pact that we would be there for each other no matter what.
D: I understand Albert and you are right and let me say I admire your devotion
to Martha.
Let’s see our other options now there are no guarantees but I would have to
discuss this further with my consultants and the head nurse anyways, to see
how we can arrange for that meeting with the maximum possible safety
measures and I will get back to you once I have done so and confirmed the
zone where you live. Can you bear with me for that?
H: Yes, I think so doctor.
ADVICE
D: Also, Albert, in case our seniors do approve this, we would want you to
know you should be in the best of health without any contact to COVID 19
suspected or confirmed patient. Also, you must not have any COVID
symptoms like fever or flu-like symptoms. Would you not agree?
H: Yes doctor.
D- Can you come to the hospital on your own?
H: Yes doctor I can.
(If no: you cannot provide hospital transport as it is not an emergency, other
solutions would be a social worker or a care person or his son can bring him to
the hospital).
D: We will also need to discuss COVID precautions, and it would be crucial to

abide with the current advice like: social distancing, face mask that covers
547 | P a g e
your nose and face and hand hygiene every time you come in and out the
hospital. Would you be able to follow these measures?
H: Yes doctor.
D: We might have to teach you also about the personal protective equipment
to protect yourself, okay?
H: Yes definitely!
D: Anything else you would like to talk about?
H: No.
D: Many thanks then Albert and nice talking to you.
You can reach out to the NHS website for more information on hospital visiting
policies, COVID symptoms and restrictions.
I will call you back once we have come to a decision alright?
H: Thank you doctor.
Breast Cancer Pain management (Back Pain)

Who you are: You are F2 in Pain management clinic.
Who the patient is: Erika Bloom 76 years old has been referred from Oncology
Department to pain clinic for pain management. She has been diagnosed with
Breast Cancer and undergone mastectomy 5 years ago. Now she has presented
again with back pain.
What you should do: Please talk to the patient, discuss a treatment plan and
(BACK pain station: SOCRATES, management: 7steps approach)
D: Hello I am one of the doctors here in the pain clinic. Am I talking to Erika?
P: Yes.
D: I can see from my notes that you have been referred from oncology here,
for some pain you have, can you tell me more?
P: Doctor. I’m having this pain, towards this area (patient holds her lower
back).
548 | P a g e
P1
PAIN SOCRATES
D: Site: I can see you are holding your lower back/ Can you point with your
finger?
P: Just all over this area.
D: Are you comfortable talking to me now or would like a painkiller? (if she
choses painkiller verbalise examination then give them )
P: No I am fine to talk doctor.
P: It started gradually.
P: It is a dull pain.
D: Radiation: Does go anywhere else? MILD PAID: 1-3
P: No. MODERATE PAIN:3-6
SEVERE PAIN:7 and above
P: It is continuous.
P: It started 3 months ago.
P: It is increasing.
D: Alleviating factors: Anything that makes it better ?
P: Nothing doctor.
P: It’s getting worse on its own.
P: 8-9.
D: Has it always been that bad?
P: No doctor it wasn’t like this when it started.
P: I took Paracetamol, but it didn’t help.
D: May I know how much you took?
P: I take 2 tablets 3 times a day.
D: How long have you been taking it?
P: Been taking it for three months now.
549 | P a g e
DDs of back pain:

AAA:
D: Do you have any pulsatile mass in the abdomen? Any tummy pain? Fainting/
dizziness/ light headedness?
Cauda Equina:
D: Some people with similar pain may have problems controlling urine or
bowels, have you had anything similar?
D: Do you ever experience pain, and numbness around the back passage?
Multiple Myeloma:
D: Do you ever feel like you are more thirsty or drinking water more than
usual? (Hypercalcemia Sx may happen)
P: No.
D: Do feel you are going to loo more often?
P: No.
D: Had any trauma / fall / accident? (disc prolapse)
FLAWS
P2
D: Have you had any similar pain before?
P: No.
D: Have you been diagnosed with any medical condition?
P: I was diagnosed with breast cancer 5 years ago.
D: I’m so sorry to hear that. Do you remember how it was treated back then?
P: I had lumpectomy. I received Radiotherapy, Chemotherapy and Hormone
Replacement Therapy for a while after that.
D: And was it well controlled after that?
P: Well it was, until 2 years back I was having back pain so I sought oncology
advice again. They did a bone scan and it showed that I have the cancer in my
bones now.
D: Seems like a difficult journey. How was that pain treated later on?
P: They already tried Radiotherapy on my back 3 months ago. It didn't work.
Then the Oncologist decided there is no point in active treatment anymore.
D: Have you ever been hospitalised?
P: No.
550 | P a g e
MAFTOSA
D: Do you take any other medications apart from the Paracetamol?
P: No.
D: Any allergies?
P: No.
D: What do you for a living?
P: I have an office job.
D: With whom do you live?
P: I live alone.
D: How has this condition affected your life? (Long period of time)
P: Doctor, it’s getting a bit harder. It’s affecting my day-to-day life. I have
trouble walking.
DESA
P: No.
D: Do you smoke?
P: No.
D: Can you tell me about your physical activity?
P: I go for a brisk walk every day.
P: I have a good diet.
ICE
IDEA
D: Any idea what the pain is?
P: Yes doctor it’s my cancer spreading.
CONCERN
P: I am glad you asked doctor, I have my granddaughter’s wedding in a few
days doctor, and I have very bad pain I am afraid I might not be able to
attend and it is really important to me. These are my last days and I would not
miss it.
OR
P: Doctor I am in severe pain, and I can’t tolerate this pain with any little
movement, I am afraid I will not be able to spend time with my grand
children.
551 | P a g e
D: I am sorry you are going through such a hard time. Let me reassure you I will
do my best to help with the pain.
EXPECTATION:
P: I’m hoping you will give me better options for painkillers.
Examination:
I would like to examine you now if you don’t mind. I would like to take your
vitals, do a general physical and also I would examine your back and your legs
as well for movements and sensation. Also your back passage for anal tone.
Based on what you told me so far, and after checking the notes, I would say
that it is basically the cancer causing you this pain, like you said. I am afraid to
say it is spreading to your bones. That’s why you are having this lower back
pain and some weakness of the legs.
You have been started on a palliative care plan and it includes proper pain
control through stronger painkillers to make sure that you are as comfortable
as possible.
I would like to discuss more about the palliative care plan with you, would you
like that?
Management:
1. Discharge:
You have already been examined by oncology and you were planned for a
special type of treatment called end of life care. Are you aware of that?
P: Yes.
D: Do you need me to explain what it is?
P: No its fine I understand, I just want something for the pain.
2. Senior
What I am going to do is I am going to involve my senior, he will need to
check and decide which painkillers we are going to start you on.
552 | P a g e
3. Investigations:
We can order some routine bloods, maybe a follow up x-ray.
4. Medications
As you have been taking Paracetamol only and it has not been effective we
will have to step it up and give you stronger pain killers.
• We can add NSAIDS like ibuprofen to your PCM which can help reduce
and control the pain.
NSAIDs can cause stomach and gut ulcers so we might have to give you
some PPIs as well to prevent that.
PCM and NSAIDs can be effective, and as you described it’s really
painful and you have a wedding that you really want to attend in just
few days without being bothered by the pain, I would recommend this
second option.
• Co-Codamol : it’s basically PCM with a stronger form of painkiller
category called opioids.
This medicine contains PCM and a weak opioid called Codeine which
can prove really helpful in your case.
• If this one was not effective as well, we can step it up to a stronger
opioid instead of Codeine called Morphine. I am sure you might have
heard about it at some point in your life. You can have it as tablets.
How would you feel about that plan?
• Some other medications might be helpful as well. One of these is
Bisphosphonate, which strengthens the bones.
P: Doctor I would like to know if these have any side effects? Because a I am
afraid, I could get very dizzy and drowsy after these opioids?
D: Well some of them may have side effects,
− Codeine can cause constipation but can we can give you laxatives to
help with that.
− Morphine can cause a bit of dizziness and can make you a bit sleepy,
but this side effect can wear off with time. It can also cause dry mouth
and you can always have small sips of water to prevent that.
− Morphine can cause respiratory depressions, so if you ever have any
problems with breathing you will need to call us or report to the GP
immediately.
553 | P a g e
− Opioids can cause tolerance which means that at some point after
prolonged use we might have to increase the dose to achieve the same
pain control, or dependence or you might call it addiction to morphine.
− Opioids can also cause withdrawal Sx if stopped abruptly, these can
include insomnia, body aches, agitation mood swings and other
bothersome symptoms. Thus it is crucial to follow the doctor’s advice
and prescription. Does all of that make sense?
− Generally, we always make sure that doesn’t happen by keeping you
on the lowest effective dose, we also maintain regular follow up
appointments to make sure how is your body responding to the pain
killers
P: Is morphine addictive?
D: This is a different issue and unlikely to happen. People who become
addicted to a drug, usually initially choose to take it and continue taking it
without having any real need for it other than wanting to get high. This is very
different from someone who is in physical pain and needs the drug to control
the pain. Do you understand?
P: Is there anything else besides tablets that you can give me? / What if I don't
want to take tablets?
D: Some other painkillers are in the form of patches but it is not the
recommended first choice.
Morphine is the best choice so we usually start with that for severe pain.
We can prescribe patches if morphine has caused any problems like:
− Morphine tolerance
− renal impairment
− poor compliance
P: I have heard about something called PCA what is that?

P: Is there any other route for the medication? Can any device be used?
D: Well there is a device called Syringe Driver. Would you like me to talk
about it?
P: Yes.
D: It’s like a small pump that gives you a continuous dose of medication
under the skin as an injection. Usually it is offered to those who have
developed some side effects after long term use of oral morphine , especially
nausea, vomiting and difficulty in swallowing.
554 | P a g e
5. Specialty:
Referral to neurosurgery if the Sx of leg weakness increase or affects bowels
or urine, they can order some detailed imaging as MRI or CT.
6. Safety netting
Your back problem, might affect your nerves therefore you can experience:
− Difficulty in walking
− Sensation of numbness or pins and needles in your legs.
− Difficulty controlling urine or bowel movements.
If you experience any of these symptoms or if you experience any of the
morphine withdrawal Sx. please come back to us urgently.
Another scenario very similar approach:

You are F2 in Pain clinic. Scott Mathews aged 63 has been referred from
Oncology Department to Pain clinic for pain management.
He has been diagnosed with Prostate Cancer 5 years ago and now he has
presented with back pain.
Please talk to the patient, outline a treatment plan and address his concerns.
Same Hx Same Management ☺

Some simple points about any pain management:
❖ Pain severity:
• 1-3 grade: mild
• 3-6 = moderate
• More than 7: Severe
555 | P a g e
❖ Pain ladder in simple points:
Source https://www.england.nhs.uk
Palliative-Care-Pain-and-Symptom-Control-Guidelines
556 | P a g e
557 | P a g e

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DEALING WITH PATIENT RELATIVES 107

PATIENT REFUSAL 147

MEDICAL ERRORS 173

PROBLEM COLLEAGUE 197

BREAKING BAD NEWS 213

HIV TEST RESULT 243

NON-ACCIDENTAL INJURY 249

APIXABAN NOSEBLEEDS 381

P1 → Any problems (system review) like: Head to toe QUICKLY

P2 → Past Medical conditions and Surgeries?

→ Past medical conditions (5 conditions) DM - HTN - Thyroid - Cardiac – Renal

→ Have you been tested for HIV or HBV?

➢ Very important questions:

✓ Changes since operation was planned?

• Stop warfarin 5 days before.

• COCP (need to be stopped a month before).

• POP (can be continued).

•If patient is on insulin → will be started on (GKI), glucose + k + insulin.

4. All patients must be started on L.M.W.H → SC deltaparin. Even if healthy,

In case of Joint (knee or hip) replacement surgery:

1. Where do you live?

VERBALISE GENERAL EXAMINATION:

• If the question says “perioperative assessment,” then full previous hx

Follow the same classic management of counselling structure but consider

- DRIVING AND SEX: 4-6 WEEKS

Any MI Procedure, Knee/Hip replacement: Double time D&S: 8- 12 w

4. In any perioperative assessment investigations required:

Types of surgery stations and possible concerns:

1. Hx taking &/or perioperative assessment.

Ankle Pin removal

Doctor: Hello, I'm dr (name), are you Ted?

D: And your diabetes, is it well controlled?

D: From the information you have given me and according to my examination,

Post operative hemiarthroplasty

Who you are: You are F2 in Orthopaedics.

Take social Qs:

1. Early mobilization is mandatory.

D: Have you got any other concerns?

Take social Qs:

P: I live in a house doctor.

Safety netting: After operation , at any time if you have:

− PE sx Let us know if you’re still hospital or ring 999 if you are at

> Swelling in your legs and calf muscles.

− Infection Sx: Contact GP if you feel

FOLLOW UP: You’ll be given an outpatient appointment to check on your

Post–operative cystectomy wound infection

Who you are: FY2 in Surgery dep.

Additional information: Post-surgical infection rate in this hospital is within the

What you should do: Talk to her address her concerns.

D: Can you confirm the first line of your address?

Safety net: about infection Sx

Post herniorrhaphy wound infection

Past Present Future

D: Hi, are you Jack?

Other Surgery Complications:

Q\ Dr why did I have this infection?

− Antibiotics → according to hospital protocol then will change it

5. Doctor I don't want to stay in hospital

P: Doctor I want to complain. I am not happy.

P: Doctor, I don’t want this to happen to anyone else.

We usually have monthly meetings in order to improve the quality of service

P: What is this meeting?