Foma’s PLAB 2 Notes

(SWAMY LECTURES
JUNE - JULY 2019)
INTRODUCTION 13
How you are checked for safety 15
UNDERSTANDING THE QUANTITATIVE FEEDBACK IN PLAB 2 17
UNDERSTANDING QUALITATIVE FEEDBACK IN PLAB 2 18
REASONS/PLAN FOR HISTORY TAKING/CONSULTATION 20
DIFFERENT TYPES OF QUESTIONS IN PLAB 2 20
FORMAT OF THE PLAB 2 QUESTIONS 21
HOW TO APPROACH THE QUESTIONS 22
HISTORY TAKING 28
PRESENTING HISTORY 30
PAST MEDICAL HISTORY 32
PERSONAL HISTORY 32
TREATED? 35
MEDICATIONS 35
TRAVEL HISTORY 36
OCCUPATION 37
SOCIAL HISTORY 37
ANYTHING ELSE 37
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EXPECTATIONS 38
HOW TO APPROACH COUNSELLING STATIONS 38
COMMUNICATION SKILLS 39
Patient refusing treatment 45
BREAKING BAD NEWS 46
What is bad news in medicine? 46
Body language 46
Steps to follow when breaking bad news 47
Types of emotions to expect these patients to go through 48
If you need to break bad news to a patient’s wife 50

1. EXTRADURAL HAEMATOMA IN A CHILD 51

2. FRACTURED PELVIS IN A CHILD 54
3. INTRACRANIAL BLEED IN AN ADULT 57
4. AORTA-FEMORAL BYPASS SURGERY 61
5. HIV - DISCUSS RESULTS 65

GENERAL CASES 66
INVESTIGATIONS DONE FOR ALL PATIENTS 66
TREATMENTS DONE FOR ALL PATIENTS 67
ECG INTERPRETATION 67
6. CHEST INFECTION - ATYPICAL PNEUMONIA 68
7. PNEUMONIA IN AN ELDERLY PATIENT 75
SEPSIS 78
Risk factors for infection and low immunity 79
What is lactate? 79
CONFUSION IN THE ELDERLY 80
8. ELDERLY MAN WITH UTI AND SEPTIC SHOCK 82
9. CONFUSION IN AN ELDERLY MAN 84

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10. CONFUSED ELDERLY: LRTI 87

FALLS 92
11. STOKES-ADAMS SYNDROME 93

12. POSTURAL HYPOTENSION 98

CHEST PAIN - PERICARDITIS 105
13A. ACS – ECG normal 106
13B. CHEST PAIN IN A 30 YEAR OLD MAN 114
14. CHEST PAIN - HERPES ZOSTER 116
15. STABLE ANGINA 122
CHEST DISCOMFORT - ARRHYTHMIAS 127
16. PALPITATIONS 128
TIREDNESS 134
17. TIREDNESS – CITALOPRAM 135
18. TIREDNESS - OBSTRUCTIVE SLEEP APNEA 138
19. TIREDNESS - COPD PATIENT ON INHALERS 141
20. TIREDNESS ? CFS, ? ANEMIA 144
21. TIREDNESS: CHRONIC FATIGUE SYNDROME 144
22. TIREDNESS (?FIBROMYALGIA) 151
23. TIREDNESS - HYPOTHYROIDISM 155
24. WEIGHT LOSS - HYPERTHYROIDISM 160
25. WEIGHT LOSS - HYPERTHYROIDISM 162
26. HEART FAILURE 168
27. DKA 173
28. DIABETIC KETOACIDOSIS 176
29. HAEMATEMESIS 177
30. CONSTIPATION 180
31. CONSTIPATION - HISTORY FROM NURSE 183
32. ACUTE GASTROENTERITIS 187

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33. DIARRHOEA IN AN ELDERLY LADY 190

DYSPHAGIA 193
34. DYSPHAGIA IN A 50 YEAR OLD MAN 194
GORD 197
35. GASTRO-OESOPHAGEAL REFLUX DISEASE 199
35B. BARRETT’S OESOPHAGUS FOR SURVEILLANCE SCAN 202

36. ABDOMINAL DISTENSION - ALCOHOLIC CIRRHOSIS 203

DRY COUGH ± HEMOPTYSIS 208
37. LUNG CANCER 212
38. MESOTHELIOMA 213
39. DRY COUGH - PCP 214
40. DRY COUGH - TB 218
SHORTNESS OF BREATH 220
41. EXERCISE-INDUCED ASTHMA 220
42. EXERCISE-INDUCED ASTHMA SCENARIO 2 223
43. PULMONARY EMBOLISM 224
44. CHEST PAIN - POST-MASTECTOMY 227
45. LADY WITH ABDOMINAL PAIN - APPENDICITIS 229
46. UTI IN FEMALE 232
Nitrofurantoin 238
47. UNRESOLVED UTI DESPITE TREATMENT 240
48. UTI and BPH 241
49. URETERIC CALCULUS 246
50. HAEMATURIA 252
VERTIGO 258
51A. VERTIGO 259
51B VERTIGO - VESTIBULAR NEURONITIS 265
52. GUILLAIN-BARRE SYNDROME 267

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53. TIA 275

54. TIA WITH CRANIAL NERVE EXAMINATION 279
55. STROKE RISK ASSESSMENT 285
56. HEAD INJURY IN AN ADULT 289
57. HEADACHE - SUBARACHNOID HAEMORRHAGE 293
58. VIRAL ENCEPHALITIS 297
59. DIABETIC RETINOPATHY 302
60. SUB-CONJUCTIVAL HAEMORRHAGE 305
61. PAINFUL RED EYE - GLAUCOMA 309

62. HEADACHE - GCA 313

63. POLYMYALGIA RHEUMATICA 316
64. RHEUMATOID ARTHRITIS 320
65. REACTIVE ARTHRITIS 324
66. GOUT 329
67. MUSCULOSKELETAL CHEST PAIN 331
68. MUSCULOSKELETAL BACK PAIN 335
69. BACK PAIN - UNKNOWN CAUSE 338
70. BACK PAIN - ABDOMINAL AORTIC ANEURYSM 344
71. LOW eGFR AFTER STARTING RAMIPRIL 350
72. HIGH INR IN PATIENT TAKING WARFARIN (CAUSED BY
CLARITHROMYCIN) 361
73. LADY ON WARFARIN - URINE SHOWED 2+ BLOOD 363
74. HYPERPARATHYROIDISM 363
75. SKIN LESION 367
76. SKIN LESION - SQUAMOUS CELL CARCINOMA 370
77. SKIN LESION - FUNGAL INFECTION 378
78. SKIN LESION (GENITAL WARTS OR ? MOLLUSCUM
CONTAGIOSUM) 381
79. COLD SORES/HERPES LABIALIS 383

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80. ISOTRETINOIN 387

ACNE – ISOTRETINOIN 388
81. EAR PAIN ?BAROTRAUMA 392

FEMALE HEALTH 395

82. PREVIOUS MISCARRIAGES 395
83. PRE-ECLAMPSIA 400
84. HYPERTENSION IN PREGNANCY 407
85. OVARIAN CYSTECTOMY 410
86. OSTEOPOROSIS 415
87. GONORRHOEA 420
88. PELVIC INFLAMMATORY DISEASE 422

89. PELVIC INFLAMMATORY DISEASE 426

90. CHRONIC PID 429
91. LADY WITH ABDOMINAL CRAMPS 432
92. ECTOPIC PREGNANCY 433
93. ECTOPIC PREGNANCY 440
94. ORAL CONTRACEPTIVE PILLS 441
95. CYCLICAL MASTALGIA 444

PEDIATRICS 446
96. HEAD INJURY IN A CHILD 451
97. INTUSSUSCEPTION 457
98. MMR 464
99. A. FEBRILE CONVULSION 470
99.B. PEDIATRIC EPILEPSY
100A. EAR INFECTION IN A CHILD 471
100B. VOMITING IN A NEWBORN CHILD 473
FACTORS SUGGESTIVE OF CHILD ABUSE 481
101. NON-ACCIDENTAL INJURY 483

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102. CHILD WITH ASTHMA 489

103. NEONATAL JAUNDICE 492
104. CHLAMYDIA EYE INFECTION IN A NEONATE 502
105. NEUROBLASTOMA – MOTHER GIVING GREEN LIQUID 504
106. NEWLY DIAGNOSED EPILEPSY IN A CHILD 507
107A. MOTHER CONCERNED ABOUT HER MINOR DAUGHTER
TAKING OCPs 512
Gillick Competence 515
107B. EMERGENCY CONTRACEPTION IN A TEENAGER 517
108. NEEDLESTICK INJURY IN A CHILD 521
109. FLUID INFUSION TO CHILD WITH APPENDICITIS 529
110. INFLUENZA VACCINATION (FLU JABS) IN A CHILD 532
111. CHEST INFECTION? BRONCHIOLITIS 539
112. DELAYED WALKING IN A CHILD 547
113. CHILD WITH NIGHT TERRORS 550

114. AUTISM 554

115. AUTISM - SCENARIO 2 558
116. CONSTIPATION IN A CHILD 562
116.B. Mother requesting Tonsillectomy
ETHICAL ISSUES 566
117. ELDERLY LADY WITH HISTORY OF FALLS 566
118. ELDERLY LADY - HISTORY OF FALLS - ABUSE 570
119. SON WANTS TO DISCUSS MOTHER’S CASE 573
120. NOISY RELATIVES AT HOSPITAL 575
121. LADY WANTS TO CHANGE COUNSELLOR 576
122. LADY WITH BOWEL CANCER - SON DOESN’T WANT MOTHER
TO KNOW 578
123. LADY WITH ACCIDENT ASKING FOR A SICK NOTE 581

TELEPHONE CONVERSATIONS 584

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124. TALKING TO CARE HOME - SEPTIC ELDERLY WOMAN 584

125. SICK CHILD WITH CHEST INFECTION - TRIAGE CALL 590

FOLLOW-UP CASES 592

126. HYPOGLYCAEMIA IN A TAXI DRIVER 592
127. HYPOGLYCAEMIA TREATMENT - EMERGENCY 596
128. PATIENT ON CARBIMAZOLE FOR HYPERTHYROIDISM 598
129. IRON DEFICIENCY ANAEMIA 605
130. WELL WOMAN CHECK - THALASSAEMIA 609
131. HIGH UNCONJUGATED BILIRUBIN - GILBERT SYNDROME 612
132. MULTIPLE MYELOMA 615
133. PCOS LADY— AMENORRHEA 619

COUNSELLING CASES 622

134. HYPOGLYCAEMIA 622
135. LADY WITH FRACTURED WRIST - TALK TO SON 626
136. EXPLAIN DISCHARGE MEDICATION 630
137. STATIN THERAPY 635
138. WARFARIN - PATIENT WITH A LEARNING DISABILITY 642

139. OBESITY 647

140. PSORIASIS AND VASCULAR DEMENTIA 652
141. INSOMNIA 657
NAI questions 658
142. NAI IN ADULTS 660
143. HYPERTENSIVE PATIENT REFUSING AMLODIPINE 664
144. ABNORMAL LFTs 665
145. AF PATIENT - DOESN’T WANT WARFARIN 672
146. COLORECTAL POLYP COLONOSCOPY 677
147. ELDERLY MAN WITH DIARRHOEA NEEDS COLONOSCOPY683
148. ASTHMA DISCHARGE MEDICATION AND PEFR 684

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149. POST-MI DISCHARGE & LIFESTYLE MODIFICATIONS 690

150. SMOKING CESSATION 695
151. HYPERTENSIVE PATIENT ON ACE INHIBITORS 700
152. EPILEPSY 704
153. NEEDLE STICK INJURY IN A NURSE 707
154. GENDER SELECTION 710
COELIAC DISEASE 712
155. COELIAC DISEASE IN A MIDDLE-AGED LADY 714
156. PATIENT WITH UNCONTROLLED DIABETES 717
157. TENSION HEADACHE - LADY REQUESTING CT SCAN 722
158. DNAR 723
159. MULTIPLE SCLEROSIS – FILL UP THE DNAR FORM 726
160. POST-MORTEM EXAM QUESTION 732
161. HIV DIAGNOSED MALE PRESENTS TO GUM CLINIC 739
162. GONORRHOEA IN MAN 742

PRE-OPERATIVE ASSESSMENT 743

163. INGUINAL HERNIA PRE-OPERATIVE ASSESSMENT 748
DAY SURGERY 757
164. DAY CARE SURGERY - PIN (SCREW REMOVAL) 759

165. HEMI-ARTHROPLASTY OF HIP JOINT 764

DEALING WITH MEDICAL ERRORS 769

166. TELEPHONE CONVERSATION WITH MOTHER ABOUT CHILD
HAVING A BUTTON IN X-RAY 770
167. MEDICAL ERROR - RASH AFTER AMOXICILLIN 775
168. MISDIAGNOSED PNEUMONIA AND UNNECESSARY ANTIBIOTICS
780
169. MISSED HAIRLINE WRIST FRACTURE IN A CHILD 784
170. MEDICAL ERROR - MISSED RENAL BIOPSY SAMPLE 786

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171. MEDICAL ERROR - MISSED MI 789

172. MEDICAL ERROR - UNLABELLED BLOOD SAMPLES 791

CONCERNED/ANGRY PATIENTS 792

173. LADY WITH UNEXPLAINED HAEMATURIA 792
174. BREAST CANCER WITH BACK PAIN MANAGEMENT 796
175. POST-HERNIORRHAPHY WOUND INFECTION 803
176. PREMATURE CHILD - MOTHER UPSET WITH NURSING CARE808
177. UNFAIR TREATMENT - CEREBRAL PALSY PATIENT 810
178. REFUSAL OF IV CANNULATION IN CHILD WITH CEREBRAL
PALSY 814
179. CONFLICT WITH PHYSIOTHERAPIST AND NURSES 816
180. WOUND INFECTION AFTER CYST REMOVAL 817
181. IV CANNULA - TALK TO UPSET PATIENT 819
182. ANKLE SPRAIN 821
183. DEMENTIA - PALLIATIVE CARE 824
184. PATIENT REQUESTING ANTIBIOTICS 828
185. CANNABIS ABUSER WITH INSOMNIA ASKING FOR SLEEPING
PILLS 831
186. MRSA - COPD PATIENT 833
187. CLOSTRIDIUM DIFFICILE INFECTION - TALK TO SON 835

HANDLING COLLEAGUE PROFESSIONALISM 841

188. ALCOHOLIC COLLEAGUE 841

189. COCAINE ABUSER - FINAL YEAR MEDICAL STUDENT 847

190. MEDICAL STUDENT COMES LATE 852
191. FY1 COLLEAGUE - DELAYED DISCHARGE 855
192. FY1 DOCTOR DID NOT INSERT IV CANNULA 857
193. POSTING PATIENT INFORMATION ON SOCIAL MEDIA BY YOUR
COLLEAGUE 859

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MISCELLANEOUS 861
194. DNACPR SIMMAN - TALK TO A NURSE 861

TEACHING STATIONS 864

195. KNEE EXAMINATION - TEACHING MEDICAL STUDENT 864
196. INGUINAL SWELLING - TEACHING MEDICAL STUDENT 871
197. TEACHING ECG TO A NURSE 875
198. AEROCHAMBER 876
Child with Asthma - explain inhaler to the mother. 877
199. CPR - TEACH ADULT BLS TO MEDICAL STUDENT 883
200. CPR - TEACH PAEDIATRIC BLS TO A MEDICAL STUDENT 886

PSYCHIATRY HISTORY AND COUNSELLING STATIONS

892
PSYCHIATRIC HISTORY TAKING 892
THE MENTAL STATUS EXAMINATION 893
SUICIDE ATTEMPT/SELF HARM RISK ASSESSMENT 903
201A. SELF HARM: CUT WRIST + OCP OVERDOSE 906
201B. SELF HARM - GAY MAN WHO OVERDOSED ON
PARACETAMOL 910
202A DEPRESSION (SUICIDAL ATTEMPT) 912
202B - SELF-HARM 914
202C depression
203. DRUG ADDICT WANTS A SELF-DISCHARGE 917
204. ANOREXIA NERVOSA 922
Information about treatment of Anorexia Nervosa 927
205. PSYCHOSIS/SCHIZOPHRENIA 930

205.B. Bpolar disorder

MINI MENTAL STATE EXAMINATION (MMSE) 935

206. DEMENTIA 937

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207. ALCOHOL ASSESSMENT 940

DRUG ABUSE ASSESSMENT 944
208. OPIOID DEPENDENCE 945
209. INSOMNIA 950
209.B. Panic attack

PHYSICAL EXAMINATION STATIONS 955

EYE EXAMINATION 956
210. Visual field examination 956
211. Fundoscopy - Sudden loss of vision - GCA 963
Fundoscopy Slide Descriptions 968
212. Hip Examination Combined Station
213. Respiratory examination
214. Meningitis examination
215. PRIMARY SURVEY
216. ATLS [Primary and secondary survey]
217. Whiplash injury
218. Brachial plexus
219.
220.
221.
222.
222. DIABETIC FOOT EXAMINATION 971
223. ALCOHOLIC FOOT EXAMINATION 976
224. CHRONIC DIARRHOEA - IBD 978
225. CEREBELLAR ATAXIA 983

MANNIKIN STATIONS 988

226. BREECH ANTENATAL EXAMINATION 988
227. CATHETERIZATION 997

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228. EAR ACHE 1004

229. HEARING LOSS - ACOUSTIC NEUROMA 1009
230. PARACETAMOL OVERDOSE AND BLOOD SAMPLING 1014
IV CANNULATION 1018
231. Post appendicectomy – IV cannulation 1018
232. IV cannulation Post operation (ruptured appendix) 1022
232. CERVICAL AND SPECULUM EXAMINATION 1023
233. CERVICAL (PAP SMEAR) 1026
234. BREAST EXAMINATION 1033
OTHER MANNIKIN STATIONS 1040
235. TESTICULAR SWELLING 1040

SIMMAN STATIONS 1046

236. HYPOGLYCAEMIA SIMWOMAN 1046

237. POST-PARTUM HAEMORRHAGE 1048
238. POST-HYSTERECTOMY FOR DUB 1053
239. SEPTICAEMIA AFTER UTI (SIM WOMAN) 1054
240. UPPER GI BLEEDING - SIMMAN 1056
241. SIMMAN - ACUTE LIMB ISCHEMIA 1060
242. SIMMAN - ANAPHYLAXIS DUE TO BLOOD TRANSFUSION OR
ANTIBIOTIC 1065
243. SIMMAN: POST-TURP INFECTION 1068
244. ACUTE ASTHMA 1070
245. HEART FAILURE AND ATRIAL FIBRILLATION - SIMMAN 1075

MISCELLANEOUS BREAKING BAD NEWS STATIONS

1079
246. MASSIVE STROKE - PALLIATIVE CARE 1079
247. CANCER LUNG (Modified Station) 1080
248. BREAST CANCER (DICU) 1080

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249. POST-OP TIA/STROKE 1084

MORE NEW STATIONS 1086

250. TIREDNESS leukemia 1086
251. Carpal Tunnel Syndrome................................................... 16
252. De Quervain’s Tenosynovitis ................................................ 5
253. Acute Tonsillitis .................................................................. 11
254. Recurrent Tonsillitis ............................................................ 14
255. Chest Pain (Mastectomy) ................................................... 17
256. Pre – Conception Counselling ............................................ 21
257. Allergic Rhnitis
258. Urticaria
259. Cholesteatoma
260. Meningitis Prophylaxis ........................................................ 31
261. Chicken Pox (Pregnancy) ................................................... 33
262. Post Herpetic Neuralgia...................................................... 35
263. Nipple Discharge ................................................................ 37
264. Prescription Writing (DVT Apixaban) .................................. 39
265. Prescription Writing (Nosebleed Apixaban) ........................ 41
266. Primary Enuresis ................................................................ 43
267. Chest Pain (Transgender) .................................................. 45
268. Concerned Daughter MMSE .............................................. 47
269. Scabies...................................................................................
270. Delayed speech
271. Twin developmental milestones (walking delay)
272. Bullying at work place lesbian
273. Analgesic Nephropathy
274. Syphilis
275. PSA Demanding patient
276. Cervical screening
277. Levothyroxine Dose Adjustment.
278. idiopathic thrombocytopenic purpura
279. Cataract
280. Age Related Macular Degeneration

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INTRODUCTION

● The two main aims of the PLAB 2 exam are to check if you are:
○ a good doctor.
○ a safe doctor
● You are expected to show:
○ Communication skills - avoid medical jargon
○ Competency (e.g Practical skills),
○ Compassionate and caring nature (ability to comfort and reassure the patient)
○ Confidence
○ Honesty

● The difference between practicing medicine in your home country and the UK is:

○ Doctor-centred vs patient-centred. Ask if it's alright, what patient thinks about it

○ Communication skills

● Listening is the most important aspect of communication. Your answer has to be appropriate.

● Examples of severe pain where you need to offer painkillers at the beginning of the encounter:
SAH, Meningitis, MI, Renal colic, Acute limb ischemia

● Assurance is the best 'painkiller'

● Empathy > Sympathy

● "I'm sorry for the ….", "I can see that you're in pain", "I can imagine", "I can't imagine", "I wish
it wasn't..."

● Tell him: "I'm going to give very good pain killers but I need to ask you a few questions before.
Can I ask you a few questions to see what the best painkiller we can give you?"

● Next step: "I would like to give painkillers to my patient.'' The examiner will tell you to assume
the drug has been given and then tell him thank you. Then, ask the patient how he feels and
then ask "Are you now comfortable to talk to me?"

● Politeness is very important

● You need to establish a good rapport.

● Scenario 1 Surgical consultant wants to get mother's medical information

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○ Call his name first e.g "Mr Brown, I can understand that you are very keen/anxious to know about
your mother and it's true that you have been a junior doctor like me. I do respect that. Yes,
consents are formalities but they are also legal obligations where we need to keep the
patient's information confidential. Would it be alright if I spoke with your mother first?"

○ Son wants to know if she had a CT scan. He is a surgeon and needs to go back and see his
patients. "Mr Brown, I know that as a surgical consultant, time is very precious for you. My only
problem is that I'm not aware. I will go and speak with your mother. I will not waste your time.

○ Son says he is the only doctor in the family and his mother will definitely come to him. "I am very
glad to know there is a doctor in the family and of course your opinion is very important to your
mother and also to us. And that's why I have to speak with her and get back to you."

● "I'm sorry I don't know the answer to that question at the moment but I will consult with my
seniors and let you know"

● Honesty shows you are a safe doctor. Giving dishonest answers can put a patient's life in jeopardy.

● You can reassure the patient by telling the patient: "Don't worry. You're in a safe place. We have
a team of experts to help your condition'

● If the patient says that he's going to die: You're in a safe place. We have a team of experts to
help your condition. We'll not let that happen.

● Rapport = Doctor-patient bonding/interaction. This occurs if a patient trusts you AND likes you.
You establish like by

○ the way you approach the patient (e.g appropriate facial expressions, showing sympathy
and empathy, tone of voice, body language),

○ ability to listen,

○ honesty,

○ talking politely,

○ praising them. e.g You praise them for coming to the hospital. "Brilliant, excellent,
amazing, I wish everyone were like you". You can praise in the beginning so they can
cooperate with you.

● If you say anything above the level of FY2 grade, you show that you are not a safe doctor. You
have to determine the right time to call for senior help.

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How you are checked for safety

● Although you are tested by common presentations, you are expected to consider
emergencies first:

○ life-threatening conditions

○ other emergencies especially those which have serious complications

● Is your advice safe or not? They should be right and in the right order.
● Scenario 1: 30 year old with headache. Take a history and examination. What is your first
diagnosis before seeing the patient? The headache must be severe enough to come to the
hospital, and there is a 70% chance of being a SAH. If she has a past medical history of
migraine, the chances of SAH is 95%.

● Scenario 2: 60 year old with headache. patient. You should think of GCA because of the risk
of permanent blindness.

● Scenario 3: 60 year old man on triple therapy presents with severe epigastric pain. You
should consider MI first, then perforated PUD, pancreatitis, cancer and gastritis.

● Scenario 4: 30 year old woman chest pain - Pulmonary embolism

● Scenario 5: 60 year old man back pain AAA

● Scenario 6: Young person: Shortness of breath - Tension pneumothorax

● Scenario 7: Young person fever - meningitis

● Scenario 8: Child crying a lot - meningitis. Look for rashes

● Scenario 9: Leg pain - Acute limb ischemia

● Scenario 10: Rashes - Meningitis

If two differential diagnoses are life-threatening, you should consider the diagnosis that can cause
death the fastest.

"If a child is having a febrile seizure, advise the mother to turn the child to the side so the tongue
falls sideways and the airway will not be blocked. Don't put anything in the mouth. Expose the
child by removing the clothes and opening the window. Keep an eye on the clock. If it's 5
minutes, then call 999".

How to recognize emergencies: Vital signs. If they are normal, the condition can still however be
an emergency.

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UNDERSTANDING THE QUANTITATIVE FEEDBACK IN

PLAB 2
A. There are 3 domains which are assessed:

● Data gathering
● Diagnosis and Management
● Interpersonal skills (IPS)

Data gathering

1. History
2. Examination
3. Investigations
4. Technical assessment e.g procedures

B. Each station has a name and the passmark is different for each station. The pass
mark is dependent on the score for all candidates who sit for the exam.

C. To pass the exam, you need to:

1. Pass 11 out of 18 stations.

2. You need to exceed the minimum pass mark
● IPS + Right diagnosis = Pass the exam
● If you feel you are about to fail a station, don't give up. Try to grab as many
marks as possible.
● If you fail the column for IPS, you will get a 0 for that station. Having just the
knowledge is not going to help you pass. If you have very good IPS but you did
not do well in your other domains, you can receive extra marks for these
domains.
● If your IPS is average, then you should ensure that you must have a very good
medical knowledge and the ability to diagnose the condition.

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UNDERSTANDING QUALITATIVE FEEDBACK IN PLAB 2

1. Consultation - History not adequate, asking irrelevant questions, no plan for taking history
2. Examination - Examination was not done or not done properly. Instruments not used
correctly. If you don't ask for the instrument you require, you can fail that station.
3. Finding - You missed the finding or you did not understand the significance of the finding. E.g
If a long term smoker presents with hemoptysis but no weight loss, still consider lung cancer.
Weight loss is a late symptom in cancer.
a. You might miss a finding in history if you don't ask the question at all or you didn't
ask the question in the right way. You should ask "Do you take any medication
including over the counter medications?"
b. You might miss a finding in examination if you don't give the patient the correct
instructions. You might also miss findings if you don't examine the side of pathology in addition
to the healthy side. More reasons to miss a finding:
i. You had an important finding but you did not tell the patient or you waste time
explaining unimportant findings
ii. You did not specify the part of the body you want to examine
c. You can miss a finding in investigations if you don't mention the specific test.
i. You can miss a finding if you don't explain an important finding to the patient,
e.g haemoglobin, liver function tests, thyroid function tests.
ii. Show patients their x-rays.
iii. Tell the patient the findings of an ECG but no need to show them.
iv. Arterial blood gases are too complicated to explain to a patient.
4. Issues - Not addressed adequately, deviating, or not understanding the priorities, using
inappropriate facial expressions. For example, you need to discuss treatment of acute
conditions before talking about lifestyle modifications. If the examiner realizes you are talking
from a script. Make sure the examiner can see and hear you.
5. Language - Medical jargon, not listening properly, checking if patient understands what you
are saying. In patients who have learning difficulties, do not use any medical terms. The
question will not state she has medical difficulties but her behaviour during the consultation
will tell you.
6. Management

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7. Time management - Did not finish on time or did not use your time properly. The timing you
should allocate for history, examination and management depends on the case scenario. When
practising case at home, aim for 7 minutes.
8. Diagnosis - Was wrong or you didn't explain to patient properly or you didn't
have a good rapport with the patient. You have to give one right diagnosis. If you give only
differential diagnoses, you will not get full marks.
9. Rapport - Call the patient by his name regularly throughout the consultation. Show
sympathy or empathy for appropriate complaints or issues.
10. Listening - Respond when patient tells you something. The patient or the
examiner may give you a clue if you're going off track. The examiner may ask you to re-read
the question if you are doing the wrong task.

● If you don't involve the patient in management, then you will fail the management and/or
rapport column.
● If you don't realise it is a breaking bad news station, then you will not be handle it as such.
Examples of bad news stations include: Pre-eclampsia, Lifelong conditions with many
complications (e. g IDDM, Epilepsy).
● The best way to make sure they understand is to ask them to repeat especially when it
comes to giving prescriptions.

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REASONS/PLAN FOR HISTORY TAKING/

CONSULTATION
1. To reach a diagnosis
2. To rule out other important differential diagnoses
3. To check for risk factors
4. To look for complications
5. To obtain information that will help in management
a. PMH to check for contraindications
b. Past Surgical history. A patient may already have done an operation.
c. Medications
d. Allergies
e. Social history

How to Show Patients Their X-Ray.

First you show the patients the organs and explain their normal appearance.

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DIFFERENT TYPES OF QUESTIONS IN PLAB 2

1. Patients presented with …….symptoms. Take a brief history, do an examination
and discuss management with the patient. [Majority of the questions]
2. Patient already diagnosed and treated. Has come for a follow-up. You do a
history, examination and management to find out how patient is doing. You
should look for patient's compliance, disease complications, medication side
effects?

3. Patient already diagnosed and treated. Patient has come back. What this means
is that something has gone wrong. He might not be improving, has developed
complications or is experiencing side effects.
4. Teaching skills assessment
5. Ability to handle medical errors
6. Colleague with a problem e.g colleague has alcohol breath.
7. Ethical issues
8. Legal issues e.g Epilepsy reporting to DVLA
9. Telephone conversations e.g talk to your consultant, talk to a child's mother to
give health advice.
10. Emergencies
11. Discharge prescriptions. You have to explain the discharge medications to the
patient - how to take them and their side effects. If you don't know the side
effects, you can check the BNF. You can read the BNF in front of the patient to
check for dose, frequency, contraindications, safety in pregnancy, etc.

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FORMAT OF THE PLAB 2 QUESTIONS

You will get 1.5 minutes outside the cubicle to read the question

1. Who and where you are

You are a FY2 doctor in the medical/surgical/GP clinic

If you are in a GP clinic and you think you need to do a CT scan, you will say you will
refer to a specialist and the specialist might do the CT scan.

If you decide it's an emergency, you need to tell the patient that you will call the
ambulance for the patient.

For an example you are in a surgery department and a patient has high BP, refer to the
medical department so that they can find out what is making the BP high and treat you.

2. About the patient

E.g A 60 year old man presenting to the hospital/GP clinic with these symptoms… ..

3. Any other information

4. Your task

Take a brief history, do a relevant examination, discuss the management with the
patient

Talk to the patient/address his concerns also means you will take a history, do an
examination, do investigations, discuss management.

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HOW TO APPROACH THE QUESTIONS

1. Read and understand the question. The question might be short or long. Make
sure you understand the question before you go in.

There is always a copy of the question in the cubicle. You can reread it if necessary.

2. Outside the door, plan what you will do when you get into the room

● Plan your time

● Start thinking of differential diagnoses

3. When you go into the room, remember:

● The important points in the question (who you are, patient's name, age,
gender)
● Your plan.
● To clean your hands with the alcohol gel

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HOW TO APPROACH THE PATIENT

GRIPS

Greet the patient

Rapport with the patient

Introduce yourself and Identify the patient

Purpose of the consultation & Privacy and chaperone

Social courtesy

● If the patient is in distress, just say hello. If he's sitting comfortably, then you can say good
morning
● You create rapport by using appropriate gestures, body language. Try to shake the hand if
the patient is not in distress. Call the patient's name by using title and last name e.g Mr
Patterson. If he says you can call me John, then proceed. Don't ask an elderly person how
you can call him.
● To introduce yourself, mention your name, designation and your department. I'm Dr John
Patterson/Dr Patterson/John, one for the junior doctors in the medical department/clinic.
● To identify the patient, use the full name. "Are you Mr John Patterson?". If it's a paediatric
patient, ask the parent, "Are you the mother of Nicola Anderson?" Then you can ask her what
you can call her.
● Privacy means talking to the patient privately, examining the patient privately.
E.g if the patient is on a general ward, then you should take the patient to a private room if
you want to discuss an important diagnosis. If you want to examine a patient, you should
draw curtains around the patient. You should ensure the door is locked or there should be a
curtain in front of the door or there should be a sign board/notice outside the door. "Please
undress. I will ensure privacy."
● If you want to examine the private part of a patient or a trunk area in general, ensure that there
is someone else with you. In the hospital, you usually use a nurse, health care assistant, or
doctor, and not the patient's relative. NEVER examine a patient without a chaperone. Tell the
patient "I'll have a chaperone with me."

4. Patients can complain many years after the encounter. Document your chaperone's name in
the notes. Use 'please', 'sorry', 'thank you'

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HOW TO STRUCTURE YOUR APPROACH

History -> Examination -> Provisional Diagnosis -> Investigations -> Definitive
Diagnosis -> Treatment

Examination

1. Check the vitals by checking the NEWS (National Early Warning Score) chart. "I
need to check your vital signs like your pulse, temperature, blood pressure, respiratory
rate".

Tell the patient if there is an abnormal vital sign.

2. Next mention the area you want to examine.

● If the examiner gives you the finding, there is no need to continue. Tell the
patient if there is a finding or not.
● The patient may show a picture. You will still tell the patient what you see in the
picture.
● If the examiner/patient does not give you a finding or picture, then proceed to
do a full examination. If you see a tool (e.g stethoscope, fundoscope), you see
the patient lying on a couch, or you see a couch in the cubicle, you might be
expected to examine.
● Sometimes, you will need to examine a manikin. If there's a manikin, there is a
95% chance there is a finding which you should not miss. You will still talk to a
patient.

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Provisional Diagnosis

Most stations require you to talk about the provisional diagnosis. Having a provisional
diagnosis guides what investigations you are going to request.

● Ask the patient if they know what's happening to them.

● Then you tell them "I suspect", "I think", "Most probably" you have a condition
what we call 'Pneumonia'. Don't say "you're suffering".
● After telling the patient the diagnosis, ask the patient if he knows anything
about the condition.
● Then you explain it with common layman language and check his
understanding. "Do you follow me?", "Do you understand?". Ask what part the
patient didn't understand and re-explain it.
● Tell the patient the seriousness of the condition

Scenario 1: You suspect pneumonia in a 35 year old man. The patient might ask you if
it's serious, tell him it is so that he will take the medication seriously even when the
symptoms abate. "Unfortunately, it is a very serious condition but the good news is
that it is a treatable condition if you take the medication properly".

If the patient asks what can happen, you can say it can cause death if not treated.

Scenario 2: 60 year old woman with provisional diagnosis of GCA

You tell the patient that it is a serious condition. "Unfortunately, It is a very serious
condition because sometimes it can cause a permanent loss of vision but if you take
the treatment as soon as possible now, we can prevent the loss of vision."

Scenario 3: A patient with UTI

It can lead to a serious complication and the infection can spread to your kidneys.

Investigations

1. "To confirm our diagnosis, we need to do some tests or investigations like:

● Blood tests - infection markers in the blood, arterial blood gases

● Chest X-ray
● Sputum to check what type of bugs causing the infection

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2. Ask if he is following
3. Take patient's consent. "Is this alright if we do that?"

4. Explain the findings to the patient. If it's an x-ray, show the patient. If there is
lymphocytosis, you can tell the patient and then still say you are waiting for
confirmatory results (e.g chest X-ray).

5. If the confirmatory result is not available, you can say, "If the investigation confirms
the diagnosis"

Treatment

● Treatable with medications or surgery

● Non-treatable
● Chemotherapy
● Palliative
● Self-limiting
● Life-style modifications

1. Tell the patient if their condition is treatable or not. "Unfortunately, this condition is
not treatable.”

2. If the condition is treatable and you want to send the patient home, name the
medication. If it is an IV antibiotic, you don't need to name it.

3. Explain the purpose for each medication, how to take it, frequency, duration, side
effects (most common & important, etc). "Like any medicine, this medication can
cause side effects and some common ones include loose stools."

4. Mention what to do if there are side effects. "If you have these side effects, please
do not stop. The side effects will stop when you complete the medication." "Rarely,
they can cause serious side effects. Stop taking the medication. Call the ambulance."

5. "This condition will subside on its own. The treatment is only for symptoms."

6. You need to mention whether you are going to admit or not. If the patient does not
require admission, "This condition does not require admission to the hospital for
treatment. It can be treated at home." If the patient requires admission, then you need
to take permission

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Scenario 1

70 year old man diagnosed with pneumonia. Patient asked how long he will be in the
hospital. "At the moment, it is difficult to give you an exact day. Usually, it takes about 5-
7 days for most patients to be well enough to go home. So, we can expect you to be on
admission for about this duration". If it is a day surgery, "Our plan is to keep you for
one day and you will come the morning and we plan for you to go home tonight unless
something happens and you may need to spend the night in the hospital."

If you decide not to admit, you have to talk about:

1. What treatment to take at home

2. Where and when you want the patient for follow-up
3. How long it will take for the symptoms to subside
4. Warning/red flag signs: if the symptoms are not improving, they are getting
worse, developing new symptoms or complications, serious side-effects. This is
called safety netting.

If the patient says he refuses the admission or treatment,

1. Ask the reason "May I ask why you don't want to be admitted?" Show concern.
2. Tell the importance of the admission or treatment. "It is a very serious condition
and the treatment needs to be given through the veins and this cannot be done
at home."
3. Tell them what will happen if they do not get admitted or treated. "This can
lead to death".
4. Try to help in solving the reason they gave

If this patient is still saying no,

1. Ask if there are any other reasons

2. Check the mental capacity. Whether she understands the gravity of the situation
or not
3. If she understands and still insisting on going home, then talk to your seniors
4. If she's still refusing, she'll need to sign a form: refused treatment/admission
against medical advice.

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Reasons why some people may need admission

● People who have no one to take care of them

● Domestic abuse
● Malingering
● Elderly people if they live alone

HISTORY TAKING
A. What you should not do while taking a history

1. Do not ask leading questions in the beginning. Ask open-ended questions

and the patient will describe it in his own words. If you're in the hospital, write
in the patient's words. If the patient is unable to describe the character of his
symptoms, then give the patient options.
2. Do not interrupt the patient. You might miss some important information. If
you MUST interrupt, the patient should not realize that you are interrupting
him. Keep showing interest and wait for a pause and repeat the last thing he
said back to him. And then ask about something else.
3. Don't be judgmental.
4. Don't ask more than one question at once.
5. Don't ask irrelevant questions.

B. What to do when taking a history

1. Start with open-ended questions

a. How may I help you?

b. What brings you to the hospital today?

c. Can you tell me more about it?

2. Offer painkillers if the patient is in pain but ask permission to ask questions
before you actually give painkillers

3. Remember your mnemonics

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P3TMAFTOSAE

Present history, Past history, Personal history, Treated

Medications

Allergies

Family history

Travel history

Occupation

Social history

Anything else

For women:

4Ps

Period

Pregnancy

Pills

Pap smear

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PRESENTING HISTORY

ODIPARAA

Onset

Duration

Intensity

Progression - Since it started, has it gotten better, worse or stayed the same? Is it
there all the time?

Aggravating factors

Relieving factors

Anything else

Associated symptoms

For pain:

SOCRATES

Site - Where the pain is, where it was when it started

Onset -

Character

Radiating

Associated symptoms

Timing

Severity

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Chest tightness - MI, asthma, GERD

Squeezing chest pain - MI

Crushing pain - MI

Burning pain - GERD, PUD

Tearing pain - Dissecting aneurysm

Sharp chest pain - pleuritic pain

Scenario 1

35 year old man with fever

You should first start with 'anything else?'. If his answer is positive, then you explore
this associated symptom briefly. And then keep asking again if there's anything else.
Explore this new symptom again but briefly.

When the patient no longer gives you any other symptoms, then you have to ask
associated symptoms.

Think of common diagnoses based on the information you have:

Pneumonia - Cough

UTI - Burning urination

Meningitis

Gastroenteritis

Ear infection

Tonsillitis

Hepatitis

Malaria - Intermittent fever, headache, chills

TB - night sweats, haemoptysis, weight loss, travel history, contact with a person with
chronic cough. There may not be any known contact.

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Scenario 2

Patient with fever, cough, chest pain

Explore each symptom but don't ask all the symptoms for each condition you suspect.

PAST MEDICAL HISTORY

- Has patient had similar problems or symptoms before?

- "Have you ever had any medical conditions?" or "Have you ever been
diagnosed with any medical conditions?"
- Name the relevant medical conditions and ask individually e.g heart conditions,
high cholesterol, high blood pressure, Diabetes
- "Have you ever had any surgeries in the past?"

PERSONAL HISTORY

SARSDEW

Smoking - "Do you smoke? Have you ever smoked before?" What do you smoke How
much do you smoke? For how long?

Alcohol

Recreational drugs

Sexual history

Diet

Exercise

Weight gain/weight loss

If you want to signpost, you can say I want to ask you some questions about your
lifestyle.

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Scenario 1

40 year old with hysteroscopy. She's getting discharged today. The ward nurse noticed
she has an alcohol problem. You are an FY2 doctor on the ward. Talk to the lady about
this problem.

● Develop a good rapport - how she's doing, talk about the hysteroscopy, how
she's feeling about the discharge.
● "You know as doctors we want everyone to have a healthy life including you.
Some people's lifestyle can affect their health and that's why I want to ask you
about your lifestyle before you go home, because we want to make sure you
have a healthy lifestyle." You can start by talking about diet and exercise before
honing in on the smoking.
● Offer confidentiality by telling her the information will remain within the medical
team.
● Tell her how you learnt about her problem.
● Ask her about the alcohol problem
● You can now tell her about the consequences of excessive alcohol
● Ask again
● Thank her for sharing the information
● "May I know what type of alcohol?"
● "How much?"
● "How long?"

Scenario 2

A pregnant lady with vaginal bleeding seen by the midwife who says there's no vaginal
bleeding. Talk to her.

It's probably domestic abuse

● Ask how the pregnancy is going

● Ask her why she's here
● Tell her the nurse did not find any vaginal bleeding
● Offer confidentiality. You can trust us. You can open up to us.
● If there's anything that can affect you or your baby, we're here to help you
● Keep assuring her
● If she says her husband is beating her, tell her sorry.

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● "When the midwife saw you, she saw some bruises and is concerned about
them. Please tell me how it happened".
● "It doesn't look like a door handle. Please tell us what happened."
Recreational drugs

If they are using IV drugs, ask if they share needles. If they do, ask "Are you aware of
the needle exchange program?"
Sexual History

You should take sexual history in UTI stations, dry cough (PCP), bilateral joint pain
(Reiter's syndrome).

● "Can I ask you some questions about your sexual life?"

● "Are you married or do you have a partner?"
● "Is your partner male or female?"
● "Do you practice safe sex?"
● "Have you ever had unprotected sex in the last 6 months?" "Have you ever had
unprotected sex with any one other than your regular partner in the last 6
months?" "Did you have unprotected sex with your partner after this
incidence?"
● "Do you have vaginal sex? Oral sex? Anal sex?"

Partner notification

If a patient has an STI, you can tell the patient, "If you are worried, we can tell your
partner without revealing your name."

Either the patient informs the partner directly or anonymously

The health authorities can tell the partner by revealing the patient's name or not. With
HIV, you have to reveal the name of the patient. If he doesn't agree to tell the partner,
convince him to do so himself. If he doesn't, then we have to inform the partner
because of legal obligations.

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Female history

1. LMP
2. Any chance you might be pregnant? Any breastfeeding? Ask this question in
most women who are of child-bearing age.
3. Do you use contraceptive pills?
4. Have you had a pap smear?

TREATED?

If the symptom has been going on for a long time, ask the patient the following
questions:

● Have you seen a doctor for this symptom?

● Have you been treated for this symptom before?
● Why are you just coming now?

MEDICATIONS

● "Are you taking any medications including over the counter medications?"
● "Why are you taking this medication?"
● "Which ones are you taking?"
● "If she doesn't know, tell her you will check the drug chart and then look at the
question."

● "When did you start taking the medication?"

Reasons for medication history

- The presenting symptom might be a side effect of a medication

- Drug interactions

- To determine if there is a need to change/stop the medication e.g warfarin

before a surgery

Scenario 1

70 year old woman operated for fracture neck of femur a week ago has a 5 day history
of constipation but she's been taking for co-codamol 3 days. The constipation will
probably not be as a result of the co-codamol.

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Scenario 2

An elderly woman collapsed while window shopping and was brought by ambulance
to the hospital. Ask her if the fall has happened before? Confirm if she fell before the
medicine was changed? If she doesn't know the name, ask her if she has the
medication with her. If she didn't bring the medication with her, ask if she has the
prescription with her. You can tell her that you will check with her GP.

TRAVEL HISTORY

"Have you traveled outside the country?"

"Where did you go?"

"When did you go?"

"When did you get back?"

"Did you have any health problems while you were there?"

Important for Pulmonary Embolism, STIs, malaria, TB. Even if it is a hostess, it can still
be PE.
OCCUPATION

"What do you do for a living?"

Scenario 1

60 year old man presenting with cough of 6 months duration. Now having
hemoptysis. After taking a history, you learn he is a smoker and a plumber. Your
provisional diagnosis is asbestosis, mesothelioma with differentials of lung cancer.

Patchy white shadow in the lining of the lungs - mesothelioma

Scenario 2

30 year old man who is a smoker and a plumber presenting with hemoptysis. He is also
a smoker and a plumber. Travel history to South Africa. Diagnosis is most likely TB.
Even if there is no positive travel or contact history, it is still most likely TB.

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SOCIAL HISTORY

If the symptoms have been going on for a long time, ask:

● "Do you have anyone to look after you?"

● "Does it affect your social life or daily activities or in any way at all?"

If the social history is very important e.g in abuse cases, then you can dig deeper.

ANYTHING ELSE
“Is there anything else which you think is important that we may need to know?”

EXPECTATIONS

"Is there anything you are expecting from us?"

HOW TO APPROACH COUNSELLING STATIONS

ICE

- Do you have any ideas? Assess the patient's knowledge until the last thing the
patient knows.
- Do you have any questions?
- Do you have any expectations?

Scenario: You are to explain post-op care to a patient

● I'm here to tell you what will happen after the operation
● Do you have any concerns about what can happen after the operation?
● Keep asking if there are any other concerns
● If she says no more, then you tell her other information that is necessary for her
to know.
● Ask her if there are any other expectations

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COMMUNICATION SKILLS
Communicating With Patients – Specific Skills

Validation & Empathy

VALIDATING PATIENTS

1. PICKING UP ON VERBAL & NON-VERBAL CUES

2. ASKING SPECIFICALLY ABOUT THE PATIENT’ S ILLNESS PERSPECTIVE

3. ASKING ABOUT PATIENT FEELINGS

1. PICKING UP ON VERBAL & NON-VERBAL CUES

It should be emphasized that cues do not only appear as verbal comments. Non-verbal
cues in body language, speech, facial expression and affect are also highly significant.
To ensure accurate interpretation of such non-verbal behaviour, it is important to
observe carefully and then sensitively verify your perceptions with the patient.

But why do doctors repeatedly fail to pick up patients' cues? Perhaps it is due in part
to issues of control. Doctors have traditionally controlled the interview via closed
questions which limit patients' contributions and render them more passive. When we
pick up patient cues, perhaps we feel that we are being taken off our pre-planned
flightpath and are uncertain of where we might be led; we start to feel out of control.
Paradoxically, cues are usually a shortcut to important areas requiring attention.

We may also fail to pick up cues to the illness framework because we are preferentially
listening for cues about disease. If the patient says 'I've been getting a lot more pains
lately', it is so easy to preferentially pick up the disease rather than the illness cue and
say 'Tell me about the pains' without returning to 'You mentioned things

have been difficult at home ... '.

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Examples of ways to pick up verbal and non-verbal cues:

ie Skills involved in discovering and responding to patients' feelings

VERBAL CUES

1. Picking tips and checking out verbal cues

a. 'You said you felt miserable, could you tell me more about how, you've
been feeling?'

b. 'You said that you were worried that the pain might be something
serious; what theories did you have yourself about what it might be?'

c. 'You mentioned that your mother had rheumatoid arthritis; did you think
that's what might be happening to you?'

2. Repetition of verbal cues

a. 'angry ...?'

b. 'upset ...?'

c. 'something could be done ...?'

NON-VERBAL CUES

Picking tips and reflecting non-verbal cues

'I sense that you're very_ tense; would it help to talk about it?'

'You sound sad when you talk about John.'

'I sense that you're not quite happy with the explanations you've been given in the
past. Is that right?'

'Am I right in thinking you're quite upset about your daughter's illness?'

2. ASKING SPECIFICALLY ABOUT THE PATIENT'S ILLNESS

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PERSPECTIVE:

Although picking up patient cues might be easier, asking specifically about the illness
perspective is still a very necessary task. Yet in ,Tucket's (1985) work, only 6% of
doctors asked patients directly for their own thoughts about their illness.

Direct questions need careful timing, with good signposting of intent and attention to
detail in wording. Bass and Coven (1982) showed that when parents in a paediatric
practice were asked 'What WORRIES you about this problem?', the majority of parents
responded with 'l em not worried whereas the phrase 'What concerns you about the
problem?' produced previously unrecognized concerns in more than a third of parents.

Different phrasing is required to ask questions about patients' ideas, concerns or

expectations.

Examples of phrasing when asking about patients' ideas, concerns or expectations

Ideas (belief )

• 'Tell me about what you think is causing it.'

• 'What do you think might be happening?'

• 'Have you any ideas about it yourself?'

• 'Do you have any clues; any theories?'

• 'You've obviously given this some thought, it would help me to know what you were

thinking it might be.'

Concerns

• 'What are you concerned that it might be?'

• 'Is there anything particular or specific that you were concerned about?'

• 'What was the worst thing you were thinking it might be?'

• 'In your darkest moments ...'

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Expectations

• 'What were you hoping we might be able to do for this?'

• `What do you think might be the best plan of action?'

• How might I best help you with this?'

• 'You've obviously given this some thought, what were you thinking would be the
best way of tackling this?'

3. ASKING ABOUT PATIENT FEELINGS

FEELINGS

Many doctors find entering the realm of patients' feelings particularly difficult. It does
not fit naturally with the objective approach of the traditional clinical method and is
something which at medical school we were often taught to avoid. Impassive
objectivity can be appealing; feelings are often difficult to handle and may be painful
to the doctor as well as the patient. Doctors are frightened of 'opening a Pandora's
box' of their patients' emotions and feelings. In comparison, it is the area that other
professionals such as counsellors and therapists are most encouraged to explore! It is
therefore particularly important to become aware of and practise the skills involved in
discovering and responding to patients' feelings.

How to Ask About Patient Feelings:

Direct questions

'How did that leave you feeling?'

Using acceptance, empathy, concern and understanding to signal to the patient that
you are interested in their feelings

'I can see that must have been hard for you.'

Early use of feelings questions to establish your interest in the subject

- Asking for particular examples

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'Can you remember a time when you felt like that? What actually happened?'

- Asking permission to enter the feelings realm

'Could you bear to tell me just how you have been feeling?'

How to end the discussion of feelings and not sink into a downward spiral with

the patient

'Thank you for telling me how you have been feeling. It helps me to understand the
situation much better. Do you think you've told me enough about how you are feeling
to help me understand things?' or

'I think I understand now a little of what you have been feeling. Let's look at the
practical things that we can do together to help.'
EMPATHY

COMMUNICATING EMPATHY TO THE PATIENT

The Aim of Empathy : - communicating your understanding back to the patient so that
they know you appreciate and are sensitive to their difficulty.

Both non-verbal and verbal skills can help us here.

Empathic non-verbal communication can say more than a thousand words. Facial
expression, proximity, touch, tone of voice or use of silence in response to a patient's
expression of feelings can clearly signal to the patient that you are sensitive to their
predicament.

But what are the verbal skills that allow you to demonstrate empathy? Empathic
statements are supportive comments that specifically link the 'I' of the doctor and the
'you' of the patient. They both name and appreciate the patient's affect or
predicament (Platt and Kelley 1994):

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Examples
• 'I can see that your husband's memory loss has been very difficult for you to cope with.'

• 'I can appreciate how difficult it is for you to talk about this.'

• 'I can sense how angry you have been feeling about your illness.'

• 'I can see that you have been very upset by hey behaviour.'

• 'I can understand that it must be frightening for you to know the pain might keep
coming back.'

Empathy vs Sympathy

It is not necessary to have shared an experience to empathize, nor to feel yourself that you
would find that experience hard. It is necessary, however, to see the problem from the
patient's position and communicate your understanding back to the patient.
Empathy should not be confused with sympathy which is a feeling of pity or concern
from outside the patient's position.

Can we Learn Empathy?

Poole and Sanson-Fishey (1979) have clearly shown that empathy is a construct that can be
learned. They utilized a nine-point evaluation scale, developed by Truax and Carkhuff
(1967),which ranges from stage 1: 'completely unaware of even the most conspicuous of the
client’s statements; responses not appropriate to the mood and content of the client's
statements' to stage 9: 'unerringly responds to the client's full range of feelings in their exact
intensity; recognizes each emotional nuance and reflects them in his words and voice;
expands the client's hints into a full-blown but tentative elaboration of feeling or experience
with unerring sensitive accuracy'! Truax has shown that psychotherapists who score highly
on this scale achieve change.

Poole and Sanson-Fishey showed that medical students' ability to empathize did not improve
over their medical school career without specific training: both first and final year students
scored poorly on the evaluation scale (average 2.1). However, after participating in eight two-
hour workshops using audio-tapes, students' scale ratings significantly improved to an
average level of

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(stage 5: 'accurately responds to all the client's discernible feelings; any misunderstandings
aye not disruptive due to their tentative nature'). After training, students also:

• used less jargon

• made clear attempts to understand the unique meaning of events, words and
symptoms to patients

• less often blocked off emotion-laden areas

• obtained descriptions of more of their patients' problem areas

• more often matched their voice tone to their patients

Patient refusing treatment

1. Ask if they understand the condition

2. Ask if they understand the treatment
3. Ask why they do not want the treatment
4. Explain the importance of treatment
5. Explain what are the risks if they do not have the treatment
6. Sort out the reason why they do not want the treatment.
7. Lastly - find out whether they agree for the treatment
8. If agreed - give warning signsIf they still not agree then offer that the seniors
will talk to them and maybe they will be able to convince them.
9. If still did not agree, mention that they have a right to refuse the treatment.
10. If they do not want to get admitted – tell them that they can sign a “Discharge
against medical advice form” and they can leave the hospital.

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BREAKING BAD NEWS

Mr Johnson who came previously with cough, SOB, weight loss and a lot of
investigations were done. They reveal that he has lung cancer. Disclose the
diagnosis to the patient and also tell the patient that he has only 6 months to live.

What is bad news in medicine?

A condition which can serious complications

Unexpected death which a doctor cannot prevent

Body language

● It is important to show sympathy and empathy to the patient.

● Keep a neutral face
● If the patient is sitting on a chair, sit down so that your eyes should be on the same
level.
● If the patient is standing, release his anxiety and then tell him "Can we sit and have a
chat please?"
● If the patient is lying flat on the bed, you can ask them to sit down and then you can
then sit down.
● If the patient is lying on an examining couch at 45 degrees, then you have to stand
near the patient and talk.
● Don't sit with a crossed leg. Sit with your legs together.
● Don't sit leaning backwards. Lean forwards a little bit: it shows that you are listening.
● Don't fold your arms/hands. Keep your hands on your lap.
● Maintain eye contact
Painless haematuria - Give provisional diagnosis of bladder cancer to patient
Bowel cancer - Give provisional diagnosis after trying to convince
Breast cancer - Don’t give any diagnosis. Refer to specialists
Lung cancer - Give provisional diagnosis to the patient
Testicular cancer - Don’t give any diagnosis
Melanoma - Name the cancer. Don’t talk of options
Oesophageal cancer - You can decide whether or not to say it is a cancer in the food
pipe

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Steps to follow when breaking bad news

1. Ask the patient how he's doing and about his symptoms
2. Assess if patient is mentally prepared to receive the news
3. Prepare the patient to receive the news
4. Break the news
5. Handle the patient’s emotions and respond to any concerns
6. Offer support

● If he tells you about his symptoms, then say "I'm here to tell you why you're
having all these symptoms"
● If he doesn't tell you about his symptoms, then you can ask if he knows why he's
here
● If he doesn't know why he's there, you can tell him that you're here to talk
about the test results. Ask if it's alright with him.
● Assess if he's mentally prepared to hear the bad news. "Before I share the
results, do you have any idea of what the results may show?"

Example 1 - Not mentally prepared

- If he's not prepared, then you need to prepare him mentally. You MUST give
two warning shots.
- The patient thinks it is a chest infection, say "I wish it were a chest infection. It is
not. I'm afraid it's not good news Mr Johnson. "Do you want to know what it
is?"
- The patient may also have no idea on what might be causing his symptoms.
- If the patient tells you he wants to know, then give the second warning shot.
- "Do you want any family members or friends to be with you when we are
talking about this?"
- Break the news straight away. Don't drag it.
- I'm afraid/I'm sorry to say/Unfortunately, the rest results show that you have a
cancer in your lungs.

Example 2 - Mentally prepared

● If the patient thinks it may be cancer, you don't need to give warning shots.
● "I wish you were wrong Mr Johnson but unfortunately, you are right. I'm very
sorry to say this."
● If you want to, you can ask "Why do you think it is cancer?"

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Types of emotions to expect these patients to go through

The patient is going to go through the 5 stages of grief:

Denial - "Mr Johnson I really wish it were just a chest infection but unfortunately, this
time it is not an infection. I'm really sorry about this. "

Anger - "I can imagine why you may be so upset about this. I wish I were wrong, but
unfortunately the test results show it is cancer. I'm really sorry about that." If the
patient is angry because he never smoked, you can say, "Mr Johnson, you are right
when you say people get cancer after smoking for a long time but sometimes, people
get lung cancer with no known reasons. It's really unfortunate that this happened to
you. I'm really sorry about that?"

If patient asks if it is his smoking habits that caused the cancer, don't make him blame
himself. "Mr Johnson is one of the reasons to get lung cancer. Sometimes, people can
get cancer for other reasons. Unfortunately, we can't be sure of what exactly caused
your cancer".

If it is a heart attack and the patient asks you if his smoking habits contributed to it, you
can let the patient know that the smoking could have led to it.

Shock - Call the patient's name. Don't ask if he's ok. Rather ask, "Are you with me?"
Talk less with long pauses.

Are you sure doctor? “I wish I were wrong.”

Are you 100% sure doctor? “I can't imagine how you may be feeling Mr Johnson. I
would have been very happy if I were wrong. Unfortunately, we have checked the
results and it is cancer. I'm so sorry about that.”

I can't believe this. “It's very hard to believe but unfortunately,. . ”

If patient says, ‘Doctor I can't take this” or if patient is 'collapsing', provide support. You
can hold his shoulders and say, I'm sorry. Is there anything I can do for you? I'm here for
you. Do you want me to call any of your relatives? Is there anything else I can do for you?"
Bargaining
If patient asks you "How long do you think I have?" I really wish that you could live for
years and years but I'm sorry to say you have a few months." If he wants to know a
specific time, say I'm so sorry that usually people at this stage live for about 6 months.

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Patient tells you that he had a friend with breast cancer who survived afterwards. "I'm
sorry your friend had breast cancer and I'm glad that she has lived for 15 years. I really
wish we could do something like that for you but unfortunately, at this stage of the
cancer , we don't have such treatment to prolong your life."

If the patient tells you to do something to help him, you can say "I'm so sorry if there
was something we could , we will definitely offer it to you."
Acceptance - If patient is now accepting of the condition and wants to know what can
be done for him

"We are going to do everything we can to keep you comfortable. We will do our best
to treat any distressing symptoms. We have a whole special team to look after you
cancer doctors, McMillan nurses, psychologists if you're feeling low."

If you need to break bad news to a patient’s wife

● "I'm here to talk to you about Mr Johnson."

● "Talk about his symptoms"
● "We did a lot of tests. We have told him, and he wants us to tell you about the
test results. Is it alright?"
● Before you tell her the results, ask her if she knows what's wrong.
● "Unfortunately it is not good news. Do you want to know?"
● "Do you want anyone to be with you? Alright, I will have to ask Mr Johnson and
come back to you."
● "I'm so sorry to tell you that Mr Johnson has a cancer in his lungs."
● If she starts crying, let her cry. Wait at least 5 seconds
● Ask if she wants tissues
● Offer her tissues. If there is none, ask the examiner. He might tell you to assume
it's been given
● You can also offer water. She may or may not accept
● For elderly, you can touch the shoulder, arm, hand or simply move your chair
closer
● When she's crying, don't interrupt or ask questions.
● When she starts talking, then you can talk

To end the station, ask if he has any questions.

“Mr Johnson, if you need any help in the future, please do not hesitate to come back to us. “
“Once again, I'm very sorry to give you this news“ “I really wish you cope well with this condition”.

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ETHICAL ISSUES for PLAB

Mental capacity Act
The Mental Capacity Act (2005) provides a statutory framework to empower and protect vulnerable
people who are not able to make their own decisions. It makes it clear who can take decisions, in which
situations, and how they should go about this. It enables people to plan ahead for a time when they may
lose capacity. The Mental Capacity Act applies to people aged 16 and over.

Principles of the Act

The Act is underpinned by five key principles:

 A presumption of capacity: every adult has the right to make his or her own decisions and must
be assumed to have capacity to do so unless it is proved otherwise.
 The right for individuals to be supported to make their own decisions: people must be given
all appropriate help before anyone concludes that they cannot make their own decisions.
 That individuals must retain the right to make what might be seen as eccentric or unwise
decisions.
 Best interests: anything done for or on behalf of people without capacity must be in their best
interests.
 Least restrictive intervention: anything done for or on behalf of people without capacity should
be the least restrictive of their basic rights and freedoms.

Assessing lack of capacity

 The Act sets out a single clear test for assessing whether a person lacks capacity to take a
particular decision at a particular time.
 It is a 'decision-specific' test. No one can be labelled 'incapable' as a result of a particular medical
condition or diagnosis.
 A lack of capacity cannot be established merely by reference to a person's age, appearance, or any
condition or aspect of a person's behaviour which might lead others to make unjustified
assumptions about capacity.

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 To test if the person has capacity:

To have capacity to make a decision, someone must be able to:

 Understand the information relevant to the decision.

 Retain the information.
 Use that information as part of the process of making the decision.
 Communicate his/her decision either by talking, signing, or any other
means.

Best interests

 Everything that is done for or on behalf of a person who lacks capacity must be in that
person's best interests.
 Carers and family members have a right to be consulted.
 All decisions must be made in the best interest of that person:
 Involve the person who lacks capacity.
 Be aware of the person's wishes and feelings.
 Consult with others who are involved in the care of the person.
 Do not make assumptions based solely on the person's age, appearance, condition or
behaviour.
 Consider whether the person is likely to regain capacity to make the decision in the
future.

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Advance care planning

The Mental Capacity Act introduced advance care planning, giving a person the right to make decisions about
their healthcare treatment in the future, for a time when they may no longer have the capacity to make such
decisions for themself.

 Advance care planning can only be made by people aged 18 years or older and considered to have mental
capacity.
 Under advance care planning, any treatment can be refused, except for those actions needed to keep a person
comfortable - eg, warmth, shelter and offering food or water by mouth.
 Wishes to have certain treatments may be expressed in advance which must be taken into account; however,
they do not have to be followed.
 An advance care plan carries the same weight as decisions made by a person with capacity and must be
followed. Therefore, best interests do not apply.
 Advance care plans may be verbal, except those about life-sustaining treatment which must be in writing and
signed by the patient and a witness, and include a statement that the decision is to apply even if life is at risk.
 The advance care plan becomes invalid if the decision is withdrawn or amended when the person still had
capacity (or even if there have been any actions suggesting they changed their mind after making the advance
decision), or if there are 'lasting powers of attorney' with powers to make the same decision after the advance
decision was made.
 The advance care plan must apply to the specific circumstance in question.
 Going against a valid and applicable advance care plan can result in claims for battery or criminal charges of
assault.

Lasting powers of attorney

 The Act allows a person to appoint an attorney to act on their behalf if they should lose capacity in the future.
 The Act allows people to let an attorney make financial, property, health and welfare decisions.
 The designated attorney must be aged 18 years or older.
 The lasting powers of attorney only come into force once the person has lost capacity and the lasting powers of
attorney must be registered with the Office of the Public Guardian.[2]
 The person making the lasting powers of attorney must have capacity when they sign a written document
confirming the powers and limitations of the powers of attorney.

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Independent Mental Capacity Advocate (IMCA)

An IMCA is someone appointed to support a person who lacks capacity but has no one to speak for them. The IMCA
makes representations about the person's wishes, feelings, beliefs and values at the same time as bringing to the
attention of the decision-maker all factors that are relevant to the decision. The IMCA can challenge the decision-
maker on behalf of the person lacking capacity if necessary.

Confidentiality
Patient’s have a right to expect that doctors will not disclose any personal information unless they give
permission
When A doctor can breach confidentiality ?
Generally speaking, if the patient gives consent for that or Information needed to be disclosed in the
patient's best interest or Public best interests
Examples:
- In presence of notifiable diseases e.g TB

- If a judge or court requested the information

- In situations where another individual, or a community, is at risk of serious harm due to the
patient’s condition or behavior (e.g. at risk of serious communicable diseases or
crime,)examples :HIV patient who is knowingly infecting others ,patient is a sex offender etc.

- The police are required to further investigate a case whereby a member of the public is armed
with, and has used, a gun or knife in a serious attack

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DNAR ( DNACPR) Do not attempt resuscitation)

- A DNACPR form is a document issued and signed by a doctor, which tells the medical team/other
paramedics staff not to attempt cardiopulmonary resuscitation (CPR) in case of cardiac arrest.
- The decision is made by the most senior physician looking after a patient after a comprehensive
assessment of the overall clinical picture.

Factors that help a clinician to decide on resuscitation :

1- Functional level and quality of life : Poor physiological reserve will make it unlikely for CPR to
be successful . eg- 60 male with advanced COPD who cannot walk more than 50 yards due to
SOB
2- Co-morbidities : end stage cancer, severe COPD , sever Heart failure ,metastatic disease …..etc
3- Patient wishes : eg if the patient already has a legal document stating that he does not want to be
resuscitated ( advanced directive )
DNAR is a medical decision . The patient /or family should be informed about it and this should be
communicated very clearly. They are not here to decide, they cannot ask you to resuscitate if you think it is
inappropriate
- If a patient with capacity refuses CPR, you respect his wishes .
- If a patient lacking capacity has a valid and applicable advance decision refusing treatment (ADRT),
specifically refusing CPR, this must be respected ( a valid, signed DNAR)
- The decision for not to resuscitate does not need a consent from the patient or family, however, all
efforts should be made to involve them in the decision.
- Patient or family can refuse treatment, but they cannot demand treatment
( i.e asking you to do CPR ), if the medical team thinks it is inappropriate.
- When disagreement between the medical team with the patient/or family arises, a second opinion
should be sought.

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Gillick competency and Fraser guidelines

 When we are trying to decide whether a child is mature enough to make decisions, people often
talk about whether a child is 'Gillick competent' or whether they meet the 'Fraser guidelines'.
 What do 'Gillick competency' and 'Fraser guidelines' refer to?
"...whether or not a child is capable of giving the necessary consent will depend on the child’s
maturity and understanding and the nature of the consent required. The child must be capable of
making a reasonable assessment of the advantages and disadvantages of the treatment proposed, so
the consent, if given, can be properly and fairly described as true consent." (Gillick v West Norfolk,
1984)

How are the Fraser Guidelines applied?

The Fraser guidelines refer to the guidelines set out by Lord Fraser in his judgment of the
Gillick case in the House of Lords (1985), which apply specifically to contraceptive advice.
Lord Fraser stated that a doctor could proceed to give advice and treatment:

"provided he is satisfied in the following criteria: that the girl (although under the age of 16
years of age) will understand his advice;
- That he cannot persuade her to inform her parents or to allow him to inform the parents
that she is seeking contraceptive advice;
- That she is very likely to continue having sexual intercourse with or without
contraceptive treatment;
- That unless she receives contraceptive advice or treatment her physical or mental health
or both are likely to suffer;
- That her best interests require him to give her contraceptive advice, treatment or both
without the parental consent." (Gillick v West Norfolk, 1985)
How is Gillick competency assessed?
Lord Scarman’s comments in his judgment of the Gillick case in the House of Lords (Gillick v West
Norfolk, 1985) are often referred to as the test of "Gillick competency": "...it is not enough that she
should understand the nature of the advice which is being given: she must also have a sufficient
maturity to understand what is involved."
He also commented more generally on parents’ versus children’s rights:
"parental right yields to the child’s right to make his own decisions when he reaches a sufficient
understanding and intelligence to be capable of making up his own mind on the matter requiring
decision."
 What are the implications for child protection?
Professionals working with children need to consider how to balance children’s rights and wishes
with their responsibility to keep children safe from harm.
Underage sexual activity should always be seen as a possible indicator of child sexual exploitation.
Sexual activity with a child under 13 is a criminal offence and should always result in a child
protection referral.

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TIA and DVLA

A patient who just had a TIA. What should he do for driving:
A) Refrain completely
B) Only drive when he is accompanied
C) Resume normally
D) Inform DVLA

Car or motorcycle drivers who have had a stroke or (TIA).

When you need to tell DVLA ?

(You do not always need to tell DVLA if you have had a single TIA or stroke).

1 You have had more than one recent stroke or TIA

2 One month after the stroke you are still suffering from weakness of the arms or legs, visual disturbance, or
problems with co-ordination, memory or understanding

3 You have had any kind of seizure, unless:

– it happened at the time of the stroke or TIA
or within the following 24 hours and you have never had a seizure, stroke or TIA before

4 You needed brain surgery as part of the treatment for the stroke

5 A person providing your medical care has said he/she is concerned about your ability to drive safely

6 You hold a current Large Goods Vehicle (LGV) or Passenger Carrying Vehicle (PCV) (Group 2) driving
licence.

7 If you are not sure whether any of the above apply to you, discuss the matter with your doctor.
Disability of your arms or legs after a stroke may not prevent you from driving. You may be able to overcome
driving difficulties by driving an automatic vehicle or one with a hand-operated accelerator and brake.

8 If there are any restrictions on the types of vehicle you can drive, these must be shown on your driving licence.

Epilepsy and Driving

Group 1 includes cars and motorcycles: Car drivers and motorcycle riders
Car drivers and motorcycle riders will usually be granted a 3-year licence as long as they:
 have not had an epileptic attack in the last 12 months, unless they have seizures that fall under one of
the concessions
 comply with the advice of their doctor or consultant concerning treatment and check-ups
Once seizure free for 5 years, drivers will usually be issued a licence valid until they’re 70.
Group 2 includes large lorries (category C) and buses (category D)
Lorry and bus drivers
Lorry and bus drivers will be given a driving licence if they remain seizure free for 10 years and without taking any
anti epilepsy medication. The duration of the licence will depend on the individual medical details of the driver.

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Breaking Bad News: Quick review

I followed this approach and got 11 in BBN. Somebody can get 12 even if they are really thorough with their
history.
Feeling the sentiments of the other person is extremely important while delivering bad news. In addition to
feeling the emotions, it is also very important to be extremely calm and composed. If the doctor is not calm
whilst delivery bad news, how do you expect to calm down you patient. Ask yourself this question, why would
a doctor in this situation feel all anxious and challenged? There should not be any nervousness and you
should be really calm, composed and understanding.
Give the patient/ relative time to comprehend what is going on. Do not worry about time. If you give them
time in the beginning, they will make things easier for you in the end. It will flow easily.
Let me summarize the points I follow in breaking bad news stations in general:
• Introduction - I have to write about this part separately because in stations like these the patients can be
very anxious and they might even be standing when they see you. What can you do about this? You need to
calm them down before anything else. Tell them you can see they are really worried; let’s have a seat and
talk. I am dr ——, one the junior doctors here. May I just confirm you name?
Please, do not forget introduction in the attempt to make them sit or while trying to make them relax. It is
very, very common to forget about introduction in these stations. Also, please, do not be taken a back if you
see the patient/relative standing, act like it is expected. You need to be ready for this.
• Data gathering is so, so important to help things come less strong when you break the bad news and also
to bring rapport with the patient/relative and also to build your case. What kind of data gathering is needed in
this case? Well, it should be a complete recap of what happened, their knowledge about what is happening
now. You have to cover entire PMH, lifestyle and MAFTOSA as well.
Tip: while collecting data, if this is a case like accident of a child, you can say something like:
it must be very difficult to go through all of this again and I am sorry for that, but it is very important for me to
ask these questions for your child’s safe and effective management.
Another tip is that if the patient or relative is in too much hurry to hear the news and pushing you, then tell
them that it is very important for you to ask these questions for the patient’s safe and effective management
or it is very important for me to ask these questions so that we can be on the same page and only then I will
be able to explain everything to you in the best possible manner.
It’s all about how you play with the words.
• Early on you can ask if someone is in the waiting area and if they want that person to be with them while we
discuss everything.
• Before breaking the bad news you can say something like eg when you first came in Mr ....., we did some
tests because of your symptoms. One of the tests was a CT-scan. The CT-scan is seen by experts and
unfortunately I do not have good news for you, the scan revealed that you have a mass in your brain, which
might be a tumor.
PAUSE; (Count 1,2,3,4 before continuing)

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• See their reaction. They will definitely give you reaction at this point. It can be anything shock, disbelieve,
anger, crying.... you need to give them a chance to react.
• Ask them if they want to call anyone for support.
If they are crying, offer tissues if only you see a box in front of you and do not take the tissue out for them.
Just slide the box. Offer them water only if there is a glass of water in front of you and again only slide it.
Tell them that it must be very hard for them and please take your time to absorb everything. I will only
continue when they are ready.
• Then continue when they tell you it is okay to continue.
Ask them what questions they have at this point. Answer those questions.
Formulate a management plan with them. Keep asking them if it is okay to do those further tests and
referrals.
• Offer them a good support system: friend, relatives, support groups and offer yourself as their support.
Ask them if they want someone to talk to and discuss things further you and your team are here for them.
If they are a cancer pt who have just been given this diagnosis and you will be referring them, do very good
safety netting and offer them support.
• Ask what they are going to do today after this meeting. If they are going to work, maybe talk about taking
some time off work. SUPPORT is so important in these cases and much, much more important than the
complex managements people are giving in these cases. Keep things SIMPLE. Give a general management
plan, talk about seniors, symptom management, specialist referrals and specialist tests, specific
management- just talk about it in general and the complex procedures can be explained to them by the
specialists- it is not your job to be a surgeon, do good safety netting and give them support system. Make
sure you have asked them their concerns.

Breaking bad news if done correctly can give you an 11/12 easily! Please, be sensitive and make sure you
offer them a lot of support. Please, give them time to absorb the news. Treat them the way you would wish
yourself to be treated if, God forbid, you were to receive a bad news.

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1.
You are the FY 2 doctor in the Paediatric department

A 10 year old boy Joshua Pilmore was brought into the hospital by the ambulance
because he met with a Road traffic accident.

A CT scan of the head showed he had extradural haematoma. Seniors are getting
ready to take him to the theatre. He is in critical condition. You have not seen the
child. Talk to his parents and address their concerns.

Dr: Hello Mr and Mrs Pilmore? ….. I am Dr ….. one of the junior doctors in the
Paediatric department. Are you the parents of Joshua?

Parents: Yes doc

Dr: I am one of the junior doctors looking after your son.

Parent: Oh, How is he, doctor?

The parents are standing because they are anxious

Dr: Joshua is in the resuscitation room now. Our team is taking care of him. I have
come here to talk to you about him. Can we sit and have a chat? Mr Pilmore, I was told
that he had an accident. Can you please tell me what happened to Joshua?

Parent: Doctor we were about to go to a restaurant and Joshua suddenly ran to cross
the road and the next thing I heard he was calling me Papa Papa. When we saw him,
he was under a car. We called an ambulance immediately. They brought him here.

Dr: I am very sorry to hear that. I can’t imagine how you feel about this. Do you
remember anything else that happened?

Doctor: When did this happen ?

Parent: About half an hour ago.

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Dr: Mr and Mrs Pilmore, I have not seen him yet, and I will be seeing him soon after I
talk to you. I do have some news about him. Can I tell you? I wish I could give you
some good news. He was brought in by the ambulance as you said but unfortunately
Joshua is in a very critical condition now

Parent: What happened why do you say that?

Dr: Mr and Mrs Pilmore, we examined him and did a CT scan of his head which
showed he had a head injury and has some bleeding inside the head.

Parent: Is it serious ?

Dr: Unfortunately, this is a very serious condition/It is a very critical condition. I am very
sorry to say this.

Parent: Don’t you have any treatment for this?

Dr: We can do surgery and try to remove the blood clot from the brain. That is what
our team is trying to do. We do have the best surgical team to deal with such
problems, and we are doing our best to save him. Most of the time, surgery is very
successful and they recover from the condition. However, sometimes it can be very
serious. In fact, sometimes it can be even life threatening.

Parent: Is he going to die doctor ?

Dr: As I mentioned, our team will try to do the best for Joshua. As I told you before,
most of the time, children do recover from the problem once we do the operation and
remove the blood clot from inside his head. However, there is a slight chance that he
may not make it. I am sorry to say this.

Mother may cry – console her and dad. (tissues – glass of water to drink).

Parent: Doctor I can’t believe this !

Dr: I can’t even imagine how you are feeling now. We will do everything possible from
our side.

Parent: Thank you doctor Parent: Can we see him?

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Dr: I can understand you want to see him. As you know, at the moment we are
resuscitating him. You may not be able to see him for a long time because we need to
operate on him as soon as possible. Maybe you can have a quick look at him now and
then, you can spend as much time as you want with him after the operation. Is that OK
Mr and Mrs Pilmore. Any other questions?

Parent: Ok doctor. Will there be any damage to the brain after the operation ?

Dr: Hopefully he will not have any brain damage. However, we can’t say much about it
now. We may know that only after the surgery.

Dr: Any other concerns Mr and Mrs Pilmore?

Parents: No doctor.

Dr: Are you Ok for us to go ahead with the operation?

Parents: Sure doctor, if you think that it is necessary. Please do whatever is best for
him.

Dr: Thank you. I need to ask you a few questions about his health? Is that OK?

Parents: OK

Dr: Can I ask you how Joshua’s health was before this happened ?

Parent: He was completely fine.

Dr: Did he have any medical conditions at all ?

Parents: No

Dr: Is he on any medications?

Parent: No

Dr: Is he allergic to anything you know?

Parent: Strawberries, doctor.

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Dr: I see. It is good that you told me about it. I will make a note of this in his notes and
let everyone know about this so that no one gives him strawberries here. Can I ask if
he is allergic to any medications at all?

Parents: No

Dr: Any medical conditions in the family members ?

Parent: No

Dr: When did he last eat or drink?

Parent: Just before this happened / in the morning.

Dr: How many hours ago is that?

Parents: … hours ago.

Dr: Thank you very much for the information. Do you have any other questions?

Parents: No

Dr: Thank you very much Mr and Mrs Pilmore. Once again I am very sorry to give this
news. I will go and see him now and will keep you informed about everything. I will be
around if you need any other help. I hope to come back with good news. Thank you very
much.

(This is a case of EXTRADURAL HAEMATOMA IN A CHILD)

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2.
You are the FY 2 doctor in the Paediatric department

10 year old boy Joshua Martin was brought into the hospital by the ambulance
because he was involved in a road traffic accident.

Investigations revealed that he has a fractured pelvis.

Pulse – high. BP – very low. He is not stable.

Talk to his parents and address their concerns.

Dr: Hello Mr and Mrs Martin ? ….. I am Dr ….. one of the junior doctors in the
Paediatric department. Are you the parents of Joshua ? Parents: Yes doc

Dr: I am one of the team of doctors looking after your son. Parent: Oh, How is he
doctor?

Dr: Joshua is in the resuscitation room now. Our team is taking care of him.

I have come here to talk to you about him. Before that – Mr Martin, I was told that he met
with an accident. Can you please tell me more about ii?

Parent: Doctor we were about to go to a restaurant and Joshua suddenly ran to cross
the road and the next thing I heard he was calling me Papa Papa. When we saw him, he
was under the car. We called an ambulance immediately. They brought him here.

Dr: I am very sorry to hear that. When did this happen ?

Parent: About half an hour ago.

Dr: Mr and Mrs Martin, I do have some news about him. I wish I could give you some
good news but unfortunately Joshua is in a very critical condition now.

Parent: What happened? Why do you say that?

Dr: Mr and Mrs Martin, we examined him and did some investigations. They show that
he has broken his hip bones. Because of that he is bleeding heavily inside in his hip area.

Parent: Is it serious ?

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Dr: This is a very serious condition. I am very sorry to say this. Parent: Don’t you have
any treatment for this?

Dr: We can do surgery and try to fix the fracture. That is what our team is trying to do.
We do have the best surgical team to deal with such problems. We are doing our best
to save him. Most of the time, surgery is very successful and they recover from the
condition.

Usually that controls the bleeding. Also we may need to give him a blood transfusion
because he would have lost a lot of blood. Is that OK for us the give the blood
transfusion?

Parents: Yes doctor you can give blood transfusion.

Dr: Mr and Mrs Martin, As I told you before, most of the time the operation is very
successful and we will be able to control the bleeding. However, sometimes it is very
difficult to control the bleeding in that case it can still be very serious and it can be
even life threatening.

Parent: Is he going to die doctor ?

Dr: As I mentioned our team will try to do the best for Joshua. As I told you before,
most of the time children do recover from the problem once we do the operation and
fix the broken bones.

However, there is a very slight chance that he may not make it.

Mother may cry – console her and dad. ( tissues – glass of water to drink). Parent:
Doctor I can’t believe this !

Dr: I can’t even imagine how you are feeling now. We will do everything possible from
our side.

Parent: Thank you doctor... Can we see him?

Dr: I can understand you want to see him. As you know at the moment, we are
resuscitating him. You may not be able to see him for a long time because we need to
operate on him as soon as possible. Maybe, you can have a quick look at him now and
you can see him properly after the operation, is that OK Mr and Mrs Martin.

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Dr: Any other concerns Mr and Mrs Martin ? Parents : No doctor. Dr:

Are you Ok for us to go ahead with the operation?

Parents: Sure doctor, if you think that it is necessary. Please do whatever is best for him.

Dr: Thank you. I need to ask you a few questions about his health ? Is that OK?
Parents: OK

Dr: Can I ask you how was Joshua’s health before this happened? Parent: He was completely
fine.

Dr: Did he have any medical conditions at all ? Parents: No

Dr: Is he on any medications? Parent: No

Dr: Is he allergic to anything you know? Parent: Strawberries doctor.

Dr: I see. It is good that you told me about it. I will make a note of this in his notes and let
everyone know about this so that no one gives him strawberries here. Can I ask is he
allergic to any medications at all? Parents - No

Dr: Any medical conditions in the family members? Parent: No

Dr: When did he last eat or drink? Parent: Just before this happened /in the
morning. Dr: How many hours ago is that? Parents … hours ago.

Dr: Thank you very much for the information. Is there any other question? Parents: No

Dr: Thank you very much Mr and Mrs Pilmore, once again I am very sorry to give this news.

We will keep you informed about everything.

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

Thank you very much.

(case name: FRACTURED PELVIS IN A CHILD)

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3.
You are the FY 2 doctor in the medical department.

62 year old man Mr Ali presented to the hospital with a headache and a CT scan of
his head showed huge intracranial bleed due to berry aneurysm. He is unconscious
but breathing on his own.

The neurosurgeon has decided that active intervention is not useful. Your
Consultant has decided for palliative treatment.

Talk to his wife Mrs Ali and address her concerns.

Dr: Hello Mrs….. I am Dr. …. How are you doing? Wife: I am OK.

Dr: I am one of the junior doctors in the medical department looking after your
husband Mr Mohammed Ali. I am here to talk to you about his condition.

Dr: Do you know anything about his condition? Wife: He had a headache and he
collapsed at home. Then we brought him in here doctor.

Dr: I am sorry to hear about that.

Dr: Can I ask you a few questions about his health? Wife: Yes doctor.

Dr : Did he have any medical conditions at all? Wife - No

Dr: Like High blood pressure ? Diabetes? Any heart conditions or kidney problems?
Wife: No

Dr: Any stroke or mini strokes before? Wife: No

Dr: How was he before ? Was he very active ? Was he working?

Wife: He was very active.

Do you know what happened after you brought him to the

hospital? Wife: No doctor.

Dr: Mrs Ali, we did a CT scan of his head and we got the result. Did anyone discuss the

CT scan result with you ? Wife: No doctor ?

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Dr: Before I tell you the result Mrs Ali can you please tell me - Do you have any idea
what may be happening to him ?

Wife: No doctor.

Dr: I am very sorry to say this - it is not a good news. He has a very serious condition.
Do you want to know about it?

Wife: Yes doctor.

Dr: Do you want any of your family members to be with you when we discuss this?
Wife: No it is OK doctor.

Dr: Mrs Ali, the CT scan of his head showed there is massive bleeding inside his head.
This is a very serious condition.

Wife: But don’t you have any treatment for that?

Dr: Sometimes, we can do surgery to treat this condition. We have discussed his
condition with the neurosurgeon but he thinks the surgery or any other treatment will
not help for your husband’s condition because the bleeding is very huge.

Unfortunately, we will not be able to treat his condition. He is in a very critical

condition.

In fact, it is a life threatening condition.

Wife: Do you mean to say he is going to die ?

Dr: I really wish I could say it is not true. But unfortunately, Mrs Ali that is true. She
may cry – Pause, offer tissues and water.
Wife: Why did this happen, doctor?

Dr: Mrs Ali There are various reasons this condition can happen. In his case, he had
some abnormal blood vessels in his head which were kind of swollen and thin and that
blood vessel suddenly ruptured and caused this heavy bleeding. Sometimes this
condition can run in the family members. Also, since he had high blood pressure -
sometimes high blood pressure can contribute to this problem. Not every case

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Wife: Are you not going to do anything?

Dr: I really wish we could do something to save his life. But Mrs Ali - unfortunately we
will not be able to save his life because the bleeding is very huge.

Wife: That means you are leaving him to die ?

Dr: I am really sorry if I made you feel that way. Mrs Ali - If there was anything more
that we could have done, we would have definitely done that for him. But our hands
are tied because there is no such treatment available to save his life.

Wife: Are you going to keep him in the Intensive therapy unit ?

Dr: Sometimes if they are not breathing on their own, we keep patients in the ITU and
attach a machine which helps them in breathing.

Mrs Ali as you may know he is still unconscious but breathing on his own at the
moment.

I really wish we could keep him in the ITU and treat him. But we keep only such
patients in the ITU to treat - with whom we expect them to recover from the condition.
Unfortunately, we are not expecting that Mr Ali will recover from his condition.
Keeping him in the ITU even if he stops breathing is not going to help him.

My consultant will discuss these things with you because your opinion is also very
important for us. What do you think Mrs Ali ?

Wife: I can understand. Are you not going to do anything at all for him ?

Dr: Mrs Ali, However we are going to do everything possible from our side to keep
him comfortable. We will provide him palliative care – that is we will be providing all
types of care to keep him comfortable.

Wife: When do you think he may die?

Dr: I really wish that I could say that he can live very long and healthy life but Mrs Ali
he may not live very long. He may die any day.

Wife: I have 2 sons. Should I tell them to come here ?

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Dr: Mrs Ali, I think you should tell them to come here because as I mentioned it is a
very serious condition now.

Wife: Can I take him home doctor ?

Dr: Yes surely Mrs. Ali. We will make all the arrangements so that you can take him
home and we will provide all types of care and support you may need to look after him as
long as he lives.

Dr: Do you have any other concerns?

Wife: No doctor.

Dr: Once again I am very sorry to give you this bad news. Wife: Thank you doctor

Dr: Thank you very much Mrs. Ali. If you need any help please do let us know.

(case: INTRACRANIAL BLEED IN AN ADULT)

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4.
You are the FY 2 doctor in the surgery department.

Mrs. … A 64 year lady had right sided Aorta-Femoral bypass surgery. She
developed heavy bleeding in the leg after the operation. She has been transfused
with 6 units of blood.

She is being taken to the theatre now. Your consultant is in the theatre.

Talk to her husband Mr… and address his concerns.

This complication was not unexpected.

Dr: Hello Mr I am Dr…. one of the junior doctors in the surgical department.

How are you doing?

Pt: I am OK

Dr: I am one of the team of doctors looking after your wife Mrs.

I am here to talk to you about her condition. Do you know anything about how her
condition is now?

Pt: She had a surgery. I just came to see her now. I don’t know how she is now. How is
she, doctor?

Dr: I really wish I had some good news for you. But Mr..I am very sorry to say this she is
in a very critical condition now.

Pt: Why doctor? What happened ?

Dr: After the surgery, she was moved to the ward and we noticed that she started
bleeding heavily. We have already transfused her 6 bags of blood. Unfortunately, the
bleeding has not stopped. So we have moved her to the operation theatre again to try
to stop the bleeding. My consultant is with her in the theatre. Our whole team is trying
our best to stop the bleeding.

Pt: OK. I need to go for my work now. Shall I come back after she is back from the
theatre?

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Dr: Mr….I am very sorry to say that this condition is very serious because we may not

be able to stop the bleeding and it is a life threatening situation now.

Pt: What do you mean? Do you mean she may not make it ?

Dr: I really wish I could say she is not in danger but unfortunately that is true Mr... We
are trying our best to stop the bleeding but it is very difficult to stop the bleeding in
such situation and if we do not succeed in stopping the bleeding she will not survive.

Pt: But why has this happened?

Dr: Unfortunately, sometimes this type of complication does happen after the surgery.

Pt: Didn’t you know this problem can happen before the surgery?

Dr: These types of problems are expected to happen after this type of surgery. Usually,
we are prepared to handle this type of problems by operating again but in your wife’s
case, it is very difficult to control the bleeding.

Pt: If you did expect this problem before then why did you do the surgery?

Dr: Unfortunately her condition was so serious that if we did not do the surgery she
would have lost her leg. That is why we did the surgery.

Husband: If you did not do that surgery, she would have just lost her leg but now you
have put her life at risk.

Dr: Mr… It is true that it is a life threatening condition now but the risk of bleeding was
very low. Usually more than 95% of people recover from this operation without any
complications at all.

We usually inform the patient of all the benefits and the risks before we do any
operation. Since the risk was very low, we did the surgery. It is very unfortunate that
this problem happened to her.
Pt: I think you did the operation unnecessarily and you are giving me my wife’s dead
body now.

Dr: I am really sorry if I made you feel that way. I can imagine why you are feeling that
way. It was essential at that time to do the surgery to save her leg.

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Pt: Why is that you say it is difficult to stop the bleeding? Where is she bleeding from?

Dr: Let me explain her condition and what operation we did on her and you can understand
where she is bleeding and why it is difficult to stop the bleeding.

We all have a big blood vessel in our tummy called Aorta which branches out into smaller
branches and it continues in to the leg as femoral artery which supplies blood

to the leg. She had a blockage in the femoral artery in the top part of her thigh so the blood
was not flowing into her leg.

We had to do an operation to restore the blood supply to her leg. So we connected an

artificial tube from the Aorta in her tummy to the femoral artery in the thigh so as to
bypass the blockage. We have succeeded in restoring the blood supply to the leg but
unfortunately she is bleeding now, and this bleeding is happening where we joined the
artificial tube to the original blood vessel. Because blood is under heavy pressure in that
area, it is very difficult for us to stop the bleeding.

However my seniors are doing their best to stop the bleeding. Let us hope they will succeed.

Pt: Doctor I have two sons. Do you think I should inform them?

Dr: Mr … Yes surely you can tell them that she is in a serious situation.

Pt: Should I tell them to come here ?

Dr: Yes, Unfortunately the condition is very serious Mr. I think you should tell them to
come here very soon.

Pt: One of my sons is in London other one is in Australia.

Dr: You can tell your sons to come here as soon as possible as she is in a critical
condition. I think they need to be informed about it.

[sometimes he may say one is in London and the other is in Somerset – both can
come here soon] Pt: OK. Thank you doctor.

Dr: Once again I am very sorry to give this bad news. Let us hope that she will be fine. If
you need any kind of help please do let me know. Thank you very much.

(case: AORTA-FEMORAL BYPASS SURGERY)

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5.
There was no CD4 count. Two tests for HIV were done 2 weeks apart for
confirmation. Discuss the results with the patient.

You can give the results first and then take a history to determine how he got it. The
most important thing to find out is if he has a partner.

Take history for symptoms of STI and HIV (urethral discharge, burning sensation
while passing urine, fever, weight loss, diarrhoea).

Find out if he has been having unprotected sex with his partner or other people. Also
check whether the wife also has symptoms of STI and HIV.

Check whether he had any infections previously.

Any other medical conditions, medications, allergies.

Ask about family, job.

Disclose the diagnosis – what does he think of the results? Then break the news in
layers (BBN)

Patient may ask if he is going to die – Reassure him that nowadays there is good
treatment. Most of the people live many years now without having much problems.

Tell the importance of telling it to his wife (test and treat her). He may be reluctant
initially. Convince him. Tell him that it can progress to AIDS. Tell him that we can tell her
on his behalf. If he does not agree to tell the wife, tell him we are legally obligated and
will have to inform her even if he does not give permission. Tell him that when we tell his
partner, we will not do it anonymously.

He repeatedly asks if we are sure that the results are accurate and that he has HIV.
Say, “Yes, that the test was done twice and both are positive to HIV.”

Patient might want to know how to reduce the chances of getting a child who is HIV
negative. Reduce his viral load and give prophylaxis.

(HIV - DISCUSS RESULTS)

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GENERAL CASES
Points to always consider:

Differential diagnoses

Red Flags

Risk Factors

Complications of the condition

Investigations

Complications and Contraindications of the medication

INVESTIGATIONS DONE FOR ALL PATIENTS

1. Blood Sugar
2. ECG
3. Blood tests - FBC, U+E, Creatinine, CRP, ABGs, Lactate, Blood culture, Clotting
factors
4. Special blood tests - LFTs, Cardiac Enzymes, TFTs
5. Urine - dipstick, urinalysis, culture, pregnancy
6. Special urine tests - Bence-Jones proteins, ketones, Legionella urine antigen
7. Images - X-rays, Ultrasound, CT scan, MRI
8. Special Images - PET scan, CTPA, Dexa scan, Echocardiogram, Doppler
9. Special tests - Biopsies, ‘Scopies’, sputum, LP

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TREATMENTS DONE FOR ALL PATIENTS

1. Admission OR NOT

2. Oxygen

3. IV fluids

4. Treat condition

5. Treat symptoms

6. Treat or prevent risk factors

7. Mention seniors & specialists

ECG INTERPRETATION

- 12 lead is for ischemia, infarction, pericarditis and bundle branch blocks

- Rhythm strip is for rate, rhythm, arrhythmia and heart blocks

1. Check rhythm
2. Check heart rate

If rhythm is regular, the heart rate = 300/#Large boxes between 2 R waves

If rhythm is irregular, the heart rate= # of ‘R’ waves in 30 large boxes (X) 10

4 walls of the heart: anterior, posterior, lateral, inferior

Inferior - II, III, aVF

Anterior - V1 - V4

Lateral - V5, V6, I, aVL

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Posterior - V1-V4 (ST depression)

To differentiate between anterior wall ischemia and posterior wall infarction, look at
leads V1 - V6. A tall R wave will be seen in V1 instead of the usual short wave.

* The R1 wave is usually short and progressively grows taller.*

If infarction is going on in one wall and ischemia going on in another wall, this is
referred to as reciprocal changes.

TREATMENT FOR STEMI

ST elevation should be in at least 2 lead areas to diagnose myocardial infarction

1st line: PCI.

If PCI not available, thrombolysis

DOOR TO BALLOON TIME = 90 MINUTES (PCI)

THROMBOLYSIS: DOOR TO NEEDLE TIME = 30 MINUTES

TREATMENT FOR NSTEMI - Heparin

As soon as the patient comes, an ECG should be done. Repeat the ECG after 30
minutes.

It might take about 4 hours for the cardiac enzymes to be released in the blood.

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6. CHEST INFECTION - ATYPICAL PNEUMONIA

- Typical pneumonia is caused by Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis.

- Atypical pneumonia is caused by Mycoplasma, Chlamydophila, and Legionella.

Atypical pneumonia usually presents with atypical symptoms:

● "Atypical" generalised symptoms such as fever, headache, sweating and

myalgia
● No response to common antibiotics such as sulphonamides and beta-lactams
like penicillin.
● No signs and symptoms of lobar consolidation meaning that the infection is
restricted to small areas, rather than involving a whole lobe. As the disease
progresses, however, the look can tend to lobar pneumonia.
● Absence of leukocytosis.
● Extra-pulmonary symptoms, related to the causative organism.
● Moderate amount of sputum, or no sputum at all (i.e. non-productive)
● Lack of alveolar exudates.
● Despite general symptoms and problems with the upper respiratory tract (such
as high fever, headache, a dry irritating cough followed later by a productive
cough with radiographs showing consolidation), there are in general few
physical signs. The patient looks better than the symptoms suggest.

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You are an FY 2 doctor

A 50 year old man presented with SOB and cough for the last 2 weeks.

GP treated him with antibiotics but he did not improve.

GP ordered for a chest x-ray and referred him to the hospital.

Take a history and discuss the management with the patient.

Hello Mr …. I am Dr… Can you please tell me what brings you to the hospital ?

Pt: Doctor, I have been having shortness of breath for the last few weeks.

Dr: I am sorry to hear that. Are you comfortable to speak to me ?

Pt: Yes doctor.

Dr: Can you please tell me more about your SOB ?

Pt: It just started like that doctor.

Dr: Can you tell me when do you feel short of breath - while doing any work or do you
feel short of breath even when you are just resting ?

Pt: Even when I am resting, I feel SOB.

Dr: What happens when you lie down – do you feel more (Heart failure) or less SOB.

Pt: No difference, doctor.

Dr: Does the weather make any difference (asthma)? No

Dr: Do you have any other symptoms other than SOB?

Pt: Yes doctor I have been coughing the last 2 weeks.

Dr: Does anything makes it better or worse? Pt : No

Dr: Do you bring out any phlegm when you cough? Pt: Yes

Dr : What colour is that? Pt: Whitish.

Dr : Any blood in that at all? Pt : No

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Dr Any other symptoms? Pt: I have chest pain also.

Dr: Where is the chest pain? Pt: Almost all over my chest doctor.

Dr Since when? Pt: Last few days

Dr: What type of pain is that? Pt: ..

Dr: Any other problems? Pt: Like what ?

Dr: Do you have a fever? Pt : Yes doctor I have been feeling hot since the last 2 weeks.

Dr: When do you get this fever – morning, evening or throughout the day and night (TB)?

Pt: Throughout, doctor.

Dr: Have you measured your temperature? Pt : Yes / No

Dr: Did you see any doctor for this? Pt : Yes I saw my GP he gave me some medicines.

Dr: Do you know which medicines? Pt : Amoxycillin

Dr: Ok. How long you have been on this medication? Pt… Dr:

Have you been taking the medication properly? Pt : Yes

Dr: Did you have any calf pain or calf swelling (PE)? No

Dr: Have come into contact with anyone who has similar problems? Pt : No

Dr: Have come into contact with anyone who has TB? Pt : No

Any loose stools? Any vomiting?

Dr: Have you had this type of problem before? No

Dr: Do you have any medical conditions at all? No

Dr: Like high blood pressure, Diabetes? No

Dr: Have you ever been diagnosed with Asthma or bronchitis? No

Dr: Do you smoke? Pt: Yes/No

Dr: Do you drink Alcohol? Pt: Yes/No

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Dr: Do you use any recreational drugs? Pt: No

Dr: Are you married or do you have any partners? Pt : I have been married for the last 30
years.

Dr: Do you practice safe sex? Yes/No

Dr: Have ever done any tests for infections like Hepatitis or HIV? Pt : No

Dr: Have you noticed any change in your weight (TB, lung cancer)? No

Dr: Are you taking any medications? Pt : No

Dr: Are you allergic to any medications? Pt: No

Dr: Have you travelled outside the UK recently (Legionnaires)? Pt: Yes I went to Spain
(When did you go there? When did you come back ?) /No

Dr: Did you stay in hotel there (Legionnaires)? Pt: Yes/No

Dr: Did you use any SPA recently (Legionnaires)? Pt: Yes/No (Legionnaires)

Dr : Did you go for swimming recently (Legionnaires)? Pt : Yes/No

Dr: Is there anything else you think is important that we need to know? Pt : No

Dr: Mr… I need to examine your chest now and also I need to check your pulse blood
pressure and temperature. [Examiner may say — there is bilateral crackles].
Look at the NEWS chart

Temperature – 38, Pulse – 90, BP – 110/80, RR- 25, Oxygen saturation – 91%.

[Explain the chart to the patient briefly. Only give a detailed examination if the
examiner tells you to explain to the patient]

Mr…Do you want to know about your pulse and blood pressure – Pt : Yes doctor

Dr: Our normal body temperature should be about 37 degree but your temperature
is 38 which is high - this means you have a fever; our normal pulse rate is usually
about 75 but in your case, it is 90 which is raised which can happen in fever, our
normal blood pressure is about 120 by 80 and yours is 110 by 80 which is almost

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normal; our normal respiratory rate is about 15 and in your case it is 25 which is
high and means you are breathing very fast which happens if there is a problem in
the lung and also normal. Your oxygen saturation is about 96%, but in your case, it
is 91% and that means you have low oxygenation of blood which again can
happen if there is a problem in the lung.

Look at the chest X Ray – may show bilateral/unilateral consolidation/normal (chest X

Ray may show unilateral or bilateral shadows or even normal in Atypical Pneumonia)

Mr…. Your chest X ray shows white opacities here both sides/one side/normal of your
lungs.

Do you want to know what may be happening to you? Pt: Yes

Dr: Looks like you have a chest infection.

You may be having some type of Pneumonia what we call as Atypical Pneumonia.

This is due to infection by a bacterial kind of bug. These types of bugs are slightly
different from the bugs which cause common Pneumonia. It is usually not a serious
condition. The common type of Pneumonia usually responds to medications like
Amoxycillin which was given to you. These kinds of bugs do not respond to

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amoxicillin type of antibiotics.

Further investigations:
There are many types of bugs which causes this Atypical Pneumonia. We need to test your
blood, urine and sputum to check what is the exact type of bug causing this infection.

Treatment:

We need to admit you to treat you. We will give you some other strong antibiotic
called Clarithromycin through your veins which usually works for these kind of bugs.
We will also give another antibiotics called Doxycycline tablets. We will also give you
some Paracetamol tablets for your fever and fluids through your veins. Is that Ok?

Pt: When can I go home?

Dr: It may take 4 to 5 days to recover from this condition. Then we can discharge you.
Any other questions? Pt : No

It may take about 2 or 3 weeks for it to completely resolve. Thank you.

How is atypical pneumonia treated?

Mycoplasma pneumonia usually goes away on its own after a few weeks or months. If the
symptoms are severe enough to require treatment, there are several types of antibiotics
available that are effective. Use of antibiotics may shorten the recovery period.

Antibiotics that are used to treat mycoplasma pneumonia, chlamydia pneumonia, and
Legionnaires’ disease include:

Macrolide antibiotics: Macrolide drugs are the preferred treatment for children and adults.
Macrolides include azithromycin (Zithromax®) and clarithromycin (Biaxin®).

Fluoroquinolones: These drugs include ciprofloxacin (Cipro®) and levofloxacin (Levaquin®).

Fluoroquinolones are not recommended for young children. Tetracyclines: This group includes
doxycycline and tetracycline. They are suitable for adults and older children.

Over the past decade, some strains of mycoplasma pneumoniae have become resistant to
macrolide antibiotics, possibly due to the widespread use of azithromycin to treat various
illnesses.

Hospitalization: People with Legionnaires disease often need to be hospitalized. Patients

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generally respond to antibiotic treatment within a few days, although complete recovery can
take from 2 to 4 months.

7.
A 75 year lady was brought into hospital with fever and cough.

Take a history and discuss management with the patient.

The risk of death at 30 days increases as the score increases:

0—0.6%, 1—2.7%, 2—6.8%, 3—14.0%, 4—27.8%, 5—27.8%

The CURB-65 is used as a means of deciding the action that is needed to be

taken for that patient.

0-1: Treat as an outpatient

2: Consider a short stay in hospital or watch very closely as an outpatient

: Requires hospitalization with consideration as to whether they need to be

in the intensive care unit

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Some of the patient’s symptoms may include:

- Cough, Fever (continuous) and SOB for 3 weeks
- Chest pain for few days
- Slight loss of weight
- No evening rise of temperature.

PHx – DM on medication. No other medical conditions.

No allergy. No Hx of contact with TB, No travel Hx.

No one else in the nursing home is ill or has similar problem.

Examination

Temp – 39C, Pulse – High, BP – 100/50, Low oxygen saturation Respiratory rate?

Chest examination – Reduced air entry, and crackles (examiner may give finding)

Investigations

Blood – infection markers, Chest X rays, Sputum and blood test for bugs, Kidney function

Blood test result given – Urea – high ( Normal – 2.5 to 7.1 mMol)

Creatinine – High (Normal – 88 – 128 mL/min in females and 98 – 137mL/min in males)

Neutrophils – high. Check for Potassium if given.

Explain examination finding and result

- Blood pressure is very low and temperature is high. There are some abnormal
findings in the lungs.

- The chest infection has affected kidney function.

- Blood test shows you have an infection in chest (bugs in the lungs). In addition,
some chemicals called urea and creatinine are raised.

- Explain x-ray if given.

Treatment

Admit, Inform seniors, Antibiotics through veins, Fluids through veins,

Pain killers. How long admission ? – may be about a week.

(case:PNEUMONIA IN AN ELDERLY PATIENT)

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SEPSIS
In the exam, sepsis = confusion + high temperature + low blood pressure

What are the symptoms of sepsis?

There are three stages of sepsis: sepsis, severe sepsis, and septic shock.

Symptoms of sepsis include:

● a fever above 101ºF (38ºC) or a temperature below 96.8ºF (36ºC)

● heart rate higher than 90 beats per minute
● respiratory rate higher than 20 breaths per minute
● probable or confirmed infection

There should be two of these symptoms to diagnose sepsis.

Severe sepsis

Severe sepsis occurs when there’s organ failure. There should be one or more of the
following signs to be diagnosed with severe sepsis:

● patches of discolored skin

● decreased urination
● changes in mental ability
● low platelet count
● problems breathing
● abnormal heart functions
● chills due to fall in body temperature - one of the most important symptoms
● unconsciousness
● extreme weakness - most important symptom

Septic shock

Symptoms of septic shock include the symptoms of severe sepsis, plus a very low
blood pressure.

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Risk factors for infection and low immunity

1. Extremes of age
2. DM**
3. Long term steroid use*
4. Cancer/chemotherapy
5. HIV
6. Organ transplant/patient on immunosuppressed

What is lactate?

Lactate is a chemical naturally produced by the body to fuel the cells during times of
stress. Its presence in elevated quantities is commonly associated with sepsis and
severe inflammatory response syndrome.

Why is lactate important?

Serum lactate is an important indicator of the septic patient’s prognosis. A level over 4
mmol/L is associated with a 27% mortality rate, with mortality dropping significantly
as the lactate level decreases. Lactate can be used as a guide for determining the
severity of the septic patient’s illness, and the effectiveness of their treatment.

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CONFUSION IN THE ELDERLY

Common causes of sudden confusion
The most common causes of sudden confusion are:
1. a lack of oxygen in the blood (hypoxia) – the cause could be anything from a
severe asthma attack to a problem with the lungs or heart
2. an infection anywhere in the body, especially in elderly people
3. a stroke or TIA ("mini stroke")
4. a low blood sugar level (hypoglycemia)
5. diabetic ketoacidosis, a serious complication of diabetes caused by a lack of
insulin in the body
6. certain medications, including digoxin, diuretics, steroids, and opiates
7. alcohol poisoning or alcohol withdrawal
8. drug misuse
9. head injury.
Less common causes of sudden confusion are:
● an infection of the brain or its lining (encephalitis or meningitis)
● an imbalance of salts and minerals in the blood
● a severely under-active thyroid gland
● thiamine (vitamin B1) deficiency
● a brain tumour
● hypoparathyroidism or hyperparathyroidism (rare hormone disorders)
● Cushing's disease (a tumour of the pituitary gland)
● an epileptic seizure
● carbon monoxide poisoning

What drugs can cause low sodium levels?

Many possible conditions and lifestyle factors can lead to hyponatraemia, including:

● Heart, kidney and liver problems.

● Syndrome of inappropriate anti-diuretic hormone (SIADH).
● Chronic, severe vomiting or diarrhea.
● Drinking too much water.
● Dehydration.
● Hormonal changes.
● The recreational drug Ecstasy.

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Potential causes of drug induced hyponatraemia (not an exhaustive list):

i. Anticancer agents: Vinca alkaloids (e.g. Vincristine), platinum compounds (e.g. Cisplatin),
Alkylating agents (e.g. Cyclophosphamide)

ii. Anti-depressants: Tricyclic antidepressants, SSRIs, MAOI

iii. Anti-epileptic medications: Carbamazepine, Sodium Valproate

iv. Anti-hypertensives: ACEi, ARB, Amlodipine

v. Antipsychotic medications: Phenothiazines, Butyrophenones

vi. Diuretics: Thiazides, Indapamide, Amiloride, loop diuretics

vii. Proton pump inhibitors: Omeprazole

A normal sodium level is between 135 and 145 milliequivalents per litre (mEq/L) of
sodium. Hyponatremia occurs when the sodium in your blood falls below 135 mEq/L.

Normal Urea level: In general, around 7 to 20 mg/dL (2.5 to 7.1 mmol/L) is

considered normal. But normal ranges may vary, depending on the reference range
used by the lab, and your age.

Normal levels of creatinine in the blood are approximately 0.6 to 1.2 milligrams (mg)
per decilitre (dL) (60–110 μmol/L) in adult males and 0.5 to 1.1 milligrams per decilitre
(about 45–90 μmol/L) in adult females.

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8.Elderly man with UTI – now presented with septic shock

An elderly man was treated for UTI 3 days ago with Trimethoprim. Culture has
shown E.coli sensitive to Trimethoprim. His wife brought him back today. Talk to
her.

Husband and wife both are inside the cubicle.

Talk to husband first – “How are you?” – he is confused and may say, “Where am I?
Who am I?” Then talk to his wife.

Causes of acute confusion

1. Sepsis
2. Hypogylcemia - Ask if patient has been diagnosed with DM
3. Uraemia
4. Head injury
5. Alcohol
6. Medications
7. Electrolyte imbalance
8. Stroke

Determine why he’s not responding to the treatment - Could he have an enlarged
prostate? Check if he has some other causes of infections (pneumonia, gastroenteritis)

Tell him he’s in the hospital and then talk to the wife. “Excuse me. I’ll come back to talk
to you shortly.”

Ask wife details.

She may give the story of having fever, burning sensation of urine 3 days ago.

Now he is confused, vomiting and has blood in the urine.

Did he complain of severe pain in tummy? Any loin pain? Loin to groin pain (ureteric
calculus)

Ask about whether he was taking the antibiotics regularly or not?

Any other medical conditions? Any Diabetes? Any other medical conditions (lowering
body immunity)?

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Was he having increased frequency (getting up to go to the loo in the night), poor
stream, dribbling of urine before ?

Any problems in the kidneys before and any kidney stones before ?

Any other medications ? Any allergy?

Check NEWS chart Pulse – very high, BP ?—90/60. Temperature 38.5

I need to examiner his chest, tummy and back passage for prostate enlargement.

Examiner may or may not give findings. Crackles in the chest in sepsis doesn’t
always mean pneumonia.
Mrs ..He has a condition that we call sepsis. This is due to the bugs which were in the
urine which have now entered the blood and caused blood poisoning. This is a very
serious condition if we do not treat him immediately.

We need to do some investigations to confirm it (blood and urine tests) to check for
bugs and other infection markers. PSA and pelvic ultrasound and biopsy.

We will have to admit him and give him very strong antibiotic medications through his
veins which are more effective than what he is taking now. Also, we need to give him
oxygen and give him fluids through his veins. We will keep him in the intensive therapy
unit to treat him now. I will inform my seniors immediately.

Any other concerns?

(ELDERLY MAN WITH UTI AND SEPTIC SHOCK)

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9. An 82 year old man was brought to hospital with sudden onset of confusion. Talk to

his daughter and discuss the management plan with her.

Blood tests are done and the results are kept inside cubicle: Results are kept on the table -
Hb marginally low, rest of FBC is normal, low Sodium, Urea and Creatinine is raised. (Level of sodium
given in exam - 115, Level of creatinine - 9.3)

History
Primary complaint? when did it start?

(daughter says that her father has been forgetful for the last 15 days and has now
forgotten her name as well)

Was he completely well before this?

R/O Infection: Fever – Ask questions about cough, headache, rashes, burning sensation of
urine

Any weakness of arms or legs, speech problem - No (stroke, TIA) – No

Past medical Hx of – Diabetes, Thyroid problem – No

High blood pressure – Yes

Which medication for HTN – daughter shows – Amlodipine and Atenolol (Enalapril , Atenolol)

Does he drink alcohol? – No

Any diarrhoea, vomiting? No

Ask questions regarding renal function:

- Is he passing enough urine? - Any weight loss? - Swollen ankles?

- Does he appear pale?
- Any history of repeated urine infections?

Check BNF - for SE of Amlodipine and Atenolol (or Enalapril) [Amlodipine and Enalapril

cause low sodium]

- Ask for family history of cancers, family history of kidney diseases.

Examination : General examination, vital signs

Management

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Explain the results to the daughter -

We have done kidney function tests. It consists of urea and creatinine.

Urea is a waste product which is formed from the breakdown of proteins. A high level
can indicate that your kidneys may not be working properly or it can also mean that he
is dehydrated.

However, creatinine is a waste product which is formed by the muscles. A high level of
creatinine also shows that your kidney isn’t working properly.

His sodium level is low which can cause confusion.

He has kidney failure. His kidney is not functioning properly. His high blood pressure
could have caused the kidney failure. Kidney failure causes raised urea which in turn
can cause confusion.
Also, the Amlodipine/Enalapril medication that he is taking for the high blood
pressure causes low sodium level in the body.
We need to do other tests to make sure that he has no other problems causing this
confusion – we need to check whether he has any infections. In addition, we need to
check his sugar levels, Thyroid function levels , vitamin B12 levels – because all these
things also can confusion.
Treatment

We need to admit him. Stop the Amlodipine/Enalapril medication. We will give some
other medication for his high blood pressure.

We will give him some fluids which contain sodium through his veins as drip. Hopefully
he will recover soon. He should drink less fluids. He may require dialysis.

Daughter may ask – will he survive this ?

“He may or may not survive because when elderly people have kidney failure, it is very
difficult to treat.”

(case: CONFUSION IN AN ELDERLY MAN)

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10.
You are the FY2 doctor on call in the A&E department.

85 year old Mr Stevan George was referred from the GP (see referral letter).
Assess and outline management with the patient.

GP Referral letter:

I am referring this patient to your hospital. He has always been active and well,
but recently has been found to be confused and irritated. He was diagnosed of
COPD 5 years ago and is currently on treatment for that.

Blood Pressure : 100/60 mm Hg Temperature : 38.4 C Heart rate : 100/

min Respiration rate : 26 breaths / min

GP Referral: Bilateral crackles on auscultation, Multiple lab investigations (look for

urea)

This scenario often varies: sometimes, the patient is confused and in some scenarios,
he might call out to his daughter Alicia. In others, he is calm and cooperative with mild
confusion. At times, he is mildly dyspneic, and other times, he is able to speak without
hindrance. He has a striking accent and this makes communication difficult for those
unfamiliar with it. There is no collateral present.

*ASSESS THE PATIENT'S SpO2 PRIOR TO HISTORY IF HE IS DYSPNEIC

If there is a low oxygen saturation - GIVE O2 via face mask.

If a patient is confused, it is very important to find out if he was accompanied by anyone.

Dr: Hello, is it Mr Brown? Pt: Yes, I am Mr George.

Dr: Hi Mr George, I’m Dr X, one of the junior doctors in the department today. I
understand you were referred from your GP today. Do you know why?

Pt: No, doctor, I don’t know.

Dr: From the note here, it looks like you may have been a little chesty lately?

Pt: Yes doctor, I’ve been coughing for the past 2 days.

Dr: Have you brought anything up with the cough Mr George ?

Pt: Just a little phlegm, sort of green in colour.

Dr: Did your GP give you any medicine for it?

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Pt - Yes, but not improving. Do you know where Alicia is doctor?

Dr: Who is Alicia? Pt: My daughter. She’s supposed to be here.

Dr: OK, we can send someone to call her in. Mr Brown, can you tell me, have you had
anything else with the cough?

Pt: Yes, you know, I felt a bit feverish last night, but I don’t have one of those things to
measure my temperature. I should have told Alicia to get one for me!

Dr: How many children do you have Mr George? Pt: Two daughters. They both live in
Australia.

Dr: Oh, so is Alicia visiting? Pt: No, she’s back home.

Dr: Whom do you live with ? Where is your wife ? Do you have anyone to look after at
home ?

*PATIENT IS CONFUSED

Dr: Ok, Mr George, a couple more questions: have you had any chest pain?

Pt: No, doctor. Where is Alicia? Dr: I will call for her now, Mr George.

R/O UTI, Gastro-Enteritis, Head injury, Hypoglycaemia (other causes of confusion)

Dr: Do you have any other illnesses, Mr George? Pt: Nothing, doctor.

Dr: Do you take any medications? Pt: Yes, I can’t remember the names, doctor.

Dr: Do you have any known allergies, Mr George? Pt: No.

Dr: Anyone around you having the same condition of cough and fever? .. No Dr ..
Dr: Anyone in family having chest/lung problem ?

Dr: Any recent history of travel or long flight ? ... No Dr ..

Dr: May I know what you do ..Pt : I am retired and I stay at home .

Dr: May I know if you smoke? .. Pt : I used to but stopped ... 5 - 6 years ago

Dr: Do you consume alcohol? .. Pt : No Dr ..

Dr: Anything else you would like to tell me? .. Pt : No .. where is ANGELA .. have you
called her?
Dr: Don't worry, Mr George .. She must be on her way .

Dr: OK, Mr George, just to confirm the GPs findings, I would need to examine your chest and

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check your pulse blood pressure and temperature. Then we can discuss how we can treat you .
Is that OK? Pt: Yes, that’s fine.

*Examiner may give findings: crackles in the chest.

Dr: I need to do some blood tests on you to check for infection markers and electrolytes
and a chest X-ray .

Examiner may give findings of raised TLC, raised urea, and a chest X Ray.

C-U-R-B-65: Criteria for admission of elderly patients with Pneumonia .

Score = 0 - No admission, 1- Investigations, 2 or more - Admission

In Mr. George's condition, the CURB score is 3. Hence requiring admission .

Dr: OK, Mr George, after listening to your chest, I suspect that you have a condition we
call Pneumonia. Have you heard of that?

Pt: No, but maybe Alicia knows.

Dr: She may, you’re right. It is a chest infection - this means there are bugs in your lungs.

Pt: Do I need to stay?

Dr: Ideally, for the best treatment plan we can offer you, we would suggest you stay in
the hospital. We can give you antibiotics through a drip to get you all better. I will
discuss this plan with my seniors and they can come down and have a chat with you
once we’ve had a look at your X-Ray.

Dr: As your Blood pressure is low .. I will be giving you fluids through your veins .

Dr: We will also give you some Paracetamol tablets for your fever. How does that sound?

Pt: Sounds like a plan, I’m sure Alicia will agree too.

Dr: Any questions OR concerns ? .. No

Dr: OK, let’s get you sorted then, Mr George.

In this station, you can do a mini mental state examination if time permits.
---------------------------------------------------------------------------------------------------------------------
patient has usually started to cough a lot after the 6 minute bell and show signs of confusion by
repeatedly taking angela's name . (case: CONFUSED ELDERLY, LRTI)

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FALLS Medical
Causes of falls include  Balance problems (cerebellar)

Medical  Postural hypotension (medications)

1. With LOC  Heart arrhythmia

a. Hypoglycemia,  Alcohol
b. Stroke  Osteoporosis
c. AS
 Dementia
d. Seizures
 Diabetes
e. Arrhythmias
2. Without LOC  Epilepsy

a. Vertigo  Joint instability

b. Vision problems
 TIA

Non medical  Stoke Adams

1. Slipping  Ear pathology

2. Tripping  Space occupying lesion

3. Dark room
4. Pushing-deliberate/accidental (Abuse)

The occupational therapist will assess non-medical causes of fall

i. Railing on stairs
ii. Bathrooms-slippery, add support
iii. Kitchen

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11. LADY WITH FRACTURED NECK OF FEMUR

A 70 Year old lady fell at home a few days back. She was brought to the A and E.
She was diagnosed with fractured neck of femur. The fracture has been treated.
Further decisions have to be made. She is vitally stable at the moment.

You are an FY 2 doctor in the medicine department.

Take a history to find the cause of the fall and discuss further management with
her.

Causes of loss of consciousness could be non-medical and medical causes

* If the patient regains consciousness immediately, you should consider postural

hypotension, syncope or arrhythmias.

* Ask her if she has lost consciousness/fallen before? When was the first time she fell?

* If she has fallen before, find out if she has seen a doctor before for the fall.

* In postural hypotension, the patient will either be getting up from a lying to standing
position OR would have been standing for a long time.

* Before you ask for symptoms, you should ask about the past medical history - DM,
heart disease, epilepsy

* One of the most important causes of postural hypotension is medications. Confirm if

she started falling before or after a change in her medication.

* Ask her what happened before, during and after the incidence

Dr: Hello Mrs Hilda, My name is Dr... I'm one of the junior doctors in the medical
department. How are you doing ? P: I am OK now.

Dr: I was told that you had a fall a few days ago and you had a broken hip bone, is that
right?

Pt: That is right.

Dr: I am really sorry to hear that. How are you feeling now? Are you comfortable talking
to me? Pt: Yes doctor, I am fine thank you.

Dr: What was done for the broken hip bone? Pt: They did an operation.

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Dr: I see, How is everything now? Pt : Everything is OK now.

Dr: That is good to know. Mrs Hilda, it’s a bit concerning to us that you fell down and it
led to such an unfortunate incident. I am here to see why you fell and if there are any
medical causes for your fall that we may need to treat that so that you don’t fall again. Is
that OK ? Pt: Ok doctor.

Dr; Can you please tell me the whole story about the day you fell down/the whole
incident?

P: Doctor, I was in the kitchen, just had my meal and was talking to my husband. Next
thing I know is that I was on the floor and had severe pain in my leg.

Dr: Oh I am really sorry about that. Were you standing when this happened? How long
were you standing for? Pt : Yes

Dr: Do you know anything about why you fell down?

Pt: No, doctor, to be honest I don’t know anything.

Dr: Ok..did you lose consciousness before you fell?

P: Yes, few seconds / Don’t know really but I don’t remember what happened. If it is
more than 2 minutes, then it cannot be due to vasovagal causes.

Dr: Was there any one with you when you fell down? Pt: Yes/No
Dr: Did anyone tell you that you had fits when this happened? Pt : No one was there at
that time.

Dr: Did you bite your tongue (epilepsy)? Pt : No

Dr: Was there any urine incontinence (epilepsy) ? Pt : No

Dr: Has it happened to you before?

Pt: Yes doctor, I have fallen four to five times in the past one year.

Dr: Did anything significant happen that led to subsequent falling?

Pt: Not that I can think of. Like what, doctor?

Pt: Any change in medication? Or any incident in family or friends? Pt: ….

Dr: Did you visit any doctor for the frequent falling? Were any investigations done? Any
possible cause identified?

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Dr: Did anyone tell you that you went pale before you fell previously also? Pt: No/Yes
my husband told me that. Going pale points to vasovagal syncope or arrhythmias.

Dr: Have you ever been diagnosed with any medical conditions in the past?

Pt: Yes I have high blood pressure .

Dr: Since when? Pt: For the last 10 years.

Dr: Are you taking any medications?

Pt: Yes I am taking medications for my blood pressure.

Dr: Since when have you been taking medications? Pt : Since the last 10 years.

Dr: Has the medications been changed recently? Pt: No doctor.

Dr: I see. Can you please tell what medication you are on right now? P: I can't
remember the name doctor

Dr: No problem Mrs... Do you have the medication with you? P: No

Dr: Are you carrying the prescription given by your GP? P: No

Dr: Ok that's fine Mrs...I will find that out from your notes.

Dr: Have you ever been diagnosed with any heart conditions ? Pt : No
Dr: Do you have diabetes? P: No

Dr: Have you had any heart related problems in the past? P: No

Dr: Have you ever had a stroke? P: No

Dr: Do you have any bone pain or other bone related problems any fractures before?

Pt: No (osteoporosis)

Dr: Have you been diagnosed with Osteoporosis ? Pt No

Dr: Do you have visual problems? P: No doctor I had my glasses checked recently?

Dr: Do you keep slipping or tripping and then fall? P: No

Dr: Did you feel like the room was spinning? P: No

Dr: Do you have a feeling of fullness in your ear? P: No

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Dr: Do you hear any high pitched noise in any ear? P: No

Dr: Do you have any balance problems while walking? P: No

Dr: Did you have palpitations (racing heart)? P: No

Dr: Did you feel that you may pass out before you fell down? Pt : No

Dr: Did you have any weakness of arms or legs when this happened (stroke)?

Dr: Did anyone tell you that you went pale before you fell down? Pt: Yes my husband
told me / No

[Pale /cyanosis – suggests epilepsy, very pale/ white – suggests syncope or

arrhythmia]

Dr: Did you notice that these falls happen after prolonged period of standing? Pt: No
(orthostatic)

Dr: Did these falls occur after any unpleasant incident, unexpected sight, sound or
smell? Pt: (Vasovagal syncope-emotional stress)

Dr: Did these incidents happen after meals usually? Pt: (Postprandial hypotension)
Dr: Did you notice that these falls happen usually when you turn your head? Pt: No

Dr: Was there any warning: light-headedness, nausea, sweating, weakness or visual
disturbance? Pt : ……

[Preceding nausea, sweating and blurred vision have been shown to be predictive
of non-cardiac syncope in the elderly]

Dr: Do you live alone or with someone? Pt: (assess for NAI)

Dr: Any of your family members have any medical conditions ? P: No

Dr: Any family history of osteoporosis? Pt: No

Dr: Do you consume alcohol? P: Yes/ No (Explore alcohol according to answer)

Examination and investigations:

Mrs. .. I need to examine you and do some tests to find out the reason you fell.

For that, we need to check your pulse and BP. I will have to check your BP while you
are lying down and while you are standing. [Examiner may not give you standing and
lying blood pressure].

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Check the change in blood pressure between lying and standing within 3 minutes of
each other. The drop in blood pressure should be 20 and 10 mmHg for systolic and
diastolic respectively.

I would also like to examine your chest to check your heart. [Start examining the
patient – stop examining if the examiner stops it] – check for irregular pulse,
examine chest – try to auscultate.)

We need to check your sugar, check whether you have anaemia and do a heart tracing.

We may also need to check your heart tracing for 24 hours to see if you have any
abnormal heart rhythms. [Examiner may not give any result]

Diagnosis:
I think you have a condition called Stokes-Adams syndrome. This is a condition in the
heart where the heart stops beating momentarily. This results in less blood flow to the
brain and this makes people lose consciousness.

We need to do some tests like continuous heart tracing to confirm the diagnosis.

If it is Stoke Adams syndrome, we can treat it with some medications called Isoprenaline
or Epinephrine. We can also treat with inserting a device called a Pacemaker into the
chest which controls the heart rate.

Any other questions ?

( case of STOKES-ADAMS SYNDROME)

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12. POSTURAL HYPOTENSION

Drugs causing Postural Hypotension

1. Hypertensive/Cardiac medications

- Methyldopa

- Clonidine

- Alpha blockers - Prazosin, Terazosin

- Beta-1 blockers (Atenolol)

- Nitrates

- Cardioselective CCBs (Verapamil, Diltiazem)

2. Genitourinary
- Alpha blockers - Prazosin

- Phosphodiesterase Inhibitors (Cialis, Viagra)

3. Anticholinergics (Oxybutynin)

4. Neuropsychiatric

- TCAs: Amitriptyline

- Antipsychotics: Clozapine

- Muscle relaxants: Baclofen

- Anti-Parkinson’s drugs: Levodopa/Carbidopa

Causes and risk factors of postural hypotension

Although the condition can occur in healthy older people, it is more common in those
who have additional risk factors. It particularly affects people on prolonged bed rest and
those aged over 74. However, it is not confined to the older population.

It can be caused by:

- Hypovolemia; - Diabetes; - Peripheral neuropathy;

- Parkinson’s disease; - Anaemia; - Adrenal insufficiency

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12.You are an FY2 in the medical department. A 64 year old lady presents with
complaints of few falls last week.
Take a history, do relevant examination and discuss management with the patient.
The question may say explore the various causes of her fall.

She has hypertension, osteoarthritis and has also had a hip and knee replacement.
- Was anyone with you? Where did this happen?

Dr: Hello Mrs.... My name is Dr... I'm one of the junior doctors in the GP clinic. What
brings you in today?

P: Hello doctor... I have been falling suddenly for a couple of weeks now...

Dr: I'm sorry to hear that Mrs. ... Could you please tell me more about it?

P: Doctor, in the last two weeks.. I have fallen suddenly a few times. Especially when I
have gone out with my friends. When I'm standing, suddenly I feel a little dizzy and then
I fall. Today, I was doing some window shopping in the town centre and I suddenly fell.
An ambulance brought me here. I like to go out with my friends. Now I am scared to go
out with my friends.

Dr: I am very sorry to hear that. We will sort out the problem very soon.

Dr: Ok.. Did you lose consciousness before or after the falls? P: No

Dr: Do you have visual disturbance? P: No

Dr: Do you keep slipping or tripping and then fall? P: No

Dr: You mentioned feeling a little dizzy prior to your fall. Did you feel like the room was
spinning? P: No

Dr: Do you have a feeling of fullness in your ear? P: No

Dr: Do you hear any high pitched noise in any ear? P: No

Dr: Do you have any balance problems while walking? P: No

Dr: Do you have palpitations? P: No

Dr: Have you been diagnosed with any medical conditions?

Pt: Yes, I have high blood pressure.

Dr: Do you have Diabetes or any other conditions like Parkinson’s? Pt : No

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Dr: Have you had any heart problems in the past? P: No

Dr: Have you ever had a stroke? P: No

Dr: Any of your family members have any medical conditions? P: No

Dr: Can you think of something that happened two weeks ago that might have triggered
this problem? P: No I can’t think of anything.

Dr: Are you taking any medications?

P: Yes I am taking medications for my blood pressure.

Dr: Can you please tell what medication you are on right now?
Pt: I can't remember the name, doctor

Dr: No problem Mrs... Do you have the medication with you? P: No

Dr: Are you carrying the prescription with you? P: No

Dr: Ok that's fine Mrs... We will get in touch with your GP to get the details. Can you please
tell me how many years you have had high BP? P: > 10 years

Dr: Has the medication been changed recently?

P: Yes, about 2 weeks ago, my GP changed my blood pressure medication.

Dr: Have you been falling like this before the GP changed the medications? P: No. It
started after that.

Dr: Do you smoke Mrs..? P: No

Dr: Do you consume alcohol? P: Yes, whenever I go out with my friends (Explore
alcohol according to answer)

Examination and investigations:

Dr: Ok, Mrs... I need to check your pulse and BP. I will have to check your BP while you
are lying down and while you are standing.

(Examiner findings: Lying - 150/90; Standing - 110/70) (postural hypotension if

standing blood pressure drop is more than 20/10 compared to lying down).

I would also like to examine your chest to check your heart.. (Examiner findings: normal)

I would like to get an ECG or heart tracing. (Examiner may hand over an ECG which
is usually normal)

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And check your blood for the sugar levels and check for anaemia. (Examiner says –
Normal).

Diagnosis:

Dr: Mrs... based on the information you have given me and the findings on examination, I
think you have a condition called postural hypotension. Do you know what that is? P: No
Dr: Postural hypotension is a condition where your BP tends to fall when you switch
from a lying down or sitting position to a standing posture. It is very common in people
after the age of 70 years. It can also be caused by other medical conditions like
Diabetes or Parkinson’s disease. However, in your case, it might be due to your new BP
medication. Certain blood pressure medications can lower your BP too much while
standing causing you to feel weak/dizzy and fall.

Are you following me Mrs...? Pt: But Doctor, I did not stand from a sitting position when
I fell down.

Dr: Sometimes, this can happen if you stand for a long time or even when you change
your posture like bending down. Pt: Ok
Treatment:

Dr: We will admit you to the hospital. We will get in touch with your GP to find out which
medication you are taking for your blood pressure. We will then have to stop it if it is the
cause and start you on some other medication for your BP. We will keep monitoring you
and when we think you are safe to go home we will discharge you.

Dr: Unfortunately, this condition can happen even after discharge, so you need to take
some precautions to reduce this problem happening again.

Take particular care in the morning because blood pressure tends to be lowest in the
morning and the symptoms are likely to be worse in the morning. Get out of bed in
stages. Cross and uncross legs firmly before you sit up and again before standing.

Avoid sudden changes in posture. Avoid sitting or standing for long periods.
Raise the head of your bed with blocks.
Wear support stockings or tights. This helps return blood to the heart. But do not wear them
when you go to bed.
Drink plenty of fluids. Drink strong tea or coffee. A morning dose of caffeine as coffee or in
tablet form can be effective. Avoid drinking excess alcohol.

Take small frequent meals because some people have large drops in blood pressure

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after meals.
If none of these measures help, then we can consider giving some medication (although
fludrocortisone is not licensed for the treatment of postural hypotension, it is usually the
drug of choice. Its actions include volume expansion and the promotion of arteriole vasoconstriction).
Dr: Are you following me? Pt : Yes. Dr: Any other questions? Pt : No Thank you

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CHEST PAIN - PERICARDITIS

Causes:

Infectious - viral, bacterial, or fungal infection.

In the developed world, viruses are believed to be the cause of about 85% of cases.

In the developing world, tuberculosis is a common cause but it is rare in the

developed world.

* Viral causes include coxsackie virus, herpes virus, mumps virus, and HIV among
others.

* Pneumococcus or tuberculous pericarditis are the most common bacterial forms.

* Anaerobic bacteria can also be a rare cause.

* Fungal pericarditis is usually due to histoplasmosis, or in immunocompromised hosts

due to Aspergillus, Candida, and Coccidioides.

* The most common cause of pericarditis worldwide is infectious pericarditis with

tuberculosis.

Other causes:

- Idiopathic: No identifiable cause found after routine testing.

- Autoimmune disease: systemic lupus erythematosus, rheumatic fever, IgG4-related

disease

- Myocardial infarction (Dressler's syndrome)

- Trauma to the heart

- Uraemia (uraemic pericarditis)

- Cancer

- Side effect of some medications, e.g. isoniazid, cyclosporine, hydralazine, warfarin,

and heparin

- Radiation induced

- Aortic dissection

- Post-pericardiotomy syndrome - such as after CABG surgery

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13A.
You are the FY 2 doctor in the medical department.

A 44 year old man, Mr … presented to the hospital with severe chest pain.

Take a history from him and discuss further management with him.

● Show sympathy/empathy
● Praise him
● Offer painkillers
● Praise him

Dr: Hello Mr …. I am Dr … one of the junior doctors in the medical department. Can
you please tell me what is happening to you ?

Pt: Doctor, I am having severe chest pain.

Dr: I am very sorry to hear that. How severe is your pain – on a scale of 1 to 10 one
being the mildest and 10 being the most severe pain?

Pt: Doctor it is 10 out of 10.

Dr: I see, don’t worry, we will give you some strong pain killer medication and you will
be better. Can I ask a few more questions to see which is the best painkiller for your
pain?

Pt : Yes

Dr: Can you please tell me more about your chest pain?

Pt: Doctor, I was just sitting on a sofa and watching television. Suddenly, the pain
started. It is almost 3 hours now. I took paracetamol, it didn’t help me at all doctor.

Dr: Anything more you can tell me ?

Pt: I don’t know what else to tell you.

Dr: Ok. Can you please tell me where exactly this pain is in your chest ?

Pt: It is here over the central part of my chest doctor.

Dr: Ok. What type of pain is that?

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Pt: I feel as if someone is crushing my chest.

Dr: Does the pain go anywhere else at all?

Pt: Yes doctor, I am having pain in my left jaw also.

Dr: Does it go to your left hand? Pt: No

Dr: Does it go to your back between your shoulder blades? Pt: No

Dr: Does the pain get relieved on leaning forward ? Pt: No

Dr: I will ask the nurses to get some good pain killer medicines for you.

Ask examiner – I want to give pain killer to my patient, what can I do ?

Examiner says – assume doctor. (If the examiner ask which pain killer – you can say

Morphine injection 5-10 mg IV)

Dr: Mr… We have given pain killer. Are you any better now?
Pt: I am slightly better.

Dr: Are you comfortable talking to me now?

Pt: Yes doctor, I can talk to you now.

Dr: Do you have any other symptoms other than pain? Pt: Like what ?

Dr: Fever? Pt: No

Dr: Cough? Pt: No

Dr: Pain in your calf (DVT – PE)? Pt: No

Dr: Do you feel short of breath at all (PE, Tension Pneumothorax, Heart failure)?

Pt: No

Dr: Did you have a long journey flight just recently (PE)? Pt: No

Dr: Do you get burning sensation (heartburn) feeling in the middle of your chest
(GORD)? Pt: No

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Dr: Did you have any injury on your chest? Pt: No

Dr: Have you had this type of problem before? Pt: No

Dr: Do you have any medical problems at all? Pt: No

Dr: Like high blood pressure? Pt: No

Dr: Diabetes? Pt: No

Dr: High cholesterol? Pt: I don’t know.

Dr: Any heart problem? Pt: No

Dr: Do you smoke? Pt: No

Dr: Do you drink Alcohol ? Pt: No

Dr: Do you use any recreational drugs (cocaine can cause chest pain)? Pt: No

Dr: Do you take any kind of medications at all? Pt: No

Dr: Are you allergic to any medications? Pt: No

Dr: Any of your family members have any medical conditions? Pt: No

Dr: Any heart problems in family members? Pt: No

Dr: Is there anything else you think that may be important that we need to know?

Pt: I don’t know, doctor.

Dr: Mr… I need to examine your chest and heart, and I also need to check your pulse
and blood pressure.

Examiner says – chest is clear. Pulse and BP stable.

Thank the examiner.

Dr: Mr… I think you have a serious condition in your heart. I am sorry to say that you
could be having a heart attack. Pause ……

However, I need to do your heart tracing (ECG) to confirm that.

ECG – examiner shows ECG. ECG – normal.

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Dr: Mr… Your heart tracing looks normal. However, it still looks like you have a minor
heart attack. Do you know what heart attack means?

Pt: I heard of it but I don’t know what exactly it means.

Dr: Let me explain. The heart needs its own blood supply for its muscles to survive.
This blood supply is provided by some blood vessels called coronary arteries. In a
heart attack, these blood vessels get blocked by a clot which stops the blood flow to a
part of your heart muscle. This causes serious damage to the heart muscles. This is a
heart attack. Sometimes, this condition is life threatening as you may know. However,
you don’t need to worry. You have come to the hospital in good time. You are in a safe
place now. We are going to look after you. You will be fine.

Pt: What are you going to do for me ?

Dr: We will admit you in the hospital and repeat the heart tracing and we will also do
some blood tests to check some heart attack markers. We will keep monitoring you.
For now, we will give you Oxygen (if saturation low) and Aspirin tablet to chew. To
relieve your pain, we will give some medication called GTN spray under your tongue
and a strong pain killer medication called Morphine as injection. Are you following
me?

Pt: Yes.

Dr: If your ECG changes in time, or blood tests come back positive for heart attack
markers, we will be able to say this is a major heart attack. If not, this is a minor heart
attack. Major heart attacks usually need urgent treatment to open the blockage in the
heart arteries to restore the blood supply to the heart muscles. For this, we do a
procedure called angioplasty.

Pt: What is angioplasty, doctor ?

Dr: This is a procedure where we pass a catheter (tube) with a balloon at its tip, from
the artery in your groin or arm to the heart into the blocked section of the coronary
artery. The balloon is blown up inside the blocked part of the artery to open it wide
again. A stent may be left in the widened section of the artery. A stent is like a wire
mesh tube which gives support to the artery and helps to keep the artery wide.
Are you following me?

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Pt: Yes

Dr: However, we may not need to do that procedure straight away because your ECG
is normal. But we may do it later after a few days. Are you following me? Is that ok?

Dr: There might be some complications of heart attack.

Do you want to know about them? Pt: Yes

Dr: It can cause abnormal heart rhythms or it can cause heart failure, or a further heart
attack may occur sometime in the future. However, we will try to prevent them and
manage them if any of these problems do happen.

We will inform the specialists to see you as soon as possible

Dr: Do you have any other questions? Pt: No, doctor. Thank you very much.

Dr: Thank you very much. I hope you recover very soon without any problem. If you
need any help please let me know.

If you have time, then mention the following:

If this is a heart attack, we will give you some blood thinner medications called
clopidogrel 600 mg and some injections called enoxaparin. These will help prevent the
formation of new clots. We will also give you medication called metoprolol which is a
beta blocker, cholesterol medicine called atorvastatin (high dose), and an ACE
inhibitor called ramipril which also protects your heart.

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6)

(Case: 13 A. ACS – ECG normal)

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13 B.
30 year man with chest pain, History and management

- Had chest pain for 3 days. Spontaneous onset.

- Sharp, retrosternal area, No radiation, on and off, relieved on leaning forward.

No – fever, cough, SOB, palpitation,

No – trauma, smoking HTN, DM, Cholesterol, Cocaine, calf pain, travel, recent surgery,
No previous blood clots.

No – family history.

No history of any viral illness, recently, TB, HIV

No medications or allergies

Examination

Vitals (for fever, hypotension in cardiac tamponade) – examiner may say normal

Neck (for engorged veins – for cardiac tamponade), Chest – for pericardial rub,
murmur and heart sounds (muffled in cardiac tamponade)

Examiner may say – all normal

Investigations

Blood – FBC, U&Es (uraemia – uraemic pericarditis), Cardiac enzymes, chest x-ray
(for pericardial effusion)

Examiner may say all normal

ECG – May show global saddle-shaped ST elevation or electrical alternans with sinus
tachycardia

ST elevation

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Electrical alternans

Diagnosis:

I think you have a condition we call Pericarditis – it is an infection of the lining covering
the heart. Sometimes, it is a serious condition.

There are several causes – for example viral or bacterial type of bugs can cause this.
Sometimes, it can be due to injury or medications. However, in your case it could be
most probably due to viral kind of bugs.

We need to do some other tests like scanning of the heart (echocardiography) to

check for any complications as sometimes, there could also be fluid surrounding the
heart (pericardial effusion), and this may cause heart failure.

Treatment

Depends on what is causing this condition.

We will admit you. I will inform my seniors.

We will give medicines like Aspirin or NSAIDS like Colchicine if it is a viral kind of bug

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causing this.

If there is fluid filled around the heart, then we may need to drain it.

This condition usually resolves on its own but it may take weeks or months.

(13 B. CHEST PAIN IN A 30 YEAR OLD MAN)

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14. CHEST PAIN - HERPES ZOSTER

Shingles: Summary

Shingles (herpes zoster) is a viral infection of nerve cells that occurs when a latent
infection with varicella-zoster virus reactivates.

Complications include post-herpetic neuralgia, secondary infection, scarring, and ocular

complications.

Diagnosis is usually made on clinical grounds:

Prodrome (several days before the rash) — including abnormal sensation in the
affected skin and sometimes headache, malaise, and fever.

Rash — usually unilateral. Macules and papules develop into vesicular lesions in a
dermatomal distribution which burst and form ulcers and crusts. Note that the rash may
be atypical in certain groups of people, for example older or immunocompromised
people.

Pain — intense neuralgic pain over the affected area, especially in people with
trigeminal nerve involvement.

Healing (2–4 weeks) — the lesions usually crust over within 7–10 days.

A person with shingles should be offered self-care advice.

To manage associated pain in adults, paracetamol alone or in combination with codeine

or ibuprofen should be offered. In severe pain, amitriptyline (off-label use), duloxetine
(off-label use), gabapentin, or pregabalin should be considered. Specialist advice
should be sought if pain is inadequately controlled by oral analgesia, or a strong opioid
(such as morphine) is being considered.

To manage severe pain, oral corticosteroids may be considered in the first 2 weeks
following rash onset in immunocompetent adults with localised shingles, but only in
combination with antiviral medication, and based on clinical judgement, taking into
account the risks and benefits of corticosteroid therapy for each person.

To manage associated pain in children, paracetamol or ibuprofen should be offered. If

these are not effective, specialist advice should be sought.

Immediate specialist advice should be sought regarding antiviral treatment for people

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with ophthalmic involvement; severely immunocompromised people;

immunocompromised people who are systemically unwell, or have a severe or
widespread rash or multiple dermatomal involvement; immunocompromised children; or
pregnant or breastfeeding women.

An oral antiviral drug (such as acyclovir) should be started within 72 hours of rash onset
for certain groups of people, such as people aged 50 years or older, people with non-
truncal involvement, and people with moderate or severe pain or rash.

If it is not possible to initiate treatment within 72 hours, antiviral treatment can be

considered up to 1 week after rash onset, especially if the person is at higher risk of
severe shingles or complications.

For immunocompetent children with shingles, antiviral treatment is not recommended.

In all people with shingles, clinical judgment should be used to decide who to refer, who
to refer to, and the urgency of the referral. For example:

Urgent admission or specialist advice may be necessary if the person has a

complication, is severely immunocompromised, or is pregnant or breastfeeding.

Less urgent referral may be necessary if new vesicles are forming after 7 days of
antiviral treatment, healing is delayed, or if shingles is recurrent.

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You are the FY2 doctor. A man has presented with chest pain. Talk to him, assess him,
form a management plan with him and address his concerns.

Dr: Hello, I am …Pt: Doctor, I am having chest pain.

Dr: That’s really unfortunate. Are you comfortable enough to talk to me? Pt: Yes

Dr: It's fine.

Dr: Thank you. Can you tell me since when have you been experiencing this pain?

Pt: Dr It’s been going on for the last one day.

Dr: And where exactly is the pain?

Pt: Doctor it’s on the right side of my chest (points to the right side beneath his
chest)

Dr: I see. And how did it start? Was it all of a sudden or it came gradually?

Pt: It started gradually, Dr.

Dr: How would you describe the pain? Pt: I feel like its burning.

Dr: Does it go anywhere else? Pt: Yes it goes to my back.

Dr: Have you noticed anything particular which makes it worse or better? Pt: It does get
worse when I walk.

Dr: On a scale of 1 to 10, how would you rate the pain? Pt: I would say 5.

Dr: Have you experienced this kind of problem before? Pt: No, Dr.

Dr: Do you have any fever? Pt: No.

Dr : Cough? No

Dr: Any difficulty in breathing? Pt: No.

Dr: Any pain or swelling in the calf? No

Dr: Did you have any injury to the chest? No

Dr: Do you have any skin lesions over chest ? Yes

Dr: Where exactly in the chest? Right side

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Dr: Since when did you notice it? ....

Dr: Does it itch? Yes /No

Dr: Is it painful? Yes

Dr: Is it spreading? Yes

Dr: Any headache? No

Dr: Any stiffness in the neck? No

Dr: Did you come into contact with anyone who had any type of skin lesions? No

Dr: Do you have a skin lesion anywhere else? No

Dr: Any skin lesions on the face near the eyes (ophthalmic shingles) or ears
(Ramsay-hunt syndrome)? No

Dr: Have you ever had any chickenpox before? Yes / No

Dr: Any allergies? No

Dr: Did you use anything new? Like new type of soap/dress/any new medicine? (r/o
allergy)

Dr: Is there anything else you think might be important for us to know? Pt: No

Dr: Do you have any medical conditions? Pt: Yes I have HTN.

Dr: Are you taking any medication for it? Pt: Yes I take amlodipine.
Rest of MAFTOSA is negative

Need to ask about risk factors for shingles/immunosuppression: Asthma, Chronic

Kidney Disease, Diabetes.

Also need to ask about a history of immunisation.

Dr: Thank you for all the information. I now need to examine you. I would be having a
look at your vitals and performing a general physical examination and I need to check
your skin lesions.

Examiner gives two cards. One has a NEWS chart which is normal.

The second card shows picture of the back which reveals lesions consistent with
HZV.

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Dr: Thank you for your cooperation, Mr From what you have told me and after my
examination, I think you might be having a condition called shingles. Do you know anything
about it? Pt: No, Dr.

Dr: Shingles (herpes zoster) is a viral infection of nerve cells that occurs when a latent
infection with varicella-zoster virus reactivates because of a decrease in immunity. This
can be many years after the primary infection. It is characterised by pain in a specific
pattern which we call as a dermatomal distribution and a localised rash as seen on your
back.

Shingles is an infection of a nerve and the skin around it caused by the varicella-zoster
virus, which is the same virus that causes chickenpox. Even after the chickenpox
infection is over, the virus may live in your nervous system for years before reactivating
as shingles. Shingles may also be referred to as herpes zoster. This type of viral
infection is characterised by a red skin rash that can cause pain and burning. Shingles
usually appear as a stripe of blisters on one side of the body, typically on the trunk,
neck, or face. Most cases of shingles clear up within two to three weeks. Shingles
rarely occur more than once in the same person.

Pt: So what is going to happen now, doctor?

Dr: After consulting with my seniors, we might start you on an antiviral medication for
about a week. This will help in healing the infection. Also, as you are having pain, we
will start you on some painkillers as well.

Pt: Doctor, my son is going to visit my place along with his grandson (who is 1 year old)
next week. Is this condition contagious ?

Dr: It’s a good thing you mentioned this because unfortunately, yes, this is a contagious
illness. It's not possible for someone to catch shingles from someone with the
condition or from someone with chickenpox. However, in people who have never
had chickenpox, it can be caught from someone with shingles.

However, there are a number of things we can advise you about so that this does not
spread. Some of them are:

o Avoid contact with people who have not had chickenpox, particularly pregnant women,
immunocompromised people, and babies younger than 1 month of age.

o Avoid sharing clothes and towels.

o Wear loose-fitting clothes to reduce irritation.

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o Cover lesions that are not under clothes while the rash is still weeping.

o Avoid use of topical creams and adhesive dressings, as they can cause irritation and
delay rash healing.

o Keep the rash clean and dry to reduce the risk of bacterial superinfection. Seek
medical advice if there is an increase in temperature, as this may indicate bacterial
infection.

o Avoid work, school, or day care if the rash is weeping and cannot be covered. If you
have shingles, you're contagious until the last blister has dried and scabbed
over. If the lesions have dried or the rash is covered, avoidance of these activities is
not necessary.

Pt: Thank you, Dr. You have been really helpful.

Dr: We will see you again after one week. If the skin lesion is spreading or if you
develop any skin lesions over face, please come back.

14. CHEST PAIN - HERPES ZOSTER

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DIFFERENTIALS
15. You are an FY2 doctor in the GP clinic
1. MI
2. Pulmonary embolism
A 75 year old male presented with chest pain for the past 3. Angina
4. Pneumonia
5. Pericarditis
two weeks. Talk to the patient and discuss further 6. Trauma and musculoskeletal
chestpain

Discuss management plan with the patient.

Dr: Hello I'm doctor ....... one of the junior doctors in the GP clinic. How can I help you
today?

Pt: doctor, I'm having this chest pain for the past two weeks and I am really worried
about it.

Dr: I'm sorry to hear that. Do you have pain right now? This might suggest an MI and is
the most important question to ask the patient so you can determine if you need to call
an ambulance immediately.

Pt: No doctor.

Dr: Good to hear that. Could you please tell me a little bit about the pain ?

Pt: It started like 2 weeks back. For exercise, I usually walk up the hill near my home. In
the past 2 weeks when I climb up the hill, I feel pain in my chest and it gets relieved
when I take a rest for some time.

Dr: Can you please tell me where exactly the pain is?

Pt: [shows the central chest part]

Dr: Is it going anywhere else? To your jaw? To your arms? Pt: No doctor [MI]

Dr: when you are having this pain, does it get better when you lean forward?
[PERICARDITIS] – No.

Dr: Any recent flu or any other illness? [PERICARDITIS]

Dr: Do you have any fever/cough/SOB ? Pt: No, doctor [PNEUMONIA & PE]

SOB might also suggest an associated heart failure

Ask of racing of heart

Find out if the patient has the symptoms when he exerts himself

Dr: Do you have any pain in your calf muscle? Pt: No [PE]

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Dr: Any recent flight travel? Pt: No [PE]

Dr: Did you have a fall or any injury to your chest? Pt: No [MUSCULOSKELETAL PAIN]

PAST HISTORY

Dr: Is this the first time you are experiencing this or has it happened before also?

Pt: This is the first time, doctor

Dr: Any medical conditions? Heart disease/High Blood pressure/Diabetes/High

cholesterol

Pt: Nothing that I am aware of, doctor

ASK MAFTOSA

[patient mentions he is completely healthy and hasn’t see any doctors in many
years]

Dr: Family h/o any medical conditions? Pt: No

Social History: Patient smokes 1 pack of cigarettes per day for the past 35 years and
drinks 2 glasses of alcohol everyday for 30 - 35 years

Pt: How's your diet? Pt: My diet is fine. I follow a mixed diet. I eat both red meat, white
meat, fruits and vegetables.

Dr: Good to hear that you are following a good diet. Pt: Thanks, doctor

Dr: Do you know your BMI? Pt: No, doctor

Dr: Is there anything else you want to tell me? Pt: No, doctor

Examination:
Dr: Mr ....... I would like to examine you. Is it okay if I examine your chest, your neck and
I would also like to measure your heart rate, your blood pressure and oxygen levels in
the blood? Pt: Ok, doctor

[examiner gives findings: PR - 80, BP - 120/80, SPO2 - 98%]

Dr: Do you know what is happening to you? Pt: No

Dr: Do you have any specific concerns in your mind?

Pt: Is it a heart attack, doctor?

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Dr: Mr ....... from what you have told me and after the examination, you do not have a
heart attack. But I suspect that you have a condition in the heart called STABLE
ANGINA. Do you know anything about it? Pt: No

Dr: I will explain it. Our heart has its own blood supply for the adequate functioning of
the heart muscles. Sometimes, the blood vessels called coronary arteries supplying
blood to the heart get narrowed, and the blood flow to the heart muscles gets reduced
which means your heart muscles will not get enough oxygen to work properly. That is
the reason why you are experiencing pain in your chest.

Smoking, having high cholesterol or high BP are some factors contributing to this
narrowing of the blood vessels. Also, this condition is often triggered by physical activity
or emotional stress. Are you following me? Pt: Yes, doctor

Dr: Don't worry, I will talk to my seniors about you. We will refer you to a Cardiologist
(heart specialist) and they will tell you how it will be managed. Is that okay with you ?

There are some blood tests and investigations that may be required. Would you like to
know about that? Dr: Yes, doctor

Dr: We will do some tests to check your blood sugar and cholesterol levels. We will
check your BMI (Body weight in relation to your height).

The specialist doctor will do some other tests like an x-ray of your chest, an ECG (heart
tracing).

They may also do other tests like coronary angiography (a scan taken after having an
injection of a dye to help highlight your heart and blood vessels),

An exercise ECG – an ECG is carried out while you are walking on a treadmill or using
an exercise bike.

A scan of the heart called Echocardiography may be needed. Are you with me? Pt: Yes

Treatment:

Do you want to know about the treatment options? Yes

We have a few options

MEDICAL: there are medications to relieve the pain such as GTN spray. I will advise you
later how to take it. If you are found to have high cholesterol then - medications such as
STATIN may be given. We may also give other medications called Beta blockers to make
slow down heart rate, or Calcium channel blockers to increase blood supply to the heart
muscles. Also, we may give medications like Aspirin to prevent blood clots.

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SURGICAL: If any narrowing of the coronary artery is detected in the tests, then the
specialist may do a procedure called Angioplasty (widening of the narrowed section of
the coronary artery) or an operation called Coronary artery bypass graft (a section of a
blood vessel is taken from another part of the body and used to reroute around
blocked or narrowed section of the artery). Are you following me? Pt: Yes doctor

Dr: Okay Mr ...... I will get in touch with my seniors right away and will do the necessary
arrangements for the referral. Is that okay?

Pt: Okay, doc!

LIFESTYLE: I sincerely advise you to stop smoking and cut down alcohol, because
they increase the risk of having a heart attack or stroke. We have a lot of options
available to help you to stop this habit if you wish. What do you think ?

Pt: I'll consider that doctor

Also if your BMI is above the normal limit, modifications in the diet should also be done
to reduce your weight because being overweight is also a risk factor.

Exercise: It is good to continue doing the exercise – but do not do heavy exercise for
now until you see the cardiologist, build up the activity gradually and take breaks. Keep
the GTN spray with you. If the chest pain lasts more than 5 min, you need to call the
ambulance.

Work – you can continue but avoid lifting heavy weights.

Sex – can continue having sex but keep GTN spray with you. You can consider using
GTN spray before the sex.

Driving – You can continue driving if you are driving light motor vehicles - Car or van. No
need to tell DVLA. [Must tell DVLA if heavy motor driving – Lorry or Bus].

Dr: Any other concerns?

Pt: No doctor. You were so kind. Thanks!

(case: STABLE ANGINA)

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16.CHEST DISCOMFORT - ARRHYTHMIAS

Causes of palpitations

I. Cardiac arrhythmias
 Supraventricular/ventricular extrasystoles, Supraventricular/ventricular tachycardias
 Bradyarrhythmias: severe sinus bradycardia, sinus pauses, second and third-degree
 atrioventricular block

 Anomalies in the functioning and/or programming of pacemakers and ICDs

II. Structural heart diseases

 Mitral valve prolapse, Severe mitral regurgitation, Severe aortic regurgitation

 Congenital heart diseases with significant shunt

 Cardiomegaly and/or heart failure of various aetiologies: Hypertrophic cardiomyopathy,

Mechanical prosthetic valves
III. Psychosomatic disorders

Anxiety, panic attacks, Depression, somatization disorders

IV. Systemic causes

Hyperthyroidism, hypoglycaemia, postmenopausal syndrome, fever, anaemia, pregnancy,

hypovolaemia, orthostatic hypotension, postural orthostatic tachycardia syndrome,
pheochromocytoma, arteriovenous fistula

V. Effects of medical and recreational drugs

 Sympathicomimetic agents in pump inhalers, vasodilators, anticholinergics,

hydralazine, Recent withdrawal of b-blockers

 Alcohol, cocaine, heroin, amphetamines, caffeine, nicotine, cannabis, synthetic drugs

Weight reductions drugs
 Other causes – Drinking excessive coffee, tea, cola

 Pheochromocytoma is a possibility in anyone with the classic triad of symptoms-

headache, sweating, and heart palpitations -- especially when there is high blood
pressure (though high blood pressure is not always present)

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16. You are an FY2 doctor in medical department.

Mr. X, 55 year old man has presented with the complaint of chest discomfort.
Patient has been having this problem for last few months.

Talk to the patient and take a history from him. Reassure and discuss with him
further management.

Dr: Hello, I am Dr…. I am one of the junior doctors in the medical department. Are you
Mr.?Patient: Yes, doctor.

Dr: How are you doing Mr…?

Patient: I am not doing very well doctor. I am having some chest discomfort. I am scared
that I might get a heart attack like my father and brother. Both of them died because of
the heart attack.

Dr: I am really sorry to hear about your father and brother but please do not be worried Mr.
X, we are here to help you. I can assure you that not everybody with a chest discomfort
gets a heart attack. Besides that there are many other factors which lead to heart attack.

Let me talk to you in detail so that we can address this problem better. Is that alright?
Patient: Ok.

Dr: Mr. X, could you please tell me what exactly the nature of this discomfort is?

Patient: I feel like my heart is fluttering.

Dr: Can you please show me where exactly you are feeling this sensation

Pt: Here doctor – patient may show chest or epigastric region.

Dr: It must be distressing. Could you please tell me for how long have you been having
this problem? Patient: For the last six months doctor.

Dr: And how many times have you felt your heart racing like this?

Patient: Five to six times in this time.

Dr: Mr… Do you have any idea how this started – like anything triggered these
symptoms? Pt: I do not know doctor.

D: Did you have any sad or shocking news before these symptoms started (post traumatic
stress syndrome)? Pt : No

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Dr: Does anything makes better or worse? Pt: No/When I sit I feel better.

Dr: I see. Could you please tell me if it happens after doing exercises or does it happen
even when you are resting? Patient: It can happen even when I am resting.

Dr: Do you get chest pain also when you have this fluttering sensation? Patient: No.

Dr: Any shortness of breath? Patient: No doctor.

Dr: Any headache (pheochromocytoma)? Pt: No

Dr: Do you get sweating when you have these symptoms (pheochromocytoma)? Pt:
No

Dr: Any dizziness? Patient: Yes, doctor.

Dr: Did you faint or felt like fainting? Patient: No.

Dr: Can you remember if what you felt as a fluttering of heart was regular or not? Can
you please tap it and show? Patient: ….

Dr: And how long does an episode last? Patient: …..

Dr: Have you noticed any recent changes in your weight (Hyperthyroidism)? Patient: No.

Dr: Any tremors in your hands? Patient: No.

Dr: Do you have preference to any particular weather like cold or hot? No

Dr: Have you ever had this problem before? Patient: No.

Dr: Have you been diagnosed with any medical conditions in the past? No

Dr: Have you ever been told that you had heart problems now or when you were a
child? (Structural/Congenital heart diseases) Patient: No.

Dr: High blood pressure? (Hypertrophic Cardiomyopathy, pheochromocytoma)

Patient: No.

Dr: Do you have diabetes? (Hypoglycaemia) Patient: No.

Dr: Can I ask how is your mood lately? (Psychosomatic disorders: Anxiety/Panic
attacks Depression) Patient: My mood is fine.
Dr: Do you drink coffee? How much do you drink (Caffeine can cause palpitation)? Pt:
- Yes, 5 cups every day (sometimes not drinking too much coffee)
Dr: Do you smoke? Patient: Yes/no.

Dr: Do you take Alcohol? Patient: Yes/no

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Dr: Do you take any other recreational drugs Mr. X? (Drug Abuse: Alcohol, cocaine,
heroin, amphetamines, caffeine, nicotine, cannabis) Patient: No.

Dr: Do you do regular exercise? Patient: No/yes

Dr: Are you taking any medications now or were you on any medications at the time you
felt your heart fluttering? Patient: No

Dr: You told me about your father and brother had heart problem. Any one in your family
has any other medical conditions like Thyroid problems ? Pt: No

Dr: Is there anything else you think is important that we may need to know? No

Examination:

I need to examine your pulse and blood pressure and your chest and heart, neck and
eyes.

(Examiner did not give findings)

Dr: From the information you have given me, it seems likely that you have what we call
Palpitations. Do you know anything about it? Patient: No.

Dr: It’s alright. Palpitations are the sensation of your heart beating. As you know, normally
we are not aware of our heart beating. Palpitations can be caused by an unusually rapid
heart rate or abnormal rhythm of heart beat. Are you following me? Patient: Yes. But is that
serious?

Dr: Please do not worry Mr. X. I must tell you that this is very common. Most cases are
actually harmless. Sometimes it can be due to some medical conditions.You did the
right thing to come to us. We will investigate further to see what might be causing this.

Patient: But why is it happening to me?

Dr: There are many reasons why the heart rate can be faster than normal. Most of them
are the normal reaction of the heart to certain things like for example it can happen
when we exercise, or during fever or if someone is worried or panics too much or
drinking excessive coffee.

Sometimes, a gland in the neck called Thyroid gland can become overactive and lead to
development of faster irregular heart rate.

In addition, smoking is another factor. The nicotine in cigarettes can cause a faster heart
rate. Are you following me ?

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Sometimes it can be due to a condition called anaemia where the red cells are low in
the blood or it could be due to problems in the heart.

Patient: Yes doctor. But why do you think I may be having this?

Dr: [Since you are drinking too much coffee – this can be one of the reasons – if
he is drinking too much coffee].

Also Mr X since your father and brother had heart problems, there could be a chance
that you too may be having heart condition causing this symptoms. We need to do
some tests to find out whether you have any heart conditions.

We would like to perform an electrocardiogram (ECG)heart tracing.

If it comes out to be normal, other tests may be used. For example, you may have an
ECG which monitors your heart over 24 or 48 hours. This is called an ambulatory ECG
or Holter Monitoring.

In some cases, you may need a scan of the heart, called an Echocardiogram. We may
also need to do a chest x-ray for you.

We will also do other investigations like some Blood Tests to check for anaemia or any
overactive thyroid.

Patient: What will be the treatment, doctor?

Dr: At the moment, we do not need to admit you to the hospital.

[Please do not drink too much coffee as I said this could be one of the reason – if
he is drinking excessive coffee].

Also, if there are any other causes found, we may need to treat that. No specific
treatment is needed unless an underlying problem gets detected.

We might also need to refer you to Cardiologist i.e. a heart specialist. If there are heart
conditions they may treat you with medications or sometimes may be with pace maker -
a devise which controls heart beat.

Also, I would like to advice you about certain things. Please avoid excessive worry and try
to stay relaxed. Drinking too much coffee, tea, cola may cause your heart to beat faster.
So, please try to cut down on such drinks. In addition, smoking is another factor. That is
good that you do not smoke, I would appreciate if you would continue this habit.

Also exercising regularly reduces heart problems.

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Dr : We will check your blood pressure and cholesterol level in your blood. We need to
make sure that the blood pressure is under control and cholesterol should not be high.
These can worsen heart problem.

Patient: What should I do if I have palpitations again ?

Dr: Occasionally, palpitations can be serious. In such situations, you should call an
ambulance immediately. For example, if you have palpitations that do not go away
quickly (within a few minutes), If you have any chest pain or severe shortness of breath
with palpitations, If you pass out, or feel as if you are going to pass out, or feel dizzy.

But at this moment, I would advise you to please not worry. We will investigate further in
order to determine the exact reason.

Patient: Okay.

Dr: Is there anything else that you need help with?

Patient: No doctor, you have been very kind. Thank you.

Dr: Thank you.

(case: PALPITATIONS)

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TIREDNESS
Causes of tiredness

F3A2M2IL2Y

Fatigue syndrome

Failures

Fibromyalgia

Anemia, Apnea (OSA)

Myasthenia Gravis, Medication e.g SSRIs

Inflammatory conditions

Low mood

Leukaemia/cancers

Y - HYpothyroidism

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17. 50 years old female complaining of tiredness you are the FY2 in a G.P Clinic.
Take a history & management.

- GRIPS

P -Doctor I am feeling tired all the time.

D - I am sorry to hear that. Can you please tell me more about it?

ODIPARA

P - I have been experiencing tiredness for the past 3 months Doctor. My friend died 3
months back and after that, I was depressed and so the psychiatrist prescribed me this
medication - Citalopram.

D - Ok I am very sorry to hear about your friend. Please accept my condolences.

D - Were you alright before these symptoms started? ........Yes, doctor

D/Ds

D - Do you have any preference for weather ? …. No

D - Any swelling in your neck? ….. No

D - Any change in your weight recently? …..No

D - Is it there all day or at any specific time of the day like morning or evening ?... All day.

D - Do you have any pain anywhere in the body ? .... No

D - Any pain in your bones? …. No

D - Bleeding from anywhere in your body like from back passage? … No

D - Weight loss or lumps or bumps anywhere in the body? … No

D - Any problem with the sleep? …. No

D - How is your mood these days? If you have to rate it on a scale of 1 – 10, 1 being low
and 10 being normal how would you rate it ?

P - Its 5 or 6 out of 10 Doctor.

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D - Any medical conditions like diabetes, Hypertension, Heart problems, kidney problems.

D - Do you smoke, take alcohol, use recreational drugs? ...... No

MAFTOSA: Ask about work and family history of similar complaints and medications.

Anything else?

“Thank you for giving me all the vital information.”

Examination: Now I would like to examine you. I would like to check your vitals, do a
general physical examination to check if there is any bleeding from anywhere in the
body and to see if there are any lumps or bumps anywhere.

Management:
I would like to do some investigations to know exactly what may be causing this
condition in you.

Blood: FBC, FBS, LFT, Urea & Electrolytes, Infection markers, thyroid profile.

(no normal values were given and examiner gave a paper with all the findings)

Na+: 129

K+: 4.8

U&E: ……

Check BNF for Citalopram

Treatment:

Well, from the history and examination we were not able to elicit any specific cause for your
tiredness. However, the medication citalopram can cause hyponatremia and this might have
to led to tiredness.

We will refer you to a Psychiatrist for further evaluation as your mood is still low and also to
change the medication. Recheck Na level after 2 weeks of changing the citalopram.

Do you have any concerns? No, doctor. Thank you.

(This was a case of TIREDNESS – CITALOPRAM)

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Information on Citalopram from NHS website:

Citalopram is a type of antidepressant known as an SSRI (selective serotonin reuptake inhibitor).

It's often used to treat depression and also sometimes for panic attacks.

It usually takes 4 to 6 weeks for citalopram to work.

Side effects such as tiredness, dry mouth and sweating are common. They are usually
mild and go away after a couple of weeks.

Citalopram-induced syndrome of inappropriate antidiuretic hormone secretion (SIADH)

causing hyponatremia is well documented; however, severe hyponatremia with small
doses has not been previously reported.

Citalopram can affect an unborn baby. Tell your doctor straight away if you’re trying to
get pregnant or become pregnant while taking it.

Like all medicines, citalopram can cause side effects in some people, but many people
have no side effects or only minor ones. Some of the common side effects of citalopram
will gradually improve as your body gets used to it. Some people who take citalopram
for panic attacks find their anxiety gets worse during the first few weeks of treatment.
This usually wears off after a few weeks but speak to your doctor if it bothers you - a
lower dose may help reduce your symptoms.

Citalopram

Is generally not recommended in pregnancy or while breastfeeding.

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18. You are an FY2 in GP Clinic. Mr. Smith, 45 years old male, has come to the
clinic today with a sleeping problem for the past 2 months. Talk to him, take
a history and discuss appropriate management with him.

Hello, Mr. Smith, My name is Dr ----------------- I am one of the junior doctors in the clinic
today. How can I help you today?

Pt: Dr. I feel tired all the time.

Dr: Mr. Smith can you please elaborate, what do you mean by tiredness?

Pt: Doctor, I feel as if I don’t have any energy to do any work during the day.

Dr: Since when have you been feeling like this?

Pt: It’s been there for about 6 weeks now.

Dr: Do you feel any pain in your body as well? Pt: No (Fibromyalgia)

Dr: How did it start? Pt: I don’t know, doctor.

Dr: Do you think something happened 2 months back which may have started this?

Pt: I can’t think of anything, doctor.

Dr: Have you tried anything which has helped you with tiredness? Pt: No, I haven’t tried
anything.

Dr: Is there anything which makes it worse? Pt: No, doctor, I haven’t noticed anything. It
is the same since it started.

Dr: Mr. Smith, you seem to be very worried about this, We will do everything we can to
help you come out of this.

Dr: Mr. Smith have you noticed any change in your weight? Pt: No. (Hypothyroidism)

Dr: ave you developed preference for any particular weather? Pt: No.
(Hypothyroidism)

Dr: Any changes in your bowel habits? Pt: No. (Hypothyroidism)

Dr: Do you feel short of breath while doing any work? (Anaemia)

Pt: No doctor, I just feel very tired.

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Dr: Is there any specific time when you are more tired? (Myasthenia)

Pt: No it stays same, doesn’t change much.

Dr: Do you feel better when you wake up? Pt: No, I am still very tired when I wake up?

Dr: Do you think you get ample sleep? Pt: Yes.

Dr: What about your sleeping environment? Pt: Doctor, it is very comfortable.

Dr: Do you think you have any trouble sleeping? Pt: No, I don’t think so but my wife is
always complaining that I snore during sleep and my breathing is very loud and noisy.
(Patients don’t know if they snore in OSA)

Dr: Do you regularly fall asleep during the day against your will? Pt: Yes, sometimes I
doze off during the day as well.

Dr: Do you take any sleeping pills? Pt:…….? (Risk factor for OSA)
Dr: Do you feel difficulty in breathing from your nose? Pt......... ? (Risk factor for OSA)

Dr: Do you have any medical conditions? Pt: No

Dr: Diabetes? No.

Dr: High blood pressure? No.

Dr: Do you smoke? Pt: Yes/No.

Dr: Do you drink alcohol? Pt: Yes only occasionally/No. (drinking alcohol, particularly
before going to sleep, can make snoring and sleep apnea worse).

Dr: May I know what do you do for a living? Pt: I am a taxi driver.

Dr: Mr. Smith, is this condition affecting your work in any way?

Pt: Yes Doctor, Sometimes I start dozing off during the day as well and so I am not able
to drive for whole day.

Dr: Mr. Smith, Is there anything else that you would like to tell us? Pt: No, doctor.

Mr. Smith, from our discussion it seems that you are feeling tired all the time because of
a condition we call as Obstructive sleep apnea. This (OSA) is a relatively common
condition where the walls of the throat relax and narrow during sleep, interrupting
normal breathing and it leads to regularly interrupted sleep. These repeated sleep
interruptions can make you feel very tired during the day.

Pt: But doctor, I don’t remember any interruptions.

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Dr: Yes Mr. Smith, people with this condition usually have no memory of their
interrupted breathing and they are unaware of having a problem.

But we would like to confirm it before proceeding further and for that purpose we can
refer you to a specialist sleep clinic where they will measure your height and weight to
calculate your BMI and they will arrange for your sleep to be assessed over night with
help of special instruments (Polysomnography). We would also like to run some blood
tests to exclude other conditions like hypothyroidism, anaemia and vitamin D deficiency.
What do you think of this?

Pt: I think I shall visit this clinic.

Dr: Okay I will arrange an appointment as soon as possible.

If it turns out to be obstructive sleep apnea, then you can do a few things which will be
of great benefit. Would you like to know those?

Pt: Yes, What are those?

Dr: These include lifestyle changes like sleeping on your side, losing weight (if over-
weight),reducing the amount of alcohol you drink and avoiding sedatives at night.
These have all been shown to help improve the symptoms of OSA.

Dr: How does all this sound to you? Pt: I think I must try these.

I really hope that these strategies will help you. Otherwise, I can arrange an
appointment with my consultant and he may guide you regarding further treatment
options like CPAP and mandibular advancement device. In severe cases we have to
resort to surgical options.

Mr. Smith I do understand OSA can have a significant impact on the quality of your life
and it has a significant emotional effect as well. If you would like I can refer you to
supports groups like British Lung Foundation and Sleep Apnea Trust. They will help
you with strategies on how to cope with this condition.

Mr. Smith, do you have any concerns? Pt: No, doctor.

Dr: Well there is one important thing, I think you must inform DVLA regarding your
condition.

As you told me earlier that this condition is also affecting your driving. They may be able to
provide you with specialist guidance regarding your driving. Pt: --. Thank you.

(case: TIREDNESS - OBSTRUCTIVE SLEEP APNEA)

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19. An old lady presents with tiredness for 2 months. She is a known COPD
patient. Her GP did blood investigations and referred her to the hospital.
Take a history and carry out management.

Pt has COPD for 20 years. Taking Blue and brown inhalers.

Blood test shows low sodium (129 mmols).

Cause of tiredness? Due to hyponatremia? Due to Corticosteroid inhalers?

Ask about diarrhoea, vomiting (can cause hypovolemic hyponatremia).

Admit for investigations to rule out and serious causes.

Check morning cortisol, Urine sodium, TFT (hypothyroidism can cause hyponatremia),

If no other cause - stop steroid inhalers and give alternative medicines talk to seniors
and discharge.

(Sodium is not very low to correct by treatment. It is a chronic condition – so no need to

admit and treat for hyponatremia).

TIREDNESS - COPD PATIENT ON INHALERS

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Causes of hyponatremia

Hypovolemic Euvolemic hyponatremia Hypervolemic

hyponatremia hyponatremia
Renal loss SIADH Congestive

Diuretic therapy Cardiac failure

Cerebral salt wasting Liver cirrhosis

Adrenocortical insufficiency Nephrotic syndrome

Salt wasting nephropathy

Extra renal loss Drugs: (not a complete list)

SSRI, Carbamazepine
Diarrhoea
Desmopressin, Phenothiazines,
Vomiting Tricyclic antidepressants,
Cyclophosphamide, Opioids,
Excessive sweating
Vincristine, NSAIDS, Clofibrate,
Proton
pump inhibitor

Third space loss Pulmonary causes:

Pneumonia, Pulmonary
Small bowel obstruction
abscess,
Pancreatitis
Tuberculosis
Burns
Neoplastic causes:

Small cell lung cancer, Lymphoma

Adrenocortical insufficiency
Hypothyroidism
Primary polydipsia
Post operative pain
CNS causes

Meningitis Stroke

Tumours

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 TIREDNESS:
Differential Diagnoses

• Chronic heart disease – SOB, Ankle swelling

• Liver disease – bloated tummy, ankle swelling
• Renal disease – Facial puffiness, Problem passing urine, Less urine
or more urine.

• Psychiatric illnesses – Mood, Any worries ?

• Thyroid disease (hypothyroidism) – Weight gain, Constipation, Cold
intolerance.
• Connective tissue diseases – Muscle pain, Rashes,
• Chronic anaemia – SOB, tiredness,
• Neoplastic disease – weight loss, Lumps and bumps, cough,
smoking, any cancers in family members.
• Chronic infections (eg, AIDS) – Have you tested for HIV
• Endocrine diseases (eg, Addison disease) - darkened skin
11. Inflammatory bowel disease – diarrhoea
12. Drug abuse – recreational drug use.
13. Diabetes - tiredness
14. Vitamin D deficiency - ask for degree of sun exposure
15. Chronic fatigue syndrome
16. Fibromyalgia

Causes of chronic fatigue syndrome

Exactly what causes chronic fatigue syndrome (CFS) is unknown, but there are several
theories.

Post viral or bacterial infection eg: glandular fever, pneumonia.

Diagnosing CFS

Other conditions should be ruled out (FBC for Hb, LFT, TFT, U&E, etc)

The person should also have one or more of these symptoms:

" Tiredness
" Difficulty sleeping or insomnia
" Muscle or joint pain without inflammation
" Headaches
" Sore throat

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 " Poor mental function, such as difficulty thinking
" Symptoms getting worse after physical or mental exertion
" Feeling unwell or having flu-like symptoms
" Dizziness or nausea
" Heart palpitations without heart disease

The symptoms listed above must have persisted for at least four months in an adult and
three months in a child or young person.

Treating chronic fatigue syndrome

Treatments for chronic fatigue syndrome (CFS) aim to help relieve the symptoms.

CFS may last a long time, but treatment often helps improve the symptoms. Over time,
many people get better and regain fully functioning lives.

1. Cognitive behavioural therapy: a type of talking therapy.

It works by helping you accept your diagnosis and trying to increase your sense of
control over your symptoms

2. Graded exercise therapy: a structured exercise programme that aims to gradually

help increase the length of time you do the exercise and the intensity.

Medication

There's no medication available to treat CFS specifically, but different medicines may be
used to relieve some of the symptoms of the condition.

1. Painkillers
2. Antidepressants if you have depression.
3. Antiemetics - If you experience severe nausea.

Lifestyle advice

As well as these treatments, you may find the lifestyle advice below helpful.

1. Pacing

Pacing may be a useful way of controlling CFS symptoms. It involves balancing periods
of activity with periods of rest.

2. Avoid stressful situations

3. Avoid alcohol, caffeine

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 20. You are the FY 2 in the GP clinic: Mr John Paterson 35 year old man presented to
the GP surgery 6 weeks ago with tiredness.

He has come for follow up. IT has crashed and his records are not available.

Take a history from him and talk to him about the further management

[If the patient does not have body aches – give chronic fatigue syndrome as the
diagnosis]

Dr: Hello, Mr John Paterson. I am Dr ... one of the junior doctors in the clinic. How can I
help you?

Pt: Doctor, I came to the GP surgery 6 weeks ago. I was told to come back again.

Dr: Mr Paterson, Unfortunately our computer system is crashed and your records are
not available. Could you please tell me again why did you come here last time ?

Pt: I have been feeling very tired for the last few months.

Dr: Since when exactly did this problem start?

Pt: Almost 6 months now, doctor

Dr: Can you figure out what would have triggered this thing at all?

Pt: I do not know

Dr: Were you completely well before this 6 months?

Pt: I had some viral infection before these symptoms started which lasted for a few
days.

Dr: May I ask what job you do?

Pt: I work as an assistant in the Lawyers office.

Dr: Does it affect your work, I mean are you able to carry out your work?
Pt: With difficulty I am managing to work. I have taken a few days off in the last few
months because I was feeling very tired.

Dr: How about your daily activities – are you able to do them?

Pt: Yes, but again I do get tired quickly.

Dr: Do you have any body pain? Pt: No

Dr: Any joint pain? Pt - No

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 Dr: Are you able to sleep properly?

Pt: My sleep is very disturbed. I don’t feel refreshed when I get up in the morning.

Dr: Do you have a headache? Pt: No

Dr: Nausea or vomiting? Pt: No

Dr: Any palpitations? Pt: No

Dr: How is your mood?

Pt: It is low because I am very tired and can’t do work.

Dr: Any worries and stress before these symptoms started? Pt: No

Dr: Do you have any swelling in the ankle? No

Dr: Bloated tummy? No

Dr: Puffiness of face? No

Pt: Do feel SOB? No Dr: Any constipation? No Dr: Weight gain or weight loss? No

Any lumps and bumps in the body? - No

Dr: Did you have this type of problem before? - No

Pt: Any medical conditions? No heart kidney or liver problems? - No

Dr: Diabetes or High blood pressure? - No

Dr: Do you smoke? - No

Dr: Do you drink Alcohol? - No

Dr: Do you use recreational drugs? - No

Dr: Have tested for HIV ? - No

Dr: Any medical conditions or any cancers in the family members? No

Dr: How much does this affects your life

Pt: It affects a lot doctor. I can’t work properly and my wife gets very annoyed with me.

Dr: I am very sorry to hear that. We will try our best to help you.

Dr: Can you please tell me whether any investigations like blood tests or urine tests
done last time when you came here? Pt: Yes/No

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 Examination: ………

Diagnosis:

D: Mr Paterson, Sometimes people have this type of problems due to some medical
conditions like when heart liver or kidney not working properly or due to thyroid disease
or other medical conditions. But if none of these medical conditions are causing this
problem then we call this condition as Chronic fatigue syndrome which I think is the
case with you.

Pt: Why did this happen, doctor?

Dr: There is no known reasons why this happens. Sometimes, it can happen after some
infections.

Pt: Is it serious, doctor?

Dr: Unfortunately, it is a serious condition because it is very disabling and affects

people’s life in many ways. However it is not life threatening.

Pt: How can you help me doctor?

Investigations:
Dr: First of all we need to do some tests to make sure it is not due to other medical
conditions. (if they are not already been done last time).

We will do some blood tests to check liver function, thyroid function, kidney function,
anaemia. Importantly, we will check the blood for any Vit D deficiency because this can
be due to Vit D deficiency too.

If the investigations are all normal, that means it is chronic fatigue syndrome. There are
no specific medications to treat this condition.

Prognosis:

This condition can last for many months or even for years but then it subsides on its
own. There are many things we can do to help you to cope with this condition.

Treatment:

If there is Vit D deficiency we will give you Vit D supplements. You need to have more
sun exposure which helps Vit D production in the body.

If it is chronic fatigue syndrome, we have something that we call Cognitive behavioural

therapy - a kind talking therapy which helps you to accept this condition and cope with that.

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 Then our physiotherapists can teach you graded exercise where you gradually increase your
body strength by gradually increasing the exercise.

Are you following me ? Pt: Yes

Dr: Also, we can give you medications like pain killers if you have pain, antidepressant
medications if you feel low.

Also, certain lifestyle changes can help like pacing where you balance your period of
activity and rest. Please avoid smoking or drinking alcohol or too much coffee.

Pt: Thank you, doctor.

Dr: Anything else you want to know

Pt: No doctor. You have been kind.

Dr: Thank you. We will keep following you up. Hope you recover soon Mr Paterson.

CHRONIC FATIGUE SYNDROME

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 21. You are the FY 2 in the GP clinic.
Mr John Paterson 35 year old man presented to the GP surgery 6 weeks ago with
tiredness.

He has come for follow up. IT has been crashed and his records are not available.
Take history from him and talk to him about the further management.

[If the patient has body ache – give Fibromyalgia as diagnosis. In CFS, tiredness is
more prominent than in fibromyalgia]

[Positive symptoms - Tiredness, body pain and sleep disturbance]

Dr: Hello Mr James Paterson. I am Dr…. one of the junior doctors in the clinic. How can
I help you?

Pt: Doctor, I came to the GP surgery 6 weeks ago. I was told to come back again.

Dr: Mr Paterson, Unfortunately our computer system is crashed and your records are
not available. Could you please tell me again why you came here the last time ?

Pt: I have been feeling very tired for the last few months.

Dr: I am very sorry to hear that. Is there anything else you can tell me? Pt: I am also
having some body ache. I can’t do my work properly.

Dr: Exactly when did all these problems start? Pt: Almost 6 months now, doctor.

Dr: Can you figure out what would have triggered these things at all? Pt: I do not know.

Dr: Were you completely well before this 6 months?

Pt: I had some viral infection before these symptoms started which lasted for a few
days.

Dr: May I ask what job you do? Pt: I work as an assistant in the Lawyers office.

Dr: Does it affect your work, I mean are you able to carry out your work?

Pt: With difficulty I am managing to work. I have taken a few days off in the last few
months because I was feeling very tired.

Dr: How about your daily activities – are you able to do them? Pt: Yes, but again I do get
tired quickly.

Dr: You said you have body pain. Since when have you been having this? Pt: About 6
months.

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 Dr: Can you please tell me where all you have pain in your body - Can you please point
it? Pt: …

Dr: Are you able to sleep properly?

Pt: My sleep is very disturbed. I don’t feel refreshed when I get up in the morning.

Dr: Do you have a headache? Pt: No

Dr: How is your mood?

Pt: It is low because I am very tired and can’t do work.

Dr: Any worries and stress before these symptoms started? Pt:No

Dr: Do you experience SOB? - No

Dr: Any constipation? - No

Dr: Weight gain or weight loss? – Pt: No

Dr: Do you have any joint swellings or joint pains (rheumatoid arthritis)? Pt: No

Dr: Any balance problem while walking (Multiple sclerosis)? Pt: No

Dr: Diabetes or High blood pressure? No

Dr: Do you smoke? No

Dr: Do you drink Alcohol? Pt: No

Dr: Do you use recreational drugs? No

Dr: Have tested for HIV? No

Dr: Any medical conditions or any cancers in the family members? No

Dr: How much does this affects your life?

Pt: It affects me a lot doctor. I can’t work properly - My wife gets very annoyed with me.

Dr: I am very sorry to hear that. We will try our best to help you.

Dr: Can you please tell me whether any investigations like blood tests or urine tests
done last time when you came here? Pt: Yes/No

Diagnosis:

D: Mr Paterson, I think you have a condition what we call as Fibromyalgia, also called

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 fibromyalgia syndrome (FMS). It is a long-term condition that causes pain all over the
body and tiredness.

Pt: Why did this happen, doctor?

Dr: The exact cause why this happens to anyone is not known but it is thought to be
related to abnormal levels of certain chemicals in the brain. Sometimes it can happen
after some infections or stressful event. Sometimes it could be an inherited condition.

Pt: Is it serious doctor?

Dr: Unfortunately, it is a serious condition because it is very disabling and affects

people’s life in many ways. However it is not life threatening.

Pt: How can you help me doctor?

Investigations:

Dr: First of all, we need to do some tests to make sure it is not due to other medical
conditions. (if they are not already been done last time).

We will do some blood tests to check liver function. Thyroid function, kidney function,
anaemia. Importantly, we will check the blood for any vitamin D deficiency because this
can be due to Vit D deficiency too.

If they are all normal, that means it is Fibromyalgia.

Prognosis:

Unfortunately, this condition may last forever.

Treatment:

If there is Vit D deficiency, we will give you Vit D supplements. You need to have more
sun exposure which helps Vit D production in the body.

If it is Fibromyalgia, unfortunately there is no cure for this condition, but there are
treatments to help relieve some of the symptoms and make the condition easier to live
with.

Treatments we can give include:

 Medications – such as antidepressants and painkillers for depression and pain.

We also have something that we call Cognitive behavioural therapy - a kind of talking
therapy

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  Lifestyle changes – such as exercise programmes swimming, cycling can help, also
relaxation techniques can help.

 Pacing where you balance your period of activity and rest also can help.

 Better sleeping habits like trying to going to bed and getting up same time every day
and relaxing before going to bed can help. Also avoid drinking coffee or smoking before
going to bed can also help.

 Some people find alternative therapies like acupuncture and massage helpful.
 You can join a Fibromyalgia support group. That may be very helpful to you. Pt: Thank you
doctor.

Dr: Anything else you want to ask me? Pt: No, doctor. You have been kind.

Dr: Thank you. We will keep following you up. Hope you recover soon, Mr Paterson
TIREDNESS (FIBROMYALGIA)

Tiredness –Fibromyalgia
Fibromyalgia, also called fibromyalgia syndrome (FMS), is a long-term condition that
causes pain all over the body.

 Symptoms
1. Widespread pain: This may be felt throughout your body, but could be worse in particular
areas, such as your back or neck.
2. Extreme sensitivity: Fibromyalgia can make you extremely sensitive to pain all over your
body, and you may find that even the slightest touch is painful. If you hurt yourself – such as
stubbing your toe – the pain may continue for much longer than it normally would.
You may hear the condition described in the following medical terms:
 Hyperalgesia – when you're extremely sensitive to pain
 Allodynia – when you feel pain from something that shouldn't be painful at all, such as a very light
touch.

3. Stiffness: Fibromyalgia can make you feel stiff.

4. Fatigue: Fibromyalgia can cause fatigue - extreme tiredness, you may feel too tired to do
anything at all.
5. Poor sleep quality: Fibromyalgia can affect your sleep. You may feel you are not refreshed
when you get up.
6. Cognitive problems ('fibro-fog') you may have:

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  trouble remembering and learning new things

 problems with attention and concentration

 slowed or confused speech

7. Headaches

8. Irritable bowel syndrome (IBS)

IBS is a common digestive condition that causes pain and bloating in your stomach. It can also
lead to constipation or diarrhoea.
9. Other symptoms
 dizziness and clumsiness
 feeling too hot or too cold – this is because you're not able to regulate your body temperature
properly

 restless legs syndrome (an overwhelming urge to move your legs)

 tingling, numbness, prickling or burning sensations in your hands and feet (pins and needles, also
known as paraesthesia)
 in women, unusually painful periods
10. Depression: losing interest in the things you usually enjoy

 constantly feeling low

 feeling hopeless and helpless

Causes of fibromyalgia: The exact cause is unknown, but it's likely that a number of factors
are involved such as

 Abnormal pain messages

One of the main theories is that people with fibromyalgia have developed changes in the way
the central nervous system processes the pain messages carried around the body. This could
be due to changes to chemicals in the nervous system.

 Sleep problems

It's possible that disturbed sleep patterns may be a cause of fibromyalgia, rather than just a
symptom.

 Genetics :genetics may play a small part in the development of fibromyalgia.

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  Possible triggers

Fibromyalgia is often triggered by a stressful event, including physical stress or emotional

(psychological) stress. Possible triggers for the condition include:
 an injury

 a viral infection

 giving birth

 having an operation

 the breakdown of a relationship

 being in an abusive relationship

 the death of a love done

However, in some cases, fibromyalgia doesn't develop after any obvious trigger
Diagnosing fibromyalgia: Diagnosing fibromyalgia can be difficult, as there's no specific
test to diagnose the condition.

Ruling out other conditions

 chronic fatigue syndrome (also known as ME) – a condition that causes long- term tiredness
 rheumatoid arthritis – a condition that causes pain and swelling in thejoints
 multiple sclerosis (MS) – a condition of the central nervous system (the brain and spinal cord)
that affects movement and balance
Tests to check for some of these conditions include urine and blood tests, although you may
also have X-rays and other scans. If you're found to have another condition, you could still have
fibromyalgia as well.

Criteria for diagnosing fibromyalgia

For fibromyalgia to be diagnosed, certain criteria usually have to be met. The most widely used
criteria for diagnosis are:
 you either have severe pain in three to six different areas of your body, or you have milder
pain in seven or more different areas.

 your symptoms have stayed at a similar level for at least three months

 no other reason for your symptoms has been found

The extent of the pain used to be assessed by applying gentle pressure to certain "tender
points", where any pain is likely to be at its worst. However, this is less common nowadays.

183
 Treating fibromyalgia

Treatment for fibromyalgia tries to ease some of your symptoms and improve quality of life, but
there's currently no cure.
This will normally be a combination of medication and lifestyle changes.

Medications:

Painkillers such as paracetamol, codeine or tramadol can sometimes help relieve the pain

Antidepressants

Antidepressant medication can also help to relieve pain for some people with fibromyalgia.
tricyclic antidepressants – such as amitriptyline
 serotonin-noradrenaline reuptake inhibitors (SNRIs) – such as duloxetine and venlafaxine
 selective serotonin reuptake inhibitors (SSRIs) – such as fluoxetine and paroxetine
A medication called pramipexole, which isn't an antidepressant, but also affects the levels of
neurotransmitters, is sometimes used as well.
Sleeping pills
As fibromyalgia can affect your sleeping patterns, you may want medicine to help you sleep.

Muscle relaxants such as diazepam.

Anticonvulsants

 You may also be prescribed an anticonvulsant (anti-seizure) medicine, as these can be

effective for those with fibromyalgia.
 The most commonly used anticonvulsants for fibromyalgia are pregabalin and
gabapentin. It can improve the pain associated with fibromyalgia in some people.
Antipsychotics: are sometimes used to help relieve long-term pain.
Other treatment options

As well as medication, there are other treatment options that can be used to help cope with the
pain of fibromyalgia, such as:
• swimming, sitting or exercising in a heated pool or warm water

• an individually tailored exercise program.

 cognitive behavioural therapy (CBT) – a talking therapy that aims to change the way you think
about things, so you can tackle problems more positively

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  psychotherapy – a talking therapy that helps you understand and deal with your thoughts and
feelings
 Relaxation techniques

 psychological support – any kind of counseling or support group that helps you deal with issues
caused by fibromyalgia
Alternative therapies

 acupuncture

 massage

 manipulation
 aromatherapy

There's little scientific evidence that such treatments help in the long term. However, some
people find that certain treatments help them to relax and feel less stressed,
Self-help for fibromyalgia

There are organizations (Fibromyalgia's support group) to support people with fibromyalgia.

Exercise

An exercise program specially suited to your condition can help you manage your symptoms
and improve your overall health.
Physiotherapist (healthcare professional trained in using physical techniques to promote
healing) can design you a personal exercise program, which is likely to involve a mixture of
aerobic and strengthening exercises.

Aerobic exercise

 walking

 cycling

 swimming
Resistance and strengthening exercises Pacing yourself

This means balancing periods of activity with periods of rest, and not overdoing it or pushing
yourself beyond your limits.

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 Relaxation can help stress.

Talking therapies, such as counseling, can also be helpful in combating stress and learning to
deal with it effectively.

Better sleeping habits

If you have problems sleeping, it may help to:

 get up at the same time every morning

 try to relax before going to bed

 try to create a bedtime routine, such as taking a bath and drinking a warm, milky drink every night

 avoid caffeine, nicotine and alcohol before going to bed

 avoid eating a heavy meal late at night

 make sure your bedroom is a comfortable temperature, and is quiet and dark

 avoid checking the time throughout the night

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 22. 30 year old female c/o tiredness for the past 18 months. Rest is not making it better.
Previously has been treated for anaemia.

All histories of tiredness is negative, goes to sleep but can’t sleep till late in the night.
Sleep hygiene good, no OSA, No NAI, no pain, no recent infections or lumps or bumps.

Mood is low, says 5.

Mother might have dementia, she might also have children to take care of and is
stressed. On the other hand, her family and friends might be alright and she has no
problem with work.

Previously treated for depression 2 years ago, stopped after consulting with psychiatrist.
No suicidal ideation now.

Recently changed houses and work and moved to a new place.

Pt asks “Dr, do you think I have some problem?”

TIREDNESS ? CFS, ? ANEMIA

187
 23.
A 60 year old woman presents with tiredness. Take a history and discuss
management with the patient.

[Positive symptoms - Tiredness, weight gain, constipation, prefers hot weather]

Dr: Hello, Mrs. .. I am Dr…. one of the junior doctors in the medical department.
How can I help you?

Pt: I have been feeling very tired for about 2 years.

Dr: I am very sorry to hear that. Is there anything else you can tell me? Pt: Like what?

Dr: Do you have any other symptoms like high temperature (fever) (TB)? Pt : No

Dr: Any headache? Pt: No

Dr: Body pain (Fibromyalgia, CFS)? Pt: No

Dr: Any changes in the bowel habit (Hypothyroidism, cancer)? Pt: I am constipated

Dr: Since when? Pt: For many months now.

Dr: Have you noticed any bleeding from the back passage (Bowel cancer)? Pt: No

Dr: What is the colour of the stool (black colour – upper GI bleed – anaemia)? Pt:
Normal

Dr: Have you noticed bleeding from anywhere like nose, gums (Anaemia)? Pt: No

Dr: Do you have SOB (Anaemia, heart failure)? Pt: No

Dr: Palpitations (anaemia)? Pt: No

Dr: Do you have any preference to any particular weather? Pt: Yes, I prefer warm
weather.

Dr: How about cold weather (hypothyroidism)?

Pt: I don’t like it – I feel too cold & can’t tolerate it.

Dr: Have you noticed any swelling in the front of your neck? Pt: No
Dr: Have you noticed any changes in your weight (hypothyroidism, cancer)? Pt: Yes, I
have gained weight

Dr: Can you please tell me how much weight did you gain in how much time? Pt :---

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 Dr: Have you noticed any changes in your voice (hoarseness in Hypothyroidism)? Pt: No

Dr: Have you had any surgeries in the neck (thyroidectomy can cause hypothyroidism)

Dr: How is your mood (hypothyroidism, depression) can you please rate in the scale
of 1 to 10, one being very low and 10 being very happy ?

Pt: It is low about 6 to 7.

Dr: Any worries and stress making you feel low? Pt: I lost my husband about 2 years ago.

Dr: I am sorry to hear that. Do you think the tiredness started after that? Pt: Yes / No

Dr: How is your sleep? Pt: Sleep is fine but I don’t get refreshed properly in the morning.

Dr: Any lumps and bumps in your body? Pt: No

Dr: Do you feel your tummy distended (heart, liver kidney failure)? Pt: No

Dr: Any swelling of feet (heart failure)? Pt: No

Dr: Have you had this type of problem before? Pt: No

Dr: Do you have any medical conditions? Pt: No

Dr: Any heart, kidney or liver problems? Pt: No

Dr: Diabetes or High blood pressure? Pt: No

Dr: Have you checked you cholesterol (fat content in the blood) before? Pt: No

Dr: Are you taking any medications (excessive thyroxin can cause hypothyroidism)

Dr: Do you smoke? Pt: No

Dr: Do you drink alcohol? Pt: No

Dr: Any medical conditions or any cancers in the family members? Pt: No
Dr: Any of your family members has any thyroid related conditions? No/yes

Dr: How much does this affects your life?

Pt: It affects it a lot doctor. I can’t work properly

Dr: Is there anything else you think is important that we need to know? Pt: No

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 Examination:

Dr: Mrs….. I need to examine you now and check your neck for any swelling and also
examine your chest and tummy. (Examiner may not give any findings)

Investigations:

Dr: Mrs.. We need to do some tests to find out what exactly is causing these symptoms.
There are lot of conditions which can cause tiredness like anaemia, diabetes, heart and
liver failure, Vit D deficiency. We will do some blood investigations to check whether you
have any of these problems. Sometimes, it could be due to an under-active thyroid.

So we need to do blood tests to check some hormones called thyroid hormones. Do you
follow me? Pt: Yes

Dr: Is that OK? Pt: Ok

[Examiner may not give TFT result – In hypothyroidism, TSH will be high and T4
will be low]

Diagnosis:

Mrs... with the information you have given me, I think you have a condition we call
Hypothyroidism otherwise called under-active thyroid. Do you know anything about it? Pt: No

Dr: We have a butterfly shaped gland in the front of the neck called a thyroid gland
which normally produces some hormones called thyroid hormones. These hormones
regulate the body's metabolism - the process that turns food into energy.

An under-active thyroid gland (hypothyroidism) is where your thyroid gland doesn't

produce enough hormones. Many of the body's functions slow down when the thyroid
doesn't produce enough of these hormones. Are you following me?

Pt : Yes. Why am I having this problem?

Dr: Most cases of an under-active thyroid are caused by the immune (body’s defence)
system attacking the thyroid gland and damaging it. Sometimes, it can be due to a
deficiency of iodine in the diet or previous treatment for overactive thyroid or sometimes
it can be due to tumour (growth) of the thyroid gland. Do you follow me? Pt: Yes

If we do not treat this condition, then it can lead to other complications – it can increase
cholesterol (bad fat) levels in the blood leading to heart problems. Sometimes, it causes
swelling in the front of the neck. So, it is very important to treat the condition.

Pt: How will you treat me, doctor?

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 Dr: We will treat you with a medication called Levothyroxine. This replaces the thyroid
hormones in the body. Initially, we need to keep checking your blood levels of thyroid
hormone regularly to find out the proper dose of the medicine you require.

We will start with the low dose and increase it gradually until the proper required dose is
reached. Usually, you will have to take one tablet per day either morning or night. Some
people start to feel better soon after the treatment, while in others it may take months to
see the improvement. Are you following me?

Pt: Yes, how long should I take this medicine?

Dr: An under-active thyroid is a lifelong condition, so you will usually need to take this
medicine for the rest of your life.

The effectiveness of the tablets can be changed by other medications, supplements or

foods, so you should swallow the tablet with water on an empty stomach, and you
should avoid eating for 30 minutes afterwards.

[mention only if asked - If you're prescribed levothyroxine because you have an

under-active thyroid, you're entitled to a medical exemption certificate. This
means you don't have to pay for your prescriptions].

Pt: Are there any side effects, doctor ?

Dr: It doesn't usually cause any side effects. Side effects usually only occur if you're
taking too much of this medicine. This can cause problems including sweating, chest
pain, headaches, diarrhoea and vomiting. Are you following me?

Pt: Yes

Dr: Any other concerns? Pt: No

Dr: Thank you very much.

TIREDNESS - HYPOTHYROIDISM

191
 What is a normal TSH level in a woman?

Normal TSH levels for the average adult range from 0.4 - 4.0 mIU/L (milli- international units per liter). However, many
organisations agree that a reading of
2.5 or less is truly ideal, with anything 2.5 – 4.0 mIU/L considered “at risk”. For those on thyroxine, goal TSH level is
between 0.5 to 2.5 mU/L.

What is the normal range for T3?

Typically, normal results range from 100 to 200 nanograms per deciliter (ng/dL).

What is a normal T4 level?

Normal results are generally from 4.5 to 11.2 micrograms per deciliter.

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 24. 22 year Miss Emilia Mills was brought in by her boyfriend because of
loss of weight.

Take a detailed history and discuss further investigations with the patient.

TSH 0.2mU/L (Normal - 0.4 - 4.0mU/l (milliunits per litre)

T4 - 35pmol/l (Normal - 9.0 - 25.0 pmol/l (picomoles per litre)

T3 - 6pmol/l (Normal - 3.5-7.8 pmol/l (picomoles per litre)

Differential Diagnoses for weight loss

" Thyrotoxicosis - heat intolerance, palpitations, ↑appetite, anxiety, family history of

thyroid disease or weight loss.

" TB – cough, night sweats, travel history, contact

" Diabetes – Increased thirst and hunger, increased frequency of urination. Family
history of diabetes.

" Cancer – lumps & bumps, change in bowel habit, cough, haemoptysis, Breast lumps,

" HIV – sexual Hx, drugs.

" Depressions - ↓mood, early morning awakening, suicidal thoughts, recent job,
changes/loss, separation from partners

" Anorexia nervosa – intentional, insight (do you think you have lost weight or
only others telling you this), role model, dieting, exercise, laxatives, diuretics,
vomiting (purging)

" Drugs – metformin, opiates. slimming agents,

" Alcohol/smoking

" Malabsorption - difficult to flush the stool in the toilet.

" Malnutrition – how is the diet (healthy eating habits)

" Addison’s disease – weakness, dizziness. ↑d pigmentation over palmar crease.

" Coeliac/Crohn’s – diarrhoea with blood mucus, pain in abdomen

193
 Positive history: Patient would have lost 5 kg in 2 months in spite of increased appetite

Examination:

Miss..., I need to examine your hands, eyes and neck

Investigations

- Thyroid function tests

- LFTs (because of carbimazole)

- Isotope scan (swallow radioactive substance in capsule or liquid)

Treatment:

- Thionamides (e.g carbimazole)

- Beta blockers

- Radio iodine (shrinks thyroid)

- Surgery.

Tell patient symptoms may take about a week to a month

Also inform her of possibility of recurrent infections.

If she is planning to get pregnant, she should inform her GP.

WEIGHT LOSS - HYPERTHYROIDISM

194
 25. You are an FY2 Doctor in GP clinic.

40 year lady presented to GP clinic 2 weeks ago with weight loss and tremors.
Thyroid function test was done. She has come now for the blood results.

Talk to her, take history and manage her.

Dr: Hello, my name is Dr… one of the junior doctors in the GP clinic. How may I call
you? Pt: You can call me....

Dr: Miss/Mrs… I can see that you visited us a few days ago.

Pt: Yes doctor, I am here for my test results. Could you give me my test report?

Dr: Yes, I do have your test results with me. However before I go on to that, I would
like to ask you a few questions. This would help us know your condition better so that
we can treat you appropriately. Okay? Pt: Okay.

Dr: Could you tell me what made you visit the hospital last time?

Pt: Doctor I am losing weight.

Dr: I am sorry to hear that. For how long have you been experiencing these symptoms?

Pt: (For a few months?)

Dr: How much weight have you lost? Pt: Two & half stones doctor.

Dr: Since when have you noticed this? Pt: …

Dr: Is there anything else that has been bothering you in any way?

Pt: Doctor, I am also experiencing shaky movements in my hands.

Dr: It must be very distressing for you. Has there been any change in your appetite?

Pt: Doctor, I am eating more than usual nowadays and despite that I am losing weight.

Dr: I see. What about your bowel habits?

Pt: Doctor I have been going to the toilet more frequently than usual. Also I am
passing loose stools for some time now. Is there a problem doctor?

Dr: Well, I need to know a few more details and then I would let you know about the

195
 results. Is that alright? Pt: Okay, doctor.

Dr: Do you have a preference for weather? Pt: I don’t like summer, doctor.
Dr: Why is that? Pt: Doctor I feel hot when others don’t really feel hot.

Dr: Do you sweat more than usual? Pt: No/Yes

Dr: Have you been experiencing your heart beating faster than usual? Pt: Yes.

Dr: Do you find it difficulty closing eyes or have you been noticing double vision? Pt: No.

Dr: Can you tell me when was your last menstrual period?

Pt: Doctor, I have been having infrequent menstrual periods for some time now.

Dr: Have you been noticing any fever? (T.B) Pt: No, doctor.

Dr: Any sweating at night time? Pt: No, doctor.

Dr: Have you been having cough lately? Pt: No, doctor.

Dr: And have you been noticing any lumps or bumps anywhere on your body? (Cancers)

Pt: No.

Dr: How has been your mood lately? (Depression) Pt: My mood is fine.

Dr: Are you intentionally trying to lose weight by any chance? (Anorexia Nervosa)? No

Dr: Do you think you have lost weight or only others are telling you this? (Anorexia
Nervosa) Pt: Doctor, I definitely think there’s something wrong with me. I eat a lot and
despite that I am losing weight.

Dr: Do not worry. Tell me if you have ever been diagnosed with any medical conditions
in the past? Pt: No, doctor.

Dr: Do you have Diabetes or High blood pressure or any gland problems in the neck?
No

Dr: Do you smoke? Pt: No.

Dr: Do you take Alcohol? Pt: No.

Dr: Have you ever done any blood tests like HIV or Hepatitis? Pt: No

196
 Dr: How are your dietary habits? Pt: My diet is fine doctor.

Dr: Are you taking any medications? Pt: No doctor.

Dr: Any allergies? Pt: No doctor.

Dr: Has anyone in your family ever been diagnosed with any gland problems in the
neck or thyroid diseases?

Pt: (Yes doctor, my mother and sister and my aunt has similar problems)

Dr: Have you travelled anywhere recently? Pt: No

Dr: Have you recently come in contact with anyone who has T.B? Pt: No

Examination:

Dr: I would like to perform Examination of your Hands, Eyes and Neck for any
abnormal swelling. I would also be checking your Pulse. Pt: Okay.
Examiner might give findings:

Pulse is raised and rest of the examination is insignificant.

Diagnosis & Explanation of Report:

Dr: Well, Miss/Mrs… from information you have given me and from the examination
and test results, I am suspecting that you have a problem of a gland that is situated in
the neck. We call this gland Thyroid Gland and this illness is called Hyperthyroidism.
Do you know what it is? Pt: No, doctor.

Dr: Hyperthyroidism means an overactive thyroid gland. When your thyroid gland is
overactive it makes too much hormone. The extra hormone causes many of your
body's functions to speed up. I would explain to you the test results and that would
make you better understand the situation here. Pt: Okay.
Test Report:

TSH 0.2 mU/L (Normal - 0.4 - 4.0 mU/l (milliunits per litre)

T4 - 35 pmol/l (Normal - 9.0 - 25.0 pmol/l (picomoles per litre)

T3 - 6 pmol/l (Normal - 3.5 - 7.8 pmol/l (picomoles per litre)

197
 Dr: As I have told you, thyroid gland produces some hormones. They are essential for
normal body functioning. T4 that is written here is actually short for Thyroxine.
Thyroxine is a body chemical (hormone) made by your thyroid gland. It is carried
around your body in your bloodstream. It helps to keep your body's functions working
at the correct pace. You see it is way above its normal range. A high level of T4
confirms hyperthyroidism.
Thyroid-stimulating hormone (TSH) is chemical made in another gland in the brain
Pituitary gland. It is released into the bloodstream. It stimulates the thyroid gland to
make thyroxine. If the level of thyroxine in the blood is high then the gland in brain
releases less TSH. Therefore, a low level of TSH means that your thyroid gland is
overactive and is making too much thyroxine which is true in your case. Are you
following me?

Pt: Yes, doctor.

Dr: Well, we would like to see further what could be the cause that is leading you to
this. One of the causes of this overproduction of hormones by this gland is a disease
called Grave’s Disease. In order to confirm that, we would perform another blood test.
This blood test may detect specific Autoantibodies which are commonly raised.

However, these can also be raised in some people without Graves' disease so this is
not a specific test for Graves' disease. Is that okay? Pt: Okay.

Dr: Also we might be performing a scan called an Isotope scan in which we would ask
you to swallow a radioactive substance in capsule or liquid form, and we later on
would take images of your neck to see the gland. It would help us better visualise the
pathology of the gland.

Pt: Alright. How will you treat me doctor?

Dr: There are a number of treatment modalities available. Antithyroid medicines can
reduce the amount of thyroxine made by an overactive thyroid gland. The most
common medicine used is Carbimazole.

Pt: Do I need to be careful about anything when I am taking this medication?

Dr: It has some side effects. It can, rarely, affect your white blood cells which fight
infection. Whilst taking carbimazole, you should see a doctor urgently for a blood test
if you develop any of the following: A fever. A sore throat. Mouth ulcers. Is that okay?

198
 (An alternative medication called Propylthiouracil is usually given instead of
carbimazole if you are pregnant. Carbimazole is safe to take if you are breast-feeding.

(Ask whether pt is pregnant or chance of becoming pregnant if pt. is young)

Pt: Okay, doctor.

Dr: Also for controlling your symptoms, we can give you medicines called Beta
Blocker, those will relieve your symptoms of thumping heart, shaky movements of
hands, sweating….etc. Is that okay? Pt: Okay.

Dr: Other treatment modalities include Radio-iodine. This will shrink the size of thyroid
gland.

The last option is Surgery, if other treatments don’t work. This involves removing a
part of your thyroid gland. It is usually a safe operation. However, as with all
operations, there is a very small risk of complications. Are you following me? Pt: Yes
doctor.

Dr: Also we will be referring you to an endocrinologist who is a specialist of diseases

such as thyroid gland. He will advise you further about it. Is that alright?

Pt: Yes, Doctor

Dr: Do you have any other concerns?

Pt: No, doctor… Thank you.

WEIGHT LOSS - HYPERTHYROIDISM

199
200
 26. Mr McKenzie, a 58 year old man was diagnosed with myocardial infarction 7
years ago. He has not been coming for follow up. Now presenting with
shortness of breath. His GP referred him to the hospital. Address his
concerns.

Patient is sitting on a chair.

Dr: Hello Mr McKenzie, I am Dr ... one of the junior doctors in the medical
department. How can I help you ?

Pt: Doctor, I am feeling very short of breath.

Dr: I am sorry to hear that. Are you comfortable talking to me? Pt: Yes.

Dr: Can you tell me more about your shortness of breath?

Pt: I have been having this problem for the last 4 months and it is getting worse.

Dr: When do you feel short of breath – when you do some work or exercise or even at
rest?

Pt: If I walk for about 100 feet, I feel short of breath.

Dr: What happens when you lie down? Pt: I feel more short of breath.

Dr: Are you able to sleep properly or do you get disturbed due this problem?

Pt: It wakes me from sleep sometimes and I have to sit up for some time and I feel
better.

Dr: Do you have any chest pain at all? Pt: No

Dr: Any cough? Pt: No

Dr: Do you have fever? Pt: No

Dr: Do you have any swelling on your ankles? Pt: Yes

Dr: Any pain or swelling in the calf muscles (PE) ? Pt: No

Dr: Did you have any surgery recently (PE)? Pt: No

Dr: Do you have any wheeze (Asthma, COPD)? Pt: No

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 Dr: Were you diagnosed with any medical conditions before?

Pt: Yes I had a heart attack about 7 years ago.

Dr: Ok. Any other medical conditions like High blood pressure, Diabetes, Asthma,
Bronchitis ? Pt: No

Dr: Have you checked your cholesterol? Pt: Last time (years ago) when I checked it was
high.

Dr: Do you smoke? Pt: Yes/No (quantify if yes).

Dr: Do you drink alcohol? Pt: Yes / No

Dr: Are you taking any medications? Pt: Yes, Statins, Aspirin, Beta blocker

Dr: Are you taking them regularly? Pt: Yes

Dr: Are you going for proper follow up with your doctor after you had a heart attack.Pt:No

Dr: May I know why?

Pt: Doctor I was too busy and I did not have problems until 4 months ago anyway.

Dr: May I know what job do you do? Pt: I am an Accountant

Dr: What kind of food do you eat?

Dr: Do you exercise? Pt: Not much

Dr: Is there anything else important you think we may need to know? Pt: I don’t know.

Examination

Dr: Mr McKenzie, I need to examine you now, I need to check your pulse and BP and
also examine your chest.

Examiner may give NEWS chart. – P-100, BP-130/90, SpO2-96%, Temp – 36.9, RR-15

O/E – Bibasal crepitations heard.

I will do ECG – Examiner may give ECG – May show ST depression in V2-3-4-5-6 - Ask
of chest pain

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 I need to do his chest X Ray – Examiner may give Chest X Ray – may show Pulmonary
Oedema
Thank the examiner. Talk to the patient.

Dr: Mr McKenzie, do you have any idea what may be happening to you?

Pt: No, doctor.

Dr: You have a condition that we call heart failure. Your heart has become very weak and it
is not pumping the blood out of the heart properly. That is why the fluid has accumulated in
your lungs which is causing shortness of breath and the fluid has accumulated in the ankle
area that is why you are having ankle swelling. Do you follow me?

Pt: Yes but why I am having this?

Dr: This is one of the complications which can happen to those people who had a

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 heart attack in the past. During the heart attack, there is damage to the muscle wall of
the heart and eventually it becomes very weak and will not work properly.

There are other contributory factors like high blood pressure, or if you do not take the
medication properly or if you continue to smoke, not eating a healthy diet and not
exercising – lot of these factors can contribute towards this problem. That is why it is
very important to have a proper follow up where we monitor all these things and
reduce the chance of having complications. Do you follow me?

Pt: Yes : What will happen to me now? Is this serious?

Dr: Mr McKenzie, This is quite a serious problem now. We need to admit you to the
hospital to treat you. Is that OK? Pt: OK

Dr: We will be giving you Oxygen, and we will give some medications called diuretics
which gets rid of the fluid from the body. You may be passing more urine because of
this.

We will have to do some more investigations on your heart called echocardiography –

a type of heart scan and also we may need to do tests to check whether you have any
narrowing of the blood vessels in your heart. Are you following me? Pt: Yes.

Dr: Is that OK? Pt: Yes.

Dr: We will be giving other medications called ACE inhibitors and beta blockers. We need to
check some chemicals in the blood and also check your cholesterol. Is that OK? Pt: Ok

Dr: I sincerely advise you to stop smoking, do some exercise and eat a balanced diet in
the future and also have a proper follow up once we discharge you. What do you say?

Pt: Yes doctor, I will follow your advice.

Dr: Good. I will talk to my seniors about you and hope you recover very soon. We will
also refer you to the cardiologists. Thank you very much.

Tell him how to prevent recurrence - lifestyle modification, taking medication

HEART FAILURE

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 27.

● Ask about symptoms dehydration (dehydration is complication of

DKA) - decreased urine output, drowsiness, tiredness, lethargy,
increased thirst

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 Q: Ask about headache and chest pain
● Ask more questions for triggers of
DKA - infections, chest symptoms,
cough, dysuria, eating lots of sugar

Q: was she admitted previously for such

problems?

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 ● In this Q: No need to rule out differentials if
the condition is already diagnosed.
● BUT: If the question says suspected, then go
through differentials – Ruptured ectopic
pregnancy, UTI, PID, Ureteric calculus,
Gastroenteritis)

● Ask about - Allergy, any other medications

(ask for steroids), Family HX

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 Diagnosis and discussion with patient

I think you have a condition called Diabetes ketoacidosis. Do you know anything about it?

I do not know.

This is a complication of diabetes where the blood sugar is very high along with some other
chemicals (called ketone bodies) also being very high. This causes a problem called acidosis.

This also causes severe dehydration.

Unfortunately, this is a very serious condition. If we do not treat you immediately, this can
even be life threatening. Fortunately we have good treatment.

● We need to admit and treat you immediately.

● We will have to treat your dehydration immediately. We will give you fluids through
your veins.
● We need to reduce your blood sugar too. For that we need to give you insulin injection
into our veins continuously like a drip. Also we need to check your sugar level hourly.
● If you have any infections we need to treat with antibiotics.

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 ● To give you all these treatment we need to admit you to the hospital. Is that OK

- No doctor, I do not want to be admitted.

- Dr: May I know why?

- I have children at home. I am getting married next week.

- I can understand your problem. This condition as I said is very serious and can even be
life threatening if we do not admit and treat you now in the hospital. So, it is very
important that you need to stay in the hospital. Is there anyone who can take care of
your children until you get better and go back home?

- How long will I need to be admitted ?

- It may take a few days for you to recover completely and then you can go home.

- Ok doctor I will arrange someone to look after my children and stay in the hospital.

- That is really good Mrs. We will do our best to treat you and hope you recover very
soon.

If patient is still refusing:

“We have to give you insulin which will be given through your veins and this can’t be
given at home. It can cause death if we don’t treat immediately.”

If the patient still does not agree for admission – say you will talk to your seniors and
may be they will convince her to be admitted. If she says there is no one to look after
her children – say we will arrange social services to look after your children.

If she still does not agree at all – tell her she has to sign a form for discharge against
medical advice and then she can go home.

Tell her how to prevent recurrence - take insulin regularly even if she's busy, if she has
infections in the future to see a doctor as soon as possible.

DKA

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 28. Young girl, very thin presents saying ‘my parents were concerned about
me’ so automatically lots of people think it is an anorexia station.

However, she says her parents were concerned about her because she was short of
breath and thirstier than usual. She has no other positive history and has never been
diagnosed with diabetes.

It is DKA since her blood sugar is high and ketones were positive in the urine. Talk
about ABGs.

Need to explain the diagnosis to her and complete management of diabetes within time
frame (she asks what is diabetes and wants to know in detail).

Must convince her to stay in the hospital telling her the complications of DKA because
she keeps saying she has exams and can’t stay.

DKA might be her initial presentation of diabetes

Rule out infections - pneumonia, UTI

Ask of complications - questions for dehydration

Ask about family history of diabetes.

Side note: ask for specific observations and tests otherwise the examiner wouldn’t give
them.

DIABETIC KETOACIDOSIS

210
 Twisted DKA station J17 January 2019
Young girl very thin presents saying ‘my parents were concerned about me’ so automatically lots
of people thought it was the anorexia station.
But she said they were concerned about her because she was short of breath and thirstier than
usual.
Automatically thought DKA but she had no other positive hx and never been diagnosed with
diabetes.
It is DKA since blood sugar is high and ketones were positive in the urine.
Talk about ABG.
Need to explain the diagnosis to her and complete management of diabetes within time frame
(she asks what is diabetes and wants to know in detail).
Must convince her to stay in the hospital telling her the complications of DKA because she keeps
saying she has exams and can’t stay.
Ask about family history of diabetes.
Side note: ask for specific observations and tests otherwise the examiner wouldn’t give them.
Dehydration, urine output, infection: fever(UTI, pneumonia), stress(he had an exam in the next
few days)
Examination: vitals: low blood pressure, examine the abdomen
Tell the diagnosis and explain DKA and discuss the management: it is complication of DM you
probably had DM and this a complication for it
If we don`t admit and treat >>>>>
you need admission treating the dehydration and the acidosis
Further management : lifelong treatmet: unfortunately you need lifelong insulin blab la

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 29. HAEMATEMESIS
Young lady vomiting blood. History and management.

Causes of hematemesis include:

• Bleeding ulcers – “Have you been diagnosed with any ulcers in tummy?" Any
pain in tummy previously, dark stool, any over the counter medications – Aspirin,
NSAIDS, Steroids, blood thinners?” Blood could be fresh or dark brown.
• Prolonged and vigorous retching that causes tears in the oesophageal mucosa
(known as Mallory-Weiss Syndrome) – No blood in the vomitus initially.
• Oesophageal, gastric or intestinal varices – “Have you been diagnosed with liver
problems before?”, Alcohol drinking habits for a long time, Fresh red coloured
blood
• Vascular malfunctions of the gastrointestinal tract
• Tumours in the stomach or oesophagus — weight loss
• Gastroenteritis, gastritis, or peptic ulcers can cause internal bleeding – Coffee
ground coloured blood.
• Radiation exposure
• Hemorrhagic fever
• Bleeding disorders
• Trauma/instrumentation

Other causes that may not be life-threatening include:

● Oral surgery that may cause the swallowing of some blood

● Some nose-bleeds cause blood to enter the digestive tract
● Coughing hard and excessively
Vomiting blood for three hours. Ask which was first – vomiting food and then started vomiting
blood OR vomiting blood from the beginning itself. (vomiting food first and the blood
may be Mallory-Weiss syndrome),

Ask about pain abdomen, dark stool, blood in stool, weight loss (gastric carcinoma)
Alcohol – (oesophageal varices), pt was drinking alcohol.
Any surgery or procedure done on the food pipe or stomach before, Any foreign body
ingestion.
Medications – was taking Ibuprofen or indomethacin (ask about over the counter
medication) for headaches for quite a long time. Not prescribed by doctor. Not taking PPIs.

Ask about weakness, drowsiness

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 Previous episodes, previous medical conditions family history, any bleeding disorders.
Bleeding from nose gums, urine, haemoptysis. LMP.
Any other medications, allergy.

Examination – I need to examine your tummy and also I need to check your pulse, BP and
temperature. Check for NEWS chart.

Examiner may say – tenderness in epigastric area.

Diagnosis - I think you are vomiting because you have some damage to the stomach walls
which can happen due to the Ibuprofen medication what you are taking for a long time.

This can be serious if we do not treat you immediately.

Investigations

We will have to do investigations - initially blood tests to check for anaemia to see how
much blood you have lost, check whether you have any bleeding disorder or liver problems
because sometimes alcohol can cause damage to the liver which in turn can cause
vomiting of blood.

Tell patient oxygen, blood transfusion, IV fluids might be needed. Request grouping and
crossmatching

- We may need to give you fluids through your veins and also transfuse you blood. Is it OK?
- We need to admit and do a special test called endoscopy which is a camera test. We pass a
long flexible tube with a camera at its tip through your mouth, the foodpipe to the stomach.
This test will show us where exactly the bleeding is and what may be the reason for
bleeding. Also, sometimes we may be able to control the bleeding while we are doing this test.

- We may also give you some medications called PPIs - this is to heal the damage what would
have happened to your stomach walls.

- I advise you in the future if you have to take pain killer medications like NSAIDS (Brufen
type medications) for a long time, please consult your GP. Otherwise, the same problem
can happen again.

- We will give you something else for the migraines

- Cut down drinking alcohol. Is this OK ? Any other concerns.

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214
215
216
 CONSTIPATION
Causes of Constipation

1. Intestinal obstruction - Constipation, vomiting, Pain abdomen

2. Bowel cancer - Change in bowel habit, Altered bowel habit, blood in the stool,
Tenesmus (feeling of opening the bowel åbut nothing comes out when trying to open
bowel), pain in the abdomen, weight loss, loss of appetite, family history, smoking,
anaemia symptoms

3. Medication - Codeine, Morphine, Antacids, Anti-epileptics, Anti- depressants,

Calcium, Iron

4. Anal fissure - Pain in the back passage on defaecation, fresh blood sticking to the
stool

5. Haemorrhoids - Fresh blood flashing on toilet bowl, Lump in the back passage

6. Medical conditions - Hypothyroidism, Multiple sclerosis, Parkinson’s disease

7. Immobility

8. Dehydration

9. Diet (No high fibre diet)

10. Pregnancy

11. Inflammatory bowel disease

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 30. 80 year old lady Mrs Edith Thompson had hip operation one week ago.
Since then she is having constipation. Take history and talk to her about the
further management.

Dr: Hello, Mrs… I am Dr….How are you doing?

Pt: Doctor I am having constipation?

Dr: Sorry to hear that. Can you please tell me what exactly you meant by constipation –
do you mean you did not open bowel for long time or you have to strain more than usual
to open the bowel.

Pt: Doctor It is both.

Dr: Since when

Pt: Since about one week now. I am having it sine this operation I had on my hip.

Dr: Are you passing any stool at all or not opened bowel at all?

Pt: I did not open bowel for the last 4 to 5 days.

Dr: Do you have any pain in your tummy? (Intestinal obstruction)

Pt: No but it is very uncomfortable

Dr: Have you vomited? (Intestinal obstruction). Pt: No

Dr: Are you able to pass wind? (Intestinal obstruction). Pt: Yes

Dr: Is there any bleeding from your back passage? (bowel cancer, anal fissure,
haemorrhoids) Pt: No

Dr: Do you have any diarrhoea also along with constipation. Pt: No

Dr: Have you noticed any change in your weight? (bowel cancer). Pt: No

Dr: How is your appetite. Pt: I don’t feel like eating

Dr: Do you get the feeling of opening the bowel but nothing comes out when trying to
open bowels? (tenesmus – rectal cancer). Pt: No
Dr: Any pain in the back passage while trying to open the bowel? (anal fissure) Pt: No

Dr: Did you feel any lump in your back passage? (haemorrhoids) Pt: No

Dr: Did you see any mucus in the stool, any joint pains? (Inflammatory bowel dx.) Pt: No

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 Dr: Do you have any medical conditions? Pt: No

Dr: Like diabetes or thyroid problems any bowel problems before? Pt: No

Dr: Are you taking any medication? Pt: Yes I am taking Co-codamol.

Dr: Since when are you taking co-codamol? Pt: Since after the operation – one week

Dr: Any of your family members have any kind of bowel problems or bowel cancer at all?

Pt: No

Dr: Do you eat enough of fruits and vegetables? Pt: Yes

Dr: Do you drink enough fluids? Pt: Yes

Dr: Have you been physically resting for long time?

Pt: Well, after this operation I am not moving around that much.

Examination:

I need to examine your tummy and your back passage. (The examiner may say hard
stool felt in the rectum).

Diagnosis:
Mrs Thompson, I think the Co -codamol medication what you are taking for pain is
causing this constipation because one of the side effects of co-codamol is constipation.

Treatment:

First of all, we will stop giving this medication and we will give you some other
medication which will not cause constipation - maybe we will give you Paracetamol if
you are not in that much pain now.

We can give you some laxatives like senna, bisacodyl and sodium pico- sulphate to
help you to open your bowel.

You should drink plenty of fluids and eat high fibre diet like fruits and vegetable or whole
wheat bread. That will help you to open bowel.

Pt: What if the laxatives do not work?

Dr: We can give you some medication like Bisacodyl as Suppository – this type of
medicine is inserted into your back passage.

Pt: What if that also does not help ?

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 Dr: Then we can give enema where a medicine like Docusate and sodium citrate in fluid
form is injected through your back passage into your large bowel.

Pt: What if they do not help

Dr: We can evacuate the stool manually once then you should be able to pass the stool.
Dr Any other concerns. Pt: No

Dr: Thank you very much

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 31. 87 year old lady was admitted to Orthopaedic ward 5 days ago with history
of fall due to trip. Patient is in physiotherapy. She is drowsy. Talk to the
nurse looking after her and discuss the management with the nurse.

Patient also may be in the cubicle. Can’t take history from patient because she is drowsy.

Dr: Hello. I am Dr... I am one of the junior doctors in the Orthopaedic department. How
may I call you? Nurse: You can call me Elaine.

Dr: How are you Elaine? Nurse: I am fine thank you doctor.

Dr: How can I help you ? Nurse we have an 87 year old lady in the ward who has
constipation. I need to talk to you about her.

Dr : Please tell me. Also may I know the name of the patient please?

Nurse: Mrs Thompson tripped and fell 5 days ago. She had a fracture of T8 vertebra.
Doctors treated her with bed rest. Now she is constipated.

Dr: Did she have any surgery for that? Nurse: No she didn't have any surgery.

Dr: what medications have been prescribed? Nurse: She is taking Aspirin, Dihydrocodiene
and Bisphosphonate.

Dr: Is she complaining of any other symptoms ? Nurse: Yes she complains of having
constipation along with bouts of diarrhoea since she came to the hospital.

Dr: Could you please tell me what she meant by constipation. Like is she having
difficulty defecating due to hard stools or has she not opened her bowel at all?

Nurse: She has not opened her bowel for the last 4 to 5 days.

Dr: Does diarrhoea alternate with constipation? Nurse: Yes she has diarrhoea and
constipation / No

Dr: Okay. So has she had constipation after she fell down or has she have constipation
even before she fell down ? (any chronic condition/Old age)

Nurse: She didn’t have constipation before she fell down.

Dr: Is she having any pain in tummy ? Nurse : No.

Dr: Has she had any vomiting. Nurse: No vomiting doctor. (Intestinal Obstruction)

Dr: Is she passing wind? Nurse: Yes/No

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 Dr: Did she tell you about any bleeding from the back passage? Nurse: No / I don’t
know about that. (Haemorrhoids/Rectal CA)

Dr: Was there any mucus in the stool when she has diarrhoea? Nurse : No
Dr Was the stool colour dark or normal when she had diarrhoea ? Nurse : Normal

Dr: It’s okay Elaine. You are providing valuable information. Thank you very much for
that. I just need to ask a few more things before we can discuss how to manage Mrs
Thompson and relieve her problem. Is that alright? Nurse: Yes doctor sure.

Dr: Do you know has she lost weight recently ? Nurse: Not sure about that too. (Bowel CA)

Dr: Does she have any pain on opening her bowel ? Nurse: No (Anal Fissure)

Dr : What about her diet and fluid intake? Nurse: Unfortunately she is not eating and
drinking well.

Dr: Ok. You said she is on bed rest now. Was she bed ridden even before the fall ? Is
she been physically resting for longer periods or has she been adequately mobile?

Nurse: I am not sure before the fall but now she is on bed rest She is on bed rest
doctor. Dr: OK,

Dr: Has she got any other problem other than constipation and diarrhoea?

Nurse: She is bit drowsy. Dr- since when? Nurse….

Dr: Did you examine her by any chance Elaine?

Nurse: Yes doctor. I did per rectal examination.

Dr: That is very good of you Elaine. May I know what did you find on rectal examination?

Nurse: The examination was normal. No hard stools.

Dr: OK alright. Did you notice any lump? or any fissure? Nurse: No

Dr: okay Is she having any other medical condition? Nurse: No doctor.

Dr: Does any of her family members have any medical conditions such as colon cancer/
IBD? Nurse: I don’t know/ No

Dr: Has she got hypothyroidism ? Nurse: No.

Dr: Does she have any intolerance to cold? Nurse: No

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 Dr: I will go and examiner her and maybe we need to do X ray of her tummy if required.

You said she is on Dihydrocodeine and bisphosphonate. Opioids That is Codeine are
known to cause constipation. We can switch her to paracetamol of she is not in much
pain. I will assess her for that. One of the side effects of bisphosphonate is also
constipation. I will discuss with my seniors about all the findings and we will manage her
medications accordingly. Nurse: okay doctor.

Dr: She may be feeling drowsy may because of the codeine - you know drowsiness is
one of the side effect of codeine. Hopefully she will become alert when we stop codeine.

Nurse : Ok

Dr: Diarrhoea can be due to constipation called as Overflow diarrhoea. So we need to

treat constipation first. Dehydration and not having high fibre food also caused
constipation. We need to ensure that she is drinking and eating well. We need to
provide her with fluids regularly. Also we need to give her diet rich in fibre with lots of
fruits and vegetables. This might relieve her bowel problem. Nurse: Certainly doctor.

Then we can use laxatives after that. If constipation is not relieved we can use
suppository. Our last resort will be Enema. Are you following, Elaine? Nurse: Yes
Doctor.

Dr: I will talk to the Ortho team to see when we can start mobilising her because you
know sometimes immobility leads to constipation. Nurse : Ok

Dr: We need to rule out a few serious conditions like bowel cancer if the constipation
does not settle. We might need to do certain invasive procedures such as colonoscopy
for that purpose. But hopefully it will be relieved soon. Nurse: OK

Dr: We also need to do some blood tests including Full blood count, Urea and
electrolytes, Thyroid function tests and serum calcium levels. Nurse: Okay Doctor.

Dr: Elaine do you have any questions ? Nurse: No doctor.

Dr: Thank You so much Elaine for providing me with all the information. I am happy to
see that you are so dedicated to patient care. I will also go and check on Mrs
Thompson now.

CONSTIPATION - HISTORY FROM NURSE

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224
 32.
Middle aged lady having diarrhoea and vomiting. Infection Control has already
been notified. History and management.

- GRIPS

- How can I help you?

P: Dr. I am having pain in my lower tummy. D: Can you please tell me more about it….

P: I am having it since past 3 days. It’s in the lower part….

Do SOCRATES and also rule out blood in the stool. This would be suggestive of
bacteria.

Dr: Do you have anything else?

P: Doctor I have been having diarrhoea and vomiting since past 3 days.

D: I am sorry to hear that. Can you please tell more about it?

P: Doctor I have been having loose stools and vomiting. And it was 5 episodes on day 1
and twice on day 2. (maybe, she will say that she came to the G.P clinic because now
she learnt that G.E is a notifiable disease.)

D: Do you have any idea why you may be having this? Did anything happen? Did you
have these symptoms before the eating the food?

P: Yes Doctor I had food with my husband and son in a restaurant and after that it
started. Even though they had similar complaints, they got better in a day.

D: Ok can you give me the name of the restaurant ?

P: Doctor it is .......................restaurant (she gave the name of the restaurant)

D: we will inform the food authorities about it.

P: No, Dr please don’t inform them as I don’t want restaurant people to face any trouble.

D: Unfortunately, we need to notify it.

Rule out differential diagnoses

- Diverticulitis - PID

- APPENDICITIS - UTI

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 Reasons for admitting such patients

- Severe vomiting - patient can’t keep the foo down

- Severe dehydration - severe lethargy

- Very high fever

- Blood in the stool

D: Do you have swelling in your neck area ? .. No

D: Any preference for weather? ….. No (hyperthyroidism)

D: Any lumps or bumps anywhere in the body ? ..... No

D: Any weight loss recently ...... No

D: Any blood along with the stools? D- Any fever? No

MAFTOSA: * Do ask her what job she does, any medications (Antibiotics)

D: Anything else? … Pt: Doctor, I am drinking enough water every day and
keeping myself hydrated Praise her

“Thank you very much for giving all the important information.”

Examination:

I would like to examine you now. I will do a general physical examination, check your
vitals, and examine your tummy ------- examiner did not give any findings.

Management:

From the information you have given me and after examining you I think you may be
having what we call as Gastroenteritis because of food poisoning. Do you know what it
is ? Pt: no. Dr: Gastroenteritis is a condition which occurs due to inflammation of the
wall of the Gut because of some bugs. This results in vomiting, diarrhoea, fever and
pain in the abdomen.

For now, we need to do some investigations including:

Blood – FBC, U&E, Infection markers, ABGs.

- For now, since you said that your symptoms are subsiding so we don’t see any need
to admit (check it before saying). We will prescribe you some ORS powder to be
mixed in water and then drink.

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 - I encourage you to notify your employer about your condition as this can spread to others.

- Do you have any concerns? No Doctor

(If she works for a carer home. If yes, then you will have to ask her to tell her employer
about it.)

You also need to talk about the need to report to Infection Control

Safety netting: If you have any severe vomiting loose stools or pain then please do
come back to us. If diarrhoea doesn’t stop within 2 weeks, she should return to the
hospital.

Thank you.

ACUTE GASTROENTERITIS

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228
 33.
65 year old lady presents with diarrhoea. Take history and discuss management.

HISTORY

Primary complaint? (patient complains of change in bowel habits)

How long did it last? (2 months/7 days) What was the colour of the stools?

What was the nature? Watery/loose/mucus?

Was there blood present? (1 episode of dark blood mixed with stools). If she mentions
bright red blood, rule out causes of fresh blood in stool - haemorrhoids, anal fissure, rectal
carcinoma. How many times did you pass in a day?

Did you experience constipation anytime during this time period? (altered bowel
habits can signify colon cancer)

Are you able to pass wind?

Did you feel any lumps on your back passage, Did you see the blood splashing in the
toilet bowl? (haemorrhoids)?

Any associated factors: - fever (Gastro-enteritis) - vomiting - tummy pain

Patient gives negative history of pain, fever, vomiting or pain in the back passage (anal
fissure) while passing stools.
Dark coloured and very foul smelling? (diverticulitis)

Do you get the sensation that you have not completely opened the bowel even after
opening the bowel? (tenesmus – rectal carcinoma)
Assess dehydration status

- are you passing reduced volume of urine?

- are you experiencing dry mouth?

- have you been feeling thirsty nowadays?

- Have you experienced any weight loss? (cancer) (patient may say no weight loss)

- Have you experienced tremors/palpitations, weather preference? (hyperthyroidism)

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 - Have you travelled anywhere recently? (gastroenteritis)

- Have you had food from outside recently?

MAFTOSA - ask specifically for medications [antibiotics (clostridium difficile),

sometimes excessive use of laxatives can cause diarrhoea] and family history of
cancers/similar history of diarrhoea.
Examination

I would like to examine your tummy and check vital signs. {examiner may say -
examination is normal}
If diarrhoea lasts for 2 months- We have to do tests to find out the exact cause.

We have to admit you and do some blood tests and stool to check for any bugs. We
would also like to check if you have dehydration.

We shall refer you to a Gastroenterologist who might do colonoscopy.

(Explain what colonoscopy is - a long flexible tube which has a camera attached to
its end that we have to pass through the back passage into the colon so that we
can have a look inside the colon and take a tissue sample.)

Diagnosis: We need to check whether you have any sinister growth in the bowel. That
is why colonoscopy is the best test compared to the other Dye X-Ray test (barium
enema) because we cannot take tissue sample in the X-Ray test.

It is very important to have this test because in case, there is any growth, it’s better to
catch it at an early stage. In addition, if it is in an early stage we can treat it easier. If
we delay the test, then the growth may spread and then it is difficult to treat.

Try to persuade her to stay in the hospital. If she still does not agree, tell her that you
will speak to the seniors and they may be able to convince her.
Treatment: depends on what we find on the investigation. If at all it is growth then it
depends on the stage of the growth. We may need to do surgery or may be Radiation
therapy.

Any cancer less than 4 weeks, you should rule out both acute and chronic causes of
diarrhoea. If more than 4 weeks, you can only rule out causes of chronic diarrhea

DIARRHOEA IN AN ELDERLY LADY

230
 DYSPHAGIA
Differential Diagnoses & Relevant Questions

PEGG COM PASS

P Palsy (Stroke/spinal injury/botulism/MS/PSP/ALS/Parkinson), Bulbar palsy

Difficulty in talking? Making sound?

Recurrent chest infections due to aspiration

Other weakness?

Difficulty initiating swallowing

E Endoscopy/instrumentation

Did you have any procedure done recently? Any camera tests done in your food
pipe?

G GORD

Belching? Burning fluid coming from your stomach to your mouth, worse on
lying?

G Globus hystericus

Do you have a sensation of a lump in your throat?

C Cancer of the Oesophagus

Starts first with solids

Weight loss? Weakness?

Smoking? FH?

Steady, gradual worsening?

O Oesophagitis Or Infection of tonsil, larynx or epiglottis (Fever), Pain

(odynophagia)

M Myasthenia

Worse in the evening? Feel weakness in evening or after exertion?

231
 P Pharyngeal pouch

Bad breath? Food on the pillow in the morning?

Old food regurgitated?

A Achalasia

Starts with liquids (this is wrong it start with both check the NHS-website). Can also
present with loss of weight. But with slower presentation than cancer.

S Stricture

Long time heartburn? Or past corrosive ingestion?

Any procedures/instrumentations done?

S Spasm (diffuse oesophageal spasm DES)

Intermittent? Cold or hot food makes it worse?

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 34. 50 year old man presents with dysphagia.
Take history, examine and discuss relevant management with the patient.

Dr: Hello Mr ...... My name is Dr…. what brings you to the hospital today?
P: I have had trouble swallowing doctor.. I also have a lot of discomfort in my lower chest

Dr: I am very sorry to hear that Mr.…. could you please tell me when this started?

P: It has been few weeks doctor

Dr: Has it worsened since then? P: Yes.. Initially it was mainly to solid food items. Now it is
also to liquids

Dr: Did it start with liquids first or solids first? P: Solids first now it is liquids also doctor.

Do you have any pain while swallowing (Odynophagia – infections)? Pt: No

Dr: Is it worse towards the end of the day (Myasthenia)? P: No

Dr: Have you had any vomiting? P: No

Dr: Have you thrown up any blood? P: No

Dr: Do you have any difficulty in talking? (Palsy, MS) Pt: No

Dr: Did you have any procedures done on you food pipe recently? P: No

Dr: Do you have heartburn/burning sensation in the middle of your chest? (GORD) P: No

Dr: Do you have a sensation of a lump in your throat (Globus hystericus)? P: No

Dr: (Pharyngeal pouch) Do you feel your breath smells bad ? P: No

Dr: Fever (tonsillitis)? P: Yes/No

Dr: (cancer) Have you noticed any change in your weight?

P: Yes my belt has become loose (quantify)

Dr: Have you noticed any lumps in your neck or your armpits? P: Yes/No

Dr: Have you been diagnosed with any medical conditions? Pt: No

Dr: Are you on any medications? P: No

Dr: Do you smoke? P: Yes, Dr: Could you tell me what you smoke and how much?

P: I smoke 15-20 cigarettes a day. I have been smoking for > 30 years

233
 Dr: Do you consume alcohol? P: Yes/No

Dr: Any of your family members have any medical conditions? P: No

Dr: Any of your family members been diagnosed with any cancers? Pt: No

Dr: Is there anything else you think is important that we need to know ? Pt: I don’t know.

Examination:

Mr… I would like to examine your oral cavity, neck, chest, abdomen and your armpits to
look for any lumps or swellings. Examiner might or might not give findings

Diagnosis:

Dr: Do you have any idea why you may be having this swallowing problem? Pt: No

Dr: I guess you have some serious condition? Do you like to know? Pt : Yes

Dr: I think you may be having cancer of the food pipe.

Pt: May be shocked ---- Silent ........ Are you sure doctor ?

Dr : That is what I think you may have, but I am not sure now. We will refer to a specialist
doctor – who is a gastroenterologist. He will do some investigations to find out the cause.

Pt: What investigations???? Dr: He may do a special test called Endoscopy which is a
camera test where a tube with a camera will be passed from your mouth to your food pipe
and to the stomach. He can visualize the problem and may take a tissue sample if he finds
any growth in the food pipe to check what exactly the growth is?

He will tell you the exact diagnosis after the investigation.

Pt: What if it is cancer, how will you treat it?

Dr: The specialist doctor will tell you how they will treat it. Generally, it depends on the
stage of the cancer – either they may do surgery or give you chemotherapy (special
medications for cancer) or Radiation therapy.

Pt : I can’t swallow anything now.

Dr : We will admit you now to do the investigation and the specialist doctor may insert a
stent (a tube in the food pipe which will help in swallowing)? Is that Okay ? Pt: OK

Dr: Any other question? Pt: No, Thank you.

DYSPHAGIA IN A 50 YEAR OLD MAN

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 GORD
INFORMATION NOTE

Gastro-oesophageal reflux disease (GORD) is a common condition, where acid from

the stomach leaks up into the oesophagus (gullet).

It usually occurs as a result of the ring of muscle at the bottom of the oesophagus
becoming weakened.

GORD causes symptoms such as heartburn and an unpleasant taste in the back of the
mouth. It may just be an occasional nuisance for some people, but for others it can be a
severe, lifelong problem.

GORD can often be controlled with self-help measures and medication. Occasionally,
surgery to correct the problem may be needed.

Symptoms of GORD can include:

- heartburn (an uncomfortable burning sensation in the chest that often occurs
after eating)

- acid reflux (where stomach acid comes back up into your mouth and causes an
unpleasant, sour taste)

- oesophagitis (a sore, inflamed oesophagus)

- bad breath

- bloating and belching

- feeling or being sick

- pain when swallowing and/or difficulty swallowing

The main treatments for GORD are:

- self-help measures – this includes eating smaller but more frequent meals, avoiding
any foods or drinks that trigger your symptoms, raising the head of your bed, and
keeping to a healthy weight

- over-the-counter medicines – ask your pharmacist to recommend an antacid or an

alginate

- stronger prescription medicines – including proton-pump inhibitors (PPIs) and H2-

receptor antagonists (H2RAs)

235
 - You may only need to take medication when you experience symptoms, although long-
term treatment may be needed if the problem continues.

- Surgery to stop stomach acid leaking into your oesophagus may be recommended if
medication isn't helping, or you don't want to take medication on a long-term basis.

Complications of GORD

If you have GORD for a long time, stomach acid can damage your oesophagus and
cause further problems.

These include:

- ulcers (sores) on the oesophagus – these may bleed and make swallowing painful

- the oesophagus becoming scarred and narrowed – this can make swallowing difficult
and may require an operation to correct it

- changes in the cells lining the oesophagus (Barrett's oesophagus) – very occasionally,
oesophageal cancer can develop from these cells, so you may need to be closely
monitored

236
 35. A 54 year old man has come with complaints of indigestion. Address his
concerns and discuss management with the patient.

D- “Hello, I am Dr ------- , one of the junior doctors in the department. How are you
doing?”

P- “Dr, I have this burning sensation in the chest”

D- “I am sorry to hear that. Could you tell me how long have you been feeling this?

D- “Can you point it where exactly are you feeling this sensation? P- Points to epigastric

region

D- “Is there anything that makes it better or worse?”

P- “Dr, I eat spicy food. Every time I have it, the sensation gets worse. Also, whenever I
burp, there is some sour fluid that comes up to my mouth and I have to swallow it. I just
can’t take it anymore”

D-“ I can imagine that you must be in distress. We will try to help you as much as we can.

Did you have any other symptoms-

Fever-NO, Tummy pain-NO, Chest pain-NO, Vomiting (Blood)-NO

Bowel problems-NO, Difficult in swallowing food/liquid-NO

MAFTOSA - He is a smoker since 15-20 years.

May gave history of consumption of alcohol. He gives history of over the counter
medications- Rennie tablets for 6 months.
(RENNIE TABLETS IS AN ANTACID BASED CALCIUM CARBONATE AND
MAGNESIUM CARBONATE FORMULA)

Examination:

D-“I would like to examine you now and will ensure privacy and chaperone. I will
examine your neck, chest and tummy. Ask for NEWS chart.

Examiner may say- All normal

D-“From what you have told me and from what I have examined, I suspect you have a
condition called GORD (Gastro Oesophageal reflux disease). Do you know anything
about it?” P- “No, Dr.”

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 D- “It is a condition where acid from the stomach leaks into the food pipe hence giving
your typical symptoms - burning sensation in your chest and unpleasant taste in your
mouth.

This condition can be caused or made worse by: Certain foods/drinks- such as coffee,
alcohol, intake of spicy food, Smoking, Anxiety
p- “ What are you going to do for me now?”
D- “We will do some blood tests - FBC as well as refer you to the gastroenterologist for
endoscopy to see if there is any damage to the stomach wall and to rule out any other
problems.” Mention H.Pylori breath tests

P-“Dr.. I don’t want an endoscopy. One of my friends had the procedure and it was quite
unpleasant. He was in a lot of pain” (Patient is aware of what is endoscopy and says it
is a camera test).

D- “I understand. But before the procedure, we will give you a local anaesthetic spray to
numb that specific area. It shouldn’t be painful after that. Will you consider that?”

P- “Alright, Doctor. That sounds better.”

D- “We will also give you medications to protect the stomach wall - PPI’s. They are
medications like Omeprazole. Hopefully, you should get better.

I can tell you some remedies that will help you relieve your symptoms:

Eat smaller frequent meals. Eat well before your bed time to avoid indigestion.

• Raise your head end of the bed by putting an extra pillow so that acid doesn’t travel
up to your mouth.

• Try to avoid all trigger factors - spicy food, smoking, alcohol. This will only worsen your
condition.

• Talk to your GP before taking any over the counter medications.

P – Will there be any problems because of this ?

D – Rarely, it can cause narrowing of the food pipe causing difficulty in swallowing,
sometimes it can cause soreness of the food pipe causing pain. Very rarely it can cause
serious problem that is cancer of the food pipe. However, if it is treated, all these
problems will not happen. Do not worry.

Is there anything else I can help you with?” P-“No, Doctor. Thank you”

GASTRO-OESOPHAGEAL REFLUX DISEASE

238
239
240
 35 B. Patient has had endoscopy and biopsy done - results are inside the cubicle.

Results show intestinal metaplasia and Barrett’s oesophagus. He is to do an endoscopy

again in 3 years. Talk to patient.

- Take a history like the station in GORD

- Patient has multiple risk factors-smoking/alcohol/diet (spicy food).

- Check whether he had GORD previously. Find out the cause of the GORD.

- Family history, weight loss, smoking.

- Reassure that Barrett's oesophagus is only a precancerous condition and is not

cancer now.

“However it can rarely become cancerous. So we will do endoscopy again after 3

years.”

“Avoid the causes/triggers of GORD to reduce the chance of changing to cancer.”

- Advise to come back if he has – weight loss, swallowing difficulty, haematemesis

- Patient keeps asking, “Do I have cancer?” He keeps saying, “Why do I have to come
again?” He also asks about treatment and if something can be done about it. Say,
“Unfortunately nothing can be done now to prevent changing to cancer other than
reducing causes of GORD, but it is rare to change to cancer.”

- If he still insists on surgery, tell him how serious and extensive surgery would be if
he were to undergo it.
35B. BARRETT’S OESOPHAGUS FOR SURVEILLANCE SCAN

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242
 36. A 40 year old man, Mr Hutchinson, presented with abdominal distension
for past 4-6 weeks. Assess him and discuss the further management with
the patient.
Causes of abdominal distension

• Fluid (ascites = exudates – cancer, TB; Transudate – liver failure,

renal failure, Heart failure)
• Fat (obesity)
• Faeces (constipation)
• Flatus
• Foetus (pregnancy)

Dr: Hello my name is Dr … I am one of the junior doctors in the department. How can I
help you today?

Pt: Doctor, my tummy is bloated. I feel heavy as if I am carrying some weight. I am

really worried about it.

Dr: Can you tell me how long you have been feeling like that?

Pt: For about 4 to 6 weeks.

Dr: Can you tell me if the swelling develop suddenly or gradually?

Pt: It developed gradually.

Dr: Any pain in your tummy? Pt: No

Dr: Any particular type of food makes it worse? Pt: No

Dr: Any nausea or vomiting? Pt: No. [If yes, ask about blood in vomitus (haematemesis)]

Dr: Any yellowish discolouration of your skin? Pt: No

Dr: Have you have itchiness? Pt: No

Dr: Any facial swelling (Renal failure)

Dr: Any bowel problems like diarrhoea or constipation (intestinal obstruction)? Pt : No

Dr: Any change in stool colour (malaena)? Pt: No

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 Dr: Have you lost any weight? Pt: No

Dr: Have you been diagnosed with any medical conditions in the past? No

Dr: Weight loss (cancer & TB)

Dr: DM/HTN? Pt: No

Dr: Have you ever had any liver problem before? Hepatitis? Jaundice? Pt : No

Dr: Any previous surgeries? Blood transfusion? Pt: No

Dr: Do you drink Alcohol? Pt: Yes

Dr: How much and for how long? ….. (Pt will say that he drinks a lot)

Dr: Do you smoke? Pt: No/Yes

Dr: Do you use recreational drugs (IV Drug abuse)? Pt: No.

Dr: Have you travelled anywhere recently? Pt : No

Dr: Are you on any medication? Pt No

Dr: Any of your family members has any medical conditions? Pt : No

Dr: Is there anything else you think is important that we need to know? Pt : No

EXAMINATION: THIS CAN BE A MANNIKIN EXAMINATION

Do a general physical examination and then an abdominal examination

I need to examine your tummy, eyes and hands Mr Hutchinson,

Can you please undress above your waist. (exposure to abdominal examination is
from mid chest to mid thigh)

Position patient – on the bed, sit upright for the first part of the examination

General inspection: Do this on the simulator

1. Hands:

No Clubbing, no nail changes or palmar erythema,

No flapping tremor (hepatic encephalopathy / uraemia / CO2 retention)

244
 2.Eyes: No jaundice, No pallor

3.Chest - No Spider naevi ( chronic liver disease) and no

gynaecomastia ( liver cirrhosis / digoxin/ spironolactone),

No Pedal edema

4.Detailed abdominal inspection, Do this on the mannikin :

 Inspection of abdomen

No operation scars, prominent veins, no visible masses or pulsation

No – bruising surrounding umbilicus [Cullen’s sign-retroperitoneal bleed

(pancreatitis/ruptured AAA)],

No bruising in the flanks [Grey-Turner’s sign – retroperitoneal bleed (pancreatitis/

ruptured AAA)]

Abdominal appears to be distended, No prominent veins (Caput medusae)

 Palpation

Observe the patient’s face throughout for signs of discomfort.

Light palpation: No tenderness, No guarding

Deep palpation - No masses felt.

Liver – Palpate over abdomen for lower border and percuss the chest from 2nd
intercostal space downwards (normal liver span is between 5th rib to costal margin
which is 9th rib) for upper border of the liver. Liver might be enlarged

Comment on the border – sharp or blunt, any nodules on the surface

Palpate for Spleen and Kidneys - not enlarged

Percussion - Shifting dullness

Auscultation - Bowel sounds are normal

Verbally mention - I will examine the groin area for hernia. I will examine the genitalia
and perform a digital rectal examination (PR)

245
 Provisional Diagnosis:
Dr: Mr Hutchinson - From the information you have given me and from the
examination, I suspect that you have Alcohol-related liver disease (ARLD). Do you
know anything about it? Pt: No.

Dr: I am really sorry to tell you that excessive intake of alcohol might have damaged
your liver that is what we call alcohol related liver disease. It may have caused fluid to
accumulate in your tummy causing it to bulge.

We need to do certain blood tests to check your liver functioning to make sure that
you do not have any other causes for distension of your tummy. Also we need to do an
ultrasound and a CT scan of your tummy. We also might need to take a fluid from your
tummy and test in the lab.
MANAGEMENT:

Dr: I am really sorry to tell you that there's currently no specific medical treatment for
this condition. The main treatment is to stop drinking alcohol for the rest of your life.
This reduces the risk of further damage to your liver and gives it the best chance of
recovering. What do you think ?

Pt: But I have been drinking all my life Doctor.

Dr: Mr … I can understand but we can help you to stop drinking alcohol if you wish to do so.

But if you don’t stop, the condition can progress and lead to failure of your liver.

- A liver transplant may be required in severe cases if the liver has stopped
functioning.
- We will admit you now to do the tests.
- We will give you some medications that we call diuretics to reduce the fluid in
your tummy. If too much fluid gets collected in your tummy, then we need to
drain the fluid.
- You can get malnourished due to this condition. So it's important to eat a
balanced diet to get all the nutrients you need. Our dietician will advise you on
the diet.
- Reducing salt in your food can reduce your risk of developing swelling in your
legs, feet and tummy caused by a build-up of fluid.

ABDOMINAL DISTENSION - ALCOHOLIC CIRRHOSIS

246
 DRY COUGH ± HEMOPTYSIS
Differentials for cough for > 3 weeks:

1. Bronchial carcinoma - Smoking, Weight loss, Haemoptysis.

2. Mesothelioma – exposure to asbestosis, building worker (roofer, plumber,

carpenter), weight loss.

3. Infection - T.B – Haemoptysis, night sweat, weight loss, contact with anyone with TB.

4. Asthma – allergy to pets, wheeze, pollen, exercise.

5. COPD - > 3 month for 2 consecutive years, wheeze.

6. CCF – ankle swelling, orthopnoea, PND.

7. Diffuse parenchymal lung disease.

8. Drugs – ACE inhibitors, Beta blockers

9. Psychogenic

10. GORD – heart burn, regurgitation.

11. Pulmonary Embolism – SOB, Chest Pain, Haemoptysis, Calf Pain, Travel, Surgery,
Recent immobilization.

Differentials for Acute cough < 3 weeks

1. Foreign body – sudden onset.

2. Infection - URTF/ Pneumonia/ Infective COPD

Patient with dry cough – Take history for the patient and tell your differentials and
investigations to the examiner.

Patient will give the same story as above

Also he may say that his son lives in Tanzania and visited him few months ago and both
of them started to having cough at the same time.

Differentials

Mesothelioma – Investigations – Chest X Ray, CY scan , Bronchosopy and biopsy

Lung Cancer Investigations – Chest X Ray, CY scan , Bronchosopy and biopsy

TB – Chest X Ray, Sputum - AFB test, Gold quantiferon test, Mantoux test.

247
 37. You are an F2 in Medicine
A 60 y/o man presents with complaints of cough for the last few months. He has
coughed up blood few times in the last week.

Take history, examine and discuss management with the patient

Dr: Hello Mr... my name is Dr... I'm one of the junior doctors in the medicine department.
What brings you to the hospital today?

P: Doctor.. I have been having this bad cough for a few months now.. And for the last
few days I have coughed up some blood as well

Dr: I'm sorry to hear that Mr... Could you please tell me when this problem started?

P: It has been over 6 months now.

Dr: Is the cough associated with any sputum/phlegm?

P: No it is a dry cough

Dr: Have you had any shortness of breath? P: Yes.

Dr: Could you please tell me when that started? P: Around the same time

Dr: Has it worsened since then? P: Yes/No

Dr: You mentioned that you had coughed up some blood few times this week. Could you
please tell me more about it? How much of blood did you cough up?

P:

Dr: Do you have any chest pain? P: No (Might say yes if mesothelioma)

Dr: Fever? P: Yes/No

Dr: Have you noticed any swellings in your neck or your armpits? P: No

Dr: Do you have any trouble swallowing? P: No

Dr: Do you have any pain in your calves? P: No

Dr: Have you noticed any change in your weight? P: Yes (assess quantity)

Dr: Do you have any other complaints that you wish to report Mr...? P: No, doctor

Dr: Do you have high BP? P: No

248
 Dr: Diabetes? P: No

Dr: Thyroid related illnesses? P: No

Dr: Are you on any medications? P: No

Dr: What is your diet generally like? P: Balanced doctor

Dr: Do you smoke Mr...? P: Yes doctor.. I have been smoking for >20 years

Dr: Could you tell me what you smoke in a day? P: 1 pack of cigarettes/day

Dr: Do you consume alcohol? P: Yes/No

Dr: Do you have any allergies? P: No

Dr: Do you have any family history of medical problems? P: No

Dr: F/H of cancers? P: No

Dr: What do you do for a living Mr...? P: I work as a plumber/carpenter/roofer (or) Patient
might not give a significant occupational history.
Dr: Have you travelled anywhere recently? P: Yes/No (look for travel to TB endemic
areas)

Dr: Ok, Mr... I would like to examine your neck, chest and hands.

(Examiner may give findings of clubbing and /or swelling in the supraclavicular
area; and decreased or reduced air entry in the left or right lung.)

Dr: Mr...Do you have any idea what may be happening to you? Pt: No, doctor.

D: Mr… It looks like you have some serious condition. Do you want to know about it?

Pt : Yes, doctor.

Dr: Based on the information you gave me, it looks like you have cancer in your lungs or
lining of the lung. Pause

Pt: Oh …. Really … I didn’t expect doctor.

[Pt may say “ my friend who was working with me had been diagnosed with
mesothelioma. Do I also have the same doctor?”]

Dr: I wish it was not true but unfortunately you are right that it is possible that you too
may be having the same problem.

249
 Dr: However we will need to do some tests to confirm that. First, we will do a chest
X-ray. Examiner might show you the chest x ray

Scenario 1 – Lung cancer

Scenario 2 – Mesothelioma

SHOW XRAY TO THE PATIENT

Dr: Mr... I have your Chest Xray with me. Would you like to take a look at it?

P: Ok doctor

Dr: These are your lungs Mr .... and this is your heart. Can you see this round opaque
shadow at the top of your lung here? P: Yes

“I am sorry to say that I do not have very good news for you. Mr ... “

“Unfortunately this looks like a cancer of the lung ... “

Dr: We will have to do further tests to confirm the diagnosis, like a CT scan of your
chest. We will also refer you to a specialist... a pulmonologist ... who will do a procedure
called a bronchoscopy, where we will have to pass a flexible tube with a camera through
your mouth into your airways to get a better view of the problem. If needed, he might
take a tissue sample and send it for further analysis. Are you following me, Mr ... ?

P: Yes, doctor. Why did this happen to me?

Dr: There are a few factors that can increase the risk of developing lung cancer. This
condition is common in those people who smoke for long time.

P: Is it treatable, doctor?

Dr: Mr ... the treatment depends upon the diagnosis. If it is cancer, then it will depend
upon the stage of the cancer, how far it has progressed and also the type of cancer. If it is
an early stage, we may be able to offer surgical options to remove the growth. But if the
cancer has advanced too much or if it is a more aggressive type of cancer, I'm afraid there
are no curative options. We might be able to offer treatment measures like Radiotherapy or
chemotherapy to prolong life and relieve the symptoms. Are you with me Mr...?

P: Yes, doctor I understand. You can go ahead with the tests..

Dr: Ok, Mr... I will speak with my consultant and arrange for them right away. Do you
have any other concerns? P: No, doctor
Dr: Once again, I'm sorry I don't have better news for you at the moment... If you have
any doubts, please feel free to ask for me.

250
 38. MESOTHELIOMA
Dr: Mr... I have your Chest X-ray with me. Would you like to take a look at it?

P: Ok, doctor

Dr: These are your lungs, Mr .... and this is your heart. Can you see this white opacity
over this lung? P: Yes

I am sorry to say that I do not have very good news for you. Mr ... Unfortunately, this
looks like cancer of the lining of your lung ... called mesothelioma.

We will have to do further tests to confirm the diagnosis, like a CT scan of your chest.
We will also refer you to a specialist... a pulmonologist ... who might try to take a
biopsy .... or a tissue sample from the lining of your lung and send it for further analysis.
Are you following me, Mr ... ?

P: Yes, doctor. Why did this happen to me?

Dr: There are a few factors that can increase the risk of developing mesothelioma.
Exposure to elements like asbestos which was used extensively in the construction of
old houses and buildings can affect the lining of the lung and cause this condition.

P: Is it treatable doctor?

Dr: Mr... Unfortunately this is a serious type of cancer. I'm afraid there are no definitive
curative options. We might be able to offer treatment measures like radiotherapy or
chemotherapy to prolong life and relieve the symptoms, but I am afraid there is no
permanent cure if you are indeed diagnosed with mesothelioma. Are you with me Mr...?

P: Yes, doctor, I understand. You can go ahead with the tests..

Dr: Ok Mr... I will speak with my consultant and arrange for them right away. Do you
have any other concerns?

P: No, doctor

Dr: Once again, I'm sorry I don't have better news for you at the moment.. If you have
any doubts, please feel free to ask for me.

Patient with dry cough – Take history for the patient and tell your differentials and
investigations to the examiner.

251
 Patient will give the same story as above

Also he may say that his son lives in Tanzania and visited him few months ago and both
of them started to having cough at the same time.

Differentials

Mesothelioma – Investigations – Chest X Ray, CT scan, Bronchosopy and biopsy

Lung Cancer - Investigations – Chest X Ray, CT scan, Bronchosopy and biopsy

TB – Chest X Ray, Sputum - AFB test, Gold quantiferon test, Mantoux test.

252
 39. You are the FY 2 doctor in the medical department.
30 year old homeless man presented with cough and shortness of breath.

Take history and examine the patient.

[Positive findings – dry cough, exertional dyspnoea, night sweat, bisexual, does
not practice safe sex, shares needles, homeless]

Dr: Hello Mr… I am Dr … one of the junior doctors in the medical department. How can I
help you Mr..?

Pt: Doctor I have been having cough for the last few weeks.

Dr: I sorry to hear that. Can you please tell me anything more about it ?

Pt: Like what, doctor?

Dr: Do you get it throughout the day or any particular time?

Pt: Throughout, doctor.

Dr: Anything makes it worse or better? Pt: No

Dr: I see. Do you bring out any phlegm when you cough? Pt: No

Dr: Do you cough up any blood? Pt : No

Dr: Do you have fever? Pt: No, but I feel a bit hot in the evening and I get sweating.

Dr: Do you have any chest pain? Pt: No (if yes – explore chest pain – since where,
when, type)

Dr: Do you have shortness of breath? Pt: Yes doctor

Dr: Since when? Pt: Since last few weeks?

Dr: When do you get breathlessness is it on exertion or even at rest do you feel short of
breath?

PT: When I exert my shortness of breath gets worse doctor.

Dr: Do you have any pain or swelling in your calf (PE) ? Pt : No

Dr: Dr: Have you noticed any change in your weight recently (Lung cancer,
Mesothelioma)? Pt: No

253
 Dr: Are you allergic to anything you know of (Asthma)? Pt: No

Dr: Have you ever came in contact with anyone who has similar symptoms (TB,
Pneumonia)? Pt: No

Dr: Have you ever been contact with anyone who has TB do you know? Pt: No

Dr: Have you travelled outside UK recently (TB) ? PT: No

Dr: Do you smoke? Pt: No

Dr: Do you drink alcohol ?Pt: No/Yes

Dr: Do you do recreational drugs? Pt: Yes.

Dr: What drug do you use? Pt: I inject heroin.

Dr: Do you share needles with others? Pt: Yes.

Dr: Are you sexually active? Pt: Yes

Dr: Do you have a regular partner? Pt: No regular partner.

Dr: Whom do you have sex with - males or females or both? Pt: I have male and
female partners. I am a bisexual, doctor.

Dr: Do you practice safe sex? Pt: No

Dr: Do you have any other medical conditions? Pt: No

Dr: Do you have diabetes or high blood pressure? Pt: No

Dr: Have you been tested for HIV or Hepatitis infections anytime? Pt : No

Dr: Are you on any medications? Pt: No

Dr: Are you allergic to any medications? Pt : No

Dr: Any of your family members has any medical conditions ?Pt: No

Dr: What job do you do? Pt: I am jobless doctor.

Dr: Where do you live ? Pt: I do not have a home doctor.

Dr: Sorry to hear that. We will try to help.

Dr : Is there anything else you think is important that we need to know?

Pt: I do not know doctor.

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 Dr: Mr .. I need to examine your chest and also check your pulse, Blood pressure and
your temperature. (examiner may or may not give any findings)

Dr: Mr… with what you told me, I think you have a condition we call Pneumocystis
Pneumonia. This is an infection of the lungs by some kind of fungus type of bugs. Do
you follow me?

Pt: OK. But why did I get this doctor?

Dr: This type of infection happens in those kind of people whose body resistance is low
for example people who have HIV infection. There could be a chance of you having this
infection because this type of infection is common in those people who do not practise
safe sex or shares needles with others when they use drugs. This infection can spread
easily this way. This is quite a serious condition if you have HIV infection also.

Are you following me Mr…

Pt: Yes. So what will happen now?

Dr: We need to do some investigations to confirm whether you have this condition. We
need to do some blood test to check for infection markers and also do chest X Ray.
[Examiner says – chest X Ray shows bilateral basal consolidation or fluffy
shadows]. Thank the examiner.

Dr: Mr… Your chest X Ray shows that you do have a chest infection. We need to do some
more tests to check what kind of bugs may be causing this this. For this, we need to test
your sputum (silver staining) if you can get some sputum – if not, we do a procedure
called bronchoscopy where we put some fluid into the wind pipe and take it out with some
instruments and then we test that for the presence of the bugs. We may also take some
tissue sample from the lungs. We may do a test called PCR (polymerase chain reaction)
to check for these bugs. Also, we may do CT scan of the chest.

Are you following me? Pt: Yes doctor.

Dr: It is better to check whether you have HIV infection also. We can treat the HIV
infection if you have it? Is that OK / Pt : Ok doctor.

Dr: Any questions? Pt: How will you treat me doctor?

Dr: To treat, we will admit you in the hospital. We will give medications called Co-
trimoxazole through your veins and another medication called Dapsone as a nebuliser -
something like steam inhalation. We may also give steroid medication to treat this bugs.

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 We may also need to treat the HIV infection if you have it.

I sincerely advise you to practice safe sex in the future and also stop using recreational
drugs. If not at least do not share needles with others. We have something called
needle exchange programme. You can get new needles for free.

Are you following me? Pt: Yes. Dr: Is that OK? Pt : Ok doctor.

Dr Any other questions? Pt : No.

Dr: We will talk to the social services and see if they can help you with shelter when we
discharge you. Thank you very much. Hope you recover soon.

DRY COUGH – PCP

256
 40.
Young man dry cough. History and management

Dry cough since 3 months, has night sweats, has blood in sputum, has weight loss, Has
been to south Africa 3 months ago. No known contact with any one with TB or similar
symptoms. Chronic smoker. Had SOB, able to talk.

Take Hx for other differentials like other dry cough stations.

Risk factor of immunosuppression HIV (recreational drugs and sexual Hx)

Works in community group with many people.

Examine the chest and hands, examiner may not give any findings. I need to check your
pulse, BP and temperature. Check for NEWS chart.

Investigations

Blood tests for infection markers, Sputum test for bugs and chest X Ray – there was
chest X Ray. May be normal or may show white shadows

Diagnosis:

You may be having a condition called Tuberculosis. Do you know anything about it?

I do not know

This is an infection of your lungs by bacterial kind of bugs called Mycobacterium

Tuberculosis.

This condition is very common in Asian and African countries. This infection can spread
from person to person by droplets while coughing or sneezing. So since you went to
Arica - may be you came into contact with someone with TB and you would have got
this from that person.

This condition can cause infection in the lung for long time including months and can
damage the lungs. Sometimes it can spread to other areas of body like brain and
kidneys and cause serious dame to those organs. Do you follow me?

We will admit you now and treat you, We will give medication like rifampicin,
ethambutol, Isoniazid, and pyrazinamide. These are like tablets which you need to take
daily. Usually you need to take all these 4 medications for first 2 months and then take
only isoniazid and rifampicin for further 4 months. My Consultant will decide how long
you may need to take this medicine.

257
 We will discharge you once you feel better. We may need to keep you in a separate
room while we treat you because this infection can spread to others if you are very
close to others.

It may be better to check whether you have any other medical conditions like HIV
because if someone has HIV then they can easily get TB also. We can treat HIV also if
you have it. Is that OK.

DRY COUGH - TB

258
 41. Mr …. Presented to the hospital with shortness of breath.
Take history from him and discuss you further management with him.

In this station, you will find a PEFR instrument & graph, a salbutamol inhaler.

Dr: Hello Mr… I am Dr …. Can you please tell me what brings you to the hospital? Pt: I
have been feeling very short of breath whenever I play football.

Dr: I am sorry to hear that. Are you short of breath now? Pt: No, I am Ok now.

Dr: Anything more you can tell me about this problem? Pt: It just started within the last
few weeks.

Dr: Do you feel short of breath when you are not exercising? Pt : No

Dr: Do you feel short of breath when you lie down (heart failure)? Pt : No

Dr: Do you have any cough? Pt: Yes, whenever I feel short of breath I get cough also.

Dr: Do you bring out any sputum? Pt: No

Dr: Any fever? Pt: No

Dr: Chest pain? Pt: No I feel my chest is tight.

Dr: Are you allergic to anything at all? Pt: No

Dr: Do you have any pets at home? Pt: No

Dr: Do you get SOB when you get exposed to plant pollens? Pt: No

Dr: Did you have any swelling or pain in your calf muscles? Pt: No

Dr: Did you travel anywhere recently? Pt: No

Dr: Did you have any operations recently? Pt: No

Dr: Any other problems like any skin rash? Pt: Yes, I have skin rash (eczema).

Dr: Have you had this problem before?

Pt: Yes, I used to feel short of breath whenever I do any exercise.

Dr: Do you have any medical conditions? Pt: No

Dr: Like bronchitis? Asthma? Heart problems? Pt: No

259
 Dr: Do you smoke? Pt: No

Dr: Are you taking any medications? Pt: No

Dr: Any of your family members have any medical conditions? Pt: My dad has asthma
and eczema.

Dr: Is there anything else important that we need to know? Pt: No

Dr: Mr… I need to examine your chest.

[Examiner may say – there is rhonchi on both sides].

Dr: Mr… I think you have asthma. I want you to do a test to check how your lung is
functioning. This test is called PEFR.

Make him do PEFR. Check his predicted normal reading on the chart provided. The
PEFR may be normal. (may be low sometimes).

Dr: Mr… Your reading is good now. Mr … you may be having a condition called
Asthma. Do you know what happens in asthma? Pt: No, doctor.

Dr: Asthma is a condition in the lung where the patient becomes short of breath
because the windpipe become narrowed. This is usually happens to people who are
allergic to something like pollen, animal fur or sometimes this can be triggered due to
exercise – probably the exercise is causing you this problem. Are you following me? Pt:
Yes.

Investigations:

We will do a chest X Ray to make sure that you do not have any other problems in the
chest. (rule out – pneumothorax).

Also, we need to do a test called Spirometry when you are exercising on a treadmill to
see your lung function. That will tell us whether it is exercise-induced Asthma.

Management

Dr: At the moment, since you are not short of breath, there is no need for admission to
the hospital. However, you may get this problem again when you exercise.

Prevention

In the future to prevent getting this asthma attacks, you need to take some steps.

You can continue doing exercise. It is better to avoid football because it involves long
periods of activity. Instead, short duration sports may be better for you. However, you need

260
 to take some inhaler medications like salbutamol (bronchodilators) about 20 minutes
before you do any kind of exercise. Avoid marathons and competitive running sports such as
running.

In addition to taking medications, warming up prior to exercising and cooling down after
exercise can help in asthma prevention.

If you have an allergy to pollen, then the exercise should be limited during high pollen days
or when temperatures are extremely low. This information can be gotten online.

If the weather is cold, exercise indoors or wear a mask or scarf over your nose and mouth.

Infections (colds, flu, sinusitis) can cause asthma and increase asthma symptoms, so it's
best to restrict your exercise when you're sick. Is that Ok? Pt : Ok doctor

Also inform patient to avoid aspirin and ibuprofen

Dr: Are you following me? Pt: Yes, Dr: Any other questions? Pt: No, Thank you.

SHORTNESS OF BREATH(EXERCISE-INDUCED ASTHMA)

42. EXERCISE-INDUCED ASTHMA SCENARIO 2

On history, the patient may say he is short of breath now.

• Ask him since when?

• What was he doing when he became short of breath?

• He may say he was playing football.

• Ask him if he is comfortable to talk.

Rest of the history is same.

Do PEFR – which may be normal or low.

Diagnosis and investigation are the same as above.

Treatment

If the PEFR is low, you can tell the patient, “We will admit you now and treat with some
medications called salbutamol nebuliser. They are called bronchodilators. This will help
to widen your windpipe.” “We will also give you some steroid tablets. This will help
prevent asthma attacks. We will discharge you once you are better which may be in a
day or two.”

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 Then talk about prevention.

What Are the Best Exercises for Someone With Asthma?

For people with exercise-induced asthma, some activities are better than others.
Activities that involve short, intermittent periods of exertion, such as volleyball,
gymnastics, baseball, walking, and wrestling, are generally well tolerated by people with
exercise-induced asthma.

Activities that involve long periods of exertion, like football, distance running, basketball,
and field hockey, may be less well tolerated, as are cold weather sports like ice hockey,
cross-country skiing, and ice skating. However, many people with asthma are able to
fully participate in these activities.

Swimming, which is a strong endurance sport, is generally better tolerated by those with
asthma because it is usually performed in a warm, moist air environment.

Maintaining an active lifestyle, even exercising with asthma, is important for both
physical and mental health. You should be able to actively participate in sports and
activities

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 43. A37 year old female patient comes with shortness of breath and chest
pain. Take history and discuss management. Vital signs - BP- 90/50 MM
HG, SPO2-84%

(If vital signs are given in the question, then IT MIGHT BE best to start the station with
stabilising the patient first, by administering Oxygen and IV fluids.) Rule out COPD.

(In the recent exam, the patient was stable)

History
- Primary complaint?

- Shortness of breath? Since when? Anything that makes it better or worse? Do

you have SOB while walking, sitting or lying down?

- Chest pain- site, nature, duration, radiation

- Associated symptoms-chest pain? Cough-phlegm/blood? Pain in the calf?

Swelling of the ankles? Fever? Previous history of DVT

DIFFERENTIAL DIAGNOSIS

• PULMONARY EMBOLISM

• MI

• ASTHMA

• COPD

• HEART FAILURE

• PNEUMONIA

MAFTOSA - ask specifically for-

• Asthma

• Smokers cough

• Recent long flights

• Surgeries?

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 • Any previous history of blood clots in the lungs or legs?

• Family history of blood clots in the lungs or legs?

• Medication-blood thinners?
IN THE EXAM, PATIENT WAS A FEMALE WHO WAS ON ORAL CONTRACEPTIVES
FOR 8 YEARS/20 YEARS
Examination

Examine chest, NEWS chart, will ensure privacy and chaperone (examination findings-
coarse crackles at left lower lung zone)
Tests - FBC, U&E, LFTs, CLOTTING SCREEN, D-DIMER, ECG, CXR (EXAMINER GIVES
AN ECG THAT SHOWS CHANGES)
“From what you have told me and from what I have examined, it seems to me you
have a condition called pulmonary embolism.

“What is it?”

“It is the blockage in one of the blood vessel in the lungs usually due to a blood clot. “

“Why did I get it?”

“Usually, the cause is a blood clot that has originally formed in a deep vein (DVT). This
clot travels through the circulation and eventually gets stuck in one of the blood
vessels in the lung. Sometimes it could be due to immobility and major surgeries.”

“Is it serious?”

“Yes, it is a life threatening condition. It has chances of recurrence even after

treatment.”

“What will you do now?”

“We shall be doing some specific blood tests: D-dimer that detects any blood clot.
The higher the level, the more likely that you have a blood clot. We need to do

another test to confirm this condition-CTPA-which is a type of CT scan that looks at

the lung arteries. (patient asks for explanation of CTPA)
We shall do an ECG (might show S1Q3T3 strain) and chest x-ray as well.

“How will you treat me?”

264
 “You will have to be admitted for this condition.
We will start you on anticoagulant treatment even before we conduct the tests. It
stops the blood from clotting. At the moment, we will start you on low molecular
weight heparin injection before the test.

If the test confirms that you have this condition, then we will switch to oral medication
(anticoagulants) - apixaban, rivoraxaban OR dabigatran

Once you are stable, we shall discharge you and will ask you to come visit us for
follow-up.”
Mention that you will talk to your seniors regarding the contraceptive pills. They might
have to be changed.
Explain warning signs

- Avoid falls

- Cuts while dealing with sharp objects

PULMONARY EMBOLISM

265
266
 44. Lady with SOB and chest pain came to A&E. Take history and discuss
management with examiner.

Lady in her 60s comes to A&E with sudden onset SOB, no exertion. Along with left
sided chest pain (precordium), not positional and only on inspiration.

No fever, no ankle swelling, DVT? Calf swelling?

PMH of DM on metformin not HTN and no other medical conditions.

Past history of breast cancer and mastectomy on the same side (left) along with
chemotherapy but no radiotherapy. (ask when mastectomy and when last chemo
session?)

Any family history of breast cancer? (possible aunt) possible OCP (unlikely as she is
postmenopausal) /travel/HRT.

Any sort of inactivity? Heart disease? Fractures? Smoking?

Examination: General physical exam focusing on chest and lower limbs along with
NEWS chart. O2 90% HR 110 Temp? BP? RR? ABG showed respiratory alkalosis with
no compensation, CXR normal, ECG showed sinus tach (examiner may not give).
Diagnosis likely PE

People with cancer may have a higher number of platelets and clotting factors in the
blood which in turn help clotting and stop bleeding. Having higher than normal amounts
of platelets and clotting factors in the body means the blood is more likely to clot.Some
people with cancer may have lower levels of proteins in the blood that help to keep it
thinned. Hence making cancer a risk factor for developing clots. Since the patient has a
positive history for DM as well, that can contribute to forming a clot as well (disease
progression may also contribute to formation of clots).

Management: Admit and do CTPA along with d-dimer. Begin LMWH immediately and
monitor. Consult seniors for advice on how to manage further and long term
anticoagulants with cancer treatment.

CHEST PAIN - POST-MASTECTOMY

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268
 LADY WITH ABDOMINAL PAIN - APPENDICITIS
Examination is extremely necessary in this case

In a woman of child bearing age (16-45 years), you should always consider her to be
pregnant until otherwise proven.

Differential diagnoses:

1. Ruptured ectopic pregnancy - ask her if her last period was normal
2. Intestinal obstruction/perforation
3. Appendicitis (ensure you ask if the patient has had an appendectomy in the past)
4. PID
5. UTI
6. Ureteric colic
7. Gastroenteritis

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 45. 42 year old lady presented with abdominal pain. Take a history and then do
the relevant examination and discuss the further management with her.

Patient complains of pain in the abdomen for the last 5 days. Initially, the pain was
coming and going. Now it is constant in the lower part of the tummy.

She also has an associated fever for the last few days.

She also complains of constipation for the last 3 days. (sometimes, she may start her
story with constipation – do not confuse this station with constipation station).
She was able to pass wind. No vomiting. Had nausea.

No urinary symptoms like burning sensation, increased frequency, haematuria, no

previous bowel problems.

LMP was 3 weeks ago. (check when was her period before that). No vaginal
bleeding now. No vaginal discharge. No unprotected sex.

No diarrhoea, No previous medical conditions, No previous history of kidney stones, No

history of previous surgery.

Ask where exactly was the pain when it started

Ask if she is on any medications

Ask family history, how many children she has

Anything else important

Examination:

I want to examine your tummy. I will ensure your privacy and have a chaperone with
me. Can you please undress above your waist and lie on the bed?

Examine abdomen:

Inspection – No distension, No visible masses

Palpation - had tenderness all over lower abdomen, right iliac fossa, supra pubic area
and left iliac fossa. When doing rebound tenderness, tell patient that you will be
pressing her tummy deeply and that you will suddenly remove your hand and it may be
painful. Ask her to please bear with you.

Percussion – normal

270
 Bowel sounds – examiner said no bowel sounds (for some candidates, examiner
said bowel sounds normal)

Per rectal examination – examiner said normal.

Check NEWS chart – Temp – 38.9°C, Pulse – 106 bpm, BP -130/80mmHg, PO2 was 97%.

Investigations:

We need to do blood tests to check for any infection markers. We also need to do an
erect chest and supine abdominal x-ray of your chest and tummy, and an ultrasound
scan of your tummy. (examiner did not give any findings).

We need to test your urine, we would also check for any blood or infection markers and
also do a pregnancy test to make sure that you are not pregnant. Is it OK?

Definitive diagnosis:

I think you may have a condition called appendicitis. My seniors will see you to confirm
this. Do you know anything about appendicitis? Pt : No

Dr: Let me explain (draw if possible).

We all have an organ in our tummy called an appendix which looks like a small finger
attached to the beginning of the large bowel located at the right lower part of the tummy.
That organ has become inflamed (sore/swollen). This is what we call Appendicitis.
Sometimes it is due to some bugs in that organ. If the condition is not treated urgently, then
this organ can perforate and can cause serious infection within the tummy.

Treatment:

The only way to treat this condition is doing an operation and removing that organ.

Pt: Won’t there be any problem if you remove that organ?

Dr: This organ has no important function in our body, so even if we remove there will not
be any problem. You can live a normal life.

Pt: How long will the operation be?

Dr: 30 to 45 minutes

Pt: How long should I be in the hospital? Dr: Two to three days.

Pt: Any complications? Dr: Very rarely, there could be bleeding or infections but we can
manage that.

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 Dr: Is it OK to go ahead with surgery? Pt: OK

Do you have any other questions? Pt: No

Thank you.

LADY WITH ABDOMINAL PAIN - APPENDICITIS

272
 46. Young lady presented with lower abdominal pain.
Take history and discuss further management with her and also write up a
prescription.

● Any problems with ovary?

● Previous UTI
● Kidney stones
● How she wipes
● Sexual history - Similar symptoms in the partner
● Gastroenteritis (diarrhoea, vomiting, fever)
Dr: Hello I am Dr … one of the junior doctors in the department. Are you Ms ? Pt: Yes

Dr: How are you doing Ms….Pt: I am OK.

Dr: How can I help you?

Pt: Doctor I am having a burning sensation when I pass urine.

Dr: Can you tell me anything more about it ?

Pt: Yes doctor it has been happening since …. days now.

Dr: Do you have fever? Pt: Yes/No since last …. days

Dr: What is the colour of urine? – Pt: Dark and cloudy it smells bad doctor

Dr: Did you notice blood in the urine? Pt: Yes/No

Dr: Any pain in tummy? Pt: yes/no (SOCRATES for pain if Yes)

Dr: Do you have pain in the loin area (Pyelonephritis) ? Pt: No

Dr: Do you feel the need to pass urine despite having just done so (strangury)? Yes/ No

Dr: Did you have this problem before? Pt: Yes/No

Dr: Do you pass urine more often than usual? Pt: Yes doctor

Dr: Do you have any nausea or vomiting? Pt: Yes/No (if unable to keep food down
consider admission)

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 Dr: Do you have any back pain (upper UTI) ? - Pt: No

Dr: Do you have any discharge from your front passage? Pt : No

Dr: Have you noticed any weight loss (cancer)? - Pt: Yes / No

Dr: Any problem opening bowel? Pt: Yes / No

Ask how she wipes her back passage.

Dr: Do you have similar problems in the past? Pt: Yes/No (repeated UTI)

Dr: Do you have any medical conditions? Pt: Yes / No

Any problems with ovary? Ask of kidney.

Dr: Do you have high blood sugar? Pt: Yes/No ( diabetes also risk factor)

Dr: Have you had any surgeries in the past? Related to urinary passage? Pt : Yes No

Dr: Did you have any kidney stones before? Pt: Yes/No

Dr: when was your Last menstrual period? Pt: … (ask to rule out pregnancy in young,
menopause in old as menopause causes increased risk for UTI)

Dr: Are you married or do you have any partner ?Pt: I am married.

Dr: Do you use any sort of contraception ?

Pt: No I am trying to get pregnant. (spermicide causes increased risk of UTI)

Dr: Are you taking any medications ?

Pt: I am taking Folic acid because I am trying to get pregnant.

Dr: Have you been told that you have Folate deficiency ? Pt : ….

Dr: Does your husband has any urinary symptoms or discharge from his penis do you
know? Pt : No

Dr: Are you allergic to any medications ?Pt: Yes/No

Examination:

Dr: Miss …. I need to examine your tummy

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 Examiner may say – There is some tenderness supra pubic area

Diagnosis:

Dr: Miss …. I think you have a condition called urinary tract infection. Basically this is
an infection in the urine means there are some bugs in the urine.

Pt: Why do I have this infection doctor?

Dr: Sometimes bugs comes from the back passage. They get into the urine through
the urethra (opening of the urine passage) or vagina.

Pt: What are you going to do for me doctor?

Investigations for UTI:

Dr: We can do test your urine called dipstick and then send it to the lab to see what
type of bugs may be causing this infection.

(Examiner may or may not show the test results. If he does explain the result if not
continue to management)

Dr: If the test shows that you have urine infection we will give you some antibiotic
medications to treat this.

Dr: Let me write the prescription for you.

Write the prescription on the paper provided. Use the BNF.

I will give you an antibiotic medication called Nitrofurantoin.

Dr: Are you allergic to this at all? Pt: No Dr: Have you taken this before ? No

Dr : Do you have any kidney disease (should not be given in kidney disease) Pt : No

Title Forename Surname DOB

Tab. Nitrofurantoin 50mg QDS (4 times/day) for 3 days.

Sign and write your name.

275
 This is a 50 mg tablet you need to take one tablet 4 times a day with food for the next
3 days. Hopefully your symptoms will subside in the next 2 to 3 days.

Like any medication, this also can give some side effects like:

● headache, dizziness;
● upset stomach;
● mild diarrhoea; or
● vaginal itching or discharge.
● They usually subside after you finish the course but if it causes you problems,
then please call your GP and take advice.

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 Do

● wipe from front to back when you go to the toilet

● try to fully empty your bladder when you go for a pee
● drink plenty of fluids
● take showers instead of baths
● wear loose, cotton underwear
● pee as soon as possible after sex

Don’t

● use perfumed bubble bath, soap or talcum powder

● hold your pee in if you feel the urge to go
● wear tight, synthetic underwear, such as nylon
● wear tight jeans or trousers
● use condoms or diaphragms with spermicidal lube on them - try non-
spermicidal lube or a different type of contraception
● Avoid having sex for a week at least.

Warning signs - Fever, weakness, loin pain

However, if the symptoms do not subside by the next 3 days, if your fever gets worse,
if you start having loin pain, you are feeling very unwell and getting too tired please
do come back . Pt: Okay

Dr. Also you can take pain killer medications like Paracetamol for your pain. Pt: Yes

Dr: Any other concerns Pt: No doctor. Dr: Thank you very much.

UTI IN FEMALE

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 Additional information
Nitrofurantoin

Dosage

For treatment of acute urinary tract infection (UTI), prescribe nitrofurantoin 50 mg four
times daily, or 100 mg (modified-release), twice daily.

For uncomplicated UTIs, treat for 3 days.

For complicated UTIs, treat for 5–10 days.

In pregnant women, treat for 7 days.

Contraindications

Avoid prescribing nitrofurantoin to people with:

1. Renal impairment
2. Acute porphyria.
3. A deficiency of glucose-6-phosphate dehydrogenase

Important information

You should not take nitrofurantoin if you are allergic to it, or if you:

● Have severe KIDNEY DISEASE;

● Have a history of jaundice or liver problems caused by taking nitrofurantoin;
● Are urinating less than usual or not at all; or
● Are in the last 2 to 4 weeks of pregnancy.
To make sure nitrofurantoin is safe for you, tell your doctor if you have:

1. anemia;
2. diabetes;
3. an electrolyte imbalance or vitamin B deficiency;
4. glucose-6-phosphate dehydrogenase (G6PD) deficiency; or
5. any type of debilitating disease.

This medicine is not expected to be harmful to an unborn baby during early

pregnancy. Tell your doctor if you are pregnant or plan to become pregnant during
treatment.

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 Nitrofurantoin can pass into breast milk and may harm a nursing baby. You should not
breast-feed while you are taking this medicine.

Take nitrofurantoin with food.

------------------------------------------------------------------

Trimethoprim

Prescription: For treatment of urinary tract infection (UTI), prescribe trimethoprim 200
mg twice daily.

For uncomplicated UTIs, treat for 3 days.

For complicated UTIs, treat for 5–10 days.

In pregnant women, treat for 7 days.

Contraindication: Bleeding disorder( ask pt about it before prescribing trimethoprim)

Side Effects: Nausea, vomiting, pruritus, and skin rashes have occasionally been reported.
These are generally mild and reversible when trimethoprim is withdrawn. (tell if patient asks)

Treatments not recommended:

1. Cranberry juice or other cranberry products are not recommended as there is no good
evidence to support their use for treating urinary tract infection.
2. Although urine alkalization has been traditionally used to relieve the symptoms of
urinary tract infection, there is a lack of good evidence to support its use.

- Prescribe an antibiotic to all women with a suspected urinary tract infection during pregnancy. Follow
local prescribing guidelines that take into account local resistance patterns if these are available.
Otherwise prescribe (in order of preference):

1. Nitrofurantoin 50 mg four times daily, or 100 mg (modified-release) twice daily, for 7 days.

2. Trimethoprim 200 mg twice daily, for 7 days (off–label use).

• Give folic acid 5 mg daily if it is the first trimester of pregnancy.

• Do not give trimethoprim if the woman is folate deficient, taking a folate antagonist,
or has been treated with trimethoprim in the past year.

279
280
 47. 17-18 yrs old female. Treated twice with antibiotics but still has UTI
(trimethoprim for 2wks)

Culture shows sensitivity to nitrofurantoin.

Symptoms not improved.

No STI symptoms and has protected sex.

Had lower abdominal pain, painful urination, no fever, no loin pain, no medical
problems, no diarrhoea. No discharge front passage, partner has no symptoms.

Rule out pyelonephritis and sepsis

Most important cause is sexual intercourse especially anal sex and then having
vaginal sex.

Also ask in history

- Compliant with medication? Any vomiting after taking the antibiotic?

- Hygienic lifestyle - Is she wiping back passage – front to back or back to front?
Perfumed soap or powders? Tight clothing? Urination after sex? History of kidney
or bladder stones? Previous UTIs? contact with anyone else with UT

Patient may give history of unprotected sex [Explore the sexual history properly. She
may say she practices safe sex but she uses pills for contraception – means she
does not know what is safe sex]. Probably not practicing safe sex is the reason for
not improving.

The definition of recurrent urinary tract infection (RUTI) is three UTIs with three positive
urine cultures during a 12-month period, or two infections during the previous 6 months

Treatment - Admit and give IV antibiotics

UNRESOLVED UTI DESPITE TREATMENT

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 48. Mr Mike Atherton, 75 years old man, came to the Surgery department
with complaints of fever and lower abdominal pain for the last 3 days.

You are the SHO in the Surgery department. Take a brief history for the patient
and talk to him about the further management and address his concerns.

Dr: Hello Mr ……. I am Dr … junior doctor in the Urology department. How are you
doing? Pt: I am OK.

Dr: How can I help you?

Pt: Doctor I am having burning sensation when I pass urine. Most of the time, the
symptom might be vague.

Dr: Can you tell me anything more about it?

Pt: Yes, doctor, it’s been happening for the last 3 days now.

Dr: Do you have fever? Pt: Yes since last 3days

Dr: What is the colour – Pt: Dark and cloudy it smells bad doctor

Dr: Did you notice blood in the urine? Pt: No

Dr: Any pain in tummy? Pt: Yes, my lower tummy

Dr: Do you have pain in the loin area (Pyelonephritis)? Pt: No

Dr: Did you have this problem before? Pt: No

Dr: Do you pass more times than usual? Pt: Yes, doctor

Dr: Do you have to get up in the night to go to the loo? Pt: Yes since few months

Dr: Any dribbling? – Pt: Yes

Dr: Is there poor stream? Pt: Yes

Dr: Do you have any back pain (secondaries in the vertebra)? Pt: No

Dr: Have you noticed any weight loss (cancer)? Pt: No

Dr: Any problem opening the bowel? Pt: No

Dr: Do you have any medical conditions? Pt: No

Dr: Did you have any kidney stones before? Pt: No

Dr: Are you taking any medications? Pt: No

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 Dr: Are you allergic to any medications?

Pt: Yes to Penicillin

Dr: Do you have anyone to look after you? Pt: On my own/Yes, I live with my wife

If he lives on his own, it will be necessary to admit him for the duration of the antibiotics
treatment. Always ask this question in people over age 50.

Examination:

Dr: Mr Edwards, I need to examine your tummy and back passage to see why this may
be happening?

Examiner says – There is some tenderness in the supra pubic area and prostate is
enlarged and smooth surface.

Diagnosis:

Dr: Mr Edwards, I think you have a condition called Urinary tract infection. Basically, this
is an infection in the urine means there are some bugs in the urine.

Pt: Why do I have this infection, doctor?

Dr: Sometimes, bugs comes from the back passage. They get into the urine through the
urethra (opening of the urine passage). In your case, there is one other problem
which may be causing this infection.

Pt: What is that doctor?

Dr: While examining your back passage, I noticed that one gland called prostate gland
which is at the base of the urine bladder is enlarged. When this gland is enlarged, it
narrows the urine passage so the urine does not flow out properly. Urine gets
accumulated in the urine bladder and the bugs grow very easily in such situations.
Sometimes, this condition causes recurrent urine infections.

Pt: What are you going to do for me doctor?

Dr: FBC, Kidney function tests, PSA, Urine culture

Investigations for UTI:

Dr: We need to confirm if you have urine infection - for that we need to test your urine
for bugs and send it to the lab to see what type of bugs may be causing this infection?

Examiner shows a paper - Urine dipstick shows – nitrites and leukocytes and pus cells.

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 Dr: Mr Edwards, your urine tests does show that you have a urine infection. We will treat
you with antibiotic medication. Since you said you are allergic to Penicillin, we will give
you some other type of antibiotic (which is called Trimethoprim 200mg twice a day
for about a week) which is good for this kind of infection.

We will keep you in the hospital to treat your urine infection. You can also take some
Paracetamol tablets for the pain and fever and drink plenty of fluids.

Investigations for Prostate gland:

Also we need to do some tests to check your prostate gland to see what type of growth
it is whether it is cancerous type or non cancerous. It looks like a non-cancerous growth
on examination. We need to do scans on the gland and we may also take some tissue
samples from that. We will also do some blood test specific for Prostate gland.

We will treat the gland according to the test result with medications:
One of them shrinks the prostate gland (5 – reductase inhibitor: Finasteride) and the other
relaxes the water bag / bladder neck (alpha blockers: tamsulosin).
Pt: What if the medications don’t work?

Dr: We may also consider doing a procedure where we pass some instruments through
the urethra and widen the urine passage or we may do an operation to remove the
prostate gland. (TURP)

Pt: Will I get this infection again?

Dr: If the prostate gland has been treated, then you may not get the infection again and
again.

Dr: Any other concerns

Pt: No, doctor.

Dr: Thank you very much.

UTI and BPH

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 Safety netting: fever persists, confusion, unable to pass urine.

Symptoms of UTI

Strong and frequent urge to urinate. Cloudy, bloody or strong smelling urine. Pain or
burning sensation when urinating. Nausea and vomiting.

Muscle aches and abdominal pains.

Important differentials: Acute appendicitis, Diverticulitis, Pelvic inflammatory

disease, Gastroenteritis.

Symptoms of BPH

1. Difficulty starting urination

2. A frequent need to urinate (nocturia)

3. Difficulty fully emptying the bladder

Examination

DRE (Digital rectal examination) – shows enlarged prostate

Investigations

1. For UTI

" Urine dipsticks – shows Nitrite – positive, leukocytes – positive.

" U&E, Creatinine, Urine Culture

2. For prostate

" LFT (Alkaline phosphatase may be raised in Cancer prostate),

" Blood PSA,

" Ultrasound of prostate.

285
 49. 45 year old man presented to the hospital with abdominal pain. Take a history
and discuss the management with the patient.

Offer painkiller. Non-steroidal anti-inflammatory drugs (NSAIDs), usually in the form of

diclofenac IM or PR, should be offered first-line for the relief of the severe pain of renal
colic. NSAIDs are more effective than opioids for this indication and have less tendency
to cause nausea. However, if parenteral morphine is required in severe renal colic pain,
this works quickly and can provide pain relief in the time taken for an NSAID to work.

Differentials of left sided abdominal pain:

" Kidney or ureteric stone – loin groin pain, hematuria. previousHx of kidney
stone. R/o UTI and Pyelonephritis – Fever, burning sensation, increased
frequency, smelly urine.
" Diverticulitis – Diarrhoea, pain relieved on defecation.
" Pancreatitis – pain from front to back. Alcohol.
" Bowel cancer – change in bowel habits, weight loss.
" Dissection of abdominal aortic aneurysm- did you ever had any scans of your
tummy and was told that you have abnormal blood vessels in your tummy.

In the Hx include risk factors

Any previous problems in kidney (stones, horseshoe kidney)

Any parathyroid gland problem (bone pains, pathological fractures – fractures

without trauma)

Any high blood pressure. Hx Gout Family. Hx of any kidney problems. Medications?

Any vomiting? Are you able to drink? Are you able to pass urine?
I need to examine your tummy. (There might be no response from the examiner)
Diagnosis

Mr… I think you have a stone in the ureter. The ureter is a tube which drains urine from
the kidney to the urine bladder.

Investigations: We need to do some tests like a CT scan of your tummy area to

confirm that. Also we need to test your urine to check whether it shows any blood and
any infection markers (examiner says – urine test shows blood). You will do a urine
bedside dipstick test. We need the check your blood to check how your kidneys are
functioning and also check some chemicals like calcium, phosphate and other things.

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 Treatment:

If the tests confirm that it is stone, we will treat it. We have various options to treat it.

Sometimes, this stone will pass out on its own if it is very small.

We will give you very good pain killers called Diclofenac as a suppository through your
back passage.

If your pain is relieved, you are able to eat and drink and able to pass urine, then you
can go home. Drink plenty of water and the stone may pass out on its own. If possible,
you should pass urine into a container or through a tea strainer or gauze to catch any
identifiable calculus. We will give you an appointment for follow up within a week.

However, if your pain is not relieved and if you keep vomiting continuously or if the scan
shows some abnormality in the kidney, then we will keep you in the hospital and treat
you.

We can give you some fluids through your veins or medications (tamsulosin or
nifedipine) which will help to flush out the stone in the urine.

If that does not work, then we have something known as shock wave treatment which
will break the stone into smaller pieces by giving some type of shock and then it will
flush out easily.

If these things do not work, then either we do a keyhole surgery and remove it or rarely
we may have to do an open operation to remove it.

If we get the stone, we will send it to the lab for further analysis. Depending on the
composition of the stone, we may give medication to prevent further stone formation.
[eg, thiazide diuretics (for calcium stones), allopurinol (for uric acid stones) and
calcium citrate (for oxalate stones)].

This condition can happen again. To prevent stones in the future,

" Drink plenty of fluids.

" Reduce salt intake.
" Reduce the amount of meat and animal protein eaten.
" Reduce oxalate intake (foods rich in oxalate include spinach, beets,
chocolate, rhubarb, nuts) and urate-rich foods (eg offal and certain fish).
" Drink regular cranberry juice: increases citrate excretion and reduces oxalate and
phosphate excretion. Do you follow me? Any concerns? Thank you.
URETERIC CALCULUS
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 Risk factors

Several risk factors are recognised to increase the potential of a susceptible individual
to develop stones. These include:

1. Anatomical anomalies in the kidneys and/or urinary tract - eg, horseshoe kidney,
ureteral stricture.
2. Family history of renal stones.
3. Hypertension.
4. Gout.
5. Hyperparathyroidism.
6. Immobilisation.
7. Relative dehydration.
8. Metabolic disorders which increase excretion of solutes - eg, chronic metabolic
acidosis, hypercalciuria, hyperuricosuria.
9. Deficiency of citrate in the urine.
10. Cystinuria (an autosomal-recessive aminoaciduria).
11. Drugs - eg, diuretics such as triamterene and calcium/vitamin D supplements.
12. More common occurrence in hot climates.
13. Increased risk of stones in higher socio-economic groups.
14. Contamination - as demonstrated by a spate of melamine-contaminated infant
milk formula.

Red flags

" Fever, chills, rigor

" Dysuria
" Hematuria
" Weight loss
" Lumps or bumps
" Past medical history of medical problems
" Prostatic symptoms (hesitancy, dribbling)
Indications for hospital admission

1. Fever.
2. Solitary kidney.
3. Known non-functioning kidney.
4. Inadequate pain relief or persistent pain.
5. Inability to take adequate fluids due to nausea and vomiting.
6. Anuria.

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 7. Pregnancy.
8. Poor social support.
9. Inability to arrange urgent outpatient department follow-up.

People over the age of 60 years should be admitted if there are concerns on clinical
condition or diagnostic certainty (a leaking aortic aneurysm may present with identical
symptoms).

Indication for urgent outpatient appointment

1. Pain has been relieved.

2. The patient is able to drink large volumes of fluid.
3. Adequate social circumstances.
4. No complications evident.
5. Initial management of acute presentation
- Provide anti-emetics and rehydration therapy if needed.
- The majority of stones will pass spontaneously but may take 1-3 weeks; patients
who have not passed a stone or who have continuing symptoms should have the
progress of the stone monitored at a minimum of weekly intervals to assess the
progression of the stone.
- Conservative management may be continued for up to three weeks unless the
patient is unable to manage the pain, or if he or she develops signs of infection or
obstruction.
- Medical expulsive therapy may be used to facilitate the passage of the stone. It is
useful in cases where there is no obvious reason for immediate surgical removal.
Calcium-channel blockers (eg, nifedipine) or alpha-blockers (eg, tamsulosin) are
given. A corticosteroid such as prednisolone is occasionally added when an
alpha-blocker is used but should not be given as monotherapy.

Managing patients at home

" All patients managed at home should drink a lot of fluids and, if possible, void
urine into a container or through a tea strainer or gauze to catch any identifiable
calculus.
" Analgesia: Paracetamol is safe and effective for mild-to-moderate pain; codeine
can be added if more pain relief is required. Paracetamol and codeine should be
prescribed separately so they can be individually titrated.
" Patients managed at home should be offered fast-track investigation initiated by
the hospital on receipt of a letter or email completed by the general practitioner.
" Patients should ideally receive an appointment for radiology within seven days of
the onset of symptoms.

289
 " An urgent urology outpatient appointment should be arranged for within one
week if renal imaging shows a problem requiring intervention.

Surgical

" Approximately 1 in 5 stones will not pass spontaneously and will require some
form of intervention.
" If the ureter is blocked or could potentially become blocked (eg, when a larger
stone will fragment following other forms of therapy), a JJ stent is usually inserted
using a cystoscope. It is a thin hollow tube with both ends coiled (pigtail). It is
also used as a temporary holding measure, as it prevents the ureter from
contracting and thus reduces pain, buying time until a more definitive measure can be
undertaken.
" Procedures to remove stones include:
" Extracorporeal shock wave lithotripsy (ESWL) - shock waves are directed over
the stone to break it apart. The stone particles will then pass spontaneously.
" Percutaneous nephrolithotomy (PCNL) - used for large stones (>2 cm), staghorn
calculi and also cystine stones. Stones are removed at the time of the procedure
using a nephroscope.
" Ureteroscopy - this involves the use of laser to break up the stone and has an
excellent success rate in experienced hands.
" Open surgery - rarely necessary and usually reserved for complicated cases or
for those in whom all the above have failed - eg, multiple stones.
" Several options are available for the treatment of bladder stones. The
percutaneous approach has lower morbidity, with similar results to transurethral
surgery while ESWL has the lowest rate of elimination of bladder stones and is
reserved for patients at high surgical risk.

Complications

" Complete blockage of the urinary flow from a kidney decreases glomerular
filtration rate (GFR) and, if it persists for more than 48 hours, may cause
irreversible renal damage.
" If ureteric stones cause symptoms after four weeks, there is a 20% risk of
complications, including deterioration of renal function, sepsis and ureteric
stricture.
" Infection can be life-threatening.
" Persisting obstruction predisposes to pyelonephritis.
" Prognosis
" Most symptomatic renal stones are small (less than 5 mm in diameter) and pass
spontaneously.

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 " Stones less than 5 mm in diameter pass spontaneously in up to 80% of people.
" Stones between 5 mm and 10 mm in diameter pass spontaneously in about 50%
of people.
" Stones larger than 1 cm in diameter usually require intervention (urgent
intervention is required if complete obstruction or infection is present).
" Two thirds of stones that pass spontaneously will do so within four weeks of
onset of symptoms.
" A stone that has not passed within 1-2 months is unlikely to pass spontaneously.
The following features predispose to recurrent stone formation:

" First attack before 25 years of age.

" Single functioning kidney.
" A disease that predisposes to stone formation.
" Abnormalities of the renal tract.

Prevention

" Recurrence of renal stones is common and therefore patients who have had a
renal stone should be advised to adapt and adopt several lifestyle measures
which will help to prevent or delay recurrence:
" Increase fluid intake to maintain urine output at 2-3 litres per day.
" Reduce salt intake.
" Reduce the amount of meat and animal protein eaten.
" Reduce oxalate intake (foods rich in oxalate include chocolate, rhubarb, nuts)
and urate-rich foods (eg, offal and certain fish).
" Drink regular cranberry juice: increases citrate excretion and reduces oxalate and
phosphate excretion.
" Maintain calcium intake at normal levels (lowering intake increases excretion of
calcium oxalate).
" Depending on the composition of the stone, medication to prevent further stone
formation is sometimes given - eg, thiazide diuretics (for calcium stones),
allopurinol (for uric acid stones) and calcium citrate (for oxalate stones).

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 50. HAEMATURIA
Red flag symptoms

1. Painless macroscopic haematuria

2. Symptomatic microscopic haematuria in absence of UTI
3. Age >50years
4. Abdominal mass on examination

History and examination

Patients presenting with haematuria should be asked about symptoms of one of the
most likely causes like UTI. Symptoms of frequency, urgency and dysuria point to this
diagnosis.

Haematuria presenting with abdominal pain 'from loin to groin' is classical of renal
calculi, and there may be a previous history of similar episodes.

On the other hand, haematuria presenting without pain raises the possibility of a bladder
or renal malignancy and should prompt urgent referral.

In the absence of a UTI, microscopic haematuria associated with systemic symptoms,

such as joint pains, a rash or fever, should lead you to suspect an inflammatory cause,
such as systemic lupus erythematosus or Henoch-Schonlein purpura.

Consider post-infectious glomerulonephritis or IgA nephropathy if there is a history of

infection. A thorough drug history will reveal any nephrotoxic medications, such as
cyclophosphamide or NSAIDs. Note that warfarin is not in itself a cause of haematuria.
Remember to ask about recent travel (schistosomiasis) and occupational exposure
(bladder malignancy).

Examination of BP (renal disease) and abdomen (urological malignancy) are vital.

Genital examination is often unhelpful although examination of the prostate is necessary
if there are symptoms of prostatism. Examine the skin and joints for signs of systemic
disease.

If you need to do a prostate examination, ask the patient if he has had this examination
done performed in the past. Tell him, “Unfortunately, it is through your back passage.”
Tell him you will preserve his privacy and have a chaperone.

Investigations

Dipstick examination will rule out other causes of red urine and may show associated
proteinuria, which hints at a renal cause.

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 An MSU should be sent for microscopy culture and sensitivity testing, and urinary protein-
creatinine or albumin-creatinine ratio obtained.

Bloods including FBC, U&Es and clotting will establish the amount of blood loss, renal
function and any coagulopathy.

Imaging may be required to investigate calculi, and a renal ultrasound may be performed.

Any patient with frank and painless haematuria requires urgent specialist investigation,
which will involve a cystoscopy and/or a CT urogram.

Causes of haematuria

1) Kidney - Glomerular diseases, Polycystic kidney disease, Kidney stones

2. Trauma (renal biopsy)

3) Renal adenocarcinoma

4) Renal TB

5) Renal vein thrombosis/Embolism

6) Benign Prostatic Hyperplasia

7) CA prostate, Ureter, Urethra

8) Urethral trauma

9) Ureteric stones

10) Bladder stones

11) CA bladder

12) Bladder Trauma

13) Inflammation (Cystitis, stones, TB) Cause of Red Urine

Other causes
1. Hemoglobinuria
1. Anticoagulants (Warfarin)
2. Myoglobinuria
2. Thrombocytopenia
3. Beetroot
3. Sickle cell disease
4. Senna
4. Malaria
5. Rifampicin
5. Schistosomiasis
6. Phenolphthalein
6. Blood dyscrasias (Hemophilia)
7. Strenuous exercises

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 294

50.You are the FY2 doctor in the Urology department.

A middle age man presented to the hospital with the history of passing blood in
the urine.

Take a relevant history and discuss the further management with the patient.

The case might be UTIs, stones, or prostate cancer

Dr: Hello Mr … I am Dr…. One of the junior doctors in the urology department. How can
I help you ?

Pt: Doctor I am passing blood in the urine.

Dr: I’m sorry to hear this. Can you tell me more about it? Pt: Like what?

Dr: Since when did you notice this? Pt: For the last few days.

Dr: Is the bleeding at the beginning of urinating (urethra or prostate) or at the end of
urinating (bladder or prostate) or throughout (bladder, kidney, ureter)?

Pt: It is throughout.

Dr: Do you have any pain while passing urine (UTI)? Pt:No

Dr: Do you have a fever (UTI)? Pt:No Dr : Increased frequency or urination?

Pt : No/Yes

Dr: When you pass urine does it flow properly or does it dribble (Prostate symptoms)?
Pt : No/Yes there is dribbling. You can also ask of hesitancy.

Dr: Do you have to run to the loo when you get the sensation of passing urine
(prostatism) Pt : Yes / No

Dr: Did you have any injury to the penis or to tummy? Pt:No

Dr : Did you ever had any kidney stones before? Pt :No

Dr: Did you have any kidney problems before (polycystic kidney) ? Pt: No

Dr: Any pain going from loin to groin at all (ureteric stone)? Pt: No

Dr: Any pain in your loin area (renal cancer)? Pt: No

Dr: Any lumps/bumps/swellings in the loin area (renal cancer)? Pt: No

294
 295

Dr: Have you noticed any change in your weight (Cancer)? PT: No/Yes (how much in how
much time?)

Dr : Do you cough (TB) ? Pt: No

Dr: Night sweats (TB)? Pt: No

Dr: Do you smoke? Pt : Yes (How many and how long ?)

Dr : Have done any strenuous exercise recently? Pt : No

Dr: Do you have any pain at the back (secondary in the vertebra – primary in the
kidney or prostate) ? Pt : No

Dr: Any procedures or operations done recently on kidney, urine bladder or urethra
(front passage)? Pt : No

Dr: Do you have any bleeding disorders? Pt: No

Dr: Did you have this problem before? Pt: No

Dr: Are you taking any kind of medication – blood thinners, for prostate, etc? Pt: No

Dr: Are you allergic to any medications? Pt : Yes Penicillin.

Dr: Have you travelled to other countries recently (schistosomiasis)? Pt:No

Examination:

Mr… I need to examine your tummy and back passage to check the prostate gland.

[ Examiner may say prostate is enlarged and smooth and no other abnormal
findings ]
Diagnosis:

Mr… While examining, I found that your prostate gland (a gland which is present at
the base of the urine bladder) is enlarged.

However, Mr…. There is a possibility that you may be having something sinister in the
urine bladder causing this problem. We need to do further tests to find out what exactly
is causing the bleeding from the urethra. (If you are the FY 2 doctor in the Urology,
mention talking to seniors about the further investigations and treatment. If you
are not in the Urology department – then mention referral to Urologists -
specialists in Kidney and urine excreting organs for further investigations and
treatment).

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 296

Pt: Do I have cancer, doctor?

Dr: At the moment we cannot say anything. However there are many other reasons for
bleeding like this. Specialists will tell you once they get all the investigation result.

Pt : Ok

Investigations:

Mr… We will have to test your urine first to check for blood or other things (protein)
which may show any problem in the kidney. We also need to do investigations like
cystoscopy to check inside the urine bladder. In this procedure, we pass a small tube
with the camera attached to that through the urethra (front passage) into the urine
bladder and we have a look inside the bladder and take any tissue samples if there is
any growth there and test that in the lab.

Also, we may need to test the prostate gland to see if there is any growth. We will have
to do ultrasound scan and do some blood test specific for the prostate gland.

Also we need to do a CT scan of the lower tummy area to check whether the cancer
has spread if at all it is cancer. Do you follow me?

Pt : Yes, doctor
Treatment:

Dr: Depending on the test result, we will treat you. If it is bladder cancer, depending on
whether it is spread or not we will treat either by doing surgery – if possible, we may
remove just the growth or we may need to remove the whole urine bladder and create
an artificial urine bladder.

We may also need to treat with chemotherapy and radiotherapy.

If it is cancer of the prostate - again depending on the result we will treat either by
surgery or chemotherapy or radiotherapy.

Are you following me? Is that OK?

Pt : Ok, doctor. Thank you very much.

HAEMATURIA

296
 297

VERTIGO
Differential Diagnoses

Peripheral vertigo Central Vertigo

1. BPPV 1. TIA/Stroke

2. Vestibular neuronitis 2. Multiple Sclerosis

3. Meniere’s disease 3. Migraines

4. Labyrinthitis 4. Acoustic neuroma

5. Head injury 5. Brain tumour

6. Medication 6. Medication

BPPV Vestibular Neuronitis Meniere’s Disease

● Mostly seen after the ● Sudden onset, lasts Hearing loss and tinnitus
age of 50. for hours. and fullness in ear present.
● Can be seen in ● Not triggered by
young people. movement but
● Precipitated by movement can
movement exacerbate
● Can follow after symptom.
injury to head or ● Can happen after
● ear viral infections like
● Last only for few flu.
seconds or ● Can have nausea
● minutes. and also vomiting.
● Episodic – happens ● There may be
on movement hearing loss
● of head. ● No other symptoms
● Associated with like pain, tinnitus,
nausea, usually no fullness in ear,.
● vomiting.
● No other symptoms
like pain
● tinnitus or fullness in
ear
If Dix Halpike test is
negative –
then it is unlikely to be
BPPV.

297
 298

51. A. You are an FY2 doctor in the Emergency Department. A 25 years old female
has been brought to emergency room with complaint of vertigo.
Take a history from the patient, talk to her and discuss further management with
her.

Dr: Hello Miss I am Dr…. How may I call you? Pt: You can call me ....

Dr: What brings you to hospital Miss..? Pt: I am having vertigo doctor.

Dr: I am sorry to hear that. Could you please tell me what exactly do you mean to as
vertigo?

Pt: Doctor every time I turn my head, I feel like my head is spinning.
Dr: It must be very distressing for you. Can you tell me more about it?

Pt: I was shopping in the market doctor and I just turned my head to have a look at
something and it felt like the whole world just spun around me. I fell down suddenly
doctor. Could you imagine?

Dr: I can understand, it must be very upsetting for you.

Pt: It is. I was brought by ambulance to the hospital.

Dr: Could you please tell me if this feeling is being provoked by any specific movements
of head or your body? (Like sitting up or leaning forward or turning the head in a
horizontal plane?)

Pt: Yes, doctor my symptoms are worsened when I tilt my head to a side. (Patient might
describe the position) (BPPV)

Dr: Can you tell me whether the feeling of head spinning is triggered by the head
movement or is exacerbated by movement? (Labrynthitis is not triggered by
movement but may be exacerbated by it vs. BPPV which is triggered by
movement).

Pt: ? Doctor I get the feeling only when I move my head. (BPPV)

Dr: Could you please tell me how long do these episodes last? (20-30 seconds in
BPPV vs. >20 min in Meniere’s disease)

Pt: It lasts for a few seconds doctor but it is unbearable.

Dr: It must be. Does anything relieve it?

Pt: Yes doctor, it resolves if I keep my head stable. (BPPV)

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 299

Dr: Is there any other symptoms other than head spinning?

Pt: Yes doctor, I have been feeling sick. (Patient is holding a cup in her hand as if
about to vomit)

Dr: Have you vomited? Pt: No, doctor. But I am afraid I might vomit any time.

Dr: Please do not worry. We might be giving you some medicine for this complaint. Are
you comfortable to talk to me? Pt: (Yes, I can bear it/No?)

Dr: Did you lose consciousness during this time period? (Syncope/TIA/Vertebrobasilar
Ischemia)

Pt: No, I didn't lose consciousness but I fell down doctor.

Dr: Did you stand up suddenly from the sitting position at the moment you fell down in
the market? (Orthostatic Hypotension) Pt: No.

Dr: Did you experience any weakness in arms or legs during this time period? (TIA/
Vertebrobasilar Ischemia) Pt: No.

Dr: Did you lose hearing from one or both ears? (Labrynthitis/Meniere's Disease/
Vestibular Neuroma) Pt: No.

Dr: Do you have pain in this ear? Pt: No.

Dr: Do you have any fever? (Otitis Media) Pt: No.

Dr: Do you hear any hissing or ringing sounds in the ear? (Tinnitus - Labrynthitis/
Meniere’s disease/Acoustic Neuroma) Pt: No.

Dr: Do you have any balance problem while walking? (Balance Problems - Meniere’s
disease/Acoustic Neuroma) Pt: No.

Dr: Do you feel any fullness in your ear? (Aural Fullness-Meniere's Disease) Pt: No.

Dr: Have you been feeling unsteadiness in walking and/or hand movement? (Ataxia -
Acoustic Neuroma) Pt: No.

Dr: Have you been feeling any one sided headaches lately? (Vestibular Migraine/
Acoustic Neuroma) Pt: No.

Dr: Did you have injury to the ears or head recently? (Trauma) Pt: No.

Dr: Is it the first time it is happening? (Multiple Sclerosis) Pt: Yes.

Dr: Did you have any infections like flu in the recent past?

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Pt: Yes, doctor I have had a flu like illness a few days before. (Viral Post-viral illness/
Viral Neuronitis can be a cause of BPPV)

Dr: How long ago was that? Pt: Almost ten days ago doctor.

Dr: Have you been diagnosed with any medical conditions in past? Pt: No
Dr: Are you taking any medications now? Pt: (No/Yes?)

Examination:

I need to examine your ear. Examiner may say: Ear examination is normal.

I will like to perform a test called Dix-Hallpike Test.

[Do the test unless the examiner stops you or gives the findings]

This will involve you sitting on the couch. I will have to ask you to lie back and move
your head in certain directions. These set movements will usually trigger an episode of
vertigo. It will help us confirm the diagnosis of what we are suspecting in you. Are you
following? Pt: Yes.

(First, rule out contraindications of performing the test)

Dr: Could you please tell me if you have any neck or back related disease or injury? No.

Dr: Any bone problems like Rheumatoid Arthritis? Pt: No.

Procedure of Hallpike Test:

" Warn the patient that transient vertigo may occur in any position.

" Ask the patient to keep their eyes open and stare at your nose.

" Prepare the couch so the headrest is down and the patient's head will overhang
the end.

" Begin with the patient sitting with their head turned 45° to the left to test the left
posterior canal. With their head in this position, quickly lay the patient down until
the head is dependent 30° below the level of the couch.

" Observe for nystagmus in each position (30 seconds) and then return the patient
to the upright position.
" Repeat with the head turned to the right to test the right posterior canal.\

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If positive:
- The patient experiences vertigo and rotary nystagmus in posterior canal BPPV. Purely
horizontal nystagmus suggests horizontal canal BPPV.

- Nystagmus (fast component) will be upbeat and in the direction of the most affected
ear. This has a limited duration, lasting <30 seconds (adaption).

- On sitting, there is more vertigo, experienced as the room spinning in the opposite
direction (with reversal of the nystagmus).

Rhomberg's Test - this is used to identify instability of either peripheral or central

cause of vertigo:

The patient stands up straight with feet together (or at a distance for them to be
steady) with arms outstretched. Then ask them to shut their eyes.

If they are unable to maintain their balance with their eyes closed, the test is
positive (usually fall to the side of the lesion so stay close by to prevent them
falling).

A positive test suggests a problem with proprioception or vestibular function.

Romberg's test can also be positive in neuromuscular disorders and may not be
reliable in very elderly people.

[Stop the examination by 6 minutes]

Diagnosis:

Pt: From the information I have gathered, I suspect that you might be suffering from a
condition called as BPPV. Do you know anything about it? Pt: No, doctor.

Dr: BPPV is a condition of the inner ear. It is a common cause of intense dizziness or
vertigo. I will tell you what it means. It is short for Benign Paroxysmal Positional
Vertigo.

Benign means that it is not due to serious cause. Paroxysmal means symptoms comes
in episodes, Positional means that the symptoms are triggered by certain positions. In
the case of BPPV, it is certain positions of the head that trigger symptoms. Vertigo is
dizziness with a sensation of movement. Are you following?

Pt: Yes, doctor but why has it happened to me?

Dr: Our inner ear has some fluid filled structures called semi circular canals which
maintains balance of our body. If any broken off fragments of the inner ear structures

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gets inside that fluid it causes vertigo when we move the head in certain directions.

Sometimes this problem can be triggered if there is any injury or infections in the head
or ear previously. Are you following?

Pt: Yes doctor. Are you going to do any tests ?

Dr: There is no need to do any investigations to diagnose this condition. However if the
condition does not resolve or gets worse then we may need to do some tests like CT
scan or MRI scan to exclude any other conditions.
However, I would like to refer you to Ear Nose and Throat specialist. Is that alright?
Pt: Alright.

Pt: Yes, doctor. But how are you going to treat me?

Dr: This condition usually resolves itself in few days or in few weeks. There is no need
for hospital admission. We have a special technique called The Epley manoeuvre. This
manoeuvre is usually very successful in stopping symptoms with just one treatment. If
the first treatment does not work, there is still a good chance that it will work in a
repeated treatment session a week or so later.

We will give you medication called Proclorperazine and antihitamines this will help to
improve your symptoms of nausea vomiting and vertigo.

Dr: Can I ask if you drive? Pt: Yes doctor.

Dr: Please do not drive until this problem is resolved and please inform the DVLA.

Pt: Do I need to be careful about anything?

Dr: [warning signs] However, if you have any symptoms like hearing loss, hearing any
abnormal hissing sounds in the ear, headache, vision problems, please do come back
because these could be due to some other serious conditions.

Pt: Yes, doctor.

Dr: Do you have any concerns? Pt: No, you have been very kind.

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51.B VERTIGO - VESTIBULAR NEURONITIS

Diagnosis
You have a condition called Vestibular neuronitis. This is an inner ear condition that causes
inflammation (swelling) of the nerve connecting the labyrinth (an organ which helps
maintaining our body balance) to the brain.
The condition is usually caused by a viral infection. It usually comes on suddenly.

Are you following me ? Pt : Yes Is this a serious condition?

Dr: This is not a serious condition. It will subside by itself in few weeks time.

Treating vestibular neuronitis

" This condition subsides on its own in about 3 to 6 week time without any treatment.

" There is no need to be admitted to the hospital for treatment.

" We can give you medications to reduce the severity of your symptoms but they do not
speed up recovery.

" We will also give you anti- sickness medication called Prochlorperazine – which can
help with symptoms of nausea and vomiting.

" [Antibiotics – if it is caused by a bacterial infection ( do not mention in the exam

because patient did not have fever so not bacterial infection)]

" However, there are some self-help measures you can take to reduce the severity of
your symptoms and help your recovery.

Self-help for vestibular neuronitis

1. If you're feeling nauseous, drink plenty of water to avoid becoming dehydrated. It's
best to drink little and often.

2. If you have quite severe vertigo and dizziness, you should rest in bed to avoid falling
and injuring yourself. After a few days, the worst of these symptoms will go away and
you will not feel dizzy all the time.

3. You can do several things to minimise any remaining feelings of dizziness by

4. Avoiding drinking alcohol (if the patient was drinking)

A. Avoiding bright lights

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B. Try to cut out noise and anything that causes stress from your surroundings
C. You should also avoid driving, using tools and machinery, or working at
heights if you're feeling dizzy and unbalanced.

5. Once the dizziness is starting to settle, you should gradually increase your activities
around your home. You should start to have walks outside as soon as possible. It
may help to be accompanied by someone, who may even hold your arm until you
become confident.

6. You won't make your condition worse by trying to be active, although it may make you
feel dizzy.
7. While you're recovering, it may help to avoid visually distracting environments such
as:
D. supermarkets

E. shopping centres

F. busy roads

Pt: Will there be any problems in the future ?

Dr: A small number of people experience dizziness and vertigo for months or even years.
This is called chronic vestibular neuronitis. It happens when the vestibular nerve fails to
recover and the balance organs can't get messages through to your brain properly.

The symptoms aren’t usually as severe as when you first get the condition, although even
mild dizziness can have a considerable impact on your quality of life, employment and other
daily activities.

If this happens, then we have something called vestibular rehabilitation therapy

(VRT) to treat this condition.

VRT attempts to "retrain" your brain and nervous system to compensate for the
abnormal signals coming from your vestibular system.

VRT is usually carried out under the supervision of a physiotherapist.

Are you following me? Pt Yes. Any other questions – No

Warning signs

Dr: Mis. You can go home now. However, if you develop headache, hearing loss, double
vision, slurred speech, balance problem while walking or weakness or numbness in arms or
legs, you should come back because these are the signs that it could be some other serious
conditions.

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52. 34 year old lady presented with difficulty walking since last few days.
History, examination and management. You are the FY 2 in GP clinic.

Dr: Hello Are you Mrs... I am Dr ... How can I help you?

Pt: I am having weakness and numbness in my legs and hands and I am not able to
walk properly.

Dr: I see. Since when you started having these symptoms (weakness spreads quickly
that within days or weeks in GBS compared to other neurological problems which
can months to progress)? Last few days.

Dr: Do you how did these symptoms started?

Pt: These numbness started in my feet and hands and now they are spreading up in the
last few days.

When do you get these symptoms – any particular time of the day or are they present
throughout?

Dr: Did you have these symptoms all these days since it started or are there any days
you did not have symptoms (Multiple sclerosis – sometimes they do not have
symptoms)? I had this every day.

Dr: do you have these symptoms in both legs and both hands or only one side hand and
leg (GBS is bilateral)? - Both arms and both legs.

Dr: Are the weakness is more severe in the evening (Myasthenia)? No

Dr: Do you have weakness anywhere else – like arms, face, neck? No

Dr: Do you have any other symptoms? Like what?

Dr: Do you have any pains in your arms, legs, back or anywhere in the body (GBS,
vasculitis, polymyositis)? I have pain in my back.

Where exactly in your back? ... Since when? Since last few days.
Dr: Do you have a fever (vasculitis) ? No

Dr: Do you feel hot and cold sensations in your legs (no sensory loss in GBS,
myasthenia and polymyositis where as there is sensory loss seen in transverse
myelitis)? Yes

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[ask symptoms from head to toe]

Dr: Any problem in your vision (Multiple sclerosis, Myasthenia) ? No

Dr; Do you have any breathing difficulty ? No

Dr: Do you have any problem in speaking ? No

Dr: Do you have any problem in swallowing ? No

Dr: Do you have diarrhoea or constipation ? No

Dr: Do you have bowel or urine incontinence {BGS, Transverse myelitis (seen
early)}? No

Dr: Do you have any problems with balance or difficulty walking (GBS) ? No

Dr: any changes in your food recently lie did you have food in restaurants or did you
have any canned food recently (botulism) ? No

[ask triggers for GBS – recent flu or bowel infections]

Dr: Did you have a fever in the recent past ? Yes, I had flu three weeks ago.

Dr: Did you have diarrhoea recently ? No

Dr: Did you have this type of problem previously ? No

Dr: Do you have any medical conditions or have been diagnosed with medical
conditions in the past ? No

Dr: Are you taking any medications ? No

Dr: Are you allergic to any medications? No

Dr: Any family members have any medical conditions ? No

Dr: Thank you very much for all the information. Is there anything else you think may be
important for us to know ? I don’t think so.

Examination:

Check the NEWS chart for any temperature.

Dr: Mrs I need to examine you now. I need to do what we call as neurological
examination.

Examiner may give the signs:

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Power reduced in legs. (Power was 3)

(Reflexes will be reduced or absent in GBS, whereas in Myasthenia and Botulism,

they will be normal and hyperreflexia in Transverse myelitis).

Pupil Normal size (not dilated), Pupils reacts normally to light – in GBS

(Ptosis, dilated and non reactive pupils seen in Botulism)

Dr: Mrs.. I could see some weakness in your legs.

Investigations :

We need to do some tests to find out what exactly is causing these problems.

" We will refer you to the specialist called Neurologist in the hospital.
" We need to do tests like Lumbar puncture (where need to take some fluid from
the lower spine and test it)
" [Elevated cerebrospinal fluid protein without elevated cell count.This may take up
to 10 days from onset of symptoms to develop].

" Also other tests what we call as Electromyography and nerve conduction tests
which tests muscle and nerve function. (Abnormal nerve conduction velocity
findings, such as slow signal conduction)

Examiner may or may not give results. Check for elevated Protein in CSF if CSF result
is given.
Diagnosis:

Dr: Mrs ..... I think you have a condition what we call as Guillain Barre syndrome.

Do you have any idea about this? No

Dr: Guillain-Barré syndrome is a very rare and serious condition that affects the nerves.
It is thought to be caused by a problem with the immune system, the body's natural
defence against illness and infection. Normally, the immune system attacks any germs
that get into the body. But in people with Guillain-Barré syndrome, something goes
wrong and it mistakenly attacks and damages the coverings of the nerves and reduces
nerve function (conducting signals from the brain to the muscles). This causes
weakness in the muscles. Do you follow me?
Pt: Yes, but how did I get this?

Dr: We do not know what exactly causes this problems. However, we think it is due to
previous infections like flu or diarrhoea. In your case, you had a flu recently. That could
have caused this problem.

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Pt: Is there any treatment, doctor?

Dr: We need to admit you to the hospital for treatment. Neurologists will see you and tell
you about the treatment.

We will give you a medicine called immunoglobulin through your veins – Immunoglobulin
is made from donated blood that helps bring your immune system under control.

We may need to do a procedure called plasma exchange (plasmapheresis) – an

alternative to immunoglobulins where a machine is used to filter your blood to remove the
harmful substances that are attacking your nerves. Our Consultant will decide what is
suitable to you.

Other treatment we may give are to reduce symptoms and support body functions, such as
painkillers.

Most people need to stay in hospital for a few weeks to a few months.

Do you follow me? Is that Okay ? Is there anything else you want to know ?

Pt: Will I improve after the treatment doctor?

Dr: Most people with Guillain-Barré syndrome make a full recovery, but this can take
months or even years.

Some people won't make a full recovery and are left with long-term problems such as:
being unable to walk without assistance, weakness in your arms, legs or face, breathing
or swallowing problem, numbness, pain or a tingling or burning sensation balance and
co-ordination problems, extreme tiredness

Therapies such as physiotherapy, occupational therapy and speech and language

therapy can help you recover and cope with any lasting difficulties.

We may also need to put you on a machine to help with breathing and/or a feeding tube
if it is required, if there is a problem with breathing or swallowing problem in the future.

Pt: Will I die because of this problem?

Dr: Most of the people recover from the condition completely. Very rarely only, it is life
threatening. Any other question ?
Warning signs:

Dr: In the future, after discharge from the hospital if you develop symptoms like difficulty
breathing, swallowing or speaking, can't move their limbs or face, faints and doesn't
regain consciousness within two minutes

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This is a medical emergency and you need to be seen in hospital as soon as possible

So please come to the A&E department immediately. Thank you.

GUILLAIN-BARRE SYNDROME

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53.
69 year old lady had presented to A&E with sudden onset facial weakness, unilateral
limb weakness and slurring of speech.

On evaluation, found to have BP of 150/90.

Neurological examination was completely normal. She is worried and has given
consent to talk to her husband.

Talk to him, take history, discuss management and address concerns.

Dr: Hello Mr.... my name is Dr... Are you Mrs. X's husband?

H: Yes doctor..

Dr: How are you doing Mr...?

H: I'm fine doctor.. I was told someone would come by to talk to me about my wife.

Dr: That's correct Mr... I am here to talk to you about your wife. Could you please tell me
what exactly happened?

H: We were at home. She was just sitting and watching TV. And all of a sudden she
wasn't able to articulate words. I noticed some change in the right side of her face and
she couldn't move her right arm as well. So I just called an ambulance within 15 minutes
they arrived here and brought her to the hospital. But after we got here, within an hour,
she was perfectly fine! ( sometimes he may say symptoms lasted 2 hours)

Dr: Ok Mr... You did the right thing. It's very good that you called for an ambulance
immediately and brought her here. I do have a few more questions to ask you about
your wife's condition prior to this incident. Would that be all right? H: Yes

Dr: Did she complain of headache? H: No

Dr: Did she lose consciousness? H: No

Dr: Has your wife had such attacks in the past? H: No

Dr: Does she have any underlying medical conditions like diabetes? H: Yes ( sometimes
he may say - No)

Dr: High Blood pressure ? H: No

Dr: Was she ever found to have high cholesterol? H: No

Dr: Has she had any heart related incidents in the past? H: No

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Dr: Did she had abnormal heart beats? H: No

Dr: Ok.. Now Mr... I have a few questions about your wife's lifestyle.

What is her diet generally like?

H: She eats a healthy balanced diet doctor. Plenty of fruits and vegetables.

Dr: Ok. That is very good Mr... Does she get exercise?

H: A little.. Yes.. Moving around the house.. Gardening etc. ... (sometimes, he may say
we go for brisk walking every day – so does good exercises)

Dr: Does she smoke? H: No

Dr: Does she consume alcohol? H: No

Dr: Is she on any medications? H: No

Dr: Ok. Does she have any allergies? H: No

Dr: Does she have any family history of heart disease? H: No

Dr: F/H of stroke? H: No

Examination and Diagnosis:

Dr: Mr... as you had mentioned, your wife's symptoms resolved within an hour.. And on
examination, she had no neurological problems. From the information we have
gathered, it appears that she has had what we call a Transient Ischemic Attack (TIA) or
a mini-stroke. Do you have any idea what that is? H: No

Dr: A TIA is a medical condition where there is a momentary decrease or loss in blood
supply to the brain. This could either be because of some narrowing of the blood
vessels in the neck that supply blood to the brain ... or because of some rhythm
problems in the heart. Are you following me Mr . ?

H: Yes doctor.. Is it serious?

Dr: Mr... A TIA as such is not serious as it usually resolves by itself within 24 hours. But
we need to evaluate and find out why it happened because if it happens again, it might
not be a TIA, but something more serious, like a complete stroke. Do you follow me?

H: Yes doctor. What are the chances that she may get stroke doctor ?

Dr: Unfortunately the risk of she getting the stroke in the next few days itself is very
high.

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Investigations:

Dr: We need run some tests... to find out why this happened.

H: What kind of tests doctor?

Dr: First we will have to do a CT scan of her head... to make sure that there is no
evidence of a stroke. We will then do an ECG or a heart tracing to look for any rhythm
problems. We will also do some blood tests to check her sugar and cholesterol levels.

Additionally, we will have to do a scan called a Doppler... of the blood vessels of her
neck to see if they are narrowed. Are you with me Mr...? H: Yes

Treatment:

Dr: Mr... on examination, we also found that your wife's BP was on the higher side. It
was 150/90. We will have to start her on a medication to control her BP. We will also
start her on Aspirin, which can help prevent such attacks in the future. We will also ask
the Neurologist (TIA clinic) to evaluate your wife. Do you have any questions for me
Mr...?

H: When can I take her home?

Dr: If all the investigations are all right, you can take her home. She will be seen within
24 hours. If the scan of the blood vessels in her neck shows significant narrowing, we
might have to consider a surgeon to correct it. We will let you know based on the
findings.

Warning signs:

If you do take her home Mr... I would like to inform you about the warning signs of a
stroke [FAST – Facial weakness, Arm weakness, Speech problem – Time to call
the ambulance]. If you notice any weakness in her face or limbs... or any slurring of her
speech, please call an ambulance and bring her to the hospital immediately as the next
time, it can be even stroke. Do you have any questions for me ?

H: No doctor.. Thank you.

TIA

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54. 50 years old male presented with a history of TIA symptoms yesterday.
Take history, do a cranial nerve examination and discuss the further management
with the patient.

[Do not do fundoscopic examination]

History

Dr: How can I help you?

Pt: I had facial weakness, weakness of arms and legs yesterday which lasted for few
hours.

Dr: Do you have those symptoms now? Pt: No

Dr: Did you see any doctor for this yesterday? Pt: No

Dr: Did you have such problems before? Pt: No

Dr: Do you have high blood pressure, diabetes, high cholesterol, heart problems
(abnormal heart rhythms i.e atrial fibrillation), stroke or mini stroke before? Pt: No

Dr: Any medications?

Ask about life style (smoking, alcohol, exercise, diet)

Family history of stroke or mini strokes or heart problems ?

Examination: [Watch the video on YouTube]

a. Olfactory nerve: Dr: Did you notice any change in smell at all? Pt: No

b. Optic nerve: Two important aspects of the optic nerve are visual acuity and visual field.

 Visual acuity

Visual acuity can easily be tested with Snellen type. If the patient normally wears
spectacles, both tests may be done with them on. You can also do it with finger counting
if the Snellen’s test is not available.

 Colour vision

Colour vision can be tested with Ishihara plates. Deterioration may be significant but
remember that 8% of men and 0.5% of women have congenital X-linked colour blindness.
 Visual fields.
 Ophthalmoscopic examination (do not do it in the exam)

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c. 3rd Oculomotor, 4th Trochlear (SO4) and 6th Abducent (LR 6)

These three nerves are examined together, as they control the external ocular muscles.

The oculomotor nerve is the third cranial nerve (CN III). It innervates extrinsic eye
muscles that enable most movements of the eye and that raise the eyelid. The nerve
also contains fibers that innervate the intrinsic eye muscles that enable pupillary
constriction and accommodation (ability to focus on near objects as in reading).

Internal ocular muscles : Direct and consensual light reflex and accommodation reflex

External ocular muscles: H test

d. 5th Trigeminal nerve

The trigeminal nerve is largely a sensory nerve but it does have a motor component in
the mandibular division.

Lightly touch each side of the face with a piece of cotton wool and ask if it feels normal
and symmetrical. Test the areas supplied by the ophthalmic, maxillary and mandibular
branches.

Ask the patient to clench his/her teeth. Both masseters should feel firm and strong. The
contracting temporalis may also be felt.

Corneal reflex (do not do in the exam)

e. 7th Facial nerve

Ask the patient to raise his/her eyebrows. Are the furrows of the forehead symmetrical?

Ask the patient to screw up his/her eyes. Gently try to pry them open. You should fail.

Ask the patient to give a broad toothy grin, demonstrating what you want. Do not say,
'Show me your teeth', or he/she may remove any dentures and hand them to you. Is the
grin full and symmetrical? - Angle of the mouth deviates to the normal side.

Paralysis of the facial nerve causes face drop. This is more marked with a lower motor
neurone (LMN) lesion than an upper motor neurone (UMN) lesion. The best way to
differentiate between the two is to test the muscles of the forehead. They have bilateral
innervation at the upper motor neurone level and so, in a UMN lesion such as a
pseudobulbar palsy, they are spared. An LMN lesion such as Bell's palsy will involve the
forehead.

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f. 8th Vestibulocochlear nerve

Testing of the vestibular component is - Hallpike's manoeuvre (do not do).

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

Either whispering or use of a high-frequency tuning fork can give a very crude assessment of
hearing. A 516 Hz (upper C) tuning fork is usually employed:

Strike the tuning fork and hold it about 2 cm from the ear, asking the patient to tell you when
it stops. Then listen to it yourself and the intensity of the sound indicates the degree of loss in
that ear.

If it is marked, place the still vibrating fork on the mastoid process and ask if it is heard. If it is
heard by bone but not air conduction, there is a marked conductive loss. With profound nerve
deafness, the patient may be hearing it by bone conduction in the other ear.

If there is significant loss in one ear, Weber's test can be employed. Strike the tuning fork and
place it on the centre of the forehead. Ask the patient in which ear it seems louder. The
vibration is conducted through bone and it will be quieter in the bad ear with nerve deafness
but louder with conductive deafness as the affected ear becomes more sensitive.

g. 9th Glossopharyngeal and 10th Vagus nerves

Assessment of the glossopharyngeal and vagus nerves is difficult.

Glossopharyngeal nerve lesions produce difficulty swallowing; impairment of taste

over the posterior one-third of the tongue and palate; impaired sensation over the
posterior one-third of the tongue, palate, and pharynx; an absent gag reflex; and
dysfunction of the parotid gland.

Vagus nerve lesions produce palatal and pharyngeal paralysis; laryngeal paralysis;
and abnormalities of oesophageal motility, gastric acid secretion, gallbladder emptying,
and heart rate; and other autonomic dysfunction.

Ask the patient to swallow. Is there any difficulty? Ask the patient to open his/her mouth
wide and to say 'Ahh'. Phonation should be clear and the uvula should not move to one
side.

The quality of the dysarthria differs for central and peripheral lesions. Central lesions
produce a strained, strangled voice quality, while peripheral lesions produce a hoarse,
breathy and nasal voice.

It is also possible to test the gag reflex by touching the pharynx with a tongue depressor.

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Most people omit this unless there is evidence of a local lesion. It is unpleasant and around
20% of normal people have a minimal or absent response.

Isolated lesions of the IX nerve are very rare. Taste to the anterior two thirds of the tongue
travels with the VII nerve until it leaves in the chorda tympani to join the V nerve. The
posterior third of the tongue is supplied from the IX nerve that also provides
parasympathetic fibres to the salivary glands. It is possible to test taste with small bottles
and a dropper. The bottles usually contain sugar or salt solution. Most generalists do not
perform this test.

h. Accessory nerve

The accessory nerve supplies the trapezius and sternomastoid muscles. Is there any
wasting? Ask the patient to shrug his/her shoulders up and try to push them down.

Ask the patient to push his/her head forwards against your hand. Both these movements
should be very difficult to resist.

LMN lesions produce weakness of both muscles on the same side. UMN lesions produce
ipsilateral sternomastoid weakness and contralateral trapezius weakness, because of
differing sources of cerebral innervation.

i. Hypoglossal nerve

It is often more convenient to assess the XII cranial nerve before the XI as the mouth is
examined for IX and X.

Ask the patient to protrude his/her tongue and note any deviation. A fluttering motion called
fibrillation rather than fasciculation may be seen with an LMN lesion.

If the tongue deviates to one side when protruded, this suggests a hypoglossal nerve
lesion. If it is an LMN lesion, the protruded tongue will deviate towards the side of the
lesion. With a UMN lesion, the tongue will deviate away from the side of the lesion.

Note the wasted left side of the tongue and deviation to the left suggesting a left LMN
lesion.

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

Mr... On examination, everything looks normal at the moment.

With what you have told me and after examination, I think you had a condition that we
call Transient ischemic attack.

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Dr: A TIA is a medical condition where there is a momentary decrease or loss in blood
supply to the brain. This could either be because of some narrowing of the blood
vessels in the neck that supply blood to the brain... or because of some rhythm
problems in the heart. Are you following me Mr...? P: Yes doctor.. Is it serious?

Dr: Mr... A TIA as such is not serious as it usually resolves by itself within 24 hours. But
there is a risk of having stroke next time which is a very serious condition.

We need to do investigations to find what exactly caused this problem and treat that
condition so as to reduce the chances of you getting a stroke. Is that Okay? Pt: Yes

P: What kind of tests, doctor???

Dr: First, we will have to do a CT scan of the head... to make sure that there is no
evidence of a stroke. We will then do an ECG or a heart tracing to look for any rhythm
problems. We will also do some blood tests to check her sugar and cholesterol levels
(high cholesterol is a risk factor for stroke).

Additionally, we will have to do a scan called a Doppler... of the blood vessels of your
neck to see if they are narrowed. Are you with me Mr...? P: Yes

Treatment:

Dr: Mr... There is no need for urgent admission to the hospital at the moment. We will
also start you on Aspirin, which can help prevent such attacks in the future. We will refer
you to the Neurologist urgently. Do you have any questions for me Mr...?

Treat other conditions if the patient has like HTN or Diabetes.

Advise life style. (diet, exercise, smoking, alcohol).

Warning signs:

I would like to inform you about the warning signs of a stroke [FAST – Facial
weakness, Arm weakness, Speech problem – Time to call the ambulance]. If you
ever notice any weakness in face or limbs... or any slurring of her speech, please call
an ambulance and come to the hospital immediately as the next time, it can be
even stroke. Do you have any questions for me ?

H: No doctor.. Thank you.

TIA WITH CRANIAL NERVE EXAMINATION

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55. You are an F2 in the GP clinic.

60 year old Mr. Zimmerman makes an appointment with the clinic because he is
very concerned about developing a stroke. The nurse has found his BP to be
160/90.

Talk to him and address his concerns.

Dr: Hello Mr. Zimmerman... I am Dr.... one of the junior doctors here in the GP clinic..

Pt: Hello doctor.. Very nice to meet you. Dr: Nice to meet you too Mr. Zimmerman. I
understand you made an appointment with the clinic because you had some concerns. Is that
correct?
Pt: Yes doctor. I'm very worried that I might develop stroke.

Dr: Could you please tell me why you are worried about it?

Pt: I had a health check by the Occupational health department 2 years ago and they
told me that my blood pressure is a bit high at that time. But I was too busy and I didn’t
bother much about it. But now I am very worried about it.

Dr: Can you please tell me why are you worried of getting stroke if your blood pressure is
high ?

Pt: My father and elder brother had high blood pressure. My father died of a stroke many
years ago and my brother had a stroke a few years ago. He has just recovered now.

Dr: I am very sorry to hear that Mr. Zimmerman. But don’t worry, Mr Zimmerman we can
help you to reduce any risk of you getting stroke.

Mr Zimmerman, do you know what is stroke and why people get this condition ? Pt: I
know people can have paralysis if they have a stroke.

Dr: That is right, Mr Zimmerman. This condition happens either because there is
bleeding in the brain and blockage to the blood supply to the brain. People who have
this condition can have paralysis. Sometimes, people do improve from this problem but
sometimes the paralysis can last forever. Sometimes, this condition can even be life
threatening. Pt: I see.
Dr: Sometimes, this condition can run in the family because of genetic reasons.
However, there are a lot of others risk factors why people get stroke. We may be able to
reduce the chances of you getting stroke if you have any other risk factors and if we can
modify those factors. I am really glad that you came to the hospital now. Let us see if
you have any other risk factors and try to sort out those. Is that OK Mr Zimmerman?

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Pt: Ok Doctor.

Dr: Did you have any strokes or mini strokes previously? Pt: No

Dr: Do you have any heart problems? Pt: No

Dr: Do you have any palpitations (Atrial fibrillation)? Pt : No

Dr: Do you have diabetes? Pt: No

Dr: You said your blood pressure was high before. Our nurse checked your blood
pressure now which is 160/90 which is quite high. High blood pressure is one of the
major risk factors which can cause rupture of the blood vessels in the brain and cause
bleeding in the brain. It is very important to keep the blood pressure under control. We
can give medications to keep the blood pressure under control. I will talk to my seniors
about it and get back to you.

However, apart from medications you may need to do a lot of other things to keep the
blood pressure under control.

Pt: What is that doctor?

Dr: One important factor is diet. Can I ask you what type of food you usually eat?

Pt: You know doctor. I am an NHS manager. I'm usually busy. I don’t have time to cook
food. So I eat out most of the time. I have to eat fast food - I eat chips, burgers, steaks,
etc

Dr: Mr Zimmerman, the kind of food that you are eating is not good because they have
very high bad fat content that is cholesterol. This can increase the blood pressure and
contribute to stroke. I advise you to eat more of white meat which has less bad fat like
chicken and fish. I also advise you to include plenty of fruits and vegetables in your diet.
Also please reduce the salt content in your food because it can increase the blood
pressure. If you want, I can refer you to a dietician who will advise you in detail about
the healthy diet. Is that OK? Pt: That is fine. Doctor.

Dr: That is good. Can I ask if you exercise ?

Pt: Not much, doctor. As I said I don’t get time to do exercise.

Dr: I understand you are very busy. However, I sincerely advise you to do some
exercise like walking for about 30 min every day at least 5 days a week. If that is not
possible, maybe you can have a treadmill at home and exercise on that while you are
watching TV. Exercising regularly will keep you healthy and also helps to keep the blood
pressure under control. What do you say ?

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Pt: Yes doctor that seems to be a good idea.

Dr: Excellent. Do you smoke Mr Zimmerman?

Pt: Yes doctor I smoke about 10 to 15 cigarettes a day for the last 15 to 20 years doctor.

Dr: Again smoking is not good for health at all as you may know. Smoking also can
increase the blood pressure and also can cause a lot of other health problems. I
strongly advise you to stop smoking. We have support services to help you to stop
smoking if you wish. Do like to consider that Mr Zimmerman?

Pt: Doctor you know my work is very stressful. In fact, the NHS is going through a lot of
financial crisis. I have to do a lot of work to prevent this financial problems. I might even
lose my job. I have to smoke to relieve my stress, doctor.

Dr: I can surely understand your problem. However, there are many other ways to
relieve stress. Maybe you can take a break from work and go for relaxation classes and
yoga classes which might help you to relieve stress. Remember stress also can
increase the blood pressure. What do you say?

Pt: Yes doctor you are right. I will try my best to do that.

Dr: Do you drink alcohol Mr Zimmerman?

Pt: Yes doctor. I drink about 2 glasses of wine every day and also whisky sometimes
over the weekends.

Dr: Mr Zimmerman, alcohol also is not good for the health. I advise you to cut down
drinking alcohol and drink within the recommended limits that is not more than 14 units
per week. We can also help you to cut down if you wish. What do you think ?

PT: Yes, doctor I will surely think of that.

Dr: Excellent. Do you have any questions?

Pt: Doctor if I follow all the advice that you gave, then will I not get a stroke?

Dr: Mr Zimmerman. There is something called modifiable and non-modifiable risk

factors for stroke. Non-modifiable factors are like age above 60 years, genetic cause
means inherited risk which we can’t do anything about these. However there are lot
other modifiable risk factors like all the factors what we discussed so far like diet,
exercise, smoking which you can modify and have a healthy lifestyle. This can
substantially reduce the risk of you getting stroke. Also there are other risk factors like
abnormal heart rhythms and narrowing of the blood vessels in the neck that supplies

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blood to the brain. We can check whether you have any problems like these and we can
treat them if you have. All these things will greatly reduce the risk of getting stroke.

Tell him that he is valued of NHS. Ask if he can share his responsibilities.

Pt: Ok Thank you very much doctor.

Dr: I advise you to follow all the recommendations. We will keep following you up.
Please be aware of the symptoms of stroke like facial weakness, arm weakness or speech
problems. If you have any of the symptoms please call the ambulance and come to the
hospital immediately because these are the symptoms of stroke. Is that Ok Mr Zimmerman.

Pt : Ok doctor.

Dr: Any other questions?

Pt : No doctor. You have been very kind.

Dr: Thank you very much Mr Zimmerman. Once again, I really appreciate that you came
here today. I wish you a very long and healthy life.

STROKE RISK ASSESSMENT

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56. HEAD INJURY IN AN ADULT

Criteria for performing a CT head scan in adults (NICE guideline)

For adults who have sustained a head injury and have any of the following risk
factors:-

Perform a CT head scan within 1 hour of the risk factor being identified:

1. GCS less than 13 on initial assessment in the emergency department.

2. GCS less than 15 at 2 hours after the injury on assessment in the emergency
department. Suspected open or depressed skull fracture
3. Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal
fluid leakage from the ear or nose, Battle's sign).
4. Post-traumatic seizure. Focal neurological deficit
5. More than 1 episode of vomiting.

For adults with any of the following risk factors who have experienced some loss of
consciousness or amnesia since the injury, perform a CT head scan within 8 hours of
the head injury:

1. Age 65 years or older.

2. Any history of bleeding or clotting disorders.

3. Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle,

an occupant ejected from a motor vehicle or a fall from a height of greater than 1
metre or5 stairs).
4. More than 30 minutes' retrograde amnesia of events immediately before the
head injury.

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56.40 year old man Mr Andrew Robert collapsed outside a pub. Take history from the
patient and discuss the management with the patient.

Dr - What brings you to the hospital?

Pt - Doctor I passed out

Dr - When

Pt - I just came out of the restaurant and passed out

Dr – Was there any one with you?

Pt - Yes my wife was with me.

Dr - How did this happen?

Pt: We were in the restaurant, we came out and suddenly I passed out.

Dr: Did you slip or trip?

Pt: I am not sure. (sometimes, he may say I tripped on the pavement)

Dr - How long did you lose consciousness?

Pt – I am not sure because when I was awake I was in the ambulance.

Dr - Did you recover completely after this, or was there any drowsiness

Pt – Yes, I did recover completely immediately after the incident

Dr - Any head injuries when fell down ? Pt – No/Yes

Dr: Did you have any head injury before you lost consciousness? Pt: No

Dr - Any headache? Pt - No

Dr: Did you vomit after this ? Pt: Yes twice

Dr – Did anyone tell you that were jerking (fit) at that time ? Pt - No

Dr - Any weakness on any side of your body? Any pins and needles? Any vacant episodes?

Dr - Did you wet your pants do you know? Pt - No

Dr: Do you know whether you had any bleeding from ear nose? Pt – No

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Dr: How much do you remember before this incident? (any amnesia for 30 min before
incident)

Pt: Sometimes, he may say I remember everything until I just passed out / sometimes
he may say I just remember going into the restaurant and then my wife told me that
when we came out I just passed out.

Dr: How much do you remember before this incident ?

Pt - I remember when I was awake I was in the ambulance and remember everything
after that.

Dr - Is this the first time …. Pt - Yes

Dr - Any medical problems like – DM, HTN, Heart conditions, Epilepsy, Stroke, Pt – No

Dr - Did you drink alcohol just before this?

Pt – Yes, doctor but it is the same type and same amount as usual
Dr - Did you use any recreational drugs just before that? Pt - No, doctor.

Dr – Do you take any medications? Any blood thinners?

Pt – No (Any drug Overdose?)

Dr – Any of your blood relatives have any medical conditions like DM, Heart conditions or
epilepsy? Pt - No

Dr - Do you live with any one? Pt – Yes, my wife

Dr: Mr Robert, I need to examine you (Examiner may not give any findings).

With what you told me, I think you have injured your head and probably you have some
bleeding inside your head. We need to admit you in the hospital and do a CT scan of
the head to check whether you have the bleeding. Is that OK?

Pt: No Doctor I am fine now. I want to go home.

Dr: Mr Robert with the symptoms you are telling me i.e the headaches and vomiting,
these are the signs of bleeding inside the head. It will be very dangerous for you to go
home. We need to admit you to treat you if you have bleeding inside your head. We
may need to do an operation on your head to remove the blood clot if you do indeed
have bleeding in the brain. We will also do some tests to see why you fell – we will do
ECG (heart tracing) and check your blood sugar.

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However, if all these tests are normal, then you can go home. Is that OK? If we
discharge you, then you should stay at home for at least 24 hours and your wife should
take care of you. If you have any symptoms like (warning signs) continued headache,
continuously vomiting, drowsiness or fits you should come back. Pt: Ok doctor. Thank
you very much.

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57. 54 year old lady Mrs Joan presented to the hospital with severe headache.
Take history, examine her and discuss the further management with her.

Dr: Hello Mrs Joan, I am Dr…. one of the junior doctors in the medical department. Can
you please tell me what brings you to the hospital?

Pt: I am having severe headache.

Dr: I am very sorry to hear that. Can you please tell me how severe is the pain – in the
scale of one to ten one being the mildest pain and ten being the most severe pain ?

Pt: It is 10 out of 10 doctor.

Dr: Do you want me to give you some pain killers? Pt: Yes please doctor.

Offer painkiller.

Dr: Can you please tell me more about your headache ?

Pt: Doctor, this headache started suddenly. This is the worst headache of my life. I felt it
like thunder clap / I thought someone hit the back of my head.

Dr: Do you mean to say you used to have headaches like this before ? Pt: Yes doctor, I
have migraines.

Dr: Is this different from migraine headache ?

Pt: Certainly, doctor. I never had a headache like this before. Dr: Where exactly in the
head you have this headache?

Pt: Back of my head doctor.

Dr: Since when are you having this headache? Pt: Almost 2 hours now.

Dr: What were you doing when you got this headache ?

Pt: Doctor, I was doing …. (subarachnoid haemorrhage sometimes happens during

physical effort or straining – such as coughing, going to the toilet, lifting
something heavy or having sex).

Dr: Did you take any medications for your headache? Pt: Yes I took paracetamol but it
didn’t help me at all.

Dr: Do you have any other symptoms other than headache? Pt: I feel sick doctor but not
vomited.

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Dr: Anything else? Pt: Like what?

Dr: Any fever ? (meningitis) Pt: No,

Dr: Neck stiffness?Pt:No

Dr: Rash on the body? Pt:No.

Dr: Any head injury recently? Pt:No

Dr: Any pain on the side of your head when combing hair? (GCA) Pt: No

Dr: Any pain in your jaw ? (GCA) Pt:No

Dr: Any vision problems? (SAH, GCA) Pt: No Dr: Any coloured halos in your vision?
(glaucoma) Pt: No

Dr: Any watering of the eyes? (cluster headache) Pt: No

Dr: Do you get headaches in the morning ? (SOL) Pt:No

Dr: Any weakness on any part of your arms or legs ? (SOL, stroke, SAH) Pt: No

Dr: Pain when you move your eyes?

Dr: Any speech problems ? (Stroke, SAH) Pt:No

Dr: Do you have any medical conditions? Pt:No

Dr: Have you ever had any medical conditions in the past? Pt:No

Dr: Diabetes? Pt:No Dr: High blood pressure ? Pt:No

Dr: Any strokes or mini strokes in the past? Pt: No

Dr: Any kidney problem? Pt: No

Dr: Do you smoke ? Pt:No Dr: Do you drink alcohol ? Pt: one bottle of wine a day

Dr: Do you use any recreational drugs? Pt: No

Dr: Are you taking any regular medications? Pt: No Dr: Are you allergic to any
medications? Pt: No

Dr: Any of your family members had headaches like this or had bleeding in their brain?
Any family history of kidney disease? Pt: No

Dr: What do you do for a living ? Pt: I am an accountant.

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Dr: Is there anything else you think may be important that we need to know? Pt: I don’t
think so doctor.
Examination:

Dr: Mrs Joan I need to examine you now and check your pulse and Blood pressure.
Examiner says – examination is normal. Her BP is 150/90, Pulse normal

" GCS
" Neurological examination - Facial movements, neck stiffness, Tone, Power
Diagnosis

Dr: Mrs Joan, I think you have a condition what we call as Subarachnoid haemorrhage -
that is bleeding in the brain. Are you following me?

Pt: Yes, but why do I have that doctor?

Dr: There are several reasons why this can happen. This usually happens because there is
some abnormal blood vessels in the brain which blood vessels becomes thin and they bulge
out what we call as aneurysm. Sometimes these blood vessels suddenly rupture and cause
severe headache like what you had. Sometimes this condition can run in the family.
Unfortunately this is a very serious condition and sometimes this could be even life
threatening. Do you follow me?

Pt: Yes, doctor. Are you sure that is what I have ?

Dr: We need to do some tests to confirm that. We will have to do a CT scan of head.
(CT scan is the first line investigation – shows bleeding in 98% of cases but
negative in 2% cases). Explain patient what CT scan is.

If examiner says – CT scan is normal. What will you do?

Dr: We will do Lumbar puncture which is usually done after 12 hours of onset of headache to
look for Xanthochromia (Lumbar puncture should ideally take place over 12 hours after
the onset of the headache because if there are red cells in the CSF, sufficient lysis will
have taken place during that time for bilirubin and oxyhaemoglobin to have formed -
xanthochromia (yellow discolouration of the spinal fluid). Explain to patient what lumbar
puncture is.

Examiner says: What will you do if the Lumbar puncture is positive for SAH? Dr: We
will admit her in the ITU and transfer to the neurosurgical ward.

Do further investigations to find out the exact location shape and size of the abnormal blood
vessels like:
1. CT Angiography 2. Magnetic Resonance Angiography(MRA) 3. ECG

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Treatment:

1. One of the problems with SAH is Cerebral ischemia due to vasospasm.

Treat her with calcium channel blocker – Nimodipine (60 mg-q4hr (every four hours) -
this is normally taken for three weeks, until the risk of secondary cerebral
ischaemia has passed) to relax the blood vessels in the brain to improve blood
circulation to the brain.

2. Labetalol - to treat hypertension; the level should be low enough to prevent

rebleeding whilst high enough to maintain cerebral perfusion.

Patients should not be given an antifibrinolytic agent or steroids.

3. She needs an operation on the brain either clipping or coiling.
4. We can give her pain killers (morphine, co-codamol, antiemetics, and anticonvulsants
- if she has fits)

There is a 50 % mortality even with the treatment.

Complications

1. Rebleeding
2. Epilepsy (1 in 20)
3. Problems with certain mental functions, such as memory, planning and
concentration
4. Changes in mood, such as depression
5. Hydrocephalus
6. Delayed cerebral ischaemia

Thank you very much to the patient and examiner.

Differential diagnosis for SAH

1. Meningitis (rarely features thunderclap headache).

2. Trauma.
3. Thunderclap headache of other aetiology.
4. Primary sexual headache.
5. Cerebral venous sinus thrombosis.
6. Cervical artery dissection.
7. Carotid artery dissection.
8. Hypertensive emergency (severely raised blood pressure).
9. Pituitary apoplexy (infarction or haemorrhage of the pituitary gland).
HEADACHE - SUBARACHNOID HAEMORRHAGE

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58. 20 year old man was brought in by his father because he suddenly became
unwell. Take history and discuss management with him.

Dr: Hello, I am Dr... Are you the father of ...

Father: Yes

Dr: How can I call you please ?

Father: You can call me ...

Dr: How can I help you Mr..

Father: Doctor, me and my son were sitting and watching television just a few hours
ago. Suddenly he started talking rubbish, was not making any sense and then he had a
fit. I am very worried doctor.

Meningitis doesn’t usually present with behavioural changes. Think of viral encephalitis
or brain abscess if these are present.

Dr: I am very sorry to hear that. Can you tell me more about it?

Father: He was saying he had a headache and fever since yesterday. Otherwise he was
ok until this suddenly happened?

Dr: Did he have any other symptoms other than headache and fever ?

Father: I don’t know.

Dr : Was he complaining of headache for a long time or just for one day?

Father – Just since yesterday?

Dr: Did he have any weakness or arms or legs (SOL) ( TIA, stroke) ? Father : No

Dr: Did he have vomiting? Father : No

Dr: Did he have earache? Father: No

Dr: Discharge from the ear? Father: No

Dr: Did he have sore throat recently? Father: Yes/No

Dr: Did he cough? Father : No

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Dr : Chest pain? Father: No

{Neck swellings - EBV}

Dr: Was he shying away from the lights? Father : I do not know?

Dr: Did you notice any rashes on his body? (Herpes) Father: No

Dr: Did he complain of burning sensation while passing urine recently? Father: No

Dr: Did he have high temperature in the evening do you know (TB)? Father : No

Dr: Did he have any head injury recently? Father: No

Dr: Did he have any similar problems in the past? Father : No

Dr: Has he been diagnosed with any medical conditions in the past? Father : No

Dr: Did he ever have TB before? Father : No

Dr: Is he sexually active?

Dr : Did he have fits like this before? Father : No

Dr: Did he have any mental health illness? Father : No

Dr: Does he smoke? Father : No

Dr: Does he use any recreational drugs? Father: No

Dr: Did he have any medical conditions like HIV infections? Father: No

Dr: Has he lost weight recently (TB)? Father : No

Dr: Is he on any medications? Father : No

Dr: Is he allergic to any medications? Father : No

Dr: Anyone in the family had similar problems or any medical conditions running in the
family do you know? Father : No

Dr: Did he travel outside UK recently? Father: No

Dr: Did he come into contact with anyone who had similar problem recently? Father :
No

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Dr: Did he come into contact with anyone who has or had TB recently? Father : No

Dr: Does he work or is he a student? Father : ....

Dr: Is there anything else you think is important that we may need to know?

Father: I can’t think of anything else.

Examination and investigations

Dr: Mr I need to examine your son to check his pulse, BP, temperature, and I also need
to check for any brain infection signs, check his conscious level, and whether he has
any rashes on his body. Also I need to check whether he has any swellings in the neck.
Then we may need to do investigations like blood tests, infection markers, CT and MRI
scan of his brain and also we need to do a test called spinal tap where we take a little
bit of fluid from his lower spine and test that.

Examiner may give a paper with a lot of information.

In the paper it may be written: Patient drowsy, No neck stiffness, Brudzinski sign
and Kernig’s sign negative, No rashes.

He has cervical lymphadenopathy.

CSF result- Pressure normal, sugar normal, protein high, lymphocytes 80%,
Monocytes 10%.

● We need do gram stain and ZN stain – examiner may that is normal.

● We will send it for culture - a type of test to check what kind of bugs may be
causing this problem.

● Also we will send this sample for another type of test what we call polymerase
chain reaction test (for Herpes simplex virus, Herpes zoster virus and
enteroviruses).
● We also need to check whether he has any HIV infection.
Talk to father about diagnosis and management

I think your son has a condition we call Encephalitis. Do you know anything about this ?

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Father : No

Dr: In this condition, there is infection of the brain by some kind of bugs. There are a
lot of different types of bugs can cause serious brain infection.

Different types of bugs like bacteria, virus and fungus type can cause this infection in
the brain.

However, the test results show it is more likely due to some kind of virus type of bugs.
Brain infection due to virus type of bugs can be dangerous some time but most of the
time, they resolve with treatment. Are you following me ?
Father: What kind of virus doctor?

Dr: We will do some blood tests to find out what exactly the type of bugs.

Father: Ok. What will happen to him now?

Dr: We are going to admit him and give some antiviral medication (Acyclovir) through
his veins. Hopefully he recovers soon. We will also be giving him oxygen and then
fluids through his veins. I will be informing my seniors also immediately about him.

Any other concerns? Father: How long he may need to be in the hospital?
Dr: That depends on the type of bugs. Sometimes he may need treatment up to 2 to 3
weeks in the hospital. Once he recovers, then we will discharge. Any other concern?
No. Thank you.

VIRAL ENCEPHALITIS

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59. You are the FY2 doctor in the GP clinic.

33 year old man was referred by Optometrist for early diabetic retinopathy. Talk to
him and address his concerns.

Dr: Hello Mr…. I am Dr. How are you doing?

Pt: Doctor, I went to the Optometrist and she said I have diabetes in my eyes. She has
given this letter to you. Doctor will I lose my vision ?

Dr: Let me have a look at the letter(Letter says – early diabetic changes seen in the eye)

Mr…. Yes, the letter does say you have diabetic changes in your eye. However to say
whether you lose vision or not I need to ask you few questions and examine you. We may be
able to reduce the chances of you becoming blind even if diabetes has affected your eyes.

Can you please tell me why did you go to the Optometrist?

Pt: Doctor, I am a painter. I can’t see small things when I paint. That is why I went to the
Optometrist.

Dr: I am sorry to hear the problem. Can I ask you since when are you having this
problem? Pt: Since the last few weeks doctor.

Dr: Do you have Diabetes? Pt:Yes doctor.

Dr: Since when are you having diabetes?Pt: Since many years.

Dr: Are you on medications for that? Pt: No, I was told to control it by diet.

Dr: Do you keep checking your sugar? Pt: Not very often.

Dr: Is it controlled well? Pt: Not really, doctor.

Dr: Do you visit your GP here regularly for your diabetes? Pt: No.

Dr: You said you can’t see small things. Do you think it is one eye problem or both
eyes? Pt: Both the eyes.

Dr: OK. Do you have any other problem in your vision ?Pt: No

Dr: Do you see anything floating in your vision area (floaters)? Pt: No

Dr: Any pain in the eye? Pt: No

Dr: Any double vision? Pt:No

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Dr: I need to examine your eyes. [examiner may say – it shows early diabetic
retinopathy. Some examiners may not say anything]

Dr: Mr… as per the information what you have given me and the Optometrist letter, you
probably have a condition called Diabetic Retinopathy. This means diabetes has
affected your eyes.

If the blood sugar is very high, it causes the blood vessels which supplies blood to the
back of the eye (called retina) to bulge out and it can start leaking blood. Sometimes
new tiny blood vessels get formed at the retina which easily gets damaged and starts
bleeding. This is called Diabetic retinopathy. This can cause vision problem. If the
condition continues, then it can cause loss of vision. Are you following me Mr… ?

Pt: Yes, I can understand what you are saying, but I don’t want to lose my vision doctor.

Dr: I can understand how you are feeling. We can definitely try to help you so that the
risk of losing vision will be reduced. This condition is mainly caused by high blood sugar
and also there are other risk factors like high blood pressure, high bad fat content in the
body and smoking which can contribute to this problem. If you control the blood sugar
properly and also reducing other risk factors if there are any then the chances of you
losing vision will be greatly reduced.

I need to ask you a few questions to see why your blood sugar is not well controlled. Pt:
OK, doctor.

Dr: How is your diet? Do you eat a healthy diet?

Pt: Not really, doctor. I eat fast food. (burger and chips)
Dr: Mr… It is very important to eat a healthy balanced diet to keep your sugar under
control. You should reduce eating food with high sugar content and fat content. So you
should reduce eating fast foods like burger and chips – they have high bad fat content.
Eat more of white meat like chicken and fish and also lots of fruits and vegetables. This
will help to keep the sugar under control. I can refer you to a dietician who can advise in
detail about it. What do you say Mr..?

Pt: Yes, surely I will consider that doctor.

Dr: Excellent. Do you do exercise at all? Pt: No, doctor.

Dr: I suggest you to do good exercise. That will reduce the bad fat in your body.

Pt: Ok doctor.

Dr: Do you smoke Mr…? Pt: Yes, doctor.

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Dr: What do you smoke and how much do you smoke?

Pt: I smoke 10 to 15 cigarettes per day for many years now.

Dr: As I mentioned earlier, this also can contribute to damage to the eye. I strongly
advise you to stop smoking. If you need we can help you to stop smoking. Would you
like to consider that Mr… ?

Pt: Yes doctor. I will try my best.

Dr: Good. Do you have high blood pressure, do you know? Pt: I don’t know doctor.

Dr: We will check that and if you have, it we will treat that also because high blood
pressure also can contribute to the eye damage.

Pt: Ok.

Dr: We will also start you on some medications for your diabetes. I will talk to my seniors
about it and let you know. All these things what we discussed now will help to keep the
sugar under control.

Pt : OK, doctor.

Dr: We will refer you to the Ophthalmologist (eye specialist doctor). They will advise
further about it. You may need keep visiting them more frequently.
Do you have any questions?

Pt: How are you going to treat my condition doctor ?

Dr: Usually in early stages of Diabetic retinopathy - it does not require any treatment.
Controlling sugar will delay the condition getting worse. Whatever damages have
already happened cannot be reversed unfortunately. However, if it gets worse meaning
in advances stages of this condition, we can treat it in many ways like Laser treatment
where we pass laser to the back of the eye (that is retina) and burn the new blood
vessels which are formed there and also seal the leaking blood vessels. This will reduce
the chance of it getting worse. Sometimes, we may have to inject some type of
medications {(anti-VEGF - ranibizumab (Lucentis) and aflibercept (Eylea)} to the
back of the eye to prevent new blood vessels forming there. Very rarely, we may do
some surgery (Vitreoretinal surgery) to remove some of the vitreous humour from the
eye. This is the transparent, jelly-like substance that fills the space behind the lens of
the eye. Pt: Ok, doctor.
Dr: Any other questions ?
DIABETIC RETINOPATHY
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60. A 72 years old male has presented to A/E with redness in eye.
You are FY2 in the department. Your task is to assess and manage your patient.

Subconjunctival haemorrhage is a benign disorder that is a common cause of acute

ocular redness. The major risk factors include trauma and contact lens usage in
younger patients, whereas among the elderly, systemic vascular diseases such as
hypertension, diabetes, and arteriosclerosis are more common.

A subconjunctival haemorrhage often occurs without any obvious harm to your eye.
Even a strong sneeze or cough can cause a blood vessel to break in the eye. But a

subconjunctival haemorrhage is usually a harmless condition that disappears within two

week.

Dr. Hello Mr. Sterling. I am Dr --------- , one of the junior doctors in the department. How
can I help you today?

Pt: Dr. this is how I woke up today. (Pt shows a picture)

Dr: Mr Sterling how did this happen ?

Pt: I don’t know doctor. I just woke up and saw myself in the mirror and this is how I
looked like.it looks really bad doctor. Please do something about this.

Dr: Mr. Sterling I am really sorry that you have to see yourself like this. We would try our
best to find out why this happened and how we can help you with this.

Dr: Has it been the same since morning or have you noticed any change in it? Pt: no
doctor it is same.

Dr: Are you able to see properly? Pt:Yes

Dr: Do you have anything else along with this? Pt: like what doctor ?

Dr: Any pain in the eye? Pt: No

Dr: Any pain elsewhere in the body? Pt: No.

Dr: Have you got any joint pains? Pt: No.

Dr: Any fever? Pt: No.

Dr: Any discharge from eye? Pt: No

Dr: Are you feeling any itching in eye ? Pt:No.

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Dr: By any chance did you hit or scratch your eye ? Pt: No.

Dr: Do you use contact lens ? Pt: No

Dr: Are you having any difficulty looking in the dark ? Pt: No.

Dr: What about looking into bright light ? Pt: No difficulty, doctor.

Dr: Have you noticed any floaters in your vision or if your vision is blurry ? Pt: No
(uveitis)

Dr: Do you have any cough or sneezing? No.

Dr: How are your bowel habits? Are you having constipation ? NO

Dr: Do you have any medical conditions? Like what doctor?

Dr: Diabetes? No

Dr: High blood pressure? No.

Dr: Any bleeding problems? No.

Dr: Are you taking any medications? Especially blood thinners? No.

Dr: Are you allergic to anything? No.

Dr: Do you smoke? No.

Dr: Do you drink alcohol? No.

Dr: May I know what you do for a living? Pt: I am retired now. I used to work in an office.
Dr: Mr. Sterling has it ever happened before? No

Dr: Did you have any recent eye surgery? No

Mr. Sterling is there anything you would like to tell us? Pt: No doctor but is it serious?

Dr: Mr. Sterling from the look of it, it does not appear so. But we are never too sure until
we do some further tests.
I would like to examine your eyes and also would like to check your blood pressure. Pt: Sure,
go ahead doctor.
- Check vision with the Snellen chart.

- Do a fundoscopic exam

- Check for complications of diabetes and blood circulation in your legs (arteriosclerosis)
(B.P normal and fundus also normal)

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Dr: Mr. Sterling, after our discussion and my examination, I think you have a condition
we call subconjunctival haemorrhage. In this condition, there is bleeding underneath the
conjunctiva layer of eye. There can be many reasons for this or sometimes it may be
without any reason as well.

We need to do further tests like CBC, PT, APTT, INR and we need to check your visual
acuity. We may have to take swabs from your eye to look for infections. We would also
like to do a test called tonometry to look for if there is increased pressure in your eye.
What do you think regarding these tests?

Sure doctor, go ahead but will it get better.?

Dr: Yes Mr. Sterling, I really hope so. If it is what I am thinking it to be, then in most of
the cases it gets better on its own and does not require any specific treatment. But I
would like you to see our consultant ophthalmologist as he may be able to tell you more
about this condition and management options that we can offer you.

Dr: What do you say? Yes I think the same.

Dr: Well then I will be arranging for your appointment as soon as possible.

Dr: Is there anything else that I can help you with?

Thank you.

SUB-CONJUCTIVAL HAEMORRHAGE

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61.PAINFUL RED EYE – GLAUCOMA

A: AACG (acute angle closure Glaucoma) - Pain worse in dark, haloes around light, DH

F: Foreign body, chemical, complication of Contact lens - “By any chance has
something gone into your eyes?” Occupation? Gritty

A: Allergy [hay fever or any gas], Running nose, itchy eyes

S: Sub conjunctival Haemorrhage - Scratchy feeling on the surface of your eye, patches
of redness, no pain

T: Trauma - “By any chance did you get hurt in your eye?”

C: Conjunctivitis [bacterial/viral/ulcer] - Contact glass irritation, Discharge, difficulty in

opening eyes in morning

A: Autoimmune – Ankylosing spondylitis (Back pain worse in morning), Systemic

Lupus Erythematosus (Butterfly rash), IBD (Abdominal pain, diarrhoea), Rheumatoid
Arthritis (small joint pain)

R: Reiter’s syndrome, Urethral discharge joint pain, Sex Hx

S: Sarcoidosis, Tender red bumps on skin, SOB, cough

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61. You are F2 in Emergency Department.56 year old lady presents with
sudden onset severe pain in her left eye. Take history, examine and
discuss management with her.

(Patient may be wearing sunglasses )

Dr: Hello Mrs... My name is Dr... one of the junior doctors in the Emergency
Department. P: Hello doctor

Dr: What brings you into the hospital today? P: I have this pain in my left eye doctor

Dr: I am very sorry Mrs... Could you tell me when it started? P: It started suddenly
around 2-3 hours ago

Dr: Do you have pain anywhere else? P: I do have pain on my left side forehead as
well. Dr: Any redness of your eye?

P: Yes doctor (She might show you a picture of the red eye)

Dr: Any watering from your eye? P: No

Dr: Have you noticed any coloured halos when you look at a light source? P: No

Dr: Do you have any problem with your vision? P: My left eye feels a little blurred.

Dr: I'm sorry to hear that Mrs... when did that start? P: Same time this morning doctor.

Dr: Do you have any discharge in the eye (conjunctivitis) ? P: No Dr: Do you have any
itching in the eye (allergy) ? P- No

Dr: Did you sustain any injury to your eye? P: No Dr: Do you wear contact lenses ? P: No

Dr: Do you have any fever (orbital cellulitis) ? P: No

Dr: Joint pains? P: No

Dr: Any rashes on your body? P: No

Dr: Have you noticed any change in your bowel habits? P: No

Dr: Do you have diabetes? P: No

Dr: High BP? P : No

Dr: Are you on any medications?

P: I'm taking amitriptyline for depression

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Dr: Since when have you been taking that? P: 6 months

Dr: Has it helped with your depression Mrs...? P: Yes doctor!

Dr: Do you have any allergies? P: No

Dr: Any family history of similar problems? P: No

[Patient may be wearing dark sunglasses]

Dr: Can I ask why are you wearing this dark glasses? P: I feel comfortable with that.

[You can ask her to remove if she’s comfortable]

Examination

I would like to examine your eye Mrs... (Patient might show a picture of a red eye)

Diagnosis:

Dr: Mrs... With the information that you have given me and after the examination, it
seems you have a condition called Glaucoma. Do you know what that is? P: No

Dr: In the eye, there are two compartments filled with fluid... Sometimes when there is
an increase in the production of fluid or a blockage in the outflow, the pressure inside
the eye can increase and that is what causes the pain and redness in the eye.

P: Oh.. Yes doctor.. I do feel like there is a lot of pressure in my eye

Dr: Mrs... This is a serious condition because if it is not treated quickly it can cause
irreversible loss of vision.

P: But why did this happen to me doctor?

Dr: There are many reasons why this can happen Mrs... But in your situation, it appears
to be because of the amitriptyline that you are taking for your depression

P: (she might get upset_ console as needed) Oh.. It’s my fault then?

Dr: No Mrs. ... it's not your fault.. It is an expected side effect of the medication and
though not everyone on the drug develops the S/E, some people might. Firstly, we have
to stop this medication. We will give some other medication for your depression.

P: Ok thank you doctor. What are you going to do for me now?

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Investigations

Dr: We will have to run some tests to confirm the diagnosis. We will do a test called
tonometry to check the pressure inside your eye.
Treatment:

We will also have to start you on treatment immediately to prevent loss of vision. We
have a number of options.

We will give you some eye drops called Pilocarpine to reduce the pressure.

We also have drops called Timolol which will also help remove the excess fluid inside
your eye.

We can also give you some medication called Acetazolamide into your vein to do that.
We will refer you immediately to an Ophthalmologist for further treatment.

Are you following me Mrs. ?

P: Yes doctor.. Will my vision become all right?

Dr: Unfortunately Mrs... I'm really sorry to say but any slight loss of vision that you may
have sustained may not be reversible... but we can prevent permanent loss of your
vision if we start treatment right away. P: Ok...

Dr: Do you have any questions for me Mrs...? P: No, doctor. Thank you very much.

Dr: I will get in touch with the ophthalmologist and we'll start your treatment immediately
Mrs... If you have any concerns, please feel free to ask for me.

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62. 67 year old lady Mrs Melinda Jones presented to the hospital with headache.
Take history from her and discuss the management with her

Differential diagnoses

1. AACG ( acute angle closure glaucoma) - Do you see coloured circles around light?
Worse in darkness? Redness of eye? Flashes

2. GCA

" Jaw claudication - Do you get pain on chewing?

" Temporal tenderness - pain while combing or touching temple area? Any vision
problems (shade coming in front of the eye, vision loss later)

3. Head injury - By any chance you got hurt on your head?

4. Meningitis - Fever, vomiting, Photophobia (feel discomfort on bright light?), Rash,

Neck stiffness (difficulty in moving your neck?)

5. SAH - Sudden onset, meningeal signs but no fever.

6. SOL - Early morning, vomiting Gradual worsening, limb weakness

7. Migraine – pattern one sided, aura, family Hx

8. Cluster headache - Comes in clusters, previous Hx of headaches, timing, red eye,

tearing

9. Tension headache – band like, worse in the evening, stress

10. Refractory error- long vision? When did you last visit optician? Do you wear
glasses? Any problem in reading or Imagine - put your finger on glabella and move to eye
then to temple and dig deeper so you will not miss the DD.

Patient gives Hx of Pain on the sides of head while combing hair and pain in the jaws
while eating. No vision problems. No - Family history. Ask about the severity of pain ( if
very severe – offer painkillers)

Management

Mrs Jones with what you told me I suspect you have a condition what we call as Giant
cell arteritis. Do you know anything about this? Pt – No

Dr: It is a condition in the blood vessels, usually in the head and neck, become
inflamed. It is sometimes called temporal arteritis because the arteries around the
temples are usually affected.

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Pt: What are going to do for me?

Dr: We will do some blood tests (inflammatory markers) to check for the possibility of
this condition. (ESR and CRP).

We need to do another test called temporal artery (blood vessel on the side of the head)
biopsy to confirm the diagnosis. During the procedure, a small sample of your temporal
artery is removed and checked in the laboratory. It can take several days to get the
results of a biopsy.

However, we need to treat you urgently before we can do the biopsy because if we
delay the treatment waiting for the test result sometimes people can lose their vision
which can be permanent. To prevent the loss of vision we need to treat you immediately.
Do you follow me?

Pt: Yes. How will you treat me?

Dr: We will treat you medication called Prednisolone tablets which is a steroid. Initially
we will give high dose steroids (60mg) which will gradually be reduced every two to four
weeks, depending on how well you respond to treatment.

If the diagnosis is confirmed with the biopsy - you may need to take prednisolone for up
to two years to prevent your symptoms returning. Your symptoms should improve
significantly within a few days of starting treatment. However, there is a chance they will
return (relapse) once treatment stops.

Please don't suddenly stop taking steroid medication because it can make you feel very
ill.

There are some side effects of steroids because you may need to take it for a long time.
Do you want to know about them?

Pt: Yes doctor.

Dr: It can cause changes in mental state - you may feel very depressed and very
anxious, or very confused.

It can also cause:

" Increased appetite, which often leads to weight gain

" Increased blood pressure
" Mood changes, such as becoming aggressive or irritable with people
" Weakening of the bones (osteoporosis)
" Stomach ulcers
" Increased risk of infection

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The risk of these side effects will be less as your dosage of prednisolone is decreased.
We will also give you another medication called Aspirin in low dose (75mg daily).

This prevents complications of giant cell arteritis, such as heart attacks or stroke.

We will give another medication called Omeprazole to protect your stomach from
stomach ulcers.

We may also give some other medication called immune-suppressants, such as

methotrexate to suppress the immune system (the body's defence against infection and
illness). This can help prevent the condition recurring.

We will follow you up regularly to see how you are responding and to reduce the dose of
prednisolone.

We will issue a steroid card which you need to carry with you at all times as it will
explain that you are regularly taking steroids.

Pt: Will there be any complications ?

Dr: Sometimes it can cause visual loss or heart attacks or stroke. However Aspirin
medication lowers the chances of getting these problems.

Another complication sometimes can happen is a condition called Polymyalgia

rheumatica which causes inflammation of the muscles and joints and causes neck and
hip pain, and stiffness of the affected muscles (which is often most obvious after waking
up).

Any other concerns ? Pt: No

Dr: Thank you very much. Hope you will recover soon.

Prednisolone should be taken with food. In the morning. If given at night, it could cause
vivid dreams.

Once the results of the biopsy are confirmed, he should be referred to the
rheumatologist within 2 weeks.

HEADACHE – GCA

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POLYMYALGIA RHEUMATICA
1. History taking case
Presenting complaint: pain in shoulder
• can you tell me more about it ? (Open question)
(Note : sometimes the simulator says like what doctor? Do not be taken back by this. Instead confidently
ask what you want to know; sometimes the simulator will tell you all about the pain so please listen
carefully)
• If simulator is describing the pain- please do some sympathy with them because they are in pain: It must
be very hard for you/ it must be very difficult for you/ i am sorry to hear that. (Note: it does not matter if
these words seem often repeated to you, all that matters is the way you say them. If you say them naturally
and with expressions, it really works)
• Are you comfortable to talk to me?/ Do you want painkillers? (Mostly simulators say yes we are
comfortable, and say no to painkillers in the start- when they say no, you can reply - throughout this
consultation, if you feel that the pain is becoming unbearable, let me know, then i will give you something
for the pain)
• Is the pain in one shoulder(left or right) or both ? ( the importance of this question is to rule out NAI;
remember PMR is bilateral symmetrical cape like pain in both shoulders; in case of NAI, the pain will be
unilateral) , Shoulder and thigh (may show around pelvis also) pain since 3 weeks.

• Cover SOCRATES - this is how i recommend to cover the details of the pain :
• Since when have you had this pain?
• Was it sudden in onset or something that developed slowly over time?
• Is it getting worse?
• How does the pain feel like? Does it feel dull, sharp, stabbing?
• Does the pain go anywhere like from shoulder to neck and head, shoulder to back, shoulder to
arms, chest or tummy?
• Is the pain continuous or off and on? (If off and on- how often do you have it? For how long each
episode of pain lasts?)
• Does anything make your pain worse like movement or body position?
• Does anything make your pain better like any body position or medications?
• (If they say medicines help/they have tried medicines but they don’t help much- explore about the
medicine- which medicine? Dose? When was the last dose taken? How many?)
• Can you grade the severity of the pain on a scale of 1-10 with 10 being the worse pain? (Do
sympathy again at this step on hearing the grade of the pain)
• Do you have any other symptom along with the pain? (Open question)
PMR will present with bilateral shoulder pain/stiffness, dull ache and gradually progressive (sometimes can
be sudden). The pain may be felt in a cape-like manner i.e shoulders, upper arms, and hips.
Along with pain most pts have stiffness as well- morning stiffness lasting up to 45 minutes .

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What DDx to rule out?

• When suspecting PMR always ask GCA questions because these conditions are highly associated.
GCA : Headache especially on the sides, pain while combing, pain in jaw while chewing, vision problems-
when asking these symptoms tell the patient these are WARNING signs and please look out for them.
(This is safety netting and you can sprinkle it a bit in the history while ruling out GCA- i recommend this)
• Trauma - ask if they hurt themselves, did they recently fell etc
• Rule out NAI while taking family history- i will tell later on about this.
• Rheumatoid arthritis - pain and stiffness in hands, other joints?
• Red flags - FLAWS ( in PMR the pt might have positive red flags like loss of appetite, lethargy)
• Ruling out 2-3 imp differentials is more than enough.
• Coping question- how are you coping with this? Ask about day to day activities? Carer? How this pain
has affected their mood? (PMR can cause depression)
• Previous similar pain?

((Patient answers: Any swelling in shoulder? No/ Any other joint pains? No/ Other joint swellings (osteoarthritis)? No, Swelling

and pains in the hand joints (rheumatoid arthritis)? No/ Any changes in the bowel habits like loose stools diarrhoea? No ))

• Past medical history (it is not enough to ask do you have any long term illness? Always specify which
illness you want to ask even if pt says no to your open question- like High blood pressure? High sugar
levels, lung or kidney problems?)
If you want to sound a bit different while asking past medical history, you can rephrase this question as
follows (recommended if you are aiming for 10 and above) :
Have you been following up with your GP for general check ups? (If yes- appreciate)
Have they ever told you that you have any issues with your blood pressure, blood sugar, lungs or kidneys?
• DESAR - diet, exercise, smoking, alcohol and drugs - select depending upon situation which questions
from these are needed in each case - in PMR, ask DESA and keep it quick.
• Tip : if pt says yes they smoke / drink alcohol- don’t turn it into a smoking cessation or alcohol cessation
station until or unless it is part of ur task/ management. Instead, just say, have you ever considered
stopping- whenever you are ready to stop, please let us know we have very good support system.
• MAFTOSA - medicines, allergies, family history - who do they live with? How is their relationship with
them? How is the environment at home (This is how you rule out NAI) does any blood relatives have
similar symptoms and chronic conditions like high blood pressure, high sugar levels; travel (not needed in
this case); occupation (does it involve lifting a lot of things? How are they coping with work?)
• Anything else that they would like to add?
This is the complete history of PMR. Follow this pattern with confidence and be natural in your approach.

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Examination:
Thank you for all the information. Now i need to examine you is it ok to check your pulse, blood pressure,
oxygen levels and temperature ; and also to examine you head to toe and also your shoulders, neck and
arms? I will ensure your privacy and have a chaperone with me and i will be as gentle as possible.
(Tip: if examiner gives any positive finding, say thank you and tell the patient if there is any positive finding-
keep them informed)
Diagnosis:
(I do not do “I” of ICE. I leave it up to you to do it or not. It really doesn’t matter as long as your are doing
the “C” of ICE that is the concerns)
From the information that you have given me and from my assessment, it seems that you have a condition
called Polymyalgia rheumatica, which is a condition that causes pain, stiffness and inflammation in the
muscles around the shoulders, neck and hips.
do you have any questions so far?
Management :
• Treatment at home with regular follow-ups
• Inform seniors
• Investigations: full blood count, ESR, CRP, blood electrolytes: calcium levels, tests to see how your
liver and kidneys are functioning (this is a good way to Talk about LFTS and KFT), TFT, rheumatoid factor
and anti-ccp. (Rule out thyroid issues as these can cause muscle pain, rule out RA), (In PMR, ESR and
CRP are elevated)
Imaging may be ordered X-ry)
• Symptomatic treatment : painkillers (PCM, NSAIDS (rule out peptic ulcer disease)
• Steroids after senior advice - for how long- depends upon response and usually given for 2 months. Talk
about checking in your book (BNF)
• Steroid card
• Safety netting (general)
• Leaflets
• Do you have any questions?
• Steroids side effects - i will cover these in detail in the next station that we will discuss. You can mention
side effects of steroids if pt asks and you have time left.
• Do not stop taking steroids abruptly
• Avoid close contact with people with chicken pox, shingles and measles - if contact- come back to us.
Note :
Specialist (rheumatologist) referral is only made when symptoms are not controlled with the recommended
dose of steroids.

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new question in which pt is diagnosed with PMR and taking steroids, bisphosphonates and
omeprazole.

• take history recap again (trust me in diagnosed cases you have to take history again - a short one. But
you have to - otherwise you will get no marks in data gathering)
• Ask about the pt’s symptoms when they first came to the gp clinic, what was given to them, did they take
those medications, how is the pain now? Pain anywhere else? Questions about Side effects of
medications; rule out GCA and do safety netting for GCA. Take lifestyle history, MAFTOSA(for details refer
to the other PMR case i posted above) and coping and carer history.
• Examination (vitals, GPE and the painful area)
• Ask the patient if they know what their condition is/ if they want you to explain their condition to them?
• Ask the pt’s concerns. In this case, the patients concerns are side effects of steroids.
• Ask if there is any particular side effect they are worried about. In this case, the patient is worried about
steroids causing weight gain and steroids being similar to those steroids that body builders take. Ask if
there is a particular reason of this concern? Explain to them that steroids do cause weight gain
unfortunately, but with healthy diet and healthy lifestyle that weight control can be controlled and we will be
making a proper diet plan for him. If needed, a dietician can also be involved after senior advice.
• Explain to the patient that the steroids that body builders take are called anabolic steroids which simply
means that they strengthen their bodies. However, the steroids he is given are used only for treatment
purposes and the dosages are adjusted accordingly and these two are completely different.
• Ask the patient if he wants to know other side effects. With each side effect that you tell, explain the
management and also say you will check this all in your book while holding or looking at BNF which will be
on the table.
• You may feel depressed (https://www.nhs.uk/conditions/clinical-depression/) and suicidal
(https://www.nhs.uk/conditions/suicide/), anxious or confused. Some people also have hallucinations
(https://www.nhs.uk/conditions/hallucinations/), (seeing or hearing things that are not there).
Contact a GP as soon as possible if you experience changes to your mental state.
Other side effects of prednisolone include:

• high blood pressure (https://www.nhs.uk/conditions/high-blood-pressure-hypertension/) - healthy diet can

help control blood pressure and we will be following you up and checking it.
• High sugar levels- healthy lifestyle and follow ups
• mood changes, such as becoming aggressive or irritable with people- this gets better with time and as
dosage is adjusted
• weakening of the bones (osteoporosis (https://www.nhs.uk/conditions/osteoporosis/))- we are giving you
a medication called bisphosphonate to strengthen your bones

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• stomach ulcers (https://www.nhs.uk/conditions/stomach-ulcer/) - we are giving you a medication called

omeprazole which is a stomach protectant
• increased risk of infection, particularly with the varicella-zoster virus, which is the virus that causes
chickenpox (https://www.nhs.uk/conditions/chickenpox/) and shingles
(https://www.nhs.uk/conditions/shingles/)
• Get immediate medical advice if you think you've been exposed to the varicella-zoster virus or if a
member of your household develops chickenpox or shingles.
• The risk of these side effects should improve as your dose of prednisolone is reduced.

Now ask pt if they have any concerns/ questions? (Mostly pt will ask for how long will he have to take these
steroids- tell it depends upon his response to treatment and usually it is given for 2 years)

Now it is very important to say the following things if you want a high score in this station.

Ensure the person is provided with a blue steroid card, and , advise them:
• Not to stop taking prednisolone abruptly and to seek medical advice if they are experiencing problems
taking it.
• Provide written information on PMR and regional patient support groups.
• Follow up planned - after 3 weeks and then will have continued follow up plans.
Advise the person to arrange a review (https://cks.nice.org.uk/polymyalgia-
rheumatica#!scenarioRecommendation:1) at other times:
• Urgently, if they develop symptoms of GCA.
• Routinely, if they develop symptoms of relapsing PMR (https://cks.nice.org.uk/polymyalgia-
rheumatica#!scenarioRecommendation:1), including proximal pain, fatigue, and morning stiffness.

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63. Elderly lady complains of shoulder and thigh pains – 3 weeks

History and management.

Shoulder and thigh (may show around pelvis also) pains since 3 weeks.

Onset – Sudden or gradual [in PMR – it is usually sudden but can be gradual too]

Worse in the morning. [in PMR, it is worse in the morning].

Any swelling in shoulder? No

Any other joint pains? No

Other joint swellings (osteoarthritis)? No

Swelling and pains in the hand joints (rheumatoid arthritis)? No

Any changes in the bowel habits like loose stools diarrhoea? No

Fever – No

Trauma ? No

Soreness in eyes?– No

Skin rashes (SLE) – No

Difficulty using shoulder? Can she lift weight? Difficulty in walking?

Pain on the side of the head? Any vision problems? Any pain in jaw while chewing?

[to r/o GCA] – No

PMHx – GORD on Omeprazole for 20 years

Any other medications?

Allergy?

Family history

Anything else important?

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Examination

I want to examine your shoulder joints and other joints and also examine your thighs

Examiner may say – shoulder movements restricted (abduction limited).

I want to examine for any swellings or muscle wasting? Examiner may say – No

[In PMR – joints movements may be restricted]

Provisional diagnosis

Mrs,,, I need to check whether the medication Omeprazole you are taking is causing
this problem. Is it OK? check BNF for side effects – it may show long term use of
Omeprazole causes Viamint D and B 12 deficiencies which may cause body aches).

Mrs.. If one takes Omeprazole for long term it may cause vitamin deficiencies which in
turn can cause body pains but they usually do not cause the pains to be worse in the
morning and restriction movements of the joints.

I think you have a condition what we call as Polymyalgia Rheumatica. Do you know
anything about this? No

Polymyalgia rheumatica is a form of arthritis – joint condition. It causes pain in the joints
and muscles of the lower back, thighs, hips, neck, shoulder and upper arms, and other
parts of the body.

The condition occurs when the lining surrounding the joints and tendons near the
shoulders and hips becomes inflamed.

The disease is centered on the joints (especially the shoulders and hips). But the
discomfort is felt in the upper arms and thighs. This type of pain is called referred pain.
It arises in one area but causes symptoms in another.

Do you follow me? Yes

Typically, polymyalgia rheumatica affects people older than 55. If not treated, it can lead
to stiffness and significant disability. In some cases, symptoms do not get worse. They
may even lessen in a few years.

In a minority of cases, polymyalgia rheumatica is associated with another condition

called giant cell arteritis (temporal arteritis). This is a condition in which blood vessels

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are inflamed, especially in the neck and head. If not treated giant cell arteritis can cause
blindness or stroke.

Do you follow me? Yes

We need to do some blood tests called ESR and CRP to check whether there are any
possibilities of this condition.

{The ESR and CRP tests may be used both to diagnose the condition and to check
whether treatment is working}.

Treatment

We will refer you to the specialist called Rheumatologists.

We can give you pain killer medication like NSAIDS but they are not very helpful.

We can give you medications called Corticosteroids, such as prednisolone. We will give
you low doses of that like 10 mg to 20 mg per day and they are highly effective.

Long term use of steroids can cause Osteoporosis that is thinning of bones. We can
give you medications to prevent osteoporosis like calcium, vitamin D and alendronate
(Fosamax).

If you have serious side effects of steroids, and if we cannot just treat with low doses of
steroids then we may give some other medications called methotrexate

We will also refer you to Physiotherapists. Physical therapy may help to control
discomfort. It can also help maintain the ability to move the joints and function.

Also mention occupational therapist and carers.

Prognosis

Treatment may be required for years. But the outlook for people with polymyalgia
rheumatica is excellent.

Warning signs:

If you develop any headaches on the sides of the head, vision problems or jaw pain
while chewing, please come to us immediately because these are the signs of serious
condition called Giant cell arteritis as I mentioned earlier. We may need to treat to you
urgently with high dose steroids.

POLYMYALGIA RHEUMATICA
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VIP: check the case after reading these notes:

Polymyalgia Rheumatica:‎
1. History taking case
Presenting complaint: pain in shoulder
• can you tell me more about it ? (Open question)
(Note : sometimes the simulator says like what doctor? Do not be taken back by this. Instead confidently ask what you
want to know; sometimes the simulator will tell you all about the pain so please listen carefully)
• If simulator is describing the pain- please do some sympathy with them because they are in pain: It must be very hard
for you/ it must be very difficult for you/ i am sorry to hear that. (Note: it does not matter if these words seem often
repeated to you, all that matters is the way you say them. If you say them naturally and with expressions, it really works)
• Are you comfortable to talk to me?/ Do you want painkillers? (Mostly simulators say yes we are comfortable, and say
no to painkillers in the start- when they say no, you can reply - throughout this consultation, if you feel that the pain is
becoming unbearable, let me know, then i will give you something for the pain)
• Is the pain in one shoulder(left or right) or both ? ( the importance of this question is to rule out NAI; remember PMR
is bilateral symmetrical cape like pain in both shoulders; in case of NAI, the pain will be unilateral)
• Cover SOCRATES - this is how i recommend to cover the details of the pain :
• Since when have you had this pain?
• Was it sudden in onset or something that developed slowly over time?
• Is it getting worse?
• How does the pain feel like? Does it feel dull, sharp, stabbing?
• Does the pain go anywhere like from shoulder to neck and head, shoulder to back, shoulder to arms, chest or tummy?
• Is the pain continuous or off and on? (If off and on- how often do you have it? For how long each episode of pain
lasts?)
• Does anything make your pain worse like movement or body position?
• Does anything make your pain better like any body position or medications?
• (If they say medicines help/they have tried medicines but they don’t help much- explore about the medicine- which
medicine? Dose? When was the last dose taken? How many?)
• Can you grade the severity of the pain on a scale of 1-10 with 10 being the worse pain? (Do sympathy again at this
step on hearing the grade of the pain)
• Do you have any other symptom along with the pain? (Open question)

PMR will present with bilateral shoulder pain/stiffness, dull ache and gradually progressive (sometimes can be sudden).
The pain may be felt in a cape-like manner i.e shoulders, upper arms, and hips.
Along with pain most pts have stiffness as well- morning stiffness lasting up to 45 minutes .
What DDx to rule out?

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• When suspecting PMR always ask GCA questions because these conditions are highly associated. GCA : Headache
especially on the sides, pain while combing, pain in jaw while chewing, vision problems- when asking these symptoms
tell the patient these are WARNING signs and please look out for them. (This is safety netting and you can sprinkle it a
bit in the history while ruling out GCA- i recommend this)
• Trauma - ask if they hurt themselves, did they recently fell etc
• Rule out NAI while taking family history- i will tell later on about this.
• Rheumatoid arthritis - pain and stiffness in hands, other joints?
• Red flags - FLAWS ( in PMR the pt might have positive red flags like loss of appetite, lethargy)
• Ruling out 2-3 imp differentials is more than enough.
• Coping question- how are you coping with this? Ask about day to day activities? Carer? How this pain has affected
their mood? (PMR can cause depression)
• Previous similar pain?
• Past medical history (it is not enough to ask do you have any long term illness? Always specify which illness you want
to ask even if pt says no to your open question- like High blood pressure? High sugar levels, lung or kidney problems?)
If you want to sound a bit different while asking past medical history, you can rephrase this question as follows
(recommended if you are aiming for 10 and above) :
Have you been following up with your GP for general check ups? (If yes- appreciate)
Have they ever told you that you have any issues with your blood pressure, blood sugar, lungs or kidneys?
• DESAR - diet, exercise, smoking, alcohol and drugs - select depending upon situation which questions from these are
needed in each case - in PMR, ask DESA and keep it quick.
• Tip : if pt says yes they smoke / drink alcohol- don’t turn it into a smoking cessation or alcohol cessation station until
or unless it is part of ur task/ management. Instead, just say, have you ever considered stopping- whenever you are
ready to stop, please let us know we have very good support system.
• MAFTOSA - medicines, allergies, family history - who do they live with? How is their relationship with them? How is
the environment at home (This is how you rule out NAI) does any blood relatives have similar symptoms and chronic
conditions like high blood pressure, high sugar levels; travel (not needed in this case); occupation (does it involve lifting
a lot of things? How are they coping with work?)
• Anything else that they would like to add?
This is the complete history of PMR. Follow this pattern with confidence and be natural in your approach.
Thank you for all the information. Now i need to examine you is it ok to check your pulse, blood pressure, oxygen levels
and temperature ; and also to examine you head to toe and also your shoulders, neck and arms? I will ensure your
privacy and have a chaperone with me and i will be as gentle as possible.
(Tip: if examiner gives any positive finding, say thank you and tell the patient if there is any positive finding- keep them
informed)
Diagnosis:

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(I do not do “I” of ICE. I leave it up to you to do it or not. It really doesn’t matter as long as your are doing the “C” of ICE
that is the concerns)
From the information that you have given me and from my assessment, it seems that you have a condition called
Polymyalgia rheumatica, which is a condition that causes pain, stiffness and inflammation in the muscles around the
shoulders, neck and hips.
do you have any questions so far?
Management :

• Treatment at home with regular follow-ups

• Inform seniors
• Investigations: full blood count, ESR, CRP, blood electrolytes: calcium levels, tests to see how your liver and kidneys
are functioning (this is a good way to Talk about LFTS and KFT), TFT, rheumatoid factor and anti-ccp. (Rule out thyroid
issues as these can cause muscle pain, rule out RA), (In PMR, ESR and CRP are elevated)
Imaging may be ordered X-ry)
• Symptomatic treatment : painkillers (PCM, NSAIDS (rule out peptic ulcer disease)
• Steroids after senior advice - for how long- depends upon response and usually given for 2 months. Talk about
checking in your book (BNF)
• Steroid card
• Safety netting (general)
• Leaflets
• Do you have any questions?
• Steroids side effects - i will cover these in detail in the next station that we will discuss. You can mention side effects
of steroids if pt asks and you have time left.
• Do not stop taking steroids abruptly
• Avoid close contact with people with chicken pox, shingles and measles - if contact- come back to us.
Note :
Specialist (rheumatologist) referral is only made when symptoms are not controlled with the recommended dose of
steroids.

new question in which pt is diagnosed with PMR and taking steroids, bisphosphonates and omeprazole.

• take history recap again (trust me in diagnosed cases you have to take history again - a short one. But you have to -
otherwise you will get no marks in data gathering)
• Ask about the pt’s symptoms when they first came to the gp clinic, what was given to them, did they take those
medications, how is the pain now? Pain anywhere else? Questions about Side effects of medications; rule out GCA and
do safety netting for GCA. Take lifestyle history, MAFTOSA(for details refer to the other PMR case i posted above) and
coping and carer history.
• Examination (vitals, GPE and the painful area)
• Ask the patient if they know what their condition is/ if they want you to explain their condition to them?

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• Ask the pt’s concerns. In this case, the patients concerns are side effects of steroids.
• Ask if there is any particular side effect they are worried about. In this case, the patient is worried about steroids
causing weight gain and steroids being similar to those steroids that body builders take. Ask if there is a particular
reason of this concern? Explain to them that steroids do cause weight gain unfortunately, but with healthy diet and
healthy lifestyle that weight control can be controlled and we will be making a proper diet plan for him. If needed, a
dietician can also be involved after senior advice.
• Explain to the patient that the steroids that body builders take are called anabolic steroids which simply means that
they strengthen their bodies. However, the steroids he is given are used only for treatment purposes and the dosages
are adjusted accordingly and these two are completely different.
• Ask the patient if he wants to know other side effects. With each side effect that you tell, explain the management
and also say you will check this all in your book while holding or looking at BNF which will be on the table.
•
You may feel depressed (https://www.nhs.uk/conditions/clinical-depression/) and suicidal
(https://www.nhs.uk/conditions/suicide/), anxious or confused. Some people also have hallucinations
(https://www.nhs.uk/conditions/hallucinations/), (seeing or hearing things that are not there).
Contact a GP as soon as possible if you experience changes to your mental state.
Other side effects of prednisolone include:

• high blood pressure (https://www.nhs.uk/conditions/high-blood-pressure-hypertension/) - healthy diet can help

control blood pressure and we will be following you up and checking it.
• High sugar levels- healthy lifestyle and follow ups
• mood changes, such as becoming aggressive or irritable with people- this gets better with time and as dosage is
adjusted
• weakening of the bones (osteoporosis (https://www.nhs.uk/conditions/osteoporosis/))- we are giving you a
medication called bisphosphonate to strengthen your bones
• stomach ulcers (https://www.nhs.uk/conditions/stomach-ulcer/) - we are giving you a medication called omeprazole
which is a stomach protectant
• increased risk of infection, particularly with the varicella-zoster virus, which is the virus that causes chickenpox
(https://www.nhs.uk/conditions/chickenpox/) and shingles (https://www.nhs.uk/conditions/shingles/)
• Get immediate medical advice if you think you've been exposed to the varicella-zoster virus or if a member of your
household develops chickenpox or shingles.
• The risk of these side effects should improve as your dose of prednisolone is reduced.

Now ask pt if they have any concerns/ questions? (Mostly pt will ask for how long will he have to take these steroids- tell
it depends upon his response to treatment and usually it is given for 2 years)

Now it is very important to say the following things if you want a high score in this station.

Ensure the person is provided with a blue steroid card, and , advise them:
• Not to stop taking prednisolone abruptly and to seek medical advice if they are experiencing problems taking it.
• Provide written information on PMR and regional patient support groups.
• Follow up planned - after 3 weeks and then will have continued follow up plans.
Advise the person to arrange a review (https://cks.nice.org.uk/polymyalgia-rheumatica#!scenarioRecommendation:1) at
other times:
• Urgently, if they develop symptoms of GCA.
• Routinely, if they develop symptoms of relapsing PMR (https://cks.nice.org.uk/polymyalgia-
rheumatica#!scenarioRecommendation:1), including proximal pain, fatigue, and morning stiffness.

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64. A 50 years old woman presented to the clinic with complaints of hand pain.
She is a known smoker for the past 20 years and has not followed up with her GP
for some time.

You are an FY2 in clinic. Take history and discuss management with her.

Dr: Hello I am Dr.-----------,are you Mrs. Anderson.

Pt: Yes, Call me Caroline.

Dr: Alright Caroline , How can I help you today ?

Pt: Dr. I have pain in both my hands.

Dr: I am so sorry to hear about this Caroline, are you comfortable talking to me?

Pt: Yes Dr. it is not much. Actually I did not even want to see a doctor. It is just that my
boss was insisting on it. He is a consultant.

Dr: Caroline may I know why didn’t you want to see a doctor?

Pt: It is just that I feel fine.

Dr: Caroline it is really good that you came to clinic today; we would try our best to help you.

I would like to know a bit more about your hand pain.

Pt: Dr. I have pain in my fingers and wrist joints.

Dr: Since when do have this pain? Pt: It has been there for the past 6--7 weeks.

Dr: How did it start? Pt: All of a sudden.

Dr: How has it progressed over time. Pt: It is getting worse.

Dr: Have you tried anything which makes it better? Pt: I take ibuprofen but the pain does
not go away completely.

Dr: Have you noticed anything which makes it worse? Pt: Nothing in particular it is just
that it is worse in the morning when I wake up.

Dr: Does it get better as the day progresses? Pt: Yes.

Dr: Have you noticed anything else along with this pain. Pt: Like what doctor ?

Can you use your fingers?

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Dr: Any rash Pt: No.

Dr: Fever Pt: No

Dr: Have you noticed any change in your bowels ? Pt: No. Dr:

Any swelling? Pt: Yes there is swelling in my finger joints. Dr:

Any swelling anywhere else in the body? Pt: No.

Dr: Have you felt that your finger and wrist joints are stiff in the morning? Pt: Yes.

Dr: And how long does that stiffness last for? Pt: I am not sure about time doctor.

Dr: Do you have pain anywhere else in the body? Pt: No

Dr. Any Pain in your neck or back? Pt: No

Dr: Any pain in eyes or vision problems? Pt:No

Dr: Have you noticed any changes in your weight? Pt: No

Dr: Have you ever had pain like this before? No.

Dr: Do you have any medical problems? Pt: Like what?

Dr: Diabetes? Pt: No.

Dr: High blood pressure? Pt: No.

Dr: Are you taking any medications? Pt: Yes occasionally ibuprofen for pain.

Dr: Are you allergic to any medication ? Pt: No.

Dr: Is there any one else in the family with the same symptoms? Pt:No.
Dr: Do you smoke? Pt: Yes 20 cigarettes a day for the last 20 years. (never tried to
stop)

Dr: Alcohol? Pt: No.

Dr: Recreational drugs? Pt: No.

Dr: May I know what do you do for a living? Pt: I am a medical secretary.

Dr: Has this condition impacted your work? Pt: Yes I am having difficulty in typing and
my boss is giving me a lot of trouble because of this.

Also ask how it is affecting her daily activities e.g dressing up, etc

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Dr: I am really sorry to hear this Caroline. I assure you we will try to find out what is
causing this pain and will do our best to relieve you of this.

Dr: Is there anything else that you would like to tell.

Pt: Doctor, somebody told me I should not be taking ibuprofen as I smoke. What do you think?

Dr: I am sure Caroline whoever told you this deeply cares about you. Smoking it self is
not good for our body as it not only causes various health risks, it also slows down the
healing process and taking ibuprofen while you are smoking increases the risk of
stomach ulcers as well.

If you would like our help regarding stopping smoking, we have various options and we would
be glad to offer those.

Pt: Ok doctor I will think about this.

Dr: Thank you Caroline for letting me know all this.

Dr: I would like to examine your hand and would like to see your news chart as well.

Examiner shows a picture of hands. (Vitals Normal)

Dr: Caroline, thank you very much for letting me examine you.

Dr: From our discussion and my examination I think that you have a condition we call
Rheumatoid Arthritis.

Would you like to know about this? Rheumatoid arthritis is an autoimmune condition in
which our body’s defence system starts attacking the cells that line your joints by
mistake, making the joints swollen, stiff and painful. It is a progressive condition.

We would like to confirm this further by doing a few tests.

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I would like to order Full blood counts, Rheumatoid factor, inflammatory markers like CRP
and ESR and a special test called Anti ccp antibody test. We would also like to do and X ray
of your hands and wrist joints. Only after these tests, we may be able to say for sure.

What do you think of this? That’s alright doctor.

Dr: Do you have any questions ?

Pt: Dr if it is this condition then do you have any treatment for it.

Dr: Unfortunately there is no permanent cure for it but we can offer you various ways
and options by which we can control these symptoms and enable you to live as active a
life as possible.

These options usually involve lifestyle changes, medication, supportive treatments and
surgery.

If you would like I can refer you to our rheumatologist so that you can discuss these
options at length. What do you say ? Yes I would like to visit him.

He may offer you medications like DMARDS which may help in reducing the rate of
progression and controlling these symptoms.

As you already told me that you are taking Ibuprofen but it is not helping with pain, I will
discuss with my seniors if we can switch you to a stronger pain killer but it is always
advised that you take this pain killer with PPI like omeprazole so that we can protect
your stomach as well.

I can refer you to occupational therapist he may help you with strategies to cope with
your work.

If you would like I can guide you to our physiotherapist as well as he may have some
helpful exercises for you.

Surgery might also be needed to correct deformities.

How does that sound to you? Pt: I think I will try all this.

Caroline it is important that you stop smoking as it can cause flares of this condition and
if you would like any help with that I can refer you to smoking cessation clinic as well.

Pt: I will think about it doctor.

RHEUMATOID ARTHRITIS
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65. You are FY2 in orthopedic surgery department.

25 years male, Mr Robert, C/O joint pains
Assess him and discuss the management with the patient.
Please take history, do relevant examination and discus the management with
the patient

Dr: Hello I am Dr .... Are you Mr Robert ... Pt: Yes.

Dr: How can I help you?

Pt: I am having pain in my knee (sometimes, he may say both knees and ankle
joints).

Dr: Is it both the knees and both ankles? Pt: Yes

Dr: I am sorry to hear that. Can you tell me more about them? Pt: It started about 2
weeks ago doctor

Dr: Do you know how it started? Pt: On its own doctor

Dr: Do you have any other symptoms other than pain in your joints ?

Pt: My eyes are bit sore since last few days.

Dr: Did you have any injury to your knee or ankles at all? Pt: No

Were you playing some sports? Any trauma?

Dr: Are all those joints swollen (hemarthrosis, reactive arthritis, septic arthritis,
rheumatoid arthritis)? Pt : Yes

Dr: Do you have a fever (septic) ? Pt : No

Dr: Are you able to walk at all (Can’t walk in septic arthritis because of severe
pain) ?

Pt: Yes I can walk.

Dr; You have pains in the small joints of your hands (Rheumatoid arthritis affects
small joints)? Pt : No

Dr: Do you have stiffness in the joints (Rheumatoid, reactive) ? Pt -Yes

When do you feel the stiffness? Pt: Morning (Morning stiffness can happen in reactive
arthritis and other causes of inflammatory arthritis)

Dr : Any pain in your back (Ankylosing spondylitis)? Pt : No

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Dr: Do you have any swelling and pain in the big toe (Gout) ? Pt : No

Dr: Did you have this type of problem before? Pt : No

Dr : Do you have any medical conditions? Pt: No

Dr: Are you taking any medications at all? Pt : No

Dr : Any of your family members has this type of conditions? Pt : No

Dr: Have you travelled outside UK recently?

Pt : I went to France about 3 months ago.

Dr: Did you have any health problems when you were there?

Pt: I had diarrhoea for a few days.

Dr: Did you take any treatment for that ?Pt : No it subsided on its own.

Dr: Did you have any unprotected sex with any one recently? Pt : No

Dr: Do you have burning sensation while passing urine? Pt: No

Dr: Any discharge from the urethra that is front opening of urine passage? Pt: No

Dr: Is there anything else you think is important that we may need to know? Pt : No

Examination

Check NEWS chart for temperature

I need to examine your knee and ankle joints. I will be very gentle during my
examination. Is that OK if I examine now? Pt : Yes.

Can you please undress below your mid thigh?

Check Gait : Could you please take a few steps (May have antalgic gait)

Can you please stand now?

Inspection of knees and ankles

No swelling, redness, scars or sinuses.

Can you please lie down on the couch?

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Palpation:

Knees

Check for temperatures (compare temperature over the knees to thighs).

Check joint line tenderness – No joint line tenderness

Check for fluid collection – milk from thigh down towards the knee and patellar tap – No
fluid in the joints.

Check movements (Active and passive) – Flexion, extension, Internal rotation external
rotation – all movements normal.

Ankles

Check for any bony tenderness – No bony tenderness, No swelling

Check movements – plantar flexion, dorsiflexion, internal rotation, external rotation.

Movements normal

[Medial and lateral stress test and anterior and posterior drawer test – do these
tests only if the time permits otherwise not necessary because these tests are
done if there is a history of trauma]

Investigations

Robert, there are no investigations to confirm the diagnosis but we will need to do some
investigations to exclude other problems. We will do some blood tests for infection markers,
Also, we will do some X Rays of your knees and ankles. Also, we need to do some tests to
check for some joint conditions like rheumatoid factors in the blood. Is that Ok? Pt : Ok doctor.
Diagnosis:

Robert, with the information you have given me and after examination I think you have a
condition we call as Reactive arthritis.

Do you know anything about this condition? Pt : No

Dr : I will explain. If someone had any infections due to some bugs in THE other parts of
body like bowel - sometimes as a reaction to that infection, people develop inflammatory
reactions (a type of reaction which causes swelling of joints) in the big joints like
knees and ankles. Since you had diarrhoea a few weeks ago which may be due to bugs
– that would have caused this condition in you. This condition causes pain in the knees
and ankles and also it causes soreness in the eyes. This condition is due to problems in
the immune system.

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Do you follow me? Pt : yes doctor

Dr: Do you have any questions at this point? Pt : No

Treatment:

Dr: Unfortunately there is no cure for this condition. However, the good news is that it
usually subsides on its own but it may take up to six months or may be even up to a
year to subside completely.

We advise you to take plenty of rest and avoid using the joints as much as possible
initially.

As your symptoms improve, you should start exercising slowly to strengthen muscles.
We will refer you to the Physiotherapist for that.

We will give you medications called Ibuprofen – that also will help you reduce the pain.

If the Ibuprofen medication does not help then we can give you medications what we
call steroids.

We will give you steroid drops to your eyes – that will help to reduce the soreness in
your eyes.

If none of these medications help then we will give medications called DMARDs
(Disease-modifying anti-rheumatic drugs) such as sulfasalazine which may help.

Pt: Can it come back again?

Unfortunately it can happen again if you develop any infection in parts of body again.

Dr: Any other questions? Pt : No Thank you.

Differentials for Joint pain

(Mnemonic – GHRRROSS)

1. Gout
2. Heamarthrosis
3. Rheumatoid arthritis
4. Reactive arthritis (Reiter’s syndrome – old name for reactive arthritis - - Uveitis,
urethritis, arthritis) - Large joints
5. Osteoarthritis - Large joints
6. Septic arthritis - Single joint
7. Sports injuries
REACTIVE ARTHRITIS
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66. Patient comes in with a concern. He is currently on bendroflumethiazide for

hypertension and some anti-allergy medicine. ((Alternate question: 52 year old
man has recently been diagnosed with GOUT. He is worried about repeated
attacks. Address his concerns.))

A man comes in with pain in his big toe (doesn’t say in the scenario). All that’s given is that
he’s come with a concern and that he’s on some medication called Bendroflumethiazide for
his hypertension and some anti-allergy medication. BNF present on the table - Check the
BNF and it states that the thiazide causes hyperuricemia and diet consists of eating lots of
steak and red meats along with high alcohol intake.

Attempt to examine the patient and the examiner will show you a picture of a foot

GRIPS

Dr- How much you know about your condition? Pt- I do not know much.

Dr- From your history, we have found that you got a condition called gout. Do you know
what it is or do you have any question? Pt- I don’t know what gout is.

Dr- Gout is caused by too much uric acid in your blood. When this happens, tiny crystals
form and collect in the joints causing pain and swelling. It usually affects the big toe but it
can occur in any joint. Pt – Can it happen again?

Dr – Unfortunately, it comes in attacks, which can develop rapidly over a few hours,
and lasts for several days if left untreated. It is possible to have one attack of gout and
never experience it again, however for many people it does return. There are several
factors that can cause recurrent attacks.

Dr: Tell me about your diet. Pt: I like red meat.

Dr: Try to avoid red meat, chocolate, beer, caffeine. (So less tea, coffee. Even be careful
when you are taking cough and cold remedies as they have caffeine.) Drink plenty of
water and eat lots of cherries.

Dr- Do you drink alcohol? Pt- Yes

Dr – What type do you prefer? Pt- Beer

Dr: Drinking alcohol causes uric acid to build up. I won’t ask you to leave it altogether
but try to take it in moderation. Not more than 21 units per week. You can use wine if
you like as it has less purine as compared to beer.

Pt: Why did I get this condition Doctor?

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Dr: In most cases, there is no known reason why you have too much uric acid. Your
body may have made too much, or your kidneys may have not got rid of enough.

Dr- Are you on any kind of medication? Pt –Yes some ‘water tablets’ for my high blood
pressure.

Dr- It could be because of these high purine food and drink you are consuming and the
medication as well. Don’t worry too much, we do have some treatment and some other
things that you can do to take control of the condition.

Pt- Do you have any treatment for this?

Dr: Yes, there are some medications and some non-medical treatment, which one you
want to know first?

Pt – Tell me about the medications

Dr - Ok now we can prescribe you NSAIDS, these are painkillers to ease your pain in
case of an acute attack, but if you cannot tolerate this (due to any side effects), then you
might be given colchicine. You might also be given some proton pump inhibitor [PPI] to
protect your stomach. You can also apply some ice packs but if you do have repeated
attacks, then there is a medication called allopurinol but it should be started after several
weeks of an acute attack

Pt – What about the other things you were talking about?

Dr- Yes, there are some advice you should follow like:

Do not fast for a long time. If you want, we will refer you to a dietician.

Alcohol: - Do you drink? If yes- As part of your treatment, it is also important to reduce the
amount of purines that you take in. Alcohol, especially beer, is high in purines, so it is
important to cut down, or cut it out completely. Is it ok with you? Pt – Ok

Exercise: Indulge in some light exercises regularly. By improving your fitness with
regular exercise and keeping a check on your cholesterol level, these will help you to
decrease the chances of having Gouty attacks in the future.

Medications:- If you wish to take any over-the-counter medications, it Is important to

contact your GP and consult the chemist for advice as medicines such as low-dose
aspirin can cause attacks of Gout.

I will give you the address of the UK Gout Society, and some other support groups, some

leaflets and useful websites. Thank You GOUT

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67. A 25/35 year old man comes to the A and E with a history of chest pain.
Take history and discuss management. DIFFERENTIALS:
D-How can I help you? P-Doctor I have bad chest pain. Pneumothorax
MI
PE
D-Could you please tell me in detail about your chest pain?
Trauma
Pneumonia
P-Sure Doctor, this pain started 3 days ago and still there Pericarditis
without any changes. It's really bothering me.

D-I am really sorry, would you like any pain killer now? Are you comfortable talking to
me? P-Yes, Doctor I am OK to talk.

D-Can you tell me where exactly the pain and how intense is that? P-

It's really bad, Dr. (simulator may point to the right axillary line) D-

What type of pain is that?

P-What do you mean by that doctor

D-Is it like stabbing pain, crushing or its just ache?

P-It is kind of mixed.

D-How severe the pain? 1-10 scale P-May be 3-4

D-Dose this pain goes anywhere else? P-No

D-Any other symptoms such as shortness of breath? Fever? Cough? Swelling of the
ankles? P-No, doctor, only this ache.
D-Do you know how did it start? P-it just started like that 3days ago.

D-Did you have any flu-like symptoms before this pain? P-No

D-Any injuries to your chest?

P-Yes Doctor, I forgot to tell you that I had a fall from bicycle few days ago.

D-Was this pain there before or after the accident? P-After.

D-Any recent travel outside the UK? P-No

D-Do you smoke? P-Yes, Dr, I have been smoking for many years..

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D-What do you smoke and how much? P-Cigarettes and I smoke 5 a day.

D-Have you noticed any change in your weight? P-Maybe, I put on some weight.

D-What about alcohol? P-I don't drink.

D-I would like to examine you. Is that OK? P-Yes, Dr.

Examination:

Vitals

Inspection for signs of trauma: No bruises, swelling, chest deformities or wounds.

Chest movements symmetrical, Expansion equal, No neck vein engorgement

(to r/o Pneumothorax)

Palpation: Trachea not shifted. Tenderness present over right anterior axillary line
along 4th and 6th intercostal spaces.

Percussion - normal except patient might not allow percussion in the pain area.

Auscultation – Air entry equal and normal vesicular breath sounds.

Provisional Diagnosis - Mr... Based on the information, what you told me, and the
examination findings, I am suspecting it might be musculoskeletal injury, but to rule
out other serious conditions and confirm the diagnosis we need to do some tests like
chest X Ray is that Okay ? Pt Ok

(to r/o rib fracture and Pneumothorax)

(Mention ECG and cardiac enzymes if the chest pain is on left side)

Do not mention cardiac enzyme if the pain is on right side chest.

Examiner may say chest x-ray normal.

D-Mr... It's a good news. The x-ray came back as normal. That is you do not have any
serious injuries like rib fracture. So what you have is just muscle pain over the chest
due to your bicycle accident.

P-Is it serious? What can you do now, doctor?

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D-It is not serious but the pain might take some time to go away on its own. We can give you
some good pain killers. Do you drive frequently or work with any machineries? P-No

D-Any medication allergy or stomach problems? P-No

D-We can give you some painkillers. It will take a few days for the pain to subside.

P-OK, thank you, Dr.

D-Do you have any other concerns?

P- Doctor, my father died because of a heart attack and brother was recently
diagnosed. Are you sure I am not having that?

D- At the moment, it doesn’t look like a heart attack.

(If it is a left side chest pain - “Your ECG is normal. However we shall test your blood
for cardiac markers to make sure it is not a heart attack. We shall repeat your ECG
later on. I will ask my seniors for expert opinion.”)

MUSCULOSKELETAL CHEST PAIN

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68.

Is there anything that makes

the pain better or worse?
(IVDP-relieves on lying flat
and worse on movement,
coughing or sneezing)

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MOST IMPORTANT is: TO RULE OUT IS CAUDA EQUINA

Any history of lifting heavy weights?

Any bowel or bladder incontinence (leakage of urine, unable to control bowel

movement) (cauda equina syndrome)
Did you experience any weakness of the legs during this event?

Did you experience any difficulty while passing urine or motion?

Loss of weight?

MAFTOSA-specifically ask for history of cancers in family

Examination - (usually verbal)

Examine back and abdomen, back passage for loss of anal tone. [Do not mention
prostate examination because patient is young].

SLR test - explain. (If SLR positive, this indicates prolapsed disc)
Investigations

Continue with normal activities as far as possible. Initially, try doing simple activities
that won’t cause much pain. Set a new goal everyday-.For example-first day: walking
around the house, Second day - walking to the next shop and so on.. You are likely to
recover quickly when you do this.

(Explain warning signs-spinal cord compression-inability to pass urine, pain

radiating to the legs. If there are symptoms, advise to come to the hospital
immediately)

MUSCULOSKELETAL BACK PAIN

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70. BACK PAIN - UNKNOWN CAUSE

Differentials

Your first diagnosis should be leaking AAA. Next should be cauda equina syndrome
and then cancer.

Ask the patient if he has cancer. If he doesn’t, then ask symptoms that can point to
cancer.

A) Secondaries

1) Prostate – nocturia, increased frequency, hesitancy, dribbling*, poor stream*,

haematuria*. Weight loss.

2) Lung – cough, haemoptysis, smoking, weight loss.

3) Kidney – problem passing urine, loin pain, loin mass, hematuria.

4) Thyroid - swelling in the neck.

5) Breast – lump in the breast (in females)

B) Prolapsed disc – sudden onset of pain while lifting heavy weights, pain
radiating to the legs. Can lead to Cauda equina - Bowel incontinence (not able to
control bowel movements) and bladder incontinence (leakage or urine), numbness in
the legs. Ask of falls and injuries.

C) Leaking abdominal aneurysm – Usually a coincidental finding - “Did you have

any ultrasound scan before which showed any abnormality in the blood vessels inside
your tummy?" Pulsatile mass, previous/chronic back pain, dizziness, palpating.

D) Osteoarthritis – stiffness in the back that gets worse by evening

E) TB - Potts disease (cough, night sweats, fever, weight loss, contact, travel).

F) Sprain – trauma, twisting suddenly, after sports. “Any falls? Any dancing? Any sports?”

G) Multiple myeloma – tiredness, weakness, palpitations, shortness of breath

(anaemia), easy bruising or bleeding, infections, pelvic/thigh/skull pain.

H) Ankylosing spondylitis – stiffness, pain and swelling in the other parts of the

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body, red eyes.

I) Renal stones – past Hx of stones.

J) Pancreatitis – if pain coming from front – ask of alcohol

K) Pancreatic cancer – Cancer of the tail of the pancreas can present with back
pain and obstructive jaundice (if it’s a cancer in the head).
[ Positive in history – back pain since 2 months, weight loss, and increased
frequency of urination ]

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69.50 year old Mr … presented to the hospital complaining of back pain. Take a brief
history and talk to him about the management.
Dr: Hello Mr ….. I am Dr …. How can I help you ? Pt: I am having pain in my back doctor.

Dr: Sorry to hear that. Are you comfortable talking to me? Pt : Yes, I am Ok to talk, doctor.

Dr Anything more you can tell me about your pain ?

Pt: It just started on its own. It is there since about 2 to 3 months doctor. Dr: Anything
more can you tell me about it?

Pt : Like what doctor?

Dr: Where exactly do you have pain? Pt: Here at my lower back. (Patient may show
the pain at the lower spine).

Dr: Does the pain go anywhere from the back (sciatica) ? Pt No

Dr: Did it started suddenly or gradually. Pt: Gradually / suddenly

Dr: Ay thing makes it better or worse? Pt: It hurts me more when I turn around.

Dr : Do you have pain anywhere else other than back ? Pt : No

Dr : Any headache or pain at the hips (MM) ? Pt : No

Dr: Did you have any fracture of bones (pathological fractures in MM) ? Pt : No

Dr: Have you notice any change in your weight (MM) ?

Pt: Yes, I have lost some weight. (Quantify - how much in how much time. Also, find
out if it is intentional)

Dr: Do you feel tired (Anaemia in MM)? Pt : No

Dr: Do you get repeated infections (decreased white blood cells in MM) ? Pt : No

Dr: Do you get bruising ? Any unusual nose or gum bleeding (decreased platelets in
MM) ? Pt : No

Dr: Do you have any pins and needles, numbness in the legs and feet

(Compression of the spinal cord due to prolapsed disc or compression fracture of

vertebra due to MM) ? Pt : No

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Dr: Do you have increased frequency of urination or nocturia? (hypercalcaemia due

to MM, diabetes) ? Pt: Yes.

Dr: Any pain in your tummy (pancreatitis, cancer of the pancreas)? Pt : No

Dr: Did you have any injury to your back (trauma) ? Pt : No

Dr: Did the pain started after lifting anything heavy (prolapsed disc) ? Pt : No

Dr: Did it start after doing any exercise or sports? Pt : No

Dr: Do you feel that your back is stiff (osteoarthritis, ankylosing spondylitis) ? Pt: No

Dr: Do you notice the urine dribbling when you pass urine (enlarged prostate) ? Pt : No/yes

Dr : Any blood in the urine (renal cancer)? Pt : No

Dr: Any urine or bowel incontinence (cauda equina due to prolapsed disc or
pathological fracture of vertebra due to MM)? Pt : No

Dr: Do you have any cough (TB) ? Pt : No

Dr: Any swelling in the front of your neck (thyroid cancer)? Pt : No

Dr: Any mass in your loin area (renal cancer)? Pt : No

Dr: Do you have any medical conditions? Pt: No Dr: Do you smoke? Pt : Yes/No

Dr: Are you taking any medications? Pt : No

Dr: Any of your family members have any medical conditions? Pt: No

Dr: What kind of job do you do? Pt: I work in the post office.

Dr : Do you lift heavy thing at your workplace? Pt : Yes / No

Dr : Is there anything else important you think we may need to know ? Pt : No

Examination:
Tell the patient – I need to examine your tummy, back and your back passage for
prostate gland Examiner may say – Prostate normal no other finding.

[Or examiner may say prostate enlarged]

Tell the examiner: I also need to do a neurological examination of the lower limb, do

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Straight leg raising test (SLR) test for prolapsed disc causing any sciatica.

[The straight leg raise, also called Lasègue's sign, Lasègue test or Lazarević's sign, is a test
done during the physical examination to determine whether a patient with low back pain has
an underlying herniated disk, often located at L5 (fifth lumbar spinal nerve.)

Technique

With the patient lying down on his or her back on an examination table or exam floor,
the examiner lifts the patient's leg while the knee is straight.

Interpretation
If the patient experiences sciatic pain when the straight leg is at an angle of between 30
and 70 degrees, then the test is positive and a herniated disc is a possible cause of the
pain. A negative test suggests a likely different cause for back pain.

Diagnosis:

We need to do some investigations to check what exactly is causing your back pain. We

will do an x-ray and MRI scan of your back. Also we need to do some blood tests. Dr:

Mr... It’s not very clear from the information what exactly is causing your back pain.

There are a lot of conditions which can cause pain at the back. Only after the
investigations, will we be able to tell you the exact cause of this pain.

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We will refer you to the bone specialist (Orthopaedicians) and they will do the
investigations and then tell you what exactly is causing this pain and they will tell you
the exact treatment.

Pt: My neighbour had Pancreatic cancer. Do I have that doctor?

Dr: It is very unlikely you also have the same problem. However, we need to check for
all the possibilities.

Treatment:

We will give painkillers for your pain. We will give you a stronger painkiller than
Paracetamol called Co-Codamol. Hopefully that will help your pain.

We can arrange physiotherapy for you. Usually most of the patients improve after
physiotherapy.

[If the examiner says prostate enlarged – On examination, I found that one gland
called prostate which is at the neck of the urine bladder is enlarged. Sometimes, if it is
a cancer type of enlargement, then it can cause pain at the back because of the
spread of cancer to the back bone. We will also do a scan of the prostate gland and
some type of blood tests to check what type of enlargement it is. If the investigations
show that you do have prostate cancer, then depending on the stage of the cancer, we
will treat you with either surgery or special cancer medicines].

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71. You are an FY2 doctor in the A&E department. A 55 year old man
presented with back pain since yesterday evening

Your task: Address his concerns and plan on INITIAL MANAGEMENT.

There will be a mannequin in this station so don’t spend too much time on the history

DIFFERENTIAL DIAGNOSES

1. AAA: To identify an unruptured aneurysm, the questions to ask include: Has he been
diagnosed with abnormal blood vessels in the tummy called aneurysm? If he has, it
would probably have been an incidental finding. Did you feel any pulsatile lump in the
tummy? Have you had a back pain in the past? Symptoms suggesting a leaking
aneurysm include an exacerbation of back pain, dizziness, heart racing.

2. CAUDA EQUINA - Caused by trauma, spinal tumours, lifting a heavy weight

3. IVDP (intervertebral disc prolapse) and SCIATICA

4. SECONDARIES {PROSTATE}

5. MUSCULOSKELETAL BACK PAIN

6. TRAUMA

Hello, I am Dr ..... one of the junior doctors in the A&E Department. How can I help you?

Pt: Doctor, I have been having a back ache since yesterday

Dr: Could you please tell me a little bit more about it?

Pt: It started on its own since yesterday, I thought it could be some muscle pain

Dr: Don’t worry. We will definitely help you. Can you please show me where exactly the
pain is?

Patient shows the middle or lower back.

Dr: What type of pain is that? Pt:

Dr: Is it going anywhere else? Pt: No

Dr: Is it going to your legs? [sciatica]

Dr: Is there any pain in you tummy? Pt: No, doctor it is just there

Dr: Is there anything that makes it better or worse? [IVDP- relieved on lying down?] Pt: No

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Dr: Is it going to your loin area? Pt: No [RENAL PATHOLOGY]

Dr: Do you have any bowel or urine incontinence? [CAUDA EQUINA] Pt: No, doctor

Dr: Any numbness around your back passage? Pt: No, doctor

Dr: Any dribbling of urine or any urinary incontinence? [CA prostate] Pt: No, doctor

Dr: Did you do any physical activity more than the usual - like running, exercise, sports,
or lifting weights [MUSCULOSKELETAL BACK PAIN] Pt: No

Dr: Any chance you may have injured your back? Any fall? Pt: No, doctor

Dr: Do you have a fever? No

Dr: Did you feel any pulsating mass in your tummy (AAA)?

Dr: Have you ever had any type of scan done on your tummy where the doctor told you
that you have some abnormal blood vessels in your tummy (AAA)?

Dr: Do you feel dizzy or feel like fainting (leaking AAA) ?

Dr: Have you had this type of problem before? No

Dr: Have you had any kidney problem before ? No

Dr: Do you have any medical conditions? HTN? DM? cholesterol? Heart problem?

MAFTOSA

Any of your family members had any abnormal blood vessels in their tummy/cancer/
heart disease/cholesterol?

Smoking [risk factor for AAA]

Note: Important risk factors for AAA are

1. High blood pressure

2. Tobacco smoking

3. Atherosclerosis

4. Hereditary

5. Age > 50

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EXAMINATION

I would like to examine your tummy(first), your back and your back passage. Is that okay?

Also, I need to measure your heart rate, blood pressure and the oxygen levels in your body. I
will have a chaperone with me and will ensure the privacy. Can you please undress from
below your chest up to the mid thigh and keep your briefs on? Pt: Ok, doctor

Examiner gives NEWS chart: PR: 94 BP: 120/80 SPO2 97%

If the BP is normal, you can still not exclude hypovolemia, as hypotension is a late sign
of blood loss. The heart compensates by beating faster.

Examiner may say - back passage and back examination is normal.

Proceed to abdominal examination - A MANNEQUIN is kept on the table

Start examining the abdomen but examiner may give the findings (if not, check for
pulsating mass): “No distension, no pulsations visible”

Palpate - tenderness above the umbilical region and pulsations might be felt all over the
abdomen. “I can feel a pulsatile mass.”

Examine the liver, spleen, hernia orifices, etc

Dr: Mr .... during the examination, I felt a mass in your tummy. From what you have told
me and after the examination, I suspect you have a condition called an ABDOMINAL
AORTIC ANEURYSM WHICH MIGHT BE LEAKING BLOOD NOW. Do you know
anything about it?

Pt: No doctor. Is it serious??

Dr: I will definitely answer your question. First of all, let me tell you what AAA is. We have a
large blood vessel in our tummy called the Aorta which branches off and gives blood supply
to organs in our tummy and our legs. Sometimes, its width increases which ends up in the
thinning of the walls of this blood vessel (part of the Aorta becomes swollen like a
balloon). This can sometimes result in bursting of the blood vessel and blood will start
leaking, which is a life threatening condition. If that happens, the patient will feel dizzy, short
of breath and experience severe pain in the tummy or back. Are you following me? Pt: Yes.
Dr: We need to admit you. We need to check whether it is leaking blood now. I will talk to
my seniors and will arrange for an USG scan of your tummy to confirm this. We would like
to run some baseline blood tests and would also like to check your cholesterol, blood
grouping and cross matching. Would that be okay?

Pt: Okay doctor. But what will you do after the scan?

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Treatment:

Dr:
" We will start you on Oxygen and IV fluids. I will refer you to the Vascular surgeon
" Take blood for FBC, grouping and crossmatching, clotting factors, LFTs
" Call Seniors (vascular surgery team) immediately

Ask if he has any other concerns.

Specialist - Treatment depends on the size of the aneurysm and also whether it is leaking or not.

If leaking - blood transfusion will be necessary. This is followed by an Urgent operation by a

vascular surgeon to control the bleeding.

If it is not leaking – and if the size is not too large, then it does not need any immediate treatment.
We will keep monitoring to check whether it grows in size or not. If the aneurysm is big, they might
put an artificial tube to prevent it from rupturing.

If the size increases and risk of rupture is there, then we have to surgically repair that.

If already ruptured, then the surgeon may need to do an immediate operation to control the
bleeding.

There are two types of surgeries

1. Open aneurysm repair – A graft (artificial tube) is placed in the Aorta through a cut
in your tummy.

2. Endovascular aneurysm repair. A graft is inserted through a blood vessel in the

groin and then passed up into the Aorta.

The type of surgery is decided by the surgical consultants.

Advise: Diet, Smoking, Exercise. Reducing weight if overweight.

After you complete the consultation, ask if he is expecting anything else.

Abdominal aortic aneurysm (info)

Men aged 65 and over are most at risk of AAAs. This is why men are invited for
screening to check for an AAA when they're 65

Symptoms of an AAA

AAAs don't usually cause any obvious symptoms, and are often only picked up during
screening or tests carried out for another reason.

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Some people with an AAA have:

" a pulsing sensation in the tummy (like a heartbeat)
" a tummy pain that doesn't go away
" lower back pain that doesn't go away

If an AAA bursts, it can cause:

" sudden, severe pain in the tummy or lower back

" dizziness
" sweaty, pale and clammy skin
" a fast heartbeat
" shortness of breath
" fainting or passing out

The recommended treatment for an AAA depends on how big it is.

Treatment isn't always needed straight away if the risk of an AAA bursting is low.

Treatment

" small AAA (3cm to 4.4cm across) – ultrasound scans are recommended every
year to check if it's getting bigger; you'll be advised about healthy lifestyle
changes to help stop it growing
" medium AAA (4.5cm to 5.4cm) – ultrasound scans are recommended every three
months to check if it's getting bigger; you'll also be advised about healthy lifestyle
changes
" large AAA (5.5cm or more) – surgery to stop it getting bigger or bursting is
usually recommended

Reducing your risk of an AAA

There are several things you can do to reduce your chances of getting an AAA or help stop
one getting bigger.

These include:
" stopping smoking
" eating healthily
" exercising regularly
" maintaining a healthy weight
" cutting down on alcohol
If you have a condition that increases your risk of an AAA, such as high blood pressure,
your GP may also recommend taking tablets to treat this.
Screening for AAAs: In England, screening for AAA is offered to men during the year they turn
65. This can help spot a swelling in the aorta early on, when it can be treated.

BACK PAIN - ABDOMINAL AORTIC ANEURYSM

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71. 63 year Larry King referred from the Well-man clinic. He was diagnosed with
High Blood Pressure 2 weeks ago. Was started on Ramipril 1.25mg once daily .

Blood tests were done one week after starting Ramipril :

1. FBC = Hb , TLC , MCV , Platelet (NORMAL)

2. U&E = Urea , all Electrolytes mentioned : NORMAL (means Potassium also

normal)

3. Ambulatory blood pressure : 150 / 100 mmHg

4. eGFR = 100 mL/min

After TWO weeks of starting Ramipril, the same blood tests were repeated :

1. FBC = Hb , TLC , MCV , Platelet ( it was written : NORMAL )

2. U&E = Urea and all Electrolytes : Normal .

3. Ambulatory Blood Pressure : 150/95 mmHg

4. eGFR = 60 mL/min.

Talk to him and discuss the further management with him.

Structure for the history:

" Assess Knowledge

" Find out why he went to the well man clinic
" What happened when he went there? What did the doctor tell him he had before
prescribing the ramipril?

" Find out if he had any kidney problems in the past?

" Take history of HTN and DM treatment and medicine and dose.
" Has the patient taking the medication properly since then?
" Find out if patient is taking NSAIDS
" Has patient has any symptoms of renal failure?
" Any other conditions or medications causing low eGFR (renal damage)?
" Find out any reason why the blood pressure is not controlled? [not taking
medication properly, not following lifestyle]
" Ask about other side effects of Ramipril

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Dr - Hello, I am Dr… a junior doctor in the medical department. Are you Mr Larry King?
Pt - Yes

Dr - How are you doing? I see from my notes that you are referred from the Well-man
clinic because your blood pressure was high.

Pt - Yes Doctor, I was having headaches on and off, so I went to get myself checked. I
was told that my blood pressure was on the higher side so they started me on a
medicine.

Dr: Do you know which medicine? Pt – Ramipril

Dr –Yes, It is written here that you have been prescribed Ramipril 1.25mg once a day.

Dr - Mr King, Are you still having the headache? Pt = No Doctor, not anymore.

Dr - My notes tell me that the clinic ran some blood tests after starting the medicine

Pt - Yes doctor a week apart ..two times.

Dr - Mr King I have your test results, but before we discuss them, may I please ask few
questions regarding your general health and lifestyle so that I can explain your test
results in a better way?

Pt - Go ahead. Dr : Thank you.

Dr - Apart from the blood pressure, are you having any medical conditions at the
moment or had any in the past? Pt – No, I have been quite well all my life.

Dr: Do you have high blood pressure or Diabetes? Pt - No

Dr: Did you have any kidney problems before? Pt - No

Ask about signs and symptoms of kidney disease:

Dr: Do you have Swelling or puffiness in your face, tummy or ankles? Pt: No

Dr: Any change in the colour of the urine? (foamy, bloody or coffee-coloured in
kidney disease) Pt: No

Dr: Are you passing more or less urine than before? Pt: No

Dr: Any blood in the urine? Pt: No

Dr: Any pain in your tummy or loin area? Pt: No

Dr: Any previous kidney stones? Pt: No

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Also ask of previous history of renal artery stenosis and PKD.

[Ask about causes of kidney disease (causes of low eGFR)]

Dr : Have you been taking the Ramipril medication properly since it was prescribed to
you two weeks ago? Pt - Yes

Dr: Any current medication or in the past apart from the Ramipril like aspirin, NSAIDs?
Herbal medication? Pt : No

Dr: Any family member with high blood pressure? Heart problems? Kidney problems?
Pt - No

[Ask about other side effects of Ramipril]

Dr: Have you been experiencing dizziness or faintness? Pt: No

Dr: Any cough or chest pain? Pt - No

Dr: Nausea / Vomiting / Diarrhoea? Pt - No

Dr - Are you allergic to any medication or anything else? Pt- No

Dr - May I know what is your occupation? Pt - I work at a grocery store.

Dr - May I know how your diet is like? Pt - Usually healthy with a lot of fruits or vegetables.

Dr - Do you smoke? Pt - Yes, about 20 cigarettes a day for 30 + years.

Dr - Do you consume alcohol? Pt - No.

Dr - Do you exercise? Pt - No

Dr - Anything else you would like to tell me about yourself? No, doctor.

Examination

Look out for kidney mass (polycystic kidney disease) and renal bruits (renal artery
stenosis). “I need to listen to the blood supply of the kidneys.”

Management:

Dr - Mr King, We did some blood tests done after you were started on your Blood
Pressure medication. Your Blood composition seemed to be normal including the
amount of certain electrolytes. But I notice that your Blood Pressure is still on the higher
side as before the treatment and the function of your kidneys seemed to decline as well
during these two weeks.

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Dr: Do you have any idea why could this be happening? Pt - I don't know Doctor.

Dr - Would you like me to show you this on the test results?

(Explain the results)

Dr: Mr … , eGFR is a marker of kidney function. Normally it should be above 90%. It

was 100% in your case before we started the treatment of high blood pressure. Now it is
only 60% now means it has markedly decreased. This means your kidney function has
markedly decreased since we started the treatment.

Explain that it is probably because or renal artery stenosis - it is a reduced blood supply
to the kidney because of narrow blood supply. In such people when given this medicine,
it can further reduce blood supply to the kidneys.

Explain what GFR is only if the patient asks about it

The eGFR is a calculation based on a serum creatinine test. Creatinine is a muscle

waste product that is filtered from the blood by the kidneys and released into the urine
at a relatively steady rate. When kidney function decreases, less creatinine is eliminated
and concentrations increase in the blood. With the creatinine test, a reasonable
estimate of the actual GFR can be determined.

Pt: Why did that happen, doctor?

Dr: There are many reasons why the kidney function can reduce like -

If a person has high blood pressure, diabetes, or previous kidney problems or if

someone takes a certain type of medication like aspirin or Ibuprofen for a long time, it
can damage the kidneys and reduce its function. In your case, you don’t seem to have
any of those reasons.

One other important reason for reduced kidney function is taking Ramipril medication.

However, we do not stop the Ramipril medication if there is a slight reduction up to

about 20% in the kidney function. However in your case the kidney function has
reduced nearly 40% which is a marked reduction in the kidney function. We may need
to stop this Ramipril medication and start you on some other type of medication which
will not affect the kidney function to control the blood pressure.

Also inform her of the possibility of renal artery stenosis.

I will have to refer you to the Kidney specialist doctor (Nephrologist) for further opinion.
They may also check whether you have any other reasons for reduced kidney function.
Pt- What medication they may give, doctor ?

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Dr: They may start you on other type of medications known as calcium channel blocker
like Amlodipine. However they will tell you about it. Is that Okay ?

Pt: That is okay, but why did you give me this medication before if it causes kidney
problems?

Dr: Because renal artery stenosis is not very common, we don’t usually check for it
before giving the medication. Ramipril is one of the good medications to control high
blood pressure. However, like any medicine it also has some side effects and one of
these is that it can reduce the kidney function. That is the reason we keep checking the
kidney function of the patients to whom we prescribe Ramipril medication. If it causes
serious kidney problems only we stop the medication. Do you follow me?

Pt: Yes, doctor.

Dr: As I mentioned earlier, your blood pressure is not controlled, it is still high. Apart
from the medication which lowers high blood pressure, you need to follow a healthy
lifestyle to control the high blood pressure. You need to eat a healthy balanced diet, do
good exercises, stop smoking and cut down drinking alcohol. If you need any help with
these, we can make another appointment. What do you think of that? Pt – Yes, doctor.
That will be helpful.

Dr: Any other concerns? Pt- No

Dr: Thank you very much. I will refer you to the Kidney specialist now and hopefully
everything will be fine soon.

Information about eGFR (Estimated Glomerular Filtration Rate)

- It is calculated from the results of your blood creatinine test, your age,
body size and gender and race.

- eGFR is estimated GFR calculated by the abbreviated MDRD (Modification

of Diet in Renal Disease Study) ( equation : 186 x (Creatinine/88.4)-1.154 x
(Age) - 0.203 x (0.742 if female) x (1.210 if black). If you have an eGFR value
calculated by a local laboratory, use that.

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What is being tested?

- Glomerular filtration rate (GFR) is a measure of the function of the kidneys. This
test measures the level of creatinine in the blood and uses the result in a
formula to calculate a number that reflects how well the kidneys are functioning,
called the estimated GFR or eGFR.

- Glomeruli are tiny filters in the kidneys that allow waste products to be removed
from the blood, while preventing the loss of important constituents, including
proteins and blood cells. Every day, healthy kidneys filter about 200 quarts of
blood and produce about 2 quarts of urine. The GFR refers to the amount of
blood that is filtered by the glomeruli per minute. As a person's kidney function
declines due to damage or disease, the filtration rate decreases and waste
products begin to accumulate in the blood.

- Chronic kidney disease (CKD) is associated with a decrease in kidney function

that is often progressive. CKD can be seen with a variety of conditions,
including diabetes and high blood pressure. Early detection of kidney
dysfunction can help to minimize the damage. This is important as symptoms of
kidney disease may not be noticeable until as much as
30-40% of kidney function is lost.

- Measuring glomerular filtration rate directly is considered the most accurate

way to detect changes in kidney status, but measuring the GFR directly is
complicated, requires experienced personnel, and is typically performed only
in research settings and transplant centres. Because of this, the estimated
GFR is usually used.

- The eGFR is a calculation based on a serum creatinine test. Creatinine is a

muscle waste product that is filtered from the blood by the kidneys and released
into the urine at a relatively steady rate. When kidney function decreases, less
creatinine is eliminated and concentrations increase in the blood. With the
creatinine test, a reasonable estimate of the actual GFR can be determined.

How is it used?
The estimated glomerular filtration rate (eGFR) is used to screen for and detect early
kidney damage, to help diagnose chronic kidney disease (CKD), and to monitor
kidney status.

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When is it ordered?

- A creatinine test and eGFR may be ordered when a healthcare practitioner

wants to evaluate a person's kidney function as part of a health checkup or if
kidney disease is suspected. Signs and symptoms of kidney disease may
include:

- Swelling or puffiness, particularly around the eyes or in the face, wrists,

abdomen, thighs, or ankles

- Urine that is foamy, bloody, or coffee-coloured

- A decrease in the amount of urine

- Problems urinating, such as a burning feeling or abnormal discharge during

urination, or a change in the frequency of urination, especially at night

- Mid-back pain (flank), below the ribs, near where the kidneys are located

- High blood pressure (hypertension)

- As kidney disease worsens, symptoms may include:

- Urinating more or less often

- Feeling itchy

- Tiredness, loss of concentration

- Loss of appetite, nausea and/or vomiting

- Swelling and/or numbness in hands and feet

- Darkened skin

- Muscle cramps
- An eGFR may be repeated if the initial result is abnormal to see if it
persists.

What does the test result mean?

- Estimated GFR results are reported as millilitres/minute/1.73m2 (mL/min/

1.73m2).

- A normal eGFR for adults is greater than 90 mL/min/1.73m2, according to the National
Kidney Foundation. (Because the calculation works best for estimating reduced kidney
function, actual numbers are only reported once values are less than 60 L/min/1.73m2).

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- An eGFR below 60 mL/min/1.73m2 suggests that some kidney damage has

occurred. The test may be repeated to see if the abnormal result persists.
Chronic kidney disease is diagnosed when a person has an eGFR less than 60
mL/min/1.73m2 for more than three months.

The following summarises estimated GFR and the stages of kidney damage:

1. Normal or minimal kidney damage with normal GFR: 90+

Protein or albumin in urine may be high, cells or casts rarely seen in urine (see
Urinalysis)

2. Mild decrease in GFR: 60-89. Protein or albumin in urine may be high, cells or
casts rarely seen in urine

3. Moderate decrease in GFR: 30-59

4. Severe decrease in GFR: 15-29

5. Kidney failure <15

• The actual amount of creatinine that a person produces and excretes is affected by
their muscle mass and by the amount of protein in their diet. Men tend to have higher
creatinine levels than women and children.

• A person's GFR decreases with age and some illnesses and usually increases
during pregnancy.

• The eGFR equations are not valid for those who are 70 years of age or older
because muscle mass normally decreases with age.

• The eGFR may also be affected by a variety of drugs, such as gentamicin, cisplatin,
and cefoxitin that increase creatinine levels, and by any condition that decreases
blood flow to the kidneys.

• At what level of deterioration in GFR or creatinine concentration rise should

specialist advice be sought:

• It has been recommended that discussion with a specialist if a patient's serum

creatinine concentration rises by 30% or whose estimated GFR falls by 20% as
an apparent consequence of ACEI/ARB use (2)

• NICE have stated, with respect to the use of ACE inhibitors in CKD. Stop renin-
angiotensin system antagonists if the serum potassium concentration increases

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to 6.0 mmol/litre or more and other drugs known to promote hyperkalaemia

have been discontinued following the introduction or dose increase of renin-
angiotensin system antagonists, do not modify the dose if either the GFR
decrease from pretreatment baseline is less than 25% or the serum creatinine
increase from baseline is less than 30%

• If there is a decrease in eGFR or increase in serum creatinine after starting or

increasing the dose of renin-angiotensin system antagonists, but it is less than
25% (eGFR) or 30% (serum creatinine) of baseline, repeat the test in 1-2 weeks.
Do not modify the renin-angiotensin system antagonist dose if the change in
eGFR is less than 25% or the change in serum creatinine is less than 30%

Causes of low eGFR (kidney disease)

- High blood pressure

- diabetes are the most common causes

- Other causes

- There are many other conditions that less commonly cause CKD,
including:

• glomerulonephritis (inflammation of the kidney)

• pyelonephritis (infection in the kidney)

• polycystic kidney disease (an inherited condition where both kidneys are larger
than normal due to the gradual growth of masses of cysts)

• failure of normal kidney development in an unborn baby while developing in

the womb

• systemic lupus erythematosus (a condition of the immune system where the

body attacks the kidney as if it were foreign tissue)

• long-term, regular use of medicines, such as lithium and non-steroidal anti-

inflammatory drugs (NSAIDs), including aspirin and ibuprofen

• blockages, for example due to kidney stones or prostate disease.

Information on Well man check

Well man clinics offer a range of health checks for men. Some NHS GP surgeries or

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hospitals offer well man clinics, but many are private.

You'll have to pay for tests at a private clinic, which can be expensive.

A well man clinic isn't a replacement for your GP. If you're ill or need medical
advice, see your GP.

What health checks do well man clinics offer?

The range of tests and health checks may vary between clinics, but any of the
following may be assessed:

" your lifestyle, including diet, exercise, alcohol and smoking

" medical history

" weight and height

" blood pressure

" cholesterol
" a urine test for diabetes or kidney infection

" hearing and vision

" lung function

" an electrocardiogram (ECG) to check for heart problems

" a chest X-ray, if you're a heavy smoker

The more common side effects that occur with Ramipril:

• Dizziness or faintness due to low blood pressure.

• Cough.

• Chest pain.

• Nausea / Vomiting / Diarrhoea.

• Weakness or tiredness.

LOW eGFR AFTER STARTING RAMIPRIL

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72. HIGH INR IN PATIENT TAKING WARFARIN

(CAUSED BY CLARITHROMYCIN)
1. Assess patient for signs or symptoms of unexpected/extensive bruising or bleeding.

2. Review history for potential causes for high INR:

a. change in medication

b. change in diet

c. excess alcohol intake in last 3-4 days

d. administration error (incorrect dose of warfarin, unintentional administration of

warfarin twice in one day)

What foods give you a high INR?

1. Green leafy Vegetables: Green beans. Asparagus. Broccoli. Carrots. Avocado.

2. Fruits: Apple. Banana. Blueberries. Grapes. Orange.
3. Meats: Beef. Chicken. Pork. Tuna. Turkey.
4. Fats and Oils: Corn oil. Margarine. Mayonnaise. Peanut oil. Olive oil.
5. Dairy Products: Butter. Cheese (cheddar) Eggs. Sour cream. Yogurt.
6. Beverages: Coffee. Cola. Fruit juices. Milk. Tea (black). Cranberry juice

The patient has a history of DVT, he is on lifelong Warfarin, INR is 6. He had a chest
Infection, so was given Clarithromycin.

Task: tell man the results.

Find the causes (given above)

Patient was given clarithromycin by GP for chest infection. Has finished the course now.

Check BNF.

Why INR is so high – Clarithromycin increases the anticoagulant effect of warfarin.

Because you had clarithromycin - So that is why it went high

Rule out any bleeding especially stroke/TIA (haematemesis, hematuria, epistaxis,

bleeding PR)

“Has it happened before like this?” In this station, the did not have any bleeding

Management : The protocol was given inside the cubicle – stop warfarin until the INR
comes down to 5 and then restart the warfarin.

Warning signs – If any bleeding occurs/comes back

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73.

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73. LADY ON WARFARIN - URINE SHOWED 2+ BLOOD

and INR:2
UTI ruled out (given in the question).

If INR is within a normal range (usually 2 in this cause), what could be causing the
bleeding?

- Find out if patient was menstruating when the sample was taken.

- Patient did not have obvious bleeding in the urine,

- No bleeding anywhere else

- No TIA/ Stroke.

- Rule out all causes of haematuria.

- No UTI symptoms

- Check for painless hematuria

- No weight loss.

Redo the test in a week. If it still shows blood in the urine, patient should be referred to
the urologist and nephrologist to rule out bladder cancer and kidney problems.

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74. You are the FY2 doctor in the GP Clinic.

A 40/50 year old lady Mrs…. came to your colleague 5 days ago. Now she has
come to collect the test reports. Your colleague is on leave. Take a focused
history and discuss management with the patient.

TEST RESULTS :

PTH : 7.1 pmol/l (approx). Normal : 1.6 - 6.9 pmol/L

Serum calcium : slightly higher . Normal : 2.2 to 2.6 mmol/l

Dr: Hello, Are you Ms. A?

pt: Yes,

Dr: I am Dr … one of the junior doctors in GP today. I see that you are here to collect
your blood test results, am I right?/ I see that you are here for a follow up, is that
correct?

PT: Yes, Dr that’s right.

Dr: Alright Mrs… I’m here to talk about the results with you. Before we get into that, can
I ask you a few questions that will help me explain the results to you better? Pt: sure

Dr: What bought you to the hospital initially?

Pt : Dr, I have been feeling very tired lately (sometimes she might say weak)

Dr: For how long may I ask?

Pt: For about 3 months now, Dr.

Dr: That must have been very difficult, could you tell me more about this Mrs.… ?

Pt : Dr it started 3 months ago and it has been increasing lately.

Dr: I’m so sorry to hear that. How were you before that?

Pt: I was fine, Dr.

Dr: Did anything stressful or traumatising happen before this started? Pt: No, Dr.

Dr: Anything else you had? Pt: I have also not been sleeping well, Dr.

Dr: Can you please tell me more about that?/Why you say that? Pt: I get up a lot at night
to go to the loo because I have been drinking a lot of water lately.

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Dr: Anything else you had? Pt: Like what, Dr?

Dr: Do you have any pain while passing urine? Pt : No

Dr: Any tummy pain? Pt : Yes/No

Dr : Pain anywhere else in the body? Pt : Yes, doctor I have pain inside my bones. I feel
like my bones are becoming weak. (Doesn’t go anywhere, nothing makes it better or
worse, no h/o fractures or falls)

Dr: Any constipation? Pt : Yes, Dr for the last 3 months.

Dr : Any weather preference? Change in weight? Change in diet? Pt: No

Dr: Any racing of the heart? Pt: No

Dr: Any lumps or bumps anywhere? Pt: No

Dr: Any medical conditions in the past?

Pt : I have high blood pressure, Dr. (Patient has been on Thiazide diuretics and
Amlodipine x 10 years)

Dr : Any recent change in medications? Pt : No, Dr

Dr: Any side effects? Pt : No, Dr

Dr : Is it well controlled? Pt: Yes, Dr.

Dr : Any over-the counter-medications or supplements that you have been taking?

Pt : Oh yes, Dr, I have been taking Calcium supplements because I thought my bones
were getting weaker (says this only on probing)

Dr : How long? Pt :….

Dr : LMP? (is she post menopausal?) Children?

Dr Any family h/o similar conditions? Pt : No

Dr : Family h/o cancers? Such as breast ca or bone cancers? (h/o of MEN syndromes)
Pt: No

Dr : Any travel history? Pt : I was in Spain and I thought I got thirsty because of the
weather. But when I came back I was still thirsty, Dr

Dr : Smoking?Alcohol? Recreational drugs? Pt : No

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Dr: You have been very helpful. Now I’d like to examine you. I’ll be checking for Pulse,
BP, temperature and then I’ll take a look at your hands (look for clubbing), neck
(adenomas?)

Examiner :….
Dr : Thank you Mrs… From what you have told me and the test results, it seems like
you have a condition called Hyperparathyroidism. Do you know anything about that?
Pt : No.

Dr : Hyperparathyroidism is where the parathyroid glands, which are in the neck near
the thyroid gland, produce too much parathyroid hormone.

This causes blood calcium levels to rise (hypercalcaemia) and phosphate levels to drop.
Left untreated, high levels of calcium in the blood can lead to a range of problems. Like
the thirst and tiredness you have. Are you following me?

Pt : Dr, is it the thyroid gland? Dr : No, these are glands near the thyroid and have
different function.

Pt : Dr, Calcium should be in the bone! Why is it in my blood? Dr: Please, don’t be
worried. Our body has calcium in the bones and free calcium in the blood as well. When
the levels in the blood increase, we get symptoms.

Pt : Dr, is it because of the supplements I’m taking that this happened?

Dr : Well, it is not the reason for this happening. I can see that you are quite anxious
about this. When we take calcium from outside, usually the parathyroid hormone
decreases. However in this condition, there is increase in the PTH level. We might need
to run a few more blood tests such as oestrogen, progesterone, vitamin D levels as well
as scans of your neck (USG) and bones (DEXA scan) to see what might be causing
this. I would advise you to stop taking the supplements for now.

We also need to review your blood pressure medications. I will talk to my seniors about
it and ?(refer you to a cardio?)

Pt : Dr, why is this happening to me?

Mrs… In most cases, this happens due to a non-cancerous growth in the neck. Very
rarely, it could be cancerous as well

Pt : What do you want to do for me now, Dr?

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Dr : I advise you to take a lot of oral fluids, and we will refer your to an Endocrinologist
who will be prescribing you medication called Bisphosphonates. If needed we might
have to do a surgery too.

Pt : Ok..

Dr : Make sure you have a healthy, balanced diet.

You don't need to avoid calcium altogether. A lack of dietary calcium is more likely to
lead to a loss of calcium from your skeleton, resulting in brittle bones (osteoporosis). If
you get any pain in the tummy or while passing urine, feel low or confused, please come
to us immediately. We might need to admit and treat you

Do you have any questions for me? Pt : No, Dr

Dr : Thank you

HYPERPARATHYROIDISM

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75. 25 year female presented with swelling on shoulder. Take relevant history
and talk to her about the management. Take informed consent for surgery.
There is no need to fill up the consent form.

Dr – How can I help? Pt- I have a swelling on my shoulder.

Dr - Since when? Pt - many years.

Dr- What made you worry about it now?

Pt - It looks ugly. I am getting married soon. It will be visible when I wear my wedding
dress. I want it to be removed.

Dr: Does the swelling bother you in any way.

Pt: It keeps rubbing on my dress. It is very uncomfortable.

Dr – have you shown it to any doctor so far? Pt- No.

Dr- do you know how it started? Pt – I do not know.

Dr - Any pain? Pt - No.

Dr - Itching? Fever? Bleeding? Discharge? Pt- No

Dr - What colour? Pt - Pinkish

Dr - Any change in colour and size or border? Pt - No.

Dr: Have you noticed any swelling in the armpit or in the neck (spread to lymph nodes in
melanoma)? Pt : No

Dr - Is it on an exposed area is it usually covered with the dress ?

Pt – it is covered with my dress but for wedding I will be wearing a dress below my
shoulder level so it will be visible.

Dr – Have you tried to treat it in any way so far? Pt –No.

Dr – Do you have any such swelling anywhere else in body Pt – No

Dr – Did you have any such swelling before? Pt - No.

Dr – Do you have any medical conditions? No

Any surgery before? No

Dr: Any medications (immunosuppression is a risk factor for melanoma) ? Pt – No.

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Dr: Have gone on holidays and exposed your skin to sun? Pt: Yes/No

Factor V Leiden thrombophilia is an inherited disorder of blood clotting. Factor V Leiden is the
name of a specific mutation (genetic alteration) that results in thrombophilia, or an increased
tendency to form abnormal blood clots in blood vessels. .... Factor V Leiden is the most common
inherited form of thrombophilia.

Dr: Have you used sunbeds for skin tanning? Pt: Yes/No

Dr – Any of your family members had any such problems (family history is a high risk
factor for melanoma)? Pt –No.

Dr- What do you do for a living?

Dr - I need to examine you to see exactly what it is?

Pt – OK. Doctor. I have a picture. [patient may show different types of pictures to
different candidates]

Dr- It looks like a growth in the skin. It looks more like a non cancerous type of growth
what we call as Mole or it could be another condition called as Papilloma. Moles are due
exposure of skin to the sun.

I also need to examine your neck and armpit for any swellings ( lymphadenopathy). Pt –
what will happen now?

Dr – This type of growth does not need to be removed for medical reasons.

However if you want it to be removed we can remove that. Pt: What will happen if I don’t
remove it?

Dr: Most of the time it can remain like that for the whole life without causing any
problem. However if it is mole it can rarely turn into cancerous type what we call
Melanoma. If that happens then we need to removeit.

So you need to keep an eye on that to watch for any changes like changes in size,
colour, border, surface or discharge or bleeding – then you need to come back to the
hospital.

Pt: Ok
Treatment options

Dr: We have several treatment options. We can surgically remove it under local
anaesthesia. (We just make the area numb by giving anaesthetic injection to the site).

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We will then stitch it up.We have other options like what we call as shave removal with a
blade.

Other ways to remove it is by freezing with liquid nitrogen. This is like a spray. It does
not require any anaesthesia. The swelling will fall off after a few days.

It can also be removed by Laser. This treatment uses intense bursts of light radiation to
break down the abnormal cells in the skin. This method usually takes two or three
treatments to remove the swelling completely.

Can I remove this at home?

Some people do it on their own. But it is better if we do that to make sure everything is
fine.

Pt – how long is the procedure?

Dr- 10 –15minutes.Pt – will it leave a scar?

Dr – We have expert doctors to do the operation. There will be small thin scar may not
be noticeable.

Pt – Will it come back?

Dr- Unfortunately sometimes they can come back. Any other concerns? Dr: Are you
happy to go ahead with the procedure? Pt: Yes.

Dr - OK. I will talk to my seniors and we will arrange further tests and the date for the
procedure. Also please take care of your skin.

You can go out in the sun; however, it is advised to wear proper sun protection like hats,
protective clothing, sun creams to prevent moles from forming in the future and to
prevent removed moles from returning.

If you develop any swellings like this, please come to us immediately. Good luck with
your wedding.

SKIN LESION

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Squamous cell carcinoma of the skin

Squamous cell carcinoma of the skin is a common form of skin cancer.

usually not life-threatening, though it can be aggressive in some cases. Untreated,

squamous cell carcinoma of the skin can grow large or spread to other parts of your
body, causing serious complications.

Most squamous cell carcinomas of the skin result from prolonged exposure to ultraviolet
(UV) radiation, either from sunlight or from tanning beds or lamps. Avoiding UV light
helps reduce your risk of squamous cell carcinoma of the skin and other forms of skin
cancer.

Symptoms

Squamous cell carcinoma of the skin most often occurs on sun-exposed skin, such as
your scalp, the backs of your hands, your ears or your lips. But squamous cell
carcinoma of the skin can occur anywhere on your body, including inside your mouth,
on your anus and on your genitals.

Signs and symptoms of squamous cell carcinoma of the skin include:

" A firm, red nodule

" A flat sore with a scaly crust
" A new sore or raised area on an old scar or ulcer
" A rough, scaly patch on your lip that may evolve to an open sore
" A red sore or rough patch inside your mouth
" A red, raised patch or wart-like sore on or in the anus or on your genitals

Causes

1. Ultraviolet light and other potential causes

2. Much of the damage to DNA in skin cells results from ultraviolet (UV) radiation
found in sunlight and in commercial tanning lamps and tanning beds.
3. But sun exposure doesn't explain skin cancers that develop on skin not ordinarily
exposed to sunlight. This indicates that other factors may contribute to your risk
of skin cancer, such as being exposed to toxic substances or having a condition
that weakens your immune system.

Risk factors

Factors that may increase your risk of squamous cell carcinoma of the skin include:

1. Fair skin. Anyone, regardless of skin color, can get squamous cell carcinoma of

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the skin. However, having less pigment (melanin) in your skin provides less
protection from damaging UV radiation.

2. If you have blond or red hair and light-colored eyes and you freckle or sunburn
easily, you're much more likely to develop skin cancer than is a person with
darker skin.

3. Excessive sun exposure. Being exposed to UV light from the sun increases your
risk of squamous cell carcinoma of the skin. Spending lots of time in the sun —
particularly if you don't cover your skin with clothing or sunblock — increases
your risk of squamous cell carcinoma of the skin even more.
4. Use of tanning beds. People who use indoor tanning beds have an increased risk
of squamous cell carcinoma of the skin.
5. A history of sunburns. Having had one or more blistering sunburns as a child or
teenager increases your risk of developing squamous cell carcinoma of the skin
as an adult. Sunburns in adulthood also are a risk factor.
6. A personal history of precancerous skin lesions. Having a precancerous skin
lesion, such as actinic keratosis or Bowen's disease, increases your risk of
squamous cell carcinoma of the skin.
7. A personal history of skin cancer. If you've had squamous cell carcinoma of the
skin once, you're much more likely to develop it again.
8. Weakened immune system. People with weakened immune systems have an
increased risk of skin cancer. This includes people who have leukemia or
lymphoma and those who take medications that suppress the immune system,
such as those who have undergone organ transplants.
9. Rare genetic disorder. People with xeroderma pigmentosum, which causes an
extreme sensitivity to sunlight, have a greatly increased risk of developing skin
cancer.

Complications

1. Untreated squamous cell carcinoma of the skin can destroy nearby healthy
tissue, spread to the lymph nodes or other organs, and may be fatal, although
this is uncommon.
2. The risk of aggressive squamous cell carcinoma of the skin may be increased in
cases where the cancer:
3. Is particularly large or deep
4. Involves the mucous membranes, such as the lips
5. Occurs in a person with a weakened immune system, such as someone who
takes anti-rejection medications after an organ transplant or someone who has
chronic leukemia

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Prevention

Most squamous cell carcinomas of the skin can be prevented. To protect yourself:
1. Avoid the sun during the middle of the day. For many people in North America,
the sun's rays are strongest between about 10 a.m. and 4 p.m. Schedule outdoor
activities for other times of the day, even during winter or when the sky is cloudy.
2. Wear sunscreen year-round. Use a broad-spectrum sunscreen with an SPF of at
least 15. Apply sunscreen generously, and reapply every two hours — or more
often if you're swimming or perspiring. Use a generous amount of sunscreen on
all exposed skin, including your lips, the tips of your ears, and the backs of your
hands and neck.
3. Wear protective clothing. Cover your skin with dark, tightly woven clothing that
covers your arms and legs, and a broad-brimmed hat, which provides more
protection than does a baseball cap or visor.
4. Some companies also sell protective clothing. A dermatologist can recommend
an appropriate brand. Don't forget sunglasses. Look for those that block both
types of UV radiation — UVA and UVB rays.
5. Avoid tanning beds. Tanning beds emit UV rays and can increase your risk of
skin cancer.
6. Check your skin regularly and report changes to your doctor. Examine your skin
often for new skin growths or changes in existing moles, freckles, bumps and
birthmarks. With the help of mirrors, check your face, neck, ears and scalp.
7. Examine your chest and trunk and the tops and undersides of your arms and
hands. Examine both the front and back of your legs and your feet, including the
soles and the spaces between your toes. Also check your genital area and
between your buttocks.

Diagnosis

Tests and procedures used to diagnose squamous cell carcinoma of the skin include:

" Physical exam. Your doctor will ask questions about your health history and
examine your skin to look for signs of squamous cell carcinoma of the skin.
" Removing a sample of tissue for testing. To confirm a squamous cell carcinoma
of the skin diagnosis, your doctor will use a tool to cut away some or all of the
suspicious skin lesion (biopsy). What type of skin biopsy you undergo depends
on your particular situation. The tissue is sent to a laboratory for examination.

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Treatment
Most squamous cell carcinomas of the skin can be completely removed with relatively
minor surgery or occasionally with a topical medication. Which squamous cell
carcinoma of the skin treatments are best for you depends on the size, location and
aggressiveness of the tumor, as well as your own preferences.

Treatments may include:

1. Electrodesiccation and curettage (ED and C). ED and C treatment involves

removing the surface of the skin cancer with a scraping instrument (curet) and
then searing the base of the cancer with an electric needle. This treatment is
often used for very small squamous cell cancers of the skin.
2. Curettage and cryotherapy. Similar to the ED and C procedure, after the tumor
removal and curettage, the base and edges of the biopsy site are treated with
liquid nitrogen.
3. Laser therapy. An intense beam of light vaporizes growths, usually with little
damage to surrounding tissue and with a reduced risk of bleeding, swelling and
scarring. Laser treatment may be an option for very superficial skin lesions.
4. Freezing. This treatment involves freezing cancer cells with liquid nitrogen
(cryosurgery). It may be an option for treating superficial skin lesions.
5. Photodynamic therapy. Photodynamic therapy combines photosensitizing drugs
and light to treat superficial skin cancers. During photodynamic therapy, a liquid
drug that makes the cancer cells sensitive to light is applied to the skin. Later, a
light that destroys the skin cancer cells is shone on the area.
6. Medicated creams or lotions. For very superficial cancers, you may apply creams
or lotions containing anticancer medications directly to your skin.
7. Simple excision. In this procedure, your doctor cuts out the cancerous tissue and
a surrounding margin of healthy skin. Your doctor may recommend removing
additional normal skin around the tumor in some cases (wide excision). To
minimize scarring, especially on your face, consult a doctor skilled in skin
reconstruction.
8. Mohs surgery. During Mohs surgery, your doctor removes the cancer layer by
layer, examining each layer under the microscope until no abnormal cells remain.
This allows the surgeon to be certain the entire growth is removed and avoid
taking an excessive amount of surrounding healthy skin.
9. Radiation therapy. Radiation therapy uses high-energy beams, such as X-rays, to
kill cancer cells. This may be an option for treating deeper tumors, those that
have a risk of returning after surgery and tumors in people who can't undergo
surgery.

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76. 63 year old man presented with skin lesion in his head. Take history and
discuss the further management with the patient.

Dr: Hello Mr… I am Dr…. How can I help you Mr…

Pt: Doctor I am having this swelling in my head. My wife noticed it first and she told me
to come here.

Dr: Since how long have you had this swelling ?

Pt: It has been there for about four weeks now doctor.
Dr: Is it the same since it started or have notice any change in that.

Pt: It is becoming a little bigger in the last one week.

Dr: Any other changes have you noticed ?

Pt: Yes doctor it is little bit bleeding also since last one week.

Dr: Is there discharge from that? Pt: No

Dr: What is the colour of that ?Pt: Pink/ Brown/ Dark

Dr: Is there any change in the colour ?Pt: No

Dr: Is it painful? Pt: No

Dr: Any itching? Pt: No

Dr: Do you have any other swelling anywhere else? Pt: No

Dr: Any swellings on your neck area ( lymphadenopathy)Pt: No

Dr: Have you exposed yourself to the sun too much/for long periods of time ? Pt: Doctor
I lived in Australia for 10 years and China for 3 years. Dr: When was that? Pt: …

Dr: Were you using sun protection/hats to cover your head during those times? Pt: No

Dr: Have you used tanning beds? Pt: No

Dr: Did you have similar problems before ?Pt: No

Dr: Do you have any medical conditions at all? Pt: No

Dr: Are you on any medications ?Pt: No

Dr: Do you smoke ? (If yes- what do you smoke, How much, How long)Pt: Yes/ No

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Dr: Any of your family members has any such swellings ?Pt: No

Dr: Is there anything else you think is important we need to know about? Pt: No

Examination:

Dr: Mr…. I need to examine that and see how it looks like. Also I need to check whether
you have any swellings around your neck.

Pt: Doctor this how it looks like (he will show a picture).

It could also be a picture of melanoma or a basal carcinoma in the pinna.

Diagnosis:

Dr: Thank you for that. Do you have any idea what it could be ? Pt: No Doctor.

Dr: I’m afraid it could be a serious condition. Do you want to know about it? Pt: Yes
doctor please tell me.

Dr: I am very sorry to say this could be a type of skin cancer what we call as Squamous
cell carcinoma. Pt: Cancer!!! Ohh..really doctor!!

Dr: I am afraid it does look like that. However, we need to do some tests to confirm that.

Investigation:

We need to refer you to a dermatologist who will take some tissue sample from that
and send it to the lab to test it. Is that OK?

Treatment:

Pt: Ok doctor. How will you treat that doctor?

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Dr: We need to confirm what type of growth is to decide what type of treatment we can
offer. If it is squamous cell carcinoma, as I mentioned before, depending on how much it
has grown or whether it has spread to any other area, then we can decide the type of
treatment. Usually, we will be able to do some surgery and remove the whole growth
and test the removed growth in the lab to check whether the cancer cells have been
removed.

However, if it has spread, then we may not be able to remove it completely in that case
we may have to treat it with some medications or Radiation therapy.

Pt: Is it dangerous doctor?

Dr: Mr… Though this is a cancer usually they do not spread so it is usually treatable.
Very rarely only it can spread to the other areas and then it can be dangerous or life
threatening.

Pt: OK

Dr: Any other concerns? Pt: No doctor. You have been very helpful

Warning signs:

Dr: However Mr… You need to be careful in the future. You should avoid too much
exposure of your skin to the sun. You can wear sun creams or wear proper protection
clothes, wear broad brimmed hat to prevent exposure to sun. If you develop any
swellings again you should inform the doctor immediately. Pt: Ok.

Dr: Thank you very much Mr… I hope everything will be fine soon.

SKIN LESION - SQUAMOUS CELL CARCINOMA

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77. A 30 years old male has come to OPD clinic. You are a FY2 doctor in the
clinic. Talk to him and address his concerns.

Hello Mr. -----------,I am Dr ---------- , one of the junior doctors in the clinic.

Dr: How can I help you today?

Pt: I have this rash on my forearm. I thought I will get it checked today.

Dr: Can you please describe this rash for me?

Pt: Yes, But what would you like to know?

Dr: Since when do you have this rash? Pt: few weeks.

Dr: Where exactly do you have this rash? Pt: Right forearm.

Dr: Which color is it? Pt: it is red in color.

Dr: How is this rash bothering you? Pt: it is very itchy and it is getting slightly bigger now.

Dr: Any Bleeding or Discharge? Pt-No

Dr: Have you shown it to any doctor so far? Pt- No.

Dr: ok, and have you tried anything which may have helped with this rash? Pt: No.

Dr: Do you know how it started? Pt: I do not know.

Dr: Any pain at site of rash? Pt: No.

Dr: Did you have any such rash before? Pt-No. (Allergies, Psoriasis)

Dr: Do you have anything else along with this rash? Pt: Like what ?

Dr: Do you have Fever? Pt: no (meningitis, infections, abscess)

Dr: Have you noticed any rash or swelling elsewhere in the body? Pt : No

Dr: Have you noticed ant weight loss ? Pt- No.( Cancer )

Dr: Did you hit your forearm anywhere ? Pt- No.(Trauma) Dr: Did you have an insect bite ?

Pt: No.

Dr: Any pain in your joints? Pt- No. (sarcoidosis, Psoriasis)

Dr: Any bowel problems? Pt: no (I.B.D)

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Dr: Do you have any medical conditions? No

Dr: Diabetes? No

Dr: Any surgery before? No

Dr: Any medications? Pt – No.( Immunosuppressant )

Dr: Are you allergic to anything? Pt- No

Dr: Any of your family members or friends had any such problems?(contact) Pt –No.

Dr: What do you do for living?

Dr: Do you smoke? Pt- No.

Dr: Any recreational drugs? No

Dr: Do you practice safe sex? Pt: Yes

Dr: Is there anything else that you would like to tell us? Pt: No.

Dr- I need to examine you to see what exactly it is?

Pt : Sure Doctor. This is how it looks like. (Pt. Shows picture)

Dr: It looks like a ringworm Infection. It is caused by fungal types of bugs. But we would
like to run some tests to confirm this. We may have to take few swabs and scrapings
from the area of rash for this purpose…..What do you think? Pt: That’s alright.

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Dr: Do you have any questions?

Pt: How did I get this?

Dr: It is a contagious disease. It usually spreads through close contact with an infected
person or animal and infected objects such as bed sheets, combs or towels. Sometimes
it can also spread by coming in contact with infected soil.

Pt: Dr. I have a wife who is pregnant, will it affect her?

Dr: Unfortunately, as it spreads through contact, there is a possibility. But we can

minimize the chances by starting treatment as soon as possible. There are few other
things which you can do to minimize its spread like wash towels and bed sheets
regularly, keep your skin clean and wash your hands after touching animals or soil.
Regularly check your skin if you have been in contact with an infected person or animal.

Dr: Do you have any other concerns?

Pt: How can you treat this?

Dr: Treatment involves antifungal medications.

If you would like I can arrange an appointment with dermatologist. He may prescribe
you anti-fungal medicines. This might be a cream, gel or spray. If required he may
prescribe you some tablets as well.

You usually need to use antifungal medicine every day for 2 weeks. It's important to
finish the whole course, even if your symptoms go away.

We can offer you some anti -allergic medicines to control this itching because it is
important that you don’t scratch a ringworm rash as this could spread it to other parts of
your body.

Thank you.
SKIN LESION - FUNGAL INFECTION

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78. Young male made urgent appointment with GP, he is embarrassed and you
must insist he share the details with you.

The diagnosis of genital warts is a higher possibility than molluscum contagious in this
case.

Offer confidentiality

Has some skin lesions on the genital area.

- First episode, no fever, no discharge

- Pain?

- No burning micturition, no lumps anywhere else, no lumps in the anal region, no

weight loss, no IV drug abuse, lives alone, no medical history or surgical history.

- Never tested for HIV/STI in the past.

- Sexual history positive for unprotected sex with multiple partners, both male and female.

- Travelled to Thailand about 2 months back, had unprotected sex there and the
swellings presented.

- Ask of eye pain, mouth ulcers,

Examination: Again, convince the pt as he is embarrassed to show. Picture given with

several bumps on the genital area, no scrotal swelling, back passage clear?

Manage: No sex until bumps clear, don’t shave or share clothing and towels?? Tested
for STIs like syphilis and HIV.

What are warts? 1 or more painless growths or lumps around the genital area caused
by HPV and can develop again later on in life, may cause itching or bleeding from
genitals or anus. Change the flow of urine (towards the side) permanently (won’t go
away after lumps have been treated)

The type of treatment: It may even heal on its own with time as it is viral. Or a cream
or liquid is applied directly to warts few times a week for several weeks, but some cases
may need to go to the clinic every week for a doctor or nurse to apply it (these
treatments can cause soreness, irritation or a burning sensation).

Surgery: a doctor or nurse can cut, burn or laser the warts off – this can cause irritation
or scarring.

Freezing: a doctor or nurse freezes the warts, usually every week for 4 weeks – this

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can cause soreness.

Do’s and don’t’s: Avoid perfumed lotions and soaps while receiving treatment, avoid
unprotected sex. (not spread via towels, toilets or sharing cups)

Can spread from skin to skin contact (vaginal and anal sex) and may spread from
mother to baby at birth (rare)

Genital warts are not cancer and do not cause cancer. HPV vaccine can help protect
against genital warts.

SKIN LESION (GENITAL WARTS OR ?

MOLLUSCUM CONTAGIOSUM)

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79. You are FY2 in GP Clinic. A 24 years old lady came with the concern of
rashes in her lower lip. Take history and address her concern.

(She will show a picture if you start asking question about her lesion)

GRIPS plus rapport

Take history:

Where exactly? Pt: lower lip

How many rashes/lesions?

For how long? Pt: 2 weeks

Is it the first time? Pt: Yes/no

Is it itchy? Pt: Yes sometimes

Any discharge? Pt: no

Any pain? Pt: No

Any bleeding from the rash? Pt: No

Any other rashes/lesions in other part of the body? Pt: No

Any weight loss? Pt: No

Any lumps/bumps in the body? Pt: No (Malignancy)

Take sexual history:

Pt said she is not sexually active. Then ask was she sexually active before?

If sexually active, take safe sex history.

Then ask about kissing history?

MAFTOSA

Pt is allergic to penicillin

Take travel history? Sun exposure history?

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Provisional diagnosis: Cold sores/Herpes Labialis

Cold sores are common and usually clear up on their own within 10 days. But there are
things you can do to help ease the pain.A cold sore usually starts with a tingling, itching
or burning feeling.

How long cold sores are contagious

Cold sores are contagious from the moment you first feel tingling or other signs of a cold
sore coming on to when the cold sore has completely healed.

Things you can do yourself

Cold sores take time to heal and they're very contagious, especially when the blisters
burst.
Do not kiss babies if you have a cold sore. It can lead to neonatal herpes, which is very
dangerous to newborn babies.
DO:

 eat cool, soft foods

 use an antiseptic mouthwash if it hurts to brush your teeth

 wash your hands with soap and water before and after applying

cream avoid anything that triggers your cold sores

 use sunblock lip balm (SPF 15 or above) if sunshine is the trigger

 take paracetamol or ibuprofen to ease pain and swelling (liquid paracetamol is

available for children) – do not give aspirin to children under 16

 drink plenty of fluids to avoid dehydration

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 wash your hands with soap and water before and after applying cream

DON’T

 do not eat acidic or salty food

 do not touch your cold sore (apart from applying

cream) do not rub cream into the cold sore – dab it

on instead do not kiss anyone while you have a

cold sore

 do not share anything that comes into contact with a cold sore (such as cold
sore creams, cutlery or lipstick)

 do not have oral sex until your cold sore completely heals – the cold sore virus
also causes genital herpes

Treatment from a GP

The GP may prescribe antiviral tabletsif your cold sores are very large, painful or keep
coming back. Newborn babies, pregnant women and people with a weakened immune
system may be referred to hospital for advice or treatment.

Why cold sores come back

Cold sores are caused by a virus called herpes simplex.Once you have the virus, it
stays in your skin for the rest of your life. Sometimes it causes a cold sore.Most people
are exposed to the virus when they're young after close contact with someone who has
a cold sore.It doesn't usually cause any symptoms until you're older. You won't know if
it's in your skin unless you get a cold sore.

NICE GUIDELINES:

When should I refer?

Consider admission to hospital if the person:

Is unable to swallow due to pain and is at risk of dehydration (especially in children).

Is immunocompromised with severe oral herpes simplex infection - they may need
intravenous antiviral drug treatment.

Has a suspected serious complication of oral herpes simplex infection - they may need
intravenous antiviral drug treatment.

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Arrange a suspected cancer pathway referral (for an appointment within 2 weeks) if

there are any red flags suggesting oral cancer.

Consider seeking specialist advice or referral to a specialist in infectious diseases or

oral medicine, depending on clinical judgement, if the person:

Is immunocompromised and has troublesome recurrent oral herpes simplex infection -

prophylactic oral antiviral treatment may be needed.

Is pregnant (particularly near term) She should be advised that the risk of infecting her
new baby by kissing are greatest when a woman acquires a new infection (new cold
sore infection) in the third trimester, particularly within 6 weeks of delivery, as viral
shedding may persist in the saliva and the baby is likely to be born before the
development of protective maternal antibodies.

Has frequent (for example, 6 or more episodes in one year), persistent and/or severe
episodes of recurrent oral herpes simplex infection - prophylactic oral antiviral treatment
may be needed.

Has herpes simplex associated with recurrent erythema multiforme - prophylactic oral
antiviral treatment may be needed.

Has lesions which are refractory to oral antiviral treatment in primary care (if clinically
indicated) after 5–7 days.

Has atypical lesions or the diagnosis is uncertain.

COLD SORES/HERPES LABIALIS

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80. ISOTRETINOIN
Pregnancy prevention is essential with oral isotretinoin use. Effective
contraception must be used.

• In women of child-bearing potential, exclude pregnancy up to 3 days

before treatment (start treatment on day 2 or 3 of the menstrual cycle),
every month during treatment (unless there are compelling reasons to
indicate that there is no risk of pregnancy), and 5 weeks after stopping
treatment—perform pregnancy test in the first 3 days of the menstrual
cycle. Women must practise effective contraception for at least 1 month
before starting treatment, during treatment, and for at least 1 month after
stopping treatment.

• Women should be advised to use at least 1 method of contraception, but

ideally they should use 2 methods of contraception. Oral progestogen-
only contraceptives are not considered effective. Barrier methods should
not be used alone, but can be used in conjunction with other
contraceptive methods. Each prescription for isotretinoin should be
limited to a supply of up to 30 days’ treatment and dispensed within 7
days of the date stated on the prescription; repeat prescriptions or faxed
prescriptions are not acceptable. Women should be advised to
discontinue treatment and to seek prompt medical attention if they
become pregnant during treatment or within 1 month of stopping
treatment.

With topical use

Females of child-bearing age must use effective contraception (oral progestogen-only

contraceptives not considered effective).

Monitoring of patient parameters

With oral use: Measure hepatic function and serum lipids before treatment, 1 month
after starting and then every 3 months (reduce dose or discontinue if transaminase or
serum lipids persistently raised).

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80.24 year old female came to the G.P clinic. She is having acne and wants
Isotretinoin medications for it.

(NOTE: Instructions paper is given in the cubicle. In the paper, it is written as

Topical Retinoid - For Mild to moderate acne treatment AND Oral retinoids for
severe acne. Start as early as possible.)

GRIPS

Pt: Dr I want Isotretinoin acid to treat my acne.

Dr. : May I know why do you specifically ask for it ?

Pt: Because my friend is having some problem and she got treated with this medication.

Dr: Ok let me ask a few questions about it. Can you please tell me more about your acne?

Pt: I am having Acne since a very long time but it has increased recently since past
couple of weeks.

Dr: I am sorry to hear that.

ODIPARA: were you alright before that/ anything makes it better or worse/ have you
tried any treatment for it earlier.

Dr: Does it bleed ? ….. NO

Dr: Is there any itching on that area? .... Yes/NO

Dr: Any pus or discharge coming out of it ? ... NO

Dr: Do you have any fever ? …. No

Dr: Are they painful ? ..... Yes / No

Dr: Were you bit by any insect by any chance ? … No

Dr: When was your LMP? days back.

Dr: any problem with the periods ?

Dr: By any chance are you pregnant (contraindication)? No

Dr: Are you planning to become pregnant (contraindication)? No

Dr : Are you breastfeeding ? Pt : No

Dr: Do you have high cholesterol, liver or kidney problem (contraindications) - No

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Do you have any medical condition called polycystic ovarian syndrome? No

(PCOS patients can get severe acne)

Do you have any abnormal hair growth in face ? Any weight gain ? (PCOS)

Dr: What is your job? May I know why you want this medication? I am a TV actress.

Ask about mood (depression) (mental health): reported high risk of sucide.

MAFTOSA ….

Any allergies (important question )… .. No positive history

Did you tried anything for treatment? Ask why do you want isoretinoni? The patient may say
my friend tried it and she benifited from it.

Dr: Anything else you would like to tell me about your condition?
Dr: No Doctor

Thank you very much for giving me all the valuable information. Now I would like to
examine you. I will be examining your skin. This involves examining your face, chest
and back. Will that be ok with you?

O/E: Patient shows a picture of a forehead with – red acne spots on it.

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Management:

Well, so far from the history you gave me and after examining you I think you are having acne.

We will refer you to our skin specialist - Dermatologist who will start you on Isotretinoin
gel (Retinoids). [Topical if mild – if picture shows only 2 to 3 acne]. (Oral if severe)

Common side effects of retinoids are:

- A brief sensation of warmth or stinging immediately after applying, peeling,

excessive dry skin, burning
- This medicine can cause severe abnormalities in the baby. You should never
become pregnant while on this medication. You should use double contraception
to prevent pregnancy. (Progesterone only pill is not effective). You should not
become pregnant for at least one month after stopping the treatment.
- Also you should not breastfeed while on this treatment.
- This can cause liver and kidney damage but we will keep monitoring them.
- Can cause severe depression and suicidal thoughts

It will take some time for the medications to act so you will start noticing changes so
please don’t stop the treatment until advised for.

There are certain things that you can do to avoid acne in the future :

1. Don't wash affected areas of skin more than twice a day. Frequent washing can
irritate the skin and make symptoms worse.
2. Wash the affected area with a mild soap or cleanser and lukewarm water. Very
hot or cold water can make acne worse.
3. Don't try to "clean out" blackheads or squeeze spots. This can make them worse
and cause permanent scarring.
4. Avoid using too much make-up and cosmetics. Use water-based products that
are described as non-comedogenic (this means the product is less likely to block
the pores in your skin).
5. Completely remove make-up before going to bed.
6. If dry skin is a problem, use a fragrance-free, water-based emollient.
7. Regular exercise can't improve your acne, but it can boost your mood and
improve your self-esteem. Shower as soon as possible once you finish
exercising, as sweat can irritate your acne.
8. Wash your hair regularly and try to avoid letting your hair fall across your face.

Dr: Do you have any concerns ? Pt: No Doctor. Thank you

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81. A lady comes with the Hx of reduced hearing in the left ear for few days
and wants you to remove the wax.

When asked why she feels there is wax, she says that her friend said that the pain is
usually due to wax.

Tell her that she might be right and then do an ODIPARA

Enquire of pain in the ear.

No Hx of fever/balance problems /tinnitus/vertigo

Ask her if she tried to remove the wax herself with earbuds

She gives a history of travel to Spain the previous week, a history of swimming/deep
sea diving and also a history of use of ear buds. History of mild pain.

Find out how long she was in Spain for and if the hearing loss occurred before her
departure from the UK.

There was no manikin for examination.

The examiner shows a picture. There was congestion with some white area. Not sure if
it was congested ear canal with pus discharge/congested tympanic membrane with
perforation or discharge.

Examiner gives findings - Weber’s lateralized to the same ear -> conductive hearing
loss in the left ear.

Diagnoses: Barotrauma

Barotrauma of the ear occurs when the eardrum becomes stretched and tense. It
causes ear pain and dulled hearing. It is due to unequal pressures that develop on
either side of the eardrum. This most commonly occurs when descending to land in a
plane and is also experienced by scuba divers.

Inform her that it is not wax.

Treatment
Most cases of ear barotrauma generally heal without medical intervention. There are
some self-care steps you can take for immediate relief. You may help relieve the effects
of air pressure on your ears by:

" yawning
" chewing gum

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" practicing breathing exercises

" taking antihistamines or decongestants

In severe cases, prescribe an antibiotic or a steroid to help in cases of infection or

inflammation.

In some cases, ear barotrauma results in a ruptured eardrum. A ruptured eardrum can
take up to two months to heal. Symptoms that don’t respond to self-care may require
surgery to prevent permanent damage to the eardrum.

Surgery

In severe or chronic cases of barotrauma, surgery may be the best option for treatment.
Chronic cases of ear barotrauma may be aided with the help of ear tubes. These small
cylinders are placed through the eardrum to stimulate airflow into the middle of the ear.
Ear tubes, also known as tympanostomy tubes or grommets, are most commonly used
in children and they can help prevent infections from ear barotrauma. These are also
commonly used in those with chronic barotrauma who frequently change altitudes, like
those who need to fly or travel often. The ear tube will typically remain in place for six to
12 months.

Audiometry may be requested.

The second surgical option involves a tiny slit being made into the eardrum to allow
pressure to equalise. This can also remove any fluid that’s present in the middle ear.
The slit will heal quickly, and may not be a permanent solution.

Ear pain can be severe but in most cases no serious damage is done to the ear.
Occasionally, the eardrum will tear (perforate). However, if this occurs, the eardrum is
likely to heal by itself, without any treatment, within several weeks

How to prevent ear pain when flying?

Ideally, anyone with a cold, respiratory infection, ear infection, etc, should not fly.
However, not many people will cancel their holiday trips for this reason. The following
may help people who develop ear pain when flying:

- Suck sweets when the plane begins to descend. Air is more likely to flow up the
Eustachian tube if you swallow, yawn or chew. For babies, it is a good idea to feed them
or give them a drink at the time of descent to encourage them to swallow.

- Try doing the following: take a breath in. Then, try to breathe out gently with your
mouth closed and pinching your nose (the Valsalva manoeuvre). In this way, no air is
blown out but you are gently pushing air into the Eustachian tube. If you do this you may

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feel your ears go 'pop' as air is pushed into the middle ear. This often cures the problem.
Repeat this every few minutes until landing - whenever you feel any discomfort in the
ear.

- Do not sleep when the plane is descending to land. (Ask the air steward to wake
you when the plane starts to descend.) If you are awake you can make sure that you
suck and swallow to encourage air to get into the middle ear.

The above usually works for most people. However, if you are particularly prone to
develop 'aeroplane ear', you may wish to also consider the following in addition to the
tips above:

- A decongestant nasal spray can dry up the mucus in the nose. For example, one
containing xylometazoline - available at pharmacies. Spray the nose about one hour
before the expected time of descent. Spray again five minutes later. Then spray every
20 minutes until landing. Decongestants are not suitable for young children.

- Air pressure-regulating ear plugs. These are cheap, reusable ear plugs that are often
sold at airports and in many pharmacies. These ear plugs may help slow the rate of air
pressure change on the eardrum. It is not yet known how effective they are but some
people find them helpful.

Give antibiotic ear drops if the diagnosis is otitis externa. This may be the diagnosis
during the exam.

Diagnosing ear barotrauma

While ear barotrauma may go away on its own, you should contact a doctor if your
symptoms include significant pain or bleeding from the ear. A medical exam may be
required to rule out an ear infection.

Many times, ear barotrauma can be detected through a physical exam. A close look
inside the ear with an otoscope can often reveal changes in the eardrum. Due to
pressure change, the eardrum may be pushed slightly outward or inward from where it
should normally sit. Your doctor may also squeeze air (insufflation) into the ear to see if
there is fluid or blood build up behind the eardrum. If there are no significant findings on
physical exam, often the situations you report that surround your symptoms will give
clues toward the correct diagnosis.

EAR PAIN ?BAROTRAUMA

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FEMALE HEALTH

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82. 28 year lady Mrs... (P 0+2) presented to the antenatal care unit. Nurse has
checked BP and tested urine for infection and protein which are normal.

She has just registered for the first time for antenatal care.

Do the initial antenatal assessment and address here concerns.

Hello Mrs..... I am Dr... How are you doing? Pt: I am fine.

Dr: how can I help you Mrs. Pt: Doctor, I am pregnant.

Dr: Is this a planned pregnancy? Pt - Yes

Dr: Congratulations. May I know how many weeks pregnant are you? Pt - 6 weeks

Dr: Do you know what we do here in the antenatal care unit? Pt – No

Dr: would you like me to explain ti to you

Dr: Don’t worry, let me explain. First of all I am very glad that you have come here. We
assess pregnant ladies to see if they have any health or other issues which can affect
the pregnancy and the baby and manage them so that they that they will not have
problems during pregnancy and ultimately have a healthy baby. We also educate
parents about how to cope with pregnancy and delivery and address any concerns they
might have. We have Obstetrics doctors, midwife and the whole team to help you to
go through this process. Do you follow me? Pt - Yes, doctor.
Dr: I need to ask few questions about your health and other things. Before that do you
have any concerns which you like to ask me?

Pt: Doctor, I was pregnant twice before and I had miscarriage.

Dr: I am very sorry to hear that. Can I know when this happened ?

Pt : One miscarriage was about 3 years and the other one year ago.

Dr: At what week of pregnancy you had these miscarriages? Pt - Both were at 8 weeks.

Pt: Did you come for antenatal visits at that time ?

Pt - No / Yes ( If no – May I know why ?)

Dr: Do you know why you had these miscarriages ? Pt - No (? Intentional abortion)

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Dr: Is this the third time you are pregnant then? Pt - Yes

Dr: Do you have any concerns now ?

Pt - Yes doctor. I worried whether the same thing will happen again.
Dr: I can understand your worries. We will try to explain your concerns. Before I
explain about the miscarriage, I need to ask you few questions:

Dr: Do you have any bleeding from the vagina now at all? (r/o- miscarriage now)? No

Dr : Any pain in tummy (ectopic pregnancy)? Pt - No

Dr: Do you have a stable partner? Pt - Yes.

Dr: Is your partner also happy with this pregnancy? Pt - Yes (r/o abuse)
Dr: Was he the father both times previously when you were pregnant? Yes.

Dr: Do you smoke? Pt - I stopped one year ago.

Dr: Do you drink alcohol? Pt - No

Dr: Do you use any recreational drugs? Pt - No

Dr: Do you drink too much coffee? Pt - No

Sometimes the risk of miscarriage is high in those mothers who smoke, drink alcohol, use
recreational drugs or drink too much coffee.

Anyway, just because you had miscarriage twice before it does not mean you will have the
same problem again. There is a good chance that you will have normal delivery this time.
However, if it happens more than 3 times then we call it recurrent miscarriage and then we
start investigating for the causes of miscarriage. One of the common causes of
miscarriage in early pregnancy is chromosome abnormality in the baby - this means
there is problem in the gene of the baby. If miscarriage happens more than 3 times,
then we check for any gene problems in the parents. Other causes of miscarriage is
development of some antibodies in the mother called antiphospholipid antibody which
causes thickening of the blood.

Again we test for this condition if the miscarriage happens more then 3 times and we give
medications like Aspirin and some heparin injections to thin the blood which helps in normal
delivery.

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Also, we look for other causes like any problem in the mother womb or any infections
which may cause recurrent infections.

So for now please do not worry about the miscarriage. Hopefully you will have normal
delivery. Is that OK? Pt - Yes

Dr: Do you have any other concerns? Pt - No

Dr: I need to ask few questions about your health now. How is your general health now?

Pt - I am fine, now.

Dr: Do you have any other symptoms like fever? Pains any where? Pt - No

Dr: Do you have any medical conditions ? Pt - No

Dr: Like high blood pressure, diabetes, any blood disorders like thalassemia, sickle cell
disease, blood clots or bleeding disorders ? Pt - No

Dr: Did you have any kind of infections before?Pt - No

Dr: Did you have any problems in your womb or ovaries were you told of ? Pt - No

Dr: Did you have any surgeries to your tummy or pelvis before ? Pt - No

Dr: Are you taking any medications ? Pt: No

Dr : Are you taking folic acid? Pt: Yes/No

Dr: Are you allergic to any thing? Pt : No

Dr: Does your partner have any medical conditions? Pt - No

Dr: Do you and your partner get along well with each other? Pt - Yes. (? Abuse)

Dr: Any mental health issues with you, your partner or both of your families? Pt - No

Dr: Any medical conditions running in your family or in your partner’s family? Pt - No

Dr: Anyone else in your or partners family had miscarriages or abnormalities in the
babies or twins ? Pt - No

Dr: Have you planned where you want to deliver – at hospital or home?

Dr: Is there anything else you like to tell me? Pt – No

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Examination

Dr: Mrs.. I will be examining your heart, lungs and tummy to check everything is fine with
you. Our nurse has already checked your blood pressure – that is normal. [if there is NEWS
chart – look at it.] Also, she has tested your urine for infections and some substance called
protein. They are all normal. We will also check your height and weight.
Investigations

We will do some blood tests to check blood group, sugar, infections like rubella
syphilis, hepatitis and HIV? Is that OK? Pt - Yes.

We will do tests to check for abnormalities in the baby like Down’s syndrome. In
addition, we will do an ultrasound scan when you are 10 to 12 week pregnant. Pt: OK

Dr: Any questions so far? Pt - No

Advice

Dr: I advise you to eat a healthy diet. It is good that you stopped smoking. We advise
you not to restart the smoking habit. Also do not drink alcohol use recreational drugs
and drink too much coffee.

We will prescribe some Folic acid tablets for you.

You can join some parent craft classes where they will teach you about coping at home
with pregnancy, labour feeding and caring of baby and other things. I also advise you
to join some exercise classes. Have proper dental check up. Avoid travelling to malaria
prone countries. Is that ok? Pt - Ok Any other questions? Pt - No

Dr: I will talk to my Consultant and arrange the date for your next visit. However if you have
any problems like bleeding or pain abdomen or any other problem, please come back.

Thank you very much.

PARENT CRAFT classes for pregnant women. They cover many topics including:-Signs
of labour· Coping at home in early labour· Pain relief in labour· Normal labour·
Infant feeding workshop· Caring for your newborn baby· Safer sleeping· Tour of the
maternity unit·

[Flight travel is allowed up to 34 weeks in most of the flights]

PREVIOUS MISCARRIAGES Antenatal assessment - lady had miscarriage previously.

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83. PRE-ECLAMPSIA
Preeclampsia is a condition that manifests after 20 weeks of gestation, characterised
by high blood pressure (140/90) and presence of proteinuria.

Severe preeclampsia : BP > 160/110 mmHg recorded over two separate occasions at
least six hours apart.

Red flag signs

1. Headache

2. Puffiness of hands and feet

3. Visual disturbances

4. Vomiting
5. Decreased foetal movements

6. IUGR

Complications

HELLP Syndrome: Haemolysis, Elevated Liver enzymes and Low Platelets

signs of imminent eclampsia

1. Headache

2. Blurring of vision

3. Epigastric pain (liver)

4. Oliguria

5. Eclampsia: Seizures +/- neurological deficits, with features of HELLP, Renal failure

Preeclampsia is an indication for ADMISSION of the patient. The earlier the diagnosis,
the better the outcome for both mother and child.

Who is affected?

Mild pre-eclampsia affects up to 6% of pregnancies, and severe cases develop in

about 1-2% of pregnancies.

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Medical conditions that can contribute to developing preeclampsia

1. Diabetes

2. Hypertension

3. Renal disease

4. Lupus or antiphospholipid syndrome

5. Preeclampsia in a previous pregnancy

Other risk factors:

1. Family history of the condition (mother or sister) Age > 40 years

2. > 10 years between two pregnancies Multiple gestation (twins or triplets) BMI 35 or over
What causes pre-eclampsia?

Although the exact cause of pre-eclampsia isn't known, it's thought to occur when there's
a problem with the placenta (after-birth).

Management: ADMISSION

Investigations - Monitor BP Q2H with serial urinalysis for proteinuria FBC, LFT, RFT,
USG Abdomen/Pelvis CTG

Treatment
Intravenous antihypertensives- Labetalol, Hydralazine or Methyldopa

Contact consultant for MgSO4 prophylaxis. If administered, monitor for side effects
(sluggish deep tendon reflexes, decreased urine output, respiratory depression)

If < 34 weeks, consider steroid prophylaxis for foetal lung maturity in anticipation of
preterm delivery
Only way to cure preeclampsia is to deliver the baby. If patient is diagnosed at 36
weeks, admit UNTIL delivery (normally at 37 – 38 weeks)

At 37 weeks, induce labour artificially. If there are signs of eclampsia or signs of foetal
distress, go for emergency C-section. Avoid oxytocin and/or ergotamines for labour
induction (because of BP).Post-delivery, continue to monitor BP and continue oral
antihypertensives if needed.

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83.Case Scenario: You are F2 in the maternity clinic.

39 year old lady is at her first pregnancy. She has come for her regular ANC follow-
up. On examination, midwife found a BP of 150/100 and protein 3+ in her urine.
Her BP during her first ANC checkup was 110/60.

Take focused history, discuss management and address patient's concerns.

- What is pre-eclampsia?
- Any scans done?
- Find out if this her first pregnancy
- If not, find out about high BP in previous pregnancies?
- Ask if any change in fetal kicks?
After taking the history and counseling her, you should ask if she has any other
concerns

If she doesn't like the hospital, you can tell her she might not be close enough to it if
she develops complications.
Dr: Hello Mrs.. My name is Dr .......I'm one of the junior doctors here in the maternity
clinic.. How are you doing today?

Hello doctor, I'm okay. I came in for a routine check up

Dr: How far along in the pregnancy are you Mrs. .. ? 36 weeks

Dr: That's great Mrs. .. Do you have any concerns that you would like me to address first?

Doctor, the midwife examined me.. And she said that my BP was a little high.. That a
doctor would come in to talk to me about it.

Dr: That's correct Mrs.. I am here to talk to you about that. Would you mind if I asked
you a few questions first?

P: No, doctor. Sure.

Dr: This is your first pregnancy, correct? P: Yes

Dr: Ok. Have you had any issues with this pregnancy? P: No

Dr: Were you told to have a high BP earlier in this pregnancy? P: No

Dr: Have you been following up with the ANC regularly? P: Yes

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Dr: That's very good Mrs..... We do advice regular ANC visits.

Dr: Do you have any headache? P: No

Dr: Any visual disturbances? P: No

Dr: Any pain in your tummy? P: No

Dr: Have you noticed any swelling of your face, hands or your feet? P: Yes my shoes
feel a little tighter

Dr: Any decrease in urine output? P: No

Dr: Are you able to appreciate your baby's kicks? P: Yes

Dr: Have you noticed any change? P: No

Dr: Ok that is very reassuring Mrs... That indicates that your baby is well..

Dr: Were you found to have any medical conditions prior to this pregnancy? HTN? P: No

Dr: Diabetes? P: No

Dr: Are you on any medications? P: No

Dr: Do you have any family history of a similar condition.. High BP during pregnancy?
P: Not that I'm aware of doctor

Dr: Mrs.. I have a few questions about your lifestyle.. Do you smoke? P: No
Dr: Do you consume alcohol? P: No

Dr: Ok Mrs.. The midwife did note that your BP was high.. It was 150/100. Your BP during
your first visit was 110/60. Additionally, your urine analysis showed proteins.

This is a condition called preeclampsia. Do you have any idea what that is Mrs...? P: I
think I've heard of it doctor.. But I don't know what it is.
Dr: Mrs.. Preeclampsia is a condition that manifests after 20 weeks of pregnancy. It is
characterised by high BP and the presence of protein in your urine.

P: Why did this happen, doctor?

Dr: There are many reasons why this can occur Mrs... but usually this is because of some
problem with the placenta.

P: Is it serious?

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Dr: Mrs... at the moment, it does not appear to be serious. But, preeclampsia can be a fairly
serious condition if not managed at the right moment. It can progress to a more life
threatening condition called eclampsia if left untreated, where you could develop fits and
that could be critical for both you and your baby. Are you following me, Mrs...?
P: Yes, doctor
Dr: For this reason Mrs... it is important that we admit you right away. We have to
monitor your BP every two hours and do serial urine tests. We will do a ultrasound
scan of your abdomen to check your baby. We will also do a CTG scan, where we can
make sure that your baby's movements and heartbeat are ok.
Pt: Oh but doctor, I don't know if I can take the time off work.. I am not scheduled for
my maternity leave yet..
Dr: I can understand your concern, Mrs... but as I mentioned, if your BP is not controlled
right away, it could progress to something more severe and that could be dangerous for
your baby. It is important that we admit you right away and manage your situation.

P: How long will I have to be in the hospital, doctor?

Dr: Mrs... in preeclampsia, we usually attempt delivery at around 37 weeks. Since you
are already at 36 weeks, we would keep you in the hospital until that time. We will
control your BP with a medication called Labetalol and consider delivering after 37
weeks.

P: I was very much hoping for a normal delivery.. If possible a water birth?
Dr: Mrs... you have every chance of having a normal delivery. If your BP is controlled
and everything is fine with your baby, we can try and induce a normal delivery.
However if before that, there is a sign of any complication or distress for your baby, we
might have to go ahead with an emergency C-section operation.

As for a water birth, we do not advise that Mrs... It is risky in this condition and we
need to continuously monitor you and your baby.

P: Ok, doctor..

Dr: Do you have any other concerns Mrs...?

P: No, doctor.. Thank you..

Dr: Ok Mrs... I will get all the paperwork in order and have you admitted right away..

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84. You are an FY2 in the GP clinic. 42 year old Mrs… has come to see you. Talk
to her and address her concerns. She is on Lisinopril/Ramipril

Dr: Hello Mrs.. My name is Dr ......I'm one of the junior doctors here. How are you doing
today?

P: Hello doctor, I'm okay. I want to get pregnant

Dr: Well, I can certainly help with the queries you might have regarding that. Could you
tell me a bit about your partner?

Pt : Dr, I got married a year ago. Me and my husband want a baby now. I just want to
know about the things I should be aware of before getting pregnant.

Dr : That’s a great thing you have come to us and we most certainly will help you. How
long have you been trying to get pregnant now?

Pt: (may say a duration or says we haven’t started trying yet)

Dr : Alright. Have you been pregnant before? Pt : No (never wanted a baby before.
Trying for the first time)

Dr : When was your LMP? Pt :…

Dr: Are your periods regular? Painful? Heavy bleeding? Pt : No

Dr : Are you on any form of contraceptives at the moment? Pt :…

Dr : Have you ever been diagnosed with any sexually transmitted illnesses before? Pt : no

Dr : Have you been diagnosed with any medical conditions in the past? Pt : Yes Dr, I
have high BP and I am taking Lisinopril / ramipril for that.

Dr: Thank you for telling me that. Is your BP well controlled? Do you monitor it at home?
Follow ups? Pt : Yes, Dr.

Dr : Any other medications? Over the counter medications? Folic acid? Pt : No

Dr: Family history of Diabetes or high BP (mother or sisters during pregnancy),

Kidney diseases? Pt : No

Patient smokes and drinks socially.

Examination

I’d like to check your vitals : BP, pulse and temperature.

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Examiner : ….

Dr : Ms… thank you for answering my questions. I have to advise you that we should
change your BP tablet before you get pregnant.

Pt: (Pt is shocked) What, doctor! No doctors ever told me that!! Will this harm my baby?

Dr : Please be reassured that we are going to take care of this. I can check in my BNF
once to confirm (doesn't say teratogenic. But ACE inhibitors have an adverse
outcome during pregnancy)

I’m afraid we will have to change you medication to another group called beta blockers if it’s
suitable for you. We may give you other medications depending on what’s suitable for you.
(labetalol, methyl dopa, nifedipine are considered). I will be referring to my seniors and
specialists who could advise you better on that Ms..

Pt : Are you sure that this will harm my baby, Dr?

Dr : We have research stating that these medications could be harmful to the baby, specially
during and after 4 months of pregnancy. We will change it to a safer group of medicines.

Pt: Is there anything else you’d be giving me, Dr?

Dr : Yes we would give you folic acid supplements and other medications. I’d be referring
you to the OBG department. They will run some blood tests and urine tests too.

Pt : Is there anything I should know of?

Dr : It's important that your antenatal team monitors you closely throughout your
pregnancy to make sure your high blood pressure is not affecting the growth of your
baby and that you don't develop a condition called pre-eclampsia. Make sure you go to
all your antenatal appointments. Am I being clear? Pt : Yes, Dr

Dr : Also, during the first half of pregnancy, a woman's blood pressure tends to fall. This
means you may be able to come off your medication for a while. But this should only be
done under your doctor's supervision. Is that alright? Pt : Yes, Dr

Dr : If at all at any point you develop headache, vision problems, swelling of your feet or
tummy pain during your pregnancy, call us or an ambulance immediately. You need
urgent care in such cases.

Pt : Is there something I can do to help this, Dr?

Dr : Keeping active and doing some physical activity each day, such as walking or
swimming, can help keep your blood pressure in the normal range. Eating a balanced

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diet and keeping your salt intake low can help to reduce blood pressure. We will also
refer you to a dietician if the BP is not under control.

I’d advise you to stop smoking. Please avoid alcohol during the course of your
pregnancy.

Dr : Do you have an other concerns? Pt : Yes/No

NICE guidelines for treatment of patient with chronic hypertension in pregnancy How

should I manage a woman with chronic hypertension?

1. Offer advice about: Healthy lifestyle (including work, exercise, and weight) as
recommended for all pregnant women. For more information, see the CKS topic on
Antenatal care - uncomplicated Pregnancy.

2. Restriction of dietary salt intake. For more information, see the CKS topic on
Hypertension - not diabetic.

3. Ensure all women with chronic hypertension are referred for obstetric care at booking
as these women are at high risk of pre-eclampsia.

4. If the woman has secondary hypertension, also consider referring to a specialist in

hypertensive disorders, or to a renal physician, endocrinologist, or specialist in
connective tissue disease as appropriate.

5. While the woman is waiting to see a specialist, if she is taking:

a. An antihypertensive other than an angiotensin-converting enzyme (ACE)

inhibitor or angiotensin-II receptor antagonist (AIIRA), consider continuing the
current medication, but seek specialist advice if there is uncertainty.

b. An ACE inhibitor or AIIRA, stop this immediately and prescribe an alternative

treatment if necessary. Explain that there is an increased risk of adverse fetal outcomes
especially if these drugs are taken during the second and third trimesters of pregnancy.

Advise women who have continued to take ACE inhibitors during the first trimester
that there is no strong evidence that this is associated with increased risk to the
fetus.

If an ACE inhibitor or AIIRA is stopped, first-line treatment is usually labetalol if not

contraindicated. Alternative treatment is with methyldopa or nifedipine, taking into
account the adverse effect profiles for the woman, fetus, and newborn infant.
HYPERTENSION IN PREGNANCY

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85. 23 years old lady presented with abdominal pain. USG has been done and it shows
a dermoid cyst in the right ovary. You consultant has decided to do open ovarian
cystectomy (Pfannenstiel incision). Talk to patient and address her concerns.
Consultant has planned to keep the patient in the hospital for 2 days after the
operation.
Assess knowledge
Dr: How much do you know about your condition? Pt: ......

Dr: Certainly, I am here to discuss the result with you. As you know, that you came with

severe pain and we did TV scan on your tummy. In which we have found that there is a fluid

filled sac on your right ovary (egg producing gland), known as ovarian cyst.

Pt: What is ovarian cyst?

Dr: An ovarian cyst is a fluid filled sac which develops in an ovary. They are very common
and do not usually cause any symptoms. In most cases, they are harmless and usually
disappear without the need for treatment. However, if the cyst is large or causing symptoms,
it may need to be surgically removed.

Pt: What’s going to happen now?

Dr: My consultant has planned for an operation to remove this cyst.

Pt: Why do you have to do an operation, what happens if not removed?

Dr: The sac is a potentially dangerous, if it is not removed now, then it can continue to
grow in that case it might rupture, bleed or twist on itself creating a situation in which we
will have to remove it by an emergency operation. Since you are here now, we can plan
ahead to avoid that situation.

Pt: What will you do?

Dr: My consultant has decided to do an operation called laparotomy in which an

incision will be given on the bikini line (Pfannenstiel incision: also called “bikini line
incision”). This is an open operation means we have to open the tummy through this
bikini line incision and then remove the cyst.

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Sometimes, in case of larger cyst, my consultant/the surgeon might decide to remove the
whole ovary.

Pt: How long will the surgery be?

Dr: 45 minutes to 1 hour.

Pt: How big will the scar be? Will it not look bad when I wear bikini?

Dr: Incision will be about 8 inches long. However, the scar will be very thin and it will
not be visible even if you wear a bikini because it will be covered by the bikini.

Pt: When can I go back home?

Dr: It depends on your operation and recovery. We are hoping that you will be able to
go home in about 2 days if everything goes well.

Pt: Is it cancerous or benign?

Dr: Most of the ovarian cysts are non-cancerous. However, we will be sending the cyst
once removed to the laboratory to confirm that.

Pt: Will I be able to conceive after removal of ovary? / Can I become a mother?

Dr: You have the problem in only one ovary so we will be removing the cyst from only
one side. The other ovary is fine. So you will be able to have babies.

Pt: What will happen to my sex life? When can I resume sex?

Dr: You can start having sex after 4-6 weeks after the surgery (laparotomy) (2-3 weeks in
laparoscopy)

Pt: When can I go back to work?

Dr: If only cyst is removed, you may be able to return to work within 2 weeks.
However, if whole ovary is removed then 5-6 weeks rest is essential.

Pt: When can I drive?

After about 4 to 6 weeks, you may be able to drive.

Pt: Are there any complications?

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Dr: Pain: You might experience some pain after the operation but do not worry we have
very good pain control team who will take care of you.
Bleeding: Do not worry, in case it does happen, we keep matched blood which can be
given to you if needed.

Infection: Again, do not worry. We will give you antibiotics.

Damage to surrounding organs: Very rare. We have an excellent team. If anything

happens, we will manage accordingly.

Dr: Do you have any other concern? Pt: No

Dr: Can I ask you few questions jut to make sure that you are fit for surgery? Pt : Yes

Dr: Do you have any medical conditions? No

Dr: Are you taking any medications? No

Dr: Have you undergone any surgeries previously? No

Dr: That is good. We will be doing some blood tests and other tests to make you that
you are fine and then we will do the surgery. Is that Ok? Pt: Ok

Thank you.

If task says laparoscopic surgery has been planned.

Smaller cysts can sometimes be removed using a procedure known as a laparoscopy.

This is a type of keyhole surgery where small cuts are made in your lower abdomen
and gas is blown into the pelvis to lift the wall of your abdomen away from the organs
inside.
A laparoscope, which is a small, tube-shaped microscope with a light on the end, will
be passed into your abdomen so the surgeon can see your internal organs. Using tiny
surgical tools, the surgeon will remove the cyst through the small cut in your skin.

After the cyst has been removed, the cuts will be closed using dissolvable stitches.
Depending on the type and size of cyst, the operation usually takes about an hour.
Most women are able to go home later on the same day or the following day.

A laparoscopy is the preferred surgical method because it causes less pain and allows
you to resume normal activity sooner.

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OVARIAN CYSTECTOMY, review:

- GRIPS
- Focused History

- Ideas/knowledge on what ovarian cystectomy is

- Type of surgery/incision

- Length of surgery

- When she can go back home - 2 days

- When she can have sex - 4 to 6 weeks

- When she can drive - 5 to 6 weeks

- When she can go back to work - 2 weeks

- Complications of surgery

- Pause when you tell her complications or possibility of oophorectomy

- Chunk and check

- Ask her if she has any concerns

- Take consent

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86. OSTEOPOROSIS
Risk factors for osteoporosis

Steroids

Reduced exercise

Diet

Family History

Important points to ask

- GRIPS

- Ask of symptoms and how she's doing now

- History to look for risk factors, who she lives with, smoking

- Assess for risk of falls - stairs in her house, visual or hearing problems

- Ask for exercise

- Management

- Occupational therapist

- Calcium + Vitamin D - Limited sun exposure

- Refer to a dietitian

- Exercise - brisk walking, dancing, aerobic classes

- Positive smoking history - "Have you ever thought of cutting down or stopping
it?" "Can you consider stopping it?" "When you decide, we have an entire clinic
dedicated to that"

- Bisphosphonates can cause jaw necrosis mostly in patients taking it

intravenously. She should inform her dentist.

- Follow up for osteoporosis?

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69 year old lady had a fracture wrist one week ago.

DEXA scan showed Osteoporosis.

Explain the result to her and address her concerns.

Hello Mrs .. I am Dr ..one of the junior doctor in the medical department.

Dr - How are you doing? Pt – I am fine, doctor.

Dr: How is your wrist fracture? Any pain now?

Pt: Not in pain now.

Dr: Can you please tell me how actually you injured your wrist?

Pt: I was coming down the stairs holding the railing. Suddenly, I felt pain in my wrist.

Dr - We did special X Ray that is DEXA scan on you. The results of that test is back
now. I am here to talk to you about the result. Is that ok?

Pt - Ok, Doctor.

Dr – Test results shows that you have a condition called Osteoporosis or thinning of
bones. Do you know anything about it? Pt – No, Doctor

Dr - Osteoporosis is a condition where the bone loses minerals which makes the bones
less dense and less strong. So the bones become weak and fragile so they break very
easily even with a minor injury.

Pt – Why did I get this, doctor?

Dr - It is commoner after the age of 60 years. It sin seen more commonly in women
compared to men. This is usually due to lack of calcium and Vit D and lack of exposure
to sunlight. There are lot reasons why people get this condition.

Can I ask you a few questions to see why you would have got this condition? Pt –
Yes, doc

Dr - Sometimes people can get this condition if they have some types of medical
conditions. Do you have any medical conditions like thyroid problems, Joint problems
(rheumatoid arthritis), Bowel problems (Crohn’s disease), Bronchitis (COPD), kidney
problems (CKD). Pt – No, doctor

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Dr – Sometimes this condition can run in Family. Any of your family members have this
condition? Pt – My mother had hip fracture.

Dr – Okay as I mentioned probably this is one of the reasons. Sometimes it can happen in
those people who takes steroid type of medications. Do you take any medications? Pt – No

Dr: Can I ask what kind of food do you eat regularly? Pt: I eat a healthy balanced diet,
doctor.

Dr: Do you drink milk?

Pt – I drink lots of milk. I use milk for cereals also.

Dr – It is very good that you drink a lot of milk. Milk contains calcium which strengthens
bones. Calcium and vitamin D are important for bone health. Your body needs adequate
supplies of vitamin D in order to absorb the calcium that you eat or drink in your diet.

We advise you to drink a pint of milk every day.

Other sources of calcium are hard cheese such as Cheddar or yoghurt, Bread, calcium-
fortified soya milk, some vegetables (curly kale, okra, spinach, and watercress) and
some fruits (dried apricots, dried figs, and mixed peel) are also good sources of
calcium.

Butter, cream, and soft cheeses do not contain much calcium. You can check how
much calcium you eat with an on-line dietary calcium calculator.

Pt: Can you give me some calcium supplements?

Dr: We can give you calcium and vit D supplements too.

Dr: Food which contain Vit D are cooked salmon or cooked mackerel or tuna fish or
sardines (both canned in oil). However Vitamin D is mainly made by your body after
exposure to the sun. The ultraviolet rays in sunshine trigger your skin to make vitamin
D. So it is better to have sun exposure.

Dr – Do you do exercise? Pt – Yes, I go for swimming and jogging.

Dr –That is really good to know that you do exercise. . Doing exercise helps to
stimulate bone-making cells and strengthens your bones.

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Regular weight-bearing exercise is best. This means exercise where your feet and
legs bear your body's weight, such as brisk walking, aerobics, dancing, running.
For most benefit you should exercise regularly - aiming for at least 30 minutes of
moderate exercise or physical activity at least five times per week.

Unfortunately swimming is not weight-bearing exercise, this is not so helpful in preventing

osteoporosis.

Dr – Do you smoke? Pt - No/Yes doctor (10 to 15/day for many years)

Dr – This one of the risk factors why people get this condition. (If no – it is really good.
Please do not start smoking, If yes - I would strongly advise you to stop smoking. We
can help you if you wish to stop smoking ).

Dr - Do you drink alcohol Pt – No/Yes doctor 1 to 2 glasses of wine every day.

Dr – This is also another risk factor. (Please cut down drinking. Again, we can help if you
wish to cut down.

Dr - Did you have any operations ?

Pt – No/I had my womb removed when I was 35 years old.

Dr – Removal of the ovaries also can contribute to this problem. Have they removed
your eggs? (Oophorectomy is a risk factor) Pt – No

Dr – Did you attain menopause and when? (early menopause is risk factor) (can be
treated with HRT if patient had early menopause) Pt – when I was 45 years old.

Dr – You should take care not to fall because you can have fractures very easily
because of weak bones.

Pt – Any medications to treat, doctor?

Dr: There are medicines called Bisphosphonates like alendronate that can help. They can
help to restore some lost bone and help to prevent further bone loss. They may also help to
reduce the chance of a second fracture if you have already had a fragility fracture.

You need to take bisphosphonate tablets whilst you are sitting up and with plenty of
water, as they can cause irritation of your gullet (oesophagus).

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Side effects: This can lead to indigestion-type symptoms such as heartburn or difficulty
swallowing. Other side-effects may include diarrhoea or constipation.

You should not eat or take other tablets for half an hour after taking your bisphosphonate
tablet. Depending on which medicine is used, you may need to take it daily, weekly, or
sometimes less frequently.

A rare side-effect from bisphosphonates is a condition called osteonecrosis of the jaw. This
condition can result in severe damage to the jaw bone and jaw pain. You should have regular
dental check-ups whilst taking a bisphosphonate. Tell your dentist that you are taking a
bisphosphonate. [Note: the risk of osteonecrosis of the jaw is low in people taking
bisphosphonate tablets as a treatment for osteoporosis. It is greater in people who are
being treated with bisphosphonates by injections into the veins (intravenously)].

Pt: Can you give me HRT ?

Dr: Hormone replacement therapy (HRT) contains oestrogen. HRT was widely used few
years ago to prevent osteoporosis. However, the recent findings showed there are
health risks of HRT like breast cancer, heart disease and stroke. So it is not used
nowadays. (except in women who have had an early menopause).

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87. 25 year old lady Mrs. Laura Thompson presented with vaginal discharge and
lower abdominal pain. You have diagnosed Gonorrhoea. Take a brief history
and tell her the diagnosis and treatment.

Hello Mrs Thomson, I am Dr .. How are you doing ? Pt – I am OK.

Dr – Do you know why you are here today? Pt – I came for test result.

Dr – I have the test results with me. Can you please tell me what problems you had ? Pt:
Doctor I had a pain in my lower tummy and I had discharge from my front passage. Dr –
Test result shows that you have infection with some bugs in your lower tummy and front
passage. This bug is called Gonorrhoea. Pt – How did I get this bug?

Dr – It is a sexually transmitted infection (STI) caused by bacteria called Gonococcus.

Gonorrhoea is easily passed between people through unprotected sex. Pt : Does that
mean that my boyfriend gave this infection to me?

Dr: Since when have you been in this relationship? Pt: Since the last three weeks.

Dr – Do you practice safe sex with your boyfriend? Pt: No

Dr: Does your boyfriend have any symptoms like discharge from his penis or has he
got burning sensation while passing urine that you know about? Pt: No

Dr: Do you use any sexual toys? Pt: No

Dr: Did you have sex with anyone else or did you have any partners before? Pt: I had
two partners before this relationship.

Dr: How long ago was that? Pt: Just before I started the relationship with my current
boyfriend?

Dr: Did any of them had symptoms like discharge from their penis or burning sensation
while passing urine – do you know? Pt : I don’t know

Dr: Were you practicing safe sex with them? Pt: No

Dr: You would have got this infection from any of them because this bug can stay in the
body for a long time without having any symptoms. It is important that we need to treat you
now. Pt – How will you treat me?

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Dr - We will treat you with a single antibiotic injection (Ceftriaxone 500 mg IM) and a single
antibiotic tablet (Azithromycin 1 g oral) . With effective treatment, most of your symptoms
should improve within a few days. We will see you again in a week and do the test again to
see whether you have cleared the infection. Can you please tell your boyfriend to come
here so that we can check whether he also has any such infection and we can treat him
(treatment should be given to the partner even if the tests are negative because
sometimes the tests can be false negative).

Pt: OK, I will tell him. [if she had unprotected sex with others within the last 3 months –
they also need to informed about the possibility of infection and they should be
asked to come to the clinic and tested and treated – contact tracing].

Dr: Please do not have sex until the infection is cleared (at least one week) and also
practice safe sex (use condoms) after that. Pt: Will there be any complications?

Dr: Usually, if the infection is cleared and if it has not spread to other areas there will not be
any complications. However, if the infection is not treated, then the infection can spread to
the womb and then it can cause serious problems sometimes like infertility, miscarriage,
pregnancy happening outside the womb, etc.

Pt: Ok, Doctor. Dr: Any other questions? Pt : No, Thank you very much.

GONORRHOEA : You are taking a history to

1. Identify allergies
2. Complications
3. Risk factors
4. Address her concerns

● Ask how her pain is

● Find out if her partner has similar symptoms
● Ask her if she practices safe sex or uses any form of contraception
● Find out her partners in the last 6 months
● Family history, not necessary
If patient asks you if her current boyfriend gave this to her, tell her "I'm really sorry I insinuated
that. This infection can stay dormant for up to 6 months."

Complications - PID - ectopic pregnancy, infertility. Advise her to get tested for other STIs.She

can't have sex for a week (and/or until she is cleared of infection) Tell her about condoms

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88. PELVIC INFLAMMATORY DISEASE

Background
• PID is an infection of the womb (uterus) and Fallopian tubes.

• Whatever is responsible for the infection usually travels from vagina or neck of womb
(cervix) into the uterus and ovaries.

• In 25% of the cases, the cause of PID is from a sexually transmitted infection.
Chlamydia and gonorrhoea are the most commonly found causes of PID. In many
other cases, it is caused by bacteria that normally live in the vagina.

• A patient might develop PID weeks or months after having sex with an infected
person.

• Some cases of PID are not due to a sexually transmitted infection. This is more of a
risk after having a baby, or after a procedure such as inserting a contraceptive coil.

Symptoms

PID often doesn't cause any obvious symptoms. Most women have mild symptoms
that may include one or more of the following:

• pain around the pelvis or lower abdomen (tummy)

• discomfort or pain during sex that's felt deep inside the pelvis

• pain during urination

• bleeding between periods and after sex

• heavy periods

• painful periods

• unusual vaginal discharge, especially if it's yellow or green. A few women become
very ill with:

• severe lower abdominal pain

• a high temperature (fever)

• nausea and vomiting

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Examination

• Abdominal

• Gynaecological, speculum

Risk factors

1. IUCD

2. Multiple partners

3. Sharing sexual toys

4. Previous PID

5. STIs

6. Trauma

7. Early sex

Complications of PID

1. Pelvic abscess

2. Infertility

3. Sepsis

4. Miscarriage

5. Ectopic pregnancy

6. Still Birth

7. Long Term Pelvic Pain (dyspareunia)

Investigations

● Endocervical swab - Chlamydial swab High vaginal swab. Negative swabs don't
rule out PID.

● Transvaginal ultrasound

● Urinalysis: protein, blood; leucocytes; nitrites

● CBC

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● In some cases, laparoscopy (keyhole surgery) may be used to diagnose PID.

(This is usually only done in more severe cases where there may be other
possible causes of the symptoms, such as appendicitis)
Treatment

Antibiotics: Needs to be started quickly, before the results of the swabs are available.
Antibiotics commonly prescribed to treat PID include:
 Ofloxacin
 metronidazole
 ceftriaxone
 doxycycline
Ceftriaxone 500 mg as a single intramuscular (IM) dose, followed by (Doxycycline 100 mg orally
and Metronidazole 400 mg) twice daily for 14 days
Painkillers
If you have pain around your pelvis or tummy (paracetamol, ibuprofen)
Avoid intercourse
You should avoid having sex until both you and your partner have completed the course
of treatment- till at least 7 days after treatment is finished.
Follow-up
 In some cases, you may be advised to have a follow-up appointment three days after
starting treatment so your doctor can check if the antibiotics are working.
 If the antibiotics seem to be working, you may have another follow-up appointment at
the end of the course to check if treatment has been successful.
Prevention

Use of barrier contraception significantly reduces the risk of PID.

Limited evidence suggests that screening for Chlamydia and treating identified
infection prior to IUCD insertion reduce the risk of PID.

The English National Chlamydia Screening Programme (NCSP) recommends that all
sexually active men and women under the age of 25 be tested for Chlamydia annually
or on change of sexual partner.

Visit local genitourinary medicine (GUM) or sexual health clinic for advice.
In case of invasive gynaecological procedure, such as insertion of a coil or an abortion,
have a check-up beforehand.

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Treating sexual partners

- Any sexual partners you've been with in the six months before your symptoms
started should be tested and treated to stop the infection recurring or being
spread to others, even if no specific cause is identified. Your doctor or sexual
health clinic can help you contact your previous partners and this can usually be
done anonymously, if you prefer.

- Advise protected sex after the treatment.

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88.25 year old Mrs Sarah Boyer was diagnosed with pelvic inflammatory disease
as she presented with discharge from front passage 4 days ago. She is already
on antibiotics and taking OCP as well. US Scan has been done which shows
Hydrosalphinx. Talk to Mrs Sarah Boyer and explain about possible complications
of PID.

Assessment - 8 steps

1. Ask her concerns

2. Assess her knowledge of her condition

3. Explain PID and its causes

4. Ask if she wants to know about a specific complication or all?

• Pelvic pain

• Deep dyspareunia

• Abscess

• Menorrhagia

• Secondary dysmenorrhoea

• Discharge

• Miscarriage

• Ectopic pregnancy

• Infertility

5. Keep checking her understanding

6. Anything else?

7. Stress on compliance

8. Partner notification programme

9. Prevention in the future

10. Follow Up - 2 weeks & anything else

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Dr: Hello, Mrs Sarah Boyer. I am one of the doctors in the Gynae/Obs department.
How can I help you?

Pt: Doctor, I was diagnosed with PID and I am on antibiotics but I am still worried
about this condition.

Dr: Mrs Sarah, I am here for this to address your concerns today regarding your
condition. I will try my best to answer your questions. So do you know what it is?

Pt: No/yes

Dr: If No, it is an infection (bugs) spreading from vagina or cervix (entrance of the
womb) into the womb and Fallopian tubes and ovaries. If yes: That is right.

Dr: May I know why you are worried?

Pt: I want to know why did it happen to me?

Dr: It’s difficult to say right at the moment but the risk is always higher in women who
are using coil or had any surgery of the womb or any instrumentation. Have you had
any of this? Pt: No

Dr: Ok. There are other causes, like this could be a sexually transmitted infection some times.

Pt: Doc, how is it possible, do you think my partner is cheating on me?

Dr: I am sorry if you misunderstood me, I did not mean that as there could be other
causes also as I told you. And also sometimes, these types of bugs persist for longer
period of time and symptoms develop later in life if not treated immediately. Usually,
only one-fourth of the time, it is due to sexually transmitted infection. Pt: What should
I do?

Dr: Do not worry; as long as you complete your treatment, everything will be fine. It is very
important for you to complete your treatment.Pt: Is there anything which can happen to me?

Dr: I am afraid if you do not get proper treatment or do not follow proper instructions
which we will give to you, there are chances to get complications like:

1. You may not be able to become pregnant, called infertility

2. If you become pregnant, you can lose your pregnancy called Miscarriage. It can be
on abnormal place called ectopic pregnancy.

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3. Your baby can be premature baby.

4. You can get pain during intercourse

5. Most importantly, this infection can spread to other parts of body which is
dangerous. Pt: what can you do for me?

Dr: I just want to tell you please don’t worry as you are already on antibiotics so please
continue your treatment as advised. Hopefully, you will be alright but a few things are
very important for you:

1) Please do not stop treatment early even if your symptoms disappear. 2) You should
avoid even safe sex till you finish complete treatment. (National Chlamydia Screening
Programme: Do not have any sex with your partner(s) until seven days after you
have both completed your treatment.)

3) Your partner should also get treated. Pt: Why?

Dr: I am afraid if he is not treated, then you can get the infection back and can get the
complications that we discussed and I am sure you don’t want that. Can you bring your
partner in? Pt: Yes. (If patient says No)

Dr: It’s fine. We have something called partner notification program in which we will
call your partner anonymously and treat him without revealing your identity.

Pt: Will it happen again?

Dr: 1 in 5 women can have it again but if you and your partner both get proper
treatment and follow advice, hopefully you will not get it. Would you like me to give
you some advice?

Pt: Yes doc, sure

Dr: 1: Please avoid multiple sexual partners. 2: Practice safe sex in future. 3: If anytime
you are suspicious of getting this infection, please come to GUM clinic immediately

{If the patient has an IUD – it needs to be removed}

89. Repeated twice in the index

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90. You are an FY 2 in OBG department? A 40 year old Ms… Came to you with h/o
abdominal pain. She is on Desogestrel. Take a history and discuss management with
the patient. The patient has a history of depression and was treated previously.

Dr : Hello Ms… I’m Dr… one of the junior doctors in this department. What brings you
here today?

Pt : Dr I have a pain in the tummy.

Dr : I’m sorry to hear about that. Are you comfortable enough to talk to me now? Pt : Yes.

Dr : Could you tell me more about the pain?

Pt : Sure. Has been there for the past 18 months (some say only 3-6 months), and in the
last 3- 6 months it has gotten worse. It is a very vague pain and sometimes it’s cramping.

Dr : Are you taking anything for this pain?

Dr : Anything that makes it better or worse? Pt…

Dr : On a scale of 1-10 can you please grade your pain? Pt: 3 or 4

Dr : Do you have any fever? Pt : No

Dr: Any vomiting? Pt : No

Dr : Any diarrhoea? Pt : No

Dr : Any discharge from the front passage? Pt : Yes, there is yellowish discharge.

Dr : Does it smell bad? Pt : Yes, Dr. (Pt doesn’t give this his right away. Only on robing)

Dr : How long? Pt : 3 months.

Dr : Has this happened before? Pt ….

Dr : Any bleeding or spotting from the from passage? Pt : no

Dr : LMP? Pt …. (she is on desogestrel)

Dr : How are your periods? Regular? Heavy bleeding?

Dr : I’m going to be asking a few questions that might sound intimate. It involves
knowing about your sexual history. Is it okay with you?

Pt : Yes, Doctor

Dr : Have you been sexually active recently? Pt : yes

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Dr: Any pain during sex? Pt : No

Dr : Any bleeding during sex? Pt : No

Dr: Do you have a stable sexual partner? Pt : Yes, I have a boyfriend.

Dr: Can I ask how long are you having this relationship? Pt : ?3 months.

Dr : Do you practice safe sex ? Pt : No

Dr : Any method of contraception? Pt: Yes, I take mini pills.

Dr : Do you have any other partners? Pt : No

Dr : Have you had unprotected sexual intercourse with anyone else in the last few
months? Pt : Yes, there were a few.

Dr : Any medical conditions before? Pt : I am on a medication for depression.

(depression because of failed relationship with husband, now divorced. Family
and friends are good. Happy with work, mood now is better)

Dr : Any other medications? Pt : No

Dr : Any surgeries? Or procedures? Pt :…(?S/P HYSTERECTOMY)

Dr : Do you smoke? Drink alcohol. Pt: No

Dr : Anything else?

Dr : Thank you, I’d like to examine you now. I ll be checking your BP, Pulse, temperature,

Check your tummy, do a speculum examination of your front passage.

Examiner : Tenderness over lower abdomen (LIF, RIF and suprapubic)

Per speculum : yellowish discharge +ve, cervical excitation +ve

Dr : Thank you examiner. From what you have told me Ms. … it seems like you have a
condition called Pelvic Inflammatory Disease. Pelvic inflammatory disease (PID) is an
infection of the female upper genital tract, including the womb, fallopian tubes and
ovaries. Are you following me? Pt : Yes.

Dr : We have to do a swab from your front passage to check for what kind of bugs you
have. We might also have to do a scan of your tummy to see where exactly the infection
has spread.

Dr : PID can be treated with a course of antibiotics, which usually lasts for 14 days.

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You'll be given a mixture of antibiotics to cover the most likely infections, and often an
injection as well as tablets.

Dr : It’s important to complete the whole course and avoid having sexual intercourse
during this time to help ensure the infection clears. Are you with me so far? Pt : yes dr

Dr: Your recent sexual partners also need to be tested and treated to stop the infection
recurring or being spread to others. Is that alright? Pt :….

Dr : I will talk to my seniors and discuss about the medications with them. Meanwhile if
you develop severe pain, bleeding, vomiting, please come back to us because it could
be anything serious. Do you have any concerns? Pt : No, doctor. Dr : thank you

CHRONIC PID

91. LADY WITH ABDOMINAL CRAMPS

Lady had C-sec done 15 years ago, taking antidepressants for last 5 years. Now
presented with abdominal pain for 1 yr/6 months. Pain comes and goes, sometimes 2
to 3 times in one day and sometimes after 2 or 3 days.
Has vaginal discharge

Some people said – she had new relationship with a man since about 6 months
and the symptoms started after that !

Taking Mini pill - Had 2 children.

Diagnosis - PID

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92. ECTOPIC PREGNANCY

Ectopic Pregnancy Information

A tubal ectopic pregnancy never survives. Possible outcomes include the following:

• The pregnancy often dies after a few days. About half of ectopic pregnancies
probably end like this. You may have no symptoms, and you may never have known
that you were pregnant. Sometimes, there is slight pain and some vaginal bleeding
like a miscarriage. Nothing further needs to be done if this occurs.

• The pregnancy may grow for a while in the narrow Fallopian tube. This can stretch
the tube and cause symptoms. This is when an ectopic pregnancy is commonly
diagnosed.

• The narrow Fallopian tube can only stretch a little. If the pregnancy grows further, it
will normally split (rupture) the Fallopian tube. This can cause heavy internal bleeding
and pain. This is a medical emergency.

An ectopic pregnancy is when a fertilised egg implants itself outside of the womb,
usually in one of the fallopian tubes. The fallopian tubes are the tubes connecting the
ovaries to the womb. If an egg gets stuck in them, it won't develop into a baby and
your health may be at risk if the pregnancy continues. Unfortunately, it's not possible
to save the pregnancy. It usually has to be removed using medicine or an operation. In
the UK, around 1 in every 80-90 pregnancies is ectopic.

Symptoms of an ectopic pregnancy usually develop between the 4th and 12th weeks
of pregnancy.

Main symptoms:

• Missing a period or positive pregnancy test

• Vaginal bleeding

• Tummy pain - typically low down on one side.

• Shoulder tip pain

Symptoms of a rupture.

• a sharp, sudden and intense pain in tummy

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• feeling very dizzy or fainting

• feeling sick

• looking very pale

What can cause an ectopic pregnancy? In many cases, it's not clear why a woman has an
ectopic pregnancy. Sometimes, it happens when there's a problem with the fallopian tubes,
such as them being narrow or blocked. The following are all associated with an increased risk
of ectopic pregnancy:

• pelvic inflammatory disease (PID) – inflammation of the female reproductive system, usually
caused by a sexually transmitted infection (STI)

• previous ectopic pregnancy – the risk of having another ectopic pregnancy is around 10%

• previous surgery on your fallopian tubes – such as an unsuccessful female sterilisation

procedure

• fertility treatment, such as IVF – taking medication to stimulate ovulation (the release of an
egg) can increase the risk of ectopic pregnancy

• becoming pregnant while using an intrauterine device (IUD) or intrauterine system (IUS)
for contraception – it's rare to get pregnant while using these, but if you do you're more
likely to have an ectopic pregnancy

• smoking

• increasing age – the risk is highest for pregnant women who are aged 35-40.

You can't always prevent an ectopic pregnancy, but you can reduce your risk by using
a condom when not trying for a baby, to protect yourself from STIs, and by stopping
smoking.

Diagnosing ectopic pregnancy

• Pregnancy test – positive

• Symptoms of ectopic pregnancy

• USG

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• Blood tests - to measure the pregnancy hormone human chorionic gonadotropin (hCG),
may also be carried out twice, 48 hours apart, to see how the level changes over time.

• Laparoscopy/Keyhole surgery

• If it's still not clear whether it is an ectopic pregnancy, or the location of the
pregnancy is unknown, a laparoscopy may be carried out.

Treating ectopic pregnancy Unfortunately, the baby cannot be saved in an ectopic

pregnancy. Treatment is usually needed to remove the pregnancy before it grows too
large.

The main treatment options are: Expectant management-Expectant approach is suitable if

the HCG at 48 h is decreasing spontaneously and the woman remains asymptomatic. If you
have no or mild symptoms and the pregnancy is very small or can't be found, you may only
need to be closely monitored. You'll have regular blood tests to check that the level of hCG in
your blood is going down. You may need medical or surgical treatments if your hormone
level doesn't go down or it increases. You'll usually have some vaginal bleeding. You may
experience some tummy pain. The main advantage of monitoring is that you won't
experience any side effects of treatment. A disadvantage is that there's still a small risk of
your fallopian tubes splitting open (rupturing) and you may eventually need treatment. If
you develop more severe symptoms come to hospital immediately.

Medication – a medicine called methotrexate is used to stop the pregnancy growing. This
works by stopping the pregnancy from growing and is given as a single injection into your
buttocks. You won't need to stay in hospital after treatment, but regular blood tests will
be carried out to check if the treatment is working. A second dose is sometimes needed
and surgery may be necessary if it doesn't work. Side effects of methotrexate include:

• tummy pain – this is usually mild and should pass within a day or two

• dizziness

• feeling and being sick

• diarrhoea

Surgery – Keyhole surgery (laparoscopy) will be carried out to remove the pregnancy before

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it becomes too large. The entire fallopian tube containing the pregnancy (salpingectomy) is
removed or only the pregnancy is removed (salpingotomy) without removing the whole tube.
Removing the affected fallopian tube is the most effective treatment and isn't thought to
reduce your chances of becoming pregnant again. Most women can leave hospital a few
days after surgery, although it can take four to six weeks to fully recover.

If your fallopian tube ruptures, you'll need emergency surgery. The surgeon will make

A larger incision in your tummy (laparotomy) to stop the bleeding and repair your
fallopian tube, if that is possible.

Counselling after ectopic pregnancy

• Explanation of diagnosis and operation

• Appropriate counselling that the woman may grieve (this is the loss of a pregnancy)

with advice about further support

• Avoid the progesterone only contraceptive pill (POP) and intrauterine contraceptive
device (IUCD) (both are associated with a slightly higher risk of ectopic pregnancy)

• Approximately 65–70 per cent of women who have had an ectopic pregnancy go on
to have a live birth following this, but there is a 10–15 per cent chance of a further
ectopic pregnancy

• Early trans-vaginal scan is indicated at around 5 weeks’ gestation to confirm the

location of any future pregnancy

• Effective contraception should be used if she does not wish to become pregnant

again at the moment

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92.18 year Miss Chloe Jones came to the hospital with lower abdominal pain. Her
pregnancy test is positive. As per hospital protocol, she needs to be admitted for
the treatment and USG should be done the following day. Talk to her and explain
the further management.

Hello Miss Chloe Jones, I am Dr... one of the junior doctors in the Obstetrics and
Gynaecology department. How can I help you?

Pt: Doctor, I am having some pain in my left lower tummy.

Dr: Can you please tell me anything more about it ? Pt: Doctor, It started few hours ago.

Dr: How severe is the pain – in the scale of 1 to 10 one being the mildest and 10 being
the most severe pain. Pt: It is about 5 out of 10.

Dr: When was your last menstrual period? Pt: 6 weeks ago.
Dr: Are you sexually active? Pt: Yes

Dr: Any chance that you are pregnant? Pt: I did the pregnancy test today. It is positive.
Dr: Do you have any bleeding from vagina? Pt: Yes.

Dr: Since when and how severe is that? Pt: It just started few hours ago. It is just
spotting not very severe.

Dr: Do you feel dizzy or feel like fainting (ruptured ectopic)? Pt No

Dr: Do you have fever? Pt: No

Dr: Do you have burning sensation while passing urine (UTI)? Pt: No

Dr: Do you have any discharge from the vagina (STI) ? Pt: No

Dr: Did you see any blood in your urine (ureteric stone) ? Pt – No

Dr: Do you have diarrhoea or vomiting (gastroenteritis)? Pt : No

Dr Were you ever pregnant before? Pt: No (If yes, ask – any previous ectopic,miscarriage)

Dr: Do you use any sort of contraception (IUD or IUS are risk factors for ectopic)? Pt: No

Dr: Did you have any infections in your pelvic area before (risk factor for ectopic) Pt : No

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Dr: Did you have any operations in your tummy before (previous surgery on fallopian
tube is a risk factor for ectopic)? Pt : No

Examination:

Miss Jones I need to examine your tummy and also check your pulse and blood
pressure. (examiner may give the finding as mild tenderness over left iliac fossa and
pulse and BP are stable).

Diagnosis: Miss Jones with you told me and with the examination findings you have a
condition what we call as ectopic pregnancy. Do you have any idea about this? Pt : No

Dr: Normally, pregnancy happens within the womb as you know. In this condition pregnancy
is not in the womb it is in the fallopian tube which is a tube which connects ovary to the
womb. In this condition, pregnancy cannot continue. Sometimes this condition can be
dangerous because the fallopian tube can rupture and cause heavy bleeding inside the
tummy. Are you following me?

Pt: Yes. What is going to happen now?

Dr: We need to do an ultra sound scan of your tummy to confirm this condition. However this
test can be done only tomorrow morning. (If she ask why not now – you can say the expert
doctor who does the scan can come only tomorrow morning).
Since at this moment, we are not suspecting you are bleeding heavily inside your tummy, we
will keep you in the hospital and keep monitoring you, and we will do the scan tomorrow.

Pt: Doctor I can’t stay in the hospital.

Dr: Why? Pt: If I stay in the hospital my parents will come to know that I am in the
hospital, and they will come to know that I am pregnant. I don’t want them to know
that I am pregnant.

Dr: Miss Jones, if you go home now - sometimes it can bleed heavily and you may not
be able to come back to the hospital in a safe time. We will not tell your parents unless
you want us to tell them. However, we strongly advise you to tell your parents because
you may need their support now. {Sometimes, she may agree. If she does not agree
– tell her that it is important that some one knows that you are in the hospital as
may need support – she may say, “I will ask my friend to come”}

Pt: What are you going to do to treat this condition?

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Dr: If the test confirms that it is ectopic pregnancy, then there are several ways we can
manage it. We will do another blood test to check a pregnancy hormone called Beta
HCG which we will do now and again after 48 hours.
Depending on the level, we can decide the treatment options. If the symptoms do not get
worse and the hormone level is decreasing after 48 hours - we can just wait and watch
because sometimes the pregnant gets dissolved by itself. If the hormone level is high, then
we will give you an injection (one injection to the buttock) called Methotrexate. This
medication will stop the pregnancy from growing. You do not need to stay in the hospital
after that but we will keep monitoring you to check if the treatment is working. If these
treatment do not work, then we may need to do an operation to remove the pregnancy.

In this procedure we will do a key hole surgery on your tummy and remove the
fallopian tube of that side along with the pregnancy if the other tube is healthy or
remove only the pregnancy if the other tube is not healthy.

If we do an operation, you may need to stay in the hospital for few days.

If it all, it starts bleeding heavily then we need to do an open operation immediately to

stop the bleeding. Are you following me? Any questions?

Pt: Will there be any complications in the future?

Dr: Sometimes you can have ectopic pregnancy again or it can cause miscarriage or
very rarely it can cause infertility. Pt: Ok

Dr: Any other question? Pt - No

Dr: We strongly advise you to practice safe sex and effective contraception until you
want to become pregnant again and if you become pregnant again and if you have
any pain in your tummy (which is a sign of ectopic pregnancy again), please come to
us immediately. Thank you very much.

93. ECTOPIC PREGNANCY

Young lady lower abdominal pain

You might be expected to examine – patient showed tenderness in RIF. No vaginal

bleeding

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94. Mrs Claire Godwin 22 year old lady came to the hospital requesting
combined pill for contraception. Talk to her and advise her about the
contraception.

Dr: How can I help you? Pt: I need combined pills for contraception

Dr: Good. Why do you specifically asking for combined pill? Pt: My friend is using that
and she said it is good.

Dr: Are you using any contraception now?

Pt: I am using female condom?

Dr: Why do you want to change it? Pt: It is not good because I became pregnant last
time because the condom tore. I want something more reliable this time.

Dr: Ok, do not worry we have several options for contraception also more reliable
ones. But I need to ask you few questions to see which type is suitable to you. Rule out
contraindications:

1) Dr: Have you ever had any clots in your lungs or legs? Pt: Yes I had it one year ago.
Dr: Were you given any blood thinner medication for that? Pt: Yes I was given warfarin.
Dr: Are you still taking warfarin? Pt: No, I finished taking the warfarin many months
ago.

2) Any family history of clots in legs or lungs?

3) Sorry to ask you this but have you or any family member been diagnosed with
cancer of the breast?

4) Have you ever experienced a migraine or a one-sided severe headache?

5) Do you have any liver disease?

6) Do you smoke?

7) Are you on any medication?

Dr: Do you have a partner? Pt: Yes, I have a husband (married)

Dr: Do you have children Pt: Yes 2 children

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Dr: Have you taken the combined pill before at any time ? Pt: No

Dr: Mrs Godwin, unfortunately the combined pill is not good for you because you have
had a blood clot in your leg before. If you take the combined pill, the blood clot can
happen again because one of the complications of combined pill is that it can give rise
to blood clots.

Combined pill has two types of hormones: oestrogen and progesterone. It is the
oestrogen part which causes blood clots. However, we have plenty of other options -
one of that is male condom – the advantage is that is 98% reliable and also it is the
only contraception which prevents sexually transmitted infections also.

Pt: I do not want it because it can also slip.

Dr: That is true. We have another option which is Progesterone only pill (POP).
PROGESTOGEN ONLY PILL – Sometimes called the ‘mini-pill’. It contains just a
progestogen hormone (it does not contain oestrogen) which works mainly by causing a
plug of mucus in the cervix that blocks sperm, and by thinning the lining of the uterus.
Also prevents ovulation.

Advantages – It is very reliable and has a success rate is 99% if taken correctly. It is easily
reversible and convenient. It does not cause clots like oestrogen and it can be used during
breast feeding.

Disadvantages – It can cause irregular periods. Some women have side-effects like
headaches, mood swings and weight gain - these are common though. They are not quite
as reliable as the combined pill. Also, you need to remember to take it at the same time
every day.

Contraceptive implant – This is a small flexible tube containing progestogen that's

inserted under the skin of your upper arm and lasts for three years. It is 99% effective. The
implant stops the release of an egg from the ovary by slowly releasing progestogen into
your body. Progestogen also thickens the cervical mucus and thins the womb lining. This
makes it harder for sperm to move through your cervix, and less likely for your womb to
accept a fertilised egg. The advantage is that you do not need to remember to take it every
day.

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An other option is INTRAUTERINE DEVICE (IUD) - A plastic and copper device is put into
the uterus. It works mainly by stopping the egg and sperm from meeting. The copper also
has a Spermicidal effect (means it kills sperms).

Advantages: It is more than 99% effective. You don’t have to remember to take pills
and it lasts 5 or more years. Disadvantages - Periods may get heavier or more painful.
It carries a small risk of serious problems including damage to the uterus and infection.

An other option is - HORMONE RELEASING INTRAUTERINE DEVICE (eg Mirena) –

This is a plastic device that contains a progestogen hormone is put into the uterus. The
progestogen is released at a slow but constant rate. It works in a similar way to the
POP. Advantages: This is also more than 99% effective. You don’t have to remember to
take pills. It can remain in place for 5 years. Periods become light or stop altogether.

Disadvantages: Side-effects may occur as with other progestogen methods. However,

they are much less likely as the hormone is mainly confined to the uterus.

If you have finished your family ie do not want to have any more children – then we
have a Permanent method – Female sterilisation – this is a procedure where we block
the part of the fallopian tubes connecting the ovary and uterus. 99% effective.
Disadvantage – very difficult to reverse and NHS may not fund.

Dr:- So Mrs Godwin, which one do you prefer ?

(Very important in this station is to rule out contraindications – patient had DVT
one year ago and was on warfarin at that time. So Combined pill cannot be given
to her. However, all other options are available to her because she is not on
warfarin now).

Female condoms are only 95% effective.

ORAL CONTRACEPTIVE PILLS

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95. You are a FY2 in GP clinic. A 28 years old lady come for lumpiness and pain in
her breasts. Take history, do relevant examination and address her concern.

GRIPS plus rapport with the patient

Take history:

Pt: I feel lumpiness in my both breasts

Dr: I am sorry to hear that! For how long? Pt: 18 months

Dr: Do you have pain now? Pt: No

Dr: Anything more can you tell me about it? Pt: Like what, doctor?

Dr: Is it painful at all? Pt: Yes, I felt pain but I don’t have pain now.

Dr: Do you have your menstrual period now? Pt: I had my LMP 2 weeks ago.

Dr: When do you feel lumpiness and pain more? Pt: During my periods

Dr: Do you drink too much tea/coffee? Alcohol? Pt: No

Dr: Do you take oral contraceptive pills? Pt: No

Dr: Have you noticed any swelling/lumps? Pt: No

Dr: Do you have fever (mastitis)? Pt: No

Dr: Did you notice any discharge (intra ductal papilloma), or blood discharge (cancer)

from the nipple? Pt: No

Dr: Have you noticed any lumps on your arm pits? Pt: No

Dr: Have you injured your breast? Pt: No

Dr: Are you currently breastfeeding, or have done in the past? Pt: Yes/ No

Dr: Did you have any swellings/lumps in the breast before? Pt: No

Dr: Any of your family members had breast lumps/cancer? Pt: No

Mrs…. I need to examine your breasts now.

Pt : Ok doctor.

Examine the breast.

Explain the procedure “while examining, I will be asking you to do some manoeuvres

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and will be looking at you and touching your breast and arm pits to feel for any lumps. If

you feel uncomfortable on any point please let me know I will stop the examination.

Exposure: Can you please undress above your waist?

I will ensure privacy and have a chaperone with me. Is that OK?

[Position: 3 different position will be used during examination. Sitting, Lying

down at 45 degrees and Standing. Do the Inspection plus Palpation]

Reassure the woman that there is no serious underlying pathology.

Dr: From the history and examination findings, I could not find any lump/swelling. We
are suspecting you are having this lumpiness and pain because of a condition what we
called Cyclical Mastalgia. This is not a serious condition. Symptoms get worse while
you are having periods/menstruation.

However, I will talk to my seniors they will do further assessment.

Dr: We will give you painkillers: Oral paracetamol and/or ibuprofen, or a topical
nonsteroidal anti-inflammatory preparation, as required. We will refer you to a Breast
specialist (As she has been having this for 18 months)

Pt: What will I do in the future?

Dr: Please wear a better-fitting bra during the day and a soft support bra at night.

Ask the woman to keep a pain diary (if she has not already done so) to evaluate the
severity and timing of the pain, and its response to treatment.

Plus give warning signs of any lumps or discharge.

Consider referring to a breast specialist if the pain is severe enough to affect

quality of life or sleep and does not respond to first-line treatment after 3 months.

Specialist treatment options include danazol and tamoxifen.

CYCLICAL MASTALGIA

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PEDIATRICS
HISTORY TAKING FORMAT

 Chief complaints

 History of presenting illness(ODPARA)

 Rule out the differential diagnosis

 Essential Questions in Paediatrics Past history

 Family history

 Allergy history

 History of presenting illness (ODPARA)

 Onset

 Duration

 Progression

 Aggravating factors

 Relieving factors

 Associated symptoms
For Paediatric History

B: Birth, How was the Birth?, Any Problem during or after birth?, +/-breastfeeding

I: Immunisations, Is the child up -to-date with vaccines or jabs?

R: Red Book (Personal Child Health Record (PCHR)) Any concerns about red book recording?

D: Development, Is his/her development okay in comparison to other same age children?

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Head injury in children

Indications for referral to hospital A&E department after head injury for children

 A high-energy head injury - eg, diving accident, high-speed motor vehicle collision.

 GCS <15 at any time since injury.

 Any loss of consciousness as a result of the injury.

 Any focal neurological deficit since the injury.

 Amnesia for events before or after the injury.

 Persistent headache since the injury.

 Any vomiting episodes since the injury (clinical judgement should be used in those aged
≤12 years).

 Any seizure since the injury.

 Irritability or altered behaviour, particularly in infants and young children.

 Any suspicion of a skull fracture or penetrating head injury since the injury (eg,
clear fluid from the ears or nose, black eye with no associated damage around
the eyes, bleeding from one or more ears, new deafness in one or more ears,
bruising behind one or more ears).

 Visible trauma to the head not covered above but still of concern to the professional

The following children meet the criteria for admission to hospital following
a head injury

 History of loss of consciousness.

 Neurological abnormality, persisting headache or vomiting.
 Clinical or radiological evidence of skull fracture or penetrating injury.
 Difficulty in making a full assessment. Suspicion of non-accidental injury.
 Other significant medical problems Not accompanied by a responsible adult or social
circumstances considered unsatisfactory.

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Selection of children (under 16 years) for CT scan [ NICE guideline]: For children who have

sustained a head injury and have any of the following risk factors, perform a CT head

scan within 1 hour of the risk factor being identified:

 Suspicion of non-accidental injury

 Post-traumatic seizure but no history of epilepsy.

 On initial emergency department assessment, GCS less than 14, or for children
under 1 year GCS (paediatric) less than 15.

At 2 hours after the injury, GCS less than 15.

 Suspected open or depressed skull fracture or tense fontanelle.

 Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal

fluid leakage from the ear or nose, Battle's sign).

 Focal neurological deficit.

 For children under 1 year, presence of bruise, swelling or laceration of more than 5
cm on the head.

A provisional written radiology report should be made available within 1 hour of the
scan being performed. [new 2014]

For children who have sustained a head injury and have more than 1 of the following
risk factors (and none of those in recommendation 1.4.9), perform a CT head scan
within 1 hour of the risk factors being identified:
 Loss of consciousness lasting more than 5 minutes (witnessed). Abnormal drowsiness.

 Three or more discrete episodes of vomiting.

 Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian,

cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury
from a projectile or other object).
 Amnesia (antegrade or retrograde) lasting more than 5 minutes[4].

A provisional written radiology report should be made available within 1 hour of the
scan being performed. [new 2014]

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Children who have sustained a head injury and have only 1 of the risk factors in
recommendation (and none of those in recommendation 1.4.9) should be observed
for a minimum of 4 hours after the head injury. If during observation any of the risk
factors below are identified, perform a CT head scan within 1 hour:

 GCS less than 15.

 Further vomiting.

 A further episode of abnormal drowsiness.

A provisional written radiology report should be made available within 1 hour of the
scan being performed. If none of these risk factors occur during observation, use
clinical judgement to determine whether a longer period of observation is needed.
[new 2014]

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96. HEAD INJURY IN A CHILD

GRIPS

"I can see that you are concerned"

"How's the child now?"

"Is she here with you?"

"I'll take a look at him"

Ask about the fall - before, during and after

How long ago, What type of floor, The height of the sofa

What was he doing

Any other children in the house

Has this happened before

Was he left alone? Where were you when he fell?

After - Did he cry immediately after, vomiting, LOC, drowsiness, bleeding, discharge
from ears or nose, swelling, fits, feeding, playing

You need to rule out NAI

Vomiting can suggest a head injury (at least 3 times)

"We try to avoid doing unnecessary investigations and we don't want to expose the
child to unnecessary radiation."

BINRD

Birth

Immunization

Nutrition

Red Book

Development

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96.You are the FY 2 doctor in the Paediatric department.

9 Month old child Jane was brought in by her mother with a history of fall from sofa.
Take history from the mother and talk to her about further management.

History should include pre –incident – incident and post incident – also
questions for Non accidental injuries)

Check for indications for CT scan of head and admission.

Hello I am Dr … one of the junior in the Paediatric department. Are you the mother of
Jane Anderson ? Mother : Yes
Dr: How can I call you please ? Mother : You can call me Mrs Anderson.
Dr: How can I help you Mrs Anderson? Mother: My daughter Jane fell from the sofa today.

Dr: I am sorry to hear that. When did this happen? Mother : About an hour ago.

Dr: Can you please tell me what happened immediately after that?

Mother : She was quite for some time then she started crying.

Dr: why you were worried about Jane to bring her to the hospital? Moher: She has some
bruise on her head.

Dr: What did you do immediately after that? Mother : I brought her here to the hospital.
Dr: It is really good that you brought her I immediately.

Can you please tell me what was Jane doing before she fell from the sofa?

Mother: She was lying on the sofa and playing.

Dr: Was she well before this happened?

Mother: She was completely fine before this happened.

Dr: How did she fall from the sofa? Mother: She rolled over and fell down. I was changing
the nappy of my other child

Dr: Ok. What type of floor was it? Carpeted or tiled floor?Mother: Carpet floor.

Dr: Did she lose consciousness after she fell down?

Mother : She was limp for few seconds but she did not lose consciousness. She started
crying immediately.

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Dr: Has been fully conscious after that until you brought her in here? Mother – Yes

Dr: was she drowsy at all after the fall? Mother : No

Dr: Did you notice any other injury on her head apart from bruise like wound or
swelling ? Mother : No

Dr: Did she have any bleeding or fluid discharge from her ear or nose ? Mother : No
Dr: Did you notice any injury anywhere else in the body?

Mother : No Dr: Did she vomit after the fall? Mother: Yes twice/once.

Dr Did she have any fits? Mother : No

Dr: Did you notice any abnormal behaviour of your child after this incident? Mother: No

Dr: Was she completely fine and playful after this incident apart from vomiting? Mother : Yes

Dr: Did Jane have any injuries in the past for which she was brought into the hospital
or even not brought into the hospital? Mother: No

Dr: May I ask who looks after Jane?

Mother: I look after Jane – sometimes my sister looks after Jane.

Dr: Do you mean your sister lives with you?

Mother: Yes/ No. Sometimes when I have work I drop Jane in my sister’s house.

Dr: Does your sister like your child ? Mother : Yes, she likes her a lot.

Dr: What about Janes’ Father? Mother: We are divorced.

Dr: Does he look after Jane anytime? Mother – Sometimes yes.

Dr: Does he take her with him to look after her ? Mother : No

Dr: Did you have any problem when you were pregnant with Jane? [ to check whether
she is the biological mother] Mother : No

Dr: How was the delivery? Did you have normal delivery or caesarean section ?
Mother: Normal delivery

Dr: Was this a planned pregnancy? Mother : Yes

Dr: Has Jane been diagnosed with any medical conditions at all? Mother: No

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Dr: Do you have any other children ? Mother: Yes I have another 3 year old daughter.
Dr: Did she have any injuries any time? Mother: No
Dr: Whom do you live with? Mother: I live on my own with my 2 children

Dr: How does the father and the children get along with each other? Mother: They are
Ok. Dr: Sorry to ask you this Does the father or any one hurt your children at all?
Mother : No Dr: Is there anything else you think that we may need to know?

Mother: I just feel guilty doctor!

Dr: Please don’t feel guilty. Sometimes it does happen.

Dr: Mrs Anderson. I need to examine your child for any signs of head injuries

[ Examiner did not give any findings – if the examiner asks - what you want to examine
– I will check for head injuries any other new or old injuries. Check the GCS and vital
signs – examiner may say child is fine apart from bruise]

Management:

I think your child has no serious head injury with the information what you have given me.
Normally we do tests like CT scan of the head to look for any bleeding inside the head if the
child vomits more than 3 times or if the bruise is more than 5 cm or if they lose consciousness
and other things. You said she vomited only twice and her bruise is very small and she is
completely fine now - the chances she is having any bleeding inside the head very very low.
So we do not need to do CT scan of the head of your child. There is no need for any
treatment. There is no need to keep her in the hospital.
You can take your child back home. It is very unlikely that she will have any further
problems. You can give her some paracetamol if she keeps crying. Is that OK Mrs
Anderson? Mother : Ok doctor.

Dr: You need to observe her at least for 24 hours at home. If she has any symptoms like:

- If she loses consciousness,

- She is abnormally drowsy (feeling sleepy) that goes on for longer than 1 hour
when they would normally be wide awake,

- you find difficulty in waking her up,

- weakness in one or more arms or legs,

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- vomiting (being sick),

- seizures (also known as convulsions or fits),

- clear fluid coming out of their ear or nose,

- bleeding from one or both ears

I suggest you call the ambulance and bring her back to the hospital emergency
department as soon as possible because these symptoms show there is bleeding
inside the head. But, as I told you, before these are very rare to happen.

Do make sure that there is a nearby telephone and you should stay within easy reach
of the hospital Any other question ? Mother: No

Dr: Thank you.

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97. Empathise with mother when she tells you get child has been crying Does she
have an idea why she's crying?

Ask if crying is continuous or intermittent Ask of falls

Symptoms of intussusception: Inconsolable cry, Diarrhoea – red currant jelly type of

stool, vomiting

So the differential should include causes of inconsolable cry of diarrheoa. The history
should also include risk factors for intussusception

Causes of inconsolable crying

• Meningitis *

• Testicular torsion

• UTI

• Gastroenteritis

• Otitis media

• NAI *

• Strangulated hernia

• Volvulus

• Chest problems

• Corneal abrasion

For more persistent crying, consider:

• Transient cow's milk intolerance.

• Transient lactose intolerance.

• Nappy rash.

• Wind (inadequate burping: try sitting a bottle-fed baby upright when feeding to
reduce air intake).

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• Woman's diet if breastfeeding (for example too much coffee, tea, or soft drinks that
contain caffeine, or too much alcohol or spicy food).
Look for symptoms which can help to rule out many differentials simultaneously

• Fever

• Diarrhoea - Red currant jelly like

• Rash

• Vomiting

• Ask of lumps in stomach, abdominal bloating

BIRND

Relate the diagnosis to the presenting complaint

Investigations include FBC, ABGs (because of the prolonged crying)

1. Admit

2. Address crying - pain medication

3. Correct dehydration

4. Manage cause of pain - intussusception

5. Discuss non-surgical treatment first and then surgical treatment.

There is a slight chance of that happening again

*Enema - a day or two

* Surgery 3-4 days

Differentials for acute diarrhea:

1. Viral gastro enteritis - watery diarrhea, contact ( others having same symptom), food
from outside

2. Bacterial – blood in stool, fever

3.Antibiotics

4.Meckel’s diverticulum – red colour stool but child is not ill, not crying.

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Risk factors for Intussusception

Causes and associated conditions

1. Non-pathological lead point (>90%)

• Viral 50% - rotavirus, adenovirus and human herpesvirus

• Amoebomata, shigella, yersinia.

• Peyer's patch hypertrophy.

2. Pathological lead point (<10%)

• Meckel's diverticulum (75%).

• Polyps and Peutz-Jeghers syndrome (16%).

• Henoch-Schönlein purpura (3%).

• Lymphoma and other tumours (3%).

• Foreign body.

• Postoperative - rarely, postoperative intussusception following operative treatment

of an intussusception has been reported.

INTUSSUSCEPTION

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97.A GP referred a 20 month old child Andrew Collins because he

was crying, lethargic, cold and pale, but making enough urine.

Take history from child’s mother, Mrs Samantha Collins, and talk to her about the
further management.
Dr: Hello, Mrs Sarah Collins. I am Dr … junior doctor in the Paediatric department.
How can I help you? Mom: My son has been crying a lot since almost 10 hours.

Dr: I am very sorry to hear that.

Dr: Do you know why he crying at all? Mom: No doctor

Dr: Did he fall or have any injuries? Mom: No doctor

Dr: Has he got any symptoms?

Mom: He has been passing loose stools since yesterday.

Dr: How many times? Mom: May be 3 to 4 times

Dr: What is the colour of the stool ?

Mom: It looks red doctor (looks like red currant jelly)

Dr: Has he been vomiting? Mom : Yes 3 to 4 times

Dr: What is in the vomit like? Mom: It is green colour liquid (Bile)
Dr: Did you notice any lump or swelling in his tummy?

Mom: Yes his tummy looks bloated

Dr: Has he got high temperature? (meningitis) Mom: No

Dr: Has he got any rash anywhere? Mom: No

Dr: Is the first time these things are happening to him? Mom: Yes

Dr: Does his urine smell bad? (UTI) Mom: No

Dr: Has he got any swelling in the groin (obstructed hernia)? Mom: No

Dr: Any swelling or redness in the scrotum? (torsion testes)? Mom: No Dr: Do you give

him breast milk or bottle milk? Mom: Bottle milk / breast milk

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Dr: Any change in his diet ? (milk allergy) Mom: No

Dr: Any change in your diet (if she is breast feeding – intolerance to dairy products
if mother is drinking too much coffee tea, dairy products)

Dr: Does he have any other medical condition? Mom: No

Dr: Did he have any problem in the tummy before? Mom: No

Dr: Did he have any operations in the tummy? Mom: No

Dr: Is he on any medications? Mom: No

Dr: Was there any problem during his birth or development? Mom: No Dr: Do
you have any other children? Mom: No

Dr: Any medical conditions in the family members? Mom: No

Examination

Dr: Mrs Collins, I need to examine your child’s tummy. (The examiner may say there is
mass in the abdomen).
Diagnosis:

With what you are telling me, I think your son has a condition we call intussusception.
Do you anything about this? Mom: No

Dr: It is a condition in the tummy. As you know, the bowel looks like a tube. In this
condition, a part of the bowel goes inside another part of the bowel like a telescope
which causes bowel obstruction. This quite a serious condition if we do not treat
immediately. This condition is usually seen in children between the age of 3 months to 24
months.
Mom: Why did this happen?

Dr: Sometimes this can happen for no known reason. Sometimes, if he had any other
medical condition affecting the bowel can cause this. (Meckel's diverticulum (75%),
Polyps, Henoch-Schönlein purpura (3%), Lymphoma and other tumours (3%), Cystic
fibrosis, An inflamed appendix, Foreign body, Postoperative).

Mom: What are you going to do, doctor?

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Investigation

Dr: First of all we need to do some tests to confirm whether this is the problem.

We will do an X ray of his tummy (to rule out perforation) and an ultrasound scan of his
tummy (USG may show doughnut or target sign, pseudo kidney/sandwich appearance).

We will also do some blood tests to check whether he is dehydrated because

sometimes children can be very dehydrated with this condition. Is that OK ?

Mom: OK

Dr: Please do not give him anything to eat or drink now until we tell you to do so. To
treat him initially we will give some fluids through his veins to hydrate him.

There are 2 different ways to treat the condition. One is by doing an operation other
one without doing any operation with a simple procedure.

First, we will try with a simple procedure - Our Radiology specialist doctors may try to
push the bowel back to the original position by giving some type of air enema (air
and water double contrast enema) with high pressure through the back passage of
your child.

If it is not possible to correct with the enema or if there are any other problems in his
tummy, we may need to do an operation and correct the condition. (Indications for
laparotomy: Peritonitis, Perforation, Prolonged history (>24 hours), High likelihood
of pathological lead point, Failed enema).

Mom: Can you leave it like that doctor ? Won’t it become normal on its own ?

Dr: It is very rare that it will correct itself. Since he already has severe symptoms it is
very unlikely it will correct itself now. If we leave it like that for long time it can cause
damage to the bowel wall and we may have to do the operation.

Mom: When can I take him back home?

Dr: If it corrected by enema, you can take him back home in a day or two. If we have to do
the surgery to correct the problem then we need to keep him in the hospital for about 3 to
4 days.

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Mom: Will there be any problem after the treatment? Dr: Usually there is no problem
after the treatment.

Mom: Will it happen again?

Dr: Very rarely, it can happen again (recurrence rate : 5-15%)

Dr: Any other concerns? Mom: No

Dr: Thank you very much. I will try to arrange the tests now and keep you informed.

INTUSSUSCEPTION

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98. You are the FY 2 doctor in the Paediatric department.

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

Dr: Are you Mrs Jennifer Anderson? Mother :Yes.

Dr: Are you the mother of Rachel Anderson? Mother : Yes

Dr: How are you doing? Mother: I am fine doctor.

Dr: How can I help you Mrs Anderson?

Mother: I was told that my daughter has to have a MMR vaccine next week. I am
concerned about it.

Dr: May I know what are you concerned about? Mother: I heard MMR vaccine causes Autism.

Dr: First of all, I am very glad that you came to us with your concerns.

Yes it was true that such an article was written by one of the Paediatric Consultant long
time ago. He was found to have misconducts.

But then the article published was proven to be wrong and the publishers withdrew their
article.

There are many studies done after that and all shows it is safe.

There are millions of people taking this vaccine around the world and they do not have
any problem.

MMR is given around 15 months of age and this is the same age around which autism
is diagnosed so there was a fake impression that autism is caused by MMR.

Mother: But why do you want to give the MMR vaccination because those diseases are
not in UK anymore?

Dr: The reason these illnesses are not seen in the UK is because we give this
vaccination to almost every one here in UK. If we stopped giving this vaccination these
illnesses would reappear in the UK.

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Also Your child may come into contact with a foreigner who has entered the UK and is
infected with Measles, Mumps or Rubella and your child may get the infections from
them.

These infections are dangerous if at all your child gets this infections -

MEASLES is a very contagious infection and may cause complications such

as diarrhoea, ear infections, pneumonia.

MUMPS is also a contagious infection. It may cause complications such as meningitis

and deafness. In girls, it may cause swelling of the ovaries. In boys, it may damage the
testicles.

RUBELLA (German measles) is usually a mid-infection; however, it can be harmful

to pregnant women. It may cause deafness, brain and heart damage, and eye defect
in unborn babies.

By giving your child a vaccination it helps to lower the chances of them contracting a
serious illness. It also helps to prevent other children from contracting the disease as
less people will have the disease to pass on.

Mother: I also heard that MMR vaccine can cause bowel problems (Colitis)!

Dr: I would like to reassure you there is no link between bowel problems (Colitis) and
the MMR vaccination.

Mother: Is there any alternative to MMR vaccine?

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

Studies have not shown any advantage of giving MMR as separate vaccinations.

If given separately, we have to wait 4 weeks in between each vaccination.

We don't want to put the child through unnecessary pain by injecting the vaccination
on three separate occasions.

Mother: How will you give the vaccine?

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Dr: I need to ask you few questions about your child to see whether it is suitable to
give vaccine now.
Take a short history for contraindication:

Is your child currently unwell? No

Does your child has any long term illnesses? No

Have they ever had any immunizations before? Yes - usual jabs

Were there any problems afterwards? No

Are they on any regular medications? No

Any allergies? No

Dr: Your child is safe to receive this vaccination. We give 2 doses of MMR vaccine –
first dose is given after the child’s first birthday, and the second the dose before pre-
school (3 and half years)
The vaccination will be given as an injection into the muscles of thigh or upper arm.

EMLA cream is a local anaesthetic cream that can be applied to the skin to suppress
the pain of injections.

After, may be your child may develop Redness and Swelling around the site of the
injection or fever. But this is very common and not dangerous – you can give Calpol
(Paracetamol syrup)

• You should contact your GP if: very high temperature, fits, high pitched cry,
huge swelling anywhere on the body but especially around the site of injection or lips
and mouth.

MMR vaccine can cause mild reaction like indurations ( thickness in the skin) and pain
at the site of injection

Mother : My child has egg allergy, is it safe to give vaccine?

Dr: Egg allergy is not a contraindication for giving the MMR vaccine. This vaccine is
not made from yolk cell.

Dr: Do you have any other concerns? Mother : No

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Dr: Are you happy to have MMR vaccine to your child now? Mother : Yes / I will think
over it.

Dr: Once again Mrs Anderson I am very glad that you came to us with your concerns
about the vaccine. I hope I was able to clear all your doubts. Hope everything goes
well.

Thank you very much

MMR
Information ON MMR

The MMR vaccine is an injection that prevents you from catching measles, mumps and
rubella.

It’s usually given during childhood as part of the routine vaccination schedule.
However, you can have the MMR vaccine at any age.

MEASLES is a very contagious infection and may cause complications such as

diarrhoea, ear infections, pneumonia.

MUMPS is also a contagious infection. It may cause complications such as meningitis

and deafness. In boys, it may damage the testicles and in girls, it may cause swelling of
the ovaries.

RUBELLA (German measles) is usually a mid-infection; however, it can be harmful to

pregnant women. It may cause deafness, brain and heart damage, and eye defect in
unborn babies.

OTHER FACTS

The MMR vaccine consists of a combination of three individual vaccine against

measles, mumps and rubella in a single shot. The three vaccine combined in MMR are
not available as single vaccine on the NHS.

This is because the NHS does not recommend single measles, mumps or rubella
vaccines as there is no evidence to support their use or to suggest that they are
“safer” than MMR.

World Health organization support the use of MMR, and none support the use of

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single vaccines.

Be aware, though, that MMR is a ‘live’ single vaccine, they will have to wait at least
four weeks until they can have the MMR vaccines.

Child may develops a mild symptoms of measles [post-vaccination symptoms] after

receiving their MMR vaccine, post-vaccination symptoms are not infectious, so your
child will not pass anything on to non-vaccinated children.

To get the best protection children should be vaccinated with the MMR vaccine at the
scheduled times-between 12 and 13 months of age and again at 3 years 4 months.

WHY IS MMR GIVEN AFTER 1 YEAR OF AGR?

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

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99. A. You are the FY 2 doctor in the Paediatric department Mrs Julia Robert has

brought her 18 months old son Ben to the hospital with complaint of an episode of fit

which lasted for few minutes today. She is worried about her son. On examination - his

ear drum was red and had high temperature. Take history from the mother and talk to

her about the further management.

A. (much history and little examination)

1. Did this happen before? What happened before ? what happended during? What hapend
after it?

3. Hello I am Dr... one of the junior doctor in the Paediatric department. Are Mrs Julia
Robert? Mother: Yes Dr: Are you the mother of Ben ? Mother: Yes

4. Dr: How can I help you Mrs Robert? Mother: Dr, My child had fits

5. Dr: Could you please tell me in detail, what happened before that?

Mother: He was sweating before fits and he was pale as well.

6. Dr: Can you please confirm the duration of fits? Mother: 2 min You did say that he was
jerking. I know it is very difficult to notice. But I still need to ask --> how much did it last?
usually she will answer <5 min

7. Dr: Is it the first time? Mother: Yes

8. Dr:How is your child after this fit? Mother:He seems to be fine now.

9. Dr: Did he have fever before this incident ? Mother: Yes, He had flu and his nose was
running. I gave him Paracetamol. But still he was hot before fits.

10. Dr: Did Ben have any rash? High grade fever? Was he crying while moving his neck?
(meningitis). Mother: No

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11. Dr: Did he have his food today as usual ? ( hypoglycaemia) ? Mother : Yes

12. Dr: Ben diagnosed with any medical condition like Diabetes, Epilepsy? Mother: No

13. Dr: Does Ben feel sick in morning? Does he have any weakness in limbs? Mother: No

14. Dr: Did he have any head injury recently? Mother : No

15. Dr: Is he on any medication? Mother – No

16. Dr: How was his birth - was there any problems during birth? Mother : No Dr: Any problems
with the development? Mother – No

17. Dr: Any one in the family has fits ? Mother: No.

18. Dr: Mrs Roberts we have examined the child and found that one of the ear drum of your
child's is red and also his temperature is high. Mother: Ok

B.

1. Diagnosis: I think your child has a condition what we call as febrile convulsions. Do you
know anything about this? Mother : No doctor

Dr: This is condition where the children get fits when they have fever.

2. Mother : Is it a dangerous condition? Dr: The vast of majority of febrile seizures are not
serious. Children usually have full recovery with no permanent damage. Most illness which
cause fever and febrile convulsions are the common coughs, colds and viral infections which
are not usually serious. However, the illness that causes the fever sometimes can be
serious- for example, pneumonia or meningitis.

3. Mother: Why my child is having fever? Dr: I think your child is fever because he has ear
infection - we need to treat the ear infection with some medications.

4. Mother: Will this fit happen again doctor ? Dr: Febrile Convulsion is common in children
aged between 6 months and 5 years, Generally, most of the children grow out of this
condition. So usually after the age of 5 years they will not get this condition. However until
they reach 5 years old they may get this fits again if they have fever.

5. Mother: What can I do if it happens again?

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a. Dr: First of all you should make sure that your child will not get high fever to prevent him
from getting the fits. If he has fever- keep giving him regular Calpol (paracetamol) to keep
the temperature under control. Keep your child very lightly dressed. You can also give him
plenty of fluids to prevent dehydration.

b. When he has a fit i. Lay them on his side with his face turned to on the side. (This will stop
them swallowing any vomit, and prevent chocking )

ii. Don't put anything , including medication, in your child's mouth while they are having a fit.
Do not put any hard objects into the mouth to prevent tongue bite because it can break teeth
and the broken teeth can go into the wind pipe and cause choking. It is better to have tongue
bite rather than broken teeth because tongue bite will heal on its own in few days.

iii. Stay with your child and Note the time. iv. Usually the fit will stop in about 5 minutes.
There is no need to bring your child to the hospital. You can tell to your GP about it.

v. If it lasts longer than five minutes, (or if it's your child's first seizure) call the ambulance.

6. Mother: Is febrile convulsion a type of epilepsy? Dr: No, the cause of a febrile convulsion
is related to the feverish illness and epilepsy is because of abnormal electrical activity in
brain. 7. Mother: Will it lead into epilepsy.

Dr: It is very rare that this will lead into epilepsy. 8. Mother: Will it cause learning disability?
Or brain damage ? Dr: There is no research that suggests simple febrile convulsions cause
long-term problems, for example brain damage or learning difficulties

9. Mother: Will you give me some medication? Dr: There are no medications required to treat
this condition. [ parents have been to taught to give per rectal diazepam if the fits lasts
longer than 5 minutes - but this is taught to only those people who live far away from the
hospital - more than 2 hours journey] (no need to tell this to the mother in exam)

10. Mother: What will you do now? Dr: I will examine and admit your child, we will do some
tests (Blood tests and urine tests). We will keep him for observation for some time. If all
investigations are normal, then it is Febrile convulsion. Then you can take your child home.

11. Dr: Any other concerns Mother : No Thank you very much.

FEBRILE CONVULSION

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FEBRILE CONVULSION

Information
A febrile seizure is a convulsion that occurs in some children (aged 6 month to 5 years) with
a high temperature (fever). The vast majority of febrile seizures are not serious. Most occur with
common illnesses such as ear infections and colds. Full recovery with no permanent damage is
usual. The main treatment is aimed at the illness that caused the fever.
Symptoms of febrile seizures: The main symptom of a febrile seizure is a fit that occurs while a
child has a fever.
ile seizures often occurs during the first day of fever, which is defined as a high
temperature of 38C (100.4F) or above.
’s fever and the
start of a seizure. Seizures can occur even if your child has mild fever.
Seeking medical advice
You should take your child to hospital or dial 999 for an ambulance if:

You suspect the seizure is being caused by another serious illness, for example meningitis.

If your child has previously had febrile seizures, it’s recommended that you telephone your GP or
call NHS 111 for advice.
You should also contact your GP or NHS 111 if your child shows signs and symptoms of
dehydration (a lack of fluid in the body). This includes:

– the soft spot usually found at the top of a young child’s head.
MANAGING A FEVER

reduce the temperature]

often to prevent them from
getting dehydrated.

on the packet. Do not give paracetamol and ibuprofen at the same time.

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ey have a fever. This causes them to shiver which can make

the temperature rise.

room.
COMPLICATIONS

DIFFERENTIAL DIAGNOSIS

ABOUT DIAZEPAM

seizures or for children who have a low threshold for seizures, especially if

once after 5 minutes if the seizure has not stopped, or one dose of buccal midazolam.

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99.B.

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100. A.
Child had fever + pulling on his ear + can’t tolerate oral feeding. On examination
right eardrum pink (usually written),
Left ear drum is red. cappliary refil less than 2 sec. Child
was kept in the A& E for few hours. Given paracetamol. Temperature come down
after the paracetamol. [Vitals before and after pcm administration:
Temp- 38.8/37celsius, RR- 40cpm/25cpm, PR130bpm/100bpm]
All the blood tests – normal.
Talk to the father. It is always ear infection in child A. Take history
1. Fever – since when ?
2. Ear pulling, discharge from ear ? - No
3. Child has nasal discharge, not eating drinking properly. No fits.
4. Has he shown the child to GP before coming to hospital ( father said GP did not give
antibiotic)
5. Any medication given
6. R/o meningitis ( shying away from light, rashes on body)
7. UTI ( crying on passing wee)
8. Past history – any medical conditions? Medications ? Allergy ? previous such
incidents.
9. Tell the father
 We have examined – child had high fever – now after Paracetamol - it has come down.

 His left ear drum is red. He has not other problem. All the blood tests are also normal.


Diagnosis: Looks like child has viral infection affecting the left ear.
Treatment:
 They usually subside on its own in the new few days.
 Antibiotic medications not required.
 Admission not required.
 Once he starts eating and drinking now - you can take him home.
 Keep giving him regular paracetamol. Give him plenty of fluids to drink.
 Hopefully he will completely improve in the next few days.

Warning signs: If he become very unwell, very lethargic and has discharge from his ear –

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these shows that he is may have developed Bacterial infection which sometimes can happen
– please bring him back to the hospital.

EAR INFECTION IN A CHILD

Report the findings and improvement to the Father

Tell him the diagnosis

 Acknowledge his concern

 Tell him what otitis media is

 Give him safety nets

 Indications for admission

o If he's not tolerating meals

o Ear infection in child

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100B. VOMITING IN A NEWBORN CHILD

You will be worried about dehydration, electrolytes, aspiration, malnutrition

Differential Diagnoses
• Obstruction
• Meningitis
• Gastroenteritis
• Head injury
• Reflux
• Poisoning
• Intolerance
• UTI
• Pneumonia
Questions about the vomitus

• Projectile
• When
• Quantity
• Frequency
• Colour

Other symptoms
• Fever
• Rash
• Loose stool
• History of a fall
• Cough
• BIRND
To explain the diagnosis to the mother, you can draw the anatomy for the mother

Investigations
ABG - Explain metabolic alkalosis to the mother

Urea and electrolytes, Blood sugar

Abdominal ultrasound

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Management

1. Admit

2. IV fluids

3. Involve seniors, surgeons

4. Talk to mother about surgery - usually keyhole but main decision is by the surgeon

5. Tell her not to give the child and food to eat or let us know beforehand

6. Vomiting in New Born Child – Pyloric stenosis

Causes of vomiting in babies

1. Meningitis: “Does your child shy away from light?” Rashes?

2. UTI: Fever, smelly urine, “Does he cry more while passing wee?”

3. Gastroenteritis: Vomiting, Fever, Diarrhoea, Other similar problem (in contacts)

4. Food or milk intolerance (Any change in food, New food introduced)

5. Gastro-oesophageal reflux: Food dribbling, Reflux is just your baby effortlessly

spitting up whatever they've swallowed. Muscles do not contract.
6. Too big a hole in the bottle teat which causes your baby to swallow too much milk
7. Over feeding: Do you think you are feeding more than usual

8: Accidentally swallowing something poisonous: “Any chance baby would have

swallowed anything poisonous?”

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

10. Strangulated hernia: Baby cries a lot, Swelling in the groin

11.Intussusception: Cries a lot, Mass felt in the tummy, red colour stool,

12. Head injury: Any injury to head?

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13. Pneumonia: Fever?

14. Middle ear infection: ?Ear discharge

Dehydration questions

Dry mouth, crying without producing tears, urinating less or not wetting many nappies,

Lethargy, floppy, Drowsy, not active

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100 B.
You are FY2 doctor in Paediatric Department.6 weeks old boy, Rhys was brought in by
his mother with history of persistent vomiting for last 2 days.

Take history from the mother Mrs Nicola Hampshire and talk to her about further
management.

Vital signs are given in question.

Hello I am Dr... one of the junior doctor in the Paediatric department. Are you the
mother of Rhys? Mother: Yes. I am
Dr: How may I call you? Mother: ? You can call me Nicola

Dr: How can I help you Miss/Mrs. . .?

Mother: My son has been vomiting a lot since last 2 days.

Dr: I am really sorry to hear about that. Can you tell me more about that?

Mother: Doctor he is throwing everything out.

Dr: How did it start? Mother: Doctor it started almost suddenly.

Dr: What do you feed him? Mother: I breastfeed him.

Dr: Does the vomiting occur in immediately after (pyloric stenosis, GER) you
breastfeed him or later ?

Mother: Yes, doctor he vomits when I feed him.

Dr: Is it like throwing up or just dribbling of the food from the mouth (Regurgitation) ?

Mother: He is throwing up.

Dr: Does the vomit go far away like a fountain (Pyloric Stenosis)? Mother : yes

Dr: How many times does he vomit in the day?

Mother: Every time I feed him, (almost instantly) he throws up.

Dr: What is the content of the vomiting?

Mother: It is just the milk.

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Dr: Is it ever green coloured (bilious – duodenal atresia) or blood stained? Mother: No.

Dr: Do you think you are feeding him more than usual (Overfeeding)? Mother : He is
very hungry all the time (may be because of pyloric stenosis also)

Dr: Does your child shy away from light? Any Rashes? (meningitis)? Mother : No

Dr: Has he got fever (Meningitis, UTI, Pneumonia, Ear infection)? Mother : No

Dr: Doe she cry a lot (meningitis, Obstructed hernia, Intussusception)? Mother : No

Dr: Have felt any lump in his tummy (Pyloric stenosis, Intussusception)? Mother Yes/ No
Dr: How is his poop? Is it normal or has he got diarrhoea (loose stool)
(Gastroenteritis)? Mother – Normal. (may be less in quantity in Pyloric stenosis) .

D: Is the poop red coloured(Intussusception) ? Mother: No

Dr: Does his urine smell bad? (UTI) Mother: No.

Dr: Is there any recent change in his feed (Milk allergy)? Mother: No doctor.

Dr: Did he have any injury to the head? Mother : No

Dr: Is his mouth dry (dehydration) ? Mother: Yes/No

Dr: How is he – is he active or drowsy (severe dehydration)? Mother: He is not active

but a bit drowsy.

Dr: How has your child been before? Has he been diagnosed with any medical
conditions? Has he ever been admitted to hospital before? Mother: No.

Dr: Any medications that your child is on? Mother: No doctor.

Dr: Does your child have any allergies? Mother: No.

Dr: Does any child in your family now or in the past have/had similar problems as
Rhys? [Family History risk factor for Pyloric Stenosis, gastroenteritis (contagious)]

Mother: Yes/No

Dr: Is he your fist child or do you have any other children?

Mother : He is my first child. (First child – risk factor for Pyloric stenosis)

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Dr: When you delivered Rhys – was it normal birth or did you have any problems ?
Mother: It was normal.

Dr: Any problems during development? Mother: No doctor.

Dr: Is there anything else you think that may be important that we may need to know ?

Mother : No

Examination:

Well, I need to examine your baby’s tummy.

(Examiner may say there is no abnormal finding)

Diagnosis:

Dr: From the information that I have gathered I think Rhys might be having a condition
what we Pyloric Stenosis. Do you know anything about it? Mother: No doctor.

Dr: It is a condition in the tummy that can sometime affect the new born children. Let
me explain it to you. Our stomach opens into the gut (bowel). The outlet of the
stomach into the gut is called the Pylorus. Stenosis means a narrowing. Pyloric
Stenosis means a narrowed outlet of the stomach. Because of the narrowing of the
outlet of the stomach food is not going to the gut. So the babies vomit the food out.

Mother: Is it serious doctor?

Dr: It is not a serious problem because we have a good treatment for this. This is not a
worrying condition.

Mother: Why did this happen?

Dr: It is not known why this occurs. This condition is seen more in boys than in girls.
And sometimes, it can run in families. Mother: What are you going to do?
Dr: We need to admit Rhys. First of all, we need to confirm whether this is the problem
with Rhys. I think Rhys is very drowsy because of severe dehydration which can happen
when they vomit a lot. We need to do some blood tests to check whether he has
severe dehydration. We will do some blood tests on him to check the blood gases.

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Examiner may give the test result. Picture is as follows:

pH = High (Normal 7.35 to 7.45)

PaCO2= normal or high

HCO3- = high

Tell the mother - The blood test shows he has some problem called metabolic alkalosis
this is due to vomiting. (If asked, then mention vomiting of acid from the tummy).

We also need to perform an ultrasound of his tummy to confirm whether this is the
condition. Mother: Ok doctor.

Treatment

Dr: We need to admit him and give some fluids through his veins for the hydration and
nutrition. So, please do not feed him until we tell you to do so. Is that Okay?

Mother: Okay. How will you treat him doctor ?

Dr: We can do a small operation to correct the narrowing of the stomach outlet and it
normally cures the problem. This operation is usually done by keyhole surgery. A small
cut is made in the skin over tummy. The operation allows the obstruction site to widen
into a normal size. This means that milk and food can pass easily out of the stomach
into the bowel.

Mother: Will there be any complication?

Dr: Some complications from the surgery include bleeding and infection. However,
complications aren't common, and the results of surgery are generally excellent.

Mother: Will he be normal after this?

Dr: Yes, he will be normal and he will grow normally without having any problems.

Dr: Any other concerns? Mother: No, Thank you.

100B. VOMITING IN A NEWBORN CHILD

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FACTORS SUGGESTIVE OF CHILD ABUSE

1. Signs of burns
2. Findings not matching the history
3. Delayed presentation - Find out how far they live from the hospital. Find out why they
delay.

4. Low socioeconomic status

5. Depressed child
6. Unexplained bruises or bruises of different ages
7. Nature of the injury
8. Unemployed parents
9. Mental/physical illness of carer
10. Young parents
11. Unplanned pregnancy
12. Who brought the child to the hospital
13. Behaviour of the child
14. History of domestic violence
15. Frequent school absence
16. Carer [non biological]
17. Past history of injury
18. Disability or chronic illness of child

Recent GMC guidance says that all doctors have a duty to report concerns that a child
may be at risk.

DIFFERENTIAL DIAGNOSES

• Medical causes of failure to thrive.

• Other causes of falls and accidental fractures - eg, epilepsy.

• Conditions causing increased bruising - eg, thrombocytopenia, leukaemia.

• Mongolian blue spot (a congenital mark), which can resemble a bruise.

• Medical conditions predisposing to fractures

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NON-ACCIDENTAL INJURY
Find out who the usual caregiver is

When swelling was noticed

Ask of previous hospitalizations

"How was your pregnancy with him? "

- Find out whether the boyfriend is the father

- Any other swellings?

- Finding out her occupation will show financial status

- Social history of mother and father

- Any other children in the house?

- BIRND

Tell her what your findings are

“We're quite worried about the findings. His bone is broken.”

- Tell mother you want to admit the child

- Involve seniors, orthopaedic specialist

- If fracture, skeletal survey and CT scan head are done

- If there is a bruise, do a clotting screen

Tell her "There's something I'm really worried about. These fractures don't just
happen. It's very important you find out why this happened so it doesn't happen
again."

"For this, I'll have to involve social services"

History

“What brings you to the hospital?”

- Elaborate the event:- What happened? Where it happened?

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- When did it happen? (if delay in presentation – “What time did you come to the
hospital?” – consider the time she was waiting to see the doctor. Usually how
much time does it take for you to come to the hospital from that place.

- If there is still delay, find out the cause of delay in presentation - “what did you
do after the incident? – Keep asking about all events till the time she brought
the child to the hospital.

“When this happened were you with the child, - if not who was there at that time, any
one witnessed at all? Where were you? What did you do immediately?”
Background
Who looks after the child? Who brought? Person who looks after the child - are they
the biological father or mother? Who else is at home? Any other children at home?
(probably they too may be abused)

Other unexplained injury: We noticed.......bruises on. .... [e.g. arm] - do you know
about this? If yes, take full details

Past incidence - Any injury in the past? If yes - did you get medical help?

Unplanned pregnancy - Was it a planned pregnancy? Any problem during or after

birth?

Late presentation - Is there any problem because you could not bring immediately?

Economic status - What do you do for a living?

INVESTIGATIONS IN CASE OF SUSPECTED NAI

If there is a bruise – R/O medical cause - FBC (platelet count for ITP) and clotting
screen for bleeding disorders.

Skeletal survey [fracture Hx]

X Ray of the affected part if signs of fracture.

Fundoscopy [for rocked/shaken baby]

Brain imaging if necessary - all children under the age one of year irrespective of signs
of head injury - in older children if there are signs of head injury.

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MANAGEMENT

● Admit [inform parent about admission]

● Symptom relief [pain killer, fluid- burn ]

● Inform senior
● Medical photography of affected area

● Assess growth

● Check for History of previous admission

● Inform Orthopaedic surgeon if fracture

● Consider checking child protection list and involve social services [senior does
this]

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101. You are the FY 2 doctor in the Paediatric department.

Miss Henna Smith brought in her 4 month old son Mitchell with swelling on his left
arm.

X Ray shows spiral fracture of left humerus.

Take history from her and discuss management with the mother.

Dr: Hello Miss Henna Collins, I am Dr …. How are you doing ? Mother: I am fine thank
you.

Dr: Can you please tell me what brings you to the hospital ?

Mother: In the morning, when I came home, I noticed swelling on Mitchell’s arm.
Dr: I am sorry to hear that. Do you know how this happened ?

Mother: I don’t know

Dr: Were you not with Mitchell last night ? Mother: No. I was at work.

Dr: Who was looking after Mitchell at that time ?

Mother: I asked my boyfriend Connor to look after Mitchell.

Dr: Did you ask your boyfriend about this swelling?

Mother: I could not ask him because he was sleeping. / I asked him but he said he did
not know anything / I could not ask him because as soon as I reached home he left for
his work.

Dr: What time did you notice this? Mother: In the morning at …

Dr: Did he have that swelling before you went for your work ? Mother: No he didn’t have that
swelling.

Dr: OK. Has he got any other injuries ?

Mother: I don’t think so. I saw only swelling in his arm.

Dr: What did you do immediately after you saw the swelling? Mother: I brought him here.

Dr: Mrs Collins. You have done very good thing. We will definitely help him.

Dr: Did Mitchell have any injuries in the past at all? Mother: No

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Dr: Has he got any medical conditions at all? Mother: No

Dr: Is he taking any medications? Mother: No

Dr: Is he allergic to anything ? Mother: No

Dr: Did you have any problem when you were pregnant with him? Mother: No

Dr: Any problem during birth ? Mother: No

Dr: Was it a planned pregnancy ? Mother: Yes

Dr: Any problem with his development ? Mother: No

Dr: Where is his father ? Mother: I don’t know.

Dr: Do you mean your boyfriend is not Mitchells father ? Mother: Yes that is right.

Dr: Do you have any other children ? Mother: No

Dr: What work do you do? Mother: I work in an Off license shop Dr: How is your
finance – any problem with that at all ? Mother: No

Dr: What does your boyfriend do ? Mother: He works as .. Dr: Does anyone of you
use drugs or drink alcohol ? Mother: No

Dr: Is there anything else you think you want to tell me ? Mother: No

Dr: Miss Smith, We have done the X ray. Unfortunately it shows that he has fracture in
his left arm bone.

Mother: OK. What are you going to do?

Dr: We will have to keep him in the hospital and treat him. We will inform the
Orthopaedic doctors. They will manage him for the fracture.

Mother: OK.

Dr: Also we may need to do the X Ray of his whole body and also CT scan of his head.
I will inform my seniors and we need to involve social services.
Mother: Why involve social services ?

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Dr: I am very sorry to say this. This fracture looks very suspicious. This type of fracture
usually do not happen due to injuries. It usually happens if someone has twisted his
arm. So we need to involve the social services. They will look into this.

Mother: Do you mean to say I am hurting my child. I am going to take my son back. I
am the mother you can’t stop me.

Dr: I am sorry if I made you feel that way. I didn’t mean that. You have brought your
son immediately here. It shows you are very caring mother. I am very sorry if I hurt your
feelings. I mean there are chances that someone has done this to your son.

Mother: Do you mean to say my boyfriend has done this?

Dr: We do not know who done that. You said you were not there when this happened.
So it is for your son’s benefit that we need to involve the social services to see how this
would have happened? Don’t you think it is good to involve the social services so that
these things may not happen to him again? What do you say?

Mother: Ok, doctor. Thank you very much

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102. 5-year old child with shortness of breath. Take a history and discuss
management

Differentials

- Asthma
• Is he already diagnosed asthma
• Previous admissions
• How often he gets attacks?
• Why he is still getting asthma attack? May be still has risk factors:
• Dust (carpet floor) - What type of floors do you have? Any
dusty areas around the child?
• Pollen (Plants inside or near home, child plays in the garden)
• Unusual too much exercise (too much playing)
• Any pets at home
• Passive smoking
• Cold weather
• Infection
• The medication is not working or not being given properly
- Pneumonia (cough, sputum, fever)
- Foreign body (do you think your child has swallowed any foreign body and
more common in crawling children)
- Heart failure (has she been diagnosed with any heart conditions , do you think
she’s more short of breath compared to other children after playing)
- Anaphylaxis (allergy, rash)
- Epiglottitis (drooling)

If the child is not diagnosed, you can ask if the shortness of breath is seasonal. Also ask
of symptoms (wheeze, cough), triggers, eczema/skin lesions, family history.

Reasons why the medication might not be working :-

1. Using expired medication

2. Wrong technique of using inhalers.
3. Wrong washing technique. If the aerochamber is not washed properly, static

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might build around the chamber and the medication might gather within the
chamber and not be delivered to the child.
● From the history, the child had fever, cough and shortness of breath for 2 days.
He has eczema and father has asthma
● Child had 2 attacks of similar episodes previously once when the child was 2
years old and he again when the child was 3 year old.
● Known asthma child. Ask whether mother gave any medicine now. Mother
gives blue inhalers.
● Has pets at home and also has a collection of flowers at home.
● No dust. No carpet floor.
● Check if is she giving medications whenever required.
● Any other past medical conditions
● Past admissions
● Any other medications?
● Allergies
Examination

1. NEWS chart
2. Chest examination – examiner may or may not give findings. If there is
consolidation in addition to the rhonchi, it is a pneumonia + asthma.
Provisional diagnosis

1. I think your child has infection in the chest – means there are bugs in the chest
which makes the asthma worse.
2. We need to do some tests like blood tests (for infection markers) and chest X-Ray
3. We need to admit the child for treatment. Give Oxygen first.
4. We may need to give him the salbutamol medicine as nebuliser (like a steam
inhalation through a machine) until he improves. The mother might ask why you
are giving salbutamol when she has already given him at home. You can tell her
that the nebuliser will make the salbutamol go much deeper and this makes it
more effective.
5. We will give him antibiotics and also paracetamol.
6. We will also give some steroid medications.
7. I will talk to my seniors.
8. Once he improves, then we will discharge your child. The admission should be
for about 2 or 3 days.

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Advise:

Avoid all trigger factors. It is better to avoid close contact with the pets and flowers
because it can exacerbate asthma. Better to have wooden floor at home rather than
carpet floor. Keep the home clean avoid dust. Avoid smoking. If the child develops a
fever, bring to the hospital as soon as possible.

Do you know how to use the inhaler properly? Check the technique if time permits.

Child with asthma, Might be with or without chest

infection

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103. 15 day old baby was noticed to have jaundice by the midwife. Talk to the
mother and discuss management with her.

1. I was told by the midwife that your child has yellowish colour of the skin. Did you
notice his skin turning yellow? – N

2. Is he active? Playful? Yes

3. Did he have fever? Vomit? No

4. Did you notice any rash? No

5. Bowel movements- how is his poo? Any colour change? Blood in the poo? Any
change in consistency? (Everything may be normal)

Any problems with the wee? Is he passing urine well? Any discolouration? Presence of
blood in the urine?

6. Do you breastfeed your child? Yes

7. Is he feeding well ? Yes

8. Was there any recent change in your diet? Changes in his diet? No

9. Did you notice any lump in the tummy? No

10. Is he gaining weight normally ? Yes

11. Were you told whether your baby had an under-active thyroid or a urine infection
after he was born ? (pathologic cause)

12. Were you told that there was some mismatch of the blood group between yours
and your baby’s blood ? (pathologic cause)

13. Do you have any other children – if so - did they have jaundice like this when they
were born ? (Crigler Najjar syndrome)

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MAFTOSA-

Does the baby have any medical conditions?

Does the mother have any medical conditions? (diabetes has an increased risk of
causing neonatal jaundice)

Is the baby/mother on any medications? Does the baby have any allergies?

Any medical conditions in the family?

DELIVERY HISTORY-

Was it normal delivery or caesarean section?

Was there any complications with the pregnancy or delivery?

Were any instruments used during the delivery? (cephalohaematoma can cause jaundice)

Is he your first child? (if not, ask for if there was any similar history of physiological
jaundice in the previous pregnancy)
Examination:

I need to examine your child. I need to check for jaundice in eyes and skin, also I need
to examine his tummy.

Ask for NEWS chart.

I shall be doing a couple of tests - FBC, LFTs

Examiner may give findings - vitals normal, Icterus present

Abdomen examination-normal

Tests - FBC - normal, total bilirubin-150 (below treatment level), direct-10

Diagnosis: From what you have told me and from what I have examined, it seems your
baby has a condition called breast milk jaundice a type of harmless jaundice.
Mother : What is that, Doctor ?

Dr: Jaundice is a common and usually harmless condition in newborn babies that
causes yellowing of the skin and the whites of the eyes.The medical term for jaundice
in babies is neonatal jaundice.

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Blood has red blood cells which are broken down and replaced frequently. When it breaks
down it produces a yellow substance called Bilirubin. Jaundice is caused by the build-up of
bilirubin in the blood. This bilirubin is usually removed from the blood by Liver. The liver in
newborn babies is also not fully developed, so it is less effective at removing the bilirubin
from the blood.

By the time a baby is about two weeks old, their liver is more effective at processing bilirubin,
so jaundice often corrects itself by this age (2 weeks) without causing any harm.

This type of Jaundice usually happens after 2nd day of birth and usually resolves by 2 weeks,
however sometimes it can last longer time what we call as prolonged physiological Jaundice.
This prolonged jaundice could be due to the breast milk.

Mother: What Is Breast Milk Jaundice?

Dr: Breast milk jaundice is a type of jaundice associated with breast-feeding. Breast Milk
Jaundice is jaundice that persists after physiologic jaundice subsides. It is seen in otherwise
healthy, full-term, breastfed babies. .................... Most babies who present with true
breast milk jaundice (only 0.5% to 2.4% of all newborns) may see another rise in bilirubin
levels at about 14 days.

It typically occurs one week after birth. The condition can sometimes last up to 12 weeks, but
it rarely causes complications in healthy, breast-fed infants. Prolonged jaundice.

The exact cause of breast milk jaundice isn’t known. However, it may be linked to a
substance in the breast milk that prevents certain proteins in the infant’s liver from breaking
down bilirubin. The condition may also run in families.

Breast milk jaundice is rare, affecting less than 3 percent of infants. When it does occur, it
usually doesn’t cause any problems and eventually goes away on its own. It’s safe to
continue breast-feeding your baby.

What Are the Symptoms of Breast Milk Jaundice?

The symptoms of breast milk jaundice often develop after the first week of life. These
may include:

● Yellow discoloration of the skin and the whites of the eyes

● Fatigue
● Listlessness

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● Poor weight gain

● High-pitched crying

Mother: How Is Breast Milk Jaundice Treated?

Dr: If the level of bilirubin is below the treatment level (Tell the mother - We have done a
blood test to check the level of bilirubin. Then show the blood test to the mother and
explain bilirubin is below treatment level).

- It’s safe to continue breast-feeding your baby. Jaundice is a temporary condition that
shouldn’t interfere with the benefits of breast milk. Mild or moderate jaundice can usually
be monitored at home. It is better to breast-feed your baby more frequently or to give your
baby formula in addition to breast milk. This can help your infant pass the bilirubin in their
stool or urine.

(If the examiner says level is above the treatment level - Severe jaundice is often
treated with phototherapy, During phototherapy, your baby is kept under a special
light for one to two days).

How Can Breast Milk Jaundice be prevented?

Most cases of breast milk jaundice can’t be prevented.

What level of bilirubin requires phototherapy?

A commonly used rule of thumb in the NICU is to start phototherapy when the total
serum bilirubin level is greater than 5 times the birth weight. Thus, in a 1-kg infant,
phototherapy is started at a bilirubin level of 5 mg/dL; in a 2-kg infant, phototherapy is
started at a bilirubin level of 10mg/dL and so on
If the bilirubin is above the treatment level –

If the level of bilirubin is high, then it can cause a condition called Kernicterus a type of
brain damage. It can cause cerebral palsy and hearing loss.
We need to start your baby on phototherapy treatment either in the hospital or at
home. This involves placing the baby in a cot under UV lamp (a special light) for one or
two days. The baby will be naked and eyes will be covered. However, you can take the
baby out for feeds and nappy changes. Your baby will wear protective glasses
throughout phototherapy to prevent eye damage.

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The light changes the structure of bilirubin molecules in a way that allows them to be
removed from the body more quickly.

We will test his bilirubin levels every 4 to 6 hours and also check his temperature once the
treatment starts and once the bilirubin levels falls, we can stop the treatment. (S.E of
phototherapy- rash, diarrhoea). The child must continue feeding even during this
treatment.
If the bilirubin levels hasn’t come down after the phototherapy treatment, exchange blood
transfusion can be done-where we have to replace the baby’s blood with new blood.

If the examiner did not say whether the bilirubin is above or below the treatment level
– then tell the mother that if the level below – what we do and if the level is high what we
do.
INFORMATION ON NEONATAL JAUNDICE

Jaundice is a common and usually harmless condition in newborn babies that causes
yellowing of the skin and the whites of the eyes.The medical term for jaundice in babies is
neonatal jaundice.

The symptoms of newborn jaundice usually develop two to three days after the birth and
tend to get better without treatment by the time the baby is about two weeks old.
PATHOPHYSIOLOGY

Jaundice is caused by the build-up of bilirubin in the blood. Bilirubin is a yellow substance
produced when red blood cells are broken down.

Jaundice is common in newborn babies because babies have a high level of red blood cells
in their blood, which are broken down and replaced frequently. The liver in newborn
babies is also not fully developed, so it's less effective at removing the bilirubin from the
blood.

By the time a baby is about two weeks old, their liver is more effective at processing
bilirubin, so jaundice often corrects itself by this age without causing any harm.

It is normal to have some bilirubin in the blood. A normal level is: Direct (also called
conjugated) bilirubin: less than 0.3 mg/dL (less than 5.1 µmol/L) Totalbilirubin: 0.1 to
1.2 mg/dL (1.71 to 20.5 µmol/L)

Jaundice is considered pathologic if it presents within the first 24 hours after birth, the

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total serum bilirubin level rises by more than 5 mg per dL (86 mol per L) per day or is
higher than 17 mg per dL (290 mol per L), or an infant has signs and symptoms
suggestive of serious illness.

SYMPTOMS
In premature babies, who are more prone to jaundice, it can take five to seven days to
appear and usually lasts about three weeks. It also tends to last longer in babies who
are breastfed, affecting some babies for a few months.

If your baby has jaundice, their skin will look slightly yellow. The yellowing of the skin
usually starts on the head and face, before spreading to the chest and stomach. In
some babies, the yellowing reaches their legs and arms. The yellowing may also
increase if you press an area of skin down with your finger.

A newborn baby with jaundice may also:

• be poor at sucking or feeding

• be sleepy

• have a high-pitched cry

• be limp and floppy

• have dark, yellow urine – it should be colourless

• have pale poo – it should be yellow or orange

CAUSES: Some causes of pathological jaundice include:

• An under-active thyroid gland (hypothyroidism) – where the thyroid gland doesn't produce
enough hormones

• Blood group incompatibility – when the mother and baby have different blood types, and
these are mixed during the pregnancy or the birth

• rhesus factor disease – a condition that can occur if the mother has rhesus-negative blood
and the baby has rhesus-positive blood

• a urinary tract infection

• Crigler-Najjar syndrome – an inherited condition that affects the enzyme responsible for
processing bilirubin

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• a blockage or problem in the bile ducts and gallbladder – these create and transport bile,
a fluid used to help digest fatty foods

• An inherited enzyme deficiency known as glucose 6 phosphate dehydrogenase (G6PD)

could also lead to jaundice or kernicterus.
TREATMENT

- Most babies with jaundice don't need treatment because the level of bilirubin in their
blood is found to be low. In these cases, the condition usually gets better within 10
to 14 days and won't cause any harm to your baby.

- If treatment is felt to be unnecessary, you should continue to breastfeed or bottle

feed your baby regularly, waking them up for feeds if necessary. If your baby's
condition gets worse or doesn't disappear after two weeks, contact your midwife,
health visitor or GP.
- Prolonged newborn jaundice (lasting longer than two weeks) can occur if your baby
was born prematurely or if he or she is solely breastfed. It usually improves without
treatment. However, further tests may be recommended if the condition lasts this
long to check for any underlying health problems.

- If your baby's jaundice doesn't improve over time or tests show high levels of
bilirubin in their blood, they may be admitted to hospital and treated with
phototherapy or an exchange transfusion.

- These treatments are recommended to reduce the risk of a rare but serious
complication of jaundice called kernicterus, which can cause brain damage.

PHOTOTHERAPY This is treatment with light. It is used in some cases of newborn

jaundice to lower the bilirubin levels in your baby's blood through a process called
photo-oxidation.

A commonly used rule of thumb in the NICU is to start phototherapy when the
total serum bilirubin level is greater than 5 times the birth weight. Thus, in a 1-kg
infant, phototherapy is started at a bilirubin level of 5 mg/dL; in a 2-kg infant,
phototherapy is started at a bilirubin level of 10mg/dL and so on

Photo-oxidation adds oxygen to the bilirubin so it dissolves easily in water. This makes
it easier for your baby's liver to break down and remove the bilirubin from their blood.

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There are two main types of phototherapy: conventional phototherapy – where your
baby is laid under a halogen or fluorescent lamp with their eyes covered fibre. Optic
phototherapy – where your baby lies on a blanket that incorporates fibre-optic cables; light
travels through the fibre-optic cables and shines on to your baby's back

Treatment won't be stopped during continuous multiple phototherapy. Instead, milk that
has been squeezed out of your breasts in advance may be given through a tube into your
baby's stomach, or fluids may be given into one of their veins (intravenously).

During phototherapy, you baby's temperature will be monitored to ensure they're not
getting too hot and they'll be checked for signs of dehydration. Your baby may need
intravenous fluids if they're becoming dehydrated and aren't able to drink a sufficient
amount.

The bilirubin levels will be tested every four to six hours after phototherapy has
started. Once levels start to fall, they'll be checked every six to 12 hours.

Phototherapy will be stopped when the bilirubin level falls to a safe level, which usually
takes a day or two.
Differential diagnosis
1. Physiological Jaundice
2. Haemolysis (ask about father’s and other’s blood group)
3. Biliary Atresia (Pale stool dark urine)
4. Sepsis ( Fever)
5. Breast milk Jaundice.

What does kernicterus cause?

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

• Drowsiness or lack of energy.

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

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104. You are a FY2 in medical ward. A 10 days old boy (PAT Murphey) had
red and sticky eyes for last 3 days. Swab been taken from the eyes and
Chloramphenicol eye drop is being given to the boy. Talk to the mother
and address her concern.

Take history:

Ask which eye one or both?

Any other symptoms:

• Any chest pain/breathing difficulties?

• Is the boy crying constantly? Any fever? Any cough? Any vomiting or diarrhoea?

• Is he eating well?

Mother: Why he is having this?

Dr: There could be many reasons of this eye infection.We have taken swab from PAT’s
eye unfortunately, it has come positive for bacterial type of bugs (Chlamydia). Our
seniors have already given antibiotics eye drop (Chloramphenicol). We called this
condition Ophthalmia neonatorum. This type of infection can happen in the first 28
days of life.

As Chlamydia is positive, after confirming with my seniors we may need to give him
Azithromycin Eye drop to kill the bugs (NICE Guidelines).

Mother: Did I give this infection to him?

Dr: I am afraid if you have sexually transmitted infection this could be the reason as
well. Can I ask few questions?

Dr: Do you practice safe sex? Mo: No

Dr: Do have a stable sexual partner?

Mo:Yes, I am in relationship with my boyfriend for last 2/3 years.

Dr: Did you have any sexually transmitted infection recently or before? Any discharge
from front passage? Any pain in your lower tummy? (Ask question about STI)

Dr: We need to take swab from your front passage to find out if you have the infection or not?

Mo: But I don’t have any symptoms!

Dr: I am afraid we still have to do those tests (swab tests) to be in the safe side.

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Mo: I have only one sexual partner! Does it mean my boyfriend cheating on me?

Dr: I am sorry if I hurt your feeling! We can’t say at the moment as we are not sure!

By any chance did your boyfriend have any Sexually transmitted infection recently?

Mo: I don’t know.

Dr: Did he have any discharge from his penis? Mo: No

Dr: We request you to bring your partner as well to find out whether he also has
infection or not!

Dr: if it is confirmed that either you or your partner have sexually transmitted infection,
then we

Need to treat you both! (If doesn’t agree about partner then talk about partner
notification programme).

Referral to Local GUM (Genito Urinary Medicine) Clinic

CHLAMYDIA EYE INFECTION IN A NEONATE

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105. Nurses notice Mrs. Devoine (mother) giving green liquids to 19 month old
child diagnosed to have Neuroblastoma and is currently being treated for
sepsis. Talk to the mother and address concerns.

Build rapport first

Dr: Hello Mrs Devoine: I am Dr... how are you doing ? I am fine doctor.

Dr: I understand your child is in the hospital. May I ask why your child is in the hospital
Mrs Devoine?

Mother: My child was prematurely born and he has Neuroblastoma.

Dr: That is right. Do you know what problem he is having currently?

Mother: I was told that he has sepsis.

Dr: That is right Mrs. Devoine. Do you know what is sepsis ? I do not know exactly.

Dr: Sepsis means he has an infection in the blood means there are bugs in his blood
which is a very serious condition. We are treating with strong antibiotic medications.

Find out if she has any concerns regarding the care her child is receiving

Dr; Are you happy with the care what we are providing? Yes

Dr: Are you happy with the treatment what we are giving? Yes doctor.

Dr: Mrs Devoine do you have any concerns regarding your child? No doctor.

Dr: Mrs Devoine, can I ask are you giving your child anything other than food ?

- Like what doctor ?

Dr: Any kind of medicine ? - No

Dr: Actually, one of our nurses noticed that you are giving some kind of green liquid to
your child and she is concerned about it. She has told us about it. We are also bit
concerned about it? May I ask are you giving any green coloured liquid to your child?

- No doctor

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Dr: Mrs Devoine, as I mentioned, we are concerned about your child’s well being
because if it all you are giving any other kind of medicine other than what we
prescribed to your child it may cause harm to your child. I am sure you don’t want that
to happen to your child isn’t it Mrs Devoine ? - Yes doctor.

Dr: May I ask again are you giving any such liquid to your child ? - Yes.

Dr: May I know what is that ? - It is some herbal medicine, doctor.

Dr: May I know what kind of herbal medicine ? - It contains minerals and vitamins.

Dr: May I know the name of the medicine ? - I don’t know that doctor.

Dr: How long have you been giving that Mrs Devoine? For few months now.

Also find out why she is giving the child and who gave her

Also ask how if she knows that the herbal medicine can cause harm to her child.

Dr: Mrs Devoine, I can see that you are a very caring mother. This herbal medicine can
cause harm to the baby. Would you mind not giving the herbal medicine your child?

Mrs D - Doctor it contains only minerals and vitamins. It is good for the health. They
are plant products. It does not cause any harm to my child.

Dr: Mrs Devoine you may be right that some of the herbal medicine may not cause
harm to the health. However, some types of herbal medicine can cause harm to the
health and also it can interact with the medicine what we are giving and can reduce
the effect of the medicine what we are giving to your child. As I mentioned your child
has a very serious infection. If at all, this herbal medicine interact with the antibiotic
medicine what we giving and the effect of the antibiotic reduces it will be a serious
problem to your child. As you may know some of the mushrooms are poisonous
though they are plants. What do you think Mrs Devoine? - No doctor it does not
cause any harm. I am giving this medicine for a long time now (for months). Has it
caused any harm?

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Dr : Well so far no harm is visible to us. However, sometimes there could be a long
term problem which we may know only after a long time. – I see.

Dr: May I ask who advised you to give that medicine to your child ? My friend told me.
She has breast cancer. She used it and she found it good.

Dr: As I mentioned before some types of herbal medicine may not cause harm but
some of them does cause harm. Beside that we are not sure what exactly does it
contain thigh you have been told that it contains vitamins and minerals. We do not
have any scientific proof of what does it contain. Mrs Devoine the type of medicine we
give is tested and researched properly before we start giving it the patients. Besides
that our medicine are regulated by the proper authorities who checks the safety of the
medicines. Where as the herbal medicine what you are giving may not be researched
properly and is not checked by the Medicines and Healthcare products Regulatory
Agency (MHRA) of the United Kingdom (UK). So Mrs Devoine do you think you can
stop giving that medicine ? - Doctor I am sure it contains minerals and vitamins?

Dr: How are you sure of that ? - The person who gave me told me about that.

Dr: Mrs Devoine, can we test in the lab to check properly what does it contain and
then we tell you about it ? Okay.

Dr: Can we get some sample of that please ? - Okay I will give you that.

Dr: Mrs Devoine can you please stop giving that medicine for the time being at least
until we get the results from the lab and we know exactly what it contains and whether
it is safe to give to the child? - Okay doctor.
Dr: Thank you very much Mrs Devoine. I can see that you’re a very caring mother and
you want the best for your child. We also want to do the best for your child. Is there
anything else you want to ask me ?
Mother – Doctor can you please give me some examples where the herbal medicine
interacts with your kind of medicines.

Dr: Yes sure

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Aspirin can interact with Garlic extract

Pseudoephedrine (nasal decongestants) can interact with Green tea supplement.

Digoxin, warfarin can interact with St. Johns wort ( herbal medicine).

Dr: Is there any other question ? – Doctor will my child die because I gave this

medicine?

Dr: Don’t worry Mrs Devoine. As I mentioned, before so far we do not see any serious
harm happened because of this. However we will keep checking for that. Also when
we get the lab test result of this medicine we will know more about it.

Any other concerns Mrs Devine ? - No doctor. You have been very kind.

Dr: Mrs We are always here to help you. If you wish to give any other kind of medicine
to your child, please ask us before you give that, Is that Okay Mrs Devoine ? - Yes
doctor surely.

Thank you once again Mrs Devoine.

NEUROBLASTOMA – MOTHER GIVING GREEN LIQUID

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106. You are the FY 2 doctor in Paediatric department.

12 year girl Anna had a fit for the second time and was diagnosed with epilepsy.
She was treated with medications by the Paediatric Neurologist. She is about to
be discharged.

Talk to her mother and address her concerns.

Dr: Hello I am Dr… one of the junior doctors in the department. Are you Anna’s mother?
Mother: Yes

Dr: How are you doing? Mother I am Ok.

D: I am one of the junior doctors looking after your daughter Anna. I am here to talk to you
about her. Is that Ok? Mother: Yes.

Dr: I understand that Anna had a fit and was brought into the hospital. Can you please tell me
a bit more about the fit?

Mother: She had a fit. Her whole body was jerking. Dr: Did she have a fit like this before ?

Mother : Yes she had a fit few months ago.

Dr: Is this the second time she had a fit? Mother: That is right.

Dr: Was she diagnosed with any medical condition at all before this? Mother: No Dr: Does

she have Diabetes? No

Dr: Did she have any headache or rashes on her body when she had fits? No

Dr: Did she have fever when she had these fits? No

Dr: Any of her family members had fits like this at all? Mother : No Dr: Do you have any

idea why Anna had that fit Mrs.. ?

Mother : No / Yes

Dr: If she says no - Unfortunately it is not good news. Do you want to know about it?
Mother: Yes

Dr: Mrs… Our Paediatric Neurologist has seen her. We have done some tests on her and
unfortunately she has a condition called Epilepsy. Do you know anything about it ?

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Mother: No doctor. Diagnosis:

Dr: I will explain everything to you. Epilepsy is a condition that affects the brain and causes
repeated fits. It is due to abnormal electrical activity in the brain. Sometimes, there is no
reason why this condition happens although sometimes it could be an inherited condition.

Mother: Is it a serious condition?

Dr: Unfortunately it is a serious condition because even if we treat she can have fits like this
again for a long time may be even for years.

Mother: What are you going to do now ?

Dr: Our specialist doctor has decided to treat her with some medications. She has to take
these medications which are tablets regularly every day without forgetting. It is important that
she takes the medicines even when she does not have fits because there should be a certain
amount of medicine in her blood all the time to prevent her having fit. [check whether the
medication is on the table. If it is, check the BNF for the dose and side effects]

Mother: Ok

Dr: If she is going to take any medications, she should tell her GP about it because other
medications can interact with epilepsy medications. Mother : Ok

Dr: We will keep monitoring her. As she grows older, we may need to increase the dose
of her medication. If she has diarrhoea and vomiting, then the medications may not be
absorbing into her system, and in that case you need to inform the GP.

Dr: There are several factors which can trigger these fits like exposure to too much light in
the cinema, watching TV for a long time.

Does she happen go to cinema or watch TV for a long time? Mother: Yes

Dr: It is better for her to avoid watching cinema or watching TV for a long time.

Dr: Does she work on computers for a long time or does she play computer games?

Mother: Yes she does.

Dr: Again I advise you to tell her to avoid looking at the computer continuously for a long
time.

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Dr: It’s better for her to avoid places with bright flashing lights like partys because flashing
lights can trigger fits. Mother: OK

Dr: Also sometimes lack of sleep or starving for a long time also trigger fits. Please tell her to
sleep well and have food at regular intervals – she should not starve for long time.

Dr: She should be careful when taking shower. It is better for her not take a bath in a tub -
instead, she should take a shower because if she ever has a fit while taking a bath in a tub, it
can be dangerous to her. Mother: OK

Dr: Does she swim? Mother: Yes she loves to swim.

Dr: If she is swimming in the swimming pool or sea or river, she should tell the lifeguards that
she has this condition. Swimming in the river or sea is more risky than swimming in the pool.

Mother: Can she dance ,doctor? She loves to dance.

Dr: She can certainly dance. But she should avoid dancing in the partys where there are
flashing lights and loud music. Also someone should be there while she dances who knows
her condition and what to do if she has fits when she dances. Mother : OK

Dr: She should not go near fire. If there is a gas cooker at home, it may be better to change
to electric cooker and it is better for her to avoid cooking.

Dr: In the future she may not be able to drive if she still has fits. You can take advice from
the DVLA at that time. Mother : OK

Dr: Please inform her school and friends about her condition and let them know how
to help her. Please make sure she wears her epilepsy bracelet all the time. Any other
concerns?

Mother : What to do if she has a fit ?

Dr: When she has a fit, lay her on her side with her face turned to on the side. (This
will stop them swallowing any vomit, and prevent choking)

Don’t put anything, including medication, in her mouth while she is having a fit. Do not put
any hard objects into the mouth to prevent tongue bite, because it can break her teeth and
the broken teeth can go into the windpipe and cause choking. It is better to have a tongue
bite rather than broken teeth because tongue bite will heal on its own in a few days. Stay
with her. If it lasts longer than five minutes, call the ambulance. Mother: Ok

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Dr : Any other concerns ? Mother: No. Thank you.

INFORMATION

Children, young people and adults with epilepsy and their families and/or carers
should be given, and have access to sources of information about (where
appropriate):

• Epilepsy in general

• Diagnosis and treatment options

• Medication and side effects seizure type(s),

• Triggers and seizure control

• Management and self-care

• Risk management first aid, safety and injury prevention at home and at school or
work

• Psychological issues

• Social security benefits and social services

• Insurance issues
• Education and healthcare at school

• Employment and independent living for adults

• Importance of disclosing epilepsy at work, if relevant (if further information or

clarification is needed, voluntary organisations should be contacted) road safety
and driving prognosis sudden death in epilepsy (SUDEP) status epilepticus
lifestyle, leisure and social issues (including recreational drugs, alcohol

NEWLY DIAGNOSED EPILEPSY IN A CHILD

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107A. Mrs. Jordan has scheduled an urgent appointment with a doctor to discuss
her daughter, 15 year old Katy Jordan. Mr and Mrs. Jordan and their daughter are
regular registered patients at the clinic and visits are logged into medical records, but
you have not seen them. Talk to the mother and address her concerns.
Dr: Hello Mrs Jordan.. My name is Dr... I am one of the junior doctors here in the clinic. How
can I help you?

M: I want to know if my daughter Katy has come to the clinic for a visit.

Dr: May I ask why, Mrs. Jordan? M: I was cleaning her room and I found some oral
contraceptive pills under her bed. I want to know if you have prescribed them.

Dr: Did you ask her about the pills, Mrs. Jordan?
M: I did. She said they were her friend Sara's and slammed the door shut. She wouldn't tell
me anything more. Can you please tell me if she has been here?

Dr: I can see that you are concerned Mrs. Jordan, but I'm sorry. We are not at liberty to
divulge that information.

M: Why not?! I'm her mother. I deserve to know!

Dr: I can see that you are a very concerned mother, Mrs. Jordan.. But as I said... I'm sorry.
I'm legally bound to keep any patient visits confidential.I can’t specifically discuss your
daughter’s records with you without her consent.

M: Doctor she is only 15! She is a minor. She is a child. I have the right to know about my
child. I have parental responsibility.

Dr: Mrs Jordan, I can completely understand that you are upset and you feel you need an
explanation. I recognise that she is 15 and that she is a minor, but to maintain the trust with
our patients we need to preserve that level of confidentiality regardless of their age. This
is exactly in the same way I would never discuss your record with anyone else without
your consent. As doctors, we do have guidelines on dealing with patients who are under
16. I can’t say that we have or have not seen your daughter but I can explain the process
we go through as doctors if a girl of your daughter’s age request contraception.

Mother: What is that process ?

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D. If a 15 year old girl came to ask for the pill, we are trained to assess their level of
maturity. We talk at great lengths about risks and benefit and we also encourage them to
talk to their parents. However, if we do feel that they are mature enough to take the pill and
they will continue to be sexually active with pill or without the pill and would therefore put
themselves at risk of becoming pregnant, we do prescribe it to them. In other words, we
act in their best interest. Does that make sense?

M: Doctor, she won't talk to me. Can't you just give me some peace of mind and just tell me?

Dr: I'm sorry Mrs Jordan... I have not seen your daughter. Medical records might have
details if she has visited the clinic, but even if that were the case, I am legally obligated to
keep that information.

Mother: She may be having sex. No one should have sex with a child. It is illegal.

Dr: I understand what you are saying. Mrs. Jordan... As per the law, sex is not illegal above
the age of 13 if it is with consent and with a partner of the same age. Mother: She may be
having sex with a 20 year old man.

Dr: Mrs Jordan, first of all we cannot tell you whether your daughter has come here or not.

However, I can reassure you that if any minor girl comes here asking for contraceptive pills,
we do advise that no adult should be having sex with them and if we come to know about
it we do take appropriate action on that.

Mother: I'm worried she could be even pregnant. What if she is your daughter how would
you feel?

Dr: Mrs Jordan, I can’t even imagine how you may be feeling. Unfortunately we cannot reveal
any information about her.

Mother: We are Catholics. It is against our culture. She should not be having sex.

Dr: I completely understand you. I sincerely advise you to talk to your daughter directly. It
often does help when parents discuss the matter with their daughter, in a safe environment
where she does not feel threatened. You should create the environment for her where she
feel safe and discuss openly with you.

Mother: But she would not tell me anything. Dr: Maybe her father can talk to her !

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Mother: I have not told this to her father. He will be very furious if he comes to know about
it.

Dr: If you like we can have a meeting with you and your daughter together if she agrees
and we can discuss these things.

Mother: OK, so if we have a meeting will you tell me whether you gave the pills to her?

Dr: Mrs Jordan, we can discuss about it if she agrees for that. But as of now we cannot even
say whether she even came here.

Mother: Ok then, I will try to talk to her.

Dr: Thank you very much. I am sorry that I was not much helpful. If we can be any help in
the future please do let us know.

Gillick Competence

People aged 16 or over are entitled to consent to their own treatment, and this
can only be overruled in exceptional circumstances. Like adults, young people
(aged 16 or 17) are presumed to have sufficient capacity to decide on their own
medical treatment, unless there's significant evidence to suggest otherwise.
Children under the age of 16 can consent to their own treatment if they're
believed to have enough intelligence, competence and understanding to fully
appreciate what's involved in their treatment. This is known as being "Gillick
competent". Otherwise, someone with "parental responsibility" can consent for
them. This could be:

• the child's mother or father

• the child's legally appointed guardian

• a person with a residence order concerning the child

• a local authority designated to care for the child

• a local authority or person with an emergency protection order for the child

The person with parental responsibility must have the capacity to give consent. If a
parent refuses to give consent to a particular treatment, this decision can be

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overruled by the courts if treatment is thought to be in the best interests of the

child. If one person with parental responsibility gives consent and another doesn't,
the healthcare professionals can choose to accept the consent and perform the
treatment in most cases. If the people with parental responsibility disagree about
what's in the child's best interests, the courts can make a decision. In an
emergency, where treatment is vital and waiting to obtain parental consent would
place the child at risk, treatment can proceed without consent

Contraception in under-16s

Contraception services are free and confidential, including for people under the
age of 16. If a child under 16 wants contraception, the doctor, nurse or pharmacist
should not tell the parents (or carer) as long as they believe that the person fully
understands their decisions and the information given. Doctors and nurses work
under strict guidelines when dealing with people under 16. They can encourage
the child to consider telling the parents, but they will and should not force the
child. The only time that a professional might tell someone else is if he/she
believes that the child is at risk of harm, such as abuse. The risk would need to be
serious, and it has to be discussed with the child first.

107. A. mother concerned about her minor daughter taking

ocps
“How may I help you?”
- Enquire from the mother if she has asked the daughter
- Acknowledge her concern
- Don’t give her any information - "I really wish I could tell you. However, I am legally
obligated’

- I’m really sorry if you feel that way”

“I understand that she's just 15 but she's also a patient and for every patient, we
maintain confidentiality”

“I'm not at liberty to disclose that information - This confidentiality covers her whether
she was here or not

“We have to maintain trust and it will be difficult to regain her trust if we break it"

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107B. You are a junior doctor in GP clinic.

14 yr old girl, Miss... has come to clinic with unprotected sexual intercourse. She is

requesting for morning after pill. She is worried.

Talk to her and address her concerns.

She's worried because she doesn’t want to get pregnant. In addition, she doesn't want
her parents to be informed. Reassure her that you can help her to prevent pregnancy
and that you will not tell her parents.

If patient asks if you will tell anyone, you can say, "it is really necessary, we will keep it
confidential.”

Dr: Hello. My name is Dr.....I'm one of the junior doctors here in the GP Clinic. How may I
call you?

P: Hello, doctor. You can call me…..

Dr: How can I help you? Pt: Doctor, I need morning after pills.

Dr: Can you please tell me why you want those pills ?

Pt: Doctor, I had sex with my partner and we did not use protection and I am worried
that I might get pregnant.

Dr: Please do not worry. Let me ask you a few questions and I will tell you what I can do.Pt: Ok

Dr: Can you please confirm your age ? Pt: I am 14 years old.

Dr: Yes, we can give you the pills if that is suitable to you. Can I ask you a few more
questions to decide about it ? Pt: Alright.

Dr: When did you last have unprotected sex? Pt: Last night about 12 hours ago.
Dr: Alright. Was it the first time that you had unprotected sex or did you have any
unprotected sex before that? Pt: This was the first time doctor.

Dr: Before this incident, have you been sexually active? Pt: Yes, doctor.

Dr: And for how long? Pt: For about a year now, doctor.

Dr: And were you using any kind of contraception?

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Pt: Yes doctor, we have been using condoms but last night we didn’t have any condoms.

Dr: Could you please tell me the age of your partner? Pt: He is a year older than me.

Dr: Did anybody who is 18 years or older have sex with you? Pt: No, doctor.

Dr: Do your parents know about this?

Pt: No, doctor. My parents do not know. Please do not tell them. Will you tell my parents?

Dr: Respecting patient confidentiality is an essential part of good care and this applies
whether the patient is a child or an adult. Please do not worry. Pt: Alright, doctor.

LMP?

Assess mental capacity

Dr: Can you please tell me why you specifically asked for pills?

Pt: My friend has used it and she said it will work.

Dr: Alright. And what do you know about pills?

Pt: Well, I have been told that it works in emergency cases if one doesn't use any
condoms for protection.

Dr: Do you know what can happen if you do not use contraception?

Pt: Yes doctor, I know that if I do not use any protection, I will become pregnant. I do
not want that doctor. Please help me.

Dr: Yes, we will help you, but do you know that if you do not use any condoms, one
might get sexually transmitted infections as well?

Pt: Yes, doctor. But would you prescribe me the pills? I am really tense. I do not want
to become pregnant.

Dr: Do not worry, we have some options to deal with such cases. I think that you have
the capacity to understand the benefits and the risks of contraception so we might be
giving you some morning after pill. But in addition to this, my seniors will talk to you
and will assess your situation a bit further. Are you following?

Pt: Yes doctor. What will you give me?

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Dr: We have two types of pills. Levonelle and EllaOne. They work mainly by
preventing or delaying the release of an egg from your ovary, which normally happens
each month (ovulation). It does not interfere with your regular method of contraception.
Are you following me?
Pt: Yes doctor. But when do I take it?

Dr: You will have to take either one of the pills as soon as possible. It has to be taken in a
single dose. The earlier you take the pill, the more effective it is. And I have to tell you this
that if you throw up within two hours after taking the pill, you will have to take it again.

Pt: How effective are these pills?

Dr: It is difficult for us to say exactly how effective it is. However, there is a good chance
of preventing pregnancy if it is taken within few hours after unprotected sex. (<72 Hours
in Levonelle and <120 hours in ellaOne)

Pt: Are there any side-effects with these pills doctor?

Dr: Side-effects are usually uncommon. However, some women feel sick for some hours
after taking the pill. This may be less likely to happen if the pill is taken with food. But as I
have told you, if you vomit within two hours of taking the pill, then take another pill as
soon as possible.

Other mild side-effects such as diarrhoea, dizziness and breast tenderness occur in
some women for a short time,

Pt: Will it work doctor? Will I not get pregnant?

Dr: Hopefully it works. However, these pills do not continue to protect you against
pregnancy. This means that if you have unprotected sex at any time after taking the
emergency pill you can become pregnant.

Pt: Do I need to be careful about anything doctor?

Dr: Yes, sometimes the pill may not work and you may become pregnant. So if your
period is more than 7 days overdue, please do a pregnancy test or come back we will
check whether you are pregnant.

Also there is a serious condition which can happen rarely is what we call as ectopic
pregnancy where the pregnancy happens outside the womb. The signs of it are: having pain

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in lower tummy and bleeding from vagina. So if do not have your period within one week of
expected period and having these symptoms please do come back.

Are you following me? Pt - Yes

Dr: Also this is not a regular contraception. It is not good to use the morning after pill
as a regular way to prevent pregnancy. It is better to follow a proper regular
contraception. Do you want me to tell you the other ways of contraception ?

Pt: No doctor not now. I will make another appointment for that.

Dr: There are some things that we need to know before prescribing you the pill. Can
you please tell me if you have any medical condition? Pt: Like what doctor?

Dr: Any liver disease? Pt: No doctor.

Dr: Asthmatic problems? Pt: No doctor.

Dr: Epilepsy? Pt: No doctor.
Dr: Alright. Are you using any medicines at the moment?
(Anti-epileptics - Phenytoin and carbamazepine. Antibiotics like rifampicin and
rifabutin. Antacids, omeprazole or ranitidine) Pt: No doctor.

Dr: Alright. Any allergies? Pt: No doctor.

Dr: Okay. Do you have any concerns?

Pt: Doctor will you tell my mother?

Dr: I do understand your worries. We highly encourage you to tell your parents but keeping
patient confidentiality is very important for us. Though you are a child, because you have
mental capacity to understand the consequences of your actions, we cannot divulge your
information to anyone else inclusive of your parents, without your permission. We have to ask
for your consent before disclosing this information. We normally keep disclosures to the
minimum necessary. Is that okay? Pt: Okay.
Dr: Do you have any other questions? Pt: No doctor.

Dr: My senior will talk to you shortly. And in future, you can come back to us if you
have any other concerns or questions. Pt: Thank you doctor.

107B. EMERGENCY CONTRACEPTION IN A

TEENAGER

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108. 3 year old child brought in by Nanny. Child had needle stick injury while
playing in the garden. Take history and talk about management.

- Take a detailed history about the incident.

- When, how, (child was coming down the slide and got injured with the needle)

- Ask about the needle – was it attached to a syringe? Was there blood in the needle or
syringe? Was it rusted?

- What did she do immediately after that? [she washed child’s finger – appreciate her]

- Ask about child's jabs specifically - Hep B – she says she does not know anything other
than that the child is up to date with all the jabs.

- Ask about parents – they are far away. Ask whether you can talk to them over the phone
and take some history from them, about the jabs and any other medical conditions. If not
possible to reach parents, tell her we can get the jabs information from the GP. Ask her of
red book.

- Ask about other medical conditions, similar incidents in the past. NAI is a possibility and
should be ruled out.

- Ask her about her concerns.

- Tell her that usually people get worried about children getting any infections from a needle
stick injury if the needle was used by some drug addicts

- Reassure her that the chances of the child getting HIV infection is almost negligible
because HIV bugs do not survive outside human body. So, usually we do not do any tests
for HIV and we do not offer any medications to prevent them getting HIV infection.

- Hep B – there are slight chances of a child getting hep B infection if the child is not
vaccinated.

- We will check from the GP whether the child had Hep B vaccine or not, and if the child did
not had Hep B vaccine we will give Hep B vaccine and another medication called Hep B
immunoglobulin to prevent child getting Hep B infection.

- She may ask if you will give antibiotics

- We will have a look at the wound {examination}, clean the wound thoroughly and if the
wound is deep, then we will give antibiotics to prevent wound infection.

- Usually, they do not get any other infection.

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- No need of admission.

- The nanny may be taking down notes – ask her why – she may say I need to tell the child’s
parents everything you say now. Appreciate her, and tell her to bring the parents later so that
you can explain everything to them directly.

- Warning signs – if the child develops redness, swelling, discharge from the wound site –
these are signs of wound infection – you need to bring the child back.

- Any other concerns?

Information on needle stick injury Prevention

" Parents, educators and health care providers should be made aware of the problem of
discarded needles.

" Children should be educated about the potential dangers of injection drug use.

" Children should be taught not to handle needles and syringes, and to report finding
them to an appropriate, responsible adult (parent, school teacher, police officer, etc),
who should then arrange for the safe disposal of the needle in a puncture-proof, closed
container.

" Community programs should be in place to keep parks and public places, where
children generally play, free of discarded needles.

" Programs should be in place for the treatment and control of injection drug addiction,
and to adequately support HIV prevention, HBV vaccination and needle-exchange
programs for injection drug users.

Management

" After the injury, the wound should be cleaned thoroughly with soap and water as soon
as possible. It should not be squeezed to induce bleeding.

" The extent of the wound, if any, or the probability of exposure of open skin lesions or
mucous membranes to blood should be assessed.

" The child’s immunization status for tetanus and HBV should be determined.
" Tetanus vaccine, with or without tetanus immunoglobulin, should be given if indicated.
" The circumstances of the injury should be documented (the date and time of injury or
exposure, where the needle was found, circumstances of the injury, type of needle,
whether there was a syringe attached, whether visible blood was present in or on the

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needle or syringe, whether the injury caused bleeding and whether the previous user of
the needle is known).

" Blood should be obtained from the child for:

" Baseline HBV, HIV and HCV status (may be stored for later testing).

" If antiretrovirals are being considered: complete blood count, differential, aspartate
aminotransferase, alanine aminotransferase, alkaline phosphatase, blood urea nitrogen
and creatinine.

" Testing needles and syringes for viruses is not indicated. Results are likely to be
negative, but a negative result does not rule out possibility of infection.

" If the user of the needle is known, attempts should be made to assess for risk factors for
blood-borne viruses and, if possible, to test for these viruses. Pending results, proceed
as for an unknown source.

- If the needle is rusted, consider tetanus and infection. Give tetanus vaccine only if child
is not vaccinated.

- Injury from used needles and syringes found in community settings arouses much
concern, especially when children find discarded needles and injure themselves while
playing with them. The user is generally unknown, and parents and health care providers
fear that the needle may have been discarded by an injection drug user. Although the
actual risk of infection from such an injury is very low, the perception of risk by parents
results in much anxiety. Evaluation and counselling are needed.

- The important pathogens to be considered in this situation are hepatitis B virus (HBV),
hepatitis C virus (HCV) and HIV. It is essential that the health care provider be
knowledgeable about the risks of acquisition of these viruses following needle stick injuries,
and the recommendations for management and follow-up. In the absence of up-to-date local
data, it is prudent to assume that the needle may have been contaminated with one or more of
these viruses.

- There have been single case reports of HBV and HCV transmission and no reported
transmission of HIV following injuries by needles discarded in the community. A review of the
literature up until September 2007 yielded 12 case series from areas of high prevalence of
blood-borne viruses. These involved a total of 483 children with follow-up for HIV, 452 for HBV
and 265 for HCV. There were no infections. The majority of children received HBV
prophylaxis, if it was indicated, but only 130 children received antiretroviral prophylaxis.

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- Follow-up after any significant needle stick injury is essential. The clinician dealing with the
initial incident should ensure that the parents and child understand the importance of follow-
up, and that appropriate arrangements are made. Parents sometimes assume that if blood
tests that are performed at the time of injury are negative, then there is no possibility of
infection and no need for further testing.

- Needle stick injuries may be prevented by educating children, parents, educators and health
care providers about the dangers of handling used needles, syringes and other objects
contaminated with blood. Children need to be made aware at an early age. In the studies of
injuries from discarded needles referred to above, the mean ages of the injured children were
five to eight years. In one study 15% of injuries occurred in children pretending to use drugs.
There is a community responsibility to provide adequate cleanup of parks and schoolyards. In
addition, community commitment is necessary to support addiction treatment and infection
prevention programs for injection drug users.

HBV

- HBV is the most stable of the blood-borne viruses and can be transmitted by a minute amount
of blood. The risk of acquiring HBV from an occupational needle stick injury when the source
is hepatitis B surface antigen (HBsAg)-positive ranges from 2% to 40%, depending on the
source’s level of viremia. HBV can survive for up to one week under optimal conditions, and
has been detected in discarded needles. A case of HBV acquired from a discarded needle
used by a known HBV carrier has been reported.

- Although HBV vaccine is now recommended for all children in Canada, most programs target
children who are older than the usual age at which they sustain accidental needle stick
injuries. Thus, the majority of injured children are likely to be susceptible to HBV infection.
Post-exposure prophylaxis with anti-HBV immunoglobulin and HBV vaccine is effective if
provided promptly.

HCV

The risk of acquiring HCV as a result of an occupational needle stick injury when the source
was infected varies from 3% to 10% . HCV is thought to be a fragile virus which would be
unlikely to survive in the environment, but there are little data at this time.
There has been a case report of HCV acquisition after an injury from a discarded needle.

Unfortunately, there is no effective post-exposure prophylaxis at present. Alpha- interferon

and ribavirin are used in therapy of chronic HCV infection, but their benefit for prophylaxis is
not known. It is important to determine whether a potential exposure results in transmission
of HCV because 50% to 60% of infected children will have persistent, asymptomatic

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infection for which follow-up by a specialist is indicated.

Chronic hepatitis will eventually develop in some of these cases, and antiviral treatment may
be required.

HIV

- The risk of acquisition of HIV from a hollow-bore needle with blood from a known HIV
seropositive source is between 0.2% and 0.5%, based on prospective studies of
occupational needle stick injuries. The risk is increased with higher viral inoculum,
which is related to the amount of blood introduced and the concentration of virus in
that blood. The size of the needle, the depth of penetration and whether blood was
injected are also important considerations. In most reported instances involving
transmission of HIV, the needle stick injury occurred within seconds or minutes after
the needle was withdrawn from the source patient.

- In contrast to the situation with health care workers, the source of blood in discarded
needles is usually unknown, injury does not occur immediately after needle use, the
needle rarely contains fresh blood, any virus present has been exposed to drying and
environmental temperatures, and injuries are usually superficial. HIV is a relatively fragile
virus and is susceptible to drying. However, survival of HIV for up to 42 days in syringes
inoculated with the virus has been demonstrated, with duration of survival dependent on
ambient temperature. One study found no traces of HIV proviral DNA in syringes discarded
by intravenous drug users, while another study found HIV DNA in visibly contaminated
needles and syringes from shooting galleries.

- It is extremely unlikely that HIV infection would occur following an injury from a
needle discarded in a public place. However, if the incident involved a needle and
syringe with fresh blood, and if some of the blood was injected, infection is
theoretically possible and prophylaxis is indicated. In occupational needle stick
exposures, zidovudine prophylaxis was shown to reduce the risk of HIV
transmission from a positive source by 80% . Prophylaxis with combination
antiretroviral therapy is presumed to be even more effective. Whether two or
three drugs should be used is controversial. The use of three drugs is based on
observations in the treatment of HIV infection and the assumption that maximum
suppression will be most effective in preventing infection. On the other hand, two
drug regimens are better tolerated and adherence may be better with two than
with three drugs.

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Hepatitis B virus (HBV) prophylaxis

1. Child known to be HBV antibody or HBsAg-positive: No action required.

2. Child has not been fully vaccinated against HBV: Test for anti-HBs antibody and
HBsAg. If results are not available in 48 h:

- Give HBIG immediately (ideally within 48 h of injury; efficacy unknown if

>7 days after injury). Dose=0.06 mL/kg intramuscularly.

- Give HBV vaccine (as soon as possible, and at latest within 7 days of
injury).

A. If anti-HBs antibody- and HBsAg-negative, complete vaccine series.

B. If anti-HBs- or HBsAg-positive, discontinue vaccine series. Arrange

appropriate follow-up if HBsAg-positive.

3. Child has been fully vaccinated against HBV: Test for anti-HBs antibody. If results are
not available in 48 h, give dose of HBV vaccine.

A. If anti-HBs antibody-positive, no further action required.

B. If anti-HBs antibody-negative, test for HBsAg:

- If HBsAg-negative, give HBIG and dose of HBV vaccine.

- If HBsAg-positive, arrange appropriate follow-up.

Risk assessment for HIV transmission

1. Source unknown but known or presumed high prevalence of HIV in injection drug
users in the region, or if source known to have HIV, consider high risk.

2. Consider the size of needle, whether it is hollow-bore, presence of visible blood in

the needle or syringe, probability of exposure to drying, heat and freezing since use.
Large lumen devices with visible blood are highest risk.

3. Consider depth and extent of trauma (scratch or deep cut, injection of blood and
bleeding at the site). Injuries with actual blood injection are high risk. Superficial
scratches are low risk. If exposure limited to mucous membranes or non-intact skin,
consider extent of exposure. For example if child put syringe with visible blood into
mouth and possibly injected blood – high risk; suspected but unobserved splash onto
eyes or lips – low risk. Splashes involving a large volume of blood (not just a few
drops) coming into contact with extensive areas of non-intact skin – high risk.

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Antiretroviral agents recommended for post-exposure prophylaxis

Age Dosage Comments

Available in oral solution 10
6 weeks to 12 years: 160
mg/mL; 100 mg capsules;
mg/m2/dose tid or 240 mg/
Nucleoside reverse 300 mg tablets. Can be
m2/dose bid
transcriptase inhibitors* taken with or without food;
Zidovudine (ZDV) may be better tolerated with
≥12 years: 300 mg/dose bid
food

1 month to 16 years: 4 mg/ Available in oral solution 10

kg/dose bid (maximum 150 mg/mL; 150 mg capsules.
mg/dose). Can be taken with or
Lamivudine (3TC)
without food; may be better
≥16 years and ≥50 kg: 300 tolerated with food
mg once daily
13 years and >37 kg: One 1 Tablet contains 300 mg
ZDV + 3TC (Combivir) tablet bid ZDV plus 150 mg 3TC

Protease inhibitor
6 months to 12 years§: (230 Available as oral solution
mg LPV/57.5 mg RTV)/m2/ (80 mg LPV/20 mg RTV)/
dose bid (maximum 400 mg mL; 200 mg LPV/50 mg
Lopinavir/ritonavir (LPV/
LPV/100 mgRTV)/dose RTV tablets.
RTV)
>12 years: (400 mg LPV/ Should be taken with a
100 mg RTV)/dose bid high-fat meal

*ZDV and 3TC are well tolerated. Occasionally children have anorexia, nausea,
vomiting, diarrhea, abdominal pain, fatigue and headache. Asymptomatic mild
neutropenia, anemia or elevation of liver enzymes may occur, which resolve after
treatment is completed.

LPV/RTV may cause nausea, vomiting, diarrhea or abdominal discomfort;

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109. Child diagnosed with Appendicitis. Planned for Appendicectomy. Child kept

nil by mouth. Consultant advised IV fluids.

Calculate and prescribe IV fluids.

Explain the father about the necessity of giving IV fluids to his child.

Do not explain about the operation.

Alternatively, this station might be that a nurse is interested in knowing how to calculate
the fluid requirements.

There will be a paper with a formula on how to calculate the fluid requirements

Child is 6 years, and Weight – 25 kg

Formula

Daily maintenance fluid requirement in paediatrics.

Formula: 100mls/kg for the first 1 to 10kg;

then 50mls/kg for the next 1 to 10kg;

then 20mls/kg for the next 1 to 10kg.

(Max – 2 litres in females and 2.5 litres in males)

Fluid bag contains 500ml.

Divide the total amount by 24 hours. E.g 1600 ml/24 hrs

Don’t forget to write in the fluid chart!

Assess knowledge

Explain condition if he is not aware – Child has appendicitis. We all have any organ
in our tummy called appendix which looks like a finger attached to the beginning of the
larger bowel ( gut). Normal it has no important function in the body. In your child this
organ in inflamed or become sore. Only treatment is operation and remove that organ.
He will lead a normal life afterwards.

When the surgery is being done, we will don General anesthesia can make some
people vomit. If he vomits, the food can go up into the food pipe and into lungs and this
can cause infection. To prevent that from happening, we want people’s tummies to be
empty and that’s why we want her to be fasting. Don’t give any food until after the
surgery. It takes 48 - 72 hours for the bowels to start working.
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Take a history

- How was your child before this ?

- Any medical conditions ? Any surgeries in the past ? Any medications ?
- Any allergy ?

Need to give him IV fluids

We cannot allow him to eat or drink at the moment until and after about one or two days of
the surgery. If his tummy has food when we give anaesthesia for the operation, sometimes
the food comes back from the stomach to the food pipe and then it can enter the windpipe
and can cause severe infections in the lungs. To prevent this from happening, his stomach
should be empty when we do the operation.

Also, since we cannot feed him by mouth for his energy requirement and to prevent
dehydration we need to give him fluids through his veins.

What type of fluids?

We will be giving him fluids which contains glucose for his energy and also salts to prevent
dehydration.

Is that OK? Any questions?

I need to write up the fluid prescription for him is that OK ? Then write a prescription on the

fluid chart provided.

(The paper includes maintenance fluid replacement formula).

Ask about Full name, DOB, past history of any medical conditions? Any medications?
Allergy (The allergy box has to be filled out. You must write NKDA if no known allergies.

Do not forget to date and sign. Calculator is kept in the cubicle.

Use the Formula

25kg child = 10kg + 10kg + 5kg

First 10kg = 100mls × 10kg = 1000mls, Next 10kg = 50mls × 10kg = 500mls, Next 5kg =

20mls × 5kg = 100mls, Total fluid = 1000mls + 500mls + 100mls = 1600mls/day.

1600 divided by 24 hours = 67ml/hour. Fill up the prescription chart

FLUID INFUSION TO CHILD WITH APPENDICITIS

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110. 3 year old child Like is due for Flu vaccination in one week. Mother
wants to talk to a doctor. Address her concerns.

Nasal spray is more effective than injections in children D: How can I help you ?

M: My son is due for Flu vaccination in one week. Does he really need it ?

D: I will explain that. Before that Can I ask you what do you know about flu ?

M: I know he can have fever and cough.

D: Yes it is a very common infection in babies and children. One can catch flu all year round,
but it's especially common in winter, which is why it's also known as seasonal flu.

Children with flu have can have symptoms like fever, chills, aching muscles, headache,
stuffy nose, dry cough and a sore throat.
Flu (influenza) is a common infectious viral illness spread by coughs and sneezes.
Symptoms usually subside within about a week on its own. However, sometimes it can
cause serious complications such as bronchitis, pneumonia (infection of the lungs) and a
painful middle ear infection.
They may need hospital treatment, and very occasionally a child may die from the flu.
In fact, healthy children under the age of 5 are more likely to have to be admitted to hospital
with flu than any other age group.

Also if children with long-term health conditions such as diabetes, asthma, heart disease or
lung disease, getting the flu can be very serious as they are more at risk of developing
serious complications.

So prevent such serious complications it is very important to prevent children getting Flu.
That is why we recommend Flu vaccine to children to prevent them from getting Flu.

D: Can I ask does your child has any medical conditions like Diabetes, asthma, any
allergies?M: No D: Has he got any runny nose ? M : No

D: Has he had Flu jab before ? M : No

D: Has he got Flu symptoms now ? M: No

(M: Is the Flu same as common cold ?)

D: Flu is not the same as the common cold. Flu is caused by a different group of viruses and
the symptoms tend to start more suddenly, be more severe and last longer).

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D: Any other concerns ?

M: How do you give the Flu vaccine ?

D: There are two ways we can Flu vaccine - one type of nasal spray and the other type is
injection. However nowadays we give nasal spray rather than injections because nasal
sprays are more effective than injections. We usually give this vaccination before the start of
winter.

M: Are there any side effects of this vaccine (what are the symptoms to watch out for?

The nasal spray flu vaccine has few side effects – most commonly getting a runny nose after
vaccination for a few days.
D: The flu vaccine for children is usually safe but like all vaccines, some children may
experience side effects. The side effects linked with the flu nasal spray vaccine are almost
always mild and short-lived.

Common side effects of the flu nasal spray vaccine

" a runny or blocked nose

" headache
" general tiredness
" loss of appetite

Rare side effects of the flu nasal spray vaccine

As with all vaccines, there's a very small chance of a severe allergic reaction (known
medically as anaphylaxis). The overall rate of anaphylaxis after vaccination is around 1
in 900,000 (so slightly more common than 1 in a million).

(Anaphylaxis is very serious but it can be treated with adrenaline. When it happens, it
does so within a few minutes of the vaccination. Staff who give vaccinations have all
been trained to spot and deal with anaphylactic reactions and children recover
completely with treatment).

Not given in children who have an egg allergy

M: What should I do if my child has a side effect from the flu nasal spray vaccine ?

D: If your child has a runny nose after their flu vaccination, simply wipe their nose with a
tissue and then discard it.

M: What if my child has to have the injected flu vaccine what are the side effects ?

D: Some children can't have the nasal spray flu vaccine and are offered the injected vaccine .

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Children having the injected vaccine may get a sore arm at the injection site, a mild
fever and aching muscles for a day or two after the vaccination.

M: How is the nasal spray flu vaccine given?

D: The vaccine is given as a single spray squirted up each nostril. Not only is it needle-
free – a big advantage for children – the nasal spray is quick, painless, and works even
better than the injected flu vaccine.

The vaccine is absorbed very quickly. It will still work even if, after the vaccination, your
child develops a runny nose, sneezes or blows their nose.

Are there any children who should delay having the nasal spray flu vaccine?

Children should have their nasal spray flu vaccination delayed if they:

 Have a runny or blocked nose or if they are wheezy

 If a child has a heavily blocked or runny nose, it might stop the vaccine getting
into their system. In this case, their flu vaccination should be postponed until
their nasal symptoms have cleared up.

 If a child is wheezy or has been wheezy in the past week, their vaccination
should be postponed until they have been wheeze-free for at least 3 days.

M: Can children with egg allergy have this vaccine ?

(Are there any children who should not have the nasal spray flu vaccine)?

D: There are a few children who should avoid the nasal spray flu vaccine.

The vaccine is not recommended for children who have:

1) a severely weakened immune system

2) severe egg allergy

3) severe asthma – that is, those being treated with steroid tablets or high-dose inhaled
steroids

4) an allergy to any of the vaccine ingredients, such as neomycin

Children unable to have the nasal spray vaccine may be able to have the injectable flu
vaccine instead.

M: How safe is the flu vaccine for children?

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D: The flu vaccine for children has a good safety record. In the UK, millions of children
have been vaccinated safely and successfully.

M : How does the children's flu vaccine work?

D :The vaccine contains live but weakened flu viruses that do not cause flu in children. It
will help your child build up immunity to the flu in a similar way as natural infection, but
without the symptoms.

Because the main flu viruses change each year, a new nasal spray vaccine has to be
given each year, in the same way as the injectable flu vaccine.

M: What are the advantages of having Flu vaccine ?

D: The nasal spray flu vaccine will not only help protect your child against flu, the
infection will also be less able to spread from them to their family, carers and the wider
population.

Children spread flu because they generally don't use tissues properly or wash their
hands.

Vaccinating children also protects others that are vulnerable to flu, such as babies, older
people, pregnant women and people with serious long-term illnesses.

M: How many doses of the flu vaccine do children need?

D: Most children only need a single dose of the nasal spray.

Children aged 2 to 9 years at risk of flu because of an underlying medical condition, who
have not received flu vaccine before, should have 2 doses of the nasal spray given at
least 4 weeks apart.

Does my child have to have the nasal spray flu vaccine?

No. As with all immunisations, flu vaccinations for children are optional. Remember,
though, that this vaccine will help protect them from what can be an unpleasant illness,
as well as stopping them spreading flu to vulnerable friends and relatives.

Why can't under-2s have a nasal spray flu vaccine?

The nasal spray vaccine isn't licensed for children younger than 2 because it can be
linked to wheezing in children this age.

Why is it just younger children who are routinely being given the nasal spray flu
vaccine?

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The children's flu vaccination programme is being rolled out in stages.

This year (2017/18) it is routinely being offered to all children aged 2 and 3, plus
children in the reception class and school years 1, 2, 3 and 4.

In some areas all primary school children will be offered the vaccine.

Over the next few years, the programme will gradually be extended to include children
in other age groups.

All children aged between 6 months and 2 years who are at risk of flu because of an
underlying health condition are already eligible for the injected flu vaccine.

Why aren't children being given the injected flu vaccine instead of a nasal spray?
The nasal spray flu vaccine is more effective than the injected flu vaccine, so it's the
preferred option.

Will the flu vaccine give my child flu?

No. The vaccine contains viruses that have been weakened to prevent them causing flu.

Does the nasal vaccine contain pork?

Yes, the nasal spray contains a highly processed form of gelatine (porcine gelatine),
which is used in a range of essential medicines.

The gelatine helps to keep the vaccine viruses stable so that the vaccine provides the
best protection against flu.

Can my child have the injected vaccine that doesn't contain gelatine instead?

The nasal vaccine provides good protection against the flu, particularly in young
children. It also reduces the risk to, for example, a baby brother or sister who is too
young to be vaccinated, as well as other family members (for example, grandparents)
who may be more vulnerable to the complications of flu.

The injected vaccine is not being offered to healthy children as part of the children's flu
vaccination programme.

However, if your child is at high risk from flu due to one or more medical conditions or
treatments and can't have the nasal flu vaccine for the reasons of faith ( vegetarians or
those who does not have pork) they should have the flu vaccine by injection.

Some faith groups accept the use of porcine gelatine in medical products – the decision
is, of course, up to you.

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M: My friends child had fits after receiving Flu jab ? Does the Flu jab cause fits ?

D : Flu vaccination by itself does not cause fits. However, children with Flu have high
temperature and that high temperature can cause fits. Flu vaccination prevents children
getting Flu.
Pt: is there any alternative to flu vaccine?? Dr: no.

INFLUENZA VACCINATION (FLU JABS) IN A

CHILD

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111. Mother Zara brought in her child Zain (4 months old) with fever,
inconsolable cry and poor feeding.

In exam, electrolytes are given…. Maybe all are normal.

Vitals: O2 saturation: 92%, R.R: 57 Pulse: 157 Temp: 38

-GRIPS

- How can I help you?

M- Doctor my little Zain he is crying a lot since past 3 days. He is not even feeding properly.

D- I am Sorry to hear that. We are here to take care of your child. He is safe hands now.

D- Can you please tell me anything more about it?

M- He has been having dry cough since past 3 days.

D – Does he cough up any phlegm at all ? Yes/no

D- Is it there at specific time or all the tim? M- It is there all the time.

D- Did you notice the cough sounds like barking ? … No

D – Any discharge from nose ?

D- Did you notice any shortness of breath?... yes /No

D- Have you noticed any rashes on his body and any neck stiffness ? .... no

D- Is he crying while passing urine/ if the urine is more smelly ? passing less urine

(dehydration) …. No

D – Have you noticed that his mouth is dry ( dehydration) ?

D- How is the poo ?any loose stool… No

D – How is the feeding? Breastfeeding or Bottle feeding ?

D - Is he active or drowsy ?

D- Any similar problems in the past? .... Yes/no

D- Any history of similar problems in the family members? … Yes his father has Asthma

D- Is he your only child? …. Yes/no

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D- How was the delivery? ….normal

D _ Has he born premature, low birth weight ? (Risk factor for Bronchiolitis)

D- Has he got the jabs so far ? … Yes

D-Any problem with the redbook so far? …. No

D- Any problem with the development? …. No

D- Who takes care of your child …. I take care

D - any other children at home ? Any other children have similar problems ?

Anyone else at home not well ?

D- Any previous heart or lung conditions ?

Thank you very much for giving me all the information.

Examination:

For now, I need to examine your child. I will do the general physical examination, check
pulse, blood pressure and temperature and examine chest.

(Examiner may give a long sheet with all the information on it)

Chest: bilateral Rhonchi and unilateral Crackles.

Temperature: Increased

SpO2: 92% (check for any other information that might be written on the paper)

Management:

Investigations:

For now we need to do some investigations to confirm the reason what may be causing
this problem in him.

1. Chest X- Ray

2. Blood tests including infection markers and electrolytes

- We need to do some type of blood test what we call Blood gases.

- Blood Tests to check for bugs.
- We do some tests on nose discharge (Nasopharyngeal aspirate for:RSV rapid
testing) for virus kind of bugs

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Diagnosis

I think your child has a condition what we call as Bronchiolitis. It is an infection of the
lungs by virus kind of bugs. It could be early onset of Asthma also since his father has
Asthma. However we need to test for that.

Treatment:

1. Admit
2. We will start your child on Oxygen
3. Nebulisation with salbutamol
4. Antibiotics – after confirming if it is viral or bacterial
5. I.V fluids.
6. Breast-feeding is considered protective in Bronchiolitis and should be
encouraged for this and other reasons.

M - Doctor please give me antibiotics I will go. I don’t want my child to get admitted as I
have some work. Try to convince her and she will agree to stay back at hospital.

Thank you.

CHEST INFECTION? BRONCHIOLITIS

Additional information on cough in Baby of 4 months:
Causes of cough

1. Cough is usually a symptom of an infection, typically the common cold virus.

2. Croup, a viral infection of the voice box and airways.
3. Whooping cough, a bacterial infection of the windpipe and airways. You will be
offered vaccination against whooping cough for your baby.
4. Bronchiolitis, a viral infection of the lungs.
5. Cough can also have non-infectious causes, such as asthma.

Bronchiolitis is an acute infectious disease of the lower respiratory tract that occurs
primarily in the very young, most commonly infants between 2 and 6 months old. It is a
clinical diagnosis based upon:

1. Breathing difficulties
2. Cough
3. Decreased feeding
4. Irritability
5. Apnoeas in the very young
6. Wheeze or crepitations on auscultation

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It is usually due to a viral infection of the bronchioles. Respiratory syncytial virus (RSV)
is the most common pathogen, causing 50-90% of cases. A combination of increased
production of mucus, cell debris and oedema produces narrowing and obstruction of
small airways.

Common Causes

" Respiratory syncytial virus (RSV)

" Human metapneumovirus (hMPV) - causes a similar spectrum of illness to RSV
and is thought to be the second most common cause[4]
" Adenovirus - occasionally causes a similar syndrome with a more virulent course
" Parainfluenza virus

Epidemiology

Peak incidence of RSV infections is in the winter months (November to March),

although the size of the peak varies from winter to winter.

By their first birthday, over 60% of children have been infected and, by 2 years of age,
over 80%. The antibodies that develop following early childhood infection do not prevent
further RSV infections throughout life.

Risk factors

" Environmental and social risk factors:

" Older siblings
" Nursery attendance
" Passive smoke, particularly maternal
" Overcrowding

Risk factors for severe disease and or complications:

" Prematurity (<37 weeks)

" Low birth weight
" Age less than 12 weeks
" Chronic lung disease (eg, cystic fibrosis, bronchopulmonary dysplasia)
" Congenital heart disease
" Neurological disease with hypotonia and pharyngeal dis-co-ordination
" Epilepsy
" Insulin-dependent diabetes
" Immunocompromise
" Congenital defects of the airways
" Down's syndrome

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Presentation Symptoms

" Early symptoms are those of a viral URTI, including mild rhinorrhoea, cough and
fever. Fever >39°C is unusual and should prompt a thorough examination and
further investigations to exclude other possible causes.

" For the 40% of infants and young children who progress to lower respiratory tract
involvement, paroxysmal cough and dyspnoea develop within 1-2 days.
" Other common symptoms include the following: wheeze, cyanosis, vomiting,
irritability and poor feeding.
" Apnoeas may occur, especially in young infants.

Signs

" Look for tachypnoea, tachycardia, fever, cyanosis and signs of dehydration. It is
unusual for a child to appear 'toxic' (suggested by drowsiness, lethargy, pallor,
mottled skin) and this should prompt urgent action in terms of the need for
immediate treatment and exclusion of other potential causes.
" Mild conjunctivitis, pharyngitis.
" Evidence of increased respiratory work: intercostal, subcostal and
supraclavicular recession, nasal flaring.
" Widespread fine inspiratory crackles are considered a key finding in the UK,
whilst high-pitched expiratory wheezing is commonly present but not essential to
a diagnosis.
" Liver and spleen may be palpable due to hyperinflation of the lungs.

Investigations

" Pulse oximetry.

" Nasopharyngeal aspirate for:
" RSV rapid testing - to enable isolation or cohort arrangements and to prevent
further, unnecessary testing.
" Viral cultures for RSV, influenza A and B, parainfluenza and adenovirus can also
be undertaken.

Other investigations that are not recommended for typical acute bronchiolitis include:

CXR: bronchiolitis produces:

" Nonspecific hyperinflation and patchy infiltrates

" Focal atelectasis
" Air trapping
" Flattened diaphragm

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" Increased anteroposterior diameter

" Peribronchial cuffing
CXR should only be performed if there is diagnostic uncertainty or an atypical course.

FBC.

Electrolytes and renal function: only perform if the child is dehydrated or on IV fluids.

Blood and urine culture: consider if pyrexia >38.5°C or the child has a 'toxic'
appearance.

Arterial blood gases: may be required in the severely ill patients, especially in those who
may need mechanical ventilation.

Management

Primary care

Most infants with acute bronchiolitis will have mild, self-limiting illness and can be
managed at home. Supportive measures are the mainstay of treatment, with attention to
fluid input, nutrition and temperature control.

Within general practice, a doctor's role is to assess current severity of illness and, for
those with mild-to-moderate disease, to support and monitor. Consider whether the
presentation is in the early stages of disease, when a child is more likely to get worse
before improving. Careful safety netting is important, teaching parents to spot
deterioration and to seek medical review should this occur.

For the majority, bronchiolitis lasts 7-10 days, with 50% asymptomatic by two weeks and
only a small subgroup still symptomatic at four weeks.

Referral: crieteria for admission:

Hospital referral is suggested where there is:

" Poor feeding (<50% usual intake over the previous 24 hours) which is inadequate
to maintain hydration
" Lethargy
" History of apnoea
" Respiratory rate >70 breaths/minute
" Nasal flaring or grunting
" Severe chest wall recession
" Cyanosis

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" Saturations ≤94%

" Uncertainty regarding diagnosis
" Where home care or rapid review cannot be assured

The threshold for admission should be lower in those with significant comorbidities,
premature infants and those under 3 months old.

PICU admission is necessary if the child has increasing severe respiratory distress with
desaturation or apnoea whilst receiving 50% oxygen. Continuous positive airway
pressure (CPAP) or intubation may be required in these cases, although one study
found that the majority of children could be managed with non-invasive ventilation
outside the PICU setting.

Secondary care

Even amongst hospitalised children, supportive care is the mainstay of treatment,

including oxygen and nasogastric feeding where necessary.

Other treatments have shown inconsistent or little evidence of benefit:

Bronchodilators: modest short-term improvement in clinical scores but no reduction in

the rate or duration of hospitalisation.

Corticosteroids: trials have consistently failed to provide evidence of benefit. A large

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

Racemic adrenaline (epinephrine) - racemic = 1:1 mixture of the dextrorotatory and

levorotatory isomers: one study reported that inhaled racemic adrenaline (epinephrine)
was no better than inhaled saline.

Hypertonic (3%) saline: thought to act by unblocking mucous plugs and reducing
airway obstruction. A Cochrane Review concluded that there was evidence its use did
reduce length of hospital stay and clinical severity scores.A later study found no
difference in clinical outcome between 3% and 0.9% saline.

Antibiotics: there is minimal evidence to support their use, except in a small subset of
patients with respiratory failure.

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Ribavirin: may reduce the need for mechanical ventilatory support and the number of
days in hospital but there is no clear evidence of clinically relevant benefits (eg,
preventing respiratory deterioration or mortality).

Chest physiotherapy does not improve the severity of the disease, respiratory
parameters, or reduce length of hospital stay or oxygen requirements in hospitalised
infants with acute bronchiolitis not on mechanical ventilation.

Prognosis

Most children with bronchiolitis make a full recovery.

Mechanical ventilation is required for some patients but one study found that the
majority can be managed without.

Most deaths occur in infants younger than 6 months or in those with underlying cardiac
or pulmonary disease..

Prevention

Vaccines

A vaccine is available for babies most at risk of developing severe, and occasionally
fatal, RSV infection. These will be very young infants born prematurely who have
predisposing conditions such as chronic lung disease, congenital heart disease or
children who are immunodeficient. It is usually given in secondary care.

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112. DELAYED WALKING IN A CHILD

14 month old boy (first child/only child) has not started walking.

What is considered delayed walking?

Most children are able to walk alone by 11 to 15 months but the rate of development is
very variable. Some children will fall outside the expected range and yet still walk
normally in the end. Walking is considered to be delayed if it has not been achieved by
18 months.

Causes of delayed walking

1. Delayed motor maturation,

2. Severe learning disabilities (more associated with fine motor skills and
language and social skills),
3. Hypertonia (cerebral palsy),
4. Muscular dystrophy (DMD: Baby boys are often normal at birth and delayed
walking may only be identified retrospectively, with symptoms really appearing
between 4 and 6 years of age), Hypotonia (Down’s Syndrome, Tay Sachs),
5. Maternal antenatal infections
6. Infections (meningitis, encephalitis),
7. Head injury,
8. Malnutrition
9. Overly protective environment when parents tend to keep children in confined
area in order to keep them safe.

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14 month old boy (first child/only child) has not started walking.

Fine motor: holds spoon, draws with crayons, crawling normal,

Also ask about other children? Or if similar history in parents?

- Says Mama and Papa, plays with blocks. No family history or development issues so
far.

- No injuries. No family history and child gets along well with other children and adults. -
- Positive family dynamic at home. No indication of NAI. Mother and father both
biological parents. Has not been encouraged by parents to walk.

Mothers main concerns are: is it normal if hasn’t walked by now?

Ask in history: issues with pregnancy? Full term normal delivery? Preterm birth? Red
book and development? Child fed well? (malnourished) Past illnesses? Family history-
parents walked? Any medical conditions in family? (muscular dystrophy or neurological
disorder) Care at home? Overprotected or neglect or emotionally deprived? Child
encouraged to walk?

Head injury, infections

Check milestones (given below) It’s important to ask when child achieved important
gross motor milestones: holding up head, sitting with support/no support, crawling,
standing or walking.

Examination: Neurological examination of the lower limbs, strength, symmetrical

movements, reflexes, muscle tone and bulk

Investigations: CPK to r/o muscular dystrophy in a child with no other developmental

delays

Diagnosis – With your information and examination everything looks normal except he
has not started walking. Sometimes this is normal to some children. They are a bit slow
to start walking.

Management: depends on examination findings. No issues - review in one month,

encourage walking by holding hands (avoid child walker use) and parents to motivate
child to walk. Paediatrician and physiotherapy referral may offer appropriate
management.

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Milestones

Gross motor developmental milestones

6 weeks: sits with curved back, needs support. Head control developing. In ventral
suspension (when held above couch with examiner's hand supporting the abdomen) can
hold head at level of body briefly.

3 months: can hold head at 90° in ventral suspension.

6 months: no head lag when pulled to sit. Can sit with support. When lying face down, can
lift up on forearms.

9 months: gets into sitting position alone. Sits unsupported and can pivot. Crawls. (Age of
crawling varies widely, and some infants never crawl.)

10 months: pulls to standing and stands holding on.

12 months: stands and walks with one hand held. May stand alone briefly. May walk alone.

18 months: walks well. Climbs stairs holding rail. Runs. Seats self in chair.

2 years: goes up and down stairs alone. Two feet per step. Kicks a ball.

3 years: climbs stairs one foot per step. Able to stand on one foot for a few seconds.

Most children are able to walk alone by 11 to 15 months but the rate of development is very
variable. Some children will fall outside the expected range and yet still walk normally in the
end. Walking is considered to be delayed if it has not been achieved by 18 months.

Red flags

" Poor head control or floppiness at 6 months.

" Unable to sit unsupported at 9 months.

" Not weight bearing through legs at 12 months.

" Not walking at 18 months.

" Not running at 2 years.

" Not climbing stairs at 3 years.

" Persistent toe walking.

" Increased muscle tone

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113. Mother has come to speak with the GP/PAEDIATRICS DEPT as she is
concerned about her 5 year old daughter Jasmine. (Daughter is not with her).

Night terrors usually happen earlier on in the night while nightmares usually occur late at night

Hello I am Dr … one of the junior doctors in the Paediatric department. Are you the
mother of Jasmine? Mother : Yes.

Dr: How can I call you please?

Mother : You can call me Mrs.….Dr: How can I help you Mrs….?

Mother: Jasmine has been waking up in the night Dr. She is not sleeping well.

Dr: I am sorry to hear that. How often has this been happening? Mother: About 2-3 months.

Dr: Could you please tell me more about this Mrs..?

Elaborate the event

Mother : Dr, she goes to sleep and wakes up at least 2-3 times every night. She
screams, shouts and looks very panicked.

Dr : that must be very terrifying for you. May I ask what you do when she screams?

Mother : I try to calm her down or wake her up. But she screams even more when I do that.

Dr : Does she remember this happening the next morning? Mo: No, Dr, she does not (In
case of night terror child wont remember but night mare child will)

Dr : Does she move her limbs abnormally when she screams? Mother : No

Dr : Do her eyes roll up during the episode? Mo: no

Dr : does she pass wee or poo during this? Mo : no

Dr : does she get breathless during the episode? (?asthma)Mo : no

Dr : Does she go blue during this? (congenital heart disease) Mo: no

Dr : does she snore during her sleep?

Dr : did she have any fever or flu recently? Mo : no

Dr : did anything significant happen in your lives before this started happening?

Mo : like what Dr?

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Dr : Death of any family member? Death of a pet? Change in environment/school? Birth

or a younger sibling?new home? Mo: she started a new school dr (no bullying history),

Dr: Was she well before this change in school?

Mother: She was completely fine before this happened.

BIRDS Questions

Dr : How was Jasmine’s birth? Did any of you need immediate medical attention after
her birth? Mo : …

Dr : How about her Jabs?

Dr : Are you satisfied with the red book?

Dr : How is her development? Similar to other kids of her age?

Medical History

Dr : Does she have any medial conditions (Tonsillitis, ADHD, Congenital heart
disease, Asthma)? Mo : No

Dr : Any medications? Mo: No

Dr : Family history of similar conditions Mo: Father had sleep walking when he was
younger and grew out of it.

Social History:

Dr : What time does she go to sleep? How is the sleeping space? Mo :…

Dr : Does she watch tv or play games before she sleeps? Or Anything scary ? Noisy
neighbours? Mo: No
NAI questions:

How is the financial situation at home? Mo : Good

Is your husband Jasmine’s Biological father? Mo : Yes

Does anybody else take care of her? Mo : No

Dr : Thank you Mrs… for answering my questions. Ideally I would like to examine Jasmine

first and talk to her as well. However, from what you have told me I think Jasmine has a

condition called night terrors. Are you familiar with that?

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Mother : Is it a nightmare ?

Dr : Its not the same Mrs.. this condition is common in children aged between 3 -12
years old. It is sort of a sleep terror disorder. A child who experiences night terrors may
scream, shout and thrash around in extreme panic. They could even jump out of bed.
Their eyes may be open, but they're not fully awake or alert as to what just occurred. It
occurs during the dreamless part of sleep. Hence she wont be able to recollect it the
next day.

Mo: Why is this happening dr?

Dr : It seems to run in families. Sometimes it may occur due to stressful situations in life.
Lie the change of school could be a reason

Mo : Will she continue to have this dr? Dr : in most cases children do grow out of this
condition. Sometimes it can continue into adulthood too.

Dr : There is some advice I would like to give you. Notice a time frame when the episodes
occur and possibly wake the child 15 mins prior to expected time for 7 days to stop the night
terrors from happening and help break the cycle (will wake the child up but will not disturb the
sleep quality). Stay calm while the child is having an episode of night terror and wait until they
calm down as well. Best not to intervene or wake the child during the episode as they may
not recognise you and become more anxious.
Communication as to discuss any stressors for the child is valuable however do not discuss
the details of the episodes with your child as it may in turn cause more anxiety.

Mo : Okay Dr

Dr : I’d also advise you have a relaxing night routine, good sleep hygiene and emptying
bladder before she goes to sleep. Please bring her here next time so that we can
examine her and run some tests to make sure nothing else is causing this.

If it is a night mare station, child will recollect the dream the next day

CHILD WITH NIGHT TERRORS

What is a nightmare?
This is synonymous with dream-anxiety attacks. Bad dreams/nightmares occur in REM sleep,
with associated severe anxiety and symptoms of increased sympathetic outflow. There is
complete alertness and recall of dreams on waking. The presence and recollection of the
dream is what helps to differentiate this condition from night terrors. Sufferers may have
experienced previous trauma that is relived. This presentation is a major symptom of post-
traumatic stress disorder (PTSD).

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114. You are a FY2 doctor in GP, mother of a 3 yrs old child Jason is
concerned about her son. Talk to her and address her concern.

Hello I am Dr … one of the junior in the GP clinic toady. Are you the mother of Jason?
Mother: Yes.

Dr: How can I call you please?

Mother: You can call me mrs.….Dr: How can I help you Mrs….?

Mother: I am worrying about my son!

Dr. May I know why?

Mother: Health assessor of Jason is concerned about him.

Dr: May I know why?

Mother: Jason is not interacting with other children at the nursery!

Dr: I am sorry about that! Can I ask few questions to help Jason with the condition?
(explore details about what does she mean by not interacting with others like playing/
talking etc)

Mother: Sure

Dr: Can you confirm the age of Jason?

Mother: 3 years

Dr: At what age did you first notice this behaviour?

Mother: ….

Dr: Is Jason your first child? Mo: Yes

Associated other Developmental Questions:

Dr: Does he respond to you when you call his name? Mo: Yes

Dr: Are there any other delays in walking or speaking? Mo: No

Dr: Is he playful? Mo: Yes, he plays with blocks

Dr: Any repetitive behavior (Autism)?

Dr: Do you notice any abnormal movements in the child?

Dr: Does he climbs stairs?

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Dr: Does he copy circles?

Dr: Does he say 2-3 words sentences?

Dr: Any spasms or increased/decreased tone of muscles?

Dr: Fixation on specific objects?

Dr: Does he seem withdrawn?

Dr: Anything significant happen recently?

Dr: Anything else? Mo: he doesn’t like cuddling!

Dr: Does his face look flattened?Short neck?Small head?Protruding tongue? (Down
syndrome)

Dr: Any vision/hearing problem? Heart problem? (Congenital Rubella Syndrome)

BIRDS Questions

Dr : How was Jason’s birth? Did any of you need immediate medical attention after his
birth? Mother : …

Dr: Was he born as pre-term or term baby?

Dr : how about his Jabs?

Mother: Yes, he has been up to date with all jabs.

Dr : Are you satisfied with the red book?

Dr : How is his development? Similar toother kids of his age?

Medical History

Dr : does he have any medical conditions (Cerebral Palsy, Epilepsy)? Mo: no

Dr :Any medications, Mo: no

Dr : Family history of similar conditions Mo: no

NAI questions

Dr: How is the financial situation at home? Mo : good

Dr: Is your husband Jason’s Biological father? Mo : yes

Dr: Does anybody else take care of him, Mo : no

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Dr : Thank you Mrs… for answering my questions.

Ideally, I would like to examine Jason first.

Dr: It could be Autism; need to talk to seniors for further assessment

To confirm diagnosis: (need at least 6 months assessment to confirm)

Referral to a specialist autism team ora healthcare professional who specialises in diagnosing
autism.

Autism is sometimes called autism spectrum disorder or ASD or Asperger

syndrome.Unfortunately, Autism is a lifelong condition that affects how people understand
and interact with the world around them, including how they communicate with other people.
Autism affects people in different ways. But most autistic people see, hear and experience
the world differently from people without autism. It's estimated about 1 in every 100 people in
the UK is autistic. More boys and men are diagnosed with autism than girls and women.But
it's now thought older girls and women may manage the condition differently and are
therefore underdiagnosed.

Although there's no "cure" for autism, with the right support many autistic people live fulfilled
and active lives.

The specialist or specialist team will make a more in-depth assessment, which should
be started within 3 months of the referral, though this can take longer in some areas.

Mother: Is he having this because of MMR Vaccine?

DR: In the past, some people believed the MMR vaccine caused autism. But this has
been investigated extensively in a number of major studies around the world, involving
millions of children, and researchers have found no evidence of a link between MMR
and autism.

Mother: Why he is having this?

Dr: The exact cause of autism is currently unknown.Autism is a complex

neurodevelopmental condition. The causes are still being investigated.Current evidence
suggests that autism may be caused by many factors that affect the way the brain
develops.These include:

genetics

environmental triggers

Genes

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Most researchers believe that certain genes a child inherits from their parents could
make them more likely to have autism. This is called a genetic predisposition.

Autism is known to run in families. For example, younger siblings of autistic children can
also be autistic. It's also common for identical twins to both be autistic.

Although scientists are still trying to identify the genes involved, signs of autism may be
a feature of some rare genetic syndromes.These include:

 Fragile X syndrome

 Williams syndrome

 Angelman syndrome

 Environmental triggers

Very few conditions are caused only by genes. Most are caused by a combination of
genes and environmental factors or triggers.Environmental triggers include lifestyle
factors, such as diet and exercise.Researchers believe that there are some possible
triggers that may increase the likelihood of being autistic.These include:

 being born prematurely (before 35 weeks of pregnancy) being exposed to alcohol in the

womb

 being exposed to certain medicines, such as sodium valproate (sometimes used to treat
epilepsy), in the womb

 What does not cause autism

In the past, a number of things were linked to autism, but extensive research has found no
evidence to suggest that any of these contribute to the condition.These things include:

 the MMR vaccine

 thiomersal – a mercury compound used as a preservative in some vaccines the way a

person has been brought up

 diet, such as eating gluten or dairy products pollution

 maternal infections in pregnancy

AUTISM
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115. Patient has already been diagnosed with Autism.

You are FY2 in GP. A 3 years old child Graham already been diagnosed with
Autism. Take history and address the concerns of the mother.

Mother was worried about how to cope up with the condition.

Unfortunately, There's no 'cure' for autism, but there are ways to support autistic people,
their families, carers and friends.

Although there's no "cure" for autism, with the right support many autistic people live fulfilled
and active lives. Support for autistic people and their families is designed to help
understand their differences, improve communication, and provide help with their
educational and social development.

It can be difficult to know what type of support will work best for you or your child
because each autistic person is different.

Help and support: National Autistic Societyand National Autistic Society's Community

Support for autistic children

The detailed assessment, management, and care and support for your child should
involve local specialist community-based multidisciplinary teams (sometimes called
"local autism teams") working together.

The team may include:

 a paediatrician

 mental health specialists, such as a psychologist and psychiatrist a learning

disability specialist (if appropriate)

 a speech and language therapist an occupational therapist

 education and social services representatives from your local council

Every child or young person diagnosed with autism should have a case manager or key
worker to manage and coordinate their care and support, as well as their transition into
adult care.

The parents of an autistic child play a crucial role in supporting them and improving their
skills.

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Helpful interventions: Some interventions can help your child's development.These include:

 Communication skills – such as using pictures, sign language or both to help

communicate as speech and language skills can be significantly delayed

 Social interaction skills – play-based strategies, comic strips and some computer-based
interventions can help

 Imaginative play skills – such as encouraging pretend play

 Learning skills – such as pre-learning skills to help concentration, reading, writing and
maths

How to communicate with your autistic child: Communication can be particularly difficult for
autistic children and young people. Helping them communicate can reduce anxiety and the
risk of behaviour that may be difficult or challenging. Try these tips when interacting with
your child:

 use your child's name so they know you're addressing them keep background noise to

a minimum

 for some autistic children, it can help if you keep the language simple and literal speak

slowly and clearly

 some parents find it useful to accompany what they say with simple gestures or pictures

allow extra time for your child to process what you have said

 Help for behaviour that may be seen as challenging

It's important to remember that behaviour is a way of communicating.

If an autistic child or young person is behaving in a challenging way and this is affecting
family life, ask for help and support from a GP or another healthcare professional.

A GP or another healthcare professional will check for things that may be causing your
child to behave in a challenging way.

They'll check: Teeth, ears or hearing, digestion, pain in an area a child or young person
cannot point to

If the GP thinks the person may have anxiety problems, they may recommend mental
health support, such as talking therapies.

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Medicines: Medicines may sometimes be prescribed to treat some of the symptoms or

conditions associated with autism.

For example:

 Sleeping problems – this may be treated with a medicine, such as melatonin

 Depression – this may be treated with a type of medicine known as a selective serotonin
reuptake inhibitor (SSRI), though these do not always work for autistic people

 Serious aggressive or self-harming behaviour – this may be treated with a type of

medicine called an antipsychotic if other support has not helped

 Epilepsy – this may be treated with a type of medicine called an anticonvulsant

 Attention deficit hyperactivity disorder (ADHD) – this may be treated with a medicine,
such as methylphenidate

These medicines can have significant side effects and should only be prescribed by a doctor
who specialises in the condition being treated.

If medicine is offered, the autistic person will have regular check-ups to assess whether
it's working.

Treatments' that are not recommended: A number of alternative treatments for autism have
been suggested. But there's no evidence to support them. And some are dangerous.
Potentially harmful "treatments" for autism include:

Neurofeedback – where brain activity is monitored (usually by placing electrodes on the

head) and the person being treated can see their brain activity on a screen and is taught
how to change it

Auditory integration training – a therapy that involves listening to music that varies in
tone, pitch and volume

Chelation therapy – this uses medication or other agents to remove metal (in particular,
mercury) from the body

Bleaching – sometimes called CD (chlorine dioxide) or MMS (Mineral Miracle Solution)

Hyperbaric oxygen therapy – treatment with oxygen in a pressurised chamber

Facilitated communication – where a therapist or another person supports and guides a

person's hand or arm while using a device such as a computer keyboard or mouse.

AUTISM - SCENARIO 2
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116. You are a FY2 in GP clinic. Mother of 2 years old boy Daniel has visited GP
1 week ago because Daniel has constipation. Daniel was examined, and
examination was normal. Dietary advice was given and asked her to come
back after 2 weeks, but she came after 1 week. Talk to her and address her
concerns.

GRIPS plus rapport first

Dr: I understand that you visited our GP practice 1 week ago as Daniel had constipation. Can
you please tell me how is he doing now? Mo: He is still having constipation!

Dr: I am sorry to hear that. Can I ask few questions to help Daniel with the condition? Mo: Ok

Dr: May I know what advice and treatment were given last time?

Mo: They gave me dietary advice and asked me to give Daniel lots of fruits and vegetables
(high fibre diet) and plenty of water.

Dr: Were you giving those? Mo: Yes

Ask details about diet plus fluids?Is he eating well? Mo:Yes

Is he physically active? Playing well?

When was the last time he passed stool? Mo: 10 days ago

Ask about potty training? Does he cry while sitting on the potty? Mo: Yes

Any overflow diarrhea? Any vomiting?

Rule out Intestinal obstruction: any tummy pain? No

Able to pass wind? Mo: Yes

Does he go to school? Yes

Anything significant happened recently?

Ask BIRD questions?

Ask MAFTOSA

Ask NAI Questions

Ideally, I need to examine the child

Management: Dietary advice plus potty training. After talking to seniors, laxatives may be
given

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Constipation in young children

Constipation is common in childhood, particularly when children are being potty trained
at around two to three years old.

Symptoms of constipation in children

Your child may be constipated if:

" they don't poo at least three times a week

" their poo is often large, hard and difficult to push out

" their poo looks like "rabbit droppings" or little pellets

" If your child is already potty trained, soiled pants can be another sign of
constipation, as runny poo (diarrhoea) may leak out around the hard, constipated
poo. This is called overflow soiling.

" If your child is constipated, they may find it painful to poo. This can create a
vicious circle: the more it hurts, the more they hold back. The more constipated
they get, the more it hurts, and so on.

Even if pooing isn't painful, once your child is really constipated, they may stop wanting
to go to the toilet altogether.

Why children get constipated

Your child may be constipated because they:

" aren't eating enough high-fibre foods like fruit and veg

" aren't drinking enough

" are having problems with potty (or toilet) training

" are worried or anxious about something, such as moving house, starting nursery
or the arrival of a new baby

How to treat your child's constipation

The treatment for constipation depends on your child’s age.

- The longer your child is constipated, the more difficult it can be for them to get
back to normal, so make sure you get help early.

- Laxatives are often recommended for children who are eating solid foods,
alongside diet and lifestyle changes.

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- It may take several months for the treatments to work,but keep trying until they
do. Remember that laxative treatment may make your child's overflow soiling
worse before it gets better.

- Once your child's constipation has been dealt with, it's important to stop it coming
back. Your GP may advise that your child keeps taking laxatives for a while to
make sure their poo stays soft enough to push out regularly.

- Try to stay calm: Getting constipated and soiling their clothes isn't something
your child is doing on purpose, so there's no reason to get cross with them.You
may both find the situation stressful, but staying calm and relaxed is the best
attitude to help your child deal with the problem.

How to prevent constipation

• Make sure your child has plenty to drink – offer breastfed babies who aren’t eating
solids yet plenty of breastfeeds. Formula-fed babies can have extra drinks of water
between their formula feeds.

• Give your child a variety of foods, including plenty of fruit and vegetables, which are a
good source of fibre. Encourage your child to be physically active.

• Get your child into a routine of regularly sitting on the potty or toilet, after meals or
before bed, and praise them whether or not they poo. This is particularly important for
potty-trained boys, who may forget about pooing once they are weeing standing up.

• Make sure your child can rest their feet flat on the floor or a step when they're using
the potty or toilet, to get them in a good position for pooing. ERIC, The Children's
Bowel & Bladder Charity's leaflet, Children’s Bowel Problems.

• Ask if they feel worried about using the potty or toilet – some children don't want to
poo in certain situations, such as at nursery or school.

• Stay calm and reassuring, so that your child doesn't see going to the toilet as a
stressful situation – you want your child to see pooing as a normal part of life, not
something to be ashamed of.If you'd like advice about taking the stress out of going to
the toilet for your child, speak to your health visitor.

ETHICAL ISSUES: Gillick competence

Fraser Guidelines only applies to contraceptives
If a parent complains about her child being given contraceptives, explain to the
parents the reason the guidelines were created. Do not tell the parent whether or not
the child came to the clinic. CONSTIPATION IN A CHILD

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116. B. Question - Mrs. Claire Johnson came to the GP clinic with her 6 years old
son Andrew. You are a FY2 in GP clinic.
Child was referred to the ENT specialist for tonsillectomy by GP because the mother
was forcing the GP, but the ENT specialist has refused to do Tonsillectomy. Talk to her
and address her concerns.
Doctor- Hello, I am Dr….. , I am one of the FY2 in this GP clinic. Are you the mother of Andrew.
Mother : Yes.
Doctor - How can I call you please ? Mother : You can call me Mrs Johnson.
Doctor - How can I help you today?
Mother - I want you to remove my child Andrew’s tonsils.
Doctor- Mrs. Johnson I can understand that you are worried about this situation but can you
please tell me why you want his tonsils to be removed.
Mother – Doctor, He keep having this tonsillitis, he suffers a lot with that. Once his tonsils are
removed he will not have these bouts of tonsillitis. He will not have fever because most of the
time he has fever and pain in throat because of tonsillitis.
Doctor – Mrs. Johnson, I can understand that being a mother you cannot see your child going
through this pain again and again. Can I ask does have sore throat now ?
Mother : No
If the child has sore throat now - take full history ( rule out quinsy)
 a sore throat

 difficulty swallowing

 hoarse or no voice

 a high temperature of 38C or above( if she has measured)

 swollen, painful glands in your neck (feels like a lump on the side of your neck)

 white pus-filled spots on your tonsils at the back of your throat – if she has seen his
throat ( quinsy)

 bad breath

Ask is it affecting him in any way – missed school

If he has symptoms now – say you want to examine him. Examiner may or may not give
findings.

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Doctor :How many times he had tonsillitis ?( ask each episode in the previous 2 years too).
Has she seen doctor for every episode or not ?
Mother : 5 times in the last year [ her answer may be different for different candidates. She might
ask that why you want to know about the episodes. She might say that there has been enough to
disturb his daily activities and he misses school because of this]
Doctor –Mrs. Johnson, May I ask what do you know about tonsillitis.
Mother : I know - it is infection of the tonsils.
Doctor: That is right, it is the infection of the tonsils either by bacteria or virus type of bugs. Most of
the time it is virus type of bugs causes this infection. Most of the time they resolve by itself without
any treatment in about a week time. However sometimes if it is caused by bacteria and if the
symptoms are severe then we give antibiotics to treat that.
However, antibiotics does not prevent it from coming again. Sometimes the children keep having
this infection recurrently and has to go through lot of problems.
As you rightly mentioned, if the tonsillitis keeps coming back again and again we do consider
removing the tonsils so that it will not come back again.
However, there are advantages and disadvantages of removing the tonsils.
Let me explain what are tonsils what is the normal function of them so that you can understand
better.
The tonsils are a pair of soft tissue masses located at the rear of the throat.

Tonsils helps to fight infections. The main function of tonsils is to trap germs (bacteria and
viruses) which we may breathe in. Proteins called antibodies produced by the immune cells in
the tonsilshelp to kill germs and help to prevent throat and lung infections.

1) Advantage of course if that the child will not suffer from tonsillitis again.
2) Disadvantages of removing the tonsils are that it reduces the body’s capacity to fight
infection and lot of complications of the operation itself like pain, nausea and vomiting,
delay to oral intake, airway obstruction with respiratory compromise, and postoperative
bleeding.

However, in certain situation we do consider removing tonsils like

1) 7 or more significant sore throats (with impact to patient and family) in the preceding 12
months or
2) 5 or more episodes in each of the preceding two years, or
3) 3 or more in each of the preceding three years)

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4) The impact of recurrent tonsillitis on a patient’s quality of life and ability to work or attend
education should be taken into consideration.
A fixed number of episodes, as described above, may not be appropriate for children and adults with
severe or uncontrolled symptoms, or if complications (e.g. quinsy) have developed.
[ If the story fits into the criteria ( including child missing the school many times) – tell her – I
will speak to my senior ( GP) about your concern and see whether we can consider again about
removing the tonsils.

If the story does not fit to the criteria try to convince her that it is not required at the moment giving
the reasons of disadvantages. Reassure that -as the children grow olderthey will not have this
recurrent infections. If she still insists -tell her that you will talk to the GP about it].

Mother – Doctor. I know why you don’t want to do surgery because its expensive. If you cannot do
it, I will take my son to private hospital.
Doctor – I can understand that you are worried about him. And let me reassure you if we find that
he needs surgery we will do it as tonsillectomy is funded by NHS. If you still feel you need to take
him to private practice that’s totally your decision as he is your son and a mother always thinks in
the best interest of their children.
If the child has symptoms of tonsillitis currently – treat accordingly
Take a swab for culture ( antibiotics if bacterial infection)
To help ease the symptoms:
 get plenty of rest

 drink cool drinks to soothe the throat

 take paracetamol or ibuprofen (do not give aspirin to children under 16)

 gargle with warm salty water (children should not try this)

Then she will say its ok doctor I will wait for the results to come back.
Then as a doctor you tell her that you will discuss the whole case with the seniors and will tell
them about tonsillectomy also. And wait for the results to come back. Thanks the mother.
What are the complications of tonsillectomy?
Tonsillectomy is one of the most common childhood operations. Possible
postoperative complications of tonsillectomy include pain, postoperative nausea and vomiting
(PONV), delay to oral intake, airway obstruction with respiratory compromise, and primary or
secondary postoperative bleeding.

Mother requesting Tonsillectomy

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117. You are the FY 2 doctor in the medical department.

Mrs Diana Roberts brought in her 85-year old mother, Mrs Margaret Roberts, with
a history of falls. Nurse noticed some bruises on her body including her axilla.
Bruises were of different ages. You are suspecting some fracture and mother is in
the X-Ray at the moment. Take a history from the daughter and discuss further
management with her.

Ask non-medical causes and then medical causes

Dr: Hello, Mrs Diana Roberts. I am Dr… one of the junior doctors in the medical
department. How are you doing ? Daughter: I am fine doctor.

Dr: How can I help you Mrs Roberts?

Daughter: My mother fell down today. I brought her in to have a check up.

(Elaborate on presenting complaint)

Dr: I am sorry to hear that. Can I ask how she fell?

Daughter: She is very old and frail. She keeps falling

Dr: Can you please elaborate about the fall today?

Daughter: She was in the room and she fell on the radiator.

Dr: What time did this happen? Daughter: Few hours ago.

Dr: What did you do immediately after that? Daughter: I brought her in here.

Dr: That is really good. Can you please tell me was she standing when she fell?

Daughter : Yes

Dr: Did she lose consciousness and then she fell, do you know?

Daughter : No she was conscious

Dr: Did she lose consciousness after she fell? Daughter: No

Dr: Was she able to get up after she fell down? Daughter: Yes Dr:

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Did she slip or trip on anything? Daughter: No

Dr: Was it dark and she could not see anything? Daughter: No

Dr: Does she have any problem with her vision? Daughter: No

Dr: Did she have dizziness just before she fell, do you know? Daughter : No

(Past history of falls and injuries)

Dr: Has it happened before? Daughter : Yes few times/first time.

Dr: Was she brought into the hospital before for this? Daughter : No

Dr: May I know why? Daughter : She was fine after she fell.

(Past medical history)

Dr: Has she got any medical conditions? Daughter : No Dr:

Is she on any medications? Daughter : No

(History for bruises - if it is mentioned in the question)

Dr: Have you noticed any injuries this time? Daughter : I am not sure.
Dr: Nurses noticed some bruises on her body - do you know how she got this?

Daughter : I don’t know about that / She fell on the radiator that is how she got it.

Dr: Is she taking any blood thinner medication or steroid medication? Daughter : No

Dr: Has she got any bleeding disorders? Daughter : No

(NAI questions)

Dr: Can I ask where does she live? Daughter: She lives with me in my house

Dr: Who looks after her? Daughter: I look after her

Dr: Do you work? Daughter: Yes I work. Dr: Who else lives at home ?

Daughter: I have 2 teenage daughters. They live with me.

Dr: Anyone else at home? Anyone else comes to visit regularly? Daughter: No

Dr: Anyone else looks after your mother apart from you? Daughter: No

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Dr: How do you and your daughters get along with your mother? Daughter: We are fine.

Dr: You seem to be very busy. Do you find it difficult to manage everything at home?

Daughter : Yes doctor, I have to work, look after my kids and my mother and I have to do house work
also.

Dr: I can imagine it must be very tiring. Have you thought of keeping her in a care home or do
you think you need any help to look after your mother at home ?

Daughter: That will be very helpful doctor if I can get help to look after her at my home.
Management:

Dr: Mrs Roberts, we need to keep your mother in the hospital and examine and treat her because she
could be having some fractures for any injuries. We also need to do some tests to find out why she
keeps falling and why she has bruises on her body. We may need to do some tests like blood tests to
check her sugar, for anaemia, ECG, her blood pressure and other things. I will inform my seniors about
this. Daughter : Ok

Dr: Mrs Roberts, I`m worried that the story doesn`t match up with Mrs Margaret injury. This type of injur
doesn`t usually happen with the story you have described and our number one concern is her will-fare.
Mrs Roberts I`m actually a little worried. What normaly happen in this situation that we tend to get an
assessment done by someone with a lot of experience than we have and I think we have to go and get
that done.
Dr: We will have to involve social services also. Daughter : Why involve the social services?
Dr: We need to involve them because we need to check if there are any other reasons like any type of
physical abuse because we cannot explain the reasons for some type of bruises she has on her body
like bruises under her armpit.

Daughter: Those bruises are because I was holding her arms.

Dr: That may be possible. However Mrs. We need to involve the social services just to be on the
safe side for your mother.

Daughter : Are you saying I am abusing my mother?

Dr: I am not saying that, Mrs Roberts. I can see that you work and look after your mother and daughters.
That shows that you are a very caring daughter and a caring mother to your daughters. Your mother may
be having fractures which are a very serious type of injuries if it is physical abuse. So it is for your
mother’s own benefit we need to involve them. They will look into this issue and they may talk to you and
your mother also. They will take further decisions about your mother. In fact, they may even help you by
arranging social carers to look after your mother if you wish.

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Daughter : Can I take her home?

Dr: As I mentioned, we need to admit her now to do some tests and treat her and then the
social services will take further decisions after talking to you and your mother.

ELDERLY LADY WITH HISTORY OF FALLS

118. Repeated case

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119. Lady had CT scan of abdomen showed growth in the ascending colon.
Suspected of bowel cancer. Talk to son.

Nothing mentioned about consent in the question.

Son is a surgical Consultant.

Wants to discuss about the test results and further plans.

Enquire – Are you working in this hospital or some other hospital? He may say he is
working in Dublin (not in Manchester). If in the same hospital, find out if he is in the
same team? He will say no.

Ask him how much he knows about his mother’s condition?

Apologize – I am sorry I cannot discuss about your mother with you at the moment
because we have not yet taken consent from his mother to talk to son. As you know
we cannot divulge patient information to anyone else unless we have consent from the
patient.

You know this better than me.

I will talk to your mother soon and ask for consent to talk to you. If she gives consent I
will surely come back immediately and talk to him about it?

Son: This consent is just a formality. Don’t worry about it. Tell me the test result and we
can make a plan for further management.

Dr. Unfortunately without having consent, I cannot discuss her condition with you Mr..

Son: Even if you don’t tell me, she will tell me everything and she will ask for my opinion.

Dr: I do understand that. Your opinion is very important for her because you are a
surgeon and your opinion is also important for us to take decisions for her. However,
without her consent, we cannot discuss anything right now. I will take consent from her
and we can discuss after that - is that Ok Mr...?

Son: You know I have to see a lot of patients today. I have to go back soon. How long
will it take for you to take consent?

Dr: I can understand. I will talk to your mother right now and come back to you as soon as
possible.

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Son: Can I be there when you talk to my mom?

Dr: Let me get the consent first – if she agrees, surely you can be there. I am sure she
will be well supported if you are there.

Son: Does she know about the result?

Dr: No, not yet. We are just about to discuss the results with her.

Son: Is it a bad news ?

Dr: I am sorry I cannot discuss anything about the results now. As soon as we get the
consent, then I will tell my consultant and he would probably discuss the result and
further plans for her. He’s in a better position to discuss with you.
Examiner may ask what will you do now?
1. I will talk to my senior about the test result and ask for further plans for the
patient.
2. Inform the patient about the test result and discuss further investigations like
biopsy to confirm the diagnosis.
3. I will also inform my senior about her son that he is a surgical consultant and
wants to know about his mother and discuss further management with the
team.
4. I will check her mental capacity. I will also ask the patient for consent to talk to
her son about her condition.

SON WANTS TO DISCUSS MOTHER’S CASE

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120. 92 year old female was admitted to the hospital after a history of fall.
She was breathless at the time of admission and she is now breathless
as well. She is terminally ill.

Other patients have complained that there are a lot of visitors, and they make a lot
of noise all the time. Your task is to talk to the grandson and discuss this matter
with him.

(No visitors allowed from 2-5pm and only 2 visitors allowed at a time)

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Grandson gives a history of his grandmother being unwell at the time of admission.
Her condition is deteriorating, and the doctors have decided not to resuscitate.
Relatives have come from far away, and wanted to see her and perform the last rites.
They are Christians, want to chant prayers and also want their priest to be there. In
addition, they also want to keep a Bible on the bed.
Ask how the prayer is carried out. Emphasise that you appreciate that the prayer is
very important to them.

Cover the following points:

1. Respect religion and understand their beliefs

2. State that other patients are disturbed because of the noise (can disturb their sleep
and can also harm their recovery) and offer solutions

3. Ask him how many visitors come at a time and what time they come.

- allowing 2 people at a time

- visitors are not allowed from 2pm to 5pm according to hospital policy. The relatives
can see her after that.
He may ask if he can keep a Bible on the bed, you can say that, “There is a risk of
infection spreading – so it is better not to keep one there.” If he still insists, “Is that
okay to keep the Bible inside a plastic bag and then keep on the bed then throw away
the plastic bag afterwards?”, this is okay.

(In the exam, grandson repeatedly says that doctors do not respect religion and the
only way that they can perform the last rites is by praying together in front of the
patient.)

Offer moving his grandmother to a private room where they can perform the last rites
at peace. (You can ask the ward manager).

Grandson: “Can I bring a priest to the private room?” Dr: Yes.

NOISY RELATIVES AT HOSPITAL

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121. 40 year old lady who went through a divorce 2 years ago and has been
attending counselling sessions. She was on medication but has discontinued
it since the past one year. She is seeing a male counsellor and is requesting
to change her counsellor. Talk to her and address her concerns.

D- “Hello, I am Dr ---------- one of the junior doctors in the department. I was told that
you wanted to speak to me. How may I help you today?”

P- “Dr, I want to change my counsellor”

D: Yes we can consider changing your counsellor but please may I know the reason
you want to discontinue seeing the counsellor ?

P: I had 2 failed relationships. I am having depression and on medication - I was seeing

him for that purpose.

D- “Alright. How long have you been taking counselling sessions?” P- …..

D-“Were you seeing the same counsellor from the start?” P- “Yes

P- “I prefer a female counsellor”

D- “Alright. I will talk to my seniors and we can arrange that for you. But is there any
other reason that you would like to change your counsellor?”

Offer confidentiality if she’s not opening up

P- “Well Dr, sometimes, he touches and hugs me.”

D- “Is this happening against your will?”

P- “No, Dr, this is not his fault. I have been encouraging it. We went out for a few
dates. But I came to know he has a girlfriend. And I feel what we are doing is wrong. I
have no complaints against him. I just want a female counsellor.”

D- “Ok, I am glad that you have opened up to me. However, I must tell my seniors
because we do not encourage this as it is against our professional ethics.” It is
unethical and illegal for a medical professional to have a relationship with a patient. It
is like using vulnerable patients.

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P- “Dr, I don’t have any complaints at all.”

D- “I understand that. Unfortunately, I must tell this to my seniors otherwise he might

misuse his position and may continue to do this kind of acts. I will also discuss your
wish to change the counsellor”

Ask his name and address where he practices

Dr: Has this incident affected you in any way? How is your mood now?

Have any other medical professionals had any such relationships with you?

Are you aware if this counsellor had any relationship with any other patients?

Offer PALS.

LADY WANTS TO CHANGE COUNSELLOR

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122. You are the FY 2 doctor in the medical department.

72 year old lady Mrs Ali has recently been diagnosed with bowel cancer. She had
a short period of confusion. Information was revealed to her daughter. Now Mrs
Ali has recovered from the confusion and she has good mental capacity. Her son,
Mr. Mohammad Ali wants to talk to you. Talk to her son.

Mrs Ali has given consent to talk to him about her condition.

Dr: Hello, Mr. Mohammad Ali, I am Dr... one of the junior doctors in the medical
department. How are you doing? Son: I am, fine doctor.

Dr: I am on the team of doctors looking after your mother, Mrs Ali. I was told that you
want to speak to me about her. Is that right? Son: Yes, doctor.

Dr: How can I help you Mr ... ?

Son: How is my mother now, doctor?

Dr: She has recovered from her confusion now and she is much better now.

Son: I was told that she has bowel cancer, is that right, doctor?

Dr: Yes that is right Mr. Ali. I am very sorry about that.

Son: Have you told her that she has cancer?

Dr: No, not yet. We could not tell her because she was a bit confused but she is fine
now so we are just about to tell her now.

Son: Doctor, please don’t tell her that she has cancer.

Dr: Why do you say that, Mr. Ali ?

Son: Doctor my dad also had cancer. She was looking after him for a long time and she
has seen all the suffering what my dad went through. My dad has died now. If she
comes to know that she also has cancer, she will be very distressed.

Dr: Mr. Ali, I am really sorry to hear about your dad. I can imagine how you are feeling. I
do understand she will be distressed to hear the news. However, Mr. Ali we need to tell
her that she has a cancer because she needs to know about her condition.

Son: Doctor, please tell her some other condition other than cancer.

Dr: Mr Ali, we need to tell her the truth as we need to be honest with our patients. She
has a right to know about her condition.

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Son: OK doctor - if you have to tell her, then tell her that she has some abnormal
growth.

Dr: I can certainly see how caring son you are. I do appreciate your concerns for your
mother. Your opinion really very important for us. However, Mr Ali, she is in the right
frame of mind to understand everything now. She has a mental capacity to understand
and to take decision for herself about her treatment. To give her the right treatment, we
need her consent. We need to tell the name of her condition to offer the right treatment.
Unless we tell the name of the real condition, we cannot get her consent to treat her.

Son: But why can’t you tell her it’s an abnormal growth?

Dr: Mr Ali, abnormal growth has a different meaning - it can be cancerous or

noncancerous growth. People usually know the word cancer. People may not
understand any other word for this condition other than the word cancer.

Even if we tell her that she has abnormal growth, she can ask us what is that abnormal
growth and that time we have to tell her that it is a cancerous type of growth.

Son: Doctor, I am her eldest son. Now I am the eldest in the family. In our culture, it is
the eldest person who takes decisions. Doctor, you don’t need her consent. I am telling
you that you can treat her without telling her the word cancer. I am giving you
permission. Anyway, she is going to ask me about what to do.

Dr: We do respect all cultures and family relationships. However, when we take medical
decisions it has to be the person’s own decision if they have the mental capacity.

Son: You doctors are only care about your duty but you don’t understand our feelings.
You don’t care for our feelings at all?

Dr: Mr Ali, I am really sorry if I made you feel that way that we don’t care about your
feelings. We definitely care for the feelings also. However, if we don’t tell her the name
of the condition, then we may not be able to offer her the right treatment with which we
may be able to prolong her life or if she is in pain, we may not be able to provide the
right kind of medication, and she will suffer more and she will be more distressed. I am
sure you don’t want her to be distressed a lot, do you?

Son: Doctor, I will tell her that she has cancer myself in private.

Dr: Mr Ali, unfortunately we have to tell the patient the diagnosis ourselves. It is our
duty. We are trying to do the best for her, and I am sure you also want the best for her.
What do you say? You tell me should we tell her or not ?

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Tell him that we break bad news sensitively. Also inform him that we usually ask patients
if they want someone in the room.

If he’s still refusing, explain to him that the earlier you start treatment, the better.

Son: Yes, doctor I can understand. You do whatever you feel is right.

Dr: Thank you very much, Mr Ali. As I said your input is very important for us to manage
her condition. If she agrees, you can also join us when we discuss with her about her
condition and all the treatment options. I am sure she needs your support to cope with
this condition. Thank you very much.

LADY WITH BOWEL CANCER - SON DOESN’T

WANT MOTHER TO KNOW

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123. A. Lady with Accident asking for a Sick Note

You are an FY2 doctor in the Accident & Emergency Department

A young female patient (? Name/ Age) had an accident 2 weeks ago.

Records in the Emergency Unit stated that she had no injuries and was certified
fit then. She has come now to ask for a sick note.

Talk to her and address her concerns.

GRIPS

Find out why she wants a sick note. Find out if she’s currently sick

Any previous injuries from her last accident?

Pt - Doctor, I need a sick note for my job.

Dr- I would definitely do everything to help you. Can you please tell me why you need a
sick note?

Pt - I actually had an accident 2 weeks ago and I want to take time to recover. So I want
a sick note to show at my workplace

Dr - Can you describe the accident in detail?

Pt- I was actually drunk and was driving my car when I got involved in the accident. So I
took 2 weeks time off from work to recover. But now I want to take a leave for a few
more days and need a Sick note from the Hospital.

Dr- Can you tell me what work do you do? Pt- ???
Dr- I will check the records at the Emergency Unit. It says in the records that you were
certified fit then and that you had no injuries at that time.

Pt- Doctor, can you please change the notes and give me a sick note which says that I
had injuries and need rest for a few more days.

Dr- Miss, we cannot change what we already wrote in our notes. Can I ask you why you
want us to do that?

Pt- Doctor, I will lose my job if you don’t give me a sick note. I don’t have any support.

Dr- Miss, I am really sorry but unfortunately, we cannot give a sick note with changed

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findings – We need to be honest when we report injuries.

Pt– Doctor, you don’t understand. My car was taken away by the police and now, I don’t
have any way to go for my work. So, please give me a sick note.

Dr- Miss, I can imagine that things are very difficult for you. Is there any way for you
arrange another means of transport? Maybe, your colleagues can help you by picking
you up.

Pt- Doctor, please give me a sick note (the lady is very persuasive and repeatedly
mentions that she doesn’t have any support and that she will lose her job).

Ask about alcohol history (CAGE). Ask if she needs help for cutting down.

If you tell her that you only give sick notes to sick people, you need to find out if she has
any medical conditions

LADY WITH ACCIDENT ASKING FOR A SICK

NOTE
There is an alternate version of the case. Check cas number 123 B.

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123 B. A female patient had a road traffic accident 2 weeks ago and sustained minor
injuries. She has recovered now and has come for a review.

Address her concerns. The patient had some minor injuries at the time of the car
accidents (some bruises on the upper limbs). She was under the influence of alcohol
while driving. There were no passengers with her and no one else got injured. She was
given a sick note for 2 weeks initially and now she says she is back to normal but
wants a sick note for 6 weeks.
Take some Hx to assess her condition (no pain now/able to use both limbs normally/
no sensory or motor deficit /bruises healed)

Dr - I would like to examine your both upper limbs and check motor and sensory
functions. I will ensure privacy and make sure a chaperone is present.
The examiner says Normal / No findings.
Dr- Mrs. , From the information, you have given me and the examination findings, I
find that you are fully recovered and don’t need any further treatment. I will inform my
seniors. I am sorry but I cannot give you a sick note for 6 weeks.

Pt – Doctor, you don’t understand. The police have booked a case against me as I was
drunk while I was driving. I will definitely lose my driving license. I will lose my job. If you
give me a sick note for 6 weeks I will be able to support myself and look for another job.
(She doesn’t specify what her job is, she just says that her job requires her to
drive around and without the driving license, she will lose her job)

Dr – Mrs , I can imagine that things are very difficult for you. However, we have to
be honest and I cannot give you a sick note as my examination findings show you don’t
need any further treatment.

o The patient starts crying and asks why can't you just write a simple sick note and help her
out. She has two teenage daughters and there is no one to support them. She says she is
paying her taxes and is entitled to the sick leave.

o She refuses to take help from Citizens Advisory Bureau or the Job centre. She says she
can find a new job on her own. She just needs some time and wants you to give you a sick
note for 6 weeks. She keeps crying in between and is very persistent about the sick note.

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 TELEPHONE CONVERSATIONS

The person on the other side of the telephone might be either a consultant or patient's
relative.

If you are receiving the call and the patient keeps talking, take their details first (name,
age, gender, telephone number and address). No need to write these details but you
can ask the examiner for a piece of paper before taking them down. If the details are
already on the table, please confirm them before talking to the patient.

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124. You are the FY2 doctor in the A&E department. 88 year old lady, Mrs
Olive Green was referred from a care home to the hospital. She is in the
A&E department.
There is no referral note from the care home.

She is confused and agitated. She did not allow you to examine her.

Her Pulse is – 120, BP – 90/60, Oxygen saturation is 88%, Temperature is 38 C.

Talk to the care home over the telephone and take her details and then talk to the
examiner about her further management.

The most important thing about this question is that this patient is unstable and you
need to reach your senior as soon as soon possible because you are an F2 doctor.

1. Plan your time - 5 minutes history and 3 minutes to talk to the examiner
2. Diagnosis - Sepsis
3. Differential diagnoses:
a. Meningitis - headache and rash, contact history
b. UTI - burning urination, increased frequency, flank pain, STI, enlarged
prostate, hygiene, vesico-ureteric reflux in children, sudden urinary
incontinence in elderly ladies
c. Pneumonia - bedridden, swallowing difficulties
d. Gastroenteritis
e. Infected bedsores
f. Nosocomial infections: IV cannula, catheterization

Dr: Hello, Is it the care home? Carer: Yes,

Dr: I am Dr … one of the junior doctors in the A&E department. May I speak to the
person who was looking after Mrs Olive Green… please?

Carer: Yes it is me. How can I help you ?

Dr: May I know your name please: Carer: I am ….

Dr: I need some information about Mrs Olive Green - she was actually referred to our
hospital today but there was no referral note from the care home. Could you give me
some information about her – why she was referred to the hospital today?

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Carer: Well doctor, I was on leave for the last 3 days. I just came back to work today. I can
look at her notes and tell you about her .............. In the records, it says she was chesty in
the last few days.

Dr: You mean she had a cough? Carer: Yes

Dr: Any information about what happened today? Carer: No

Dr: How long was she chesty? Carer: Last few days

Dr: Did she have chest pain? Carer: Yes.

Dr: Did she have fever? Carer: Yes

Dr: Was she coughing up any phlegm or blood do you know?

Carer: Yes she had some phlegm.

Dr: What colour is that?

Carer: Greenish/ Yellowish.

Dr: Was she confused before? No, just today.

Dr: Did she have any burning sensation while passing urine (UTI)? Carer: No

Dr: Any urinary incontinence? Carer: No

Dr: Was the urine very smelly? Carer: No

Dr: Was she complaining of headache (meningitis)? Carer: No

Dr: Did she have any rashes on her body (meningitis)? Carer: No

Dr: Did she have any diarrhoea (Gastro-enteritis)? Carer: No

Dr: Vomiting? Carer: No

Dr: Was she complaining of any pain in her abdomen? Carer: No

Dr: You have been very helpful. Can you please tell me if she was mobile or bed
ridden?

Carer: She was mostly bed-ridden but we are trying to mobilise her as much as
possible.

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Dr: Did she have any bed sores (infected bed sores)? Carer: No

Dr: Was she eating and drinking well?

Carer: She has a swallowing problem. She had choked on food a few times and 3
months ago, she had this problem. (sometimes - there is no swallowing problem).

Dr: Has she been seen by any doctor for this problem before today? No

Dr: Has she got any medical conditions ?

Carer: Yes she has high blood pressure, and she had a stroke 3 years ago.

Dr: Did she have diabetes or any heart problem? Carer: No

Dr: Does she smoke or drink alcohol (for cause of confusion and aspiration)? Carer: No

Dr: Is she on any medications ?

Carer: Yes she is taking Ramipril, Aspirin and Atorvastatin.

Dr: Is she allergic to any medication? Carer: Yes, Penicillin.

Dr: Do you know whether any of her family members has any medical conditions ?

Carer: I do not know

Dr: Is there anyone else who is not well at the care home recently? Carer: No

Dr: Can I know about her family members please – anyone visiting her ?

Carer: No one has visited her for the last 3 months…

Dr: Can I get the telephone number of the next kin please? Carer: Yes….…

Dr: Is there any information in her records about any decisions about what should be
the treatment if she is not well?

Carer: DNAR decision was taken last time when she was in the hospital.

Dr: Any other information about any treatment to be given or not?

Carer: Nothing else is written.

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Dr: Ok. Thank you very much Miss … You have been most helpful. Is there anything
else you think is important that we may need to know?

Carer: No. What is happening to her doctor?

Dr: I do appreciate your concerns about her. As you know, she is not well. We are
treating her. Unfortunately, I cannot give more information about her because we are
supposed to keep the patient’s health information confidential. You have been most
helpful. Thank you very much for the information.

Talk to the examiner.

Dr: I think Mrs Olivia … is in sepsis because of aspiration pneumonia.

(if she was not vomiting, just pneumonia but do not mention aspiration
pneumonia)

Examiner: Why do you think so ?

Dr: She has been choking on food, she was chesty in the last few days. She had cough
and chest pain, and she has a fever on examination. That is why I think she has
aspiration pneumonia.

Because she is confused and she has tachycardia and hypotension, I think she has
sepsis.

Examiner: What will you do?

Dr:

● First of all, I would have resuscitated her by giving her Oxygen and IV fluids and
stabilize before calling the care home. Now, I would check her notes for DNR or
any other decision about active treatment to be given or not. Will proceed
according to that.
● I will try to examine her again.
● I will give her Oxygen
● Take blood for – FBC, U&Es, Sugar, Creatinine, CRP, Blood culture, LFT and
Blood lactate. I will also check the ABG. Start her on IV fluids (Normal saline).
● I will catheterise her and monitor urine output.
● Test the urine – dipsticks and send the urine for culture and sensitivity.

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● I will arrange for Chest X Ray and sputum culture.

● Stop Ramipril.
● Will inform the seniors immediately
● Start her on broad spectrum antibiotics as per hospital protocol bearing in mind
that she is allergic to Penicillin.
● May start her on Vasopressors after consulting with seniors.
● May shift her to ITU for further treatment.
● Will contact her family members to inform about her and get further
information about her.
● Thank you.

TALKING TO CARE HOME - SEPTIC ELDERLY

WOMAN

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125. You are an FY2 in a Paediatric Ward.

A young baby 10 months old has been sick for two days and is on a triage care call.
His mother, Mrs Sharon Stone, is concerned.

Task – Talk to the mother and discuss the initial management plan with her.

(Mom sounds very worried and is panicking) Phone is present in the station.

Dr- Hello, I am Dr ..., F2 at the Paediatric department. Are you Mrs. ... ?(Confirm the
child’s name & age)

Mother- Doctor, can you please come and see my baby? He is very ill.

Dr- Mrs. .. , Please don’t worry. We will do our best to help you. Can I ask a few
questions to know about your baby’s condition to see how we can help you?

Find out if the child is crying. If he is, it means the child is alive and conscious.

Dr - Can you tell me what happened? Mom: Yes, he is very breathless (gasping)

Mom - My baby has had a fever for the last 2 days. I recorded it with my home thermometer
and it showed 39 C. I have been giving him Paracetamol but the fever is not improving.
Dr: Since when? Since the last 12 hours but it is worse he is gasping for breath now.

Tell her that you will send the ambulance straight away and it will take about 10 - 15
minutes and then we can keep talking in the meantime

Dr: I can imagine this must be very distressing for you.

Dr- Is your baby active? M - No doctor. He has been listless and is lethargic.
Dr: Has he got a cough? Yes, since yesterday.

Dr- Does he have any nasal discharge? P- No

Dr- Mrs , Is your baby feeding well ? M– No doctor. He hasn’t been feeding at all since yesterday.

Dr: Has he got any other problems? Mom : Like what?

Dr: Has he got any rashes on the body? No (meningitis)

Dr: Any fits? (meningitis)

Dr: Did you notice if he had any difficulty moving his neck? Mom – No

Dr: Does he shy away from light? No

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Dr- Did he passing urine normally? M- No. I haven’t changed his diaper since yesterday.

Dr: Did you see any discharge from his ear (Ear infection)? Mom: No

Dr: Was he crying while passing urine (UTI)? Mom: No

Dr: Is he having loose stools (GE)? Mom: No

Dr- Do you feel his development is normal? P- Yes

Dr- Did your baby have any similar problems in the past? M – No

Dr- Is your baby on any medications? M - No

Dr- Is your baby allergic to anything? M - No

Dr: Do you have any other children at home?

Dr: Any one at home has any kind of infection or who is not well? No

Dr Did he come into contact with anyone who is not well recently?

Dr: Can you think of anything else which might be important for us to know?
Mom: No Dr, I am just worried about my son. He is also a bit drowsy so I am very concerned.

Dr: ask if she had (the mother) symptoms? (check the health of the mother)

Dr– Thank you for the information you have given me. Your baby needs immediate admission
and treatment in the hospital. I will send an ambulance to your place immediately. Is that Okay ?
Ask about social Hx: childs in the home and also tell her to prepare her self to come to the
hospital.

[Do not advise the mother to bring the child to the hospital on her own]

Mom: But Doctor, what is wrong with him?

Dr: I am suspecting that he might be having some kind of chest infection but to be sure, we
need to examine him. We may need to do some blood tests and a chest X-ray and urine test.
If we find out that is an infection, we need to give him antibiotics. Is that Okay?

Mom: Okay. When will the ambulance arrive here?

Dr: When the ambulance gets there, please accompany the baby. Any other concerns?
Mom: No Thank you.
SICK CHILD WITH CHEST INFECTION - TRIAGE CALL

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 FOLLOW-UP CASES
I.How patient is doing now? Same/better or worse?
II.If patient is not improving, you want to find out why. Is it due to not taking the
medications properly or poor lifestyle?
III.Are there any complications?
IV.Any side effects of the medications?
V.Does patient come for regular follow-up?

HISTORY -> EXAMINATION -> MANAGEMENT & COUNSELLING

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126. Young man-known patient of Insulin dependent diabetes. He was at a party a

few days ago and ate a lot of sweets. He injected himself with a large dose of
insulin to reduce the sugar level. Then while he was driving, he almost felt like
collapsing. He stopped the car and had some sweets and felt better.

Now he has come for follow up. His HbA1c is 61.

Talk to him

“How are you doing?”

“Understand that you have Diabetes? How is everything with your Diabetes? Any
problems?”

He gives the story of being in a party, eating a lot of sweets and injecting himself with
a large dose of insulin one month ago. He almost passed out while driving. He
stopped, ate chocolate and felt better.

- Ask about any such incidents any other time?

- Is he controlling his sugar well?

- Is he taking Insulin regularly?

- Any other medical conditions like high blood pressure, Heart, kidney problems ?

- Any problem in the vision, Any chest pains, any wounds in the legs?

“We have checked your blood sugar level and done what we call HbA1c which tells us
how your blood sugar level has been in the last 3 months. Normally, it should be about
48mmol/mol (6.5%) for diabetic patients. In your case, it is 61mmol/mol which is very
high. This means your sugar level was very high in the last few months.”

“Do you know the problems of not controlling the sugar?”

“It can cause heart problems, can affect the eyes and kidneys and nerves in the legs.”

“The incident that happened after taking the large dose of Insulin is what we refer to
as hypoglycaemia, and this means having very low sugar in the blood.

Dr: Has this incident happened before? Pt: No

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“It is very dangerous to have low sugar – it can cause sudden death if the sugar in the
body becomes very low. It is better to have high blood sugar than sudden severe low
blood sugar. It can cause sudden brain damage. So please do not inject large doses of
insulin even if you eat a lot of sugar. So it is better to control sugar well.”

“Eat a healthy balanced diet. Avoid eating too much sugar.” “Do regular exercise.”

- Ask whether he has a glucometer at home? He should measure his sugar at home.
Record the readings in a diabetic diary.

Warn about early symptoms of Hypoglycaemia

Shakiness, Dizziness, Sweating, Hunger, Irritability or moodiness, Anxiety or

nervousness, Vomiting, Headache. If any such symptoms occur, eat chocolate or sugary
drinks. He should keep sweets at all times with him and take them if he feels
hypoglycaemic.

Advice to avoid triggers of hypoglycaemia in the future:

● Injecting large doses of Insulin

● Eating less food or skipping meals
● More than usual exercise.
● Alcohol
● Vomiting

“You need to inform the DVLA about this hypoglycaemia incident.”

Pt: No doctor, I do not want to inform them.

Dr: May I know why? Pt: They will stop me from driving.

Dr: May I know what you do for a living? Pt: I am a taxi driver.
Dr: I can understand your problem. Since you are a taxi driver – it is very important to
inform the DVLA and your local council since they have some guidance for those who
are diabetic patients and drives taxis.

They may not ban you from driving because of one incident of hypoglycaemia. However, if
it happens repeatedly then they might ban you from driving. That is why it is important to
prevent hypoglycaemia.

Please wear your diabetic bracelet at all times.

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Keep the sugar level in Type 1 diabetes:

Upon waking - 5 to 7 mmol/L, Before meals - 4 to 7 mmol/L

At least 90 minutes after meals - 5 to 9 mmol/L

Information:

Diabetes and Driving for Work

● People with diabetes are able to drive taxis and passenger carrying vehicles
● Having diabetes can make it more difficult to drive large passenger carrying vehicles
(PCVs), especially if you are treated with insulin.
● People who are able to demonstrate good diabetes control are eligible to drive large PCVs.
● While insulin users may be discouraged from driving emergency vehicles, some people with
type 1 diabetes have applied successfully and been employed.
● If you have diabetes and work as a driver, your eligibility to continue driving will depend on a
number of factors.

How do I apply for a vocational driving licence?

● The process of getting your vocational entitlement to drive is a three-step process:
● Initial application forms
● A medical questionnaire
● A further medical questionnaire and an examination by your consultant
● Diabetes and ‘blue light’ emergency services
● A blanket ban has previously stopped people with insulin-treated diabetes from driving ‘blue
light’ emergency services vehicles.
● But in recent years, several people with type 1 diabetes have been judged as suitable for blue
light driving.
● However, it is a necessity to ensure excellent control of your blood glucose levels and diabetes
management in order to continue driving emergency service vehicles.
● Taxi drivers with diabetes
● Local councils issue licences for taxis and minicabs. Their policies may vary throughout the UK
and it is best to check with individual councils for further information.
● Taxi drivers who are dependent on insulin may find it harder than those on tablets, but there is
no blanket ban across the UK.

HYPOGLYCAEMIA IN A TAXI- DRIVER

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127. You are the FY2 doctor in the A&E department. There is a patient in
the department. History and management.

Inside the cubicle, there is a man lying on the couch, just able to communicate.

How can I help you? Doctor I came for the follow up of my condition. I am not feeling well.

YOU CAN ALSO CHECK HIS VITALS

What exactly is happening to you? I am feeling very tired and I feel I am going to faint.
Has this happened to you like this before?? No

Do you have any medical condition ? Yes I am diabetic. I take Insulin.

Have you eaten today? Yes. Did you take your Insulin ? Yes. Was it normal dose ? Yes.
I need to check your pulse, blood pressure and also I need to check your blood sugar.

Examiner shows glucometer (if the examiner does not give it, look for it ).

Demonstrate how you will check blood sugar in glucometer.

(Watch video on YouTube : How to test your blood glucose levels)

Examiner gives the blood glucose level 2.1 mmol (very low)

[normal blood sugar level - Between 4.0 to 5.4 mmol/L (72 to 99 mg/dL) when fasting.
Up to 7.8 mmol/L (140 mg/dL) 2 hours after eating].

Don’t forget to throw the lancet away in the sharps bin!!

Tell the patient, “Your blood sugar is very low. We need to give you glucose urgently
through your vein.

[There are a lot of options on the table - A drip stand with normal saline fluid hung on it,
several labelled (but empty) 10ml syringes and other things.]

Pick up the syringe labelled 20% Dextrose – tell the examiner I will give 100ml of 20%
glucose IV over 15 minutes and recheck blood sugar after 10 min].

Patient improves and start to talk normally. “Are you feeling better now?” Yes

 Check whether he knows the dangers of hypoglycaemia [it can kill people immediately ]

 Check all the causes of hypoglycaemia Look if there is a HbA1C result

 Find out if he’s driving - does he have a DM bracelet?

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Causes of hypoglycaemia

" Skipped meal

" Not had enough food
" Not had food containing high sugar
" Overdose of Insulin
" Over exercise

- If you find any reason – tell him to avoid that to prevent this from happening again

- Check awareness of Hypoglycaemia symptoms.

- Refer him to Diabetic team for further management.

Information on hypoglycaemia treatment

If IV access available, give 75-100ml of 20% glucose over 15 minutes, (e.g. 300-400ml/
hr). A 100ml preparation of 20% glucose is now available that will deliver the required
amount after being run through a standard giving set. If an infusion pump is available
use this, but if not readily available the infusion should not be delayed. Repeat capillary
blood glucose measurement 10 minutes later. If it is still less than 4.0mmol/L, repeat.

HYPOGLYCAEMIA TREATMENT - EMERGENCY

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128. You are an FY2 in the GP clinic. Lucy Talbot was diagnosed with
Thyrotoxicosis and started on carbimazole a year back. She has come now
for her annual follow-up.
Discuss and agree on a management plan with her.

Inside the cubicle, there may be a knee hammer and BNF on the table. The
simulator is sitting on a chair and there was no couch or any other equipment
inside the cubicle.

- Determine if she is getting better, worse or still the same i.e is she euthyroid,
hypothyroid or hyperthyroid?
- Is she having complications?
- Is she having any side-effects to the medication?
- Is she pregnant now or planning to get pregnant?

This station requires examination

Dr: How can I help you ?

Pt: I had an overactive thyroid. I am on medication. I have come for follow up.

Dr: I am glad that you came for the follow-up. Is it ok to ask few questions to see if
everything is ok with your condition ?

Dr: Do you have any problems with that now ?

Dr: May I know what medications are you taking now? Pt: Carbimazole

Dr: How much? Pt: 5 mg once a day. Check BNF for the correct dose

Dr: Are you taking it regularly? Pt: Yes

Dr: Since how long have you had this problem? Pt: Since – One year / ? ...

Dr: Do you have any other medical conditions at all? Pt: No

Dr: Are you taking any other medications? Pt: No

Dr: How are the symptoms you had before we started taking the medications? Pt:
They are all gone now.

Ask about hyper and hypo - thyroid symptoms

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“Do you feel any irregular or unusually fast heart rate (palpitations)?”

“Any problems with vision (double vision)?”

“Any twitching or trembling in hands?”

“Loose stools or constipation?”

“Change in voice?”

“Weight loss or weight gain?”

“Any problem with periods?”

“Any sensitivity to heat?”

“Any swelling in your neck from an enlarged thyroid gland (goitre)?”

“Tiredness?”

“Being sensitive to the cold?”

“Are you taking your medications properly? Pt: Yes/No

- Ask about Side-effects of carbimazole:

Any joint pains, headaches, jaundice, itching, rash, taste disturbance?

Rare side effect: agranulocytosis (ask about recurrent infections)

Patient may say no for all the symptoms.

Dr: Are you pregnant at all? Pt: No

Dr: Any plans for pregnancy? Pt: No, my husband had a vasectomy.

Dr: Is there anything else you want to tell me

“That is good that you do not have any symptoms.”

“I need to examine you now. I need to examine your hands, eyes and your neck – is
that okay?”

“Can you please undress your neck and upper part of chest please?”

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Thyroid Examination: check it

Position: Sitting
Inspection:
● Hands
● No Dryness (hypothyroid) or Sweatiness (hyperthyroid)
● No Clubbing
● No Palmar Erythema (Hyperthyroid)
● No Tremor: Ask patient to outstretch arms and place a paper on the back of hands and
observe the tremor. (Hyperthyroid)
Pulse: Tachycardia (Hyper), Bradycardia (hypo), Irregular-AF (Hyper) check the NEWS
chart if present – if not ask for it.

Eyes:

Exophthalmos (Inspect from front and side)

Lid lag: Ask patient to look at your moving finger without moving head. Move it from
upper to lower part of visual field and note for delay in descent of upper eyelid to that
of eyeball.

Lid retraction: It is present if sclera is visible above the iris.

Thyroid:

Inspect the midline of neck: Ask the patient to move chin up a bit. Comment on:

• Swelling

• Skin changes

• Scar

Swallow Test:

• Ask patient to swallow some water.

• Observe any movement of mass. Most swellings move upwards on swallowing.

Tongue Protrusion:

• Look at neck and ask the patient to bring out the tongue.

• Thyroglossal cysts will move upwards.

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Palpation:

• Inform the patient that you are going to feel the neck from behind.

• Stand behind the patient and ask the patient to bend the neck. (To help relax the
sternocleidomastoid muscle)

• Place your hands on either side of neck.

Thyroid:
• Place 3 fingers along the midline of the neck below the chin and slide downwards
until the area of thyroid gland, which is just located below the thyroid cartilage.

• With 1 hand, fix one side of the thyroid and palpate the other side with the help of 3
fingers. Do the same on the other side.

• Feel for the gland and ask patient to swallow some more water and feel for any
swelling moving with your hands.

• Verbalise that there is no abnormality noted.

Lymph Nodes:

Check all groups of lymph nodes

• Submental

• Submandibular

• Anterior cervical chain (Tonsillar and deep cervical lymph nodes)

• Posterior cervical chain

• Pre auricular

• Post auricular

• Occipital

• Supraclavicular

PERCUSSION: Percuss down starting from sternal notch to listen for retrosternal
dullness.
AUSCULTATION: Auscultate both lobes of thyroid. (Thyroid bruit in Grave’s disease)

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LEGS

● Pre-tibial myxoedema:

● Ask patient to roll up trouser or skirt to the knees.

● Look for the raised, discoloured appearance over legs.

REFLEXES

Upper limb reflexes: Biceps, triceps and supinator.

Thank the patient.

Mrs.. With the information you have given me and after the examination, everything
looks normal. However, we need to do blood tests to check your thyroid function.
(examiner may not give results).

I will let you know once we get the blood results. Is that ok with you?

Do you have any concerns? No

You are doing fine now. Usually, we give medications for about 18 months and stop it
if everything is fine. You may be able to continue the medication with the same dose.

I will discuss with my seniors about you and get back to you.
[ If patient is already on Carbimazole for 18 months - We need to consider
stopping the Carbimazole as you may not need it any more – I will discuss with my
seniors and get back to you about it ].

PATIENT ON CARBIMAZOLE FOR HYPERTHYROIDISM

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129. You are an FY2 in the GP clinic. Mr. Curtis, a 45 year old male has
come to the clinic today to receive his test results.

He had a blood test done three weeks ago which showed:

Hb: 10 g/dl (11-15) TLC: 4000/cmm Plt: 430,000 MCV: 78 (80-100)

He had blood tests done one week ago as well which show:

Hb: 10.2 g/dl (11-15) TLC : 4300/cmm Plt: 400,000 U&E: Normal Range LFTs: Normal

Serum Iron: Low; Serum Ferritin: Low; MCV: 78 (80-100), Test for celiac disease:
Negative.

Discuss these test results with Mr. Curtis, take appropriate history and discuss
management.

Hello Mr. Curtis, I am Dr -------------- , One of the junior doctors in the clinic.

How can I help you today?

Pt: I came here for my results today.

Dr: Yes Mr. Curtis I have your results with me but please tell me if there is a specific
reason you had these tests.

Pt: No specific reason doctor. I feel fine, it’s just that my wife is very conscious about health
and she convinced me to have this well man checkup.

Dr: Mr. Curtis, you are very fortunate to have such caring wife. You did a very good thing by
having these tests and this is actually an excellent practice. Do you have any specific
questions for us today?

Pt: No, I just want to know my test results.

Dr: Ok, Let’s discuss your report then.

(Discuss all test results and explain that everything looks normal but Hemoglobin is low
and there is iron deficiency as well)

Dr: Mr. Curtis we would like to investigate for the cause of low level of iron in your blood. Would it
be alright if I ask you a few questions which may lead us to the reason for low hemoglobin?

Pt: Sure doctor, what would you like to know?

Dr: Do you feel tired all the time or as if you don’t have energy to do any work? Pt: No, I feel fine.

Dr: Do you feel short of breath while doing any work? Pt: No.

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Dr: Have you ever felt your heart is racing? Pt: No. (Palpitations)

Dr: How is your diet? Pt: I eat healthy doctor. I eat both vegetables and meat. Dr:

Do you drink lots of tea or coffee? Pt: No.

Dr: Mr. Curtis how are your bowel habits? Pt: They are normal doctor, once a day. Dr:

Have you noticed any change in your bowels? Pt: No.

Dr: Are your stools difficult to flush? Pt: No. (malabsorption syndromes) Dr:

Any bleeding in your poo or is it black coloured? Pt: No. (G.I blood loss)

Dr: Have you ever noticed any bleeding from your back passage? Pt: No. (Haemorrhoids)

Ask for other sites of bleeding e.g hematuria

Dr: Any weight loss? Pt: No. (Cancer)

Dr: Any lumps or bumps in your body? Pt: No. (Cancer)

Dr: Mr. Curtis do you have any medical conditions? Pt: No doctor, I have enjoyed a very healthy
life.

Dr: Did you have any surgeries in the past? Pt: No.

Dr: Are you taking any medications including over the counter medicines? Pt: Yes Dr. I
take multivitamin supplements.

Dr: Were you prescribed those by a doctor? Pt: No, I buy them from supermarket. I have
been taking them for a long period of time, they are very good.

Dr: It is really good to see that you are so conscious and concerned about your health. It’s
not every day that we come across patients like you.

Dr: Mr. Curtis, do you smoke? Pt: No.

Dr: Do you drink alcohol? Pt: No.

Dr: Has anyone in your family been diagnosed with cancer? Pt: no.

Dr: Is there anything else that you would like to tell us? Pt: No.

Dr: Mr. Curtis there can be many causes for iron deficiency in blood but mostly it is
because of inadequate diet, loss of iron in bleeding or malabsorption of iron from our gut.

From our discussion, there is no apparent reason for low level of iron and haemoglobin in
your blood.

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But we can do some specific tests to find out what’s the reason. Would you like to know
these tests?

Pt: Yes doctor, what are those?

Dr: We have done most of these tests already but if you would like, I can refer you to
Gastroenterologist.

He may do a camera test (Endoscopy). In that way, not only we can find out if there is any
bleeding, we also can take some samples from your bowels to test under microscope and
hopefully it will lead to a diagnosis. How does that sound to you?

Pt: I would think about this and will inform you.

Dr: That’s alright and Mr. Curtis, for now we can offer you Iron tablets. I know you are
already taking multivitamins and I’m sure they must be really good but these tablets will be
stronger. Would you like to try them? Pt: Ok, if it will help me.

Dr: You'll have to take these tablets for about 6 months after which we will repeat your
blood tests. In some people, these tablets can cause some side effects like constipation or
diarrhoea, tummy pain, heartburn, feeling sick and black poo. Try taking the tablets with or
soon after food to reduce the chance of side effects. It's important to keep taking the tablets
even if you get side effects.

Dr: Mr. Curtis you already told me that you eat healthy which is very good. But I am no
expert on diet. If you would like, I can arrange an appointment with a dietician. I think it
would help us greatly in finding out if there is anything deficient in diet and it will greatly
benefit you in making a well-balanced diet plan. What do you think?

Pt: Ok, I guess there is no harm in that.

Dr: That’s great Mr. Curtis. I would arrange an appointment as soon as possible.

Dr: Mr. Curtis thank you very much for coming to the clinic today because it is really important
that we treat this low level of iron as it is very important for our body defense system and it also
prevents us from developing any complications affecting our heart and lungs.

If you would like, I can provide you with few leaflets which will be of great help if you
want to know more about this condition.

Pt: Yes I would like to read them.

Dr: That’s great, Mr. Curtis. Is there anything else I can help you with? Pt:

No Doctor. Thank you very much. Dr: Thank you.

IRON DEFICIENCY ANAEMIA

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130. You are the FY2 doctor at a GP practice. Mrs Henderson had attended for a
well woman check. You have found on bloods low Hb and low MCV. No further
abnormalities noted on blood investigations. Address her concerns.

Be aware of normal values.

Dr: Hello, I’m Dr X, one of the junior doctors in the practice today. Are you Mrs
Henderson? Pt: Yes, I am.

Dr: How can I help you today?

Pt: I’m just here for a regular follow-up doctor. I had blood drawn the last time, just as
routine and I think I’m due for the results.

Dr: Yes, that’s correct Mrs Henderson. How have you been thus far? Pt:

I have been well doctor, I’ve had no issues.

Dr: I’m glad to hear! We have found in your previous blood that your haemoglobin is low.

Pt: Oh, that’s a first. What does that mean for me now doctor?

Dr: Well, there’s a few things we need to rule out as a cause for your low haemoglobin
level, or as you have heard, people call it anaemia?

Pt: Well, yes I have heard that before.

Dr: Do you have any palpitations? Chest pain? Swelling of the legs? Pt:

No at all doctor, I’ve been really healthy.

Dr: That’s good. How about your diet? How has that been?

Pt: Just the usual doctor, I am getting enough veggies in and I know you need to eat a fair
amount of red meat for iron. I’d say I have a balanced diet.

Dr: Great. Have you noticed any blood in your stools? Pt: No doctor.
Dr: Any indigestion? Pt: No, not at all.

Dr: Have you previously had anaemia? Pt: No. Dr:

Have you noticed any weight loss? Pt: No. Dr: Is

there any family history of any anaemias?

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*DO MAFTOSA

Pt: Well, actually, I don’t know if it’s the same thing, but my sister has Thalassaemia? Dr:

Yes, that could be a cause. When was p your sister diagnosed with this condition? Pt: She

was diagnosed when she was pregnant.

Dr: OK, how is she doing now?

Pt: She’s on medication, she’s fine doctor. Do you think I have this condition, doctor?

Dr: Well, your blood results are suggestive, but I will discuss this with my seniors as to the
further management from now.

Pt: OK. What exactly is it?

ADVISE HER OF GENETIC COUNSELLING OTHERWISE HER CHILD MIGHT HAVE

THALASSAEMIA

Dr: Thalassaemia is the name for a group of inherited conditions that affect a substance in the
blood called haemoglobin, which makes sense as to your sister also having the condition.

People with the condition produce either no or too little haemoglobin, which is used by red
blood cells to carry oxygen around the body. This can make them very anaemic (tired, short
of breath and pale). It mainly affects people of Mediterranean, South Asian, Southeast Asian
and Middle Eastern origin. Are you following me Mrs Henderson?

Pt: Yes, it sounds familiar doctor. What’s going to happen now? Is there any specific
treatment?

Dr: Well, yes, it depends on your haemoglobin level and whether you’re symptomatic or
not. Important to note is that it is a lifelong condition that will require lifelong management.
Pt: Yes, I am aware doctor.

Examination: vital signs and abdominal examination for splenomegaly

Investigation: hemoglobin-electrophoresis

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Dr: The main treatments are:

 Blood transfusions – regular blood transfusions are given to treat and prevent anaemia; in
severe cases these are needed around once a month.

 Chelation therapy – treatment with medications to remove the excess iron from the body that
builds up as a result of having regular blood transfusions. Some people experience a build-
up of iron even without transfusions and need treatment for this.

Are you following?

Pt: Yes. I know I’m supposed to eat healthy too?

Dr: Yes, absolutely! Eating a healthy diet, doing regular exercise and not smoking or
drinking excessive amounts of alcohol can also help to ensure you stay as healthy as
possible.

Pt: Is there a cure doctor?

Dr: The only possible cure for thalassaemia is a stem cell or bone marrow transplant, but
this isn't done very often because of the significant risks involved.

Pt: Oh…

Dr: Don’t despair, Mrs Henderson. For now, I will discuss with my seniors the full
management plan and we can take it from there. How does that sound?

Pt: Yes, I’d like that. Thank you doctor. Dr:

No problem at all, Mrs Henderson.

WELL WOMAN CHECK - THALASSAEMIA

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131. HIGH UNCONJUGATED BILIRUBIN - GILBERT

SYNDROME
It is normal to have some bilirubin in the blood.

Normal levels:

1. Direct (also called conjugated) bilirubin: less than 0.3 mg/dL (less than 5.1 µmol/L)

2. Total bilirubin: 0.1 to 1.2 mg/dL (1.71 to 20.5 µmol/L)

The indirect bilirubin level in the bloodstream is the total bilirubin minus the direct
bilirubin levels in the bloodstream.

Rule out other causes of jaundice

1. Hepatitis A and B, C (fever, diarrhoea, vomiting, tiredness, eating out, contact history,
travel history, unprotected sex, blood transfusion, sharing needles),

2. Obstructive causes like gallstones, Cancer head of pancreas – Itching, pale stool,
dark urine, weight loss),

3. Alcoholic hepatitis.

Patient’s values: AST 20, ALT 30, ALP high ( ?), GGT?, Bilirubin elevated (direct -
normal, indirect (unconjugated)- elevated), FBC normal, glucose normal. Pt has no
symptoms (P/C??) no itch, father had some liver issues (elaborate more)

Possible Gilbert's syndrome: is an inherited (usually autosomal recessive - Family

history is very important) metabolic disorder that causes intermittently raised
unconjugated bilirubin levels due to defective conjugating enzymes in the liver. There is
normal liver function and no evidence of haemolysis. People with the syndrome have a
faulty gene which causes the liver to have problems removing bilirubin from the blood
which is the breakdown substance of red blood cells.

Symptoms of Gilbert’s: abdominal pain, fatigue, loss of appetite, feeling sick, IBS, a
general sense of feeling unwell, mild jaundice can lead to Hep C or cirrhosis

Some of the possible triggers linked with the condition include: being dehydrated,
fasting, infection, being stressed, physical exertion, not getting enough sleep, having
surgery, female menstrual cycle.

Gilbert's syndrome affects more men than women. It's usually diagnosed during a
person's late teens or early twenties. Episodes of jaundice and any associated
symptoms are usually short-lived and eventually pass.

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(One of his questions is whether his children will get it? He has 2 children so do ask him
what the genders are) – Yes some children may get it but not necessarily all the children
will get it. (autosomal recessive)

“At present, there is no established genetic test for Gilbert’s Syndrome.”

Further things to ask in the history: Contact tracing? Occupation? Diet? Hygiene?
Family history? Elaborate on family history (especially father’s liver issues) Pain? Itch?
Jaundice?

Examination:

General physical exam focusing on the abdominal examination along with the eyes.

PATIENT INFORMATION FOR GILBERT’S SYNDROME

Gilbert's syndrome is a genetic disorder that's hereditary (it runs in families). People
with the syndrome have a faulty gene which causes the liver to have problems removing
bilirubin from the blood.

Normally, when red blood cells reach the end of their life (after about 120 days), haemoglobin
– the red pigment that carries oxygen in the blood – breaks down into bilirubin.

The liver converts bilirubin into a water-soluble form, which passes into bile and is eventually
removed from the body in pee or poo. Bilirubin gives pee its light yellow colour and poo its
dark brown colour.

In Gilbert's syndrome, the faulty gene means that bilirubin isn't passed into bile (a fluid
produced by the liver to help with digestion) at the normal rate. Instead, it builds up
in the bloodstream, giving the skin and white of the eyes a yellowish tinge.

Other than inheriting the faulty gene, there are no known risk factors for developing
Gilbert's syndrome. It isn't related to lifestyle habits, environmental factors or serious
underlying liver problems, such as cirrhosis or hepatitis C.

Diagnosing Gilbert's syndrome

Gilbert's syndrome can be diagnosed using a blood test to measure the levels of
bilirubin in your blood and a liver function test.

When the liver is damaged, it releases enzymes into the blood. At the same time, levels
of proteins that the liver produces to keep the body healthy begin to drop. By measuring
the levels of these enzymes and proteins, it's possible to build up a reasonably accurate
picture of how well the liver is functioning.

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If the test results show you have high levels of bilirubin in your blood, but your liver is
otherwise working normally, a confident diagnosis of Gilbert's syndrome can usually be
made.

In certain cases, a genetic test may be necessary to confirm a diagnosis of Gilbert's

syndrome.

Living with Gilbert's syndrome

- Gilbert's syndrome is a lifelong disorder. However, it doesn't require treatment

because it doesn't pose a threat to health and doesn't cause complications or an
increased risk of liver disease.

- Episodes of jaundice and any associated symptoms are usually short-lived and
eventually pass.

- Changing your diet or the amount of exercise you do won't affect whether you
have the condition. But, it's still important to make sure you eat a healthy,
balanced diet and carry out physical activity.

- You may find it useful to avoid the things you know trigger episodes of jaundice, such
as dehydration and stress.

- If you have Gilbert's syndrome, the problem with your liver may also mean you're at
risk of developing jaundice or other side effects after taking certain medications such
as medications for high cholesterol. Therefore, seek medical advice before taking any
new medication and make sure you mention to any doctors treating you for the first time that
you have Gilbert's syndrome.

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132. 65 year old Mrs… She came to get her test results back

You are an FY2 in GP clinic. Discuss the results and address her concerns.

Test results are given below

FBC : normal

Hb : 10g/dl (anemia)

MCV : Normal

MCH : Normal

Platelets : 450 x 109/L (N :150 and 450 x 109/L)

LFTs : Normal

RFTs : ?

Rheumatoid factor : negative

Serum electrophoresis : Increased IgG levels

Urine : Bence Jones protein +ve

Dr: Hello, Are you Mrs…? Pt : Yes

Dr: I am Dr … one of the junior doctors in GP today. I see that you are here to collect
your blood test results, am I right?/ I see that you are here for a follow up, is that correct.
PT: Yes Dr that’s right.

Dr: Alright Mrs… I’m here to talk about the results with you. Before we get into that, can
I ask you a few questions that will help me explain the results to you better?

Pt: Can you please give me the results? (Pt wants to know the result right away and
doesn’t let you take much history)

Dr : Well, I am going to get into that. However, it would be better for both of us to
discuss the results if I knew more. Would that be okay with you Mrs… Pt : okay

Dr: What brought you to the hospital initially?

PT : I have been having this terrible back pain, Dr.

Dr: I’m so sorry to hear that. It must be really difficult for you. Are you in pain right now?
Are you okay enough to talk to me? PT : Yes, Dr

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Dr: Thank you so much. Can you tell me more about the pain?

Pt : Dr, it started 3-4 months ago and it has been increasing lately. It doesn’t go
anywhere and nothing makes it better.

Dr: How were you before that? Pt: I was fine Dr.

Dr: Is the pain inside your bones Mrs..? Pt:….

Dr: On a scale of 1 to 10, 1 being the least pain and 10 being the worst pain could you
grade the pain for me? Pt :….

Associated symptoms:

Dr: Any thirst? Pt :..

Dr : Any wt loss? Pt : No

Dr: Any loss of appetite? Pt : No

Dr : Any falls/ fractures? Pt : No

Dr : Any urinary problems? Pt : No

Dr: Do you feel thirsty? Pt :…

Dr : Any weakness in the legs? Pt no

Dr: Do you have any pain while passing urine? Pt : No

Dr: Any tummy pain? Pt : Yes/No

Dr : pain anywhere else in the body?

Dr: Any racing of the heart? Pt: No

Dr: Any lumps or bumps anywhere? Pt: No

Anaemia symptoms

Dr : Do you feel tired? Pt : Yes, Dr. I feel very tired for the past 3 months

Dr: Any racing of the heart? Pt…

Dr: Any medical conditions in the past?

Dr: Any family h/o similar conditions? Pt :No (The patient might be irritated with the questions.
Pressure her)

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Social history : to r/o NAI (this part can be done at the end too since patient might
not cooperate)

Dr: Do you live with anyone? Pt…

Dr: How would you describe your relationship with them as?

Dr : Financial conditions?

Dr:vYou have been very helpful and patient with me. Now, I am going to talk to you
about the results. We did a lot of tests on your blood and urine. The haemoglobin in
your blood is lesser than usual. You seem to be anaemic. Are you following me? Pt…

These are some proteins that are in our body and the have increased (serum Ig G).
And there are some unusual proteins in your urine that we call the Bence-Jones protein.

Pt : What does that mean, doctor?

At the moment, from the information you have given me and these test results there
could possibly be two outcomes. Best case scenario, it can be just a portion
abnormality. However in a worst case scenario it could be something sinister.

Pt : Is it cancer, Dr?

Dr: Unfortunately Mrs…. It could be cancer. It might be a condition called Multiple

myeloma. Are you with me so far? Pt:…

Dr : Multiple myeloma, also known as myeloma, is a type of bone marrow cancer. The
bone marrow is the spongy tissue at the centre of some bones that produces the body's
blood cells.

It's called multiple myeloma as the cancer often affects several areas of the body, such
as the spine, skull, pelvis and ribs.

Pt : Are you sure about this doctor?

Dr : Mrs … at the moment I cannot be very sure. We would be running a few more tests
in your blood. We might need a sample of your bone marrow as well (BM Aspirate,
trephine biopsy). We also have to run run some scans such as a whole body MRI.
(skeletal survey) For this, we have to refer you to a hematologist.

Pt : When will you refer me, Dr? Dr: It would be an urgent referral, Mrs..

Pt : Dr, are you sure its not rheumatoid arthritis?

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Dr : The tests indicate you do not have Rheumatoid arthritis (can ask her why she thinks so
and symptoms if time is there)

Pt : What are the treatment options?

Dr : Treatment can often help to control the condition for several years, but most cases
of multiple myeloma can't be cured. Research is ongoing to try to find new treatments.

Treatment for multiple myeloma usually includes:

1. Anti-myeloma medicines to destroy the myeloma cells or control the cancer when it
comes back (relapses)

2. Medicines and procedures to prevent and treat problems caused by myeloma – such
as bone pain, fractures and anaemia. Depending on your health a bone marrow
transplant can be done as well.

But lets not get ahead of ourselves before confirming this. For now, I will talk to my
seniors and prescribe strong painkillers for you. Does that sound alright?

Dr :Do you have any concerns? Pt…

MULTIPLE MYELOMA

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133. You are an FY2 in a GP clinic.

20/24 year old girl has come to the GP with h/o amenorrhea for 6-8 months. Gp
had ordered some test results. She is here to collect the results. Talk to her and
address her concerns.

Test results : (testosterone level not given)

FSH : normal

LH: high ( LH :FSH ratio >2 is significant for pros. Normal is 1:1)

Dr: Hello, Are you Ms? Pt : Yes

Dr: I am Dr … one of the junior doctors in GP today. I see that you are here to collect
your blood test results, Can I ask a few questions before we get into this? Pt : yes

Dr: What brought you to the hospital initially?

PT : Dr I haven't had my period since the last 6 months.

Dr: That must be quite worrying for you. When was your LMP? Pt..

Dr : This might be a very obvious question to you, but I need to ask. Is there any chance
that you are pregnant? Pt : No

Dr : Are you on any form of contraception? (OCP can cause high LH)

Pt: No, Dr. I don’t have a partner. My last relationship was 3 years ago.

Dr : Alright. Thank you. Did you have irregular periods before this? Pt: Yes/No

Dr: Did you have heavy bleeding in the past? Pt : Yes/No

Dr : Did you feel like there was excess hair growth on your body than usual for example
on your face, chest or back? (hirsutism) Pt: : Yes, Dr. I was quite worried about that
too. (reassure her), any thinning of hair from the head? Pt : I…

Dr : Do you have acne? Pt : Yes, Dr. It is stressing me out. I can’t go anywhere

Dr : Any weight gain? Pt: Yes. I gained weight in the last 12 months.

Dr: Is there any chance you were trying to get pregnant and couldn’t? Pt : No, Dr. I don’t
want kids now. I’m just concerned about my periods and acne.

Dr : We will talk about it shortly. Please bear with me for a few more questions, if thats
alright. Pt : Ok

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Dr: Any preference to cold weather? Change in bowel habits? Pt : No

Dr : Any medical conditions? Pt : No (no diabetes or family h/o diabetes) No family

history of PCOS or infertility. Has 3 brothers

Dr : Any medications (Steroids? For Cushing’s, thyroid medication)? Allergies? Pt : No.

Dr : Any medications (steroids? For cushings, thyroid medication)? Allergies? Pt : No.

Dr : How about your life style? Pt : likes to sleep a lot, doesn’t exercise, eats fish and
chips, burgers and occasionally vegetables. Doesn’t smoke or drink.

Dr : Ms… thank you for answering my questions patiently. I can discuss your results
now. Do you have any idea what this could be? Pt: No

Dr : These are your results and if you see, this is a hormone LH from the ovaries. These
are increased in your body. You also mentioned about your weight gain, we measured
your weight against your height. This is called Body Mass Index. It seems to be on the
higher side too. (It is considered healthy to fall between 18.5 to 24.9). With all the
symptoms you have told me and these results, I think you have a condition called
Polycystic ovarian Syndrome. Do you have any idea about this? Pt : No/Yes.

Dr : Polycystic ovary syndrome (PCOS) is a common condition that affects how a

woman's ovaries work.

The 3 main features of PCOS are:

1. Irregular periods – which means your ovaries do not regularly release eggs
(ovulation)

2. Excess androgen – high levels of "male hormones" in your body, which may cause
physical signs such as excess facial or body hair

3. Polycystic ovaries – your ovaries become enlarged and contain many fluid-filled
sacs (follicles) that are not actually cysts.

Dr : Are you following me so far? Pt : Yes, Dr

Dr : However, we need to do some more blood tests to check for your blood sugars,
blood cholesterol, testosterone level, thyroid levels and also a scan of your tummy to
see the ovaries. For this, we’ll be referring you to OBG specialists.

pt: Why did I get this?/Hoe can you treat me?

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Dr : There are medications as well as some lifestyle changes that you can do. Which
one do you want to know first?

Pt : I want only natural remedies dr. I don’t want any medications

Dr : Can I ask why? Pt…

Dr : Well, there are certainly some measures that can help with this. If you have PCOS
and you're overweight, losing weight and eating a healthy, balanced diet with lesser
carbs and more healthy fats can make some symptoms better. We could refer you to a
dietician for that. Is that something you could do? Pt : Ok. Dr.

dr: Will I be able to have children in the future?

Dr : That is a very good question. Chances of not being able to bear a child in women
with PCOS is high. But the good news is that we have excellent treatment for that.
Women with PCOS are advised on weight control and exercise. Weight loss has been
shown to improve fertility. Along with this, there are several medications and procedures
that would improve the outcome if done together. Please inform us when you are
planning to get pregnant so that we can guide you accordingly.

Pt : When will I get my periods?

Dr: Well, I can’t confirm about that exactly. Since you told me that you haven’t gotten
your periods after the weight gain, it could become normal once there is some weight
loss. However, I can’t completely assure you on that

Dr: Do you have any other questions for me? Pt: …..

PCOS LADY— AMENORRHEA

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 COUNSELLING CASES
GRIPS

Idea - e.g What medications you are taking?

Concerns

Expectations of the doctor

134. A middle aged man is brought to the emergency department in an ambulance;

his blood glucose in ambulance is 2.1/mmol. He had fits and became unconscious
half an hour back. Presently, he is conscious and wants to talk to a doctor. You
are an FY2 in the A&E, talk to the patient and address his concerns.
Vitals: BP=100/50 Pulse= 100/min Spo2=98% Hba1c= High

You need to check the blood sugar again now

GRIPS

D-Hello I am…P-….
D- I understand from my notes that you were brought to the hospital. Could you tell me what
happened?

P- Dr I am diabetic and had taken my insulin injections after which I started feeling
dizzy and weak and next thing I remember is waking up a little later

D- If it’s okay , I would like to ask you a few questions about your diabetes, so that I
am able to help you in a better way.

D- Do you have any medical conditions other than diabetes? P- No….

D- Since when have you been diagnosed with Diabetes?

P- Since my childhood

D-Which medications are you taking for the diabetes?

P- Dr I have been on Insulin injections for the last 20 years.

D- Are you taking it regularly? P- yes.

D- How often do you take it?

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P- I take it whenever I feel tired

D-So does that mean you don’t take it at the same time every day?

p- No I take it only when I feel tired

D- Are you monitoring your sugar levels regularly? P - No I don’t

D- Are you following up with your GP regularly?

P- No I haven’t been going to my GP for follow up for some time

D- Could you please tell me what happened today in detail?

P - Dr I was really busy today as I was planning my wedding which is going to take
place next week. Hence I skipped my breakfast as well as my lunch. I took my usual
dose of insulin injection. After which I suddenly started sweating and felt dizzy. And
then I lost my consciousness and I was brought to the hospital.

D - Congratulations on the wedding. And I am very sorry to hear this incident. It must
have been very distressing for you. But please don’t worry. Now that you are here. We
will take care of you.

D - Did you vomit before this incident? Did you do any exercise before the incident ?

D-Has this ever happened before?

P - This has happened twice before. I felt dizzy both of the times but this is the first
time I lost my consciousness

D-What were you doing when this happened?

P- I was running around trying to organize my wedding details

D - Was there anyone with you at the time this happened? P- ….

D - What job do you do?

P- I am a clerk

D-Do you have any problems with your vision? Any chest pain? Racing of your heart?
Numbness or tingling of your arms or legs?Any urinary problems?

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D-Do you eat a healthy diet and regular meals

P - Nowadays I am not able to eat proper meals as I am very busy

D-Well we examined you and found out that your blood pressure is very low (explain
vitals to the patient)

Explain that he is unwell, and he needs to be admitted right away

Patient refuses admission saying that he is busy and he has lots of planning to do
for the wedding

Give the following points:

● It’s a very serious condition and life threatening if left untreated.

● That’s why we need to admit you.

● Patient says that can’t I get any treatment which I can do at home?

D - Presently, this is a serious condition and your sugar levels are too low. For this we
need to admit you and give you fluids which contains sugar through your veins. This
cannot be done at home.

P - What happens if I don’t get treatment?

D - It’s very dangerous to have low sugar. It can cause sudden death if the sugar in the
body is low. I am sure your partner (male partner) also wants to see you healthy and
get treatment so that you are fit for the wedding.

P - No I have lots of work, I don’t have time to get admitted?

D - I can imagine you must be very busy and it must be very tiring for you. However
your health is a priority right now and you are in a dangerous situation if left without
treatment.

D - Is there anyone else who could help you with the work?

P - I like doing things by my own as I am a very organized person and I like everything
to be organized well.

D - What do you think of getting the help of a wedding planner? (person who plans
wedding event)?

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P - Yes I could do that..it’s a good idea

D -So will it be alright if we admit you now?

P - Yes. What are you going to do after I get admitted?

P - We will give you some fluids which has sugar through your veins. We will give
insulin also through your veins while monitoring sugar level continuously.

We will also check whether you have any complications of diabetes.

We will refer you to the Diabetic Clinic, once your stable

P - When will you discharge me?

D - We will discharge you once your stable and your sugar levels are well controlled

Once we discharge you, make sure that you have your meals regularly on time and if
you do not eat any food then please do not take Insulin because it can bring down the
sugar level.

We will also asses the dose of insulin you’re taking and alter it if necessary.

Make sure that you take your correct dose of insulin regularly. Always remember low
sugar levels are more dangerous than high sugar levels and can even lead to death

If at all at any time you experience symptoms like shakiness, dizziness, sweating,
hunger, headache, eat sweets immediately as it indicates your sugar level is low. Keep
some chocolates with you at all times.

If you drive, you need to inform DVLA that you area diabetic on insulin, and you would
need to wear a diabetic bracelet at all times.

Do you have any more concerns?

HYPOGLYCAEMIA

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135. You are the FY2 doctor in the Orthopaedic department.

84 year old lady Mrs Margaret Edwards had a simple fall at home and sustained a
fractured wrist on the non-dominant hand. She has been treated and the
multidisciplinary team (MDT) consisting of doctors, physiotherapists and occupational
therapists have assessed her and decided to send her home with twice a day visit by
the carers.

She is also being arranged for the follow-up at the fracture clinic every week. She was
given a walking stick. She is lucid. She also wants to go home and she lives alone. She
has given consent to talk to her son.

Her son wants to talk to a doctor about her. Talk to him and address his concerns.

The son is not here for giving us info. We will give info to him. Can she fall again? Yes.
But the team has decided to send her home - this means they have found the cause
already.

● The son came to speak to you. He came to you. You haven't called him.
● If he hadn't come, you wouldn’t pursue him for history. The MDT has assessed.
Everything has been done already. This means this is only a counselling station.
You will not do an NAI investigation.
● She doesn’t need any treatment in the hospital and you can’t keep her for 6
weeks.
● Follow up has been arranged (weekly)
● Prepare yourself by reading the notes and anticipating what he can ask you.
Dr: Hello Mr Edwards ? Son: Yes

Dr: I am Dr… a junior doctor in the Orthopaedic department. Are you the son of Mrs

Margaret Edwards? Son: Yes

Dr: I am one of the team of doctors looking after your mother. I was told that you want
to speak to a doctor about your mother. How can I help you, Mr Edwards ?

Son: Yes, doctor. How is she ?

Dr: She is doing well at the moment. May I ask - do you know what has actually
happened to her so that I can answer all your questions better ?

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Son: I was told that she had a fracture in her wrist.

Dr: That is right, Mr Edwards. Do you know what happened after that ? Son: No

Dr: Okay, let me explain. Fracture has been treated now. Our Multidisciplinary team
consisting of doctors, physiotherapists and occupational therapists have assessed her
and decided to send her home. We have arranged twice a day visits by the carers until
she is better and also we have arranged follow up for her in our fracture clinic every
week until she completely recovers.

Son: Are you sure she can take care of herself at home ?

Dr: Yes we think so. She has been fully assessed by our team including her home
conditions and the team believes she will be able to manage herself at home with the
help of carers visiting her twice a day to help her. Also her fracture was in a non-
dominant hand. We have given her a walking stick also. So we are hoping it should not
be any problems.

Son: What will the carers do?

Dr: They will do everything to help her daily activities like cooking, feeding, dressing,
shower, shopping, giving her medications and any other necessary things.

Son : Why was she given a walking stick?

Dr: Because she has a fracture in one hand, she was given a walking stick so that she
can support herself and prevent herself from falling if she loses balance while walking.
This is given temporarily until her fracture heals. She may not need it afterwards.

Son: Doctor, I live about 50 miles away from my mother’s house. It will be very difficult
for me to visit her and look after her. Can you please keep her in the hospital until she
is completely fine.

Dr: I can understand your concerns. However, Mr Edwards, we have assessed her and
she does not need to stay in the hospital for further treatment. We believe she will be
able to manage herself at home with carers help. We are not expecting you to take
care of her on a daily basis. Beside that, she wants to go to her home. We appreciate
if you can visit her whenever you have time.

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Son: She may say that she will manage herself, but I am sure she won’t be able to
manage herself. What if she falls again ?

Dr: May I ask why do you think she will fall again?

Son: She already fell once so she may fall again. Are you sure she will not fall again at home?

Dr: I can understand why you are so worried. Mr Edwards, we have minimised the risk
of her falling again. We have assessed her and we did not see any medical causes for
her fall. Our team has visited her home also and made sure everything is safe. We do
not see any medical reasons for her to fall again

Son: Well, I don’t know. But if she falls again then the hospital will be responsible for that.

Dr: Mr Edwards, as we have mentioned we have checked for all the medical causes
and we do not see any medical causes for her to fall. If you have any other reasons to
believe she may fall again at home, please do let us know. We will look into that again.

“Is there anything else you are expecting from us?”

Son: Doctor can you please tell her to go to a care home or residential home ?

Dr: May I ask - why do you want her to go to the care home ?

Son: She lives alone and I live so far away from her home. I have a wife and children to
look after. I am too busy. It will be better for her to live in a care home or a nursing
home.

Dr: Mr Edwards, I can see that you are a very caring son. I can imagine why you want
her to be in the care home. However, it is her decision because she has a mental
capacity to decide for herself what she wants. Have you discussed this with her?

He may get upset that you are not respecting his opinions. Let him know that his
opinions are respected.

Son: No, doctor. It is embarrassing for the family members to suggest this to her. It is
better you doctors suggest that to her.

Dr: If we have seen any medical reasons that it is not safe for her to live alone in her
house then we could have suggested for to live in the care home or nursing home. I
sincerely advise you to discuss this matter with her.

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Dr: Is there anything you expect from us ?

Son: I believe she will not be safe at home. Can you at least arrange 24 carers ?

Dr: Mr Edwards. I can see you are very concerned about her. We also want the best for her
as much as you want that for her. If you wish, we can have a meeting again with the whole
team and you can raise any concerns and see if anything more we can do for her.

Son: But you already had a meeting!

Dr: That is right, but at that time you were not in the meeting. We can arrange the
meeting again if your mother agrees for that. Mr Edwards, please be reassured that
we will do everything possible from our side to keep her safe at home. If needed,
maybe we can increase the frequency of carer’s visits to her home.

Son: Ok Doctor.

Dr: Thank you very much Mr Edwards. I will talk to my Consultant now and inform him
about your concerns. Thank you very much for coming here and sharing your concerns.
We really appreciate that. Thank you again.

Ask the patient if he's happy now.

LADY WITH FRACTURED WRIST - TALK TO SON

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136. 70 year old lady getting discharged from the hospital. Explain medications to her.
How to approach a discussion about discharge medications

1. Congratulate the patient on his/her discharge

2. Assess knowledge of the conditions what they are having.
3. Why she got admitted? How is she now ?
4. Has she got any medical conditions other than the reason why she was admitted
for?
5. Was she on any medications before she was admitted to the hospital?
6. Any allergies?
7. If she is a young lady – ask about pregnancy, breast feeding, pills
8. Explain the medications :-
a. Name of the medicine, What is it for,
b. How to take it – tablet to swallow, injection, ointment to apply on skin,
suppository
c. When to take it – before or after food,
d. How many times in a day – for how many days, Side effects, What to do if
there are side effects
e. Ask the patient to repeat at least the dose of one or two medicines to
check the understanding

(Prescription of medications was given in the cubicle)

1. Amoxiclav

2. Codeine …. 1 tab PRN

3. Alendronate 70mg every Sunday 30mins before breakfast

4. Calcitriol + Vit D medication … OD

5. Lisinopril 5mg OD– Previously 10mg and now changed to 5 mg

7. PCM 2 tabs BD/ PRN

8. Atorvastatin 10mg OD previously taking it so no need to explain.

Dr: Hello I am Dr... one of the junior doctors in the medical department . Are you Mrs ...
Pt – Yes Dr: How are you doing today ? Pt : I am fine doctor.

Dr : I understand you are getting discharged today. How do you feel about going home ?

Pt : I am feeling good doctor.

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Dr: Mrs... Congratulations. My consultant has prescribed some medications which you
need to take at home once you get discharged. I am here to explain to you how you
need to take those medicines. Is that Okay ? Pt : Yes doctor

Before I explain the medications may I ask you do you know why you are in the hospital?

Pt: Yes doctor – I had a urine infection or she may say - I had a fracture of my hip bone
because of Osteoporosis

Dr: That is right. Do you have any other medical conditions other than urine infection /
osteoporosis ? Pt : Yes I have high blood pressure

Dr : Were you taking any medications before you got admitted to the hospital ?

Pt : Yes I was taking blood pressure medicines.

Dr : Are you allergic to any medicines? No

Dr: Okay, I will explain the medicines. You have been given 8 medicines:

1. Amoxiclav 2. Codeine 3. Alendronate 4. Calcitriol + Vit D

5. Lisinopril 6. PCM 7. Atorvastatin

Is there any medicine which you want to know first ?

Pt: Yes doctor, tell me about this ... [then explain whichever she is interested in knowing
first, if she says nothing in particular - then you can start with the new medicines or the
ones which have a dose change like - alendronate, amoxicillin, Lisinopril]

1. Amoxiclav… This is an antibiotic given for the infection to resolve soon. You will
have to take this medicine ………. times a day for ……. many days ( check the
prescription).

You may get some side effects but they are not serious – like nausea, vomiting or loose
stools after taking this medication. These side effects go away on its own after some
time. Please do not stop taking medication if you have these side effects. You can drink
plenty of fluids to replenish the fluids you lose in loose stools.

Very rarely, you may get allergic reaction – if you have this allergy then you may
develop skin rashes, breathing difficulty, swelling of the lips and tongue – if you have
any of these symptoms you must stop taking this medicine and call the ambulance and
come to the hospital immediately. Do you follow me? Pt: Yes
“Please tell me how many tablets you take and how many days?”

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2. Alendronate: This is the medication we give to slow down the rate of osteoporosis
so that the bone becomes strong and prevent fractures.

You need to take one tablet which is 70 mg every Sunday 30 min before breakfast.

Tablets should be swallowed whole and should be taken with plenty of water while
sitting or standing, on an empty stomach at least 30 minutes before breakfast (or
another oral medicine). Also, you should stand or sit upright for at least 30 minutes after
taking the tablet.

Like any medicine, this also can give some side effects like hair loss, joint pain,
constipation, muscle pains.

Sometimes, it can cause serious side effects like damage to the food pipe – you may
have painful swallowing if you have this side effect, or it can cause damage to the jaw
– you may have pain in the jaw if you have this side effect. If you have these side
effects, you must stop the medicines and come back to us.

You may need to take it for about 5 years. We will keep monitoring your calcium levels
when you are on this medication.

3. Lisinopril: This is a tablet to lower blood pressure and keep it under control. You
have to take one tablet which is 5 mg. Once a day.

You were taking 10 mg of this Lisinopril before you were admitted to the hospital but we
reduced the dose to 5 mg now because your blood pressure was too low with 10 mg. If
the blood pressure is very low, it can make people fall ( postural hypotension). [maybe
that is the reason she fell and had a fracture hip bone – tell this to her - if it is
given in the question or she gives the story of fall and fracture]

Side effects of this medicine are cough, dizziness, extreme tiredness, diarrhoea. If these
side effects bother you, please do come back we will sort it out.

4. Codeine: This medication is given for P\pain. (check in the question why she is
getting it for).

You can take it as is prescribed (check the prescription). There are certain side effects
of it like constipation, feeling sick or vomiting, feeling sleepy, dizziness, dry mouth, so if
you have any of these side effects please do come back to us.

Dr: Do you have any concerns? Pt: No Doctor.

5. Calcitriol + Vit D: These are calcium supplement medications that we give for bone
strengthening. So, please take it every day at the same time and for ……………

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number of days (as per prescription). If you get nausea, vomiting, loss of appetite,
and drowsiness, please come back to us.
6. Atorvastatin: This tablet is to lower the cholesterol level in the body. You need to
take one tablet at night for the rest of your life. Side effects include: muscle pain,
confusion, unusual tiredness, dark-colored urine, weight gain, urinating less than usual
or not at all.

7. Paracetamol: This table is to reduce the pain.

Dr : Do you have any concerns so far?. Pt: Yes Doctor it’s clear to me.

If you have any concerns at all about any of the medications, then please come back to
us.

I hope I was able to explain everything to you. We will be following you up. I wish you
good health.

Thank you.

EXPLAIN DISCHARGE MEDICATION

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137. STATIN THERAPY

Cholesterol level - Healthy adults should have a total cholesterol level below 5 mmol/
L.

Accepted BMI ranges are

Normal weight: 18.5 to 25,

Underweight: under 18.5 kg/m2,

Overweight: 25 to 30,

Obese: over 30 to 40

Morbid Obesity – Over 40 ( needs Bariatric surgery along with life style )

QRISK2 (the most recent version of QRISK) is a prediction algorithm for cardiovascular
disease (CVD) that uses traditional risk factors (age, systolic blood pressure, smoking
status and ratio of total serum cholesterol to high-density lipoprotein cholesterol)
together with body mass index, ethnicity, measures of deprivation, family history,
chronic kidney disease, rheumatoid arthritis, atrial fibrillation, diabetes mellitus, and
antihypertensive treatment.

RISK FACTORS FOR CARDIOVASCULAR DISEASE

NON-MODIFIABLE: Gender, Age, Sex, Ethnicity, Genetic

MODIFIABLE:

Lifestyle: Smoking, Alcohol, Diet, Exercise.

Medical causes: Hypertension, Diabetes, Hypercholesterolemia, Obesity, Atrial

fibrillation, Kidney disease, etc

A QRISK2 over 10 (10% risk of CVD event over the next ten years) indicates that
primary prevention with lipid lowering therapy (such as statins) should be considered.

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65 year old lady with BMI – 28. Blood pressure of 150/89. Blood cholesterol 6.9
mmol/l.

Other blood tests – FBC, LFT, HbA1c all normal.

Her Q risk score is 18.

According to Q RISK score is fit to be started on Statin therapy.

Talk to her about starting statin therapy and address her concerns.

In your history, you want to find out if she has:

● Any other risk factors besides the ones mentioned in the question.
● Any complications (cardiac disease/stroke): Ask if she has already been
diagnosed.
● Any symptoms pointing to a complication: If she hasn’t, then ask her for
cardiovascular symptoms.
● Other medical conditions (contraindications): Liver disease, Pregnancy, Breast
feeding, Kidney disease
● Other medications: Macrolides, OCPs, HRT

Dr: Hello Mrs... I am doctor ... How are you doing today? Pt: I am fine doctor

Dr: Do you know why you are here today?

Pt: I am here to collect my blood result.

Dr: Mrs... Yes your blood results are here with me. Before we discuss the blood results,
can I ask a few questions that will help better understand your health and it will also
help me know the best management to offer you. What was the reason you came to
the hospital the last time/had the blood tests for?

Pt: I just wanted to have a general check up/I had ... (symptoms) / I was worried about
getting a stroke/heart problem.

Dr: How is your general health now? Pt: I am OK

Dr: Have you been diagnosed with any medical conditions? Pt: Yes / no

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Dr: High blood pressure, Diabetes, Liver problems (liver disease is a contraindication)
? Pt: No

Dr: Do you get any chest pains or shortness of breath, exercise tolerance and any
pains in legs ? Pt: No

Dr: Any medications? No

Dr: Any allergies? Pt : No

Dr: Any chance of pregnancy (if the lady is young) ?

(pregnancy is a contraindication)

Dr: Any medical conditions in family members? Pt: No

Counselling and management

ICE

Find out if she knows that she has the risk factors (high cholesterol) and if she knows
what the risk factors are.

Find out her concerns. Questions she might ask include: She might want to know what
normal is, how it will harm, how to reduce it, what medication to take, how to take it,
how long to take it for, any side effects of the medication, if the condition is serious,
how to reduce her other risk factors

Dr: May I know if you have any concerns about your health ?

Pt: My friend had stroke I am worried about it?

SHOW SYMPATHY/EMPATHY, PRAISE AND REASSURE. AFTER REASSURING, ASK

HOW SHE FEELS ABOUT IT NOW.

Dr: Sorry to hear about your friend. If your friend had a stroke, may I know why are
you worried about getting a stroke?

Pt: He was told he had high cholesterol and because of that, he had a stroke. I am
worried whether I too have high cholesterol and whether I will also get stroke.

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Dr: You are right Mrs.. Having high cholesterol is one of the risk factors for getting
stroke. Also there are many other risk factors too for getting stroke. Please do not be
worried about you getting stroke. I am glad that you have come here. Since you have
come here now, we can see if you have any risk factors for getting stroke and we can
reduce those risk factors and reduce the chance of you getting stroke or any such
serious health problems. How do you feel about it now?

Pt: It will be really good if you can reduce the chances of me getting stroke.

Dr: Yes surely we will help you with that. Last time when you visited us we checked for
some risk factors for getting a stroke also we did some blood tests. Can we discuss
about it? Pt: Yes

Dr: We have done blood tests - most of the blood tests are normal like your liver
function tests and blood sugar are normal. However, some blood tests are not normal.

It shows that your cholesterol content in the blood is quite high.

Do you know anything about cholesterol? Pt: No

Dr: Cholesterol is a fatty substance known as a lipid and is important for the normal
functioning of the body. It's mainly made by the liver, but can also be found in some
foods.

Having an excessively high level of lipids in your blood (hyperlipidemia) can have an
effect on your health. High cholesterol itself doesn't usually cause any symptoms, but
it increases your risk of serious health conditions.

Pt: What health conditions doctor?

Dr: Having high cholesterol can increase the risk of stroke. Also it increases the
chances of having a heart attack and thickening of the blood vessels which causes
reduced blood supply to the legs.

Pt: What should my cholesterol levels be?

Dr: As a general guide, total cholesterol levels should be:

5mmol/L or less for healthy adults and 4mmol/L or less for those at high risk.

In your case the cholesterol level is 6.9 mmol/l which is quite high.

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Pt: What causes high cholesterol?

Dr: There are many reasons why the cholesterol can increase in the body.

As I mentioned earlier cholesterol is made in the liver but also it is found in the food.

Generally, when these things do not help to reduce the cholesterol levels we prescribe
medications to reduce cholesterol levels.

Pt: How can I reduce the cholesterol level ?

Dr: There are many ways to reduce the cholesterol level. One is by taking medications
to reduce the production of cholesterol in the liver other thing is to reduce eating food
containing high cholesterol.

As per your test results and our guidelines you require these medications. Do you want
to know about these medications ? Yes

These medications are called statins. [check BNF if required].

There are many types of statins like atorvastatin, simvastatin and others. My
Consultant will decide what type may be suitable to you.

"Statins" are a class of medicines that lowers the level of cholesterol in the blood by
reducing the production of cholesterol by the liver.

Statins come as tablets that are taken once a day. The tablets should normally be
taken at the same time each day – most people take them just before going to bed.

In most cases, treatment with statins continues for life, as stopping the medication
causes your cholesterol to return to a high level within a few weeks.The liver will have
a rebound increase in cholesterol.

Remember the cholesterol lowering medicine will only reduce the cholesterol which is
made in the liver. You still need to eat healthy food to reduce the cholesterol coming
from food.

Pt: Do they have any side effects doctor ?

Dr: Mrs... Many people who take statins experience no or very few side effects. Others
experience some troublesome – but usually minor – side effects, such as an upset
stomach, headache or feeling sick.

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Very rarely it can cause severe muscle pains. Also, rarely it can damage the liver and
kidneys.

Once we start the medicines we will keep monitoring you. We will keep checking your
blood tests to monitor your liver and kidney function.

Do you follow me? Pt-Yes Dr: Do you have any other question on statins? Pt : No

When giving advice, you should ask if the patient will consider what you are
counselling them to do. Find out if they can do it i.e make the change.

Dr: One of the main reasons is eating an unhealthy diet – in particular, eating high
levels of fat.

May I ask what type of food you eat on a regular basis?

Pt: I eat steak, chips and burger most of the time.

Dr: This type of food contain high cholesterol. I advise you to reduce eating this kind
of food. Instead you can eat chicken and fish that is white meat which contain less
cholesterol. Also, you should include a lot of fruits and vegetables in your diet. Eating
healthy balanced food will help in reducing the body weight. We can refer you to the
dietician who will advise you in detail about the diet. What do you say Mr. ?

Pr: Yes doctor that is a good idea.

Dr: Not doing regular exercise is another reason for high cholesterol. May I ask, do you
do exercises? No, doctor.

Dr: I sincerely advise you to do regular exercise. You can do brisk walking bout 30
minutes daily. What do you think?

Pt: Yes doctor I will consider that.

Dr: Other reasons are – smoking and drinking too much alcohol. If you have those
habits, I advise you to stop it and that will help in having good health. Pt: Okay.

Being overweight, having high blood pressure, diabetes, or some health conditions
can also increase cholesterol levels.

We had checked your weight last time and we found that your weight is on the higher side.

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I sincerely advise you to reduce your weight. Eating healthy diet and doing regular
exercise will help in reducing the body weight. Is that Okay? Pt: Okay.

Dr: Also your blood pressure is high. May I know whether you had high blood pressure
previously? Pt: Yes/No

Dr: You need to keep it under control. I will discuss with my senior to check whether we need
to give any medications to control your high blood pressure. However generally this can be
controlled with a healthy lifestyle.

Any other concerns? No.

Do you have any other expectations?

When you came in, you were worried about getting a stroke. How do you feel now
after we’ve had this talk? Thank you.

Types of statin

There are five types of statin available via prescription in the UK:

1. atorvastatin (Lipitor)
2. fluvastatin (Lescol)
3. pravastatin (Lipostat)
4. rosuvastatin (Crestor)
5. simvastatin (Zocor)

Cautions and interactions: Statins can sometimes interact with other medicines,
increasing the risk of unpleasant side effects, such as muscle damage. Some types of
statin can also interact with grapefruit juice.

Caution - statins should be used with caution in those with a history of liver disease or
high alcohol intake; it is advised that liver function tests should be undertaken before
and within 1-3 months of starting treatment and thereafter at intervals of 6 months
and 1 year, or sooner if clinical features suggestive of hepatotoxicity. If serum
transaminase concentration rises to, and persists at, 3 times the upper limit of the
reference range, then treatment should be discontinued

Contra-indications include:
● active liver disease
● Pregnancy
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138. Mr/Mrs 48 year old lady/man has been diagnosed with DVT.
He/She is being discharged from the hospital today. Your consultant has
commenced her on warfarin tablets.

Talk to the patient and address his/her concerns.

Patient is slow to understand and keeps forgetting.

Steps to take when doing this station

1. GRIPS

2. Assess knowledge

3. Ask her if she know what warfarin does

4. Find out if she has any contraindications

5. Talk about warfarin side effects and what to be careful about

6. Who needs to be informed

7. Warfarin bracelet

8. Follow up and INR

9. General advice: diet, contraception, alcohol, other medications

10.Safety netting

Greet the examiner. (Prescription, Warfarin packet, BNF and INR book may be kept
inside the cubicle)

Contents of the yellow anticoagulant therapy record:

- Patient information

- INR book (should be brought for every visit)

Before you start telling her about warfarin,

" Let her know that she can stop you and ask you questions

" Also let her know you can repeat the information.

" Tell her that you can write the info down

" Tell her that there is a booklet that she can read.

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Check the Warfarin dose (usually 5mg OD) - also check the BNF briefly for the side effects.

Dr - Good morning, Mrs Jones. I am Dr ..... One of the junior doctors in the medical dept.

Dr - How are you doing today? Pt - I am well doctor. I am going home today.

Dr - Congratulations. My consultant has prescribed some medications which you need

to take at home. I am going to explain to you how to take them at home. If you do not
understand anything at any time, please do let me know. Is that OK? Pt – Ok, doc.

Dr - I need to ask you a few questions before I explain these medications to you.

Dr - Any allergy to any medications? - Pt - No

Dr - Do you have any other medical conditions? Pt – No

(Contraindications for warfarin - Liver disease, Peptic Ulcer, Severe HTN)

Are you taking any other medications? Pt – No (Sometimes, he may say I take mini Aspirin).

Dr - Any chance of pregnancy, breast feeding, or taking OCP? Pt – No

(warfarin should not be given in first and third trimester pregnancy).

Explain medicines to the patient

Dr: This warfarin tablet is a blood thinning tablets. This stops blood from clotting. (patient
may say you are using big words – then explain clotting means blood may become
thick again like what you already had)

“This should be taken regularly, everyday at the same time for about six months. It’s better
to take it in the evening. You need to take it by mouth. It is important to take it every day
without forgetting.”

(Can you remember to take the tablet? Can you keep an alarm to remind you to
take it every day, or do you have anyone to remind you to take the medicine every
day? If so, I will explain everything to that person. If no one to remind - then we
will do something to remind you take it every day).

“Warfarin can be taken with or without food. The dosage will depend on the blood test
that we do on you regularly. This is called as INR for which you will have to come to the
hospital every week or so and bring the INR booklet (yellow booklet) with you.”

Pt: What will I do if I miss taking the tablets?

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Dr: First of all - it is very important that you should take this every day without forgetting,
otherwise you may develop blood clot again which may travel up to the lungs which can
be life threatening.

If possible, keep a regular alarm to remind you every day.

If you are taking an evening dose and if you forget to take it in the evening but
remember before midnight on the same day, take the missed dose. If midnight has
passed, leave that dose and take your normal dose the next day at the usual time.

Tell her to stick to the days written on the blister pack.

Pt - Doctor, what if I forget to take the medicines with me when I go on a holiday?

Tell her to have her prescription at all times.

Dr – If you forget to take the medicines with you when you go on a holiday, you should
go to the hospital there and get the medicine and take it every day.

Talk to her about the side effects from the yellow patient information booklet.

Side effects

1. Bleeding - Since this is a blood thinning medicine, you are prone to bleeding. If you
notice bleeding, black stools, bruising on the skin, bleeding gums, blood in urine,
please report to your GP.

2. Other uncommon side effects are: Skin rash, Jaundice, Hair loss, Diarrhoea - please
inform your GP.

3. If you develop chest pain or shortness of breath (PE), please call the ambulance and
come to the hospital immediately.

Specific advice

1. If you need pain killers, you can take Paracetamol but not Aspirin. [If patient is taking mini
Aspirin – you will have to stop it. “I will inform my seniors about it”].

2. If you are going to see a new doctor or dentist, please tell them that you are taking warfarin.

3. [If the patient is a sexually active lady taking combined pill – maybe the pill itself has
caused the clot and the pill can interact with warfarin and reduce the effect. Please stop
taking combined pill and talk to your GP for other suitable contraception]. Contraception is
important because warfarin is teratogenic.

4. For a sexually active young lady not using any contraception – please use some contraception.

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5. Do not become pregnant when you are taking this medicine

6. Changing your diet suddenly can affect your INR, especially if you begin to eat more vegetables
and salad. So, do not keep changing your diet frequently.

7. Drink alcohol in moderation if she is drinking alcohol. Never binge drink.

8. It's best if you avoid cranberry and grape juice altogether. (Cranberry and grape juice are
P450 inducers).

9. Wear a warfarin bracelet

10. “Be careful while handling sharp objects and try not not injure yourself.” They need to be
careful about falling. Enquire about recurrent falls in the past.

If you still have time left, then tell the following :

• Advice on illness

• Wear pressure stockings

• Avoid long journey flights

WARFARIN - PATIENT WITH A LEARNING

DISABILITY

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139. 55 year female came with of overweight. Talk to her and address her concerns
Take a history to find out:

● The cause of her overweight,

● Any complications already due to overweight,
● Any symptoms of complications,
● Contraindications for medication,
● Allergy

It is very important to check the patient’s BMI in this scenario.

Assess the knowledge of risk of overweight

Find out why she wants to lose weight. If she says that she wants to reduce her weight
because she knows that it can cause a lot of medical problems, you can tell that is
right.

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It's very important to take steps to tackle obesity because, as well as causing obvious
physical changes, it can lead to a number of serious and potentially life-threatening
conditions, such as:

● Type 2 diabetes
● Coronary heart disease
● Some types of cancer, such as breast cancer and bowel cancer
● Stroke
● Obesity can also affect your quality of life and lead to psychological problems,
such as depression and low self-esteem.

Do you know your BMI? - Examiner may say 40.

Defining obesity

There are many ways in which a person's health in relation to their weight can be
classified, but the most widely used method is body mass index (BMI).

BMI is a measure of whether you're a healthy weight for your height. You can use the
BMI healthy weight calculator to work out your score.

For most adults, a BMI of:

 18.5 to 24.9 means you're a healthy weight

 25 to 29.9 means you're overweight
 30 to 39.9 means you're obese
 40 or above means you're severely obese

BMI isn't used to definitively diagnose obesity, because people who are very muscular
sometimes have a high BMI without excess fat. But for most people, BMI is a useful
indication of whether they're a healthy weight, overweight or obese.

A better measure of excess fat is waist circumference, which can be used as an

additional measure in people who are overweight (with a BMI of 25 to 29.9) or
moderately obese (with a BMI of 30 to 34.9).

Generally, men with a waist circumference of 94cm (37in) or more and women with a
waist circumference of 80cm (about 31.5in) or more are more likely to develop obesity-
related health problems.

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Treating obesity

The best way to treat obesity is to eat a healthy, reduced-calorie diet and exercise regularly.

To do this you should:

 Eat a balanced, calorie-controlled diet. We can refer you to dietitian who can advise you on
that.

 Join a local weight loss group

 Take up activities such as fast walking, jogging, swimming or tennis. Non-weight bearing
exercise like swimming is easier for them.

 Eat slowly and avoid situations where you know you could be tempted to over-eat

 We can refer you to Psychologists who can help change the way you think about food and
eating.

 If lifestyle changes alone don't help you lose weight, we can prescribe a medication
called Orlistat. If taken correctly, this medication works by reducing the amount of fat
you absorb during digestion.

Since your BMI is 40 which is very high, we may be able to do surgery to reduce your weight.

Weight loss surgery, also called bariatric or metabolic surgery, is sometimes used as a
treatment for people who are very obese.

It can lead to significant weight loss and help improve many obesity-related
conditions, such as type 2 diabetes or high blood pressure.
NHS weight loss surgery

Weight loss surgery is available on the NHS for people who meet certain criteria. these include:

● you have a body mass index (BMI) of 40 or more, or a BMI between 35 and 40 and an
obesity-related condition that might improve if you lost weight (such as type 2 diabetes or
high blood pressure)
● you've tried all other weight loss methods, such as dieting and exercise, but have struggled to
lose weight or keep it off
● you agree to long-term follow-up after surgery – such as making healthy lifestyle changes and
attending regular check-ups

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● You may also pay for surgery privately, although this can be expensive.

Types of weight loss surgery

There are several types of weight loss surgery.

The most common types are:

1. Gastric band – a band is placed around the stomach, so you don't need to eat
as much to feel full
2. 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
3. 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

All these operations can lead to significant weight loss within a few years, but each has
advantages and disadvantages. I can talk to my seniors about which option they
recommend.
Life after weight loss surgery

1. Weight loss surgery can achieve dramatic weight loss, but it's not a cure for
obesity on its own.
2. You'll need to commit to making permanent lifestyle changes after surgery to
avoid putting weight back on.
3. You'll need to change your diet – you'll be on a liquid or soft food diet in the
weeks after surgery, but will gradually move onto a normal balanced diet that
you need to stay on for life
4. You’ll also need to exercise regularly – once you've recovered from surgery,
you'll be advised to start an exercise plan and continue it for life
5. Attend regular follow-up appointments to check how things are going after
surgery and get advice or support if you need it
6. Women who have weight loss surgery will also usually need to avoid becoming
pregnant during the first 12 to 18 months after surgery.

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Risks of weight loss surgery

Weight loss surgery carries a small risk of complications. These include:

 Being left with excess folds of skin – you may need further surgery to remove these.

 Not getting enough vitamins and minerals from your diet – you'll probably need
to take supplements for the rest of your life after surgery

 gallstones (small, hard stones that form in the gallbladder)

 a blood clot in the leg (deep vein thrombosis) or lungs (pulmonary embolism)

 the gastric band slipping out of place, food leaking from the join between the
stomach and small intestine, or the gut becoming blocked or narrowed

Benefits of reducing weight

Even losing what seems like a small amount of weight, such as 3% or more of your
original body weight, and maintaining this for life, can significantly reduce your risk of
developing obesity-related complications like diabetes and heart disease.

OBESITY

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140. Mrs Katherine is diagnosed with psoriasis for many years and she is
taking skin emollients for a long time as a part of her treatment. Her BMI is
32 Talk to her and address her concerns…

D-Katherine I understand that you were diagnosed with some skin condition and you
are on treatment. I'm here to address any concerns you may have.

P-Skin condition? No doctor I'm here to talk about vascular dementia.

(Patient shows disinterest in talking about psoriasis and wants to talk about
vascular dementia)

P-Thank you Dr.. I am really worried about the chances of me getting vascular dementia..

D-Can you tell me how much you know about vascular dementia?

P-I know everything about the condition but I am worried if I would get it.

(If patient doesn’t know, explain vascular dementia. Vascular dementia is a common
type of dementia that is caused by reduced blood flow to the brain. As a result, you
will have difficulty in remembering things, feel confused and might experience some
mood and personality changes as well.)

D- OK. Can you please tell me why are you worried about vascular dementia?

P-Dr one of my family member had stroke and diagnosed with vascular dementia and
now one of my close friends is suffering from the same problem.
D - I am really sorry to hear about your family member and your friend. Can you please tell
me if that family member is a blood relative. P - Yes, Dr.

D - Psoriasis has some links with Vascular dementia. This condition sometimes run in
families. But it's not the only risk factor.. There are many reasons why someone could get
this. Is it alright if I can ask you few questions to get to the bottom of this? P - Sure

D- Do you have difficulty in remembering things?

Have you been experiencing any mood changes?

Do you have difficulty in walking or keeping balance?

Are you able to do your daily activities?

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Have you experienced any difficulty while passing urine?

D - Have you been diagnosed with any medical conditions? DM? High BP? Bad fat? P - No

D - Are you taking any medications? P - No

D - Are you allergic to any medications? P - No

D - Have you been diagnosed before to have any heart conditions? P-No

D - We noticed that your BMI is too high. ( 32). (Show the BMI and explain what it is.
Your weight is at a higher level compared to your height). Heavy body weight can
increase the risk of vascular dementia.
D - May I know what medication you are using for your skin condition ?

P – (may say – steroid cream)

D - Let's talk about your eating habit. Do you follow a healthy diet?

P - I have a busy life and I don't have time to cook and eat so mostly I eat out..

D - What kind of food you eat outside?

P - Due to insufficient time, I eat in fast food outlets

D - I can imagine that you must be a very busy person, but eating in fast food outlets
can increase the chances of building up bad fat called cholesterol in your body. Your
BMI is high as well. This it self can increase the risk of vascular dementia.

P - WHAT IS THE CONNECTION BETWEEN CHOLESTEROL AND VASCULAR

DEMENTIA?

D - High cholesterol can narrow the arteries that supplies blood to your heart as well
as brain which may lead to stroke then can contribute to dementia.

P - Ohh I will stop eating out.. What else Dr?

D - May I ask if you smoke or drink?

P - Dr I don't smoke but I drink a lot.

D - I really appreciate the fact that you don’t smoke. Could you tell me how much do
you drink and for how long?

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P - Strong alcohol sometimes wine.. 2 bottles a day.

D - Katherine, is it possible that you can cut down your drinking?

P - Ok Dr I will try

D - Also you need to loose weight.. As your BMI is too high.. 32.

P- What can I do to loose weight?

D - You can adopt some lifestyles changes like modifying your diet and including
exercise daily. You need to include more fruits and vegetables in your diet and have
more white meat like chicken and fish. Avoid fried items.

I can refer you to a dietician for your diet, cardiologist for further assessment and
obesity clinic as well.

P - is there anything you would like to do now?

D - I shall be doing some blood tests to check your cholesterol level and Q risk
assessment to see your risk of having stroke..
PSORIASIS AND VASCULAR DEMENTIA

INTRODUCTION

Vascular dementia is a common type of dementia caused by reduced blood flow to the
brain. It's estimated to affect around 150,000 people in the UK.
Symptoms of vascular dementia: Vascular dementia can start suddenly or come on slowly over

time. Symptoms include:

 slowness of thought

 difficulty with planning and understanding problems with concentration

 mood, personality or behavioural changes feeling disorientated and confused difficulty

walking and keeping balance

 symptoms of Alzheimer's disease, such as problems with memory and language (many
people with vascular dementia also have Alzheimer's)

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These problems can make daily activities increasingly difficult and someone with the
condition may eventually be unable to look after themselves.

Tests for vascular dementia: There's no single test for vascular dementia. The following are
needed to make a diagnosis:
 an assessment of symptoms – for example, whether there are typical symptoms of
 vascular dementia

 a full medical history, including asking about a history of conditions related to

vascular dementia, such as strokes or high blood pressure

 an assessment of mental abilities-this will usually involve a number of tasks and

questions

 a brain scan, such as an MRI scan, CT scan or a single photon-emission computed

tomography (SPECT) scan – this can detect signs of dementia and damage to the
blood vessels in the brain

Treatments for vascular dementia

There's currently no cure for vascular dementia and there is no way to reverse any loss
of brain cells that occurred before the condition was diagnosed.

But treatment can sometimes help slow down vascular dementia.

Treatment aims to tackle the underlying cause, which may reduce the speed at which
brain cells are lost. This will often involve:

 eating healthily

 losing weight if you're overweight stopping smoking

 getting fit

 cutting down on alcohol

 taking medication, such as medicines to treat high blood pressure, lower cholesterol or
prevent blood clots

 Other treatments including physiotherapy, occupational therapy, dementia activities

(such as memory cafés) and psychological therapies can help reduce the impact of
any existing problems. PSORIASIS AND VASCULAR DEMENTIA

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141. 34 year old female complains of insomnia. She has visited GP clinic 6
months ago for follow up of OCP. Assess the patient and discuss
appropriate management.

Differential diagnoses of insomnia

1. Depression
2. Sleeping during the day
3. Anxiety
4. Exercise before bed
5. Coffee at night
6. Alcohol at night
7. Watching TV, reading books, talking on the phone
8. Too much noise
9. Too much light

History-Ask her primary complaint and how long she has been having this problem.

She complains of insomnia for a period of 2 months. Ask her about sleep hygiene,
medical conditions, medications that she might be consuming.

She is completely anxious throughout the station. Ask her what is bothering her.

Reassure you that you are there to help her.

Later on after repeated probing (offering confidentiality), she gives a history of

domestic violence by her husband. Her husband is a businessman and is very stressed.
He comes home and hurts her by pulling her hair.

INSOMNIA

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NAI questions
How long has this been going on?

Who else lives at home?

Do you have children? If yes, ask the following questions-

- Does he hurt the children?

- Is he the biological father?
- Was it a planned pregnancy?
Has she confided this to someone else?

Do you work?

Is he under the influence of alcohol when he beats you?

Does he hurt you like sexually or emotionally?

Ask about mood scale

Husband doesn't drink. Pulls hair and pushes her around.

Management -

1. Offer national domestic helpline and women aids group

2. Police and inform social services

(Insomnia can be due to the domestic violence. Explain to her that she should be able
to sleep again as before once this is sorted out. If she still complains of lack of sleep,
advise her sleep hygiene methods.)
(Patient is not interested in discussing about OCP)

. Insomnia: Woman comes in with history of insomnia since 2 months. No positive

history for coffee, bed comfort, neighbours, loud noises, flashy lights, exercise. She
asks for confidentiality and then talks about husband abuse. Husband is stressed at
work and hence the abuse. She feels scared to even have children with him. Her
parents are down south, so it is relatively difficult to visit them. She considers Women’s
aid group and the hotline service and a short period of stay with her parents eventually.

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142. You are the FY 2 doctor in the OBG department.

Ms Caroline Anderson is a 35 year old female who is 12 weeks pregnant
presented to the OBG department with a history of bleeding per vagina. On
examination, the midwife did not find any blood in the vagina but she noticed
multiple bruises which looked like finger marking on her wrists and other parts of
her body. The midwife asked you to talk to the patient. USG is done and her baby
is fine.

Talk to the patient. Do not examine her.

Explore the bleeding very briefly.

PICK UP HER NON-VERBAL CUES AND VERBALISE IT.

Her voice will be quiet but don’t lean in too close and don’t ask her t9 speak up.

If she says, she wants to go home:

YOU CAN GO HOME.”

Let her know that doctors can help in other ways besides medical.

“It looks like someone’s grabbed your arm very hard.”

“You are in a very vulnerable state and it’s very important that you are stress free,
as stress can affect the baby so if there’s anything, let us know.”

“If the bruising is caused by some medical condition, do let us know because it might
also affect the baby.”

ONCE SHE OPENS UP, THANK HER FOR OPENING UP AND THEN YOU CAN ASK
THE FOLLOWING QUESTIONS:

- Since when?

- How often?

- Why?

- What type of abuse?

- Does he hurt her under the influence of alcohol or drugs?

- Anybody else e.g other child, elderly person

- Has she confided in anyone?

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- Emergency plans?

- How she’s coping?

- Mood?

- If she has a child, ask how old the child is, if he is the biological father of the
child, if she is the biological mother of the child, how his relationship with the
child is, if it’s a planned pregnancy, if he abuses her in front of the child, and if he
abuses her.

" Questions about the abuser - occupation, problems with the law before, how he
feels about the pregnancy

" If he abuses her under the influence of alcohol or drugs, we are obligated to get
social services and police to get involved. If a child is involved, then it is also a
medicolegal case.

" Questions about her - If she is working or dependent on the partner, her mood,
support, emergency plan

" Questions about the baby - unplanned pregnancy, is he the biological father
Dr: Hello, Mrs Anderson, I am Dr …. One of the junior doctors in the Obstetrics and
Gynaecology department. How are you doing ?

Can you please tell me what brings you here to the hospital? Pt: I had some bleeding
from my front passage.

Dr: Ok. Did you have any other problems? Pt: No

Dr: How far along are you? Ask her a little about the bleeding

Dr: Mrs Anderson, the midwife examined you and she said there is no blood in the front
passage and you are fine and your baby is also fine. Is there anything else I can help with?

Dr: Mrs Anderson, the midwife told us that he noticed some bruises on your wrists. Would
you like to tell us about it? Be assured that we will keep the information confidential within our
team unless you want us to disclose it to anyone or it is necessary.

Pt: No, doctor. I am fine I just want to go home.

Dr: Mrs Anderson, we are here to help you and your baby and anyone else you are
close to if needed. You seem to be in some danger. Please do not be worried. If you talk
to us, we may be able to help you. Can I have a look at your wrists please? I can see
bruises, can you please tell me how did you get this bruises?

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Pt: I just banged the door - that is how it happened?

Dr: Your bruise does not look like it happened because of banging the door. It looks as if
some has pressed with the fingers. Mrs Anderson, don’t be worried. We are here to help
you. You can feel free to talk to me.

Pt: Doctor, my partner Derek beats me sometimes but he is otherwise OK.

Dr: How long has this is happening? Pt: Since my first child was born

Dr: You mean you have a child?

Pt: Yes doctor. I have a 3 year old daughter Lacy.

Dr: Did you try to stop him in any way? Did you try to take help from anyone about this?
Pt: No doctor?

Dr: Can I ask why you didn’t?

Pt: I don’t want to put him in any trouble. I don’t want anything bad to happen to my daughter.

Dr: Has he hurt her also? Pt: No he does not hit her. He loves her.

Dr: Is he the biological father of your daughter? Pt:Yes

Dr: Is he the father of the baby in your womb? Pt:Yes

Dr: Is this a planned pregnancy? Pt:Yes.

Dr: Is your first daughter was a planned pregnancy? Pt : Yes.

Dr: Is there anyone else at home apart from your daughter? Pt: No

Dr: Do you know why does he beat you?

Pt: Sometimes he gets too stressed and he beats me. Sometimes, it is my fault. I do not
do the work at home properly.

Dr: Is he under the influence of alcohol or drugs when he beats you? Pt: No

Dr: Does he hurt you in any other ways like sexually or emotionally? Pt:No

Dr: Do you work? Pt: No.

Dr: Does he work? Pt: Yes he is a plumber (mechanic)

Dr: Mrs Anderson does this problem affect you in any way? Do you feel low because of
this? Pt: Yes, I feel low (Mood may be 5)

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Dr: Did you ever think of harming yourself? Pt: No

Dr: Do you have any emergency plans if something serious happens? Pt: No

Dr: Have you spoken about this to your family members or friends? They may be able to
help you. Pt: I haven’t told anyone. He has barred me from telling any of them.

Dr: Mrs Anderson, I am very sorry that this is happening to you. You do not deserve this.
There are a lot of help is available for such problems in the community. There is a
national domestic helpline and women’s Aid group. You can talk to them. We can
involve the Police and social services to help you.

Pt: I do not want to inform the police or anyone. Social services may take away my
child. I don’t want them to know. If I inform them, then where will I go? I don’t have any
other place to live.

Dr: I can imagine your problems. However, Mrs Anderson, this is for your own safety
and the child’s safety that social services must get involved. Also, if you are not safe to
go back home, they can make some arrangements for you and your child to stay in a
safe place. I am sure they will take care of everything. Is that OK?

Social services will do a risk assessment. They want to keep families together and they
will keep her safe from the source of danger.

Pt: Ok Thank you doctor. I will talk to my mother.

Dr: Please do let us know if you need any kind of help in the future. Thank you.

We’re doing this for you and your baby’s safety. It’s my duty to protect you I know you
might be upset with me.

NAI IN ADULTS

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143. Diabetic patient was admitted 2 weeks ago for cellulitis. During admission,
she was diagnosed with hypertension. Today she came for follow up.
Address her concerns.

Rule out causes of ankle and leg swelling. This time, the patient says that she does not want
to take the medication because she noticed swelling of the ankles after taking AMLODIPINE.

Check BNF-One of the common side effects of amlodipine is swelling of ankles. tell him not

to stop the mediation next time without seeing a doctor first

Tell her that you would discuss with your seniors and consider changing the medication. You
can mention diuretics if patient/examiner insists

If a patient is on enalapril and it is causing cough, find out causes of cough and tell him not
to stop the mediation next time without seeing a doctor first

HYPERTENSIVE PATIENT REFUSING AMLODIPINE

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144. ABNORMAL LFTs

 Bilirubin –(Normal 3 – 17 micromols/L)

 ALT –(Normal 3 - 35 IU/L )

 AST – (Normal 3 - 35 IU/L )

 ALP – (Normal 3 - 150 IU/L)

How do we compare the rise in ALT and ALP?

● A greater than 10-fold increase in ALT and a less than 3-fold increase in ALP
suggests a predominantly hepatocellular injury
● A less than 10-fold increase in ALT and a more than 3-fold increase in ALP
suggests cholestasis

• It is possible to have a mixed picture involving hepatocellular injury and cholestasis

(e.g. ALT < 10-fold increase and ALP > 3-fold increase)

What about Gamma-glutamyl transferase?

If there is a rise in ALP, it important to review the level of gamma-glutamyl transferase

(GGT). A raised GGT can be suggestive of biliary epithelial damage and bile flow

obstruction. It can also be raised in response to alcohol and drugs such as phenytoin.

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A markedly raised ALP with a raised GGT is highly suggestive of cholestasis.

A raised ALP in the absence of a raised GGT should raise your suspicion of non-
hepatobiliary pathology. Alkaline phosphatase is also present in bone. Therefore
anything that leads to increased bone breakdown can elevate ALP.

The ALT/AST ratio can be used to determine the likely cause of LFT derangement:

• ALT > AST is seen in chronic liver disease

• AST > ALT is seen in cirrhosis and acute alcoholic hepatitis

Symptoms of Hepatitis A - Fever, nausea, vomiting, diarrhoea, fatigue/lethargy

Symptoms of Hepatitis B - Abdominal pain, mild fever

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144.You are the FY 2 doctor in the GP clinic.

47 year old lady Miss Rachel Campbell came to the GP clinic a few days ago
with abdominal discomfort. Some blood tests were done.

She has come for a follow-up. Talk to her about the further management.

Liver Function Tests (given in the question) - Miss Rachel Campbell

Bilirubin – 25, ALT – 581, AST – 110, ALP – 50

Dr: Hello Miss Rachel Campbell, I am Dr… junior doctor here in the GP clinic. How can I help
you? Pt: I have come to collect my blood test report.

Dr: Yes it is here. We had done your Liver function tests last time.

Dr: Can you please tell me what is happening to you?

Pt: Doctor, I have pain in my tummy

Dr: Can you please tell me more about it?

Pt: It is here in the right side upper part

Dr: Since when have you been having this pain?

Pt: Since the last two weeks.

Dr: What type of pain is that? Pt: It is like a dull pain, sometimes it is just discomfort

Dr: Is it there all the time or comes and goes? Pt: It is there all the time

Dr: Does the pain go anywhere else at all? Pt: No

Dr: To the back (pancreatitis, gall stones) Pt: No

Dr: Do you have any other problem other than pain? Pt: I feel a bit tired.

Dr: Since when? Pt: Since last few weeks.

Dr: Any fever? Pt: No

Dr: Any yellowish discolouration of skin or eye (Jaundice) Pt: No

Dr: Nausea or Vomiting Pt: I feel sickly

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Dr: Diarrhoea Pt: No

Dr: Any itching? Pt: No

Dr: What is the colour of the stool? Pt: Normal brown

Dr: What is the colour of the urine? Pt: Normal

Dr: Do you keep eating outside in restaurants?

Pt. Yes .I like to eat uncooked shell fish (oyster) in restaurants. I have been doing it for
many months.

Dr: Was it in one particular restaurant or do you keep changing the restaurants ?

Pt: One particular restaurant / different restaurant.

Dr: Have you travelled outside UK recently ?

Pt: Not for the last one year.

Dr: Did you have any blood transfusion? Pt: No

Dr: Are you sexually active? Pt: Yes I am married.

Dr: Do you practice safe sex? Pt: No.

Dr: Did you have Hep A or B vaccine? Pt: No

Dr: Did you have any problem in your liver or gall bladder previously? Pt: No

Dr: Do you feel that your tummy is bloated or any ankle swelling (liver failure)? Pt: No

Dr: Did you have such problem before? Pt: No

Dr: Do you have any medical conditions at all? Pt: No

Dr: Do you have Diabetes or high blood pressure? Pt: No

Dr: Have you had any surgeries before?Pt: No

Dr: Do you use any recreational drugs or share needle with others? Pt: No

Dr: Do you drink alcohol? Pt: No

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Dr: Any chance that you are pregnant? Pt: No

Dr: Are you taking any medications? Pt: No

Dr: Any family members have such problem or liver problem in family members? Pt: No

Dr: Did you come into contact with anyone who had jaundice? Pt: No

Dr: What do you do for a living? Pt: …

Examination: Miss Campbell I need to examine your eyes for jaundice and your tummy.

[examiner may say no jaundice mild tenderness in the right upper quadrant]

Diagnosis:

Dr: Miss Campbell. We checked your blood test to see how your liver is functioning. It shows
that something is abnormal in your liver. Do you want to see the result? Pt: Yes doctor.

Dr: Bilirubin is high – Bilirubin is a break down product of red blood cells.It is normally cleared
by the Liver. If the liver is damaged or diseased then the bilirubin will not be cleared from the
blood. Bilirubin is a yellow coloured pigment - so when its level increases in the blood it gives
yellowish colour to the skin which we call jaundice. AST and ALT – these are some type of
enzymes produced by the liver when they are damaged. They are elevated and ALT is higher
than AST – means it could be due to some type of infections in the liver. ALP is normal means
you do not have problems like gall stones etc.

It could be due to what we call Hepatitis A. This is a liver infection caused by a virus
that's spread in the stool of an infected person. Sometimes, it can be due to
uncooked shellfish. This could be as a result of the food you are having in the
restaurants. Do you follow me? Pt: Yes doctor.

Dr: We need to do some more blood tests (immunoglobulins, serologies) to confirm

the viral infection.. We may also need to do a scan of your tummy and liver to exclude
any other problems.

( Examiner may give IgM level which is high )

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 IgA: raised in elderly, chronic infection, cirrhotic liver disease.

 IgM: raised primary biliary cirrhosis, acute infection, EBV, CMV, TB.

 IgG: marked polyclonal elevation is seen in HIV and Sjögren’s syndrome

less marked elevation in chronic inflammatory and infective conditions
including TB, occult abscess and protozoal infection.

Dr: This is not a serious condition because it will normally subside on its own within a
couple of months. So there is no treatment required and no hospital admission
required. You can usually look after yourself at home.

● Get plenty of rest.

● Take painkillers such as paracetamol if you have pain.
● Eat smaller, lighter meals to help reduce nausea and vomiting.
● Stay off work
● Practise good hygiene measures, such as washing your hands with soap and
water regularly

Hepatitis A can occasionally last for many months and, in rare cases, it can cause
serious conditions that make the liver to stop working properly (liver failure).

Once it subsides, you normally develop life-long immunity against the virus. However, I
still advise you not to eat uncooked oysters.

We have to inform the food standard agency about the restaurant.

Pt: Please do not inform them because the restaurant owners are my friends.

Dr: I am sorry we need to inform them otherwise even other people may get affected.

Dr: Any concerns? Pt : No

Dr: I will inform my seniors about this and you can go home and follow the advice and
we will keep following you up. Thank you.

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145.
You are a FY2 doctor in medical unit.

A middle aged man, Mr.… has been diagnosed with Atrial Fibrillation and Stroke. Your
consultant has prescribed Warfarin. But the patient has refused the treatment.

Your colleague has already discussed the risk and benefits with him but he still doesn't
want it. Assess his mental capacity.

Talk to the patient and address patient’s concerns.

Dr: Hello, I am Dr…. I am one of the junior doctors in the medical department. Are you
Mr…? Patient: Yes, doctor.

Dr: How are you doing Mr…? Patient: I am doing well doctor.

Dr: My Consultant has prescribed you some medications which you need to take. I am
here to explain to you about this medicine. If you do not understand anything at any
time, please do let me know. Is that OK? Pt: Ok.

Dr: Well, Mr.… From your notes, I have gathered that you have been diagnosed with a
condition called Atrial Fibrillation and you have suffered a stroke as well. I am really
sorry about that. Has anybody explained to you about your condition?

Patient: I am aware that I have clots in my heart and these can go to my brain. But I do
not want warfarin. That is a rat poison.

Dr: I am sorry that you are not happy with the warfarin medicine. Yes, you are right
that the rat poison also has the same composition. But you need this medicine. Is
there any reason you don’t like this medicine?

Patient: I just do not want this medicine doctor. My dad used this medicine and he fell
down and had a head injury and then he had too much bleeding in his brain and he
died because of that. I do not want the same thing to happen to me.

Dr: I am really sorry to hear about your father but you have to understand that this
medicine is vital for your health and safety.
Patient: I do not see the point of it doctor. My father was told the same thing. He was
on warfarin and look what it did to him.

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Dr: I can understand why you are so reluctant to take this medicine. And I am really sorry that
it happened to him but do you have any idea why he was on warfarin? Patient: …..

Dr: I see. Well, Mr… there are many other factors which might have lead to a massive
bleeding in his head. Sometimes it can happen if the blood is too thin. However, in
your case, it is imperative that you take this medicine. Please let me talk to you in
detail so that we can address this together. Is that Okay? Patient: Okay, doctor.
Dr: Mr… could you please tell me how much you know about your condition?

Patient: I just know that I had clots in my heart and these travelled to my brain.

Dr: Yes, you have been told right Mr…. You have a condition called Atrial Fibrillation.
Do you know what it is? Patient: No.

Dr: It’s alright. I will explain it to you. This is actually a condition which causes a fast
and irregular heartbeat. Are you following me?
Patient: Yes, doctor. Can’t you give me any medicine to control my heart rate?

Dr: Yes, Mr.… Although medicines can be used to control this abnormality in heart
rate, yet one of the most important complications of this condition is that it can cause
blood clots to form in the heart. This blood clot can then travel in the blood vessels
until it becomes stuck in a smaller blood vessel in the brain. Part of the blood supply
to the brain may then be cut off, which causes an injury to the brain. This is what we
call as stroke. This is the reason why you suffered from the stroke. Are you following
me Mr…? Patient: Yes.

Dr: Warfarin tablet is a blood thinning tablets which means that it stops blood from clotting.
It is essential for you to take this medicine because if you don’t, then blood clots might
result in obstruction to the blood supply to your brain and unfortunately, a stroke may
happen again. You know sometimes the stroke can even be life threatening. And I am
sure, you wouldn’t want that to happen to you isn’t it ?
Patient: Yes doctor. But if I take it, then if I fall then I can bleed in the brain and then I
will die like my father. So, why should I take this medicine?
Dr: I can certainly understand your concern. Unfortunately this is one of the known problems
which can happen to those people who take warfarin. The chances of bleeding becomes
high if the blood is too thin. That is why we keep checking the patient’s blood regularly to
make sure the blood is not too thin or not too thick. This blood test is what we call INR.

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Also the patients who are taking warfarin needs to be careful so that they don’t fall or
injure themselves when using any sharp instruments.

However despite keeping the blood not too thin, bleeding can still happen if someone
falls and has a head injury.
Pt: So, then it can happen to me!

Dr: Yes Mr… That is true. But the chances of you getting a stroke again which can be
even life threatening as I mentioned earlier is much higher than you falling and having
bleeding in the brain. If you do not take this warfarin, you are almost certain to get
this stroke again.
I sincerely advise you to be careful not to fall and careful not to have any injuries while
using sharp objects. Also, if you want, we can send our Occupational therapists to your
home to see if there is anything which can make you fall and they can rectify those
things. However, you need to be careful whenever you go outside not to fall.

Pt: But doctor you can’t prevent me from falling. That can happen to me any time any
day. You know falls happens accidentally.

Dr: I do understand what you are saying. However, if there is any medical cause which
makes you fall then we can sort out those issues. But you need to be careful about
accidental falls like slipping and tripping.
Mr… I am saying this to you because this medicine is very important for you and for your own
benefit I am advising you on this. What do you think now? Would you like to take it?

Pr: Yes, doctor you have convinced me about it. Thank you very much. But doctor
since I had a stroke last time my memory is not very good. What if I forget to take this
medicine?

Dr : It is good you told me about it. It is very important to take this medicine regularly
every day. If you do not take the medicine, your blood can become thick again and
cause more strokes. I advise you to make a habit to take it the same time every day so
that you do not forget. Also you can keep an alarm which can ring at the same time
every day to remind you to take this medicine. Also if you live with someone you can
tell them to remind you to take this medicine every day. Is that OK ?
Pt - Ok doctor. Thank you.

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Warning signs

Dr: Thank you Mr.. I am sure you will be fine with this medicine. However, if you fall
please call the ambulance immediately or tell someone else to call the ambulance
immediately in case if you fall. Is that Okay Mr..

Pt: Ok doctor. Thank you. You have been very kind.

Dr: Thank you very much for talking to me. I really wish all the good health for you Mr..

If the patient asks for alternative to warfarin

Yes, we do have newer type of blood thinner medications alternative to warfarin.

They are called – Apixaban (Eliquis)/ Dabigatran (Pradaxa)/ Edoxaban (Savaysa)/

Rivaroxaban (Xarelto).

Advantages of newer anticoagulants –

- No need to tests INR as frequently as if you were on warfarin (with warfarin,

INR needs to be checked every month)

- Altering the food does not cause problems (If taking warfarin should change
green leafy vegetables which contains Vit K)

- Not suitable for everyone - I will have to talk with my seniors.

Less chances of bleeding in the brain but higher chance of bleeding in the tummy.

No antidote if bleeding occurs

If the patient still not convinced

Dr: I am sorry that I wasn’t able to convince you about the importance of taking this
warfarin. I can see that you have mental capacity. You do have the right to refuse any
treatment what we advise. However, I will talk to my seniors and may be they will be
able to convince you about it. Thank you very much for talking to me. I really wish all
the good health for you Mr….

AF PATIENT - DOESN’T WANT WARFARIN

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146.
You are an FY2 in Gastroenterology ward. Alice McCoy, 55 years old female has come
to department today with complaint of bleeding per rectum 6 weeks ago.

She had undergone sigmoidoscopy two weeks ago and it showed she had a polyp.

She requires colonoscopy now.

Talk to her and address her concerns.

Dr: Hello I am Dr ------------ , one of the junior doctors in Gastroenterology, are you Alice
McCoy? Pt: Yes Doctor, call me Alice. Dr: How can I help you today?
Pt: Doctor I had a camera test two weeks ago and first they took two weeks to give me
results and now they have asked me to come back and have a camera test again. See
this note.

(Pt. hands over the letter from consultant), On the letter it is written

Your sigmoidoscopy showed that you had a polyp. Biopsy confirms it to be adenoma
(Dysplasia: Benign Lesion). You are requested to come back for a colonoscopy.

Signed: Consultant Gastroenterologist.

Dr: Alice do you know about these tests and what is in this letter?

Pt: Yes doctor I know it is a camera test but I don’t understand other things in this letter.

Dr: Yes Alice you are right this is a camera test and I know that we have made you wait
for quite some time for the results but that’s because we also tested few tissue samples
under a microscope and it is a very sensitive test and it takes time to be assessed and
report to be confirmed.

I am sorry we made you wait for your results but we have your results now and I am
here to answer if you have any questions or concerns.

Pt: Okay doctor but why do I need another camera test?

Dr: Alice, You have been invited to have a colonoscopy because we found a small
growth called a polyp in your rectum in your sigmoidoscopy test. This means there is a
chance you have polyps further up the bowel as well. A sigmoidoscopy is just for lower
part of the large bowel but colonoscopy checks further up the bowel.

Pt: But doctor it was very uncomfortable the last time.

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Dr: I am really sorry about that, Alice. We can offer you a sedative medication through your
veins before the procedure which is known to make this procedure more comfortable and we
will also apply numbing gel locally so that you don’t feel any pain or discomfort during the
procedure. Would it be right then?

Pt: Okay Doctor, but is it serious?

Dr: Right now the tests show that it is not very serious but we are never too sure until
we test the whole bowel.

In order to tell you more about this condition I need to ask few questions from you,
would you be comfortable with that?

Pt: Yes doctor, what do you want to know?

Dr: Alice what was the reason that you had first camera test?

Pt: Doctor I had bleeding from my back passage 6 weeks back and at first I thought it
was just haemorrhoids as I had it previously as well, 30 years back when my daughter
was born. But I had bleeding from the back passage again 2 weeks back and then I
went to my GP and he suggested camera test.

Dr: Alice, you did really well by going to your GP. It is a very healthy and positive attitude
and it allows us to find things at an early stage and in turn we have better options to
offer to patients.

Alice, you told me about bleeding, how was it like?

Pt: I don’t really know doctor; it’s just that I had it twice.

Dr: Do you have anything else along-with this bleeding? Pt: Like what doctor?

Dr: Any pain in your tummy? Pt: No.

Dr: Any pain at your back passage? Pt: No.

Dr: Have you noticed any change in your bowels? Pt: Not really doctor.

Dr: What are you usual bowel habits?

Pt: Dr: I have constipation for last 2 years. I take bisacodyl for it and it gets relieved.

Dr: Have you noticed if your constipation alternates with diarrhea? Pt: No.

Dr: Have you noticed any changes in your weight recently?

Pt: No doctor.

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Dr: Any mass or lump in your back passage? Pt: No.

Dr: Any mass or lump in your tummy or elsewhere in the body? Pt: No.
Dr: Do you have any medical conditions? Pt: No

Dr: Any surgeries previously? Pt: No.

Dr: Are you taking any medications including over the counter medicines?
Pt: Just bisacodyl occasionally.

Dr: Are you allergic to anything? Pt: No.

Dr: Do you smoke? Pt: No.

Dr: Do you drink alcohol? Pt: No.

Dr: Is there anyone in your family who has been diagnosed with cancer?

Pt: No, Doctor. Am I having Cancer? (Pt. acts shocked and worried at word cancer)

Dr: I really hope not Alice,,,It is one of routine questions. You know cancer is a very
dangerous condition and we just cannot take risk of missing it. That’s why we always
ask questions and investigate for it.

Pt: Okay. So, doctor what is that I am having?

Dr: Alice, It is really hard to tell for sure without colonoscopy but from our discussion it
does not look to be serious and your biopsy test result also showed that although you
had a growth but it is not a serious one. But there is a chance that it can turn into cancer
sometimes. Also there may be more polyps much higher in the colon – if it is there they
also may turn into cancer. That is why it is important to do this camera test and check
and remove them if they are present.

What do you think?

Pt: Yes doctor, I think there is no harm in doing this test.

Dr: That’s perfect; I would be making all the necessary arrangements as soon as
possible. It was really nice talking to you. It pleases us to see patients who are so
conscious and concerned about their health, it makes our work easier.

Is there anything else I can do for you?

Pt: No doctor, Thank you very much.

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Bowel polyps

Bowel polyps are small growths on the inner lining of the large intestine (colon) or rectum.

Bowel polyps are very common, affecting around 1 in 4 people at some point in their
lives. They are slightly more common in men than women and are most common in
people over the age of 60.

Some people develop just one polyp, while others may have a few.

Symptoms of bowel polyps

Bowel polyps don't usually cause any symptoms, so most people with polyps won't
know they have them. They are often picked up during screening for bowel cancer.

However, some larger polyps can cause:

" a small amount of slime (mucus) or blood in your poo (rectal bleeding)
" diarrhoea or constipation
" pain in your tummy (abdominal pain)

Bowel cancer risk

Polyps don't usually turn into cancer. But if some types of polyps (called adenomas) are not
removed, there's a chance they may eventually become cancerous. Doctors believe that
most bowel cancers develop from adenoma polyps.

However, very few polyps will turn into cancer, and it takes many years for this to happen.

Because of the risk of bowel polyps developing into cancer, your doctor will always
recommend getting polyps treated.

Treatments for bowel polyps

There are several methods for treating polyps, but the most common procedure
involves physically removing the polyp using a wire loop. This happens during a
procedure called a colonoscopy.

The colonoscopy involves passing a flexible tube called a colonoscope through your bottom
and up into your bowel. The colonoscope has a wire attached to it with an electric current
through it. This wire is used to either burn off (cauterise) or cut off (snare) the polyp. Both of
these methods are painless.
In rare cases, polyps may need to be treated by surgically removing part of the bowel. This is
usually only done when the polyp has some cell changes, if it is particularly large, or if there
are a lot of polyps.

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After the polyp or polyps have been removed, they are sent to specialists in a
laboratory, who will inform your consultant if:

" the polyp has been completely removed

" there is any risk of it regrowing
" there is any cancerous change in the polyp
" If there is a cancerous change in the polyp, you may need further treatment
(depending on the degree and extent of change). Your specialist will be able to
advise you on this.

Causes of bowel polyps

Doctors don't know the exact cause of bowel polyps. It is thought that they are caused
by the body producing too many cells in the lining of the bowel. These extra cells then
form into a bump, which is the polyp.

You may be more likely to develop bowel polyps if:

" a member of your family has had bowel polyps or bowel cancer
" you have a condition that affects your gut, such as colitis or Crohn's disease
" you are overweight or smoke
Diagnosing bowel polyps

Bowel polyps are usually found when your bowel is being looked at for another reason
or during screening for bowel cancer.

If polyps are found, a colonoscopy or CT colonography is needed to view the whole of

the large bowel and remove them at the same time.

Monitoring bowel polyps

Some people with a certain type of polyp may be at risk of it coming back in the future (recurring).

This is uncommon, but means you'll need examining (by colonoscopy) at regular intervals of around
three to five years. This is to catch any further polyps that may develop and potentially turn into bowel
cancer.

Adenomatous polyps (adenomas) of the colon and rectum are benign (noncancerous) growths, but
may be precursor lesions to colorectal cancer. Polyps greater than one centimeter in diameter are
associated with a greater risk of cancer. If polyps are not removed, they continue to grow and can
become cancerous.

Polyps don't always become cancerous, but your risk of developing cancer increases with the number
and size of colon polyps you have. Approximately one percent of polyps with a diameter less than a
centimeter are cancerous

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Current theories propose it will take about 10 years for a small adenoma to transform into a cancer

Research suggests that making the following changes may have health benefits and may lower
your chances of developing colon polyps:

Eating more fruits, vegetables, and other foods with fiber , such as beans and bran cereal.

Losing weight if you're overweight and not gaining weight if you're already at a healthy weight.

If a polyp is removed completely, it is unusual for it to return in the same place. The same factors
that caused it to grow in the first place, however, could cause polyp growth at another location in the
colon or rectum.
COLORECTAL POLYP COLONOSCOPY

147. ELDERLY MAN WITH DIARRHOEA NEEDS

COLONOSCOPY
Elderly man needs colonoscopy. He presents with abdominal cramps in the lower
abdominal region that have been going on for several years.

Ask about stress (causing IBS) - Pain relieved on defecation

Ask about weight loss, family history, smoking

In this station, the positive history was alteration in bowel habits and he’s 65. It is either
IBS or bowel cancer. So, colonoscopy is required to rule out bowel cancer. [convince
for colonoscopy]

Tell patient we need to make sure there is no cancer.

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148.
Mr George Harrison was admitted to the hospital 2 days ago with shortness of
breath. He was diagnosed with Asthma and was treated.

Assess whether he is fit to be discharged and explain to him about the

medication he has to take at home.

(You will also have to do PEFR and tell him how to plot the reading on the chart –
however this part may not be mentioned in the question).

There will be 2 inhalers, a PEFR instrument, a box of tablets, two graphs, and a tethoscope.

Greet the examiner.

The history doesn’t need to be extensive. Ask if he still has the symptoms he came in
with: SOB, chest pain/tightness, wheeze, cough.

Ask of other medical conditions, medications and allergies.

Check pulse, BP, oxygen saturation and respiratory rate.

Do an examination. Mention privacy and chaperone. The examiner will probably ask
you to move on and tell you everything is normal.

Explain the instrument to the patient. “The PEFR helps us to know how well the lungs
are working.”

Steps to take during this station:

1. GRIPS
2. Assess: brief history, examination, quantitative assessment (PEFR & plot on graph)

3. PEFR instrument and Asthma diary

4. Explain medications - salbutamol, beclomethasone & prednisolone

5. Safety netting

Dr: Hello Mr George Harrison, I am Dr ...... How are you doing today. Pt: I am OK.

Dr: We are thinking of discharging you today if you are fine. I am here to check if you
are fit enough to go back home. Is that OK?

Pt: Yes, Doctor.

Dr: How is your shortness of breath now? Pt : It is much better, doctor.

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Dr: Any chest pain? No

Dr: I need to examine your chest. (examiner says – chest is clear).

Dr: I need you to do a test called PEFR to see how well your lungs are functioning now.
Have you done this test before? Pt: No, doctor.

Dr Let me explain this to you.

Explain PEFR

This is a device called PEFR meter which has 2 parts – one cylindrical part with
readings in litres/min which has a pointer which moves along the reader to show the
reading and the other one mouthpiece.

You need to stand or sit straight but not lying down to do the test (to allow maximum
lung expansion).

Attach the mouth piece to the device, hold it in both hands horizontally without blocking
the pointer in the reader, take a few breaths in and out, take a deep breath in, keep the
mouthpiece in your mouth, make tight seal of your lips around the mouth piece and blow
though that as hard and as fast as possible at one go and check the reading and note it
down. Repeat the test 3 times and record the highest of the 3 readings on a chart which
will give you later.

Demonstrate the test and ask him to do the test and correct him if he makes mistakes.

Check the readings, ask his normal readings. If he does not know his normal reading,
then ask his/her height and age and determine what should have been normal using the
chart for them and tell the patient this should have been your normal readings but this is
your reading now.

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(His PEFR readings may be almost equal to predicted normal readings. The PEFR
should be at least 75% of his normal to discharge him).

Dr: Mr Harrison, you are doing fine now. The test shows that your lungs are functioning
well now. Congratulations - you are fit to go home now. But you need to do this test at
home and record it in the chart which I will explain later.

In this chart – please write the dates – at the bottom, and mark it properly for each
morning or evening line corresponding to the readings. Check patient’s understanding
by giving him the example reading, asking him to show where will you mark it.

The patient should record treatments taken and any triggers, if any.

“If the readings are going up, it means you are improving, please bring the chart with
you in your next visit which will be after 2 weeks.”

“If the readings are not going up – you are not improving. Please see your GP or come
back to him/her if you do not see improvement in the next 3 to 4 days.”

“If the readings are going down, that means you are getting worse. If you are severely
short of breath and if the medicines do not help, please call the ambulance and come to
the hospital A&E department.”

“You should also take the medications at home.”

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Check
a) The prescription chart for patient’s identity and for all the medications,

b) Medicines for expiry date and strength of tablets:

- Salbutamol inhaler 2 puffs PRN Beclometasone BD (400 micrograms)

- Tab Prednisolone 30mg PO OD for 3 days.

Explain medications

Dr: This is called a Salbutamol inhaler which widens your airways. This is blue coloured.
They are called relievers because they relieve Asthma symptoms, and they cause the
windpipe to open. To be used twenty minutes before exercise and when needed. Should
be taken everywhere.

Also talk about side-effects.

You need to take 2 puffs of spray into your mouth whenever you have shortness of
breath. Maximum 4 times in a day i.e 8 times.

Newly opened inhalers should be shaken and press the canister into the air to activate it.

Dr: Do you know how to use this inhaler? Pt: No doctor.

Dr: Let me explain the inhaler technique

Remove the cap and shake well

Take few breaths in and out. Then take a deep breath out

Put the mouthpiece in your mouth and make a tight seal of your lips around the mouth
piece and take a deep breath in. As you begin to breath in - press this canister down
once for one puff and continue to inhale deeply. Then take it out of your mouth.

Hold your breath for 10 seconds and then breathe out.

For the second dose (Puff), wait for approximately 30 seconds before repeating the
whole procedure again.

Can you please show me how you are going to use it? [make him repeat – correct if
he does any mistakes]

Dr: Make sure that you keep your salbutamol inhaler with you all the time in case you
need to use it.

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Like any other medications, this can also give some side effects but they are not serious.
You may feel your hands shaking, you may get palpitations and headache but they all will go
away after some time on their own. Are you following me? Pt: Yes.

Dr: The next medicine is Beclomethasone inhaler. This is for maintaining. It is a steroid
inhaler which is brown in colour, and this prevents asthma attack. You should take it
regularly 2 puffs in the morning and 2 puffs in the evening for two weeks. (if the
strength of each puff is 200micrograms). The way to use it is the same as the
Salbutamol inhaler. You should wash your mouth after using this inhaler otherwise it will
cause fungal infection in the mouth.

Are you following me? Pt: Yes

Dr: The next one is Prednisolone tablets (eg 30 mg once day PO for 3 days in the
morning) (If one tab is 5 mg - take 6 tablets)

You should take 6 tablets once a day for 3 days by mouth in the morning after food. This
also helps to prevent Asthma.

This may cause pain in the tummy especially if you take it on an empty stomach.

Usually, there are no other serious side effects since you are taking these for a short period.

Dr: Are you with me? Pt: Yes doctor

Talk to the patient about using paracetamol. Also tell patient to come back immediately if
he has any of the symptoms he initially presented with.

ASTHMA DISCHARGE MEDICATION AND PEFR

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149. You are an FY2 in the cardiology ward.

60 year old Mr was admitted with chest pain a few days ago and was treated for
Acute Myocardial Infarction. He is now stable, on medical therapy and is fit to be
discharged. Your consultant has commenced him on medical therapy. Talk to the
patient, assess him clinically, and speak to him about lifestyle modifications.

Dr: Good morning, Mr... I am Dr One of the junior doctors in the cardiology dept. How
are you doing today? Pt: I am well doctor. I am going home today.

Dr: Congratulations. My consultant has prescribed some medications. Do you have any
questions about them? Pt: No doctor, I know about the medicines.

Dr: Well that is fine. Could you please tell me how much you know about your condition?

Pt: I was told there is some problem in my heart.

Dr: Yes, that is right. You had a heart attack. Do you know anything about it?

Pt: No doctor, not really.

Dr: Okay, let me explain it to you.

The heart needs its own blood supply for it to survive. Blood supply is provided by some
blood vessels specially for the heart muscles. Heart attacks are caused by the blood
supply to the heart being suddenly interrupted.This can happen due to narrowing or
obstruction which results in reduced blood supply to the heart leading to damage of the
heart muscle. Do you follow me? Pt: Yes, doctor.

Dr: We have given you an appropriate treatment to restore the blood supply to the
heart. Though, you are doing well, sometimes this condition can be really serious and
even life threatening. And we want what is best for you and we do not want this to
happen to you again. Are you following me? Pt: Yes, doctor.

Dr: Do you know why people get this condition? Pt: No doctor.

Dr: Well, Mr... there are certain risk factors which can lead to heart attacks. Some of them
are not modifiable while most of them are. And if we are able to control the modifiable risk
factors, we can maximally reduce the risk of getting heart attack. Do you understand?

Pt: Yes doctor. What are these risk factors?

Dr: There are a lot of other risk factors for heart attack. I would like to ask you a few questions
to know if you have any of these risk factors so that we can address them and help you cope
with this condition. We may be able to reduce the risk if we can modify those factors. Pt: I see.

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Dr: Do you have any heart problems in the past? Pt : (No/Yes?)

Dr: Did you have any strokes or mini-strokes previously ? Pt: (No/Yes?)

Dr: Do you have diabetes? Pt: (No/Yes?)

Dr: Do you have high levels of cholesterol in your blood? Pt: (No/Yes?)

Dr: Cholesterol is involved in the formation of a blood clot that can lead to blockade of
artery supplying the heart. Are you following? Pt: Yes doctor.

Dr: Do you have high blood pressure? Pt: (No/Yes?)

Dr: High blood pressure is one of the major risk factors which can cause lead to
weakening of the heart muscle. It is very important to keep the blood pressure under
control. However, as I have told you apart from medications you may need to do a lot of
other things to keep the blood pressure under control. Pt: What is that doctor?

Dr: One important factor is diet. Can I ask you what type of food you usually eat?

Pt: You know doctor. I don’t know how to cook food. So, I eat out most of the time. I
have to eat fast food - I eat chips, burgers, steaks, etc

Dr: Mr, the kind of food that you are eating is not good because they have very high bad
fat content that is cholesterol. This can increase the blood pressure and contribute to a
heart attack. I sincerely advise you to eat more of white meat which has less bad fat like
chicken and fish. I also advise you to include plenty of fruits and vegetables in your diet.
Also please reduce the salt content in your food because it can increase the blood
pressure. I will refer you to a dietician who will advise you in detail about the healthy
diet. Is that OK ? Pt: That is fine. Doctor.

Dr: That is good. Do you exercise ?

Pt: No doctor. I am an old man. I don't do much exercise.

Dr: I can understand. However, I sincerely advise you to do some exercise. However, at
least for the first one month do minimal exercise like walking inside the house but later,
you can do some exercise like brisk walking for about 30 min every day at least 5 days
a week. Exercising regularly will keep you healthy and also helps to keep the blood
pressure and cholesterol under control. What do you say? Pt: Yes doctor that seems
to be a good idea.

Dr: Excellent. Do you smoke Mr...?

Pt: Yes doctor - I smoke about 10 to 15 cigarettes a day for the last 15 to 20 years doctor.

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Dr: Again smoking is not good for health at all as you may know. Smoking also can
increase the blood pressure and also can cause lots of other health problems. I strongly
advise you to stop smoking. We can help you to stop smoking if you wish. Do like to
consider that Mr...?

Pt: Doctor, you know my life is very lonely. I am going through a lot of financial crisis and
I get stressed some times.

Dr: I can surely understand your problem. However, there are many other ways to
relieve stress. Maybe you can take some relaxation classes and yoga classes which
might help you to relieve stress. Remember stress also can increase the blood
pressure. What do you say?

Pt: Yes doctor you are right. I will try my best to do that.

Dr: Do you drink alcohol Mr ... ?

Pt: Yes doctor. I drink about 2 glasses of wine every day and also whisky sometimes
over the weekends.

Dr: Mr .... alcohol also is not good for the health. I sincerely advise you to cut down
drinking alcohol and drink within the recommended limits that is not more than 14 units
per week. We can help you to cut down if you wish. What do you think ?

PT: Yes doctor I will surely think of that.

Dr: Do you work?

Pt: No (Following a heart attack, most people can go back to work within 2-3 months)

Dr: Could you tell me if you drive? Pt: Yes doctor.

Dr: You should not drive for at least four weeks after a heart attack. Could someone
help you with that? Pt: (Yes doctor, my wife can drive?)
Dr: That is good. It is always sensible to contact the Driver and Vehicle Licensing Agency
(DVLA) to be sure. Also I would like to tell you something about air flight travels. You can
usually fly as a passenger within two to three weeks of a heart attack, as long as you have no
complications. This means that you have returned to your usual daily activities, your condition
is stable and you don't have any symptoms, or your symptoms are controlled. Are you
following me? Pt: Yes.

POST MI CABG, Angioplasty - 1 month no driving

Post MI Angiogram - 1 week no driving

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Dr: Regarding your sex life, I would like to recommend you that for a 3 to 4 weeks it is
probably best avoided. If you are able to walk without discomfort, then a return to sexual
relationships should not cause any problems. If sex causes angina chest pains, then tell
your doctor. Pt: Yes.

Dr: You should have an annual influenza jab and be immunised against the
pneumococcal germ (bacterium). Okay? Pt: Yes.

Dr: Excellent. Do you have any questions?

Pt: Doctor if I follow all the advice you gave, then will I not get heart attack again?

Dr: As I have told you that there are both modifiable and non- modifiable risk factors for
developing heart attack. Non-modifiable factors are like age above 60 years, genetic cause
means inherited risk which we can’t do anything about these. However there are lot other
modifiable risk factors like all the factors what we discussed so far like diet, exercise, smoking
which you can modify and have a healthy lifestyle. This can substantially reduce the risk of
you getting heart attack.

Pt: Ok thank you very much doctor.

Dr: Try to follow the recommendation. We will keep following you up. If at any time you
develop chest pain or breathlessness, immediately call 999. If you have any of the
symptoms, please call an ambulance and come to the hospital immediately because
these are the symptoms of a serious condition. Is that okay Mr... ? Pt : Ok doctor.

Dr: Any other questions ? Pt : No doctor. You have been very kind.

POST-MI DISCHARGE & LIFESTYLE

MODIFICATIONS

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150. You are the FY 2 doctor in the medical department. Mrs Joan Thomas has
been planned for angioplasty. She is a chronic smoker.

Talk to patient and advise her to quit smoking.

1. GRIPS

2. Ask if she has any questions or concerns about the procedure

3. Assess knowledge about condition and if she knows the pathophysiology and explain

4. Find out her risk factors (medical conditions and lifestyle)

Dr: Hello Mrs Joan Thomas, I am Dr .... one of the junior doctors in the medical
department. How are you doing? Pt: I am OK.

Dr: I am here to talk to you about your condition.

Pt: If you have come here to tell me not to smoke, please don’t talk to me.

Dr: It seems that you have been annoyed by others, don’t worry I am not going to annoy you.
I am here to talk to about your health condition and to advise you how you can prevent that
problem in the future. Is that OK? Pt: OK

Dr: Do you know why you are scheduled for an angioplasty?

Dr: Mrs Thomas, Can you please tell me how much do you know about your condition.

Pt: I was told there is some problem in my heart.

Dr: That is right. You had something like a minor heart attack. Let me explain that to you.
The heart needs its own blood supply for it to survive. Blood supply is provided by some
blood vessels specially for the heart muscles. These blood vessels have become narrowed
in your case which has caused reduced blood supply to your heart muscle.That is why you
had this pain in your chest. We are doing a procedure called angioplasty where we are
widening the blood vessels in our heart to restore the blood supply to the heart muscles.
Do you follow me? Pt: Yes

Dr: Do you know why these blood vessels would have become narrowed? Pt: No

Dr: There are several reasons why these blood vessels can become narrow.
Sometimes, this happens with those people who do not eat healthy balanced diet or
who do not exercise or who have some medical conditions like high blood pressure or
diabetes.
Dr: Can I ask you how's your diet? Pt: I eat a healthy diet, doctor.

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Dr: That is very good to know. Please continue eating healthy food. Do you exercise?
Pt: Yes doctor.

Dr: That is also very good. Please do continue doing exercise. (If she says no, tell her, “I
advise you to do some good exercise. That will be very good for your heart and your health).

Pt: OK

Dr: Do you have any medical conditions like high blood pressure, high cholesterol or
diabetes? Pt: No

Dr: That is excellent. That means it is none of these problems which are causing the
problem in your heart. One other reason why people get this problem in the heart is
smoking for long time.

Find out of family history of a similar condition

Dr: Can I ask you if you smoke, Mrs Thomas? Pt: Yes

Dr: Can I ask you what do you smoke and how much do you smoke? Pt: 20 cigarettes a day.

Dr: For how long? Pt: For about 20 years now.

Dr: Well, Mrs. Thomas, there is a very high chance that this smoking habit has caused
the problem in your heart. Cigarette contains harmful substances like - Tar: A substance
that causes cancer, Nicotine: it is addictive and increases bad fat cholesterol levels in
your body and Carbon monoxide: which reduces oxygen in the body. I sincerely advise
you to stop smoking so that you do not get this problem again.

Pt: Why do you say it is smoking caused this? My dad was smoking the bu of his life he
had no health problems at all (there are so many people who smoke they do not have
any health problem).

Dr: I am really glad to know that your dad had no health problem at all despite smoking
for many years. However, Mrs Thomas there is evidence that people who smoke for a
long time do get a lot of health problems like stroke, cancer, high blood pressure and
including heart attack. In some people, skin becomes more wrinkled. Also, people who
stay smokers experience passive smoking which can happen to your children if you
have any at home. You may be spending a lot of money on smoking I guess.
Additionally, you can get a major heart attack next time and it may be even life
threatening. I am sure you don‘t want that to happen to you, do you?

Pt: You said you are going to widen the blood vessels in my heart. So why should I get
this problem again?

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Dr: Mrs Thomas we are treating this condition now, but if you continue smoking, then
blood vessels in your heart will become narrow again and it can cause a serious
problem next time.

There are many benefits of stopping smoking:

Carbon monoxide and nicotine will be eliminated from the body, blood circulation will
improve, lungs start clearing out smoking debris, skin becomes less wrinkled, coughing
and wheezing stop.

Excess risk of heart attack and lung cancer reduces by half. Also you could save a lot of
money which you spend on buying cigarettes and you can use that money for
something else.

Pt: But doctor I enjoy smoking. I can’t stop it.

Dr: Many people say that they enjoy it but that enjoyment comes at the expense of your
health. If you want to enjoy your life, you need to remain healthy. You can try doing
some other things to enjoy life which will be good for your health–maybe going for some
exercise classes, relaxation therapy or yoga classes where you meet a lot of people
and you may enjoy that.

If you wish, we can help you in stopping smoking. We have something called a smoking
cessation clinic. I can refer you to them. There are support groups. You may benefit
from that.

We also have some medicines called Bupropion and Varenicline which can help in
stopping the craving for cigarettes, but at the end of the day it is your willpower that is
the most important thing. What do you say Mrs Thomas? Do you want to consider this?

Pt: I will think over it.

Dr: That is really good. Please do let us know and we will do everything possible from
our side to help you.

(If she says no, “I can’t stop smoking”, say “I can understand that it is not easy to give
up old habits. However, you may need more time to think over that. I advise you to think
about it seriously and let us know anytime you need our help, we are always here to
help you.”

Thank you very much.

[do not mention - I will tell my seniors – they will come to talk to you]

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BENEFITS FROM SMOKING CESSATION WITH TIME SINCE QUITTING

Time since quitting

BENEFITS

20 minutes - Pulse returns to normal.

8hours - Nicotine level is reduced by 90%, carbon monoxide levels in the blood reduce
by 75%, and oxygen levels return to normal, circulation improves.

24hours - Carbon monoxide and nicotine are eliminated from the body. Lungs start to
clear out smoking debris.

48hours - All traces of nicotine are removed from the body. Sense of taste and smell
improves.

72hours - Breathing is easier. Bronchial tubes begin to relax and energy. 2–

12weeks - Circulation improves.

1month - Physical appearance improves owing to improved skin perfusion. Skin loses
its grey pallor and becomes less wrinkled.

3–9months - Coughing and wheezing declines.

1year - Excess risk of heart attack reduces by half.

10years - Risk of lung cancer falls to about half that of a continuing

15years - Risk of MI falls to the same level as someone who has never smoked.

Sample concerns and responses

Pt: “All the damage is already done.''

Dr: “There are immediate benefits from the day you quit”.

Pt: “I am already 70, I want to enjoy the rest of my life.”

Dr: “You are only 70, you have many more years to live happily. You can enjoy your life.”

Pt: “A lot of doctors smoke”.

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Dr: “That doesn’t make it healthy or less harmful. Very few doctors smoke and many more
have given up”.

Dr: “I’ve switched to a low tar cigarette”.

Pt: “The health claims about low tar cigarettes are very misleading. People tend to
inhale more deeply and more often. Low tar cigarettes does not reduce the risk of heart
disease in smokers.

Pt: “I smoked in my last pregnancy and my baby was a normal weight”.

Dr: “Each pregnancy is different. It’s like gambling with your baby’s health.

Problem–Stress

Many patients use tobacco to cope with stress.

Recommend simple relaxation exercises, e.g. “Take a slow, deep breath and, as you
breathe out, say to yourself ''relax”.

Problem: Weight Gain [Smoking appears to lower the efficiency of caloric storage and/
or to increase metabolic rate. After cessation, average weight gain is only 2.3kg.]

Stress that the health benefits of quitting smoking far exceed the risks of the average
weight gain.

There are better ways to reduce weight rather than smoking cigarettes.

First, the patient should quit tobacco while allowing the weight to accumulate; Second,
when the habit is gone for good, he/she should focus on losing weight.

Smoking cessation clinics help tackle the psychological, social and medical problems

“That’s a heavy price to pay” - if she says that she enjoys smoking.

SMOKING CESSATION

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151. Mr Pat Brown 50 year old man was admitted to the hospital 4 weeks ago for
cellulitis and was noted to have high blood pressure and treated for HTN
with medications. He was discharged 2 weeks ago and he has come back
for follow up of his blood pressure.

He also has diet controlled diabetes. Measure his Blood pressure and Address
his concerns.

Dr: Hello Mr Pat Brown I am Dr … How are you?

Dr: I understand you had high blood pressure last time when you were in the hospital ?
Can I please check your blood pressure now ?

(examiner says – his blood pressure now is 165/95).

Dr: Mr Brown your blood pressure is still quite high ? Are you taking your blood pressure
medications?

Pt: I stopped taking them a few days ago. Dr: Why ?

Pt: They are giving me too much cough. I can’t sleep and my wife also can’t sleep
because I keep coughing too much

Dr: I am very sorry to hear that. Can you please tell me which medications are you
taking? Pt: I am taking these doctor (he will show Aspirin, Enalapril and Simvastatin)

Dr: Do you have any other problem other than cough? Pt: No

Dr: Any fever? (Pneumonia) Pt: No

Dr: Any sweats in the night time ? (TB) Pt: No

Dr: Have you noticed any change in your weight? (TB) Pt: No

Dr: Have been diagnosed with Asthma before? Pt: No

Dr: Do you have any other medical condition? Pt: Yes, I have diabetes.

Dr: Do you take any medication for that? Pt: No

Dr: Are you allergic anything including to any medications? Pt: No

Dr: Ok, let me check the book and let you know. Check the BNF

It is the Enalapril medication is giving you cough. One of the side effects of this
medication is cough.

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Mr Parker, it is very important to take this medication to control your blood pressure. Do
you think you can continue taking this medication?

Dr: No, doctor I don’t want this medication. It is causing me too much problems.
Dr: OK don’t worry. We have some other medication to treat hypertension and it is
called Losartan (Angiotensin receptor blocker – ARB). That will help to control your
high blood pressure as well as it is good for the kidneys also.

Dr: Ok then this should be good for you. Pt: How do I take it ?

Dr: It can be taken by mouth with or without food. Dose will be 50mg once a day but
then we will adjust the dose according to your blood pressure.

Pt: Will there be any side effects for that?

Dr: This medication doesn’t usually cause cough but rarely, it might happen in a few
people. Very rarely it can cause allergic reaction – in that case you should stop it. It can
also cause body pain – please tell your GP if that happens.

Dr: It is very important to take medications regularly. You should not stop taking
medications on your own without talking to your doctor. If you do not take medications
regularly your blood pressure can shoot up and it can cause other serious problems.

Dr: Any other concerns Pt: No

Dr: Mr Parker – Do you want to know about your other medications ? Pt: No, doctor

If he says he wants to know, then talk about them -

ASPIRIN:- This is a blood thinner tablet. It reduces the risk of clots forming in your
blood. This reduces your risk of having a stroke or heart attack. Dose as mentioned in
the prescription. (75 mg one tablet, Once a day, by mouth, after food)

Side Effects - Can cause tummy irritation, slight bleeding in the stomach and you may
notice dark stool. If it happens, please inform your GP.

SIMVASTATIN: 20 mg nocte. This lowers the cholesterol (bad fat). Take one dose of
simvastatin each day, in the evening.

You can take simvastatin before or after food.

Side Effects – Can cause Muscle cramps - can be a serious problem sometimes
(inform your GP). Can also cause hair loss, headache, dizziness. These medications
are taken lifelong].

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Dr: Mr Parker it is very important that you should keep your blood pressure under
control. Otherwise, it can cause serious health problems like heart problems and even
stroke.

Dr: Do you exercise? Pt : No

Dr: You should go for regular exercise – jogging or at least a brisk walk for 30 minutes at
least every day for about 5 days a week. This helps to keep the blood pressure under
control.

Dr: How is your diet? Pt: I eat fast food/healthy food .

Dr: You should eat less of foods which contains high fat like red meat. Instead, you can eat
chicken and fish. You should also eat more of fruits and vegetables.Pt: Ok

Dr: Since you have diabetes, it is important to keep the sugar under control otherwise
high blood pressure and diabetes combined together can cause serious health
problems.

Dr: Do you smoke? Pt: No Dr: Good

Dr: Do you drink alcohol? Pt: Not much Dr: Good.

Dr: Any other concerns? Pt: No

Dr: Thank you very much. We will keep following you up. If you need any help at any
time, please do come back.

HYPERTENSIVE PATIENT ON ACE INHIBITORS

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152. You are the FY 2 doctor in the medical department.

Mr Sandeep Singh, a 28 year man was diagnosed with epilepsy a few weeks ago.
He has come for follow up.

Take history and address his concerns.

There may be a medication box with Sodium Valproate 300 mg BD written on it AND a BNF

Ask about headaches, fever, vomiting, weight change, circumstances, compliance, side
effects (jaundice, tremors), psychosocial effects of the seizure episodes, driving.

Dr: Hello Mr Sandeep Singh, I a Dr… one of the junior doctors in the medical
department. How are you doing? Pt: I am OK, doctor.

Dr: I understand you were diagnosed to have epilepsy. I am sorry about it. How is your
condition now? Pt: Doctor I had fits again after that.

Dr: I am sorry to hear about it. When exactly was that ?

Pt: Once a few days ago and once about a week ago when I was in a party. Why did
that happen, doctor?

Dr: There could be many reasons why people still have fits even after treatment. Can I ask
you a few questions to see why this would have happened to you? Pt: Yes, doctor.

Dr: Have you been given medications for that? Pt: Yes, Can I ask you which medications?

Pt: I take this doctor. (Patient may show Sodium Valproate tablets).

Dr: It is written 300 mg twice a day here. Are you taking the same dose? Pt: Yes.
Dr: Let me check the book whether the dose is right for you. (check the BNF for dose
and side effects). Mr Singh – the dose seems to be right for you. Are you taking these
medications regularly ? Pt: Yes I am.

Dr: Are you taking it as prescribed by us? Pt:Yes

Dr: Please tell me when you take it? Pt: Whenever I have a fit, I take it doctor.

Dr: Does it mean that you do not take every day. Pt: Yes that is right?

Dr: Can I ask you why you are not taking it daily? Pt: I forget to take it.

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Dr: Mr Singh, It is very important to take these medications regularly every day even
when you do not have fits. There should be certain amount of medications in your blood
all the time to prevent you from getting fits. I advise you to keep an alarm to remind you
to take this medication regularly. Is that OK? Pt: OK, doctor I will do that.

[sometimes patient may say – I was told to take the medications only when I have
fits – I am sorry if that is what you were told. There could be some
misunderstanding].

Sometimes this problem can happen if the medications are not absorbed into the
system if people have vomiting or diarrhoea. Do you have vomiting or diarrhoea ?

Pt: No doctor.

Dr: Do you have any other medical conditions at all? Pt: No

Dr: Are taking any other medications? Pt: No

Dr: Sometimes people can get fits if the dose is not enough or the medications do not
work for them. In that case we need to change the medications. We will see that again after
sometime if you still get fits after taking the medications regularly. Pt: Ok, doctor

Dr: There are reasons also why people can fits like if they are exposed to some triggering
factors like exposure to too much light in cinema, watching TV for a long time?

Dr: Do you go to the cinema or watch TV for a long time? Pt: Yes doctor.

Dr: I advise you to avoid them

Dr: Do you work on the computers for a long time?

Pt: I am a student doctor. I have to work nearly 5 to 6 hours every day on the computer.

Dr: Again I advise you to avoid looking at the computer continuously for a long time. It is
better to take print outs and use them.

Dr: Do you go to pubs where there are flashing lights? Pt: Yes doctor

Dr: I advise you to avoid that because flashing lights can trigger fits.

Also sometimes lack of sleep or starving for long time also trigger fits. I advise you to
sleep well and have food at regular intervals - do not starve for long time.

Dr: Do you drink alcohol? Pt:Yes

Dr: Alcohol also can trigger fits, please avoid drinking alcohol. Pt: Ok

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Dr: You need to be careful when you have fits. Avoid going near the fire. Who cooks
food for you? Pt: I live with few other friends. I cook food.

Dr: Maybe your friends can cook food for you, and you can do some other work for them.

Also avoid using gas cookers. Electric cookers are better. When transferring food to a
plate, please take the plate to the pan and not hot pan to the plate.

You should be careful when taking shower. Do not take a bath in the bath tub - instead
take a shower. Pt: OK

Dr: Do you swim? Pt: Yes.

Dr: If you are swimming in the swimming pool or sea or river, please tell the lifeguards
that you have this condition. Swimming in the river or sea is more risky than swimming
in the pool. Pt: OK

Dr: Do you drive?

Pt: I am about to take a practical driving test next week.

Dr: I am afraid you should not drive maybe for about a year now. Please inform the
DVLA about it and they will advise you when you can start driving. Please inform your
friends at your college if he is a student (or colleagues at your work place if he is
working) that you have this condition and let them know how to help you. Please wear
your bracelet all the time. Any other concerns?

Pt: No, doctor.

Dr: Thank you very much. Hope you will not have a fit again.

Arrange for follow-up for 2 - 4 weeks. Monitor weight because dose may need to be
changed of the dose changes.

If the patient is a young lady – ask about contraception

[Sodium valproate does not affect combined pills - so she can continue. Carbamazepine
reduces the effects of combined pill so they should increase the dose i.e double the
dose of oestrogen in the combined pill and also use other forms of contraception.]

EPILEPSY

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153. You are the FY2 doctor in the A & E department.

Mrs Andrea Jones, a 23 year nurse in your hospital came to the A & E department
because she had a needle stick injury while she was drawing blood from a
patient.

Talk to her and address her concerns.

Dr: Hello Mrs Andrea Jones. I am Dr …. How are you doing ?

Nurse: I am not feeling good, doctor. I pricked myself with the needle when I was taking
blood from a patient.

Dr: I am very sorry to hear that. Can you tell me more about it?

Nurse: I was just taking blood from a patient. After that, I accidentally pricked myself
with the needle. I happened just half an hour ago.

Dr: Did you prick yourself after you used on the patient or was it a new needle ( not
used on anyone)

Nurse: It is the same needle I used on the patient and then I pricked myself Dr: Was it a
hollow-bore needle? Nurse: Yes

Dr: Which part of your body did you prick yourself? Nurse: My finger Dr: What did
you do after that?

Nurse: I washed it with soap and water. My senior staff told me to come here.

Dr: Good that you washed it soap and water. You are not supposed to use any
antiseptics to wash and also you are not supposed to put the area in the mouth. Was
the wound deep or superficial?

Nurse: Just superficial / it is deep.

Dr: Were you wearing gloves at that time? Nurse:Yes

Dr: When was your last hep B vaccine and tetanus vaccine?

Nurse: I had both about 2 years ago.

Dr: Do you have any medical condition? Nurse: No

Dr: Have tested for HIV or Hepatitis recently? Nurse: No

Dr: Are you taking any medications? Nurse: No

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Dr: Are you allergic to anything at all ? Any chance you are pregnant?

Dr: Do you practice safe sex? Nurse: I am married, so don’t practice safe sex /
sometimes she may say I have a partner and practice safe sex.

Dr: Did you have any such incidents previously? Nurse: No

Dr: Do you use any drugs and share needles with others ? Nurse : No
Dr: Do you know what is wrong with the patient?

Nurse: He has Meningitis? Dr: OK. Is he conscious? Nurse:Yes/No

Dr: Do you know whether he has any infections other than meningitis like Hepatitis or
HIV ? Nurse: I don’t know.

Dr: Did you tell him about this incident? Nurse:No

Dr: Mrs Jones, I am once again very sorry this happened to you. Do you have any
concerns about this incident ?

Nurse: Yes doctor I am worried. Will I get HIV or Hepatitis or any other infections ?

Dr: I can certainly imagine your worries. However Mrs Jones, Regarding HIV - the
chances of people getting HIV infections through the needle stick injury is very low
compared to other routes like sexual route or drug addicts sharing needle. The risk of
getting HIV from a needle stick injury is 0.3%. That means only 3 people out of 1000
people who had needle stick injury will get this infection.

- We will inform the Occupational health department, and they will inform the
patient about it and take his consent to do blood test on him for any infections
like HIV, hepatitis or others.

- We will need to take your blood also to do tests.

- We have post exposure prophylaxis against HIV. You need to take this as soon
as possible that is within one hour. The latest you can take this is 72 hours. The
medication is called Zidovudine. The treatment duration is 28 days.

- Side effects include: nausea, vomiting, diarrhoea, myalgia, headaches and

fatigue. It is important to continue treatment even if you have all these side
effects.

- You should practice safe sex and do not donate blood during this period.

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- You will be followed up by the Occupational health department, and you may be
retested at 6 weeks, 3 month, 6 months and 9 months.

Dr: Are you following me? Nurse: yes Dr: Any questions about HIV? Nurse:No
Dr: Regarding Hep B – since you are already immunised against Hep B, the chances of
getting Hep B infection is almost negligible. The risk is 30% in those who are not
immunised. However, we need to do blood tests and check the antibody level for Hep B.
If you do not have enough antibody, then we may give you immunoglobulin and booster
dose of the Hep B vaccine. Hep B booster dose can be given within one week of the
incident.

Dr: Any questions about Hep B? Nurse: No

Dr: Unfortunately there is no pre or post exposure prophylaxis for Hep C. The risk is
1.8% so very low chance again.

Dr: Since the patient is having meningitis – we will give you prophylaxis for meningitis
also.

Dr: Occupational health department will follow you up. They will check for side effects
and do blood tests: FBC, Us and Es, LFTs, HIV, Hep B and Hep C at 3 months and 6
months.

Occupational Health can also provide you counselling and support if required. Any other
concerns?

Nurse: No Thank you very much.

Occupational health will tell her when she can go back to work.

NEEDLE STICK INJURY IN A NURSE

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154. Isabelle 36 years old female has come to clinic. She is on combined oral
contraceptive pills for last 6 years. She has three daughters of 14, 8 and 6
years of age respectively.

You are an FY2 doctor in clinic. Talk to her and find out the reason for her visit?

(When you enter the cubicle patient greets you actively and looks very happy)

Dr: Hello I am Dr -------------- , one of the junior doctors in clinic. How may I call you?

Pt: Call me Isabelle.

Dr: Okay Isabelle how can I help you today?

Pt: Dr. I want a baby boy can you help me with it?

Dr: Isabelle can you please elaborate?

Pt: Doctor me any my husband already have three daughters and now we would like to
have a male baby. My husband wants to continue the family name.

Dr: Is that what you want as well?

Pt: Yes I want the same.

Ask her if it’s also her partner’s wish

Dr: Isabelle as far as I know from a medical point of view, with every pregnancy there is a 50
% chance of it being a male or female. May I know specifically what you want from us?

Pt: Doctor I want to know if there is any procedure or technique to ensure that my next
child will be male ?

Dr: Isabelle yes although there is a technique of pre-implantation genetic diagnosis

which can be used for this purpose but its use for the purpose of gender selection is
banned and illegal in U.K.

I am really sorry but we may not be able to help you with this technique.

But I would be happy to help you if you require anything else.

Pt: Ok doctor what about alternative medicine. Is there anything which may help me?

Dr: Isabelle, although there have been many claims by people practicing alternative
medicine regarding this like having sex near the ovulation date and eating specific kind
of food but none of those methods have been medically proven and as such have no
scientific basis to them.

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Pt: Okay doctor, if I get pregnant then how early can you let me know about the gender
of the baby?

Dr: Yes, we can do an ultrasound scan to know the gender of the baby. We can do this
earliest by 18th to 21st week of your pregnancy. But it is not true all the time as a
sonographer will not be able to be 100% ascertain about your baby's sex.

Dr: Isabelle may I know if you are under any pressure or stress to have a male child?

Pt: No doctor it is just that I want to have a male child.

Pt: Can I abort if it is a girl?

Dr: Isabelle, abortion solely on the basis of preference of gender, where there are no health
implications for the baby or for the woman are unlawful and we will not help you with that.

Pt: But isn’t it my right to have an abortion?

Dr: Yes generally it is a woman’s right to have an abortion but let me tell you the only
conditions in which law permits someone to have an abortion.

Abortions in England, Wales and Scotland are carried out before 24 weeks of
pregnancy only by registered medical practitioners in cases when termination of the
pregnancy is necessary to prevent grave permanent injury to the physical or mental
health of the pregnant woman or if the child when born would suffer from such physical
or mental abnormalities as to be seriously handicapped.

Dr: Do you have any questions regarding this? Pt: No doctor.

Isabelle, if you would like I can arrange an appointment with my consultant and he may
be able to guide you further on this subject.

Thank you

GENDER SELECTION

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COELIAC DISEASE
Coeliac Disease - Patient Concerned about endoscopy

Information:

Coeliac disease is a common digestive condition where the small intestine becomes
inflamed and unable to absorb nutrients.

It can cause a range of symptoms including diarrhoea, abdominal pain and bloating.

Coeliac disease is caused by an adverse reaction to gluten, a dietary protein found in

three types of cereal:wheat, barley, rye

Gluten is found in any food that contains the above cereals, including:

Pasta, cakes, breakfast cereals, most types of bread, certain types of sauces, some
types of ready meals. In addition, most beers are made from barley.

Symptoms of coeliac disease

Eating foods containing gluten can trigger a range of gut-related symptoms, such as:
diarrhoea, which may smell particularly unpleasant, abdominal pain, bloating and
flatulence, indigestion, constipation.

Coeliac disease can also cause a number of more general symptoms, including: fatigue
as a result of malnutrition (not getting enough nutrients from food) , unexpected weight
loss, an itchy rash (dermatitis herpetiformis), problems getting pregnant, nerve damage
(peripheral neuropathy), disorders that affect coordination, balance and speech.
Children with coeliac disease may not grow at the expected rate and may have delayed
puberty.

What causes coeliac disease?

Coeliac disease is an autoimmune condition. This is where the immune system – the
body's defence against infection – mistakenly attacks healthy tissue.

In coeliac disease, the immune system mistakes substances found inside gluten as a
threat to the body and attacks them.

This damages the surface of the small bowel (intestines), disrupting the body's ability to
absorb nutrients from food. It's not entirely clear what causes the immune system to act
in this way, but a combination of genetics and the environment appear to play a part.

Coeliac disease isn't an allergy or an intolerance to gluten.

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Treating coeliac disease

There's no cure for coeliac disease, but switching to a gluten-free diet should help
control symptoms and prevent the long-term consequences of the condition.

Complications of coeliac disease only tend to affect people who continue to eat
gluten, Potential long-term complications include:

" Osteoporosis (weakening of the bones), iron deficiency anaemia, vitamin B12
and folate deficiency anaemia
" Less common and more serious complications include those affecting pregnancy,
such as having a low-birth weight baby, and some types of cancers, such as
bowel cancer.

Transglutaminase Test (screening test) :

For most children and adults, the best way to screen for celiac disease is with the
Tissue Transglutaminase IgA antibody, plus an IgA antibody in order to ensure that the
patient generates enough of this antibody to render the celiac disease test accurate. For
young children (around age 2 years or below), Deamidated Gliadin IgA and IgG
antibodies should also be included. All celiac disease blood tests require that you be on
a gluten-containing diet to be accurate.

Tissue Transglutaminase Antibodies (tTG-IgA) – The tTG-IgA test will be positive in

about 98% of patients with celiac disease who are on a gluten-containing diet. This is
called the test’s sensitivity. The same test will come back negative in about 95% of
healthy people without celiac disease. This is called the test’s specificity. Though rare,
this means patients with celiac disease could have a negative antibody test result.

There is also a slight risk of a false positive test result, especially for people with
associated autoimmune disorders like type 1 diabetes, autoimmune liver disease,
Hashimoto’s thyroiditis, psoriatic or rheumatoid arthritis, and heart failure, who do not
have celiac disease.

There are other antibody tests available to double-check for potential false positives or
false negatives, but because of potential for false antibody test results, a biopsy of the
small intestines is the only way to diagnose celiac disease.

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155. A Middle aged lady is on Iron tablets as she is diagnosed to have iron deficiency
anaemia. Despite the medication, her condition isn’t improving. She had undergone
some tests and found to have tissue transglutaminase test to be positive.
Endoscopy to be planned for the patient. Talk to her and address her concerns.

D- “Hello, I am Dr ------ , one of the junior doctors in the department. I was told that you
wanted to talk to me. How can I help you?”

P-“Yes, I was told that I have Iron deficiency anaemia and some test is positive for
Coeliac disease.

D- “Did anyone explain to you regarding your condition?”

If patient says no, say:

“I understand from my notes that you have iron deficiency anemia and your condition
wasn’t improving despite the medication. Hence we tested for some antibodies in your
blood- tissue transglutaminase. This is an indication for coeliac disease.

“It is a condition of the bowel caused by an adverse reaction to gluten, which is a dietary
protein found in cereals. As a result, you might face some symptoms such as tummy
pain, bowel problems and indigestion.”

“We had tested for the antibodies in the blood which was found to be positive. However,
to confirm the condition and to manage you further, we need to do an endoscopy”

P- “Dr, why do you want to do an endoscopy? Isn’t the blood tests enough?”

D- “The blood tests showed you had antibodies present. However, it is quite a sensitive
test and not necessarily mean that you have this condition. We need to make sure with
the help of an endoscopy so that we can give you the proper treatment”

P – Endoscopy is uncomfortable. I am still concerned about this procedure. Could you

tell me how it is done?”
D- “Sure. I am glad that you asked.

An endoscopy is basically a camera test that will help us to visualise the inside of your
body. This procedure is performed with the help of an instrument called an endoscope.
An endoscope is a flexible tube that has a light source and camera at one end. This is
connected to a television screen which will give images.

However, before this procedure is performed, we ask the patient to avoid eating and
drinking for several hours beforehand. The diet to be followed is a gluten-containing diet
so that better results are obtained.

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Sometimes, we give antibiotics to reduce chances of infection

(Are you taking any blood thinner medications? No (It needs to be stopped a few days
before the procedure).

I can see that you might be concerned about the pain.

Before the procedure, we give a local anaesthetic in the form of a spray to numb the specific
area of your body. You may also be given a sedative to help you relax and make you less
aware of what is going on around you.

After that, we shall carefully insert the tube from your mouth into the stomach and have a
look inside the stomach and take a tissue sample.

This procedure usually takes between 15 and 60 minutes. You will be allowed to leave on
the same day if there are no complications thereafter.

However, please make sure you have a friend or relative along with you to take you back
home as it takes time for the sedation to wear off.

Complications are usually rare. However the possible one could be an infection or bleeding.

Warning signs:

When you go back home, please do watch out for any signs of infection -

Fever, Shortness of breath, Vomiting /vomiting blood, Redness, pain or swelling, Chest pain

If you experience any of these symptoms, please do come back to us.

P- “Alright doctor, thank you. But the blood tests already shows that I have anaemia.
Can’t you just treat that rather than going for endoscopy?”

D- “Yes, you are right that you have anaemia. But we need to find out the cause behind
it and treat it accordingly. Most likely it is Coeliac disease is causing the iron deficiency
anaemia in your case.

P - Alright Doctor. Is there any risk of bowel cancer developing because of this condition?

D – There is a very rare chance that bowel cancer may develop.

D- “Do you have any concerns? No.

D - Will you be happy to go ahead with the procedure? - Yes

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D - I would like to tell you that there are some dietary restrictions for celiac disease

P- Yes, Dr, I know that. My cousins have the same condition and I cook for them.

D- “Alright, would you like me to refer you to the dietician so that you have a better idea
about the diet that you can follow? P - Yes, I shall consider that

D - Do you have any concerns ? P- No, Dr. Thank you D - Thank you

--------------------------------------------------------------------------------------------------------

WHY IS ENDOSCOPY DONE FOR COELIAC DISEASE?

- Blood tests are helpful in diagnosing celiac disease but they aren’t perfect. False
negatives and false positives are possible.

- In the small intestine, there are finger like projections called villi that helps absorb
nutrients. In celiac disease, gluten damages the villi and causes them to flatten. Hence
endoscopy findings will show the following-:

1. inflammation or damage to small intestine

2. flattened villi

COELIAC DISEASE IN A MIDDLE-AGED LADY

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156. You are an FY2 in a medical department.

Mr. George Tindal, 55 year old man has been a diagnosed case of type-1 Diabetes
Mellitus since 14 years of age. He came to the hospital 4 months ago. He was given
Insulin for one month but he did not come back for getting more Insulin. He has come
now to the hospital.

Blood and Urine tests were sent to the laboratory. His urine test reveals Proteinuria
and Glycosuria. His blood has been collected for HbA1c, ESR, Cholesterol tests. In
addition, the patient has been diagnosed with Diabetic Nephropathy, Neuropathy and
Retinopathy (Fundoscopy shows dot and blot hemorrhages).

Talk to the patient, explain him about the sugar control and discuss with him the
further management.

Dr: Hello, I am Dr…. I am one of the junior doctors in the medical department. Are you
Mr. Tindal? Patient: Yes, doctor.

Dr: How are you doing Mr. Tindal?Patient: I am doing fine doctor.

Dr: Well, Mr. Tindal I am here to talk to you about your condition. From the notes, I have
gathered that you have Diabetes. Is that right? Patient: Yes.

Dr: Well, Mr. Tindal, could you please tell me how long do you have this condition?

Patient: Since I was 14 years old.

Dr: I see, and how much do you know about your condition?

Patient: I only know that I have diabetes doctor.

Dr: I see. Well, Mr. Tindal, could you please tell me what medicines are you taking to
treat your condition?

Patient: I was given insulin 4 months ago. But I stopped taking it.

Dr: Could you please tell me why did you stop taking insulin?

Patient: I don’t think it was necessary.

Dr: I see. Well, Mr. Tindal, I would like to ask you some questions in order to see how
much this disease has progressed. Is that alright?Patient: Okay.

Dr: Could you please tell me if you have any symptoms now?Patient: Like what doctor?

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Dr: Have you been noticing any change in your vision?

Patient: Yes doctor, my vision has worsened over last few months.

Dr: Have you ever had any heart problem, chest pain or shortness of breath? Patient: No

Dr: I see. Do you have any numbness, tingling, or pain in your hands, legs, or feet? Pt:Yes/No

Dr: I am sorry to hear that. Have you had any kidney problems in the past? Patient: No.

Dr: Have you been diagnosed with high blood pressure, high cholesterol?Patient: No.

Dr: Do you smoke? Patient: No/Yes

Dr: Do you take Alcohol? How often and how much do you drink? Patient: No/Yes

Dr: What is your typical diet? What are your eating habits and patterns? Patient: ..

Dr: Do you exercise regularly? Pt:…

Dr: Are you taking any other medicines at all?Patient: No doctor.

Management:

Dr: Well, Mr. Tindal, from the information I have gathered and from the investigations
done on your blood and urine, unfortunately theDiabetes has advanced quite a lot in
your system and has developed certain Complications due to the poor control of sugar.
Are you following?

Patient: But why did it happen doctor?

Dr: As you may knowInsulin usually controls the blood sugar level.Diabetes occurs
when the level of sugar (glucose) in blood becomes higher than normal. This happens
either when your body does not make enough insulin, or if the insulin that you do make
does not work properly on the body's cells.

Because you stopped taking Insulin since the last few months the blood glucose levels
have begun to increase and caused a lot of problems.

Now the diabetes has affected your kidneys, eyes and the nerves in your legs. That is
why you may be having poor vision and tingling numbness in your legs. Are you
following me? Pt: Yes.

Dr: If the blood sugar level is not controlled it can cause other problems such as heart
attacks, stroke. Do you understand Mr. Tindal?
Pt: Yes. Is that serious doctor?

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Dr: Unfortunately, it is serious if it the sugar is not controlled. Therefore, it is very

important to keep the blood sugar under control to prevent this complications
progressing further. Pt: What should I do doctor?

Dr: You will need Insulin injections for the rest of your life. You should take it regularly.
You will need to monitor your blood sugar levels by using a monitor at home and keep
the sugar level under control. Pt: Alright.

Dr: Also, you should eat a healthy diet. Basically, you should aim to eat a diet low in fat,
salt and sugar and high in fibre and with plenty of fruit and vegetables. We will refer you
to a dietician for detailed advice.

Also, you should keep your blood pressure under control ( if he has high blood pressure).

We have taken your blood to check cholesterol levels. If the cholesterol level is high we
will give some medications to reduce the cholesterol levels but you need to cut down
eating fatty food. Is that Ok ?Pt : Okay doctor.

Dr: Smoking can worsen the condition. I sincerely advise you to stop smoking. We can
help you for this if you need. Would you consider doing that? Pt: Yes doctor.

Dr: Exercising regularly also helps in controlling the sugar. Pt: Ok

Pt: What happens to the complications what I already have doctor?

Dr: If you take Insulin regularly and keep the sugar under control it will delay the
complications from becoming worse. Do you understand Mr. Tindal?Pt: Yes, doctor.

Dr: Mr. Tindal, our hospitals have special Diabetes Clinics. Doctors, nurses, dieticians,
specialists in foot care (podiatrists), specialists in eye health (optometrists), and other
healthcare workers all play a role in giving advice and checking on progress.

Regular checks may include Eye checks to detect problems which can often be
prevented from becoming worse and can usually be treated. Now because you have
developed changes in your eye already, we can refer you to Eye Specialist in order to
treat your eyes.

Also, we can schedule Foot checks by referring you to a podiatrist- to help to prevent
foot ulcers because the nerves in your feet seem to be affected.

Urine tests, blood tests will be performed after a few weeks as well to see how well your
kidneys are functioning and to see the blood sugar control over months.

It is important to have regular checks, as some of these complications can be treated. Is

that okay? Pt: Yes doctor, thank you very much.

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Dr: Also, you should be immunized against infection from pneumococcal germs. These
infections can be particularly unpleasant if you have diabetes.Pt: Alright.

Dr: Is there anything else that you need help with? Pt: No doctor, you are very kind.

Dr: Thank you.

Only if the patient asks

Pt: Are there any no alternatives to injecting insulin?

Dr: There has been plenty of research done in recent years to develop ways to administer
insulin other than by injection. These have included insulin nasal and oral sprays, patches,
tablets and inhalers. After many years of work, some of the methods being researched are
showing a degree of success. However, it will be some time before any of these devices will
be available to people with diabetes in the UK. Is that alright?
PATIENT WITH UNCONTROLLED DIABETES

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157. LADY REQUESTING CT SCAN

Take full history – Where is the headache, Since when ? Any stress ?

Rule out Differentials.

Rule out space occupying lesion – early morning headache, early morning vomiting,
weakness arms or legs, any vision problem, family history of any brain tumours.

Tell her the diagnosis – tension headache because of stress. Treatment is to avoid
stress and to offer pain killers.

No investigation needed

She requests for investigations (CT scan) - ask why

Her friend had a brain tumour and the doctor did not do CT scan thinking it is migraine.

Show sympathy to her friend. Show empathy - I can imagine why you are so worried

Reassure - Tell her that you have already asked for the symptoms of brain tumour but
she does not have those symptoms. It is very unlikely she has a brain tumour. She does
not need CT scan

CT scan has its own problem can cause high radiation and can itself cause cancer. Tell
her that if it was required, you would advise her to do it.

If she still insists, tell her you will involve seniors and they will explain.

Warning signs – any symptoms of space occupying lesion to come back and we will do
the scan if she has symptoms of that.

Sometimes, the diagnosis might be a migraine.

TENSION HEADACHE -

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158. You are the FY 2 doctor in medicine department. Mr James Walker, a 72 year old
man has recently been admitted to the medical ward for pneumonia and has
been treated. He is about to be discharged. He has some concerns. He wants to
talk to a doctor. Talk to him and address his concerns.

The patient will not come to you telling you that he doesn’t want DNAR. He usually
wants to talk about a treatment he’s refusing.

Ask why he’s refusing treatment.

We also need to ensure that they are making an informed decision. To do this, we need to:

- Assess their knowledge about their condition,

- Assess their knowledge regarding their treatment

- Their understanding of the complications that may arise if they refuse treatment

Mental capacity is assessed indirectly throughout the encounter. Find out if there any
contributory factors leading to this decision for example

- Depression,

- Finances (ask how they support themselves financially and/or if they are
financially stable)

- Chronic pain/co-morbidities

- Support system: “Do you have close family and friends who you can confide in?
Have you discussed this decision with your family?”

They have a right to refuse treatment.

Don’t pity or force the patient.

Find out if he’s willing to accept other forms of treatment:

- Active treatment with medications, and

- CPR.

Talk to them about emergency treatments like IV fluids, CPR - explain what will happen
and assess their knowledge of it and consequences of refusing. “In the case of
emergencies, we give life-saving medication like CPR. Do you know what we do if the
heart stops working?” Ask them if they know what it is. If they refuse, find out why they
are refusing. Find out if they understand the consequences of stopping.

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Inform the patient that DNAR is reversible and they can change their mind at anytime.
They do however have to let the doctor know directly.

Inform the patient about the form and that you will get your consultant to co-sign.

Dr: Hello Mr James Walker ? I am Dr…. A junior doctor in the medical department. How
are you doing today? Pt: I am ok.

Dr: How is your pneumonia? Pt: I am OK now.

Dr: I was told that you have some concerns and you want to talk to a doctor is that
right? Pt: Yes

Dr: Can I help you?

Pt: Doctor, I don’t want to take this medication anymore?

Dr: Why is that? Pt: They make me sleepy?

Dr: Can you please show me which medications? Patient shows – Enalapril, Aspirin and
Simvastatin

Dr: Why are you taking these medications?

Pt: I was given those medications 12 years ago when I had heart failure.

Dr: Did you have any other medical conditions?

Pt: Yes, I had bypass surgery to my heart 20 years ago.

Dr: OK. We will see which one of this medication is making you sleepy. We will change
that medication and give some other medication. Will you take them?

Pt: Doctor, I am tired of taking these medications. I don’t want to take medications any more.

Dr: Why do you say that?

Pt: I had enough in my life. I just want to go without suffering.

Dr: Can I ask you why you feel that way?

Pt: Doctor, I already had whatever I need in this life. I had enough. I have accomplished
everything in my life.

Dr: Is there any medical problem you have which is making you feel this way? Pt: No doctor.

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Dr: Is there any other reason making you feel this way like are you feeling low for any
reason? Pt: No - Not at all

Dr: Is there anything we can help you with if you want to change your decision? Pt:
No, nothing like that.

Dr: Can you please tell me if you do any job? Pt: No I am retired now.

Dr: What about your family?

Pt: My wife died of cancer a few years ago. I have a daughter but she has rheumatoid arthritis.

Dr: Do you live with anyone at all?

Pt: I live on my own. My daughter has arranged someone to take care of me.

Dr: She is very caring. What do you mean by you’ve had enough? What do you have in
your mind?

Pt: Doctor I want to die in dignity.

Dr: What exactly do you mean by that?

Pt: I was told you doctors do CPR if the heart stops beating. I don’t want that to be done
on me.

Dr: I see. Do you understand what is the meaning of CPR?

Pt: Yes, I was told you compress the chest if the heart stops beating to make the heart
beat again.

Dr: That is right. But do you understand what will happen if we do not do CPR? Pt:Yes
I understand that the patient will die.

Dr: Is that what you really want. Pt: Yes that is what I want.

Dr: Have you discussed this with your family members at all?

Pt: I don’t need to discuss with them

Dr: Is it that you don’t want us not to do CPR only or do want us not to give you any
active treatment if you fall ill like giving medications through your veins?

Pt: Well, I don’t mind having active treatment but I don’t want CPR to be done. Can you
please bring that form?

Dr: Surely, I do respect your views. However this the decision has to be taken between
you and my consultant. I will speak to my consultant and get back to you. I need to tell

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you one thing, even if you decide not to have CPR now, you can always change your
decision later on if you feel like it.

Pt: OK thank you doctor. Dr: Thank you very much

DNAR

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159. You are an FY2 doctor of the medical department in a hospital.

75 year old lady diagnosed with MS and she is at the end stage of the condition.
She is under palliative care now. She is aware of her condition and wants to talk
about her end of life care wishes.

You are visiting the patient at her home as a part of the palliative care.

Assess the patient, address her concerns and take an informed decision on her
DNAR request.

Assess her knowledge of her condition

Find out what she can do - is she depending on others for her daily activities?

Find out if she needs any help from us.

Concerns?

Find out what she’s expecting from us - “Is there anything else you are expecting from us?”

If she tells you she wants to go, ask her to clarify. Do not assume!

Hello, I am doctor ....... one of the doctors in the medical team who is looking after you.
How are you doing today?

Pt: Not very well, I just want to die, doctor!

Dr: I'm sorry to hear that, and I know from the notes that you are going through a difficult
time because of your condition [express sympathy and empathy] but could you
please tell me what do you mean by that you want to die ??

Pt: I’ve had enough in my life, doctor

Dr: I'm sorry to hear that. Could you please tell me how much you know about your
condition?

Pt: I was diagnosed with MS a few years ago and it is very difficult for me to cope with
the condition. I can’t do anything on my own.

Dr: Mrs. .....I can't even imagine what you are going through right now, I wish I could
help you. But as you know, we don't have any specific treatment for the condition. Pt: I know

Dr: Were you on any medications before we started you on palliative care?

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Pt: It was [MS] coming and going in the past years. Sometimes, I didn't have any
symptoms and after a few months, the symptoms will reappear. I was on steroids for a
few years, but eventually, the condition progressed and doctors found that now it is at
an advanced stage of disease and told me that no medications will work anymore.

There is no cure and she can not regain bodily functions which have been lost.
Dr: Yes Mrs. ... if the condition has progressed to an advanced stage, no medications will
work. Once again, I'm really sorry to hear that. Assess her mental capacity by asking
her to explain briefly what MS is

Pt: That is why I told you that I want to die and I don’t need any treatment of any kind if I
fall ill.

Dr: Do you mean we should not resuscitate you?

Then explain the types of resuscitation. Describe CPR and giving drugs to treat
infections, etc

Dr: Do you know what is CPR?

Pt: Yes, doctors will try to restart my heart if it stops beating.

Dr: Yes, you are right. What about any kind of active treatment?

Pt: What do you mean by that, doctor?

Dr: If you fall ill, is it okay if we give medications through your veins to prolong your life?

Also mention that if a patient’s lungs stop working, they might be placed on a breathing
machine

Pt: I don’t want that either!

Dr: Mrs. ......I can see that this condition is affecting your life, but may I ask, if there is
any other medical condition you have that makes you think like that? Pt: No, doctor.

Dr: Do you understand what can happen to you if we do not give you active treatment or
do not do CPR if your heart stop beating?

Pt: Yes, I do understand the outcomes if you don't do the CPR or any active treatment, I
may die. I know that.

Dr: Have you discussed it with anyone?

Pt: I discussed it with my husband and he is really supportive of me.

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Dr: Well Mrs....... patients’ concerns and wishes are our first priority and I do respect
your wishes. I can see that you have the mental capacity to understand your condition and
you are aware of what will happen if we do not do CPR or any active treatment. Let me fill up
the form and I will explain to you how we do that. You can also confirm her mood.

EXAMINER HANDS OVER THE DNAR FORM

(fill up the form)

Mrs. ...... I have filled and signed the form. But as I am a junior doctor, I cannot take the
final decision on this matter. My consultant will assess you once again and he will
counter sign the form and after that (The consultant has to countersign the form
within 24 hours). Then it would be valid. Would that be okay?? Pt: Okay doctor

Dr: Mrs. .... I want you to know that this decision is always reversible. If you ever change
your mind, do let us know and we can reverse this decision for you. Pt: I understand, doc!

Dr: Do you have any other concerns? Pt: No

Dr: Thank you Mrs.... ....

Filling up the form eg:

Does the Patient has the capacity to make and communicate the decision – Yes

Summary of main clinical problems and reasons why CPR is inappropriate,

unsuccessful or not in the patient’s best interest – Advanced stage Multiple sclerosis

Summary of the communication with patient or (Welfare Attorney) patient - Patient

wishes DNACPR.

Summary of communication with patient’s relatives and friends – Not discussed

Names of members of multidisciplinary team contributing to this decision – Not discussed

Healthcare professional recording this CPR – sign and write position – FY2 doctor, Date

Review and endorsement by most senior professional – Leave blank (Consultant to sign
later)

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MULTIPLE SCLEROSIS – FILL UP THE DNAR

FORM

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160. You are the FY 2 doctor in the medical department.

Mr Peter Green 64 year old man was treated for Pneumonia by the GP with
antibiotics because he had shortness of breath for 2 weeks. He was hospitalised
one week ago because it got worse. He died of suspected Respiratory failure.

His wife Mrs Green want to talk to a doctor about this issue. Talk to his wife Mrs
Green and address her concerns.

Post mortem may not be mentioned in the question

Dr: Hello Mrs Green, I am Dr …. A junior doctor in the medical department. How are
you doing?

Wife: I am not feeling good, doctor. I don’t know what happened to my husband. He
died suddenly.

Dr: I am very sorry about it. Please accept my condolences for the loss of your precious
one. I can’t even imagine how you are feeling. I was told that you want to talk to a
doctor about it. Do you have any concerns?

Wife: I am just wondering doctor why this happened so suddenly. He was doing good.

Dr: We think it could be due to an infection in his lungs which resulted in failure of the
lungs and eventually led to this. But we are not very sure about it. However we need to
know more about this. Can you please tell me what happened before he was brought
into the hospital?

Wife: He was short of breath since the last 2 weeks. We went to the GP and he said he
had a chest infection and gave him antibiotics. He was getting more ill since the last one
week and we brought him to the hospital and he was admitted a week ago. Now
suddenly this happened.

Dr: Did he have any medical conditions? Any operations done recently? Any
medications? Any allergies?

Wife: Doctor, he had no medical problems at all. He has never been to the hospitals or
GP before this. He was completely fit and well. Why did this happen, doctor?

Dr: As I mentioned before, we think it could be due to infection in the lungs. We are not
sure. I think it is a better idea to do a post-mortem and find out about it. What do you
think?

Wife: My niece works as a nurse – she also told me that it is good to have the post- mortem.

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Dr: OK, surely we can request for that if you wish to. Do you know what we do in the
post- mortem? Wife: I don’t know

Dr: We do the post-mortem to find the exact cause of death when we are not sure about
the exact cause of death. We do that in an examination room that looks similar to an
operating theatre.

Pathologists (specialist doctors) do the post-mortem.

During the procedure, they open the body and remove the organs for examination.
Sometimes they know the cause of death by looking at the organs. Some organs need
to be examined in close detail during a post-mortem and these investigations can take
several weeks to complete. They also will take some tissue samples from the organs
and keep it for future testing.

The pathologist will return the organs to the body after the post-mortem has been completed.

Wife: Who decides to hold the post-mortem?

Dr: It can be requested by a coroner (judge) or hospital or the close relative, in this case
like you, can request for the post-mortem.

Wife: When will you do the post-mortem?

Dr: We usually do the post-mortem within two to three working days of a person's death.
Wife: Can I see him?

Dr: Surely you can see him before we do the post-mortem if you wish to or you can see
him after the post-mortem also.

Wife: Will it delay the funeral?

Dr: After the post-mortem they will give release papers and after that you can hold the
funeral. Wife: When will I get the death certificate?

Dr: They usually give the death certificate once they know the cause of death. However,
you do not need to wait until you get the death certificate to hold the funeral for him.

Wife: Will they keep the organs?

Dr: Usually they return the organs back to the body after taking some tissue samples. If
they need to retain any organ, they will ask your consent for that. Do you know what
was your husband’s wishes about the organs - did he mention anything about what to
do for the organs before he died? If he had mentioned anything like that before he died -
then his wishes will be respected.

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Wife: We did not discuss this issue because this happened unexpectedly. Which parts
of the body do you open?

Dr: We open only head, chest and tummy area only. We do not touch face, arms and
legs. We stitch it up once the organs are returned to the body. Stitched areas are
usually covered by the dressing of the body by the mortician. So there will not be any
disfigurement to the face and arms.

Wife: How will this post-mortem help us doctor? Dr: It will help you and others a lot in
many ways.

First of all, you will have a peace of mind and feeling of closure if you know the cause of
his death.

If it all he died of some genetically inherited condition, we can check for that problem in
his family members or if you have children we can check your children also and maybe
we will be able to treat them.

Also, if it all he died of a contagious disease, we can protect others who came in contact
with him.

Also, it helps us a lot in our studies and future training. Wife: Will you request to do the
post-mortem doctor?

Dr: Yes surely. I will talk to my Consultant and then we will request the concerned
authorities to do that.

Dr: Is there anything else I can do for you? Wife: No doctor. You have been kind

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INFORMATION ON POST-MORTEM EXAMINATIONS

Learning more about illnesses and medical conditions benefits patients too, because it
means they'll receive more effective treatment in the future.

When post-mortems are carried out

A post-mortem examination will be carried out if it's been requested by:

" a coroner – because the cause of death is unknown, or following a sudden, violent or
unexpected death

" a hospital doctor – to find out more about an illness or the cause of death, or to further
medical research and understanding

" the partner or relative of the deceased person. He/she will request a hospital post-
mortem to find out more about the cause of death.

Coroner’s post-mortem examination

A coroner is a judicial officer responsible for investigating deaths in certain situations.

Coroners are usually lawyers or doctors with a minimum of five years' experience.

In most cases, a doctor or the police refer a death to the coroner. A death will be referred to
the coroner if:

" it's unexpected, such as the sudden death of a baby (cot death)

" it's violent, unnatural or suspicious, such as a suicide or drug overdose

" it's the result of an accident or injury

" it occurred during or soon after a hospital procedure, such as surgery

" the cause of death is unknown

The main aim of a post-mortem requested by a coroner is to find out how someone died and
decide whether an inquest is needed. An inquest is a legal investigation into the
circumstances surrounding a person's death.

If someone related to you has died and their death has been referred to a coroner, you won't
be asked to give consent (permission) for a post-mortem to take place. This is because the
coroner is required by law to carry out a post-mortem when a death is suspicious, sudden or
unnatural.

A coroner may decide to hold an inquest after a post-mortem has been completed. Samples
of organs and tissues may need to be retained until after the inquest has finished.

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If the death occurred in suspicious circumstances, samples may also need to be kept by the
police, as evidence, for a longer period. In some cases, samples may need to be kept for a
number of months or even years.

The coroner's office will discuss the situation with you if, following an inquest, tissue samples
need to be retained for a certain length of time.

Hospital post-mortem examination

Post-mortems are sometimes requested by hospital doctors to provide more information

about an illness or the cause of death, or to further medical research.

Hospital post-mortems can only be carried out with consent. Sometimes, a person may have
given their consent before they died. If this isn't the case, a person who is close to the
deceased can give their consent for a post-mortem to take place.

Hospital post-mortems may be limited to particular areas of the body, such as the head,
chest or abdomen. When you're asked to give your consent, this will be discussed with you.
During the post-mortem, only the organs or tissue that you've agreed to can be removed for
examination.

You will be given at least 24 hours to consider your decision about the post-mortem
examination..

What happens during a post-mortem?

A post-mortem will be carried out as soon as possible, usually within two to three working
days

of a person's death. In some cases, it may be possible for it to take place within 24 hours.
Depending upon when the examination is due to take place, you may be able to see the body
before the post-mortem is carried out.

The post-mortem takes place in an examination room that looks similar to an operating theatre.

During the procedure, the deceased person's body is opened and the organs removed for
examination. A diagnosis can sometimes be made by looking at the organs. Some organs
need to be examined in close detail during a post-mortem and these investigations can take
several weeks to complete. The pathologist will return the organs to the body after the post-
mortem has been completed. If you wish, you'll usually be able to view the body after the
examination.

Once release papers have been issued, the undertakers you've appointed will be able to
collect the body from the mortuary in preparation for the funeral.

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What happens after a post-mortem?

After a post-mortem, the pathologist writes a report of the findings.

If the post-mortem was requested by the coroner, the coroner or coroner's officer will let
you know the cause of death determined by the pathologist. If the post-mortem was
requested by a hospital doctor, you'll have to request the results from the hospital where
the post-mortem took place.

That in some cases you will be asked to make some decisions. These may be to
discuss any need for consent, or to decide what happens to organs and tissue samples
that may need to be removed for investigation. Your wishes will be respected.

Any particular needs that you have, which could be cultural, religious or practical, will be
taken into account as far as possible. Where consent is not given for storage of organs
or tissue samples they are disposed of in a timely and respectful manner.

In some circumstances, a Coroner may open an inquest into the death of an individual
after a post- mortem examination. If the Pathologist certifies that they have a bearing on
the cause of death, the Coroner may require that any retained organs and tissue blocks
and slides are kept until the Coroner’s function is complete. Similarly, if there is a
possibility of criminal involvement in the death, tissue may be needed by the police as
evidence, separate to the Coroner’s requirements.

In both cases, the tissue samples, blocks and slides or organs may need to be kept for
several months, in some cases, years. As a result, this may affect what you want to
happen to them.

Why do organs and tissue need to be retained?

In around 20% of adult post-mortem examinations and in most paediatric post-mortem

examinations, the cause of death is not immediately obvious. A diagnosis can only be
made by retaining small tissue samples of relevant organs for a more detailed
examination. The Pathologist may need to retain a whole organ for a full assessment to
allow an accurate diagnosis of the cause of death to be made. When this happens, the
organ or tissue is normally sent to a specialist unit.

These full assessments often take weeks or even a few months to complete, depending
on the extent of the investigations required. Once they are complete, the Pathologist will
produce a report for the Coroner or the medical staff responsible for the care of the
person before they died.

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What happens when the post-mortem examination is complete?

When the post-mortem examination is complete, you will be told whether tissue
samples and organs have been retained. If tissue samples and organs have been
retained, then you should expect to be given a choice about what happens to them
when they are no longer needed by the Coroner or the hospital. Your consent will be
needed for any tissue samples or organs to be kept for future use such as research or
education and training of medical staff.

Blocks and slides

With your consent, the tissue blocks and slides may be stored as part of the record of
the post- mortem examination, sometimes called the pathology or medical record, in
case they are useful to your family in the future. If the post-mortem examination takes
place in a Local Authority Public Mortuary, rather than an NHS Mortuary, then your
consent will be taken to mean that you agree to the transfer and storage of the blocks
and slides within the healthcare sector.

The samples may also be useful for one or more of the following: teaching, research,
clinical audit or quality assurance etc. The organisation storing the blocks and slides
may dispose of them.

If a funeral has already taken place, then the blocks and slides can be returned to you,
usually via your funeral director. There may also be health and safety issues that may
prevent this option.

The blocks and slides may be returned with the body before the funeral. It is important
to realise that choosing this option could significantly delay the funeral. Some
crematoria do not allow blocks and slides to be cremated with the body.

Whole organs and tissue samples

Organs and tissue samples cannot be stored as part of the medical record in the same
way that blocks and slides are. They can be reunited with the body, or buried or
cremated separately. Alternatively they can be retained for future use in teaching,
ethically approved research, audit and other clinical purposes, but only with your
consent.

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Who can give consent for retention of organs?

The most important wishes to consider are those of the person who has died. If it is
known that the person who has died gave consent or specifically did not want to give
consent to the retention of tissue samples or organs, then those wishes must be
respected.

If their wishes are not known, then a person nominated by them when they were alive,
or someone in a relationship with them or closely related, must give consent. The
spouse or partner is highest on the list, and a long term friend is at the bottom.

POST-MORTEM EXAM QUESTION

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161. HIV diagnosed male presents to GUM clinic from GP. Address his concerns.
A young male presents to the GUM clinic (no need to BBN because he knows about
HIV and is not worried) has a swelling in the groin (lymphadenopathy?). He has been
married for 3 years and had a one-night stand with a male recently on a holiday (this is
the reason for HIV diagnosis).

He refuses to tell wife of the diagnosis - advise about partner notification and convince him
to tell wife. If he does not agree, we will have to tell her with or without his permission.

Further points to ask: elaborate on the swelling in the groin along with a possible
examination and ask for any findings. Ask about medications and viral load or CD4
count. R/O other factors for HIV status: IVD abuse? Any other lifestyle preferences? Any
STI symptoms? Any other medical conditions, meds, allergy?

His concern is about having children in the future.

Find out if his wife is HIV positive

Fortunately, with some careful planning, it is possible to have a safe and successful
pregnancy while preventing HIV from passing to the HIV-negative partner (or to the
baby). First, the male needs to have an undetectable viral load; this minimises the risk
of infecting his partner. For that he would have to be on antiretroviral treatment (ART).
Both partners should be checked for STIs regularly. This is good practice whenever two
people are planning a pregnancy. STIs can sometimes increase the risk of passing
on HIV to the negative partner. Thirdly, the chance of conceiving is highest when his
partner is ovulating. Ovulation is the middle of the woman’s monthly cycle, about 14
days before her period. This reduces the number of times they have unprotected sex
and thus lowers the risk of HIV transmission

In addition, the HIV-negative female partner may take HIV medications as prophylaxis to
reduce the risk of infection with HIV, beginning in advance of attempts at conception and
continuing afterward (called pre-exposure prophylaxis or PrEP), though it is not clear that
this step is necessary if the woman's HIV viral load is undetectable. If the male partner has
an undetectable viral load, that eliminates the risk that he will pass on HIV, but PrEP also
allows the female partner to be in control of her own protection against HIV.

Sperm washing with in vitro fertilisation or intrauterine insemination may be considered.

Sperm washing is intended to isolate individual sperm from the HIV virus in the semen.
These methods would involve the assistance of a reproductive specialist or fertility clinic.

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What is the best treatment for HIV?

Most people who are getting treated for HIV take 3 or more drugs. This is called
combination therapy or "the cocktail." It also has a longer name: antiretroviral therapy
(ART) or highly active antiretroviral therapy (HAART). Combination therapy is the most
effective treatment for HIV.

When should you start HIV treatment?

Though the treatment guidelines recommend antiretroviral is started soon after HIV is
diagnosed—the decision to begin therapy also depends on your physical health
and your mental readiness to start treatment and stick with it. In the past, the
treatment recommendations were based on an individual's CD4 cell count.

How does HAART treatment work?

ART are medications that treat HIV. The drugs do not kill or cure the virus. However,
when taken in combination they can prevent the growth of the virus. When the virus is
slowed down, so is HIV disease.

How long does it take for antiretrovirals to work?

These reactions usually disappear within three weeks of starting to take the treatment.
Everyone who is infected with HIV and has TB has to take ARVs. If you developed TB
before starting your ARV medication, the TB treatment has to be started two weeks a
head of the ARVs

Is undetectable safe?
HIV is not infectious in saliva, which makes kissing safe, even deep kissing. By using a
condom when you have anal sex, you are cutting out the highest risk factor ..... More
recently, other studies, including the PARTNER study, have reported that when viral
load is undetectable, the risk from sex is likely to be zero.

How much viral load is undetectable?

When copies of HIV cannot be detected by standard viral load tests, an HIV-positive
person is said to have an “undetectable viral load.” For most tests used clinically today,
this means fewer than 50 copies of HIV per millilitre of blood (<50 copies/mL). Reaching
an undetectable viral load is a key goal of ART.

HIV DIAGNOSED MALE PRESENTS TO GUM

CLINIC

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162. Young man treated for gonorrhoea, his initial HIV is negative he is not
disclosing, his contact nurse asked you to talk to him.

He says that he got it from a woman in Germany and doesn't have any contact with her.
He was not agreeing to bring his wife for treatment but agreed finally.

HE ASKS ABOUT HIV

- Ask about symptoms.

- Check for other STIs

- Advise safe sex

GONORRHOEA IN MAN

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PRE-OPERATIVE ASSESSMENT
 The objective is to make sure whether the patient is suitable for the elective operation
as well as for anaesthesia and to optimise his condition for the operation. In some
cases surgery may need to be postponed until the patient is optimised.
 Assessment consists of taking a full history, examining to see whether any new changes
has happened since his operation was decided. To do necessary investigations to help in
anaesthesia and to prescribe some pre op medications if needed.
 Also, the procedure and the need for the operation need to be explained to the patient
patient needs to be explained about the procedure in order to take his consent.

History taking

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Drug History: Steroids, anti-hypertensives, for diabetes, Thyroid medications, Anti-

coagulants, Antibiotics, Oral contraceptive pills

* Oral contraceptive pills (should be stopped 4 weeks before surgery and

alternative contraception should be prescribed).

* Smoking can cause hypoxia and delay wound healing.

* Change warfarin to heparin at least 5 days

* Does patient have anyone to look after them?

Systemic enquiry

In order to make sure you do not miss any new acute symptoms, you may want to go
through the following list of symptoms with your patient.

Cardiovascular: chest pain, shortness of breath, paroxysmal nocturnal dyspnea,

oedema, palpitations.

Respiratory: cough, sputum, haemoptysis, wheeze stridor

Gastrointestinal: nausea, vomiting, dysphagia, acid reflux, haematemesis, abdominal

pain, abdominal swelling, altered bowel habit, malaena/rectal bleed, weight loss,
appetite.

Genitourinary: Dysuria, haematuria, dribbling, voiding difficulties, incontinence,

nocturia.

Neurological: fits or seizures, faints, funny turns, loss of power, vision, or sensation.
Any problems in the neck.

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Investigations
Depends on operation

Pre-operative Management

I. Diabetic patients having surgery need close blood glucose (BM) control peri-
operatively. The anaesthetist will usually advise when this is to be started. This is
usually achieved by using a sliding scale insulin infusion or a glucose –potassium-insulin
(GKI) protocol depending on local preference. Generally, this should be continued
until the patient is eating and drinking normally in the postoperative period, at which
point the patient’s usual diabetic medication can be restarted. Ideally, all diabetic
patients should be first on an operation list.

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Oral medication:
Metformin: It should not be discontinued and it should be given following surgery as
soon as the patient can take oral medication.

Gliclazide, glipizide etc : need to be stopped on the day of operation.

Recommencing oral medication:

All tablets should be given on the first postoperative day to control the blood sugar. The
patient should remain on a dextrose/saline infusion until they are drinking adequately.

Patients on IV sliding scale:

Patient should remain on an IV sliding scale for up to 48 hours, after which it can be
stopped.

II. Patients taking steroids

- Change to IV hydrocortisone to avoid adrenal shutdown, and recommence when eating

normally. It is essential to appreciate that any patient on long-term steroids will have
impaired adrenal function and is likely to cope badly with the stress of surgery when
endogenous steroid production is increased. This means replacing oral steroids with IV
steroids to avoid an addisonian crisis.

III. Patients on anticoagulation:

- International normalised ratio (INR) should be & 1.5 for most operations, and 1 if a
spinal/epidural is to be used.

- Stop warfarin 3 days before surgery

- Intravenous heparin needed while off warfarin if patient has a prosthetic heart valve.

- Maintain activated partial thromboplastin time (APTT) ratio at 2-3

IV. Patients taking antiplatelet medication (Clopidogrel, Aspirin)

- Discuss with anaesthetist

- Stop 1 week prior to surgery

- In the emergency setting a platelet transfusion will reverse effects

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V. Women on hormone replacement therapy/Oral contraceptive pill:

Combined OCP needs to be stopped 1 month before operation

Progesterone only OCP can be continued

HRT needs DVT prophylaxis (LMWH)

VI. Alcohol dependent patients requires vitamin supplementation and sedation.

VII. Jaundiced patients requires Vitamin K.

VIII. May need DVT prophylaxis.

IX. Consent (Ideally, the person who operates should take the consent).

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163. INGUINAL HERNIA PRE-OPERATIVE

ASSESSMENT
Reasons for taking a history in this station are:

1. To do a pre-op assessment

Most important questions to ask when doing a pre-op assessment are:

Past Medical and past surgical history

On the day of the surgery, you also want to find out:

Last time he had something to eat and drink

2. Risk factors for hernia which include:

Chronic cough and smoking

Chronic constipation

Occupation (lifting heavy weights)

Difficulty urinating

3. Complications of hernia. You will need to ask of pain and constipation

- On the day of the operation, hypertensive patients are supposed to take their
anti-hypertensive medication.
- You will tell the patient that the surgery cannot be done and that you will refer him
to the medical team to determine why his blood pressure is high.
- You can mention you will check his respiratory system, cardiovascular system,
abdomen, but what is most important to note is that this is a history and
counselling station.

After you completing the examination, the next steps are

1. Investigations - ECG, Chest X-ray

2. Management and Counselling

ICE

" When explaining a hernia to a patient, it is best to use a pen and paper but it is
also possible that the examiner might tell you to simply explain it verbally.

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" Answer any questions.

" Take consent
" Talk about the type of anaesthesia
" Explain the surgery. There are 2 different tes: keyhole and open surgery. Keyhole is
short cuts and open surgery is long cuts. Ask him what type of surgery the consultant
had already told him.
" If it is an open surgery, tell him about the incision (above the swelling about 6 - 8 cm)
and then the procedure itself. Enquire from the patient if he is following you.
" Reassure the patient that he will not feel the pain during the surgery and that you
will give strong painkillers after the surgery.
" Tell the patient the surgery length (30 - 45 minutes), expected length of hospital stay (1
- 3 days) if not day surgery
" Talk to him about when he can go back to work (about 2 weeks), when he can drive
(open suregery 4 weeks and keyhole surgery 2 weeks), when he can have sex (after
about 2 weeks when the wound heals), exercise (4-6 weeks)
" Talk about the risk factors: the hernia will come back if the intra-abdominal pressure
increases. Tell him to avoid lifting heavy weights after the surgery, encourage to eat high
fibre diets and drinking plenty of fluids, stop smoking and see a specialist if he is having
chronic cough and difficulty micturating
" Follow-up in a week

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163.You are an FY2 Doctor in Surgical Department.

45 years old man has been admitted to the ward for the Hernia Operation.

On pre-operative assessment, the nurse has found the blood pressure to be 155/88.

He has been assessed for the hernia already. Your Surgery Consultant is due to come
to take consent for the surgery.

Talk to the patient, do the pre-op assessment, describe the operation, and address his
concerns.

Dr: Hello. I am Dr...a junior doctor in the surgery department. How may I call you?

Pt: You can call me...

Dr: How are you doing Mr...? Pt: I am fine doctor.

Dr: That is good. Mr. Do you know why you are here today ?

Pt: I have a hernia, doctor. Your Consultant told me I need to have an operation. They
wanted to assess me before the operation.

Dr: That is right. Do you know about your condition and why we are planning to do the
operation for that ?

Pt: No, doctor, I don't know much really but I know I have a hernia.

Dr: OK. Do you want me to explain everything to you? Pt: Yes doctor, I will like that.

Dr: A hernia occurs when an internal part of the body like intestines in the tummy
pushes through a weakness or gap in the tummy wall and comes out like a swelling. Are
you following me? Pt: Yes.

Dr: This usually happen if the pressure inside the tummy is increased for example due
to coughing or straining while opening bowel. Most of the time this swelling goes in and
out because the contents of the hernia goes inside the tummy when you lie down and
comes out again while standing our coughing.

Let me draw it for you on this page and maybe you can understand it better.

(Examiner might give a piece of paper and a pen for you to draw for making the
patient figure it out better)
Dr: Are you following me? Pt: Yes, doctor.

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Dr: If we do not treat this condition sometimes this hernia gets obstructed means the
contents do not go inside the tummy and it can become a serious problem. So it is very
important to treat the condition now. Do you follow me? Pt -Yes.

Dr: Do you have any idea how we are going to treat you?

Pt: Yes doctor, I was told that surgeon would operate on me.

Dr: Yes, that is right Mr... Unfortunately we cannot treat this condition with any medication.
Only option we have is to do the operation. Do you have any concerns at this stage? Pt – No

Dr: I need to ask you a few questions about your health because for this operation, you
need to be fit in regards to your health. Also after the operation, we might have to
request you to make some lifestyle changes to prevent similar problems from happening
again in the future. Is that fine? Pt: Yes doctor.

Dr: How is your general health at the moment? Pt: It is OK doc.

Dr Did you undergo any surgeries previously? Pt : No

Dr: Have you been diagnosed with any medical conditions at all? Pt: No doctor.

Dr: I see. Well, Mr... I would like to tell you that nurse examined your blood pressure and
she found that it was a bit on the higher side. Have you ever been diagnosed with high
blood pressure before ? Pt: No doctor.

Dr: I see. Your blood pressure is mildly elevated so you do not need to worry. However, we
might have to take Opinion from Cardiology Consultant that is the specialized doctor for such
problems. We will have to see why you are having high blood pressure and control the blood
pressure before we can do the surgery. Is that alright? Pt: Yes doctor. Thank you.

Dr: Do you have any symptoms like Cough?Constipation? Straining on Urination? Pt: No

Dr: Do you smoke? Pt: Yes doctor.

Dr: Could you please tell me how much do you smoke and for how long?

Pt: I smoke almost 20 cigarettes or more daily for 20 years.

Dr: Could you tell me what do you do for a living? Pt: I work in a warehouse/ construction company

Dr: Does your work involve lifting or pushing heavy weights or standing for long periods
of time? Pt: Yes. I work in a warehouse.

Dr: Okay, Mr... I would now like to explain to you how we are going to do the operation.

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Let me tell you about your options. Is that alright? Pt: Okay.

Dr: Surgery is the main treatment for hernias. It’s a very common operation and a highly
successful procedure when done by a well-trained surgeon so you do not need to worry
about anything because we have the best surgical team.
We have two types of surgeries either an Open Surgery or a Key-Hole Surgery.

Did my Consultant tell you what type of surgery we are going to do on you ? Pt: open type.

Dr: Do you want to know how we do the open surgery ? Pt – Yes.

Dr: Open repair involves making an incision or cut on the skin into the groin. This incision is
usually about 6-8cm long. After this, surgeon will return the contents inside the hernia like
intestines back to the tummy and then he will repair the tummy wall defect. A mesh is placed
in the wall, at the weak spot where the hernia came through, to strengthen it. When the repair
is complete, your skin will be sealed with stitches. These usually dissolve on their own over
the course of a few days after the operation. This might leave a bigger scar.
Pt: What is this mesh made up of?

Dr: It is made up of a material called polypropylene a type of synthetic plastic.

Dr: I see. Do you have any concerns related to the surgery?

Pt: Yes, doctor. My Father had hernia too. Doctors gave him a truss to wear. Will you
give me that as well?

Dr: I see. Mr…hernia truss is a supportive undergarment for men designed to keep the
hernia in place and relieve discomfort. This is only a temporary procedure but it does
not treat the hernia. It is used be used temporarily until we do the surgery or for those
people who are not fit to undergo surgery. Are you following me?

Talk about truss only if the patient asks about it.

Pt: Will it hurt during or after the operation?

Dr: Unfortunately all surgical procedures are associated with pain more or less. But you
do not need to worry we will manage your pain very well.

During the operation, we will be giving you local Anaesthesia where the anaesthetic
medication is injected to the swelling area, or spinal anaesthesia where the anaesthetic
medication is injected into the spine and the lower part of the body is made numb. You
will be awake during the procedure, but the area being operated on will be numb so you
won't experience any pain. In some cases, a general anaesthetic is used. This means
you'll be asleep during the procedure and won't feel any pain.

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Are you following me ? Pt: Yes Dr: Any concerns so far ? Pt – No

Dr: After the operation as with any surgical procedure, there will be some pain during
recovery. Your pain will be most severe the first few days. Initially we will give you strong
pain killer medicine like morphine then we will give you pain killer tablets called Co-
codamol when you are ready to go home.

Pt: How long will the operation last doctor?

Dr: The operation usually takes about 30-45 minutes to complete if there are no
problems during the operation.

Pt: When will I be able to walk after the operation?

Dr: After the surgery, you'll be encouraged to move about as soon as possible
immediately after the operation the same day.

Pt: When can I return to normal activities?

Dr: Most people are able to do light activities, such as shopping, after 1-2 weeks, but
you should avoid heavy lifting and strenuous exercise for about 4-6 weeks.
Pt: When will I be able to have sex?

Dr: You may be able to have sex after about 2 weeks.

Pt: When can I drive doctor?

Dr: It's usually advisable to avoid driving until you're able to perform an emergency stop
without feeling any pain or discomfort (you can practice this without starting your car). It
will usually be about 4 weeks after open surgery.

Pt: When will I be able to go back home?

Dr: You'll be able to go back home on the same day. Some people stay in the hospital
overnight if they have other medical problems or if they live alone. Do you have anyone
to look after you after the operation ?Pt: Yes/No?

Dr: You should have someone to look after you at home for at least 24 hours. They
should stay at your home to look after you. Avoid drinking alcohol, operating machinery
or signing legal documents for at least 48 hours after any operation if it involves general
anaesthesia.

Pt: Ok doctor. Will there be any complications of the operation doctor?

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Dr: There can be infection, bleeding or pain at the incision site. But we will be giving you
antibiotics, and painkillers so the chances of these problems are very less.

Pt: Can it happen again doctor?

Dr: Yes Mr ... Unfortunately, there is a very small risk of recurrence after surgery.
Although the risk is small, yet I would like you to make certain changes in your lifestyle
that will prevent this from happening again.

You have been smoking for many years now. Smoking can make the body tissues weak
and also leads you to coughing and that can make the hernia comes back. I'd request
you to consider quitting the cigarette smoking and if you need any assistance for that
then a lot of help is available. Would you like that? Pt: Yes doctor.

Dr: In addition if you have to strain while opening bowel then also hernia can come back. I
advise you to eat a high fibre diet and drink plenty of fluids to avoid having constipation.Pt: Yes.

Dr: Also, you should Avoid Lifting Heavy Weights following the operation. As you have
told me, your work involves lifting/pushing heavy weights, it is very important that you do
not do it because this could result in reappearance of this or similar swelling on the
opposite side or elsewhere. Is there a way you could change your work type?

Pt: I don't think so. It is my job as a doctor. I have done it all my life.

Dr: I can understand. I advise you to talk to Job Centre and see if you can get any other
suitable job where you won't have to do a physically straining work. Okay? Pt: Okay.

Dr: Also you must Maintain a healthy weight.

Pt:Do I need to come back for a follow up after the operation?

Dr: You should make an appointment for your follow-up visit in two weeks.
Warning signs

Pt: Is there anything I need to be careful about after I go back home?

Dr: If you have fever, bleeding, increased swelling, pain in your abdomen, pain not
relieved by painkillers, persistent nausea or vomiting, coughing or shortness of breath,
increasing redness surrounding your incisions or difficulty passing urine you need to
come back to see us. Is that alright? Pt: Yes, doctor.

Dr: Do you have any other concerns?

Pt: No, thank you doctor. You have been very kind.

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DAY SURGERY
Day surgery is best defined as ‘the admission of selected patients on the day of the
operation to the hospital for a planned surgical procedure, returning home on the
same day.

Common operations done as Day case surgery

1. Inguinal Hernia

2. Varicose veins

3. Termination of pregnancy

4. Cataract

5. SMR ( submucosal resection for the deviated nasal septum)

6. Extraction of wisdom teeth

7. Cystoscopy/TUR of bladder tumor

8. Arthroscopic menisectomy

9. Excision of Dupuytren’s contracture

10. Myringotomy/grommets
● Assess patient’s home circumstances, and for certain types of surgery, access to
the patient’s home.

● Check that an emergency contact number has been given, and that the patient
understands what to do should a problem arise.

● Post-operative support: 24-hour support should be provided from the day

surgery unit.

● Patients with stable chronic disease such as diabetes, asthma or epilepsy are
often best managed as day case as to ensure minimal disruption to their daily
routine.

● Patients should usually be able to mobilize themselves before discharge

although full mobilization is not always essential.

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Criteria for Day case surgery

1. Age less than 70 years

2. ASA Grade 1 or 2

3. BMI less than 30

4. Availability of a responsible adult to care

5. Access to a telephone

6. Live within an hour’s travelling time from the hospital

7. Patients requiring extensive investigation are not suitable for day case surgery

GENERALLY, DAY OPERATIONS SHOULD:

1. Be of short duration

2. Have a low incidence of post–operative complications

3. Not require blood transfusion

4. Not require major postoperative analgesia

* The patient’s last meal should be at least 6 hours before surgery. For insulin
dependent patients, they should skip their morning dose of insulin the morning of the
surgery.

* If a patient has IDDM and his blood sugar well is controlled for the last 3 months, he
is deemed suitable for daycare surgery. He should not take his morning dose of insulin.

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164. Mr Alex Thomas 50 year old man had a fracture ankle 18 months ago
which was fixed with the pins. Now the fracture has healed. He has come
for pin removal.

Do the pre - operative assessment to check his suitability to bring him as day case
surgery and also tell him the preparation for the operation and post operative
management.

Ask if the patient has anyone to look after him at home

Tell the patient if he is fit for day care surgery

Dr: Hello Mr Thomas. I am Dr ….. How are you doing ? --

Pt: I am fine doctor.

Dr: How is your ankle now ?

Pt: It is good, doc . I can walk on that without any problem.

Dr: Good. It is time now to pull out the pins from your ankle. We need to do a small
operation to pull out the pins. You need to be fit in regard to your health as we may need
to give general Anaesthesia (put you to sleep during the time of the operation). I am here to
see whether you are fit to undergo this operation and well as to see whether this can be
done as a day case procedure.

Pt: Are you going to give me general Anaesthesia?

Dr: We may be able to do it under local anaesthesia however if we find any problem
during the procedure we may need to give you general anaesthesia. So we need to
prepare you for the general anaesthesia also.

Dr: Do you know what is day case surgery? Pt: No, doctor.

Dr: We will give you a date for the surgery. You need to come to the hospital on the
same day of the surgery and after the surgery, we will discharge you on the very same
day if everything is fine. Pt: Ok

Dr: I need to ask you a few questions regarding your health and I will be examining
you later and we may also do some tests on you. Is that ok? - Pt: Yes, doctor.

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Dr: How is your general health at the moment? Pt: It is OK doc.

Dr: Do you have any symptoms like Fever? Shortness of breath? Diarrhoea? Pt: No

Dr: Do you have any medical problems at all now or did have any medical problems in
the past ? Pt: Yes doctor I have diabetes.

Dr: Do you take any medications for that ? Pt: I take Insulin doc.

Dr: How many times do you take Insulin?

Pt: I take short acting 3 times a day and long acting one at night (Lantus or ultra lente).

Dr: Do you keep checking your sugar regularly and is controlled well at least in the last
few months ? Pt: Yes doc.

Dr: Did you have any problems during or after the last surgery when we fixed the
fracture? Pt: No

Dr: Do you have any other medical conditions apart from diabetes? Pt : No

Dr: Do you smoke ? Pt: No

Dr: That is good. Do you drink alcohol? Pt : No

Dr: Good. Are you taking any other medications apart from Insulin? Pt: No

Dr: Are you allergic to anything at all? Pt: No

Dr: Do you have any loose teeth or denture? Pt: No

Dr: Any problems in the neck? Pt : No

Dr: Do you have anyone to look after you after the operation ?

Pt: Yes, my neighbour will pick up and take me back home after the operation.

Dr: You should have some adult to look after you at home for at least 24 hours after
we send you home. They should stay at your home to look after you. Do you have
anyone like that to look after you?

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Pt: Ok doctor I will ask my neighbour. They will do that. (If patient says he cannot
arrange anyone to stay at his home to look after him – tell him that we may not be able
to do it as a day case surgery and we may need to keep you in the hospital for a day at
least before we can discharge)

Dr: How far do you live from the hospital?

Pt: It is about 10 minutes drive from the hospital doc.

Dr: Is there anything else which may be important that we need to know? Pt: No

Examination

I need to examine your heart lungs and nervous system and also we need to check
your pulse and blood pressure and check your height and weight. Examiner may say
everything is normal.

Investigations

We need to do some blood tests, heart tracing (ECG), and chest X Ray.

We need to check your blood sugar also.

The examiner may say – all tests normal.

Counselling

Dr: Mr Thomas, with the information you have given, it seems that you are fit to
undergo this operation and we can bring you for day care surgery. However, after we
receive the test results we can say whether you are definitely fit for this procedure and
for day case surgery.

Preparation: You need to come prepared properly for this surgery. You should be on
an empty stomach for at least 6 hours before we do the operation. So please do not
have your breakfast and your morning Insulin on the day of the surgery. When you
come to the hospital we will check the sugar and give the Insulin if required.

Dr: Do you have any concern?

Pt: Doctor last time after the surgery I was sick many times. Will it happen again after
this surgery? In that case can you still do this as day case surgery?

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Dr: Mr Thomas, Sometimes people do vomit after the operation because of the effect of
the anaesthetic medication or as a side effect of pain killer medication. Just because it
happened last time it does not necessarily mean that it will happen this time also.
We can still post you for day case surgery. However, if you do vomit this time, we will give
you an anti-sickness medication and if it helps, then we can send you home.
However, if you continuously keep vomiting even after giving you the anti-sickness
medication, we will keep you in the hospital. So we may not be able to send you home that
evening.

Post – operative management:

After the operation once you recover from the anaesthesia you can have some food and
take your usual insulin. If you take it at that time and wait for some time and if everything is
fine, we will discharge you on the same day.

After the procedure, do not sign any important documents or work near heavy machinery
for at least 24 hours.

Please do not drive until you are able to apply an emergency break without any problem
which may take about 2 weeks.

Also, make someone stay with you to look after you for at least 24 hours after the
procedure.

After the operation – when you go home we will give you our telephone number – you can
contact us if you need any help after the operation. Are you ok with these ?

Pt: Will there be any complications?

Dr: Very rarely, there can be damage to the nerves when we remove the pins and
infection in the operated area later. If there is any redness, pain or pus discharge from
the operated site these are the signs of infection – if you have these - please come
back. Pt: Ok

Dr: Any other questions? Pt: No Dr: Thank you.

DAY CARE SURGERY - PIN (SCREW REMOVAL)

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165. You are the FY 2 doctor in the Orthopaedic department.

A 70 year old lady Mrs Edith Malone fell at home and could not walk after that.
She was brought into the hospital and the X Ray was done which showed fracture
neck of femur. Your Consultant planned to do hemi-arthroplasty of hip joint.

Your colleague has already told her about the operation and Anaesthetic colleague
has already explained her about the pain management.

Talk to her about the post - operative management.

Dr - Hello Mrs Edith Malone, I am Dr …one of the junior doctor in the Orthopaedic
department. How are you doing ? Pt: I am OK doctor.

Dr - I am sorry to hear about what happened to you. Are you in pain now ? Do you
need any pain killers? Pt : It is OK doctor. Nurse just gave me some pain killers.

Dr: Are comfortable to speak to me? Pt: Yes doctor.

Dr: Mrs Malone - do you know what has happened to your hip ? Pt - Yes doc, I was
told that I have a broken bone in my hip.

Dr - That is right, I am sorry about that. Mrs. Jones do you know what we are going to
do for that?

Pt - Yes, your consultant told me I need to have a surgery.

Dr - Yes that is right. We are going to put a new joint to your hip. I was told one my
colleague has already told you about the operation and how we are going to manage
your pain. Is that right? Pt - Yes doc.
Dr – Mrs. Malone, do you have any concerns of what may happen after the surgery?

Pt – Doctor, I am worried because one of my friend had some surgery and she had
some blood clot in her lungs and she became very serious with that. Will the same
thing happen to me also doctor?

Dr: I am really sorry to hear about your friend. Unfortunately people do get blood clots
in the legs or lungs after major surgeries like the one what we are planning do for you.
However, not everyone has this type of operation will get clots. Mrs Jones we take all
types of precautions so that you will not get this problem. Even if you get it we will try
to manage that.

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Pt: Thank you very much doctor.

Dr: Mrs Malone, It is usually the blood clots which develops in the legs which travels to
the lungs. There are lot of risk factors why people get this type of problems. Can I ask
few questions about your health to see if you have any risk factors to develop this clot.
Dr: Can I ask you did you have any blood clots in your legs or lungs before ? Pt: No

Dr: Do you have any medical conditions? Pt: No

Dr: Are you taking any kind of medications? Pt: No

Dr: Do you have any kind of blood disorder? Pt: No

Dr: Any of your family members had blood clots ? Pt: No

Dr: OK. That is good. You do not have much risk factors to develop clots. The chances
of you getting blood clots are low. However, since this is a major operation around the
hip there are still some chances of getting blood clots. As I mentioned earlier we still
take all precautions to prevent you having this problem.
Pt: What will you do so that I will not get clot doctor ?

Dr: We do take lot of measures so that this problem does not happen - like we give
some blood thinner injections to you every day before the surgery itself and also we
continue to give that after the surgery for few days to prevent you getting clots. We
will give you some special stocking ( T.E.D stocking) to wear on your legs – this
improves blood circulation in the legs and also we have some special types device
which also improves the circulation in the legs by changing air pressure ( intermittent
pneumatic compression therapy).

If people lie down on the bed for long time they can get clots in the legs. We will try
to mobilize you as soon as possible after the surgery to prevent you getting clots.
Pt: Thank you very much doctor. How will I know if I get clots in my legs or lungs?

Dr: If you have blood clot in the legs you will have pain and swelling in your calf and if
you get blood clot in the lungs you will have pain in the chest and shortness of breath.
If you develop any of this symptoms you need to inform us immediately. If you develop
this problem at home after we discharge you need to call the ambulance and come to
the hospital immediately.

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Dr: Do you have any other concerns? Pt: When will I walk again?

Dr: As I mentioned earlier we will try to mobilize you as soon as possible either the
same day after the surgery if not the next day itself to prevent clots. However you will
not be able to walk without any support. You will use some type of crutches to support
and also there will be physiotherapist supporting you.

Pt: When will I walk on my own without any support?

Dr: It usually takes about 6 weeks for the operation site to heal properly and the tissues
around that to become strong. So after about 6 weeks you may be able to walk on your
own without any support.

Dr: Any other concerns? Pt: When will I go home ?

Dr: - If you are generally fit and well, we will discharge you within about three to five days.
However we need to make sure that you will be able to cope at home before we discharge
you. Our Occupational therapist will visit your home before we discharge you to check
whether you can cope at home when we discharge you. They will make any adjustments
required so that you can cope at home. You may not be able to walk up and down the stairs
for some time if you have stairs at home. Do you have stairs at home ?

Pt: Yes, I have stairs at home. (sometimes she may say no I live in a bungalow)

Dr: Occupational therapist will look at these problems. They may arrange everything
to be in one floor ( like bedroom kitchen and bathroom) so that you don’t have to go
up and down the stairs until your joint becomes strong ( may be about 3 months).

They will also advise about any equipment you may need to help you to be
independent in your daily activities.
Dr: Any other concerns? Pt: Is there anything I need to be careful about?

Dr: One other problem after this hip surgery is that the joint can easily dislocate means the
bones may pop out of the joint. You should be very careful that this will not happen.

You should take care not to fall. Also physiotherapist will teach you some exercises
after the operation so that that hip becomes strong.

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You should do take care so that the joint will not dislocate like:

 avoid bending your hip more than 90° (a right angle) during any activity

 avoid twisting your hip

 when you turn around, take small steps

 do not cross your legs over each other

 avoid sitting on low chairs and toilet seats.

Pt : When will I be completely be normal doctor ?

Dr - Generally, you should be able to stop using your crutches within four to six weeks
and feel more or less normal after three months, by which time you should be able to
perform all your normal activities. It is best to avoid extreme movements or sports
where there is a risk of falling, such as skiing or riding.
Pt: Can I play ball game?

Dr: You can play ball game after your hip should become strong which may take about
3 months to 4 months.

Dr: Do you drive ? Pt: No

Dr – You should be careful while getting in and out of your car. It is best to ease
yourself in backwards and swing both legs round together. ( Driving is allowed after
about 6 weeks).
Dr Any other concerns ? Pt : No doctor.

Dr: Mrs Jones there could be some other complications which may happen rarely like
infections or bleeding but again we take all care so that these things will not happen.
Thank you very much. Hope you recover soon and go home soon.
-----------------------------------------------------------------------------------------------------

Say these only if the patient ask :

[ Pt - When can I go back to work? - After six and 12 weeks after your operation.

Pt: When can I have sex after this operation ? After about 6 weeks.

Pt - Will I need another new hip? - Nowadays, most hip implants last for 20 years or
more. You may need another operation after about 20 years.]
HEMI-ARTHROPLASTY OF HIP JOINT
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 DEALING WITH MEDICAL ERRORS

1. Assess knowledge
2. Inform about the error if the patient is not aware of it.
3. Check any harm happened.
4. Apologize. Reassure if no harm happened. Inform the patient if any harm happened.

5. Rectify the error if possible.

6. Report the incident/Inform patient to complain if they wish (PALS)
7. Root cause analysis meeting will take place to find the exact cause
8. Take steps to prevent the error from happening again.
9. Inform the patient about the reasons for error – apologise and reassure that
necessary steps will be taken to prevent it happening again and appropriate
actions will be taken against the person who was responsible for the error.

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166.
You are an FY2 doctor in A & E Department.

A mother brought her 2 year child to the A&E department for swallowing of foreign
body.

You examined her and did the X Ray. You thought the X-ray was normal and
discharged the child.

Later on, the Radiologist called and said there is some button (foreign body) in the
Oesophagus of the child.

Call the mother who is at her home over the telephone and tell her to bring the child
back to the hospital.

[X-Ray may be on the table – Look at the X Ray before you call the mother].

Mother and child information (Name and address) may be written on the table –
confirm that with the mother.

Dr: Hello I am Dr ... a junior doctor from the accident and emergency department of
the hospital. Are you Amie’s mother speaking?

Mother: Yes Dr I am. What is the matter, doctor?

Dr: Actually, Ms Jane you brought your daughter to the emergency in the morning. Is
that right? Mother: Yes
Dr: I am the same doctor who saw your child and did the X Ray. I told you that her X-
ray is normal and told you that you can take her home. Mother: That is right.

Dr: How is she now? Mother: She is fine now.

Dr: That’s good. Ms Jane, our Radiologist had a look at Amie’s X ray again. He said
that there is some foreign body in her food pipe. It looks like a button. I am really sorry
that I told you that the X Ray does not show any foreign bodies. Mother: Ok
Dr: Do you have any idea what she might have swallowed? Any button from any dress
missing do you know ?

Mother: Yes doctor she was wearing a buttoned shirt today. I don’t know now whether
any buttons missing.

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Dr: Alright. Is she having any sort of breathing difficulty? Mother : No

Stridor might also occur if there is partial obstruction.

Chest pain might be suggestive of oesophageal perforation

Dr: Is there any other problem like drooling from her mouth? Mother : No

Dr: Did she pass stool? Mother: no

Dr: Is she eating and feeding well?

Mother: She ate and drank after I brought her back and she is fine.

Dr : Did she vomit? Mother: No, doctor, she is completely alright.

If the child vomited, ask if she saw any foreign body in the vomitus.

Dr: did she pass stool? Mother: no.

Dr: Okay, that is good. Ms Jane can you please bring her to the hospital for further
assessment. Would that be alright?

Mother: I don’t get it if she is alright, why do I have to bring her to the hospital? I am
getting late for work.

Dr: I am really sorry, Ms Jane about the problems you have to go through because of
the missed finding. But as it is shown in the X ray that the foreign body is in the food
pipe (oesophagus), she requires observation and reassessment. We may need to do
some procedures to remove it if required. For that, you have to please bring her to the
hospital immediately.

Mother: Is she in any danger?

Dr: I am really sorry to say this because sometimes the object which is in the food pipe
can get stuck there and may not go down or if it is some type of poisonous objects,
then it can cause damage to the food pipe.

But as she is having no symptoms so hopefully there is nothing to worry about. When
she will gets here, we will assess her again. We will treat her depending on the level at
which the foreign body is in the food pipe.

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If we think it may cause problems especially if it is still in the food pipe, then we will try
to remove it. But if it has already gone down to the stomach, then it may not cause any
problem, then you can take her back because it will pass out on its own. Is that ok?

Mother: But why did this mistake happe?

Dr: Mrs .. Actually, I made the mistake as I told you. I am a junior doctor here and I am
not that experienced in reading the x-rays. It was not easily visible in the X Ray. Only
the expert doctor that is a radiologist could see that. However, I do apologize for the
incident. I will go for some courses and learn how to read the X Rays very soon. Also I
will always ask my seniors opinion before I treat or discharge patients. I will reassure
that such a mistake will happen again Mrs…

Mother: That is fine. I don’t have a car. I don’t even have money to pay for the taxi. I
can’t come.

Dr: I am really sorry for the incident again. Mrs… We can send an ambulance. Can you
please bring your child in the ambulance? Mother: Yes, doctor.

[sometimes she may say that she has not time at all – in that case, say “Is that ok if
we send the social services – can you please send Amie with them?” Mother – Ok]

Pt: Once again, I am really sorry, Ms Jane for causing you all the problem to come to
hospital again. I am really regretful and I apologize that it was missed in the morning. I
am really glad to hear that Amie’s is doing alright at the moment. We will see her
again soon. Mother: Yes, doctor.
Dr: I will be reporting this incident to my seniors. If you want you can also make a
formal complaint about this. We have a special department called PALS (Patient
advisory liaison service) who will assist you regarding this when you come to the
hospital. Mother: Okay doctor.

Dr: Do you have any other concern, Ms Jane? Mother: No.

Dr: Okay hope to see you and Amie in the hospital again soon.

TELEPHONE CONVERSATION WITH MOTHER ABOUT

CHILD HAVING A BUTTON IN X-RAY

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ADDITIONAL INFORMATION ON SWALLOWED FOREIGN BODIES (FB)

A. BACKGROUND

Ingested foreign bodies rarely cause problems. However when problems do occur
it can be life threatening e.g. oesophageal rupture, aorto-oesophageal fistula,
tracheo-oesophageal fistula. The following guidelines have been developed
following multi-disciplinary consensus agreement based on current best-practice.

B. NON-HAZARDOUS, SWALLOWED FOREIGN BODIES

Non-metallic and non-hazardous Metallic, non-hazardous object

objects. Eating OK.

Metal detector

Negative OR positive and below xiphisternum Equivocal OR

level. Eating OK. positive and above xiphisternum level

AP CXR. If not seen or if symptoms dictate, consider AXR and / or lateral soft tissue XR of neck

Seen in upper 1/3 oesophagus OR

Seen below upper 1/3 oesophagus
not seen but likely to be a
ie. below level of clavicle
radiolucent FB

Eat and drink plus repeat metal detector

Still detected above Refer to Paediatric surgeon not

Detected below xiphisternum level
xiphisternum level ENT

Reassure but DO NOT instruct parents Consider foley balloon catheter removal
to inspect faeces for FB. Clinical / (especially for coins)
radiological review only if symptomatic

Admit for endoscopy under GA

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C. HAZARDOUS, SWALLOWED FOREIGN BODIES

Hazardous = sharp object, very large object, button battery or filled balloons

Additional Points:

If history of coughing or choking, consider inhalation of foreign body If there is evidence

of complications, films should be requested.

A metal detector will pick up aluminium, e.g. can ring-pulls, which may not be seen on an
X-ray.
D. INGESTION OF BUTTON BATTERIES Background

These batteries can be dangerous if ingested as the seal on them is dissolved by

gastric acid and the contents are toxic. There is also a danger of local erosion of the
mucosa by current passing from the battery, if the battery is a fresh one. If possible,
obtain the battery details from the packet of another battery of the same sort and
contact the poisons centre via toxbase for more up to date information.

Management

- All children who have swallowed a battery should have an X-ray of the chest (and
abdomen if not visible on CXR) to locate the battery as soon as possible. A metal
detector is unreliable, as some batteries cannot be detected by the use of a metal
detector.

- If the battery is in the oesophagus, urgent referral to the Paediatric Surgeons is needed.
- If the battery is below the diaphragm, the child can eat and drink normally. Repeat
the AXR after 12 hours, or as soon after this time in order to be done in daylight hours.
The child can go home between films, providing the parents are instructed to bring the
child in sooner if any abdominal symptoms develop.

- If the battery has not moved on the second X-ray, refer to the surgeons urgently.
The battery may have become adherent to the gastric mucosa, leading to a high risk of
erosion.

- If the battery has moved position below the diaphragm and is not fragmenting
(i.e. out of the stomach) the patient can be safely discharged.
Do not instruct parents to “look for FB in the stools”.

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167.
You are an FY 2 doctor in the A&E Department. 8 year child Amie was given oral
amoxicillin for a chest infection and was sent home from the A&E department last
night. She has developed a rash. Her mother, Mrs Jenny Carr, has some concerns.
Talk to her.

Acknowledge the error, apologize profusely, ensure the patient is not in immediate
danger, inform about incident report form, root cause analysis, and further means of
escalation.

Dr: Hello, I am Dr ... one of the junior doctors in the department. Are you Amie’s mother?

Mother: Yes, Dr.

Dr: How can I help you?

Mother: Doctor, I brought my daughter last night because she had a fever and cough.
The doctors here told me she had a chest infection. They gave some medications to
her to take at home. I gave the medicines to her and now she has developed rashes.

Ask how the daughter is doing now.

Dr: Oh I am really sorry about that Mrs...... Do you know what medications was that?
Mother: Amoxicillin

Dr: How many times did you give this medicine to her? Mother: Twice.

Dr: Which part of the body does she have the rashes? Mother: All over her body.

Dr: Is the rash spreading?/Is it widespread? Mother: No

Dr: Is the rash painful? Mother: No (for Toxic epidermal necrolysis - Steven
Johnson)

Dr: Is it itching? Mother: Yes/No

Dr: Does she have any SOB? Mother: No

Dr: Does she have a sore throat (Infectious mononucleosis)? Mother : No

Dr: Swelling anywhere in body especially face and lips? Mother: No

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Find out if she’s drinking and eating well.

Dr: Does she have any fever (meningitis, Pneumonia)? Mother: No

Sometimes, the mother may say that her child developed allergic rashes straight
away and ask you - why are you asking other questions ?

Dr: May I know why do you think it is allergic rashes ?

Mother: She has had this allergic rash before.

Dr: May I know when?

Mother: A few months ago. She was given the same medicine and she developed
rash. I was told that she is allergic to Amoxicillin.

Dr: You may be right, Mrs... It could be an allergic rash. I still need to make sure that
it is not due to any other serious medical condition like meningitis, because as you
may know, there could be rashes even in meningitis.

Dr: Does she have any headache, Neck stiffness (meningitis)? Mother: No

Dr: Lumps or bumps anywhere in the body? Mother:... (lymphadenopathy for Drug
hypersensitivity syndrome, infectious mononucleosis)

Dr: Is this the first time this has happened?

Mother: No actually, it happened five months ago as well....

Dr: Was it the same medication? What problem was the medication given for back
then? Symptoms at that time? Mother: … She was given the same medication. She
had a rash that time also.

Dr: Were you told that she is allergic to amoxicillin. Mother: Yes

Dr: Has she been diagnosed with any medical conditions? Mother: No ...

Dr: Does any of her family members have any medical condition such allergies ? Mother: No

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EXAMINE:

Tell the examiner - I would do a general physical examination including BP and Pulse.
Also I need to examine her face for any swelling and also have a look at the rash.

Mother shows the picture

Mother: What has happened to my daughter?

Dr: Mrs .... I think these are allergic rashes due to Amoxicillin.

Mother: Is she going to be fine? Is it dangerous?

Dr: Mrs .... I can understand why you are so worried. Sometimes, medication allergies
can be serious, but thankfully she is not in danger as the rash is localized with no other
symptoms. She is in good hands, and we will ensure that she is well treated and
completely alright.

Mother: What will you do now?

Dr: We will be admitting her and keeping her under observation for sometime. We will
stop the Amoxycillin immediately. We will look for any worsening of symptoms. Is that
alright? Mother: Yes .

Dr: We will give her some medication known as an antihistamine syrup by mouth and some
medication to apply locally on the rash which will be a mild steroid. The rash will take a week
almost to clear out. We will also give some other antibiotic for her chest infection.

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Dr: Is she allergic to Erythromycin? Mother…: No

Dr: Maybe, we can give Erythromycin to her. I will talk to my seniors and then we will
give that antibiotic for her chest infection.

Dr: Were you asked about any allergies before giving the medication by the staff? Did
the doctor tell you what medication he was giving you?

Mother: No one asked me about it.

Dr: Oh, I am really sorry about that. This question is one of the routine and important
questions we should ask before giving any medication.

Mother: Why did no one ask me? Why did they give that medicine to her?

Dr: As I mentioned earlier, whoever gave the medicine should have asked for allergies before
giving the medicine. This is a mistake on our part. I am really sorry for what happened.

Mother: Will it happen to her again, Doctor?

Dr: Mrs...If she’s given again. We need to be careful because it is likely to happen again
if the medication amoxicillin or any medication from the class penicillin is given to her. We
will give you all the necessary information in written form on the discharge paper. In the
future, if you take her to the doctor or hospital, please mention the allergy. We will also
update this information in all her electronic medical records. You should also educate her
about this as she grows up. Would that be alright? Mother: Yes

Mother: Can this allergy be prevented anyway?

Dr: Yes, we will be documenting details of everything regarding this incident and also
the previous incident. You should carry this document with you at all times. So that it
can be shown to any health care professional to prevent it from happening again.

In addition, we can give a test dose before giving any new medicine that is known
to cause allergy. If the person is found allergic to it, we give an alternative medication.
Are you following me?

Mother: Yes, doctor. What will you do in the future so that these things will not happen
again to others?

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Dr: I really appreciate your concerns. Your feedback is very important. We are
constantly looking for ways to improve our health system. I will inform my seniors
about this. We have something called a root cause analysis meeting where we discuss
any such issues and we take all the steps to rectify any such problems and prevent it
from happening again. You can also help us by reporting the matter. We have a
separate unit to deal with such concerns known as PALS (Patient advisory liaison
service). Also mention incident form. Mother: Okay

Mother: Will she have any scar because of this allergic reaction?

Dr: Allergic rashes usually heal completely without leaving any scar. Please do not be
worried about it.

Dr: Is there any other way I can help you?

Mother : No, doctor. Thank you.

Dr: Hopefully ... will get better soon. If you have any concerns later on don’t hesitate
asking. Thank You.

MEDICAL ERROR - RASH AFTER AMOXICILLIN

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168. You are an FY2 Doctor.

65 years old Mr. Pat Harding was diagnosed with Pneumonia 4 weeks ago.

On looking at his notes, you noticed that at the time of his presentation, an X-ray
of the chest was done. He was told that his X-ray result showed chest infection and
he was admitted for a week and was given IV antibiotics for 2 days and then later
on oral antibiotics.

Today, you have received a call from the Radiology Department. You are informed
about the mixing up of X-ray Reports. Mr. Pat Harding's X-ray report is reanalyzed
and is found to be normal.

Your consultant believes that he was misdiagnosed with Pneumonia and

unnecessary antibiotic treatment was prescribed to him.

Mr. Pat is here with you today for the follow-up. Talk to him, tell him about the
error and address his concerns.
Apologize for unnecessary admission and antibiotics

Dr: Hello Mr. Harding. I am Dr …. One of the junior doctors in the medical department.
How are you doing today? Pt: I am ok

Dr: Can you please tell me in detail what happened last time ?

Pt: I had some chest symptoms. I came here about 4 weeks ago and the doctors did
the chest X ray and they told me I had a chest infection. I was admitted for a week.
They gave me antibiotics through my veins. I have improved now.

Dr : Which antibiotic? Pt: Amoxicillin.

Dr: Any chest symptoms at all now? Pt: No. I have improved completely now.
Thank you very much for treating me, doctor.

Dr: Mr Harding, I need to tell you something. A mistake happened at that time of your
previous presentation. The doctors did your Chest X-ray at that time and they told you
that you have infection in your chest because they thought your chest X ray showed
chest infection. But in reality, this was not the case.

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Unfortunately, another patient's report was mixed up with your X-ray report. The
doctors misdiagnosed you with pneumonia and you were started on antibiotic which
was unnecessary. Your test result was later on found to be completely normal. I am
very sorry to say this. I sincerely apologise on behalf of the hospital. This should never
have happened.

Pt: What!!! But why did this mistake happen?

Dr: Mr. Harding, as I have told you another patient's test results got mistakenly mixed
up with your reports. I can only apologise to you now.

Pt: You doctors are very irresponsible. Why did the X-Rays gets mixed up?

Dr: Mr Harding.. I can see that you are very upset. I can perfectly understand that.

Whenever we check any test results like blood tests or X Rays, we doctors are
supposed the check the identity on the X ray before we read the X Ray. I guess
whoever saw the X ray at that time did not check the identity properly or some other
problem has happened. I am really sorry about this Mr. Harding. We usually take the
maximum caution to prevent such mistake happening.

Pt: Who is responsible for this mistake?

Dr: We do not know exactly who is responsible for this at this moment but we are
going to look into all this.

Pt: You people do not care for other people's lives.

Dr: I am really sorry for what happened. I can certainly imagine why you are feeling
that way. We do care for everyone but sometimes mistakes do happen. We do take all
the measures so that mistakes do not happen. Mr… did you have any problems
because of this medication what we gave last time ?

Pt: I had sickness and loose stools unnecessarily.

Dr: Mr… you had to go through all those problems unnecessarily. I sincerely apologize
for what happened.

Pt: Will I develop any long term problems with this antibiotics?

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Dr: I'd like to reassure you Mr. Harding that no serious complication will happen in
long term. Very rarely, bugs can develop resistance to this antibiotic but other than
that, there will be no potential threat to your health at all.

Pt: What will you do so that these mistakes will not happen again ?

Dr: We will investigate this matter further. We have a procedure where we report such
incidents to the appropriate authorities. We have something that we call “Root Cause
Analysis meeting” where we discuss such matters and take appropriate actions so
that these mistakes do not happen again. Also, some actions may be taken over
defaulting persons.
We will educate staff, provide better supervision for juniors in every department, We
will instruct everyone to check the identity properly on any test results and may be a
mandatory training for staff about dealing with such problems.
Mr Harding, if you like to escalate the matter further, you can do it. We have a
dedicated department for this what we call “ Patient Advisory Liaison Service” – you
can talk to them about it.

Pt: Thank you, doctor, I will consider that.

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

MISDIAGNOSED PNEUMONIA AND

UNNECESSARY ANTIBIOTICS

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

Father: I am fine. I was told to come back. What happened, doctor?

Dr: I was told that your son had a wrist injury. Can you please tell me in detail how it
happened and what happened here in the hospital and what was told to you?

Father: He fell down from the sofa / he fell while playing in the garden – 2 days ago and
he had pain and swelling in his wrist. I brought him here. Doctors did an X-Ray and they
told me that he had no bony injury and he has only injured his muscle. They prescribed
some pain killer medications for him.
Dr: Yes. Mr… That is what I understand from his notes. But Mr… I need to tell you something
about it. After he was discharged from the hospital Radiologist saw the X-ray and that your
son’s X-Ray showed a small fracture in the wrist bone what we call a hairline fracture.
Unfortunately, the doctor who saw your son did not see that fracture, and he thought there was
no fracture. I am very sorry to tell you that this mistake happened.

Father: What …mistake happened!!! How is it that the doctor did not see the fracture if
the other doctor can see that?

Dr: Mr… I cannot tell you why exactly the mistake happened. The fracture is what we call a
hairline fracture which is very difficult to see in X-Rays unless one is very experienced in reading
the X-rays. A radiologist is an expert doctor in reading X-Rays, so he could see that. The doctor
who saw your son … is not that much experienced in reading X-Rays. Maybe, that is why he
missed the fracture in the X-ray. Once again, I am very sorry the mistake happened.

Father: This is ridiculous. How can you keep such inexperienced doctors to treat patients?

Dr: Mr… I can see that you are very upset. You have all the reasons to be upset. We do
have junior to senior doctors in every department. Whenever junior doctors have any
doubt about anything, they are supposed to consult the senior doctors before they treat
the patients. Maybe the doctor who saw your son had no doubt in his mind about the X-

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Ray. Maybe that is why he would have missed the fracture. However, at the moment I
cannot tell you for sure why this mistake would have happened.

Father: So what will happen to my son now?

Dr: Mr… First of all thank you very much for bringing your son back here. My seniors will
see him now. We will do another x-ray. The bone specialist will decide what to.
Depending on the degree of fracture and if the arm has bent then we may need to
manipulate (do some procedures) to straighten that bone and then we may have to put a
cast (like a plaster or splint) or his wrist and arm to treat the fracture.

Father: How long will he be on cast?

Dr: Usually it takes about 3 to 4 weeks for the fracture to heal. So he may need to be on
the cast for 3 to 4 weeks.
Father: Can these type of mistakes keep happening again and again?

Dr: I can imagine why you are feeling so upset about the incident. I would like to
reassure you that I will report this incident to my seniors. This incident will be taken very
seriously. In fact, we have something we call a “Root cause analysis meeting” where
we discuss this type of issues and take necessary steps so that such incidents will not
happen again. Hopefully this type of mistakes won’t happen again.

Father: I want to complain about this.

Dr: Surely Mr..you have all the rights to complain. We have a dedicated department for
this what we call as PALS (Patient Advisory Liaison service). You can talk to them and
they will help you to put formal complaint.

As I said before, I will also talk to my seniors about this. I am sure appropriate action will
be taken. Any other concerns? Father - No

Dr: Again I am very sorry for what happened. I do sincerely apologise on the hospital’s
behalf for the incident. Thank you very much for bringing your son back to us. I am sure
your son will recover soon.

An alternate question might state that the orthopaedic doctors have already seen
the child and have decided to put a cast and review in 2 weeks.

MISSED HAIRLINE WRIST FRACTURE IN A CHILD

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170. 21 year old presents with suspected post streptococcal glomerulonephritis.

A renal biopsy was done 2 days ago. The lab said they did not receive the
specimen. Talk to the patient about the missed sample.
Dr: Hello Mr.... I am Dr.... How are you doing? Pt : I am fine, doctor.

Dr: Can you please tell me what symptoms you had? Pt : ...

Dr: How are your symptoms now? Are they the same or getting worse? Pt : Same.
He said yes doctor please tell me about the results. I told him I'm here to talk to you about
your test result but would it be okay if we have a quick discussion about your general health
first? He agreed
So I asked him why did you have this procedure done in the first place?
How did he find the procedure?
How are you doing now?
Then: MAFTOSA
Medical condition, Medication
Allergy family hx
Occupation
Smoking, Alcohol.
Then I said I will also examine his vitals to make sure he is fine.

Dr: Mr... 2 days ago, we did a procedure on you to take a sample - what we call a specimen -
from the kidney to test the condition you have - do you remember? Pt : Yes, doctor.

Dr: Mr... (I wish I had better news for you today but your sample is missing) I am
extremely sorry to say this, the specimen that we took is missing. We are not able to
trace it. I sincerely apologize for this.

He was yelling all the time I was answering with I'm sorry I can imagine what you
are feeling right now.

Pt : What? How can this happen?

Dr: Mr... After the procedure, we sent the specimen to the lab but the lab is now
telling us that they did not receive the specimen. We have tried our best to trace it but
we could not. I am very sorry once again.

Pt : How can you people be so irresponsible?

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Dr: Mr.. I can imagine how you may be feeling now. I am really sorry for what
happened. Usually, we are very careful so that these mistakes do not happen. But
unfortunately, some mistake happened somewhere and the specimen is missing.
Pt : I do not understand – if you are so careful, how can the specimen go missing?

Dr: Mr... I can see that you are very upset. I can perfectly understand. You have all the reason
to be upset. Usually, after we do a procedure, we label the specimen and then someone takes
the specimen to the lab. So the mistake could have happened anywhere from labelling, or
taking the specimen to the lab, or collection at the lab or it could have been lost in the lab. At
the moment, The mistake could happen at any point of this chain and we are looking at that
right now. Such mistakes are taken seriously by the hospital. I cannot tell you where exactly
the mistake happened. We are trying to find out what really happened. He was shouting and
kept saying you are careless and is that frequent? tell him that such mistakes are not
common
Pt : Who is responsible for this?

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

Pt : So what will happen now?

Dr: Mr.. I would like to reassure that there no serious harm has happened. However,
since the specimen is missing, unfortunately we need to take the specimen again. I
see you are frustrated and disappointed. I know it was a painful experience but I'm
afraid to tell you that we need to take another sample. Will that be ok Mr...?
Pt : impossible. Is it my mistake? Dr: no it's a mistake from our side.

Pt: you will lose it again you are careless, What will you do so that this will not happen again ?

Dr: I really understand why you are think that way but we will reassure you that we
will take the utmost care this time so that this mistake will not happen again. If you
give us another chance we will give you the first possible appointment and I will
supervise your sample myself at every step of this chain and I can update you at
every step that your sample is sent to the lab and that is now processed and so on.
Mr--- it's very important step of your treatment and your health is a priority.

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Pt: even If I go through that again it will be in a different place.

(( I apologized and validated his worries and asked him to give us another chance
he said I will complaint about this I told him it's your right. He was yelling and the
bell rang on him speaking in the exam I didn`t finish to the end but I got 11 in the
station)).
Pt : I want to complain about this.
Dr: I perfectly understand your feelings. You can surely put a formal complaint about this. We
have a dedicated department called PALS (that is patient advisory liaison service) and
they will help with the complaint procedure. I can reassure that this complaint will be taken
very seriously and appropriate action will be taken.
Pt : What will you do so that this mistake will not happen to others?

Dr: I really appreciate your concerns for others. We have something called a root cause
analysis meeting where we discuss this issue to find out why this happened and we
take all the measures so that this kind of mistakes do not happen again.

Any other concerns? Pt : No

Dr: Once again, I sincerely apologize for the mistake. I will do the procedure again
now and I am sure you will feel better after the treatment. I wish you a speedy
recovery. Thank you again for listening to me.

MEDICAL ERROR - MISSED RENAL BIOPSY

SAMPLE

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171. You are the medical FY 2 on the cardiology ward. 35 year old Mr
Michael was admitted with a chest pain 3 days ago and was treated for
Acute inferior myocardial infarction. Now he is stable on medical
therapy.

On looking at his notes, you noticed that 2 days before his admission, he attended
the emergency department complaining of chest pain and he was told that his
ECG is normal and it was a musculoskeletal pain. Your Cardiology consultant
noticed that he had a high troponin levels at that time and no one had checked the
result. In addition, there was a T wave inversion in the ECG.

In spite of this, he was sent home. After discharge, he had chest pain constantly
and then he came back 3 days ago and was admitted. Your consultant believes
that his diagnosis was missed by the emergency department as there was no
follow up to the blood results. Assess him clinically and speak to the patient about
what happened.

Dr: Hello Mr Michael? I am Dr …. a junior doctor in the Cardiology department.

How are you doing today? Pt: I am OK doctor.

Dr: Any chest pain? Palpitations? Swelling in your legs? Pt: No

Dr: I need to examine your chest. Examiner says – chest is normal

Dr: I will check your ECG. Examiner says – ECG normal.

Dr: Mr Michael everything seems to fine now. You are recovering well.

Dr: I need to talk to you about your condition. Do you know what exactly has
happened to you?

Pt: I am told that I have a heart attack.

Dr: Yes, that is right. We have treated you for that now. I understand you came to our
hospital A& E department 5 days ago. Could you please tell me why you came to the
hospital that time and what happened in the hospital ?

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Pt: Doctor, I had pain in my chest. I came to the A&E department. They did some tests
and told me I have muscle pain and my heart is fine. I was told to go home.

Dr: Yes that is right. That is what we found out from your notes.

Dr: Mr Michael, I need to tell you something - there was a mistake happened at that
time. The A& E doctors did the ECG at that time and there were some changes in the
ECG but they thought it was normal and they also did some blood tests which are
specific or heart attack.

They told you that you do not have any problem in the heart because they thought the ECG was
normal, and also they did not check the blood result which actually showed that you had a heart
problem that time. We should have kept you in the hospital and treated you for the heart problem
that time itself. I am very sorry to say this. I do apologise on behalf of the hospital.

This should not have happened.

Pt: But why did this mistake happen?

Dr: Mr Michael, I do not know why this mistake happened. I can only apologise to you
now. I assure that you are fine now and no serious harm has happened to you.

Pt: Who is responsible for this mistake?

Dr : We do not know exactly who is responsible for this at this moment but we are
going to look into all this.

Pt: You people do not care for others’ life! I would have died!

Dr: I am really sorry for what happened. I can imagine why you are feeling that way.
We do care for every one but sometimes mistakes do happen. We do take all the
measures so that mistakes do not happen

Pt: What will you do so that these mistakes will not happen again?

Dr: We will investigate this matter further. We have a procedure incident form where we
report such incidents to the appropriate authorities. We have something we call a “Root
Cause Analysis meeting” where we discuss such matters and take appropriate actions so
that these mistakes do not happen again. Also, some actions may be taken over defaulting
persons.

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We also educate staff, provide better supervision for juniors in A&E and maybe a
mandatory training for staff about dealing with chest pain and may also include asking
to lab staff to call doctors if blood test results shows some serious conditions.

Pt: I would like to talk to your Consultant.

Dr: Surely you can talk to my Consultant. I will let him know about it. Mr Michael, if you
like to escalate the matter further you can do so. We have a dedicated department for
this that we call a “Patient Advisory Liaison Service”, you can talk to them about it.

Pt: Thank you doctor, I will consider that.

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

MEDICAL ERROR - MISSED MI

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172. Telephone Conversation

As part of pre-op assessment (herniorrhaphy) of a patient, you took samples for FBC,
EUCr. The laboratory denies the receipt of the samples. It appears you were too busy in
the clinic and you forgot to label the samples. Call the patient and tell the patient to
come back so you can re-collect the samples. Patient has been informed you will be
calling. Patients name, address, DOB and hospital number given.

General overview of unlabelled blood sample case which came in my exam ...
I scored 11 with this approach. Phone conversation
I introduced myself (dr..., talking from gmc hospital)
I confirmed pt name
Pt age
Pt’s address
Pt’s telephone number in case phone line disconnects
(These are must do steps in case of telephone conversation)

How is the pt doing?

A bit of recap of yesterday’s events that the patient came in and I took blood sample (at this point the
patient said yes doctor and I was expecting a call from you)
I told the patient that I have something to discuss with him. Then, said I am really sorry to tell him this
that when I took your blood sample and sent it to the lab we usually label it but in your case I made a
mistake and unfortunately I forgot to label it ... I apologized once again
The patient did not get angry my tone of voice was very sweet and apologetic.
And then I offered solution. (I said give me a chance to fix things for you)
First I asked him if he lives near the hospital... when is he coming near this area next time... he
refused to come before his surgery so I talked about offering phlebotomist ( a person who takes blood
sample) to his house for taking blood
He agreed and told me I am very kind.
I was very apologetic throughout and reflected his anger and emotions and inconvenience etc
He asked how can I make sure this doesn’t happen again... i talked about following his sample this
time, making sure it is labeled, and documenting this, discussing this with seniors and taking
necessary actions to improve our services ...
Then I did MAFTOSA in the end, asked about his care as it was knee operation... and did safety
netting. Finished it in 6 min... The examiner was v happy in the end gave me a big smile.

MEDICAL ERROR - UNLABELLED BLOOD

SAMPLES

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CONCERNED/ANGRY PATIENTS

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173. Mrs Zainab ... was treated for heart failure after she suffered a heart attack. Now
she has developed haematuria while she was being treated for heart failure. All
investigations have been done to find the cause of the haematuria but no cause
has been found.

Her son/nephew Mr Sanjay ... wants to talk to you. Talk to him and address his concerns.

Mother has given consent to talk to the son.

The question can be changed where there is no history of bleeding. It only says – Lady
treated for heart failure. Son is concerned - talk to him.
Talk about haematuria only if mentioned in the question! If the question did not
mention if the cause of the haematuria had been found — then just mention that we
will try our best to find the cause and treat it. The question might say that the patient is
not eating well.

Dr: Hello Mr Sanjay … I am Dr…. How are you doing?

Relative: I am fine. I want to know what is happening to my mother/aunt

Dr: Surely, I will tell you everything. Before I tell you about her, can you please tell me
how much you know about her so that I can explain better about her ?

Relative: I know that she has a heart problem/I know that she had heart failure.

Dr: That is right - we are treating her for that. Do you have any concerns Mr Sanjay ..?

Relative: I was told that she has blood in her urine. Is that true, doctor?

Dr: That is true, Mr Sanjay … Relative: So why has she got the blood in the urine?

Dr: Mr Sanjay .… There are many reasons why one could have bleeding in the urine.For example
one of the reasons is that it can happen after we insert a urine catheter to drain the urine.

Relative: But she had the catheter 10 days ago. I was told that the bleeding will stop in
a few days if it is due to the catheter. Why does she have the bleeding even now?

Dr: You are right Mr Sanjay .… If the bleeding is due to catheterisation, usually it will
stop in a few days. However, sometimes it can last for a longer period if there are any
other medical causes contributing to it. We do not think that is the cause because we
have done investigations and could not find the exact cause.

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Also, there are many other reasons why the patient can have bleeding in the urine for
example - if the patient is taking any blood thinner medication or if they have any
bleeding disorder. Sometimes, if there are any other medical conditions affecting the
kidney or urine tract also there could be bleeding in the urine.

We have looked into almost all the reasons but unfortunately so far we have not been
able to find the actual reason for her bleeding.

Relative: You have been doing investigations for such a long time and still you do not
know why she is having bleeding. You doctors are very careless.
Dr: I am very sorry if you feel that way. I can imagine why you are so upset. But Mr…
We do care for all the patients. I can reassure that we are doing our best to find the
cause. Hopefully, we will know the cause soon and we will be able to treat her soon.

Relative: You have been telling me this for so many days. No one is telling me what is
happening here. I was told that she is not eating well? Why is she not eating well?
Dr: May I ask how you know about this? When did you notice this? Relative ....

Dr: Sometimes, when people are ill, they lose appetite. That could be the reason. Or
she might not like the hospital food. However, we will look into this and let you know
what is happening.

Relative: Yesterday, I called the nurse asking about my mother but the nurse told me
she has many patients here and she has no time to talk to the relatives.
Dr: I am really sorry if that has happened, Mr Sanjay. Sometimes, the nurses can’t give
the patient’s information over the phone to others because we are supposed to keep
the patient information confidential. We have to be sure about whom we are speaking
to, and in addition, we need to make sure that we have the patient’s consent to talk to
the relative about them before we can speak to the relatives about the patient over
the phone. It could have been for any of these reasons. However, if they had consent
to talk to you and they were sure of whom they were talking, then they should have
explained everything to you however busy they are. She could also have called you
back. I do apologise for the incident. I will certainly inform my seniors about it and
they will talk to the nursing supervisors. I am sure they will enquire about this matter
and appropriate action will be taken.

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Pt: Moreover, I came yesterday and asked a doctor, he said he does not know why she has
this bleeding. He told me to come today and talk to you. You also do not know why she is
bleeding. Is this how you take care of her?

Dr: I am really sorry to hear that. Maybe the doctor whom you spoke yesterday was not the
one looking after Mrs Zainab. He may have been one of the doctors in the on- call team.…
That is probably why he would have told you to come and speak to us today.

Relative: Are you the one looking after my mother/Aunt ?

Dr: Yes, I am one of the team of doctors looking after Mrs Zainab …

Relative: How come you also do not know why she is having this bleeding ?

Dr: Mr… I can see that you are a very caring son/nephew. I really appreciate your
concerns for her. As I told you, we are doing our best to find the cause and hopefully,
we will be able to treat her soon.

Relative: I want to speak to your Consultant.

Dr: Mr Sanjay … Surely you can speak to my Consultant. He can explain everything in
detail to you.

Relative: Is he also going to say the same thing that he also does not know why she is
having bleeding?

Dr: Mr… I am afraid he too will say that we do not know the cause of the bleeding at
the moment.
However, he may be able to answer you better if you have any other concerns about her.

Relative: What is the point of talking to him then? No one knows what is happening to
her. No one tells me what and why these things are happening to her.
Dr: Mr… I am very sorry you were not informed on time. I will make sure that we will
keep you informed about her condition all the time.
Once again I am very glad that you came all the way up to here to talk to me about
you mother/Aunt. It shows me how much of a caring son you are. I really appreciate
that. We will give her the best possible care. I am sure she will recover soon from all
her problems. Thank you very much for talking to me.

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Relative: I want to complain about this.

Dr: Mr Sanjay … Surely you can put a formal complaint if you are not happy with the
care given to her. We have a dedicated department that we call PALS, and they can
help you with this. I am sure all the necessary steps will be taken to make sure that she
is taken care of properly. Anything else I can help you with Mr….?

Relative: Nothing else.

Dr: Thank you Mr…

LADY WITH UNEXPLAINED HAEMATURIA

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174. 62 year old female, who is a known case of breast cancer presents with
back pain. Talk to her about the pain management.

Sympathy and empathy is very important in this station

Ask if she knows why she is having back pain.

Dr: Hello I am Dr .... I am one of the junior doctors in the department. Are you Mrs ....?

Pt: Yes doctor.

Dr: How can I help you?

Pt: Dr I have pain in my back for the past four months. I don’t want to have this pain.
Please do something doctor.

Dr: I am really sorry about that Mrs..... it must be really distressing for you. We will
definitely help you. Can you tell me more about the pain?
Pt: Yes, I have had it for the past four months. I have been taking Paracetamol for it -
two tablets 4 times a day. Now I have to attend this wedding in the next few days. I
don’t want to be in pain.

Dr: That must be very difficult for you. Can you grade your pain for me? Like on a
scale of one to ten how will you grade your pain? Pt: …

Dr: Are you comfortable enough to talk to me now? Pt Yes

Dr: Do you have any idea why you have this back pain?

Patient may say that she had breast cancer 5 years ago and had an operation and
radiotherapy treatment for that and is told that the cancer has spread to her back
bones now.

Dr: I am very sorry to hear that.

If the patient did not know the cause of back pain – Take brief history

Do you know how the pain started ?

Did you left anything heavy ? Did you have any type of injury to your back ?

Do you have pain anywhere else? Are you on any pain medication?

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Rule out cauda equina

Dr: Mrs. Your back pain can be due to cancer which would have spread to the spine. We will
do investigations to confirm that. However, we can still manage the pain while we wait for the
investigations and hopefully, you will be able to attend the wedding pain free.

Dr: Do you have any other problem other than pain ?

Pt : Like what? Dr: Any problem passing urine or opening your bowel? (bowel and
bladder incontinence due to spontaneous fracture vertebra). Pt : No

Dr: Mrs.. Sometimes people can have fractures in the back bones very easily because
the back bones are very weak if it has cancer cells. Sometimes even minor trauma can
cause a fracture. I need to examine your back to check whether you have any chance of
having a fracture.

(examiner may or may not give any findings)

Also, we will do an X Ray of your back to see if you have any broken bones? Is that ok
Mrs …? Pt: Yes.

Dr: Mrs... please do not need to worry about the pain. We are going to do everything
possible to control this pain and help you to cope with this condition.

We have a whole special team here to help control your pain.

I will tell you about the various options we have for pain control. Are you following
me? Pt: Yes doctor. What are you going to do?

Dr: We are going to give you stronger painkillers than Paracetamol. First option are
the weak opioids such as codeine. These are tablets which you can swallow. Like any
medications, these too have some side effects. However, we will keep monitoring you
all the time and we will sort out any problems if you develop them.

Do you want me to tell you the side effects ? Pt: Yes doc please tell me.

Dr: This can cause drowsiness.

Pt: Doctor, please do not give me any medicine which will make me feel drowsy
because I need to attend my niece’s wedding in the next 2 weeks…

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Dr: Mrs.. Unfortunately, all the good pain killer medicines makes people feel drowsy,
but most of the time, drowsiness wears off after a few days of starting the treatment.

Also we can add Paracetamol to the codeine and reduce the content of codeine in the
tablet which gives drowsiness. How do you feel about this? Pt : That sounds good.

Another option we have is we can add some other medicine like steroids along with
Paracetamol that will not make you drowsy or we can give you some NSAID type of
medication that we call Diclofenac which also does not make you drowsy. I will talk to my
seniors and let you know what may be best for you. Is that OK? Pt : OK

Dr: In the initial few days, you may feel drowsy if you are taking Codeine tablets, so
you should not drive, and work near any heavy machinery. However, this drowsiness
will wear off after a few days as I told you. You may be able to drive if you are not
feeling drowsy after few days.

Pt: How can I work if I feel drowsy?

Dr: What work do you do? Pt: ...

Dr: Drowsiness will wear off after a few days so you can take a break from your work if
you wish to in the first few days when you may feel drowsy. Pt: Ok doc

If patient requests non-sedating medication, you also add co-codamol or diclofenac

noting that your seniors will decide

Dr: Other side effect is it can cause dryness of mouth - you can chew ice cubes or
Pineapple slices or chew sugar-free gum. If they do not help, we can give some
artificial saliva. Pt: OK doc.

Dr: Constipation is another problem with this medication, but if you eat a lot of
vegetables and fruits with high fibre then this may not be a big problem. We can also
give some laxatives. Sometimes, we may be able to adjust the dose to overcome this
problem. Are you comfortable with this medication? Pt: Yes

Dr – As the cancer progresses, the pain can get worse and if your pain is not
controlled by codeine, we will give you strong opioids such as morphine which can
also be taken by mouth. It has the same side-effects as codeine.

You can take this as an injection too - this is what we call as patient controlled

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analgesia. There will be a small device which contains the medication (morphine) which
you need to keep with you. That will be attached to your vein with a tube. You can
press a button on the device and the medication will be delivered to your veins. The
advantage is that it works faster than taking a tablet and more effective. You do not
need to wait for someone else to come and give injections to you. This can be used at
home too and the nurses will train on how to use it.

Pt: Will I get an overdose if I press the button too many times ?

Dr: You will not get overdosed because there is a safety device.

Pt - Will I get addicted ?

Dr – Unfortunately, all the opioid type of medicines causes addiction. However, if you
take the medication at the right dose and the right time, then there are less chances of
addiction. Pt – Ok.

Dr – Hopefully, your pain will be managed by this. If your pain does get worse, in that
case we can change morphine to even stronger painkillers - what we call Fentanyl
which can be worn as patches over your arm. Is that Ok ? Pt – OK doc.

Dr: Do you have any concerns? Pt: No.

Dr: One of the best things you can do to prevent back pain is to exercise regularly and
keep your back muscles strong. We can also refer you for physiotherapy.

Some people find complementary and holistic medicine like acupuncture, hypnosis,
massage techniques helpful to control the pain.

Other medications like bisphosphonates can relieve pain.

Other tips for managing back pain:

1. Hot or cold packs, or a combination of the two, can soothe a sore back. Heat
can help reduce muscle spasms and cold can help reduce inflammation.

2. Eat a healthy diet that includes enough calcium and vitamin D to keep your
spine and bones as strong as they can be.
3. Maintain a healthy weight to ease stress and strain on your back.
4. Practice good posture and support your back properly when you have to sit for
a long time.

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5. Avoid lifting heavy items. If you do have to lift something, keep your back straight
(don't bend over to pick up the object). Instead, bend your knees and then lift the item.
This puts the stress on your legs and hips rather than your back.

Keep a pain diary

Please keep a diary of your pain like when do you get pain, how long it lasts, how
severe it is, what type of pain, what medication you took – this will help us decide
what is the best way to treat your pain.

Dr: You should get urgent medical advice if you have difficulty walking or difficulty
controlling urine and/or bowel movements (Warning sign of spinal cord compression
common in breast secondaries)

Dr – Do you have any other questions? Pt – No, doctor.

Dr – I wish you cope well with this. As I mentioned earlier, there is a specialist team
including Psychologists, Macmillan nurses to help you to cope with the pain. We will
make sure you will be comfortable. If you need any help in the future, please do
contact us. Thank you very much.

Radiotherapy, TENS, and Nerve blocks can also be used to treat the pain

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175. A 35 year old man underwent herniorrhaphy one week ago. Now he
presents with discharge, swelling, oozing and redness at the site of
incision in the groin area.Talk to the patient.

Infection rate in this hospital is not more than National infection rate.

Dr - I am Dr… one of the junior doctors in the surgery department in the hospital. How
can I help you?

Pt – You are a junior doctor. I don’t want to speak to you. I had surgery a week ago
and see now what has happened? Some dirty discharge is coming out of my wound, it
is smelling horribly, my wife is not coming near me, I can’t even go to my work. My
wound is healing. I want to talk to your consultant.

Dr – I can certainly imagine how you are feeling. I’m sorry for what is happening to
you. I do understand that you want to speak to my consultant but my consultant is
busy at the moment. Don’t worry I’m here for you. I will try to explain to you what is
happening and we will do our best to help you. My consultant will see you as soon as
he gets free.

Dr: Can I ask a few questions about it? Pt: Yes

Dr: Since when did you start having this discharge from the wound ? Pt: Last few days

Dr: Do you have any pain there? Pt: Yes / No

Dr: Do you have any fever? Pt : No

Dr: Do you have any other medical conditions? Pt: No

Dr Do have diabetes? No

Dr: Are you taking any medications? Pt: No

Dr: Are you allergic to any medications? Pt : No

Dr: I need to examine your tummy.

[Patient will show a picture – “Doctor, this is how it looks like”]

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Dr: I can see your wound is bit red and there is some pus discharge there.

Pt – Why has this happened to me?

Dr – This happens when there is an infection of the wound, which means there are
germs/bugs growing there.

Pt – How/From where did I get this infection?

Dr – Mr…It could be due to many reasons. These bugs could be from inside or outside
the hospital. We do take all measures to prevent people from getting infections after
an operation. We do the operation in a clean theatre, sometimes we give antibiotics
and keep cleaning and changing the dressing regularly to prevent infections.
Unfortunately, sometimes people get infections despite all the measures we take
because new patients keep coming every day and they may bring bugs with them if
they have infections.

However, sometimes this infection can happen from outside the hospital. If the
dressing on the wound becomes dirty and if it is not kept clean, bugs can get into the
wound.

Dr: Can I please ask you were you able to take care of the wound? Who was changing
the dressing for you? Patient: Yes I was able to take care of the wound properly / I was
not able to take care of the wound properly.

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Dr: I am sorry this happened to you. You have done a good thing by coming to the
hospital. Right now what’s important is that we take care of you.

Pt: My friend had some operation in some other hospital and he was given antibiotics and
he did not have an infection. Is it because I was not given antibiotics that I got infection?

Dr: Mr… I am glad to know that your friend did not have any infection after his
operation. To prevent infection, we do give antibiotics after operations only for those
types that the chance of infection is very high. For example if it is dirty wound or if the
patient has low body immunity. We do not give antibiotics if the chance of infection is
low. If we give antibiotics even for types of operations where the chance of infection is
low – the bugs can develop resistance and later on if the person has infection with
similar kind of bugs then those antibiotics will not work and the infection can become
very serious. That is the reason we avoid giving antibiotics unnecessarily. However we
do advise those patients to come back if they have signs of infection as the infection
can be treated even later.
Pt – What will you do for me now?

Dr - We need to admit you now. We will clean the wound, change the dressing and give you
pain killers & antibiotics medications. We will also take a blood sample and sample from the
wound to check which exact bugs causing this infection and send it to lab.

Pt – What! Admit me again? I can’t get admitted again?

Dr: May I know why you can’t get admitted again!

Pt: I have to work! I have to look after my family.

Dr – I can understand your problems. We are trying to do best for you. If you wish, we
can give you a sick note.

Pt – But I am self - employed. I will lose my income.

Dr – I can imagine your problems. You may still be entitled for some benefits.
However, your health is more important. We need to give antibiotics through your
veins which cannot be given at home.

If you go to work, it might get worse because you may catch other bugs which will be
more difficult to treat then.

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You may be entitled to tax benefits and child tax credit. You can take advice from
Citizen Advice Bureau.

Pt – How long will I be admitted for?

Dr – It may be for a few days. As soon as the infection is cleared, you can go home

Pt: What will you do so that these things will not happen again?

Dr: We look into all these type of problems very seriously. I will report this matter to
my seniors. We have something called a Root cause analysis meeting where we discuss
these type of issues. If there is anything which needs to be changed in our practice, we
will do that. Pt – I want to complain

Dr – Yes you can if you wish to do so. You can talk to the Patient Advisory Liaison
Service (PALS) and they will help you. Pt – OK

Dr – Any other concerns? Pt – No

Dr – Thank you very much.

POST-HERNIORRHAPHY WOUND INFECTION

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176. Child born at 24 weeks (premature birth) was in the hospital for 10
months. Mother is very upset with the nursing care. Talk to her.

Dr: Hello Mrs.. I am Dr... How can I help you?

Mother: My child was prematurely born and he has been in this hospital for the last 10
months. I am very upset with the nurses.

Dr: I am very sorry you felt that way. May I know why your child is in the hospital ?

Mother : He has ... condition.

Dr: I am sorry that your child is in the hospital for such a long time. May I know exactly
why you are upset with the nurses ?

Mother: Whenever I come to see my child I see the poo and vomit is on my child’s
body. These nurses don’t even clean my child.

GIVE HER YOUR OPINION AND FIND OUT IF SHE’S OKAY WITH YOUR PROFFERED SOLUTION.

Dr: I am very sorry to hear that. You are right to be upset about this. It is unfair that
this should happen to John. This should not have happened. I will talk to my seniors
about this issue. They will talk to the nursing supervisors and find out why this is
happening. We will make sure that this will never happen again. How do you feel
about this?/Is that Okay?

Mother: I did mention this to the nursing staff before. But they don’t care for my child.
These nurses are temporary nurses. They don’t even know what is happening to my
child. That is why they don’t care!

Dr: Once again, I feel deeply sorry about the incident. You are right that if it was
permanent nurses, then they would know the patients well and would get attached to
the patients especially if they are children. We always prefer to have permanent
nurses. Unfortunately, because of shortage of nurses, sometimes it is very difficult for
us to appoint permanent nurses and we have to take temporary nurses to fill up the
gap. However this should not be the reason for them not to show good care for our
patients. As I mentioned earlier, I will talk to my seniors and I am sure we can come up

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with some solutions to this problem. How do you feel about this Mrs.. ? Mother:
Thank you doctor.

Dr: Do you have any other concerns? Mother: My child was in the intensive therapy
unit and there my child was looked after well but when he was shifted to the ward,
these problems are happening. Why is that doctor?

Dr: Mrs... I am glad to hear your child was looked after well in the ITU. It may be
because in the ITU we have one-to-one care. This means one nurse will be taking care
of only one patient whereas in the ward, one nurse has to look after many patients.
However, this cannot be an excuse not to look after the patients well. As I mentioned
earlier, we will make sure that your child will be looked after well in the ward also. Is
that Okay? Mother: Okay.
Dr: Other than this incidence, are you happy with other care provided by John?/How is the
medical care by doctors? Are you happy or not? Mother: I am happy with the doctors.

Dr: I am glad to know that. However, if you feel anything is not right, please do let us know

Mother: Do you think I should take my child to a private hospital?

Dr: Is it for this reason or do you have any other reason? I am really sorry if you are not
happy with the way we have treated you and your child here. If you even have to think
of taking your child to the private hospital, that shows that we showed very poor care
for your child. I will reassure you once again that we will definitely try our best to
improve the care. Your child really deserves it.

However, you know what is best for your child. If you still feel that you need to take your
child to a private hospital, it is up to you. But if you decide to stay with us, we will definitely
look after your child really well. We also want the best for your child. What you do think
Mrs.. ? Mother: You made me relieved. I will keep my child here doctor.

Praise mother

“Please feel free to talk with us if you have any to her issues in the future.”

Dr: Are there any other expectations from us? Any suggestions to improve our patient
care, Mrs ... ? Mother: No doctor. Thank you very much.
Offer PALS Thank you
PREMATURE CHILD - MOTHER UPSET WITH NURSING CARE

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177. 20 year old man with cerebral palsy was brought into the A&E 5 days ago
because he fell from a wheelchair. He had a foot injury. He was treated with
just pain killers without doing any X Ray to rule out fracture. X Ray was not
needed at that time because there was no bony tenderness. He was treated
with Paracetamol.

Father brought him again today requesting for X Ray.

Talk to the father and address his concerns.

1. Points to cover
2. Ask what happened
3. History during the first presentation and what was done and told to him
4. How patient is progressing
5. Why he is worried
6. Tell the reason why X Ray was not done last time
7. Reassure that you will do X Ray this time if needed
8. With his information – X Ray not needed now.
9. Reassure that it is just soft tissue injury and it takes time to heal.
10. Explain that the discrimination is unlikely. We treat everyone equally
11. If he still feels that the discrimination has been done – apologise and say that he
can complain.
Dr: Hello I am one of the junior doctors in the department. How may I call you?

Father: You can call me Mr Fredrick.

Dr: How can I help you Mr Fredrick?

Father: My son was brought into the hospital a few days ago. I am very disappointed
with the treatment given to him.

Dr: I am really sorry that you feel that way. Can you please tell me what happened to your son?

Father: He has cerebral palsy. He fell down when I was shifting him from the wheel chair to
his bed 5 days ago. He injured his foot. I brought him here 5 days ago.
Doctors did not even do any x-ray and said he has just muscle pain and gave just
paracetamol. Instead of providing special care my son was treated very unfairly. I am very
upset about it. This is not how it should be.

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Dr: Why do you think that he was treated unfairly, Mr Fredrick?

Father: He injured his foot and none of the doctors did an x-ray of his foot. They just
gave him few medicines and sent us away. That shouldn’t be the way in a hospital.

Dr: Certainly you are right, Mr Fredrick, as no patient should be ignored or neglected
in any setting. We try our level best to give the good l care to all our patients. Can you
please tell me what symptoms he was experiencing when you brought him to the
hospital last time?

Pt: He was having pain in the ankle and he was crying. Initially he could put weight on
the foot. But later on he couldn’t even put weight on the foot. He also had swelling
and bruising on the ankle. I have been so worried. They should have done an X ray to
check if there was bone damage.

Dr: Mr Fredrick, I can understand why you are worried. We normally do an X-Ray if
there is suspicion of fracture when we examine a patient. But if there is no suspicion of
fracture, then we do not do an X Ray. Sometimes it’s apparent from the history and
assessment that there is no bone damage. It might have been the case. Was he able to
move his toes after the injury? Father....

Dr: How is the swelling around the ankle now?

Father: The swelling has subsided now but there is still a bruise.

Dr: That is a good sign that the swelling has decreased. It means that the injury is
healing. The bruise will take slightly longer to go away.

Dr: Has the pain been the same since injury or has it changed in intensity? Father:...

Dr: What did the doctor advise him in the last visit?

Father: The doctor said there is no fracture. Maybe he has a fracture. Isn't it still better
to do an X-Ray. Don’t people have X-Ray done for the smallest of reasons? My son
actually had a fall. I feel as if he was treated as a second grade citizen and deemed not
worthy of equal care as others. He can't put weight on his feet though in the
beginning he could. It worries me I want to have an X-Ray done for him now.

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Dr: I can understand how you feel Mr Fredrick. It is very difficult to see your child in
pain. I want to assure you that all our patients are equally dear to us. We try our best
to provide all of them with the best care possible. Also we try to keep our patients
safe and try not to give them unnecessary treatments. If the Xray was really needed,
we would have done it. Father: What if he is having a fracture?
Dr: I can see that you are a very concerned father. I will definitely examine him again and
see whether he needs an X Ray now and if he needs it, we will definitely do that now.

(Talk about examination – the examiner may say, “there is no bony tenderness and
the swelling has subsided. Just a bruise is seen”. Tell the father, “I examined him
now and there is no pain over the bone and the swelling has gone down”). With
the information that you are giving me that his swelling has reduced since the injury
and after examining him, I still do not think he has a fracture and I do not think we
need to do an X-Ray.
Let me explain in detail about the reasons we do the x-rays and when we avoid doing
them - For ankle or foot injuries, we do a preliminary assessment of the patient and
see if he is able to put on weight initially. If one can put weight on his foot, it is very
unlikely that the bone is broken. On examining the patient, if there is pain when we
press on the bony points which suggests there could be fracture, then we do the X
Ray. But if there is no pain when we press on the bony points which suggest the
fracture is very unlikely, then we avoid doing the X Ray because doing unnecessary X
rays can cause radiation which itself can cause cancers. So we try to avoid doing
unnecessary X Rays for patient’s own benefit.

I see that you are worried about him because of the bruise. It may take a few more days for
the bruise to go down. Are you following me Mr Fredrick? Father: Yes.

Dr: Mr Fredrick I want to reassure you again. There is a standard procedure we

normally follow whether the patient is a normal person or differently abled person. It is
very unlikely that he was treated unfairly because of his condition. However, if you still
want to escalate the matter you can make a formal complaint. We have a separate
department for this purpose called Patient Advisory Liaison Service (PALS). They will
help you make the complaint. Any complaint will be taken seriously and respective
authorities will assess the matter and I assure that if there is any sort of discrimination
there will be action taken on the concerned person.

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Father: Thank You, Doctor. I will see about that. I feel relieved after talking to you.

Dr: I am glad I could help, Mr Fredrick. I hope your son recovers soon. If you have any
problems please do not hesitate to come to us. We are here for you.

Father: Thank You Doctor.

Sometimes the question may say that only the father is here in the hospital. In that case
ask the father to bring his son – We will examine him and see whether he requires an X-
Ray.

UNFAIR TREATMENT - CEREBRAL PALSY

PATIENT

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178. Child with cerebral palsy………Mother doesn’t want IV cannula.

You are an FY2 in the Paediatrics department. A 4 year old child, Teddie, is
admitted with severe pneumonia. This is the 4th time he is being admitted with
pneumonia. He has been prescribed a course of I/V antibiotics for 5 days. This is
the second day of treatment.

The patient has fever and tachypnea. On the x-ray, there is consolidation.

Talk to mother and address her concerns.

Dr: Hello I am Dr… .............. , One of the junior doctors in the department. Are you the
mother of Teddie? Mother: Yes.

Dr: How may I call you? Mother: Call me Stacey.

Dr: Alright Stacey, How may I help you today?

Pt: Doctor, I don’t want Teddie to have an IV Cannula.

Dr: Stacey, is there any reason for you to say that?

Pt: Yes Doctor, He is already in a lot of discomfort. He has very thin and small veins. Doctors
and nurses keep pricking him again and again. He cries a lot, it is really hard for me to see
that.

Dr: Stacey your concern is valid, I do understand this process can be painful. You are a
very caring mother and I know it is your love for your son which is making you say this…
but do you know why are we trying to pass cannula?

Ask her if there is anything else she is expecting

Pt: Yes doctor I know that Teddie has a chest infection and you want to give him
medicine through his veins. But it is very painful for him and I cannot allow that. Give
him some other medicine, give him syrup or tablets.

Dr: Yes Stacey you are right, Teddie has pneumonia and I really wish we could give him
medicine in the form of syrups or tablets. But these are not as effective as medicines
through veins. As you know, this is the fourth time that he is being admitted with
pneumonia and this time it is severe. So, I am afraid, syrups and tablets won’t help
Teddie much with this condition.

These medicines are antibiotics and they are necessary for Teddie. It is really important
that we complete their course for five days.

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Pt: Yes doctor I want Teddie to get better but this is too difficult for me to watch. Doctors
and nurses prick him like he is a pin cushion. He doesn’t speak much but pain shows on
his face.

Dr: I am really sorry that you have to see all this. Even though we know that it is painful,
we have no other option. We are sorry and we are only doing all this because we want
Teddie to get better as soon as possible. As you are aware that Teddie unfortunately
has cerebral palsy. In this condition, the muscles of the chest wall are weak and if any
chest infection is left untreated or if the treatment is not adequate, it can be very
dangerous. So we have to act very fast. This can only be done if we give him medicines
through his veins.

If you would like, I would request the most senior person to put in the I/V cannula if
possible. We would also apply a local anaesthetic cream on him arm before the
procedure so that he doesn’t feel any pain. What do you think?

Pt: Okay, doctor you may pass the cannula. I just don’t want to see him in pain.
Dr: Stacey, We will be very careful and once the cannula is in place we will make every
effort that it is maintained and we don’t have to repeat the procedure.

Is there anything else we can do for you?

Pt: No doctor, Thank you.

Dr: Thank you very much Stacey for understanding the need and allowing us to pass I/V
line.

If there is anything else, We will be glad to help you.

REFUSAL OF IV CANNULATION IN CHILD WITH

CEREBRAL PALSY

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179. A lady had an angiogram and had conflict with Physiotherapist and Nurses.
Old lady with MI who had angiography done today morning. Physiotherapist has
advised her to walk but she is afraid. Talk to her.

Assess knowledge – Had angiogram and the physiotherapist told her to walk.

Ask concern

She does not want to walk because she is tired. Also nurses told her not to walk. She is
confused.

Ask her any other reason she can’t walk (like any pain and imbalance) - “Besides that,
the physiotherapist was very rude.” Does not want that physiotherapist. Wants some
other physiotherapist.

Apologise for the conflict of opinion. “This should not have happened. I will talk to the
physiotherapist and the nurses to find why did they say that to see is there any
particular reason to say that.”

“Usually patients do walk a few hours after the procedure. However, I will talk to the
physiotherapist and my seniors and let you know when you can walk.”

Talk about PALS, incident report.

We will take appropriate action so that this will not happen again.

CONFLICT WITH PHYSIOTHERAPIST AND

NURSES

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180. A 25 year old lady underwent an operation to remove a cyst from her knee
2 weeks ago. She developed an infection in her wound after that. She was
admitted and again treated with IV antibiotics. The infection has cleared
now. She wants to talk to a doctor.

Talk to her and address her concerns.

Dr - I am Dr… one of the junior doctors in the surgery department in the hospital. I
understand that you want to talk to a doctor. Can I help you Miss… ?

Pt – Yes doctor. I had an operation to remove a cyst from my knee 2 weeks ago.

I was sent home and then I had an infection in the operation site. I was admitted here
again, and they gave me some medicine. The infection has cleared now. I want to know
why I got this infection.

Dr: I am very sorry that you had to go through this problem. Can I ask you for a few
more details about it so that I can answer your questions better? Pt : Yes

Dr: Did any doctor explain the operation properly to you before the operation? Pt : Yes

Dr : Did he mention the benefits and problems you may have after the operation?

Pt: Yes, they told me something but I can’t remember everything now.

Dr: No problem Miss… Can you please tell me what happened after the operation –
how long you were in the hospital? Pt : It was a day case surgery, so I was sent home
on the same day.

Dr: I see. What was told to you when you were discharged – did any one explain to you
how to take care of the wound like changing the dressing or how to keep the operation
area clean? Pt: Yes they told me to change the dressing ….

Dr: Were you given any medications to take at home like any pain killer medication or
any antibiotic medications ?

Pt: I was given pain killer medication but not antibiotics.

Dr: Ok Thank you for the information. You asked me why you got this infection - Let me
answer your question now Miss… Usually after almost every operation, there are chances of
people getting infection. We take a lot of measures so that people do not get an infection
after an operation: we do the operation in a surgical theatre which is very sterile and clean,
and we keep the hospital very clean to prevent getting infection from other patients. We
change the dressings on the wound frequently in a very clean manner to prevent infection.

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Also, in some type of operations, if the chance of infection is very high, then we give
antibiotics to prevent people getting the infection. However, despite all our efforts sometimes
people do get infections for so many reasons.

We usually mention the benefits and risks of operation, including the risk of people
getting infection after the operation to the people before they undergo the operation. It is
very unfortunate that you got this infection.

Pt: Why was I not given antibiotics? Maybe that is why I got this infection.

Dr: Miss. We usually give antibiotics to only such operations where the chance of
people getting an infection is very high. We do not give antibiotics if the chance of
people getting infection is very low, because if we give antibiotics to everyone even
when the chance of infection is very low, then the bugs can develop resistance to these
antibiotics. In the future, if the people get infections from similar bugs then these
antibiotics do not work and the condition can become very serious, and it can even be
life threatening. That is why we avoid giving unnecessary antibiotics. The type of
operation that was done for you – the chance of people getting infection after the
operation is very low. That is why you were not given antibiotics.

Pt: But I got an infection.

Dr: It is unfortunate that you got it. We generally advise patients that there is a slight
chance of getting infection and we advise them of the signs and symptoms of infection,
and ask them to come back if they have such symptoms. We are usually able to treat
the infection if it does develop. That is what was done in your case Miss…

Pt: I am happy about this.

Dr: I can certainly imagine how you may be feeling about this. I will be reporting this
incident. I can reassure you that the concerned authorities will look at this and take
appropriate steps for this. In the future, if a lot of patients get infections after this type of
surgery, maybe we need to think of giving antibiotics to prevent the infection.

Miss.. You have all every right to put in a formal complaint about this if you wish. We
have a dedicated department for this called PALS. They will help you with this.

Pt: Thank you. I will think about that.

Dr Any other concerns Miss..? Pt: No

Dr: Thank you very much Miss. Once again I am sorry that you had this problem.

WOUND INFECTION AFTER CYST REMOVAL

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181. Your Junior Colleague (FY1doctor), Dr John David did not insert an IV
cannula for Mrs Williams who was supposed to receive IV antibiotics for an
insect bite. Talk to Mrs Williams.

" Listen
" Apologise
" Show empathy/empathy
" Provide solutions
" Know your limitations
" Will take appropriate actions
Hello Mrs Williams, I am doctor… How can I help you?

Pt - Doc, your colleague told me that he is going to come back and insert a cannula in
my hand and he did not come back since then. I am due for antibiotics through my
veins. I am supposed to go home now. I have a meeting to attend in the next one hour.

Dr - I am very sorry for what happened, but I will insert the cannula for you now.

Pt - Thank you for that, but why is it that your colleague did not come back to insert the
cannula?

Dr - I am not sure why he did not come to insert the cannula, maybe he is caught up in
some other emergencies. But as I told you, I will insert the cannula now and I will ask
him to come and tell you what happened. I would like to reassure that nothing serious
has happened to your health now. Is that OK?

Pt: What about him?

Dr: I will ask him to come and explain to you about what happened. Pt: I don't want to
see him. Will you take any action on him.

Dr: We do take all such incidents very seriously. We will all the measures so that these
type of problems will not happen again.

Pt - I don’t want such things to happen to me or anyone else again.

Dr - Yes, sure we will make sure that these things will not happen. I will inform my
seniors about this.

Pt – I want to put a written complaint.

Dr – You can surely do that if you wish to. We have a patient advice liaison service and
you can talk to them about it and they will help you. Pt – Thank you.

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PALS

The Patient Advice and Liaison Service (PALS) offers confidential advice, support, and
information on health-related matters. They provide a point of contact for patients, their
families and their carers.

How can PALS help?

PALS provides help in many ways. For example, it can :

1. Help you with health related questions

2. Help resolve concerns or problems when you’re using theNHS
3. Tell you how to get more involved in your own healthcare

PALS can give you information about:

" The NHS complaints procedure, including how to get independent if you want to
make a complaint.
" Support groups outside the NHS - PALS also helps to improve the NHS by
listening to your concerns and suggestions. Making a complaint

- If you’re not happy with an NHS service, you can make a complaint. You should
complain to the person or organisation providing the service first, such as a GP,
dentist, hospital or pharmacist. Alternatively, you can complain to the
commissioner of that service – either NHS England or the area clinical
commissioning group (CCG)
- In general, NHS England commissions most primary care services, such as GP
and dental services. CCGs oversee the commissioning of secondary care, such
as hospital care and some community services.

IV CANNULA - TALK TO UPSET PATIENT

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182. You are the FY 2 doctor in the A&E department.

30 year Mrs Anna Henley presented to the hospital in the morning because she
fell on the grass while she was going home from work. She had pain, swelling
and bruise in her ankle. X Ray was done in the morning.

She has come back to get the X Ray result.

Take a history and talk to her about the further management.

Dr: Hello Mrs Henley I am Dr.. How can I help you ?

Pt: I came in the morning to the hospital because I injured my ankle. They did an X Ray but I
could not wait for the X Ray result at that time. I have come now for the X Ray result.

Dr: Could you please tell me how did you injured your ankle?

Pt: I work as a cleaner in a school. I fell inside the school premises while working and
that is how I injured my ankle.

Dr: Mrs Henly, it is written in our notes that you fell on the grass outside the school
premises

Pt: Oh, Yes I made a mistake in the morning. I was not thinking properly that is why I
told I fell outside the school premises. Doctor can you please change what is written in
the notes and write that I fell inside the school premises?

Dr: Mrs Henly, we can not erase what we already wrote in our notes. However, we can
write that you have requested us to change the story of how it happened.

Pt: No doctor, don’t write like that. Please erase what you wrote in the morning and write
what I told you now.

Dr: Can I ask you why do want us to do that?

Pt: If I mention that I fell inside the school premises, I will be entitled for compensation
because the injury happened at the workplace.

Dr: I can imagine why you want to do that. Unfortunately, we cannot do that – we should
be honest.

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PRICE stands for:

Protection – Protect the affected area from further injury by using a supporter, wearing
shoes.

Rest – Avoid activity for the first 48 to 72 hours. We can give you crutches to help you to
walk.

Ice – For the first 48 to 72 hours after the injury, apply ice wrapped in a damp towel to
the injured area for 15 to 20 minutes every two to three hours during the day. Don't
leave the ice on while you're asleep, and don't allow the ice to touch your skin directly
because it could cause a cold burn.

Compression – We will put an elasticated bandage to the ankle to limit the swelling
and movement that could damage it further. You can use a simple elastic bandage or
elasticated tubular bandage. Remove the bandage before you go to sleep.

Elevation – Keep the injured area raised and supported on a pillow to help reduce
swelling.

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You should avoid HARM

Heat – such as hot baths, saunas or heat packs.

Alcohol – drinking alcohol will increase bleeding and swelling, and slow healing.

Running – or any other form of exercise that could cause more damage.

Massage – which may increase bleeding and swelling.

Generally, you should try to start moving a sprained joint as soon as it's not too painful
to do so.

Leave certificate - 2 to 3 days

Pt: When can I walk properly, doctor?

Dr: Usually, you'll probably be able to walk one or 2 weeks after the injury. We can give you
crutches to help you walk until then. You will be able to use your ankle fully after 6 to 8 weeks

Avoid driving until strength and mobility have returned which may take 6 to 8 weeks.
You can return to sporting activities after 8 to 12 weeks if you do any sports.

Contact your GP if your injury doesn't improve as expected or your symptoms get
worse. Surgery – is not needed to treat sprains unless the injury is very severe.

ANKLE SPRAIN

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183. You are the FY 2 doctor the medical ward.

Mrs Mary Black is an 88 years old female with a diagnosis of advanced dementia. She
was admitted to the hospital 4 weeks ago with general deterioration and poor oral
intake as she is refusing to eat or drink. She is losing weight and she is also agitated.
Your consultant has planned not to give any aggressive treatment. He has decided for
palliative treatment.

Speak to the daughter, Mrs Sarah Black, about her condition and address her concerns.

Dr: Hello Mrs Sarah Black. I am Dr …. One of the junior doctors in the medical department
looking after your mother Mrs Mary Black.

How are you doing?

Daughter: I am fine doctor. How is my mother?

Dr: She is ok now but to explain better, can you please tell me how much you know
about what is happening to her.

Daughter: I was told that she has dementia.

Dr: Do you know what is dementia? Daughter: No

Dr: Dementia is a condition of the brain that causes gradual, progressive loss of mental
ability. It affects all aspects of a person’s mental ability. This can cause memory loss,
reduced appetite, incontinence, swallowing difficulty, inability to communicate.

Dr: Does she have any other medical condition? Daughter: No

Dr: Do you have any concerns about her?

Daughter: Yes, doctor. She is not eating properly. She is losing weight. I am very concerned.
She has looked after me a lot. She has done a lot for me. I want to do the best for her.

Dr: I can see you want to do what’s best for her, and I can’t imagine how you must be
feeling watching her not eat properly and lose weight. How was she at home before she
was brought in – was she eating well? Was she active? Was she mobile?

Daughter: She was eating OK but she was not very active.
Dr: We have examined her, and found out that she has no other medical problems apart
from Dementia. Yes, we have noticed that she is not eating well and losing weight. This
is because of her dementia which is at an advanced stage now.

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Because of all these, my consultant thinks it is not good to give her any active or
aggressive treatment as her condition is not going to be any better. So he thinks it is
better we give her only palliative care.

Daughter: What is palliative care?

Dr: Palliative care is a gentle approach to management and we manage them

systematically. In palliative care, we do not give active aggressive treatment or any
invasive procedure to a medical condition which is advanced and progressive, but we
give complete supportive care for patients and their families. We manage their pain and
other distressing symptoms. We provide all types of supports like psychological, social
and spiritual support. We try to give the best quality of life for patients and their families.
We offer a support system to help patients live in dignity and as comfortable as possible
as long as they live.

Daughter: Doctor, who provides Palliative Care ?

Dr: We have a specialist team called Multidisciplinary palliative care team who provides
this type of care. There are specialist consultants and nurses and physiotherapists,
occupational therapists, dieticians, pharmacists, social workers and those who are able
to give spiritual and psychological support. Someone can even stay at patient’s home to
give care at home.

Daughter: Does this mean it is the end of her life?

Dr: Palliative care is not just given for end of life care: it is also given to those who need
such help early in the disease many months well before expected death.

Daughter: But she is not eating properly. She is losing weight.

Dr: In advanced stage dementia, these things do happen. They lose appetite and they
refuse to eat. Also, Dementia patients lose weight even if they eat normally.

Daughter: Don’t you have any methods to feed her?

IT’S BETTER TO TALK ABOUT THE FEEDING METHODS WE WILL OFFER AND
BRIEFLY TOUCH THE OTHER ONES AFTERWARDS.

Dr: We do have a lot of methods to feed patients artificially. We can give fluids
subcutaneously that is under the skin and also we can pass a tube from her nose to
stomach (NG tube) and feed her through that and we have another method that we call
PEG where we make a small hole from the tummy and pass a tube directly from the
tummy wall to the stomach and feed her through that.

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However, all these methods are not good for her because she will only be distressed
more with these types of feeding. Instead, we allow them to eat and drink as they like
though there are some risks involved. This is what we call comfort feeding. It is a gentler
approach to feeding. If required, she can be hand fed rather than tube fed.

Daughter: Why is it better?

Dr: Because dementia patients have reduced appetite, and they lose weight despite
feeding artificially. Artificial feeding will not improve appetite. Also even in artificial
feeding, there are risks that food may still go into the lungs. It does not improve quality
of life. Survival is not prolonged in artificially fed patients.

Feeding through the nose tube can be applied temporarily for a few weeks in someone
whose swallowing are likely to recover. In your mother’s case, we are not expecting her
to improve or recover. It cannot be put for a long time and also it is distressing to the
patient and can make them more agitated.

PEG: Disadvantage is that it is an invasive procedure, can be dislodged by an agitated

patient. Moreover, it requires training to carers or family.

It is better to feed her by hand. Feeding by hand improves the communication and
interaction with the patient by being close to them while feeding. It will also be better if
she’s fed by someone who is close to her. Also they require much less energy. She can
be fed high energy foods or fortified food. Our dietician can advise what types of food
are better for her.

Daughter: Can you feed her forcibly?

Dr: It is not good to do that. As I mentioned, she will not improve even if we force feed
her. It will only distress her more.

Daughter: Can I take her home?

Dr: Yes, surely you can take her home if you wish to. Have you thought of keeping her
in the hospice – this is similar to staying at home. Here, only this type of patients are
cared for.

Daughter: What is hospice? What do they do there?

Dr: In Hospice, there are doctors, nurses, social workers, therapists, counsellors, and
trained volunteers. Hospices aim to feel more like a home than hospitals do. They can
provide individual care more suited to the person who is approaching the end of life, in a
gentler and calmer atmosphere than a hospital.

Daughter: OK. I would like to take her home now and think about the hospice later.

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Dr: Ok that is fine. We will make arrangements for that. Do you need any help to take
care of her at home? If you need, we can arrange nurses and social care workers to
help you to look after her.

Daughter: Thank you doctor.

Dr: Thank you.

DEMENTIA - PALLIATIVE CARE

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184. You are the FY 2 doctor in the GP clinic.

22 year old Miss Chris Barnes presented to the GP clinic 2 days ago with sore throat.
The nurse practitioner did a throat swab which showed no bacterial growth.

The nurse advised her to take mild pain killers and do a steam inhalation. She has
come back again and wants to talk to the doctor.

Assess her current condition and address her concerns.

Find out if she has developed bacterial Pharyngitis

Has it spread to become pneumonia or meningitis?

Dr: Hello Miss Chris Barnes, I am Dr…. How can I help you Miss Barnes?

Pt: I am having a sore throat, doctor. I came here 2 days ago and the nurse told me to
take pain killers and do a steam inhalation. I am not getting any better. Can you please
give me antibiotics?

Dr: Can I ask you why are you asking for antibiotics?

Pt: Last time, I had some infection and I was given antibiotics and I improved very
quickly. Please give me antibiotics. I have to attend some function in the next few days.
I want to get better before that.

Dr: I can understand your concerns. Do you know what infection you had last time? Pt :
I can’t remember now.

Dr: No problem. Can I ask you a few questions to see whether you need antibiotics. If
you need it, we will definitely give it. Pt: Yes, doctor. Thank you.

Dr: Since when are you having this sore throat? Pt: Almost 4 days now, doctor.

Dr: Do you have any pain while swallowing ? Pt: Yes, slightly.

Dr: Are you able to swallow food or drink? Pt: Yes

Dr: Do you have any breathing difficulties? Pt: No

Dr: Are your symptoms getting any better or the same or getting worse?

Pt: It is the same doctor not getting better. I feel slightly better when I use steam inhalation.

Dr: Do you have any other problems apart from sore throat?

Pt: I am having pain all over the body.

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Dr: Any other problems? Pt : Like what?

Dr: Do you have fever? Pt: No

Dr: Do you have a cough and cold? Pt: Yes

Dr: Do you bring out any phlegm? Pt: No

Dr: Do you have pain in the ear? Pt: No

Dr: Any chest pain (Pneumonia)? Pt: No

Dr: Any discharge from the nose? Pt: Yes

Dr: Any headache (meningitis)? Pt: No

Dr: Any rashes on the body (meningitis, glandular fever)? Pt: No

Dr: Any swellings on the neck or armpit (glandular fever)? Pt: No

Dr: Did you have a similar problem before at all? Pt: No

Dr: Do you have any medical conditions? Pt: No

Dr: Are you taking any medications other than pain killers and steam inhalation? Pt: No
Dr: Are you allergic to any medications? Pt: No

Examination:

Dr: Miss Barnes, I need to examine your throat and chest.

Examiner may say – Examination is normal.

Diagnosis:

Dr: Miss Barnes, with the information you have given me and after the examination, I
think you have a sore throat due to viral type of bugs. This type of virus infection will
subside on its own without any special treatment. The only treatment required is for the
symptoms like pain killers and the steam inhalation which you are already taking.

Pt: But I am not getting better doctor!

Dr: Miss Barnes, sometimes it may take about a week for the condition to subside. I
advise you to continue taking the pain killers and the steam inhalation for few more days
and you will feel better in the next few days.

Dr: Doctor, I have to attend a function in the next few days. I want to feel better soon to
attend that function. Please give me antibiotics.

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Dr: Miss Barnes, antibiotics are given only for infections due to bacterial kind of bugs
not for infection due to virus type of bugs. They do not help for viral infections. Besides
that, antibiotics have their own side effects. So you may develop unnecessary side
effects.

Pt: Doctor, last time I improved very quickly after taking the antibiotics!

Dr: I am not sure why the antibiotics were given to you last time. Maybe you had an
infection due to bacterial type of bugs. This time, it is not a bacterial infection. The nurse
took a swab from your throat last time to check whether you have bacterial infection.
That test also shows this is not a bacterial infection..

Miss Barnes, if we give antibiotics unnecessarily, bugs may develop resistance to these
antibiotics and next time if at all you get bacterial infections these antibiotics may not
work and it may lead to serious complications. If you needed antibiotics, we would have
definitely given that to you. Your condition does not require it. You will feel better soon.

Pt: Ok doctor.

Informing patient of warning signs are very important here

Dr: Thank you, miss Barnes. You can go home now and continue taking pain killers and
the steam inhalation. However, if you are getting very unwell, or start developing chest
pain and high fever or if you see rashes on the body, these could be signs that you are
developing some complications like chest infection or meningitis, so please do come
back.

Hope you recover soon and be able to attend the function.

PATIENT REQUESTING ANTIBIOTICS

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185. You are an FY2 in the GP Clinic. A young man came with concerns of
sleep disturbance and is requesting for sleeping pills. Talk to him and
address his concern.

" GRIPS plus rapport

" Ask how long he has been having this sleep disturbance

" Explore causes of Insomnia

" Ask about sleep hygiene/sleeping environment

Patient plays computer games till late night about 3:30-4am.

" Ask about anxiety/stress? Patient says he has anxiety but doesn’t know the cause.

" Then explore the cause of anxiety.

" Ask about mood? Calculate mood score 1-10?

" Ask about Tea/coffee drinking history? Pt: No

" Ask about alcohol and smoking.

" Ask about recreational drugs. Pt says he smokes marijuana/cannabis.

" Explore how long he has been taking it. Any other recreational drugs? Pt: No

" Ask if anything significant happened. Any shocking or Take other social history

MAFTOSA

- Any medical Condition? Pt: No

- Any medication?

- Ask about occupation

- Patient keeps saying “can you give me sleeping pills?”

- Give advice - sleeping pills have side effects and one can develop dependence.
Without lifestyle modifications, sleeping pills will not help!

- Give lifestyle advice

- Give advice to quit smoking marijuana

- Advice about maintaining good sleep hygiene and keeping sleep diary

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- Also avoid playing computer games till late night (triggers of insomnia).

- Talk to seniors for further assessment and whether to give sleeping pills or not.

- Offer help for Marijuana smoking (Narcotics anonymous group/support group).

CANNABIS ABUSER WITH INSOMNIA ASKING
FOR SLEEPING PILLS

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186. You are the FY 2 doctor in the medical department.

Mr Charles Roper 56 year old man has been admitted to the hospital for COPD.
His nose swab showed MRSA.

He has been isolated and been treated appropriately. His wife Mrs Helen Roper is
concerned about him. Please talk to her and address her concerns.

Dr: Hello, Mrs Helen Roper! Wife: Yes.

Dr: I am Dr. …. One of the junior doctors in the medical department. How are you doing
Mrs Roper?

Wife: I am OK. I am worried about my husband! I just came to see him. He has been
shifted to some other room. I can see doctors and nurses wearing aprons and gloves.
What is happening to him doctor?

Dr: I can see that you are very concerned, I will explain everything. Before that, can you
please tell me how much you know about what is happening to him?

Wife: I know he has COPD!

Dr: Yes, That is right Mrs Roper. He has COPD and was treated as you know. But we
did some swab test on his nose and it showed that he has some bugs in his nose.

Wife: What kind of bugs?

Dr: These bacterial kind of bugs are called MRSA in other words they are called
superbugs. Do you anything about these bugs Mrs Roper?

Wife: Superbugs! I have heard of them. From where did he get this bugs? Is it because
the hospital is dirty?

Dr: Sometimes, the bacteria normally live on the people’s skin without causing any
problem. Sometimes, these bugs are spread through skin-to-skin contact with someone
who has an MRSA infection. These bugs also spread through contact with contaminated
objects such as towels, sheets, clothes, dressings, surfaces, door handles and floors.

Sometimes people may get this infection outside the hospital also.
We do keep the hospital very clean to minimise the spread of this infection. When
doctors and nurses enter the room of the patient’s with this infection, they wash their
hands thoroughly and wear aprons and gloves to minimise the chance of spreading the
infection.

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However, sometimes people can get this infection because new patients keep coming
into the hospital and they may have this bugs on their skin and it spreads to others.

People in the hospital might have a lower immunity.

Wife: Is it a serious problem, doctor?

Dr: At the moment, these bugs are confined to the nose and are not causing any
problems to him. So it is not a serious problem to him at the moment.

However, if the bugs gets inside the body and cause an infection, then it can become a
serious problem. Sometimes, the bugs can get inside the body and cause an infection if
their body resistance goes down or if they have a break in their skin like operated
wounds. It can also enter inside the body through urine catheters or IV cannulas (the
tubes through which we give medication into the veins).

In your husband’s case because he has COPD, his body resistance would be low. So
there is a chance that bugs may get inside his body and cause infection.

Wife: Do you mean to say he may die, doctor?

Dr: Mrs Roper, as I told you at the moment, there is no problem because the bugs are
just present in is body. It is not very common that people die because of this bug. It can
happen only if the people gets serious infection with this bugs and bugs do not respond
to any treatment.

Wife: How are you treating him doctor?

At the moment, bugs are just present on his body. So we are treating him appropriately
to get rid of these bugs. Usually, we put some antibiotic cream on the nose and use
antibacterial body wash products and powders to get rid of these bugs from the body.

However, if the bugs get inside the body and cause an infection, it can cause problems
because these bugs are resistant to most of the antibiotics we usually use to kill the bugs.
But they usually do respond to one type of superdrug/antibiotic called Vancomycin. We treat
patients with Vancomycin injections if they have an infection with this kind of bugs.

Wife: Why he has been shifted to the other room?

Dr: Mrs Roper, I can imagine why you are so worried. As I explained, this infection can
spread from one patient to another patient easily if they are close to each other in the
same room. We have to keep him in a separate room so that the bugs will not spread. It
is beneficial to him also because there are no other patients in that room, so he may not
get any other kind of bugs from others.

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Wife: How long will he need to be in the hospital?

Dr: It may take a few days to get rid of this bug. We will keep checking that. Once he get
rid of these bugs and he has no other problem, then we will discharge him.

Wife: Can I see him, doctor?

Dr: Surely you can see him. However, we suggest you to wash your hands thoroughly
before and after you enter the room and minimise touching him or anything else inside
the room so that this bugs will not spread. Is that alright Mrs Roper? Find out if she is
pregnant, on any medications that can affect her immune system (e.g steroids), has any
other medical conditions. Wear protective clothing. Do not take anything into or out of
the room.

Wife: Ok, doctor.

Dr: Any other concerns? Wife: No doctor.

Dr: Thank you very much Mrs Roper, I hope he will recover soon. If you need any other
help please let me know.

MRSA - COPD PATIENT

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187. You are FY 2 doctor in the medical department.

Mr. Andrew Reece 65 year old man had been admitted to hospital for exacerbated
COPD (or Pneumonia) 10 days ago. He has been treated with the appropriate IV
antibiotics and has now developed acute diarrhoea.

His stool samples were taken and revealed the presence of C. difficile Toxin.

He has been shifted to a bay with other people with a similar condition and been
started on treatment. His son is concerned about him. Please talk to him and
address his concerns.

Dr: Hello. Are you Mr. Andrew Reece’s son? Son: Yes.

Dr: I am Dr …. One of the junior doctors in the medical department. How can I call you? Son:.

Dr: How are you doing Mr...?

Son: I am fine. I am worried about my father. I just came to see him. He has been
shifted to some other room. I can see doctors and nurses wearing aprons and gloves.
What is happening to him doctor?

Dr: I can see that you are very concerned, I will explain everything. Before that, can you
please tell me how much you know about what is happening to him?

Son: I know that he has COPD. Now, he has developed diarrhoea. I think he has got
food poisoning because of the food that you give him in the hospital.

Dr: You are right that he had COPD and yes, he has developed diarrhoea but it is not
food poisoning and neither it is because of the food that we are giving him in the
hospital. We actually did some tests on him and it showed that he has got some bugs in
his colon. Son: What kind of bugs?

Dr: These are bacterial kind of bugs called C. Difficile. Do you know anything about
these bugs?

Son: No doctor. I don't know about the bugs but I know that you are responsible for this.
He was perfectly fine before.

Dr: You are a very caring son. I can imagine why you are so anxious. But let me assure
you, we take really good care of all our patients.

Son: Then from where did he get these bugs?

Dr: Please let me explain to you why your father has developed diarrhoea. Son: Okay.

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Dr: Infections with this bug most commonly occur in people who are in hospital and recently
had a course of antibiotics like your father. Are you following me? Son: Yes.

Dr: Actually, this bug is normally present in the gut of many people. But it lives
harmlessly. The number of these bugs that live in the gut of healthy people is kept in
check by all the other harmless bugs that also live in the gut. So, in other words, some
of us normally have small numbers of these bugs living in our guts, which do no harm.

If someone takes antibiotics for any infection as in your father's case, this antibiotic that
he took not only killed the bacteria that caused the chest infection, but also killed many
of the harmless bacteria that lived in his gut. C. difficile type of bugs did not get killed by
this antibiotic. When other harmless bacteria are killed, then this allowed the C. difficile
type of bug to multiply. This bug also started to produce poisons which are called toxins
and these toxins caused him diarrhoea.

Son: But, doctor, many other patients have developed diarrhoea as well. It has to be
because of the dirty hospital food.

Dr: I can see why you are thinking that it is because of the hospital food. But let me tell
you that we do keep the hospital very clean. We take really good care of hospital
hygiene. The food provided in our ward is prepared under strict aseptic techniques.
Every member of the health care team washes their hands thoroughly and wear aprons
and gloves to minimise the chance of spread of any kind of infection to patients.

Son: Well, other people get it. Why did they get this bug?

Dr: Despite the good medical care, sometimes, it can spread to other people. It can
happen that the spores produced by the bugs can spread from the faeces of an infected
person to a non-living surface and from there can spread to the patients who are prone
to this infection.

Sometimes people can get this infection because new patients keep coming into the
hospital and they may have this infection and it spreads to patients already admitted in
the hospital. These bugs also spread through contact with contaminated objects such
as towels, sheets, clothes, dressings, surfaces, door handles and floors. And so
regretfully, sometimes further spread can occur via the hands of healthcare workers
despite all the caution.

Son: Are you sure that he had this bug?

Dr: Yes, as I have mentioned we have tested the blood of Mr. Herman. We have found
C. Difficile type of bug in his blood and it is risen because of the antibiotic that he used
in order to treat his chest infection. Son: But why did he get this bug?

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Dr: Well, as I have told antibiotics are the main cause of this infection. And above 60
years, there is an increased threat of getting infected with this bug. Also, in your father's
case because he has COPD, his body resistance would be low. So there is a fair
chance that bugs get inside his body and causes this infection.

Son: How are you treating him doctor ?

Dr: Well, Mr. Herman is closely monitored. We have stopped the antibiotics that we were
giving him previously for his chest illness. This will allow the normal harmless bugs to thrive
again in the gut. The overgrowth of C. difficile should then reduce and diarrhoea will stop.

However, we will be starting him on a different antibiotic that is known to kill C. difficile. This is
usually vancomycin or metronidazole. Symptoms then usually ease within 2-3 days.

Treatments are for at least 10 days

As with any cause for diarrhoea, it is important that we replace the fluids that are lost in
the diarrhoea. So, we will be giving him fluids through a drip into his veins to keep him
hydrated. Are you following me? Son: Is it serious doctor?

Dr: At the moment, these bugs are just present in his colon and they are not causing any
problems to him. So it is not a serious problem to him at the moment. However, in very rare
cases, if the infection is not treated at the right time, it can become very serious.

Son: Can there be any complications?

Dr: In small number of cases, if not managed at the right time, it can progress into a
serious illness in which swelling of intestine develops and for that, surgery may be
needed. Son: Why has he been shifted to the other room?

Dr: I can imagine why you are so worried. As I explained, this infection can spread from
one patient to another patient easily if they are close to each other in the same room.
We have to keep him in a separate room so that the bugs will not spread. It is beneficial
to him also because there are no other patients in that room, so he may not get any
other kind of bugs from others.

Son: Can't you give him any medicine to stop his diarrhoea?

Dr: Anti-diarrhoeal medicines are not recommended in this infection. This is because it
is thought that they may slow down the rate at which the poisons (toxins) produced by
the bacteria are cleared from your gut.

Son: How long will he need to be in the hospital?

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Dr: It may take a few days to get rid of this bug. We will keep checking that. Once he
gets rid of these bugs and he has no other problem, then we will discharge him.

Son: Can I see him doctor?

Dr: Surely you can see him if you do not have any medical conditions because if you
have any medical conditions then you may catch this bugs easily. You can enter his
room and see him. However, we suggest you to wash your hands thoroughly before and
after you enter the room also you should wear apron and gloves and minimise touching
him or anything else inside the room so that these bugs will not spread. Don’t take
anything out of the room. Dispose of their protective clothing appropriately. Is that
alright?

Find out if patient is pregnant or on any other medications (e.g immunosuppressants).

Son: Ok doctor.

Dr: Any other concerns?

Son: No doctor.

Dr: Thank you very much, I hope Mr. Herman will recover soon. If you need any other
help please let me know.

CLOSTRIDIUM DIFFICILE INFECTION - TALK TO

SON

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Information on C. Difficile management

Management of mild, moderate, and severe CDI

If a patient has strong a pre-test suspicion for CDI, empiric therapy for CDI should be
considered regardless of the laboratory testing result, as the negative predictive values
for CDI are insufficiently high to exclude disease in these patients. (Strong
recommendation, moderate-quality evidence)

Any inciting antimicrobial agent(s) should be discontinued, if possible. (Strong

recommendation, high-quality evidence)

Patients with mild-to-moderate CDI should be treated with metronidazole 500 mg orally
three times per day for 10 days. (Strong recommendation, high-quality evidence)

Patients with severe CDI should be treated with vancomycin 125 mg four times daily for
10 days (Conditional recommendation, moderate-quality evidence)

Failure to respond to metronidazole therapy within 5–7 days should prompt

consideration of a change in therapy to vancomycin at standard dosing. (Strong
recommendation, moderate-quality evidence)

For mild-to-moderate CDI in patients who are intolerant/allergic to metronidazole and for
pregnant/breastfeeding women, vancomycin should be used at standard dosing.
(Strong recommendation, high-quality evidence)

In patients in whom oral antibiotics cannot reach a segment of the colon, such as with
Hartman’s pouch, ileostomy, or colon diversion, vancomycin therapy delivered via
enema should be added to treatments above until the patient improves. (Conditional
recommendation, low-quality evidence)

The use of antiperistaltic agents to control diarrhoea from confirmed or suspected CDI
should be limited or avoided, as they may obscure symptoms and precipitate
complicated disease. Use of antiperistaltic agents in the setting of CDI must always be
accompanied by medical therapy for CDI. (Strong recommendation, low-quality
evidence)

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HANDLING COLLEAGUE PROFESSIONALISM

Follow the acronym

S = Seek information - make him admit, find the reason (stressor), duration, if he has
made any efforts to cut down, if he has support

P = Patient safety - find out if he saw any patients especially emergency, send him to
go home, ask him not to come until he has sorted out the issues

I = Initiate - try to help him stop, make him understand the importance of stopping
alcohol

E = Escalate - Tell the seniors

S = Support - Offer your support. Remind him of family, psychiatrist support

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188. You are an FY2 in the medical department.

During ward rounds, you have come across your colleague, Dr. Jonathan smelling
of alcohol. This is the second time you have encountered him in this state. Take
your colleague to a private room and talk to him.

Dr: Hello Jonathan, I am... How are you doing? Colleague: I am fine.

Dr: How’s the work going on? Colleague: It is going alright.

Dr: That sounds good. Have you been able to manage all your duties well?

Colleague: Yes, I could manage.

Dr: I see. Well, Jonathan, I'm a bit concerned about something. If you can take some
time off your ward work, I'd like to talk to you privately about it.

Colleague: Yes, it's fine. I am free for now. We can talk now.

Dr: Well Jonathan, I have been noticing something for some time now. Is there
anything you want to share with me?

Colleague: No, everything is alright.

If colleague asks you if you will keep the information confidential, inform him that you
will tell only the concerned people

“I’m here to help you. I don’t want you getting into trouble. You know what can
happen if patients find out.”

(Seek Information)

Dr: Actually, today during ward rounds, I found you smelling of alcohol. Can we talk
about it?

Colleague: No, you must be mistaken.

Dr: Well, Jonathan, I don't think it could be a mistake because it's the second time I've
happened to notice this. You know, you can share with me if something troubling is
leading you to take alcohol.

Colleague: I might have taken some last night but not today.

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Dr: But Jonathan, I can still sense the smell of alcohol.

Colleague: I do not think I took too much of it.

Dr: I see. Did you drink in the morning? Colleague: I might have.

If he doesn't admit, you can try to scare him about consequences of being found out
later by your consultant and GMC.

Dr: Could you please tell me since when have you been taking alcohol? (Stressor &
Duration) Find out why he’s drinking

Colleague: You see it's not that long. I started taking it a few weeks ago when my
girlfriend broke up with me.

Dr: It must be distressing for you.

Colleague: It is. I don't know what to do now when she's gone. I am devastated.

Dr: I am so sorry Jonathan. Colleague: Thank you.

Dr: Could you please tell me how much you drink daily Jonathan?

Colleague: (?) Just a bottle of whiskey and a few shots of gin.

Dr: Jonathan, I can understand that you are very gloomy but did you try to stop taking
it or reduce the amount? (Cut Down)

Colleague: Not really. I have been miserable you know. I miss my girlfriend.

Dr: Alright. I can see that your mood is low Jonathan, could you grade it for me on the
scale of 1 to 10? Colleague: 8 out of 10.

Dr: Do you live with your family Jonathan?

Colleague: I live in the hospital accommodation. My parents live in some other part of
the UK.

Dr: Have you got any friends in here? Colleague: I do hang out with my friends
sometimes.

Dr: That is good. Could you tell me if you have noticed that drinking has been
impacting your life and work? Colleague: (No?)

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Dr: Have you ever come to the ward before like this? Colleague: No. Dr:

Have you encountered any similar problems before? Colleague: No.

(Patient Safety)

Dr: Could you please tell me what time you started working in the ward today?

Colleague: I started in the morning.

Dr: Jonathan, I need to tell you that for the wellbeing of patients, it's important that
we review all the patients you have been seeing since morning. This is because under
the effect of alcohol, you might have missed some necessary steps in providing the
best possible care to patients. Are you following me? Colleague: Yes.

Dr: Could you please tell me how many patients you saw Jonathan? Colleague: (?)

Dr: Did you happen to look after any patient who seemed to require an emergency
care or immediate referral? Colleague: (?)

Dr: You see Jonathan, all of us want what is best for our patients, I feel you should stop
working now and take a rest for the rest of the day, what do you say ?

Colleague: That is right. I can understand. What will happen with them?

Dr: Well, I think these patients need to be reviewed. Do not worry. I will take care of
that for now. Colleague: Thank you.
(Initiate)

Dr: I can see that you are having some troubles and that's why you're consuming
alcohol. I would appreciate if you can understand how it can impact our work place.
Are you understanding? Colleague: Yes.
Dr: As you know, our patients could be very sensitive Jonathan and it is important that
we are not under the effect of anything toxic that can affect our judgement while
dealing with the patients. What do you think? Colleague: I can understand.

Dr: I am pleased that you understand. I can see that you wish the best of health for
your patients. So, I would like to suggest you that it'd be better for you if you take
some time off from your work. What do you say?

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Colleague: I still don't think it is that big an issue. Also I have my annual leave starting
after 2 weeks. I am going to stay with my parents.
Dr: Jonathan, it is important to us that patients do not get affected by this. In such
circumstances, any negligence, although involuntary, can lead to a complaint against
you. And NHS takes such complaints very seriously. A strict action could be taken
against you if a patient gets harmed. It can even cost you your registration with GMC.
Now, I know you don't want that. Isn't that so? Colleague: Yes.
(Escalate)

Dr: Also, I would like to let you know that we need to inform the Consultant about
this. It'd be better that you do that. What do you say Jonathan?

Colleague: Is it really necessary?

Dr: Yes, Jonathan it is really important that our senior know this.

Colleague: Will you tell the consultant?

Tell him that you can both go together

Dr: If you don't, I am afraid I have to because it is crucial for the safety of patients. I
think you will agree with me on this. Also, he may come to know from others even if I
don't tell him. It may be better if you tell this to him yourself rather than others. Will
you do that?

Colleague: Thank you for your suggestion.

(Support)

Dr: Jonathan, I must remind you that a range of help is available for you to cope with
this difficult time. Would you like me to tell you some options? Colleague: Yes.

Dr: First of all, you should consider taking your time off from work for some days. This
will allow you to relax and will help you deal with your situation with an open mind.
Would you consider that?

Colleague: But what about my duties?

Dr: I can see that you are really concerned about your work but you do not need to
worry because I can provide your replacement until the department makes necessary
arrangements for it. Colleague: Thank you so much for that.

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Dr: Also Jonathan, I think you need support from your loved ones, I would suggest you
that you let your family and friends know about this. They might be able to assist you
deal with this hard time. Also, you might be able to go to your parent's place for some
time. It might do you a great deal of good. What do you think?

Colleague: Yes, I would consider that.

Dr: Also, as you would be talking to consultant, he might also be able to assist you..
Okay? Colleague: Yes.

Dr: You also know that we do have all kinds of psychiatric help available. Some talking
therapy might help you. Our consultant will be able to assess you for that. Is that
okay? Colleague: Okay.

Dr: Do you have any concerns Jonathan?

Colleague: No, thank you for your help.

Dr: You can totally rely on me. Let me know if there is anything troubling you.

Colleague: Okay. Thank you.

ALCOHOLIC COLLEAGUE

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189. You are an FY2 doctor in the ward.

You went to a birthday party last night. There was a final year medical student,
Joan Halas whom you saw drinking heavily and snorting cocaine. In the morning at
work, you have found the medical student agitated and hyper-excited. You
overheard the nurses making fun of him, saying that he snorts cocaine at work.

Talk to the medical student, and assess whether or not it is safe for him to stay in
the hospital.
Dr: Hello Joan, I am... How are you doing? Student: I am fine.

Dr: How are the studies going on? Student: It is going alright.

Dr: That sounds good. Are you learning how to taking history or examining patients in
the ward? Student: yes I am.

Dr: I see. Well Joan, I'm a bit concerned about something. If you have some time, I'd like
to talk to you. Student: Yes, it's fine. I am free for now.
Dr: Well Joan, I happened to be at a birthday party last night. It seems that you also have
been at the same party. Isn't that so? Student: Yes, I was out with friends last night.

Dr: I see. Joan, don't mind me asking you this, did you take any drugs when you were
hanging out with friends? Student: No, I did not.

Dr: Well Joan, I myself saw you snorting drugs. Student: Oh! you were there?

Dr: Yes, Joan I was. Student: It must be someone else. Are you sure you saw me?

Dr: Yes, I am sure. Also, I saw you drinking heavily. Is that right Joan?

“I’m here to help you. This information might go to your educational supervisors.”

Student: Will you keep it confidential if I tell you?

Dr: You see it is very important that we talk about this. I might be able to assess you
once we talk and maybe we can determine how we can solve it right here. Sometimes,
we might need to get some help but in any case, this issue will always remain inside
the medical team.

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Student: Okay. I might have taken some drugs. But I have never done drugs at work.

Dr: I have come to know that nurses have been talking about you snorting cocaine at
work place and that you have been behaving a little different.

Student: I don't think so.

Dr: Well, Joan, have you been feeling agitated or excited more than usual ?

Student: I am feeling completely normal. Besides that, everybody does drugs

nowadays. I don't think it is that big a deal. Don't you do drugs?

Dr: Well, Joan, I do not and also, I think that considering the environment we are
working in, no health care provider could afford to do anything like that. It would be
wrong if we are not careful while being in the vicinity of patients. It, in fact, is a very
concerning matter.

Student: But I have never done anything wrong. I am doing very well in studies, you
can confirm from my supervisor too.

Dr: I really appreciate that you are serious about your academics Joan but this matter
is of a great ethical importance. I would like to ask you some questions in order to get
to the bottom of this.

Student: But I do not think I took too much of either of the two.

Dr: I see. But did you take it in the morning? (Seek Info)

Student: I might have.

Dr: Could you please tell me since have you have been doing drugs and drinking alcohol?
(Duration) Student: I have just done it - not more than once or twice.

Dr: Was there any incident like sad or shocking or anything that might have lead you
to start it? (Stressor) Student: No. Everything is fine.
Dr: Could you please tell me what drugs do you take? Student: Cocaine.

Dr: How much are you taking daily? Student: (?)

Dr: I see. Could you please tell me how you drink daily Joan?

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Student: Just a bottle of whisky and a few shots of gin.

Dr: Joan, I can understand that you have not been taking it for a very long time but
did you try to stop taking the cocaine and alcohol or reduce the amount? (Cut Down)

Student: Not really. I don't think it is too much.

Dr: Alright. Could you tell me how has been your mood lately? Grade it for me on the
scale of 1 to 10? Student: 10 out of 10.

Dr: I can see that you have friends and you like hanging out with them. Do you live
with your family Joan? Student: Yes/No

Dr: Any trouble with the law? Student: No.

Dr: That is good. Could you tell me if you have noticed that drugs have been
impacting your life and studies ? Student: (No?)
Dr: Have you ever come to ward before like this? Student: No.

Dr: Could you please tell me what time did you come to the ward today?

Student: I started some time ago.

Patient safety

Dr: Joan, I need to tell you that for the wellbeing of patients, it's important that we
review all the patients you have been seeing since morning to check any trouble or
harm has been caused to patients. Are you following? Student: Yes.

Student: That is fine. But I still think I did not do anything wrong.

(Initiate)

Dr: I can see that you have the notion that taking drugs is not that big an issue but I
would appreciate if you can understand how immensely it can impact our patients. Are
you following me? Student: Yes.
Dr: As you know Joan, one day, you are going to get into the professional medical
field. It is very crucial that you learn about patient safety and medical ethics now. You
must try to understand that medical professionals should not be under the effect of
anything toxic that can affect their judgement while dealing with diseased patients.
What do you think? Student: Yes, I can understand.

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Dr: I am pleased that you understand. I think you also wish the best of health for the
patients. So, I would like to suggest you that it'd be better for you if you do not stay at the
hospital today because you are under the effect of drugs and alcohol. What do you say?

Student: I am not harming anyone.

Dr: Well Joan, I understand but it is important that patients do not get affected by
your behaviour in any way whatsoever. Also if you do not rectify your mistakes now, it
might lead you into some trouble later on. Your negligence can lead to a complaint
against you. And such complaints could be taken very seriously by the NHS. A strict
action could be taken against you if a patient gets harmed. Now, I know you will not
want that. Isn't that so? Student: Yes.

(Escalate)

Dr: Also, it is essential that you inform your Education supervisor about this. It'd be
better that you do that. What do you say Joan?
Student: Is it really necessary?

Dr: Yes, Joan it is really important that your education supervisor know about this. I
think you will agree with me on this. Also he may come to know from nurses even if I
don't tell him. It may be better if you tell this to him yourself rather than others. Will
you do that?

Student: Okay, I will go straight to my supervisor. Thank you for your suggestion.

(Support)

Dr: Joan, I must remind you that a range of help is available. Would you like me to tell
you some options?

Student: Yes. What kind of help are you talking about?

Dr: As I would sincerely advise you to quit this habit Joan, you might need to know
that some medicines are available that could help you if you have trouble dealing with
you cravings and for your withdrawal symptoms once you stop doing drugs. Also
Psychiatrist can help you if you need. Is that okay? Student: All right.

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Dr: Joan, I also think you better avoid going out to places that will make you want to
do drugs and drink. I would suggest you that you let your friends know about this and
how important it is for you to not get involved in drugs. They might be able to
understand your situation or you might avoid going out to pubs and parties. This will
do you a great deal of good. What do you think? Student: Yes, I would consider that.
Dr: As you would be talking to your supervisor, he might be able to tell you if you
need some time off from your ward duties or not. Is that alright? Student: Okay.

Dr: Do you have any concerns Joan? Student: No, thank you for your help.

Dr: Once again Joan, you can totally rely on me if you ever encounter any problem in
future. Let me know if there is anything troubling you. Student: Okay. Thank you.

COCAINE ABUSER - FINAL YEAR MEDICAL STUDENT

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190. MEDICAL STUDENT COMES LATE

Ensure you ask the student leading questions

● Ask about possible reasons for coming late

● How often he comes late
● Tell him about the noble profession of medicine and the importance of setting a
good example
● We can not learn effectively from our colleagues as compared to our teachers

In the exam, one reason may be he was using computers until late. He may also say, “I
thought it is the final year, so I thought of taking it easy and enjoy life”, or he may say
he did not realise he is coming late or no apparent reason at all,

Any traffic problems?

Any other job before coming to the hospital?

Getting up late – if so why ?

He might say he’s not getting sleep

Reasons why he’s not getting sleep - pain, noise, bright light, depression, stress,
uncomfortable bed

Going to bed late – why – late night parties, reading until late, watching TV, using
computers until late, drinking coffee alcohol late night.
SPIES

Seek info – what is the problem?

How are you doing? How do you find medical school? What about the hospital
posting? Do you like it? Do you talk to patients in the hospital ? Do you enjoy that?
Any problems at all ? Do you come regularly? Do you come in time to the hospital?

He may or may not admit to coming late

“We noticed that you are coming late to the hospital may I ask why?”

He may say that he gets up late. But I am late only few minutes.

Find out why he gets up late? Any sleep problem?

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Any medical conditions?

Any travel problems?

Anything else bothering him?

How is he in studies? – praise him if he says he is good in studies.

Patient safety – “It is not a good habit to come late. We being doctors we should be
very prompt in our work. We should be very punctual in our job. It is better that you
develop that habit now itself. If the habit of coming late to the job continues – once
you become a doctor and come late to the work it may affect patient safety. GMC can
take actions which is not good for you.”

Initiate: As professionals, we need to have good discipline at our work place. It is

better to develop a good discipline from now.

Do you keep an alarm? I suggest you do that. Make a habit of going to the bed early
and getting up early. Once you do it for sometime, then you will get used to it and you
may even like it. So you can reach the hospital in time. As doctors, we need to set an
example to others by being prompt and punctual in our work.
Escalate:

“Do you have educational supervisor? Have you talked to him about this? I think it is
better you inform him about what is happening. If he hears from others, it is not good
for you.”

“Will you tell my Consultant?”

“No, I won’t tell your Consultant.”

Support:

Is there any way I can help you? Do you have any other problems? I am sure your
educational supervisor also will help you in any way possible.

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191. Your FY1 colleague, Dr Gupta, is in the medical ward covering for another
doctor who is on sick leave. He was supposed to discharge Mrs Storm but
her discharge got delayed for a few hours. Mrs Storm wants to complain.

Management also wants beds for patients in the ER and they repeatedly called
the nurse to enquire for beds.

You are the FY2 doctor in the same department. Go and talk to your colleague and
find out what happened.

(You enter the cubicle and FY1 colleague is acting very busy)

Dr : Hi Dr Gupta. I am Dr…. I am in the same department. How are you doing today?

FY1 : I am fine doctor. You can call me Sam.

Dr : Ok Sam . You seem to be really busy. Is everything alright?

Sam : Yes doctor, this is my first job. All these things were not taught in medical school.

Dr : I think I can understand your situation. Things are tough at the start of your job and
with time, you get used to the system and I believe you will start enjoying it then.

If you would like, I can guide you to a few workshops which will make this process
easier for you.

Sam : It is just that this is my first job and I think I am overworked. But if it would help
me, I might consider joining a workshop.

Dr : Yes, Sam, I really think it would help. I can see that you are really busy today but
there is one thing that I would like to discuss. Do you have a few moments to spare?

Sam : Yes doctor. I think we can talk now.

Dr : Alright Sam. It is regarding discharging Mrs Storm. She was supposed to be

discharged few hours back. She has been waiting since then and now she wants to
complain.

Sam : Yes doctor. I am aware that I had to discharge her. It is just that I was doing work
and it kept me busy.

Dr : Sam do you feel you have any problem prioritising jobs ?

Sam : No doctor. I have a to-do list and I note things on this. Actually, I was busy with critical
patients/important things and her discharge just kept on going down and down on my list.

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Ask to see his job list and praise him if he prioritised properly

Ask him what jobs he had to do earlier on

Dr : Sam, do you think if there is a problem or you could have done things in a better way?

Sam : I am not sure of what I could have done better. This is my first job and when I
came in the morning, I informed the management that it would be difficult for me as I am
the only one in the ward today.

Dr : Yes Sam I think I can understand what you are going through. You could have told
me and I would have been happy to share your workload.

Sam : Yes doctor I wanted to but you are the first doctor I am seeing today.

Dr : Well Sam, you should have informed the ward nurse or the nurse in charge that you
are held in an emergency and are bit delayed. What do you think about it?

Sam : Yes, doctor I think I could have done that.

Dr : Yes Sam. What’s important is that this should not happen again and we keep on
learning and improving from every experience.

So I think you should report this incident so that it is discussed in The Root cause
analysis meeting and we can find ways to avoid this kind of situation in future.

Sam: Yes doctor I will do that.

Dr: Sam I think you should also go to Mrs Storm and explain your situation. And if she
wants to complain, then guide her to PALS.

Sam: Yes doctor, I will go to her now but will you tell the consultant?

Dr : Sam you must tell the consultant yourself. He is going to find about this incident
anyway so it would be better if you did it yourself as you would have a chance to explain
the situation. I am sure he will help you further.

Sam: Yes doctor I will talk to him as soon as possible.

Dr: Sam, one more thing if you are very busy or overwhelmed, ask for help. If you need
help with anything in future, we are always with you. You cannot expect to do everything
yourself. We work as a team here. This is very important for patient safety. You should
go and talk to Mrs Storm and I will cover for you in the meantime.

Ask him if he needs any other help.

FY1 COLLEAGUE - DELAYED DISCHARGE
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192. Your junior colleague (FY1 doctor) Dr Wilson did not insert an IV cannula for Mrs
Williams who was supposed to receive IV antibiotics. Talk to your colleague.

You – Hi Wilson, I am Peter. How are you doing? Him- I am fine, Peter

You – How’s the work going on? Him - It is good not bad.

You – Was it very busy today? Him – Not so much. I could manage.

Him- It is good not bad.

You – was it very busy today? Him – Not so much. I could manage.

You – She has put a complaint saying that you didn’t insert an IV cannula and she’s
been waiting for a long time.

Him – Oh really. But there is 2 hours’ time for the next antibiotics. I don’t understand
why she has to complain.

You – What did you tell her about the cannula?

Him – Well, I told her that I will be back in about 15 minutes to insert cannula but then I
saw an interesting X ray, I went to the library to read about it.

You – It is good to know that you are interested in learning. But I think since you had
already told her that you will be back in 15 minutes to insert the cannula, you should
have done that first or you could have told her that you will be back to insert the cannula
before the next dose is due.

Him – Well yes, I think I should have done that.

You - Do you have any issues prioritising or getting your work done on time? When I
started working I also had the problem of prioritising, then I went to a course, it helped
me a lot. May be you too can attend one course like that if you want to.

Him – Ok, I will surely try that.

You – I think you need to talk to Mrs Williams and explain to her and may be apologise
to her if you think so. Him – Yes, I will

You can also ask him what he thinks we can do.

You - I think you can insert the cannula now and tell her that no harm has happened also I
suggest you to fill up a clinical incident form. You should also tell the patient about PALS

Him – Yes, thank for your suggestion. Will you tell the consultant?

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You – I guess he may come to know that from others. It may be better you tell him
yourself rather than he hearing it from others.

Let him know that the consultant is not a monster and is there to help.

Him – Yes, thank you. You – Thank you.

-------------------------------------------------------------------------------------

- Sometimes, the colleague says he forgot to insert the cannula. You can ask him to
maintain a diary so that he will not forget the jobs.

- Sometimes he says he was caught up in doing CPR. You can tell him that he could
have told you to insert the cannula or he could have informed the nurses in the ward to
tell the patient that he would be late.

FY1 DOCTOR DID NOT INSERT IV CANNULA

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193. Your Colleague FY1 doctor made a post on Facebook about an elderly lady
in the Emergency Department with confusion considered herself to be the
Queen of England, Elizabeth. Talk to your FY1 colleague and address his
concerns.

SPIES (S = Seek information, P = Patient safety, I = Initiate, E = Escalate, S = Support)

When you enter the cubicle, he is not serious at all. He will start the conversation.

GRIPS plus rapport with your colleague first (Introduce yourself as FY2 and build
rapport).

Then ask him if he has any idea why you have arranged this meeting. He says no.

When you will tell him, “I am here because I want to talk about the post you made on
Facebook regarding one of our patients”, then he will start laughing, he might say “Yeah!
What a funny story!”

FY1 Colleague: She was making some funny comments like she lost her crown and she
was looking for it.

He will talk a lot there and will tell the whole story.(Explore here whether he wrote
down the name of the hospital/department).

Dr: Posting patient information on social media is a breach of confidentiality. Being a

medical professional, we must obey the rules and regulations of NHS.

FY1 Colleague: I didn’t write down the patient’s name and age; I posted it on my
personal account.

Dr: I am afraid, communications intended for friends or family may become more widely
available (sharing the post by your Facebook friends). Although individual pieces of
information may not breach confidentiality on their own, the sum of published
information online could be enough to identify a patient or someone close to them. If we
do things like this, the patient will lose trust in the NHS. NHS takes this sort of incident
seriously. I am sorry to say, it may even cost your GMC registration!

[According to Good Medical Practice book by GMC (page 21, para 69), when
communicating publicly, including speaking to or writing in the media, you must maintain
patient confidentiality. You should remember when using social media that
communications intended for friends or family may become more widely available]

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[Although individual pieces of information may not breach confidentiality on their own,
the sum of published information online could be enough to identify a patient or
someone close to them]

Related Link: Doctors use of social media

FY1 Colleague: Where can I find these principles and regulations you talking about?

Dr: You can get it from the Good Medical Practice book. Also, you can attend some
workshops for medical ethics.

He will say, “I was only joking it's just with my friends in my personal account, I didn't
mean to break confidentiality.”

FY1 Colleague: Am I in real trouble? What shall I do then?

Dr: I highly encourage you to delete the post immediately. Write down an incident form
as well. I sincerely advice you not to do it in the future. Also, please inform your seniors/
consultant. He might be able to help you. It will be very bad for you if your consultant
hears it from others.

(If patient is conscious/has full mental capacity, encourage him to talk to the patient and
apologise for what he did).

End station with offering support.

POSTING PATIENT INFORMATION ON SOCIAL

MEDIA BY YOUR COLLEAGUE

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MISCELLANEOUS
194. You are an FY2 in department for elderly medicine
80 years old Mr. Albert Corrigon has been admitted for some time with lung
cancer. He has been receiving treatment.

The nurse wants to talk to you about Mr. Albert Corrigon.

Speak to the nurse, assess the patient and write medical notes.

Hello my name is doctor --------- --. I am one of the Junior doctors in the department.

Are you nurse------------? Yes

Dr: I understand that you wanted to talk to me, how can I help you today?

Nurse: Doctor, Mr. Corrigon is admitted with us for the past few weeks. For the last 10
days, he has not been well and today he suddenly became like this.

Dr: Ok, let me just have a look at Mr Corrigon.

Dr: Hello Mr. Corrigan............... no response.

Mr. Corrigon, next tapped the patient, no response.

Assess airway, check carotid pulse and look for breathing. (Patient has no pulse and is
not breathing.)

Dr: It seems that Mr Corrigon is in cardiac arrest. Please help me connect the monitor to
confirm.

Nurse: Sorry doctor, there are no monitors here.

Dr: Ok then we must start CPR. Please call the crash team but before that, I would like
to know if Mr Corrigon had any end of Life Care wishes.

Nurse: Yes doctor, Mr. Corrigon had signed a DNACPR form. Here, I have the form if
you want to have a look at it. (It is completely filled form with lots of information.

Dr: Yes, you are right, It appears that Mr. Corrigon had wished for no resuscitation and
we must respect that.

(There is a stethoscope and a pen torch inside the cubicle).

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Confirm patient’s death and write in notes

Death Confirmation Assessment:

" Identity confirmed as Mr./Mrs. from wrist band.

" Patient lying in bed, eyes closed, no signs of life.
" No respiratory effort noted.
" No response to verbal or painful stimuli.
" No carotid pulse palpable.
" Pupils fixed and dilated bilaterally.
" No heart sounds noted during 3 minutes of auscultation.
" No breath sounds noted during 3 minutes of auscultation.

Death Confirmed at (time), on (date).

No concerns from staff members or patients family.

Signature
Name
GMC Reg No:

Dr: I would like to contact Mr Corrigon’s family so that we can break the news to them.

Nurse: Sorry doctor, they are not around.

Dr: Ok, do we have their contact numbers? Nurse: Yes

Dr: We should contact and inform them of Mr Corrigon’s death.

Nurse: I will contact them and you can speak to them.

Dr: That would be great, Thank you.

Dr: I will discuss with my seniors regarding cause of death before completing and
signing the form.

Thank you.

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DNACPR SIMMAN - TALK TO A NURSE

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TEACHING STATIONS
You might need to teach a student, FY1 or patient

Your job is to get the student/FY1 to come with you to the patient

The student might either be indifferent or hyperactive

Never get the student to touch the patient

Greet: I’m DR N...Call me …..

Rapport: How’s it going?

Assess how much he/she knows.… Have you ever seen a … examination?

Teach: Get him involved and ask him direct questions, praise him and correct him

Make sure he understands

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195. KNEE EXAMINATION - TEACHING MEDICAL

STUDENT
Teach the medical student about the knee examination. Do not tell the medical
student to examine the patient after teaching.
Dr: Hello I am Dr …. How are you doing today David?

Student: I am doing fine. How are you?

Dr: I am good too how are your studies going?

Student: They are going alright. I actually need your help regarding an examination of
Mr Smith’s knee.

Dr: Yes sure I will help you. It’s a very good thing that you are keen to learn. Do you
have any prior knowledge about the topic? Student: No.

Dr: That’s alright David, I will tell you. Now if you don’t understand anything, just tell
me. I will try to explain it in a better way. Is that alright? Student: Okay.

Dr: So first of all whenever you are about to examine any patient, you need to first
identify and take consent from the patient. Have you taken consent from the patient? Very
good that you got consent. You still have to get consent from the patient.Student: Yes/No

Dr: Okay I will show you. Let’s start.

Dr: Hello I am Dr … I am one of the junior doctors in the department. He is David, and
he is a medical student. How may I call you?

Pt: You can call me Mr Smith.

Dr: Okay Mr Smith how are you doing today? Pt: I am doing alright. I just have some
pain in my knee.

Dr: Oh I am really sorry about that. would that be alright if we examine your knee
joint? We will try to be as gentle as possible. Pt: Yes it’s fine.

Dr: May I please know which side is it? This examination involves inspecting your knee joint,
touching it and performing few movements, as David might have already mentioned to
you.

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May I explain/teach David throughout the examination? We’re going to be using some
medical words. (talk to student : So after the consent David, we just explained our
purpose of examination, next we need to ask about the exposure).

The bed should be flat.

Inspection

If patient is standing, ask him to be in an anatomical position:

1. Alignment of joints: Knees, SAIS, medial malleoli

2. MDRSSS
3. Popliteal fullness

When sitting:

1. MDRSSS
2. Popliteal fullness

Palpation

1. Tenderness
2. Ulse
3. Patellar tap

Movements

1. Flexion
2. Extension

Special Tests

1. Anterior and Posterior Cruciate (Drawer’s Test)

2. MCL and LCL (Valgus & Varus stress test)
3. Medial and lateral menisci (McMurray)

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Exposure:
Dr: For the purpose of this examination, I would like you to get undressed below your
waist please but you can remain in you briefs. I will ensure your privacy and request for
a chaperone.

Mr Smith: Okay.

(Talk to David) Sometimes, the patient is in the bed and knees are already exposed. In
that case, don't ask for exposure but say, thank you for adequate exposure.

Position:

Standing and lying flat. (Sometimes in exam, the examiner might not allow you to
make the patient stand. In that case, do everything in a lying position only but don’t
comment on the level of joints).

Inspection:

Ask the patient to stand up.

Make patient stand in anatomical position with arms tucked in by sides, feet together
and palms facing towards you.

Front:

● Comment on levels of Anterior Superior Iliac Supine, Knees and Medial

Malleoli.
● Note any deformity. Genu Valgum (knock knee) or Genu Varum (Bow legs)
● Scars, Sinuses, Erythema, Muscle wasting

Back:

Popliteal swelling indicates baker’s cyst

Gait:

Ask patient to take a few steps. Observe the gait and comment on either normal
(smooth & symmetrical) or antalgic (limp to avoid pain) gait.

Ask patient to lie down on the couch which must be flat.

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Feel:

● Warm up your hands

● Temperature: Assess temperature, compare on both sides.

Palpation:

Look at the patient's face for tenderness.

Joint lines:

● Ask the patient to flex knee slightly. Feel both tibial and femoral joint lines and
look for any tenderness.
● Palpate above (Quadriceps tendon) & below (Patellar tendon) patella and look
for tenderness.

Move

● Flexion: With patient supine, ask to “bend knees up and bring foot as close to
hip as possible”
● Extension: Tell patient to extend (straighten) the leg back down to the couch.
Ask patient to lift one leg from couch and look at full knee extension. Do it on
both sides.

Comment on full and free/restricted/painful movements.

Special Tests

Tests of stability

Collateral ligament

Extend patient’s knee fully and hold the ankle between your elbow and side.

Valgus: Apply force laterally on knee with one hand to feel for laxity or pain. It
suggests medial collateral ligament injury.

Varus: Apply force medially on knee with one hand to feel for laxity or pain. It
suggests lateral collateral ligament injury. (Give your findings)

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McMurray’s Test

Medial Meniscus

1. Passively flex the knee fully.

2. Externally rotating the foot, heel facing medially, abduct the upper leg at
the hip.
3. Extend the knee smoothly. In medial meniscus tear a click/clunk is heard
or pain is felt.

Lateral Meniscus

1. Passively flex the knee fully.

2. Internally rotate the foot, heel facing laterally, adduct the leg at hip.
3. Extend the knee smoothly. In lateral meniscus tear, a click/clunk is heard
or pain is felt.

(Give your findings)

Drawer’s Test:

Fix the patient’s knee to 90 degrees and maintain this position by sitting with your
thigh trapping the patient’s foot.

Anterior drawer sign:

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

Posterior drawer sign:

Push backwards on tibia. Significant movement of tibia suggests posterior cruciate

ligament injury. (Give your findings)

Patellar Tap:

1. With patient knee extended, empty the supra patellar pouch by sliding your left
hand down the thigh until you reach the upper edge of the patella.

2. Keep your one hand there and with the fingertips of the other hand, press down
briskly over the patella. You may feel a fluid impulse in your left hand.

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Neurovascular

● Check distal pulse. (Dorsalis pedis)

● Ask patient to wriggle the toes.

Thank the patient and ask to dress up.

Finish your station by saying “I will examine joint above and below”.

General advice:

P: Protection: Avoid activity which causes pain to allow the inflammation to heal.

R: Rest

I: Ice packs

C: Compression

E: Elevation

NSAIDs: we will give you some painkillers to relieve the pain

Physiotherapy: an appointment with physiotherapist

Follow up appointment: we will see you in the follow up appointment to see how well
you are doing.

Surgical treatment: if the above measures fail then we can refer you to a specialist
doctor, who can consider an operation.

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196. INGUINAL SWELLING - TEACHING MEDICAL

STUDENT
You are the FY2 in surgery department. A 40 year old man has come for a check up
for his hernia. Ross is a medical student. Teach Ross groin and genital examination

Only teach him how to examine and not to take a history

(Inside the station – mannikin, student, and examiner)

D - Hello, I am John.

Ross - Hello I’m Ross, a third year medical student

If he doesn’t mention what year he is, ask him what year he is.

D - How are you doing? How are your studies? (Brief talk) Ross -…

D - Well, I understand that you are here to learn about the groin and genital
examination? Do you know anything about it? R - No

D – Don’t worry. I will do my best to teach you. If you have any doubts, please feel free
to ask me R- Thank you ..

D - Well Ross, Mr.…has come to us today for a check up for his hernia. Do you have
any idea what a hernia is? R- No doctor

D - Well a hernia occurs when the internal organs in our body such as the intestines
push through the wall of the abdomen due to a weakness and comes out like a
swelling. This patient has come with hernia in his groin area. Let us discuss about this
for the moment. Are you following me? R-Yes
Examination to check for direct or indirect hernia or is it scrotal swellings like hydrocele.

Direct hernia is the hernia which comes out directly from the abdominal wall because of
weakness in the abdominal wall whereas indirect hernia comes out through the deep
ring and passes through the inguinal canal then comes out through superficial ring.

D - Now thank the patient for his cooperation and then take his permission for
examination.

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Exposure- below chest up to mid-thigh

Ensure privacy and request for chaperone

Position – abdomen examination – in supine position

Local examination – Groin

Ideally should be examined in the standing position. However, since this is the manikin
let us examine in the lying down position.

Inspection - inspect all regions for swelling,

If a visible swelling present -

Position, unilateral or bilateral, size of swelling, visible peristalsis, skin over the
swelling, change in colour

If no swelling is present –

Cough impulse - ask the patient to turn his face away and cough . Look for swelling.

Inspect penis – Any swelling, buried in the scrotum, pushed to one side,

Position of the penis (You can ask the patient to hold his penis away from the swelling).

Assume gloved

Palpation

Swelling – palpate from front, sides and back for temperature, tenderness, size and shape,
Verbalize position and extent – in relation to anterior superior iliac spine, pubic tubercle

(The pubic tubercle is a projected part of the superior pubic ramus just ( 2cm )
lateral to the pubic symphysis)

Position –
Above and medial to pubic tubercle – inguinal hernia

Below and lateral to pubic tubercle – femoral hernia

To get above the swelling – try to hold the root of the scrotum between the thumb
and other fingers: If possible to hold then scrotal swelling, If not possibleto hold
then inguino-scrotal swelling ( hernia extending into the scrotum)

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Impulse on coughing – if swelling is present, hold the swelling at its root and ask
patient to cough

Cough impulse will be absent in case of strangulation

Anatomical location of superficial and deep ring:

 Deep ring – ½ inch above mid inguinal point

 Superficial ring – 1.25 cm above the pubic tubercle

 Ring occlusion test to differentiate between direct and indirect hernia.

Reduce the swelling. ( cannot be reduced in case it is obstructed and irreducible)

Block the deep ring with the thumb and ask the patient to cough. If the swelling
appears it is direct hernia if the swelling did not appear it is indirect hernia.

Fluctuation test of the scrotum

Over the scrotum

Transillumination test-(torch provided) - By holding a light from side of the scrotum

one can easily determine whether the mass is cystic (light shines through and look
through scotoscope) or solid (light blocked by the mass). No transillumination in
hernia.

Transillumination occurs in hydrocele

Percussion – resonant note – intestine

Dull note – omentum

Auscultation-Peristaltic sounds in case of entereocele

Palpate for Inguinal and femoral group of lymph nodes

Examination of the Testis, epididymis and spermatic cord.

Examine tone of Abdominal muscles-in lying position ask the patient to raise his
shoulders against resistance
Thank the patients always for their co-operation and Cover the patient or ask them to dress up.

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197. TEACHING ECG TO A NURSE

A nurse wants to learn about the basics of ECG. Teach her. (note : she might be
holding 3-4 ECGs in her hand)

Hello I am Dr A junior Doctor in this department. How may I call you ?

Dr you can call me How are you doing today? Doctor I am fine. I want to learn
about the basics of the ECG can you please teach me.

D: I can see that you are so much interested in learning about the ECG. I really
appreciate it.(keep praising).

(Note: Questions by Nurse: How to check the Heart rate , What are the Waves? How
are the waves produced? What is a normal and an abnormal ECG?)

Well, I will teach you everything about it but before that, can you please tell me how
much do you know about the ECG?

N: Doctor I know how to record ECG on a machine but (might also say I don’t know
much about how to read it. Doctor please teach me ok. Here is the ECG (Usually a
normal ECG)

D: Ok, so firstly we need to know how ECG is recorded. Sensors attached to the skin are
used to detect the electrical signals produced by your heart each time it beats.
These signals are recorded by a machine and are looked at by a doctor to see if
they're unusual. We use ECG to diagnose if there are any heart related issues like
Arrhythmias, Heart attack, Coronary heart disease and Cardiomyopathy.

Am I clear so far? …. Yes Doctor.

D: Ok now moving forward to calculate the heart rate, you need to count the number
of large boxes between 2 R waves and divide it with 300. So, for example if you get 4
boxes between 2 R waves then it will be 300/4= 75. Which is actually a normal heart
rate. However if you see any changes or if the heart beats you think is fast then report
to the Doctor immediately…… Ok Doctor.

N: Doctor what is normal and abnormal ECG?

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D: Well as I mentioned earlier, if the heart rate goes beyond 120 while calculating then
it can be something abnormal and needs to be looked into. This is called tachycardia.
It can be related to some heart issue. Also talk about bradycardia.

D: Now I will teach you about the rhythm of the ECG. Regular rhythm at a rate of
60-100 bpm (or age-appropriate rate in children).

Each QRS complex is preceded by a normal P wave.

If you notice any abnormality in this, then please refer to a Doctor.

D: Do you want to learn about the S.T elevation which we use to detect M.I ?

N: No Doctor I am ok with this knowledge on ECG.

Please do let me know if you want to know anything more.

I once again am very happy that you are keen on learning and if you have any doubt in
anything then please come back to us.

Thank you.

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198. AEROCHAMBER
Child with Asthma - explain inhaler to the mother.

3 year child known to have asthma was admitted to the hospital multiple times in
the past for exacerbations but he improves when he is in the hospital but he
deteriorates when sent home.

Take a focused history and assess whether the spacer technique mother is using is
right or not.

I - How long ago was he admitted? If child is on medications? Are his symptoms
controlled? If she follows up with her GP? How many admissions?

E - Ask of allergens (any new pets, is floor carpeted, parents smoking, dust, allergic to
perfumes?), Technique

Ask her the details of the problems

Since when? How bad is he when he becomes short of breath ?

How does he improve? When was the last time he was admitted ? How many times
admitted in how many years?

Any other medical conditions? Allergy? Family history of asthma ?

Any triggering factors at home? Pets, dust mites, exposure to pollens? Is it worse in
any particular seasons ? Does he has frequent infections ?

Ask her whether she knows why her son gets this attack frequently ?

Does she know how to use the inhalers? She may say yes. Ask her to demonstrate. She
will show wrong technique.
Ask her does she know anything about asthma and the medications – she may say she
knows everything about it.

If there is no other reason for his frequent exacerbations – tell her that it could be due
to wrong inhaler technique.

Teach her the correct technique.

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Spacer the salbutamol inhaler, spirit swabs may be kept inside the cubicle.

2 puffs of salbutamol. Each puff child should breathe for 6 to 10 breaths

She may ask how to count the number of breaths when the child is crying ?Tell her use
the mask with the spacer to look and count the movement of the exhalation valve at
the spacer.

She may say the spacers gets dirty can you give more spacers to take home. Tell her
there is no need to keep too many spacers at home. Teach her the cleaning technique.
She can just keep 2 or 3 spacers at home when she is washing and drying one – she
can use the other one.

Check the age of the child properly and advise her which colour spacer to use
according to the age of the child.
ORANGE

Small Mask (0 - 18 months) Anatomically shaped face mask creates a secure seal using
minimal effort

– critical for parents and caregivers administering aerosol medications to infants.

YELLOW

Medium Mask (1 - 5 years)

Slightly larger mask will provide a secure seal as the child grows.

BLUE

Mouthpiece (5 years+). Guidelines recommend patients be transitioned to a

mouthpiece product as soon as they are able – usually around 5 years of age.

BLUE

Large Mask (5 years+).

Suitable for patients who may have difficulty with a mouthpiece, or who prefer the
security a mask provides (e.g. elderly or older youth).

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Counsel the dad of the child who suffers with asthma about how to use the spacer.

(Do initial approach, assess knowledge, introduce the spacer, explain the purpose of
use, explain how to use, check the understanding by asking him to perform, correct
mistakes. Advice further and answer the question)

Greet and Introduce: Good morning I am Dr…..

Ask Mum: “How is your little John doing? I have come through notes that your little
one is suffering from asthma…

She says: Yes

Purpose: I am very sorry to hear that. Because of his condition he will have to take
certain medications through a device called Aerochamber, on a regular basis and I am
here to tell you about it and how to use it. Have you ever heard about it?

She says: No

“I am here to talk to you about it. If you have any questions, stop me whenever you
want.”Hold the Aerochamber in your hand and say:“This device has two openings on
each side, at one end there is a mouthpiece and at the other end there is a hole for the
inhaler to fit into.
[ SPACER WITH FACEMASK (USUALLY FOR CHILDREN <3 YEARS)]

The spacer with face mask is only for young children who cannot manage the spacer
with mouthpiece ].

Technique

Prepare your child by reducing anxiety in your normal way (for example cuddles,
favourite music or story.)

Position your child so they are comfortable - sitting position or lying down.

Remove the cap of the inhaler.

Look inside Aerochamber to check there is nothing inside.

Shake the inhaler and insert in the end of Aerochamber. Place the mask on the child’s
face making sure that it is well sealed around their mouth and nose.

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If the child is with the mask on their face, let them breathe in and out slowly five times
– known as ‘tidal breathing’.

Shake the inhaler well to mix the medicine before each puff.

Attach the inhaler to the non mouth-end and press the inhaler top to give one puff
only. Your child will not get all of their medicine if more than one puff is put in the
spacer at the same time.

5:1:6 per puff: Count five breaths. Once the child’s breathing pattern is well
established, press the inhaler down once and leave it in the Aerochamber as the child
continues to breathe in and out 6 times.

You will see the exhalation valve moving.

There should be minimal time delay between inhaler actuation and inhalation
Count out loud (one, two, three four, five and six) at the same time as the child is
breathing.

Remove the Aerochamber from the child’s face.

If your child needs more than one puff, remove the spacer and allow your child to
breathe normally for 20-30 seconds between puffs and repeat the procedure.

Put the cap back on the inhaler

If your child is using a steroid preventer inhaler e.g. Beclomethasone, wash your child's
face with warm water after use. This will remove any unwanted traces of steroid from
the skin.

Ask the mom/dad to demonstrate the technique back to you

When they demonstrate they should be using the aerochamber touching their face.

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CLEANING - BEFORE FIRST USE THEN AT WEEKLY INTERVALS

Beclomethasone - wash the equipment every 3 days:

 Remove metered dose inhaler from the back of the Aerochamber.

 Remove inhaler port from the back of the Aerochamber, do not remove the mask.

 Soak both parts for 15 minutes in lukewarm water with one drop of a mild
liquid detergent.

 Agitate gently.

DO NOT RINSE. Do not scrub its inside to prevent any scratches

 Drying

 Allow dripping dry. Do not rub dry.

 Do not dry spacers with a cloth as this can increase the static charge;
increasing the amount of drug that sticks to the inside of the spacer.

The mouthpiece should be wiped clean of detergent before use.

It should be cleaned at least once a week and more depending on the frequency of use.

 Replacement

It needs to be replaced when there is obvious breakage, any staining inside.

Ask: Does little one go to school? If yes, the school nurse should have a spacer too.

SPACER WITH MOUTHPIECE (without mask). (FOR MOST CHILDREN OVER 3 YEARS)

– The spacer works better without the face mask and should be used with the mouthpiece
where possible.
– Your child can sit or stand whilst using the spacer. Their breathing should be as relaxed as
possible. Slow deep inspirations are best.
– Ensure your child does not push their tongue through the mouthpiece as this may reduce
the amount of medicine they get.
– If a whistle sound is heard whilst breathing in, he might be hyperventilating. Encourage
your child to slow their breathing rate down.

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STORAGE AND DISPOSAL OF YOUR CHILD'S INHALER

Store your child's inhaler at room temperature, away from direct light.

Replace your child's spacer every 12 months.

Do not leave baby/infant with the Aerochamber - it is not a toy.

What if my baby objects to use aerochamber?

If baby/infant objects to using the Aerochamber and cries, he/she will still inhale the
medication you are giving as he/she will be opening his/her mouth to take big breaths
in order to protest – so persevere if you can, it only takes a few minutes - followed by a
cuddle, it can make all the difference to the baby’s breathing. Watch the valve as it
moves during expiration. Count the movement of the valve 6 times.

To hold a protesting baby - Prepare the Aerochamber and inhaler. Sit baby with his/
her back to your front. Hold his/her arms down by wrapping one arm around his/her
front. Use your other arm to administer the medication.

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199. CPR - TEACH ADULT BLS TO MEDICAL STUDENT

You are the FY2 doctor.

You have organised a BLS workshop for medical students.

Teach BLS to the first year medical student and check his understanding.

BLS is a life-saving skill where we resuscitate and make the heart and lungs work again
if they have stopped working.

You: Hello I am Dr … What is your name? Are you a medical student? How are you
doing?

Do you want to learn about CPR? Student: Yes.

You: Do you know anything about CPR. Student : No

Dr: It is a life saving skill where we resuscitate to save the life of a person whose heart
and lungs have stopped working.

Let me demonstrate on the manikin here. Please watch me and then you can repeat it
and show me how you will do it. Is it OK ?

Student: Ok

You: Let us imagine this is an adult collapsed and lying on the floor. This condition can
happen inside or outside the hospital

First of all, before you approach him – make sure the area is safe to approach. If the
patient is not in a safe area – then you move him to a safe area.

Then you check the victim for a response

Gently shake his shoulders and ask loudly: “Are you all right?" If no response, Turn the victim

onto his back

Place your hand on his forehead and gently tilt his head back; with your fingertips under
the point of the victim's chin, lift the chin to open the airway.

If there is any foreign body in the airway remove it carefully without pushing it down to
his throat.

Then Look, listen and feel for normal breathing for no more than 10 seconds and
keep two fingers on his carotid pulse and check the carotid pulse at the same time.

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Keep your chin near to the patient’s mouth and check chest movement while breathing
and listen to his breath sounds and feel for breathing hitting on your cheeks. If there is
no carotid pulse, it means that the patient is in cardiac arrest. If patient not breathing,
then you call for help.

If you are in the hospital you can call the cardiac arrest team but if you are outside the
hospital call the Ambulance.

" Ask a helper to call if possible otherwise call them yourself

" Stay with the victim when making the call if possible

Send someone to get an AED if available

Then start CPR.

Start with chest compressions

" Kneel by the side of the victim

" Place the heel of the dominant hand in the centre of the victim’s chest - which is
the lower half of the victim's sternum.

" Place the heel of your other hand on top of the first hand

" Interlock the fingers of your hands and ensure that pressure is not applied over
the victim's ribs. Keep your fingers away from the chest wall.

" Keep your arms straight, elbow locked

" Your body should be perpendicular to the patient and the compressions should
come from your body weight

" Do not apply any pressure over the upper abdomen or xiphisternum.

" Position your shoulders vertically above the victim's chest and press down on the
sternum to a depth of 5 - 6cm

" After each compression, release all the pressure on the chest without losing
contact between your hands and the sternum;

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Repeat at a rate of 100–120 per min

After 30 compressions, open the airway again using head tilt and chin lift and
give 2 rescue breaths

" Pinch the soft part of the nose closed, using the index finger and thumb of your
hand on the forehead so the air doesn’t come out through the nose

" Allow the mouth to open, but maintain chin lift

Take a normal breath and place your lips around his mouth, making sure that you have
a good seal

" Blow steadily into the mouth while watching for the chest to rise, taking about 1
second as in normal breathing; this is an effective rescue breath

" Maintaining head tilt and chin lift, take your mouth away from the victim and
watch for the chest to fall as air comes out

" Take another normal breath and blow into the victim’s mouth once more to
achieve a total of two effective rescue breaths. Do not interrupt compressions by
more than 10 seconds to deliver two breaths. Then return your hands without
delay to the correct position on the sternum and give a further 30 chest
compressions

The chest may not rise if you don’t tilt the head properly, you don’t seal the mouth
adequately, you didn’t pinch the nose, and you’re not blowing hard enough. Continue
with chest compressions and rescue breaths in a ratio of 30:2

Do not interrupt resuscitation until:

" The victim shows signs of life like moving, opening eyes and breathing normally
" The help arrives
" You become exhausted.

You: Did you follow me? Can you please show me how will you do it.

Correct him if he does any mistake. Praise him first

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200. CPR - TEACH PAEDIATRIC BLS TO A MEDICAL STUDENT

Child is 5 years old
Definitions

• A newborn is a child just after birth.

• A neonate is a child in the first 28 days of life.

• An infant is a child under 1 year.

• A child is between 1 year and puberty.

In children,the most common cause of cardiac arrest is respiratory (from foreign body inhalation).

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Those with a duty to respond to paediatric emergencies (usually healthcare

professional teams) should use the following sequence:

1. Ensure the safety of rescuer and child.

2. Check the child’s responsiveness:

Gently stimulate the child and ask loudly, ``Are you all right?’

3. If the child does not respond:

- Shout for help.

- Turn the child onto his back and open the airway using head tilt and chin lift:
- Place your hand on his forehead and gently tilted his head back.
- With your fingertip(s) under the point of the child’s chin, lift the chin.
- Do not push on the soft tissues under the chin as this may block the airway.
- If you still have difficulty in opening the airway, try the jaw thrust method: place
the first two fingers of each hand behind each side of the child’s mandible (jaw
bone) and push the jaw forward.
- Have a low threshold for suspecting injury to the neck. If you suspect this, try to
open the airway using jaw thrust alone. If this is unsuccessful, add head tilt
gradually until the airway is open. Establishing an open airway takes priority over
concerns about the cervical spine.

4. Keeping the airway open, look, listen, and feel for normal breathing by putting
your face close to the child’s face and looking along the chest:

Look for chest movements.

Listen at the child’s nose and mouth for breath sounds.

Feel for air movement on your cheek.

In the first few minutes after cardiac arrest a child may be taking infrequent, noisy
gasps. Do not confuse this with normal breathing. Look, listen, and feel for no more than
10 seconds before deciding – if you have any doubts whether breathing is normal, act
as if it is not normal.

5. If the breathing is NOT normal or absent:

Carefully remove any obvious airway obstruction.

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Give 5 initial rescue breaths. -> Check signs of life before CPR at least one
minute -> Call for help

You don’t have to use 2 hands in children. One hand is enough. You can
consider recovery if carotid pulse > 60bpm

Although rescue breaths are described here, it is common in healthcare environments

to have access to bag-mask devices. Providers trained in their use should use them as
soon as they are available.

While performing the rescue breaths, note any gag or cough response to your action.
These responses, or their absence, will form part of your assessment of ‘signs of life’,
described below.

Rescue breaths for a child over 1 year:

- Ensure head tilt and chin lift.

- Pinch the soft part of his nose closed with the index finger and thumb of your
hand on his forehead.
- Open his mouth a little, but maintain the chin lift.
- Take a breath and place your lips around his mouth, making sure that you have a
good seal.
- Blow steadily into his mouth over 1 second sufficient to make the chest rise
visibly.
- Maintaining head tilt and chin lift, take your mouth away and watch for his chest
to fall as air comes out.
- Take another breath and repeat this sequence four more times. Identify
effectiveness by seeing that the child’s chest has risen and fallen in a similar
fashion to the movement produced by a normal breath.
- Make up to 5 attempts to achieve effective breaths. If still unsuccessful, move on
to chest compression.

6. Assess the circulation (signs of life):

Take no more than 10 seconds to:

Look for signs of life. These include any movement, coughing, or normal breathing (not
abnormal gasps or infrequent, irregular breaths).

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If you check the pulse, take no more than 10 seconds:

In a child aged over 1 year – feel for the carotid pulse in the neck.

In an infant – feel for the brachial pulse on the inner aspect of the upper arm.

For both infants and children the femoral pulse in the groin (mid-way between the
anterior superior iliac spine and the symphysis pubis) can also be used.

7A. If confident that you can detect signs of a circulation within 10 seconds:

Continue rescue breathing, if necessary, until the child starts breathing effectively on his
own.

Turn the child onto his side (into the recovery position) if he starts breathing effectively
but remains unconscious.

Re-assess the child frequently.

7B. If there are no signs of life, unless you are CERTAIN that you can feel a
definite pulse of greater than 60 min - 1 within 10 seconds:

Start chest compressions.

Combine rescue breathing and chest compressions.

For all children, compress the lower half of the sternum:

To avoid compressing the upper abdomen, locate the xiphisternum by finding the angle
where the lowest ribs join in the middle. Compress the sternum one finger’s breadth
above this.

Compression should be sufficient to depress the sternum by at least one-third of the

depth of the chest, which is approximately 4 cm for an infant and 5 cm for a child.

Release the pressure completely, then repeat at a rate of 100–120 min-1.

Allow the chest to return to its resting position before starting the next compression.

After 15 compressions, tilt the head, lift the chin, and give two effective breaths.

Continue compressions and breaths in a ratio of 15:2.

The best method for compression varies slightly between infants and children.

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Chest compression in children aged over 1 year:

Place the heel of one hand over the lower half of the sternum (as above).

Lift the fingers to ensure that pressure is not applied over the child’s ribs.

Position yourself vertically above the victim’s chest and, with your arm straight,
compress the sternum to depress it by at least one-third of the depth of the chest,
approximately 5 cm.

In larger children, or for small rescuers, this may be achieved most easily by using both
hands with the fingers interlocked.

8. Continue resuscitation until:

" The child shows signs of life (normal breathing, coughing, movement or definite
pulse of greater than 60 min-1).
" Further qualified help arrives.
" You become exhausted.

When to call for assistance

It is vital for rescuers to get help as quickly as possible when a child collapses:

" When more than one rescuer is available, one (or more) starts resuscitation while
another goes for assistance.
" If only one rescuer is present, undertake resuscitation for about 1 min before
going for assistance. To minimise interruptions in CPR, it may be possible to
carry an infant or small child whilst summoning help.

The only exception to performing 1 min of CPR before going for help is in the unlikely
event of a child with a witnessed, sudden collapse when the rescuer is alone and
primary cardiac arrest is suspected. In this situation, a shockable rhythm is likely and
the child may need defibrillation. Seek help immediately if there is no one to go for you.

Recovery position

An unconscious child whose airway is clear and who is breathing normally should be
turned onto his side into the recovery position.

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PSYCHIATRY HISTORY AND COUNSELLING STATIONS

PSYCHIATRIC HISTORY TAKING

History Taking, MSE and Management Proforma

A. Chief Complaint

B. History of present illness:

1) Onset

2) Duration

3) Progression (clinical Features including ICD 10, risk and differentials)

Important – In almost every Psychiatric station – Suicidal thoughts is a must-ask

(eg: Depression, Psychosis, Drug and Alcohol abuse, Bipolar disorders,

Anorexia nervosa, SSRI, Panic attack)

If the patient does not talk or is hesitating to talk – you can offer confidentiality

“Whatever you say will be kept confidential within our team” and also gain his trust by
saying “We are here to help you”.

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THE MENTAL STATUS EXAMINATION

It is a structured way of observing and describing a patient's current state of mind, under the
domains of appearance, behaviour, speech, cognition, mood, thoughts, perception and
insight.

(Mnemonic : ABS – MC – SHIT )

I. Appearance (observed)

II. Behaviour (observed)

III. Speech and Language (observed)

IV. Mood (inquired)

V. Cognition (Orientation) (inquired)

VI. Suicidality and Homicidality (inquired)

VII. Hallucination

VIII. Insight and Judgment (observed/inquired)

IX. Thought Process/Form (observed/inquired),

X. Thought Content (observed/inquired)

Components of the Mental Status Examination

I. Appearance (Observed) - Possible descriptors:

Gait, posture, clothes, grooming.

● Apparent age

● Ethnicity

● Cleanliness & personal hygiene. Is there any evidence of self-neglect?

● Attire (is it appropriate for weather, surroundings etc... May be important sign in
a manic patient)

● Any abnormal involuntary movements e.g. tics, grimaces, tremors, stereotypies etc

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II. Behaviour (Observed)

● Appropriateness of behaviour

● Level of eye contact

● Rapport

● Is patient easily distracted? (distractibility)

● Restlessness, anxiety

● Socially inappropriate e.g. embarrassing, over-familiar and sexually forward

behaviour (may be seen in manic patients)

● Aggression, violence etc.....

III. Speech and Language (Observed)

Quantity, Rate, Volume, Fluency and Rhythm

A. Quantity - Possible descriptors:

• Talkative, spontaneous, expansive, paucity, poverty.

B. Rate - Possible descriptors:

• Fast, slow, normal, pressured.

C. Volume (Tone) - Possible descriptors:

• Loud, soft, monotone, weak, strong.

•
D. Fluency and Rhythm - Possible descriptors:

• Slurred, clear, with appropriately placed inflections, hesitant, with good articulation,
aphasic.

• ‘Flight of ideas': does patient move quickly between subjects?

• New or made up words (neologisms) or any other abnormal use of language?

• Logicality: Is speech appropriate for the situation e.g. does patient answer questions
appropriately, is the content of speech appropriate to the situation?

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IV. Mood (Inquired): A sustained state of inner feeling – Possible questions for patient:

• “How are your spirits?”

• “How are you feeling?”

• “Have you been discouraged/depressed/low/blue lately?”

• “Have you been energized/elated/high/out of control lately?”

• “Have you been angry/irritable/edgy lately?”

● Ask about depressed mood e.g. concentration, appetite, feelings of guilt,

worry, sleeping patterns, sexual relationships

● Ask about self-harm e.g feelings about the future, 'have you ever thought that
life was not worth living?’, thoughts of ending life, any preparations, any
previous attempts at self-harm/suicide?

“How is your mood now? Can you please grade your mood in 1 to 10 scale where 1
being low and 10 being very happiest mood?”

V. Cognition (Orientation) (Inquired)

Possible questions for patient:

• “What is your full name?”

• “Where are we at (floor, building, city, county, and state)?”

• “What is the full date today (date, month, year, day of the week, and season of
the year)?”

• “How would you describe the situation we are in?”

VI. Suicidality and Homicidality

A. Suicidality - Possible questions for patient:

• “Do you ever feel that life isn‟t worth living? Or that you would just as soon be dead?”

• “Have you ever thought of doing away with yourself? If so, how?”

• “What would happen after you were dead?”

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Suicide Risk Assessment

If the station/task also states “perform a suicide risk assessment”, then you must also
ask the following 11 questions about : the patient’s life (at present, past and future)
and suicidal risk using the mnemonic FAMISH (4 Fs – Family, Finance, Friends and
Forensics, Alcohol, Medications and illness, Insight, Suicidal thoughts, Hallucinations):

● How do you feel about life at the moment?

● How do you feel about the future?

● Have you felt life is not worth living?

● Do you ever wish it would end?

● Have you thought about ending it?

● Have you thought how you would do this?

● Have you ever attempted to end your life before?

● How is your current social support, do you have many good friends?

● How are things with your family?

● Are you currently in financial trouble, are you working?

● Are you in trouble with the law?

B. Homicidality – Possible questions for patient:

• “Do you think about hurting others or getting even with people who have wronged
you?”

• “Have you had desires to hurt others? If so, how?”

VII. Hallucination

Assess the patient‟s perception by asking appropriate questions. You can open the
conversation by saying: “I'd like to ask you a couple of questions about some
experiences some people have but may find difficult to talk about. I ask everyone
these questions.

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Then use questions such as:

● “Have you ever heard voices speaking when there seems to be no-one
around?”

● “Do you ever feel that people are discussing you negatively?” (If so, get
context!)

● “Do you fear that people may be out to get you‟?”

● “Have you ever felt that something or someone is able to put thoughts into
your head?” (thought insertion)

● “Have you ever felt that something or someone can remove thoughts from your
brain?” (thought withdrawal)

● “Do you ever see (visual), hear (auditory), smell (olfactory), taste (gustatory),
and feel (tactile)things that are not really there, such as voices or
visions?” (Hallucinations are false perceptions)

● “Do you sometimes misinterpret real things that are around you, such as
muffled noises or shadows?” (Illusions are misinterpreted perceptions)
VIII. Insight and Judgment (Inquired/Observed)

Possible questions for patient:

• “What brings you here today?”

• “What seems to be the problem?”

• “What do you think is causing your problems?”

• “How do you understand your problems?”

• “How would you describe your role in this situation?”

• “Do you think that these thoughts, moods, perceptions, are abnormal?”

• “How do you plan to get help for this problem?”

• “What will you do when occurs?”

“How will you manage if happens?”

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• “If you found a stamped, addressed envelope on the street, what would you do with
it?”

• “If you were in a movie theatre and smelled smoke, what would you do?”

IX. Thought Processes or Thought Form (Inquired/Observed):

Logic, relevance, organization, flow and coherence of thought in response to general

questioning during the interview.

Possible descriptors:

Linear, goal-directed, circumstantial, tangential, loose associations, incoherent,

evasive, racing, blocking, perseveration, neologisms.

X. Thought Content (Inquired/Observed) – Possible questions for patient:

• “What do you think about when you are sad/angry?”

• “What‟s been on your mind lately?”

• “Do you find yourself ruminating about things?”

• “Are there thoughts or images that you have a really difficult time getting out of your head?”

• “Are you worried/scared/frightened about something or other?”

• “Do you have personal beliefs that are not shared by others?” (Delusions are fixed,
false, unshared beliefs.)

• “Do you ever feel detached/removed/changed/different from others around you?”

• “Do things seem unnatural/unreal to you?”

• “What do you think about the reports in papers such as Daily mirror?”

• “Do you think someone or some group intend to harm you in some way?”

• [In response to something the patient says] “What do you think they meant by that?”

• “Does it ever seem like people are stealing your thoughts, or perhaps inserting
thoughts into your head? Does it ever seem like your own thoughts are broadcast out
loud?”

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Combine Suicide risk assessment and Psychiatric mnemonics to form ABC FAMISH

- Appearance: Aggressive, calm, composed, eye contact

- Behaviour

- Cognition

- Family, Friends, Forensics (legal problems), Finance

- Alcohol/Recreational Drugs

- Mood/Mental health conditions/Mental health conditions in the family/ Medications/Medical

conditions

- Insight/Impact on work, Family and Social life. How is it affecting your work? Are you able
to go out and see your friends at all?

- Suicide Questions/Speech

- Homicide Questions/Hallucinations/Thoughts

Management of Psychiatric Cases

Inpatient admission if risks are high and then Community mental health, (which is a
MDT) after discharge.
Bio-Psycho-Social Model

● Biological aspect: Medications (Anti-depressants, Anti psychotics, Mood

stabilisers)

● Psychological Aspect

● Sociological Aspect: Led by Consultant psychiatrist who gives the medications.

1. Community Psychiatry Nurse (CPN)/Care coordinator to monitor your mental

health and medications in the community.

2. Social worker to look after your finances and accommodation.

3. Occupational therapist to make the necessary changes in your house to maximise

you potential in activities of daily living.

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4. Mental health support workers support to adapt to ordinary life within the
community. Including individual support and counselling via such activities as shopping
with people who need care and support, taking them to appointments, developing
everyday skills such as how to make a cup of tea or prepare and cook a meal safely, or
simply being with them in their home environment.

5. Psychologist for the psychological input in the form of counselling.

Suicidal Risk:

1) High - Inpatient admission

2) Low: GP, wellbeing services and Emergency numbers to contact.

Heroine:

Two types of management:

1. Replacement (can be done in community or on the ward) with Methadone or

Buprenorphine

2. Detox (can be done in community or on the ward)

Impotent admission is needed for detox:

Lofexidine is used as a treatment for withdrawal symptoms like chills, sweating, muscle
pain, stomach cramps, runny nose and difficulty in sleeping. Other available treatments
include:

● Ibuprofen

● Buscopan

● Naloxone (opioid antagonist)

● Metaclopramide

● Loperamide

● Benzodiazepines

Firstly, we would be stabilising the patient by admitting him and we will detoxify him. My
consultant will be taking the final decision but I can let you know about the treatment options.

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(No single detox is the same, varies individually i.e. each programme is tailored to
meet a meet a person’s individual needs)

Community drug team-worker will tell you when and how often to take the medicine.

Alcohol detoxification

We can admit you for detoxification and it can be done either in the community by
GP/ADS (The Alcohol & Drug Service) or as an in-patient.

● Chlordiazepoxide

● Disulfiram

● Acamprosate

● Pabrinex

Rehabilitation: After detox, (both Heroin and alcohol, we refer to rehab centre for
12-16 weeks for psychotherapy and also help you stabilise socially, financially by
looking for job placements)

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SUICIDE ATTEMPT/SELF HARM RISK ASSESSMENT

Deliberate self-harm is defined as an act with a non-fatal outcome in which an individual
deliberately did one or more of the following:

1. A behaviour (e.g self cutting the wrists) intended to cause self-harm.

2. Ingesting a substance in excess of the prescribed or recognised therapeutic dose.

3. Ingesting a non-ingestible substance or object.

Deliberate self-harm is not an attempt at suicide in the vast majority of cases. It is

usually an attempt to maintain control in very stressful situations or emotional pressures
- eg, bullying, abuse, academic pressure or work pressure.

Self-harm is usually done in private and hidden from anyone else.

Assessment

The best way to ask about suicide attempts is to explore it by asking questions to find
out what happened before, during and after the incidence

History of Presenting Complaint - Elaborate the Event

Before: Prior events/Plan/Escape/Prep/Tell Anyone

During: Sequence/Expectations/Alcohol-Drugs

After: Discovery/Anger-Regret/Lingering Thoughts/Insight/Mood

Example of questions that may be asked

Before

- What did you do to harm yourself? When? Where ?

- Were you alone? What time of the day was it?

- Did you tell anyone? Who found you?

- Who brought you to the hospital?

- Why did you try to harm yourself?

- Was there any particular event that pushed you into it?

- Did you understand the fatality of the method used by you?

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- Did you prepare yourself for this incident?

- How long have you been planning?

- Do you normally consume alcohol? Were you intoxicated just before committing the act?

- Did you write a suicide note?

- Who did you address it to? What did you write on it?

During

To explore how high the risk is

- Tell me what happened

- Why you took them/did it?

- Where did you get them from?

- What did you take them with?

- Was there anybody with you?

- How did you do it?

- Was it a very deep cut?

- Did you do this with the intent of ending your life?

After

- How are you feeling now?

Past

- Have you tried this before?

- Do you keep having thoughts or keep making plans?

- Did you make arrangements and take care of your affairs?

Future

- Do you regret what you did?

- Would you try it again?

- Where do you see yourself in 5 years?

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Management

If the station/task states present findings/management, then as a rule, the patient with
low suicide risk, regret and with a supportive home family unit should be discharged
with follow up. Any other patient should be admitted after consultation with senior
colleagues.

Key Points

- Take time to build a rapport with the patient.

- Explore triggers by asking about the 4Fs

When presenting findings to the examiner, comment on 3 important points first

1)If the patient is depressed (low mood, easy fatiguability, and anhedonia)

2) High or low suicidal risk

3) Admit or not

Then, if you have time - comment on the patient’s Appearance, Behaviour, Speech

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201. A. 16 years old Ms Jessica Thompson was brought to the hospital because
she cut her wrist and took overdose of OCP pills. You are FY 2 doctor in
psychiatric department. Take history from the patient and discuss the
management with her.

(OFFER CONFIDENTIALITY IF PATIENT DOESN’T SPEAK)

START WITH ONSET, DURATION, THEN DO BEFORE, DURING, AFTER, MOOD, FAMISH

“Has anybody looked at your wrist?”

“Did any doctor talk to you about the chances of being pregnant?”

Ask of abdominal symptoms - “Did you vomit, abdominal pain?”

“I’m from a different department. We’re just doing this for your safety. We want to make
sure you are absolutely safe before she can go home.”

Confirm age of boyfriend

Dr: Hello Ms Thompson, I am Dr... one of the junior doctors in the Psychiatry
department. How can I call you? Jessica: You can call me Jessica.

Dr: Jessica, can you please tell me, what brings you to the hospital?

Jessica: I took pills and cut my wrist.

Dr: I am really sorry to hear that. How are you feeling now? Jessica: I am okay.

Dr: Alright... can you please tell me why did you do this ?

Jessica: I was stressed because I missed my period and I was worried that I am
pregnant. So I took some OCP yesterday and I was hoping to have my period today.
Today, I still haven’t seen my period – so I told my boyfriend about it. He broke up with
me because he didn’t want me to be pregnant. I got upset and cut my wrist.

Dr: I am very sorry hear about this Jessica. When was your last period?

Jessica: It was 5 weeks ago.

Dr: How many OCP pills did you take? Jessica: I took 20 tablets.

Dr: Where did you get these tablets? Jessica: They are my mom’s pills.

Dr: Where did you take these tablets? Jessica: In my room.

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Dr - Was there any one with you at that time? Jessica – No

Dr: Where were you when you cut your wrist this morning?

Jessica: I cut my wrist in the bathroom.

Dr: Was there any one with you at that time?

Jessica: I was alone when I cut my wrist

Dr: Who brought you to the hospital?

Jessica: I came to the hospital myself

Dr: I see. Were you under the influence of alcohol when this happened Jessica ? Jessica: No

Dr: Did you plan to harm yourself at all?

Jessica: No. It just happened. I was not thinking properly at that time.
Dr: I am sorry to ask this - Did you think of ending your life at all? Jessica : No

Dr: Okay Did you inform anyone about this? Jessica: No

Dr: Was the wound deep? Jessica: No, it was not deep: it’s just a graze.

Dr: How do you see your future? Jessica: Very bright. I am going to university for
further studies. Ask what she wants to study and where and praise her.

Dr: Are you going to do this again?

Jessica: No, Doctor. I am not happy about what has happened. I am regretting what I did.

Dr: Have you ever tried to harm yourself before? Jessica: No

Dr: Do you have any medical condition? Jessica : No

Dr: Are you taking any medication? Allergic to any medications? Jessica: No

Dr: How do you feel in your Mood on scale of 1-10,1 being sad, gloomy and 10 being
normal, happy? Jessica: 7-8

Dr: Do you see / hear noises when nobody is around ? Jessica: No

Dr: Do you feel that someone is telling you to do things? or reading your mind? / making
you do things? Jessica: No

Dr: Do you smoke? / Drink Alcohol? / use recreational Drugs ? Jessica:No

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Dr: Do you feel that this has affected your family life/social life/work? (ASK INDIVIDUAL
QUESTIONS) Jessica: YES/NO
Dr: Are you a student? What are you studying? Try to determine if she has any financial
problems? Any other worries?

Dr: Do you think you need any help from us for your stress or if you are feeling low?

Jessica: I am ok now

Dr: Do you have any mental health conditions? Jessica: No

Dr: Any of your family members have any mental health conditions? Jessica: No

Dr: Have you ever been in trouble with the law before? Jessica: No

Dr: Do you live alone or with others?

Jessica: I live with my mother and brother.

Dr: Have you told your mother or brother about this? Jessica : No

Dr: Do you have any financial problem? Jessica : No

Dr: Do you have friends? Jessica : Yes

Dr: Has anyone looked at your wound? Jessica : Yes / No

Dr: Did any specialist doctor talk to you about the chance of pregnancy to you ?Jessica:Yes/ No

Dr: Thank you very much for all the information.

MANAGEMENT

Jessica, I am very sorry you have to go through this problem. Do not worry we are here
to help you.

We will refer you to a gynaecologist as regards the chance of pregnancy (if not already
sorted out)

We will also take a look at your wrist and treat accordingly (if not already sorted out)

We will also contact the poison information centre if you need any treatment for the
tablets you have taken and would treat you accordingly.

However, since you said you are regretting what you have done and you are sure that
you are not going to do this again, I don’t think we need to admit you for any Psychiatric
reasons. I will talk to my seniors and then you can go home.

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I sincerely advise you to talk to your mother about this. I am sure she will understand your
problem and support you in the future. What do you say - will you talk to your mother?

Jessica : Yes doctor. [If she says no - ask her - Can we talk to your mother and
explain what happened with you. I am sure she will understand your problem –
what do you say? Jessica – OK. If she still says no – then mention that your
seniors will talk to her before we discharge her]

We are also here to support you if you need us any time. We will give the telephone number of
a helpline to call if you feel very stressed out like this any time in the future and they will help
you calm down and advise you on what to do. Also, we would like to have a follow up in the
community clinic after 2 weeks. Is that OK ? Jessica : Ok

Offer patient a crisis card

Dr: Thank you very much.

201A. SELF HARM: CUT WRIST + OCP OVERDOSE

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201 B. You are an FY 2 doctor in Emergency department.

18/20 years old Mr ..... was brought to the hospital because he took over dose of
Paracetamol tablets.

Take history from the patient and discuss the management with him

(OFFER CONFIDENTIALITY IF PATIENT DOESN’T SPEAK)

START WITH ONSET, DURATION, THEN DO BEFORE, DURING, AFTER

Timing is very important. Paracetamol levels should be done after 4 hours and activated
charcoal can be given if patient presents less than 4 hours after ingestion of the
paracetamol.

He took 16 tablets of paracetamol 2 hours ago.

Boyfriend brought him to the hospital.

He had an argument with his mother because mother was very upset because she
found out that he is gay.

He is regretting that now. Not going to do it again. Sees future bright.

Lives alone.

Find out his job, any financial problems, and any other worries.

MANAGEMENT

Mr.. I am very sorry you have to go through this problem. Do not worry we are here to
help you.

Mr… Unfortunately, an overdose of Paracetamol can damage your liver and kidneys.

First of all, we need to do some blood tests to see if you have any damage to the liver
and kidneys.

Also, we need to check whether you need any treatment with antidote medicine for
overdose of Paracetamol. For that, we need to test the level of paracetamol in your
blood after 2 hours (i.e 4 hours after the ingestion).

I will talk to my seniors about it. Also, we will refer you to the Psychiatry specialist. They
will help you further. Pt: Do I need to be admitted?

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Dr: At the moment, yes you need to be in the hospital because we need to do these
tests to see whether you need any treatment for the overdose of the tablets you have
taken.

However, if the level of paracetamol is not very high or if there is no damage to your
organs, then you do not need to be admitted here.

But the Psychiatrist has to see you and then they will tell you about the further
management. However since you are regretting what you have done and you are sure
you are not going to do such things again, they may not admit you. They may advise
you about the help they can provide and follow up with you later. Is that OK ?

Pt : Ok

Dr Any other concerns? Pt : No

Dr: Thank you very much.

201B. SELF HARM - GAY MAN WHO OVERDOSED ON

PARACETAMOL

911
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202. A.
Mr Graeme Hick, 35 years old man was brought to the hospital because he had
taken an overdose of Paracetamol Tablets. He was admitted and treated for this.
His condition is stable medically. You are the SHO in psychiatric department. Do a
Psychiatric Assessment and discuss the Suicidal Risk for Mr Graeme with the
examiner.

(The question can be: Do a mental state examination / Please do MSE “OR”
please do psychiatric assessment “OR” please take a detailed psychiatric
history).

GRIPS (Do ABS in your mind, Ask about – present, past and future ( Suicidal risk)

Dr: Hello Mr Hick. I am Dr ….. How are you feeling?

Mr Hick: Doctor, I do not want to live.

Dr: Mr Hick, Why do you not want to live? Mr Hick: I have gone through a lot.

Dr: I am sorry to hear that. Did you try to harm yourself in any way?

Mr. Hick: I took some paracetamol tablets

Dr: When did you do that? Mr Hick: This morning.

Dr: How many tablets did you take? Mr Hick: I took about 40 tablets.

Dr: Was there anyone with you? Mr Hick: No, Doctor.

Dr: Who brought you to the hospital? Mr Hick: My wife

Dr: Have you done anything like this before? (Past) Mr Hick: Yes / No

Dr: Did you plan it? Mr Hick: Yes

Dr: Did you write a suicide note? Mr Hick: Yes

Dr: Did you inform anyone before doing it? Mr Hick: No

Dr: Will you do it again? (Future) How do you see yourself in 5 years?

Mr Hick: As I told you, I don’t want to live. / I may do it again / I am not sure.

Dr: How is your mood nowadays? Mr Hick: Not good.

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Dr: How would grade your mood, 1 being the saddest and 10 being the happiest?

Mr Hick: Very Sad, I would say 3/10.

Dr: It might sound bit irrelevant but I need to ask you few questions, Can you please tell
me what day is today? /Where are you now? (Cognition)

Mr Hick: (He will give you correct answers)

Dr: Do you live with family? Mr Hick: Yes. But I do not like my family

Dr: Do you have friends? Mr Hick: No

Dr: Are you currently in financial trouble, are you working?

Dr: Do you have any problem with the law?

Dr: Do you know why you are in the hospital? Do you need any help (Insight) Mr Hick: Yes

Dr: I’d like to ask you a couple of questions about things sometimes people have but may find
difficult to talk about. I ask everyone these questions. “Have you ever had experiences of
hearing noises or voices when there was nobody around?” Mr Hick: No

Dr: “Are your thoughts actually taken out or sent out of your mind? / Do there seem to
be thoughts in your mind which are not your own; which seem to come from somewhere
else?” “Do your thoughts seem to be somehow public; not private to yourself, so that
others can know what you are thinking?” Mr Hick: No

Dr: Thank you, Mr Hick.

Give your inference to the examiner (stop Hx at 4 -1/2min and talk to the
examiner): -

I will admit the patient. My patient is very depressed and has a high suicidal risk
because 1) He planned to harm himself 2) He made a suicide note 3) he may do
the same again in the future and 4) His mood is very low.

202 A.DEPRESSION (SUICIDAL ATTEMPT)

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202.B. - 28 years old Ms Isabella Jane was brought to the hospital because she has
cut her wrist. She was admitted and treated few hours ago. Her condition is medically
stable. You are SHO in psychiatry department. You have been asked to do suicidal risk
assessment, and discuss your management (inference) with the examiner.

Dr: Hello Ms Jane. I am Dr … I am here you help you. Could you please tell me what
really had happened ?

Isabella: Doctor I cut my wrist. (IF PATIENT DOESN’T SPEAK, OFFER CONFIDENTIALITY)

Dr: I am really sorry to hear that. How are you feeling now? Isabella: I am okay.

Dr: Why did you try to harm yourself?

Isabella: I did it because I had some misunderstanding with my boyfriend. (sometimes

she may say “I had a row with my boyfriend”)

Dr: When did this happen? Isabella: A few hours ago.

Dr: Where were you when this happened? {DURING}

Isabella: I was in the bathroom when I cut my wrist. After that, I screamed. My boyfriend
was watching football downstairs. He heard me and then, he brought me to the hospital.

Dr: Was there any one with you at that time?

Isabella: I was alone when I cut my wrist (sometimes she may say - my boyfriend/
mother was present in the other room and came into the room after I cut my wrist)

Dr: I am sorry to ask you, but do you drink alcohol? Isabella: Yes, Occasionally

Dr: Were you under the influence of alcohol when this happened?

Isabella: I had couple of glasses of wine.

Dr: Did you plan this? {BEFORE} Isabella: No

Dr: Did you inform anyone about this? Isabella: No

Dr: Did you write any suicide note? Isabella: No

Dr: Was the wound deep? Isabella: No, it was not deep.
Dr: How is your mood now? Can you please grade your mood in 1 to 10 scale with 1
being low and 10 being very happy? Isabella: My mood is okay. I would say 8/10.

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Dr: Do you feel /see/hear noises when nobody is around? Isabella: No

Dr: Do you feel that somebody is trying to tell you to do things/or Is reading your mind?

Isabella: No

Dr: Do you smoke/do you use recreational drugs? Isabella: No

Dr: Do you think that this will affect your family life/work/social life? Isabella: No

Dr: Have you ever tried to harm yourself before? Isabella: No

Dr: How do you see your future? {AFTER}

Isabella: Brilliant, I am very happy with my boyfriend, He is very helpful.

Dr: Are you going to do this again?

Isabella: No, Doctor. I am not happy about what has happened.

Dr: Do you have any medical condition? / are you taking any medication?/Allergic to any

medications? Isabella: No

Dr: Did you have any mental conditions in the past? Isabella: No

Dr: Do you have any Family history of any mental conditions? Isabella: No

Dr: Do you live alone? Isabella: No, I live with my boyfriend.

Dr: What do you do for living? Isabella: I work in a coffee shop.

Dr: Did you have any problem with law? Isabella: No.

Dr: Thank you very much for all the information you have given me. We will try our best
to help you.

Tell your management to the examiner

From the history, Isabella has low suicidal risk (insight is present, mood is 8/10,
regretful, happy with boyfriend, has job). I will discharge her after discussing with
my seniors and arrange for follow-ups. (No admission)
SELF-HARM

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202.C. You are FY 2 doctor in psychiatric department. ‎50 year old man Mr Adam Thompson had
met with road traffic accident 5 days ago. He was ‎diagnosed with whiplash injury after the X Ray
showed no fracture in his cervical bones. He was ‎treated with pain killers. He has come back now c/o
pain in his neck. He has low mood. Take ‎history from the patient and discuss the management with
the examiner.‎
Dr: Hello Mr Thompson, Can you please tell me, what brought you to the

hospital?‎

Adam: I had met with an accident 5 days ago. I still have pain in my neck.‎

Dr: I am really sorry to hear that. Yes we have seen the X-Ray of your neck

and there were ‎no fracture in your neck bones. This pain will go away after

some time on its own. Just keep ‎taking some pain killers until then.‎‎‎Is there

anything else bothering you ?‎

Adam: Doctor, I am feeling very low now a days.‎

Dr: Is this after the accident?‎‎‎ Adam: No

Dr: Since when are you feeling low?‎‎‎ Adam: Since about last 6 months.‎

Dr: Any particular reason you are feeling low ? ‎

‎Adam: I am not earning well. My wife is spending her money on me and our

children.‎ I am feeling bad. (Sometimes he may say he keeps having

arguments with his wife).‎

Dr: Do you work ? Adam: Yes I am a fire fighter but I don’t go to my work all

the time.‎

Dr –Is there any other problems ? ‎ Adam – No. It is just I have this

financial problem.‎

Dr: How is your mood now? Can you please grade your mood in 1 to 10

scale where 1 ‎being low and 10 being very happiest mood?‎‎‎‎Adam: My

mood is okay. I would say 3/10.‎

Dr: Some people get a feeling of harming themselves or ending their life

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when they feel very low. Has this type of feeling crossed your mind?‎‎‎ Adam:

I do feel like killing myself ?‎

Dr:Have you tried to do anything to end your life? ‎ Adam: No

Dr: Have you ever had such low feeling before this 6 months ?‎‎‎‎‎Adam: No

Dr: How do you see your future?

Adam: I am just living with my wife’s money. I don’t feel like living anymore.‎

Dr: Do you have any medical or mental health problem at all ?‎‎‎Adam : No

Dr: Whom do you live with ?‎‎‎Adam: I live with my wife and children.‎

Dr: Are they supportive Adam: Yes

Dr; Do you have many good friends? Adam: Not many.‎

Dr: Have you have any trouble with the law ?‎‎‎‎Adam: No

Dr: I would like to ask you a couple of questions about sometimes people

have but may find difficult to talk about. I ask everyone these questions

‎Have you ever heard voices speaking when there seems to be no-one

around ?‎ Adam: No

Dr: Do you have personal beliefs that are not shared by others ?‎‎‎ Adam :

No

Dr: Do you get any feelings to harm others?‎‎‎‎ Adam: No

Dr: Do you know where you are now.‎‎‎ Adam : Yes doctor, I am in the

hospital.‎

Dr: Do you drink alcohol?‎‎‎ Adam : No

Dr: Thank you very much for all the information. ‎

Management with the examiner: I will admit him. My patient is very

depressed. He has ‎suicidal thoughts. ‎

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203. You are an FY2 Doctor in acute medical care unit.

A 27 year old lady, Miss.… has been admitted to the acute medical care unit.
Patient is a known drug addict and a diagnosed case of Infective Endocarditis.
Patient has been started on intravenous antibiotics. To complete treatment,
patient needs IV antibiotics for several weeks as an inpatient.

Nurse has come to you and informed you that patient wants self-discharge.

Talk to the patient, inquire why she wants a self-discharge and address her
concerns.
Dr: Hello, I am Dr…. I am one of the junior doctors in the medical department. Are you
Miss…? Patient: Yes doctor.

Dr: How are you doing Miss…?

Patient: I do not like this hospital, doctor. I want to go home.

Dr: Miss… could you please tell me why you do not want to stay in the hospital?

Patient: The nurses are very rude to me.

Dr: I am really sorry if someone was rude to you. Nobody should be made to feel this
way. I will look into this matter (talk to nurses and seniors). Please do not be upset.
Could you please tell me what happened?

Patient: No, doctor. I do not want to stay in this hospital any more. I want to get
discharged. Please discharge me.

Dr: Well, Miss… could you please explain to me why you do not want to stay in the
hospital? If you tell me what is bothering you, I will be able to help you.

Patient: No doctor, the nurses have been very impolite with me. They are calling me a
drug abuser. I want to go home.

Dr: Well, Miss… I can clearly understand that you are very much offended by what
happened and I apologise to you for such behaviour, but it is very important for you to
stay admitted in the hospital as we need to give you medicines through your veins.
However, I want to reassure you that if you can tell me what happened, all the
information you give me will be kept confidential within our team. Could you please
open up to me about the matter?

Patient: Doctor, you see, it is also because the nurses object that I cannot smoke
cigarettes in the hospital.

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Dr: I see. I can understand that you must be very troubled by all this. I apologise to you
again. However, I would like to tell you that it is important for you to stay admitted.

Could you please tell me how much you know about your condition?

Patient: I have been told that I have infection in my heart.

Dr: Yes, you have been told right, Miss… You have a condition called Infective
Endocarditis. This is an infection that affects the tissue that lines the inside of the heart
chambers. This results in significant damage to heart valves. Also, it can cause other
serious complications if it is not treated quickly with antibiotics. Are you following me?

Patient: Yes, doctor. But I do not want to stay in the hospital. Why should I stay in the
hospital?

Dr: You see, Miss… it is a very serious infection and can be even life-threatening if not
treated in time. The earlier the condition is treated, the better the likely outcome.

Patient: But you can give me antibiotic tablets doctor I can take at home?

Dr: Miss…Unfortunately this condition cannot be treated with just antibiotic tablets.
Tablets are not as effective as injections into veins. That is why we want you to stay in
the hospital so that we can give this antibiotics through your veins.

Pt: I can’t stay here. Nurses don’t let me smoke and it is not bearable for me to continue
without it. Can’t I just pop out and smoke ?

Dr: I can understand why you are so upset. It must really be very distressing for you.

Well I can’t stop you...you can pop out and smoke but it is not advisable at all.

If you do not mind, I will be asking you some questions about your general health, if that
is alright with you. Patient: Okay.

Dr: Could you please tell me how much do you smoke? Patient: 20 cigarettes per day.

Dr: I see, and for how many years? Patient: ?

Dr: Do you take any recreational drugs? Patient: I take heroin.

Dr: How much? Patient:

Dr: For how long have you been taking it? Patient: Years/months

Dr: How do you take it? Patient: I inject it through my veins.

Dr: And do you exchange needles? Patient: No, doctor.

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Dr: That’s good. And have you ever tried to cut it down or stop it altogether?

Patient: No doctor, I cannot.

Dr: I see. Could you please tell me how your mood has been lately?

Patient: I feel very alone doctor/feel very low

Dr: And why is that? Patient: I do not have any friends.

Dr: I am really sorry about that. Could you please tell me what work do you do?

Patient: I am jobless.

Dr: And where do you live? Do you live with your family?

Patient: I am homeless, doctor. I have no family.

Dr: It must be really upsetting for you Miss… I can recognise that you have a very
stressful life. However, I’d like to tell you that a lot of help is available for you to cope
with this state of affairs. Do you know why this condition would have happened to you ?

No need to offer sympathy and empathy for joblessness.

Patient: Why doctor?

Dr: Miss... unfortunately, people who inject street drugs may also inject bugs/germs into
their bloodstream if they use dirty or contaminated needles. These bugs may then settle
on a heart tissue. The infection can damage heart valves and may spread to other
areas of heart tissue. Unfortunately, this might have happened and led you to develop
this infection in the heart.

Pt: But doctor I just want to go home.

Dr: Miss … If you do not get treated now serious complications usually develop - for
example, it can lead to problems such as heart failure. Sometimes the infection can
spread to other organs and can cause damage to the other organs too. It can life
threatening too if you do not stay in the hospital and get treated. That is why it is very
important that you stay in the hospital and get treated.

Patient: But I can’t smoke, I can’t do anything here.

Dr: I would sincerely advise you to consider quitting smoking. Smoking is not only
hazardous to your lungs but to your heart also. It can worsen your condition in the heart.

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know that it must be really unbearable for you to not smoke. We can give you help to
cut down and quit it. However, for now if you really want it, we can give nicotine
patches. Is that Ok? Pt: May be, yes.

Dr: Also, I would like to tell you that we can provide you help to cut down on drugs. We
have a lot of medicines available to help you cope with this.

Pt: You will only give Methadone!

Dr: Miss… We have many different options to help you cut down on using drugs. I will
tell you what your options are. In order to reduce the craving of the drug, we can give
you medicines. Also, in order to decrease withdrawal symptoms we can give you
another medicine called Lofexidine. Also, we might later on refer you to some support
groups e.g narcotics anonymous to help you quit drugs. Would you consider it? What do
you think about it? Patient: Well I will think about it.

Dr: So would you consider staying in the hospital for getting this infection cleared off from
you? Patient: Yes, doctor I would.

Dr: Is there anything else you want to know? Patient: No doctor, you are very kind.

Dr: Thank you very much Miss…

If the patient is still not convinced.

Dr: I am sorry that I wasn’t able to convince you about the importance of you staying in
the hospital for the treatment. You do have the right to refuse any treatment what we
advise.

However, I will talk to my seniors and may be they will be able to convince you about it.
If you still do not want to stay in the hospital you can sign a “self - discharge form” and
then you can go home. Thank you very much for talking to me. I really wish all the good
health for you Miss..

DRUG ADDICT WANTS A SELF-DISCHARGE

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

Background

" People with anorexia nervosa have extreme weight loss as a result of very strict
dieting.

" In spite of this, they believe they are fat and are terrified of becoming what is, in
reality, a normal weight or shape. They do not accept that they are losing weight
and they do not believe they need any help.

" Distorted body image and abnormal attitudes to food and weight

" Amenorrhoea and often other signs of starvation are present

" Bulimia nervosa – They usually accept they have a problem and they recognise
the need for treatment.

Assessment

You must assess the following 6 steps for assessment of eating disorder in real life.

In the exam - only first 3 steps.

Step 1: History of development of the disorder and patient’s ideas (Body Image
distortion, Compensatory mechanisms, Daily diet and exercise)

Step 2: SCOFF

Step 3 : Mental state examination for depression

Step 4 : Interview parents and other informants

Step 5 : Assess family interaction in especially attitudes in relation to food

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

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History:

" Onset
" Triggers
" Daily Diet Pattern: What/How Much/When/Where/Alone/Progression
" Amenorrhoea
" Palpitations, fainting, dizziness
" Bruising

B - Body image: “How do you view yourself/ your body?” - Feel fat/Fear of fatness

M - Mirrors - “Do you find yourself looking into the mirrors excessively? Or weighing yourself
frequently?”

W - Weight loss: “Have you been losing weight? How much have you lost?” >1 stone in 3
months is a lot

C - Clothes “What kind of clothes do you prefer?” - Prefers baggy clothes

L - Laxatives

E - Exercise

V - Vomiting (Self-Induced): “Do you make yourself feel sick?”

E - Eating habits: Food domination, Binge eating

R - Role model “Who do you look up to?”

Step 3: FAMISH History format

Step 4: Insight

(Mnemonic – SCOFF)

S – Do you make yourself Sick because you feel uncomfortably full? C – Do you worry that you

have lost Control over how much you eat?

O – Have you recently lost more than One stone in a three month period? (one stone =
6.3 kilos or 14 pounds) (1 kilo = 2.2 pounds)

F – Do you believe yourself to be Fat when others say you are too thin? F – Would you say Food

dominates your life ?

If the patient has 2 or more positive answers, it indicates a likely case of Anorexia or Bulimia.

If BMI < 16, admit and if > 16, treat on an outpatient basis.

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

Dr: Hello are you Miss Jessica Thomson ? Miss: Thompson: Yes

Dr: I am Dr… one of the junior doctor in the psychiatry department. Can you please tell
me what brought you to the hospital?

Miss: Thompson: I am here because of my parents; they think that I have been losing
too much weight.

Dr: Can you please tell me, how much weight did you lose?

Miss Thompson: I have lost about 15 pounds (more than one stone, 6.8 kg) in the last 3
months.

Dr: Have you been trying to lose weight? Miss: Thompson: Yes

Dr: Could you please tell me, why are you losing weight?

Miss: Thompson: Dr, I want to be like my friend.

Dr: Can you please tell me, why do you want to be like your friend?

Miss: Thompson: She is slim and good looking. My friend has found a boyfriend.

Dr: Do you think that you are fat? Miss: Thompson Yes doctor.

Dr What do you do? Do you work or you are a student ?

Miss: Thompson: I am a university student.

Dr: Can we talk about your general life style?

Miss: Thompson of course, Doctor.

Dr: What is your diet like? / What do you eat in breakfast/ lunch/ dinner?

Miss: Thompson: At breakfast, I eat ----. In lunch, generally I do eat ---- I take ----- at
night.

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Dr: Have you any time eating too much food and could not have any control on eating.
(Binge eating)

Dr: Do you do any exercise?

Miss: Thompson Yes, doctor. I enjoy running (doing exercise).

Dr: How often do you do exercise?

Miss: Thompson I do it every day for about 2 hours.

Dr: Do you take any medications to lose weight? Miss: Thompson No

Dr: Do you make yourself sick because you feel you are uncomfortably full? Miss: Thomp.:No

Dr: Do you have any preference for clothes?

Miss: Thompson: Yes, Doctor, I like to wear baggy clothes.

Dr: Do you have any role models? Miss: Thompson I am very big fan of -----

Dr: Can you please tell me, do you like looking yourself in the mirror repeatedly?

Miss: Thompson : No, doctor.

Dr: Do you keep checking your weight frequently? Miss: Thompson: Yes, doctor.

Dr: How has been your mood? Can you please grade it, 1 being the saddest and 10
being the happiest? Miss: Thompson: It has not been good. (3/10)

Dr: Have you ever thought of harming yourself? Miss: Thompson: No

Dr: Do you think that you have been losing too much weight?

Miss: Thompson: No, Dr. / I feel uncomfortable when I do not follow my daily routine of
diet and exercise.

Dr: How is your general health?

Miss: Thompson Dr, I feel weak nowadays, I want to sleep most of the time.

Dr: How you ever had any mental health problem before? Miss: Thompson: No.

Dr: Are the family members supportive? Miss: Thompson: Yes they are supportive.

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Dr : Any problems with your colleagues in the university? (Bullying?) Miss: Thompson: No

Dr How are your periods?

Miss: Thompson: I am waiting for my period; it has not come for last 8 weeks. I am
worried about it.

Dr: Do you have any health symptoms like palpitation, Feeling faint or any other
symptoms? Miss: Thompson No

Dr: Thank you very much for all the information.

Miss .. We have measured your height and weight. Your weight is far less than what it
should be for your height. I think you have lost too much weight. This is not good for
you. In medical terms, we call this condition as Anorexia Nervosa.

Do you know anything about this at all? No

Anorexia nervosa is a serious mental health condition. It's an eating disorder where a
person keeps their body weight as low as possible and thinks that they weigh more than
they really do. If it continues like this, it can lead to lot of other conditions like depression
and medical problems like Osteoporosis and sometimes people with this condition may
not be able to conceive children. Do you follow me? Yes

We can help you to treat this condition.

Treatment

We can help you by a combination of psychological therapy and supervised weight gain.
We have a team of specialists like Psychiatrists, Psychologists, dieticians and specialist
nurses here to help you

We as Psychiatrists can help you by Psychotherapy - otherwise we call it Cognitive

analytic therapy and Cognitive behavioural therapy. We can involve your family
members also if do not mind to help the treatment.

Our dieticians can teach you what type of food you can eat to gain weight. We do not
need to admit you at this moment. We can do all these as an outpatient and see how
things goes. Is that OK? What do you think about this?

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Information about treatment of Anorexia Nervosa

Psychological treatment

A number of different psychological treatments can be used to treat anorexia.

Depending on the severity of the condition, treatment will last for at least 6 to 12 months
or more.

1. Cognitive analytic therapy (CAT)

Cognitive analytic therapy (CAT) is based on the theory that mental health conditions
such as anorexia are caused by unhealthy patterns of behaviour and thinking developed
in the past, usually during childhood.

CAT involves a three-stage process:

a. reformulation – looking at past events that may explain why the unhealthy
patterns developed

b. recognition – helping people see how these patterns are contributing towards
the anorexia

c. revision – identifying changes that can break these unhealthy patterns

2. Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is based on the theory that how we think about a
situation affects how we act and, in turn, our actions can affect how we think and feel.

In terms of anorexia, the therapist will attempt to show how the condition is often
associated with unhealthy and unrealistic thoughts and beliefs about food and diet.

The therapist will encourage the adoption of healthier, more realistic ways of thinking
that should lead to more positive behaviour.

3. Interpersonal therapy (IPT)

Interpersonal therapy (IPT) is based on the theory that relationships with other people
and the outside world in general have a powerful effect on mental health.

Anorexia may be associated with feelings of low self-esteem, anxiety and self-doubt
caused by problems interacting with people.

During IPT, the therapist will explore negative issues associated with your interpersonal
relationships and how these issues can be resolved.

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4. Focal psychodynamic therapy (FPT)

Focal psychodynamic therapy (FPT) is based on the theory that mental health
conditions may be associated with unresolved conflicts that occurred in the past, usually
during childhood.

The therapy encourages people with anorexia to think about how early childhood
experiences may have affected them. The aim is to find more successful ways of coping
with stressful situations and negative thoughts and emotions.

5. Family interventions

Anorexia doesn't just impact on one individual – it can have a big impact on the whole
family. Family intervention is an important part of treatment for young people with
anorexia.

Family intervention should focus on the eating disorder, and involves the family
discussing how anorexia has affected them. It can also help the family understand the
condition and how they can help.

Gaining weight safely

The care plan will include advice about how to increase the amount eaten so weight is
gained safely.

Physical health – as well as weight – is monitored closely. The height of children and
young people will also be regularly checked to make sure they're developing as
expected.
To begin with, the person will be given small amounts of food to eat, with the amount
gradually increasing as their body gets used to dealing with normal amounts.

The eventual aim is to have a regular eating pattern, with three meals a day, possibly
with vitamin and mineral supplements.

An outpatient target is an average gain of 0.5 kg (1.1lbs) a week. In a specialist unit, the
aim will usually be to gain an average of around 0.5-1kg (1.1-2.2lbs) a week.

Compulsory treatment

Occasionally, someone with anorexia may refuse treatment even though they're severely ill
and their life is at risk.

In these cases, as a last resort, doctors may decide to admit the person to hospital for
compulsory treatment under the Mental Health Act. This is sometimes known as sectioning or
being sectioned.

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Treating additional problems

As well as the main treatments mentioned above, other health problems caused by
anorexia will also need to be treated.

1. If you make yourself vomit regularly, you'll be given dental hygiene advice to help
prevent stomach acid damaging the enamel on your teeth.

2. For example, you may be advised not to brush your teeth soon after vomiting to avoid
further abrasion to tooth enamel, and to rinse out your mouth with water instead.

3. Avoiding acidic foods and mouth washes may be recommended. You'll also be
advised to visit a dentist regularly so they can check for any problems.

4. If you've been taking laxatives or diuretics in an attempt to lose weight, you'll be

advised to reduce them gradually so your body can adjust. Stopping them suddenly can
cause problems such as nausea and constipation.

Medication

Medication alone isn't usually effective in treating anorexia. It's often only used in
combination with the measures mentioned above to treat associated psychological
problems, such as obsessive compulsive disorder (OCD) or depression.

Two of the main types of medication used to treat people with anorexia are:

1. Selective serotonin reuptake inhibitors (SSRIs) – a type of antidepressant

medication that can help people with co-existing psychological problems such as
depression and anxiety

2. Olanzapine – a medication that can help reduce feelings of anxiety related to issues
such as weight and diet in people who haven't responded to other treatments

SSRIs tend to be avoided until a person with anorexia has started to gain weight
because the risk of more serious side effects is increased in people who are severely
underweight. Additionally, the drugs are only used cautiously in young people under the
age of 18.

ANOREXIA NERVOSA

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205. Mr James Smith, 25 years old man was brought to the hospital by police.
According to the police, Mr Smith went to the police station and was
convinced that he has done something wrong. After investigations, Police
found that it was a false claim.

You are the FY 2 doctor in the Psychiatry department, talk to the patient and do a
mental state examination and talk to him about further management.

The simulator can be pacing the room and you have to calm him down. Reassure him
and then when you get the opportunity, introduce yourself and confirm his identity.

Dr : Hello Mr Smith, I’m Dr …. One of the junior doctor in the Psych Dept/in this
hospital. I’m here to talk to you and help you. Can you please tell me what happened?

Mr Smith: Police are after me all the time…see they are standing by the door.

Dr : Do not worry Mr Smith they will not come inside. See I’m a doctor here and I‟ll
not allow them to come inside. Please tell me why do you think they are after you?

Mr Smith: I did something wrong, So the police were after me.

Dr: I assure you that you are in a safe place, and nobody will harm you.

Mr Smith: They have planted cameras in my room.

Dr: Don’t worry Mr Smith, the hospital is a secure place, and nobody can see you
outside this room.

Dr : Do you know where you are now? (Cognition) Mr Smith: This is a hospital.

Dr : Do you know who brought you here? Mr Smith : The police brought me here.

Dr: Did the police catch you or did you go to them?

Mr Smith: I was hiding from them for a long time but I got tired and I turned myself in.

Dr: Have you been harmed in anyway? Mr Smith: No

Dr: Since when have you been feeling this way? Mr Smith: Since the last few weeks

Dr: Were you alright before? Mr Smith: Yes

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Dr: How is your mood? Can you please rate your mood on scale of 1-10,1 being sad/
low, and 10 being normal/happy? Mr Smith: 4-5
Dr: Are you able to eat/sleep well? Carry out daily activities normally? Mr Smith: No/Yes

Dr: Do you ever see or hear things that are not really there, such as voices or visions?
(hallucination/perception) Mr Smith: No
Dr: Do you feel that someone is plotting anything against you? Mr Smith: Yes.

Dr: Have people been interfering with your thoughts (thought insertion). Mr Smith: No.

Dr: Do you think someone or some group intend to harm you in some way?

Mr Smith: Yes, I feel the Police will punish me.

Dr: Do feel like hurting yourself/doing harm to self? Mr Smith: No

Dr : Do you live with family or alone?

Mr Smith : I live on my own (sometimes he may say : I live with my mother).

Dr : Do you have any friends? Mr Smith : No

Dr : Do you have any problem with finance? Mr Smith : No

Dr : Do you have any legal problems? Have you been in trouble with law anytime?
(Forensic history) Mr Smith : No.

Dr: Do you drink alcohol? Mr Smith : sometimes

Dr: Do you smoke? Mr Smith: Yes/no

Dr: Do you use recreational drugs ? Mr Smith:No

Dr: Do you think you have any problem, do you think you need any help? (Insight)Mr Smith: No

Dr: Do you feel that this has affected your work/family life/social life?(Impact)Mr Smith: No/Yes

Dr: Do you have any medical conditions? Mr Smith : No

Dr: Did you have any mental health conditions before? Mr Smith : No

Dr: Any of your family members have any mental health conditions? Mr Smith : No

Dr : Do you take any medications? Mr Smith : No

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Dr: Are you allergic to any medications? Mr Smith:No

Dr : Do you have any medical problems at all? Mr Smith : No

Dr : Mr Smith why do you think all this is happening to you? Mr Smith: I don‟t know

Dr : Thank you very much Mr Smith, we will try our best to help you.

DIAGNOSIS: From the information you have given me, you have a mental health
condition called Psychosis. Psychosis is a condition where in people loose touch with
reality and start to see, hear and believe things that are not true. It happens due to
chemical imbalance in the brain. It is not an uncommon condition, 1 in 100 people are
affected by it. There are many reasons why people can have this condition like life
events, it runs in some families.

INVESTIGATIONS:

We will admit you and do some tests to find the reason. This test would include Blood
tests (toxicology, liver function), and CT Scan of your brain.

MANAGEMENT:

If the investigations are normal and symptoms persist for 6 months, it could be a
condition called Schizophrenia. We will treat that condition with medications to help
restore the chemical imbalance in the brain. (Risperidone or Olanzapine – no need to
tell the names of medications to the patient).
We will provide all kinds of Psychological help and Social support.

[The treatment could be a Bio-psycho-social model]

Investigations for Psychosis

● Abnormal LFTs and macrocytosis on FBC are highly suggestive of alcohol abuse.
● Serological tests for syphilis should not be forgotten.
● Screening for AIDS should be preceded by counselling.
● Urine screen for drugs of abuse. Light recreational use of cannabis can produce
a positive test for the subsequent fortnight. Heavy and chronic use can produce
a positive result for months after the last use.

● CT brain scan may be contributory (eg, to exclude a space-occupying lesion or

cerebral atrophy) if focal signs are present but not otherwise.
PSYCHOSIS/SCHIZOPHRENIA
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Causes of Psychosis
2) Depression,

3) Bipolar disorder (manic-depressive illness),

4) Puerperal psychosis,

5) Drug abuse,

6) Alcohol abuse,

7) Neurological conditions,

8) Drugs not associated with abuse.

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205.B. Bipolar disorder

Bipolar disorder, formerly known as manic depression, is a condition that affects moods, which can
swing from one extreme to another.
There will be periods or episodes of:
 depression – feeling very low and lethargic
 mania – feeling very high and overactive

Unlike simple mood swings, each extreme episode of bipolar disorder can last for several weeks (or even
longer), and some people may not experience a "normal" mood very often.

Depression
The depression phase of bipolar disorder is often diagnosed first and manic episode later (sometimes years
later).

Mania

During a manic phase of bipolar disorder, patient may feel very happy and have lots of ambitious plans and
ideas. They may spend large amounts of money on things they cannot afford and would not normally want.
Not feeling like eating or sleeping, talking quickly and becoming annoyed easily are also common
characteristics of this phase.
They may feel very creative and view the manic phase of bipolar as a positive experience. However, they
may also experience symptoms of psychosis (where they see or hear things that are not there or become
convinced of things that are not true).

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Miss Sarah Collins 30 year lady was brought into the hospital with cuts on her wrists.
‎Medical management has been done and she is medically stable. While she was in the
‎hospital nurse noticed strange behaviour. You are the SHO in the Psychiatric department.
‎Talk to the patient and tell your diagnosis to the examiner.‎
‎( This station assesses your ability to take history in a patient with elevated mood). ‎
Dr: Hello Mrs Collins I am Dr… How can I help you ?‎‎‎ Pt: I cut my wrists
Dr: I am sorry to hear that. How did this happen?‎
‎Pt : Doctor, I have a very nice dress and I wanted to buy a matching shoe. When I went ‎for shopping for
the shoe shop was closed. I saw a pair of perfectly matching shoe on the ‎glass window of the shop, so I
smashed the window to get the shoe and I got hurt on my ‎wrist.‎
Dr: I am very sorry to hear that. But why did you smash the window?‎
‎Pt: Oh doctor I was in a very good mood.‎
Dr: Has this happened to you before.‎ Pt: Doctor I am very happy since the last two weeks. ‎
Dr: Is there any particular reason why you are so happy?‎‎ Pt: Nothing special.‎
Dr: Has this happened to you before ?‎‎
Pt: No doctor in fact some time ago I was very depressed and I left going to the ‎University.‎
Dr: When was that ?‎‎ Pt: This happened about a month ago.‎
Dr: Why were you so depressed ?‎‎ Pt: I do not know why.‎
Dr: How is your mood now in the scale of one to ten, one being lowest mood and 10 being ‎the happiest
mood ?‎‎ Pt: 10 out of 10 doctor.‎
Dr: Have you ever had low mood ?‎‎ Pt: I was feeling very low about a month ago.‎
Dr: Do have any thoughts of harming yourself or ending your life ?‎
‎Pt: No doctor. I used to have that feeling before but now I am very happy.‎
Dr: Have been treated for depression or any other mental health problems before?‎Pt: No
Dr: What do you do for living ?‎‎Pt: I work as a waitress in hotel.‎
Dr: Are you financially stable.‎Pt: No doc. I am almost bankrupt.‎
Dr; Have you ever been involved in any legal problems?‎Pt: No
Dr: Who do you live with? Pt : My parents but we don’t have good communication.‎
Dr: Do you hear any noises when no one else is around Pt: No doctor
Dr: Do you think you have any mental health problem?‎‎Pt: No
Dr: Do you have any problems with the sexual life?‎Pt: No
D: Do you drink alcohol?‎‎‎Pt: No
Dr: Do you use any recreation drugs?‎Pt: No
Dr: Thank you very for all the information.‎‎‎Tell you diagnosis to the examiner: Bipolar disorder.‎When
discussing management: lithum

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MINI MENTAL STATE EXAMINATION (MMSE)

Background

● The MMSE is a brief 30-point questionnaire test that is used to screen for
cognitive and memory impairment.

● It is commonly used in medicine to screen for dementia.

● It is also used to estimate the severity of cognitive impairment and to follow the
course of cognitive changes in an individual over time, thus making it an
effective way to document an individual's response to treatment.

Key Points

● Perform your assessment for the entire 6 minutes.

● Offer sympathy and empathy. (this is very important in this station)

● Take time to build a rapport with the patient.

● Do not rush the patient, but if he gets frustrated, support and encourage him.

● Use the pen and paper on the table and you can score if you wish ( eg 1 +2 + 3+ 2 )

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Orientation Year/Season/ Month/ Day /Date ---/ 5

Time
(one score for each right answer)

Place Country/ County City/town Street Building/ 1. What country are we in now?
floor ---/ 5 2. What county are we in?
(one score for each right answer) 3. What city are we in?
4. What building are we in?
5. What floor of the building are we in?
(When you ask which floor you are in – he may
step on the floor and say “ I am on this floor” –
give zero score)
Registration 3objects Ask to repeat 3 words [allow one second “ I am going to name 3 objects, I want you
between each word, repeat them up to 5 to repeat them. Please remember these
times] ---/3 words, I am going to ask you to name then
(one score for each right answer) again in a few minutes.
These three objects are : APPLE, TABLE,
PENNY”. Please repeat the 3 words for me.

(If the patient cannot say correctly then

repeat until learned or up to maximum 5
times).
Attention WORLD Ask to spell the word “world” and correct if Could you spell the word “world”? Now
and wrong and ask to spell it back ward which could you please spell backward?
Calculation gives score. Give one score for each correct
answer until the order of the spelling is ( you should not spell backwards to help
correct. Eg : D,L,R,W,O (score is 3 here)--- him)
/5
OET:
SPEAKING:
3 recall Ask to recall those 3 words Could you please repeat those 3 words I
1.
--/3 asked you to remember?
One score for each correct answer. ( do not remind him the words)
Name 2 Ask to name 2 objects --/2 Show 2 objects one by one, Could you
2.
objects One score for each correct answer. please name this object?
( eg – pen, paper)
LISENING:
Repeat- Ask to repeat NO IFS, ANDS, or BUTS --/1 I want you to repeat exactly what I say
1.
sentence Give one score if the whole sentence is NO IFS, ANDS, OR BUTS
correct otherwise zero.
3 step- Ask to perform a 3 steps act --/3 Ask pt which is his dominant hand. Ask him
2.
command
One score for each right step. to do the following steps in non- dominant
hand.
Please take this paper with in your left
hand ( if he is right handed), fold it in
half once with both the hands and put
the paper down on the floor .(don’t
show any gesture)
READING:
Read Read and Write a command on the paper and ask him to do Please read this and do what it says.
carry out that --/1 Write on the paper - [Please close your

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the eyes]
Give one score if he closes his eyes not for
command
reading.
If the patient just repeats but does not
close the eyes, you can repeat the
instruction 3 times, but you do not
close your eyes to show him.
WRITING:
1. Write Write a Ask to write a sentence,look for meaningful Could you please write a sentence in
sentence sentence --/1 this paper?
please One score for a meaningful sentence (ignore
spelling errors).
2. Copy Copy Ask to copy 2 intersecting pentagons where Can you please copy this design.
this inter-section box has 4 sides only. --/1
diagram Give one score if drawn correctly (Must have
drawn 4 sided figure between two 5 sided
figures).
Allow multiple attempts until Pt is finished
and hands it back to you.

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206. DEMENTIA
MMSE/ MENTAL HIGHER FUNCTION ASSESSMENT/ COGNITION

ASSESMENT

Common causes of dementia:

1. Alzheimer's disease (about 50%). Degeneration of the cerebral cortex.

2. Vascular dementia (about 25%). Brain damage due to cerebrovascular disease:

either major stroke, multiple smaller unrecognised strokes (multi-infarct) or chronic
changes in smaller vessels (subcortical dementia).

3. Dementia with Lewy bodies (DLB) (about 15%). Deposition of abnormal protein
within neurones in the brain stem and neocortex.

4. Frontotemporal dementia (less than 5%). Specific degeneration/atrophy of the

frontal and temporal lobes of the brain. One type of frontotemporal dementia is
Pick's disease, where protein tangles (Pick's bodies) are seen histologically.

5. Mixed dementia

6. Parkinson's disease

7. Potentially treatable dementias (fewer than 5%):

8. Substance abuse

9. Hypothyroidism

10. Space-occupying intracranial lesions

11. Normal pressure hydrocephalus

12. Syphilis

13. Vitamin B12 deficiency

14. Folate deficiency

15. Pellagra

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206. A 75 year old man has been brought to the hospital because he was

found confused and wandering. All blood investigations are done and results are
normal. You are the doctor in the Psychiatric department. Assess this patient and
discuss the initial management with the examiner.
Dr. Hello Mr Adam Williams, My name is. ....... I am one of the doctors in the

Psychiatry department.

Dr - Can you confirm your name for me Pt:- Mr Adam Williams

Dr - Do you know where you are now ? Pt: - Where am I ?

Dr - You are in the hospital, Do you know who brought you here?

Pt: Who brought me here ?

Dr - The police brought you here Pt: Am I in trouble?

Dr - You're not in trouble. Do you know where do you live? Pt: I don’t know.

Dr: Ok Don’t worry. You are in a safe place now. Pt: Sure.

Dr: - I would like to ask you a few questions to know how well you remember things, is
that okay with you

Orientation

Time Year/Season/ Month/ Day /Date -- / 5

(one score for each right answer)

Place Country/ County City or town/Street Building/ floor -- / 5

(one score for each right answer)

1. What country are we in now?

2. What county are we in?

3. What city are we in?

4. What building are we in?

5. What floor of the building are we in?

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(When you ask which floor you are in – he may step on the floor and say “ I am on this
floor” – give zero score)

Registration: 3 objects Ask to repeat 3 words [allow one second between each word,
repeat them up to 5 times] —/3 (one score for each right answer)

“ I am going to name 3 objects, I want you to repeat them. Please remember these
words, I am going to ask you to name then again in a few minutes. These three objects
are : APPLE, TABLE, PENNY”. Please repeat the 3 words for me.

(If the patient cannot say correctly, then repeat until learned or up to maximum 5 times).

Attention and Calculation: “WORLD”: Ask to spell the word “world” and correct if
wrong and ask to spell it back ward which gives score. Give one score for each correct
answer until the order of the spelling is correct. Eg : D,L,R,W,O (score is 3 here) ---/5

Could you spell the word “world”? Now could you please spell backward? (you should
not spell backwards to help him)

Recall: Ask to recall those 3 words Could you please repeat those 3 words?

24-30 : Normal cognition

20-23 : Mild cognitive impairment

10-19 : Moderate cognitive impairment

0 -9 : Severe cognitive impairment

At the 6th minute bell :- Stop the assessment and discuss the management with the
examiner (SOMETIMES EXAMINER SAYS TO COMPLETE THE ASSESSMENT)

DIAGNOSIS:

From the above history and cognitive assessment the patient has impaired cognition.
He is able to PERFORM/NOT PERFORM most of the instructions. My provisional
diagnosis is dementia. (TELL THE SCORE/TYPE OF COGNITIVE IMPAIRMENT)

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INVESTIGATIONS & MANAGEMENT

I would like to admit the patient since he has dementia so it is not safe to send him
home and do investigations like CXR, urine test. A brain CT scan to check for any
cause for dementia and also find out more information from the GP about past history
and family about onset and progression of his condition. Inform seniors. REFER TO
DEMENTIA CLINIC/DEMENTIA Team

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207. ALCOHOL ASSESSMENT

You must assess the following 6 steps and if required discuss your findings with the
patient or the examiner.

Step 1: Presenting Complaint

Step 2: History of Present Complaint

Daily Drinking Pattern: What/How Much/When/Where/Alone/Progression

CAGE Questions: CAGE SCREENING TOOL

• “Have you ever felt that you should Cut down on your drinking?”

• “Have people Annoyed you by criticizing your drinking?”

• “Have you ever felt bad or Guilty about your drinking?”

• “Have you ever had a drink first thing in the morning to steady you nerves or get rid of a
hangover (Eye-opener)?”

Scoring: Two or more positive responses correlate with substance abuse.

Step 3: Features of Dependence

- Can you carry out your daily activities without drinking?

- How much of your daily activities depend on drinking?

TDW - Tolerance/Dependence/Withdrawal/Previous Treatment

Step 4: Consequences

- Friends/Family/Finances/Forensic

Step 5: Complications

Physical/Depression(Mood)/Psychosis/Self Harm

Step 6: Insight

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Management

If the station/task states present findings/management/counsel, then as a rule, you

should discuss:

● Referral to Alcohol Support Worker

● Lifestyle changes

● Outpatient Counselling Groups such as Alcoholics Anonymous

● Outpatient medication management

● Inpatient Detoxification

● Change of occupation if required

Key Points
● Be honest and non-judgemental.

● Do not start station by discussing alcohol directly - mention that their test
results may be due to alcohol intake as well as many other causes and that you
want to ask some questions to rule alcohol out as a cause.

● Many patients drink in secret and may not want to discuss the issue.

● If patient is denying drinking alcohol – you can offer confidentiality. “Mr….,

whatever you discuss with us will be kept confidential”

● The patient needs to accept that there is a problem before therapy can start.

Government Recommended Allowances

Male and Female: 14 UNITS PER WEEK

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207. Mrs Tames Parker, 45 years old woman who had hysteroscopy. The nurse

noticed she has got a bad drinking habit and wants you to talk to her about it. You are
the SHO in the Psychiatric department. Take history for alcohol abuse from the patient
and talk to her about the management.

(GRIPS Followed by CAGE,T/D/W)

Offer confidentiality to encourage patient to open up

Dr: Hello, Mrs Parker, I am Dr ......................., one of the doctors in Psychiatric department.
I am here to talk to you and help you.

Dr: Can you please tell me how are you doing?

Mrs Parker: I am much better, just a bit sore but I guess it’s expected. Dr: I am sorry to hear that

Mrs Parker: I am OK now.‎

Dr: Mrs Parker I want to talk to you about alcohol, is that okay ?‎Mrs Parker: Yes, Doctor. ‎
Dr: Do you drink alcohol Mrs Parker ?‎ ‎Mrs Parker: Yes ‎
Dr : For how long have you been drinking? ‎Mrs Parker : I have been drinking for last 20 years.‎
Dr: How much do you drink? (How frequently?)‎
Mrs Parker: Doctor, I drink 3 pints of beer and 1 shot whisky daily
‎( Then ask CAGETDW – cut down, annoyance, guilty, eye opener, tolerance, dependence,
‎withdrawal questions )‎
Dr:Have you ever felt you should try to cut down on your drinking?‎
Mrs Parker: Yes, Doctor, I went to Alcohol Anonymous (AA) Group 6 months ago to cut‎down alcohol.
But sometimes, I went for drinks because of my friends. ‎
Dr: Does it mean that you still keep drinking.‎‎‎Mrs Parker : Yes doctor
Dr: Can you please tell me why did you try to cut down drinking?(INSIGHT)‎
Mrs Parker : It is not good for health.‎
Dr: Have people annoyed you by criticizing your drinking?‎
Mrs Parker: Yes, My husband is really annoyed about it
Dr: Have you ever felt bad or guilty about your drinking?‎‎‎
Mrs Parker: Yes, Doctor, Sometimes
Dr: Have you ever had a drink in the morning (eye-opener) to steady your nerves or get rid ‎of a
hangover?‎‎‎Mrs Parker : Yes, Doctor.‎
‎(Patients with two or more positive responses are likely to be alcohol dependent).‎

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Dr: Do you think that you have to take more and more alcohol to get the same effect as before?
‎(Tolerance)‎‎‎Mrs Parker: No, Doctor.‎
Dr : Do you feel you cannot do your daily activities without drinking alcohol? ‎(Dependence)‎
Mrs Parker : Yes
Dr: How do you feel when you do not drink alcohol for a long time ? ( Withdrawal)‎
Mrs Parker: Doctor, when I do not drink, I feel restless, I start sweating and sometimes I ‎feel that
my heart is racing. It happened to me 1 year ago.‎
Dr: What do you do for living? Mrs Parker: I own a winery ( a place where wine is made).‎
Dr: Do you live with your family?‎‎‎Mrs Parker: Yes, with my husband
Dr : Do you have any financial problems?‎‎‎Mrs Parker : No
Dr: How is your mood? How would you grade your mood in 1 to 10 scale where 1 being ‎low and 10
being very happiest mood? ( Mood) ‎‎Mrs Parker: My mood is fine (7/10)‎
Dr: At any point, THOUGHT of harming yourself or ending your life? ( Suicidal)‎
Mrs Parker: No, doctor.‎
Dr : Do you ever see or hear things that other people seem unable to see or hear? ‎
‎( HALLUCINATION/PERCEPTION)‎‎‎‎Mrs Parker : No
Dr:DO you feel that this has affected your work/family life/social life?(IMPACT)‎
Mrs parker: NO/YES
Dr:DO you tend to drink alcohol to relieve ur stress?(STRESSOR)‎‎Mrs parker:No
Dr: Do you have any health problem at all apart from the problem for which you had the ‎procedure
now? Mrs Parker : No
Dr:did you have any mental health problems in ur past?‎‎‎Mrs parker:NO
Dr:are you taking any medications?/are you allergic to any medications?‎‎‎Mrs parker:NO
Dr:do you have family history of any mental health conditions?‎‎‎Mrs parker:NO
Dr:Do you have any legal problems?‎‎Mrs parker:NO
Dr: Thank you very much for all the information. We will try our best to help you.‎
.

DIAGNOSIS: Mrs Parker, you are experiencing soreness and withdrawal symptoms because
of your ALCOHOL use. From the information, I think you have alcohol dependence.

 Cause and effect : From what you told me Mrs Parker, You seem to be taking too much
alcohol which is dangerous for you. This can damage your liver and risk your life.

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MANAGEMENT:

Stop alcohol: If you stop drinking, it will not only help you in this problem, but also in your
overall health. We can help you on that.

Medications : We can give medications to prevent withdrawal effects (anti-withdrawals-

chlordiazepoxide) and also to help you stop drinking alcohol (anti-craving medications – disulfiram,
Acamprosate).

Counselling :

1. You can try to attend Alcohol anonymous, or we can help by offering you
counselling sessions (CBT)

2. Rehabilitation: If needed, we can admit for rehabilitation (Job, Finances and

accommodation)

3. Avoid going to the winery, triggers (seeing other people drinking): may be you can try to
change your job (if he is a bar tender) or try to avoid going to the bar floor (If he is a bar
owner).

4. Cultivate new habits and do things that don’t require you to take alcohol

5. Referral to alcohol liaison team

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DRUG ABUSE ASSESSMENT

Assessment

You must assess the following 6 steps and if required discuss your findings with the
patient or the examiner.

Step 1: Presenting Complaint

Step 2: History of Present Complaint

- Daily Drug Pattern: What/How Much/When/Where/Alone/Progression

- CAGE Questions: Cut Down/Annoyed/Guilty/Eye Opener

Step 3: Features of Dependence

Tolerance/Withdrawal/ Previous Treatment (Hep B)

Step 4: Consequences

Friends/Family/Finances/Forensic

Step 5: Complications

Physical/Depression(Mood)/Psychosis/Self Harm

Step 6: Insight

Management

If station/task states present findings/management/counsel, then as a rule, you should

discuss:

• Referral to Narcotic Support Worker and Lifestyle changes

• Outpatient Counselling Groups such as Narcotics Anonymous

• Outpatient medication management (Methadone/needle sharing)

• Inpatient Detoxification

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208. You are the FY 2 doctor in the Psychiatry department.

30 year old, Mr Henry Williams, has been referred to the hospital from his GP
because he is opioid dependent and he wants to quit the habit.

Take a history from Mr Henry and discuss the further management with him.

{GRIPS-CAGE, T/D/W, Which DRUG, DOSAGE, ROUTE OF INJECTION}

Dr: Hello Mr Williams, I am Dr… one of the junior doctors from the Psychiatry Dept.
How can I help you Mr Williams?

Mr Williams: Dr, I use drugs and I want to stop and I need help.

Dr: It is really good to know that you wish to quit drug habit. ”I am really glad that
you have come to us. We can surely help you with that. The first step is the hardest
step and we will help you with this newfound journey. I’m so happy that you can
put your trust in us.”

Dr: Can you please tell me, which drugs do you use? Mr Williams: Doctor, I use Heroin.

Dr: For how long have you been taking it?

Mr Williams: It has been 10 years; I started taking it when I was 20 years old.

Dr: How much do you take it? Mr Williams: About 1 gram.

Dr: How often do you take it? Mr Williams: I take it two times daily.

Dr: How do you use it?

Mr Williams: I inject in my blood channels nowadays, before I used to snort it.

Dr : Do you know of the needle exchange programme? Mr Williams: Yes, I am aware of it.

Dr: Apart from heroin, do you take anything?

Mr Williams: No doctor (sometimes he may say - I use cocaine, marijuana and amphetamine).

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(Ask CAGE/TDW questions)

Dr: Have you thought of Cutting down or quitting them?

Mr Williams: I tried to quit it two times before (5 months and 7 months before), but it

did not work as I had serious withdrawal symptoms

Dr: Why did you try to cut down before?

I was having some health problems. I had some infections on my arm where I used to
inject myself.

Dr: Do you sometime get Annoyed when people talk about your habit?

Mr Williams: No (sometimes yes, because of my wife/girlfriend)

Dr: Do you have any sort of Guilt feeling that you are using opioid?

Mr Williams: Yes, Doctor, Sometimes I feel guilty in front of my wife/ girlfriend.

Dr: Do you take them in the morning as well? (EYE OPENER)

Mr Williams: Yes, Doctor. First thing I do in the morning is to take these drugs.

Dr: Do you think that you have to take more and more drugs to get the same effect as

before? (TOLERANCE) Mr Williams: No, Doctor.

Dr : Do you feel you cannot do your daily activities without taking drugs? (Dependence)

Mr Williams : Yes

Dr: How do you feel when you do not take these drugs? (WITHDRAWAL)

Mr Williams: Doctor, when I do not take these drugs, I feel restless, I start sweating
and sometimes I feel that my heart is racing. It happened to me 1 year ago.

Dr: What do you do for living? Mr Williams: I am on benefits

Dr: Do you live with your family? Mr Williams: Yes girlfriend who also uses opioids.

Dr : Do you smoke or consume alcohol? Mr Williams: No

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Dr: How is your mood? How would you grade your mood in 1 to 10 scale where 1
being low and 10 being very happiest mood?

Mr Williams: My mood is fine (8/10)

Dr: Do you ever feel that someone is telling you to do things/or controlling your mind? Mr: No

Dr: At any point, thought of harming yourself or ending your life? Mr Williams: No.

Dr: At any point, you have gone to wrong side of the law? (FORENSICS)

Mr Williams: No(sometimes he may say - I was arrested when I was young for pick pocketing).

Dr : Do you ever see or hear things that other people seem unable to see or hear?

(hallucination) Mr Williams: No

Dr:Is there any Stress which is making you take this drug? (STRESSOR) Mr Williams: No/Yes

Dr: Do you think this is affecting your health or social life /Family life? (Impact) Mr: Yes

Dr : Do you think you need help? (Insight) Mr Williams: Yes Doctor.

Dr : How do you see your future? Mr Williams: Good if I can stop this habit

Dr: Did you suffer from any mental health conditions in the past? Mr Williams: No

Dr: Do you have any other medical conditions? Mr Williams: No

Dr:Are you allergic to any medications? Are you taking any medicines? Mr Williams: No

Dr:Do you have family history of any mental health conditions? Mr Williams: No

Dr : Thank you Mr Williams

Management:

• As you know it is not good for health as well as for your social life.
We can help you to quit the habit if you are willing to do so.

• We have a Drug de-addiction (DETOXIFICATION) programme which can help you where we

can Admit and rehabilitate.

• WE will give you a drug called LOFEXIDINE,TO HELP You with the withdrawal effects.

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 We will also treat you symptomatically. For example: METOCLOPARAMIDE for Nausea,

LOPERAMIDE for Loose Motions, BENZODIAZEPINES for Palpitations.

 *REPLACEMENT THERAPY: We have some medications called Methadone or Buprenorphine

(tell the names of the medications to the patient) we can give you to help you.

 *We have talking therapies, such as counselling, can help you to understand and overcome
your addiction and plan for your future.

 *We can refer you to a support group (self help group - Narcotics Anonymous) where
you can meet other people with similar problems and share your experiences which
can help you.

 *Talk about NEEDLE EXCHANGE PROGRAM - highlight complications of taking IV

drugs, talk about importance of stopping but if the patient cannot stop, then you
can offer it

 *Advise about his girlfriend – if your girlfriend wishes to stop her drug habit we can
help her too.

Do you follow me? Any questions ?

OPIOID DEPENDENCE

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209. INSOMNIA
Causes of insomnia

A. Physical health conditions

1. Long-term pain

2. Sleep disorders – such as snoring and sleep apnoea, restless legs

3. Syndrome, narcolepsy, night terrors and sleepwalking

4. Problems with the genital or urinary organs – such as urinary

5. Incontinence or an enlarged prostate

6. Joint or muscle problems – such as arthritis

7. Hormonal problems – such as an overactive thyroid

8. Neurological conditions – such as Alzheimer's disease or

9. Parkinson's disease

10. Respiratory conditions – such as chronic obstructive pulmonary

11. Disease (COPD) or asthma

12. Heart conditions – such as angina or heart failure

13. In women, childbirth can sometimes lead to insomnia.

B. Medication as a side effect.

● Certain antidepressants

● Medicines for high blood pressure, such as beta-blockers

● Epilepsy medicines

● Steroid medication

● Non-steroidal anti-inflammatory drugs (NSAIDs)

● stimulant medicines used to treat attention deficit hyperactivity

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● Disorder (ADHD) or narcolepsy

● Some medicines used to treat asthma, such as salbutamol,

● Salmeterol and theophylline

C. Mental health conditions

● Mood disorders – such as depression or bipolar disorder

● Anxiety disorders – such as generalised anxiety, panic

● Disorder or post-traumatic stress disorder

● Psychotic disorders – such as schizophrenia

D. Stress and anxiety

● Stressful events, such as a bereavement, problems at work, or financial

difficulties.

● Having more general worries – for example, about work, family or health – are
also likely to keep you awake at night.

● These can cause your mind to start racing while you lie in bed, which can be
made worse by also worrying about not being able to sleep.
E. Lifestyle factors

● Drinking alcohol before going to bed and taking certain recreational drugs,
stimulants such as nicotine (found in cigarettes) and caffeine (found in tea,
coffee and energy drinks). These should be avoided in the evenings.

● Changes to your sleeping patterns can also contribute to insomnia – for example,
because shift work changing time zones after a long-haul flight (jet lag).

F. Poor sleep routine and sleeping environment

● You may struggle to get a good night's sleep if you go to bed at inconsistent
times, nap during the day

● A poor sleeping environment can also contribute to insomnia – for instance, an

uncomfortable bed or a bedroom that's too bright, noisy, hot or cold.

G. Idiopathic: Sometimes it's not possible to identify a clear cause.

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209. You are the FY2 doctor in the Rhuematology clinic

Mrs Sarah Johnson, 60 years old lady, has come to the Rheumatology clinic for a
follow up because she was diagnosed with Rheumatoid arthritis. She is on
Paracetamol and Methotrexate and Folate for RA. She complains of unable to
sleep. Talk to her and address her concerns

Dr: Hello Mrs Johnson, I am Dr. … one of the junior doctors in the medical department.

How are you doing today ?

Mrs Johnson: I am Ok doctor

Dr: What brought you to the hospital?

Mrs Johnson: I have difficulty in sleeping.

Dr: I am really sorry to hear that. When did it start?

Mrs Johnson: It started 6 months before.

Dr: Can you please tell me about your difficulty in sleeping? Do you find it difficult to sleep
when you go to bed or difficulty in maintaining sleep or you wake up early in morning?

Mrs Johnson: I get into bed at 9 or 10 o’clock but I can sleep only after 3 o’clock.

Dr: Has anything happened recently which might be the cause of this problem - like
any take a short nap in the afternoon?

Dr: Do you keep watching TV or computer until late in the night ? Mrs Johnson: No.

ASK QUESTIONS RELATED TO THOUGHTS, PERCEPTION, IMPACT

(Work,Family,Social Life)

Diagnosis & Management:

Counselling:

Dr: Mrs Johnson - There are many reasons why people do not get sleep. In your case though
the cause is not very clear sometimes people who have Rheumatoid arthritis do have this
problem
- sometimes due to pain, but sometimes it can happen without any known reasons in
patients with this condition.

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However, you can improve your sleep by what we call sleep hygiene:

• use a sleep diary to keep track of your sleeping habits

If she is doing any of the following then advise accordingly:-

• avoid sleeping during the day (sometimes she is sleeping in the day time)

• avoid tea, coffee and any other products that contain caffeine after midday

(sometimes she drinks too much coffee in the night time)

• don’t eat or drink large amounts just before bedtime

• avoid drinking alcohol if your sleep is disturbed

• don’t smoke before bedtime or during the night

Sometimes she may say – her neighbours are too noisy – you can request them not

to make too much noise if they do not listen – you can report to the council)

• exercise regularly (but not within three hours of going to bed)

• keep the bedroom dark, quiet and at a comfortable temperature

• check that your mattress and pillows are comfortable

• set up a relaxing routine – try to go to bed and wake up at the same time each day

• take a warm bath before going to bed.

Relaxation techniques and Talking therapy (CBT) may also be help you. We will refer
you to the Psychiatrists who are experts in this.

Mrs Johnson: Doctor, will you give me sleeping pills ?

Dr: There are many sleeping pills but they have side effects and they may cause
addiction and also medications may not help in the long term. Medications are not
recommended for more than four or five weeks. However, if nothing else helps we can
consider giving you sleeping pills Is this ok? Mrs Johnson : Ok, doctor I will try.
Dr: We will keep following you up. Thank you very much.

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209.B. PANIC ATTACK

Anxiety is a feeling of unease. It can range from mild to severe and can include feelings of worry
and fear.
There are several conditions that can cause severe anxiety including
 Phobias – an extreme or irrational fear of an object, place, situation, feeling or animal
 Generalised anxiety disorder (GAD) – a long-term condition that causes excessive anxiety
and worry relating to a variety of situations
 Post-traumatic stress disorder – a condition with psychological and physical symptoms
caused by distressing or frightening events

A panic attack is a severe attack of anxiety and fear which occurs suddenly, often without
warning, and for no apparent reason. In addition to the anxiety, various other symptoms may
also occur during a panic attack. These include one or more of the following:
1. Palpitations.
2. Sweating and trembling.
3. Dry mouth.
4. Hot flushes or chills.
5. Feeling short of breath, sometimes with choking sensations.
6. Chest pains.
7. Feeling sick , dizzy, or faint.
8. Fear of dying or going crazy.
9. Numbness or pins and needles.
Assessment
You must assess the following 4 steps as part of this station/task.
Step 1: Presenting Complaint
Step 2: History of Present Complaint
 Onset
 Symptoms (explore above)
 Description
 Triggers
 Recent change in circumstances
 Severity
 Progression
 Effect on activities of daily living

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 4Fs
 Mood (Score 1-10)
 Risk
Step 3: FAMISH History
Step 4: Insight
Suggested Questions
How long have you been having problem?
What happens to you ?
Do you have heart racing, feeling dizzy and numb,
Do you have breathing problems and have a sense impending doom(You feel as though something
extremely bad is going to happen but you are not sure what. You may also feel as though your world is
coming to an end)?
What brings it on? How long has this been going on?
Does it occur only when you are faced with such a situation or at any time?
Can you go out of the house at all ?
Are you afraid of crowds and people?
Any special fear?
Is this hampering your daily life?
What do you do to subside them?
Is your family and friends supportive?
Is there stress at work /family?
Do you enjoy your daily activities /interest/otherwise?
Is this problem making you suicidal?
Any other medical /mental condition you wish us to know of? Are you on any medications?
YOU are FY2 doctor in the Psychiatry department, Miss Sarah Jones, 25 years old lady has been
referred to the hospital by her GP. She went ‎to GP because she thinks that she is very anxious
nowadays. All investigations have been ‎done and are normal. You are SHO in the hospital. Take
history from Miss Jones.‎

Dr: Hello Mrs Jones, I am Dr… one of the junior doctor in the Psychiatry department. How ‎are you doing ?‎‎
‎Miss Jones: I am very worried doctor.‎
Dr : What are you worried about ?‎
Miss Jones: Dr, I become anxious nowadays. I Feel like my heart is racing and mouth is ‎dry. Sometimes, I
even have choking sensation.‎
Dr: When did it start?‎‎‎Miss Jones: It started few months ago.‎

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Dr: When was the last time you had symptoms?‎

Miss Jones: I had these symptoms two weeks ago when I went to the party and I met my ‎family members.‎
Dr: Can you please tell me, how did it start at first time?‎
Miss Jones: It started when I was at shopping centre. And I started having symptoms.‎
Dr: Do you have any idea what can be the cause of these symptoms, any recent ‎change/incident in your life?‎
Miss Jones: Yes doctor. My husband left me 8 months ago, and I got divorced after that.‎
Dr: Is there any particular thing which makes you anxious?‎‎‎
Miss Jones: No doctor. However, it happens when I go out.‎
Dr: Does it affect your daily life?‎‎‎Miss Jones: Yes.‎
Dr: How does it affect your life?‎
Miss Jones: I cannot go out nowadays as I am afraid that if I go out I might get these ‎symptoms.‎
Dr: Do you have any concerns about your life, any responsibility?‎
Miss Jones: Yes, Doctor, I am concerned about my three kids.‎
Dr: Do you have any family to support you?‎
Miss Jones: Yes, Doctor my sister supports me.‎
Dr: What do you do for living?‎‎Miss Jones: I am not working right now; I lost my job 4 months ago.‎
Dr: How has been your mood?‎‎‎Miss Jones: It has been good ‎
Dr: Have you ever thought of harming yourself?‎‎Miss Jones: No
Dr: Do u drink alcohol? ‎Miss Jones: doctor, I am really worried about my heart.‎
Dr: Don’t worry, my GP colleague did all the investigations and fortunately everything is ‎fine and there is
nothing wrong with your heart. ( Mention this only if the patient ask you ‎this question, otherwise just say
“thank you very much for all the information”). ‎
‎[This is only history taking station]‎

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Mr Jeremy Williams 30 years old man has been referred to you from GP. This man was ‎prescribed
paroxetine. Talk to the patient and address patient’s concern.‎
Dr. Hello Mr Williams I am Dr… One of the junior doctor in the Psychiatry department. ‎How are you doing
today?‎
Pt: The medicine what you gave me is useless doctor.‎
Dr: Why do you say that?‎‎‎‎Pt: They are not at all helping me.‎
Dr: Which medication are you talking about ?‎
Pt: I was prescribed this medication 10 days ago because I was feeling very low.‎
Dr: Do you take it regularly? ‎Pt: Yes.‎
Dr: Are you still taking the medication or have you stopped taking them.‎
Pt: I am still taking them.‎
Dr: Mr Williams, unfortunately you may not see the effect of this medication within 10 ‎days. It takes 4-6
weeks to build up its best effects so please continue your medication ‎regularly. Please do not stop taking
this medication on your own. You will see the effect in ‎the next few weeks.‎
Dr: Do you have any other concerns about this medication ?‎
Pt : I heard that it can cause problems with sex life. Is that true ?‎
Dr: It is true. It can very rarely cause sexual dysfunction like low sex drive or erectile ‎problems. However
we will keep monitoring the medication. Any other concerns ?‎
Pt: Do they have any other side effects ?‎
Dr: Yes, Common ones are headache, vomiting, diarrhoea or constipation and sometimes ‎stomach ache.It
can either make you very sleepy or you may not get good sleep at all. This ‎medication might cause poor
sleep. So please don’t take it in night, take it early morning.‎
Pt: Doctor is it addictive? ‎
Dr: It is not addictive. We will not stop this medication suddenly. We will gradually ‎decrease the dose of
medication. So you will not experience any side effect. ‎
Dr: Do you have the feeling of harming yourself or ending your life ? ‎
Pt: No ( is he says yes – admit him)‎
Dr: If at all you get these feelings any time later please do come back to us. We will keep ‎following you up. ‎
SSRI Counselling ( Fluoxetine) ( Antidepressant) : In this station, you must emphasise the
importance of staying on the medications to achieve ‎the best beneficial effect.‎

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 PHYSICAL EXAMINATION STATIONS

“May I examine you?”

1. Body parts
2. Privacy chaperone I have a chaperone
3. Describe
4. Exposure
5. Consent
6. Provisional diagnosis - I suspect most likely
7. Define diagnosis
8. Investigations
9. Management
● Admission or not
● Medications
● Surgery
● Recovery time
● Safety netting/warning signs

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210. You are the FY 2 doctor in the Medical department.

Mr Stephen George 45 year presented to the hospital with bumping into

neighbouring objects while driving and even walking. His wife advised him to go
for a check up with the doctor.

Take a brief history and do the relevant examination and discuss your findings and
further management plan with the patient.

 Causes of tunnel vision

 Glaucoma - Halos, Pai,; triggered by amitryptilline, red watery eyes

 Retinitis pigmentosa:
- Symptoms often start in childhood with impaired night vision (nyctalopia) or dark adaptation.
- Progressive loss of peripheral vision is common (resulting in a tendency to trip over things),
although there may be loss of central vision which tends to occur later. This eventually leads
to impaired sight at a variable rate.

- The symptoms usually become apparent between the ages of 10 and 30, although
some changes may become apparent in childhood.

 Eye strokes or occlusions

 Detached retina- sudden onset, like a curtain coming down.

 Brain damage from stroke ( headache, weakness in any part of body), disease or head injury

 Optic neuritis - usually affects one eye, Pain. Vision loss, Loss of colour vision, Flashing lights.

 Compressed optic nerve head (papilledema) Concussions (head injuries)

 Pituitary adenoma – bitemporal hemianopsia, tunnel vision, family history of vision

problem or tumours in the brain, milk discharge from breast

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Hello Mr Stephen George, I am Dr.. How can I help you ?

Pt: Doctor, I keep bumping to the neighbouring cars when I try to reverse park my car.
Also I keep bumping into the walls on the sides when I walk sometimes. My wife told
me to go for a check up.

“That must be difficult/distressing”

Ask him if he has hurt himself. Praise his wife..”your wife must be concerned/caring”

Dr: Sorry to hear about this. Since when are you having this problem? Pt: This has
been happening for the last few weeks

Dr: Do you have any problem in your vision? Pt: I am not sure Do you wear
eyeglasses? No

Do you enjoy reading Have you noticed difficulty reading? Have you noticed any
changesAre you able to read books? Yes

Can you read the signs when you drive? Are you able to see the distant objects? Yes

Do you have any blurring of vision? No

Do you see anything floating in your vision area ? No

Do you have any pain in the eye (glaucoma, optic neuritis) ? No

Do you see any coloured halos around the light (glaucoma) ? No

Do you have any headache (Stroke, Brain tumour, pituitary tumour) ? No Did you
have any injury to the eye or head ? No

Did this happen suddenly? No doctor

Did you feel like a curtain coming down suddenly and blocking your vision (retinal
detachment) ? No

Has your night vision different than before (retinitis pigmentosa)? No Do you have any
weakness in any part of the body (stroke) ? No

Have you bumped your head recently? (Trauma)

Have noticed any whitish discharge from your nipple (pituitary adenoma) ? No

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Any change in shoe size?

Any change in ring size?

Any vomiting (brain tumour) ? No

Any difficulty with colours? Can you distinguish colours well? (optic neuritis)

Similar conditions in the past?

Do you have any medical conditions ? No

Are you taking any medications ? No

Allergies?

Any of your blood relatives have such problems (pituitary adenoma) ? No Mr George I
need to examine your eyes and check your vision. Is that OK OK doctor
Examination

Inspection:

Anterior:

● Symmetrical
● Inflammation: discharge, swelling, redness, tearing
● Ptosis

Posterior
● Proptosis - “Please look up without moving your head”

Nystagmus (do a cross sign.”Please follow my finger without moving my head”). His
eye has to go all the way to the corners of the eye and go very slowly.. “I didn’t
appreciate any vertical or horizontal nystagmus”)

Reflexes
● Red reflex - for cataract & hemorrhage (check it at 100cm and 30cm)..”May I please
dim the room” Right hand, right eye, right hand
● Pupillary reflex - to check for direct and consensual. Do it once for each eye. Ask
patient to put his hand on the bridge of his nose without covering his eyes.
● Accommodation - tell the patient to look straight ahead and ask the patient to look at
your finger when he sees it.

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Visual acuity – Snellen or Ishihara test - finger counting is done instead during the
exam. Sit down close enough without touching his legs. Say Snellen not present then
do the finger counting. Ask how many fingers patient can see.

Visual field:

● Peripheral (white pen) [Finding may be tunnel vision or rarely bitemporal

hemianopia]. Place your right hand on your right eye first and then change your
hand to the left. In bitemporal, can see nasal but temporal. In tunnel vision, he
can’t see temporal and nasal.
● Central (red pen) - Ask patient what colour the pen is. Only done if peripheral
visual field test not positive. It could be central scotoma. “Patient’s blind spot
matches mine.”

If patient wears glasses, he has to be wearing them when testing for visual acuity and
visual fields.

Provisional diagnosis, investigations and treatment

Mr George, after assessment I can see that you are not able to see especially outer
part of your vision area. That is the reason you may be bumping onto the things. This
could be due to a problem in the brain. I suspect there is a tumour (growth) in a gland
in the brain called the Pituitary gland which is located at the base of your brain near
your nasal passages. This gland produces hormones. This gland is pressing on the
nerves supplying the eyes. Most likely this a non-cancerous growth. Do you follow me?

“Yes doctor.”
We need to do some tests to confirm it. We will do some blood tests check some
chemicals in your blood we call them (prolactin and growth hormone) and also some
imaging (MRI scan) of the brain to look for this tumour. Is that OK? Ok doctor.

“Would you like to know about the treatment if it is confirmed as what we are suspecting?”

If the tests does show that you have this growth of the Pituitary gland, then depending
on what type of growth it is we will treat with either medication (Cabergoline is the
drug of choice. Bromocriptine is also possible). Surgery (if patient doesn’t respond)or
radiation therapy. Will inform seniors. Most likely your vision will come back after the
treatment. Any questions?

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This patient doesn’t need admission.

Information about Pituitary tumour

The Pituitary Gland

The pituitary is a small gland that is located at the base of your brain near your nasal
passages. These are located just above the back of the roof of your mouth. It is about
the size of peas. This gland is responsible for producing the hormones that control the
other glands in your body. Some even call this small gland “the master control gland.”
Tumors can occur in the pituitary gland. These tumors are also referred to as pituitary
adenomas. These tumors are generally not cancerous and do not spread to other parts
of the body. They are typically very slow growing. These tumors are also fairly
common. In fact about 1 in 10,000 people will get a pituitary adenoma at some point
in their life.
What Causes Pituitary Adenoma?
The exact cause or causes of pituitary tumors is unknown. They may be caused by
genetics or exposure to radiation, but many times the cause is unknown. If you have a
family history of pituitary tumors this can also increase your risk for someday getting a
tumor. There are no known ways to prevent or reduce your risk.

Pituitary Tumors and the Eyes

Pituitary tumors are often small, sometimes 1 cm or smaller, but can still cause serious
medical issues and symptoms. Pituitary tumors can cause various symptoms including
headaches, hormonal imbalances and nausea.

They also commonly cause vision problems including tunnel vision. In fact vision
problems are often one of the first symptoms that people notice when they have these
tumors. One reason that pituitary tumors lead to vision problems is due to the close
proximity of this gland to the eye and optic nerve. As the tumor grows larger it may
press on the optic nerve. This can result in full tunnel vision or a slight blurring of your
peripheral vision.

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Diagnosis of Pituitary Adenoma

If you experience vision changes or tunnel vision it is important to go to the doctor to

find out the cause. If a pituitary adenoma is expected you will likely be asked to visit
an endocrinologist which is a doctor that specializes in hormonal problems. They will
then conduct a variety of different tests to determine if you have this condition. These
tests can include blood tests, urine tests, vision tests and MRI scans as well as other
specialized tests.
What Are the Treatment Options?

Luckily, pituitary tumors are generally curable and the available treatment options are often
highly effective. Surgery is one common treatment option for this condition. The tumor is
generally removed during a surgical procedure which may or may not damage the rest of the
pituitary gland. If damage is done to the gland hormone replacement therapy may be
needed to restore normal hormone levels.
Another common form of treatment for pituitary tumors is radiation therapy. Radiation can be
very effective at killing the tumor cells. In cases of pituitary tumors there are three common
types of radiation therapy that may be used. One is conventional therapy where radiation
makes its way to the tumor from an outside source. Stereotactic radiosurgery involves
directing a radiation beam at the tumor. Finally proton beam radiotherapy may be used which
involves sending a beam of positively charged protons at the tumor. In some cases tumor
shrinking medications can also be used.

Generally once treatment is complete, vision will return to normal. It is also important
to realize that pituitary tumors are not cancerous and will generally

EYE EXAMINATION
210. Visual field examination

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211. You are the FY 2 doctor in the Medical department.

59 year old Mrs Jane Anderson presented to the hospital sudden loss of vision.
Take a detailed history from her and do the necessary examination and talk to her
about the further management.

Determine Causes of Sudden Loss of Vision

Questions

1) When happened?

2) One eye or both eyes? – which eye?

3) Can you still see something with that eye or you can’t see anything at all?

4) Has it lasted only for a short time or do you still have the problem?

5) Painful or not – Glaucoma, Optic neuritis

6) Headache – GCA (combing hair, jaw claudication), Ocular migraine (wavy vision)

7) Medications? Cialis, Viagra, and Levitra.

8) Loss of speech and loss of feeling in one side of the body for a short time (Amaurosis
fugax)

9) Curtain coming in front of the eye (Retinal detachment)

10) Blurry vision or the presence of spots in your visual field (Vitreous Hemorrhage)

11) Brain tumour, Stroke (rare causes)

Take a brief history as above. Patient gives history of pain on head while combing hair
and pain in the jaw while chewing.

Past history

Family History

Sudden loss of vision left eye only - Candidates should say I need to examine your eyes

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Examination

Inspection:

Done at eye level

“Orbit and appendages are normal”

Anterior:

● Symmetrical: “Both Eyes are at the same level”

● Inflammation: discharge, swelling, redness, tearing. “No signs of inflammation”
● Ptosis
Posterior

● Proptosis - “Please look up without moving your head”

Reflexes

● Check instruments
● Check power of lens.
● Check light – BIG FULL MOON
● Red reflex - for cataract & hemorrhage (check it at 100cm and 30cm)..”May I
please dim the room” Look through the fundoscope for the red reflex (seen in
normal eye and it means media is clear). “Media is clear therefore I will proceed
to fundoscopy.”

“In a real patient, I would have examined with the fundoscope light on, but in exam
since there is a bright light shining from back I may have a reflection or glare so I
would like to examine now with the fundoscope light switched off.”

Fundoscopy

● Optic disc - Colour, well defined margins, contour, cup:disc ratio, blood vessels:
where they origin from (from the optic disc), straight or tortured, shape, caliber
● Macula: Normal and healthy
● Look on the periphery at the retina (no exudates)

“I would ideally start from the normal side”

Do red reflex and fundoscopy on mannikin

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Fundoscopy slides were normal in both eyes.

Explain Procedure: I need to examine the back of your eye with a special instrument called
an opthalmoscope . For that, I will be shining a bright light on your eyes. During the
examination, I will be coming very close to you and will be touching your cheek and face. I will
be using some dilating drops which might dim or blur your vision; therefore you are advised
not to drive home alone or to sign any important legal documents during the day.

Exposure/Position: You can blink normally during the procedure but don't move your
head and sit comfortably. I will be dimming the lights of the room and you should fix
your vision at a distant object .
Talk to the patient: Based on our discussion and the examination, I suspect that you
have a condition called GCA – explain the diagnosis. This condition has affected the
eyes that is why you are having blindness. We are going to do some blood tests to
check for inflammatory markers (ESR).

Tell patient that you will need to admit her to give her high dose steroids through her
veins to prevent blindness of other eye. Then switch to oral steroids after 2 - 3 days.

Then investigation to confirm (temporal artery biopsy - take a sample of her blood
vessels - result takes 2 weeks to be available). Then long term treatment with oral low
dose steroids for 2 years if biopsy is positive (or wean off in 2 weeks if biopsy is negative).

If patient asks how long she will need to stay in the hospital: “We will keep you for
at least 2 or 3 days until we change you to the oral steroids. I will check with my
seniors first to be sure.”

Patient will also continue on aspirin (to prevent strokes and MI), bisphosphonates and PPIs.

If patients asks if the blindness is permanent? – Unfortunately, yes.

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NORMAL FUNDUS

A. Optic disc – Always nasal

• Colour – Pinkish pale or pinkishyellow

• Margins – Well defined

• Circular or Rounded inContour

• Cup disc Ratio – 0.3 –0.5

B. Blood Vessels - Originating from Optic disc, straight not tortuous, normal calibre of

Vessels - A :V2:3

C. Periphery and rest of retina – Healthy and Normal – no exudates, no haemorrhage

D. Macula – Healthy and Normal

211. Fundoscopy - Sudden loss of vision - GCA

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Fundoscopy Slide Descriptions

SLIDE OF NORMAL FUNDUS: SLIDE 9 - I can see the OD, pinkish pale or pink yellow
in colour, well defined margins, circular in contour CD ratio is normal. Vessels are
originating from the OD, Straight not tortuous, normal in calibre. Periphery and rest of
retina and macula appears healthy and normal. Therefore my diagnosis is NORMAL
FUNDUS.

SLIDE OF OPTIC ATROPHY - I can see the OD, pale or chalky white in colour, margin
well defined, and circular in contour. Cup cannot be appreciated. Origin of vessels not
clear, they are straight and normal in calibre. Macula and periphery and rest of retina
appear healthy and normal. Therefore my diagnosis is Optic Atrophy.

SLIDE OF DISC CUPPING: SLIDE 10 - I can see the OD, pinkish pale in colour, circular
in contour, margins ill defined. CD ratio is increased in size indicating cupping of the
optic disc. Origins of vessels not clear, they are straight not tortuous, normal in
calibre . Macula and periphery and rest of retina appear healthy and normal. Therefore
my diagnosis is Disc Cupping most probably due to glaucoma. Treatment: Urgent
reduction of intraocular pressure e.g. mannitol or acetazolamide.

SLIDE OF PAPILLOEDEMA: SLIDE 11 - I can see the OD which is swollen,

oedematous, hyperaemic and bulging, margins are blurred or ill defined and cup
cannot be appreciated. Origin of vessels are not clear but vessels are engorged,
tortuous and congested. Periphery and rest of retina appears hyperaemic. Therefore
my diagnosis is Papilloedema. Urgent MRI to rule out intracranial mass.

SLIDE OF CENTRAL RETINAL VEIN OCCLUSION: SLIDE 15 - I cannot appreciate the

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

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

SLIDE OF BACKGROUND DIABETIC RETINOPATHY: SLIDE 1

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

SLIDE OF PRE-PROLIFERATIVE DIABETIC RETINOPATHY: SLIDE 3

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

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

SLIDE OF PROLIFERATIVE DIABETIC RETINOPATHY: SLIDE 4

Can appreciate neovascularization around OD and elsewhere along the vascular

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

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

control.

In the early stages of diabetic retinopathy, controlling diabetes can help prevent vision
problems developing.

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In the more advanced stages, when vision is affected or at risk, keeping diabetes under
control can help stop the condition getting worse.

Treatment for advance diabetic retinopathies:

1. Laser treatment: To treat the growth of new blood vessels at the retina in case of
proliferative diabeticretinopathy.

2. Eye injections: Anti-VEGF

3. Eye surgery: To remove blood or scar tissue from the eye if laser treatment is not possible.

SLIDE OF SUB HYALOID HAEMORRHAGE: SLIDE 22 -Can appreciate massive boat shaped
haemorrhage in , which is most probably a subhyaloid haemorrhage . Can also appreciate a few,
micro aneurysms, dot and blot haemorrhages. Therefore my most probably diagnosis is Pre-
Proliferative Diabetic Retinopathy with pre-retinal haemorrhage.

SLIDE OF LASER COAGULATION: SLIDE 7 - Can appreciate a few scar marks at the periphery
of the retina, which are homogeneously distributed throughout the periphery and are most
probable due to laser burns. Therefore most probably diagnosis is diabetic retinopathy treated
with laser photocoagulation.

SLIDE OF HYPERTENSIVE RETINOPATHY: SLIDE 14 - Can see diffusive narrowing and

tortuosity of arterioles. Can also appreciate changes at arteriovenous crossings along infero
temporal arcade (A-V nipping). Absence of haemorrhages (flame shaped) and disc swelling
suggest early changes or chronic hypertension.

Grade 1: Arteriolar narrowing

Grade 2: A-V nipping

Grade 3: Exudates, haemorrhages, cotton wool spots

Grade 4: Papilloedema

Hypertensive retinopathy is managed primarily by controlling hypertension. If vision loss

occurs, treatment of the retinal edema with laser or with intravitreal injection of corticosteroids
or anti-VEGF drugs may be useful.

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212. Hip Examination Combined Station

You are an FY2 in GP. 44 year old lady has come to your clinic with pain in both
hip joints for 3 weeks. Please talk to her, do relevant examination, discuss the
management plan and address her concerns.
D: What brought you to the hospital today? P: I have pain in my hip D: May I know which
side? P: Right side
D: SOCRATES
P: For 3 weeks. Pain just started. Getting worse with time. Continuous. Dull pain. Doing some
activities makes pain worse.
D: Did you hurt yourself? P: No
D: Any previous medical diagnosis? P: No
D: Any regular medications? P: No
D: Any allergies? P: No
Ex: I am going to examine your hip.
D: Any surgeries to the hip? P: No
D: Are you able to stand and walk? P: Yes
Joint examination: LOOK (Standing)/ FEEL (Lying flat)/ MOVE (Lying flat) & Special Tests
Look (Inspection):
Anatomical position: Joint symmetry
Front: Skin changes/ scars/ swelling/ level of ASIS/ Quadriceps muscle wasting Side:
Lumbar lordosis (Normal or Hyper lordosis)
Back: Scoliosis / gluteal wasting / pelvic tilt Gait: Normal/ Antalgic/ Trendelenburg
Trendelenburg Test
Fell (Palpation):
Temperature
Tenderness: Around the joint/ Greater trochanter (Tenderness on palpation of greater
trochanter suggests greater trochanteric bursitis).
Leg length: True/ Apparent. True: Umbilicus to the tip of medial malleolus. Apparent: ASIS
to the tip of medial malleolus
Move (Movements):
Active: Flexion: Bring your right knee towards the chest and relax. Bring your left knee
towards the chest and relax.
Abduction/Adduction: Bring your right leg at the edge of the couch. Bring your right leg and

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cross it over the left leg.

Bring your left leg at the edge of the couch. Bring your left leg and cross it over the left leg.
Internal and external rotation: Join your toes and keep your heel apart. Join your heel and
keep the toes apart.
Special Tests:

Thomas Test:
. Place the hand on the patient spine.
. Flex the unaffected leg as far as you are able to and your hand should detect the lumber
lordosis is now flattened.
. The test is positive if the affected thigh raises off the bed indicating a loss of extension in the
hip. This would suggest a fixed flexion deformity in the affected hip.
(NOTE: Don’t do if hip replacement)

Trendelenburg Test:
. Place your hands on the iliac crest on either side of the pelvis.
. Ask the patient to stand on the affected side for 30 second and observe your hands to see
which moves up and down.
. Normally the iliac crest on the side with the foot off (Unaffected) the ground should rise up.
. The test would be positive if the pelvis falls on the side with the foot off the ground
(Unaffected). The abnormal result suggests weak hip abductors on the contralateral side.
I would like to finish my examination by examining a joint above (lumbar spine) and a
joint below (Knee).
I would also like to do a full neurological examination of lower limbs including checking
for distal pulses.

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Management:
From my assessment, you seem to be having a condition called: Greater Trochanteric
Bursitis. This means, inflammation of bursa on the bony bump called greater trochanter, on
the outside of your hip. (Bursa is a fluid filled sac that provides cushion around bony
prominences).

Do PRICE avoid HARM

Rest – try not to move the joint too much and avoid activities that'll put pressure on it.
Ice – gently hold an ice pack (or a bag of frozen peas) wrapped in a tea towel on the
area for around 10 minutes at a time and repeat every few hours during the day.
Anti-inflammatory medication
Avoid aggravating positions Stretches
Physiotherapy
In persistent cases steroid injection may be helpful.
P: What causes GTPS (Greater Trochanteric Pain Syndrome?
D: It is most common in middle aged females. The most cases of greater trochanteric pain
syndrome are due to minor tears or damage to the nearby muscles, tendons or fascia, so that
an inflamed bursa is an uncommon cause. So, rather than the term trochanteric bursitis, the
more general term, greater trochanteric pain syndrome, is now preferred.
The exact causes of GTPS are not fully understood, but there are many factors that can
contribute to it, including: direct fall on outside edge of hip
excessive load, for example prolonged walking or running. Poor running style can also lead to
increased load on this area of the hip.
prolonged or excessive pressure to your hip area (for example, sitting in bucket car seats, or
sleeping on your affected side, may aggravate the problem)
weakness of the muscles surrounding the hip, called the gluteus Medius and minimus.
P: How long does it take to get better?
D: Everybody will improve differently, but for most people it will take six to nine months of
focused rehabilitation to make a return to full normal activities without pain.
If you have a very high temperature, cannot move the affected joint and you have very severe,
sharp or shooting pains in the joint come back to the GP.

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213. Respiratory Examination

You are an FY2 in Medicine. Danial James is a 2 nd year medical student. Teach
him Respiratory Examination. Patient came with ankle sprain surgery and is about
to leave the hospital. Patient has agreed to be the surrogate in this teaching.

Rapport: Shake hands with the student, Politely introduce yourself that am your
colleague ((not senior etc)))
Then ask about studies and challenges (((2 questions and listen to him as attentively as
you are very much interested in his studies)))))
Assess his knowledge: I am been asked to teach you chest exam James....right;
may I know what do you know about chest exam (((he will say no nothing I know))), you
can tell: Chest examination is a vast topic So what would you like me to teach about it
specifically……….
Which patient we should do chest examination: Then tell him the cases where we
do chest exams for example pneumonia ,TB, asthma etc
(((((????? I don`t think we have time for : james whenever these problem happen in
people they do come in with symptoms like: Chest pain, Coughing, Shortness of breath.
And JAMES we take history before doing exam Such as asking questions about
coughing is it dry or bloody or producing sputum, Then we ask generally about fever
loss of appetite and weight and lethargy to rule out red flags, Then previous health
conditions like lung or heart problems, And we do ask about lifestyle habits of patient
like smoking or alcohol etc, Then is he on regular medicine, Any allergies and what he
is doing for living???)))
Any questions so far James...

Now after that we do chest exam

Which mainly consist of four parts: Inspection/ Palpation/ Percussion/ Auscultation
(((Teach these four along-with expected findings in chest))))

GIPPEEC

Look at the patient from foot end:

Patient is not coughing, no expiratory wheeze, no stridor.

 Hands: Inspect the hands:We are looking for Nicotine tar staining, Clubbing,

Peripheral cyanosis, Skin changes or any rheumatological diseases.

 Palpate pulse – rate and rhythm

 I will check for the respiratory rate as well. There is no fine or flapping tremor.

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Head and neck:

There is no conjunctival Pallor.

Central cyanosis – bluish discolouration of the lips / inferior aspect of tongue

Jugular venous pressure (JVP): At 45°. Measure the JVP – number of centimetres
measured vertically from the sternal angle to the upper border of pulsation

Inspection:
Chest is moving bilateral symmetrical, no scars or skin changes and no
deformities.

Palpation:
There are no Engorged neck veins. Trachea is central in position.
Chest expansion is normal.
Apex beat: Normal position is 5th intercostal space – mid-clavicular line

Percussion
Percuss the following areas, comparing side to side:
1. Supraclavicular (lung apices)
2. Infraclavicular
3. Chest wall (3-4 locations bilaterally)
4. Axilla

Auscultation:

Ask the patient to take deep breaths in and out through their mouth.

Assess quality:
Vesicular (normal)
Bronchial (harsh sounding – similar to auscultating over the trachea – inspiration and
expiration are equal and there is a pause between) – associated with consolidation

Added sounds:
Wheeze – asthma / COPD
Coarse crackles – pneumonia / bronchiectasis / fluid overload Fine crackles – pulmonary
fibrosis

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Vocal resonance:
Ask patient to say “99” repeatedly and auscultate the chest again
Increased volume over an area suggests increased tissue density (especially if there is a
dull percussion note over the same area) – consolidation / tumour / lobar collapse
Decreased volume over an area (especially if there is an associated dull percussion
note) suggests fluid outside of the lung (pleural effusion)

Ask patient to sit forwards Lymph nodes:

Palpate the following areas:

Anterior and posterior triangles, Supraclavicular region and Axillary region

Assess the posterior chest:

Repeat inspection, chest expansion, percussion and auscultation on the posterior aspect
of the chest.

We will Examine the sacrum for oedema and Examine the legs Pitting oedema. Assess

the calves for signs of deep vein thrombosis

Thank you
Concerns:What is abnormal breath sound?
Topic – Trauma and other stations
Glasgow Coma Scale
Response Scale Score
Spontaneously 4 Points
EYE OPENING
To verbal command, speech, or shout. 3 points'
RESPONSE
(E4) To pain (Not applied to face) 2 points
No response 1 point

Oriented to time, place and person or

(Oriented x 3) 5 points
Confused conversation, but able to answer
VERBAL questions 4 points
RESPONSE Inappropriate response or speech, words
(V5) discernible 3 points
Incomprehensive sound or sound 2 points
No Verbal response 1 point

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Obeys commands for movement 6 points

Moves to localised pain or
Purposeful movement to painful stimulus or
Localises pain 5 points
Flexion withdrawal from pain or
MOTOR Normal flexion 4 points
RESPONSE Abnormal (spastic) flexion, decorticate
(M6) posture 3 points
Abnormal extension or
Extensor(Rigid) response or
Decerebate posture or
Extension to pain 2 points
No Motor response or
Flaccid 1 point
Minor Brain Injury = 13-15 points;
Moderate Brain Injury = 9-12 points;
Severe Brain Injury = 3-8 points
214. Meningitis examination
25 year old man Mr Edwards came to the hospital c/o headache.
Assess the patient and tell your diagnosis and management to the examiner.

Differentials for headache

Sinusitis – Headache gets worse on leaning forward
Glaucoma – Pain behind the eyes, Halos around the light
Refractory error – Do you have problem in vision while reading or driving
Cluster headache – Headache coming in clusters, watering in the eyes.
GCA – Headache on temple area , pain while chewing, vision problem
Migraine – one sided headache
SAH – Occipital headache, Worse headache
Head injury – Trauma
Meningitis – Fever, photophobia, Neck stiffness, contact history
Brain tumour – early morning headache, weakness in limbs,
Stroke – Weakness in limbs, speech problem

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Greet the examiner. Go to the patient

Patient is lying down with hands over the eyes ( covering eyes) / or he may be wearing
dark glasses.
Talk to the patient.
Hello Mr Edwards, I am Dr ... one of the junior doctor in the emergency department, I am
here to examine you. Pt - OK
How can I help you ? Pt - I have severe headache doctor.
Dr: I am sorry to hear that. Do you need any pain killers ? Pt : Yes doctor.
{ Or Patient may make incomprehensible sounds only}
Dr – Ok I will you pain killers. Tell the examiner I would like to give pain killers to my patient.
What should I do ? Examiner says – Assume you have given.
Ask patient - do you feel better.
Ask patient why are you covering your eyes
Pt – Doc the lights are too bright I can’t open my eyes.
Dr – Ok don’t worry I will dim the light
Tell the examiner I would like to dim the light what should I do ?
Examiner may say – assume or may tell you to dim the light.
Tell the patient – the light is dim now – can you please open your eyes – can you please
put your hand down ( remove hand from over the yes) ( If patient is wearing dark glasses –
ask him to remove the glasses, if he is making incomprehensible sounds you remove his
glasses).
Take history if the patient is talking. [ If the patient is making incomprehensible sounds –
then you cannot take history]
Dr: How can I help you Mr Edwards ? Pt: I am having Headache doctor.
Dr: Since when ? Pt: Since last few hours.
Dr: How severe is your headache Can you please rate your pain in the scale of one to ten
one being the mildest and 10 being the most severe pain. 8 out of 10. ( SAH)
Dr: Where is the headache ? ( SAH, Migraine) Pt: All over the head,
Dr: Do you have any fever? ( Meningitis)Pt: Yes.
Dr: Do you have vomiting?( Meningitis, SOL) Pt: No

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Dr: Do you have any pain in the eye ( glaucoma) ? Pt: No

Dr: Did you have any injury to your head recently ? Pt: No
Dr: Did you feel weakness in any arms or legs ? (SOL) Pt: No
Dr: Did you have headaches like this before ? Pt: No
Dr: Are you taking any medications ? Pt: No
Dr: Are you allergic to anything ? Pt: No
Dr: Did you come into contact with any one with similar symptoms ? Pt: No
Dr: I need to examine you now.
Check the NEWs chart for temperature.
Then do the GCS :
( In this station GCS can be anything between 6 to 15. Most of the time it was 9)
Tell the GCS to the examiner
Then check for Meningism signs:- Neck Stiffness:
 Support patient’s head with your fingers at the occiput and flex the head gently until chin
touches the chest.
 If neck stiffness is present then neck cannot be passively flexed and you will feel spasm in
neck muscles.

Brudzinski’s sign: while trying to touch chin to chest, look at the flexion of knees in
response to neck flexion which indicates +ve Brudzinski’s sign.

Kernig’s Sign

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 Flex one of patient’s legs at the hip and knee, with your other hand placed over the medial
hamstrings.
 Use one hand to extend the knee while the hip is maintained in flexion.
 Kernig’s sign is positive when
1) Extension is resisted by spasm in the hamstring.
2) The other limb may flex at the hip and knee.
3) Complains of pain at the back
4) Bends his head
Exposure : - If the GCS is 15 tell the patient – Can you please undress I will ensure privacy
and have a chaperone with me.
If the GCS is low tell the examiner – in real life I will undress him completely – what shall I do here.
Examiner says – assume

Look for rash - The check for rashes all over the exposed area including face neck back, arms
and legs ( you can use the pen torch to look for rashes).
If you find any rashes tell the examiner – I will check whether it is blanching or not.
( If there is no rash – say there is no rash over the exposed areas, however I will check all over the
body for the rashes).
Ideally I will do Neurological examination.
Cover the patient.
Thank the patient.
Tell your diagnosis and management to the examiner

Diagnosis – I think he has meningitis( Reasons for diagnosis – He has headache,

photophobia, Low GCS, Neck stiffness, Kernigs sign and Brudzuski sign positive and also has
rashes ( if there are any rashes).

Management
Investigations
1) Blood – FBC, U&Es, CRP, Blood culture,
2) CT scan of brain
3) Lumbar Puncture
Treatment
4) Admit
5) Inform seniors
6) IV antibiotics ( Ceftriaxone, vancomycin – according to hospital protocol)

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Manage infection
7) Isolate the patient
8) Inform Infection Control team.

Trace all close contacts and give prophylactic medication. ( Ciprofloxacin or Rifampicin)

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Advance Trauma and Life support

It is a guideline to assess and manage the patients who have met with high velocity trauma.
Initial assessment of a patient who have met with a high velocity trauma

Airway patent A – Airway with Airway patent

cervical stabilization
and O2
If breathing means B - Breathing No Breathing
has circulation. Then
check for chest
injuries
Check for bleeding C - Circulation No circulation
Disability D - Disability Means cardiac arrest
Exposure E - Exposure Do CPR
ATLS BLS / ALS

TRAUMA TEAM:

1. A&E Doctors & Nurses

2. Surgeons
3. Anaesthetists
4. Orthopaedicians

AIM –is to prioritize and to save time of assessment of the trauma victims to save life.

ATLS is divided into 2 parts:

1. PRIMARY SURVEY:
Look for immediately life threatening and limb threatening injuries in the order of priority,
manage them and stabilize the patient.

2. SECONDARY SURVEY:

Take a detailed history and then do a thorough head to toe examination to look for other
nonlife threatening injuries.
(Done after the primary survey once the patient is stabilized)
PRIMARY SURVEY:
A -Airway with Cervical Stabilization
B -Breathing With Ventilation
C -Circulation with Control of hemorrhage
D -Disability
E -Exposure

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AIRWAY:
If the patient is able to speak in a normal speech there can’t be any obstruction in their
airway.

Cervical Stabilization:
Assume all the major trauma victims to be having neck injury and stabilize their neck to
prevent any cord injury happening, if it is not already injured.
Two ways to stabilize 1 ) Manual inline immobilization, 2) Triple immobilization.
Give High flow oxygen

BREATHING:

1. Tension Pneumothorax:
Signs & Symptoms: Breathless, Engorged Neck Veins, Trachea Shifted To Opposite
Side, Decreased Chest + Wall Movement, Hyper-Resonance, Absent Breath
Sound,(Tachycardia, Hypotension, Hypoxia.)
Management:
Emergency Needle Thoracocentest to decompress the chest: Insert wide bore needle in
the 2nd intercostal space, mid clavicular line on the affected side and leave the cannula
in situ. Listen for hissing sound of gush of air coming out. Then reassess.
Definitive Management:
Intercostal chest drain in the 5th intercostal space which is connected to the underwater
sealed bottle.

2. Open Pneumothorax
Signs & Symptoms: Breathlessness, no engorged neck veins or tracheal shift,
decreased chest wall movement, open wound over the chest, hyper-resonance,
diminished breath sounds.
Management: Cover the wound with a bandage which is stuck on three sides only
which allows the air to escape out, but prevents air getting sucked in.
Definitive Management:Intercostal Chest Drain

3. Massive Heamothorax: Has double problem: Blood Loss and Lung Compression
Signs & Symptoms
Decreased level of consciousness, pallor, cold periphery, Breathlessness, tracheal shift,
collapsed neck veins,
Decreased chest wall movement, bruises, dullness on percussion, absent or diminished
breath sounds.
Management
Resuscitate; Oxygen, IV Access, Blood Testing, IV Fluids, Chest Drain, Thoracotomy
and repairing of all the damages.

4. Cardiac Tamponade: Can die of reduced cardiac output

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Signs & Symptoms

Decreased level of consciousness, cold peripheries,
Becks’ triad- engorged neck veins, hypotension, muffled heart sounds.
Management: Oxygen, IV Access, Maintenance fluid, Attach Cardiac Monitor,
Defibrillator should be available
Pericardiocentesis by seniors

5. Flail Chest
Fracture of two or more ribs at two or more sites.
Causes pulmonary contusion causing hypoxia.
Pain – shallow breathing –hypoxia.
May have associated injuries like pneumothorax or heamothorax.
Management
Oxygen, analgesics, fluid resuscitation, strapping the segment, IPPV

CIRCULATION:
External Bleeding:
Direct Pressure Bandage, IV fluids if required and wound repair.
Internal Bleeding
Chest, Abdomen, Pelvis and Thigh
Intra Abdominal Bleeding-
Signs and Symptoms: Distension, bruises, wounds, tenderness, rigidity, guarding, flank
dullness, absent or sluggish bowel sounds.
Management
Resuscitate
Call for surgeons and make arrangements to shift the patient to theatre for urgent
laparatomy.

-Pelvic Fracture
Signs and symptoms: Bruises, pelvic deformity, blood at the external urethral meatus,
scrotal or perineal heamatoma
Spring test: Spring test can dislodge clot or rupture more pelvic vessels causing more
bleeding - so do it only if necessary to do it.
Management
Resuscitate
Apply pelvic strapping, call for Orthopeadicians for external pelvic fixators and for further
management.

- THIGH; fracture of shaft of femur can cause internal bleeding up to about 2 liters on
one side itself.
Signs and Symptoms
LOOK – swelling, bruises, deformity.
FEEL – distal pulses
MOVE- Do not try to move if there is a swelling seen over the thigh also do not try to move
his legs if he had pain on his pelvis( ie –if spring test was positive).
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Management
Resuscitate, Thomas splint, call for Orthopeadicians for further management.
Look for swelling or deformity in any other part of the limbs, and if any check distal pulse
DISABILITY :
Check level of consciousness ( GCS )
Also check the pupils
Look for head injury signs – swelling, lacerations or bruise on head and forehead.
Check the sugar

EXPOSURE: expose the patient completely but keep him covered with warm blankets to
prevent hypothermia.

ADJUNCTS IN PRIMARY SURVEY:

1) MONITORS: Cardiac Monitor

2) PRIMARY SERIES OF X RAYS

A) Chest X Ray
B) Pelvic X Ray

3) TUBES
C) Nasogastric tube
D) Urinary catheter
E) (Urethral catheter if no urethral injury and Supra Public Cystostomy if
F) Urethral injury)

3 things to assume in a patient met with high velocity trauma

1) Neck injury
2) Hypoxia
Hypovolemia

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215. You are the FY 2 doctor in the A& E department.

Mr Robinson is a 30 year old man fell from 2 meter height onto concrete floor from a
building while painting the building about half an hour ago. He was brought into the
hospital A&E Department.

His pulse is 100/min and BP is 90/40.

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

Greet the examiner, Tell the examiner – I assume I have taken all Universal precautions (gloves,
gown and goggles) and I will call the Trauma team.

Airway

Patient lying down with collar.

Check response. Hello Mr Robinson, I am Dr… one of the junior doctor in the A&E department. I am
here to examine you. Is that OK ?
Patient - OK.
Tell the examiner – Since he is speaking - he is conscious and airway is patent.
His neck is already stabilized with collar. I will give him high flow oxygen.

Mr Robinson – can please tell me what happened?

Pt: I fell from a building while painting.
Dr – Do you have any pain anywhere at all?
Pt: Yes/ No .

Tell the patient about the exposure - Mr Robinson, I need to examine now, for that we need to
undress you by cutting all the clothes. I will ensure privacy and have chaperone with me. Is that OK ?
Pt – OK doctor.
Ask the examiner – what shall I do ? Examiner says – assume he is exposed.

Breathing

Inspection – I will check for Breathlessness,

Neck – I will check for engorged neck veins, tracheal shift.
Chest – Bruises, open wound, flail chest, asymmetry of movement.
Palpation – Expansion is equal
Percussion – I will check for hyper resonance or dullness.
Auscultation- I will check for absent or diminished breath sounds and muffled heart
sounds.

If nothing, I assume the chest is fine.

Circulation

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There are no signs of external bleeding

I will check for pallor and cold peripheries.

Pulse and BP (check the monitor, or NEWS chart – mention the reading to the examiner. If there is
no monitor or NEWS chart then ask the examiner for the vital signs)

Check for internal Bleeding--

Abdomen-: Inspection - bruises, distension, wounds,

Palpation – Tenderness, rigidity, Guarding
Percussion- Flank dullness
Auscultation – Sluggish or absent bowel sounds

If no signs – I assume the abdomen is fine.

Pelvis: Inspection – I will check for bruises, deformity, scrotal or perineal hematoma or blood at the
external urethral meatus.
Then do the spring test - First warn the patient - I will be pressing your hips and if it hurts please let me
know. Gently press on his pelvis either trying to open it or to close it.
If no signs – Pelvis is fine.

In the exam if they keep Pelvic fracture as the diagnosis patient will scream with pain.
Tell the patient - I am sorry to hurt you.

Thigh - Inspection – There are no bruises, swelling and deformity

Palpation – I will check distal pulses.
Movement – Do not check.
If there is no swelling of the thigh – I assume there is no fracture femur both sides.

Disability

Do the GCS. Use the GCS chart on the wall. GCS may be 15.
I will check for head injury signs like swelling laceration and any bruises on head and forehead. Any
bleeding from nose and ears.
Check the pupils – pupils are equal in size and reacting to light.
I will check the sugar
Exposure

I will cover him with warm blankets to prevent hypothermia

I will tell the nurses to arrange for Chest and Pelvic X Rays.

Tubes
I will insert urinary catheter and Nasogastric tube.

Once he is stable I will do secondary survey.

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Thank the patient and the Examiner.

At 6th min – stop the assessment if you have completed and discuss further management with the
examiner

Tell you diagnosis and management – Fracture pelvis, or fracture pelvis and intra abdominal
bleeding.

I will send the blood testing (FBC, U/E, Group and X-match 4 units, sugar, ABG, clotting screen)

I will give him IV Fluids - 2 litres of warm Hartman’s solution. ( One litre fast ( within 10 min) next
one litre in the next one hour). – arrange blood transfusion immediately – may be O negative then
cross matched blood.

I will stabilize the pelvis with pelvic strapping and inform the Orthopaedicians for external
pelvic fixator and for further management.

If signs of intra - abdominal bleeding – I think he has intra - abdominal bleeding, I will resuscitate,
inform the surgeons and shift him to the theatre for urgent laparotomy.

If there is swelling of thigh – I can see swelling of thigh, I will check distal pulse, I think he has
fracture femur, I will resuscitate, apply Thomas splint, and inform Orthopaedicians for further
management.

PRIMARY SURVEY ( Initial assessment after trauma)

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

Examine the abdomen:

Inspection : No distension, bruises or open wounds.
Palpation – No tenderness and rigidity or guarding.
Percussion – No flank dullness
Auscultation – No absent or sluggish bowel sounds.
I assume the abdomen is fine.
Examine the pelvis:
I will check the pelvis for bruises, deformity and for any blood in the external urethral
meatus.
Do Spring test – if patient did not show signs of tenderness – I assume the pelvis is
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fine.
Examine the thighs:
There are no swellings or deformities on both the thighs. I assume there is no femur
fracture.
Disability
Dr: Sarah, what is his blood sugar? Nurse : It is 5.7 mmols doc.
Check conscious level with GCS – patient is responsive to the verbal stimulus. Tell the
score to the examiner.
Check the pupils with torch – both pupils are equal in size and reacting to light.
I will check the head for injuries – There are no swellings or lacerations on the head
but I can see bruise on the left side forehead.
There are no bleeding or CSF leakage in the ears and nose.
Do quick neurological examination.
I can’t do sensory and motor because he is not conscious.
Reflexes are normal in all 4 limbs including plantar reflex.
I will log roll the patient with the help of 3 other people and examine the back for any
injuries, any spinal injuries, I will do per rectal examination.

Dr: Thank you. Can you please send his blood for group and cross match, FBC and U&E.
Can you also ask the radiographer to do chest and pelvic X Rays.
I will insert NG tube and urinary catheter.
Talk to the examiner - I think he has head injury because he has low conscious level and
has bruise on the forehead.
I will inform the seniors immediately and start with IV fluids and arrange CT scan of his head.
Will consider giving Mannitol after consulting seniors.
Patient may need surgery if he has intracranial bleeding. I will inform the Neurosurgeon.
I will do the secondary survey one he is stable.
Since he is not conscious I cannot take history.
( If patient is responding take brief history
What happened, when happened, Any pain anywhere? Any medical conditions, Any
medications, Any allergies? When did you eat or drink last?)
Head to toe examination.
No swelling lacerations on head. Bruise is present on the left side fore head.
Eyes appears fine.
There are no swelling bruises on cheeks or jaws.
I will examine thoroughly for any injuries over neck, chest, abdomen and pelvis again.
There are no swellings or deformities in the upper limbs. Radial pulse is present both
sides.
There are no swellings or deformities in the lower limbs. Dorsalis pedis pulse is
present both the sides.
I will remove the collar if there are no signs of neck injury. I will cover the patient.
I will keep monitoring the patient until the trauma team arrives.
Thank you Sarah. Thank the examiner

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ATLS [Primary and secondary survey]

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217. Whiplash injury

Information.
This is a soft tissue injury in the back of the neck due excessive movement of the neck (eg -
in Road traffic accidents) which causes stretching of muscles and ligaments in the back of
the neck. There is no bony injury or spinal cord injury.
Symptoms usually appear after few hours or may the next day. Symptoms are pain in the
back of the neck and stiffness of the neck which usually lasts about 2 to 3 weeks and
subsides on their own.
Other symptoms: Headache, Pain in shoulders and arms, dizziness, Blurred vision, pins and
needles in arms, memory loss, irritability.
Treatment – Analgesics, neck exercise and ice compressions. If they do not subside in 2 to
3 weeks time then - Physiotherapy.
Advise them not to drive until pain and stiffness subsides.
In some people symptoms can lasts for few months.

Neck Injury
Differentials – Whiplash injury, Stable fracture of the cervical vertebra, Radiculopathy
( root compression – causes tingling numbness in hands).

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QQ: 30 year old Mr Morrison met with a road traffic accident 2 hours ago. He came
to the hospital now complaining of pain and stiffness in his neck. Take a brief
history and do the necessary examination and discuss the further management
with the patient.
Patient may be sitting on the chair or couch.
History :
Dr: How can I help you ?
Pt : I met with the road accident about 2 hours ago. Now I have pain in my neck.
Dr. I a sorry to hear about the accident. Can you please tell me more about the accident ?
Pt: I was driving my car. Another car hit the back of my car.
Dr: What happened after that ?
Pt: I was fine initially. I went to the office then I started to have pain in my neck.
Dr: Where in the neck you have this pain? –Pt: Back of the neck.
Dr: Since when? Pt: There was no pain immediately after the accident but then I went to the
office I started to have pain - almost one hour now.
Dr: Does the pain go anywhere from the neck ? Pt: No
Dr: Anything else? – My neck is stiff. Since when?- Pt: Since the last 1-hour.
Dr: Anything else? – Like what doctor?
Dr : Do you have headache? Pt : No
Dr Any dizziness ? Pt : No
Dr: Any problem in your vision? Pt : No
Dr: Any tingling or numbness in your hands? – Pt: No
Dr: Any problem in the neck before this accident? – Pt: No
Dr: where there anyone else in the car ? Anyone else had serious injuries?
Pt : No ( sometimes he may say driver was driving the car but he is fine).
Examination :
I need to examine you now. [ patient may be adequately exposed. If not mention about the
exposure. Can you please undress above the waist ? Pt - Ok. Patient may then remove the
shirt]
Inspection of the neck :
Look all around the neck ( front sides and back)
No swelling, no bruise or wounds around the neck. No neck deformity.
Palpation : I’m going to feel the back of your neck over the spine with my thumb. Please tell
me if it hurts. Just say yes or no but do not move your head too much. – Pt: Ok Doctor.
Then check for tenderness over the cervical spine up to about 2nd thoracic vertebra : (there
may or may not be any tenderness over the spine)
Then check for tenderness over both the para-spinal areas : ( Usually there is tenderness
there).
Then do neurological examination. –
Sensory – fine touch (with wisp of cotton) on both the upper limbs.
Then check for pain sensation with neuropin : [No sensory loss].
C4 – top of shoulder, C5 – Outer aspect of upper arm, C6 – outer aspect of hand ( thumb
area), C7 – middle finger, C8 – Little finger, T1 – Medial aspect of elbow.
Check the vibration sensation and Joint position.

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Motor – C5- Shoulder abduction and Elbow flexion, C6 - Elbow flexion and wrist extension,
C7 – Elbow extension and wrist flexion and finger extension, C8 – finger flexion, T1 – Finger
abduction: No motor deficits.
Check reflexes in upper limbs : Biceps reflex ( C5), Brachioradialis reflex ( C6), Triceps reflex
(C7). --- Normal
No need to do neck X Rays if there is no bony tenderness.
If there is bony tenderness - Tell the examiner I will make him lie down and stabilize his
neck and send him for X rays of his neck. Can I know the X-ray result please ? ( Examiner
may say – X Ray – normal )
I will remove his collar and check for neck movements.
Ask the patient - Please turn your head to right, left, up and down and both sides- flexion
movements. Movements are restricted ( whichever direction). Thank you.
Management with the patient : You have a condition what we call us whiplash injury. It is
due to sudden stretching of muscles and ligaments at the back of your neck which happens
due to excessive movements of the neck during the accident. Usually there is tearing of
muscles and ligaments at the back of the neck. But you do not have any serious problems like
fracture or spinal cord injuries.
The symptoms of whiplash injuries – that is pain and stiffness will subside on their own in
about 2 to 3 weeks.
Please take pain killers like Paracetamol and keep doing some neck exercises until then.
Sometimes it can last for months. If it does not subside in 2 to 3 weeks we will arrange
physiotherapy. Is it Ok? Any questions.
Pt: Can you please give me a collar to the neck
Dr: We used to give collar previously but we found out that the collar will only worsen the stiffness of
your neck. So nowadays we do not give collar. It is better that you keep moving your neck.
Pt; Can I drive doctor?
Dr: It is better not to drive until your pain and stiffness in your neck subsides.
Pt; Why did I get pain in my neck after few hours not immediately?
Dr: This is what usually happens in whiplash injury because it takes some time for the inflammation (
soreness) to start and then it becomes painful.

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218. 38 year old Mrs Sharon ... had Road Traffic Accident one year ago. She had brachial
plexus injury. She wants to go back to her work. Assess her condition to check
whether she is fit to go back to work. At 6th min bell examiner will ask you
questions.
Dr: Hello Mrs Sharon .. I am Dr.... one of the Junior doctor in the ... department. How can I
help you ?
Pt: Doctor I met with a road traffic accident one year ago. Had injury to Brachial plexus on my
right side. I was undergoing physiotherapy for that. I was not working all this time since the
accident. I want to know whether I can go back to work now ?
Dr: First of all I am very sorry to hear about the accident and the injury you had. You said you
had brachial plexus injury – do you know what type of injury was that – were the nerves cut or
was the nerves just got stretched ?Pt: I don`t know.
Dr: Were you told that you had any fracture in the neck bones or any disc prolapsed in the
neck? Pt: No /Yes
Dr: Ok. Did you have any wounds over the neck ? Pt: No
Dr: Ok, May I know what is your job ?
Pt: I work as engineer at Royal Air Forse ( RAF). My work involves tightening screws (
rotational movements at wrist)
Dr: Did you have any problem working on computer or any other type of work before you had
this accident ?
Pt: No doctor. I was perfectly fine. I could do all the jobs properly.
Dr: May I know what functions in the hand you could not do after the accident ?
Pt: Doctor I could not do ......
Dr: Have you tried doing those jobs now ?
Pt: Yes, I can do all those now. Can I go back to work ?
Dr: Let me assess you completely and then I will tell you if that is OK with you ? Pt: Ok
Dr: Are you able to write with a pen on paper ? Pt: Yes I can now.
Dr: Are you able to eat food with a spoon? Pt: Yes
Dr: Do you feel hot and cold sensations in your hands ? Pt: Yes
Dr: Do you have any other medical conditions ? Pt: No
Dr: Are you on any medications ? Pt: No
Dr: Mrs Sharon .. I need to examine your neck and hands now Is that OK? Could you please
undress those area. Pt: Yes doctor

Examination
Inspection of neck.
No scars over the neck, No deformity or swellings.
Do the upper limb neurological examination.
Sensory - fine touch and pain
Check Joint position and vibration
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Check power – C 5 – shoulder abduction, C6 – elbow flexion, C7 – elbow extension. C8 –

finger extension, T1 – finger abduction.
Check the grip – ask the patient to hold your 2 fingers tight and you try to pull that out.
Ask the patient to touch his thumb to tips of other fingers in the same hand.
Check the typing action movement of fingers.
Check reflexes
Everything will be normal or there may be weakness.
Dr: Thank you Mrs Sharon ...

Talk to the examiner

I would to talk to the physiotherapist and the Occupational therapist and seniors and take their
opinion about this. We may need to do nerve conduction studies. However, so far with the
information what Mrs Sharon gave me and with the examination findings which were are
normal, I think she is fit to go back to work / she still has weakness – so she is not fit to go
back to work. She may need to continue Physiotherapy.

Brachial plexus injury

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222. DIABETIC FOOT EXAMINATION

You are the FY 2 doctor in the Medical department.

45 year old Mr Henry Rickman is a known Diabetic patient on diet control diabetes
came to the hospital for routine follow up.

Take a brief history and do the necessary examination and talk to him about the
further management.

I - How long has he had DM, Medications, Is it controlled, Follow up with GP’s
appointments and instructions

C - Ask patient if he has any concerns. Would you like me to explain anything about DM?

E - look for complications - kidneys, eyes, heart, neuropathy, blood vessels

Hello Mr Henry Rickman I am Dr … one of the junior doctors in the medical

department. How are you doing ?

Pt: I am fine doctor.

Dr: I understand you have diabetes? How is your diabetes now – are you monitoring
your sugar regularly? Is it controlled well?

Pt: I am monitoring the sugar. It is controlled well.

Dr: Are you taking any medications for diabetes? Pt: No

Dr: Do you have any concerns ?

Pt: My friend has diabetes and doctors have amputated his toes. I am worried whether
I too will end up having the same problem.

Dr: Mr Rickman, Don’t worry everyone who has diabetes will not end up having their toes
amputated. These things happens only if the sugar is not controlled well for a long time. If
you control your sugar well and take care of your foot this problem will not happen.

Dr: Can I ask a few questions to see whether the diabetes has affected any organs or
your legs ? Pt: Yes doctor.

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Dr: [Eye] Do you have blurry vision or any other problem with your vision? Pt : No

Dr: [Kidney] Do you pass more urine than normal – do you have to go to the loo more
times than usual recently? Pt: No

Dr: [ Heart] Any chest pain or palpitations? Shortness of breath? Pt – No

Dr: [ Nerve] – Any tingling or numbness in the hands or legs ? Pt – No

Dr: Do you have any pain in your legs ? Pt - No

Dr: Any pain in your calf muscles after walking for some time? Pt – No

Dr : Do you have any other medical conditions like high blood pressure ? Pt – No

Dr- Have you checked your cholesterol recently ? Pt - No

D: Do you smoke ? Pt- No / Yes

Examination

Dr: Mr Rickman I need to examine your legs. Could you please undress below your
mid-thigh area. Pt: Ok

Mention chaperone and privacy

Inspection of the legs

MDRSS (Also used for feet, arms, legs)

Muscular atrophy

Deformity

Redness

Swelling

Scarring

Sinuses

There is no Swelling, Redness, Pallor, Muscle wasting.

Check for loss of hair, shiny skin, nail changes, fungal infections between the web
spaces of toes, pressure sores. Check the heels for pressure sores by lifting the legs.

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Palpation

- Temperature
- Tenderness
- Pulse - Start with dorsalis pedis first and then to posterior tibial
- Capillary refill time (press down for 5 seconds)

● Temperature in both legs – normal [cool (e.g. PVD) / hot (e.g. cellulitis)]
● Dorsalis pedis artery – lateral to extensor hallucis longus tendon
● Posterior tibial artery – posterior and inferior to the medial malleolus

Sensation

● Fine touch with cotton wool – distal to proximal. Throw cotton wool into the
clinical waste bin. Use monofilament for sole (tip of big toe and then base of
other toes).
● Pain (with neuropin) – throw into sharp bin. Ask the examiner what side of the
neuropain he wants you to use.
● Vibration – use tuning fork – 128 Hz
● Joint position sense

Check if there is any sensory loss and if there is sensory loss up to what level ?

Motor – Check the knee and ankle reflexes

Check the gait

● Observe the patient walking whilst assessing:

● Symmetry / balance
● Turning – quick / slow / staggered
● Abnormalities – broad based gait / foot drop / antalgia

Examine footwear

● Note pattern of wear on soles – asymmetrical wearing – gait abnormality

● Ensure the shoes are the correct size for the patient
● Note holes and material inside the shoes that could cause foot injury

Findings – usually there will be loss of sensation either below mid shin or below
the knee.

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[Stop the examination at 6th minute bell if you have at least finished the sensory
part of fine touch and pain – if not finish sensory]

Diagnosis:

Mr Rickman, you have a loss of sensation on your legs. This is because the diabetes
has affected the nerves supplying the legs. Do you follow me?

Pt: Yes doctor.

Investigations:

We need to do a blood test to check your sugar control (Hb A1c)

We also need to check your cholesterol, kidney function tests and liver function
tests.You could also do some nerve conduction tests.

Treatment:

● We may need to start you on medications (metformin) to control your sugar. I

will discuss this with my seniors and let you know.
● It is very important to control your sugar properly. Eat healthy balanced diet.
Check your sugar regularly.
● It is very important to take care of your feet. Wear comfortable shoes.
● We will refer you to a podiatrist, ophthalmologist
● Avoid going barefoot, test water temperature before stepping into a bath.
● Trim your toenails to the shape of the toe; remove sharp edges.
● Wash and check feet daily for any injuries or infections.
● Stop smoking because it can worsen the condition if he is a smoker.
● Do regular exercises.

Unfortunately, the sensations what you have lost in your legs may not come back.
However we can stop it from getting worse if you follow all our advice.

Thank you very much.

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223. ALCOHOLIC FOOT EXAMINATION

Causes of burning sensation on feet:

● Diabetes
● Alcohol
● Chronic kidney disease (uremia)
● Vitamin deficiency (vitamin B12, folate, and occasionally vitamin B6)
● Hypothyroidism
● HIV/AIDS
● Drug side effects, including chemotherapy drugs, vitamin B6 overdose, HIV
medicines, amiodarone, isoniazid, metformin, and others
● Erythromelalgia
● Vasculitis (inflammation of blood vessels)
● Guillain-Barre syndrome (GBS)
● Infections and inflammation of the feet can also cause a burning sensation. The
most common of these is athlete's foot, an infection of the skin caused by
fungus.
● Peripheral artery disease (PAD) also commonly causes burning feet.

You are the FY 2 doctor in the medical department.

50 year old lady Mrs Sarah Boyer presented with burning sensation on feet. She is
a chronic alcoholic. She was on alcoholic rehabilitation programme 5 years ago.
Take a focused history, do the relevant examination and discuss the management
with her.

Hello Mrs Sarah Boyer I am Dr … one of the junior doctors in the medical department.
How are you doing ? Pt : I am Ok

Dr: How can I help you Mrs Boyer ?

Dr: I am having burning sensation in my feet.

Dr: Since when are you having this problem? Pt: Since the last few weeks. Dr: Do you
have burning sensation in hands also? Pt: No

Dr: Are you able to walk properly? Pt: Yes

Dr: Any tingling numbness in hands and feet ? Pt: No Dr: Do you have any medical conditions.Pt:no

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Dr: Like - Diabetes, High blood pressure ? High cholesterol? Kidney or Thyroid disease ? Pt - No

Dr: Do you smoke ? ( can cause PVD) Pt: No / Yes Dr: Do you drink alcohol ? Pt: Yes

Dr: What do you drink ? How much ? how long ? Pt – I drink …

Dr: Have tried to cut down drinking alcohol? Pt: I tried 5 years ago. I was in the
rehabilitation program for that. Offer her support if she said she quit because she had
no support when she tried to quit in the past.

Dr: How is your diet – do you eat healthy diet fruits and vegetables in your diet ?
( vitamin deficiency)? Pt: Yes

Dr: Are you taking any medications? Pt : No

Dr: Mrs Boyer I need to examine your legs now. Can you please undress below your mid-
thigh area? Pt: Ok doctor.

Examination

Same as diabetic foot examination.

[ Stop examination at 6th Minute bell ].

Management

Mrs Boyer, I think you have a condition what we call as alcoholic neuropathy – that
could be due to alcohol as the alcohol might have affected the nerves in your legs.

We will do some tests to check whether you have any other causes – like anemia, liver
function, renal function, diabetes and blood circulatory problems. Also, we will do
some nerve conduction tests.

Treatment

● Unfortunately there is no cure for this condition.

● However we can give you some medications to relieve the burning sensation
like amitriptyline, carbamazepine, gabapentin.
● We will give you some vitamin tablets.
● You must cut down drinking alcohol to prevent progression of this condition.
● Also eat a healthy diet.

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224. CHRONIC DIARRHOEA - IBD

Acute – up to 4 weeks:

1. Gastroenteritis – vomiting, change in diet, travel hx, contact hx., fever.

2. Antibiotics
3. Laxative abuse

Chronic - more than 4 weeks

1. Bowel cancer – loss of appetite, loss of weight, blood in the stool, mucus, pain
abdomen, constipation, anaemia symptoms, smoking hx.
2. Medications – Antibiotics, PPIs, Cimetidine, cytotoxics, NSAIDs, Digoxin
3. Diverticulosis – left sided pain is generally exacerbated by eating and
diminished with defecation or passing flatus. Rarely weight loss. altered bowel
habits, puss, (fever if diverticulitis) Risk factors for diverticulosis – low fibre diet,
obesity ( do you think your weight is on the higher side than normal) , smoking
Complications - perforation, abscess, fistula (any faeces or air comes along with
urination) , stricture/obstruction, Bleeding – red or maroon colour stool
4. IBD – blood and mucus in the stool, pain in abdomen, joint pains, pus,
stress, weight loss. There may be symptoms of systemic upset, including
malaise, fever, weight loss and symptoms of extra-intestinal (joint, cutaneous
and eye) manifestations, mouth ulcers.
5. Alcohol
6. IBS – altered bowel habits, stress, mucus, pain relieved by stooling, alternating
between diarrhoea, constipation
7. Malabsorption – difficult to flush the stool
8. Colonic polyp – blood and mucus, family hx

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50 year old man Mr… presented to the hospital with a history of passing loose
stools for the last 2 months. Take history and do the necessary examinations and
discuss further management with him.

Hello Mr. I am Dr.. Please tell me what brings you to the hospital ? Pt: I am having
diarrhoea since about 2 months.

Dr: Any thing more you can tell me about it ? Pt: Like what?

Dr: Is it watery or loose stools? Pt: It is loose stool

Dr: How many times in a day you get this diarrhoea? Pt; 5 to 6 times

Dr: Have you noticed any blood along with that ? Pt: No/ Yes once

Dr Is the blood mixed with the stool or separate from the stool ?

Pt: It is mixed with the stool.

Dr: Any mucus in the stool? Pt: No

Dr: Is the stool difficult to flush in the toilet? Pt: No

Dr: Any pain in your tummy? Pt: Yes left lower part of my tummy. Show empathy

Dr: Since how long ? Pt: Since almost 2 months.

Dr: Does the pain gets relieved on passing stool ? Pt: No

Dr: Any fever ? Pt: No

Dr: Any vomiting ? Pt: No

Dr Have you lost weight recently ? Pt: Yes my belt has become loose.

Dr: How is your diet? Pt: I eat healthy diet – plenty of fruits and vegetables.

Dr: Did you have this problem before this 2 months ? Pt: No

Dr: Do have any medical conditions ? Pt: No

Dr: Diabetes or thyroid disease ? Pt : No

Dr: Have you undergone surgery on your tummy before ? Pt : No

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Dr: Any of your family members have any medical conditions or bowel problems? Pt :
No Dr: Have you travelled outside UK recently? Pt : No

Dr: Is there anything else you think is important that we need to know? Pt : No

Tell the patient – I need to examine your tummy and back passage.

Examination

Can you please undress above the waist and lie on the bed? [Ideal exposure for
abdominal examination is from mid chest to mid thigh].

Inspection:

No abdominal distension, no visible peristalsis, no scar, mass or veins.

Superficial palpation:

Temperature, Tenderness (mild tenderness on the left iliac fossa).

Deep palpation:

No palpable mass. Patient’s legs can be flexed to feel the organs better.

Percussion

No shifting dullness or fluid thrill

Auscultation

Bowel sounds normal

Tell the examiner – I need to examine the back passage. Examiner says – no
abnormal findings.
Tell the management to the patient.

Diagnosis: Mr …. With the information you have given and after examination I think you have
a condition what we call as Inflammatory bowel disease most likely a type called Ulcerative
colitis. This is a condition in the bowel. This condition can be due to genetic reasons or
sometimes due to disruption to the immune system (the body’s defence against infection).
Autoimmune - body’s defense mechanisms turn against your own tissues.

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Are you following me? Yes

Investigations: We need to do some tests (stool culture) to confirm the diagnosis as well as
to make sure that there is no bowel cancer, blood tests (inflammatory markers, FBC)

We will be doing some test called colonoscopy where we pass a tube with camera
through the back passage into the colon - we can see the inside of the colon and also
take some tissue samples. We will also do X Ray of your tummy. We will do a test on
the stool to check for any bugs.
Pt: I don’t like colonoscopy. It may be very uncomfortable. Can you do any other test doctor?

Dr: Did you have colonoscopy before? Pt: Yes / No

Dr: We can another test what we call barium enema which is a special dye X Ray, but it
is not as good as colonoscopy because we can look properly inside of the colon during
colonoscopy and also take tissue sample which we cannot do in barium enema test.
We can give you sedation during the colonoscopy so that you will not be
uncomfortable. Is that OK? Pt - Ok doctor.

Dr; Are you following me? Pt: Yes.

Treatment

Dr: We will admit you to do the investigations and to treat. Unfortunately, there is
currently no cure for this condition. We can treat the symptoms and prevent them from
returning.

We can give medications like Aminosalicylates (mesalazine), or corticosteroids – to reduce

inflammation and immune-suppressants – to reduce the activity of the immune system. If it
does not respond to medications sometimes we may have to surgically remove the affected
part. Are you following me? Pt: Yes.

Dr: Any concerns ? Pt : No.

Thank you

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225. CEREBELLAR ATAXIA

60 year Lady Mrs Cathleen Nelson presented to the GP with unsteady feet. GP referred

her to you for suspected “Cerebellar ataxia”.

Take focused history from the patient, examine and talk to her about the management.

Dr: Hello Mrs Cathleen Nelson… I am Dr… Can you please tell me what brings you to
the hospital?

Pt: Doctor, My hands are very clumsy. I can’t knit sweater. I keep dropping things from
my hands. (patient may or may not give history of unsteady feet)

Dr: Is it one hand or both hands? Pt: Both hands.

Dr: Since when did this problem start? Pt: Since last few weeks.

Dr: Did this happen suddenly or gradually you noticed this problem? Pt: Suddenly /
sometimes she may say gradually.

Dr: Did you have any other symptoms when you developed this problem?

Dr: Do you have any pain in your neck ? Pt: Yes/ No

Dr: If there is pain – does the pain go anywhere ? (to the arms – radiation)? Pt – Yes/ No

Dr: Any stiffness in the neck ? Pt: Yes/ No

[ Pain and stiffness in the neck are symptoms of cervical spondylosis]

Dr: Any tingling numbness in your hands? Pt: No

Dr: Do you have any tremors in hands ? Pt: Yes/No

Dr: Are you able to eat with the help of spoon? Pt: Yes

Dr: Do you have any balance problems while walking ?

Pt: Yes / sometimes she may say no [If she says no – ask her - did you see your GP
before for any balance problems because the GP has mentioned in his notes – she
may then admit it.]

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Dr: Any vision problem (MS) ? Pt : No

Dr: Any bowel or urine incontinence (MS, Cervical spondylosis) ? Pt - No

Dr: Do you have a headache (stroke, brain tumours)? Pt: No

Dr: Did you have such problems any time before this last few weeks? Pt: No

Dr: When these symptoms started – at that time did you have a headache, fever,

vomiting? Any skin rashes? Head injury? (Stroke, brain infections, chicken pox – all

risk factors for cerebellar ataxia).

Dr: Do you have any medical conditions? Pt : I have diabetes.

Dr: Are you taking medications for that?Pt: Yes I am taking Insulin.

Dr: Do you keep checking the sugar level - Is the sugar controlled well do you know ?
Pt : Yes/No

Dr: Any thyroid problems (risk factor for cerebellar ataxia) ? Pt: No

Dr: Do you drink alcohol? (risk factor for Cerebellar ataxia) Pt : Not much.

Dr: Thank you very much. I need to examine you now. Is that OK? Pt: Yes doctor

Examination

Neurological examination of the upper limbs

Exposure - Above waist

Inspection – No muscle wasting, Tremors, No deformity of joints.

Sensory - Fine touch, Pain, vibration

Motor - Power – shoulder – abduction and adduction, elbow –flexion and extension,
finger extension at wrist. Finger abduction and grip. Examiner may say – power is
normal.

Reflexes – Biceps, triceps and supinator. - Examiner may say normal.

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Neck

Inspection: (MDRSSS) No swelling redness, etc

Movements of neck: side to side, flexion, extension, to each shoulder

Palpate for spinal and paraspinal tenderness

Cerebellum

● British constitution
● Nystagmus
● Finger-nose test (Past pointing)
● Heel to Shin test.
● Dysdiadochokinesia
● Rhomberg test
● Check the Gait (broad based gait in cerebellar ataxia)
● Tandem gait. First say “Are you able to stand by yourself?” [Stop examination
at 6 minutes].

Management:

Mrs. Nelson, on examination, I do not see anything abnormal. However, since you are
having these symptoms – we need to evaluate it further to find out why you are having
these symptoms. We will refer you to a neurologist who is a specialist in this type of
problems. They may do tests like X Rays of your neck, CT and MRI scans of your head
and neck. They may also do some nerve conduction tests. They may also do some
blood tests like liver function and thyroid function and tests for any vitamin
deficiencies. Is that OK?

Pt: Do you think I have a brain tumour or stroke?

Dr: Mrs. Nelson, with the examination findings it does look like you have any such
condition. However after the investigations, the neurologists may be able to say
exactly what may be the problem.

Pt – Ok Is this a serious condition ?

Dr: Mrs. Please do not be worried. Most of the time this type of problems are not
serious at all. However, only after the investigations we will be able to tell you
properly. Pt: Any treatment?

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Dr: Mrs Nelson, treatment depends on the diagnosis. However, specialists may arrange for
physiotherapy and also he may refer you to Occupational therapists if you need any kind of
aids. Also, please keep checking your sugar and keep it under control.

If the patient gives the history of neck pain and stiffness – give the diagnosis of
cervical spondylosis

Mrs – Nelson, I think you may be having condition called cervical spondylosis. This is
due to degeneration (I mean a wear and tear of the bones and the discs - soft
cushions betweens the bones) at the neck. In this condition, some extra bony lumps
develop in the bones of the neck which presses on the spinal cord and nerves, and this
causes these type of muscle weakness in the hands and sometimes balance problems when
walking. Do you follow me ? Pt : Yes.

Dr: We will refer you to the Orthopaedicians who are bone specialists who may do
investigations like X Rays, CT and MRI scans of your neck and also nerve conduction
tests to check whether this is the problem. Do you follow me?

Pt : Yes. How will you treat me doctor?

Dr: Treatment depends on the diagnosis. If it is cervical spondylosis - then the

specialist may give pain killers – if you have pain, and he may also arrange
physiotherapy, and other investigations. If there is pressure on the spinal cord ,they
may advise surgery to relieve pressure on the spinal cord. Do you follow me ? Pt : Is
that OK? Pt : Yes.

Dr Any other questions ? No

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Causes of Acquired cerebellar ataxia

1. Severe head injury– after a car crash or fall, for example

2. Bacterial brain infection, such as meningitis or encephalitis (an infection of the brain
itself)

3. Viral infection – some viral infections, such as chickenpox or measles, can spread to
the brain, although this is very rare

4. Conditions that disrupt the supply of blood to the brain, such as a stroke,
haemorrhage or a transient ischaemic attack(TIA)

5. Cerebral palsy – a condition that can occur if the brain develops abnormally or is
damaged before, during or shortly afterbirth

6. Multiple sclerosis – a long-term condition that damages the nerve fibres of the
central nervous system

7. Sustained long-term alcohol misuse

8. An underactive thyroid gland

9. Vitamin B12deficiency

10. Brain tumours and other types of cancer

11. Certain toxic chemicals, such as mercury and some solvents – these can trigger
ataxia if a person is exposed to enough of them

12. Medications such as benzodiazepines can occasionally trigger ataxia as a side

effect

1019
 1020

1020
 1021

MANNIKIN STATIONS

226. BREECH ANTENATAL EXAMINATION

You are an FY2 doctor in the OBG department

Mrs Catherine Anderson, a 20 year old lady has come to the hospital with
gestational amenorrhoea of 36 weeks. The midwife suspected breech
presentation. She has checked the vitals and they are normal.

Take a brief history, do the examination, confirm the diagnosis and talk to the
patient about further management.
Dr: Hello Mrs Catherine Anderson, I am Dr … one of the junior doctors in the OBG
department. How are you doing? Pt: I am OK, doctor.

Dr: How is your pregnancy? Any problem at all? Pt: No problems

Dr: I was told that the midwife has examined you and she was a bit concerned about
the position of the baby. Is that right ? Pt: Yes that is right.

Dr: How many weeks pregnancy now? Pt: 36 weeks, doctor

Dr: Do you feel your baby kicking? Pt: Yes

Dr: Did you have any problems before in this pregnancy at all? Pt: No

Dr: Have you been pregnant before? Pt: Yes, twice before.

Dr: How are the children now? Pt: They are fine

Dr: Was it normal delivery or caesarean section? Pt: Both were normal delivery

Dr: Was there any problem with the position of the babies during delivery in your
previous pregnancy? Pt: No

Dr: Mrs Anderson, can I examine your tummy now? This examination involves
inspecting and touching your tummy to feel for the structures and position of baby.
The reason it is performed is to ensure yours and your baby’s wellbeing.

1021
 1022

Exposure/position, privacy and Chaperone: “For the sake of the examination, I

would like you to lie down and undress below your breasts, keeping your underwear
on. For which I will ensure adequate privacy and have a chaperone.”

Consent: “Can I proceed?” (Verbal consent)

“Is there any question you would like to ask me or have you got any concerns? Thank you
very much for your cooperation. I will continue the examination on the mannequin.”

Ask the examiner: “Where is the head end?” Ask this question only if you cannot make
out which is the head or foot end. Undress gently from the down side.
Tip: Never expose the breast. If examiner didn’t show the head end, undress manikin
gently. If you expose the breast, say sorry and roll down and go back to the other side.

Inspection:

“On inspection of the abdomen, there is a distended abdomen consistent with the
days of amenorrhea.”

I can’t see any cutaneous signs of pregnancy, such as striae gravidarum and linea nigra.

There are no visible scars, veins, peristalsis, bruises; umbilicus seems to be inverted/ inside.

There are no obvious fetal movements.”

Palpation:

“I would ask mother if she is tender anywhere on abdomen before touching, and also
ask if she feels discomfort or pain to let me know.”

Temperature: Warm your hands and compare temperature with the other side. “There
is no local rise in temperature.”

Tenderness: “I will look for any tenderness by looking at the face of the patient.”

Deep palpation: For palpation, start from the middle to up and come back to down.

Lie: Fix one hand and palpate with the other hand, while checking the sides.

The measurement in centimetres and should closely match the fetus gestational
age in weeks, within 1 or 2 cm, e.g., a pregnant woman's uterus at 22 weeks
should measure 20 to 24 cm.

1022
 1023

“The fetus is clinically normal/small/large of dates”

If the fundal height is high, it could be caused by:

1. Polyhydramnios
2. Multiple pregnancies
3. Wrong date of LMP
4. Large baby

Auscultation:

The fetal heart is best heard in the back of the fetus

In a cephalic or normal fetus, it is on either side of the umbilicus (below and lateral to
the umbilicus) along the back of the fetus.

In the GMC manikin, there are actual heart sounds. That means you should try to hear
any sound on the tummy of the manikin with the help of the fetal stethoscope
provided to you. The wider part of the fetal stethoscope should be on the tummy and
the smaller part to your ear to listen to the heart of the fetus.

Let the examiner know if you can hear a fetal heart sound.

Thank the patient and ask her to dress up.

Baby in vertex - or 'head' down position.

1. Assessing the height of the fundus (lower area of the baby) - seeing how many
finger breadths below the xiphisternum (bottom of the woman’s sternum bone).

1023
 1024

2. Assessing the size of baby and feeling for the baby's back and limbs.

3. Pawlik's grip -the lower part of the uterus is grasped by the midwife to determine the presenting part.

1024
 1025

4. Pelvic palpation to determine the position of the baby's head.

5. Measuring the height of the fundus which generally corresponds to the number of weeks of
gestation

6. Listening to the baby's heart beat.

1025
 1026

Baby in breech position - or 'bottom' down position

1. Checking the height of the fundus (the highest point of the uterus). At 20 weeks,
this measurement is taken from the belly button. When the pregnancy is at term
(37-40 weeks), it's taken from the lower end of the woman's sternum bone (the
xiphisternum)

2. Assessing the baby's position and size. Feeling for the baby's head, back and limb

1026
 1027

3. Using ‘Pawlik's grip’ to check that the baby's buttocks are in the pelvis.

4. Listening to the baby's heart beat.

1027
 1028

Dr: Mrs Anderson – I think your baby is in a breech position. Do you know anything
about this? Pt: No

Dr: Breech means your baby is lying in a bottom first i.e the bottom of the baby is
facing down instead of the usual head first position. Usually, by 36 to 37 weeks of
pregnancy babies are ready to be born in the head down position.

Pt: Is there any problem with this?

Dr: Unfortunately, sometimes this can cause serious problems during delivery because the
head of the baby can get caught inside the birth canal and the delivery can be very difficult.

Sometimes, we may need to use the instruments to deliver the baby if the head gets
caught inside the birth canal.

Pt: Why is this happening, doctor?

Dr: Sometimes it is just a matter of chance but sometimes it may be due to excessive
or less fluid in the womb or the position of the placenta causing this.

Pt: What will happen now?

Dr: We need to do an ultrasound scan of your tummy to check the type of breech and
also we need to check the size of the baby and the size of your birth canal. We can do
several things.

Sometimes, we may have to wait for a few more days and see whether the baby will
turn on its own to the normal position because most of the times babies do turn to a
normal position by 37 weeks.

Otherwise, my seniors may try to change the position to a normal position by manually
turning the baby by moving it over the tummy. If that is not possible, then we may do
caesarean section. If the scan shows it is safe to deliver through the vagina, then we
may deliver the baby through the vaginal route. However, if we decide to deliver
through the vagina, sometimes we may need to use some instruments to deliver the
head of the baby. Caesarean section may be safer than vaginal delivery in that case.

1028
 1029

227. CATHETERIZATION
You are the FY 2 doctor in the surgery department.

Mr. Graham Martin, a 55 year old male patient, presented to the hospital with pain
in his abdomen and he is unable to pass urine.

Take a brief history

Do a relevant procedure and talk to him about the further management.

Dr : How can I help you? Pt: Doctor I have pain in my tummy

Dr : Since when? Pt: Since yesterday.

Dr : Where is the pain? Pt: Lower part of my tummy

Dr : Any other problem other than pain?

Pt: I could not pass urine since yesterday it is almost 24 hours now

Dr : I am sorry to hear that.

Dr : Did you have this problem before? Pt: No

Dr : Did you have any problem passing urine before like burning sensation while
passing urine ? Pt: No

Dr : Did you have any surgery recently? Pt: No

Dr : Were you going to the loo more times than usual, especially at night? Pt: Yes since
the last few months

Dr : Any dribbling of urine? Pt: Yes

Dr: Any fever? Pt: No

Dr : Do you have back pain (for secondaries in the vertebrae)? Pt: No

Dr: Weight loss (for cancer prostate)? No

Dr : Did you have any injury to or instrumentation done on urethra? Pt: No

Dr: Any kidney stones before? Pt: No

1029
 1030

Dr : How are your bowel habits? Pt: That is fine.

Dr : Are you taking any medications (opioids, antipsychotics CCB)? - Pt: No

Dr: Any medical conditions (MS, DM, Parkinson's) Pt: No

Examination - I need to examine your tummy and back passage to see what is causing
this problem.

Examiner says – Bladder is distended and prostate is smooth surface and enlarged.
Thank you.

Management:

Dr : Mr Martin, Your urinary bladder is enlarged because the urine is collected in the
bladder. I think you had this problem because a gland called prostate which is present
at the base or the urine bladder which surrounds the urine passage is enlarged and
making the urine passage narrow.

We need to do further tests to see what type of enlargement this is, whether it is
cancerous or non-cancerous. On examination, it looks like a non-cancerous type of
enlargement.

We need to do some blood tests which are specific for the prostate gland, do a scan
and take some tissue sample from the gland and treat the condition either with
medication or we may need to do some surgery to widen the urine passage. We will
keep you in the hospital for all this.

Dr: Do you follow me?

Pt: Yes what will happen to me now?

Dr: For now, I am going to pass a tube to your urine bladder through the penis and
drain the urine out. Take Consent: would that be okay with you?

Pt: OK doctor.

1030
 1031

Short history to rule out contraindications:

1. Any injury to the urethra? No

2. Any bleeding from the urethra? No

Exposure/chaperone: For the purpose of this procedure I would like you to get
undressed below your waist please, lie comfortably on your back. I will ensure your
privacy and request for a chaperone.
PROCEDURE

1. The catheter set is kept open and ready – it will be kept inside the bag opened at the
top.
2. Wash hands, put on an apron, clean the trolley you are going to use with a wipe.
3. Collect equipment.
4. Make sure the clinical waste bin is near you before starting.
5. Open the catheter pack without touching the contents and place the inner pack on
clean surface
6. Wash your hands. Now open the catheter pack by just touching the edges and underside.
This creates your sterile field. Everything in this is sterile and shouldn’t be touched unless
you are wearing sterile gloves.
7. Open the urinary catheter outer packaging and lubricant without touching the
contents. Place them carefully in your sterile field.
8. Open the urinary drainage bag and place it between the patient’s leg for easy access
when needed.
9. Pour cleaning solution into the container. Open a pair of sterile gloves to the side of your
sterile field.

1031
 1032

10. Wash your hands, put on your gloves, take care not to contaminate them by touching the
outside of the gloves with your hands. Place the drape over your patient to create a clean
area.
11. One hand (right) is now going to be your clean hand, which can be used to pick things out
of the sterile field. The other hand (left) will be your dirty hand, which will be used to hold
the penis using gauze. This hand cannot enter the sterile field.
12. Retract the prepuce (if the mannequin has it and only if it is possible to retract, most
of the mannequins you won’t be able to retract it, then you will have to clean over the
prepuce) for adequate exposure of the glans and meatus

s .

13. Pick up a swab with the help of forceps, dip it in cleaning solution and clean the glans from
centre to periphery in a circumferential manner with single stroke. Repeat the procedure to
clean area around glans also (3 times).
14. Discard the swab and plastic forceps in clinical waste bin.
15. Take the lubricant and inject it down the urethra. Change your gloves, clean hands in
between. Remove the outer packaging from syringe of water, so it is ready to be used, place
the kidney tray between the patient’s legs.
16. Tear off the tip of the bag covering the catheter. Hold the catheter by the bag in your clean
hand, and use your dirty hand to hold the penis. Push catheter with the no-touch-
technique (don’t touch the catheter or glans with hand ). Push up to Y Pick-junction.
17. Inflate the bulb with distilled water. Inject in about 5 ml of it slowly, looking at the patient’s
face. Then inject the rest of distilled water. Give a slight tug to make sure the catheter is
properly placed inside. Discard the syringe to clinical waste bin.
18. Replace the retracted prepuce if possible and Discard the shaft holding gauze piece to
clinical bin and hold Y junction with left hand. Connect the urine bag. (You can leave the bag on the
floor, place it below the mannequin level.)

1032
 1033

19. Tear the drape. Discard it in the clinical waste bin.

20. Stick the catheter (size 16) on the thigh with the help of a tape.

1033
 1034

The equipment needed for this station

● Catheter pack: includes drape, forceps, gauze, cotton wool, fluid container,
kidney tray
● Cleaning solution
● 2 pairs of sterile gloves
● Pre-filled syringe with anaesthetic gel
● Catheter (this comes double packed and includes a syringe of water to inflate
the balloon).
● Urinary bag
● Clinical waste bin

Make sure that the patient is left clean, tidy up equipment, explain to the patient that
the procedure is over and if they have any pain or discomfort with catheter, to inform
the member of staff.

Record findings: “I would record the volume and colour of urine, size of catheter, and
time and date and put my signature”

- Ask the patient to redress. Thank the patient and ask him to dress up.

Dr: Urine is drained out now. How do you feel? Pt: Much better, doctor
Pt: How long should I be in the hospital?

Dr: It may take a few days to do the tests and also we need to remove the catheter to
see whether you can pass the urine without the catheter [Trial without catheter
(TWOC)]. After that, we can discharge you.

Pt: How long should I have this catheter ?

Dr : Most probably for a few days only until we find the cause of the retention and
treat it. Very rare chance that you need it for a long time.

1034
 1035

228. 21 year old Mr …. Presented to the hospital complaining of earache.

Take history, examine the patient and discuss the further management with the
patient.
Dr: Hello Mr …. I am Dr…. How can I help you? Pt: Doctor I am having pain in my ear.

Dr: Can you tell me anything more about it?

Pt: It has been there for a few days now doctor. I took some painkillers and it is not going.

Dr: Which ear you have the pain? Pt: Right ear.

Dr: Do you have any discharge from that ear? Pt: No

Dr: Do you have any fever? (Otitis media may or may not have fever) Pt: Yes since the last few days.

Dr: Are able to hear in that ear properly? Pt: Yes

Dr: Do you hear any sound or noise in the ear (tinnitus – meniere’s disease)? Pt: No
Dr: Do you feel your head is spinning (meniere’s disease, labyrinthitis)? Pt: No

Dr: Do you have any balance problems while walking(labyrinthitis)? Pt: No

Dr: Did you have any injury to the ear? Pt: No

Dr: Any rashes around the ear or face (Ramsay hunt syndrome)? Pt: No

Dr: Did you go for swimming recently (trauma ,furunculosis)? Pt: No

Dr: Any recent flight travel? (Barotrauma?) Pt: No

Pt: Any headache (GCA, Meningitis, Migraine)? Pt: No

Dr: Any problem in the other ear at all? Pt: No

Dr: Have you had any problems in the ear before? Pt: No

Dr: Do you have any medical conditions? Pt: No

Dr: Ae you on any medications? Pt: No

Dr: Are you allergic to anything? Pt : Yes, Penicillin

1035
 1036

Examination:

I need to examine your ear. During the examination I will be coming very close to you
and will be touching your ear, cheek and face.
Examine the affected ear first (In real life, examine normal ear first).

Inspection: (on the patient)

- Pre auricular: “There are no scars, sinus, discharge , redness, swelling , previous marks of
surgery.”

- Auricular: “No swelling, obvious haematoma, deformity, vesicles, bleeding discharge”

- Post-Auricular: Same as pre auricular + no mastoid bruises / discolouration.

Palpation: (On the patient)

Temperature

Tenderness-> looking at patient’s face

Pre-auricular-> pulp of finger — no obvious swelling or tenderness

Auricular -> thumb + index finger

Post auricular-> pulp of finger — no obvious swelling or mastoid tenderness.

* TRAGUS TEST (if positive – Contraindication to otoscopy. If negative – proceed

with Otoscopic examination on the mannikin).

Explain Procedure: “I need to examine the inside of your ear with a special instrument
called an Otoscope.”

Position: Sitting with head and neck slightly tilted to the other side .

Check Instrument - Check if the Otoscope is working. Use the large size speculum.
Hold the Otoscope in a pen holding position

External auditory Canal – Throw Light

Comment - “No discharge, bleeding, inflammation, wax, foreign body”

1036
 1037

Tympanic Membrane

Left hand on head, pull pinna upward +backwards with thumb and index finger.

LOOK AT THE SLIDE

Withdraw the instrument, Look at the speculum, comment on bleeding, discharge or

wax over speculum. Remove and dispose it in clinical waste bin.

DESCRIPTION OF SLIDE:

Comment on:

● Cone Of Light

● Handle of Malleus

● Umbo

● Annulus

● Pars Flaccida/Pars Tensa (Any Findings in Tympanic Membrane)

SLIDE OF AOM WITHOUT EFFUSION

“I can see the TM which is red, inflamed, congested, oedematous and tense. There is
no air fluid level. Cone of light, handle of malleus and umbo cannot be appreciated.
The annulus can be appreciated. Therefore, the diagnosis is AOM without effusion.

Ideally, I will do the Rinne’s and Weber’s test to check for any hearing loss.”

(No need to do the Rinne’s and Weber’s tests in the exam as the tuning forks are
not usually kept in the cubicle.)

Check the hearing with a finger clicking sound.

Examine the Lymph nodes (if you have time): Submental, Submandibular, Pre-
auricular, Post-auricular, Cervical, Occipital

[stop the examination by 6 minutes]

Diagnosis
Mr… You have an infection in the right ear. This could be due to Bacteria type of bugs. Pt: Ok

1037
 1038

Treatment:

We will give you an antibiotic called Erythromycin (since the patient is allergic to
Penicillin) which you need to take for 5 days.

We will also give you some pain killer medication. Usually, this condition subsides in
about 5 to 7 days.

Pt: Any complications, doctor?

Dr: Rarely, this can cause an infection in the nearby area — such as infection in the
bone (mastoiditis) and also an infection of the covering layer of the brain called
meningitis.

Warning signs:

You can take this medication at home. If the condition is getting worse, or if you
develop headache, rashes on the body — these signs of meningitis — please call the
ambulance and come to the hospital.
[No need to do – Romberg’s and Marching test because there is no hearing loss
and balance problem.]

EAR ACHE

1038
 1039

229. 50 year old Mrs... presented to the hospital complaining of hearing loss for
the last 3 weeks. Take a history, examine the patient and discuss further
management with the patient.
Dr: Hello Mr …. I am Dr…. How can I help you? Pt: Doctor, I am losing my hearing.

Dr: I am so sorry to hear about that. Can you tell me anything more about it?

Pt: It has been there for quite some days now, doctor. It is not getting any better.

Dr: Which ear are you losing the hearing from? Pt: Left ear.

Dr: Any problem in the right ear? No

Dr: When did it start? Pt: Almost 3 weeks doctor.

Dr: How did it start? Was it sudden or gradual? Pt: (Sudden/gradual?)

Dr: Do you have pain in this ear? Pt: No, doctor.

Dr: Do you have any fever? (Otitis Media) Pt: No.

Dr: Do you have any discharge from that ear? (Otitis Media) Pt: No.

Dr: Do you hear any hissing or ringing sounds in the ear? (Tinnitus - Meniere’s
disease/Acoustic Neuroma) Pt: No.

Dr: Have you been feeling dizzy lately? (Meniere’s disease) Pt: Yes, doctor.

Dr: Do you feel that your head is spinning? (Vertigo - Meniere’s disease) Pt: Yes.

Dr: How long do these episodes last? (>20 min in Vertigo - Meniere’s disease)

Dr: Do you have any balance problem while walking? (Balance Problems - Meniere’s
disease/Acoustic Neuroma) Pt: (No )

Dr: Do you feel any fullness in your ear (Aural Fullness - Meniere's Disease)? No

Dr: Have you been feeling any pain or numbness on your face? (Acoustic Neuroma?)Pt: No

Dr: Have you been feeling any headaches lately? (Acoustic Neuroma) Pt: No.

Dr: Did you have any injury to this ear or head recently? (Trauma) Pt: No.

1039
 1040

Dr: Were you exposed to any sudden loud noise when it start? (Noise-induced)No.

Dr: Did you go for swimming recently? (Trauma) Pt: No.

Dr: Any recent flight travel? (Barotrauma) Pt: No.

Dr: Did you have any medical conditions in the past? Pt: No

Dr: Are you taking any medications now? Pt: No

Dr: Have you received any IV antibiotics, salicylates, diuretics or chemotherapy?

(Ototoxic HL) Pt: No.

Examination:

I need to examine your ear. During the examination, I will be coming very close to you
and will be touching your ear, cheek and face.

Examine the affected ear first (In real life, examine normal ear first).

Inspection: (on the patient)

“ There are no scars, discharge, redness, swelling , previous marks of surgery or

discolouration over the ear and around the ear.”
Palpation : (On the patient)

Tragus Test: (if positive – Contraindication to otoscopy).

I need to examine the inside of your ear now with a special instrument called an Otoscope.
Position : Sitting with head and neck slightly tilted to the other side .

Check Instrument - Check if the Otoscope is working

Use the large size speculum. Hold theOtoscope in a pen holding position

External auditory Canal –Throw Light

Comment on – No discharge, bleeding, inflammation, wax, FB

Tympanic Membrane

1040
 1041

LOOK AT THE SLIDE

Withdraw the instrument, Look at speculum, comment on bleeding, discharge or wax

over speculum. Remove and dispose it in clinical waste bin.
DESCRIPTION OF SLIDE only if the examiner wants you to

Comment on:

● Cone Of Light

● Handle of Malleus

● Umbo

● Annulus

● Pars Flaccida/Pars Tensa (Any Findings In Tympanic Membrane)

*SLIDE OF TYMPANIC MEMBRANE (NORMAL)

“Can appreciate cone of light in antero-inferior quadrant, handle of malleus in antero-

superior quadrant and umbo at the junction of cone of light and handle of malleus.

Pars flaccida, Pars tensa and annulus appear normal

No retraction, no bulging, no air fluid level, no per formation, no bleeding, no

discharge, no wax over TM

Therefore, this is a Normal Tympanic Membrane.

I will now do Rinne’s and Weber’s test to check for any hearing loss.”

Patient will show the following results:

Rinne's Test: AC>BC

Weber's Test: Lateralization to Right Ear. (Indicating that patient has SNHL in Left Ear.)

Examine the Lymph nodes (if you have time, otherwise verbalise)

Do Rhomberg's Test (only if you have time).

[stop the examination by 6 minutes]

1041
 1042

Diagnosis:
Pt: From the information I have gathered, I suspect you have a problem called
Sensorineural Hearing Loss. This is actually a problem of the inner ear and the nerves
that supply this part of the ear. Are you following? Pt: Yes, doctor.

Dr: This problem could be due to condition called Acoustic Neuroma. Do you know
what it is? Pt: No doctor.

Dr: Well, it is a growth (tumour) in the brain. This is a non - cancerous type of growth.
This tumour grows on a nerve in the brain near to the ear. It can cause problems with
hearing and balance. Pt: Are you sure that I have it doctor?

Doctor: This what I am suspecting now. We need to do some tests like MRI scan of the
brain to confirm that. Pt: Okay

Dr: Another test is Audiometry. This is a test which will enable precise understanding
of the degree of hearing loss.

Pt: Why did I get it doctor? Dr: In most cases, the cause is unknown.

Management:

Dr: We will refer you to an Ear Nose and Throat specialist. Pt: How are you going to treat me?

Dr: If tests show that you have a very small acoustic neuroma, then it does not require
any treatment but we will monitor it closely by regular scans. This is because these
growths are very slow-growing and may not cause any problems for a long time. If it is
big, then we may do surgery or radiotherapy.

Dr: Also, for the hearing loss we can give you Hearing aids. Is that OK? Pt: OK

[Patient needs to inform the DVLA if they drive]

Pt: Will I never get my hearing back?

Dr: I am sorry to tell you that even if the tumour is removed with surgery or destroyed
with radiotherapy, unfortunately a degree of hearing loss will be permanent.

Dr: Do you have any concerns? Pt: No, you have been very kind. Dr: Thank you

HEARING LOSS - ACOUSTIC NEUROMA

1042
 1043

230. Ms Victoria Jones has taken over dose of some tablets. Take a history from
her, do the necessary investigations and then talk to her about the further
management.

Dr - Hello Ms Victoria Jones. I am Dr .. one of the junior doctors in the Emergency

department. I understand you took some tablets today, is that right?

Pt - Yes doc. (If denies - offer confidentiality say – Ms Jones, Whatever you say, we
will keep that information confidential. We are here to help you).

Dr -What did you take? ----- Pt - Paracetamol tablets.

Dr - How many did you take ? ----- Pt - About 40 tab.

Dr - When did you take them? ---- Pt - 6 hours ago.

Dr - Did you take anything else with that like alcohol, other medication of recreational drugs? –
Pt - No.

Dr - Did you throw up (Vomit) after this ? Pt - Yes or no.

Dr - Any pain in tummy? Pt - No.

Dr – Any chance are you pregnant? Pt -No.

Dr - Ms Jones, you have taken too much of Paracetamol which can be dangerous to your health
as it can damage your liver and kidneys. We need to do some blood tests on you to check how
your liver and kidneys are functioning as well as the level of Paracetamol in the blood to see if
you need any treatment. Is that ok? Pt – OK

Explain the procedure:

For the purpose of investigations, I need to draw some blood from your vein. For that,
I would introduce a needle in your forearm, you will feel a sharp scratch but I would be
as gentle as possible.

Consent: Will that be okay with you?

Risk: The procedure can sometimes result in bruising but again it is very rare, so please
do not worry about it.

1043
 1044

1. Have you got any pain anywhere in your arms?

2. Have you got any blood disorders that you are aware of?

3. Do you use any medications like, warfarin etc

4. From which arm, would you like me to take blood?

PROCEDURE

1. Put on apron, wash hands.

2. Clean the tray with the wipe you are going to use.

3. Collect the equipment in a tray :

● Tourniquet, alcohol wipe, gauze pieces

● Vacutainer, vacutainer holder and vacutainer needle

● Sharps bin (yellow ),

● Waste bin

● Pair of non-sterile disposable gloves

● Blood request form

4. Check tourniquet and place it on the arm.

5. Remove the correct end (smaller, white) of the needle and load vacutainer holder
with needle. Throw the cap in clinical waste bin.

Tip: if you open the wrong end of the needle or touch it discard it in the sharps bin
and take a new one.

6. Palpate the vein. (above Y junction)

7. Fasten tourniquet.

8. Palpate the vein again.

9. Wipe the alcohol sterets, one stroke only, then discard it in the waste bin.

10. Unsheathe the needle (green end) and throw cap in clinical waste bin.

1044
 1045

11. Warn the patient before inserting needle “ you will feel a sharp scratch”.

12. Stretch the skin and introduce needle.

Tip: Don’t try to insert the whole needle inside. The moment the resistance has
gone, you’re inside the vein.

13. When you get blood, stabilise vacutainer holder with left hand and insert
vacutainer one by one for collecting blood samples

14. Shake the bottle and put it inside the kidney tray.

15. Loosen the tourniquet.

16. Take gauze piece and press on needle and withdraw the needle. Ask the patient to
keep it pressed to attain adequate hemostasis.

17. Discard the vacutainer holder in sharp’s bin with the needle.

18. Label the samples (patient’s name, DOB and hospital number, procedure, date and
signature) and mention I will send them to a lab along with the blood request form.

19. Remove the gloves and discard in clinical waste bin.

20. Enquire how the patient feels and thank the patient for his cooperation and ask her
to roll down sleeves”
– Use a yellow cap vacutainer for Paracetamol level, LFT and U&Es. If the examiner
says colour does not matter, then use any colour vacutainer given.

Once you take the blood, the examiner gives the paracetamol level as 94 mg at 6
hours. Plot the level on the below chart. 94 mg is above the treatment line at 6 hours.

1045
 1046

Dr – Miss Jone, I got the paracetamol level result back from the lab. It shows the
paracetamol level in the blood is very high and you need treatment with some
antidote medication. This will reduce the harmful effects of the Paracetamol tablets.
This medication is called N-Acetyl cysteine. Is that OK?

This is only one dose which will be given as a drip though your vein for 21 hours.

We will admit you in the hospital and keep monitoring you while we treat and once the
treatment is finished and if you are fine we will refer you to our Psychiatric specialist
doctors who will help your further. Are you following me ? Is that Ok?

Pt - Why, am I mad ?

Dr - No you may need help if you are feeling low and stressed out and they can help.

Dr - Any questions? Pt: No

Dr: Thank you

PARACETAMOL OVERDOSE AND BLOOD
SAMPLING

1046
 1047

IV CANNULATION
231. Post appendicectomy – IV cannulation

Mrs Stevens had an appendicectomy operation few hours ago. His IV cannula has
been blocked.

Take a brief history and do the necessary procedure and talk to the examiner
about the further management.

Dr: Hello Mrs Stevens I am Dr …one of the junior doctor in the surgical department. How
are you doing ? Pt: I am OK doc

Dr: Do you have any problem like pain ? Pt: Yes I still have pain over the operation area.

Dr: Ok, we will give you some pain killers (Confirm if he is already receiving any painkillers
and if yes, what type. Also confirm if he is on any other medication i.e antibiotics)

Dr: Any vomiting? - Pt: Yes, doctor

Dr: Any pain in Calf or Shortness of breath? Pt:-No

Dr: Any fever? Pt: - No

Dr: Mrs Stevens, I need to put a cannula in your arm now because the one that you have now
is blocked. Then I can give you your medications through your vein. Is that Ok? Pt: Ok, doctor
Then insert cannula

Explain procedure: “It will be a little uncomfortable and you will feel a sharp scratch
but I will be as gentle as possible. Also, I would need to repeat the procedure again, if
I do not get blood in the first attempt.”

Consent: “Are you happy for me to go ahead with this procedure? Are you allergic to
anything? Have you got any pain anywhere in your arms? Which arm would you like
me to do the procedure on?”

Complications: “This procedure also carries a risk of infection (phlebitis) and swelling
(haematoma), but please do not worry about it as we take great care to prevent this
from happening.”

1047
 1048

PROCEDURE

1. Put on apron, wash hands.

2. Clean the tray with the wipe you are going to use.

3. Collect equipment in tray:

● 1 Pair of gloves

● Cannula (pink or blue)

● Alcohol swabs

● Gauze piece

● Tegaderm

● Tourniquet

● 2cc syringes filled with normal saline or syringe and saline vial

● Clinical waste bin

● Sharp bin — yellow Make sure the sharps bin is close by and open the sharps
bin.

5. Check the tourniquet and place it on the arm. (loose, don’t tie it yet)

6. Check the site and the vein. (below Y junction if the mannequin has Y-junction)

7. Remove cannula from the sheath with no touch technique and place it back in clean tray.

8. Take out stopper; place it on clean area facing upwards.

9. Fasten tourniquet.

10. Palpate the vein again.

11. Clean the area with alcohol sterets in one direction with single stroke. Discard it
into clinical waste bin.

12. Take a three point grip of the cannula, with your thumb on the white cap or the
projecting part of the stylet, index finger on the coloured cap, and middle finger on
the wing. Apply counter-traction to the overlying skin with your other hand to help
anchor the vein during insertion.

1048
 1049

13. Before introducing needle, you should warn the patient, so say, “You will feel a
sharp scratch now”.

14. Stretch the skin and insert cannula with bevel end upwards at 30 to 40 degrees.
Then reduce to a 15° angle to advance the needle inside the vein.

Information written on a paper on the table

Patient has been prescribed Morphine 5 mg every 4 hours. Last dose given one
hour ago.
Talk to the examiner about the further management.

Since patient was given morphine just one hour ago, I cannot give Morphine for the next 3
hours. Since the patient has pain now – I will give him Paracetamol - 1gm IV and
Metoclopramide –10 mg IV for vomiting and also IV fluids – Normal saline. I will give her IV
antibiotics.

Since the patient is complaining of pain in her abdomen, I will examine her abdomen and
check for any signs of intra-abdominal bleeding. I will check her Haemoglobin for bleeding.

Aftercare advice: Inform patient the cannula will be checked and flushed 3 times a
day and will be removed after 72 hours. Inform patient to alert staff if:

● The cannula site becomes painful/sore/hot.

● The insertion site looks infected/red/swollen.

● The cannula is knocked

● The dressing is coming loose or is wet

● They feel the cannula is limiting their self care.

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232. IV cannulation Post operation (ruptured appendix)

Stop at 6th minute bell if you did not get the blood.

Check on the table for any paper which may be written – 5 mg Morphine to be given
every 4 hours. Last dose was given one hour ago.

Management – talk to the examiner

Check NEWS chart — there may be Hypoxia, Check the pulse and blood pressure
also.

- I will give her painkillers – Diclofenac 75 mg IV for pain (if she complains of
pain in her abdomen) since the last dose of Morphine just given one hour ago.

- I will give her Cyclizine for vomiting — 50 mg IV

- I will examiner her for any signs of bleeding because she has hypoxia like pallor
and abdomen for distension generalised tenderness.

- I will do blood tests like FBC, U& Es, Group and cross match and clotting screen

- I will also examine her chest for any signs of Atelectasis and PE.

- I will inform my seniors about this.

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232. CERVICAL AND SPECULUM EXAMINATION

Teach a final year medical student about Per Speculum Examination.

- Introduce yourself to the medical student; build a rapport with him/her. Ask how his/ her
studies are going, offer any help with regard to studies.

- Assess his/her knowledge about Per Speculum Examination. Remember to make sure that
the student is following what you are teaching and praise the student.

- Explain why we do PS examination.

“Bivalve (cusco) speculum is the instrument most commonly used to inspect the vagina.”

“The purpose of the examination is to look at the size and shape of external and internal
reproductive organs.”

The external examination will involve:

● examination of anatomy

● looking for any lesions, ulcers, discharge or other signs of disease

● palpation of the abdomen

The internal examination will involve:
● palpation of the vulva and vaginal walls

● examination of the cervix

● Assessing the size and position of the uterus.

● palpating for any adnexal tenderness

● location of the cervix using the speculum

● performing any appropriate swabs or smears using the speculum

Preparation and Introduction

- Introduce yourself to Patient – (GRIPS – Greet, Rapport, Introduce and Identify and
Explain Procedure) and wash your hands

- Ask the patient whether they are experiencing any symptoms and explain the
purpose of the examination

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 1052

- Explain that it will involve undressing fully from the lower half and the examination
may be a bit uncomfortable but should not be painful

- Gain consent and offer a chaperone

- Before the patient undresses, perform a general examination, looking for signs of
hormonal disorders, for example hirsutism and acne

Explain to the patient that the position they should be lying in is supine, with knees
bent, heels brought up towards bottom, and then letting legs fall to either side of the
bed. Let the patient undress in privacy behind the curtain and provide them with a
blanket to maintain their dignity.

Prepare trolley and equipment: flexible light source, gloves, lubricating jelly, speculum.

Allow the patient to become comfortable before starting

Inspection
Begin with a general abdominal examination

Inspect the external genitalia for hair distribution, swelling, scarring, signs of infection
for example warts or ulcers

Ask the patient to cough looking for signs of prolapse.

Speculum Examination

Think about the size of the speculum needed and use lubrication

Explain to the patient what you are going to do before proceeding

1. Expose the introitus by spreading the labia from below using the index and middle finger

2. Gently insert the speculum at a 45 degree angle and pointing slightly downward

3. Gently rotate the speculum to a horizontal position and gently open the blades until the
cervix is in view (the blades may not need to be fully opened)

4. Secure the speculum by turning the thumb nut

5. Visualise the cervix and vaginal walls for any abnormalities, such as ectopy, cysts or polyps

6. Comment on whether the cervical os is open or closed? (parous or nulliparous)

1052
 1053

7. Perform any necessary tests, obtaining samples for culture and cytology (below)

8. Withdraw the speculum slightly to clear the cervix and gently loosen the speculum
to close the blades

9. Continue to withdraw whilst rotating the speculum to 45 degrees, avoiding contact

with the vaginal walls

10.Tell the patient that you have finished, give a towel to the patient to wipe herself.

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233. CERVICAL (PAP SMEAR)

Info : All women who are registered with the GP are invited for cervical screening:

Aged: 25 to 49 – every 3 years.

Aged 50 to 64 – every 5 years

Over 65 – only women who have recently had abnormal cells.

Before proceeding, rule out any contraindications like:

● Pregnancy

● Active menstruation

● Active Vaginal bleeding

● Recent Sexual intercourse

● Recent use of spermicidal gel

1054
 1055

You are an FY2 doctor in the GP clinic.

A 43 year old lady is invited to the clinic for routine pap smear.

Her last smear was 3 years ago and findings / result was normal.

Take relevant history, assess the patient and do the necessary procedure.

Dr: Hello... I’m Dr ...........one of the junior doctors in the GP clinic. How are you doing?

Pt: I’m fine doctor.

Dr: How may I call you? Pt: ..........

Dr: Okay Mrs. .... How can I help you?

Pt: I got a letter from the clinic. They told me to book an appointment for cervical sampling.

Dr: I’m glad that you came here for the check-up. And of course, it’s a good practice to have
the pap smear examination in appropriate time intervals. Thanks for coming in. Pt: ...........

Dr: May I ask you a little bit about you before the procedure, if that’s okay with you? Pt: Sure.

Dr: Mrs....... Can you please confirm your age for me? Pt: I’m 43, doctor

Dr: Alright! When was the last time you had a smear sampling?

Pt: It was 3 years ago. The doctor said that my smear was normal, and advised me to
undergo sampling every 3 years.

Dr: I’m glad to hear that the last smear was normal and yes, we do perform cervical
smear every 3 years even if the results are normal. The main purpose of this
examination is to check whether if there are any abnormal cells in the smear which can
later develop into cancer. Are you following me? Yes
Dr: Mrs...... may I ask when was your last menstrual period (C. I)? Pt: It was 3 weeks ago doc!

Dr: Are your periods normal? Yes.

Dr: Do you have any bleeding from the vagina in between your periods or during
intercourse (symptoms of cervical cancer)? No

Dr: Alright. Do you have children?

Pt: Yes doctor, I have two children. The older one is 13 and the other one is 10.

1055
 1056

Dr: So your last child birth was 10 years back. Is that right? Pt: Yes!

Dr: Were both of the deliveries normal? Pt: Yes.

Dr: Do you have any bleeding? Any discharge? From your front passage Pt: No doctor!

Dr: Dr: Are you using any contraceptives now? (ask about IUD) Pt: No

Dr: Are you sexually active now? Do you practice safe sex? Pt: ......................

Dr: When was the recent sexual intercourse (C.I) ? ....

Dr: Have you used any spermicidal for contraception recently (C. I)? No

Dr: Okay Mrs. .. was there any surgery or any instrumentation done to your tummy or
your front passage recently? Pt: No, doctor.

Pt: Do you have any medical conditions? No

Dr: Are you on any medications now? No

Thank you Mrs........ now I would like to perform the smear sampling.

Could you please empty your urine bladder first and then please undress from below
your chest to mid thigh. I will have a chaperone with me and will provide you adequate
privacy. Pt: Okay, doctor

SMEAR SAMPLING

COMMENT ON THE POSITION (MODIFIED LITHOTOMY):

Position the patient correctly: she should be lying on her back, heels drawn up
towards her bottom and knees gently relaxing open.
CHECK FOR THE EQUIPMENTS IN THE TRAY. PROCEED TO THE MANNEQUIN.

Check the trolley for:

● Pair of gloves

● Cusco’s speculum

● Cervical brush

● Sure Path

1056
 1057

● Few wipes

● Lubricating Jelly

● Clinical waste bin

● Good source light

1. Wear Gloves

2. Perform a quick inspection of the abdomen and genital area and comment on the findings.

“Abdomen is normal, no distension, no scars, no visible pulsations, no dilated veins,

no visible peristalsis.”

“No vaginal bleeding, discharge, no obvious masses or visible swellings in the groin.
Hair patterns looks normal.”

3. Tell the patient about the procedure before you begin.

4. Warm the speculum and add lubricating jelly to it.

5. Warn the patient before introducing the speculum – part the labia and insert the
speculum closed position (blades vertical), rotate (blades horizontal), and open the blades
and when you visualize the cervix, retain the speculum and fix it.

6. Insert the brush deep enough to allow full contact with the cervix

7. Verbalise: “I can see the cervix, the os is closed and there is no cervical erosion, no
bleeding, discharge or any growth.”

8. Push gently the brush and rotate 5 times in a clock wise direction

9. Gently remove the brush and dip it 10 times in the Thin Prep Bottle, and then shake it
well.

10. Inspect for any remaining cells then discard the brush in the clinical waste bin.

11. Tighten the cap of the bottle and send it to the lab after recording patient’s details on it.

If the bottle is sure path, drop the brush in the container.

1057
 1058

12. Warn the patient that, “I am going to remove the speculum”: release the screw, unlock
the blades, and remove it little outside (to make the cervix free), de-rotate the speculum.

13. Look for any bleeding or any discharge, and then send it for sterilization.

DISPOSABLE SPECULUM - DISCARD

METALLIC speculum - SEND FOR STERILISATION

Thank the patient. Give wipes for cleaning and ask her to dress up.

Dr: Once again, I would like to appreciate you for coming in today. My seniors will get
in touch with you soon after we get the result.

Pt: Thank you, doctor

The results of your screening test will be sent to you in the post in about 2 to 3 weeks
time, with a copy sent to your GP.

Any concerns? No Thank you.

----------------------------------------------------------------------------------------------------------------

Talk about the information below only if the patient asks any thing :

The types of screening result you may get depends on how your screening sample was
tested.

1. The first test carried out on the cell sample is either:

● to look for abnormal cells (cytology) or

● to test for human papilloma virus (HPV) — this is called HPV primary screening

2. Test results for abnormal cells

If the first test carried out on your sample is to look for abnormal cells (cytology), you
should receive one of the following results.

Normal

A normal test result means no abnormal cell changes have been found. No action is
needed and you don't need another cervical screening test until it's routinely due.

1058
 1059

Inadequate

You may be told you need to have a repeat test because the first one couldn't be read
properly.

This may be because:

● not enough cells were collected

● the cells couldn't be seen clearly enough

● an infection was present

You'll be asked to go back so another sample of cells can be taken, usually after about
3 months.

Abnormal

If you have abnormal results, you may be told you have:

● borderline or low-grade changes dyskaryosis

● moderate or severe (high-grade) dyskaryosis

If your result is low-grade, it means that although there are some abnormal cell
changes, they're very close to being normal and may disappear without treatment.

In this case, your sample will be tested for HPV.

- If HPV isn't found, you're at a very low risk of developing cervical cancer before your
next screening test.

You'll be invited back for routine screening in 3 to 5 years (depending on your age).

- If HPV is found, you'll be offered an examination called colposcopy, which looks at

the cervix more closely.
If your result is high-grade dyskaryosis, your sample won't be tested for HPV, but
you'll be offered colposcopy to check the changes in your cervical cells.

All these results show you have abnormal cell changes. This doesn't mean you have
cancer or will get cancer.

1059
 1060

It just means that some of your cells are abnormal, and if they're not treated they may
develop into cervical cancer.

A colposcopy is a simple procedure used to look at cervix, the lower part of the womb
at the top of the vagina. It is often done if cervical screening finds abnormal cells in
your cervix.

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 1061

You are the FY2 doctor in the surgical department.

Mrs .. Moulton, a 44 year lady presented to the hospital because she is concerned
about a lump in her breast.

Take a history, examine the patient and talk to her about the further management.

Dr: Hello Mrs…Moulton, Pt: Hello

Dr: I am Dr … one of the junior doctor in the surgical department. How can I help you
Mrs Moulton?

Pt: Doctor, I noticed a lump in my breast. I am really worried, doctor.

Dr: Mrs Moulton, do not worry about it because most of the lumps are not any serious
condition. Can you tell me anything more about it please?

Pt: I noticed it today morning when I was having a shower. Dr: Anything more can you
tell me about it?

Pt: Like what doctor?

Dr: Is it painful at all (mastitis) ? Pt: No

Dr: Which side breast is that? Pt: Right side doctor.

Dr: Have you noticed any swelling on the left side? Pt: No

Dr: How many lumps have you felt? Pt: One/two doctor.

Dr: Do you have fever (mastitis)? Pt: No

Dr: Did you notice any discharge (intra ductal papilloma), or blood discharge (cancer)
from the nipple? Pt: No

Dr: Do you get your menstrual period now? Pt: Yes / No

Dr: If yes - Do you have your menstrual period now (Fibroadenosis – lumps are felt
during the menstrual period)? Pt: No

Dr: Have you noticed any lumps on your arm pits? Pt: No

Dr: Have you injured your breast? Pt: No

1061
 1062

Dr: Are you currently breastfeeding, or have done in the past? Pt: Yes/No

Dr: Did you have any such swellings in the breast before? Pt:No

Dr: Any of your family members had breast lumps? Pt: No/Yes.

Mrs Moulton I need to examine your breasts now. Pt : Ok doctor.

Examine the breast.

Explain the procedure “While examining, I will be asking you to do some manoeuvres and will
be looking at you and touching your breast and arm pits to feel for any lumps. If you feel
uncomfortable at any point, please let me know and I will stop the examination.”

Exposure: Can you please undress above your waist?

I will ensure privacy and have a chaperone with me. Is that OK?

[Position: 3 different positions will be used during examination. Sitting, Lying down
at 45 degrees and Standing.]

Ask for exposure by saying, “May I ask you to sit down please.”

The patient will go and sit on the edge of couch. Begin the examination with inspection

1062
 1063

Inspection: all in sitting position, and examine both the breasts at the same time. Do it in 5
different positions, all sitting:-

1. Sitting straight, hands on thighs. Ask “Could you please rest your hand on your thighs?”

● Both the breasts are symmetrical.

● The level of nipples is on the same line.

● There are no skin changes or any pigmentation.

● I cannot see any obvious lump.

● There is no redness, scar, swelling or sinuses

2. Sitting, hands on sides and bending forward. Ask “Could please place your hands
on your hips and lean a bit forward?”

“I cannot see any lump or swelling becoming obvious on bending forward.”

1063
 1064

3. Sitting, Inframammary region. Ask “Can you lift your breasts with two fingers?”

There is no eczema or fungal infection in infra-mammary region.

4. Nipples. Ask “Can you squeeze your nipple with your two fingers?” (You (the
doctor) must not squeeze).

“There is no bleeding or discharge expressed from the nipples.”

5. Lymph Nodes. Ask “Please raise your hands and put behind the head please?”

“I cannot see Axillary fullness or supra clavicular fullness.”

Palpation:

Palpation is in the lying position and at 45 degrees. If it is not at 45 degrees, ask the examiner.

Tell the patient: “Could you please lie down on the couch?”

Warn the patient: “I am going to touch your breasts now. If you feel discomfort or
tenderness please let me know.”

During palpation you should not poke with fingers. Feel with the fingers kept close
together, providing a flat surface.

Temperature: Warm your hands and check for the local rise of temperature comparing
with the opposite breast of each quadrant and say: “There is no rise in temperature.”

Tenderness: Start with the superficial palpation. Do an anti-clockwise palpation. Check

the patient’s face for tenderness. “There is no tenderness in superficial palpation.”

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 1065

Deep palpation: Warn the patient: “This time, I am going to touch your breast
deeper.”

- Palpate axillary tail of spence

- Check peri-areolar region for any swelling.

- Then check all the quadrants moving anti-clockwise.

If a lump is present, describe the lump.

Site: e.g. upper outer quadrant of right breast

Size: e.g. 2X2cms

Surface: smooth /irregular

Consistency: soft / firm /hard

Margins: well defined/ill-defined

Relation to overlying skin and underlying structures

Mobility

Tenderness

 Summarise your findings: eg

“On deep palpation, there is a mass of about 2 cm by 2 cm, present in the right upper outer
quadrant, which is not tender on palpation, not attached to overlying skin, attached to
deep structure and it is mobile.”
Axillary Lymph nodes: In standing position

Inform the patient that: “I will be examining the lymph nodes or swellings in your arm
pit. Could you stand up for me please? ”

For checking patient’s right side, say: “Can you please put your right hand on my right
shoulder?” Put your right hand on her right shoulder and examine axilla with left hand.
Examine all groups of Axillary lymph nodes; apical, medial, anterior

1065
 1066

Ask the patient: “Can you please cross your hands in front of you?”

Go to the back with permission and examine lateral and posterior lymph nodes. You
can examine both sides together.

“Ideally, I will finish my examination by examining the supraclavicular lymph nodes.”

Thank the patient. “Thank you very much, you can dress up now.”
Talk to the patient:

Mrs Moulton, I have found a (one or two) swellings on your right/left breast.

Do you have any idea what it could be? Pt : Is it cancer, doctor ?

Dr: Mrs Moulton, please do not be worried now because as I already told you before,
most of the time lumps in the breast are the non cancerous type. Very rarely only, they
can be cancerous. At this moment, we cannot say what exactly it is.

We will refer you to the breast specialist. They may do investigations like what we call
triple assessment — that the specialist will examine you and then he may do some
tests like Ultra sound scan (type of gel test that they do on pregnant ladies) or
Mammography a type of special X-Ray of the breasts. Thirdly, they may do another
test where they take a small tissue sample with the needle from the breast.
Pt: What is the treatment, doctor?

Dr: The specialist will tell you depending on the investigation result. Is that OK? Pt : OK.
Dr: Once again Mrs ,please do not be worried too much about it.
------------------------------------------------------------------------------------------------------------
Do not give the diagnosis of cancer or fibroadenoma even if you are sure of
Fibroadenoma.

Breast Examination is the same even if the patient had breast augmentation. The
breast lump will be more prominent if the patient had breast augmentation because
the breast implant will be inserted behind the breast tissue.

OTHER MANNIKIN STATIONS

Case 36

Case 196

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235.
A 25 year man made an urgent appointment to see you.

Talk to him and do the relevant examination.

Assume you are gloved.

Dr: Hello Mr... How can I help you?

Pt: Doctor, I went to a testicular cancer awareness campaign / I saw a poster on testicular
cancer / went to a program of testicular cancer. Then I went home and checked myself. I
think I have a lump in my testicles. I am very worried that it is a cancer.

Dr: Mr...Please do not be worried. Not all the testicular lumps are cancerous. Even if it
is cancer, there is good treatment available. Can you please tell me more about it ?

Pt: I just noticed it yesterday. I don’t know what else to tell you.

Dr: Which side? Left side.

Dr: How many swellings did you notice ? One

Dr: Does it come and go (i.e does it disappear on lying and appears on standing up?
Or is it present all the time (hernia)? No difference.

Dr: Does it come out when you cough (hernia)? No

Dr: Ok. Do you have any pain (torsion, epididymitis) ? No

Dr: Fever (epididymitis)? No

Dr: Any discharge from the urethra? No.

Dr: Any other swellings anywhere else? No

Dr: Any swellings in your groin area? Pt: No

Did you hurt yourself on the testicle recently (haematoma)? Pt: No

Weight loss? Pt: No

Have you had any such swellings in your testicles before?

Any operations on testicle previously (undescended testis)? No

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 1068

Did you have a condition called undescended testis – normally the testis is within the tummy
wall until birth and the testis moves down into scrotum by the time of birth.
Did you have this condition where the testis did not move down into the testis when you were
born ?

Any other medical conditions? No

Any medications ? No

Do you smoke? No

Any of your family members had cancers in their testicles do you know? No

Anything else you think is important that we need to know? No

Examination:
Mr: I need to examine your genitals which involves penis, testicle and the surrounding
areas. Could you please undress below the waist? I will ensure the privacy and have
chaperone with me. Is that Ok ? Pt: Ok doctor.
Examine the manikin: (lying down or standing position)

Tell the examiner – I assume I am wearing gloves.

Inspection:

Penis: Looks normal, Groin area — appears — normal, No swellings in the groin area.

Scrotum: Each side separately.

Ask the patient to move the penis to a side. Then you move the penis to a side
yourself.

Inspect the scrotum front and back of the scrotum by lifting each side.

Left side slightly swollen than right. No skin changes, no redness, ulcers, scars or
sinuses.
Palpation:

Palpate front and back of the testicles.

Tell the patient : I am going feel the testicles - "if you feel any pain or discomfort
please let me know”.

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 1069

Feel the right side scrotum:

“Non-tender. No lumps felt.”

Feel the superior pole – “can get above the swelling.”

Epididymis (posterior aspect) and spermatic cord (superior pole) – feel with thumb
and index finger - “feels normal.”
Palpate left side : “Non-tender. 2cm X 2cm lump felt at the infero –lateral part of the
testicle. Not attached to the skin. Feels attached to the testicle. Firm in consistency.”

Feel the superior pole – can get above the swelling. Epididymis and spermatic cord
feels normal.

First of all, mention no swelling in the scrotum, then feel for the root of the scrotum
(Say, ‘I can get above the swelling’)

Cough impulse: ask patient to cough and check for any swelling in the groin area : No swelling.

Fluctuation test: feels firm, not cystic.

Do transillumination test if the fluctuation test positive :

Tell the examiner: I would examine the abdomen for any masses for lymph node
enlargement. (the testicle drains to the para - aortic lymph nodes, penis and
scrotum drains to the inguinal lymph nodes).
Tell the patient: Thank you very much. Could you please dress up now ?

Pt: What do you think, doctor?

Dr: Mr ..... I did feel a small lump on your left side testicle. It seems attached to the
testicle. It could be a lump of the testicle itself. We will urgently (next few days) refer you to
the specialist doctor called Urologist. They will do further tests like blood tests to check some
tumour markers and then an ultrasound scan of the testicle, and also a CT scan of your tummy
and Chest X Ray. Pt: Doctor, is it cancer?

Dr: I can understand that you must be very worried. However, unfortunately I cannot answer
your question at the moment. The specialist doctor will tell you that after all the investigations.

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As I mentioned earlier, even if it is cancer we have good treatment.

Only if the patient asks – mention the following:

Pt: How do you treat if it is cancer?

Dr: If all the investigations that I mentioned earlier suggest that the chance of cancer is
very high, then we need to remove the whole testicle by doing an operation and the
sending it to the lab to confirm the diagnosis.

Pt: Why remove the whole testicle? Why can’t you take a small sample from the
testicle and test for cancer?

Dr: Unfortunately, we cannot take a small tissue sample from the testicle because if we
do that, then if it is cancer it can spread very fast. However we remove the testicle only
if the chance of cancer is very high on other investigations and if it is cancer, most of
the time removing testicle will cure the condition.

Sometimes, we may need to treat with chemotherapy (special cancer medications)

and Radiation therapy.

Pt: Can I become a father if you remove my testicle?

Dr: Yes, surely you can as long as the other testicle is fine. Another option is that we
can store the semen if you wish.

Pt: Won’t my scrotum look odd ?

Dr : We can insert prosthesis and it will look normal again.

Pt: Will it come back doctor once you remove it?

Dr : Unfortunately, there is a slight chance that it may recur.

Pt: Will I get cancer in the other testicle?

Dr: Unfortunately, there is a slightly increased chance of getting cancer in the other
side testicle compared to those who never had testicular cancer. It is very important to
keep checking for that. You need to keep going for proper follow up.

Any other concerns? No Thank you.

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Testicular malignancy

Peak age range between 20-40

Between 20-30, non-seminomatous germ cell tumours such as teratomas Between 30-40

more likely to be a seminoma

If suspicion, all patients should have urgent ultrasound scan of testicles, chest x-ray and
tumour markers checked (Beta-HCG, Alpha fetoprotein and Lactate Dehydrogenase [LDH])

Treatment is most commonly INGUINAL orchidectomy due to lymph node drainage of the
testicle

1071
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1072
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SIMMAN STATIONS

236. Lady scheduled for discharge today. She was admitted 6 days ago. A nurse
called you because the patient stopped responding. Evaluate and manage.
Talk to the examiner while examining.

It’s a Simwoman on the couch and her hands are dangling on the side. Only the
Examiner is inside. There is a table nearby with different syringes labelled with
Dextrose, a glucometer and a sheet with a list of her medications. Patient has been
treated for pneumonia.

Dr : Hello I’m Dr…. A junior doctor in this department, can you confirm your name please?

Pt : no response. (for some candidates, the eyes might be blinking)

Look at the monitor : Vitals are stable. HR : 72, BP : 145/90, SpO2 : 96%, Temp : 36.5,

Dr : Checking airway Examiner: clear

Dr : Checking breathing Examiner: Auscultation b/l crepitations +

Dr : Circulation - will be checking capillary refill Examiner : normal

Dr : I want to check her notes

Examiner takes the files from underneath two other files and gives you

Notes say : she is hypertensive, Diabetic on Tab Gliclazide 20 mg.

Dr : Disability - I’d like to check my patient’s blood sugar level. Examiner : 2.1mmol/l

Dr : Thank you examiner, I’d like to put an IV cannula and give 100 ml of 20% dextrose
intravenously

Examiner : What is your immediate management?

Dr : I want to check for response now

Examiner : The blinking has increased

Dr : I will talk to her

Examiner : She is well now, assess her

1073
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Dr : I will check for her diet today and assess her medications

Examiner : What else would you like to do?

Dr : Since she is a hypertensive, I would assess her plantar response to see if she had a stroke

Examiner : No response.

Dr : I’d check pupillary response and the size of the pupils

Examiner : Normal, what else?

Dr : I would run investigations : Urea, electrolytes, chest X-ray since she still has crepitations,
review her medications. I would call my seniors and inform them about the patient.
HYPOGLYCAEMIA SIMWOMAN

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237. POST-PARTUM HAEMORRHAGE

A 35 year old lady had her 5th delivery just now. She is bleeding. Assess and
discuss the management.

There is usually a nurse inside the cubicle.

Talk to the nurse first. Find out how much blood was lost, what type of delivery it was
and when it was.

Hello I am Dr.... May I know your name please ...

Nurse – I am ... Doctor, this lady had her 5th delivery just now and she is bleeding.

Dr: May I know what time she had the delivery (bleeding within 24 hour of delivery is
primary postpartum haemorrhage)? Nurse - ..

Talk to the patient

Dr - How can I help you? Patient only says hmm haa hmm (or she may say I can’t breath)

Check the monitor

Shows very low oxygen saturation, low BP and high pulse.

- Tell the nurse to give high flow oxygen (15 Litres/min) with mask with reservoir bag.
Saturation improves.

- Tell the patient I need to examine your chest and tummy.

- Remove dress from chest and abdomen. Blood visible in the vagina.

- Ask nurse: “Do you know how much blood she lost already?” She may show a bucket
which has blood in it (heavy bleeding).

- Ask the nurse the type of delivery: C/S vs vaginal

Reassure patient. “You are having some bleeding from your front passage. Please
don’t worry. We can manage that. We need to give you some fluid through your veins
and also a blood transfusion. I will call my seniors immediately. Is that okay?”

Pt – Yes doctor.

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- Tell the nurse to insert 2 large bore IV cannulae (grey colour 16G) in both forearms
and start her on 2 L Hartman’s solution (rapid infusion). “We also need to transfuse
blood immediately. Can you please take some blood for FBC, U& Es, Group and cross
match 4 units, clotting profile, LFT, Creatinine.” Nurse pretends to give fluids.

- Check the monitor. Blood pressure improves.

- Ask the patient: “Do you feel better?” Pt – Yes.

Dr - Do you have any problem now? Pt – No

- Auscultate chest, Examine abdomen. – Normal

- Ask patient “Have you had this type of problem before in your previous deliveries?” Pt: No

Dr: Do you have any bleeding disorders? Pt: No

Dr: bleeding from anywasre else? (role out DIC)

- Ask the nurse if she had any vaginal tear or episiotomy during this delivery? Nurse: Yes/ No

- “Was the delivery of placenta complete?” Nurse: Yes/No

- Tell the nurse to insert a urine catheter and monitor vitals and urine output.

- Tell the nurse we may need to give Oxytocin 10 mg IV.

- FBC, CLOTTING, GROUPING AND CROSSMATCHING

- “Let me call the seniors and Anaesthetist immediately.”

Examiner may ask questions (or may pretend as if he/she is the registrar).

1. What happened and what have you done so far ?

2. Why do you think there is a bleeding? What are the causes of postpartum haemorrhage?

Uterine atony, Incomplete delivery of placenta, Bleeding disorders and trauma during delivery.

3. What else do you think we may need to do to control the bleeding ?

We can give Oxytocin 10 mg IV, can be repeated once again. Or we can give
syntometrine. If the medical methods do not help, then we can do:

Bimanual compression of uterus, balloon tamponade, haemostatic brace suturing, bilateral

ligation of the uterine arteries or the internal iliac arteries, selective arterial embolisation or a
hysterectomy may be needed. She may need to be shifted to the operation theatre for some
of these procedures.

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Information

Postpartum haemorrhage is the second leading direct cause of maternal deaths in the UK.

It is defined as a blood loss of more than 500 ml from the female genital tract after delivery of
the foetus (or >1000 mL after a caesarean section).

Primary postpartum haemorrhage occurs within the first 24 hours of delivery, whereas
secondary postpartum haemorrhage occurs between 24 hours and 12 weeks after
delivery and is less common.

A PPH may be accompanied by one or more clinical signs and/or symptoms depending on the
amount of blood loss. Clinical signs of a PPH include palpitations, dizziness, tachycardia,
weakness, sweating, restlessness and pallor, and ultimately collapse.

If the blood loss is 500ml to 1000ml with no clinical signs of shock, then it is regarded as a
minor PPH. When there is a loss of over 1000ml, or the woman has signs or symptoms of
shock, then it is a major PPH .

Once a PPH is identified, four components of management should be instigated

simultaneously: communication, resuscitation, monitoring and investigation, as well as
measurements to control the bleeding.

Communication

The midwife should communicate to the woman and her birth partner the need to summon
help quickly and press the emergency buzzer.

If it is a minor PPH, the midwife in charge and first-line obstetric and anaesthetic staff should
be contacted in the first instance. For a major PPH, summon the obstetric, anaesthetic and
haematology consultants, as well as the blood transfusion laboratory and porters.

Resuscitation – the woman should be laid flat, her breathing assessed and she should be
kept warm. If required, she should be given a high flow oxygen mask at 10L to 15L per minute.

In the event of a minor PPH, with no clinical signs of shock, insert one large bore cannula and
start rapid fluid resuscitation with two litres of crystalloid.

For a major PPH, or if the woman is displaying signs and symptoms of clinical shock, insert
two large bore cannulae and transfuse blood as soon as possible. Until blood is available,
start a rapid warmed infusion of up to 3.5L of crystalloid (Hartmann’s solution two litres) and/or
one to two litres of colloid.

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Monitoring and investigation

In order to monitor the woman’s condition, her respiratory rate, pulse and blood pressure
should be assessed and a modified obstetric early warning system chart should be completed.

For a minor PPH, bloods for group and screen, full blood count and coagulation screen should
be taken and identified. The woman’s pulse, respiration rate, temperature and blood pressure
should also be recorded every 15 minutes. A foley catheter should be inserted and the
woman’s urine output should be monitored.

For a major PPH, in addition to the management above, these measures should be
considered: the woman’s blood being taken for crossmatch (four units minimum), a full blood
count and renal and liver function for baseline.

Also, the pulse oximetry, blood pressure and respiratory rate should be continuously recorded.
It is important to try to identify the possible cause or causes of the PPH . Then measures
should be taken to stop the bleeding.

Stopping a bleed

If the cause is uterine atony, the midwife should massage the uterus to expel any clots, and
administer drugs to promote contractions. The drug treatment used will depend on local
guidelines.

If management of the third stage was physiological, then either 10mg of oxytocin or one
ampule of syntometrine should be administered intramuscularly (IM), depending on clinical
circumstances and availability. If the woman has already received an oxytocic drug, a second
dose should be given. The RCOG and WHO recommend five units of oxytocin by slow IV
infusion, which may be repeated if required.

The WHO recommends that if IV oxytocin cannot be administered, or if the bleeding does not
respond to it, then IV ergometrine, syntometrine, or a prostaglandin drug should be given.

If the bleeding is unresponsive to oxytocin then a slow IV injection of 0.5mg of

ergometrine be given, unless there is a history of hypertension. However, ergometrine is not
advised if the placenta is still inside the uterus.

If the uterus contracts after these measures, a syntocinon IV infusion should be administered,
unless there is fluid restriction.

If a uterus is still not well contracted after the second dose of an oxytocic drug,
carboprost 0.25mg by IM injection repeated at intervals of no less than 15 minutes to a
maximum of eight doses (contraindicated in women with asthma) or misoprostol 1000μg
rectally should be used.

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Should these physical and pharmacological methods fail to control excessive blood loss, then
balloon tamponade, haemostatic brace suturing, bilateral ligation of the uterine arteries or the
internal iliac arteries, selective arterial embolisation or a hysterectomy may be needed.

Most causes of PPH will be successfully controlled via a second dose of oxytoc500 mlic drug,
bladder catheterisation and repair of vaginal tears. However, if not, subsequent management
is most effectively performed in the operating theatre.

Identifying possible causes of PPH

The four T’s to look for:

" Tone: Failure of the myometrium to contract adequately (atonic uterus) after the birth is
the most common cause of PPH.
" Tissue (retained products of conception): The placenta and membranes should be
checked to ensure they are complete

" Trauma: A vaginal examination should be carried out to check for any bleeding from
the genital tract. If this is the cause, the woman should be stabilised and the tear
repaired
" Thrombin (abnormalities of coagulation)

The woman’s blood loss should be observed to assess whether it is clotting.

Bimanual compression of uterus

1. Wearing gloves, place one hand inside the vagina, form a fist and push up in the direction of
the anterior vaginal fornix

2. Place the other hand on the abdominal wall and push down behind the uterus, pulling it
forwards and towards the symphysis

3. Press the hands together to compress the uterus

4. Maintain the pressure until the uterus contracts and remains retracted.

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238. POST-HYSTERECTOMY FOR DUB

Simwoman - condition has deteriorated now, not much given in the scenario
description outside the door. Go in and see her.

Presenting complaint: Feeling faint/dizzy and heart is racing

BP was 80/60 (give 2L Hartmann's solution via wide bore cannula but no further
improvement - means active bleeding internally?)

O2 stats in 70s (give O2 100% with Hudson mask and stats rise).

- Talk about blood transfusion.

- When vaginal examination is performed, no visible bleeding is observed.

- Chest will usually be clear, equal air entry bilaterally (possible PE). Vasopressors not
present to give for low BP.

- Had a hysterectomy for DUB and discuss reasons for dysfunctional uterine bleeding
(polyps, fibroids or cancer?) and deterioration at the 6 minute bell with the examiner - ?
haemodynamic shock from internal bleeding or shock?

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239. You are an FY2 in the Medicine Department.

An elderly lady (? Name/Age) was admitted 3 days ago for UTI

The nurse has called you and says that the patient has been “feeling poorly” and
that you are the only doctor available to see her.

Assess the patient and manage her appropriately.

When you enter the cubicle, there is no nurse to ask history. Breathing sounds are
heard from the speaker.

Only SIMWOMAN is inside with the monitors attached:

Temperature - 39 C

B.P-Low (for some, the B.P was normal)

Oxygen saturation – 88%

SW: “ I can’t breathe”

Look at the monitor

Dr: Don’t worry, Mrs. , You are in safe hands, we will do everything we can to help
you. I am going to give you some oxygen to help you breathe.

- Attach the oxygen mask and start O2 at 15 litres per min.

The examiner increases the SpO2 to 93%

Dr - Mrs. , I hope you are feeling better now. Your blood pressure is low so I will be
giving you some fluids through your vein.

A stand with IV fluid bag is present, connect the IV line to the cannula (no need to open
the cork). The examiner increases the blood pressure to normal.

Dr - The patient's temperature is very high so I would like to give Paracetamol IV.

Ask her why she is in hospital, she might tell you that she was admitted with UTI and
was being treated with antibiotics. Take a brief history

The examiner doesn’t respond.

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 1082

Dr - Mrs. , I would like to do a head to toe examination to find out the reason for your
condition. I would like to examine your chest and abdomen. For this, I would like you to
undress completely. I will ensure your privacy and make sure a chaperone is with me.

The examiner doesn’t say anything (doesn’t even say assume). You undress the
patient and proceed with the examination.

Chest examination - Bilateral crackles are present all over the lungs. This may occur in
SIRS (Systemic Inflammatory Response Syndrome).

Abdominal examination - Look for any distension, Guarding, Rigidity or any Supra-
pubic tenderness. Observe if any catheter is attached.

The examiner doesn’t confirm/deny the findings.

Dr - Mrs. , thank you for your cooperation. You can get dressed now (you cover
the SIMWOMAN)

“From the observations on the monitor and the examination findings, I think you may be
having a condition called septic shock, this means that the infection from your urinary
tract has spread throughout your body.”

“I would like to inform my seniors about your condition. I will check for any advance care
decisions whether to give active treatment or not. We may have to shift you to the ICU
so that you can receive the appropriate care.”

“I would like to arrange for a Chest X-ray. I would also like to do a FBC, Urea and
Electrolytes, Blood culture, and ABG and also test your urine for bugs. I would also like
to insert a catheter so that we can monitor your urine output (if it is not already
inserted).”

“We will contact and inform your relatives.”

- You might tell the patient that you want to look for Advanced Care

“We will review the antibiotics you are receiving. We will be starting you on some
stronger antibiotics through your veins to treat you. We may change these later when
the culture reports come back.”

SEPTICAEMIA AFTER UTI (SIM WOMAN)

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240. You are the FY 2 doctor in the A&E department.

Mr Alex .. a 60 year man is brought in by his wife to A&E department because he
is feeling dizzy and faint. Assess and discuss further management with him.

SimMan and Nurse are present inside the cubicle. Wife is not present inside the
cubicle.

Talk to the nurse first.

Dr: Hello, I am Dr.. May I know your name please? Can you please tell me about the
patient?

Nurse: Hello Doctor, I am Hawkins we have a patient here, Mr Alex, brought in by his
wife, I have attached the monitors, please look at the patient.

Dr: Do you know why he was brought in?

Nurse: He has some problems. You can talk to him, doctor.

- Look at the monitor – vitals may be stable/fluctuating (keep looking at the monitor)

- Then talk to the patient.

Dr: Hello Mr. Alex .. I am Dr .... How can I help you?

Pt: Doctor I am having dizziness and feeling faint.

Dr: Since when? Pt: Since the last 3 days.

Dr: When do you feel dizzy? Pt: When I walk for some time.

Dr: How is it now? Pt: It is getting worse.

Dr: Anything else other than dizziness? Pt: Like what?

Dr: Did you lose consciousness? Pt: No, but I feel like I am going to faint.

Dr: Do you chest pain? Pt: No, I feel some discomfort in my chest.

Dr: What do you mean by discomfort? Can you please describe it? Pt: I can’t describe –
I feel it all over my chest.

Dr: Any was shortness of breath? Pt: Yes/No

Dr: Do you feel your heart beating fast or slow (palpitation)? Pt: Yes/no

Dr: Do you have any headache? No

1083
 1084

Dr: Any weakness in your arms or legs (TIA)? Pt: No

Dr: Any earache? Pt: No

Dr: Any balance problems? Pt: No

Dr: Do you have pain in your tummy? Pt: No

Dr: Any change in your bowel habits?

Dr: Any loose stools? Pt: Yes/no

Dr: Any bleeding from your back passage? Pt: Yes/No

Dr: What is the colour of your stool? Pt: Normal/Dark colour/I didn’t look my stool
recently.

Past history

Dr: Have you had this problem before? Pt: No

Dr: Did you have any medical conditions previously?

Pt: I have Osteoarthritis - knee joint pain.

Dr: Do you take any medications for that? Pt: Yes/No painkillers

Dr: Which one? Pt: Diclofenac.

Dr: Who gave you that (prescribed doctor or over the counter)?

Dr: How long have been taking this medication? Pt: For many months.

Dr: Any other medications (PPIs, Steroids, Blood thinners)? Pt: No

Dr: Do you have bleeding from anywhere like – urine, nose, gums ? No

Dr: Do you have any bleeding disorders? Pt: No

Dr: Any heart problems? Pt: No Dr: HTN? Pt: No Dr: DM? Pt: No

Dr: Do you have any allergies? Pt: No

Patient says – I soiled myself now doctor/I am dying doctor.

Dr: I see. Don’t worry. You are in a safe place. I need to examine you.

Check the monitor again – Blood drops to 90/60, Pulse – very high. Low oxygen
saturation.

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 1085

Ask nurse to give IV fluid immediately (Hartman’s – one litre bolus within 10 min). Use 2
large bore cannulae (Grey colour – 16G) in 2 arms;

Give Oxygen (mask may be present on the manikin)

Nurse will put cannula on the arm. Examiner says assume she has given fluid.

Check the monitor again.

Blood pressure picks up and Oxygen saturation improves.

Ask patient “Are you feeling better?” Pt: Yes, doctor.

Dr: I need to examine your chest and tummy. Can you please undress?

Doctor you do it. Remove his hospital gown.

Examine chest

Inspection - Chest appears normal on inspection. Movements symmetrical. Auscultation

– normal.

Examine abdomen – Inspection, palpation percussion auscultation normal.

Remove inners – Malaena – dark stool visible.

Cover him

Diagnosis:

I can see you have passed dark loose stools now. Looks like you have bleeding in your
tummy. It could be due to the Diclofenac medication you are taking which causes
damage to the stomach wall or ulcers in the stomach and causes bleeding in the
stomach.

Further investigation and treatment

Dr: We need to do some more blood tests – check for anaemia, blood group and cross
match, clotting tests. We need to give blood transfusion immediately. Is that okay? Pt:
Yes, doctor.

“We will call the specialist doctors called Gastroenterologists. They will do a test called
Endoscopy which is a camera test where they pass a tube with a camera at its tip
through your mouth to the food pipe and stomach. This will help to check where the
bleeding is, and also it will help to stop the bleeding. We will also give some medication
called PPIs.

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Pt: Can I go home? Dr: No unfortunately this is a very serious condition. We need to
keep you in the hospital and treat you.

Tell the nurse. Could you please send the blood for the tests and keep monitoring the
patient and arrange for blood transfusion. I will inform my seniors and call the
Gastroenterologists to come immediately. Nurse – Okay, doc

Thank the patient, nurse and the examiner.

UPPER GI BLEEDING - SIMMAN

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241. You are an FY2 doctor in the A&E department

A 55 year old female presented with a history of severe pain on her right leg since
the morning of that day.

Take history, examine the patient and comment on the management.

Differential diagnoses:

1. Peripheral arterial disease

2. DVT - pain in calf
3. Acute limb ischemia - the pain is below the obstruction and the foot will be painful
4. Sciatica
5. Neuropathy (Diabetes, Alcohol, Vitamin B12 deficiency)
6. Cellulitis
7. Trauma (causing a fracture)

Causes of acute limb ischemia

" Trauma
" Atrial fibrillation (commonest cause)
" Atherosclerosis - the patient might have a history of intermittent claudication
" Compartment syndrome - caused by trauma or a cast

Dr: Hello, I’m doctor............. One of the junior doctors in the A&E department. How can I
help you today?

PT: I am having pain in my right leg, doctor! I was absolutely fine until yesterday. I can’t
take this pain anymore. Please help me!

Dr: I’m sorry to hear that Mrs ..........but don’t worry. I will definitely help you. Could you
please tell me a little bit more about this pain?

PT: It has just started on its own since this morning. …I don’t know why this happened…

DR: Are you comfortable talking to me right now? Pt: Okay doctor

DR: Can you please tell me where exactly the pain is?

PT: It’s all over my right leg, doctor.

DR: Can you grade the pain for me from 1 to 10, 1 being the mildest and 10 being the
most severe? PT: ………..

DR: Is it coming from the back of your body, and travelling to your leg? (sciatica) PT: No

1087
 1088

DR: Is it getting better or worse? PT: It’s the same, doctor

DR: Is there anything that is making it better or worse?? PT: No doctor.

DR: Are there any other symptoms, apart from the pain?

PT: I feel my legs are weak, doctor.

Did you fall or were you involved in a road traffic accident?

Did you have any fracture or cast put in your leg?

DR: I’m really sorry about that as well. Do you feel weakness in both of the legs or just
the right leg? (Nerve compression) PT: My right leg, only doctor.

DR: Any other symptoms?? PT: No

DR: Were you having pain in the legs while walking for some distance? PT: No (PVD –
Limb ischemia)

DR: Was there any pain in your legs at night? (LIMB ISCHEMIA)

DR: Do you have pain in your chest?? (DVT AND PE) Pt: I had pain 2 weeks back. But
it’s not there now.

DR: What else did you have in addition to the chest pain?? Pt: I felt my heart was
thumping at that moment.

Dr : Do you have palpitations – racing of heart? Yes/no

DR: Do you feel short of breath?? PT: No (PE and AF)

DR: Do you have more pain on your calf muscle? PT: No (DVT)

DR: Have you taken any recent flight travel? PT: No (DVT and PE)

DR: Did you undergo any recent surgeries? PT: No (DVT)

DR: Alright. Do you have a fever? (CELLULITIS) PT: No

DR: Did you have any injury to your leg? (TRAUMA)

DR: Is this the first time that you are having a pain like this? PT: Yes, doctor

DR: Do you have any medical condition? HTN? DM/High cholesterol? Heart disease
(atrial fibrillation) No

DR: Are you on any medications now??? PT: No

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 1089

DR: Are you allergic to any medications? PT: No

DR: Do you smoke? PT: Yes ..(most common risk factor for PVD)

(She may be a chronic smoker)

DR: Is there anything else you would like to tell me?? PT: No doctor

Examination:

Okay Mrs….. I would like to examine you. Check monitor. I would like to examine your
hands, chest and your legs as well. Would that be okay? I will ensure your privacy and
will have a chaperone with me. Pt: ok doctor.

Exposure: Could you please undress below the waist? Patient says you do it.

Remove the dress below the waist.

Legs: (Inspection: color, swellining and ulcers) Right leg will be bluish in colour. On
inspection, compare both legs. Look for pressure sores and mention you don’t see them.

Temperature: Compare both the legs (right leg may be cold)

No need to check for tenderness

Check femoral, popliteal, dorsalis pedis and posterior tibial pulses in both legs and compare.

Distal pulses (dorsalis pedis and posterior tibial pulses) absent on right leg

CHEST :

Inspection - Chest appears normal

Auscultation – No murmur heard. Normal heart sounds.

Thank you, could you please dress up now.

Cover the manikin.

Monitor shows Atrial fibrillation (very imp. Don`t forget). It is very important that you
look at the monitor!

Stop the examination at the 6th minute and proceed with management

Do you have any idea about what is happening to you? Pt: No, doctor

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 1090

Dr: On examination, your heart is beating irregularly. Your leg is bluish in colour and the
pulses in your lower part of legs are absent as well. From the information you have
given me and after the examination, I suspect you have a condition called ACUTE LIMB
ISCHEMIA. Do you know anything about it? Pt: No

Let me explain: we have blood vessels in our legs which supply blood to various parts of
the legs. Sometimes, this blood supply to the legs gets blocked with blood clots, which
we call emboli. Are you following me?? Yes, doctor

As I told you, your heart beating has an abnormal rhythm. In your case, I suspect it is an
emboli (blood clot) in the heart that is causing this problem. Usually, emboli are formed
in the heart, when there is an abnormal rhythm in the heart. It can travel from your heart
to the blood vessels in the legs and can block the blood vessels and stopping the blood
supply to the legs.. Are you able to follow me?

PT: Doctor, Am I going to lose my legs??

Dr: Unfortunately, this is a serious condition if left untreated. We need to admit you right
away? Would that be okay with you? Pt: Yes, doctor!

Dr: I would like to run a few tests. I will inform my seniors and the Vascular surgeons
immediately.

Give oxygen

I would like to do some blood tests, your blood sugar, blood cholesterol, clotting tests

[INR, APTT, U&E, creatine kinase, platelet count – don’t mention these to patient).

I would also like to take an x-ray of the chest, an ECG, which is a tracing of your heart
and an arterial doppler scan of your leg to confirm the condition. Specialists may also
consider doing CT angiography or MR angiography.

Pt: Ok, doctor..how are you going to treat me?? Is there any treatment for this?

Dr: Sure! I will explain the treatment options.

In order to relieve the symptoms, we will be starting you on painkillers (IV MORPHINE 5
mg) and would like to start on Oxygen to improve oxygen circulation in the legs.

If there is a cast, you need to remove the entire cast.

1090
 1091

The treatment depends on the test results. Vascular surgeons will assess you and they
will tell you the exact treatment. If the condition can be managed with medications, they
will give you a medication called heparin through your veins. If it is found that there is an
emboli as I mentioned, then surgeons have to do a procedure called embolectomy to
remove the clot from the leg (Fogarty catheter) or a vascular bypass to restore the
blood flow to the legs.

Are you following me??? PT: Yes, doctor

I sincerely advise you to stop smoking because smoking is the most common risk factor
for developing this condition. Also we would also check your cholesterol level and will
inform you accordingly

Dr: Any other concerns??

Pt: No, doctor. Thank you,

Dr: Okay, Mrs….. I will inform my seniors right now. Thank you .

SIMMAN - ACUTE LIMB ISCHEMIA

1091
 1092

242. A middle aged patient had undergone surgery on the abdomen and was
given one unit of blood. He was given another unit of blood and
experienced shortness of breath.

(Inside the cubicle, there is a Simman. He also has a wristband that stated
penicillin allergy. There is a bag of blood that is connected and a transfusion is
taking place at the moment. There is also a bag of IV fluid, adrenaline, colloid on
the table nearby.)

Monitor findings: ECG - normal Oxygen - 80-85% BP-Low

S - “Dr, I have shortness of breath”

D - “I am really sorry to hear about that”

S -“Dr, I can’t speak properly. My lips and tongue have swollen up, hands are itchy”

1. The first step is to stop the blood transfusion. Mention to the examiner – “I would like
to stop the blood transfusion immediately” – The examiner may say assume).

2. Check the monitor for vitals and tell the findings to the examiner.

3. D – Mr.. Please don’t worry I am going to give you some Oxygen now. You should
feel better. Mention high flow Oxygen (with reservoir bag) to the examiner. Oxygen
saturation may increase.

4. If saturation does not improve – auscultate chest – there may be rhonchi – give
salbutamol nebuliser – 5 mg – change to nebuliser mask.

5. Next step is to increase blood pressure.

Tell the examiner, “I would like to give”:

" 0.5 ml (500 micrograms) 1:1000 adrenaline (repeat after 5 min if no better) IM
" IV fluid (Normal saline - fluid challenge): Adult - 500 ml
" Chlorphenamine (IM or slow IV) - 10 mg
" Hydrocortisone (IM or slow IV) - 200 mg

Examiner may say - Assume Doctor.

The blood pressure may return to normal. Patient begins to speak properly

If the blood pressure does not improve – repeat the Adrenaline IM – call seniors
immediately. The seniors might give adrenaline IV infusion

D: Can you please tell me more about what is happening to you?

1092
 1093

“Dr, I had a surgery done on my tummy. Since then, I have been experiencing shortness of breath”

D - “Do you know if any antibiotics was given after the surgery?”
P - Yes (Which antibiotic do you know) / No

D - “Do you know your blood group?” P - “I am sorry Doctor, I do not know”

D - Are you allergic to anything you know of before ? P - Penicillin

Examination:

Check the wristband – Band may show allergy to Penicillin

D - “Is it alright if I examine you? I will ensure your privacy and I have a chaperone with me.”

Simman asks you to expose him on your own.

Examination findings - red spots all over the chest and dressing on the abdomen.

Cover the Simman

Diagnosis and management

D - From what you have told me, and from what I have examined, it seems that you
had a serious allergic reaction that we call an anaphylactic reaction. It happens when
you are allergic to something. In your case, it could be due to a reaction to the blood
transfusion or antibiotics.

I will check your notes as to see what kind of antibiotics were given to you after the
surgery. If it belongs to the penicillin group, then that could explain the symptoms.
However, I need to check if there has been any mismatch of blood as well.

I sincerely apologise for all you have been going through. I will talk to my seniors about this.

Examiner asks about further management

1. Blood bag to be sent to the lab for further investigation.

2. Patients blood sample for Blood group incompatibility.
3. Further investigations – Blood – FBC, U&Es, Creatinine, ABG, Clotting screen,
LFT,
4. Check for blood in the urine.
5. Inform seniors and blood bank immediately. Contact allergy specialist and
haematologist immediately.
SIMMAN - ANAPHYLAXIS DUE TO BLOOD TRANSFUSION OR ANTIBIOTIC

1093
 1071

243. An 80 year old man was brought in by wife, and he is feeling sick. Talk to him
and address his concerns.

(Inside the cubicle, you may find a Simman in a hospital robe and connected to the
monitors. Monitor reading: ECG - Normal, Pulse - 100 (tachycardia), Blood Pressure -
100/70 mm hg, SPO2-97%, Temperature - 37 degree Celsius)

S = Simman D= Doctor

D - “Hello, I am Dr ------ , one of the junior doctors in the department.” How can I help you?

S - “Dr., I am feeling sick”

D - “Do not worry, I am here to help you. Could you tell me more about it?”

S - “I am feeling very tired. I haven’t peed for a day and it is quite uncomfortable.

D - “I am really sorry to hear about that. Is it alright if I can ask a few questions to know
more about your condition?” S “Yes”

D - “Did you have tummy pain?

Did you vomit?

Do you have a fever? – I felt feverish

Were you able to pee well before this? No

Did you have to get up in the night many times to go to the loo? Yes

Dribbling? Pain while passing urine? - Yes there was dribbling.

Bowel movement-loose stools/constipation?

D - Any back pain? Weight loss (for cancer prostate?) - No

D – Any kidney stones before ? No

D - Any medical conditions? No

D - Are you on any medications? No

D - Are you allergic to anything ? No

D - Have you had any operations done on your tummy? Any history of catheterisations?

S - Yes, Dr. I was operated for TURP 4 days ago”

1071
 1072

D - Did you have any problems after the operation?

Examination:

Check NEWS chart: (temp, Bp (hypotesive) and pulse)

D - “I would like to examine you and will ensure privacy and chaperone. I would like to
examine your chest and tummy. Check for suprapubic masses and tenderness. Also
percuss for the bladder. Simman will ask you to undress him.

(Remove the hospital robe as well as the shorts underneath.)

Urine catheter attached to urine bag may show yellowish turbid urine with pus
collection. (No blood)

Examiner may say - chest is normal. Abdomen is normal except for supra-pubic tenderness.

Cover the patient after examination.

Talk to the examiner (or the patient if he asks you):

E - “Dr, what do you think this is?”

D - “I think this is urinary tract infection - probably after TURP. One of the most common
complications after TURP is infection.”

E - Alright, what would you like to do now ?

D-“I would like to take sample from the catheter bag - test for culture and sensitivity. I would
also like to test for urea and electrolytes as well as the FBC, blood culture and blood gases.

Examiner may show ABG: ABG shows metabolic acidosis. pH - low, Low HCO3, Low or
normal CO2.
E – How do you manage ?
“I would like to involve my seniors. I will give him broad spectrum antibiotics according to the
hospital protocol. I would like to do a USG (only say this if there is diagnosis of prostatic
enlargement) E- “Ok” don`t forget to change the catheter.

-------------------------------------------------------------------------------------------------------------

(Different scenario - Simman presents with enlarged prostate and had not passed
urine for 2 days. He was catheterised. He is posted for surgery 6 months later)

Similar to above except the operation was planned later.

SIMMAN: POST-TURP INFECTION

1072
 1073

244. A 30 year old man came to the emergency department with complaints of
SOB. Take history, examine and discuss your diagnosis and management
with the examiner.

Differentials for Shortness of breath

" Acute Asthma

" Acute exacerbation of COPD
" Heart failure
" PE
" Pneumonia
" Pneumothorax
" Anaphylaxis
" Arrhythmias (SVT)

Dr - Hello Mr ... I am doctor ... How can I help you Mr... ?

Pt - Doctor, I can’t breathe properly

Dr - Since when? Pt - Since the last few hours.

Dr - Did you have this problem before? Pt – Yes, I have asthma (known Asthma patient)

[If patient says – no, ask “Do you have Asthma or smoker’s cough?”, then patient may
say – “I have asthma”]

Dr - Did you take your medication?

Pt - Yes, it is not helping me. They are on the table. (Inhalers may be kept on the
table – Look at the medicines).

Look at the monitor for Oxygen saturation, Respiratory rate, Pulse and BP, Temperature,
ECG rhythm and tell the examiner. Usually oxygen saturation is 82 to about 84%. Tell the
examiner - I will give high flow oxygen 100% concentration with a flow rate of 15 litres/min.

Tell the patient – I am going to give you some oxygen you will feel better. Put the Hudson
mask with reservoir bag on the mannequin face and tie properly. Make sure it covers the
nose and the mouth.

1073
 1074

The maximum concentration you can give in a simple face mask is 60%. This is
because there are holes.

Expired air can go out of the Hudson mask but atmospheric air doesn’t go out.

Venturi devices are for patients with COPD. This helps to control the oxygen so
that you can give a low concentration. Blue is for 24%.

You can give a nebulizer mask if the patient is not responding to the oxygen that
you have given.

Dr - Any chest pain? (MI leading to heart failure)? Pt-No

Dr: Does SOB gets better or worse while lying down (heart failure)? No
change, doctor.

Dr: Have you had any heart problem before? Pt - No

Dr: What were you doing when this started (exercise-induced)? Pt: I

was just resting Dr - Any fever? (Pneumonia) Pt - No

Any triggers e.g pets, dust, pollen?

Keep looking at the patient monitor – Continue taking the history for a few
seconds while watching the monitor. Oxygen saturation should improve by
this time to about 96%. If not, check to see if the mask is fitted properly and
 1075

then jump to treatment. You will need to give a bronchodilator with a

nebulised mask. (I will put Salbutamol 5 mg in the chamber, change the mask
and also along with oxygen and call my senior immediately). Make sure the
saturation improves. And then continue.

Dr: Do you smoke (COPD)? Pt: Yes / No Dr: Any pain or swelling in c

Dr : Do you take any other medications other than inhalers? Pt – No

Check the monitor for oxygen saturation.

Examination

Exposure - Dr - I need to examine your chest. Can you please undress above
your waist?

Patient (mannikin) may say - you do it [and then you expose the
mannikin].

General Inspection

“Appears severely breathless, No cyanosis in hands and lips”

“No neck vein engorgement, No tracheal shift” (to r/o tension

pneumothorax) Chest:

Inspection – Movements symmetrical.

Palpation - Movements

symmetrical, Percussion – No

hyper - resonance or dullness

Auscultation: Air entry bilaterally equal, Wheeze heard bilaterally all over the lung fields.
No crepitations.

Cover the patient. Thank you

Tell the patient: “It looks like your Asthma has come back. We will
give you some medicine and you will feel better soon.”
Then talk to the
 1076

examiner.

Diagnosis – Acute

Severe Asthma

Tell the rest of the management to the examiner.

 I will admit the patient.

 Salbutamol nebuliser – 5 mg (usually given at the end of the

station but can be given in the beginning)

 Ipratropium bromide 0.5 mg Neb Hydrocortisone 100 mg IV every 6

hours

 Keep monitoring the oxygen saturation, respiratory rate, ABGs

 Do a portable chest X Ray (to rule out chest infections or

pneumothorax) and ECG If no improvement – repeat salbutamol

nebuliser every 15 minutes.

 I will call the seniors immediately.

 If no improvement – IV Magnesium 2gm over 20 minutes

 If no improvement, talk to seniors and consider Aminophylline infusion

 If still no improvement – needs intubation and ventilation so I will call

the anaesthetist also.

[If the patient says, ‘I am dying’ or appears to be in distress – stop

taking history or examination, check the monitor reassure the patient
that you will give medicine and he will be better soon, and tell the
management to the examiner and then continue].

Keep looking at the monitor at all times – jump to the treatment

immediately if the saturation does not go above 94% or if it drops
any time, or if the patient says I am dying or if the patient shows
signs of respiratory distress].
 1077

Talk to the patient

“Mr ... Your Asthma has come back. Your inhaler medication is not
working. So we need to keep you in the hospital and treat you with
nebuliser medications – salbutamol to widen your airways. This
medication will be given like a steam inhalation. We will also be giving
some steroid medication through your veins. Any questions?”

“We need to do some tests like chest X Ray to make sure that you do
not have any other problems. Also we will be doing some blood tests to
check blood gases and other things. Once you have improved then we
will discharge you. Is that OK?”

“Any concerns?”

If the patient does not know what is Asthma - then explain.

Dr: In this condition, your airways become narrow which causes

breathing difficulty. Sometimes, this condition runs in the family. Most of
the time, it is due to an allergy to dust, animal fur, pollen or sometimes it
may be due to exercise.

ACUTE ASTHMA
245. A 60 year old presented with feeling dizzy. Take a history and
perform examination and discuss the management with the
examiner. At the 6th minute, discuss findings with the
examiner.

(Positive findings – Dizziness, SOB and palpitations for about 2 weeks)

Find out about whether the dizziness and palpitations occur at the same
time.

Dr: Hello Mrs ... I am Dr ... a junior doctor in the medical department. How
can I help you?
 1078

Pt: I have been feeling dizzy and getting palpitations since the last 2 weeks.
Dr: I am sorry to hear that. Is there anything else you can

tell me about it? Pt: Doctor, it just started on its own. I

was perfectly fine before that.

Dr: You said you felt dizzy – is it like lightheadedness or you feel the

room is spinning? Pt: I feel like lightheadedness/not like the room is

spinning

Dr: Can you please tell me when you experience the dizziness – all
the time or it only happens sometimes? Pt : It happens only
sometimes

Dr: How many times it has happened since

it started? Pt: -- Dr: How long does it last?

Pt: ---

Dr: Did you lost consciousness any time at all? Pt : No

Dr Do you have any balance problem? Pt: Yes, I feel as if I don’t have balance
when I feel dizzy

Dr: Any problem in your ears like – hearing problem, any ringing sound

in ears? Pt : No Dr: You said palpitations – since how long you had

this? Pt : About 2 weeks.

Dr: Does it also comes once in a while or is it continuous? Pt: -

Dr: How many times you think you had this problem since it started ? Pt :

Dr: Do you feel dizzy when you get palpitations or they occur at different
times? Pt –

Dr: How do you feel the palpitations – do you feel as if the heart is racing or missing
heart beat? Pt –
 1079

Dr: Do you have any chest pain or did you have any chest
pain when all these symptoms started? Pt : No

Dr: Do you have shortness of breath? Pt : Yes

Dr: Since when? Pt: The same time as the palpitations.

Dr: When do you get SOB – all the time or when you lie down or when

doing exercise? Dr: Any swelling in your ankle (Heart failure)? Pt :

Yes/No

Dr: Did you have any recent surgery (PE) ? Pt: No

Dr: Recent travel (PE)? Pt: No

Dr: Do you get too tired (Anaemia)? Pt : No

Dr: Have noticed any bleeding from gums or back passage (anaemia)? Pt:
No

Dr: Any changes in bowel habits

(hyperthyroidism)? Pt: No Dr: Any weather

preference (Hyperthyroidism)? Pt: No

Dr: Have you been diagnosed with any medical

conditions? Pt : No Dr: Like high blood pressure? Pt

: No

Dr: Diabetes? Pt- No

Dr: Heart conditions? Pt: No

Dr: Are you taking any kind of

medications? Pt: No Dr: Are you

allergic to any medications? Pt:

No Dr: Do you live with any one?

Pt
 1080

: Yes/No

Dr: Is there anything else you think is important that we may need to know? Pt: No

Examination:

Mrs….. I need to examine your chest. Could you please undress

above the waist? I will ensure your privacy and have a chaperone
with me.

- Mannikin may say - Doctor, you do it. Then undress the manikin
(do not undress if the examiner says assume the patient is
exposed)

- Examine the hands – “no clubbing, palmar erythema, no cyanosis.”

Ankle – No pedal oedema

“Ideally, I will check for raised JVP (Can’t check JVP in Manikin)”

- Check the pulse (for about 10 seconds) – may show irregular rhythm.
- Examine the chest – “No scars or deformities in the chest.”

“I will check for the apex beat to look for a shift in it” (manikin has no apex
beat)

“No palpable thrill, No Parasternal heave”

- Auscultate all the areas for heart sounds and murmurs (may be
Pansystolic murmur). Compare the murmur with the carotid pulse
and if this is not available, then use the brachial or radial pulse.

- Auscultate for basal crepitations (on the sides of the chest because
you can’t make the manikin sit up) (there may be basal
crepitations)

" Check the monitor for Pulse rate, BP, Respiratory rate,
Temperature and tell the examiner your findings
" Check the ECG on the monitor – may show Atrial fibrillation
(irregularly irregular rhythm, narrow QRS complex, Absent
P wave) (Look at the ECG on the monitor for at least 15
seconds otherwise you may miss AF because sometimes a
 1081

normal rhythm comes in between an irregular rhythm)

" Cover the patient. Thank the patient.

Talk to the examiner

The patient has palpitations, dizziness and shortness of breath for the
last 2 weeks. Had no medical problems previously. On examination, I
found that the patient has a pansystolic murmur, basal crepitations and
the ECG shows atrial fibrillation with the pulse of ... and BP ...I think the
patient has heart failure, maybe secondary to mitral valve regurgitation
with Atrial fibrillation.

I want to do further investigations like FBC, U&Es, Cardiac enzymes,

Thyroid function tests, 12-lead ECG, chest X Ray.

Examiner may not give any results.

I will admit the patient, inform my seniors, give Oxygen, Insert IV cannula.

If the chest X ray shows heart failure, I will give her diuretics
(furosemide - start with 40 mg IV) and catheterise her.

We may need to do Echocardiography.

She may need to be treated with beta blockers and

anticoagulation for Atrial fibrillation. I will refer her to cardiology for
further management.

Sometimes the diagnosis is only – atrial fibrillation. There is no

history of SOB, ankle oedema, No murmur and basal crepitation
HEART FAILURE AND ATRIAL FIBRILLATION - SIMMAN
MISCELLANEOUS BREAKING BAD NEWS
STATIONS
 1082

MISCELLANEOUS BREAKING BAD NEWS

STATIONS
246. A 60 year old man was admitted one week ago with
ischaemic stroke. He had another ischaemic stroke
now. GCS is only 3. MDT decided not to ventilate.
Planned for palliative care only. You talk to the
daughter who is pregnant.

Assess knowledge

Break the news. “He has had a massive stroke: there is a big blood clot
in the brain – so there is no blood supply to the part of the brain. He is
unconscious now. Unfortunately, he will not recover. Our team has
planned not to resuscitate if his heart stops beating.
Also, the team has decided not to put him on a breathing machine if he
stops breathing because any of these procedures will not help him. “

Address concerns

Her main concern

Daughter: Can you please keep him alive until my baby is born which may be
next week?

Dr: First of all, congratulations on your pregnancy and that you’re

having a baby soon. I really wish we could keep your father alive until
your baby is born. But unfortunately, he is in a very critical condition
now. He may not survive.( And as I mentioned our team has decided
not to do any resuscitation) don`t use the word decided at any
chance
if his heart stops beating or if he stops breathing also.

Ask – any other concerns – Any help required.

MASSIVE STROKE - PALLIATIVE CARE

 1083

247. CANCER LUNG (Modified Station)

60yr old man referred by GP on account of shortness of breath.

NB: Patient isn't coughing, only 6 months history of

breathlessness and weight loss with significant smoking
history. Xray showed cannon ball appearance on the apical lobe
of the left lung(normal x ray for lung CA)

248. Patient 58 years old female has been called to the surgery
outpatient clinic to receive the results of her breast
screening mammogram and FNAC. Results show ductal
carcinoma in situ (Early cancer).

She has been self-examining herself. You are an FY2 in surgery.

Talk to her and give her management options.

(When you enter the cubicle, patient acts anxious and worried)

Risk factors for breast cancer

" Smoking

" Early menarche

" Late menopause

" Not breastfeeding

" Nulliparity

" Previous use of OCPs or HRT

" Family History

Dr: Hello I am Dr ----------- Are you Mrs Sharon? Pt: Yes, Dr.

Dr: How are you doing today Mrs Sharon?

 1084

Pt: Dr. I am really worried. I keep on self-examining. I have not found

anything. A few weeks back, I came for routine tests, they did an X-ray
and took some samples. Then a few weeks later, I received a letter
from your office and I came to get my results.

Dr: It is really good that you kept self-examining as it shows how

keen you are about your health. Sharon, I know that we have made
you wait for quite some time but biopsies usually take time to be
assessed and report to be confirmed. I am sorry we made you wait
for your results, but I have your results with me and I would be
discussing those shortly.

Would it be alright if I ask you a few questions first so that I can

explain test results better? Pt: Sure doctor what would you like to
know?

Dr: You mentioned that you haven’t found any lump in your breast.
Have you noticed any lump elsewhere in the body? No

Dr: Have you noticed any discharge from

your breast? No Dr: Any bleeding? No.

Dr: Have you noticed any change in your weight ? No.

Dr: Is there any history of you taking oral

contraceptive pills? No Dr: Have you ever

received hormone replacement therapy? No Dr:

Have you had breast cancer in the past?

Dr: Did you have any surgeries in the past? No

Dr: Does anyone else in your family have

breast cancer? No Dr: Do you smoke? No

Dr: Do you drink alcohol? No

 1085

Dr: And when was your last menstrual period? Pt: It has been years
doctor, may be 6 to 7 years now.

Dr: Sharon, is there anything specific that you are concerned about?

Pt: Dr, I am worried that I have cancer. I just want to know the results.

Dr: Yes Sharon I do have the results of your tests. Pt: What is it doctor?

Dr: Unfortunately, I don’t have good news for you.

Would you like to hear it alone or shall I call someone

to be with you? Pt: That is fine - you can tell me the

results.

Dr: Sharon, as you know we did a mammogram and FNAC biopsy,

unfortunately the
results show that you have an early form of

cancer in your breast. Pt: Takes a pause (acting

as if she is shocked)

Pt: But, doctor how it could happen? I have been self-examining since
I was young. I never felt any lump. How is it possible? (pt starts
blaming herself that may be she is not doing the test properly)

Dr: Mrs Sharon, I can’t even imagine what you must be going through
right now. But you are not to be blamed for this. It is an early form of
breast cancer. It usually has no symptoms. Most cases are found during
routine breast screening or if a mammogram (breast x-ray) is done for
some other reason.

If patient asks why she got breast cancer, you can say sometimes
breast cancer occurs in people who have (name some of the risk
factors) but in your case, we did not find a reason in your case.
Sometimes, cancer can happen without any known cause

Pt: Dr. I am really worried about breast cancer. Is there any hope for me?
 1086

Dr: Mrs Sharon your concern is really valid. We would help you in
whatever way we can. Let me reassure you although it is a cancer but
luckily it is at an early stage and as far as I know this particular cancer
carries a good prognosis. But I would like you to have a detailed
discussion with my consultant Surgeon and he may be able to tell you
about this condition in detail and you can discuss treatment options as
well.

Pt: Oh that’s why I got a call from surgery department.

Dr: Yes, Mrs Sharon, as far as I know the treatment usually revolves
around surgery. Surgical removal, with or without additional radiation
therapy or tamoxifen, is the recommended treatment for this type of
cancer.

Dr: Once again, Mrs Sharon I really wish that I had better news to tell you
today. Is there anything else I can do for you?

If the patient asks you what type of treatment is available for breast cancer,
you can ask her what she knows about it and she will tell you what she
knows.

Pt: Dr. I have been going through the internet and I was reading about
lumpectomy and mastectomy, can you please tell me more about them.

Dr: Mrs Sharon I am really glad that you are so concerned about your
health. It’s not every day that we come across patients who are so well
informed and concerned about their health.

Lumpectomy is a surgical removal of a discrete portion or "lump" of breast.

In this surgery, the tumour is removed along with the healthy margin
surrounding it. It is considered a viable breast conservation therapy, as the
amount of tissue removed is limited compared to a full-breast mastectomy.
The breast is not removed.

While in mastectomy, whole of breast tissue is removed.

The consultant is the one who decides what surgery will be suitable for you.

Dr: Mrs Sharon, is there anything else we can do for you? Pt: No doctor, this is
 1087

all.

Dr: In that case, Mrs Sharon I would be arranging an

appointment for you with my consultant surgeon as soon as
possible.

Dr: Mrs Sharon, I want you to know that you are not alone in this; we
are always here for you.

Dr: And I am very glad to see you so much interested about your
health. If you would like, I can give you few leaflets regarding your
condition which may help you in understanding it better.

Pt: Thank you very much doctor.

BREAST CANCER (DICU)

 1088

249. You are an FY2 working in Surgery department.

Mrs. Dollores, an 80 year old had been diagnosed with an
intracranial tumour. She had been operated on. While in the
recovery after the operation, she was noted to have developed left
sided facial weakness. She has been seen by a multidisciplinary
team and all tests have been done (FBC, Urea & Electrolytes, LFTs,
RFTs , ECG area all normal). A CT scan was done and she was
found to have had an ischaemic stroke. Her son is concerned
about his mother and would like to speak to you.

Assume consent has been taken to talk to the son

Task : Talk to the son and address his concerns. Discuss further
management

Find out where she lives and who she lives with, if she was independent
before the incidence. Find out where she’s going to be discharged to.
She might need 24 hour care
- either home care or being discharged to a care home

Dr: Hello, Mr... I am Dr... one of the junior doctors in the

surgical department. Dr: How are you doing? Pt: I am OK

Dr: I am one of the team of doctors looking after your mother. I am here
to talk to you about her condition. Do you know anything about how her
condition is now?

Pt: She had surgery for a brain tumour. I don’t know doctor how she is now.
How is she,Doc?

Dr: Is it okay if I ask you a few questions about your mother’s health
before discussing her condition? Pt: Okay, doctor

Dr: Does your mother have any

medical conditions? Pt: Yes, she

has arthritis since few years.

Dr: Do you know what medication she is taking for the arthritis? Pt: No
 1089

Dr: Did she have any high blood pressure? Diabetes? Any Kidney or Liver
disease? Pt: No

Dr: Any stroke or mini strokes before ? Son: No

Dr: How was she before ? Was she very

active? Son: Yes Dr: I am sorry to say I

don’t have good news.

Pt: Please tell me doctor, Is my mother okay?

Dr: Mr , As you know we have done an operation to remove the

tumour in her brain. While she was recovering from the surgery, we
noticed that she developed weakness on the left side of her face. Our
team of doctors did some blood tests and they came out normal.
However, I am sorry to say that when we did a CT scan we noticed that
she had an ischaemic stroke in her brain.

Pt: What does this mean doctor?

Dr: Ischaemic stroke occurs when a blood clot blocks the flow of blood and
oxygen to the brain. This starves the brain of oxygen and nutrients it needs,
which damages the brain cells.

Son: Why did this happen?

Dr: There are many reasons why an ischaemic stroke occurs. Blood
clots typically form in areas where the arteries have been narrowed or
blocked over time by fatty deposits known as plaques. As one gets
older, the arteries can naturally narrow, but certain things can
dangerously accelerate the process. These include smoking, high
blood pressure, obesity, high cholesterol levels, diabetes, excessive
alcohol intake.

Son: How will you treat my mother now?

Dr: We have started her on a combination of medications to treat
the condition and prevent it from happening again. Also at the time
of discharge, we will review her medicines. We will start her on
 1090

Physiotherapy to improve her condition.

Son: Will she recover soon?

Dr: Although some people may recover quite quickly, many people
who have a stroke need long-term support to help them regain as
much independence as possible. This process of rehabilitation
depends on the symptoms and their severity.

Son: My mother lives on her own a few houses down the lane from my
house. How can we provide care to her?

Find out her social history, who she lives with or who cares for her.
She will need 24 hour care. You have to contact the MDT for full
management after discharge.

Dr: Mr , I can see that you are a very caring son. We will talk to the
Social Services and they will arrange appropriate care and support
for your mother.

POST-OP TIA/STROKE
 1091

MORE NEW STATIONS

250. You are an F2 in GP. John Bernard aged, 55 came to the clinic
with gum bleeding/Wellman check-up. Please talk to the patient,
discuss plan of management with the patient and address his
concerns.

D: What brought you to the hospital today? P: I had gum

bleeding today morning D: I am sorry to hear that. Do you have any idea
how much blood did you lose? P: No D: Is it the first time you had
this? P: Yes
D: How did the bleeding start? P: On its own
D: By any chance did you hurt yourself? P: No
D: Do you have any other symptoms? P: No
D: do you feel tired these days? P: No
D: Any shortness of breath? P: No
D: any dizziness or heart racing? P: No
D: Any rash or bruise anywhere in the body? P: No
D: Any fever or flu like illness recently? P: No
D: Any bleeding from anywhere? P: No
D: Any change in the colour of stool that you noticed? P: No
D: Any lumps or bumps anywhere in the body? P: No
D: Any weight loss recently you noticed? P: No
D: has anyone told you that you are losing weight? P: No
D: How’s your appetite? P: Its good

D: Have you been diagnosed with any medical condition in the past or
any blood disorder?
P: No
D: Are you currently on any medication? P: No
D: By any chance any blood thinners? P: No
D: Any family history of any significant health issues or any blood
disorder in the family?
P: No

D: Do you smoke? P: No
D: Do you drink Alcohol? P: No
D: Tell meat about your diet? P: Healthy
 1092

I would like to do a GPE, check the vitals and Examine your tummy. I
would like to order initial investigation routine blood test.

Examiner: Abdomen: Splenomegaly. WBC count: >100,000

From our assessment we suspect you are having a condition called

Leukaemia. Leukaemia is a cancer of the white blood cells of our body.
We will be referring you to a specialist and a team of doctors within 2
weeks’ time and they will do further investigations like taking some
sample from your bone marrow to confirm the diagnosis. The treatment
depends on the type of leukaemia. There are chemotherapy and
radiotherapy available for leukaemia. In some cases, intensive
chemotherapy and radiotherapy may be needed, in combination with a
bone marrow or stem cell transplant.

TIREDNESS,Leukaemia
 1093

251. You are an F2 in GP. Lucy aged, 34 came to the clinic with pain in
both the wrist and hand. Please talk to the patient, discuss plan of
management with the patient and address her concerns.

D: What brought you to the hospital today? P: I have pain in my hands

and wrists D: Could you tell me more about it? P: Like what
D: When did it start? P: 7 days ago
D: Was it sudden or gradual? P: Gradual
D: Is it continuous or comes and goes? P: Continuous
D: What type of pain is it? P: Electric shock like pain
D: Does it move to any anywhere else?
P: It’s moving from my wrists to hands
D: Is there anything that makes it better?
P: Changing hand posture or shaking the wrist
D: Is there anything that makes it worse?
P: Gets worse at night/repetitive movements of hand or wrist

D: Has it changed since started? P: It’s getting worse

D: Could you rate the pain on a a scale of o to 10, where 0 b

and 10 being the worst you have ever experienced? P: 7
D: Do you have any other symptoms? P: No
D: Any pain in other joints in the body? P: No
D: By any chance did you hurt yourself? P: No
D: Any redness or swelling in the joints? P: No
D: Do have any tingling or numbness in your Hands? P: No
D: Do you have any difficulty gripping things by your hand? P: No
D: Any nausea, vomiting or swelling in the ankles? P: No
D: Do you feel cold when others around feeling normal? (Hypothyroid) P: No
D: Any change in your bowel habit recently? (Hypothyroid) P: No
D: Do you feel more tired? (Hypothyroid) P: No

D: Did you have similar condition in the past? P: No

D: have you been diagnosed with any medical condition in the past?
P: No
D: Any joint problems? P: No
D: Are you currently on any medication? P: No
D: Are you allergic to any medication? P: No
 1094

D: Any family history of any significant health issues or joint problems?

P: No

D: Do you smoke? P: No
D: Do you drink Alcohol? P: No
D: Tell me about your diet? P: Balanced
D: What you do for living? P: I worked as a typist in an office.
D: When was your LMP? P: I delivered the baby one month back.
D: Whom do you live with? P: With my husband

I would like to do a GPE, check the vitals and Examine your hand and
wrist.
Examiner: Examine doctor

 Tinel’s sign. In this test, the physician taps over the median nerve at
the wrist to see if it produces a tingling sensation in the fingers.
 Wrist flexion test (or Phalen test). The doctor will tell you to press
the backs of your hands and fingers together with your wrists flexed and
your fingers pointed down. You'll stay that way for 1-2 minutes. If your
fingers tingle or get numb, you have carpal tunnel syndrome.

From our assessment we suspect you are having a condition called

Carpal tunnel syndrome. It occurs due to pressure on a nerve in your
wrist. It causes tingling, numbness and pain in your hand and fingers.

P: Why did I have it?

D: There could be many reasons for it. But as it seems in your case it
could be due to your pregnancy or your job.
P: What’s the treatment?

CTS sometimes clears up by itself in a few months, particularly if you

have it because you're pregnant.

Wear a wrist splint

A wrist splint is something you wear on your hand to keep your wrist
straight. It helps to relieve pressure on the nerve. You wear it at night
while you sleep. You'll have to wear a splint for at least 4 weeks before
you start to feel better. You can buy wrist splints online or from
pharmacies. If a wrist splint does not help, your GP might recommend a
 1095

steroid injection into your wrist. This brings down swelling around the
nerve, easing the symptoms of CTS.

Stop or cut down on things that may be causing it. Stop or cut down on
anything that causes you to frequently bend your wrist or grip hard, such
as using vibrating tools for work or playing an instrument.

Painkillers like paracetamol or ibuprofen may offer short-term relief from

carpal tunnel pain.

Surgery
If your CTS is getting worse and other treatments have not worked, your
GP might refer you to a specialist to discuss surgery. Surgery usually
cures CTS. You and your specialist will decide together if it's the right
treatment for you. An injection numbs your wrist, so you do not feel pain
(local anaesthetic) and a small cut is made in your hand. The carpal
tunnel inside your wrist is cut so it no longer puts pressure on the nerve.
The operation takes around 20 minutes and you do not have to stay in
hospital overnight. It can take a month after the operation to get back to
normal activities.

Carpal Tunnel Syndrome

 1096

252. De Quervain’s Tenosynovitis

You are an FY2 in GP. Patient
D: How can I help you? P: Pain in the thumb. S/S
1. pain or tenderness at the base of your thumb.
2. Swelling near the base of your thumb.
3. Numbness along the back of your thumb and index finger.
4. A catching or snapping feeling when you move your thumb.

Risk Factors:
 You are a woman.
 You are 40 years of age or older.
 Your hobby or job involves repetitive hand and wrist motions. This is
a very common cause.
 You have injured your wrist. Scar tissue can restrict the movement
of your tendons.
 You are pregnant. Hormonal changes during pregnancy can cause it.
 You have arthritis.

To diagnose de Quervain’s tenosynovitis, your doctor may do a simple

test. It is called the Finkelstein test.

Treatment for de Quervain’s tenosynovitis focuses on reducing pain and

swelling. It includes:
 Applying heat or ice to the affected area.
 Taking a nonsteroidal anti-inflammatory drug (NSAID). These
include ibuprofen (Advil, Motrin) or naproxen (Aleve).
 Avoiding activities that cause pain and swelling. Especially avoid
those that involve repetitive hand and wrist motions.
 Wearing a splint 24 hours a day for 4 to 6 weeks to rest your thumb
and wrist.

Getting injections of steroids or a local anesthetic (numbing medicine)

into the tendon sheath. These injections are very effective and are used
regularly.

A physical therapist or occupational therapist can show you how to

change the way you move. This can reduce stress on your wrist. He or
 1097

she can also teach you exercises to strengthen your muscles.

Most people notice improvement after 4 to 6 weeks of treatment. They are

able to use their hands and wrists without pain once the swelling is gone.
 1098

Hand & Wrist Examination

Rapport
Assess his knowledge.

GIPPEEC

Look:
Inspect hands from Dorsum:
There are no skin, nail changes, scar marks, swelling, deformities or
muscle wasting.

Palms up:
There are no scars and swelling, Dupuytren’s contracture or thenar and
hypothenar muscle wasting.

Elbows:
There are no evidence of psoriatic plaques or rheumatoid nodules

Feel:
Palms up

Temperature:
Assess and compare the temperature of the wrists and small joints of the
hand.

Radial and ulnar pulse:

Palpate the radial and ulnar pulse to confirm there is adequate blood
supply to the hand

Thenar/hypothenar eminence bulk:

The muscle bulk of the thenar and hypothenar eminences is normal.
There is no palmar thickening

Median, ulnar and radial nerve nerve sensation:

median nerve sensation over the thenar eminence and index finger ulnar
nerve sensation over the hypothenar eminence and little finger Radial
nerve sensation over the first dorsal web space
 1099

Dorsum:

Assess and compare temperature using the back of your hand:

Wrist and MCP joint.

Gently squeeze across the metacarpophalangeal (MCP) joints,

Bimanually palpate the joints of the hand (MCPJ/PIPJ/DIPJ/CMCJ)

Assess and compare joints for tenderness, irregularities and warmth:

Metacarpophalangeal joint (MCPJ), Proximal interphalangeal joint (PIPJ),
Distal interphalangeal joint (DIPJ), Carpometacarpal joint (CMCJ) of the
thumb (squaring of the joint is associated with OA). Palpate the wrists for
evidence of joint line irregularities or tenderness

Palpate the anatomical snuffbox: Tenderness may suggest scaphoid

fracture.

Palpate the elbow: Along the ulnar border to the elbow feel for any
rheumatoid nodules or psoriatic plaques (extensor surface).

Move:
Active movements:
Finger flexion – Make a fist.
Finger extension – Open your fist and splay your fingers
Wrist extension – Put the palms of your hands together and extend your
wrists fully. Wrist flexion – Put the backs of your hands together and flex
your wrists fully

Passive movement:
Assess movements passively, feeling for crepitus and noting any pain.

Motor assessment
Wrist/finger extension – radial nerve
Finger ABduction of the index finger – ulnar nerve Thumb ABduction –
median nerve

Function
Assess the patient’s hand function using the following screening tests:
Power grip – “Squeeze my fingers with your hands”
Pincer grip – “Squeeze my finger between your thumb and index finger “
 1100

Pick up a small object or undo a shirt button – “Can you pick up this small
coin out of my hand?”

Special tests Tinel’s test:

Tinel’s test is used to identify nerve irritation and can be useful in the
diagnosis of carpal tunnel syndrome.
Tap over the carpal tunnel with your finger. If the patient develops tingling
in the thumb and radial two and a half fingers this is suggestive
of median nerve irritation and compression.

Phalen’s test:
Ask the patient to hold their wrist in complete and forced flexion (pushing
the dorsal surfaces of both hands together) for 60 seconds.
patient’s symptoms of carpal tunnel syndrome are reproduced then the
test
is positive (e.g burning, tingling or numb sensation in the thumb, index,
middle and ring fingers)

To finish the examination, I will do full neurological examination, I will

examine one joint above.
 1101

253. You are an F2 in GP. Samaira aged, 34 came to the clinic

with sore throat. Please talk to the patient, discuss plan of
management with the patient and address her concerns.

D: What brought you to the hospital today? P: I have sore throat

D: Could you tell me more about it? P: like what
D: When did it start? P: 7 days ago
D: Was it sudden or gradual? P: Gradual
D: Is it continuous or comes and goes? P: Continuous
D: What type of pain is it? P: Dull pain
D: Is there anything that makes it better? P: No
D: Is there anything that makes it worse? P: When I swallow
D: Has it changed since started? P: It’s getting worse
D: Could you rate the pain on a scale of o to 10, where 0 being no pain
and 10 being the worst you have ever experienced? P: 7

D: Do you have any other symptoms? P: I feel feverish

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

D: Any other symptoms? P: No

D: Any ear pain or hearing problems? P: No
D: Any neck stiffness? P: No
D: Any problem with voice? P: No
D: Any nausea or vomiting? P: No

D: Any tiredness? P: No
D: Any headache? (Infectious mononucleosis) P: No
D: Any tummy pain? (Infectious mononucleosis) P: No
D: Any diarrhoea? (HIV) P: No

1101
 1102

D: Did you have similar condition in the past?

P: Yes, I had it 6 months back and was given antibiotics.
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: Any allergies from any food or medications?
P: Yes, I am allergic to penicillin
D: Any previous hospital stays or surgeries? P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No
D: Do you smoke? P: No
D: Do you drink Alcohol? P: No
D: Tell me about your diet? P: Healthy
D: Are you physically active? P: I try to be.

D: Are you currently sexually active? P: Yes

D: Are you in a stable relationship? P: Yes
D: Do you use practice safe sex? P: Yes

I would like to do a GPE, check the vitals and Examine your tummy, neck
and throat.

From our assessment we suspect you are having a condition called

tonsillitis. It is an infection and inflammation of the tonsils caused by a bug
or virus. For your condition we will be giving you painkiller and we will
start you on antibiotics. As you are allergic to penicillin, we will be giving
you something else (Erythromycin or Clarithromycin).
Also, you can take Lozenges, throat spray and antiseptic solutions to ease
the symptoms. To help ease the symptoms:

1102
 1103

• get plenty of rest

• drink cool drinks to soothe the throat
• gargle with warm salty water

If you get difficulty speaking, difficulty swallowing, difficulty breathing,

difficulty opening your mouth please come to the hospital.
An antibiotic may be advised in certain situations. For example:
 If the infection is severe (Systemic features)
 If it is not easing after a few days. (3-5 days)
 A history of rheumatic fever
 Unilateral Peri tonsillitis
 If your immune system is not working properly (for example, if you
have had your spleen removed, if you are taking chemotherapy, etc).
 Acute tonsillitis with three or more Centor criteria present
There are four Centor Criteria that may be used:
a. History of Fever.
b. Tonsillar Exudates
c. No Cough.
d. Tender Anterior Cervical Lymphadenopathy.

Acute Tonsillitis

1103
 1104

254. You are F2 working in GP. Anne, mother of 6-year-old boy,

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

D: How can I help you today?

P: I am here for my son. He had recently been referred to ENT surgery
from GP and the referral got rejected.

D: I am really sorry for your experience. Would you mind if I ask you a few
questions regarding your son to have better understanding of your son’s
health.
P: Ok

D: Could you tell me why he had been referred to the ENT surgery?
P: He had 5 episodes of tonsillitis in the last 1 year

D: Could you give a brief recap of the episodes?

P: The first episode was about 10 months ago. He had sore throat and
fever and was advised to have steam inhalation. The 2nd and 3rd
episodes the symptoms were more severe, and he was given antibiotics.
And the last 2 episodes was like the first episode and it got better with
steam inhalation as well.

D: I can understand It must be very tough for him.

P: Yes, so why did the referral get rejected?

D: As you already know the referral was made upon your request. But to
be honest with you your son doesn’t meet the criteria to have the surgery
for the tonsil removal.
P: What criteria are you talking about?

D: I do understand your concern. Let explain this to you further. There are
few criteria’s that has been set to decide which patients need tonsil
removal surgery. One of those criteria is having at least 7 attacks in a
year. You mentioned your son had 5 attacks. Possibly that’s why the
referral got rejected.
 1105

P: Dr forget about the criteria. I can’t see him suffer like that. Please
arrange the surgery anyhow.
D: I can really see you are worried about son. But let me tell you the
criteria are made in a way to avoid unnecessary surgery and ensure
better care for the patients. And every surgery has a lot of complications.
We don’t want your son to go through the unnecessary stress of the
surgery without any strong reason. Another thing is that tonsils are very
important part of the defence mechanism of our body that fight against
infection. That is why we don’t want to remove them unless it’s necessary.

P: Dr I just thing NHS is doing it for budget cutting. Don’t you think so Dr?
D: I am really sorry you felt this way. But NHS has planned those surgery
and set those criteria for delivering the best possible care to the patients.

P: Alright
D: For now, we will give him painkillers to relieve the pain. Please ensure
he is taking plenty of rest. And gurgling with warm salty water can be
helpful. By any chance if your son’s condition gets worse or he develop
neck stiffness or he can’t even swallow, please bring him back to us.
If you have repeated (recurring) tonsillitis you may wonder about having your
tonsils removed. ‎Guidelines suggest it may be an option to have your tonsils
removed (tonsillectomy) if you:‎
• Have had seven or more episodes of tonsillitis in the preceding year; or
• Five or more such episodes in each of the preceding two years; or
• Three or more such episodes in each of the preceding three years.‎
• And ...‎
• The bouts of tonsillitis affect normal functioning. For example, they are
severe enough to ‎make you need time off from work or from school.‎

Recurrent Tonsillitis
 1106

255. You are an FY2 in A&E. Maria aged 60 presented with SOB
and chest pain. Take history and discuss management.

D: How can I help you?

P: Chest Pain, Along with left side, only on inspiration. (Full Socrates)

D: Anything else? P: No
D: Any Fever? P: No
D: Any Leg Pain, swelling? P: No
D: Do you feel out of breath? P: No
Any Cough, Dizziness, Trauma, Skin Lesion.

PMH:
DM on Metformin.
Breast cancer and mastectomy on the left along with chemotherapy.
D: When was the time for the chemo?

Personal History:

Examination: GPE, Vitals. Sats: 90% PR 110 Temp: 37. BP: 120/80
ABG: Respiratory alkalosis
CXR Normal.

People with cancer may have a higher number of platelets and clotting
factors in the blood which in turn help clotting and stop bleeding. Having
higher than normal amounts of platelets and clotting factors in the body
means the blood is more likely to clot. Some people with cancer may
have lower levels of proteins in the blood that help to keep it thinned.
Hence making cancer a risk factor for developing clots. Since the patient
has a positive history for DM as well that can contribute to forming a clot
as well.

Management: Admit and do CTPA along with d-dimer. Begin LMWH

immediately and monitor. Consult Sr for advice on how to manage further
and long term anticoagulants with cancer treatment.

Risk factors: Prolonged Immobilisation, Pregnancy, Pills, HRT, Previous

PE/DVT, Malignancy
 Thrombophilia
 1107

Investigation: FBC, Urine (Pregnancy), ABG, D-Dimer, CXR, ECG, CTPA

Treatment:
O2.
Morphine & Metoclopramide Anticoagulation Heparin 5 Days Warfarin 
3-6 Months
Prevention (Compression Stockings, Stop HRT/Pills, Anticoagulation
administered to Immobile patient)

Chest Pain (Mastectomy)

 1108

256. You are an FY2 in GP. Lucy, 36 year old female presented
to your clinic. She wants to become pregnant and is here for advice
regarding that. Please talk to her and address her concerns.

1. Discuss about the potential impact of maternal age on fertility and

birth outcomes. Women over 35 have an increased risk of miscarriage,
chromosomal abnormalities and obstetric complication compared with
younger women.
2. Discuss interpregnancy interval (ideally 18-59 months)
3. Advise that sexual intercourse every 2-3 days optimizes the
chance of pregnancy
4. Advise women who are risk for NTD to take folic acid daily
5. Eat healthy and balanced diet and maintain a healthy weight
6. Stop smoking, avoid drinking alcohol and avoid taking any
recreational drugs.
 1109

Pre – Conception Counselling

 1110

257. You are an FY2 in GP. Luke aged 25 has come with
complaints of runny nose from the past 2 days. Take history and
address his concerns.

D: How can I help you? P: I have got runny nose.

D: Tell me more about it?
P: IT has been 2 days I am having this, and it is getting worse.
D: What is the colour of the fluid? P: Clear watery fluid
D: Anything makes it better or worse? P: It gets worse in the winter season.

D: Anything else? P: No

D: Any itching? P: No
D: Any swelling or redness? P: No

D: Any fever and flu like symptoms? P: No (Infective rhinitis)

D: Any pain or discharge from ear? (Ear Infection) P: No
D: Any numbness or tingling on the face? P: No (Cranial Nerve Tumours)
D: Have you had similar kind of problem in the past? P: No

D: Have you been diagnosed with any medical condition in the past?
P: I have got skin allergy (Atophy)

D: Any DM, history eczema or asthma? P: No.

D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications? P: No.
D: Any allergy to the pollens or dusts? P: No
D: Any previous hospital stays or surgeries? P: No.

D: Has anyone in the family been diagnosed with any medical condition?
P: Siblings have Eczema and Asthma

D: Do you smoke? P: Yes/no

D: Do you drink alcohol? P: Yes/No
D: Tell me about your diet? P: I don’t eat healthy.
D: Do you do physical exercise? P: I don’t have much time.
D: Do you have any kind of stress? P: No.
 1111

D: What do you do for the living? P: I am a driver.

I would like to check your vitals and examine your eye, ear, nose, throat.

The main lines of treatment are education, allergy avoidance,

antihistamines and topical steroids.

Please regularly rinse your nasal passages with a saltwater solution to

keep your nose free of irritants.

I may send for some initial investigations including routine blood test
(IgE), skin prick test. Nasal Endoscopy might be done in case we suspect
any Polyp.
As the patient is driver so we will make sure we will prescribe non-drowsy
antihistamines. There are many types of antihistamine.
They're usually divided into two main groups:
• older antihistamines that make you feel sleepy – such as
chlorphenamine, hydroxyzine and promethazine
• newer, non-drowsy antihistamines that are less likely to make you
feel sleepy – such as cetirizine, loratadine and fexofenadine

We can prescribe a stronger medication, such as a nasal spray containing

corticosteroids. Inhalers and nasal sprays such as beclomethasone and
fluticasone can be used.

Allergic Rhinitis
 1112

258. Urticaria

You are an FY2 in GP. Mother of 5-year-old Daniel has got some
concerns. Talk to her and address her concerns.

PC: He has rash. Whole body. It is itchy.

It has happened 2-3 times. Once, after shower and the other time after
playing sports with friends.
Disappears after few minutes to hours.
PMH: Negative. Fam Hx of Asthma or Allergy: Negative. Lifestyle: All
Good
Ex: Image was given when asked to examine. (Lateral view of head with
rash all over face).

Urticaria (possibly cholinergic)

Mx: In many cases, treatment isn't needed for urticaria, because the rash
often gets better within a few days.
If the itchiness is causing discomfort, antihistamines can help.
A short course of steroid tablets (oral corticosteroids) may occasionally be
needed for more severe cases of urticaria.
For persistent urticaria, refer to a skin specialist (dermatologist).
Treatment usually involves medication to relieve the symptoms, while
identifying and avoiding potential triggers.
Certain triggers for Urticaria:

 drinking alcohol or caffeine

 emotional stress
 warm temperature
Causes of Urticaria:

 an allergic reaction – such as a food allergy or a reaction to an

insect bite or sting
 cold or heat exposure
 infection – such as a cold
 certain medications – such as non-steroidal anti-inflammatory drugs
(NSAIDs)or antibiotics
 1113

Concerns: The school is worried if the Rash is contagious. Whether son

can go to school or not.

Return to School:

o Hives cannot be spread to others.

o Your child can go back to school once feeling better. The hives
shouldn't keep him from normal activities.
o For hives from an infection, can go back after the fever is gone. Your
child should feel well enough to join in normal activities
 1114

259. You are FY2 in GP. Patient came to the clinic complaining
of pain in the ear. Talk to the patient and discuss the management
with the patient.

D: How can I help? P: I have pain in my right ear.

D: Can you tell me more about it?
P: I have been having this pain for 1 month, I took paracetamol, but it is
not improving. It is getting worse.
(SOCRATES)
D: Anything else? P: I can’t hear properly with my right ear.
D: How about the other ear? P: It is fine
D: Any Fever (OM, Meningitis)
D: Vertigo, Tinnitus, Numbness or tingling in the face? (Cranial Nerve
Involvement)
D: Aural fullness?
D: Any trouble with the vision? (Blurring)
D: Any recent travel? (Flight)
D: Have you been swimming recently? (OE)

Ask Past Medical History Ask Lifestyle

Symptoms:
Ear infection sometimes can lead to brain abscess or meningitis, Hearing
loss,
Vertigo, Tinnitus,
Facial nerve damage.

Risk Factors:
Trauma, Otitis media, Tympanic membrane perforation.

Differentials Diagnosis:
Otitis media with effusion, Otitis externa,
Tympanosclerosis (Seen after grommet insertion), Osteonecrosis

Examination:
GPE, Vitals, Ear examination, Otoscopy, Hearing Test and Balance Test.

Examiner: Conductive Hearing Loss, Otoscopy: Perforation in the Middle

Ear usually Pars Flacida
 1115

Investigation:
Routine blood test, CT, MRI

Treatment:
Surgery followed by topical antibiotics and topical steroids. After the
cholesteatoma has been taken out, your ear may be packed with a
dressing. This will need to be removed a few weeks later. The surgeon
may be able to improve your hearing by a tiny artificial hearing bone
(prosthesis) In some cases, it may not be possible to reconstruct the
hearing, or a further operation may be needed.

The benefits of removing a cholesteatoma usually far outweigh the

complications. However, as with any type of surgery, there's a small risk
of facial nerve damage resulting in weakness of the side of the face.
Medical treatment where surgery is not possible, that will be antibiotics
and regular ear cleaning.

Prognosis:
It can recur again in 5-30% cases.
Around 10% can get it in another ear as well.

If you develop discharge or significant bleeding from your ear or wound,

fever, and severe pain come to the hospital.

Cholesteatoma
 1116

260. You are an FY2 in GP/A&E. Olivia, aged 30, has some
concerns about meningitis prophylaxis. Talk to her and address her
concerns.

D: How can I help you? P: I am worried I might get Meningitis.

D: May I know why? P: My sister’s daughter was diagnosed with
meningitis and she is in ICU at the moment. The Doctor mentioned that
she should take meningitis prophylaxis. My sister called and told that son
should also take the prophylaxis.

D: Have you been in contact with your niece? P: No

D: When was the last time you were in contact with her? P: Around 2
months ago in a shopping mall.

She works at Nursery School. She is a manager at the school.

PMH:
D: Anyone in family having meningitis? P: I live alone.

Preventing the spread of Infection

The risk of someone with meningitis spreading the infection to others is

generally low. But if someone is thought to be at high risk of infection,
they may be given a dose of antibiotics as a precautionary measure.

Meningococcal Infection Chemoprophylaxis

The decision to initiate contact tracing in respect of meningococcal

infection will be made by the Consultant in Public Health Medicine
(CPHM) in conjunction with relevant clinicians. Responsibility for contact
tracing and organising the administration of chemoprophylaxis also lies
with the CPHM. Chemoprophylaxis must ONLY be prescribed on the
instruction of the CPHM. It should be given as soon as possible (ideally
within 24 hours) after diagnosis of the index case.

CPHM will establish a list of close contacts; who may include:

• Those who have had prolonged close contact with the case in a
household type setting during the seven days before onset of illness.
Examples of such contacts would be those living and / or sleeping in the
same household (including extended household), pupils in the same
 1117

dormitory, boy/girlfriends, or university students sharing a kitchen in a

hall of residence.
• Those who have had transient close contact with a case only if they
have been directly exposed to large particle droplets / secretions from the
respiratory tract of a case around the time of admission to hospital.

The use of single dose ciprofloxacin is recommended by a Cochrane

Review and included in the Public Health England’s Guidance for public
health management of meningococcal disease in the UK’. Ciprofloxacin
is licensed in adults for the prophylaxis of invasive infections due to
Neisseria meningitidis; however, its use in children and adolescents
remains ‘off label’.

If further cases occur within a group of close contacts in the four weeks
after receiving prophylaxis, an alternative agent should be used for repeat
prophylaxis. Rifampicin may be used as outlined in Table 2 below (except
in pregnancy). Azithromycin as a single dose of 500mg may be used as
an alternative in pregnancy.

Concerns:
Is it preventable?
What do you mean by Septicaemia?

Meningitis Prophylaxis
 1118

261. You are an FY2 in GP. Sophia Jenkins, 30-year-old female

came to you with some concerns. Talk to her and discuss the plan
of management.

Complications for the unborn baby:

Complications that can affect the unborn baby vary, depending on how
many weeks pregnant you are. If you catch chickenpox:
- Before 28 weeks pregnant: there's no evidence you are at increased
risk of suffering a miscarriage. However, there's a small risk your baby
could develop foetal varicella syndrome (FVS). FVS can damage the
baby's skin, eyes, legs, arms, brain, bladder or bowel.
- Between weeks 28 and 36 of pregnancy: the virus stays in the
baby's body but doesn't cause any symptoms. However, it may become
active again in the first few years of the baby's life, causing shingles.
- After 36 weeks of pregnancy: your baby may be infected and could
be born with chickenpox.

Antiviral Medicine:
You may be offered acyclovir, an antiviral medicine, which should be
given within 24 hours of the chickenpox rash appearing. Acyclovir doesn't
cure chickenpox, but it can make the symptoms, such as fever, less
severe and help prevent complications. Acyclovir is usually only
recommended if you're more than 20 weeks pregnant, but in some cases
your doctor may suggest it if you're less than 20 weeks pregnant.
Discuss the risks and benefits with your doctor.

Self help
To help relieve your symptoms, you can try the following:
• drink plenty of fluids
• take paracetamol to lower a temperature or help with pain
• use cooling creams or gels from your pharmacy

Will my baby need to be treated?

Once you have chickenpox, there's no treatment that can prevent your
baby getting chickenpox in the uterus.
After the birth, your GP may consider treating your baby with chickenpox
antibodies called varicella zoster immune globulin (VZIG) if:
 1119

 your baby's born within 7 days of you developing a chickenpox rash

 you develop a chickenpox rash within 7 days of giving birth
 your baby's exposed to chickenpox or shingles within 7 days of birth
and they aren't immune to the chickenpox virus

If your new born baby develops chickenpox, your GP may treat them with
acyclovir.
Complications for pregnant women:
You have a higher risk of complications from chickenpox if you're
pregnant and smoke, have a lung condition, such as bronchitis or
emphysema, are taking or have taken steroids during the last three
months and are more than 20 weeks pregnant.

There is a small risk of complications in pregnant women with

chickenpox. These are rare and include: pneumonia, encephalitis, and
hepatitis. Complications that arise from catching chickenpox during
pregnancy can be fatal. However, with antiviral therapy and improved
intensive care, this is very rare.

Complications for the newborn baby:

Your baby may develop severe chickenpox and will need treatment if you
catch it:
 around the time of birth and the baby is born within seven days of
your rash developing
 up to seven days after giving birth
If you're pregnant, have chickenpox and develop chest and breathing
problems, headache, drowsiness, vomiting or feeling sick, vaginal
bleeding, a rash that's bleeding , a severe rash you should be admitted to
hospital.

These symptoms are a sign that you may be developing complications of

chickenpox and need specialist care.

Chicken Pox (Pregnancy)

 1120

262. You are FY2 in GP. Benjamin White, aged 72, has come for
consultation. He was diagnosed with Shingles 2 months back and
was given Acyclovir. He saw his GP 1 month back for the pain on the
right side of his chest and was given Paracetamol and Codeine.
Talk to him and address his concerns.

D: How can I help you? P: I am still in pain.

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

D: Can you score the pain?

P: 3/4 normally but during night the bedsheets touch the area and I get
unbearable sharp pain.

D: How has it impacted you?

P: It is hindering my daily life, as I am taking care of my wife who is on
wheelchair and has RA.

D: How are you feeling? P: I feel tired all the time.

D: Do you have rash on your body? P: No, they are gone.

D: Did you have similar condition in the past?

P: Yes, I had it 6 months back and was given antibiotics.
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: Any allergies from any food or medications? P: No
D: Any previous hospital stays or surgeries? P: No
D: Has anyone in the family been diagnosed with any medical condition?
P: No

D: Do you smoke? P: No
D: Do you drink Alcohol? P: No
D: Tell me about your diet? P: Healthy
D: Are you physically active? P: I try
D: Do you get any help looking after your wife?
P: Yes, Nurse comes Twice a week.
 1121

Ask about Sleep, depression, rule out Cancer (As age is 72) and other
causes of Tiredness.
Treatment:
To help reduce the pain and irritation of post-herpetic neuralgia wear
comfortable clothing and use cold packs – some people find cooling the
affected area with an ice pack helps.

We can give you Lidocaine plasters and Capsaicin cream (Capsaicin is

the substance that makes chilli peppers hot. It's thought to work for nerve
pain by stopping the nerves sending pain messages to the brain).
Antidepressants:Amitriptyline and duloxetine are the two main
antidepressants prescribed for post-herpetic neuralgia.
Anticonvulsants: Gabapentin and pregabalin are the two main
anticonvulsants prescribed for post-herpetic neuralgia.
We can also prescribe Tramadol or Morphine if symptoms are not
relieved. Follow the pain ladder.

Living with post-herpetic neuralgia can be very difficult because it can

affect your ability to carry out simple daily activities, such as dressing and
bathing. It can also lead to further problems, including extreme tiredness,
sleeping difficulties and depression.

Concerns:
P: How to get rid of this Pain? P: How to manage tiredness?

P: Can you give something else other than tablets?

Post Herpetic Neuralgia

 1122

263. You are an FY2 in GP. Yara White, aged 29, has come to
you because of Nipple Discharge. Talk to her and address her
concerns.

D: How can I help? P: I have some discharge coming from my nipples.

(Single or Both)
D: Elaborate: When? How long? Colour? Consistency? Blood stained?

D: Do you have anything else? P: No

D: Any change in shape and size of the breast? P: No
D: Any change in the skin of the breast? P: No
D: Any swelling or mass? P: No
D: Any lumps and bumps in the body? P: No
D: Any weight loss? P: No
D: Any loss of appetite? P: No
D: Any SOB or tiredness? P: No
D: Any fever or flu like symptoms? P: No

D: Tell me about your periods, when was tour last menstrual period?
P: 2 weeks ago
D: Is it regular? P: Yes
D: Any heavy periods or bleeding in between the periods? P: No
D: Any pregnancy? If yes how many kids?
D: Are you sexually active now? P: Yes
D: Are you using any method of contraception? P: Yes/No

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

D: Have you been diagnosed with any medical condition in the past?P: No
D: Any breast problem in the past? P: No
D: Are you taking any medications including OTC or supplements?
P: No
D: Any hormonal therapy? P: No
D: Has anyone in the family been diagnosed with any medical condition?
P: Yes/No
D: Do you smoke? P: No
D: Do you drink alcohol? P: No
D: Tell me about your diet? P: Healthy
D: Are you physically active? P: I try to be.
 1123

I would like to do a GPE, check the vitals and examine your breasts.

We may refer you to a hospital or breast clinic for further tests. At the
hospital or breast clinic, you may have a:
• breast examination
• scan – usually a breast X-ray (mammogram) or ultrasound
• biopsy – where a needle is inserted into your breast to remove

some cells for testing The tests are often done during the same visit.

You'll usually be told the results on the same day, although biopsy results
can take longer – you should get them in a week or two.

See a GP if you have nipple discharge and any of these:

• it happens regularly and isn't just a one-off
• it only comes from 1 breast
• it's bloodstained or smelly
• you're not breastfeeding, and it leaks out without any pressure on
your breast
• you're over 50
• you have other symptoms – such as a lump, pain, redness or
swelling in your breast
• you're a man

Causes:
• breastfeeding or pregnancy – see leaking nipples in pregnancy
• a blocked or enlarged milk duct
• a small, non-cancerous lump in the breast
• a breast infection (mastitis)
• a side effect of a medicine – including the contraceptive pill

Nipple Discharge
 Nipple discharge isn't usually a sign of anything serious, but
sometimes it's a good idea to get it checked just in case.
 Nipple discharge is often normal
 Lots of women have nipple discharge from time to time. It may just
be normal for you.
 It's also not unusual for babies (boys and girls) to have milky nipple
 1124

discharge soon after they're born. This should stop in a few weeks.
 Nipple discharge in men isn't normal.
 The colour of your discharge isn't a good way of telling if it's anything
serious. Normal discharge can be lots of colours.

Nipple Discharge
 1125

264. Prescription Writing (DVT Apixaban)

Amelia May, aged 50, was admitted to the hospital with DVT. This is
her third admission with DVT. She is prescribed with Apixaban.
Please talk to the patient, explain her about the medication,
prescribe Apixaban and address her concerns.

D: Hello, how are you feeling today?

P: I am feeling fine. Could you please tell me about my medication?

D: Yes, I am going to talk to you about your medication and address all
your concerns. But before that let me ask you few questions.
P: Okay

D: May I know why were you admitted to the hospital? P: I had leg swelling

D: May I know since when? P: For 2 days.

D: Do you know about your diagnosis?

P: Yes. Clot in my legs. This is the third time I am having this condition.

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

D: Any pain or swelling? P: No

D: Have you been diagnosed with any other medical condition in the
past? P: No
D: Any other medical conditions DM, Heart/Kidney disease or high
cholesterol? P: No
D: Are you taking any regular medications including OTC or
supplements? P: No
D: Any allergies from any food or medications? P: Penicillin
D: Any previous hospital stays or surgeries? P: No
D: Has anyone in the family been diagnosed with any medical condition?
P: No

D: Do you smoke? P: Yes/No

D: Do you drink alcohol? P: Yes/No
D: Tell me about your diet? P: Good/Bad
 1126

D: Are you physically active? P: Yes/No

D: What do you do for a living? P:
D: Whom do you live with? P:

D: Thank you for answering all my questions.

We are going to prescribe you a medication called Apixaban, which is a

blood thinner. This will prevent from future clot formation in the legs.
Prescribe APIXABAN on the drug chart in the section for
anticoagulation. Apixaban – Treatment dose 10 mg BD for Days 1-7
Apixaban – Maintenance 5 mg BD for long term from day 8 (for
recurrent DVT).
(Also write about Penicillin allergy on the drug chart on the front in allergy
column)

You have to take this medication twice a day preferably at the same time,
regularly and as prescribed without missing any dose. As you had this
condition for three times, you have to take this medication for a long time
(possibly lifelong).
1127
1128
1129
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1131
1132
1133
1134
1135
1136
1137
1138
1139
1140
 1141

265. (Nosebleed Apixaban)

James Carter, aged 25, has had a nosebleed. He is on Apixaban. Talk

to him and complete the prescription.

Patient had a clot 3 years ago. Was prescribed Apixaban. Concern was:
What do I do when I get bleeding?

Assess the patient and compliance of Apixban.

Nasal bleed episodes:
1st one: 1 wk ago (was picking nose)
Go to the A&E: 2nd one: 1 day ago spontaneous
-Dr: What have you done to stop the
- your nosebleed lasts longer than 10 to 15 bleeding ? -Pt: squeezed my nostrils
*No bruises *No bleeding from other
minutes sites *PMH: DVT & PE (after long
- the bleeding seems excessive flight 3 years ago followed by taking
Apixaban with regular follow up with
- you’re swallowing a large amount of blood his GP since then
that makes you vomit *FH: not sign.
*Travel hx: no recent. #Qs from the pt:
- the bleeding started after a blow to your 1) what is the cause of the bleeding ?
head 2) what should I do about it ? 3) How
- you’re feeling weak or dizzy will you treat me ?
4) Any precautions ? 5) Do I need to
- you’re having difficulty breathing stop Apixaban ?

How to stop a nosebleed yourself

You should:
- sit or stand upright (don't lie down)
- pinch your nose just above your nostrils for 10 to 15 minutes
- lean forward and breathe through your mouth
- place an icepack (or a bag of frozen peas wrapped in a teatowel) at
the top of your nose
Hospital Treatment

If doctors can see where the blood is coming from, they may seal it by
pressing a stick with a chemical on it to stop the bleeding.
If this isn't possible, doctors might pack your nose with sponges to stop
the bleeding. You may need to stay in hospital for a day or two.
 1142

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
 1143

266. You are an FY2 in GP Surgery. Rachel Williams, mother of

4-year-old David Williams, has brought him in to the clinic because
of Bed Wetting. Talk to her and address her concerns.

D: What brought you to the hospital? P: My child is not dry at night.

D: Tell me more about the it? P: Dr he is 4 years old but still he
wets the bed in the night.
 must ask child’s age (the management is child’s age dependent; they on
purpose will not add child’s age in the task just to check if we ask the age or
not; vvvvv imp ques)
D: Did you child use to be dry at night before?
P: my child has never been dry before.
D: Is it daily or off and on? P: It is daily doctor.
D: Have you noticed any dry nights before or in between? P: No
D: Did anything significant happen before the onset that led to this
condition? P: No
D: What is bathroom routine of child before going to bed.?

 Explore about the amount of fluids the child takes and how many hours
before going to bed does the child take fluids.

D: Anything else? P: No

D: Any fever? P: Yes/No

D: Any daytime wetting? P: Yes/No

D: Excessive crying? P: Yes/No

D: Any burning while passing urine? P: Yes/No
D: Any cloudy/smelly urine? P: Yes/No
D: Any lethargy? P: Yes/No
D: Loss of appetite? P: Yes/No
D: Weight loss? P: Yes/No
D: Any abnormal swellings in tummy? P: Yes/No
D: Has he been diagnosed with any medical condition in the past (or bladder or
kidney issues.)? P: No
D: Is she taking any medications including OTC or supplements? P: No
D: Any allergies from any food or medications? P: No
D: Has anyone in the family been diagnosed with any medical condition?
P: No
 1144

D: How was the birth of your baby? P: It was normal vaginal delivery.
D: Are you happy with the red book? P: Yes.
D: Is she up to date with all her jabs? P: Yes.
D: Has she received any recent jab? P: No
D: Is she feeding well? P: Yes. She is feeding very well.
Complete DIET history and feeding history
D: Does she have any problems with her wee and poo? P: No.
D: Who looks after her? P: It’s me.
D: are you the main carer of the child?
D: who else lives with the child P: Me and my husband.
D: Any other child? P: No
D: how is the relationship and environment at home????? Is this type of qq
right????
D: Is he going to school? P: Yes.
D: Any problem at school? P: No
Examination:
I would like to check the vitals, general physical examination and
abdominal examination.

Bedwetting is common in young children and children usually grow out of

it. We can devise a plan to help your child with this.

Plan:
 Fluids intake stop 2 hours before going to bed; can feed normally
throughout the day; no need of restricting fluid; just don’t give fluids 2
hours before going to bed.
 Avoid drinks that contain caffeine, such as cola, tea, coffee or hot
chocolate, because they increase the urge to wee.
 Encourage your child to go to the toilet regularly during the day.

• If the child wakes up at night, encourage them to go to toilet.

• Make a habit of asking your child to go to toilet before going to bed.
 Reward your child for having plenty of drinks during the day and
remembering to have a wee before bed

 We will be following your child up and if these measures did not help,
or your child developed daytime wetting, or your child did not outgrow of
this after 5 years of age, then we will further test your child.
 1145

Further plan of action:

• Referral to enuresis clinic/ specialist.
• Urine test
• Alarm clock for encouraging the child to visit the loo

 GP may suggest a medicine called desmopressin.

Please Come for the follow up and come back to the hospital with your
child if he develops fever, lethargy, tummy swelling, daytime symptoms
and your child has suddenly started wetting the bed after they've been
dry at night for a while.

We will give you leaflet.

Note: if child is above 5 years, then you have to make referral, offer
general advice same as above and also include alarm clock and positive
reward system. If child is of any age and has daytime symptoms as well,
make referral to enuresis clinic. If child was dry before and now started
wetting the bed, make referral.

Safety netting :

Come back to us with your child if he develops fever, lethargy, tummy swelling,
day time symptoms.

Primary Enuresis
 1146

267. You are and FY2 in A & E. Chanella Oliver, 28 Years Old,
has come to the hospital with Chest Pain. He is under transition
from Male to Female.Talk to her and address her concerns.
D: How can I help you? P: I have Chest Pain
D: Where is it exactly? P: Left Side
D: Does it go anywhere? P: No
Pain gets worse on inspiration. (Complete SOCRATES), alarm
symptoms (chest pain, SOB, calf or abdominal pain)

D: Any other symptoms? P: No

D: Any Fever? P: No
D: Any Leg Pain? P: Yes, 2 days ago.
(Elaborate)
D: Do you feel out of breath? P: No
Any Cough, Dizziness, Trauma, Skin Lesion.
Was there any previous flight, immobility due to fractures
please check for HTN, hyperlipidemia, diabetes and clotting disorders,
cancer(Thrombophilia), recent surgery (and immobility due to fractures),
+ smoking, HRT, Previous PE/DVT

PMH: Oestrogen from 6 months taking more than prescribed.

Spironolactone the same time.
Medications: “male to female transgender treatment” you have to find out
WHAT MEDICINE- she may say high dose estrogen therapy with 200mg
progesterone
Personal:
D: Have you travelled anywhere recently? P: No
D: Are you currently sexually active? P: No
D: Who do you live with? P: Alone
Please you don’t need: sexual history in this case, it is too sensitive,
don’t ask her why she wants to change her sexual orientation
Examination: Examiner said it is normal. BP: 120/80, Sats: 99%.

Mention the treatment and review the medication Oestrogen and

spironolactone by the specialist.
Investigation: FBC, ???? Urine (Pregnancy)?????????, ABG, D-Dimer,
CXR, ECG, CTPA
 1147

Treatment:
- O2.
- Morphine & Metoclopramide
- Anticoagulation Heparin 5 Days, Warfarin  3-6 Months
- Prevention (Compression Stockings, Stop HRT/Pills, Anticoagulation
administered to Immobile patient)
- Tell her there is a risk with using estrogen therapy (but it is important to
rule out other causes); stopping the hormone treatment is an option but
we have her best interests at heart. We can always explore other
options. FIRST finding out if there is another cause of the PE and making
sure it is treated with anticoagulation therapy, we have to make sure that
this therapy doesn’t interact with her hormone therapy; we can also
research into other hormonal therapies that are low in estrogen (the
transdermal route may be better than oral doses); there is also the option
of IVC- inferior venacava filters that will help manage any emboli to the
lungs.
- IPS: this may be challenging, but we are here to help you continue this
transition safely, PE’s are life threatening and the hormone replacement
is important to you. keep her on DVT surveillance in the future and teach
her safety netting for PE

Risks
There's some uncertainty about the possible risks of long-term
masculinising and feminising hormone treatment. You ‎should be made
aware of the potential risks and the importance of regular monitoring
before treatment begins.‎
Some of the potential problems most closely associated with hormone
therapy include:‎
• Blood clots
• gall stones
• Weight gain
• Acne
• Hair loss from the scalp
• sleep apnoea – a condition that causes interrupted breathing during
sleep

Chest Pain (Transgender)

1148
 1149

268. You are an FY2 in GP. Mariah Smith, aged 55, came to the
clinic with some concern. Talk to her and address her concerns.

D: How can I help you? P: My daughter wanted me to see you.

D: Why? P: She said I keep forgetting things.
D: Do you think there has been any changes in you? P: No
D: Are you able to remember things? P: Yes, I remember most of the things.

Rule out vascular dementia. Ask PMH and personal history.

Examiner: MMSE 26, Routine Test – Normal Examiner: Which investigation

you want to do: some laboratory tests such as FBC, U&Es, LFT, calcium,
vitamin B12, thyroid function tests and random or fasting blood sugar, CT
scan or MRI of the brain.

Differential Diagnosis:
1. Neurodegenerative disorders for example Multiple sclerosis.
2. Other CNS disorders for example Brain tumours, Epilepsy and Trauma.
3. Infectious disease such as HIV.
4. Metabolic disorders such as Hypercalcemia, Hyponatremia.
5. Endocrine disorders such as Addison disease, Cushing syndrome and
thyroid problems.
6. Vitamin deficiencies such as vitamin B12, folate, thiamine, niacin
deficiency.
7. Medications such as anabolic steroids, corticosteroids, cimetidine and
some antibiotics such as penicillin.
8. Substance abuse such as Amphetamines, Cocaine, Alcohol, Cannabis.
9. Related psychiatric disorders such as Schizophrenia, delirium, Mood
disorders with delusional symptoms (manic or depressive type), Obsessive-
compulsive disorder.
According to the NICE guidelines, 25-30 - Normal.
21-24 - Mild Cognitive Impairment
10-20 - Moderate Cognitive Impairment
< 10 - Severe Cognitive Impairment.

Patient concern:What Investigation will you do Doctor?

Concerned Daughter MMSE

1150
 1151

269. You are an FY2 in GP. Parents of Sacha aged 2 have come
to you with some complaint. Sacha had gone for a pit walk with her
father. Talk to the mother and address her concerns.

D: How can I help you? P: Sacha is scratching all over.

D: Since when? P: 1 week.
D: Is there any rash? P: Yes
D: How did it start? P: It started

between her fingers and now it’s all over her body.

D: Any other symptoms? P: Like what?

D: Any Fever? P: No
D: Any Discharge? P: No

D: Has she been diagnosed with any medical condition in the past?
P: No
D: Is she taking any medications including OTC or supplements? P: No
D: Any allergies from any food or medications? P: No
D: Has anyone in the family been diagnosed with any medical condition?
P: No

D: Is Sacha the only child? P: Yes

D: How was the birth of Sacha? P: It was normal vaginal
delivery. D: Are you happy with the red book? P: Yes.
D: Is she up to date with all her jabs? P: Yes.
D: Has she received any recent jab? P: No
D: Is she feeding well? P: Yes. She is feeding very well.
D: Does she have any problems with her wee? P: No.
D: Is Sacha a playful child? P: Yes
D: Is Sacha playing well? P: Does not go out to play

D: Has Sacha come in contact with anyone with same complaint? P: No

D: I need to have a look at Sacha. P: I have a picture of the rash.

 1152

(Red rashes on knuckles and web spaces)

Investigation:

1. Diagnosis is clinically mainly. A magnifying lens may help in

identification of burrows or even occasionally mites.
2. The ink burrow test can be helpful in confirming burrows. Ink is rubbed
over a burrow (for example, with the surface of a fountain pen nib) then
wiped off with an alcohol swab. Ink will track into a burrow, outlining it.
3. Skin Biopsy - presence of mite, eosinophilic infiltrate; rarely eggs and
mite faecal material.
Treatment:
Symptomatic Treatment:
1. Anti-histaminics
2. Low dose steroid cream.

Non-crusted scabies – Permethrin Topical (5%)

Crusted (Norwegian) Scabies – Combination therapy with Permethrin +
Ivermectin (As an adjunct
All members of the household, close contacts, and sexual contacts
should be treated simultaneously with the index patient. It is important
that all contacts apply treatment on the same day to reduce the risk of re-
infestation from an untreated contact.
The primary method of treatment for scabies is by topical application of a
parasiticidal preparation overnight to the whole body from head to toe.
Apply treatment to the whole body, including the scalp, neck, face, and
ears, and especially between the fingers and toes and under the nails.
Treatment should not be applied after a hot bath (as this increases
systemic absorption and removes the drug from its treatment site). If the
 1153

hands are washed, the liquid or cream must be reapplied. This should be
repeated a week later.
Complication:
1. Scabies can cause flaring or reactivation of eczema or psoriasis.
2. Secondary bacterial infection.

Do
- wash all bedding and clothing in the house at 50C or higher on the
first day of treatment
- put clothing that cannot be washed in a sealed bag for 3 days until
the mites die
- stop babies and children sucking treatment from their hands by
putting socks or mittens on them

Don't
- do not have sex or close physical contact until you have completed
the full course of treatment
- do not share bedding, clothing or towels with someone with scabies
Risk factors:
Overcrowding, Poverty, poor nutritional status, Homelessness, Poor
hygiene, Institutions. Residential care homes in the UK, refugee camps in
some parts of the world, Sexual contact, Children, especially in
developing countries, Immune suppression.

Concerns:
P: How many days will it take to go away? P: What will you do for her?
P: What happens if it gets worse?

Differentials

Impetigo Tinea
Dermatitis herpetiformis Psoriasis
SLE

Scabies
1154
 1155

270. Delayed speech:

Case- delayed speech at 12 months
(By 12 months child should say atleast mama, baba)

• intro
• Parent’s concern
• Does your child make sound on crying?
• Does your child say any word at all?
• Is your child able to open their mouth?
• Any problem with the tongue?
• Is your child stuttering?
• Does your child recognize you?
• Does your child respond to you when you come in room?
• Did your child have any ear infection, which was left untreated?
• Any history of ear discharge, ear trauma?
• Any history if drooling from mouth?
• Fever, lethargy
• Now do BIRDD
- B: Birth history : Ask age of gestation when your child was born? Was your child
kept in special baby unit for any reason? Any chance of injury during birth?
- I: Immunization history : Has your both received jabs ?
- R: Are you satisfied with their personal health record book? (Red book)
- D: Other developmental history : response to any sound at all, smile, attachment to
you, supporting head, sitting, picking things? Etc
- D: Diet history : can you describe his diet a bit?
• Now do PMH and relevant parts of MAFTOSA : Past medical history : were any of
them diagnosed with any medical condition after birth?
• (MAFTOSA) Medications, allergies, family history of similar problems in childhood,
How many family members at home and main carers
• Examination : ask if child is there with her; if not, ask her to bring the child so that
you can assess the child’s vitals and general assessment.
• Offer hearing tests and evaluation of mouth and tongue
• Senior advice
• Specialist referral : ENT specialist, speech pathologist
• General advice :
- Talk to your child everyday
- Saturate their environment with speech
- Watch educational videos together
- Look at books with pictures together
- Ask your child questions
- Look at them in eyes and mouth your words to them
General safety netting
 1156

271. Twin developmental milestones (walking delay)

 Mother says one child runs around and other does not.
 What happens when he tries to stand/ walk? Does he fall or his legs get floppy?
 When changing diaper, did you notice any extra folds of skin in the hip area?
 Does his hip look a little bit unsteady/unbalanced? Does he tilt to one side? Does
his leg look curved in or out?
 When your child tries to stand does he support himself on his arms?
 Can you describe his routine to me? Do you carry him around a lot? Does he
spend time in walker? Does he have enough opportunity/ space in the house?
 There any difference in the way you are doing things with both twins? Are you
giving more time, attention or holding him more?
Now do BIRDD
- B: Birth history: Ask age of gestation when twins were born? Who was born first?
Was the child with delayed walking kept in special baby unit for any reason? Any
chance of injury during birth? Everything okay with the other child?
- I: Immunization history: Have they both received jabs especially polio vaccine?
- R: Are you satisfied with their personal health record book? (Red book)
- D: Other developmental history: response to sound, smile, attachment to you,
making sounds, picking things? Etc
- D: Diet history: can you describe his diet a bit? What does he eat? Enough
exposure to sun? (Tell about importance of vitamin D and calcium fortified milk and
cereals)
 Now do PMH and relevant parts of MAFTOSA: Past medical history: were any of
them diagnosed with any medical condition after birth?
 (MAFTOSA) Medications, allergies, family history of similar problems in
childhood, family history of joint problems and bone fragility problems? How many
family members at home and main carers of the twins?
 Examination: ask if child is there with her; if not, ask her to bring the child so that
you can assess the child’s vitals and legs.
 Now it’s time for counseling
You should know what is normally expected so that you can counsel confidently.
Children are expected to walk well by 14-15 months. Some children take time and
can start walking well by 16-17 months, so we have to wait till that time before any
further treatment.
Management (delayed walking) :
 I can see that you are worried. It is true that learning to walk is a big achievement
 1157

and an important step in a child’s development. As parents, it can be very much

concerning that their child is not taking steps. But babies develop skills at different
pace. Some develop skills very quickly, but some take time to do so. This is
something normal for babies to walk at different rates and this is usually nothing to
worry about. Give your child some time.
 You can encourage them to walk by appreciating them, holding their both hands
and kneeling and standing with them. Avoid putting your child in baby walkers or
holding them too much. Encourage them to stand with the support of sofas and
chairs. You can put their toys away from them, so they can make efforts to reach
them. Avoid keeping shoes on all the time. Keep them barefoot, so that they get a
chance to grow and balance themselves.
 I will discuss this all with my senior for further advice.
 Talk about sending routine blood tests and CPK levels if child is supporting
themselves with their hands while standing.
 If he does not walk by 18 months, specialist will be involved.(pediatricians and
physiotherapists)
 What you can do is give your child some time and in the meanwhile, you can
write down all your concerns in a diary and these questions will be answered in your
next follow-up appointment in GP clinic.
 Safety netting (generally unwell, not walking at all by 18 months, going all floppy)
1158
 1159

272.

 There will be a lady looking down and a bit depressed. Talk to her like you talk to
a friend. Inquire if everything is ok. Is there anything she would like to talk about?
Let her know that you are here for her. Tell her that you will do everything to make
things right for her. Let her know you are deeply concerned for her. When she
doesn’t open up, then you can offer her confidentiality. Make sure you keep
confidentiality as your 3rd/4th option- never offer confidentiality as the first option
 The history in this case is a bit different. It does not follow the general pattern of
MAFTOSA. She will present with panic attacks or low mood. Take short history of
these. Once she opens up about bullying being the cause of this. Then take
complete history of bullying first- she says people at her work place are bullying
her.

 Ask- can you tell me more about it ?

 Since when? What type of bullying is this- verbal, physical? Have they ever done
damage to your property? (If property or physical damage, then let her know that it
is a police case as well) is this bullying confined to the work place or they do it at
home too like via messages, email, social media? Why are they bullying her? Is it
because of her beliefs, race, gender or sexual orientation? (Here is how you will
know that she is a lesbian). Is there anyone else at workplace to who is being
bullied as well? Have you ever confronted them? Have you talked to anyone about
this? Have you talked to your employer? Or human resource department?
 1160

 Then after taking thorough history of bullying, you move towards your
FAMISH. I hope that you all know about famish. If not let me clarify it for you:
- F: friends, family, finance and forensics( have you told your friends/ family
about this? Are they supportive?)
- A: addictions (alcohol, smoking, drugs) and allergies (sometimes to cope
with situations like these, people resort to things like alcohol, drugs, is this the
case with you?)
- M: medications, medical conditions, mood (focus on mood in this one; it is
your personal choice if you want to grade mood or not; but do enquire about
mood in general)
- I : insight
- S: suicide risk (good way to ask about this is : sometimes when people ago
through similar situations, they try to harm themselves- is this the case with
you?)
- H: Homicide risk (good way to ask about this in this case is : have you ever
thought about retaliating?)
- No need to ask about hallucinations, thought problems, delusions in this
case (if she is severely depressed, then you can rule out these things)
 1161

Now your history is complete.

Talk about generally examining her.
Then, address her panic attacks / low mood- senior advice and referral to
psychiatrist for talking therapy.

Then, address the main underlying cause of these symptoms -

- Bullying is not acceptable at all, and nobody deserves to go through this.
- It is very brave of her to come here and talk about this.
- Me and my team will stand by her in this and we will help you as much as
possible.
- Advice her to collect evidences of the bullying- if she is receiving emails or
anything like this, keep them safe.
- Talk to the colleagues bullying her and talk to your employer- talk to your
employer in written via email and keep that email safe.
- If no response from them, then contact HMRC department.
- If still no response, we can involve legal attorneys and LGBT communities.
- Joint complaint - if someone else at workplace is being bullied as well.
- This all will not only help her but also other people in similar situations.
Safety netting: contact us if things seen overwhelming; or if she feels she can’t
handle this.
 1162

Bullying at work place lesbian

 1163

273.
 1164

Analgesic nephropathy
 1165

274.
 1166

Syphilis
 1167

275.
 1168

PSA- demanding patient

 1169

276.
 1170

Cervical screening (lesbian)

 1171

277.
 1172

Levothyroxine Dose Adjustment.

 1173

278.
 1174

idiopathic thrombocytopenic purpura.

 1175

279. You are a FY2 doctor in a GP clinic. A 66 years old man Mr. Simon Toufal
came to the clinic with concerns regarding his eye sight. Take a brief history, address his
concerns and talk about the appropriate management.
Dr. - Hello, I am Dr….. one of the junior doctor in this clinic. Are you Mr. Simon Toufal.
Patient - Yes.
Dr. - How can I address you. Patient - Call me…….
Dr. - Mr.Toufal, how can I help you today.
Patient – Doctor, since the last few days I am having trouble in my vision.
Dr. - I am sorry to hear about that. Can you please tell me what exactly are you experiencing?
Patient - Well doctor from the last 3-4 weeks I am having blurry vision. I feel like lights are
too bright for me. This has never happened before doctor.(He can also say other symptoms
such as he is finding it harder to see in low light, colours look faded to him, having difficulty
in driving, misty vision, hard to see in low light, halos around lights.)
Dr. - So sorry to hear about that. I can understand it can be very distressing. Can you please
tell me are you having these symptoms in one eye or both ? (He can say one eye or both.
Usually cataracts appear in both eyes. Cataracts may not necessarily develop at the same time
or be the same in each eye.)
Dr. - Mr.Toufal in order to understand this condition better is it ok if I ask you few more
questions. (Rule out differentials) Patient - Yes
Dr. - Do you have any pain in your eyes? Any blurry vision? (Glaucoma) Patient - No
Dr. - Did you notice any red eye or irritation in your eyes? (Conjuctivitis and Foreign body)
Patient - No doctor.
Dr. - Do you have pain while combing the head especially on one side of the head? (GCA)
Patient - No.
Dr. - Do you have any headache that comes and goes after few days with watery eye? (Cluster
Headache) Patient - No doctor.
Dr. - Do you find difficulty in reading and recognizing faces? (Age related macular
degeneration as in ARMD middle part of vision is affected.) Patient - No doctor.
If the patient wear glasses then ask this - Mr.Toufal do you need to clean your glasses again
and again even when they are not dirty? He might say yes as this is one of the main symptom
of cataract due to development of cloudy patches on the lens
 1176

Risk Factors - Ask him about

1) Family history of cataracts.
2) Does he Smoke? As it’s a risk factor.
3) Diabetes.
4) Long term use of steroids.
5) Drinking too much alcohol.
6) High Myopia.
Ask him about MAFTOSA and any history of taking a medication from a long time as few
medications can lead to cataract.
He will deny all medications and other symptoms. He will give history positive for cataract
symptoms which are mentioned earlier.
Examination : Doctor - Mr.Toufal, I would like to do some test which will include Visual
acuity (Means checking your eyesight). Tell him you would like to do a red reflex and if its
 1177

positive then fundoscopy as red reflex still occurs in immature cataracts and in dense cataract
red reflex is absent.
Examiner may or may not give findings.
Patient – Doctor can you please tell me what is it I am having? Is it a serious condition? Will I
lose my vision?
Dr - Mr.Toufal from the information you have given me I suspect you have a condition known
as Cataract. Do you know what cataract is?
Patient- May say yes or no. (So explain the condition)
Dr. - Mr. Toufal we have lens in our eyes. This lens is like a small transparent disc inside our
eye. Sometimes this lens can develop cloudy patches on it. When we are young our lenses are
usually like clear glass allowing us to see through them. As we get older they started to
become frosted like bathroom glass and begin to limit our vision. This is what we called
Cataract. This condition usually develops in both eyes.
Patient: why did I have it? Dr: there could be reasons for it. But in your case it`s due to age.

Management–
Dr: Mr.Toufal, with good treatment on time there is very less chance that someone can lose
vision due to cataract now days and fortunately we have very good treatment available for
this.I will refer you to a specialist of eyes known as ophthalmologist. They might do some
more tests and depending on the results they might go for a cataract surgery in which a new
clear plastic lens is inserted into the affected eye and old one is removed.

Only explain about the surgery if patient want to know about it.
Doctor - Mr.Toufal do you drive? Patient - Yes doctor.
Doctor - Mr.Toufal I would highly suggest you to inform DVLA as it can be dangerous to
drive with cataract. DVLA can guide you better regarding this. Patient - Ok doctor, I will.
Doctor - Mr.Toufal is there anything else I can do for you today?
Patient - No doctor, that is all. Thank you for your help.
Doctor- Mr.Toufal I just want to let you know that if there is anything else that we can do for
you please do not hesitate to contact us again. And if you feel that your vision is getting worse
drastically please ask someone to take you straight to the A&E.
Patient – Thank you doctor. You have been very helpful.
Cataract
 1178

280. A 55 Year old man Mr. Alex Sharp presented to GP clinic with complaint in his
vision. You are a FY2 in GP clinic talk to him, address his concerns and discuss a
management plan.
Doctor - Hello I am FY2 Dr…. in this GP clinic. Can you please confirm your name and age for
me.
Patient - Doctor my name…. and my age is….
Dr. - How can I help you today?
Patient– Doctor, I have problem in my vision.
Dr. - I am sorry to hear that. Can you please tell me what exactly are you experiencing?
Patient– Doctor, I have blurred vision, I have trouble reading, watching TV. I see a dark spot in
the centre when I read or watch something (or wavy lines). (He can say any of these symptoms)
*AMD can make things like reading, watching TV, driving or recognising
faces difficult. If it get worse people might struggle to see anything in the
middle of their vision.*
Doctor - Is this affecting your both eyes?
Patient - No doctor, its affecting my right eye only. (ARMD can affect one or both eyes together.)
Doctor – Mr.Alex can I please ask you further questions in order to understand this situation
better. Pt - Yes doctor.
Dr. - Since when you are experiencing these symptoms? What I mean that did you develop these
symptoms gradually over several years or quickly over a few weeks or months?
He might say over years or over months as this can happen gradually over several years ("dry
AMD"), or quickly over a few weeks or months ("wet AMD").
Dr. - Do you have any pain in your eyes? (Glaucoma)Patient - No doctor.
Dr: any nausea or vomiting? Patient: no
Dr. - Did you notice any red eye or irritation in your eyes? (Conjuctivitis and Foreign body)
Patient - No doctor.
Dr. - Do you have pain while combing the head especially on one side of the head? (GCA)
Patient - No.
Dr. - Do you have any headache that comes and goes after few days with watery eye? (Cluster
Headache) Patient - No doctor.
Dr. - Is it difficult to see in low light, colours look faded to you, misty vision, halos around lights.
(Cataract) Patient - No doctor.
Dr: did you notice any wt loss? Patient: no
Dr: How is your appetite? Patient: good.
Dr: any dizziness or heart racing? Patient: no
Dr: do you feel tired these days? Patient: no
 1179

Ask him about other sign and symptoms of ARMD –

1. Does he see a straight line as wavy or crooked?
2. Objects look smaller than usual.
3. Colors are less bright than usual.
4. Is he having difficulty recognizing faces?

Ask him about the risk factors: Smoking, High B.P, Overweight, Family History of AMD.

Examination:
I need to examine your eyes – check your vision and examine the back of your eyes with
fundoscope. Examiner may or may not give you a picture.

Dr. - Mr.Alex thank you for answering all my questions. From the symptoms you have given me I
 1180

suspect that you have a condition known as Age related macular degeneration.Would you like to
know about it. Patient - Yes Doctor.

Explain AMD - Macular degeneration, also known as age-related macular

degeneration (AMD or ARMD), is a medical condition which may which affects the macula a
tiny part at the back of the eye - retina. This results in blurred or no vision in the center of
the visual field. Early on there are often no symptoms. Over time, however, some people
experience a gradual worsening of vision that may affect one or both eyes. While it does not result
in complete blindness, loss of central vision can make it hard to recognize faces, drive, read, or
perform other activities of daily life.
[Visual hallucinations may also occur but these do not represent a mental illness].

Doctor - Mr. Alex we will refer you to the eye specialist Ophthalmologist as soon as possible.
They will see you within the 24 hours. Once it is confirmed that it is AMD we can start the
treatment depending on type of AMD you have as it can be wet or dry.

Dr. - Mr.Alex are you following me? Patient – Yes doctor.

Doctor - We may do a Referral to a specialist of an eye, eye doctor (ophthalmologist) or
specialist AMD service.

You may have to take more tests, such as a scan of the back of your eyes.

Patient – Dr. what happens if I am diagnosed with AMD?

If you're diagnosed with AMD, the specialist will talk to you about, what type you have and what
the treatment options are.

 Types of AMD

It might be difficult to take in everything the specialist tells you.

Treatment depends on the type of AMD you have.

 Dry AMD – Caused by a build-up of a fatty substance called drusen at the back of the eyes(
Retina).Unfortunately there's no treatment for this one, but vision aids can help reduce the effect
on your life. Gets worse gradually – usually over several years
 Wet AMD – Caused by the growth of abnormal blood vessels at the back of the eyes( Retina).
Can get worse quickly – sometimes in days or weeks. If its wet AMD may need regular eye
injections and, very occasionally, a light treatment called "photodynamic therapy" to stop your
vision getting worse.
 1181

Doctor – Would you like to know about the treatment options. [ tell him the details only if he
wants to know.

Then explain him the treatment options that are available for wet AMD.
Eye Injections
Anti-VEGF medicines – ranibizumab (Lucentis) and aflibercept (Eylea), Injections given directly
into the eyes.

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

Photodynamic therapy (PDT)

A light is shined at the back of the eyes to destroy the abnormal blood vessels that cause wet
AMD.

 may be recommended alongside eye injections if injections alone don't help

 usually needs to be repeated every few months
side effects include temporary vision problems, and the eyes and skin being sensitive to light for a
few days or weeks

 Tell him about the life style changes and devices that can help in vision.
 Useful devices – such as magnifying lenses
 Changes you can make to your home – such as brighter lighting
 Software and mobile apps that can make computers and phones easier to use
If you have poor vision in both eyes, specialist may refer you for a type of training called eccentric
viewing training.This involves learning techniques that help make the most of your remaining
vision.

Staying healthy

AMD is often linked to an unhealthy lifestyle. If you have it, try to:

 eat a balanced diet

 Exercise regularly.
 1182

 lose weight if you're overweight

 stop smoking if you smoke
Ask him about driving and tell him about DVLA.

AMD can make it unsafe for you to drive. Ask the specialist if they think you should stop driving.

You're required by law to tell DVLA about your condition if:

 it affects both eyes

 it only affects one eye but your remaining vision is below the minimum.

Monitoring and check-ups

You'll have regular check-ups with your specialist to monitor your condition.

Warning signs :Get an urgent opticians appointment if:

 Your vision gets suddenly worse

 You have a dark "curtain" or shadow moving across your vision
 Your eye is red and painful
These aren't symptoms of AMD but can be signs of other eye problems that need to be treated
immediately.

Doctor – So Mr.Alex is it ok if I refer you now. I hope that I was of help and I wish you good luck
for the future.

If you have any other inquires or you want to know anything else, please do not hesitate to contact
us again or come back to us.Thank the patient.

Patient - Thank you doctor you have been very helpful.

AGE RELATED MACULAR DEGENERATION