PLAB 2 Notes Part 1

Page |1
Dr Swamy PLAB 2 Course
Sl .No Video Page

ID Number Station name availability number
1 2001 Introduction Part 1 Video available
17 2021 Medical ethics Part 1 Video available
23 2029 Uncontrolled epilepsy Video available
24 2030 Gaint cell arteritis Video available
25 2031 Tension headache Video available
26 2033 Subarachnoid heamorrhage - Video available
27 2034 TIA - talk to husband Not available
28 2035 Stroke risk assessment Video available
29 2036 Head injury in adult Not available
30 2037 Guillian Barre syndrome Not available
31 2053 Glaucoma Video available
32 2054 Subconjuctival heamorrhage - eye Video available
33 2055 Diabetic retinopathy Video available
34 2056 Cataract- Not available
35 2057 Age related macular degeneration Not available
36 2058 Optic neuritis (multiple sclerosis) Not available
38 2074 Cholestetoma - ear Video available
39 2075 Barotrauma - ear Not available
40 2077 Vestibular neuronitis -ear Not available
41 2078 BPPV -ear - Not available
42 2088 Nose bleed - Pt on Apixaban Not available
43 2089 Allergic Rhinitis Video available
Page |2
44 2099 Tonsillitis Not available

45 2109 ECG teaching to the nurse Not available
46 2111 Stable Angina-Chest Pain Video available
47 2112 Pericarditis - chest pain Video available
48 2113 Palpitation Video available
49 2114 Musculo-skeletal-Chest Pain Video available
50 2115 Herpes Zoster - Chest Pain Video available
51 2116 Heart Failure Video available
52 Pulmonary Embolism ( risk factor OCP) Video available
2129 - Chest Pain/SOB/
53 Pulmonary Embolism ( risk factor Not available
2130 Breast cancer) - Chest Pain/SOB/
54 2131 Chest pain PE transgender Video available
55 2132 Pneumonia in elderly-Chest Pain Video available
56 2133 Pneumonia - confused elderly man Not available
57 2134 Peumocystis Pneumonia Not available
58 2135 Atypical Pneumonia Video available
59 2136 TB Not available
60 2137 Asthma - teach patient PEFR Not available
61 2138 Exercise induced Asthma Video available
62 2139 Sepsis ( in elderly Tel conversation) Video available
63 2141 Cancer Lung - Notes Done Video available
64 2158 Nipple discharge - Video available
65 2165 Back Pain- causes Video available
66 Leaking abdominal aortic anuerysm - Not available
2166 Back pain
67 2167 Muskulo-skeletal- Back pain Not available
68 2168 Prolapsed disc- Back pain Not available
69 2169 Multiple myeloma- Back pain Video available
70 2184 GORD - oesophagus Video available
71 2185 Barrets oesophagus Not available
72 2186 Dysphagia - Cancer oesophagus Not available
73 2187 Hemetemesis due to Ibuprofen Not available
74 2198 Gilbert's syndrome - liver Not available
75 2200 Alcoholic hepatitis Video available
76 2218 Appendicitis Video available
77 2219 Gastro-enteritis Not available
78 2221 Inflammatory bowel disease Not available
79 2222 Bowel cancer Video available
80 Low GFR because of Ramipril - Bilateral Not available
2239 renal artery stenosis
81 2240 Ureteric calculus Video available
82 Heamaturia in lady who is taking Not available
2252 warfarin
83 2262 UTI BPH Video available
84 2273 Inguino-scrotal swelling teaching Not available
85 2280 Testicular swelling Not available
86 2282 Erectile dysfunction Not available
2283 Gonorrhea in man Video available
Page |3
87 2292 Urine dipstick – teaching Not available

88 2297 Reactive Arthritis- Not available
89 2298 Rheumatoid Arthritis Not available
90 2299 Gout Not available
91 2300 Polymyalgia Rheumatica Video available
92 2301 Hemiarthroplasty Not available
93 2302 Osteoporosis Video available
94 2312 Skin lesion-Squamous cell carcinoma Video available
95 2313 Skin lesion-Melanoma/mole Video available
96 2314 Molluscum contagiosam Not available
97 2315 Skin lesion-Fungal infection Video available
98 2316 Cold sore- herpes labiali Not available
99 2317 Cellulitis due to insect bite - Video available
100 2318 Pt requesting Retinoids for Acne Video available
101 2319 Seborrheic keratosis Not available
102 2320 Urticaria Not available
103 2321 Urticaria Not available
104 2322 Post herpetic neuralgia - Video available
105 2323 Post Herpetic Neuralgia Not available
106 2324 Subcutaneous injection teaching Not available
107 2325 Scabies Ali new Video available
108 2326 Patient with lymphadenopathy-STI Not available
109 High INR - patient on warfarin took Not available
2345 Clarythromycin
110 2346 Patient refusing warfarin Video available
111 2348 Iron deficiency Anaemia Video available
112 2349 Thalassemia Not available
113 2350 Multiple Myeloma Not available
114 2351 Leukaemia Video available
115 2352 Uncontrolled diabetes Not available
116 2365 Hyperthyroidism Not available
117 2366 Hypothyroidism Video available
118 2367 Hyperparathyroidism Video available
119 Hypoglycemia after taking large dose Video available
2368 Insulin
120 2369 Hypoglycaemic fit after skipped meal Not available
121 2370 DKA in adult refusing admission Video available
122 2372 Postural hypotension - fall Not available
123 2373 Arrhythmia in elderly - fall Not available
124 Pre-operative assessment for pin Not available
2386 removal from ankle
125 Inguinal Hernia - Pre-operative Video available
2387 assessment and counselling
126 2398 Chronic fatigue syndrome Video available
127 2399 Fibromyalgia Video available
128 2400 Obstructive sleep Apnea Video available
129 2401 Citalopram (low sodium) Video available
130 2402 COPD on inhaler (hyponatremia) Video available
131 2404 Tiredness - Anaemia Video available
Page |4
132 2420 Statin Therapy Video available

133 2421 Obesity Counselling Video available
134 Obesity Psoriasis and Vascular Video available
2422 dementia
135 2423 Worried about stroke - counselling Not available
136 Post MI Discharge &Lifestyle Video available
2424 Modifications
137 2425 Smoking Video available
138 2440 Antenatal examination Video available
139 2441 Catheterization Video available
140 Paracetamol overdose and blood Video available
2442 sampling
141 2443 Post appendicectomy IV cannulation Video available
142 otoscopy earache Hearing Loss Acoustic Video available
2444 neuroma
143 speculum examination and Cervical Pap Video available
2445 Smear
144 2446 breast examination Video available
145 2447 testicular swelling Video available
146 Inguinal swelling teaching medical Video available
2448 student
147 2449 CPR BLS Video available
148 2450 Aerochamber. Video available
149 Alcoholic liver disease - abdominal Video available
2451 examination manikin.
150 Leaking Abdominal aortic anuerysm Video available
2452 manikin
151 2453 cyclic mastalgia Not available
152 2454 Prostate examination Not available
153 2455 Fundoscopic examination GCA Video available
154 2456 Arterial blood gas procedure Not available
2457 ABG interpretation part 1 Video available
2458 ABG interpretation part 2 Video available
155 2467 DNACPR simman Video available
156 2468 Anaphylaxis simman Video available
157 Upper GI bleeding after taking Video available
2469 diclofenac simman
158 2470 Post partum heamorrhage simman Video available
159 Post hysterectomy for DUB bleeding/ Video available
2471 PE simman
160 2472 Post TURP sepsis simman Video available
161 Sepsis after UTI in elderly lady Video available
2473 simwoman
162 2474 Hypoglycaemia - simman Video available
163 2475 Asthma - simman Video available
164 2476 Acute limb ischemia Video available
165 2477 Atrial fibrillation Video available
166 2502 Alcoholic foot examination Video available
167 2503 Diabetic foot examination Video available
168 2504 Visual field examination Video available
169 2505 Knee examination Video available
Page |5
170 2506 Neurological examination - ataxia Video available

171 2507 Cranial nerve examination Not available
172 2508 Hip examination Video available
173 2509 8th cranial nerve examination Video available
174 2510 Teaching 8th cranial nerve examination Not available
175 2511 De Quervain's Tenosynovitis Video available
176 2512 Not available
177 TENNIS ELBOW – LATERAL Video available
EPICONDYLITIS
2513
178 2514 Carpal tunnel syndrome Video available
179 TEACHING RESPIRATORY SYSTEM Video available
2515 EXAMINATION
180 2516 Thyroid examination Video available
181 2517 How to do GCS Video available
182 Meningitis – headache Video available
2518
183 2519 Primary survey (Part 1)ATLS Video available
184 2520 Primary survey (Part 2) ATLS Video available
185 2521 Primary and Secondary survey ATLS Video available
2522 Whiplash injury Video available
2523 Brachial plexus injury Video available
186 2548 MMR mother concerned Video available
187 2549 Flu vaccine mother concerned Video available
188 2550 Ear infection in child ( otitis media) Video available
189 2551 Febrile convulsion due to ear infection Video available
190 Not available
2552 Night terror and night mare
191 Constipation in child / Missing repeated Not available
2553 20580
192 Not available
2554 Asthma in child with chest infection
Not available
2555 Chest infection in child triage tel call
193 2556 Bronchiolitis Video available
194 Video available
2557 Extradural Heamatoma in child BBN
195 Not available
2558 Fracture Pelvis in child BBN
196 Not available
2559 Neonatal jaundice
197 2560 Primary nocturnal enuresis Video available
198 2561 Pyloric stenosis Video available
199 2562 Intussusception in child Video available
200 Constipation in a child/ Missing Not available
2563 /repeated 20570
201 2564 Head injury in child Video available
202 Not available
2565 Mother does not want IV cannula
203 Not available
2566 Cerebral palsy child unfairly treated
204 Not available
2567 Epipen Use - Teaching
205 2568 Newly diagnosed Epilepsy in child Video available
Page |6
206 Mother concerned about child taking Not available

2570 OCP
207 Not available
2571 Autism 2 cases
208 Not available
2572 chlamydia infection in neonate
209 Not available
2573 Delayed walking in child
210 Not available
2574 Mother requesting Tonsillectomy
211 2575 Fluid calculation appendicectomy Video available
212 Not available
2576 Cystic fibrosis-prenatal counseling
213 Not available
2577 Child with tantrums
214 Not available
2578 Meningitis prophylaxis – Talk to Father
215 2610 Pelvic inflammatory disease Video available
216 2611 Ovarian cystectomy Video available
217 Antenatal assessment -lady had Not available
2612 miscarriages previously
218 2614 Ectopic pregnancy Video available
219 2616 PCOS Video available
220 2617 Hypertension and pregnancy Video available
221 Combined pill contraception Not available
2618 counselling
222 2619 Pre conception counselling Video available
223 2620 Emergency contraception Video available
224 Not available
2621 Premature ovarian insufficiency
225 Not available
2622 PID Hydrosalphinx
226 Not available
2623 Bacterial vaginosis
227 Not available
2624 Premenstrual syndrome
228 2625 Pre eclampsia regular follow up Video available
229 2672 Psychosis Video available
230 Schizophrenia ali new -Ali new Video available
(Psychosis includes Schizophrenia topic
2673 in notes)
231 2674 Bipolar disorder Not available
232 2675 Depression - paracetamol overdose Video available
233 Depression - paracetamol overdose gay Not available
2676 man
234 2677 Young lady cut wrist and OCP overdose Video available
235 Not available
2678 Depression-CBT failed
236 Not available
2679 Panic Attack
237 2680 AlcoholDrug Abuse Video available
238 2681 MMSE Not available
239 2682 Anorexia Nervosa Video available
240 Not available
2683 SSRI - Fluoxetine
241 2684 Mental State Examination Not available
Page |7
242 Not available

2725 Lesbian lady bullied
243 Non accidental injury (sexual Not available
2726 harassment)
244 Teenager confused about sexual Not available
2727 orientation
245 2728 Lesbian want to have a child Ali new Video available
246 Child swallowed foreign body - Medical Video available
2748 Error stations
247 2749 Rash after Amoxycillin - Medical error Video available
248 Misdiagnosed Pneumonia - Medical Video available
2750 error
249 Missed hair line wrist fracture - Medical Video available
2751 error
250 Missed renal biopsy sample- Medical Video available
2752 error
251 Unlabelled blood Samples - Medical Video available
2753 Error
252 2754 Missed MI - Medical error /Notes done Video available
253 FY1 delayed discharge -Talk to Video available
2774 colleague
254 2776 Late Iv cannula talk to Patient Video available
255 2777 Alcoholic colleague Video available
256 Alcoholic and drug abuser medical Not available
2778 student
257 2779 Late medical student Video available
258 2802 NAI - pregnant Lady Video available
259 2803 NAI - Adult lady ( Insomnia) Video available
260 2804 NAI - Elderly lady Video available
261 2805 NAI Child Spiral Fracture Video available
262 Massive stroke - Talk to pregnant Not available
2822 daughter
263 Not available
2823 Post opreative stroke
264 2824 Dementia - weight loss Video available
265 2825 HIV test positive - tell the result Not available
267 Intra cranial bleeding ( SAH in adult) Video available
2826 BBN
268 2827 Aorto femoral bypass surgery BBN Video available
269 2828 Breast cancer FNAC result Video available
270 Not available
2829 Intracerebral heamorrhage BBN Tel -
271 Not available
2846 Lady asking for sick note after accident
272 Not available
2847 Ankle sprain wants to change the notes
273 Patient with sore throat demanding Video available
2848 antibiotic cs
274 2866 Different councillor Video available
275 2867 Pneumonia pt requesting DNAR Not available
276 Multiple sclerosis patient requesting Video available
2868 DNAR
277 2884 Post herniorrhaphy wound infection Not available
Page |8
278 2885 Post cyst removal wound infection Video available

279 Angiogram lady - conflict with Not available
2886 Physiotherapist
280 Lady with UTI - write out patient Not available
2909 prescription
281 2910 Explaining discharge medication Video available
282 2912 Asthma discharge medication Not available
283 2913 Breast cancer pain management Video available
284 2914 Apixaban Prescription Video available
285 Insomnia in known pt of Rheumatoid Not available
2932 arthritis
286 Cannabis abuser with Insomnia asking Video available
2933 for sleeping pills
287 2934 Obstructive sleep apneoa Not available
288 2950 Confusion - Oxybutinin side effect Video available
289 2951 Constipation pt on cocodamol Not available
290 2952 HTN - dry cough change to Losartan Video available
291 2954 Feeling unwell-on oxybutynin Not available
292 2970 Needle stick injury in the nurse Video available
293 2971 MRSA Video available
294 2972 Claustridium difficille Video available
295 2973 Post mortem counselling Video available
296 2974 Colorectal polyp needs colonoscopy Video available
297 2975 Coeliac disease needs endoscopy Video available
298 2976 Fracture wrist in elderly lady Video available
299 Son doesn't want his mother to know Not available
2977 that she has cancer
Son who is a Surgical consultant wants Video available
2978 to know about his mothers condition
300 2979 Gender selection Video available
301 2980 Noisy relatives Video available
302 2981 Drug addict wants self discharge Video available
303 Ethical - FY2 doctor put message about Not available
2982 pt in the Facebook
Dr Swamy PLAB 2 Course

Page |9
Introduction to the PLAB 2 exam has 16 parts of videos.

Id number from 2001 till 2016.
Notes are the same ( from page number 10 till page number 21) for all parts
of Introduction videos.
Introduction
Professional and Linguistic Assessment Board.
PLAB 2.
What is assessed?
Professionalism and Language ( Communication skills / Interpersonal skills)
This is a type of OSCE (Objective structured clinical examination).
Areas of assessment – History taking skills, Clinical examination skills, Patient management
skills, Practical procedures at a junior doctor level.
15 OSCE stations plus 3 rest stations. Total 18 stations.
One and a half minute to read the question and eight minutes to perform the task.
Total nine and a half minutes for each station. Total time duration of the exam – 171 minutes
( nearly 3 hours).
Station timings
Start bell Begin 2 minutes Move on to

next
remaining station
I---------------------------I---------------------------------------------I------------------------
I------------
One and half minutes 6 minutes 2 minutes Next
Read question Task
Examination rooms
Rest
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
Candidates standing outside the cubicles when reading the question
18 17 16 15 14 13 12 11 10
18 17 16 15 14 13 12 11 10
Rest Rest
What is to be demonstrated ?
Competency, SAFE doctor

P a g e | 10
Communication skills
Listen to the patient
Compassion ( Sympathy and Empathy)
Caring ( comfort, feeling ) Offer adequate analgesia if the patient is in severe pain before taking
a detailed history. ( eg – SAH, Meningitis, MI, Ureteric calculus, Acute limb ischemia)
Confidence,
Reassurance,
Build and maintain Rapport [ Patient should like you, trust you. Involve the patient in the
management (Patient centred) ]
Praise,
Be honest
Humble (Be Polite – Say Please, Sorry, Thank you when required)
Patient centred approach
10 Key words
to remember whenever you explain anything to the patient ( like diagnosis, investigations or
treatment )
1. Simple ( Avoid medical jargon )

2. Sweet ( compassion, address feelings, I can understand what you are saying)
3. Short
4. Clear
5. Complete
6. To the point
7. Appropriate
8. Check the understanding
9. Ask for concerns
10. Ask for expectations (Anything you are expecting from us ? Anything else we can do
for you ? Do you have any suggestions on your mind?
Type of questions in the PLAB 2 exam
1. Patient came to the hospital with some symptoms. Take History, examine and talk
about the management to the patient
2. Patient was already treated previously. Now the patient has come for follow up.
3. Patient was treated previously. Now the patient has come back
4. Ethical and Legal issues
5. Teaching
6. Colleagues with problem ( colleague under the influence of alcohol or recreational
drug during the work hours)
7. Breaking bad news
8. Counselling
9. Telephone conversation
10. Drug prescription
11. Difficult ( stubborn or demanding) patient
12. Angry patient
13. Medical error
How do they mark ?

Almost equal mark for knowledge and Interpersonal skills
Quantitative and Qualitative ( skills area)
P a g e | 11
How to start a station ?

GRIPS
Greet
Develop good rapport
Introduce yourself to the patient and Identify the patient
Purpose of your consultation / Privacy and chaperone.
Situation ( Observe patient and understand the situation)
How to Approach a station ?

GRIPS – Take history – Examine – Provisional diagnosis – Investigation – Definitive
diagnosis – Treatment including safety netting.
Examination – Examine the Patient ( actor or simulator or manikin)
First examine vital signs ( NEWS chart ) given inside the room. Tell the vital signs to the
patient.
Verbally mention the area of the body you want to examine.
1. Examiner may give you the examination findings – tell the patient
2. Patient may show picture – Tell your observation to the patient
3. If the examiner does not give finding s or the patient does not show picture then you
really examine the patient.
How to tell the diagnosis ?

I think ( I suspect, most probably, possibly, could be ) you have a condition called
Pneumonia ( use the medical word ). Ask if they have any idea about it?
If not explain in a simple way the patient can understand. Check the understanding?
Ask for concerns ?
Doctor is it serious? -
Explain the investigations –

Check the understanding, Take consent.
How to talk about the treatment ?

Treatable or not?
What is the treatment ?
Medicine – name, what is it for, how to take it. When ( before or after food), how many
times in a day, how many days, Side effects what to do if there are side effects?
Is it surgery
Chemo /Radio/Physio /Palliative/ Self subsiding.
Safety netting when sending a patient home

Tell the treatment ( is it treatable or not)
When and where is the follow up
How long will it take for the patient to recover ?
Warning signs or red flag signs. To come back if
 Symptoms gets worse
P a g e | 12
 New symptoms ( may be the patient developed complications)

 Not improved by the expected time.
 Any serious side effects
Reasons for taking History

1. To reach a diagnosis
2. To rule out differentials
3. To check for risk factors
4. To check for complications
5. To for associated conditions
6. Information which can help in the management
a. Other medical conditions ( contra-indications)
b. Other medications ( Drug interactions)
c. Allergy
d. Social history ( can the patient cope at home)
e. Advance are planning
Pneumonic for taking history

Present – ODIPARAAA (Onset, duration, Intensity, progression, Aggravating and relieving
factors, Anything else, Associated symptoms, Associated disease.
Past history
Treatment taken for this before
Medications
Allergy
Family history
Travel history
Occupation
Social History
Anything else important patient want to tell you?
Any concerns
BNF ( British national Formulary) may be kept in every station ( use it if necessary)
NEWS chart
P a g e | 13
Doctor grade in the NHS ( National Health service) Hospital

Consultant
Registrar
SHO ( senior house officer) Foundation year 2
HO Foundation year 1
P a g e | 14
Question format
Where are you

1. You are a FY2 doctor in the medical/surgical/Psychiatry department / GP clinic
2. About the patient

Mr Kevin Peterson has presented to the hospital ?GP clinic with chest pain.
3. Other information
He is a chronic smoker and diabetic patient
4. Task
Take a brief history, examine the patient and discuss the management the
patient.
What do you do in the one and a half minute while reading the question
Read
Understand
Plan ( time management, Differentials, Findings, diagnosis, Treatment)
Remember
Consultation
Disorganized/unstructured consultation. Includes illogical and disordered approach

to questioning.
You did not demonstrate sufficiently the ability to follow a logical structure in your
consultation. For example, your history taking may have appeared disjointed, with your
line of questioning erratic and not following reasoned thinking. You may have undertaken
practical tasks or examination in an illogical order that suggested you did not have a full
grasp of the reason for completing them or a plan for the consultation.
Issues
Does not recognize the issues or priorities in the consultation. For example, the patient's
key problem or the immediate management of an acutely ill patient.
You did not recognize the key element of importance in the station. For example, giving
health and lifestyle advice to acutely ill patient.
Time
Shows poor time management.
You showed poor time management, probably taking too long over some elements of the
encounter at the expense of other, perhaps more important areas.
Findings
Does not identify abnormal findings, results or fails to recognise their implications.
You did not identify or recognise significant findings in the history examination or data
interpretation.
Examination
Does not undertake physical examination competently, or use instruments proficiently.
P a g e | 15
Diagnosis
Does not make the correct working diagnosis or identify an appropriate range of
differential possibilities.
Management
Does not develop a management plan reflecting current best practice, including follow up
and safety netting.
Rapport
Does not appear to develop rapport or show sensitivity for the patient's feelings and
concerns, including use of stock phrases.
You did not demonstrate sufficiently the ability to conduct a patient centred consultation.
Perhaps you did not show appropriate empathy or sympathy or understanding of the
patient's concerns. You may have used stock phrases that show that you were not sensitive
to the patient as an individual, or failed to seek agreement to your management plan.
Listening
Does not make adequate use of verbal and non-verbal cues. poor active listening
skills.
You did not demonstrate sufficiently that you were paying full attention to the patient's
agenda, beliefs and preferences. For example, you may have asked a series of questions
but not listened to the answers and acted on them.
Language
Does not use language AND/OR explanations that are relevant and understandable to the
patient, including not checking understanding.
The examiner may have felt. For example, you used medical jargon or spoken too quickly
for the patient to take in what you were saying.
P a g e | 16
P a g e | 17
P a g e | 18
P a g e | 19
P a g e | 20
P a g e | 21
Id numbers 2021, 2022, 2023 and 2024 Video available
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.
 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
P a g e | 22
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.
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.
P a g e | 23
 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.
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
P a g e | 24
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.
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?

Gillick competency and Fraser guidelines refer to a legal case which looked
specifically at whether doctors should be able to give contraceptive advice or
treatment to under 16-year-olds without parental consent. But since then, they have
been more widely used to help assess whether a child has the maturity to make their
own decisions and to understand the implications of those decisions.
In 1982 Mrs Victoria Gillick took her local health authority (West Norfolk and
Wisbech Area Health Authority) and the Department of Health and Social Security to
court in an attempt to stop doctors from giving contraceptive advice or treatment to
under 16-year-olds without parental consent.
The case went to the High Court in 1984 where Mr Justice Woolf dismissed Mrs
Gillick’s claims. The Court of Appeal reversed this decision, but in 1985 it went to
P a g e | 25
the House of Lords and the Law Lords (Lord Scarman, Lord Fraser and Lord Bridge)
ruled in favour of the original judgment delivered by Mr Justice Woolf:
"...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
P a g e | 26
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.
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
P a g e | 27
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.
P a g e | 28
2517 Video available

(How to do GCS ) 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
questions 4 points
VERBAL
Inappropriate response or speech, words
RESPONSE (V5)
discernible 3 points
Incomprehensive sound or sound 2 points
No Verbal response 1 point
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 (M6)
Abnormal (spastic) flexion, decorticate 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
P a g e | 29
EPILEPSY
You are the FY 2 doctor in the medical department.
Mr Sandeep Singh 28 year man was diagnosed with epilepsy few weeks ago.
He has come for follow up.
Take history and address his concerns.
There may be medication box written as Sodium Valproate 300 mg BD and BNF
Dr: Hello Mr Sandeep Singh, I a Dr… one of the junior doctor in

themedical department. How areyou doing? Pt: I am OKdoctor.
Dr: I understand you were diagnosed to have epilepsy. I am sorry about it.
Howis your conditionnow? Pt: Doctor I had fits again afterthat.
Dr: I am sorry to hear about it. When exactly was that ?
Pt: Once few days ago and once about a week ago when I was in the party. Why
did that happen doctor ?
Dr: There could be many reasons why people still have fits even after
treatment.Can I ask you few questions to see why this would have
happenedtoyou?
Pt:Yesdoctor.
Dr: Have been given medications forthat?
Pt:YesCan I ask you which medications?

Pt: I take this doctor. (Patient may show Sodium Valproate tablets).
It is written 300mg twice a day here. Are you taking the samedose? 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 – dose seems to be right for you. Are you
taking these medications regularly ?
Pt: Yes I am.
Dr: Are you taking it as prescribed byus?
Pt:YesDr: Please tell me when do you takeit?

Pt: Whenever I have fit I take it doctor.
P a g e | 30
Dr: Does it mean that you do not takeeveryday. Pt: Yes that isright?
Dr: Can I ask you why you are not taking itdaily? Pt: I forget to
takeit.
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
alarm to remind you to take this medications regularly. Is that OK?
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 atall?
Pt:NoDr: Are taking anyothermedications?
Pt:No
Dr: Sometimes people can get fits if the dose is not enough or the medications
donot 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
themedicationsregularly.
Pt: Okdoctor
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
long time ?
Do you go to cinema or watch TV for long time? Pt: Yes doctor. Dr: I advise
you to avoid them
Dr: Do you work on the computers for long time?
Pt: I am 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 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.
P a g e | 31
Dr: Do you drinkalcohol? Pt:Yes

Dr: Alcohol also can trigger fits, please avoid drinking alcohol. Pt: Ok
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: May be your friends cook food for you and you can do some other work for
them.
Also avoid using gas cookers. Electric cookers are better. When transferring the
food to 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 bath in bath tub instead take
a shower.
Pt: OK
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 may be 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

atyour 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 the fit again.
If the patient is a young lady – ask about Contraception
[ sodium valproate does not affect the combined pills - so she can continue.
Carbamazepine reduces the effects of combined pill so they should increase the dose
9double the dose) of oestrogen in the combined pill and also use other forms of
contraception.]
P a g e | 32
P a g e | 33
Headache – GCA
67 year old lady Mrs Melinda Jones presented to the hospital with
headache. Take history from her and discuss the management with her.
AACG ( acute angle Do you see coloured circles around light? Worse in
closure glaucoma) darkness? Redness of eye? Flashes
GCA Jaw claudication-Do you get pain on chewing?
[temporal artery] Temporal tenderness-pain while combing or touching
temple area? Any vision problems ( shade coming in front
Head injury [bone] of
Bythe
anyeye, vision
chance youloss
gotlater)
hurt on your head?
Meningitis[meninges] Fever, vomiting, Photophobia-feel discomfort on bright
light? Rash-any rash in your body?
SAH[Below meninges] Neck stiffness-difficulty

Sudden onset, meningealinsigns
moving your
but no neck?
fever.
SOL[brain] Early morning, vomiting Gradual worsening, limb
weakness
Migraine– pattern- one sided, aura, family Hx
Cluster headache- Comes in cluster – previous Hx of headaches, timing,

redeye, tearing
Tension head ache –band like, worse in evening, stress
Refractory error- long do you wear glasses? Any problem in reading or

vision? When did you last
visit optician?
Differential Diagnosis
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 severity of pain ( if
very severe – offer pain killers)
P a g e | 34
Management
Mrs Jones with what you told me I suspect you have a condition what we call as Giant
cell arteritis. Do you know anythingaboutthis? 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.
Pt: What are going to do for me?
Dr: We will do some blood tests 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 totreatment.
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 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 bloodpressure
 mood changes, such as becoming aggressive or irritable withpeople
 weakening of the bones(osteoporosis)
 stomachulcers
 increased risk ofinfection

P a g e | 35
The risk of these side effects will be lesser 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 causeVisual 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
rheumatic 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 ?
Tension headache 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 vomit,
weakness arms or legs, any vision problem, family history of any brain tumours.
Tell the diagnosis – tension headache because of stress. Treatment avoid stress and pain
killers.
No investigation needed
She request for investigation ( CT scan ) ask why
Her friend had brain tumour and the doctor did not do CT scan thinking it is migraine.
P a g e | 36
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 ahs brain tumour. She does not need
CT scan
CT scan has its own problem can cause high radiation and can itself cause cancer.
If 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.
Sub Arachnoid Haemorrhage
Headache - history and management
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 doctor in the medical department.
Can you please tell me what brings you to the hospital?
Pt: I am having severe headache.

P a g e | 37
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 pain killer.
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 migraine.
Dr: Is this different than migraine headache ?
Pt: Certainly doctor. I never had 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.
Dr: Anythingelse? Pt: Likewhat?
Dr: Any fever ? ( meningitis) Pt: No, Dr: Neck stiffness?Pt:No Dr:
Rashonthebody? Pt:No.
Dr: Any head injury recently? Pt:No
Dr: Any pain on the side of your head when combing hair ? ( GCA) Pt: No
P a g e | 38
Dr: Any pain in your jaw ? ( GCA) Pt:No

Dr: Any vision problem ? ( SAH, GCA)Pt: No Dr: Any coloured halosinyour
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:NoDr: Any speech problems ? ( Stroke SAH) Pt:No
Dr: Do you have any medicalconditions? Pt:No
Dr: Have you ever had any medical conditions in thepast?

Pt:NoDr: Diabetes ? Pt:No Dr:
High blood pressure ? Pt:No
Dr: Any strokes or mini strokes in thepast ? Pt:
NoDr: Any kidney problem ? Pt:No
Dr: Do you smoke ? Pt:No Dr: Do you drink alcohol ? Pt: onebottlewine
aday
Dr: Do you use anyrecreationaldrugs? 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 ? Pt:No
Dr: What do you do for living ? Pt: I am an accountant.
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
Diagnosis
P a g e | 39
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 CT scan of head.
( CT scan is the first line investigation – shows bleeding in 98% of cases but
negative in 2% cases)
Examiner said – CT scan is normal. What will you do?
Dr: We will do Lumbar puncture which is usually done after 12 hours of oncet 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 ).
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
 CTAngiography
 Magnetic Resonance Angiography(MRA)
 ECG
Treatment: One of problem with SAH is Cerebral ischemia due to vasospasm.
Treat her with calcium channel blocker – Nimodipine ( 60 mg four-hourly - 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.
P a g e | 40
Labetolol - 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.
She needs operation on the brain either clipping or coiling.
We can give her pain killers ( morphine, cocodamol, anti-emetics, and

anticonvulsants - if she has fits)
There is 50 % mortality even with the treatment.

Complications
- Rebleeding
- Epilepsy ( 1 in20)
- problems with certain mental functions, such as memory, planningand
concentration
- changes in mood, such asdepression
- Hydrocephalus,
- Delayed cerebralischaemia
Thank you very much to the patient and examiner.
Differential diagnosis for SAH
 Other causes ofstroke.

 Meningitis (rarely features thunderclapheadache).
 Trauma.
 Thunderclap headache of otheraetiology.
 Primary sexualheadache.
 Cerebral venous sinusthrombosis.
 Cervical arterydissection.
 Carotid arterydissection.
 Hypertensive emergency (severely raised bloodpressure).
 Pituitary apoplexy (infarction or haemorrhage of the pituitarygland).
P a g e | 41
2034 Video not available
TIA
P a g e | 42
P a g e | 43
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 her 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
Dr: Did she had abnormal heart beats? H: No
Dr: Ok.. Now Mr... I have a few questions about your wife's lifestyle.
P a g e | 44
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.
We need to admit her and treat her immediately to reduce the chance of she getting the stroke
in the next few days.
Investigations
Dr: We need run some tests... to find out why this happened.
H: What kind of tests doctor?

P a g e | 45
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 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 within a day or two Mr... If the scan
of the blood vessels in her neck show significant narrowing, we might have to consider a surgery
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 ever
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.
STROKE RISK ASSESSMENT
You are F2 in the GP clinic.

60 year old Mr. Zimmerman makes an appointment with the clinic because he is
P a g e | 46
very concerned about developing 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 bit high at that time. But I was too busy and I didn’t bother
much about it. But now I am very worried 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 stroke
many years ago and my brother had stroke 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 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 be even life
threatening. Pt: I see.
Dr: Sometimes this condition can run in the family because of genetic reasons. However,
there are 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?
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
factor 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 lot of other things to keep the
P a g e | 47
blood pressure under control.

Pt: What is that doctor ?
Dr: One important factor is diet. Can I ask you what type of food do you eat usually?
Pt: You know doctor. I am a 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, burger, steaksetc
Dr: Mr Zimmerman, the kind of food what 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 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 also 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. Can I ask do you do 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 may be 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 ?
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 lot 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 Zimmerman.
Pt: Doctor you know my work is very stressful. In fact NHS is going through lot of
financial crisis. I have to do 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. May be you can take some break from work and go for relaxation classes and
yoga classes which might help you to relieve from 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 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:
P a g e | 48
Excellent. Do you have any questions?

Pt: Doctor if I follow all the advices what you gave then will I not get stroke?
Dr: Mr Zimmerman. There is something called as 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 life style. 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 which supplies 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.
Pt: Ok Thank you very much doctor.
Dr: I sincerely advise you to follow all the advices. 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.
Head injury in adult

Criteria for performing a CT head scan in adults ( NICE guideline)
P a g e | 49
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:
GCS less than 13 on initial assessment in the emergency department.
GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
Suspected open or depressed skull fracture
Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid
leakage from the ear or nose, Battle's sign).
Post-traumatic seizure.
Focal neurological deficit
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:
• Age 65 years orolder.
• Any history of bleeding or clottingdisorders.
• 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).
• More than 30 minutes' retrograde amnesia of events immediately before the headinjury.
Question
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.
P a g e | 50
Dr - How did this happen - Pt: We are in the restaurant, we

came out and suddenly I
passedout.
Dr: Did you slipped or tripped ? 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 Pt – yes, I did recover
any drowsiness completely immediately after
the incident
Dr - Any head injuries when fell down ? Pt – No/Yes
Dr: Did you had any head injury before you lost Pt:No
consciousness ?
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 Pt - no
time ?
Did you wet your pants do you know ? Pt - no
Dr: Do you know whether you had any bleeding from ear Pt - no
nose ?
Dr: How much do you remember before this incident ? Pt: Sometimes he may say I
( any amnesia for 30 min beforeincident) 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 Pt – No
conditions, Epilepsy, Stroke
Dr -Did you drink alcohol just before this Pt – Yes doctor but it is same
type and same amount as usual
Dr -Did you use any recreational drugs just before that Pt - No doctor.
P a g e | 51
happened …
Dr – Do you take any medications ? Pt – No ( Any drug Overdose)
Any blood thinners ?
Dr – Any of your blood relatives have any medical Pt - No
conditions like DM, Heart conditions or epilepsy ?
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 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:MrRobertwiththesymptomswhatyouaretellingmelikethatyouhaveheadacheand
vomiting, these are the signs of bleeding inside the head. It will be very dangerous for you
togohome.Weneedtoadmityoutreat youifyouhavebleedinginsideyourhead.Wemay
needtodooperationonyourheadtoremovethebloodclotifatallyouhavethebleeding
inthebrain.Wewillalsodosometeststoseewhydidyoufall–likewewilldoECG(heart tracing,
check your bloodsugar).
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 at least for 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.
P a g e | 52
1. Guillain-Barre syndrome
2. Symptoms of GBS
Symptoms often start in your feet and hands before spreading to your arms and legs.
At first you may have:

numbness
pins and needles
muscle weakness
pain
problems with balance and co-ordination
These symptoms may continue to get worse over the next few days or weeks before they
start to slowly improve. In severe cases, you may have difficulty moving, walking, breathing
and/or swallowing.
3. Question:
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 the legs and both hands or only one side hand and
leg ( GBS is bilateral) ? - Both the 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 arms, legs, back or anywhere in the body (GBS, vasculitis,
polymyositis) ? I have pain in my back.
P a g e | 53
Where exactly in your back ? ... Since when ? Since last few days.
Dr: Do you have 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
[ ask symptoms from head to toe]

Dr: Any problem in your vision ( Multiple sclerosis, Mysthenia) ? 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 diarrheoa or constipation ? No
Dr: Do you have bowel or urine incontinence { BGS, Transverse myelitis ( seen early)}? No
Dr: Do you have any problem in 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 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:
Power reduced in legs. ( Power was 3)

Reflexes will be reduced or absent in GBS, where as in Myasthenia and Botulism they will
be normal and hyperreflexia in Tranverse 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
P a g e | 54
days from onset of symptoms to develop].

Also other tests what we call as Eletromyography and nerve conduction testwhich 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
( condutcting signals from brain to the muscles). This causes weakness in the muscles.
Do you follow me ? 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 infection like flu or diarrhoea. In your case you had flu recently. That could have
caused this problem.
Pt: Is there any treatment doctor?
Dr: We need to admit you to the hospital for the treatment. Neurologist will see you and
tell you about the treatment.
We will 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 immunoglobulin 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
P a g e | 55
Therapies such as physiotherapy, occupational therapy and speech and language

therapycan help you recover and cope with any lasting difficulties.
Also we may need to put on machine to help with breathing and/or a feeding tube if it is
required if there is 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
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.

Differential Diagnosis for GBS
Disease/ Differentiating
Differentiating Tests
Condition Signs/Symptoms
Transverse myelitis Spinal cord disorders Cerebrospinal fluid (CSF)

including transverse myelitis analysis: pleocytosis with modest
present with asymmetric number of lymphocytes and
motor or sensory loss usually increase in total protein.
involving lower extremities,
Magnetic resonance imaging
early bowel or bladder
(MRI) shows focal demyelination
dysfunction with persistent
with possible enhancement at the
incontinence, and segmental
appropriate level.
radicular pain.
Physical exam demonstrates
upper motor neuron signs
(hyperreflexia, positive
Babinski response) and a
sensory level.
Myasthenia gravis Early involvement of muscle Electrophysiological study shows

groups including extraocular, normal nerve conduction and
levator, pharyngeal jaw, neck, presence of decremental
and respiratory muscles. response to repetitive nerve
Sometimes presents without stimulation.
limb weakness.
Electromyogram (EMG) shows
Excessive fatigability and abnormal jitter and blocking.
variation of symptoms and
P a g e | 56
signs through the day is Edrophonium test is normally

common. positive. However, many centers
do not routinely perform this test
Reflexes are preserved, and
because of potential side effects.
sensory features,
dysautonomia, and bladder
dysfunction are absent.
Lambert-Eaton Can be difficult to differentiate Electrophysiologic study: hallmark

myasthenic because of similar clinical is a low amplitude compound
syndrome (LEMS) characteristics. However, muscle action potential (CMAP)
some characteristics are after single nerve stimulus,
more typical for LEMS. These increase in CMAP amplitude after
include slower development voluntary contraction, or repetitive
of clinical symptoms, dry stimulation at high frequencies. [137]
mouth, lack of objective
sensory loss, rare
involvement of respiratory
muscle group, and
potentiation of reflexes after
exercise or contraction.
Botulism History of ingesting food Electrophysiologic study: reduced

tainted with botulinum toxin.
amplitude of evoked muscle
potentials, increase in amplitude
Descending paralysis begins
with repetitive nerve stimulation
in the bulbar muscles then
and increased number of
the limbs, face, neck, and
myopathic units, which is atypical
respiratory muscles.
for GBS.
Respiratory muscles are
involved with mild limb
weakness, and reflexes are
usually preserved.
Ptosis, dilated nonreactive
pupils are present. Dilated
nonreactive pupils are
uncommon in GBS, but more
common in botulism.
Constipation is also a
characteristic feature of
botulism.
Polymyositis Presence of pain and muscle Elevated erythrocyte

tenderness usually in the sedimentation rate (ESR) and
shoulder and upper arm, creatine kinase (CK), normal
involvement of flexor neck nerve conduction study, and
muscle disproportionate to myopathic changes with
limb weakness, absence of fibrillation on EMG.
sensory symptoms,
Muscle biopsy shows muscle
preservation of reflexes,
fiber destruction and
P a g e | 57
absence of dysautonomia, regeneration, and lymphocyte

and presence of skin lesions, infiltrates.
which are uncommon
presentation for GBS.
Vasculitic Common features include May have elevated ESR.

neuropathy painful asymmetric
CSF does not show
presentation of muscle
albuminocytologic dissociation.
weakness, uncommon
involvement of cranial nerves, Electrophysiologic study shows
respiratory paralysis, and evidence of denervation.
sphincter dysfunction.
Nerve biopsy shows signs of
Usually patients complain of inflammation and scarring. [137]
fever, fatigue, weakness, and
arthralgia.

Painful Red Eye -Glaucoma
A AACG(acute angle closure Glaucoma) Pain worse in dark, haloes around light,
DH
F Foreign body, chemical, By any chance something has gone into

complication of Contact lens 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, no
T Trauma By any chance you got hurt in your eye

P a g e | 58
C Conjunctivitis[bacterial/viral/ulcer] Discharge, difficulty in opening eyes in

morning
Contact glass irritation
A Autoimmune –Ankylosing AS Back pain worse in morning

spondylitis
Systemic Lupus Erytheramatosis IBD SLE Butter fly rash
Rheumatoid Arthritis
IBD Abd pain, diarrhea etc
RA Small joint pain
R Rieter’s syndrome Urethral discharge joint pain, Sex Hx

S Sarcoidosis Tender red bumps on skin, SOB, cough
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 )

P a g e | 59
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: Once again 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 the 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
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
P a g e | 60
[Patient may be wearing dark sun glasses]

Dr: Can I ask why are you wearing this dark glasses?
P: I feel comfortable with that.
[You can ask her to remove if it not 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 whatthatis? 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 the 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?
Investigation
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 Timololwhich 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 the Ophthalmologist for the 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 treatmentrightaway.
P a g e | 61
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.

Sub Conjunctival Haemorrhage 28th June
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 hemorrhage 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 hemorrhage often occurs without any obvious harm to youreye. Even a strong sneeze
or cough can cause a blood vessel to break in the eye. ... But a subconjunctival hemorrhage is usually a
harmless condition that disappears within two weeks or s
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 ?
P a g e | 62
Dr: Any pain in the eye? Pt: No

Dr: Any pain elsewhere in 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.
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 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 living? Pt: I am retired now. I used to work in 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. Or diabetes and blood circulation in your legs ( arteriosclerosis)
Sure go ahead doctor.

(B.P normal and fundus also normal)
Dr: Mr. Sterling after our discussion and my examination I think you have a condition we call
as 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.
P a g e | 63
Diabetic Retinopathy
Exam question
You are the FY2 doctor in the GP clinic.

33 year old man was referred by Optometrist for early diabetic retinopathy.
Dr: Hello Mr…. IamDr. How are youdoing?

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 haveDiabetes? Pt:Yesdoctor.
Dr: Since when are you having diabetes?Pt: Since manyyears.
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
P a g e | 64
Dr: Do you see anything floating in your vision area ( floaters)? Pt: No
Dr: Any pain in the eye ?Pt: No
Dr: Anydouble vision? Pt:No
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
probably you 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 gets bulged 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 few questions to see why your blood sugar is not controlled well.
Pt: OK doctor.
Dr: How is your diet? Do you eat healthy diet?
Pt: Not really doctor. I eat fast food. ( burger and chips)
Dr: Mr… It is very important to eat 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 thatdoctor.
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.
P a g e | 65
Pt: Ok doctor.
Dr: Do you smoke Mr…?Pt: Yes doctor.
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 has already
happened cannot be reversedunfortunately. However if it gets worse means 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 it getting worse. Sometimes
we may have to inject some type 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 ?
P a g e | 66
Pt: If I do everything what you suggested, will I not lose my vision doctor ?
Dr: Mr.. If you do everything what I suggested the chances of you losing vision will be
greatly be reduced. So, I sincerely suggest you to follow everything we discussed.
Pt: Ok doctor.
Dr: Any otherquestions?
Pt:No.Dr: Thank you very

muchMr…

Cataract
Question- 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? (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 recognising 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
P a g e | 67
symptom of cataract due to development of cloudy patches on the lens

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 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.
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.
P a g e | 68
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 been very helpful.

AGE RELATED MACULAR DEGENERATION
Question– 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. (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").
P a g e | 69
Dr. - Do you have any pain in your eyes? (Glaucoma)Patient - No doctor.

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.
Ask him about other sign and symptoms of ARMD –
1. Does he see a straight line as wavy or crooked.
2. Objects look smaller then usual.
3. Colours are less bright then usual.
4. Is he having difficulty recognising 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 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.

P a g e | 70
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.
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

P a g e | 71
 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.
 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.
P a g e | 72
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.
MULTIPLE SCLEROSIS – Fill up the DNAR Form

Question:
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 want 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.
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 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 few years ago and it is very difficult for me to cope up 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 that we don't have any specific treatment for the condition.Pt: I know
Dr: Were you on any medications before we started on the palliative care?
Pt: It was [MS] coming and going in the past years. Sometimes I didn't have any symptoms
and after few months the symptoms will reappear. I was on steroids for few years, but
eventually, the condition progressed and doctors found that now it is the advanced stage of
disease and told me that no medications will work anymore.
Dr: Yes Mrs.... if the conditions has progressed to an advanced stage, no medications will
work. Once again, I'm really sorry to hear that.
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 do CPR if you become ill.Pt: Yes!
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?
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?
P a g e | 73
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.
Dr: Well Mrs....... patients concerns and wishes are our first priority and I do respect your
wishes. I can see that 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 you how we do that.
EXAMINER HANDS OVER THE DNAR FORM

( fill up the form)
Mrs....... I have filled and signed the form. But as I am the 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 ( Consultant has to counter sign the form within 24 hours).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 we can reverse this decision for you.Pt: I understood 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

wishesDNACPR.
Summary of communication with patient’s relatives and friends – Not discussed
Names of members of multi disciplinary team contributing to this decision – not discussed
Healthcare professional recording this CPR – sign and write position–FY2 doctor, Date
Review and endorsement by most senior professional – Leave blank ( Consultant to sign
later)
P a g e | 74
P a g e | 75

CHOLESTEATOMA
Question: You are an FY2 in GP Surgery. Lydia Black is a 40 years-old
female. Take a focused history, perform relevant examination and discuss
management with the patient.
Hello. Lydia Black? Hi, my name is Dr. ……… I am one of the junior doctors here in the
GP Surgery.
What would you like me to call you? – Hi, Mrs. Black is fine
How can we help you today Mrs. Black? – I have this pain in my ear
Which ear are we talking about? – It’s my left ear
Can you tell me a little bit more? – Yes, it’s been causing me discomfort for some time now
For how long have you had this pain? –2 weeks
Can you point to me where you feel pain – Yes, it’s in my ear and sometimes behind it too
Has this developed suddenly or gradually? – It’s gradually come about over a few weeks
How would you describe the nature of this pain? – It feels like a dull ache
Does the pain travel anywhere else? – Behind the ear
Does the pain get worse with anything you do? –Yes, if I touch it or try to wash my ear
And does the pain improve with anything you do? – No
Is the pain worse at any particular time of day? – No
On a scale of 1-10, 1 being the least amount of pain and 10 being the most how would you
describe it? – 2 or a 3
Has the pain gotten better, worse or remained the same? – Same
Is the anything else you’d like to add, that I may have missed? – No, like what?
Do you have any other symptoms other than the ear pain? – Like what?
Rule out common ear pathologies; Cholesteatoma,Otitis Externa, AOM, CSOM, Middle
Ear Osteoma, FB, Trauma, Ramsay-Hunt Syndrome
- Ear Discharge? (Cholesteatoma, OE, AOM, CSOM, FB, Trauma)

- Hearing loss? (Cholesteatoma, OE, AOM, CSOM, MEO, FB, Trauma)
- Itching? Irritation? Redness? Swelling? Rash? Skin Changes? (OE, R-H Syndrome)
- Fullness in the Ear? (Cholesteatoma, OE, AOM, CSOM, MEO, FB)
- Pulling on the ears? Headache? Neck Pain? (AOM, CSOM)
- Fever? (OE, AOM, CSOM)
- Vertigo? (Cholesteatoma, AOM, CSOM, MEO, FB, Trauma)
- Bleeding? Nausea? Vomiting? Cough? (Trauma)
Past Hx - Is this the first time you’re experiencing these symptoms? – Yes, doctor
Did you have this type of problem before – No
How much does it affect your life/Are you able to do your work and daily activities? – Yes
Have you ever been diagnosed with any medical condition before? – No. Like Diabetes,
Hypertension, Heart, Liver or Kidney problems? – No
Risk factors for Cholesteatoma – Chronic Ear Infection, Sinus Infections (Sinusitis),
P a g e | 76
Cold, Allergies, Congenital
Anything else you would to add? – No
Examination:
Mrs. Black,is ok forme to examine you now? I need to check your pulse, blood pressure,
breathing rate, temperature and levels of oxygen in your blood (Normal).
We need to check your earstoo, to take a closer look for any discharge, redness, swelling,
skin changes, scar marks, bleeding or a foreign body. I’ll gently be touching your ears to
assess for the temperature and any tenderness (Tragus Test). We will also need to look
inside your ear canal using a gadget here called an Otoscope. You might experience some
discomfort as I pull your ear gently.
Examiner may give these findings on Inspection of the ear and Otoscopy.
Provisional diagnosis:
Mrs. Black, do you have any idea why you may be having all these problems? –No,what is
it doctor?
Well Mrs. Black, it seems to be a rare condition, would you like to know more about it
now? – Yes
It looks like you may have may have an abnormal collection of skin in the middle section
of your ear - near your eardrum - that we call a cholesteatoma.
Oh Are you sure doctor?
I really hope it is not. However, with the ear pain that you are having combined with what
I’ve seen in your ear canal, there seems to be a whitish accumulation of cells which is the
common appearance of a cholesteatoma.
Do you know anything about Cholesteatoma? – No
A cholesteatoma is a collection of non-cancerous cells and often develops as a cyst, or sac,

that sheds layers of old skin. As these dead skin cells accumulate, the growth can increase
P a g e | 77
in size and destroy the delicate bones of the middle ear. This can cause ear pain and
discharge, affect hearing, balance, and the function of facial muscles. It may be a birth
defect but it’s commonly caused by repeated infections to the middle part of your ear.
Is it cancer doctor?
Cholesteatoma is a collection of non-cancerous cells, and after having examined your ear
canal it does appear very likely to be a cholesteatoma. However, it’s difficult for me to say
at this time before we have conducted any tests. At this stage we simple can’t rule it out.
Is it serious?
Ear cholesteatomas can be dangerous and should never be ignored. Bone erosion can cause
the infection to spread into the surrounding areas, including the inner part of the ear and the
brain. If untreated, complications can occur.
What do you mean by complications?
When left untreated, a cholesteatoma will grow larger and cause complications that range
from mild to very severe. The dead skin cells that accumulate in the ear provide an ideal
environment for bacteria and fungus to thrive. This means the cyst can become infected,
causing inflammation and continual ear drainage.
Over time, a cholesteatoma may also destroy the surrounding bone. It can damage the
eardrum, the bones inside the ear, the bones near the brain, and the nerves of the face.
The cyst may even spread into the face if it continues to grow, causing facial weakness.
Other potential complications include:
 permanent hearing loss
 chronic infection of the ear
 swelling of the inner ear
 paralysis of the facial muscles
 meningitis, which is a life-threatening brain infection
 brain abscesses, or collections of pus in the brain
So what are you going to do for me?
MANAGEMENT
First of all, we will do some routine blood tests to check your blood count (increased white
cells, coagulation profile)
We will book you an urgent referral to the ear nose and throat (ENT) specialist at the
hospital. This appointment would be within 2 weeks.
Doctor, I wasn’t expecting to go to the hospital

P a g e | 78
I do understand it may come as a surprise, but it is something we must be pro-active about.

They may perform some further tests such as;
o Hearing and balance test
o X-rays of your head
o CT Scan (3-dimensional X-Rays) or MRI Scan
Ok doctor, how will you treat me?
The specialist will tell you in detail about the treatment if it is a Cholesteatoma
.
 Specialist may start with the careful cleaning of the ear, antibiotics, and eardrops.
Therapy aims to stop drainage in the ear by controlling the infection. The extent or
growth characteristics of a cholesteatoma must also be evaluated.
 To remove a cholesteatoma, you usually need to have surgery under

general anaesthesia. After the cholesteatoma has been taken out, your ear may be
packed with a dressing. This will need to be removed a few weeks later, and you'll be
told how to look after it in the meantime. As well as removing the cholesteatoma, the
surgeon may be able to improve your hearing if you have hearing loss. This can be
done in a number of ways. For example, a tiny artificial hearing bone (prosthesis) can
be inserted to bridge the gap between your eardrum and the cochlea (hearing organ). 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 associated
with having anaesthetic, and a very small chance of facial nerve damage resulting in
weakness of the side of the face. Discuss the risks with your surgeon before having the
operation.
 Admission to the hospital is usually done the morning of surgery, and if the surgery is
performed early in the morning, discharge may be the same day. For some patients, an
overnight stay is necessary. In rare cases of serious infection, prolonged hospitalization
for antibiotic treatment may be necessary. Time off from work is typically one to two
weeks.
 When you get home, you'll need to keep the affected ear dry. You should be able to
wash your hair after a week, provided you don't get water inside the ear. To avoid this,
you can plug the ear with Vaseline-coated cotton wool. You may be advised to avoid
flying, swimming and doing strenuous activities or sports for a few weeks after
surgery. At your follow-up appointment, ask when it will be safe to return to your usual
activities.
 Follow-up office visits after surgical treatment are necessary and important, because
cholesteatoma sometimes recurs and you could get one in your other ear. Visits every
few months are needed in order to clean the area and prevent new infections. In some
patients, life-long periodic ear examinations are required.
 If your stitches aren't dissolvable, they may need to be removed by your practice nurse
after a week or two.
 Sometimes a second operation is needed after about a year to check for any skin cells
left behind. However, MRI scans are now often used instead of surgery to check for
this.
P a g e | 79
 I do have some reading material available with me to give you entitled – Cholesteatoma
 Is there anything else I can help you with?
Was there anything in particular you were expecting to get out of this consultation? –No
If your symptoms do get worse or if you have any other concerns please do come back.
Thank-you very much.

Ear pain - Barotrauma
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.
Question
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.
No Hx of fever / balance problems / tinnitus/ vertigo
She gives travel Hx to Spain the previous week, Hx of swimming and also Hx of use of ear
buds. Hx of mild pain.
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 lateralised to the same ear  conductive hearing loss in
P a g e | 80
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 either side of the eardrum. This most commonly occurs when descending to land in a
plane and is also experienced by scuba divers.
TreatmentMost 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
 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.
The second surgical option involves a tiny slit being made into the eardrum to better allow
pressure to equalize. 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 I fly?

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 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.
P a g e | 81
 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.
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.

P a g e | 82
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

If you're feeling nauseous, drink plenty of water to avoid becoming dehydrated. It's best to
drink little and often.
If you have quite severe vertigo and dizziness, you should rest in bed to avoid falling and
injuring yourself. After a few days, the worst of these symptoms will go away and you will
not feel dizzy all the time.
You can do several things to minimise any remaining feelings of dizziness by
 Avoiding drinking alcohol ( if the patient drinking)

 avoiding bright lights
 try to cut out noise and anything that causes stress from your surroundings
You should also avoid driving, using tools and machinery, or working at heights if
you're feeling dizzy and unbalanced.
Once the dizziness is starting to settle, you should gradually increase your activities
around your home. You should start to have walks outside as soon as possible. It may help to
be accompanied by someone, who may even hold your arm until you become confident.
You won't make your condition worse by trying to be active, although it may make you feel
dizzy. While you're recovering, it may help to avoid visually distracting environments such
as:
 supermarkets
 shopping centres
 busy roads
Pt: Will there be any problem in the future ?
Dr: A small number of people experience dizziness and vertigo for months or even
P a g e | 83
years.This is calledchronic 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: Miss. 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.
Vertigo
You are FY2 doctor in Emergency Department.
25 years old female has been brought to emergency room with complaint of Vertigo.
Take history from the patient, talk to her and discuss further management with her.
BPPV Vestibular neuronitis Meniere’s
disease
Mostly seen after the age of 50. Sudden oncet, lasts for hours. Hearing
Can be seen in young people. Not triggered by movement but loss and
Precipitated by movement movement can exacerbate symptom. tinnitus and
Can follow after injury to head or Can happen after viral infections like fullness in
ear flu. ear present.
Last only for few seconds or Can have nausea and also vomiting.
minutes. There may be hearing loss
Episodic – happens on movement
of head. No other symptoms like pain, tinnitus,
Associated with nausea, usually no fullness in ear,.
vomiting.
No other symptoms like pain
tinnitus or fullness in ear
P a g e | 84
If Dix Halpike test is negative –

then it is unlikely to be BPPV.
Causes of
Peripheral vertigo Central vertigo
 benign paroxysmal positional vertigo  migraines –
(BPPV)  multiple sclerosis
 head injury  acoustic neuroma

 a brain tumour
 labyrinthitis
 a transient ischaemic attack
 vestibular neuronitis (TIA) or a stroke
 Ménière's disease  taking certain types of
 taking certain types of medication medication
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)
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 mightbe 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
P a g e | 85
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?
Pt: Yes, doctor I have had a flu like illness a few days before. (Viral Post-viral illness
(Viral Neuronitis) a cause of BPPV)
Dr: How long ago was that? Pt: Almost ten days ago doctor.
Dr: Have 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.
(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 Rhumatoid Arthritis? Pt: No.
Procedure of Hallpike Test:
1. Warn the patient that transient vertigo may occur in any position.
2. Ask the patient to keep their eyes open and stare at your nose.
3. Prepare the couch so the headrest is down and the patient's head will overhang the
end.
4. 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.
5. Observe for nystagmus in each position (30 seconds) and then return the patient to
the upright position.
6. Repeat with the head turned to the right to test the right posterior canal.
7. If positive:
8. The patient experiences vertigo and rotary nystagmus in posterior canal BPPV.
Purely horizontal nystagmus suggests horizontal canal BPPV.
9. Nystagmus (fast component) will be upbeat and in the direction of the most affected
ear. This has a limited duration, lasting <30 seconds (adaption).
10. On sitting, there is more vertigo, experienced as the room spinning in the opposite
direction (with reversal of the nystagmus).
P a g e | 86
 Rhomberg's Test - this is used to identify instability of either peripheral or central

cause of vertigo:
1. 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.
2. 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).
3. 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 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
P a g e | 87
abnormal hissing sounds in the ear, headache vision problem 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.
Apixaban Prescription
30 year old lady recently been diagnosed to be having DVT. Your consultant has
prescribed Apixaban to her. Talk to her and write the medicine in the prescription chart.
Take history Why is she here today ?
What symptoms she had ?Ask currently any symptoms like SOB, Chest pain.
Does she knows what condition she has ? ( she usually knows in the exam)
Explain if she does not know: There is blood clots in the veins of her legs.
Ask about risk factors of DVT :
Recent travel, recent surgery, OCP, Previous blood clots in legs or lungs. Family history.
Smoking, ( other medical conditions – cancer)
Ask whether she knows what medication has been prescribed
Explain: Tablet Apixaban, it is a blood thinning tablet. This will thin the blood and prevent the
blood clot travelling from leg veins to the lung which is a very serious condition in fact a life
threatening condition.
Ask about contra-indications
 Allergic reaction to apixaban or any other medicines in the past

 Is she trying to get pregnant or are already pregnant - apixaban can be harmful to your
baby. Is she breast feeding ?
 have liver problems
P a g e | 88
 have had a recent spinal injury or surgery

 are taking any other medicines that affect blood clotting, such as warfarin
 have any injuries that are currently bleeding a lot, such as a wound or a stomach ulcer
 are taking the herbal remedy St John's wort (often taken for depression)
Write Apixaban in the prescription chart ( there may be many prescription charts on the table –
chose anticoagulant prescription or regular prescription chart.
Fill up the details which is given in a page ( may be kept on the table) – Including patient
details, Consultant name, ward name.
Ask for allergy and fill up. If no allergy write NKDA.
Write the year, date and month.
Apixaban is usually given 10 mg BD for seven days and then 5 mg BD after that up to usually
for 3 months. Usually it is given at 8am and 8pm. Circle the times properly in the chart. If 8am
or 8pm is not given in the chart then write the time by hand as shown in the figure below. If
there is prescription date in the chart fill up the date
(your exam date).
Put a cross mark (X) across whole box on the days and the times when the patient should not be
taking the medicine. You can see the image below patient has to take Apixaban 10mg from 1st
Feb up to 7th Feb at 8.00am and 20 hours and then cross means not to take it after that. He has to
take Apixaban 5mg from 8th Feb onwards ( crossed boxes from 1st Feb till 7th Feb means not to
take them on those days) twice daily for up to 3 months.
P a g e | 89
Do not forget to sign and write your name and bleep number ( if there is a box for that – you
can simply write 123)
Explain she should take 2 tablets of 5 mg each ( total 10mg) of Apixaban for first seven days
by mouth twice daily morning and evening same time every day. After that she should take only
of 5 mg Apixaban twice daily for the next 3 months.
Check understanding of the dose and timings and duration.
Explain side effects :
Like all medicine this also can side effects and not all of them get it.
Most important is it can cause bleeding easily if there is any injury because it is a blood
thinning medicine. She should be careful while handling any sharps like knife to avoid injuring
herself.
It can cause bleeding in the eyes, nose, stomach which can cause dark stool, back passage and
the urine. She can have heavy periods. Bleeding from nose or small cuts usually stops within 10
minutes by pressing on the nose or small cuts. If she notices any such bleeding which does not
stop even after 10 minutes she should come back immediately to the hospital.
Other side effects are rare.
Important information : if she is going to see new doctor they should know that she is taking
this medicine. If she is going for any dental procedures Dentist should know about this.
Do not become pregnant when on this medicine. Do not breast feed. Do not take any other
medicine without talking to doctor as they can interact. Can take paracetamol but not Aspirin or
NSAIDS, Do not take St. Johns wort ( herbal medicine for depression)
She should carry anticoagulation alert card with her all the time.

ALLERGIC RHINITIS
P a g e | 90
Question: You are an FY2 in GP Surgery. Jordan Patterson is a 30 years-old

man who has presented with some concerns. Take a focused history and
address his concerns.
Hello. Jordan Patterson? Hi, my name is Dr. ……… I am one of the junior doctors here in
the GP Surgery.
What would you like me to call you? – Hi, Jordan

*sniffles repeated throughout consultation*
How can we help you today Jordan? – I’ve got a really runny nose
Can you tell me a little bit more? – Yes, it’s been causing me discomfort for some time now
I can see that you’re having the problem now, is that right? – Yes
Would you like some tissues? Are you ok to carry on? - Yes
Is it from 1 side of the nose or both sides? - Both
For how long have you had this problem? –1 week, but it’s been going on for years
And have you been having the problem throughout the whole week or did it get better on
any of the day? – Yes, daily, as soon as I wake up and before I go to sleep it’s constant
Has this developed suddenly or gradually? – It’s suddenly come about, but it always
happens to me. It’s been happening since I was a teenager so about 10-15 years
Has your runny nose gotten better, worse or remained the same over this time? – Every
year it seems to be getting worse
How does it get better? By itself? Medication? – By itself
Does it get worse with anything you do? –Yes, it’s worse during the winter period
Ok, you said that it always happens to you, is there any reason why you didn’t come before
and have come now? – I just want it to stop once and for all
And this recent episode that’s lasted 7days, can you tell me how much fluid has come from
your nose? – A lot, I mean I’m running out of tissues!
Is the fluid colourless or coloured? – It’s really watery and colourless
Is there anything else you’d like to add, that I may have missed? – No, like what?
Do you have any other symptoms other than the runny nose? – Like what?
Rule out commonRhinorrhoea (runny nose) causes;

Allergic Rhinitis(SeasonalorPerennial[Dust, Pollen, Mould Spores, Pets, Carpet Fibres])
Non-Allergic Rhinitis (Anatomic [Adenoidal Hypertrophy, Choanal Atresia, Polyps, FB,
Tumour] or Non-Anatomic [Non-Allergic Rhinitis with Eosinophilia, Vasomotor Rhinitis, Rhinitis
Medicamentosa, Infectious Rhinosinusitis]), URTI (Common Cold, Influenza [flu]), Bacterial
Sinusitis, CSF leak (CSF Rhinorrhoea)
- Sneezing? Itchiness? Nose Irritation? Alternating blocked/runny

nose?(Allergic/Non-Allergic Rhinitis, URTI) – Yes
- Eye Irritation? Watering of the eyes? – Yes
- Headache? (Allergic Rhinitis, URTI, Sinusitis) – No
- Fever? (URTI, Sinusitis) – No
- Sore Throat? (Allergic Rhinitis, URTI, Sinusitis) – No
- Breathing problems? SOB? (Anatomical Non-Allergic Rhinitis, URTI, Sinusitis) – No
- Cough? (Allergic Rhinitis) Sputum? (URTI, Sinusitis) – No
- Pus like discharge? (URTI, Sinusitis) – No
- Tiredness/Fatigue/Malaise? Muscle aches/pains (URTI, Sinusitis) – No
- Did you hurt yourself at all? Bleeding? (FB, Trauma) – No
- Skins problems? (Eczema)– No
- Sleep problems? – No
P a g e | 91
Past Hx - Is this the first time you’re experiencing these symptoms? – No, it’s yearly
Did you have this type of problem before – Yes, I had the same thing last year
How much does it affect your life/Are you able to do your work and daily activities? – Yes
Have you ever been diagnosed with any medical condition before? – No. LikeAsthma,
Eczema? – No
Do you have anyAllergies – No
Does anyone in your Family have similar symptoms? – No
What is you Occupation? – Unemployed
u Risk factors for Allergic Rhinitis – Family Hx of Allergy, Asthma or

Eczema, cigarette smoke, chemicals, pollen, pets and hair dander (dead skin),
cold temperatures, humidity, wind, air pollution, hairspray, perfumes, wood smoke,
fumes, carpet fibres.
Examination:
Jordan,is ok forme to examine you now? I need to check your pulse, blood pressure,
breathing rate, temperature and levels of oxygen in your blood (Normal).
We need to take a closer look at your nosetoo, to look for any discharge, redness, polyp,
swelling, skin changes, scar marks, bleeding or a foreign body. I’ll gently be touching your
nose to assess for the temperature and any tenderness. Ideally, I would like to look at the
inside of your nasal passageways using a nasal speculum. You might experience some
discomfort as I manipulated your nose gently.
Examiner may give findings on Inspection of the nose with naked eye and speculum:
There is profuse clear watery discharge coming from both nostrils.
Thank-you for letting me examine you.
From what you have told me and from what I have seen, you seem to be having colourless
profuse discharge from both sides of your nose - for the past 1 week - which happens
annually – Yes
Jordan, do you have any idea at all why you may be having this problem? –No,what is it
doctor?
Well Jordan, it seems to be a quite common condition, would you like to know more about
it? – Yes
It looks like you may have may have a condition that we call Allergic Rhinitis.Do you
know anything about Allergic Rhinitis? – No
Allergic rhinitis typically causes cold-like symptoms, such as sneezing, itchiness and a
P a g e | 92
blocked or runny nose. These symptoms usually start soon after being exposed to an
allergen – something that causes an allergic response.Some people only get allergic
rhinitis for a few months at a time or a particular time of the year, because they're sensitive
to seasonal allergens, such as grass pollen or in your case cold temperatures. Other people
get allergic rhinitis all year round.Most people with allergic rhinitis have mild symptoms
that can be easily and effectively treated. But for some people symptoms can be severe and
persistent, causing sleep problems and interfering with everyday life.The symptoms of
allergic rhinitis occasionally improve with time, but this can take many years and it's
unlikely that the condition will disappear completely.
Do you follow? – Yes
Not all cases of rhinitis are caused by an allergic reaction. Some cases are the result of:
 an infection, such as the common cold

 oversensitive blood vessels in the nose
 overuse of nasal decongestants
This type of rhinitis is known as non-allergic rhinitis. However, I do believe that in your
case, the precipitant of your runny nose is likely to be exposure to colder temperatures over
the winter period – something that we term Allergic Rhinitis.It is likely that that cold
acts as an irritant to your nose and makes it runny.
But why is it happening to me?

Allergic rhinitis is caused by the immune system reacting to an allergen as if it were
harmful. Every individual’s immune system is different. This results in cells releasing a
number of chemicals that cause the inside layer of your nose (the mucous membrane) to
become swollen and too much mucus to be produced.Common allergens that cause allergic
rhinitis include pollen (this type of allergic rhinitis is known as hay fever), as well
as mould spores, house dust mites, and flakes of skin or droplets of urine or saliva from
certain animals.
Allergic Rhinitis is relatively mild, but it can lead to some complications.
What do you mean by complications?
Allergic rhinitis can lead to complications in some cases, which are unfavourable results of
an illness.
These include:
 nasal polyps – abnormal but non-cancerous (benign) sacs of fluid that grow
inside the nasal passages and sinuses
 sinusitis – an infection caused by nasal inflammation and swelling that prevents
mucus draining from the sinuses
 middle ear infections – infection of part of the ear located directly behind the
eardrum
P a g e | 93
These problems can often be treated with medication, although surgery is sometimes
needed in severe or long-term cases.
MANAGEMENT
 It's difficult to completely avoid potential allergens, but we can take steps to reduce
exposure to a particular allergen you know or suspect is triggering your allergic rhinitis.
This will help improve your symptoms.
 First of all, we may need to do some routine blood tests to check your blood count
(increased white cells – Eosinophilia).
 We may have to perform a Skin Prick Test, which is one of the most common tests
done to check for allergy. Here we place several substances onto your skin to see how
your body reacts to each one. Usually, a small red bump appears if you’re allergic to a
substance.
 Another blood test, radioallergosorbent test (RAST), is also common. The RAST
measures the amount of Immunoglobulin E Antibodies to particular allergens in
your blood. These are the markers of an allergic response.
 If your condition is mild, you can also help reduce the symptoms by taking over-the-
counter medications, such as Non-Sedating Antihistamines (Cetirizine).
 You can useDecongestants over a short period, usually no longer than three days, to
relieve a stuffy nose and sinus pressure. Using them for a longer time can cause a
rebound effect, meaning once you stop your symptoms will actually get worse.
 Eye drops and Nasal Sprays can help relieve itchiness and other allergy-related
symptoms for a short time. Like decongestants, overusing certain eye drops and nose
drops can also cause a rebound effect.
 Stronger medication, such as a nasal spray containing Corticosteroids may
sometimes be required if the aforementioned steps are ineffective. Corticosteroids can
help with inflammation and immune responses. These do not cause a rebound effect.
Steroid nasal sprays are commonly recommended as a long-term, useful way to manage
allergy symptoms. They are available both over the counter and by prescription.
 Immunotherapy, or allergy shots, if you have severe allergies. These shots decrease
your immune response to particular allergens over time. They do require a long-term
commitment to a treatment plan. An allergy shot regimen begins with a build-up phase.
During this phase, you’ll go to your allergist for a shot one to three times per week for
about three to six months to let your body get used to the allergen in the shot. During
the maintenance phase, you will likely need to see your allergist for shots every two to
four weeks over the course of three to five years. You may not notice a change until
over a year after the maintenance phase begins. Once you reach this point, it’s possible
that your allergy symptoms will fade or disappear altogether. Some people can
experience severe allergic reactions to an allergen in their shot. Many allergists ask you
to wait in the office for 30 to 45 minutes after a shot to ensure that you don’t have an
intense or life-threatening response to it.
 Sublingual Immunotherapy (SLIT) involves placing a tablet containing a mixture of
several allergens under your tongue. It works similarly to allergy shots but without an
injection. Currently, it is effective for treating rhinitis and asthma allergies caused by
grass, tree pollen, cat dander, dust mites, and ragweed. Your first dose of any SLIT will
take place in your doctor’s office. Possible side effects include itching in the mouth or
ear and throat irritation. In rare cases, SLIT treatments can cause anaphylaxis.
 Home Remedies will depend on your allergens. If you have seasonal or pollen
P a g e | 94
allergies, you can try using an air conditioner instead of opening your windows. If
possible, add a filter designed for allergies.
 Regularly rinsing your nasal passages with a salt water solution to keep your nose free
of irritants.
 Using aDehumidifier or a high-efficiency particulate air (HEPA) filter can help you
control your allergies while indoors. If you’re allergic to dust mites, wash your sheets
and blankets in hot water that’s above 130°F (54.4°C). Adding a HEPA filter to your
vacuum and vacuuming weekly may also help. Limiting carpet in your home can also
be useful.
 If your symptoms do not seem to be improving, we may need to involve an Allergist -
the specialist who deals with the diagnosis and treatment of asthma and other allergic
illnesses.
 I do have some reading material available with me to give you entitled – Allergic
Rhinitis
Is there anything else I can help you with? – No
 If the symptoms of allergic rhinitis are disrupting your sleep, preventing you carrying
out everyday activities, or adversely affecting your performance at work or schoolor if
you have any other concerns please do come back and visit us at the GP Surgery.
No Allergic Hx. No Family Hx. No Travel Hx. Unemployed – studying part-time. Non-
Smoker. Drinks alcohol occasionally. Does not use recreational drugs. Diet healthy. No
pets. Carpet at home. Lives in rented accommodation – flat – with his siblings. Siblings are
fine and healthy – asymptomatic. Hygiene good. Exercises a lot – walks to gym daily.
Enjoys cycling.
Mother requesting Tonsillectomy

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.
SIGN (Scottish Intercollegiate Guidelines Network ) criteria for tonsillectomy :

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
P a g e | 95
3) 3 or more in each of the preceding three years)

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.
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.
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.
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.
P a g e | 96
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 tonsils help 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)
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.
[ 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.
P a g e | 97
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.
TEACHING ECG TO NURSE:

SCENARIO 4: Nurse wants to learn about the basics of ECG. Teach her.
( note : she might be holding 3-4 ECGs in hand)
Hello I am Dr. ……. 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 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 it is produced?
What is normal and abnormal ecg?)
Well I will teach you every thing about it but before that can you please tell me how much do you know
about the ECG?

P a g e | 98
N: Doctor I know how to record ECG on machine but (might say) I don’t know much of how to read it.
Doctor please teach ok. Here is the ECG(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
on ? …. Yes Doctor.
D: Ok now moving forward to calculate the heart rate you need to count 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?
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.
 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 ?
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.

Stable Angina
Question:
You are an FY2 doctor in the GP clinic

75 year old male presented with chest pain for the past two weeks.
Talk to the patient and discuss further management plan with the patient.
P a g e | 99
DIFFERENTIALS
1. MI
2.PULMONORY EMBOLISM
3. ANGINA
4.PNEUMONIA
5.PERICARDITIS
6.TRAUMA AND MUSCULOSKELETEL CHEST PAIN
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?
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
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 getting 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]
Dr: Do you have any pain on your calf muscle ? Pt: No [PE]
Dr: Any recent flight travel? Pt: no [PE]
Dr: did you have a fall or any injury to your chest? Pt: No [MUSCULOSKELETEL 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 haven't see any doctors in many years]
Dr: family h/o any medical conditions? Pt: No
Social History: Patient smoke 1 pack of cigarettes per day for the past 35 years
and drinks 2 glasses of alcohol every day for 30 - 35 years
Pt: How's your diet? Pt: my diet is fine. I follow a mixed diet. I eat both red meat and white
meat, also 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
also I wish 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%]

P a g e | 100
Dr: do you know what is happening to you ? Pt: No

Dr: Do you have any specific concerns in your mind?
Pt: Is it heart attack doctor?
Dr: Mr....... from what you have told me and after the examination, you do not have heart
attack. But I suspect that you have a condition in the heat called STABLE ANGINA. Do you
know anything about it? Pt: No doc
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 on 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 to 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 test 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).
Specialist doctor will do some other tests like 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 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 few options
MEDICAL : medications are there 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.
SURGICAL: if there is any narrowing of the coronary artery is detected in the tests then
specialist may do a procedure called Angioplasty ( widening the narrowed section of the
coronary artery) or an operation called Coronary artery bypass graft (a section of the
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 advice you to stop smoking and cut down alcohol because they
increase the risk of having heart attack or stroke. We have 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
P a g e | 101
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,
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!
P a g e | 102

Chest pain – Pericarditis
Causes:
Infectious
Pericarditis may be caused by 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 coxsackievirus, herpesvirus, mumps virus, and HIV among others.
Pneumococcus or tuberculous pericarditis are the most common bacterial forms.
Anaerobic bacteriacan also be a rare cause.
Fungal pericarditis is usually due to histoplasmosis, or
in immunocompromised hosts 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.[4]
 Autoimmune disease: systemic lupus erythematosus, rheumatic fever, IgG4-related
disease
 Myocardial infarction (Dressler's syndrome)
 Trauma to the heart
 Uremia (uremic pericarditis)
 Cancer
 Side effect of some medications, e.g. isoniazid, cyclosporine, hydralazine, warfarin,
and heparin
 Radiation induced
 Aortic dissection
 Postpericardiotomy syndrome - such as after CABG surgery

Scenario -
30 year man with chest pain
History and management
Had chest pain for 3 days. Spontaneous oncet.
Sharp, retro sterna 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 allergy.
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 – uremic pericarditis) , Cardiac enzymes, chest X Ray (for pericardial
effusion)
P a g e | 103
Examiner may say all normal

ECG – May show – global saddle shaped ST elevation or electrical alternanswih sinus tachycardia
St elevation
Electrical alternans
–Diagnosis:
I think you have condition what we call as Pericarditis – it an infection of the lining covering the
heart. Sometimes it is a serious serious condition.
There are several causes – like viral or bacterial type of bugs can cause this. Sometimes it can be due
to injury or medications. However in your case it could me 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 like sometimes there could be fluid surrounding the heart ( pericardial effusion).
Which 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 viral kind of bugs causing this.
If there is fluid filled around the heart then we may need to drain it.
P a g e | 104
This condition usually resolves on its own but it may take weeks or months.

Chest Discomfort – Arrhythmias- Repeated 2373
Causes of palpitation:
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
1. 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
1. Psychosomatic disorders
Anxiety, panic attacks, Depression, somatization disorders
1. Systemic causes
Hyperthyroidism, hypoglycaemia, postmenopausal syndrome, fever,
anaemia, pregnancy, hypovolaemia, orthostatic hypotension,
postural orthostatic tachycardia syndrome, pheochromocytoma,
arteriovenous fistula
1. 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
Pheochromocytomais 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)
Exam question
You are 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 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 chest discomfort. I am scared that I
P a g e | 105
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 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
Dr: Does anything makes better or worse? Pt: No/When I sit I feel better.
Dr: I see. Could you please tell me does it happen 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? (Hypoglycemia)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
Dr: Do you take any other recreational drugs Mr. X? (Drug Abuse- Alcohol, cocaine,
P a g e | 106
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 what you have given me, it seems likely that you have what we
call as 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 ?
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 reason – if he is
drinking too much coffee].
Also Mr X since your father and brother had heart problems there could be 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 perform an HYPERLINK "https://patient.info/health/electrocardiogram-

ecg"electrocardiogram (ECG HYPERLINK
"https://patient.info/health/electrocardiogram-ecg") HYPERLINK
"https://patient.info/health/electrocardiogram-ecg"heart HYPERLINK
"https://patient.info/health/electrocardiogram-ecg" 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 HYPERLINK
P a g e | 107
"https://patient.info/health/ambulatory-electrocardiogram-ecg"ambulatory ECG or
HYPERLINK "https://patient.info/health/ambulatory-electrocardiogram-ecg"Holter
HYPERLINK "https://patient.info/health/ambulatory-electrocardiogram-ecg" Monitoring.
HYPERLINK "https://patient.info/health/ambulatory-electrocardiogram-ecg"
In some cases you may need a scan of the heart, called an HYPERLINK
"https://patient.info/health/echocardiogram"Echocardiogram HYPERLINK
"https://patient.info/health/echocardiogram". Also, we may need to do aChestXRay for
you.
We do other investigations like some Blood Tests to check for anaemia or any overactive
HYPERLINK "https://patient.info/health/overactive-thyroid-gland-
hyperthyroidism"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. heart specialist. If there is 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.
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.
P a g e | 108

P a g e | 109
Musculoskeletal back pain.

SCENARIO-
A young man with back pain came to the emergency department, c/o back pain. Your
task is to take history and discuss management with the patient.
Patient gives history of back pain after playing squash. He had not played squash for 5
years. No sciatica.
History-
1. Primary complaint?
2. Could you point out where exactly is the pain?
3. How did it happen?
4. Since when?
5. Grade the pain on a scale of 1 to 10 (in the exam, scale was 5)
6. Is there anything that makes the pain better or worse? (IVDP-relieves on
lying flat and worse on movement, coughing or sneezing)
7. How will you describe the pain?
8. Does the pain radiate anywhere? (loin to groin, to the legs)
9. Is it the first time you are experiencing this kind of pain?
10. Any pain anywhere else ? Any joint pains ?
11. Any history of lifting heavy weight?
12. Any bowel or bladder incontinence ( leakage of urine, unable to control
bowel movement) ( cauda equina syndrome)
13. Any fever, cough Travel and contact history - for TB
14. Were you told to have any weak bones?
15. Any history of repeated bruises or infections?
16. Did you experience any weakness of the legs during this event?
17. Did you experience any difficulty while passing urine or motion?
41.
18. Loss of weight?
19. MAFTOSA- specifically ask for history of cancers in family
Examination- (verbal)
1. Examine back and abdomen. [ Do not mention prostate examination because
patient is young].
2. SLR test- explain. (If SLR positive-prolapsed disc)
Examiner may say – tenderness over paraspinal area, SLR negative.
Investigations
No tests required if you are thinking of muscular pain.
“From what you have told me and from what I have examined, it seems to me you have
a muscle pain. It might have occurred after sudden movement of the back after
playing squash after a long period of time.
This is not a serious condition. It will subside on its own in few days or weeks.
We shall give you pain killers to ease with the pain. The pain should subside after few
days. If it did not subside after about 2 weeks, please come back.
Pt: Will you arrange physiotherapy.
Dr: Yes we will. Physiotherapist will tell you when they can start physiotherapy.
If SLR TEST POSITIVE INDICATING PROLAPSED DISC, MANAGEMENT IS DIFFERENT)-
P a g e | 110
Continue with normal activities as far as possible. Initially, try doing simple activities
that won’t cause much of 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.
We can give you painkillers to ease with the pain. If it doesn’t subside- refer to
physiotherapist.
(Surgery-if symptoms persist for more than 6 weeks)}

(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)

ST
HERPES ZOSTER (31 Oct)
Question
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 Its fine.
Dr: Thank you. Can you tell me since when have you been experiencing this pain?
Pt: Dr It is going on since the last one day.
Dr: And where exactly is it paining?
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

P a g e | 111
Dr: Any difficulty in breathing?Pt: No.
Dr: Any pain or swelling in 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
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 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 skin lesion anywhere else ? No
Dr: Any skin lesions on face near the eyes ( ophthalmic shingles) or ears
( Ramsay hut syndrome) ? No
Dr: Have you ever had any chicken pox before ? Yes / No
Any allergies ? No
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 MAFTOSA is negative
Need to ask about risk factors for shingles:

Asthma, chronic kidney disease, immune - compromised, diabetes.
Also need to ask about history of immunization.
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 back which reveals lesions consistent with HZV.
P a g e | 112
Dr: Thank you for your co operation 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 characterized by pain in a specific pattern which we call as
a dermatomal distribution and a localised rash as seen on your back.
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 pain killers 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.However, there are a number of things we can advise you about so that this does not
spread. Some of them are:
 Avoid contact with people who have not had chickenpox, particularly pregnant women,
immunocompromised people, and babies younger than 1 month of age.
 Avoid sharing clothes and towels.
 Wear loose-fitting clothes to reduce irritation.
 Cover lesions that are not under clothes while the rash is still weeping.
 Avoid use of topical creams and adhesive dressings, as they can cause irritation and delay rash
healing.
 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.
 Avoid work, school, or day care if the rash is weeping and cannot be covered. 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 it is skin lesion spreading or if you develop any skin
lesions over face please come back.
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:
o Prodrome (several days before the rash) — including abnormal sensation in the affected
skin and sometimes headache, malaise, and fever.
o 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.
P a g e | 113
o Pain — intense neuralgic pain over the affected area, especially in people with trigeminal
nerve involvement.
o 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 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 aciclovir) 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.
o 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.
o For immunocompetent children with shingles, antiviral treatment is not recommended.
 In all people with shingles, clinical judgement should be used to decide who to refer, who to
refer to, and the urgency of the referral. For example:
o 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.
P a g e | 114

Heart failure.
Mr McKenzie 58 year old man was diagnosed with myocardial infarction 7 years ago.
He was not coming for follow up. Now presented with Shortness of breath. GP
referred him to the hospital. Address his concerns.
Patient was sitting on chair.
Dr: Hello Mr McKenzie, I am Dr ... one of the junior doctor 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 to talk to me? Pt: Yes.
Dr: Can you tell me more about your shortness of breath ?
Pt: I am having this problem since last 4 months and it is getting worse.
Dr: When do you feel short of breath – I mean you feel short of breath when you do some
work or exercise or even at rest you feel SOB ?
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 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 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 wheez ( Asthma, COPD)? Pt: No
Dr: Were you diagnosed with any medical conditions before ?
Pt: Yes I had heart attack about 7 years ago.

P a g e | 115
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 heart attack. Pt:
No
Dr: May I know why?
Pt: Doctor I was too busy and I did not have problem 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 do 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.
P a g e | 116
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 McKenzei, Do you have any idea what may be happening to you?
Pt: No doctor.
Dr: You have a condition what we call as 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 had
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 complication which can happen to those people who had heart attack
P a g e | 117
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 and not eating 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 complication. Do
you follow me?
Pt: Yes : What happen to me now?
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 good exercise and eat 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. Thank you very much.
PULMONARY EMBOLISM
INFORMATION
PE results from obstruction within the pulmonary arterial tree. The emboli can be caused by:
• Thrombosis - accounts for the majority of cases and has usually arisen from a distant vein and travelled
to the lungs via the venous system.
• Fat - following long bone fracture or orthopaedic surgery.
• Amniotic fluid.[1]
• Air - following neck vein cannulation or bronchial trauma.

P a g e | 118
Risk factors for venous thromboembolism[3]

Major risk factors: relative risk of 5-
Minor risk factors: relative risk of 2-4
20
Surgery: Cardiovascular:
• Major abdominal/pelvic surgery • Congenital heart disease.
or hip/knee replacement • Congestive cardiac failure.
(risk lower if prophylaxis used).
• Postoperative intensive care. • Hypertension.
Obstetrics: • Paralytic stroke.
• Late pregnancy. Oestrogens:
• Puerperium. • Pregnancy (but see major risk factors for late
pregnancy and puerperium).
• Caesarean section.
Lower limb problems: • Combined oral contraceptive.
• Fracture. • Hormone replacement therapy.
• Varicose veins - previous Haematological:
varicose vein surgery; • Thrombotic disorders (a detailed list is
superficial thrombophlebitis; varicose available)
veins per se are not a risk factor. Consider this in cases of PE aged <40
Malignancy: years, recurrent VTE or a positive family
• Abdominal/pelvic. history.
• Myeloproliferative disorders.
• Advanced/metastatic. Renal:
Reduced mobility: • Nephrotic syndrome.
• Chronic dialysis.
• Hospitalisation. • Paroxysmal nocturnal haemoglobinuria.
• Institutional care. Miscellaneous:
Previous proven VTE: • Chronic obstructive pulmonary disease
• Intravenous (IV) drug use (COPD).
(could be major or • Neurological disability.
minor risk factor:
no data on relative risk). • Occult malignancy.
Other: • Long-distance sedentary travel.
• Major trauma.
• Obesity.
• Spinal cord injury.
• Other chronic diseases: inflammatory bowel
• Central venous lines. disease, Behçet's disease.
SYMPTOMS
• Dyspnoea.
• Pleuritic chest pain, retrosternal chest pain.
• Cough and haemoptysis.
• Any chest symptoms in a patient with symptoms suggesting a deep vein thrombosis (DVT).
• In severe cases, right heart failure causes dizziness or syncope.
Signs include:
• Tachypnoea, tachycardia.
• Hypoxia, which may cause anxiety, restlessness, agitation and impaired consciousness.
P a g e | 119
• Pyrexia.
• Elevated jugular venous pressure.
• Gallop heart rhythm, a widely split second heart sound, tricuspidregurgitant murmur.
• Pleural rub.
• Systemic hypotension and cardiogenic shock.
Investigations
General investigations[3]
• Baseline investigations - as for any ill patient: oxygen saturation, FBC, biochemistry, baseline
clotting screen. Troponin and brain natriuretic peptide levels may also be elevated.
• ECG - may be normal, or show any of these changes: sinus tachycardia, atrial fibrillation,
nonspecific ST or T-wave abnormalities, right ventricular strain pattern V1-3, right axis
deviation, right bundle branch block (RBBB), or deep S-waves in I with Q waves in III and
inverted T waves in III ('S1,Q3,T3' pattern). A large PE can show ECG features of acute
cardiac ischaemia (eg, ST depression).[6]
• CXR - mainly useful to exclude other chest disease, and is needed for interpreting V/Q scans. It
is usually normal, but may show: decreased vascular markings, atelectasis or a small pleural
effusion. An occasional late sign may be an homogeneous wedge-shaped area of pulmonary
infarction in the lung periphery (Hampton's hump) with its base contiguous to a visceral
pleural surface and its rounded convex apex directed toward the hilum.
• Arterial blood gases - may show reduced PaO2, reduced PaCO2 due to hyperventilation or
acidosis.
• Echocardiography - may show thrombus in proximal pulmonary arteries and, if normal, can
exclude haemodynamically important PE. It cannot exclude smaller PEs. It may show signs
of right ventricular strain or right ventricular hypokinesis.
• Cardiac troponins - can be indicative of right heart strain.
• D-dimers - fibrin D-dimer is a degradation product of cross-linked fibrin. The concentration
increases in patients with acute VTE and provides a very sensitive test to exclude acute DVT
or PE. D-dimer tests have less specificity and are less useful in some groups of patients - eg,
those with high clinical probability; those admitted to hospital for another reason, in whom
the suspicion of PE is raised during their hospital stay; individuals older than 65 years;
pregnant women.[2]
CTPA has become the method of choice for imaging the pulmonary vasculature in patients
with suspected PE.
Management
Initial resuscitation
• Oxygen 100%.
• Obtain IV access, monitor closely, start baseline investigations.
• Give analgesia if necessary (eg, morphine).
• Assess circulation: suspect massive PE if systolic BP is <90 mm Hg or there is a fall of 40 mm
Hg, for 15 minutes, not due to other causes.
•
Anticoagulation therapy[4]
P a g e | 120
• Offer a choice of low molecular weight heparin (LMWH) or fondaparinux to patients with
confirmed PE, with the following exceptions:
• For patients with severe renal impairment or established chronic kidney disease
(estimated glomerular filtration rate (eGFR) <30 ml/min/1.73 m2) offer unfractionated
heparin (UFH) with dose adjustments based on the activated partial thromboplastin time
(aPTT) or LMWH with dose adjustments based on an anti-Xa assay.
• For patients with an increased risk of bleeding, consider UFH.
• For patients with PE and haemodynamic instability, offer UFH and consider thrombolytic
therapy.
1. Start the LMWH, fondaparinux or UFH as soon as possible and continue it for at least
five days or until the international normalised ratio (INR) is 2 or above for at least 24 hours,
whichever is longer.
2. Offer LMWH to patients with active cancer and confirmed PE, and continue the LMWH
for six months. At six months, assess the risks and benefits of continuing anticoagulation.
3. Offer a vitamin K antagonist (VKA) to patients with confirmed PE within 24 hours of
diagnosis and continue the VKA for three months. At three months, assess the risks and benefits
of continuing VKA treatment.
4. Offer a VKA beyond three months to patients with an unprovoked PE, taking into
account the patient's risk of VTE recurrence and whether they are at increased risk of bleeding.
Scenario-37 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 I think its best to start the station with stabilising
the patient first, by administering Oxygen and IV fluids.)
(In the recent exam,patient was stable)
History-
• Primary complaint?
• Shortness of breath? Since when? Anything that makes it better or worser? 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?
DIFFERENTIAL DIAGNOSIS-
• PULMONARY EMBOLISM
• MI
• ASTHMA
• COPD
• HEART FAILURE
• PNEUMONIA
MAFTOSA- ask specifically for-

• Asthma
P a g e | 121
• Smokers cough
• Recent long flights
• Surgeries?
• Any previous history of blood clots in the lungs or legs?
• Family history of blood clots in the lungs or legs?
• Medication-blood thinner?
• IN THE EXAM, PATIENT WAS A FEMALE WHO WAS ON ORAL
CONTRACEPTIVES FOR 8 YEARS/20 YEARS
Examination- examine chest,NEWSchart,will ensure privacy and

chaperone(examination findings-coarse crackles at left lower lung zone)
Tests- FBC,U&E,LFT,CLOTTING SCREEN,D-DIMER,ECG,CXR (EXAMINER

GIVES 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 explaination of ctpa)
We shall do ECG (might show S1Q3T3 strain) and chest Xray as well.
“How will you treat me?”

“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.
Address that you will talk to your seniors regarding the contraceptive pills-might
have to change it.
Explain warning signs-

• Avoid falls
P a g e | 122
• Cuts while dealing with sharp objects
Lady‌‌with‌‌breast‌‌cancer‌‌(‌‌already‌‌had‌‌mastectomy)‌‌chest‌‌pain‌‌
-‌‌PE‌ ‌ ‌January‌‌16:‌‌
La‌dy‌‌with‌‌SOB‌‌and‌‌chest‌‌pain‌‌came‌‌to‌‌A&E.‌‌Take‌‌history‌‌and‌‌discuss‌‌management‌‌with‌‌
examiner.‌‌
‌
Lady‌‌in‌‌her‌‌60s‌‌comes‌‌to‌‌A&E‌‌with‌‌sudden‌‌onset‌‌SOB,‌‌no‌‌exertion.‌‌Along‌‌with‌‌left‌‌sided‌‌
chest‌‌pain‌‌(precordium),‌‌not‌‌positional‌‌and‌‌only‌‌on‌‌inspiration.‌‌No‌‌fever,‌‌no‌‌ankle‌‌swelling,‌‌
DVT?‌‌Calf‌‌swelling?‌‌PMH‌‌of‌‌DM‌‌on‌‌metformin‌‌not‌‌HTN‌‌and‌‌no‌‌other‌‌medical‌‌conditions.‌‌
Past‌‌history‌‌of‌‌breast‌‌cancer‌‌and‌‌mastectomy‌‌on‌‌the‌‌same‌‌side‌‌(left)‌‌along‌‌with‌‌
chemotherapy,‌‌no‌‌radiotherapy.‌‌(ask‌‌when‌‌mastectomy‌‌and‌‌when‌‌last‌‌chemo‌‌session?)‌‌Any‌‌
family‌‌history‌‌of‌‌breast‌‌cancer?‌‌(possible‌‌aunt)‌‌possible‌‌OCP‌‌(unlikely‌‌as‌‌she‌‌is‌‌
postmenopausal)‌‌/travel/HRT.‌‌Any‌‌sort‌‌of‌‌inactivity?‌‌Heart‌‌disease?‌‌Fractures?‌‌Smoking?‌‌‌
Examination:‌‌‌general‌‌physical‌‌exam‌‌focusing‌‌on‌‌chest‌‌and‌‌lower‌‌limbs‌‌along‌‌with‌‌NEWS‌‌
chart.‌‌O2‌‌90%‌‌HR‌‌110‌‌Temp?‌‌BP?‌‌RR?‌‌ABG‌‌showed‌‌respiratory‌‌alkalosis‌‌with‌‌no‌‌
compensation,‌‌CXR‌‌normal,‌‌ECG‌‌showed‌‌sinus‌‌tach‌‌(examiner‌‌may‌‌not‌‌give).‌‌Diagnosis‌‌
likely‌‌PE‌‌
People‌‌with‌‌cancer‌‌may‌‌have‌‌a‌‌higher‌‌number‌‌of‌‌platelets‌‌and‌‌clotting‌‌factors‌‌in‌‌the‌‌blood‌‌
which‌‌in‌‌turn‌‌help‌‌clotting‌‌and‌‌stop‌‌bleeding.‌‌Having‌‌higher‌‌than‌‌normal‌‌amounts‌‌of‌‌platelets‌‌
and‌‌clotting‌‌factors‌‌in‌‌the‌‌body‌‌means‌‌the‌‌blood‌‌is‌‌more‌‌likely‌‌to‌‌clot.Some‌‌people‌‌with‌‌
cancer‌‌may‌‌have‌‌lower‌‌levels‌‌of‌‌proteins‌‌in‌‌the‌‌blood‌‌that‌‌help‌‌to‌‌keep‌‌it‌‌thinned.‌‌Hence‌‌
making‌‌cancer‌‌a‌‌risk‌‌factor‌‌for‌‌developing‌‌clots.‌‌Since‌‌the‌‌pt‌‌has‌‌a‌‌positive‌‌history‌‌for‌‌DM‌‌as‌‌
well‌‌that‌‌can‌‌contribute‌‌to‌‌forming‌‌a‌‌clot‌‌as‌‌well.‌‌(disease‌‌progression‌‌may‌‌also‌‌contribute‌‌to‌‌
formation‌‌of‌‌clots)‌‌
Management:‌‌‌Admit‌‌and‌‌do‌‌CTPA‌‌along‌‌with‌‌d-dimer.‌‌Begin‌‌LMWH‌‌immediately‌‌and‌‌
monitor.‌‌Consult‌‌Sr‌‌for‌‌advice‌‌on‌‌how‌‌to‌‌manage‌‌further‌‌and‌‌long‌‌term‌‌anticoagulants‌‌with‌‌
cancer‌‌treatment.‌‌‌
‌
CHEST PAIN (PE) - TRANSGENDER

Question: You are an FY2 in GP Surgery. Amanda Love is a 26 years-old
woman who has presented with some concerns. Talk to the patient and
address her concerns.
Hello. Amanda Love? Hi, my name is Dr. ……… I am one of the junior doctors here in the GP
Surgery.
What would you like me to call you? – Amanda, please

Can you confirm for me your age please? – 26
How can we help you today Amanda? – Doctor, I’m having some pain in my chest
P a g e | 123
 Are you in pain now? – Yes

 Are you ok to continue? – Yes (if no, ask next question)
Can you tell me a little bit more about the pain you are having? – Yes, doctor it started earlier on
today and… It really hurts
 Have you been offered any painkillers? – No (if no, ask next question)
 Would you like me to give you some painkillers? – No (if yes, ask next question)
 Are you allergic to any medication at all? – No
How long have you been having this pain exactly? – Just today. 4 hours
Can you tell me where exactly is the pain located? Can you pin-point it with a finger? – Yes, right
here in the middle of my chest
And how did it come about? Sudden/Gradual? – All of a sudden
And how would you describe the nature of this pain? – It’s really sharp, stabbing
Does the pain travel to any other part of your body? – No
Is the pain aggravated by anything you do? Activity? – Walking to the A&E was a nightmare. It
was just so painful. It’s also painful when I breathe
And did it improve with anything? Resting? Medication? – No
Is the pain worse at a particular time of the day? – No
On a scale of 1-10, 1 being the least amount of pain and 10 being the worst. How would you
describe it? – 7
Has the pain gotten worse or better? – Worse
Do you have any other symptoms other than the chest pain? – No
Rule out common Acute Chest Pain causes;

Pulmonary Embolism, Acute Coronary Syndrome (MI, Angina), Pneumothorax, Pneumonia, Acute
Congestive Heart Failure, Cardiac Arrhythmia, Asthma, Acute Exacerbation of Chronic Lung
Disease (COPD), Dissecting or Rupturing Aortic Aneurysm, Pericarditis, GERD, Post-Herpetic
Neuralgia, Musculoskeletal Chest Pain [Trauma], Panic Attack
Breathing Difficulty?(PE, ACS, PT, Pneumonia, Acute CHF, Cardiac Arrhythmia, Asthma,
Acute Exacerbation of COPD, Pericarditis, Panic Attack) – No
Coughing up of Blood [Haemoptysis]?(PE) – No
Leg Pain? Leg Swelling? Redness of calves? (PE, Heart Failure) – Yes, I have noticed
that my right leg has been a bit swollen and sore for the past couple of days. It’s not that painful,
just a little tender. I don’t think it’s a big problem
Chest Pain related to your breathing? (PE, PT, Asthma, Pericarditis) – Yes
Pain travel down your left arm/neck/jaw? Sweating? Nausea/Vomiting?(ACS) – No
Pain travel to your back?(Aortic Dissection, Post-Herpetic Neuralgia) – No
Headache? (HTN – Aortic Aneurysm/Dissection) – No
Fever? (Pneumonia, Acute Exacerbation of COPD) – No
Cough? (Pneumonia, Acute Exacerbation of COPD, Asthma) – No
Racing of the heart? Palpitations? (Arrhythmia, Panic Attack) – No
Heartburn? Difficulty swallowing? Regurgitation of food or sour liquid? Lump in throat? (GERD) –
No
Do you think you could have hurt yourself in any way? (Trauma) – No
Is there anything else that you would like to add, that I may have missed? – No
 Risk Factors for PE– Age >40, Obesity, Smoking, Prolonged

Immobilization (>3 days), Long-Distance Travel, Recent Surgery (<4
weeks), Previous DVT/PE, Multiple Trauma, Cancer, Pregnancy, Post-
P a g e | 124
Partum Period, Heart Failure, Coagulation Disorders, Cancer, Oestrogen

or Progesterone Treatment (OCP or HRT).
Is this the first time you are experiencing these symptoms? – Yes
Have you ever been diagnosed with any medical condition before? – Like what?
High Blood Sugar? High Blood Pressure?DVT? PE?Cancer? – No
Have you ever undergone a surgical procedure before? – No
Are you currently taking any prescribed Medication? OTC?–Yes, I’m currently taking
Oestrogen tablets for my gender transitioning. I’m currently transitioning from a male to a
female. I’ve been on Oestrogen for about 6 months now. I don’t have my medication with me
today and I can’t remember what the exact dose was. I was told to have 1 tablet a day, but during
the last 1 month, I am taking 3 tablets a day because I want the transitioning to go faster. I’m also
taking 100mg Spironolactone daily, as prescribed by my GP. I’m not using any other OTC
medication or medication from online resources
First off, kudos to you for taking the transitioning step.
How have you been coping? At home? Family? – Well. They are very supportive
How has the transition period been? – Slow, that’s why I started taking 3 tablets a day
Were you told of any potential side-effects of your medication? – Yes, but I forgot
OESTROGEN USE
The purpose of oestrogen treatment for transgender women is to cause physical changes
that make the body more feminine. The combination of a testosterone blocker with
oestrogen can lead to the following types of desired changes in the body:
 breast growth
 decreased body and facial hair
 redistribution of body fat
 softening and smoothing of the skin
 reduced acne
All of these are changes that can reduce gender dysphoria and improve quality of life.
There are also some changes that occur that are less obvious. Some of these, like a
reduction in testosterone, fewer penile erections, and a decline in blood pressure are
generally considered to be positive changes. Others, like decreased sex drive and changes
in cholesterol and other cardiovascular factors, may be less desirable.
The physical changes associated with oestrogen treatment may start within a few months.
However, changes can take two to three years to be fully realized. This is particularly
true for breast growth. As many as two-thirds of transgender women are not satisfied with
breast growth and may seek breast augmentation.
Oestrogen can be taken in a number of different ways. People receive oestrogen through a
pill, injection, patch, or even a topical cream. It's not just a matter of preference. The
route by which people take oestrogen affects some of the risks of oestrogen treatment—
oestrogen is absorbed by the body differently depending on how you take it.
Much of the research on the risks of oestrogen treatment focus on oral oestrogens—those
taken by mouth. What research has found is that oral oestrogen seems to put women at an
increased risk of a number of problematic side effects when compared to topical or injected
oestrogens. This is because of the effects of ingested oestrogen on the liver when it passes
through that organ during the process of digestion.
P a g e | 125
This is referred to as the hepatic first pass effect and it is not an issue for oestrogen
treatment that isn't taken in pill form. The hepatic first pass effect causes changes in a
number of physiological markers that affect cardiovascular health. Changes are found in:
 C-Reactive Protein
 Insulin-like growth factor-1
 Angiotensin (a protein in the blood)
 Other liver proteins
These changes may lead to an increase in blood clotting and reduced cardiovascular health.
They are not seen as often, if at all, with non-oral oestrogens. Therefore, non-oral
oestrogens may be a safer option for transgender women.
It is important to note that much of the research on the safety of oestrogen treatment has
been done in cisgender women taking oral contraceptives or hormone replacement therapy.
This is potentially problematic as many of these treatments also contain progesterone, and
the type of progesterone in these formulations has also been shown to affect the risk of
cardiovascular disease. Transgender women do not usually receive progesterone treatment.
 Types of Oestrogens
In addition to the different routes of administration of oestrogen treatment, there are also
different types of oestrogens used for treatment. These include:
 oral 17B-estradiol
 oral conjugated oestrogens
 17B-Estradiol patch (usually replaced every three to five days)
 oestradiol valerate injection (every one to two weeks)
 oestradiol cypionate injection (every one to two weeks)
Endocrine Society guidelines specifically suggest that oral ethinyl oestradiol should not be
used in transgender women. This is because oral ethinyl oestradiol is the treatment most
associated with thromboembolic events such as deep vein thrombosis, heart attack,
pulmonary embolism, and stroke.
No matter what type of oestrogen treatment is used, monitoring is important. The doctor
who prescribes your oestrogen should monitor the levels of oestrogen in your blood.
The goal is to make certain you have similar levels of oestrogen to premenopausal
cisgender women, which is about 100 to 200 picogram/millilitre (pg/ml). Your doctor will
also need to monitor the effects of your anti-androgen by checking your testosterone levels.
The testosterone levels should also be the same as for premenopausal cisgender women
(less than 50 nanograms per decilitre). However, androgen levels that are too low may lead
to depression and generally feeling less well.
 Risks and Benefits

By Route of Administration
In general, topical or injected oestrogen treatment is thought to be safer than oral
treatment. This is because there is no hepatic first pass effect. Topical and injectable
oestrogens also need to be taken less often, which may make dealing with them easier.
P a g e | 126
However, there are downsides to these options as well.
It is easier for people to maintain steady levels of oestrogen on pills than with other forms
of oestrogen. This can affect how some women feel when taking hormone treatment. Since
levels of oestrogen peak and then decline with injections and transdermal (patch/cream)
formulations, it can also be harder for doctors to figure out the right level to prescribe.
In addition, some people experience skin rashes and irritation from oestrogen patches.
Oestrogen creams can be difficult to deal with for people who live with others who might
be exposed by touching treated skin. Injections may require visiting the doctor regularly for
people who are not comfortable giving them to themselves.
By Type of Oestrogen
Oral ethinyl oestradiol is not recommended for use in transgender women because it is
associated with an increased risk of blood clots. Conjugated oestrogens may also put
women at higher risk than use of 17B-estradiol. Risk of thrombosis (blood clots) is
particularly high for women who smoke. Therefore, it is recommended that smokers
always be put on transdermal 17B-estradiol, if that is an option.
SPIRONOLACTONE USE
Spironolactone is frequently used as a component of feminizing hormone therapy in transgender
women, usually in addition to oestrogen. Other clinical effects include decreased male pattern
body hair, the induction of breast development, feminization in general, and lack of spontaneous
erections. It is used in high dosages of 100 to 400 mg/day in feminizing hormone therapy for
transgender women. The most common side effect of spironolactone is frequent urination. Other
general side effects include dehydration, drowziness, dizziness and rashes.
Have you been experiencing any frequent weeing? Dehydration? Drowziness? Dizziness? Rash? –
No
Are there any illnesses which run in the Family?HTN? Breast CA?– No
Have you Travelledanywhere recently? Long-distance? – No
Do you Smoke? – No
How would you describe your Diet? – I eat very healthily, lots of water, fruit and veg
EXAMINATION
What I would like to do now is to examine your vitals and check your pulse, blood pressure,
breathing rate, temperature and levels of oxygen in your blood.
I would also like to take a closer look at your chest, and take a look at your breathing system and
your heart.
Finally, I would also like to take a look at both your legs.
CONSENT. EXPOSURE. CHAPERONE. PRIVACY. CONFIDENTIALITY.
PROVISIONAL DIAGNOSIS
From what you have told me and from what I have seen, your heart rate seems to be raised. The
P a g e | 127
rest of your breathing system and heart examination was normal. Upon closer look at your legs,
on your right leg, I could appreciate some redness, swelling and skin changes. The temperature
was raised and there was also some tenderness.
Amanda, do you have any idea at all why you may be having this problem? –No
Unfortunately, it is likely that you could be suffering from something quite serious. You’ve done
really well in coming to the A&E department promptly. I suspect that you may be suffering from a
condition called a Pulmonary Embolism.
Is that something you might have heard of before? – No

Would you like me to tell you more about it? – Yes
A pulmonary embolism is a blocked blood vessel in your lungs. This clot in your lungs
can be life-threatening if not treated quickly.The common symptoms of pulmonary
embolism include; pain in your chest or upper back, difficulty breathing and coughing up
blood. Commonly, there is also pain, redness and swelling in 1 of your legs (usually in the
calf). These are symptoms of a blood clot, also called deep vein thrombosis (DVT) in your
leg. This clot can travel in your blood and lodge in one of the blood vessels in your lungs,
and that is why I believe you are experiencing chest pain and fast heart rate.
Are you following me? – Yes
How to use the two-level PE Wells score to estimate the clinical probability of PE:
 Clinical features of deep vein thrombosis (DVT [minimum of leg swelling and pain with
palpation of the deep veins]) {+ 3 points}
 Heart rate greater than 100 beats per minute {+ 1.5 points}
 Immobilization for more than 3 days or surgery in the previous 4 weeks {+ 1.5 points}
 Previous DVT or PE {+ 1.5 points}
 Haemoptysis{+ 1 point}
 Cancer (receiving treatment, treated in the last 6 months, or palliative) {+ 1 point}
 An alternative diagnosis is less likely than PE {+ 3 points}
Why did it happen to me?

That is a good question. Unfortunately, you do have some risk factors that increase the likelihood
of you having a PE. Of those, the most concerning is your use of Oestrogen Medication. You
did mention you have been using more than the prescribed amount of tablets for the past 1
month, and that you were unaware of the side-effects of oestrogen.
The main side effects of taking oestrogen include; bloating, breast tenderness or swelling, swelling
in other parts of the body, feeling sick, leg cramps, headaches and indigestion.
Have you experience any of these side effects? – No/YesTo ease side effects, you can try:
 taking your oestrogen dose with food, which may help feelings of sickness and indigestion
 eating a low-fat, high-carbohydrate diet, which may reduce breast tenderness
 doing regular exercise and stretching, to help leg cramps
If side effects persist, we may haveto switch to a different way of taking oestrogen (for
example, changing from a tablet to a patch), changing the medicine you're taking, or
P a g e | 128
lowering your dose.
More serious risks of Oestrogen include an Increased Risk of Blood Clots and
certain types of cancer.
MANAGEMENT
 We will have to arrange an Ambulance for you and refer you for immediate Admission,
because we are suspecting something quite serious.
 For people with a Wells score of more than 4 points (PE likely),
arrange hospital admission for an immediate computed tomography pulmonary
angiogram (CTPA) and, where necessary, other investigations.
o If there will be a delay in the person receiving a CTPA, give immediate interim
low molecular weight heparin (LMWH [dalteparin, enoxaparin, or tinzaparin])
or fondaparinux, and arrange hospital admission.
 For people with a Wells score of 4 points or less (PE

unlikely),arrange a D-dimer test:
o If the test is positive, arrange admission to hospital for an immediate CTPA and,
where necessary, other investigations. If a CTPA cannot be carried out
immediately, give immediate interim LMWH (dalteparin, enoxaparin,
or tinzaparin) or fondaparinux, and arrange hospital admission.
o If the test is negative, consider an alternative diagnosis.
 We may need to form a special test called a Computer Tomography Pulmonary

Angiographyor CTPA for short. It may sound really complicated, but all it does is, is that it
helps us visualize the blood vessels supplying your lungs.
 We may also need to start you on some medication called Heparin. Heparin is a blood
thinning medication (anticoagulant) that prevents the formation of blood clots. If tests
confirm you have a pulmonary embolism, you'll continue with anticoagulant injections for
at least 5 days. You'll also need to take anticoagulant tablets for at least 3 months.Side
effects are uncommon, but can include pain in your tummy, back pain, bleeding from your
gums when you brush, blood in your urine, coughing up blood, dizziness, headaches,
unexplained nosebleeds and vomiting of blood or material that looks like coffee grounds.
 Other tests we may need to perform include;
o D-dimer testing — in people with a Wells score of 4 points or less when PE is

P a g e | 129
thought to be unlikely.
o We may have to perform some Routine Blood Tests.
o Arterial blood gases — although up to 20% of people with PE have a normal
arterial oxygen pressure.
o Chest X-ray and electrocardiography (ECG) — mainly to exclude
an alternative diagnosis.
o Lower limb compression venous ultrasound — may be useful for
pregnant women in whom irradiation from other imaging may be harmful.
o Ventilation-perfusion or perfusion scintigraphy (isotope lung
scanning) — may be done in certain circumstances (for example, half-dose
perfusion scintigraphy in pregnancy).
o Echocardiography — for people with hypotension (clinically 'massive' PE). The
absence of right heart failure excludes PE.
 Because you’re taking Oestrogen, it may be necessary to ReviewMedications that are

known to increase the risk of DVT/PE. As you can’t recall the medication dose, we may need
to alter the medication for your general wellbeing. I will have to discuss this with my
seniors. We may further need to consult with your GP. This is important, as
PE is a life-threatening condition and you could die from this condition. However,
Transdermal Oestrogens - whether patch or gel - have shown to have a lower risk for
clotting problems than other forms of oestrogen. Transdermal oestrogen, has been reported
to have the least thrombogenic profile in transgender women, although there are no head-to-
head studies with other oestrogen products.Injected Oestrogensare also available.It is
important to avoid the use of ethinyl oestradiol in transgender individuals, as it has a
significantly higher risk for clotting problems than other formulations of oestrogen. The
duration of hormone use has been associated with an increased risk of clotting problems.
There is a 4-fold risk increase in clotting problems in women who take oestrogen for 8 years
compared to those who take oestrogen for 2 years or less. There is an additional risk
associated with the use of progestins. Finally, even if the risk from exogenous oestrogen use
remains significant statistically, the absolute clinical risk remains low.
 We may have to seek help from a Specialist at a Gender Identity Clinic (GIC). They
will usually give us a better understanding about your condition. These clinics can offer
ongoing assessments, treatments, support and advice, including:
o mental health support, such as counselling

o cross-sex hormone treatment
o speech and language therapy – to help alter your voice, to sound more typical of
your gender identity
o hair removal treatments, particularly facial hair
o peer support groups, to meet other people
o relatives' support groups, for your family
For some people, support and advice from a clinic are all they need to feel comfortable in
their gender identity. Others will need more extensive treatment, such as a full transition to
P a g e | 130
the opposite sex. The amount of treatment you have is completely up to you.
There's some uncertainty about the possible risks of long-term feminising hormone
treatment. You should be aware of the potential risks and the importance of regular
monitoring before treatment continues.
Some of the potential problems most closely associated with hormone therapy include:
- blood clots
- gallstones
- weight gain
- acne
- hair loss from the scalp
- sleep apnoea – a condition that causes interrupted breathing during sleep
Hormone therapy will also make you less fertile and, eventually, completely infertile. Your
specialist at the GIC should discuss the implications for fertility, and they may talk to you
about the option of storing eggs or sperm (known as gamete storage) in case you want to
have children in the future. However, this isn't likely to be available on the NHS.
There's no guarantee that fertility will return to normal if hormones are stopped.
 While you're taking these hormones, you'll need to have regular check-ups, either at
your GIC or your local GP surgery. You'll be assessed, to check for any signs of
possible health problems and to find out if the hormone treatment is working.If you
don't think that hormone treatment is working, talk to the healthcare professionals at
your GIC who are treating you. If necessary, you can stop taking the hormones
(although some changes are irreversible, such as a deeper voice in trans men and breast
growth in trans women). Alternatively, you may be frustrated with how long hormone
therapy takes to produce results, as it can take months to years for some changes to
develop. Hormones can't change the shape of your skeleton, such as how wide your
shoulders or your hips are. It also can't change your height. Hormones for gender
dysphoria are also available from other sources, such as the internet, and it may be
tempting to get them from here instead of through your clinic. However, hormones
from other sources may not be licensed and safe.
 If you want to have genital reconstructive surgery, you'll usually first need to live in
your preferred gender identity full time for at least a year. This is known as "social
gender role transition" (previously known as "real life experience" or "RLE") and it
will help in confirming whether permanent surgery is the right option. You can start
your social gender role transition as soon as you're ready, after discussing it with your
care team, who can offer support throughout the process.The length of the transition
period recommended can vary, but it's usually one to two years. This will allow enough
time for you to have a range of experiences in your preferred gender role, such as work,
holidays and family events. For some types of surgery, such as a bilateral mastectomy
(removal of both breasts) in trans men, you may not need to complete the entire
transition period before having the operation.
 Once you've completed your social gender role transition and you and your care team
feels you're ready, you may decide to have surgery to permanently alter your sex. You
can talk to members of your team and the surgeon at your consultation about the full
range available. For trans women, surgery may involve:
P a g e | 131
 an orchidectomy (removal of the testes)

 a penectomy (removal of the penis)
 vaginoplasty (construction of a vagina)
 vulvoplasty (construction of the vulva)
 clitoroplasty (construction of a clitoris with sensation)
 breast implants
 facial feminisation surgery (to make your face a more feminine shape)
The vagina is usually created and lined with skin from the penis, with tissue from the
scrotum (the sack that holds the testes) used to create the labia. The urethra (urine tube) is
shortened and repositioned. In some cases, a piece of bowel may be used during a
vaginoplasty if hormone therapy has caused the penis and scrotum to shrink a significant
amount.
The aim of this type of surgery is to create a functioning vagina with an acceptable
appearance and retained sexual sensation.
Some transwomen can't have a full vaginoplasty for medical reasons, or they may not want
to have a functioning vagina. In such cases, a cosmetic vulvoplasty and clitoroplasty is an
option, as well as removing the testes and penis.
 After surgery, most trans women and men are happy with their new sex and feel
comfortable with their gender identity. One review of a number of studies that were
carried out over a 20-year period found that 96% of people who had genital
reconstructive surgery were satisfied.Despite high levels of personal satisfaction,
people who have had genital reconstructive surgery may face prejudice or
discrimination because of their condition. Treatment can sometimes leave people
feeling:
o isolated, if they're not with people who understand what they're going through
o stressed about or afraid of not being accepted socially
o discriminated against at work
 There are legal safeguards to protect against discrimination, but other types of
prejudice may be harder to deal with. If you're feeling anxious or depressed since
having your treatment, speak to your GP or a healthcare professional at your GIC.
 I do have some reading materials available to give you entitled – Gender Dysphoria and
DVT & PE
Is there anything else I can help you with? – Yes
Will I be ok? Is there anything else I can do?

P a g e | 132
You can expect to make a full recovery from a pulmonary embolism if it's spotted and
treated early.
You can reduce your risk of a pulmonary embolism by taking measures to prevent DVT.
If you're being treated in hospital for another condition, your medical team should take
steps to prevent the progression of the DVT.
You can occasionally develop DVT on journeys lasting more than 6 hours. You can take
steps to reduce your risk of travel-related DVT.
DO
 sit comfortably in your seat and lie back as much as possible

 wear loose-fitting clothing
 make sure you have plenty of leg room
 drink water regularly
 take regular breaks from sitting
 bend and straighten legs, feet and toes every 30 minutes while seated
 press the balls of your feet down hard against the floor every so often
 wear special stockings called ThromboEmbolism Deterrent (TED) Stockings
DON’T
 sit for long periods without moving

 drink alcohol
 drink too much coffee and other caffeine-based drinks
 take sleeping pills
.
Do you have any other concerns? – No
No Allergies. Family Hx. unremarkable. No Travel Hx. Unemployed. Unmarried. Sexually Inactive.
Non-Smoker. Occasional Alcohol drinker. Does not use recreational drugs. Lives alone. Undergoing
Gender Transitioning now as finally feels ready after many years of hesitation and contemplation.
Mood – Very happy at transitioning treatment, very concerned about chest pain.
Vitals – Pulse 112/min, BP 135/85mmHg, RR 18/min, O₂ Saturation 98%, Temp 37.7°C

Respiratory System Examination – Normal
Cardiovascular System Examination – Tachycardia 112/min, rest Normal
Leg Examination – Swollen R Leg, visible colour changes, temperature raised, tender.
Pneumonia in elderly patient

75 year lady was brought into hospital with fever and cough.
Take history and management with the patient.
P a g e | 133
CURB-65
Symptom Points
The risk of death at 30 days increases as the score
Confusion 1
increases:[1]
BUN>7 mmol/l 1
 0—0.6% Respiratory rate≥30 1
 1—2.7%
SBP<90mmHg,
 2—6.8% 1
DBP≤60mmHg
 3—14.0%
 4—27.8% Age≥65 1
 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
 3-5: Requires hospitalization with consideration as to whether they need to be in the
intensive care unit
Cough, Fever ( continous) 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,
Chest examination – Reduced air entry, and crackles ( examiner gave 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.
Chest infection has affected kidney function.

P a g e | 134
Blood test shows you have infection in chest( bugs in the lungs) also 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.

Confused elderly: LRTI
Scenario
You are the FY2 doctor on call in the A&E department.
85 year old MrStevan 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)
In this scenario, the patient is confused, for some he calls out to his daughter Alicia, for
others, he is calm and cooperative with mild confusion. At times, he is mildly dyspnoeic,
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 PATIENTS spO2 PRIOR TO HISTORY IF HE IS DYSPNOEIC and

low oxygen saturation - GIVE O2 via face mask.
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?
P a g e | 135
Pt: Yes doctor, I’ve been coughing for the past 2 days.
Dr: Have you brought anything up with the cough MrGeorge ?
Pt: Just a little phlegm, sort of green in colour.
Dr: Did your GP give you any medicine for it ...

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 MrGeorge ? 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 any one to look after at
home ?
*PATIENT IS CONFUSED
Dr: Ok MrGeorge, a couple more questions- have you had any chest pain?
Pt: No doctor. Where is Alicia? Dr: I will call for her now MrGeorge.
R/o UTI, Gastro-Enteritis, Head injury, Hypoglycaemia ( other causes of cinfusion)
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 , stay at home .
Dr = May I know do you smoke ? .. Pt : I used to but left ... 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, MrGeorge, just to confirm the GPs findings, I would need to examine your chest
and 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 do some blood test on you to check for infection markers and electrolytes and a chest X-
P a g e | 136
ray .
Examiner may give findings of raised TLC, raised urea, and 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, for what I’ve found when listening to your chest, 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 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 in 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 MrGeorge.
----------------------------------------------------------------------------------------------------------------------
PATIENT HAS USUALLY STARTED TO COUGH A LOT AFTER THE 6 MINUTE BELL AND
SHOW SIGNS OF CONFUSION BY REPEATEDLY TAKING ANGELA'S NAME .
Dry Cough - PCP

Exam question
P a g e | 137
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 doctor 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
Dr: Are you allergic to anything you know of ( Asthma)? Pt: No

P a g e | 138
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 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?
Dr: Mr .. I need to examine your chest and also check your pulse, Blood pressure and your
P a g e | 139
temperature. ( examiner may or may not give any findings)
Dr: Mr… with what you told me I think you have a condition what we call as
Pneumocystis Pneumonia. This is 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 chance of you having this
infection because this type of infection 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 you to the examiner.
Dr: Mr… Your chest X Ray shows that you do have 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
instruemnts 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 vein and another medication called Dapsone as a nebuliser -
P a g e | 140
something like steam inhalation. We may also give steroid medication to treat this bugs.
We may also need to treat the HIV infection if you have.
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.

Chest infection – Atypical Pneumonia
You are FY 2 doctor
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 the chest X Ray and referred him to the hospital.
Take history and discuss the management with the patient.
Typical pneumonia is caused by Streptococcus pneumoniae, Haemophilus influenzae,

and Moraxella catarrhalis.
Atypical pneumonia is caused by Mycoplasma, Chlamydophila, and Legionella.
Usually the atypical causes also involve atypical symptoms:

"atypical" generalized symptoms such as fever, headache, sweating and myalgia
 No response to common antibiotics such

as sulfonamide and betalactams 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.
 Extrapulmonary symptoms, related to the causing 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.
P a g e | 141
Hello Mr …. I am Dr… Can you please tell me what brings you to the hospital ?
Pt: Doctor I am 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 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 am coughing also since 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
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 fever ? Pt : Yes doctor I feel hot since the last 2 weeks.
Dr: When do you get fever – morning evening or throughout 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 have been on this medication? Pt…
Dr: Have 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
Dr: Did you have 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
Dr: Do you use any recreational drugs ? Pt: No
Dr: Are you married or do you have any partners ? Pt : I am married for 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 UK recently (Legionnaires) ? Pt: Yes I went Spain
( When did you go there ? when did you come back ? ) /No
Dr: Did you stay in hotel there (Legionnaires) ?Pt : 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
P a g e | 142
Examination:
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 – 85, BP – 110/80, RR- 18, Oxygen saturation – 91%.
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 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 bugs. This type of bugs are slightly different
than the bugs which causes common Pneumonia. It is usually not a serious condition.
Common type of Pneumonia usually responds to medications like Amoxycillin which was
given to you. These kind of bugs do not respond to amoxicillin type of antibiotics.
Further investigation :
There are many types of bugs which causes this Atypical Pneumonia. We need to do test
your blood, urine and sputum to check which is the exact type of bug causing this
infection.
Treatment.
We need to admit you to treat you. We will some other strong antibiotic called
Clarithromycin through you veins which usually works for these kind of bugs. We will also
give another antibiotics called Doxycycline tablets. Also we will give 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
Thank you.
P a g e | 143
If the vital signs pulse above 90 and Resp rate above 20 give the diagnosis as Sepsis.
If the diagnosis is sepsis - then talk about the investigation and treatment of sepsis.
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

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

Dry cough ? TB
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 ( rec 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.
P a g e | 144
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.
We will discharge 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.
Centor criteria to aid diagnosis of Group A beta-haemolytic streptococcus

(GABHS)as a cause of presentation with a sore throat:
o tonsillar exudate
o tender anterior cervical lymph nodes
o absence of cough
o history of fever
 presence of three or four of these clinical signs suggests that the
chance of the patient having GABHS is between 40% and 60%, so
the patient may benefit from antibiotic treatment
 absence of three or four of the signs suggests that there is an 80%
chance that the patient doesn't have the infection, and antibiotics
are unlikely to be necessary
 in patients with tonsillitis who are unwell, and have three out of four
of these criteria, the risk of quinsy is 1:60 compared with 1:400 in
those who are not unwell
 centor criteria is not ideal, and will lead to some patients with
bacterial pharyngitis not being treated and result in unnecessary
antibiotic treatment for others
P a g e | 145

Asthma discharge medication and
PEFR ( new exam question)
Mr George Harrison was admitted to the hospital 2 days with shortness of breath.
He was diagnosed as Asthma and was treated.
Assess whether he is fit to be discharged and explain him about the medication he
has to take at home.
( You will have to do PEFR also and tell him how to plot the reading s on the
chart – however this part may not be mentioned in the question).
Greet the examiner.
Dr: Hello Mr George Harrison, I am Dr ..... How are you doing today.
Pt: I am OK.
Dr:Wearethinkingofdischargingyoutodayifyouarefine.Iheretocheckwhetheryouare 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.
Dr: Any chestpain ? No
Dr: I need to examine yourchest? ( examiner says – chest isclear).
Dr:IneedyoutodoatestcalledPEFRtoseehowwellyourlungsarefunctioningnow.How 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 mouth piece.
You need to stand or sit straight but not lying down to do the test.
Attach the mouth piece to the devise, hold it in both the hands horizontally without
blocking the pointer in the reader, take few breaths in and out, take deep breath in, keep
the mouth piece 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 the check the reading
and note it
P a g e | 146
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 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
readings now.
( His PEFR readings may be almost equal to predicted normal readings. PEFR should be at
least 75% of his normal to discharge him)
Dr: Mr Harrison, You are doing fine now. Test shows that your lungs are functions 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.
You should take the medications also at home.
[Check - a) prescription chart for patient 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
P a g e | 147
Dr: This is called as Salbutamol inhaler which widens your airways. This is blue
coloured. They are called relievers because they relieve Asthma symptoms.
You need take 2 puffs of spray into your mouth whenever you have shortness of breath.
Maximum 4 times in a day.
Dr: Do you know how to use this inhaler ?
Pt: No doctor.
Dr: Let me explain the inhaler techinque

1) Remove the cap and shakewell
2) Take few breaths in and out. Then take a deep breathout
3) Put mouth peice in mouth and make tight seal of your lips around the mouth peice 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 yourmouth.
4) Hold breath for 10 seconds and then breathout.
5) For second dose ( Puff) wait for approximately 30 seconds before repeating thewhole
procedureagain.
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.
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: Next medicne is Beclometasone inhaler. This is steriod inhaler which is brown in
colour, 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.
Pt: Yes
Dr: Next one is Prednisolone tablets ( eg 30mg once day PO for 3 days in the morning)
(If one tab is 5mg - 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 empty stomch. Usually there
is no other serious side effects since you are taking these for a short period.
Are you with me.
Pt: Yes doctor
P a g e | 148
Explain Asthma Dairy

Please keep takings medicines at home as prescribed and do this PEFR test home every day
twice ( each time 3 times) and plot the highest of the three readings on this chart.
In this chart – please write the dates – at the bottom, and mark it properly for each day
morning or evening line corresponding to the readings. Check patient understanding by
giving him the example reading an asking him to show where will you mark it.
If the readings are going up 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
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.

Exercise induced Asthma
Mr …. Presented to the hospital with shortness of breath.

Take history from him and discuss you further management with him.
Dr: Hell Mr… I am Dr …. Can you please tell me what brings you to the hospital? Pt: I am
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 last few weeks.
Dr: Do you feel short of breath when you are not doing exercise ? Pt : No
P a g e | 149
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: Did
you have 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 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. 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 is asthma ? Pt: No doctor.
Dr: Asthma is a condition in the lung where the patient becomes short of breath because
the wind pipe become narrowed. This is usually happens to people who are allergic to
something like pollens, 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.
Investigation: We will do chest X Ray to make sure that you do not have any other
problem 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 ae 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 do exercises. It is better to avoid football because it involves long period of
activity. Instead short duration sports may better for you. However you need to take some
inhaler medications like salbutamol ( broncho dilators) about 20 minutes before you do any
kind of exercise.
P a g e | 150
In addition to taking medications, warming up prior to exercising and cooling down after
exercise can help in asthma prevention.
If you have allergy to pollen then the exercise should be limited during high pollen days or
when temperatures are extremely low.
If the weather is cold, exercise indoors or wear a mask or scarf over your nose and mouth.
Infections can cause asthma (colds, flu, sinusitis) and increase asthma symptoms, so it's
best to restrict your exercise when you're sick.
Is that Ok ? Pt : Ok doctor
Dr: Are you following me? Pt: YesDr: Any other questions ? Pt: No Thank you.
Another scenario for exercise induced Asthma
On history 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 foot ball.
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
We will admit you ow and treat with some medications called salbutamol nebuliser. They
are called broncho dilators. This will help to widen your wind pipe.
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 a day or two.
Then talk about prevention.

Information
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
P a g e | 151

Sepsis – telephone conversation
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
• breathing 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 HYPERLINK "https://www.healthline.com/health/discolored-skin-
patches"discolored HYPERLINK "https://www.healthline.com/health/discolored-
skin-patches" skin
• decreased urination
• changes in mental ability
• low platelet (blood clotting cells) count
• problems breathing
• abnormal heart functions
• chills due to fall in body temperature
• unconsciousness
• extreme weakness
Septic shock
Symptoms of septic shock include the symptoms of severe sepsis, plus a very low blood
pressure.
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.
2. 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
P a g e | 152
lactate level decreases[1]. Lactate can be used as a guide for determining the severity of the
septic patient’s illness, and the effectiveness of their treatment.
Exam question:
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.
Dr: Hello, Is it the care home ?

Carer : Yes,
Dr: I am Dr … one of the junior doctor 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 ?
Carer: Well doctor I was on leave for the last 3 days. I just came back to work today. I can
P a g e | 153
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 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, only today she is confused.
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) ? No

Dr: Did she have any rashes on her body ( meningitis) ? No
Dr: Did she have any diarrhoea ( Gastro-enteritis) ? - No Vomiting ? Carer: No

Was she complaining of any pain abdomen ? Carer: No
Dr: You have been very helpful. Can you please tell me was she mobile or bed ridden ?
Carer: She was mostly bed ridden but we are trying to mobilise her as much as possible.
Dr: Did she have any bed sores ( infected bed sores ) ?Carer: No
Dr: Was she eating drinking well ?
Carer: She has swallowing problem. She had choked on food 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 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
P a g e | 154
Dr: Is she on any medication ?

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 medication conditions ?
Carer: I do not know
Dr: Is there anyone else who is not well at care home recently ?
Carer : No
Dr:Can I know about her family members please – any one visiting her ?
Carer: No one has visited her for the last 3 months…
Dr:Can I get the tel 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.
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 and she was chesty in the last few days and she had cough
and chest pain and she has fever on examination. That is why I think she has aspiration
P a g e | 155
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 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.
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.
Also consider giving steroids and Insulin.
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.
P a g e | 156

Ca Lung (Modified old station)
60yr old man referred by GP on account of shortness of breath.
NB: Patient isn't coughing, only 6months 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)

NIPPLE DISCHARGE
Question: You are an FY2 in GP Surgery. Katy Beckett is a 25 years-old
woman who has presented with some concerns. Take a focused history,
perform relevant assessment and address her concerns.
Hello. Katy Beckett? Hi, my name is Dr. ……… I am one of the junior doctors here in the GP Surgery.
What would you like me to call you? – Katy

Can you just confirm for me your age please? – 25
How can we help you today Katy? – Yes, there seems to be some liquid coming from my breasts
Is it coming from both breasts or just one? – Both
Are you having the problem right now? – Yes, but I washed it before I came
Can you tell me a little bit more about the discharge coming from your breasts? – Yes, it started 5
days ago and I’m really worried about it
Was it just the once that the liquid came? – It’s happened twice now. 5 days ago and yesterday
Can you just elaborate a little further about the discharge? Colour? Thickness? Bloody? Volume?
Smell?– It was pale yellow – whitish, milky, and slightly thicker than water. There wasn’t any
blood. It was around a tea-spoon and it spoiled my bra. It didn’t smell of anything.
And how did it come about? Spontaneous/Squeeze? Sudden/Gradual? – I just woke up one
morning and noticed some fluid coming. I squeezed my nipple to see how much
Has it gotten better, worse or is it about the same? – It’s happened twice, and each time it’s been
the same
Do you perhaps think it was aggravated by something you might have done? – No
Did it relieve by itself or did you do something to make it go away? – It stopped by itself.I just
wiped it away
Is there anything at all that I may have missed that you would like to add? – No
Do you have any idea at all why this might be happening? – No doctor, that’s why I’m here. I’m
really worried it might be cancer
I can understand that you might be concerned. Unfortunately, I do have some more questions to
ask you, and after you’ve answered them, I may be in a better position to address your concerns,
answer any questions and help you.
Do you have any other symptoms other than the discharge from your left breast? – Nothing
Rule out commonnipple discharge causes;

Galactorrhoea,(Menstrual Cycle Hormonal Changes, Stimulation, Pregnancy, Post-Partum,
Breastfeeding, Hypothyroidism, Prolactinoma, Medication & Drug Use {Anti-Psychotics, OCPs,
P a g e | 157
Codeine, Morphine, Marijuana}), Purulent (Mastitis), Serosanguinous (Fibrocystic Change,

Intraductal Papilloma, Mammary Duct Fistula, Eczema, Mammary Duct Ectasia, Paget’s Disease,
Cancer)
 Breast Tenderness? [Cyclical/Acyclical Mastalgia] (Menstrual Cycle
Hormonal Changes, Pregnancy, Post-Partum, Prolactinoma, Mastitis, Fibrocystic Changes,
Eczema, CA)– My breasts do feel sore towards the end of my cycles
 Breast Lump?(Galactocoele, Fibrocystic Change, Intraductal Papilloma, CA) – No
 Is there any chance that you could be pregnant? (Pregnancy) – No
 And have you given birth recently? Are you breastfeeding? (Post-Partum, Breastfeeding)
– No
 Tiredness? Weight Gain? Hair Changes? Irregular Menstrual Periods? Cold intolerance?
Constipation? Facial Swelling {Myxoedema}? Leg swelling {Pre-tibial Myxoedema}?
(Hypothyroidism) – No
 Headache? Vision Problems? Irregular Menstrual Periods {Oligomenorrhoea}? Absent
Menstrual Periods {Amenorrhoea}? Painful intercourse {Dyspareunia}? Infertility? Acne?
Excessive Facial Hair growth {Hirsutism}? (Prolactinoma) – No
 Fever? Skin Changes? Cracked Nipples? Breastfeeding? (Mastitis) – No
 Bleeding? (Intraductal Papilloma, Paget’s Disease, CA) – No
 Lumps & Bumps? Weight Loss? Loss of Appetite? (Breast CA)
 Is it possible that you may have hurt yourself? (Trauma) – No, I don’t think so
 Risk Factors for Nipple Discharge – Stimulation, Menstrual Cycle

Hormonal Changes, Pregnancy, Post-Partum, Breastfeeding, COCPs,
Prolactinoma, Hypothyroidism, Medications, Infection, Abscess, Fistula,
Ectasia, Cancer, Trauma
Is this the first time you are experiencing these symptoms? – Yes
Have you ever had discharge come from your breasts before? – No
How has it affectedyour life? – There hasn’t been much of a change at all
Are you able to continue with your daily activities? Hobbies? Job? Relationships? Sleep? – Yes.
There hasn’t been a problem
Have you ever been diagnosed with any medical condition before? – No
High Blood Sugar? High Blood Pressure? Hypothyroidism? Prolactinoma? – No
Have you ever undergone a surgical procedure before? – Tonsillectomy 15 years ago
Are you currently taking any Medication? OTC?–No
Are there any illnesses which run in the Family? Breast CA? Ovarian CA?
Are you Sexually Active? 1 partner or more? Stable relationship? Male/Female? Last time?
Kind of sex? (O/V/A) Breast manipulation? Breast self-exam? Squeeze nipples? Safe sex? Casual?
Abroad? STI? – No
LMP? Menarche? Regularity? Cycle duration? Days you bleed? Excessive bleeding? Clots?
Excessive pain? Contraception (Birth Control Pills)? Cervical smear? Results of last cervical smear?
Do you think the discharge could possibly be related to your menstrual cycle? – I don’t know
Do you wear tight-fitting undergarments? Sports bra? – Occasionally
EXAMINATION
What I would like to do now is to examine you and check your pulse, blood pressure, breathing
rate, temperature and levels of oxygen in your blood.
P a g e | 158
I would also like to take a closer look now at both your breasts, and the glands in your armpit and
chest. CONSENT. EXPOSURE. CHAPERONE. PRIVACY. CONFIDENTIALITY.
Inspection
Palpation
I. Breast
II. LNs
From what you have told me and from what I have seen, your observations seem to be normal
and both your breasts seem to be fine. I could not appreciate any discharge, redness, skin
changes, scars or lump. The temperature was normal and there wasn’t any tenderness. None of
your glands were enlarged in your armpit or chest.
Katy, do you have any idea at all why you may be having this problem? –No
It seems to methat it is most likely to be an exaggerated response to the normal Menstrual

Cycle Hormonal Changes that occur during a woman’s menstruation cycle combined with
Stimulation of your nipples. The way you described the fluid as pale-yellow/whitish, and
slightly thicker than water, I do believe it’s very likely your breasts released Milk or a Milk-like
Substance, which is called Galactorrhoea. However, at this stage we do need to rule out
other things which may cause similar symptoms.
Are you following me? - Yes
Most nipple discharge is either normal or caused by a benign medical condition.Galactorrhoea –

although it might sound scary – simplydescribes a condition in which a woman's breast secretes milk
or a milky nipple discharge even though she is not breastfeeding. Galactorrhoea is not a disease and
has many possible causes. These include:
o Normal (Physiologic) – Pregnancy, fluctuating hormone levels

o Pituitary gland tumours
o Hypothyroidism
o Certain medications, including some hormones and psychotropic drugs
o Some herbs, such as anise and fennel
o Illegal drugs, including marijuana
There are instances, though, when discharge from the breast may be a symptom of some forms
of Breast Cancer. This likelihood is greater if your nipple discharge is accompanied by a lump or
mass within the breast. However, on examination of your breast I was unable to find any unusual
findings.
Could it be Cancer?
Nipple discharge by itself isn’t usually a sign of Breast CA. There are a large number of non-
cancerous conditions that can cause nipple discharge and they are far more frequent than
cancerous conditions. There are certain factors that make it extremely unlikely for your
condition to be caused by cancer.
What do you know about Breast CA? – Nothing
P a g e | 159
Firstly, breast cancer is one of the commonest forms of cancer in Women. It is however more
frequent in older Age groups (>40 years). Usually, there is a strong Family History of breast
cancer. Breast cancer usually affects a single breast. It can present as one-sided, bloody
discharge from the breast, but more commonly it presents as a palpable lump in the breast,
breast tenderness and in the later stages overlying skin changes. There can be a more systemic
presentation as well, with weight loss, loss of appetite and lumps and bumps around the body –
especially the armpits – where enlarged glands can appear.
Is there any particular reason you’re worried it might be cancer? – My friends grandma had it
and she died because of it
I’m really sorry to hear that. It’s extremely unlikely to be Breast CA, but at this stage we
simply cannot rule it out without conducting further tests.
Do you know anything about Menstrual Cycle Hormonal Changes? – No
Breasts can go through normal changes during the menstrual cycle. They get tender, and
even seem to shift a bit in size and shape. Hormones such as oestrogen and progesterone
vary during the course of your cycle and breast symptoms can appear and are the strongest
just before your period starts. They usually improve either during or right after it.Every
woman is different. But it’s common to have one or more of the following:
 Swelling
 Tenderness
 Aches
 Soreness
 Changes in texture
 Milk-like Nipple Discharge
 Is nipple discharge normal?

There are some causes of normal (physiological) nipple discharge, which include:
 Menstrual Hormonal Changes – when the levels of oestrogen and progesterone

vary, during the latter part of your cycle you may experience nipple discharge.
 In the early stages of Pregnancy, some women notice clear breast discharge coming from
their nipples. In the later stages of pregnancy, this discharge may take on a watery, milky
appearance.
 Breastfeeding. Even after you have stopped nursing your baby, you may notice that a
milk-like breast discharge persists for a while.
 Stimulation. Nipples may secrete fluid when they are stimulated or squeezed. Normal
nipple discharge may also occur when your nipples are repeatedly chafed by your bra or
during vigorous physical exercise, such as jogging.
Normal nipple discharge more commonly occurs in both nipples and is often released when
the nipples are compressed, squeezed or stimulated.
I do believe that in your case, your normal menstrual hormonal changes combined with the fact that
you’re sexually active and your breasts are stimulated, they have resulted in a secretion of milk like
fluid from the glands in your breast.
 What is abnormal nipple discharge?

Bloody nipple discharge is never normal. Other signs of abnormality include nipple
discharge from only one breast and discharge that occurs spontaneously without anything
P a g e | 160
touching, stimulating, or irritating your breast.

Colour isn't usually helpful in deciding if the discharge is normal or abnormal. Both
abnormal and normal nipple discharge can be clear, yellow, white or green in colour.
Most frequently, abnormal nipple discharge has a benign cause. Causes can include;
benign ductal disorders (intraductal papilloma, mammary duct ectasia, fibrocystic
changes), endocrine disorders (prolactinoma, hypothyroidism), liver disorders, breast
abscesses or infections, or use of certain drugs. Of these causes, intraductal papilloma is
probably the most common; it is also the most common cause of a bloody nipple
discharge without a breast mass.Endocrine causes involve elevation of Prolactin levels,
which has numerous causes including hypothyroidism.
Cancer (usually intraductal carcinoma or invasive ductal carcinoma) causes < 10% of
cases.
Common causes of abnormal discharge include:
 Fibrocystic Breast Changes. Fibrocystic refers to the presence or development of fibrous

tissue and cysts. Fibrocystic changes in your breasts may cause lumps or thickenings in your
breast tissue. They do not indicate, though, the presence of cancer. In addition to causing pain
and itching, fibrocystic breast changes can, at times, cause secretion of clear, white, yellow, or
green nipple discharge.
 Infection. Nipple discharge that contains pus may indicate an infection in your breast. This is
also known as mastitis. Mastitis is usually seen in women who are breastfeeding. But it can
develop in women who are not lactating. If you have an infection or abscess in your breast,
you may also notice that your breast is sore, red, or warm to the touch.
 Mammary Duct Ectasia. This is the second most common cause of abnormal nipple discharge.
It is typically seen in women who are approaching menopause. This condition results
in inflammation and possible blockage of ducts located underneath the nipple. When this
occurs, an infection may develop that results in thick, greenish nipple discharge.
 Intraductal Papilloma. These are noncancerous growths in the ducts of the breast. They are
the most common reason women experience abnormal nipple discharge. When they become
inflamed, intraductal papillomas may result in nipple discharge that contains blood or is sticky
in texture.
 What is the connection between nipple discharge and Breast

CA?
Most nipple discharge is either normal or caused by a benign medical condition. There are
instances, though, when discharge from the breast may be a symptom of some forms of breast
cancer. This likelihood is greater if your nipple discharge is accompanied by a lump or mass
within the breast or if you have had an abnormal mammogram.
One form of breast cancer that may cause breast discharge isintraductal carcinoma. This
cancer develops within the ducts of the breast located beneath the nipple.
Another rare form of breast cancer that may result in nipple discharge is Paget's disease. This
condition develops in the ducts of the breast and then moves to the nipple. It may cause the
nipple and the surrounding areola – the darker area surrounding your nipple – tobleed or ooze.
So what are you going to do?

MANAGEMENT
P a g e | 161
 For women who aren't breastfeeding, the sight of nipple discharge can be alarming. But if you
notice discharge from your nipple, I would like to Reassureyou that there's no reason to panic.
While nipple discharge can be serious, in most cases, it's either Normal or due to a minor
condition.Lots of women have nipple discharge from time to time. It may just be normal for
you.
 Some women who are concerned about breast secretions may actually cause it to worsen.
They do this by repeatedly squeezing their nipples to check for nipple discharge. In these
instances, leaving the nipples alone for a while may help the condition to improve.
 It's also not unusual for babies (boys and girls) to have milky nipple discharge soon after
they're born. This should stop in a few weeks.
 Nipple discharge in men isn't normal.
 The colour of your discharge isn't a good way of telling if it's anything serious. Normal
discharge can be lots of colours.
 We may have to perform some Routine Blood Tests.
 We may also have to check for a hormone called Prolactin in your blood. This hormone
stimulates your breasts to produce milk. A Magnetic Resonance Imaging (MRI) is
the most sensitive test for detecting a prolactinoma – which are a type of hormone-producing
tumour of a gland in the brain.
 If the prolactin level is high, another blood test - called a Thyroid Function Test- may be
required. Under-functioning of the thyroid gland – Hypothyroidism – is a possible cause of
discharge from the nipples.
 If you’re taking any medication, it may be necessary to ReviewMedication that are
known to raise prolactin secretion.
 We may have to refer you to a hospital or breast clinic for further tests. These will usually give
us a better understanding about your condition. What happens at the breast clinic is that you
may have something we call a Triple Assessment:
 thorough 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 and 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.
 It is likely that this discharge is a one-off. However, if it does happen regularly it’s important to
wipe away any discharge using a clean, sterile gauze and note the type of discharge, colour,
volume, smell, day, time and in relativity to menstrual cycle. A Diary can be useful.
 If the discharge continues to occur, we may need to obtain a sample and send it for further
tests to check for any infection – Culture & Sensitivity.
 I do have some reading material available with me to give you entitled – How Your
Breasts Change During Your Monthly Cycle
 You should reach out to us if:
 you have Changes in
o the size or shape of your Breast that doesn’t go away after your period.
o the size of your Nipple, such as if it becomes more pointed or turns inward.
o your breast’s Skin, including itching, redness, scaling, dimples, or puckering
P a g e | 162
 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
Is there anything I can do at home?

There are a few steps you can take to curb changes in your breasts during your monthly
cycle:
 Eat a diet lower in fat, avoiding high-fat foods.

 Skip caffeine, which means no coffee, tea, cola, and chocolate.
 Avoid salt 1 to 2 week before your period starts.
 Wear a bra that fits you properly and provides good breast support.
 Aim for a daily cardio workout.
 We can arrange a follow up in 7 days’ time.
Do you have any other concerns? – No
No Past Medical Hx. Tonsillectomy 15 years ago. No Medication Hx. No Allergies. Family Hx.
unremarkable. No Travel Hx. Works as a Hair Stylist. Unmarried, has a boyfriend Gregory. Sexually
active with boyfriend for the last 6-months. 1 partner-only. Practices safe sex. Oral/Vaginal +
Nipple Stimulation. Regularly gets tested for STIs. Menstrual cycle regular, 27days/5days bleed.
Smokes 2 cigarettes/day. Last cervical smear 6 months ago – Normal. Smoker – 2 cigarettes/day.
Occasional Alcohol drinker, 10units/week. Does not use recreational drugs. At home there is Greg
only. They live in a flat with their dog.
Vitals – Normal
Breast Examination – Normal

Back Pain - ? cause
50 year old Mr … presented to the hospital complaining of back pain. Take a brief
history and talk to him about the management.
Differentials
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.
P a g e | 163
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, Cauda equina - Bowel incontinence ( not able to control bowel movements) and
bladder incontinence ( leakage or urine).
C) Leaking abdominal aneurysm – did you have any ultrasound scan before which
showed any abnormality in the blood vessels inside your tummy.
D) Osteo arthritis – morning stiffness in the back,
E) TB - Pottts disease ( cough, night sweats, fever, weight loss. Contact, travel.
F) Sprain – trauma, twisting suddenly, after sports
G) Multiple myeloma – tiredness weakness ( anaemia), easy bruising or bleeding.
H) Ankylosing spondylitis – stiffness, pain and swelling in the other parts of the body.
I) Renal stones – past Hx of stones.
J) Pancreatitis – if pain coming from front – alcohol
K) Pancreatic cancer – Cancer of the tail of the pancreas can present with back pain.
[ Positive in history – back pain since 2 months, weight loss, and increased frequency
of urination ]
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 to talk 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)
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
Dr: Do you have increased frequency of urination ( 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 ( osteo arthritis, ankylosing spondylitis) ? Pt: No Dr:
Do the urine dribble when you pass urine ( enlarged prostate) ? Pt : No/yes
P a g e | 164
Dr : Any blood in the urine ( renal cancer)? Pt : No

Dr: Any urine or bowel incontinence ( cauda equine 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 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 job do you do ? Pt: I work in the post office.
Dr : Do you lift heavy thing at your work place ? 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 neurological examination of the lower limb, do
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 a possible cause of the pain. A
negative test suggests a likely different cause for back pain.
P a g e | 165
Diagnosis :
We need to do some investigations to check what exactly is causing your back pain.
We will do X ray and MRI scan of your back. Also we need to do some blood tests.
Mr: Mr... It s not very clear from the information what exactly is causing your back pain.
There are lot of conditions which can cause pain at the back. Only after the investigations
we will be able to tell you the exact cause of this pain.
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 pain killers for your pain. We will give you stronger pain killer than
Paracetamol what we call 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 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].

BACK PAIN - ABDOMINAL AORTIC ANEURYSM
DDs :
1. AAA
2. CAUDA EQUINA
3. IVDP and SCIATICA
4 SECONDARIES { PROSATE}
5. MUSCLOSKELETEL BACK PAIN
6. TRAUMA
Question:
You are an FY2 doctor in the A&E department
55 year old man presented with back pain since yesterday evening
Your task: Address his concerns and plan on INITIAL MANAGEMENT.
P a g e | 166
Hello, I am Dr .... one of the junior doctor in the A&E Department. How can I help you ?
Pt: doctor I am having back pain 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 back 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
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 weight [MUSCULOSKELETEL BACK PAIN] Pt; No
Dr: Any chance you may have injured your back? Any fall? Pt: no doctor
Dr: Do you have fever ? No

Dr: Did you feel any pulsating mass in your tummy (AAA) ?
Dr: have you ever had any type of scans done on your tummy where the doctor told you tht
you have some abnormal blood vessels in your tummy ( AAA)?
Dr: Do you feel dizzy or feel like fainting ( leaking AAA) ?

Dr: Did you have 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
EXAMINATION
I would like to examine your back, your back passage and your tummy is that okay?
Also I need to measure your heart rate, blood pressure and 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? Pt: ok doctor
Examiner gives NEWS chart PR: 94 BP: 120/80 SPO2 97%

P a g e | 167
Examiner may say - back passage and back examination is normal.
Proceed to abdominal examination MANNEQUIN kept on the table

Start examining the abdomen but examiner may gives the findings ( if not check for pulsating
mass):
Tenderness above the umbilical region and pulsations felt all over the abdomen.
Dr: Mr.... from what you have told me and after the examination, I suspect you have a
condition called ABDOMINAL AORTIC ANEURYSM. 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 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). This can
sometime result in bursting of the blood vessel and blood will start leaking, which is a life
threatening condition. If that happens patient will feel dizzy, short of breath and experience
severe pain the tummy or back. Are you following me? Pt: yes doctor.
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 test 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
Treatment:
Dr: We will start you on Oxygen and IV fluids. I will refer you to the Vascular surgeon
( Specialist). Treatment depends on the size of the aneurysm and also whether it is leaking
or not.
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 size increases and risk of rupture is there, then we have to surgically repair that.
There are two types of surgeries

1. Open aneurysm repair – A graft ( artificial tbe) is placed in the Aorta through cut in your
tummy.
2. Endovascualr 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 over weight.
If already ruptured then the surgeon may need to do immediate operation to control the
bleeding .
Abdominal aortic aneurysm
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
P a g e | 168
AAAs don't usually cause any obvious symptoms, and are often only picked up during
screening or tests carried out for another reason.
Some people with an AAA have:

a pulsing sensation in the tummy (like a heartbeat)
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 for a:
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.
P a g e | 169

Musculoskeletal back pain.
SCENARIO-
A young man with back pain came to the emergency department, c/o back pain. Your
task is to take history and discuss management with the patient.
Patient gives history of back pain after playing squash. He had not played squash for 5
years. No sciatica.
History-
20. Primary complaint?
21. Could you point out where exactly is the pain?
22. How did it happen?
23. Since when?
24. Grade the pain on a scale of 1 to 10 (in the exam, scale was 5)
25. Is there anything that makes the pain better or worse? (IVDP-relieves on lying
flat and worse on movement, coughing or sneezing)
26. How will you describe the pain?
27. Does the pain radiate anywhere? (loin to groin, to the legs)
28. Is it the first time you are experiencing this kind of pain?
29. Any pain anywhere else ? Any joint pains ?
30. Any history of lifting heavy weight?
31. Any bowel or bladder incontinence ( leakage of urine, unable to control bowel
movement) ( cauda equina syndrome)
32. Any fever, cough Travel and contact history - for TB
33. Were you told to have any weak bones?
34. Any history of repeated bruises or infections?
35. Did you experience any weakness of the legs during this event?
36. Did you experience any difficulty while passing urine or motion?
37. Loss of weight?
38. MAFTOSA- specifically ask for history of cancers in family
Examination- (verbal)
3. Examine back and abdomen. [ Do not mention prostate examination because patient
is young].
4. SLR test- explain. (If SLR positive-prolapsed disc)
Examiner may say – tenderness over paraspinal area, SLR negative.
Investigations
No tests required if you are thinking of muscular pain.
“From what you have told me and from what I have examined, it seems to me you have a
muscle pain. It might have occurred after sudden movement of the back after playing
squash after a long period of time.
This is not a serious condition. It will subside on its own in few days or weeks.
We shall give you pain killers to ease with the pain. The pain should subside after few days.
If it did not subside after about 2 weeks, please come back.
Pt: Will you arrange physiotherapy.
Dr: Yes we will. Physiotherapist will tell you when they can start physiotherapy.
If SLR TEST POSITIVE INDICATING PROLAPSED DISC, MANAGEMENT IS
DIFFERENT)-
P a g e | 170
Continue with normal activities as far as possible. Initially, try doing simple activities that
won’t cause much of 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.
We can give you painkillers to ease with the pain. If it doesn’t subside- refer to
physiotherapist.
(Surgery-if symptoms persist for more than 6 weeks)}

(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)

Back Pain - ? cause
50 year old Mr … presented to the hospital complaining of back pain. Take
a brief history and talk to him about the management.
Differentials
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.
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, Cauda equina - Bowel incontinence ( not able to control bowel movements)
and bladder incontinence ( leakage or urine).
C) Leaking abdominal aneurysm – did you have any ultrasound scan before which
showed any abnormality in the blood vessels inside your tummy.
D) Osteo arthritis – morning stiffness in the back,
E) TB - Pottts disease ( cough, night sweats, fever, weight loss. Contact, travel.
F) Sprain – trauma, twisting suddenly, after sports
G) Multiple myeloma – tiredness weakness ( anaemia), easy bruising or bleeding.
H) Ankylosing spondylitis – stiffness, pain and swelling in the other parts of the
body.
I) Renal stones – past Hx of stones.
J) Pancreatitis – if pain coming from front – alcohol
K) Pancreatic cancer – Cancer of the tail of the pancreas can present with back pain.
[ Positive in history – back pain since 2 months, weight loss, and increased
frequency of urination ]
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 to talk to me? Pt : Yes, I am Ok to talk
P a g e | 171
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)
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
Dr: Do you have increased frequency of urination ( 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 ( osteo arthritis, ankylosing spondylitis) ? Pt: No
Dr: Do the urine dribble 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 equine 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 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 job do you do ? Pt: I work in the post office.
Dr : Do you lift heavy thing at your work place ? 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 neurological examination of the lower limb, do
Straight leg raising test (SLR) test for prolapsed disc causing any sciatica.
P a g e | 172
[ 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 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 X ray and MRI scan of your back. Also we need to do some blood tests.
Mr: Mr... It s not very clear from the information what exactly is causing your back pain.
There are lot of conditions which can cause pain at the back. Only after the
investigations we will be able to tell you the exact cause of this pain.
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 pain killers for your pain. We will give you stronger pain killer than
P a g e | 173
Paracetamol what we call 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 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].
Multiple Myeloma - march 19th

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 doctor 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
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
P a g e | 174
the pain for me? Pt :….

Associated symptoms:
Dr: Any thirst? Pt :..
Dr : any wt loss. Pt : no 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
Anemia symptoms
Dr : Do you feel tired ? Pt : yes dr. I feel very tired for the past 3 months
Dr: Any racing fo the heart? Pt…
Dr: Any medical conditions in the past?
Dr: Any family h/o similar conditions? pt :no (pt might be irritated with the questions.
Pressure her)
Social history : to r/o NAI( this part can be done at the end too since pt might not cooperate)
Dr: Do you live with anyone? Pt…
Dr: How would you describe your relationship with them is?
Dr :Financial conditions?
Dr:You 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 hemoglobin in your blood is lesser
than usual. You seem to be anemic. Are you following me? Pt…
These are some proteins that are in our body and the have increased (serum igG). And there
are some unusual proteins in your urine that we call the Bence Jones
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. 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?
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:
• anti-myeloma medicines to destroy the myeloma cells or control the cancer when it
comes back (relapses)
medicines and procedures to prevent and treat problems caused by myeloma – such as bone
P a g e | 175
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 you with strong painkillers. Does that sound alright? Dr :Do you have any
concerns? Pt…

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. Read more about the causes of GORD.
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)
You may only need to take medication when you experience symptoms, although long-term
treatment may be needed if the problem continues.
P a g e | 176
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
Scenario-
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? P-
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 and from what I have examined, I suspect you have a condition
called GORD-Gastro Oesophaegeal reflux disease. Do you know anything about it?”
P- “No, Dr.”
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 a g e | 177
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.”
P-“Dr.. I don’t want endoscopy. One of my friends had the procedure and it as 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 problem will not happen. Do not worry.
Is there anything Else I can help you with?”

P-“No, Doctor. Thank you”

Barrets esophagus for surveillance scan
pt has had endoscopy n biopsy done-results are inside the cubicle-results talk abt intestinal
metaplasia and barrets esophagus-and to do endoscopy again again 3yrs-talk to pt.
Take history like the station in GORD

Check whether he had GORD previously, cause of GORD,
Family history, weight loss, smoking.
Reassure Barrets oesophagus is only a precancerous condition not cancer now.
However it can rarely become cancerous. So we will do endoscopy again after 3 years.
Avoid the cause of GORD to reduce chance of changing to cancer.
Advise to come back in the mean time if he has – weight loss, swallowing difficulty,
hemetemesis
Has multiple risk factors-smoking/alcohol/diet.

Pt keeps asking do I have cancer ? Keeps saying why do I have to come again and about
treatment and to do something about it. ( 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.
P a g e | 178

DYSPHAGIA
Dysphagia Differentials
Differentials Relevant Questions
P Palsy(Stroke/spine Difficulty in talking? Making sound?

injury/botulism/MS/PSP/ALS/Parkinson) Other weakness?
Bulbar palsy Difficulty initiating swallowing
E Endoscopy Did you have any procedure ( camera test)
done on your food pipe recently?
G GORD Belching? Heartburn ( burning sensation in

the middle of the chest), worse on lying?
G Globus hystericus Do you have a sensation of lump in your

throat?
C Cancer Oesophagus Starts first with solids
Weight loss? Weakness?
Smoking? FH?
Steady, gradual worsening?
O Oesophagitis or Infection of tonsil, larynx Fever, pain
or epiglottis (odynophagia)
M Myasthenia Worse in the evening? Feel weakness in

evening or after exertion?
P Pharyngeal pouch Bad breadth? Food on pillow in morning?
Old food regurgitated?
A Achalasia Starts with liquids
S Stricture Long time heart burn? Or past corrosive

Ingestion?
Any procedures/instrumentations done?
S Spasm (diffuse oesophageal Intermittent? Cold or hot food makes it
Spasm DES) worse?
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
P a g e | 179
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 ( Myesthenia )? 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 I 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 lump in your throat ( Globushystericus) ? 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 lose.(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
Dr: Do you consume alcohol? P: Yes/No
Dr: Any of your family members has 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 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 of 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 Gastroenterologist. He will do some investigations to find out what exactly is the cause.
Pt: What investigation ?
Dr: He may do a special test called Endoscopy which is a camera test where a tube with 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?
P a g e | 180
He will tell you the exact diagnosis after the investigation.

Pt: What if it is cancer, how will you treat?
Dr: Specialist doctor will tell you how they will treat. 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 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
Any other question ? No Thank you.

Hemetemesis
Young lady vomiting blood. History and management.
There can be many causes of hematemesis, such as:
 bleeding ulcers – Have been diagnosed with and ulcers in tummy,

Any pain in tummy previously, dark stool, any over the counter
medications – Aspirin, NSAIDS, Steriods, blood thinners. Blood
could be fresh or dark brown.
 prolonged and vigorous retching that causes tears in the
esophageal mucosa (known as Mallory-Weiss Syndrome) – No
blood in the vomitus initially.
 gastric or intestinal varices – Have been diagnosed with liver
problems before, Alcohol drinking habits for long time, Fresh red
coloured blood
 vascular malfunctions of the gastroentestinal tract
 tumors in the stomach or esophagus – weight loss
 gastroenteritis, gastritis, or peptic ulcers can cause internal
bleeding – Coffee ground coloured blood.
 radiation exposure
 hemorrhagic fever
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 – no, dark 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
P a g e | 181
the counter medication) for headaches for quite long time. Not
prescribed by doctor. Not taken PPIs.
Ask about weakness, drowsiness,.
Previous episodes, previous medical conditions family history, any
bleeding disorders. Bleeding from nose gums, urine, hemoptysis. LMP.
Examination –I need to examine tour tummy and also I need to check
your pulse, BP and temperature. Check for NEWS chart.
Examiner may say – tenderness in epigastric area.
Any other medications, allergy.
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 long time.
This can be serious if we do not treat you immediately.
We will have to do investigations initially blood tests to check for

anaemia to see how much blood you would 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,
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 tube with a camera at its tip through your mouth
to the stomach. This test ill show us where exactly is the bleeding and
what may be 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 long time, please consult your GP.
Otherwise same problem can happen again.
Cut down drinking alcohol.
Is this OK ? Any other concerns.

Abnormal LFT ( high unconjugated bilirubin) ? Gilbert syndrome
January 16:
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)
Total bilirubin: 0.1 to 1.2 mg/dL (1.71 to 20.5 µmol/L)

P a g e | 182
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 – Hepatitis A and B, C ( fever, diarrhoea vomiting,
tiredness, eating out, contact history, travel history, unprotected sex, blood transfusion,
sharing needles), Obstrutive causes like gallstones, Cancer head of pancreas – Itching, pale
stool, dark urine, weight loss), Alcoholic hepatitis.
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 Gilberts 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 Gilberts: 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.
(one of his questions is will his children 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 GS.
Further to ask in history: contact tracing? Occupation? Diet? Hygiene? Family history?
Elaborate on family history (esp father’s liver issues) Pain? Itch? Jaundice?
Examination: general physical exam focusing on the abdominal examination along with eyes.
Symptoms of Gilbert's syndrome

Most people with Gilbert's syndrome experience occasional and short-lived episodes
of jaundice (yellowing of the skin and whites of the eyes) due to the build-up of bilirubin in
the blood.
As Gilbert's syndrome usually only causes a slight increase in bilirubin levels, the yellowing
of jaundice is often mild. The eyes are usually affected most.
Some people also report other problems during episodes of jaundice, including:
abdominal (tummy) pain
feeling very tired (fatigue)
P a g e | 183
loss of appetite
feeling sick
dizziness
irritable bowel syndrome (IBS) – a common digestive disorder that causes stomach cramps,
bloating, diarrhoea and constipation
problems concentrating and thinking clearly (brain fog)
a general sense of feeling unwell
However, these problems aren't necessarily thought to be directly related to increased

bilirubin levels, and could indicate a condition other than Gilbert's syndrome.
Around 1 in 3 people with Gilbert's syndrome don't experience any symptoms at all.
Therefore, you may not realise you have the syndrome until tests for an unrelated problem are
carried out.
What causes 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.
What triggers the symptoms?

People with Gilbert's syndrome often find there are certain triggers that can bring on
an episode of jaundice.
Some of the possible triggers linked with the condition include:
being dehydrated
going without food for long periods of time (fasting)
being ill with an infection
being stressed
physical exertion
not getting enough sleep
having surgery
in women, having their monthly period
Where possible, avoiding known triggers can reduce your chance of experiencing episodes of
jaundice.
P a g e | 184
Who's affected
Gilbert's syndrome is common, but it's difficult to know exactly how many people are affected
because it doesn't always cause obvious symptoms.
In the UK, it's thought that at least 1 in 20 people (probably more) are affected by Gilbert's
syndrome.
Gilbert's syndrome affects more men than women. It's usually diagnosed during a person's late
teens or early twenties.
 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.
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.
P a g e | 185
Alcoholic hepatitis
You are FY2 in GP clinic. A man aged,40 came for the blood reports. Explain
results to him and discuss further management.
Bilirubin-Normal ALT-
Normal
AST-63(Raised)
P a g e | 186
History
Dr:Hello,I understand you are here for your blood tests. Before we discuss that, can I
ask why did you in the first place?
Pt:Just for my regular blood checkup. Dr:Alright,do you any symptoms at the
moment? Pt:No
Dr:Any tummy pains? Pt:No
Dr:Any fever? Pt:No
Dr:Any yellowish discoloration of body
Pt:No
Dr:Any vomiting or diarrhea(Hepatitis A)? Pt:No
Dr:Any color change of stools or urine?(Obstructive jaundice)
Pt:No
Dr:Any weight loss or lumps and bumps in body?(Malignancy)
Pt:No
Dr:Any blood transfusions ,tattoos?(Hepatitis B) Pt:No
Dr:Have you ever been diagnosed with any STI?(Hepatitis B,C)
Pt:No
Dr:Ask sexual history from the patient Dr:Do you have any
health problems? Pt:No
Dr:Are you using any medication? Pt:No
Dr:Any allergies? Pt:No
Dr:Anyone in the family with liver problems? Pt:No

Dr:Do you smoke? Pt:No
Dr:By any chance do you use recreational drugs? Pt:No
Dr:Do you drink alcohol?
Pt:Yes,half glass of wine daily from last 20 years (Do CAGE for alcohol
consumption)
Examination
I would like to check your vitals i.e. your BP,pulse,temperature and respiratory rate.
Also I will do general examination of you including your tummy examination in
particular to liver and spleen.
Management
Explain results.
P a g e | 187
Dr:From what you have told me and from your blood results, we think that you are
having a condition called alcoholic hepatitis unfortunately. It means that your liver has
been affected by your excess alcoholintake.
Pt:What can you do now?

Dr:We will do further tests like GGT and Ultrasound scan of your tummy.
Pt:Ok
Dr:We will refer you to specialist doctor called gastroenterologist who will talk to you in
detail. Is that ok?
Pt:Ok
Dr:We would advise you to stop drinking as well. What do you think?
Pt:I love alcohol, I can’t stop
Dr:(Convince the patient on alcohol cessation and offer replacement and support)
Dr:We will arrange your follow up in 2 weeks. In the meantime, if you feel any tummy
pains, any yellow discoloration of your body, bleeding from anywhere in your body, please
let us know.
Reference information:
Symptoms of alcohol-related liver disease (ARLD)
ARLD does not usually cause any symptoms until the liver has been severely
damaged.
When this happens, symptoms can include:

 feelingsick
 weightloss
 loss of appetite
 yellowing of the eyes and skin(jaundice)
 swelling in the ankles andtummy
 confusion ordrowsiness
 vomiting blood or passing blood in yourstools
This means ARLD is frequently diagnosed during tests for other conditions, or at a
stage of advanced liver damage.
Treating alcohol-related liver disease (ARLD)
P a g e | 188
There's currently no specific medical treatment for ARLD. The main treatment is to
stop drinking, preferably for the rest of your life.
This reduces the risk of further damage to liver and gives it the best chance of
recovering.
If a person is dependent on alcohol, stopping drinking can be very difficult.
But support, advice and medical treatment may be available through local alcohol
supportservices.
 spread your drinking over 3 days or more if you drink as much as 14 units
aweek
A unit of alcohol is equal to about half a pint of normal- strength lager or a pub measure
(25ml) of spirits.
A liver transplantmay be required in severe cases where the liver has stopped
functioning and does not improve when you stop drinking alcohol.
You'll only be considered for a liver transplant if you have developed complications
of cirrhosisdespite having stopped drinking.
All liver transplant units require a person to not drink alcohol while awaiting the
transplant, and for the rest of their life.
Complications
Life-threatening complications of ARLD include:
 internal (variceal)bleeding
 build-up of toxins in the brain(encephalopathy)
 fluid accumulation in the abdomen (ascites) with associated kidneyfailure
 livercancer
 increased vulnerability toinfection
4. Preventing alcohol-related liver disease (ARLD)

The most effective way to prevent ARLD is to stop drinking alcohol or stick to the
recommended limits:
 men and women are advised not to regularly drink more than 14 units aweek.
P a g e | 189

Lady with pain abdomen - Appendicitis.
42 year old lady presented with abdominal pain. Take history and then do the relevant
examination and discuss the further management with her.
Patient was complaining of pain abdomen for the last 5 days. Initially the pain was coming and
going. Now it is constant in the lower part of tummy.
She was feeling feverish for the last few days.
She was also complaining 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 was she 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 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.
Percussion – normal
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. Also we need to do
X Ray of your tummy and chest, and Ultra sound scan of your tummy. ( examiner did not give any
findings).
We need to test your urine also to check for any blood or infection markers and also do pregnancy
test to make sure that you are not pregnant. Is it OK?
Definitive diagnosis
P a g e | 190
I think you may have a condition called Appendicitis. Do you know any thing abiut this ? Pt : No
Dr: Let me explain ( draw if possible).
We all have an organ in our tummy called Appendix which looks like a small finger attached the
beginning of the large bowel located at the right lower part of the tummy. That organ has become
inflamed ( it is sore / swollen) This is what we call Appendicits. 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 ant
problem. You can live a normal life.
Pt: How long will be operation ?
Dr: 30 min to 45 min
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.
Dr: Is that OK to go ahead with surgery ?Pt: OK

Do you have any other questions ?Pt: No
Thank you.

Acute Gastro Enteritis
Exam question
Middle aged lady having diarrhoea and vomiting.

Infection controls have already been notified.
History and management.
-GRIPS
- How can I help you?
P: Dr. I am having pain in lower tummy. D: Can you please tell me more about it….
P: I am having it since past 3 days. Its in the lower part…. Do Socrates and also rule out
Do you have anything else?

P: Doctor I am 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. ( may be 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 happened?
P: Yes Doctor I had food with my husband and son in a restaurant and after that it started.
P a g e | 191
Even they had similar complaints but 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 D.Ds
D.Ds like , Diverticulitis, PID, APPENCITIES, UTI.
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 weightloss 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 … Doctor I am drinking enough water everyday and keep myself hydrated.
…. Praise her
Thank you verymuch for giving me all the important information.
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 ?
Gastro enteritis 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 abdomen.
For now we need to do some investigations on you like we will do

Bloods – FBC, U&E, Infection markers, ABG.
- 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.
I encourage you to notify your employer about your condition as this can spread to others.
Do you have any concerns? No Doctor
( may be she works for the carer home. If yes then you will have to ask her to tell her
employer about it.)
Safety netting: If you have any severe vomiting loose stools or pain then please do come back
to us.
Thank you.
P a g e | 192
Diarrhoea ? Inflammatory Boweldisease

Causes of diarrhoea:
Acute – up to 4 Chronic - more than 4 weeks
weeks
Gastroenteritis – Bowel cancer – loss of appetite, loss of
vomiting, change in diet, weight, blood in the stool, mucus, pain
travel hx, contact hx., abdomen, constipation, anaemia symptoms,
Medications – Diverticulosis – left sided pain is generally
Antibiotics, PPIs, exacerbated by eating and diminished with
Cemetedine, cytotoxics, defecation or passing flatus. Rarely weight
NSAIDs, Digoxin 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 feaces or air comes along with
urination) , stricture/obstruction, Bleeding –
red or maroon colour stool
Laxative abuse IBD – blood and mucus in thestool,pain 
abdomen, joint pains, puss. Weight loss
There may be symptoms ofsystemicupset, 
including malaise, fever, weight loss
and symptoms of extra-intestinal (joint,
cutaneous
and eye) manifestations.
Alcohol IBS – altered bowel habits, stress, mucus
Malabsorption – difficult to flush the stool
Colonic polyp – blood and mucus, family hx
P a g e | 193
50 year old man Mr… presented to the hospital with a history of passing lose 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 stool ?
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 inthestool? 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.
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 weightrecently? Pt: Yes my belt hasbecomeloose. 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
Dr: Any of your family members have any medical conditions or bowel problems? Pt : No
Dr: Have you travelled outsideUKrecently? Pt :No
Dr: Is there anything else you think important that we needtoknow? Pt:No
Tell the patient – I need to examine your tummy and backpassage.
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, mass or veins.
Palpation – Superficial palpation – mild tenderness on the left iliac fossa.
Deep palpation – no palpable mass.
Percussion – No 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 what 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
P a g e | 194
5. genetic reasons or sometimes due to disruption to the immune

system (the body’s defence against infection).
Are you following me? Yes
Investigations: We need to do some tests to confirm the diagnosis as well as to make

sure that there is no bowel cancer..
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 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.
Wecan give you sedation during the colonoscopy so that you will not be uncomfortable.
Is that OK? Pt - Okdoctor.
Dr; Are youfollowingme? 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, 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

P a g e | 195
Lady with bowel cancer –

Son does not want mother to know.
72 year old lady Mrs Ali was recently been diagnosed as 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 the 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 doctor in the medical
department. How are you doing?
Son: I am, fine doctor.
Dr: I am one 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 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 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.
P a g e | 196
24
Dr: Mr Ali we need to tell her the truth we need to be honest with our patients. She has a
right to know about her condition.
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 to your
mother. Your opinion really very important for us. However, Mr Ali she is in a 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 tell her abnormal growth?
Dr: Mr abnormal growth has 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 tell her that it is cancer type of growth.
Son: Doctor, I am her eldest son. Now I am the eldest in the family. In our culture it is the
elder person who takes decisions. Doctor you don’t need her consent. I am telling you that
you treat her without telling her the word cancer. I am giving you permission. Anywayshe
is going to ask me only about what todo.
Dr: We do respect all cultures and family relationships. However when we take medical
decisions it has to be 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 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 her 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 isn’t it ?
Son: Doctor I will tell her that she has cancer myself in private.
Dr: Mr Ali Unfortunately we have to tell the diagnosis to the patient our self. 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 you say ? You tell me should we tell her or not ?
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.
P a g e | 197

Low eGFR after starting Ramipril
Information about eGFR (Estimated Glomerular Filtration Rate )
It is calculated from the results of your blood creatinine test, your age, body size and gender
andrace.
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.
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.
When is it ordered?
© Dr Swamy PLAB Courses Ltd
This manual is a Dr Swamy PLAB Courses Ltd copyright©. All rights reserved. No part of this manual may be
reproduced, stored in a retrieval system or transmitted in any form by any means: electronical, mechanical, photocopying,
recording or otherwise, without the prior permission of the copyright owner. Anyone violating the copyright act will be
committing a criminal offence.
P a g e | 198
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-colored
 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 milliliters/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 mL/min/1.73m2).
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 table summarizes estimated GFR and the stages of kidney damage:
DESCRIPTION ESTIMATED GFR

KIDNEY
DAMAGE (ML/MIN/1.73M ) 2
STAGE
1
Normal or minimal 90+ Protein or albumin in urine may
kidney damage with be high, cells or casts rarely seen
normal GFR in urine (see Urinalysis)
2
Mild decrease in 60-89 Protein or albumin in urine may
GFR be high, cells or casts rarely seen
in urine
3
Moderate decrease in 30-59
GFR
4
Severe decrease in 15-29
P a g e | 199
GFR
5
Kidney failure <15
Is there anything else I should know?

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 use of ACE inhibitors in CKD
o stop renin-angiotensin system antagonists if the serum potassium concentration
increases to 6.0 mmol/litre or more and other drugs known to promote
hyperkalaemia have been discontinued
o 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%
o 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%

P a g e | 200
 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 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.
P a g e | 201
Chest pain.
Nausea / Vomiting / Diarrhoea.
Weakness or tiredness.
Question :-
63 year Larry King referred from Wellman 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 later of starting Ramipril :
1. FBC = Hb , TLC , MCV , Pltetc (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 , same blood tests were repeated :
1. FBC = Hb , TLC , MCV , Pltetc ( 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
Take history about HTN treatment and medicine and dose.
Has the patient taking the medication properly since then.
Has patient has any symptoms of renal failure.
Any other conditions or medications causing low eGFR( renal damage).
Find our any reason why the blood pressure is not controlled ? [ not taking medication properly, not
following life style]
Ask about other side effects of Ramipril
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 Wellman clinic because
your blood pressure was high.
Pt = Yes Doctor, I was heaving 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.
P a g e | 202
Dr = Mr King, Are you still having the headache? Pt = No Doctor, not anymore.
Dr = My notes tells 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 bood pressure or Diabetes ? No
Dr: Did you have any kidney problems before ? No
[ ask about signs and symptoms of kidney disease;
Dr: Do you have Swelling or puffiness in the face tummy or ankles ? No

Dr: Any change in the colour of the urine? (foamy, bloody or coffee-colored in kidney disease) No
Dr: Are you passing more or less urine than before ? No
Dr: Any blood in the urine? No
Dr: Any pain in your tummy or loin area ? No
Dr: Any previous kidney stones ? No ]
[Ask about causes of kidney disease ( causes of low eGFR)
Dr : Have been taking the Ramipril medication properly since it was prescribed to you two weeks ago ?
Pt - Yes
Any current medication or in the past apart from the Ramipril like aspirin, NSAIDs ? Pt : No
Dr = Any family member with high blood pressure ?heart problems ? kidney problems? Pt - No ]
[ ask about other side effects ofRamipril:
Dr: Do you have Dizziness or faintness ?No

Dr: any Cough or chest pain ? No
Dr: Nausea / Vomiting / Diarrhoea ? 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 is your diet 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.
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

P a g e | 203
kidneys seemed to decline as well during these two weeks.

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 result:
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 what is eGFR only if the patient ask 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 that happened 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 certain
type of medications like aspirin or Ibuprofen for 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 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 to control the blood pressure which will not affect the kidney function.
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 ?

Dr: they may start you on other type of medication what we call 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 was causing kidney problem?
Dr: Ramipril is one of the good medication to control high blood pressure. However like any medicine
it also has some side effects and one of it is that it can reduce the kidney function. That is the reason we
keep checking the kidney function of the patients 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 the high blood pressure you need to follow healthy life style to control the
high blood pressure. You need to eat healthy balanced diet, do good exercises and 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
Thank you very much. I will refer you to the Kidney specialist now and hopefully everything will be
fine soon.

P a g e | 204

Ureteric calculus
Risk factors
Several risk factors are recognised to increase the potential of a susceptible individual to
develop stones. These include:
 Anatomical anomalies in the kidneys and/or urinary tract - eg, horseshoe kidney, ureteral
stricture.
 Family history of renal stones.
 Hypertension.
 Gout.
 Hyperparathyroidism.
 Immobilisation.
 Relative dehydration.
 Metabolic disorders which increase excretion of solutes - eg, chronic metabolic acidosis,
hypercalciuria, hyperuricosuria.
 Deficiency of citrate in the urine.
 Cystinuria (an autosomal-recessive aminoaciduria).
 Drugs - eg, diuretics such as triamterene and calcium/vitamin D supplements.
 More common occurrence in hot climates.
 Increased risk of stones in higher socio-economic groups.
 Contamination - as demonstrated by a spate of melamine-contaminated infant milk
formula.
Indications for hospital admission
 Fever.
 Solitary kidney.
 Known non-functioning kidney.
 Inadequate pain relief or persistent pain.
 Inability to take adequate fluids due to nausea and vomiting.
 Anuria.
 Pregnancy.
 Poor social support.
 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).

P a g e | 205
Indication for urgent outpatient appointment
 Pain has been relieved.

 The patient is able to drink large volumes of fluid.
 Adequate social circumstances.
 No complications evident.
Initial management of acute presentation
 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.
 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.
 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

P a g e | 206
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.[7]
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.
 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:

P a g e | 207
 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).
Question :45 year old man presented to the hospital with abdominal pain.
Take history and discuss the management with the patient.
Offer pain killer.
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 defeacation.
Pancreatitis – pain from front to back. Alcohol.
Bowel cancer – change in bowel habit, 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

In problem in kidney before ( 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. (No response from the examiner)
Diagnosis

P a g e | 208
Mr… I think you have a stone in the ureter. Ureter is a tube which drains urine from the
kidney to the urine bladder.
Investigations: We need to do some tests like 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). We need the check your blood to check
how your kidneys are functioning and also check some chemicals like for calcium,
phosphate and other things.
Treatment: If the tests confirm that it is stone we 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 killer medication what we call as Diclofenac as a
suppository through your back passage.
If your pain is relieved and 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 what we call as shock wave treatment where
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 can do a key hole surgery and remove it or rarely
we may have to do 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 givemedication 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 fluid.

 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.Do you follow me? Any concerns?Thank you.

P a g e | 209
Heamaturia
Red flag symptoms
• Painless macroscopichaematuria
• Symptomatic microscopic haematuria in absence ofUTI
• Age >50years
• Abdominal mass on
examination History andexamination
Patients presenting with haematuria should be asked about symptoms of one of the most
likely causes, a 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.

P a g e | 210
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.
Investigations
Dipstick examination will rule out other causes of red urine and may show associated
proteinuria, which hints at a renal cause.
An MSU should be sent for microscopy culture and sensitivity testing, and a 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 4) Prostate
Glomerular diseases Benign Prostatic Hyperplasia

Polycystic kidney disease CA prostate
Kidney stones
Trauma (renal biopsy)
Renal adenocarcinoma
Renal TB
Renal vein thrombosis
Embolism

reproduced, stored in a retrieval system or transmitted in any form by any means: electronical, mechanical,
photocopying, recording or otherwise, without the prior permission of the copyright owner. Anyone violating the
copyright act will be committing a criminal offence.
P a g e | 211
2) Ureter 5) Urethra
Urethral trauma

P a g e | 212
Ureteric stones Urethral stones

Neoplasm Neoplasm
Trauma
3) Bladder General causes
Bladder stones Anticoagulants (Warfarin)

CA bladder Thrombocytopoenia
Bladder Trauma Sickle cell disease
Inflammation (Cystitis, stones, TB) Malaria
Schistosomiasis
Blood dyscarias (Hemophilia)
Sternous exercises
Red urine
Hemoglobinuria
Myoglobinuria
Beetroot
Senna
Rifampicin
Phenopthalein
Exam question
You are the FY2 doctor in the Urology department.
Middle age man presented to the hospital with the history of passing blood in the
urine.
Take relevant history and discuss the further management with the patient.
Dr: Hello Mr … I am Dr…. One of the junior doctor in the urology department.
Pt: Doctor I am passing blood in the urine.
Dr: Can you tell me anything more aboutit? Pt: Likewhat?
Dr: Since when did you noticethis? Pt: Since last fewdays.
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 fever (UTI)? Pt:No Dr : Increased frequency orurination?

P a g e | 213
Pt : No/ Yes
Dr: When you pass urine does it flow properly or does it dribble ( Prostate symptoms) ?
Pt : No/ Yes there is dribbling.
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 totummy? Pt:NoDr :
Did you ever had any kidney stones before ? Pt :No
Dr: Did you have any kidney problems before (polycystickidney) ? Pt:NoDr:
Any pain going from loin to groin at all ( ureteric stone)? Pt :No
Dr: Any pain in your loin area ( renalcancer)? Pt:NoDr:
Any mass in the loin area (renalcancer)? Pt:NoDr:
Have you noticed any change in your weightCancer)? PT:
No / Yes ( how much in how much time?)
Dr : Do you cough ( TB) ? Pt:No Dr: Night sweats ( TB) ? Pt:NoDr:
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 bleedingdisorders? Pt:NoDr:
Did you have this problembefore? Pt :No
Dr: Are you taking any kind of medication –bloodthinners? Pt:NoDr:
Are you allergic to anymedications? 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 ]
This manual is a Dr Swamy PLAB Courses Ltd copyright©. All rights reserved. No part of this manual may be reproduced,
stored in a retrieval system or transmitted in any form by any means: electronical, mechanical, photocopying, recording or
otherwise, without the prior permission of the copyright owner. Anyone violating the copyright act will be committing a
criminal offence.
P a g e | 214
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 some growth 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 not in the Urology department –
then mention referral to Urologists specialists in Kidney and urine excreting organs for
further investigations and treatment).
Pt: Do I have cancer doctor?

Dr: At the moment we cannot say anything. However there are many other reasons for the
bleeding like this. Specialist 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 the blood or other things (protein)
which may show any problem in the kidney. We need to do investigations like cystoscopy to
check inside the urine bladder. In this procedure we pass a 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 what type of growth it is whether it is
cancerous or non - cancerous. We will have to do ultrasound scan and do some blood test
specific for the prostate gland.
Also we need to do 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 at 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 at all it is cancer of the prostate - again depending on the result we will treat either by
surgery or chemotherapy or radiotherapy.
criminal offence.
P a g e | 215
Are you following me? Is that OK?

Pt : Ok doctor. Thank you very much.

UTI and BPH
Symptoms of UTI Symptoms of BPH
Strong and frequent urge to urinate.  difficulty startingurination

Cloudy, bloody or strong smelling  a frequent need to urinate
urine. Pain or burning sensation when ( nocturia)
urinating. Nausea and vomiting.
Muscle aches and abdominal pains.  difficulty fully emptying the
bladder
Important differentials :Acute appendicitis,Diverticulitis.Pelvic inflammatory disease,

Gastroenteritis.
Examination DRE ( Digital rectal examination) –
shows enlarged prostate
Investigations For UTI - Urine dipsticks – shows
Nitrite – positive, leucocytes – positive.
U&E, Creatinine, Urineculture
For prostate :LFT ( Alkaline
phosphatase may be raised in Cancer
prostate), Blood PSA, Ultrasound of
prostate.
Question :
Mr Mike Atherton, 75 years old man, came to the Surgery department with
complaint 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 amOK.
criminal offence.
P a g e | 216
Dr: How can I help you?

Pt: Doctor I am having burning sensation when I pass urine.
Dr: Can you tell me anything more about it ?
Pt: Yes doctor it is happening since 3 days now.

Dr: Do you havefever? Pt: Yes since last 3days
Dr: What is thecolour – Pt: Dark and cloudy it smellsbaddoctor Dr: Did you
notice blood in theurine? Pt:No
Dr: Any pain intummy? Pt: yes mylowertummy Dr: Do you have
pain in the loin area (Peylonephritis)? Pt: No Dr: Did you
have this problembefore? Pt:No
Dr: Do you pass more times thanusual? Pt:Yesdoctor Dr: Do
you have to get up in the night to go toloo? Pt: Yes sincefewmonths
Dr: Any dribbling? – Pt: YesIs it 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 openingbowel ? Pt: No

Dr: Do you have anymedical conditions? Pt: No
Dr: Did you have any kidneystonesbefore? Pt: No
Dr: Are you taking anymedications? Pt: No
Dr: Are you allergic to any medications ? Pt Yes to Penicillin

:
Dr: Do you have any one to look after you ? on my Pt: yes, I live with my wife/ I
own. live
Examination:
Dr: Mr Edwards I need to examine your tummy and back passage to see why this
criminal offence.
P a g e | 217
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 as Urinary tract infection
basically this this is 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 glad called prostate gland which
is the base of the urine bladder is enlarged. When this glad 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 grows very easily in such situations. Sometimes this condition causes
recurrent
urine infections.
Pt: What are you going to do for me doctor?
Investigations for UTI:

Dr: We need to confirm whether 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 leucocytes and pus cells.
Dr: Mr Edwards your urine tests does show that you have 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 antibiotics which are called Trimethoprim( 200mg twice a day for
about
a week) which are good for this kind of infection.
We will keep you in the hospitals 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 test to check your prostate gland to see what type of growth it is
whether it is cancerous type or non cancerous. It looks like non cancerous on examination.
We need to do scans on the gland and also we may 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 either with medications –

criminal offence.
P a g e | 218
One of them shrinks the prostate gland (5 a – reductase inhibitor –Fenestaride) and the
other
relaxes the water bag / bladder (its neck) alpha blockers –tamsulosin).
Pt: What if the medications don’t work ?
Dr: We may also consider doing a procedure ( TURP) where we pass some instruments
through the urethra and widen the urine passage or we may do an operation to remove the
prostate gland.
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: Nodoctor. Dr: Thank you verymuch.
-----------------------------------------------------------------
If the patient lives with his wife – There is no need to be admitted to the hospital for this
you can take this medications at home. It may take up to a week to clear this infection.
However if you become very unwell or if you becoming confused you need to come back
to
the hospital. Please tell this to your wife.
Inguinal swelling teaching medical student

( New station on 12th April )
You are the FY2 in surgery department. A 40 year old man has come for a checkup for
his hernia. Ross is a medical student. Teach Ross groin and genital examination
(Inside the station – mannikin, student, and examiner)
D- Hello, I am John.
Ross- hello I’m Ross, third year medical student
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 checkup for his hernia. Do you have any idea
what a hernia is?R- No doctor
criminal offence.
P a g e | 219
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. There are
different types of hernia which I will explain to you in detail a little later. 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 inguinal canal then comes out through superficial ring.
D- Now take his permission for examination.

Exposure- below chest up to mid-thigh
Ensure privacy and request for chaperone
Position – abdomen examination – in supine position
Rule out Intestinal Obstruction
Abdomen examination-inspection- redness, scars, sinuses, swellings
Palpation- tenderness, guarding, rigidity
Auscultation – bowel sounds
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 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
( 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 –scrotal swelling
If not possible – inguino - scrotal swelling ( hernia extending into the scrotum)
Consistency of the swelling – to find the content of the hernia sac

criminal offence.
P a g e | 220
Doughy and granular – omentum

Elastic – enetrocele (intestine)
Strangulated – tense , tender
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
If swelling is not present
–
Deep ring – ½ inch above mid inguinal point – cover with index finger
Superficial ring – 1.25 cms above the pubic tubercle- cover with middle finger
Now ask the patient to lie down
Reducible swelling – try to reduce the swelling ( cannot be reduced in case it is obstructed
and irreducible)
Ring occlusion test – reduce the hernia, make the patient stand, keep thumb pressed on deep
inguinal ring, ask patient to cough,
Direct hernia – bulging medial to occluding finger
Indirect hernia – no bulging.
Fluctuation test
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.

criminal offence.
P a g e | 221
Thank the patients always for their co-operation and Cover the patient or ask them to dress
up.
Explain the findings of the examination to the patient and further management options
accordingly.
Strangulated Hernia- Urgent Laprotomy
Obstructed Hernia- Open or Laproscopic Hernia Repair
Reducible Hernia- Elective hernioplasty/herniorrhaphy
Always advise about the major risk factors for recurrence- smoking, constipation, heavy
weight lifting.

Testicular swelling ( new station on 22/03/2018)
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 atesticular 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 my testicle. I am very worried whether 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. How many swellings did you notice ? One
Does it comes and goes ( like does it disappear on lying and appears on standing up ? or is it
present all the time ( hernia) ? No difference. Does it come out when you cough ( hernia) ?
No
Dr: Ok. Do you have any pain ( torsion, epididimitis) ? No
Fever ( epididimitis) ? No Any discharge from the urethra ? No.
Any other swellings anywhere else ? No Any swellings in your groin area ? No
Did you hurt yourself on the testicle recently ( hematoma) ? No
Weight loss ? No
Did you have any such swellings in the testicle before ?
Any operations on testicle previously ( undescended testis) ? No
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
criminal offence.
P a g e | 222
Do you smoke ? No
Any of your family members had cancers in their testicles do you know ? No
Anything else do 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 privacy and have chaperone with
me. Is that Ok ? Pt: Ok doctor.
Examine on 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”.
Feel the right side scrotum :
Non tender. No lumps felt. Feel the superior pole – can get above the swelling.
Epididimis ( 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. Epididimis and spermatic cord feels
normal.
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 :

criminal offence.
P a g e | 223
Tell the examiner: I would examine the abdomen for any masses for lymph node
enlargement. ( 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 Ultra sound scan of the testicle, and also the 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
to your question at the moment. Specialist doctor will tell you that after all the investigations.
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 what I mentioned earlier suggests that the chance of cancer is very
high then we need to remove the whole testicle by doing operation and send it to the lab to
confirm the diagnosis.
Pt: why remove the whole testicle ?why can’t you take 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 father if you remove my testicle?
Dr: Yes, surely you can as long as the other testicle is fine. Other option is 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 slight chance that it may recur.
Pt: Will I get cancer in the other testicle?

Dr: Unfortunately, there is slight 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
criminal offence.
P a g e | 224
that. You need to keep going for proper follow up.
Any other concerns ? No

Thank you.
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
Erectile dysfunction
You are FY2 in GP.A middle aged man wants to talk to you. Talk to him and
address his concerns.
History
Dr:Hello,how can I help you?

Pt:Doc,it is little bit embarrassing but it is about my erection
Dr:Please tell me more Pt: I am not able to do sex
Dr:From how long are you having this problem? Pt:2,3 months ago
Dr:Do you get erections in the morning or during masturbation?
Pt:No
Dr:Any weight loss or lumps or bumps in body? Pt:No
Dr:Do you have any health problems? Pt:I am hypertensive
Dr:What are you taking for it?
Pt:Labetolol Dr:From how long? Pt:15 years
Dr:Are you using any other medication like Nitrates? Pt:No
Dr:What you do for living? Pt:Accountant
Dr:What about alcohol? Pt:Occasionally
Dr:By any chance, any recreational drugs? Pt:No
Examination
Dr:I would like to check your vitals i.e. your BP,pulse,temperature and respiratory
rate .also examination of your genitals.is that ok?
Pt:Ok

criminal offence.
P a g e | 225
Management
Dr:From what you have told me most likely you are having this erectile dysfunction due to
labetalol unfortunately (check BNF).It is a very common problem, so you don’t have to
worry about that.
Pt:So what can we do now?
Dr:We will talk to our seniors and then we will change labetalol to some other anti
hypertensive medicine like amlodipine, what do you think?
Pt:Ok,will it cause the same problem?
Dr:It is very rare with amlodipine, also we can offer you some medicine called Viagra to
help you in erection
Pt:Ok
Dr: It usually takes 30 to 60 minutes for sildenafil to work for erectile dysfunction. You
can take it up to 4 hours before you want to have sex.
• Taking sildenafil alone will not cause an erection. You need to be aroused for it to
work.
• The most common side effects are headaches, feeling sick, hot flushes and
dizziness. Many men have no side effects or only mild ones.
Dr:Any other concerns? Pt:No

Dr:We will do your blood tests to see if everything is fine with your liver,kidneys,your
sugar, cholesterol and hormones levels.
Pt:Ok
Dr:We will arrange your follow up in a month.in the meantime, if you feel that you are not
improving, any chest pains, prolong and painful erections,please come back to us. Thank
you
Treatment for erection problems depends on the cause

Treatments for erectile dysfunction are usually effective and the problem often goes away.
There are also specific treatments for some of the causes of erectile dysfunction.
Treatments for some causes of erectile dysfunction
Possible cause Treatment
Narrowing of penis blood vessels, high blood pressure, high cholesterol
Medicine to lower blood pressure, statins to lower cholesterol
Hormone problems Hormone replacement (for

example, testosterone)
Side effects of prescribed medicine
Change to medicine after discussion with GP
Things you can do to help with erectile dysfunction Healthy lifestyle changes can

criminal offence.
P a g e | 226
sometimes help erectile Do

• lose weight if you're overweight
• stop smoking
• eat a healthy diet
• exercise daily
• try to reduce stress and anxiety
Don’t
• do not cycle for a while (if you cycle for more than 3 hours a week)
• do not drink more than 14 units of alcohol a week
Emotional (psychological) problems
It's more likely to be an emotional problem if you only have erection problems some of the
time. For example, you get an erection when waking up in the morning, but not during
sexual activity.
Anxiety and depression can be treated with counselling and cognitive behavioural therapy
(CBT).
Do not take sildenafil if you:
• have had an allergic reaction to sildenafil (Viagra) or any other medicines in the
past
• are taking medicines called nitrates for chest pain
• have a serious heart or liver problem
• have recently had a s troke or a heart attack

• have low blood pressure
• have a rare inherited eye disease, such as retinitis pigmentosa

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

criminal offence.
P a g e | 227
GonorrhoeaInformation
Gonorrhoea is a sexually transmitted infection (STI) caused by bacteria called Neisseria

gonorrhoeae or gonococcus.
The bacteria are mainly found in discharge from the penis and in vaginal fluid.
Transmission
 Unprotected vaginal, oral or anal sex
 Sharing vibrators or other sex toys that haven't been washed or covered with a new
condom each time they're used
 The infection can also be passed from a pregnant woman to her baby.
Signs and symptoms

A thick green or yellow discharge from the vagin, pain when urinating and (in women) bleeding
between periods.
However, around 1 in 10 infected men and almost half of infected women don't experience any
symptoms.
Diagnosis
Gonorrhoea can be easily diagnosed by testing a sample of discharge picked up using a swab.
Treatment
Gonorrhoea is usually treated with a single antibiotic injection and a single antibiotic tablet.
Prevention
Gonorrhoea and other STIs can be successfully prevented by using appropriate contraception
and taking other precautions, such as:
using male condoms or female condoms every time you have vaginal sex, or male condoms
during anal sex
using a condom to cover the penis, or a latex or plastic square (dam) to cover the female
genitals, if you have oral sex
not sharing sex toys, or washing them and covering them with a new condom before anyone else
uses them
Visit your local GUM or sexual health clinic for advice.
Gonorrhoea - exam question

criminal offence.
P a g e | 228
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.

criminal offence.
P a g e | 229

P a g e | 230
Dr – I have the test results with me. Can you please tell me what problems you had ? Pt:
Doctor I had 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 re you having this relationship?
Pt: Since 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 do you know ?
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 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 long time without having any symptoms.
It is important that we need to treat you now. Pt
– How will you treat me?
Dr - We will treat you with a single antibiotic injection (Ceftriaxone 500mg IM) and a single
antibiotic tablet (Azithromycin 1g 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.

P a g e | 231
Urine dipstick – teaching

Question: You are an FY2 in theNephrology Department
Abby Gale is a student nurse. This is her first day in the Nephrology department. She
wants to learn how to perform a urine dipstick test.
(On the table there is a sample of urine, a box of urine dipsticks and a stop watch)
Hello.My name is ……… I am one of the junior doctors here in the Nephrology
Department.
I am Abby.
Hello, Abby. Nice to meet you. I understand it is your first day in the nephrology
department. How are finding it?
Good. Thank you.
I understand that you wanted to learn about the urine dipstick test.
That’s right. I want to know how to perform the test.
What do you know so far about testing urine?
I don’t know anything about it.
That’s fine. Let’s sit down and start by discussing by some general principles. Is that okay?
All right.
Well, whenever we perform a test it’s important not only to look at the sample but the
patient as a whole. You would ideally want to know something about the patient’s history-
like what the patient came in with. So what could symptoms could the patient have come in
with for us to want to perform a urine dipstick?
I don’t know.
Well, it might be that they have pain or burning sensation while passing urine. They might
have noticed a change in the appearance of the urine. Or they may have come in with
tummy pain that we suspect may be caused by some problem in the urinary system. Does
that make sense?
Yes
P a g e | 232
Normally urine is 95% water and 5% other chemical substances. Due to different
pathologies there might be some abnormal substances found in the urine or the normal
substances may increase in amount. Can you name something common that if we find in
urine indicates pathology?
Blood?
Yes, that’s right. Very good. Similarly we might find excess proteins or glucose.
If we find substances such as nitrites or leukocytes, it indicates an infection in the urinary

tract.
Abnormal constituents of urine:

 Ketones
 Blood
 Bilirubin (urobilinogen)
 Glucose
 Protein
 Nitrates
 Leukocytes
 Drugs
A urine dipstick test is the quickest way to test urine. It involves dipping a specially treated
paper strip into a sample of urine
Urine dipstick test consists of a reagent strip, which is literally dipped into the urine sample
triggering a series of color changes along its length, which correspond to the presence, and
concentrations of specific molecules. So we detect the presence as well to some extent the
quantity of these substances in the urine. Different substances give clues as to the
pathology.
Do you have any questions so far?
When do we see blood in the urine?
That’s a very good question-
Blood is seen in urine during menstruation, in kidney disorders such as glomerulonephritis

when the kidney’s filter system is damaged, stones or tumors in the urinary tract as well
urinary tract infections. It’s also important to find out if the patient takes any blood thinners
or has any blood disorders. Does that answer your question?
Yes.
 Glucose - is found when its concentration in plasma exceed the renal threshold may
indicate diabetes
 Bilirubin/urobilinogen – indicates excess in the plasma. Commonest cause of
positive results is liver cell injury e.g. hepatitis, paracetamol overdose, late-stage
cirrhosis.
P a g e | 233
 Ketones – due to excessive breakdown of body fat. Common in fasting, may

indicate low carbohydrate diet, vomiting & fever, present in starvation
 Protein – excess albumen in the urine is unusually due increased permeability in the
glomeruli. Positive results in acute and chronic kidney disease, pre-eclampsia.
 Nitrite – UTI – most of the organisms that infect the urinary tract contains an
enzyme that convers nitrate (normally found in urine) to nitrite, which is not found
in urine in the absence of infection.
 Leucocytes – leucocytes enter inflamed tissue from the blood and are shed into the
urine. UTI is commonest cause of positive results.
Also measured by the Dipstick test is-
 Specific gravity – a measure of solute concentration. High values can be found in

dehydration. Low values found in high fluid intake. Diabetes insipidus; chronic
renal failure; hypercalcaemia; hypokalaemia.
 pH – high values - commonest cause of high vales is stale urine; large intake of
antacids;UTI with ammonia forming organisms. Low values – acidosis (diabetic &
lactic); starvation; potassium depletion. )
To start with we must collect the sample-we should instruct the patient on how to collect a
mid-stream sample in a sterile container. The sample should be labeled with the patient’s
name and hospital ID.
Collect al the materials needed-

Reagent/test strips – in-date and stored correctly
Stop-watch
Urine sample in suitable container
Gloves
Paper Towels
Apron
Access to hand washing and drying
A clinical waste bin
Before you start -wear gloves and apron and confirm Sample details- patient name, hospital
number and date of birth
First is gross inspection this includes the color of urine and its turbidity some might also
include odor.
Normally urine is straw coloured.
Colour: The colour and clarity of the urine has significant implications and should always
be noted. The colour of normal urine varies with its concentration, from deep yellow to
almost clear. In disease, the colour may be abnormal due to excretion of the endogenous
pigments as well as drugs and their metabolites.
The color which would concerns someone the most is red as it is most often result of
bleeding somewhere in the GU tract. The source of bleeding can be the kidneys, the ureters

P a g e | 234
the bladder or the urethra. Sometimes the blood is minimal and no colour change is noticed
but the strip is able to detect small amounts hemoglobin.
Clarity/turbidity
Cloudy urine may be due to:

 Contamination with vaginal mucus or epithelial cells.
 Excess phosphate crystals precipitating in alkaline urine (no clinical significance).
 Pyuria secondary to infection.
 Chyluria (presence of chyle/lymph in the urine)
 Hyperuricosuria secondary to a diet high in purine-rich foods.
 Lipiduria.
 Hyperoxaluria.
Odour: Odour in the urine of patients who have a urinary tract infection, is often due to the
urea-splitting organisms. This makes it smell ammonia. The presence of urinary ketones, as
in diabetic ketoacidosis, leads to an acetone smell. The presence of malodorous urine does
not indicate the presence of infection and does not negate the need for testing.
1. Check the expiry date on the container.

2. Take one strip from the container and dip it into the urine sample ensuring that all
the zones are immersed into the sample.
3. Dip briefly and remove immediately to avoid dissolving out the reagents.
4. While removing the strip, run the edge against the rim of the urine container to
remove excess urine.
5. Place the strip in a horizontal position on the paper towels to prevent possible
mixing of chemicals from the adjacent areas.
6. Start the stopwatch.
7. Tests require different times to complete. These times are noted on the side of the
container. Interpret each test (colour change) at an appropriate time interval (keep
an eye on the stopwatch) and go from least time to most time) using the urine
dipstick analysis chart given on the container.
8. After interpreting, discard the materials in the clinical waste bin.
9. Document all the results in the patient notes.
So could you name two common conditions where we might get a finding in the urine
dipstick?
Infection and kidney stones?
Yes, that’s right!
Do you have any questions for me?
No.
Thank you, Abby. If you have any questions or want to learn something else pleased don’t
hesitate to contact me.

P a g e | 235

Reactive Arthritis
25 years male, Mr Robert, C/O joint pains. Assess him and discuss the management with the
patient.
Differentials for Joint pain. ( Pneumonic – GHRRROSS)
Gout
Heamarthrosis
Rheumatoid arthritis
Reactive arthritis ( Reiter’s syndrome – old name for reactive arthritis)
Osteo arthritis
Septic arthritis
Sports injuries
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 the ankles ? Pt: Yes
Dr: I am sorry to hear that. Can you tell me anything 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
Dr: Are all those joints swollen ( heamarthrosis, reactive arthritis, septic arthritis, rheumatoid
arthritis) ) ? Pt : Yes
Dr: Do you have 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
Dr : Any pain in your back ( ankylosing spondilitis) ? Pt : No
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 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 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 while examination. Is that OK if I

P a g e | 236
examine now ?Pt : Yes.

Can you please undress below your mid thigh.
Check Gait : Could you please take 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.
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 do 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 fexion, dorsi flexion.
- 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 history of trauma]
InvestigationsRobert we need to do some investigations to find out what exactly is the problem. We
will do some blood tests for infection markers, Also we will do the 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 condition
what 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 other parts of body like bowel -
sometimes as reaction to that infection people develop inflammatory ( a type of reaction which causes
swelling of joints) reactions in the big joints like knees and ankles. Since you had diarrhoea few
weeks ago which may be due to bugs – that would have caused this condition in you. This condition
causes pains in the knees and ankles and also it causes soreness in the eyes. This condition is due to
problem in the immune system.
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

P a g e | 237
subsides on its own but it may take upto 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 doing exercise 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 do 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.

Rheumatoid Arthritis (28th June)
A 50 years old woman has presented to clinic with complaint of hand pain.
She is a known smoker for past 20 years and has not followed up with her GP for some time.
You are 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 my both hands.
Dr: I am so sorry to hear about this Caroline, are you comfortable to talk 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 is there for 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 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 ?
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 at my finger joints.
Dr: Any swelling any where else in body ? Pt: NO.
P a g e | 238
Dr: Have you felt that your finger and wrist joints are stiff in 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 body ? Pt: NO
Dr. Any Pain in your neck or back ? Pt: No
Dr: Any 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 occasionaly ibuprofen for pain.
Dr: Are you allergic to any medication ? Pt: No.
Dr: Is there any one else in the family with same symptoms ? Pt:No.
Dr: Do you smoke ? Pt:Yes 20 cigarretes a day for 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 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.
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 who so ever 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 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: Thankyou 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 as Rheumatoid
Arthritis.
Would you like to know about this ? Rheumatoid arthritis is an autoimmune condition in which our
body defence system starts attacking the cells that line your joints by mistake, making the joints
swollen, stiff and painful.
We would like to confirm this further by doing few tests.
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 this tests we may be able to say for sure.
P a g e | 239
What do you think of this?

That’s alright doctor.
Dr: Do you have any questions ?
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 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.
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.
January 17: Gout

Man who comes in with pain in his big toe (doesn’t say in 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- checked the BNF the thiazide causes
hyperuricemia and diet consists of eating lots of steak and red meats along with high alcohol intake.
Q: 52 years old man has recently been diagnosed with GOUT. He is worried
about repeated attacks. Address his concerns.
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 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 last 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.

P a g e | 240
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 do you prefer? Pt- beer
Dr: Drinking alcohol cause 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?
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 medication 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 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 advise 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

P a g e | 241

Shoulder and thigh pain – Polymyalgia Rheumatica
Exam question
Elderly lady
C/o shoulder and thigh pains – 3 weeks
Shoulder and thigh ( may show around pelvis also) pains since 3 weeks.
Oncet – 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 shoulders - ? No
Any other joint pains ? No, Other joint swellings ( osteo arthritis) ? 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?
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 wastings ? Examiner may say – No
[ In PMR – joints movements may be restricted]
Provisional diagnosis
Mrs,,, I need to check whether the medication Omeprazole what you are taking is causing
this problem. Is it OK? check BNF for side effects – it may show long term use of
Omeprazole causes Vit D and B 12 deficiencies which may cause body aches).
Mrs.. If one takes Omeprazole for long term it may cause vit deficiencies which in turn can
cause body pains but they usually do not cause the pains to be worse in the morning and
P a g e | 242
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 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.
 Prognosis : Treatment may be required for years. But the outlook for people
with polymyalgia rheumatica is excellent.
P a g e | 243
Warning signs: If you develop any headaches on the sides of the head or vision problems or
jaw pain while chewing please come to us immediately because these are the signs of serious
condition called Gaint cell arteritis as I mentioned earlier. We may need to treat to you
urgently with high dose steroids.
Hemi-arthroplasty of Hip Joint
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 hemiarthroplasty 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 you
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.
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
P a g e | 244
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
tomobilize 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.
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 ( bungalow
is one floor house).
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).
P a g e | 245
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.
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.]

P a g e | 246
Osteoporosis
69 year old lady had 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 becomes 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 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),

P a g e | 247
Bowel problems( crohn’s disease), Bronchitis ( COPD), kidney problems (CKD).
Pt – No doctor
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 healthy balanced diet doctor.
Dr: Do you drink milk ?
Pt – I drink lot of milk. I use milk for cereals also.
Dr – It is very good that you drink 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. 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.

P a g e | 248
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 since 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 year old.
Dr – Removal of the ovaries also can contribute to this problem. Have they removed your eggs?
( Oopherectomy is 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 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).
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

P a g e | 249
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).
Skin lesion: ? Suqamous cell carcinoma

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 is there since about four weeks now doctor.
Dr: Is it the same since it started or have notice any change in that.
Pt: It is becoming 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 ( lymphandenopathy)Pt: No
P a g e | 250
Dr: Have you exposed yourself to sun too much ? Pt: Doctor I lived in Australia for 10
years. Dr: When was that? Pt: …
Dr: Have been using hats to cover your head during those time ?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
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).
Diagnosis:
Dr: Thank you for that. Do you have any idea what it could be ? Pt: No Doctor.
Dr: I 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.

P a g e | 251
Investigation:
We need to 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?
Dr: We need to confirm what type of growth is that 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 has 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.
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

P a g e | 252
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
When to see a doctor
.
 Causes
Ultraviolet light and other potential causes
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.
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:
 Fair skin. Anyone, regardless of skin color, can get squamous cell carcinoma of the
skin. However, having less pigment (melanin) in your skin provides less protection
from damaging UV radiation.
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.

P a g e | 253
 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.
 Use of tanning beds. People who use indoor tanning beds have an increased risk of
squamous cell carcinoma of the skin.
 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.
 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.
 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.
 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.
 Rare genetic disorder. People with xeroderma pigmentosum, which causes an extreme
sensitivity to sunlight, have a greatly increased risk of developing skin cancer.
 Complications
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.
The risk of aggressive squamous cell carcinoma of the skin may be increased in cases
where the cancer:
 Is particularly large or deep

 Involves the mucous membranes, such as the lips
 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
 Prevention
Most squamous cell carcinomas of the skin can be prevented. To protect yourself:
 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

P a g e | 254
for other times of the day, even during winter or when the sky is cloudy.
 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.
 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.
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.
 Avoid tanning beds. Tanning beds emit UV rays and can increase your risk of skin
cancer.
 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.
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.
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

P a g e | 255
aggressiveness of the tumor, as well as your own preferences.
Treatments may include:
 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.
 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.
 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.
 Freezing. This treatment involves freezing cancer cells with liquid nitrogen
(cryosurgery). It may be an option for treating superficial skin lesions.
 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 shined on the area.
 Medicated creams or lotions. For very superficial cancers, you may apply creams or
lotions containing anti-cancer medications directly to your skin.
 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.
 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.
 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.

P a g e | 256
Skin lesion
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 canIhelp? Pt- I have a swelling
onmyshoulder. Dr-Sincewhen? Pt- manyyears.
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 howitstarted? Pt – I
donotknow. Dr-anypain? Pt-No.
Dr- itching? Fever?Bleeding?Discharge? Pt-no

P a g e | 257
Dr- any change in colour and size orborder? Pt-No.
Dr: Have you noticed any swelling in the arm pit or in the neck ( spread to lymph
node 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 waysofar? Pt –No.
Dr – Do you have any such swelling anywhere elseinbody Pt–
NoDr – Did you have any suchswellingbefore? 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.
Dr: Have gone on holidays and exposed your skin to sun ? Pt: Yes/No
Dr: Have you used sun beds for skin tanning? Pt: Yes/No
Dr – Any of your family members had any such problems ( family history is ahigh
risk factor formelanoma)? Pt –No.
Dr- What do you do for living?
Dr- I need to examine you to see what exactly it is?
Pt – OK. Doctor. I have a picture. [ patient may showdifferent types of pictures to
different candidates]

P a g e | 258
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:

P a g e | 259
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).
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 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 istheprocedure? Dr- 10 –
15minutes.Pt – will it leave ascar?
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 it all you develop any swellings like this please come to us immediately.
Good luck with your wedding.

P a g e | 260
Skin lesion (genital warts {higher possibility} or molluscum

contagiosum??) January 24:
Young male made urgent appt with GP, he is embarrassed and must insist he share the details with
you. 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 wt loss, no IVD abuse, lives
alone, no med hx or surgical hx. 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.
Examination: again insist 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 (wont go away after lumps have been treated)
The type of treatment: may even heal on its own with time as it is viral. cream or liquid: applied
directly to warts few times a week for several weeks, but some cases may need to go to the clinic
every week for a doctor or nurse to apply it (these treatments can cause soreness, irritation or a
burning sensation).
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 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.

P a g e | 261

Skin Lesion-----Fungal Infection
A 30 years old male has come to OPD clinic. You are Fy2 doctor in the clinic.
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)
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)

P a g e | 262
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.
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.

P a g e | 263

Cold Sores/Herpes Labialis (17 April 2019)
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

P a g e | 264
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?
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
 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

P a g e | 265
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:
o Is unable to swallow due to pain and is at risk of dehydration (especially in children).

o Is immunocompromised with severe oral herpes simplex infection - they may need
intravenous antiviral drug treatment.
o Has a suspected serious complication of oral herpes simplex infection - they may need
intravenous antiviral drug treatment.
 Arrange a suspected cancer pathway referral (for an appointment within 2 weeks) if there
are any red flags suggesting oral cancer.
 Consider seeking specialist advice or referral to a specialist in infectious diseases or oral
medicine, depending on clinical judgement, if the person:
o Is immunocompromised and has troublesome recurrent oral herpes simplex infection
- prophylactic oral antiviral treatment may be needed.
o 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.
o 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.
o Has herpes simplex associated with recurrent erythema multiforme - prophylactic oral
antiviral treatment may be needed.
o Has lesions which are refractory to oral antiviral treatment in primary care (if clinically
indicated) after 5–7 days.

P a g e | 266
o Has atypical lesions or the diagnosis is uncertain.

INSECT BITE - CELLULITIS
Question: You are an FY2 in theGP Surgery. Arya Banks is a 36 years-old lady
who has presented to you with some concerns. Assess the patient and address
her concerns.
Hello. Arya Banks. Hi, my name is Dr. ……… I am one of the junior doctors here in the GP Surgery.
What would you like me to call you? – Arya is fine

Can you please confirm for me your age? – 36
How can we help you today Arya? – Doctor, I have this rash on my right leg. I think that might have
been caused by an insect bite, can you please take a look at it?
Sure

P a g e | 267
Is there any reason you think it may be an insect bite? – No, just a suspicion
Can you tell me a little bit more about the rash? – Like what?
How long have you had this rash for? – Since yesterday
And how did it come about? Sudden/Gradual? – Suddenly
Has the rash gotten better or worse? – The rash has been getting worse. It’s increasing
Is the rash aggravated by anything you do? Activity? Medication? – No
And does it improve with anything? Resting? Medication? – No
Do you have a rash anywhere else? – No
Is the rash always there? – Yes
Do you have any other symptoms other than the rash? – Yes, it’s quite itchy
Rule out common Rash/Ulcer/Limb Discolouration causes;

Insect Bite,Dermatitis/Eczema, Hives/Urticaria, Impetigo, Psoriasis, Ringworm, Scabies, Allergic
Reaction, Adverse Drug Reaction (ADR), Erythema Multiforme, Trauma, DVT, Acute Limb Ischaemia
(ALI), Varicose Veins
Pain? (Insect Bite, Trauma, DVT, ALI) – It’s not painful

Fever? (Insect Bite, Dermatitis, Hives, Scabies, Allergy/ADR) – I don’t think so
Breathing Difficulty? Dizziness? Swelling of Face/Mouth? (Insect Bite, Allergic/ADR,
EM, DVT/PE) – No
Itching? (Insect Bite, Dermatitis, Hives, Impetigo, Psoriasis, Ringworm, Scabies, Allergic/ADR) – Yes
Bleeding? (Insect Bite, Dermatitis, Impetigo) – No
Skin Dryness(Dermatitis, Psoriasis) – No
Honey Coloured Crusts (Impetigo) – No
Hands/Folds of skin? (Scabies) – No
Do you think it could be an allergic reaction to anything you might have taken? (Allergy/ADR) – No
Do you think you could have hurt yourself in any way? (Trauma) – No
Chest Pain? – (DVT/PE)
Is this the first time you have experience a rash like this? – Yes
Risk Factors for Insect Bite:

 Work or spend a lot of time outdoors
 Live in warmer climates
 Fail to use proper protection
 Own pets
 Fail to use flea/tick preventive measures
 Collect insects as a hobby
Have you ever been diagnosed with any medical condition before? – No, like what?
High blood sugar? High blood pressure?Asthma?– No, I’m otherwise fit and well
Are you currently taking any prescribed Medication? OTC?– No

P a g e | 268
Are you Allergic to anything?– No

Have you Travelled anywhere recently? (Woods/Forest) – No
And what do you do as anOccupation? I’m a teacher
Has it been affecting your day-to-day activities? – Not really
Anything else you would to add that I may have missed? – No
Is there anything in particular that you’re concerned about? – No
EXAMINATION
What I would like to do now is to examine your vitals and check your pulse, blood pressure,
breathing rate, temperature and levels of oxygen in your blood.
I would also like to take a closer look at your right leg again and check both of your lower limbs.
CONSENT. EXPOSURE. CHAPERONE. PRIVACY. CONFIDENTIALITY.
Inspection
 Discharge
 Redness
 Swelling
 Skin Changes
 Scar Marks
Palpation
 Temperature
 Tenderness
 Passive Movements
 Active Movements
Do you think it’s an insect bite?

From everything you have told me and from what I have seen, you seem to have a low-grade fever
(38°C) and a slightly raised pulse (102 bpm). Upon closer look at your right leg, I could appreciate
a large Rash on the inner part of your lower leg extending up to and behind the knee joint. There is
also an Ulcer approximately 1cm x 1cm in size. The temperature surrounding the skin is raised and
there does not seem to be any tenderness. Movement was unrestricted and seemed fine.
It is quite likely that you may have experienced an insect bite to your leg and you’ve done the right
thing by coming to the GP Surgery to get it checked. It is likely to be a condition called Cellulitis
P a g e | 269
secondary to the insect bite. Cellulitis is simply a skin infection.
Insect bites and stings are caused by:
A. Biting Insects—such as mosquitoes, fleas, and ticks

B. Stinging Insects—such as bees, yellow jackets, hornets, wasps, and fire ants
Most insect bites and stings are not serious and will get better within a few hours or
days. Occasionally they can become infected, cause a severe allergic reaction (anaphylaxis)
or spread serious illnesses such as Lyme Disease and Malaria. Bugs that bite or sting include
wasps, hornets, bees, horseflies, ticks, mosquitoes, fleas, bedbugs, spiders and midges.
Are you following me so far? – Yes
Insect bites and stings will usually cause a red, swollen lump to develop on the skin. This
may be painful and, in some cases, can be very itchy.The symptoms will normally improve
within a few hours or days, although sometimes they can last a little longer.Some people have
a mild allergic reaction and a larger area of skin around the bite or sting becomes swollen, red
and painful. This should pass within a week.
Occasionally, a severe allergic reaction can occur, causing symptoms such as breathing
difficulties, dizziness and a swollen face or mouth. This requires immediate medical
treatment.
It can be difficult to identify what you were bitten or stung by if you did not see it happen.
But don’t worry, if you’re not sure – the treatment for most bites and stings is similar.
Do you understand? – Yes
1. Wasp and hornet stings

P a g e | 270
A wasp or hornet sting causes a sudden, sharp pain at first. A swollen red mark may then
form on your skin, which can last a few hours and may be painful and itchy.
Sometimes a larger area around the sting can be painful, red and swollen for up to a week.
This is a minor allergic reaction that is not usually anything to worry about.
A few people may experience a serious allergic reaction (Anaphylaxis) causing breathing
difficulties, dizziness and a swollen face or mouth.
Dial 999 for an ambulance immediately if you have these symptoms.
2. Bee stings
A bee sting feels similar to a wasp sting, but the sting will often be left in the wound.
The sting can cause pain, redness and swelling for a few hours. As with wasp stings, some
people may have a mild allergic reaction that lasts up to a week.
Serious allergic reactions can also occasionally occur, causing breathing

difficulties, dizziness and a swollen face or mouth.
Dial 999 for an ambulance immediately if you have these symptoms.
3. Mosquito bites

P a g e | 271
Bites from mosquitoes often cause small red lumps on your skin. These are usually very
itchy. Some people may also develop fluid-filled blisters.
Mosquitoes don't cause major harm in the UK, but in some parts of the world they can spread
serious illnesses such as Malaria.
Get medical help right away if you develop worrying symptoms, such as a high temperature,
chills, headaches and feeling sick, after a mosquito bite abroad.
4. Tick bites

P a g e | 272
Tick bites are not usually painful, so you may not realise you've been bitten straight away.
Symptoms of a tick bite can include:
o a small red lump on the skin

o swelling
o itchiness
o blistering and bruising
Ticks in the UK can sometimes carry a potentially serious infection called Lyme disease, so
they should be removed as soon as possible if you find one attached to your skin.
See your GP if you develop any symptoms of Lyme Disease, such as a rash that looks like a
"bull's-eye on a dartboard" or a fever.
5. Horsefly bites
A bite from a horsefly can be very painful and the bitten area of skin will usually be red and
P a g e | 273
raised.
You may also experience:
o a larger red, raised rash (called Hives/Urticaria)

o dizziness
o weakness
o wheezing
o part of your body becoming puffy and swollen
Horsefly bites can take a while to heal and can become infected. See your GP if you have
symptoms of an infection, such as pus or increasing pain, redness and swelling.
Midge or gnat bites
Midge and gnat bites often look similar to mosquito bites.
They usually cause small, red lumps that can be painful and very itchy, and can
sometimes swell up alarmingly.
Some people may also develop fluid-filled blisters.
6. Bedbug bites

P a g e | 274
Bedbug bites typically occur on the face, neck, hands or arms. They're typically found
in straight lines across the skin.
The bites are not usually painful, and if you've not been bitten by bedbugs before, you may
not have any symptoms.
If you have been bitten before, you may develop itchy red bumps that can last for several
days.
Mite bites
Mite bites cause very itchy red lumps to develop on the skin and can sometimes also cause
blisters.
Mites usually bite uncovered skin, but you may be bitten on your tummy and thighs if your
pet has mites and has been sitting on your lap.

P a g e | 275
Some mites burrow into the skin and cause a condition called Scabies.
Flea bites
Flea bites can cause small, itchy red lumps that are sometimes grouped in lines or clusters.
Blisters may also occasionally develop.
Fleas from cats and dogs often bite below the knee, commonly around the ankles. You may
also get flea bites on your forearms if you've been stroking or holding your pet.
Spider bites
Bites from spiders in the UK are uncommon, but some native spiders – such as the false
widow spider – are capable of giving a nasty bite.
Spider bites leave small puncture marks on the skin, which can be painful and cause redness
P a g e | 276
and swelling.
Some spiders’ bites can cause you to feel or be sick, sweating and dizziness. Bites can also
become infected or cause a severe allergic reaction in rare cases. Get medical help
immediately if you have any severe or worrying symptoms after a spider bite.
Ant stings and bites
The most common ant in the UK, the black garden variety, does not sting or bite, but red ants,
wood ants and flying ants sometimes do.
Ant bites and stings are generally harmless, although you'll probably feel a nip and a pale
pink mark may develop on your skin.
Sometimes the bitten area may be painful, itchy and swollen.
Ladybird bites
All ladybirds can bite, but a type called the harlequin ladybird found throughout much of the
UK is more aggressive and tends to bite more often.
The harlequin ladybird can be red or orange with multiple spots. Look out for a white spot on
its head – other ladybirds do not have these patches.
Ladybird bites can be painful, but are not usually anything to worry about.
Flower bug bites

P a g e | 277
Flower bugs are common insects that feed on aphids and mites. You can identify the common
flower bug by its tiny oval body, reflective wings and orange-brown legs.
Flower bugs bites can be painful and very itchy, and are often slow to heal.
Caterpillar hairs
The caterpillars of the oak processionary moth are a real pest. They were first found in the
UK in 2006 and are now in London and parts of southeast England.
In late spring and summer, the caterpillars have thousands of tiny hairs that can cause itchy
rashes, eye problems and sore throats – and very occasionally breathing difficulties. The
caterpillars walk up and down trees in nose-to-tail processions.
If you find them, or spot one of their white silken nests, report it to the Forestry Commission
or to your local council.
What are you going to do about it?
MANAGEMENT
 Most insect bites will improve within a few hours or days and can be treated at home.
Symptoms such as pain, swelling and itchiness can sometimes last a few days and require
Conservative Management only:
 To treat an insect bite or sting follow simple First Aid:
o remove the sting or tick if it's still in the skin
o wash the affected area with soap and water
o apply a cold compress (such as a flannel or cloth cooled with cold water) or an ice pack
to any swelling for at least 10 minutes
o raise or elevate the affected area if possible, as this can help reduce swelling
o avoid scratching the area, to reduce the risk of infection
o avoid traditional home remedies, such as vinegar and bicarbonate of soda, as they're
unlikely to help

P a g e | 278
 For pain or discomfort – take over-the-counter painkillers, such as

Paracetamolor Ibuprofen (children under 16 years of age shouldn't be given aspirin)
 For itching, suitable treatments include Crotamiton Cream or Calamine Lotion,
Hydrocortisone cream or ointment and antihistamine tablets
 For swelling – try regularly applying a cold compress or ice pack to the affected area. Over the
counter antihistamine tablets such as Cetirizine can sometimes prove beneficial
 We may have to perform some Investigations, such as Routine Blood Tests (FBC, LFT,
RFT, S/E, BSR, PT, aPTT & INR)
 We may have to check for a protein in your blood that helps us assess the level of inflammation
called CRP.
nd
 I would like to consult my seniors for a 2 Opinion and hopefully they can answer any of your
questions that I may not have been able to answer.
 I would like to give you some Reading Material about insect bites.
.
Do you have any other concerns? – Yes
What if it gets worse?
If it gets worse;
1) We may have to send you to the Hospital

2) Admission may be required under the medical team
3) They may start you on some medication called IV Antibiotics
What can I do to prevent it happening again?
There are some simple precautions you can take to reduce your risk of being bitten or stung
by insects.
For example, you should:
 remain calm and move away slowly if you encounter wasps, hornets or bees – don't wave
your arms around or swat at them. Do not disturb bee or wasp nests
 cover exposed skin by wearing long sleeves and trousers
 wear gloves when gardening
 wear shoes when outdoors
 apply insect repellent to exposed skin – repellents that contain 50%
Diethyltoluamide (DEET) are most effective
 avoid using products with strong perfumes, such as soaps, shampoos and deodorants – these
can attract insects
 be careful around flowering plants, rubbish, compost, stagnant water, and in outdoor areas
where food is served

P a g e | 279
 avoid wearing bright colours

 stay inside at dawn and dusk. Mosquitoes are most active during these times
 stay away from areas where mosquitoes breed, such as areas around still water
You may need to take extra precautions if you're travelling to part of the world where there's
a risk of serious illnesses. For example, you may be advised to take antimalarial tablets
to help prevent malaria.
Not taking any prescribed/OTC medications. No Allergies. Family Hx unremarkable. No significant

Travel Hx. Teacher. Unmarried. Sexually inactive. Healthy diet, lots of water, fruit and veg.
Occasional alcohol drinker. Non-smoker. Plentiful exercise. Mild stress. Does not use recreational
drugs. Lives alone. Otherwise fit and well. Mood – Good.
Vitals – Pulse 102/min, BP 110/75mmHg, RR 13/min, O₂ Saturation 98% on air, Temp 38°C
Examination – Rash 15cm x 8cm on inner aspect of right lower leg, swelling +, visible colour changes
(erythema), temperature raised, non-tender. Movements normal.

ACNE – ISOTRETINOIN( retinoid)
Scenario 2: 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. It is given in it as Topical Retinoid- For Mild to
moderate acne treatment and Oral retinods for severe acne. Start as early as possible.)
Pregnancy prevention
With oral 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 menstrual cycle), every month during treatment (unless there are compelling reasons

P a g e | 280
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).
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 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 breast feeding ? Pt : No
Dr: Do you have high cholesterol, liver or kidney problem ( contraindications) - No
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 ? I am TV actress.

MAFTOSA ….
Any allergies ( important question )….. No positive history
Dr: Anything else you would like to tell me about your condition?
P a g e | 281
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 - Picture of forehead with –red acne spots on it.
Mild ( may be only one or two acne) Moderate
Severe
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,

P a g e | 282
This medicine can cause severe abnormalities in the baby. You should never become pregnant
while on these medication. You should use double contraception to prevent pregnancy. ( Progesterone
only pill is not effective). You should not become pregnant at least one month after stopping the
treatment.
Also you should not breast feed while on these treatment.

This can cause liver and kidney damage but we will keep monitoring them.
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 it in future :
Don't wash affected areas of skin more than twice a day. Frequent washing can irritate the skin and
make symptoms worse.
Wash the affected area with a mild soap or cleanser and lukewarm water. Very hot or cold water can
make acne worse.
Don't try to "clean out" blackheads or squeeze spots. This can make them worse and cause
permanent scarring.
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).
Completely remove make-up before going to bed.
If dry skin is a problem, use a fragrance-free, water-based emollient.
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.
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

Seborrheic keratosis
You are FY2 in GP.Nancy James, aged 70 emailed you a picture of skin lesion. Talk
to her and address concerns.

P a g e | 283
History
Dr: Hello,how can I help you?
Pt:I noticed the lesion on my breast Dr:Tell me more about it
Pt:Like what?
Dr:When did you notice it? Pt: 2 months ago
Dr:Is it the first time you have such type of lesion? Pt:Yes
Dr:Is it painful,itchy? Pt:No
Dr:Is it bleeding? Pt:No
Dr:What about the site,size,shape and color?
Pt:Right,outer quadrant of breast,greyish in color,irregular in shape
Dr:Is it growing? Pt:Yes

Dr:Any lumps in breast other than this? Pt:No
Dr:Any discharge through nipples? Pt:No
Dr:Any pain in breasts or fever? Pt:No
Dr:Lesion anywhere else on the body? Pt:No
Dr:Any weight loss? Pt:No
Dr:Any lumps or bumps in body? Pt:No
Dr:Do you go out in sun more often? Pt:No I don’t
Dr:Any tanning beds? Pt:No
Dr:Do you have any health problems? Pt:No

Dr:Any one in the family with skin cancer? Pt:Yes,my dad has
Dr:Sorry for that, what you do for living? Pt:I am retired
Dr:With whom do you live? Pt:My wife
Examination
I would like to check to your vitals i.e. your BP,pulse,temperature and respiratory rate. I
would also like to examine your breasts for lesion(Picture is in the cubicle)
Diagnosis
Dr:From what we have discussed ,we think that you have a condition called seborrheic
keratosis.It is non cancerous growths of outer layer of skin.
Pt:Is it cancer?
Dr:No it is non cancerous growth, don’t worry Pt:What can you do for me?
Dr:Treatment options are:
Cryosurgery
Liquid nitrogen, a very cold liquid gas, is applied to the growth with a cotton swab or spray
gun to “freeze” it. A blister may form under the growth which dries into a scab-like crust.
The keratosis usually falls off within a few weeks. Occasionally, there will be a small dark
or light spot that usually fades over time.
Curettage
The keratosis is scraped from the skin. An injection or spray is first used to anaesthetise
(numb) the area before the growth is removed (curetted). No stitches are necessary, and the
minimal bleeding can be controlled by simply applying pressure or the application of a
P a g e | 284
blood-clotting chemical.
Electro surgery
The growth is anaesthetised (numbed) and an electric current is used to burn the growth,
which is then scraped off.
Pt:Ok doc,any other precautions ?
Dr: If you have this keratoses it's important to avoid any further sun damage. This will stop
you getting more skin patches and will lower your chance of getting skin cancer.
Do
• use sunscreen with a sun protection factor (SPF) of at least 30 before going out into
the sun and reapply regularly
• wear a hat and clothing that fully covers your legs and arms when you're out in the
sunlight
Don’t
• do not use sunlamps or sunbeds as these can also cause skin damage
• do not go into the sun between 11am and 3pm – this is when the sun is at its
strongest.
Dr:We will also arrange your referral to skin specialist so that he can also assess you. Is
that ok?
Pt:Ok doc
Dr:We will book your follow up appointment in a month.in the meantime if you feel that
your lesion is growing ,changing its color, any bleeding from it or any weight loss, please
let us know. Thank you
Seborrhoeic keratoses are often confused with warts or moles, but they are quite different.
Seborrhoeic keratoses are non-cancerous growths of the outer layer of skin. There may be
just one growth or many which occur in clusters. They are usually brown, but can vary in
colour from light tan to black and range in size from a fraction of an inch in diameter to
larger than a £2 coin. A main feature of Seborrhoeic
keratoses is their waxy, “pasted-on” or “stuck-on” appearance. They sometimes look like a
dab of warm brown candle wax that has dropped onto the skin or like barnacles attached to
the skin.
Causes of Seborrhoeic Keratoses:
The exact cause of seborrheic keratoses is unknown; however, they seem to run in families.
They are not caused by sunlight and can be found on both sun- exposed and non-exposed
areas. Seborrhoeic keratoses are more common and numerous with advancing age.
Although seborrheic keratoses may first appear in one spot and seem to spread to another,
they are not contagious.
Development of Seborrhoeic Keratoses:
Anyone may develop seborrhoeic keratoses. Some people develop many over time, while
others develop only a few. As people age, they may simply develop more.
Facts about Seborrhoeic keratoses:
Seborrhoeic keratoses are most often located on the chest or back, although they also can
be found on the scalp, face, neck, or almost anywhere on the body. The growths usually
begin one at a time as small, rough,
itchy bumps which eventually thicken and develop a warty surface.
Seborrhoeic keratoses are benign (non-cancerous) and are NOT serious and are not
generally treated by a dermatologist in secondary care, you can speak with your GP who
P a g e | 285
can offer you the treatment. Removal may be recommended if they become large, irritated,
itch, or bleed easily.
Treatments
Creams, ointments, or other medication can neither cure nor prevent seborrheic keratoses.
Most often seborrhoeic keratoses are removed by cryosurgery, curettage, or electro
surgery.
Cryosurgery
Liquid nitrogen, a very cold liquid gas, is applied to the growth with a cotton swab or spray
gun to “freeze” it. A blister may form under the growth which dries into a scab-like crust.
The keratosis usually falls off within a few weeks. Occasionally, there will be a small dark
or light spot that usually fades over time.
Curettage
The keratosis is scraped from the skin. An injection or spray is first used to anaesthetise
(numb) the area before the growth is removed (curetted). No stitches
are necessary, and the minimal bleeding can be controlled by simply applying pressure or
the application of a blood-clotting chemical.
Electro surgery
The growth is anaesthetised (numbed) and an electric current is used to burn the growth,
which is then scraped off.
If you have this keratoses it's important to avoid any further sun damage. This will stop you
getting more skin patches and will lower your chance of getting skin cancer.
Do
• use sunscreen with a sun protection factor (SPF) of at least 30 before going out into
the sun and reapply regularly
• wear a hat and clothing that fully covers your legs and arms when you're out in the
sunlight
Don’t
• do not use sunlamps or sunbeds as these can also cause skin damage
• do not go into the sun between 11am and 3pm – this is when the sun is at its
strongest.
Urticaria
You are an FY2 in GP. Mother of 5-year-old Daniel has got some concerns. Talk to
her and address her concerns.

P a g e | 286
History
Dr: Hello my name is Dr XYZ,I am one of the junior doctors in GP clinic. How can I help
you?
Pt: My son has rash on his whole body
Dr:I am sorry to hear about that. Please tell me more about it.
Pt:It has happened 2-3 times. Once, after shower and this time he was playing in the
garden.
Dr:For how long it stays?
Pt:Disappears after few minutes to hours. Dr:Is it ichy?
Pt:Yes
Dr:Any one in family with similar symptoms? Pt:No
Dr: Is it painful?
Pt:No
Dr:Is it bleeding? Pt:No
Dr:Any fever? Pt:No
Dr:Any shortness of breath(Anaphylaxis)? Pt:No
Dr:Any wheeze? Pt:No
Dr:Any swelling of face? Pt:No
Dr:Any dizziness? Pt:No
Dr:Does he have any health problems any asthma or allergy?
Pt:No
Dr:Is he using any medication? Pt:No
Dr:Any allergies to food or medicine? Pt:No
Dr:Family history of asthma or allergy? Pt:No

Dr:How was his birth? Pt:Fine
Dr:How is his development overall? Pt:It is normal
Dr:Is he up to date with his jabs? Pt:Yes
Examination
Image was given when asked to examine. (Lateral view of head with rash all over face).
Diagnosis
Dr:From what we have assessed we think that he got this rash due to a condition called
urticaria.It is allergic rash that develops on exposure to some allergen.
Pt:Is it contagious? Dr:No it is not contagious
Pt:Can my child go to his school? Dr:Absolutely once he feels better Pt:So what can you
do for him?
Management
In many cases, treatment isn't needed for urticaria, because the rash often gets better within
a few days.
If the itchiness is causing discomfort, antihistamines can help.
A short course of steroid tablets (oral corticosteroids) may occasionally be needed for more
severe cases of urticaria.
For persistent urticaria, refer to a skin specialist (dermatologist). Treatment usually
involves
medication to relieve the symptoms, while identifying and avoiding potential triggers.
Certain triggers for Urticaria:
• drinking alcohol or caffeine
• emotional stress
• warm temperature Causes of Urticaria:
P a g e | 287
• an allergic reaction – such as a food allergy or a reaction to an insect bite or sting

• cold or heat exposure
• infection – such as a cold
• certain medications – such as non-steroidal anti- inflammatory drugs (NSAIDs)or

antibiotics.
Dr:We will arrange a follow up In a month .in the meantime if he feels any shortness of
breath, fever or if the rash is spreading, please let us know. Thank you.

URTICARIA/HIVES
Where you are

You are an FY2 in GP Surgery
Who the patient is
Samantha Howell has presented with her 6 years-old child Zach
Other information you have about the patient
None
What you must do
Talk to the mother, take a focused history, discuss management with the
mother and address her concerns.
CONSULTATION
1. GRIPS Mother [Greet, Rapport, Introduce, Posture, Smile]
Hello. Samantha Howell? Hi, my name is Dr. Swamy, I am one of the junior doctors here in the GP
Surgery.
 What would you like me to call you?

 Sam please
 I understand you are Zach’s mum, is that correct?

P a g e | 288
 Yes
2. PC FODPARA  DDx  SR
 How can we help you today Sam?

 I’m really worried about this rash that Zack gets sometimes
Oh, I’m really sorry to hear that.
 Can you tell me a little bit more about it?

 Yes, it just appears sometimes, and I don’t know what it is. I’m really worried
 Where does he get this rash?
 It’s mostly on his arms and chest, but sometimes it’s the whole body
 Is this the first time Zack is experiencing these symptoms?

 No doctor, it’s happened twice now
 And how did it come about? Sudden/Gradual
 Well it started off all of a sudden
 And for how long did Zach have this rash?
 Not long, it was just a few hours and then it disappeared - about 3 days ago
 Has it been getting better or worse?
 I don’t know
 Is the rash aggravated by anything he does? Eating? Activity?
 Well the first time, it was after he had had a hot bath. And then the following morning when he
went outdoors with his grandpa, he was playing in the park and it happened again
 And did it improve with anything? Resting? Medication?
 It just disappeared by itself. No medications
 Is there anything else you’d like to add?
 No doctor, I’m just really worried it might be meningitis. The school is also quite worried it might
be contagious and it may spread to others
 Is there any particular reason you’re worried it may be meningitis?

 I just saw this poster once, and it had rashes like the one I saw on Zach’s arms
 Does he have the rash now? Can I see it? Do you have a picture of it?
 Yes Doctor.

P a g e | 289
 Urticaria
 Contact Dermatitis
 Atopic Dermatitis
 Insect Bite
 Adverse Drug Reaction
 Viral Exanthem
 Erythema Multiforme
 Henoch-Schonlein Purpura
 Are the rashes painful?

 No
 Do they itch?
 Yes
 Do they bleed?
 No
 Are they raised, flat or sunken?
 Raised
 What colour are they?
 Pinkish
 Do they grow bigger, stay the same or get smaller?
 I don’t know doctor
 Fever? Headache? Photophobia? Neck stiffness? Nausea? Vomiting? Muscle aches? Seizures?
Drowziness/Confusion? SOB? Chest Pain? Cough? Tummy pain? Problems with the wee/poo?
 No

P a g e | 290
3. 2PMAFTOSA
 No past Medical Hx
 No Medication Hx
 No Allergy Hx
 No Family Hx
 No Travel Hx
 Goes to school, in Year 2
 No Social Hx
 Personal
o No smoking at home
o No pets at home
o No carpet
o Diet healthy
o Good hygiene
o Lots of activity – football, running
o Has missed 1 day at school
4. RISK FACTORS
u Allergic Reaction. Such as a food allergy or a reaction to an insect

bite or sting.
u Temperature. Exposure to cold or heat
u Infection. Such as a cold.
u Medications. Such as NSAIDs or Antibiotics
However, in most instances of Urticaria, no obvious cause can be found.
Some cases of long-term urticaria may be caused by the immune system mistakenly attacking healthy
tissue. However, this is difficult to diagnose and the treatment options are the same.
Certain triggers may also make the symptoms worse. These include:
u Drinking alcohol/caffeine
u emotional stress
Urticaria occurs when a trigger causes high levels of histamine and other chemical messengers to be
released in the skin. These substances cause the blood vessels in the affected area of skin to open up
(often resulting in redness or pinkness) and become leaky. This extra fluid in the tissues causes swelling
and itchiness.

P a g e | 291
5. EXAMINATION
I. VITALS - (Pulse 88/min, BP 110/70mmHg, RR 14/min, Temp 37.6 °C, O2 Saturation 100%)
EXAMINER’S PROMPT: GIVE OBSERVATIONS FINDINGS WHEN CANDIDATE MENTIONS WHAT HE/SHE
WOULD LIKE TO EXAMINE
II. HEAD & NECK
EXAMINER’S PROMPT: RAISED, PINKISH LESIONS ON BOTH SIDES OF THE FACE
III. SKIN
EXAMINER’S PROMPT: GIVE PICTURE WHEN CANDIDATE WANTS TO EXAMINE THE PATIENTS SKIN
6. FINDINGS & Dx
6. What is it?
From what you have told me, Zach has had an itchy, raised, pinkish rash around his body that started a
few days ago. When I examined Zach, I found lesions throughout his body exactly as you described
them. I do believe that Zach may have a condition called Hives.
 Do you know anything about that?

P a g e | 292
 Hives – also known as urticaria, weals, welts or nettle rash – is a raised, itchy rash that appears on
the skin. It may appear on one part of the body or be spread across large areas.
 The rash is usually very itchy and ranges in size from a few millimetres to the size of a hand.
 Although the affected area may change in appearance within 24 hours, the rash usually settles
within a few days.
 Do you follow? – YES
 Urticaria can be described as either:
A. Acute – if the rash clears completely within 6 weeks

B. Chronic –in rarer cases, where the rash persists or comes and goes for more than 6 weeks, often
over many years
 A much rarer type of urticaria, known as urticaria vasculitis, can cause blood vessels inside the
skin to become inflamed. In these cases, the weals last longer than 24 hours, are more painful,
and can leave a bruise.
 Acute urticaria is a common condition, estimated to affect around 1in 5 people at some point in
their lives.
 Children are often affected by the condition, as well as women aged 30 to 60, and people with a
history of allergies.
 Usually the rash disappears within 48 hours.
What caused it?
There are a few possible causes that can trigger an episode of Hives. You did mention that the first time
Zach experienced the rash was after a hot bath. And also when he went outdoors. So in Zach’s case, it
is possible that the rash was brought upon by exposure to heat.
Is it contagious?
Hives themselves are not contagious unless they contain agents such as viruses that can be transmitted
from an infected individual to another. The vast majority of hives are not contagious.
Could it be meningitis?
It’s extremely unlikely to be meningitis, and I don’t think that it is.
 What do you know about Meningitis? – It causes a rash

P a g e | 293
 You are absolutely right; it can cause a rash sometimes. However, there can be other
symptoms that are also associated with meningitis, such as;
Fever/Headache/Photophobia/Neck stiffness/Nausea/Vomiting/Muscle aches/Rash/
Seizures/Drowziness &Confusion.
 Meningitis is the inflammation of the layers surrounding the brain and spinal cord.
 It can be a potentially serious condition that affects the brain and nerves if not treated quickly.
 It can affect anyone, but more commonly it is babies, children and young adults who are
affected the most.
 It is an airborne disease, so transmission mainly occurs through close contact via

sneezing/coughing/kissing.
 It can be caused by bacteria but more often it is a virus that is the causative organism.
 A number of vaccinations are available that prevent meningitis and sometimes we give
‘prophylaxis’, which is giving treatment to prevent an illness.
 The rash of meningitis differs from hives. In Meningitis the rash does not disappear on its own.
7. INVESTIGATION
There is no need to perform any tests right now.
We may need to perform a Full Blood Count (FBC) if the symptoms persist.
We may also need to rule out an allergic reaction as a cause of the rash, so you may be referred to an
allergy clinic for an allergy test.
However, if the urticaria persists for most days for more than 6 weeks, it's unlikely to be the result
of an allergy.
8. MANAGEMENT
 Hives is a self-limiting condition, and the vast majority of skin lesions settle down within 24 –
48 hours. It is important not to scratch the rash if it’s itchy
 Writing a diary is a simple way of identifying what the possible trigger/s may be. It’s important
to write the date, time, site, size and duration and trigger

P a g e | 294
 There are some medications that can be given called antihistamines. These prevent the release
of a chemical called histamine, which is responsible for the redness and swelling. They also
reduce the itchiness of the rash. Cetirizine is a non-sedating anti-histamine, which means there
won’t be any side-effects such as drowziness, so Zach can concentrate in school and not fall
asleep!
 A short course of steroid tablets (oral corticosteroids) may occasionally be needed for more
severe cases of urticaria
 We can follow-up in 10 days’ time to see how Zach’s progressing
 Meanwhile, if the rash worsens, causes a lot of distress, disrupts daily activities or occurs
alongside other symptoms, do come back to us or go to A&E. Also if you notice its painful,
bleeding, swollen, discharging or there are severe skin changes, don’t hesitate to come back to
us or go to the A&E immediately
 If it doesn’t settle, we may have to involve a specialist – Dermatologist
 I would like to consult my seniors if I missed anything, or was unable to answer any of your
questions so I can get back to you with the appropriate information
 I do have some reading material available about the condition that’s affecting Zach, called
Urticaria/Hives.
 Is there anything else I can help you with? - YES
Can Zach go back to school?
If the symptoms are not
 severe
 causing a lot of distress
 disrupting daily activities
 occurring alongside other symptoms
Then there shouldn’t be any reason why Zach shouldn’t go to school.
Complications of Urticaria
ANGIOEDEMA

P a g e | 295
Angioedema is swelling in the deeper layers of a person's skin. It's often severe and is caused by
a build-up of fluid. The symptoms of angioedema can affect any part of the body, but usually
affect the:
 eyes
 lips
 genitals
 hands
 feet
Medication such as antihistamines and short courses of oral corticosteroids (tablets) can be used
to relieve the swelling.
EMOTIONAL IMPACT
Living with any long-term condition can be difficult. Chronic urticaria can have a considerable
negative impact on a person's mood and quality of life. Living with itchy skin can be
particularly upsetting.
It also found that 1 in 7 people with chronic urticaria had some sort of psychological or
emotional problem, such as:
 stress
 anxiety
 depression
See your GP if your urticaria is getting you down. Effective treatments are available to improve
your symptoms.
Talking to friends and family can also improve feelings of isolation and help you cope better
with the condition.
ANAPHYLAXIS
Urticaria can be one of the first symptoms of a severe allergic reaction known as anaphylaxis.
Other symptoms of anaphylaxis include:
 swollen eyes, lips, hands and feet

 feeling lightheaded, faint, collapsing and becoming unconscious
 narrowing of the airways, which can cause wheezing and breathing difficulties
 abdominal pain, nausea and vomiting
Anaphylaxis should always be treated as a medical emergency.
Call 999 immediately and ask for an ambulance if someone else is experiencing
anaphylaxis. Tell the operator about the symptoms.

P a g e | 296
 Is there anything else I can help you with? - NO
 Was there anything in particular you were expecting to get out of this consultation. – I
really thought it was meningitis, but you’ve cleared all that up.

POST-HERPETIC NEURALGIA: SHINGLES
Where you are

Who the patient is
Benjamin White is a 72 years-old man
None
What you must do
Talk to the patient, address his concerns and discuss management plan with
the patient.
CONSULTATION
9. GRIPS Patient [Greet, Rapport, Introduce, Posture, Smile]
Hello. Benjamin White? Hi, my name is Dr. Swamy, I am one of the junior doctors here in the GP
Surgery.

 Ben is fine
10.PC SOCRATES PDA  DDx  SR

P a g e | 297
 How can we help you today Ben?

 I have this really nasty pain in my chest
 Are you in pain now? – Yes

 Are you ok to continue? – Yes (if no, ask next question)
 Have you been offered any painkillers? – No (if no, ask next question)
 Would you like me to give you some painkillers? – No (if yes, ask next question)
 Are you allergic to any medication at all? – No
 Can you tell me a little bit more about the pain you are having?
 Yes, I’m generally well but the pain has been really concerning
 Where exactly is the pain located? Can you pin-point it with a finger?
 No. it’s just on the right side of my chest and back
 Is this the first time you’re experiencing these symptoms?
 Yes
 Well it started all of a sudden
 And how would you describe the nature of this pain?
 It’s really sharp. Like a shooting or stabbing pain. Sometimes burning
 Does the pain travel to any other part of your body?
 Yes, I can feel it go towards my side and on to my back
 Is the pain aggravated by anything you do? Activity?
 I don’t think so
 And did it improve with anything? Resting? Medication?
 No. I tried Paracetamol and Ibuprofen but it made no difference
 Is the pain worse at a particular time of the day?
 No, it’s there all day
 On a scale of 1-10, 1 being the least amount of pain and 10 being the worst. How would you
describe it?
 I’d say it’s a 5
 Has the pain gotten worse of better?
 I would say it’s about the same
 How long have you been experiencing this pain?
 Well it started a few days ago. 2 days
 Is there anything else you would like to add?
 No, I’m just really worried it’s a heart attack
 Shingles
 Oesophagitis
 PE
 GERD
 MI
 Oesophageal Spasm
 Angina
 Gastritis
 Pericarditis
 PUD
 VHD
© Dr Swamy PLABCourses Trauma
Ltd
Cardiomyopathy
 This manual is a Dr Swamy PLAB Courses Ltd copyright©. All rights reserved. No part of this manual may be
 by Rib
reproduced, stored in a retrieval system or transmitted in any form Fracture
any means: electronical, mechanical,
Aortic Dissection
 photocopying, recording or otherwise, without the prior permission of the copyright owner. Anyone violating the
copyright act will be committing a criminal offence.  Costochondritis
 TAA
 Pneumonia
P a g e | 298
u CNS: Headache? Fever? Dizziness? Vision problems? Hearing Problems? Loss of consciousness?
Seizures? - NO
u CVS: Palpitations? Orthopnoea? PND? Exertional dyspnoea? Leg swelling? - NO
u Resp: SOB? Dyspnoea? Cough? Tachypnoea? Sputum? - NO
u GIT: Abdominal pain? Nausea? Vomiting? Diarrhoea? Dysphagia? Heartburn? Jaundice?
Problems with your poo? Altered bowel habits? Weight loss? - NO
u GUT: Problems with your wee? Haematuria? Polyuria? Pain passing urine? Frequency?
Nocturia? Straining? Hesitation? Urgency? Discharge? - NO
u MSK: Joint problems? - NO Rash – YES
u CA: Weight loss? Loss of appetite? Lumps & bumps? - NO
 Is there any particular reason you’re worried it may be a heart attack?

 I read somewhere that in my age, heart problems are really common
 Do you have the rash now? Can I see it? Do you have a picture of it?
 Yes Doctor.

P a g e | 299
 Does the rash itch?

 Yes
 Does it bleed?
 When I scratch it, yes
 Have you noticed any change in colour?
 No
 Do they grow bigger, stay the same or get smaller?
 It stays the same, in the same area I guess
 Do you have a rash elsewhere on your body?
 No
11.2PMAFTOSA
 Chickenpox 3 months ago

 Took Acyclovir for 2 weeks. Took PCM & Ibuprofen for pain – made no difference.
 No Allergy Hx
 No Family Hx
 No Travel Hx
 No effect on daily activities
 Retired
 Personal –
o Non-smoker
o Occasionally drinks alcohol
o No history of recreational drug use
o Healthy diet
o Adequate exercise – looks after grandchild
o No stress
o Good hygiene
o Sleep has been disturbed due to pain
12.RISK FACTORS
u Old Age –as you age, your immunity may decrease, and shingles most
commonly occurs in people over 70 years old.

P a g e | 300
u Physical and Emotional Stress – the chemicals released by your body

when you're stressed can prevent your immune system working
properly.
u HIV/AIDS – people with HIV are much more likely to get shingles than
the rest of the population because their immune system is weak.
u Recently having a Bone Marrow Transplant – the conditioning you

require before the transplant weakens your immune system.
u Recently having an Organ Transplant – you may need to take

medication to suppress your immune system so your body accepts
the donated organ.
u Chemotherapy – chemotherapy medication, often used to treat cancer

can temporarily weaken your immune system.
However, young people who appear otherwise healthy can also sometimes develop shingles.
13.EXAMINATION
IV. VITALS - (Pulse 102/min, BP 130/70mmHg, RR 14/min, Temp 37.5 °C, O2 Saturation 98%)
EXAMINER’S PROMPT: GIVE OBSERVATIONS FINDINGS WHEN CANDIDATE MENTIONS WHAT HE/SHE
WOULD LIKE TO OBSERVE
V. SKIN

P a g e | 301
EXAMINER’S PROMPT: PHOTO + RASH IS WARMER THAN THE SURROUNDING SKIN & TENDER TO
TOUCH
VI. CVS - EXAMINER’S PROMPT: UNREMARKABLE
VII. RESP - EXAMINER’S PROMPT: UNREMARKABLE
IF CANDIDATE WANTS TO EXAMINE ANYTHING ELSE, ASK THE CANDIDATE WHY AND COMMENT NO
ABNORMAL FINDINGS
14.FINDINGS & Dx
7. What is wrong with me?
So from what you have told me, you have had right-sided chest pain for the past 2 days which came
about quite suddenly. The pain was associated with a rash, and both symptoms travelled towards your
back. After having examined you, I could appreciate a rash on the right side of your chest that spread
to your back. I also found some fluid filled blisters that we call vesicles.

P a g e | 302
Taking into consideration that you did also suffer from a bout of chickenpox 3 months ago and took
Acyclovir for 2 weeks, I do believe that you may be suffering from a condition called Shingles.
 Do you know anything about Shingles? – NO
Shingles, also known as Herpes Zoster, is an infection of a nerve and the skin around it. It's caused by
the varicella-zoster virus, which also causes chickenpox.
Most people have chickenpox in childhood, but after the illness has gone, the varicella-zoster
virus remains dormant (inactive) in the nervous system. The immune system keeps the virus in
check, but later in life it can be reactivated and cause shingles.
It's possible to have shingles more than once, but it's very rare to get it more than twice.
It's not known exactly why the shingles virus is reactivated at a later stage in life, but most
cases are thought to be caused by having lowered immunity.
It is quite common and it is estimated that around one in four people will have at least one episode of
shingles during their life.
 Do you understand? - YES
The main symptom of shingles is pain, followed by a rash that develops into itchy
blisters, similar in appearance to chickenpox. New blisters may appear for up to a week, but a
few days after appearing they become yellowish in colour, flatten and dry out.
Scabs then form where the blisters were, which may leave some slight scarring.
The pain may be a constant, dull or burning sensation and its intensity can vary from mild to
severe. You may have sharp stabbing pains from time to time, and the affected area of skin will
usually be tender.
In some cases, shingles may cause some early symptoms that develop a few days before the
painful rash first appears. These early symptoms can include:
 a headache
 burning, tingling, numbness or itchiness of the skin in the affected area
 a feeling of being generally unwell
 fever
An episode of shingles typically lasts around two to four weeks. It usually affects a specific area
on one side of the body and doesn't cross over the midline of the body. Any part of your body
can be affected, including your face and eyes, but the chest and abdomen (tummy) are the most
common areas.

P a g e | 303
So, it’s not a heart attack?
From what you have told me, and from what I’ve examined it does not seem to be a heart attack. The
features of a heart attack include;
o Left-sided Chest Pain which is severe, crushing/tightening/squeezing in nature

o Radiates to the neck, jaw, back or left arm
o Nausea, indigestion, heartburn or abdominal pain
o Shortness of breath
o Fatigue
o Light-headedness or sudden dizziness
o Does not relieve by itself
o Cold sweating
If you ever experience this collection of symptoms, then do call and ambulance and go to the A&E for
an urgent assessment.
Is it serious?
Shingles is not usually serious. However, the symptoms can sometimes be alarming, especially if there
is sudden, sharp, burning like pain.
It is something that we are able to diagnose based on your symptoms and the appearance of the
rash.
Early treatment may help reduce the severity of your symptoms and the risk of developing
complications.
Do I need to get admitted?
It's uncommon for someone with shingles to be referred to hospital, but we may need to
consider seeking specialist advice if:
 there is a complication of shingles, such as meningitis or encephalitis

 shingles is affecting one of your eyes – there's a risk you could develop permanent vision problems
if the condition isn't treated quickly
 a diagnosis isn't certain
 you have an unusually persistent case of shingles that's not responding to treatment

P a g e | 304
 you've been diagnosed with the condition more than twice

 you're pregnant
 you have a weakened immune system – particularly in severe cases or cases affecting children
15. MANAGEMENT
I would like to re-assure you that although Shingles is not a curable condition, it is treatable. Treatment
can help ease your symptoms until the condition improves. In many cases, shingles gets better within
around two to four weeks.
u Self-Care:
If you develop the shingles rash, there are a number of things you can do to help relieve your
symptoms, such as:
 Cover the rash

 Use a non-adherent dressing (a dressing that will not stick to the rash) if you need to cover
the blisters – this avoids passing the virus to anyone else
 Do not use topical (rub-on) antibiotics or adhesive dressings such as plasters – this can
slow down the healing process
 Avoid touching or scratching the rash
 Wash your hands often, and maintain good hygiene
 Keep the rash as clean and dry as possible – this will reduce the risk of the rash becoming
infected with bacteria
 Wear loose-fitting clothing – this may help you feel more comfortable
 Calamine lotion has a soothing, cooling effect on the skin and can be used to relieve the
itching.
 If you have any weeping blisters, you can use a cool compress (a cloth or a flannel cooled
with tap water) several times a day to help soothe the skin and keep blisters clean.
 It's important to only use the compress for around 15 - 20 minutes at a time and stop using
them once the blisters stop oozing. Don't share any cloths, towels or flannels if you have
the shingles rash.
Is it contagious?
Anyone who has had chickenpox in the past can develop shingles; even children can get
shingles. However, shingles cannot be passed from one person to another.
The virus that causes shingles, varicella zoster virus (VZV) can spread from a person with
active shingles and cause chickenpox in someone who had never had chickenpox or received
chickenpox vaccine.

P a g e | 305
VZV spreads through direct contact with fluid from the rash blisters.
Most people who develop shingles have only one episode during their lifetime. However, you
can get the disease more than once.
A person with active shingles can spread the virus when the rash is in the blister-phase. You are
not infectious before the blisters appear. Once the rash crusts, you are no longer infectious.
VZV from a person with shingles is less contagious than the virus from someone with
chickenpox. The risk of spreading the virus is low if you cover the shingles rash.
Avoid contact with the following people until your rash crusts:
o Pregnant women who have never had the chickenpox or chickenpox vaccine
o Premature of low birth weight infants
o People with weakened immune systems such as those receiving immunosuppressive

medication or undergoing chemotherapy, organ transplant recipients and people with
Human Immunodeficiency Virus (HIV) infection.
Can I pass it onto my grandson?
 Can you tell me a little bit about your grandson? Name? Age?
 His name is Andrew, and he’s 11 years old
 Has Andrew ever got the chickenpox before? Has he been fully vaccinated?
 He’s never had chickenpox, and he has been fully vaccinated
If Andrew has been fully vaccinated, then the chances of him getting shingles are very low.
Nevertheless, when the rash is at the vesicular stage, and contains fluid-filled vesicles, it is highly
infectious and can be transmitted from person to person. It is therefore better to avoid any direct
contact during this time, and allow the rash to crust over.
 Do you understand? - YES
u Antiviral Medication:
Some people with shingles may also be prescribed a course of antiviral tablets lasting 7 to 10
days. Commonly prescribed antiviral medicines include acyclovir, valaciclovir and famciclovir.
These medications cannot kill the shingles virus, but can help stop it multiplying. This may:
 reduce the severity of your shingles

 reduce how long your shingles lasts
 prevent complications of shingles. such as postherpetic neuralgia
P a g e | 306
Antiviral medicines are most effective when taken within 72 hours of your rash appearing,
although they may be started up to a week after your rash appears if you are at risk of severe
shingles or developing complications.
Side effects of antiviral medication are very uncommon, but can include:
 feeling sick
 vomiting
 diarrhoea
 abdominal (tummy) pain
 headaches
 dizziness
i. Who may be prescribed antiviral medication?

If you are over 50 years of age and have symptoms of shingles, it is likely you will be
prescribed an antiviral medication.
You may also be prescribed antiviral medication if you have:
 shingles that affects one of your eyes

 a weakened immune system
 moderate to severe pain
 a moderate to severe rash
ii. Pregnancy and antiviral medication

If you are pregnant and have shingles, it is likely your case will be discussed with a specialist to
decide whether the benefits of antiviral medication significantly outweigh any possible risks.
Shingles will not harm your unborn baby.
If you are under 50 years of age, you are at less risk of developing complications from shingles
anyway, so you may not need antiviral medication.
iii. Children and antiviral medication

Antiviral medication is not usually necessary for otherwise healthy children because they
usually only experience mild symptoms of shingles and have a small risk of developing
complications.
However, if your child has a weakened immune system, they may need to be admitted to
hospital to receive antiviral medication directly into a vein (intravenously).

P a g e | 307
u Pain Management
To ease the pain caused by shingles, you may require painkilling medication. Some of the main
medications used to relieve pain associated with shingles are described below.
Paracetamol
The most commonly used painkiller is paracetamol, which is available without a prescription.
Always read the manufacturer's instructions to make sure the medicine is suitable and you are
taking the correct dose.
Non-steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs, such as ibuprofen, are an alternative type of painkilling medicine also available
without a prescription.
However, NSAIDs may not be suitable if you:
 have stomach, liver or kidney problems, such as a stomach ulcer, or had them in the past
 have asthma
 are pregnant or breastfeeding
I’ve tried PCM & Ibuprofen. They just don’t help. What else is
available?
IV. Opioids
For more severe pain, you may prescribe an opioid, such as codeine. This is a stronger type of
painkiller sometimes prescribed alongside paracetamol.
Occasionally, we may consider seeking specialist advice before prescribing an even stronger
opioid, such as morphine.
V. Antidepressants
If you have severe pain as a result of shingles, you may be prescribed an antidepressant
medicine. These medications are commonly used to treat depression, but they have also proven
to be useful in relieving nerve pain, such as the pain associated with shingles.
The antidepressants most often used to treat shingles pain are known as tricyclic antidepressants
(TCAs). Examples of TCAs most commonly prescribed for people with shingles are
amitriptyline, imipramine and nortriptyline.
Side effects of TCAs can include:
 constipation
 difficulty urinating
 blurred vision

P a g e | 308
 dry mouth
 weight gain
 drowsiness
If you have shingles, you will usually be prescribed a much lower dose of TCAs than if you
were being treated for depression. This will usually be a tablet to take at night. Your dose may
be increased until your pain settles down.
It may take several weeks before you start to feel the antidepressants working, although this is
not always the case.
VI. Anticonvulsants
Anticonvulsants are most commonly used to control seizures (fits) caused by epilepsy, but they
are also useful in relieving nerve pain.
Gabapentin and pregabalin are the most commonly prescribed anticonvulsants for shingles pain.
Side effects of these medications can include:
 dizziness
 drowsiness
 increased appetite
 weight gain
 feeling sick
 vomiting
As with antidepressants, you may need to take anticonvulsants for several weeks before you
notice it working.
If your pain does not improve, your dose may be gradually increased until your symptoms are
effectively managed.
u Complications of Shingles
Complications can sometimes occur as a result of shingles. They are more likely if you have a
weakened immune system (the body's natural defence system) or are elderly.
Some of the main complications associated with shingles are described below.
 Postherpetic Neuralgia
Postherpetic neuralgia is the most common complication of shingles. It's not clear exactly how
many people are affected, but some estimates suggest that as many as one in five people over
50 could develop postherpetic neuralgia as the result of shingles.

P a g e | 309
Postherpetic neuralgia can cause severe nerve pain (neuralgia) and intense itching that persists
after the rash and any other symptoms of shingles have gone.
Types of pain experienced by people with postherpetic neuralgia include:
 constant or intermittent burning, aching, throbbing, stabbing, or shooting pain

 allodynia – where you feel pain from something that should not be painful, such as changes in
temperature or the wind
 hyperalgesia – where you are very sensitive to pain
Postherpetic neuralgia sometimes resolves after around three to six months, although it can last
for years and some cases can be permanent. It can be treated with a number of different
painkilling medicines.
 Eye Problems
If one of your eyes is affected by shingles (ophthalmic shingles), there is a risk you could
develop further problems in the affected eye, such as:
 ulceration (sores) and permanent scarring of the surface of your eye (cornea)
 inflammation of the eye and optic nerve (the nerve that transmits signals from the eye to the
brain)
 glaucoma – where pressure builds up inside the eye
If not treated promptly, there is a risk that ophthalmic shingles could cause a degree of
permanent vision loss.
 Ramsay-Hunt Syndrome
Ramsay-Hunt syndrome is a complication that can occur if shingles affects certain nerves in
your head.
In the US, Ramsay-Hunt syndrome is estimated to affect 5 in 100,000 people every year and it
may affect a similar number of people in the UK.
Ramsay-Hunt syndrome can cause:
 earache
 hearing loss
 dizziness
 vertigo (the sensation that you or the environment around you is moving or spinning)
 tinnitus (hearing sounds coming from inside your body, rather than an outside source)
 a rash around the ear
 loss of taste
 paralysis (weakness) of your face
Ramsay-Hunt syndrome is usually treated with antiviral medication and corticosteroids.

P a g e | 310
The earlier treatment is started, the better the outcome. Around three-quarters of people given
antiviral medication within 72 hours of the start of their symptoms usually make a complete
recovery.
If treatment is delayed, only about half of those treated will recover completely.
Those who don't make a full recovery may be left with permanent problems, such as a degree of
permanent facial paralysis or hearing loss.
 Other Complications
A number of other possible problems can also sometimes develop as a result of shingles,
including:
 the rash becoming infected with bacteria – do come back to us if you develop a high temperature,
as this could be a sign of a bacterial infection
 white patches (a loss of pigment) or scarring in the area of the rash
 inflammation of the lungs (pneumonia), liver (hepatitis), brain (encephalitis), spinal cord
(transverse myelitis), or protective membranes that surround the brain and spinal
cord (meningitis) – these complications are rare, however
Shingles is rarely life threatening, but complications such as those mentioned above mean that
around 1 in every 1,000 cases in adults over the age of 70 is fatal.
u Shingles Vaccination
 A vaccine to prevent shingles is available on the NHS to people in their 70s.

 The shingles vaccine is given as a single injection into the upper arm. Unlike the flu jab,
you'll only need to have the vaccination once and you can have it at any time of the year.
 The shingles vaccine is expected to reduce your risk of getting shingles. If you do go on to
have the disease, your symptoms may be milder and the illness shorter.
 It's fine to have the shingles vaccine if you've already had shingles. The shingles vaccine
works very well in people who have had shingles before and it will boost your immunity
against further shingles attacks.
Who can have the shingles vaccination?
 You're eligible for the shingles vaccine if you are aged between 70 - 79 years old.
 In addition, anyone who was previously eligible (born on or after 2 September 1942)
but missed out on their shingles vaccination remains eligible until their 80th birthday.
 When you're eligible, you can have the shingles vaccination at any time of year.
 The shingles vaccine is not available on the NHS to anyone aged 80 or over because it
seems to be less effective in this age group.
How do I get the shingles vaccine?

P a g e | 311
Once you become eligible for shingles vaccination your doctor will take the opportunity to
vaccinate you when you attend the surgery for general reasons, or for your annual flu
vaccination.
If you are worried that you may miss out on the shingles vaccination, contact your GP surgery
to arrange an appointment to have the vaccine.
What is the brand name of the shingles vaccine?
The brand name of the shingles vaccine given in the UK is Zostavax. It can be given at any time
of the year.
How does the shingles vaccine work?
The vaccine contains a weakened chickenpox virus (varicella-zoster virus). It's similar, but not
identical to, the chickenpox vaccine.
Very occasionally, people develop a chickenpox-like illness following shingles vaccination

(fewer than 1 in 10,000 individuals).
How long will the shingles vaccine protect me for?
It's difficult to be precise, but research suggests the shingles vaccine will protect you for
at least 5 years, probably longer.
How safe is the shingles vaccine?
There is a lot of evidence showing that the shingles vaccine is very safe. It's already been used
in several countries, including the US and Canada, and no safety concerns have been raised.
The vaccine also has few side effects.
 We can follow-up in 10 days’ time to see how you are progressing
 Meanwhile, if the pain worsens, causes a lot of distress, disrupts daily activities or if the rash
worsens, do come back to us or go to A&E. Also if you notice its painful, bleeding, swollen,
discharging or there are severe skin changes, don’t hesitate to come back to us or go to the
A&E immediately
 If it doesn’t settle, we may have to involve a specialist – Dermatologist
 I would like to consult my seniors if I missed anything, or was unable to answer any of your
questions so I can get back to you with the appropriate information
 I do have some reading material available about the condition that’s affecting you, called
Shingles.
P a g e | 312
 Is there anything else I can help you with? – No
 Is there anything in particular you were expecting to get out of this consultation? - No
Wonderful. I hope that we have covered everything and that you have a speedy recovery.
Post Herpetic Neuralgia

You are FY2 in GP. Benjamin White, aged 72, has come for consultation. He was
diagnosed with Shingles 2 months back and was given Acyclovir. He saw his GP 1
month back for the pain on the right side of his chest and was given Paracetamol
and Codeine. Talk to him and address his concerns.

P a g e | 313
8. History
Dr: How can I help you? Pt: I am still
in pain.
Dr: Is the pain still in the same place? Pt: Yes, it’s on the
right side.
Dr: Is it always there? Pt: Yes
Dr: Can you score the pain?
Pt: 3/4 normally but during night the bedsheets touch the area and I get unbearable
sharp pain.
Dr: How has it impacted you?
Pt: It is hindering my daily life, as I am taking care of my wife who is on wheelchair and
has RA.
Dr: How are you feeling? Pt: I feel tired all

thetime.
Dr: Do you have rash on your body? Pt: No, they are gone.
Dr: Did you have similar condition in the past?
Pt: Yes, I had it 6 months back and was given antibiotics.
Dr: Have you been diagnosed with any medical condition in the past?
Pt: No
Dr: Are you taking any medications including OTC or supplements?
Pt:No
Dr: Any allergies from any food or medications? Pt:No
Dr: Any previous hospital stays or surgeries? Pt:No
Dr: Has anyone in the family been diagnosed with any medical condition?
Pt: No
Dr: Do you smoke?
Pt:No
Dr: Do you drink Alcohol? Pt:No
Dr: Tell me about your diet? Pt: Healthy
Dr: Are you physically active? Pt: I try to be
Dr: Do you get any help looking after your wife? Pt: Yes, Nurse comes twice a

P a g e | 314
week.
(Ask about Sleep, depression, rule out Cancer (As age is

72) and other causes of Tiredness)
Examination
I would like to check your vitals i.e. your BP,pulse,temperature and respiratory rate.
Also rash on your body.
Diagnosis
Dr:From what we have assessed think that you are having this pain due to a condition
called post herpetic neuralgia. It is lasting nerve pain in an area previously affected by
shingles.
Pt:What can you do for me?
Management
 To help reduce the pain and irritation of postherpetic neuralgia wear
comfortable clothing and use cold packs – some people find cooling the
affected area with an ice packhelps.
 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- herpeticneuralgia.
 Anticonvulsants: Gabapentin and pregabalin are the two main anticonvulsants
prescribed for post- herpeticneuralgia.
 We can also prescribe Tramadol or Morphine if symptoms are notrelieved.
 Living with post-herpetic neuralgia can be very difficult because it can affect
your ability to carry out simple daily activities, such as dressing and bathing.
Support the patient and talk about support groups andwebsites.
Patient Concerns:
Pt: How to get rid of this Pain? Pt: How to
managetiredness?
Pt: Can you give something else other thantablets?

P a g e | 315
Investigations and follow up

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

You are FY2 in skills lab.Lorrie 3rdyear medical student is here.Teach him how to
administer subcutaneous injection. Don’t ask him to perform theprocedure.
Teaching:
A subcutaneous injection is given into the subcutaneous fat under the skin. The skin is
made up of different layers. Underneath the epidermis and dermis, which contain sweat
glands and hair follicles, is a layer of fat. This is the area into which subcutaneous
injections are given.
Getting ready to give the subcutaneous injection

You will need
• Yellow/sharps bin
• Cleaning wipe
• Medicine bottle
• Syringe package
• Cotton wool or gauze
• Site rotation chart
What to do
1. Wash your hands
2. Wipe the top of the medicine bottle with the cleaning wipe and leave to dry
3. Choose the injection site for this dose
4. Open the syringe package and put on a clean surface
5. Insert the needle into the top of the bottle at an angle of 90°
6. Pull back the plunger and draw up slightly more than the prescribed dosage
7. Remove the needle from the bottle
P a g e | 316
Note: If you are using an auto injector or pen device, load it according to the instructions in
the package and how you have been taught.
Giving the subcutaneous injection
What to do
8. Holding the needle upwards, tap the syringe gently to move any air bubbles towards
the needle
9. Push the plunger gently to remove the air bubble and squirt a small amount of the
medicine into the air
10. Lift the skin in the chosen injection area between your thumb and index finger
11. Holding the needle at a 90° or 45° angle ,insert the needle into the skin fold
12. Continue to hold the skin and push the syringe plunger to inject the medicine while
counting to 10 slowly. Do not aspirate or rub the skin afterwards.
13. Remove the needle from the skin and let go of the skin fold
14. Put a piece of cotton wool or gauze over the injection site for a few seconds
15. Throw the syringe away in a ‘sharps’ bin.
16. Mark the injection site on your site rotation chart
17. Please document the details of procedure and medication administered.
Sites of subcutaneous injection
o Abdomen-2 inches away from umbilicus
o Upper outer aspect of arm
o Upper outer aspect of upper thigh
o Upper buttock
o Do not use the site which is inflamed, scarred or bruised.
o If multiple injections needed, use different sites for each injection.

Post injection care
It is normal for the injection site to be sore for one or two days. Advise that if they
experience worsening pain after 48 hours, they should seek medical help.
Some rare complications of subcutaneous injection are hematoma formation, persistent
nodules, local irritation and rarely anaphylaxis

P a g e | 317
3a. Lift the skin between thumb and 3b: Incorrect technique
two fingers with one hand, pulling
the skin and fat away from the
underlying muscle

SCABIES
Question: You are an FY2 in GP Surgery. Sharon Alexander is a 33 years-old
woman who has presented with some concerns. Take a focused history and
address her concerns.
Hello. Sharon Alexander? Hi, my name is Dr. ……… I am one of the junior doctors here in the GP
Surgery.
What would you like me to call you? – Hi, Sharon please

How can we help you today Sharon? – Yes, it’s my daughter Rose, her skin has been really itchy
and she’s got rashes all over her body
Can you tell me a little bit more about Rose, how old is she? – Yes, she’s 3
Is Rose with us here today? – No I left her at home with her dad, she was too poorly
Can you tell me a bit more about the itching and rash? Which came first?– Well, I’m not exactly
sure. It started almost at the same time. The itching came first and now there are red spots where
she’s been itching that’s left behind a rash. It’s really sore and she constantly scratches away
Where exactly is the rash and itching located? – On her hands, arms, feet and it’s started on her
head now as well. In between her fingers. It’s all over her body!
Do you have a picture of the rash that she’s having? – Yes
For how long has she had this problem? – 5 days

And is there a reason why you’ve come now, and not earlier? – Yes, we thought it would go away
P a g e | 318
by itself but it seems to have gotten worse

Does it flare up with anything she does? Activity?–Yes, when she scratches it in her sleep
Do you have any idea why she might be having these symptoms? – No doctor, that’s why I’m here.
I’m really worried
I can understand that you might be concerned. Unfortunately, I do have some more questions to
ask you, and after you’ve answered them, I may be in a better position to address your concerns,
answer any questions and help you.
Does the rash and itching get better at all? Morning/Afternoon/Evening? Medication? – No
Has she been having the problem continuously during the 5 days or did it change at any time? –
It’s gotten worse to be honest. At first it was just like a silvery-white line with a spot on one end.
But now there are patches of large pinkish-red areas. Night times are the worst, her itching just
doesn’t stop and she can’t sleep because she constantly scratches
Has there been any bleeding from the rash? – Once or twice when she really scratches hard
Is there anything else you’d like to add, that I may have missed? – Yes, her dad Simon has also got
the same problem. But his is much milder and only one his left hand is involved.
Does Rose have any other symptoms other than the rash and itching? – No, she just cries
Rule out commonskin lesion causes;

Scabies, Eczema,Impetigo, Insect Bite, Tinea Corporis, Psoriasis, Syphilis, Viral Exanthems
[Measles, Rubella, Roseola, Hand Foot & Mouth Disease], Skin Malignancy
 Scales? Blisters? Sores? Burrows? Tracks?(Scabies) – Yes

 Skin Creases?(Scabies, Eczema) – Yes
 Soles of Feet? Scalp? (Scabies, Hand Foot and Mouth, Insect Bite) – No
 Skin dryness? Breathing problems? Asthma? (Eczema) – No
 Yellowish-brown crusts? Oozing? Nose and Mouth? (Impetigo) – No
 Elevated? Discharge? Flaky? (Tinea Corporis) – No
 Fever? (Impetigo, Tinea Corporis, Syphilis, Viral Exanthem) – No
 Loss of weight? Loss of appetite? Lumps and bumps? (Skin CA) – No
 Sleep problems? – Yes, she can’t sleep at night
 Risk factors for Scabies – Overcrowding, Poverty, Poor Nutritional

Status, Homelessness, Poor Hygiene, Institutions/Hotels, Residential Care
Homes, Refugee Camps, Dementia, Sexual Contact, Children,
Immunosuppression (HIV, Elderly)
Past Hx - Is this the first time Rose is experiencing these symptoms? – Yes
How has it affectedher life/Is she able to go to school and do her daily activities? – She finds it
hard to sleep at night. She hasn’t been going to the nursey because they’re afraid the other
children might get it
Has she ever been diagnosed with any medical condition before? – No. LikeAsthma, Eczema?
– No
Does you have anyAllergies?– No
Apart from her dad, does anyone else in the family have similar symptoms?–No

P a g e | 319
Has Rose Travelled anywhere recently? How long? Stay? – Yes, we all went to Spain for a
holiday 4 weeks ago, she was completely fine there. We stayed there for 3 weeks. We all shared
a single bed and hotel room
Who else is at home? – It’s just me, Rose and her dad
Examination:
Ideally, I would have like to examine Rose and check her pulse, blood pressure, breathing rate,
temperature and levels of oxygen in her blood (Normal).
Thank-you for showing me the photos of Rose’s rash. They were really helpful, but ideally, it
would have been really helpful for me to examine the rest of her skin, including her; arms up to
the armpits, head, neck and scalp, chest, groin area, buttocks, legs and feet, and especially the
soles.
From what you have told me and from what I have seen, Rose seems to be having clusters of an
itchy pinkish rash, more so on her hands and in between her fingers. I can appreciate sores,
burrows and tracks which may suggest an infection of her skin.
Sharon, do you have any idea at all why Rose may be having this problem? –I don’t
It seems to be a quite common condition that involves the skin, would you like to know more
about it? – Yes
It looks like Rose may be having an infection of her skin, something that we call - Scabies.Do you
know anything about Scabies? – No
Scabies is very common and anyone can get it. One of the first symptoms is intense itching,
especially at night.The scabies rash usually spreads across the whole body, and usually spares the
head. Elderly people, those with a weakened immune system and young children like Rose, may
also develop a rash on their head and neck too. Tiny mites lay eggs in the skin, leaving silvery lines
with a dot at 1 end. The rash can appear anywhere, but it often starts between the fingers, then
spreads and turns into tiny red spots.
Do you follow? – YesIt should be treated quickly to stop it spreading.
But why is it happening to Rose?

Some individuals, such as young children in Rose’s age group are vulnerable to getting
scabies skin infection because their immune system is not as well developed as an adult.
Furthermore, you did mention a recent travel abroad to Spain, where you stayed at a hotel for 3
weeks. There you all stayed in a single room and slept in the same bed in close confinement.As
scabies is a very contagious skin mite that can live in bedding and mattresses, it is commonly
contracted at hotels were overcrowding, direct contact and sharing of fomites can occur.

P a g e | 320
You don’t think they both have the same condition, do you?
This would explain why Simon has also started experiencing some symptoms of Scabies infection,
however I would advise you to bring Simon in along with Rose so we can take a closer look at
them both.
Contagious? So could I get it from Rose? Can I hold/kiss her?

Scabies is contagious – which means it could spread from one person to another. It is quite
possible for you to get a scabies skin infection from your partner or from Rose, if they do have
scabies. It is also entirely possible that you could have gotten scabies from the hotel and haven’t
experienced any symptoms as of yet. The eggs hatch and become adult mites within 10 day but
the onset of Symptoms can take 4-8 Weeks.
Have you been experiencing any itching/rash?– No
Still, it is important to make sure you have not been infected, so I would also like to take a
closer look at your skin, especially your hands. Symptoms, primarily itching, appear
approximately four weeks from the time of contact as a result of sensitization to the
presence of immature mites. A person with scabies isconsidered infectious as
long as they have not been treated, therefore we may need to start Rose & Simon
on treatment as early as possible, before you can get direct skin-to-skin contact.Scabies are
passed from person to person by skin-to-skin contact. You cannot get scabies from
pets.People who live or work closely together such as in hotels, nurseries, university halls
of residence or nursing homes are more at risk.Anyone can get scabies. It has
nothing to do with poor hygiene.Scabies is not usually a serious condition, but it
does need to be treated.
Complications?
Scratching the rash can cause skin infections likeimpetigo and your skin can become
irritated and inflamed through excessive itching.Scabies can make conditions like eczema
or psoriasis worse.
Crusted scabies is a rare but more severe form of scabies, where a large number of mites are in
the skin. This can develop in older people and those with a lowered immunity.
So what are you going to do?

MANAGEMENT
 A pharmacist will recommend a Cream or Lotion that you apply over your whole
body. It's important to read the instructions carefully.
 The 2 most widely used treatments for scabies are Permethrin cream
and Malathion lotion (brand name Derbac M). Both medications contain insecticides
that kill the scabies mite. 5 %Permethrin cream is usually recommended as the first

P a g e | 321
treatment. 0.5% Malathion lotion is used if permethrin is ineffective.
 The product should usually be applied to the whole body from the chin and ears downwards
paying special attention to the areas between the fingers and toes and under the nails,
However, in people who are immunosuppressed, the very young, and elderly people, the
insecticide should be applied to the whole body including the face and scalp.
 The treatment should be applied to cool dry skin (not after a hot bath) and allowed to dry
before the person dresses in clean clothes.
 Permethrin should be washed off after 8 to 12 hours, and malathion
after 24 hours. Body areas that are washed within 8 hours of permethrin application or 24
hours of malathion application should be treated again.
 A second application is required one week after the first.
 Pregnancy and breastfeeding are not contraindications to the use of permethrin or malathion.
 Everyone in the household needs to be treated at the same time, even if

they do not have symptoms.
 Treat dry skin/eczema with Emollients if necessary.
 Anyone you have had sexual contact with in the past 8 weeks should also be treated.
 Things you can do during treatment to stop scabies spreading:
 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
o do not have sex or close physical contact until you have completed the full
course of treatment
o do not share bedding, clothing or towels with someone with scabies
 For people with persistent nodular scabies, refer to a Dermatologist. As

treatment with high-potency topical steroids, intralesional steroids, or oral steroids may
be required.
 Seek specialist advice (e.g. from a Paediatric Dermatologist) if treatment is
required in children under 2 months of age.
 I do have some reading material available with me to give you entitled – Scabies.
When can Rose go back to nursery?
 You or your child can go back to work, nursery or school 24 hours after the first
treatment.Although the treatment kills the scabies mites quickly, the itching can

P a g e | 322
carry on for a few weeks.
 If the symptoms of scabies are disrupting sleep, prevent carrying out everyday
activities, or adversely affecting performance at work or schoolor if your skin is still
itching 4 weeks after the treatment has finished come back and visit us at the GP
Surgery.
Patient with lymphadenopathy-STI

You are FY2 in General practice. A 23 year old male is coming with some
complaints. Address them and discuss further management.

P a g e | 323
History
Dr:Hello,my name id dr XYZ.I am one of the junior doctors in GP clinic. How
can I help you?
Pt:I felt some swellings/lumps in my groin area.
Dr:I am sorry to hear about that. Please tell me more about it.
Pt:Like what doc?
Dr:From how long are you having these swellings? Pt:From last 2 weeks
Dr:How many swellings are there in groin area? Pt:Around 2 to 3
Dr:Swellings on any other part of the body? Pt:No
Dr:Do you any idea how did it happened? Pt:No
Dr:Are these swellings painful or itchy? Pt:No

Dr:Any discharge through penis? Pt:No
Dr:Any burning sensation while passing urine? Pt:No
Dr:Any fever? Pt:No
Dr:Any rashes over the body? Pt:No
Dr:Any weight loss? Pt:No
Dr:Is it the first time it is happening to you? Pt:Yes
Dr:Do you have any health problems? Pt:No
Take sexual history:

Dr:Are you sexually active? Pt:Yes
Dr:Do you have stable partner? Pt:No
Dr:Do you practice safe sex? Pt:Sometimes
Dr:What is your sexual preference? Pt:I am bisexual
Dr:What route of sex do you prefer? Pt:Mostly anal
Dr:Is any of your partners having similar symptoms? Pt:I don’t know
Dr:Have you ever been diagnosed with STI? Pt:No
Dr:Did you travel anywhere recently? Pt:Yes,I travelled to
Thailand Dr:When did youtravel?
Pt:3 weeks ago
Dr:What did you do there?

P a g e | 324
Pt:I had sex with my partner Dr:Was it

protected?
Pt:No
Dr:What you do for living? Pt:I am a

student
Dr:Do you have tattoos? Pt:No
Dr:Do you drink alcohol? Pt:
Occasionally
Dr:By any chance do you use recreational drugs? Pt:No
Examination
I would like to check your vitals i.e. your blood pressure,pulse, temperature and
respiratory rate.Also,general examination of your whole body.
(Examiner will give findings)
Findings:Generalized lymphadenopathy in whole body including axilla,groin andneck.
Tell the findings to thepatient.
Diagnosis
Dr:From what we have discussed and assessed, we think that you may be having a
condition called sexually transmitted infection unfortunately. I am afraid that it
could be something like HIV.
Pt:Are you sure?
Dr:We are not sure at the moment, we will some of your blood tests for
HIV,Gonorrhea,syphilis and then we can say anything for sure.
Pt:How did I get it?
Dr:Unfortunately,you may have gotten this from one of your partners.
Pt:What can you do now?
Dr:We will do some blood tests and also discuss with seniors.
Pt:Ok
Dr:Any concerns? Pt:No
Dr:I would advice you to avoid/practice safe sex until everything is sure about your
condition. Is that ok?
Pt:Ok
Dr:We will arrange a follow up in 2 weeks time,In the meantime, if you feel any
P a g e | 325
fever,discharge through penis,weight loss or increased lumps, please let us

know.Thankyou
Reference information
D/D’s of lymphadenopathy plus sexual history +ve.
 HIV seroconversion illness(Acutepresentation)

o Fever
o Sore throat
o Diarrhea
o Weightloss
o Rashes
o Lymphadenopathy
 Other STI’s like Chlamydia ,Gonorrhea,Syphilis

o Discharge throughpenis/vagina
o Burning in genitaltract.
o Penileulcer

High INR in patient takingwarfarin ( cause 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?
Vegetables. Green beans. Asparagus. Broccoli. Carrots. Avocado.
P a g e | 326
Fruits. Apple. Banana. Blueberries. Grapes. Orange.

Meats. Beef. Chicken. Pork. Tuna. Turkey.
Fats and Oils. Corn oil. Margarine. Mayonnaise. Peanut oil. Olive oil.
Dairy Products. Butter. Cheese (cheddar) Eggs. Sour cream. Yogurt.
Beverages. Coffee. Cola. Fruit juices. Milk. Tea (black)
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 inthrombophilia,
or an increased tendency to form abnormal blood clots in blood vessels. ... Factor V
Leiden is the most common inherited form of thrombophilia.
Question
Thrombophila Lieden Factor 5 , H/o DVT, he is on lifelong Warfarin, INR is 6, he had Chest
Infection, so was given Clarithromycin." (All this is given on Paper outside door)
Task: tell man the results.

Find the causes ( given above)
Patient as 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 clrithromycin - So that is why it went high
Rule out any bleeding especially stroke/TIA ( hemetemesis, mematuria, epistaxis, bleedimg
PR)
Has it happened before like this?
Patient did not have any bleeding
Management : protocol was given inside the cubicle – stop warfarin until the INR comes
down to 5 and then restart the warfarin.
Warning signs – any bleeding come back

AF Patient – Doesn’t want Warfarin.
How to handle if the patient does not want any treatment
1: Ask why they do not want the treatment

P a g e | 327
2: Explain the importance of treatment
3: Explain what are the risks if they do not have the treatment
4: Sort out the reason why they do not want the treatment.
5: Lastly - find out whether they agree for the treatment
6: If agreed give warning signs
7: If they still not agree then offer that the seniors will talk to them and may be they will be
able to convince them.
8: If still did not agree mention that they have a right to refuse the treatment.
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.
Exam question;
You are FY2 doctor in medical unit.
A middle aged man, Mr.… has been diagnosed with Atrial Fibrillation and Stroke.
Consultant has prescribed Warfarin. But patient has refused the treatment.
Your colleague has already discussed with him the risk and benefits 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 doctor 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 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.
P a g e | 328
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.
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 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 do 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 brain. This is what we call as stroke. This is
the reason why you suffered from the stroke. Ae 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 bleeding 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
problem 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.
Also the patients who are taking warfarin needs to be careful so that they don’t fall or
P a g e | 329
injure themselves when using any sharp instruments.

However despite keeping the blood not too thin, bleeding can still happen if someone falls
and has 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 taken 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 injures 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 to rectify those
things. However you need to be careful whenever you go outside not to fall.
Pt: But doctor you can’t prevent me falling. That can happen to me any time any day. You
know the falls happens accidentally.
Dr: I do understand what you are saying. However, if there is any medical causes 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 this to you. 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 stroke last time my memory is not very good. What if I forget to take thimedicine ?
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 blood can become thick again an cause more
strokes. I advise you to make a habit to take it same time every day so that you do not
forget. Also you can keep an alarm which can ring 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.
Warning signs
Dr: Thank you Mr.. I am sure you will be fine with this medicine. However, if at 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 ask 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 ( warfarin INR needs to be
P a g e | 330
checked every month)

Altering the food does not cause problems ( If taking warfarin should change green leafy
vegetables which contains Vit K)
Less chances of bleeding in the brain.
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. 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..

Iron Deficiency Anemia
You are FY2 in GP clinic. Mr. Curtis, 45 years old male has come to clinic today to receive
his test results.
He had blood test done three weeks back 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 back 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 in actual is 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

P a g e | 331
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 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 doctor, I
feel fine.
Dr: Do you feel short of breath while doing any work? Pt: No.
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 lot of tea or coffee? Pt: No.
Dr: Mr. Curtis how is 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 if it is black colored? Pt: No. (G.I blood loss)
Dr: Have you ever noticed any bleeding from your back passage? Pt: No. (Hemorrhoids)
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 any one 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 hemoglobin in your
blood.
But we can do some specific tests to find out what’s the reason. Would you like to know these
tests?

P a g e | 332
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 diarrhea,
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 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 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.

P a g e | 333

P a g e | 334
Thalassaemia
Question:
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.
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 am just here for a regular follow-up doctor. I had bloods drawn the last time, just as
routine and I think I am 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 am glad to hear! We have found in your previous bloods that your haemoglobin is low.
Pt: Oh, 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.
[ ask for symptoms of anaemia]
Dr: Do you have any tiredness, shortness of breath, palpitations? Chest pain? Swelling of the
legs?
Pt: No at all doctor, I’ve been really healthy.Dr: That’s good.
[ check any bleeding ]

Dr: Have you noticed any blood in your stools? Pt: No doctor.
Dr: Do you have heavy menstrual bleed ? Pt: No
[check for absorption problem]

Dr: 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: Any indigestion? Pt: No, not at all.
Dr: Do you have loose stool ( malabsorption) ? No
Dr: Have you previously had anaemia? Pt: No.

Dr: Have you noticed any weight loss? Pt: No.
Dr: Any family member has anaemia ?
Pt: Well, actually, I don’t know if it’s the same thing, but my sister has Thalassaemia minor
Dr: Yes, that could be the cause. Since when does your sister have 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.
Dr: Do you know whether your parents have Thalassemia ? No
Dr: Is there any other thing important you think I may need to know ? Pt: I don’t think so.
Examination:
I need to examine your tummy to check for any spleen enlargement.

P a g e | 335
Investigation:
We need to do some more blood tests to check for type of anaemia what we call as
hemoglobin electrophoresis.
Diagnosis:
Dr: Mrs Henderson, you may be having the same condition like your sister that is
Thalassemia.
Pt: OK. What exactly is it?

Dr: Thalassaemia is the name for a group of inherited conditions that affect a substance in the
blood called haemoglobin.It occurs when there is an abnormality in one of the genes involved
in hemoglobin production. You inherit this genetic defect from your parents.
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). Are you following me Mrs Henderson? Pt: Yes
Dr: However, there are many different types of Thalassemia what we call as alpha or beta
types which can be major or minor. Thalassemia major is a serious form where as
Thalassemia minor is not a serious condition. Since you had no symptoms of anaemia so
far, most likely you may be having Thalassemia minor. However, after the investigation
result we will know about it.
Pt: How will you treat me doctor.

Dr: Mrs Henderson, treatment depends on the type of Thalssemia. If it is a major type which
is a serious form then patients need regular blood transfusion, Chelation therapy –
treatment with medications to remove the excess iron from the body that builds up as a result
of having regular blood transfusions. However if it is minor type then patients do not
require any special treatments because it does not cause any problem. People with the
minor type usually lead almost a normal life.
However, we can give you folic acid tablets to help improve anaemia. Also healthy life
style like not smoking or drinking alcohol and doing regular exercise will also help.
You should avoid taking Iron tablets to improve anaemia especially if it is major type
because when we blood transfusion it increases iron in the body. Excessive iron in the body
can cause serious harm to the health. Also should avoid eating food which contains high
amount of iron like some green leafy vegetables, Fortified breakfast cereals, red meat,
chicken and fish. Also try to avoid drinking juices rich in Vit C because it helps in iron
absorption.
[ examples of food which contains high iron:

Iron is also found in many plant-based foods such as:
green vegetables, for example spinach, silverbeet and broccoli.lentils and beans.nuts
and seeds.grains, for example whole wheat, brown rice and fortified breakfast cereals,
dried fruit.Beans and lentils.Baked potatoes. Cashews.
Dark green leafy vegetables such as spinach.Fortified breakfast cereals.
Whole-grain and enriched breads].

P a g e | 336
Do you follow me ? Yes
Dr: May I ask are you married or do you have partner ? I am not married.
Dr: If your partner also have thalassemia then your child can get serious form of Thalassemia.
You should have genetic counseling before you plan to have a child. Is that Okay. Yes
doctor.
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: Okay
Dr: 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?
Dr: We will regularly monitor you. If you have symptoms of anaemia like feeling very tired,
shortness of breath, palpitations please come back.
Pt: Okay. Thank you doctor.Dr: No problem at all, Mrs Henderson.

Multiple Myeloma - march 19th
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

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.
ask you a few questions that will help me explain the results to you better?

P a g e | 337
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
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 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 : pain anywhere else in the body? Dr: Any racing of the heart? Pt: No
Anemia symptoms
Dr : Do you feel tired ? Pt : yes dr. I feel very tired for the past 3 months
Dr: Any racing fo the heart? Pt…
Dr: Any family h/o similar conditions? pt :no (pt might be irritated with the questions.
Pressure her)
Social history : to r/o NAI( this part can be done at the end too since pt might not cooperate)
Dr: Do you live with anyone? Pt…
Dr: How would you describe your relationship with them is?
Dr :Financial conditions?
Dr:You 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 hemoglobin in your blood is
lesser than usual. You seem to be anemic. Are you following me? Pt…
These are some proteins that are in our body and the have increased (serum igG). And there
are some unusual proteins in your urine that we call the Bence Jones
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. Bone
P a g e | 338
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?
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:
• anti-myeloma medicines to destroy the myeloma cells or control the cancer when it
comes back (relapses)
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 you with strong painkillers. Does that sound alright? Dr :Do you have any
concerns? Pt…

P a g e | 339

LEUKAEMIA– 30/MALE
Where you are

Who the patient is
Alan Hutton is a 30 years-old male
None
What you must do
Talk to the patient, take a focused history, perform relevant examinations and discuss
management with the patient.
P a g e | 340
CONSULTATION
16. GRIPS Patient [Greet, Rapport, Introduce, Posture, Smile]
Hello. Alan Hutton? Hi, my name is Dr. Swamy, I am one of the junior doctors here in the
department.
 Hi, Alan is fine
17. PC FODPARA  DDx  SR
 How can we help you today Alan?

 Doctor, I’ve been feeling really tired lately
 Can you tell me a little bit more?
 Normally I’m quite fit and well. What would you like to know?
 Is this the first time you’re experiencing these symptoms?
 Yes doctor
 Well it started suddenly, quite recently
 And for how long have you been feeling tired?
 Well I felt completely fine 2 weeks ago, but this last week has been really bad
 And has it been getting better or worse?

 Worse
 Is the tiredness aggravated by anything you do? Walking? Exercising? Resting?
 No Doctor
 And is it improved by anything? Resting? Medication? Activity?
 No Doctor
 Yes doctor, I do have this rash on my arm.
 May I take a look at the rash?
 Yes Doctor.
P a g e | 341
 Can you tell me a little bit more about the rash?

 Yes, it started about a month ago, I don’t think it’s serious
 Is this the first time you’re experiencing this rash?
 I did have a rash on my leg, but that went away
 All of a sudden
 And for how long have you been having rashes?
 Almost 2 months
 And has it been getting better or worse?
 They come and go, but they do get better. They have been coming more frequently.
 Are the rashes aggravated by anything you do? Exercising? Activity? Trauma?
 No Doctor
 And is it improved by anything? Resting? Medication? Activity?
 No Doctor
 No doctor
 Are the rashes painful? Do they itch? Do they bleed? Are they raised, flat or
sunken? What colour are they? Do they grow bigger, stay the same or get smaller?
 I don’t know doctor
9. Why am I tired all the time?
I’m not quite sure. I do have a few more questions to ask you. Maybe after answering
those I may have a better understanding.
P a g e | 342
 Leukaemia
 Meningitis
 Anaemia (Iron Deficiency, Blood
 Malignancy/Cancer
Loss)
 Hypothyroidism
 Lymphoma
 Bleeding Disorder
 Coeliac Disease
 Fever - NO
 Headaches? Vision Problems? Neck Pain? Dizziness? Confusion? Loss of
Consciousness? Seizures? – NO
 Bleeding Gums – YES, especially when I brush my teeth
 Chest Pain? Palpitations? - NO
 Shortness of breath? Difficulty breathing? Cough? Haemoptysis? – NO
 Tummy pains? Problem with passing your poo? Blood in poo? Diarrhoea?
Constipation? Altered bowel habits? – NO
 Problem with your wee? Blood in your wee? – NO
 Problem with your joints? Pain? Swelling? – NO
 Rashes elsewhere? YES, my arms both sides.
 Lumps & bumps? Nausea? Weight loss? Loss of appetite? Muscle aches? - NO
 Anything else I may have missed? – NO
18. 2PMAFTOSA
Unremarkable
19. EXAMINATION
In order to get a better understanding of what’s happening, is it ok for me to examine you?
– YES
VIII. VITALS - (Pulse 98/min, BP 120/80mmHg, RR 18/min, Temp 37.8°C, O2 Saturation

99%)
IX. SKIN – Rashes on arms bilaterally & left leg
X. HANDS – No pallor
XI. FACE – No pallor/jaundice. Hyperplastic, bleeding gums.
XII. CVS - Unremarkable
XIII. RESP - Unremarkable
P a g e | 343
XIV. GIT – Moderate splenomegaly

XV. LNs – Palpable
EXAMINER’S PROMPT: GIVE EXAMINATION FINDINGS WHEN

CANDIDATE MENTIONS WHAT HE/SHE WOULD LIKE TO EXAMINE
Thankyou Examiner.
20. FINDINGS & DIAGNOSIS
Ok Alan. Thank-you for letting me

examine you. From what you have told me,
you have been experiencing tiredness for
about a week, and you’ve also been
experiencing some rashes on your skin.
When I examined you, I noticed that there
was some bleeding from your gums and
your gums were enlarged. Also when I
examined your tummy your spleen was
enlarged. Some of your glands were
enlarged too.
 Are you following me? - YES
With the symptoms you are having, it’s

difficult from me to say exactly what it is
you have at the moment, as you are
exhibiting a few signs of illness. We do need to perform a few tests to get a better picture
of what is happening. It could be something as simple as an infection, however with the
particular symptoms that you have, such as tiredness, rash and bleeding gums, it could be
cancer of your blood.
*PAUSE – Check for Response*
Have I got cancer doctor?
At this point in time, it’s difficult for me to rule it out. You are experiencing a few
symptoms and some of those could be a feature of cancer. It is something we must
consider at this time.
 Are you ok to continue? – YES
 Do you know anything about Leukaemia? – NO

P a g e | 344
Leukaemia is cancer of the white blood cells, which are responsible for fighting off
infection. Acute Leukaemia means it progresses quite rapidly, and usually requires
immediate treatment.
So what’s going to happen to me?
21. INVESTIGATION
What I would like to do now Alan is perform a few routine investigations.
 FBC
 LFT
 RFT (Urea & Electrolytes)
 Coagulation Profile (PT, APTT, INR)
 Blood Group & Cross Match
 Blood Sugar Levels
22. MANAGEMENT
 I would like to book you an urgent referral to the blood specialist at the hospital –
called a Haematologist. This appointment would be within 2 weeks.
 Doctor, I wasn’t expecting to go to the hospital
I do understand it may come as a surprise, but it is something we must be pro-active about.
 They may perform some further tests such as;

o Blood Film
o CXR
o Bone Biopsy
 They may start you on some medications called chemotherapy.
 They may also give you something called radiotherapy.
 If however, you do experience a worsening of your symptoms, if at all you feel dizzy
or lose consciousness, do not hesitate to call an ambulance and pay a visit to the
A&E.
 I would like to just briefly consult with my seniors anything I may have missed or
was unable to answer so I can get back to you with the adequate information.
 I do have some reading material available with me to give you entitled – Leukaemia.
 Is there anything else I can help you with?
I do have a holiday booked for Spain in 5 days. Can I go?
Unfortunately, at this time I do believe that going on holiday is not the right thing to do, as
the Haematologist could invite you in for an appointment on any day in the next 2 weeks.
P a g e | 345
 Was there anything in particular you were expecting to get out of this consultation.
- NO
Tiredness - Hypothyroidism
Differentials
 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 anemia – 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
 Diabetes : increased thirst and hunger, Increased urination, family Hx of DM
 Endocrine diseases (eg, Addison disease) -
 Inflammatory bowel disease – tiredness, darkened skin
 Drug abuse – recreational drug use.
Exam question : -
60 year old presents with tiredness. History and management with the patient.
[Positive symptoms- Tiredness, weight gain, constipation, prefers hot weather]
Dr: Hello Mrs. .. I am Dr…. one of the junior doctor in the medical department.
How can I help you?
Pt: I am 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
P a g e | 346
constipated
Dr: Since when ?Pt: Since 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: No
Dr: Have you noticed bleeding from anywhere
like nose, gums ( Anaemia) ? Pt: No
Dr: Do you have SOB ( Anaemia, heart failure)
?Pt: No
Dr: Palpitation ( 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 I 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 :---
Dr: Have you noticed any changes in your
voice (hoarseness in Hypothryroidism) ?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 I the morning.
Dr: Any lumps and bumps in the body? Pt: No

Do you feel your tummy distended ( heart, liver kidney failure) ? Pt: No
Dr: Any swelling of feet ( heart failure)?Pt: No
Dr: Did you have this type of problems before? Pt: No
Pt: 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)
P a g e | 347
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 a lot doctor. I can’t work properly
Dr: Is there anything else you think is important that we need to know? Pt: No
Examination :
Dr: Mrs. I need to examine 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 in you. There are lot of conditions which can cause tiredness like
anaemia, diabetes, heart and liver failure, Vit D deficiency. We will do blood
investigations to check whether you have any of these problems. Sometimes it
could be due to underactive thyroid.
So we need to do blood tests to check some hormones in 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]
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.
Diagnosis: Mrs... with the information you have given me, I think you have
condition what we call as Hypothroidism otherwise called underactive thyroid.
Do you know anything about it? Pt: No
Dr: We have a butter fly shaped gland in front of the neck called thyroid gland
which normally produces some hormones called thyroid hormones.
These hormonesregulate the body's metabolism - the process that turns food into
energy.
An underactive 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 underactive thyroid are caused by the immune( body’s defence)
system attacking the thyroid gland and damaging it. Sometimes it can be due to
P a g e | 348
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?
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 underactive 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
underactive 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.

P a g e | 349
Patient with Uncontrolled Diabetes

You are 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?
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
doctor.
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: ..
P a g e | 350
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 it happened 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?
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.
P a g e | 351
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.
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?
Hyperthyroidism Weightloss
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 perlitre)

T4 - 35pmol/l ( Normal - 9.0 - 25.0 pmol/l (picomolesperlitre) T3
- 6pmol/l (Normal - 3.5-7.8 pmol/l (picomoles perlitre)
P a g e | 352
D/D
1. Thyrotoxicosis - heat intolerance, palpitation, ↑appetite, anxiety, family history of
thyroid disease or weightloss.
2. TB – cough, night sweats, travel history,contact,
3. Diabetes – Increased thirst and hunger, increased frequency of urination. Family
history ofdiabetes.
4. Cancer – lumps & bumps, change in bowel habit, cough, haemoptysis, Breastlumps,
5. HIV – sexual Hx,drugs.
6. Depressions - ↓mood, early morning awakening, suicidal thoughts. Recentjob,
changes/loss, separation frompartners
7. Anorexia nervosa – intentional, insight (do you think you have lost weight or only
others telling you this), role model. dieting, exercise, laxatives, diuretic, vomiting
(purging)
8. Drugs – metformin, opiates. slimmingagents,
9. Alcohol/smoking
10. Malabsorption- difficult to flush the stool in thetoilet.
11. Malnutrition – how is the diet ( healthy eatinghabits)
12. Addison’s disease – weakness, dizziness. ↑d pigmentation over palmercrease.
13. Coeliac/crohn’s – diarrhoea with blood mucus, painabdomen

P a g e | 353
PositveHx - How much, how long - Lost 5 kg in 2months,↑appetite, Palpitation,
Examination
Miss – I need to examine your hands, eyes and yourneck.
( examiner did not give anyfinding’s)
Invt.
TFT - T3 N, T4 TSH ↓
↑,
Isotope scan (swallow radioactive substance in capsule orliquid), Technetium
Rx – thionamides (carbamazole, prophylthiouracil)
Beta blockers
Radio-iodine – shrinks Thyroid – so ↓

hormones
Surgery – if recurrent overactive thyroid.

HYPERPARATHYROIDISM
Exam question:
You are the FY2 doctor in the GP Clinic.
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 focused history and discuss management
with patient.
TEST RESULTS :
PTH : 7.1 pmol/l (approx). Normal : 1.6 - 6.9 pmol/L
P a g e | 354
Serum calcium : slightly higher . Normal : 2.2 to 2.6 mmol/l

Dr: Hello, Are you Ms. A?
pt: Yes,
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.
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 traumatizing happen before this started? Pt: no dr.
Dr: anything else you had? pt: I have also not been sleeping well dr.
Dr: can you pls tell me more about that like 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.
Dr: anything else you had? pt: like what dr?
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 wt? Change in diet? Pt: no
Dr: Any racing of the heart? Pt: No
Pt : I have high blood pressure dr. ( Is 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 though 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
Dr:You have been very helpful. Now I’d like to examine you. I ll be checking for Pulse, bp,
temperature and 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

P a g e | 355
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 estrogen, 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?

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 Bisphosphanates. 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

5. Hypoglyceamia in Taxi driver
Question:
Young man– known patient of Insulin dependent diabetes. He was in a party few days
ago and ate lot of sweets. He injected himself with the 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.
P a g e | 356
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 about diabetes ? Any problems ?
He gives the story of being in a party and eating a lot of sweets and injected himself large
dose of Insulin one month ago. He almost passed out while driving. He stopped and ate
chocolate and felt better.
Ask about any such incidents any other time?

Is he controlling 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 what we call as HbA1c which tells us how was your
sugar level in your blood 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 eyes and kidneys and nerves in the legs.
The incident what happened after taking large dose of Insulin is what we call as
Hypoglycaemia means having very low blood sugar in the blood.
Dr: Has this incident happened before ? Pt; No
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.
So please do not inject large doses of Insulin even if you eat lot of sugar.
So it is better to control sugar well.
Eat healthy balanced diet. Avoid eating too much sugar.

Do regular exercise.
Warn about early symptoms of Hypoglycaemia;
Shakiness, Dizziness, Sweating, Hunger, Irritability or moodiness, Anxiety or nervousness,

Headache. If any such symptoms eat chocolate of sugary drinks. Keep sweets at all times
with him.
Ask whether he has glucometer at home? Measure sugar at home.
Advise to avoid hypoglycaemia in the future:

Injecting large dose of Insulin,
P a g e | 357
Eating less food, Or skipping meals

More than usual exercise.
Record the readings in the diabetic diary.
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 do what do you do for 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 again
the prevent hypoglycaemia.
Please wear your diabetic bracelet at all times.
Keep the sugar level Type 1 diabetes –

Upon waking - Before meals At least 90 minutes after meals
5 to 7 mmol/L 4 to 7 mmol/L 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 HYPERLINK "https://www.diabetes.co.uk/type1-diabetes.html"diabeteshave
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: [18]
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.
P a g e | 358
But in recent years, several people with type 1 diabetes have been judged as suitable for blue
light driving. 1
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 treatment
Question :-
You are the FY2 doctor in the A& E department. There is a patient in the department.
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.
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 in you tube : www.youtube.com/watch?v=rMMpeLLgdgY )
Examiner gives the blood glucose level 2.1 mmol ( very low)
[ normal bood 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].
Tell the patient your blood sugar is very low. We need to give you glucose urgently through
your vein.
[ There were 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.

P a g e | 359
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
• Skipped meal
• Not had enough food
• Not had food containing high sugar
• Over dose of Insulin
• Over exercise
If you find any reason – tell him to avoid that to prevent this happening again
Check awareness of Hypoglycaemia symptoms.
Refer him to Diabetic team for further management.
Information of 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.

2. DKA
30 year lady ( suspected) diagnosed of DKA. You are called to the emergency department to
assess patient.
Take history and discuss management with her. She is refusing admission. Talk to her.
BP – 90/45, Pulse – high, RR – 15, O2 sat – 96%

Ask her problems
She had tummy pain when she went to drop her children to school. Had nausea, had 2 loose
stools.
Ask in detail about pain abdomen ( Socrates),
P a g e | 360
Ask about fever, headache, chest pains

Ask about symptoms dehydration ( dehydration is complication of DKA) ( decreased urine
output, drowsiness, increased thirst)
No need to rule out differentials if the condition is already diagnosed.
( if the question say suspected then go through differentials – Ruptured ectopic pregnancy,
UTI, PID, Ureteric calculus, Gastroenteritis)
Past history – is it first time, Any medical conditions – she may say she has diabetes since she
was 14 years old. She taking insulin for that.
Ask more questions for triggers of DKA - infections, chest symptoms, cough, dysuria, )
Main trigger factor is not taking Insulin – ask her whether she is taking insulin regularly, has
been checking sugar regularly, if she is not taking insulin regularly why she is not taking
regularly.
[ she may say that she was not eating well and also not taking Insulin for the last few days
because she was too busy]
Was she admitted previously for such problems
Smoking, alcohol,
Ask about - Family hX, allergy, any other medications,
I need to examine you – your tummy chest, I need to check your pulse, blood pressure and
temperature. Check for NEWS chart.
I need to do investigations to find the cause - blood sugar level, blood investigations to
check for infection markers, blood gases, urine for sugar and ketones and dipstix to check for
infection and send for culture
Other investigations ( chest x ray if she has cough and chest pain)
Abdomimal x ray.
Examiner may show blood test result- sugar – 30mmol, ABG shows – metabolic acidosis –
ph low, CO2 may be high or normal , HCO3 will be low) Urine – glucose+++, Ketone+++
( Blood test results may be already given in the question).
Urine shows glycosuria,
Diagnosis
I think you have a condition called Diabetes keto acidosis. 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 also very high what we call as ketone bodies. This causes a problem called
acidosis.
P a g e | 361
This also causes severe dehydration.
Unfortunately, this is 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.
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.
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 be even life
threatening if we do not admit and treat to 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 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 the patient does not agree for admission – say you will talk to seniors and may be they will
convince her for the admission. 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 did not agree at all – tell her she has to sign a form for discharge against medical
advice and then she can go home.
P a g e | 362
2372 Video not availble

Postural Hypotension
Causes of falls
Non Medical Medical

Poor vision
Poor light Balance problem ( cerebellar)
Slippery floor Postural hypotension ( medications)
tripping Diabetes Heart arrhythmia
Pushed( Abuse) Alcohol
Osteoporosis
Dementia
Drugs causing Postural Hypotension
• Hypertensive/Cardiac medications
o Methyldopa
o Clonidine
o Alpha blockers- Prazosin, Terazosin
o Beta-1 blockers (Atenolol)
o Nitrates
o Cardioselective CCBs (Verapamil, Diltiazem)
• Genitourinary
o Alpha blockers- Prazosin
o Phosphodiesterase Inhibitors (Cialis, Viagra)
o Anticholinergics (Oxybutynin)
• Neuropsychiatric
o TCAs- Amitriptyline
o Antipsychotics- Clozapine
o Muscle relaxants- Baclofen
o Antiparkinsonian 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 bedrest and
those aged over 74. However, it is not confined to the older population.
P a g e | 363
It can be caused by:
Hypovolaemia; Diabetes; Peripheral neuropathy

Parkinson’s disease; Anaemia; Adrenal insufficiency
EXAM question
You are FY2 in the medical department.

64 year old lady presents with complaints of few falls last week.
Take history, do relevant examination and discuss management with the patient.
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 all of a sudden 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 also I was doing window shopping in the town centre and I suddenly fell.
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.. Have you lost 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 problem 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 Parkinsons ? Pt : No
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? P: I can't remember the
name doctor
P a g e | 364
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 for how many years you have had high BP?
P: > 10 years
Dr: Has the medications been changed recently.
P: Yes about 2 weeks ago GP changed my blood pressure medication.
Dr: Have 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 is 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 a heart tracing. (Examiner may hand over an ECG- usually
normal)
And check your blood for the sugar levels and check for anaemia. (Examiner says –
Normal).
Diagnosis:
Dr: Mrs... based on the information you have told 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 caused by other medical conditions like Diabetes o
Parkinson’s disease. However in your case it might be due to your new BP medication.
Certain blood pressure mediations 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: Sometime this can happen if you stand for long time or even when you change your
posture like bending down. Pt: OK
Treatment:
Dr: We will admit you now to the hospital. We will get in touch with your GP to find out
P a g e | 365
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 worst in the morning. Get out of beds 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 the bed.
Drink plenty of fluids and also drink strong tea or coffee. Take small frequent meals
because some people have large drops in blood pressure after meals.
Avoid drinking excess alcohol.
If none of these measures helps you 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) Are you following me ?
Pt : Yes. Dr: Any other questions ? Pt : No Thank you

Chest Discomfort – Arrhythmias (A3)- Repeated 20353
Causes of palpitation:
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
2. 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
P a g e | 366
Hypertrophic cardiomyopathy, Mechanical prosthetic valves

2. Psychosomatic disorders
Anxiety, panic attacks, Depression, somatization disorders
2. Systemic causes
Hyperthyroidism, hypoglycaemia, postmenopausal syndrome, fever,
anaemia, pregnancy, hypovolaemia, orthostatic hypotension,
postural orthostatic tachycardia syndrome, pheochromocytoma,
arteriovenous fistula
2. 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
Pheochromocytomais 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)
Exam question
You are 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 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 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 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.
P a g e | 367
Dr: Mr… Do you have any idea how this started – like anything triggered these symptoms?
D: Did you have any sad or shocking news before these symptoms started ( post traumatic
stress syndrome) ? Pt : No
Dr: Does anything makes better or worse? Pt: No/When I sit I feel better.
Dr: I see. Could you please tell me does it happen 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? (Hypoglycemia)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
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)
P a g e | 368
Dr: From the information what you have given me, it seems likely that you have what we call
as 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.
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 reason – if he is
drinking too much coffee].
Also Mr X since your father and brother had heart problems there could be 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 perform an HYPERLINK "https://patient.info/health/electrocardiogram-

ecg"electrocardiogram (ECG HYPERLINK
"https://patient.info/health/electrocardiogram-ecg") HYPERLINK
"https://patient.info/health/electrocardiogram-ecg"heart HYPERLINK
"https://patient.info/health/electrocardiogram-ecg" 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 HYPERLINK
"https://patient.info/health/ambulatory-electrocardiogram-ecg"ambulatory ECG or
HYPERLINK "https://patient.info/health/ambulatory-electrocardiogram-ecg"Holter
HYPERLINK "https://patient.info/health/ambulatory-electrocardiogram-ecg" Monitoring.
HYPERLINK "https://patient.info/health/ambulatory-electrocardiogram-ecg"
In some cases you may need a scan of the heart, called an HYPERLINK
"https://patient.info/health/echocardiogram"Echocardiogram HYPERLINK
"https://patient.info/health/echocardiogram". Also, we may need to do aChestXRay for you.
We do other investigations like some Blood Tests to check for anaemia or any overactive
P a g e | 369
HYPERLINK "https://patient.info/health/overactive-thyroid-gland-
hyperthyroidism"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. heart specialist. If there is 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.
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.

[ exam question]
Day case surgery – Pin( screw) removal
Mr Alex Thomas 50 year old man had fracture ankle 18 months ago which was fixed with
the pins. Now the fracture has healed. He has come for pin removal.
P a g e | 370
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.
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 regards 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 me give me general Anaesthesia?
Dr: We may be able to do it under local anesthesia 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 anesthesia 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 few questions regarding your health and I will be examining you
later and also we may do some tests on you. Is that Ok? - Pt: Yes doctor.
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 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 any one to look after you after the operation ?
Pt: Yes, my neighbor will pick up and drop me back to home after the operation.
Dr: You should have some adult to look after you at home at least for 24 hours after we
send you home. They should stay at your home to look after you. Do you have any one
like that to look after you?
Pt: Ok doctor I will ask my neighbor. They will do that. ( If patient says he cannot
arrange any one to stay at his home to look after him – tell him that we may not be able
to do it as day case surgery then we may need to keep you in the hospital for a day at
P a g e | 371
least before we can discharge)

Dr: How far away 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 yur
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. Examiner may say – all tests normal.
Counselling:-
- Dr: Mr Thomas, with the information what 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
empty stomach at least for 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?
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 necessary 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
anti-sickness medication and if it helps then we can send you home but if you
continuously keep vomiting even after the 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 at that time
and wait for some time and if everything is fine, we will discharge you on the same day.
After the procedure and do not sign any important documents or work near heavy
machinery at least for 24 hours.
Please do not drive until you are able to apply emergency break without any problem
which may take about 2 weeks.
Also make someone stay with you to look after you at least for 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
P a g e | 372
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.

Inguinal Hernia Pre-operative Assessment & Address
concerns
You are FY2 Doctor in Surgical Department.
45 years old man has been admitted to the ward for the Hernia Operation.
On pre-operative assessment, 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...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 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 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 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)
P a g e | 373
Dr: Are you following me? Pt: Yes, doctor.
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 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 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 of 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 the 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 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?
P a g e | 374
Pt: Yes. I work in a warehouse.
Dr: Okay, Mr... I would now like to explain you how we are going to do the operation. 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: He said 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 to 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.
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
P a g e | 375
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 is 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 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 exercises 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 any one to look after you after the
operation ?Pt: Yes/No?
Dr: You should have someone to look after you at home at least for 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?

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 come 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 high fibre diet and drink plenty of fluids to avoid having constipation.
P a g e | 376
Pt: Yes doctor.

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 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 concerns?
Pt: No, thank you doctor. You have been very kind.
Tiredness : Chronic fatigue syndrome

Differentials
 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 anemia – 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) -
 Inflammatory bowel disease – tiredness, darkened skin
 Drug abuse – recreational drug use.
P a g e | 377
Causes of chronic fatigue syndrome
Exactly what causes chronic fatigue syndrome (CFS) is unknown, but there are several theories.
Post viral or bacterial infectioneg: glandular fever, pneumonia.
Diagnosing CFS
1) Other conditions should be ruled out ( FBC for Hb, LFT, TFT, U&Es, etc
2) 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
 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
3) 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.
Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is a type of talking therapy.
It works by helping you accept your diagnosis and trying to increase your sense of control over your
symptoms
Graded exercise therapy

Graded exercise therapy (GET) is a structured exercise programme that aims to gradually
increase:
 the length of time you do the exercise

 the intensity of the exercise
P a g e | 378
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.
Painkillers
Antidepressants if you have depression.
Antiemetic - If you experience severe nausea.
Lifestyle advice
As well as these treatments, you may find the lifestyle advice below helpful.
Pacing
Pacing may be a useful way of controlling CFS symptoms. It involves balancing periods of activity
with periods of rest.
Other recommendations
The following recommendations may also help:
 avoid stressful situations

 avoid alcohol, caffeine,
Exam question Chronic Fatigue Syndrome

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 did not have body ache – give chronic fatigue syndrome as
diagnosis]
Dr: Hello Mr John Paterson. I am Dr…. one of the junior doctor 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 am feeling very tired for the last few months.
Dr: Since when exactly this problem started?
Pt: Almost 6 months now doctor?
Dr: Can you figure out what would have triggered this thing at all?
P a g e | 379
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 few days.
Dr: May I ask what job do 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 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
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 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, Bloated tummy -No, 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 problems 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 My wife gets very annoyed with me.
P a g e | 380
Dr:I am very sorry to hear that. We will try our best you 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, 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 happened 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 VitD 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 is no specific
medications to treat this conditions.
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 VitDsuppliments. You need to have more sun
exposure which helps Vit D production in the body.
If it is chronic fatigue syndrome;
We have something what we call Cognitive behavioural therapy- a kind talking therapy which
helps you to accept this condition and cope with that. Then our physiotherapists can teachyou
graded exercisewhere you gradually increase your body strength by gradually increasing the
exercise. Are you following me ?
P a g e | 381
Pt: Yes
Dr: Also we can give you medications like pain killers if you have pain, anti-depressant
medications if you feel low.
Also certain life style 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.
Tiredness –Fibromyalgia
Causes of chronic tiredness

Heart failure Depression
Liver failureVit D Deficiency
Kidney failureChronic fatigue syndrome
HypothyroidismFibromyalagia
AnaemiaHIV
Cancer
Fibromyalgia, also called fibromyalgia syndrome (FMS), is a long-term condition that causes
pain all over the body.
Symptoms
Widespread pain
This may be felt throughout your body, but could be worse in particular areas, such as your back or
neck.
P a g e | 382
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 topain
 allodynia – when you feel pain from something that shouldn't be painful at all, such as a
very lighttouch
Stiffness
Fibromyalgia can make you feel stiff.
Fatigue
Fibromyalgia can cause fatigue - extreme tiredness, you may feel too tired to do anything at all.
Poor sleep quality

Fibromyalgia can affect your sleep. You may feel you are not refreshed when you get up.
Cognitive problems ('fibro-fog') you may have:

 trouble remembering and learning newthings
 problems with attention andconcentration
 slowed or confusedspeech
Headaches
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.
Other symptoms
 dizziness andclumsiness
 feeling too hot or too cold – this is because you're not able to regulate your body
temperatureproperly
 restless legs syndrome (an overwhelming urge to move yourlegs)
 tingling, numbness, prickling or burning sensations in your hands and feet (pins and
needles, also known asparaesthesia)
 in women, unusually painfulperiods
Depression
 constantly feelinglow
 feeling hopeless andhelpless
losing interest in the things you usuallyenjoy
Causes of fibromyalgia
The exact cause is unknown, but it's likely that a number of factors are involved such as
P a g e | 383
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.
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 viralinfection
 givingbirth
 having anoperation
 the breakdown of arelationship
 being in an abusiverelationship
 the death of a lovedone
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-
termtiredness
 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 andbalance
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
P a g e | 384
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 differentareas.
 your symptoms have stayed at a similar level for at least threemonths
no other reason for your symptoms has beenfound
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.
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 fluoxetineand 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. 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
P a g e | 385
pain of fibromyalgia, such as:

 swimming, sitting or exercising in a heated pool or warmwater
 an individually tailored exerciseprogramme

 cognitive behavioural therapy (CBT) – a talking therapy that aims to changethe way you
think about things, so you can tackle problems morepositively
 psychotherapy – a talking therapy that helps you understand and deal withyour thoughts
andfeelings
 relaxationtechniques
 psychological support – any kind of counselling or support group that helps you deal with
issues caused byfibromyalgia
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 organisations (Fibromyalgia's support group) to support people with

fibromyalgia.
Exercise
An exercise programme 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 programme, 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.
Relaxation can help stress.

P a g e | 386
Talking therapies, such as counselling, 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 everymorning
 try to relax before going tobed

 try to create a bedtime routine, such as taking a bath and drinking a warm, milky drink
everynight
 avoid caffeine, nicotine and alcohol before going tobed
 avoid eating a heavy meal late atnight
 make sure your bedroom is a comfortable temperature, and is quiet anddark
avoid checking the time throughout thenight
Examquestion Tiredness ( ?Fibromyalgia)
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]
[Positive symptoms- Tiredness, body pain and sleep disturbance]
Dr: Hello Mr James Paterson. I am Dr…. one of the junior doctor 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 am 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 having body ache also. I can’t do my work properly.
Dr: Since when exactly all these problems started? 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 few days. Dr: May
I ask what job do 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 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 are you having this? Pt:
P a g e | 387
Since again about 6 months.

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 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 Pt: Do
feel 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 ( Multiplesclerosis)? 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 ?-NoDr: Any
medical conditions or any cancers in the family members ? - No Dr: How much
does this affects yourlife?
Pt: It affects 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 you 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
fibromyalgia syndrome (FMS). It is a long-term condition that causes pain all over the
body and tiredness.
Pt: Why did this happened doctor?

Dr: The exact cause why this happens to anyone is not known but it's 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 VitD 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.
P a g e | 388
Treatment:
If there is Vit D deficiency we will give you VitDsuppliments. 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 are like we can give
 medications– such as antidepressants and painkillers for depression andpain.
We have something what we call Cognitive behavioural therapy - a kind talking
 Lifestyle changes – such as exercise programmes swimming, cycling can help, also
relaxation techniques canhelp.
 Pacing where you balance your period of activity and rest also canhelp.
 Better sleeping habits like trying to going to bed and getting up same timeevery day
and relaxing before going to bed can help. Also avoid drinking coffee or smoking
before going to bed can alsohelp.
 Some people find alternative therapies like acupuncture and massagehelpful.
 You can join Fibromyalgia support group. That may be very helpful to you.
Pt: Thank youdoctor.
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 – COPD patient on inhalers
Question
Old lady presents with tiredness for 2 months. Known COPD patient. GP did blood
investigations and referred to the hospital. History and 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 Corticosteriod inhalers.

Ask about diarrheoa, vomit ( can cause hypovolumic 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 chronic condition – so no need to admit
P a g e | 389
and treat for hyponatremia).
Causes of hyponatremia
Hypovolemic hyponatremia Euvolemic hyponatremia Hypervolemic hyponatremia
Renal loss SIADH Congestive Cardiac failure

Diuretic therapy Cerebral salt Drugs: (not complete list) Liver cirrhosis
wasting Adrenocortical SSRI, Carbamazepine Nephrotic syndrome
insufficiency Salt wasting Desmopressin, Phenothiazines
nephropathy Tricyclic antidepressants,
Cyclophosphamide, Opioids
Extra renal loss Vincristine, NSAIDS,
Diarrhoea Vomiting Excessive Clofibrate, Proton pump
sweating inhibitor
Third space loss: Pulmonary causes:

Small bowel obstruction Pneumonia,
Pancreatitis Pulmonary abscess
Burns Tuberculosis
Neoplastic: Small cell lung
cancer Lymphoma
CNS: Meningitis Stroke
Tumours
Post operative pain
Adrenocortical insufficiency
Hypothyroidism
Primary polydipsia

Tiredness Obstructive Sleep Apnoea
You are Fy2 in GP Clinic. Mr. Smith, 45 years old male, has come to clinic today
with sleeping problem for past 2 months.
Talk to him, take history and discuss appropriate management with him.
Hello, Mr. Smith, My name is Dr. ---------------, I am one of the junior doctors in clinic
P a g e | 390
today.
How can I help you today?
Pt: Dr. I feel tired all the time.
Dr: Mr. Smith can you please elaborate, what do mean by tiredness?
Pt: Doctor I feel as if I don’t have any energy to do work during day.
Dr: Since when are you 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: can’t think of anything doctor.
Dr: Have you tried anything which has helped you with tiredness? Pt: No, haven’t tried
anything.
Dr: Is there anything which makes it worse? Pt: No doctor 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: Have 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.
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.
P a g e | 391
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 apnoea worse.)
Dr: May I know what do you do for 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 tell us? Pt: No doctor.
Diagnosis
Mr. Smith from our discussion it seems that you are feeling tired all the time because of
a condition we call as Obstructive sleep apnoea. 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.
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 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 do test called Polysomnography to study sleep problem .
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 apnoea then you can do few things which will be of
great benefit. Would you like to know those?
Pt: Yes, What are those?
Dr: These include life style changes like sleeping on your side, losing weight (if over-
P a g e | 392
weight), reducing the amount of alcohol you drink and avoiding sedatives at night.
These 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 Apnoea 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:--------------.
Thankyou.

TIREDNESS – CITALOPRAM
Exam question
50 years old female complaining of tiredness you are the Fy2 in G.P Clinic. Take 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?
ODPIPARA
P- I am having tiredness since past 3 months Doctor. My friend died 3 months back and after
that I was depressed and so psychiatrist prescribed me this medication- Citalopram.
D- Ok I am very sorry to hear about your friend. Please accept my condolence.
D- were you alright before these symptoms started?........ Yes doctor
D/Ds
P a g e | 393
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 the day or at any specific time of the day like morning or evening ?... all the day.
D- DO you have any pain anywhere in the body ?.... no
D- Any pain in bone pain ? …. No
D- Bleeding from anywhere in your body like from back passage? … No
D- Weight loss or lumps or bumps any where 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.
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?
Thankyou for giving me all the vital information.
Examination: Now I would like to exam you. I would like to check your vitals, Do a general
physical examination to check if there is any bleed 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 what exactly 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 Citallopram
Treatment: well for 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 Psychiatrist for further evaluation as your mood is still low and also to
change the medication.
Do you have any concerns?
No doctor.
Thankyou.
Information on Citallopram 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.

P a g e | 394
 Citalopram-induced syndrome of inappropriate antidiuretic hormone secretion
(SIADH) causing hyponatremia is well documented; however,
severehyponatremia 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.

TIREDNESS ? CFS, ? ANEMIA
30 yearold female c/o tiredness for the past 18 months. Rest is not making it better.
Previously has been treated for anemia.
All histories of tiredness is negative, goes to sleep but cant 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. Some say : Mother has dementia, she has children too to take care of and is
stressed. Some say family and friends are alright, has no problem with work.
Previously treated for depression 2 years ago, stopped after consulting with psychiatrist. No
suicidal ideation now.
Recently changed house and worked and moved to a new place.
Pt asks “dr do you think I have some problem?”

P a g e | 395
6. Statin Therapy
Cholesterol level - Healthy adults should have a total cholesterol level below5 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 cholesterolto 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.
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.
Question
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.
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
what was the reason why you had the blood tests for ?
P a g e | 396
58.
Pt: I just wanted to have a general check up / I had ... ( symptoms) / I was worried about getting
stroke/ heart problem.
Dr: How is your general health now ? Pt: I am OK
Dr: Have you diagnosed with any medical conditions ? Pt: Yes / no
Dr: High blood pressure, Diabetes, Liver problems ( liver disease is a contra indication) ? Pt: No
Dr: Do you get any chest pains or shortness of breath 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 contra indication)
Dr: Any medical conditions in family members? Pt: No
Dr: May I know do you have any concerns about your health ?
Pt: My friend had stroke I am worried about it?
Dr: Sorry to hear about your friend. May I know if your friend had a stroke why are you worried
about getting stroke ?
Pt: He was told he had high cholesterol and because of that he got stroke. I am worried whether I
too have high cholesterol and whether I will also get stroke.
Dr: You are right Mrs.. Having high cholesterol is one of the risk factor 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 ?
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 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 test is
and blood sugar are normal. However, some blood tests are not normal.
It shows that your cholesterol content in the blood is quite high.
59.
P a g e | 397
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 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.
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 the cholesterol levels.
Pt: How can I reduce the cholesterol level ?
Dr: There are many way 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.
60.
P a g e | 398
"Statins" is 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.
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.
Very rarely it can cause severe muscle pains. Also rarely it can damage 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
Dr: One of the main reason is eating an unhealthy diet – in particular, eating high levels of fat.
May I ask what type of food you eat on 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 fish that is whit meat which contain less cholesterol. Also you
should include 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. What do you think?
Pt: Yes doctor I will consider that.
61.
P a g e | 399
Dr: Other reasons are – smoking and drinking too much alcohol. If you have those habits I advise
you to stop itand 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. 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 healthy life styles.
Any other concerns ? No. I hope you have a healthy and happy life. Thank you.
4 Types of statin
There are five types of statin available via prescription in the UK:
atorvastatin (Lipitor)
fluvastatin (Lescol)
pravastatin (Lipostat)
rosuvastatin (Crestor)
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:
o active liver disease
o pregnancy
P a g e | 400
8.Middle aged lady Obesity talk to her.

Exam question
55 year female came with of over weight,talk to her and address her concerns
History –
to find the cause of overweight,
Any complications already due to overweight,
Any symptoms of complications,
Contraindications for medication,
Allergy
Assess the knowledge of risk of overweight
I am obese I want lose weight.
It is really good that you have come to us. Certainly we can help with that.
Take history to r/o hypothyroidism ( do you have problem tolerating hot or cold
weather? Any constipation?)
Any medications ( steroids)
Lack of physical activity – do you do any exercise ? What is your job ( ? sedentary job)
Familial cause – any of your family members are overweight ? Yes
Diet – what do you eat on a regular basis – eats junk food and says can’t stop eating.
Have you tried losing weight yourself – by cutting down on eating fatty food exercising?
Have you taken any weight reducing medications ?any weight reduction surgeries in the
past?
Do you have any problems because of overweight?
Do you know what problems you can have because of over weight ?
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
P a g e | 401
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.
 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.
P a g e | 402
eat slowly and avoid situations where you know you could be tempted to overeat
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
You may can 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:
gastric band – a band is placed around the stomach, so you don't need to eat as much to feel
full
gastric bypass – the top part of the stomach is joined to the small intestine, so you feel
fuller sooner and don't absorb as many calories from food
sleeve gastrectomy – some of the stomach is removed, so you can't eat as much as you could
before and you'll feel full sooner
All these operations can lead to significant weight loss within a few years, but each has
advantages and disadvantages.
P a g e | 403
Life after weight loss surgery
Weight loss surgery can achieve dramatic weight loss, but it's not a cure for obesity on its
own.
You'll need to commit to making permanent lifestyle changes after surgery to avoid putting
weight back on.
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
exercise regularly – once you've recovered from surgery, you'll be advised to start an exercise
plan and continue it for life
attend regular follow-up appointments to check how things are going after surgery and get
advice or support if you need it
Women who have weight loss surgery will also usually need to avoid becoming pregnant
during the first 12 to 18 months after surgery.
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.
8. PSORIASIS AND VASCULAR DEMENTIA

INTRODUCTION
P a g e | 404
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)
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
P a g e | 405
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.
Question:-
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- Psorias 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?
P a g e | 406
Do you have difficulty in walking or keeping balance?

Are you able to do your daily activities?
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..
M- what kind of food you eat outside?
P- Due to insufficient time, I eat in fast food outlets
M- 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?
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?
M- 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?
M- I shall be doing some blood tests to check your cholesterol level and Q risk assessment to
see your risk of having stroke..
P a g e | 407
Massive stroke – Palliative care BBN

60 year old man was admitted one week ago with ischemic stroke. He had another
ischemic stroke now. GCS is only 3. MDT decided for DNAR and not to ventilate.
Planned for palliative care only.
You talk to the daughter who is pregnant.
Assess knowledge
Break the news. He has a massive stroke ( there is 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 breathing machine if he
stops breathing because any of these procedures o not help him.
Address concerns
Her main concern
Can you please keep him alive until my baby is born which may be next week ?
First of all congratulations on your pregnancy and 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 resuscitation if his heart stops beating or if
he stops breathing also.
Ask – any other concerns – Any help required.

Post MI Discharge & Lifestyle Modifications
You are medical FY2 in cardiology ward.
60 years old Mr.... was admitted with a chest pain a few days ago and was treated
for Acute Myocardial Infarction. Now, he is stable on medical therapy and is fit to
be discharged. Your consultant has commenced him on the medical therapy. Talk
to the patient, assess him clinically, and speak to him about lifestyle modifications.
P a g e | 408
Dr: Good morining, Mr... I am Dr .... One of the junior doctor in the cardiology dept.
How are you doing today? Pt: I am well doctor. I am going home today.
Dr: Congratualtions. 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 do 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 that to you.
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 heart leading to damage of the heart
muscle. Do you follow me?
Pt: Yes doctor.

Dr: We have given you apropriate treatment to restore the blood supply to heart. Though,
you are doing well, sometimes this condition can be really serious and even life
threatening. And we want what is the 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. Are you
understanding?
Pt: Yes doctor. What are these risk factors?
Dr: There are lot of others risk factors why people get heart attack. I would like to ask
you a few questions to know if you have any of those 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.
Dr: Do you have any heartproblems 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 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?)
P a g e | 409
Dr: High blood pressure is one of the major risk factor which can cause lead to
weakening of 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 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 do you eat usually?
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, burger, steaksetc
Dr: Mr, the kind of food what 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
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 also 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. Can I ask do you do 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.
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 lot 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 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. May be you can take some relaxation classes and yoga classes which
might help you to relieve from 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.
P a g e | 410
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.
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 the 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 advices what 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 life style. This can
substantially reduce the risk of you getting heart attack.
Pt: Ok thank you very much doctor.
Dr: I sincerely advise you to follow all the advices. 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 the ambulance and come to the hospital immediately
because these are the symptoms of serious condition. Is that okay Mr... ? Pt : Ok
doctor.
Dr: Any other questions ? Pt : No doctor. You have been very kind.

P a g e | 411
SMOKING
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.
Dr:HelloMrsJoanThomas,IamDr.....oneofthejuniordoctorinthemedicaldepartment. 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.Iamheretotalkto you aboutyourhealthconditionandtoadviseyouhowyoucanprevent
that problem in the future. Is that OK?
Pt: OK
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 some thing like a minor heart attack. Let me explain that to
you.
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 casewhichhascausedreducedbloodsupplytoyourheartmuscle.Thatiswhyyouhadthis
paininyourchest.Wearedoingaprocedurecalledangioplastywherewearewideningthis 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 this blood vessels would have become narrowed?
Pt: No
Dr: There several reasons why this blood vessels can become narrow. Sometimes this
happenswiththosepeoplewhodonoteathealthybalanceddietorwhodonotdoexercise or
who have some medical conditions like high blood pressure or diabetes. Can I ask you
how is yourdiet? Pt: I eat healthy diet doctor.
Dr: That is very good to know. Please continue eating healthy food. Do you do
exercise ? Pt: Yes doctor.
Dr:Thatisalsoverygood.Pleasedocontinuedoing exercises.(Ifshesaidno–Iadviseyou to
do some good exercises . That will be very good for your heart and yourhealth).
Pt:OK
Dr: Do you have any medical conditions like high blood pressure or
diabetes? Pt: No
P a g e | 412
Dr:Thatisexcellent. Thatmeansitisnonoftheseproblemswhicharecausingtheproblem
inyourheart.Oneotherreasonwhypeoplegetthisproblemintheheartissmokingforlong
time.
Can I ask you do 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 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 whole of his life
he had no health problem at all ? ( there are so many people 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 long time do get lot of health problmes like stroke, cancers, high blood
pressure and including heart
attack.Insomepeopleskinbecomesmorewrinkled.Alsopeoplestayneartoyougetpassive
smoking which can hppen even to your children if you have at home. You may be
spending lot of money on smoking Iguess.
You already had some minor heart problem in your heart now. If you continue that you can
get major heart attack next time and it may be even life threatening. I am sure you don‘t
wantthat to happen to you isn’t it ?
Pt: You said you are going to widen the blood vessels in my heart. So why should I get
this problem again?
Dr: Mrs Thomas we are treating this condition now, but if you continue smoking - blood
vesselsinyourheartwillbecomenarrowagainanditcancauseseriousproblemnexttime.
There are many benefits of stopping the smoking:
Carbon monoxide and nicotine will be eliminated from the body, blood circulation will
improve.Lungsstarttoclearoutsmokingdebris.Skinbecomeslesswrinkled.Coughingand
wheezingstop.
Excess risk of heart attack and lung cancers reduces by half. Also you could save 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
P a g e | 413
health. If you want to enjoy your life you need to remain healthy. You can try doing some
otherthingstoenjoylifewhichwillbegoodforyourhealth–maybegoingforsomeexercise
classes,relaxationtherapyoryogaclasseswhereyoumeetlotofpeopleandyoumayenjoy that.
If you wish we can help you in stopping smoking. We have some thing called as
smoking cessation clinic. I can refer you to them. There are support help groups. You
may be benefitted from that.
WealsohavesomemedicinescalledBupropionandVareniclinewhichcanhelpinstopping
the craving for cigarettes, but at the end of the day it is your willpower that is the most
importantthing.WhatdoyousayMrsThomas?Do you wanttoconsiderthis?
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.
(ifshesaidnoIcan’tstopsmoking-Icanunderstandthatitisnoteasytogiveupthehabits.
However, youmayneedmoretimetothinkoverthat.Iadviseyoutothinkaboutitseriously and
let us know any time if you need our help, we are always here to helpyou.
Thank you very much.
[ do not mention - I will tell my seniors – they will come to talk to you]
BENEFITS FROM SMOKING CESSATION WITH TIME SINCE
Time BENEFITS
since
quitting
20 minutes Pulse return to normal.
8hours Nicotinelevelisreducedby90%, 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.
P a g e | 414
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
ISSUE SOLUTION
 “All the “There are immediate benefits from the day you quit”.
damageis
already
done”.
 I am already 70, I want You are only 70, you have many more years to live
enjoythe rest of mylife. happily. You can enjoy your
 “A lot of doctorssmoke”. “Very few doctors’ smoke and many more have
given up”.
 “I’ve switched to a “The health claims about low tar cigarettes are very
lowtar cigarette”. misleading. People tend to inhale more deeply and more
often. Low tar cigarettes have no effect on heart disease
in smokers and anytiny
 “I smoked in my “Each pregnancy is different. It’s like gambling
lastpregnancy and my with your baby’s health”.
baby was a normal
weight”.
 Problem–Stress Recommend simple relaxation exercises, e.g. “Take
a slow, deep breath and, as you breathe out, say to
 Many patients use yourself “relax” .Give a stress
tobacco to cope
withstress.
 Problem–Weight Stress that the health benefits of quitting smoking
Gain [Smoking far exceed the risks of the average weight gain.
appears to lower There are better ways to reduce weight rather than
the efficiency of smoking cigarettes.
caloric storage Or First, the patient should quit tobacco while allowing
and/or to increase the weight to accumulate; Second, when the habit is
metabolic rate. after gone for good, he/she should focus on losing weight.
cessation, average
weight gain is
only2.3kg.]

Breech Antenatal examination
P a g e | 415
You are FY2 doctor in the OBG department
Mrs Catherine Anderson, 20 years old lady has come to the hospital with
gestational amenorrhoea of 36 weeks. Midwife suspected breech presentation.
Midwife 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 Midwife has examined you and she was 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 problem before in this pregnancy at all? Pt: No
Dr: Were you 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 problems 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.
P a g e | 416
Exposure/ position, privacy and Chaperone: “for the sake of 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
mannequin.
Ask the examiner: “Where is the head end?” ask this question only if you cannot
make out which is 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 the
other side.
Inspection:
• On inspection of 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.
P a g e | 417
Presentation: ( cephalic or breech) palpate upper pole and lower pole separately.
Fundal Grip: Upper pole, hard and globular head “on the upper pole, I can feel hard
globular structure, most likely it is head.”
Back of the fetus: (either left or right)
One side you will feel irregular structure limbs on the left/right, I can feel
irregular structures, most likely the limbs.”
The other side you will feel a curved structure - back on the right/left, I can feel
a curved structure, most likely is back of fetus.”
Pelvic Grip: Lower pole, round and soft buttocks “on the lower pole, I can feel soft
round structure; most likely it is buttock of fetus.”
Engagement:
• Head is free or engaged in the pelvis
• Insertion of fingers
Height:
Measure the symphysio-fundal height from pubic symphysis to the maximum
of the fundus with the help of measuring tape.
•
P a g e | 418
The measurement in centimeters 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.
Fetus is clinically normal/ small/ large of dates

If the fundal height is high:
Polyhydramnios
Multiple pregnancies
Wrong date of LMP.
Large baby
Auscultation:
• The fetal heart is best heard in the back of the fetus
• In cephalic or normal fetus, it is on either sides of the umbilicus (below and
lateral to umbilicus) along the back of the fetus.
• In the GMC manikin, there is 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. Wider part of fetal stethoscope should be on the
tummy and smaller part to your ear to listen to the heart of the fetus.
• Let the examiner know if you can hear fetal heart sound.
Thank the patient and ask her to dress up.
Baby in vertex - or 'head' down position.

P a g e | 419
1. Assessing the height of the fundus

(lower area of the baby) - seeing how
many finger breadths below the 2.
xiphisternum (bottom of the Assessing the size of baby and
woman’s sternumbone). feeling for the baby's back and
limbs.
4.
3.
Pawlik's grip - the lower part of the
uterus is grasped by the midwife to Pelvic palpation to determine the
determine the presenting part. position of the baby's head.
P a g e | 420
6. Listening to the baby's heartbeat.
5. Measuring the height of the fundus

which generally corresponds to the
number of weeks of gestation
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 2.
button. When the pregnancy is at Assessing the baby's position and
term (37-40 weeks), it's taken from size. Feeling for the baby's head,
the lower end of the woman's back and limbs.
sternum bone (the xiphisternum).
P a g e | 421
3. Using ‘Pawlik's grip’ to check that

the baby's buttocks are in the pelvis. 4.
Listening to the baby's heartbeat.
Dr: Mrs Anderson – I think your baby is in a breech position? Do you know anything about it ?
Pt: No
Dr: Breech means your baby is lying in a bottom first ie bottom of the baby is facing down
instead of 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 problem during delivery because 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 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 wait for 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 normal position by 37 weeks.
Otherwise my seniors may try to change the position to 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
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 is safer than vaginal
delivery.
My seniors will discuss with you and you can decide which way you can have the
delivery. Are you following me? Pt: Yes doctor
Dr: Any questions? Pt; No
doctor. Thank you very much.
P a g e | 422

Catheter
You are the FY 2 doctor in surgery department.
Mr. Graham Martin a 55 year old male patient presented to the hospital with pain
abdomen and unable to pass urine.
Take brief history
Do the 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 loo more times than usual especially in the
night ? Pt: Yes since last few months Dr : Any dribbling of urine ?
Pt: yes
Pt: Any fever – Pt:No
Dr : Do you have back pain ( for secondaries in the vertebra) ? Pt:
No Pt: 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
Dr : How is bowel habits - Pt: That is fine.
Dr : Are you taking any medications ( opiods, antipsychotics CCB)? - Pt:

No Dr: Any medical conditions ( MS, DM, Parkinsons) 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 urine 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 test to see what type of enlargement is this whether it is
cancerous or non-cancerous. On examination it looks like non-cancerous type of
enlargement.
We need to do some blood tests which is specific for prostate gland and also
do the scan for the gland and take some tissue sample from the gland and
treat the condition either with medication or we may need to some surgery
P a g e | 423
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.
Short history to rule out contraindications:

1.Any injury to the urethra ? No
2.Any bleeding from theurethra ? 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
Catheter set is kept open and ready – catheter will be kept inside bag opened at the top.
1. Wash hands, put on apron, clean the trolley you are going to use withwipe.
2. Collect equipment.
Catheter pack: it includes ( drape, forceps, gauze, cotton wool, fluid container, kidney
tray)
Cleaning solution
2 pairs of sterile gloves
Prefilled syringe with anaesthetic gel
Catheter ( this comes double packed and includes a syringe of water to inflate the
balloon.
Urinary bag Clinical waste
P a g e | 424
bin
-----------------------------
Make sure the clinical waste bin is near you before starting
3. Open the catheter pack without touching the contents and place the inner pack on
clean surface
4. 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.
5. Open the urinary catheter outer packaging and lubricant without touching the
contents. Place them carefully in your sterile field.
6. Open the urinary drainage bag and place it between the patients leg for easy
access when needed.
7. Pour cleaning solution into the container. Open a pair of sterile gloves to the side of
your sterile field.
8. 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.
9. 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.
10. 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
P a g e | 425
11. 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. Discard the swab and plastic forceps in clinical waste in.
12. Take the lubricant and inject it down the urethra.
13. 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.
14. 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 no-touch-
technique ( don’t touch catheter or glans with hand ). Push up to Y junction.
P a g e | 426
15. Inflate the bulb with distilled water. Inject in about 5ml of it slowly, looking at the
patient’s face. Then inject the rest of distilled water. Give a slight tug to make sure
catheter is properly placed inside. Discard the syringe to clinical waste in.
P a g e | 427
16. 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).
P a g e | 428
• Tear the drape. Discard it to clinical waste in.
• Stick the catheter on the thigh with the help of tape.

P a g e | 429
• Make sure that the patient is left clean, tidy up equipment, explain the
patient that 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 color 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 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 few days only until we find the cause of the retention and treat it.
Very rare chance that you need it for long time.
Paracetamol overdose and blood

sampling
( mannequin)
Ms Victoria Jones has taken over dose of some tablets. Take history from her and do
the necessary investigation and then talk to her about the further management.
Dr -Hello Ms Victoria Jones. I am Dr .. one of the junior doctor in the Emergency

P a g e | 430
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 may 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 rec 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.
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 wipe you are going to use.
3. Collect the equipment in tray :
Tourniquet, alcohol wipe, gauze
pieces
Vacutainer, vacutainer holder and vacutainer
needle Sharps bin (yellow ),
Waste bin
P a g e | 431
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.
P a g e | 432
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.
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
1. Shake the bottle and put it inside the kidney tray.
2. Loosen the tourniquet.
3. Take gauze piece and press on needle and withdraw the needle. Ask the
patient to keep it pressed to attain adequate hemostasis.
4. Discard the vacutainer holder in sharp’s bin with the needle.
5. Label the samples (patient’s name, DOB and hospital number,

procedure, date and signature) and mention I will send them to lab
along with the blood request form.”
6. Remove the gloves and discard in clinical waste bin.
7. Enquire how the patient feels and thank the patient for his cooperation
and ask her to roll down sleeves”
– Use yellow cap vacutainer for Paracetamol level, LFT and

U&Es. If the examiner say colour does not matter then use any
colour vacutainer given.
Once you take the blood, 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.
P a g e | 433
Dr – Miss Jones 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 Paracetamol tables. This medication
is called as 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 okay?
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.
Post appendicectomy – IV cannulation

Mrs Stevens had 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.
P a g e | 434
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
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 to your hand now because the one what you have now is
blocked. Then I can give medications through your vein. Is that Ok
Ok doctor
Then insert cannula
Explainprocedure:ItwillbealittleuncomfortableandyouwillfeelasharpscratchbutIwouldbe as gentle
as possible. Also, I would need to repeat the procedure again, if I do not get blood in the
firstattempt.
Consent: Are you happy for me to go ahead with this procedure?
1.Are you allergic to anything?

• Have you got any pain anywhere in yourarms?
• Which arm would you like me to do the procedureon?
Complications: This procedure also carries a risk of infection (phlebitis) and swelling (haematoma)
but please do not worry about it, we take great care to prevent this from happening.
PROCEDURE
• Put on apron, washhands.
• Clean the tray with wipe you are going touse.
Collect equipment in tray:

• 1 Pair ofgloves
• Cannula (pink orblue)
• Alcohol sterets
• Gauzepiece
• Tegaderm
• Tourniquet
• 2cc syringes filled with normal saline or syringe and salinevial
• Clinical waste bin
• Sharp bin –yellow
Make sure sharps bin is close by and open the sharps bin.
• Check tourniquet and place it on arm. (loose, don’t tie ityet)
• Check the site and the vein. (below Y junction if the mannequin has Yjunction)
P a g e | 435
• Remove cannula from the sheath with no touch technique and place it back in cleantray.
• Take out stopper; place it on clean area facingupwards.

• Fastentourniquet.
• Palpate the veinagain.
• Cleantheareawithalcoholsteretsinonedirectionwithsinglestroke.Discarditintoclinic
al wastebin.
• 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 countertraction to the overlying skin with your other hand to
help anchor the vein during insertion.
• Beforeintroducingneedleyoushouldwarnthepatient,sosay“youwillfeelasharpscratc
h now”.
• Stretchtheskinandinsertcannulawithbevelendupwardsat30to40degree.Thenreduc
e to a 15° angle to advance the needle inside thevein.
• When blood gushes back, change your grip, so the thumb and middle finger are on the
white cap to withdraw the needle about 5 mm to produce the second flashback.
Importantly the index finger provides countertraction on the wing so that cannula will
stay inside and only needle is withdrawn out, but notfully.
• With just the index finger remaining in place at the wing, advance the cannula along the
vein.
• Release thetourniquet.
• Place a gauze between cannula and underlying skin. Press over the vein around the tip of
cannula with the index finger of left hand so that blood does not leakout.
• Remove the needle and discard into sharpsbin.
• Position and stabilise the cannula with leftthumb.
• Put the stopper at the end ofcannula.
• Take2ccsyringewithnormalsalineandflushthroughthirdopening(openinginupwards), go
slowly, feel for the flow and see for patient’s comfort and say “I would check any
resistance or swelling or reports of pain from the patient”. Then push all the remaining
P a g e | 436
normal saline in the syringe and close theopening.

Apply tegaderm: mentioning date and time on the tegaderm.
•
• Inform the patient to please not move hisarm.
Information written on a paper on the table
Patient has been prescribed Morphine 5mg 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
Metaclopramide –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 staffif:
• The cannula site becomespainful/sore/hot.
• The insertion site looksinfected/red/swollen.
• The cannula isknocked
• The dressing is coming loose or iswet
• They feel the cannula is limiting their selfcare.
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.
P a g e | 437
I will give her pain killer – Diclofenac 75mg IV for pain ( if she complains of pain abdomen)
since the last dose of Morphine just given one hour ago.
I will give her Cyclizine for vomiting – 50mg 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 senior about this.

Earache
Exam question
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 is there for few days now doctor. I took some pain killers it is not going.
Dr: Which ear you havethepain? Pt: Rightear.
Dr: Do you have any discharge fromthatear? 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 earproperly? 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 problem while walking(labyrinthitis) Pt: No
Dr: Did you have any injury tothe ear? Pt: No
Dr: Any rashes around the ear or face ( Ramsay huntsyndrome)? 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 earatall? Pt: No
Dr: Did you have any problems in the earbefore ? Pt:No
Dr: Do you have any medicalconditions? Pt:No
Dr: Ae you on anymedications? Pt:No
Dr: Are you allergic toanything? Pt : Yes Penicillin
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.
P a g e | 438
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 haemotoma, 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).
Tragus negative – proceed with Otoscopic examination on the mannikin.
Explain Procedure : I am need to examine the inside of your ear with a special instrument
called an Otoscope .
Rightexamination Left earexamination
Position : Sitting with head and neck slightly tilted to the other side .
Check Instrument - Check the Otoscopeworking

Use the large size speculum. Hold the Otoscope in pen holding position
External auditory Canal –Throw Light
Comment on – No discharge, bleeding, inflammation, wax, FB
Tympanic Membrane
Left hand on head, pull pinna upward +backwards with thumb and indexfinger.-
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:
Comment on:
• Cone OfLight
P a g e | 439
• Handle ofMelleus
• Umbo
• Annulus
• Pars Flaccida/Pars Tensa (Any Findings InTympanic
Membrane)
SLIDE OF AOM WITHOUT EFFUSION
I can see the TM which is red, inflamed, congested, edematous and tense
There is no air fluid level
Cone of light, handle of malleus and umbo cannot be appreciated
Annulus can be appreciated.
Therefore diagnosis is AOM without effusion
Ideally, I will do Rinne’s and Weber’s test to check for any hearing loss.
( no need to do these test in the exam as the tuning forks were not kept in the cubicle).
Check the hearing with finger clicking sound.
Examine the Lymph nodes ( if you have time)

• Submental
• Submandibular
• Pre –auricular
• PostAuricular
• Cervical
• Occipital
Diagnosis
Mr… You have infection in the right ear. This could be due to Bacteria type of bugs.
Pt: Ok
Treatment:
We will give you antibiotic called Erythromycin ( since the patient 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 doctors?

Dr: Rarely this can cause infection in the nearby ear area like infection in the bone
( mastoiditis) and also infection of the covering layer of the brain calledmeningitis.
Warning signs:
You can take this medication at home. If the condition is getting worse, or if youdevelop
headache, rashes on the body – these signs of meningitis - please call the ambulance and
come to thehospital.
[ No need to do – Rhombergs and Marching test because there is no hearing loss and
balance problem].
P a g e | 440
For information only
SLIDE OF TYMPANIC MEMBRANE (NORMAL)

Coneof Light- Directed downwards andanteriorly
HandleofMalleus- anterosuperior
Umbo- Central portion which joins handle with cone oflight
rd
Upper1/3 ParsFlaccida
Lower1/3rd ParsTensa
Annulus Outer fibrous ring around TM joining TM to surrounding
bony
Structure
• Pearly grey in colour

• Semitransplant
• NormalTissue
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 diagnosis is Normal Tympanic Membrane.
SLIDE OF WAX
I can see the TM
Colour in transition from pale yellow-golden yellow-yellow brown – finally brown or
cannot see TM , obscured by golden material.
Cone of light, handle of malleus and umbo cannot be appreciated.
Can appreciate annulus.
Therefore my diagnosis is cerumen over TM.
Treatments to remove earwax:
The main treatments are:
eardrops – drops used several times a day for a few days to soften the earwax so that it
falls out by itself
ear irrigation – a quick and painless procedure where an electric pump is used to push
water into ear and wash the earwax out
microsuction – a quick and painless procedure where a small device is used to suck the
earwax out of ear
aural toilet – where a thin instrument with a small hoop at one end is used to clean the ear
and scrape out the earwax.
SLIDE OF ACUTE OTITIS MEDIA WITH EFFUSION

Can appreciate an air fluid level in antero superior and postero superior quadrants.
Therefore diagnosis is AOM with effusion.
P a g e | 441
SLIDE OF AOM WITHOUT EFFUSION

There is no air fluid level
SLIDE OF AOM WITH BULGING

Can appreciate an bulge in TM which is in the postero inferior quadrant due to pus or fluid
behind TM.
Therefore diagnosis is AOM with bulging which may progress to perforation or it is an
impending perforation.
Treating middle ear infection:
Most middle ear infections (otitis media) clear up within three to five days and don't need
any specific treatment.
Paracetamol or Ibuprofen to relieve pain.
Antibiotics aren't routinely used to treat middle ear infections as there's no evidence that
they speed up the healing process. Many cases are caused by viruses, which antibiotics
aren't effective against.If antibiotics are needed, a five-day course of an antibiotic called
amoxicillin is usually prescribed.An alternative antibiotic such as erythromycin or
clarithromycin may be used for people allergic to amoxicillin.
SLIDE OF CENTRAL PERFORATION WITH TYMPANOSCLEROSIS
can see the TM
Cone of light, Umbo be appreciated but can appreciate handle of malleus which is
distorted.
Can appreciate a large central perforation in anteroinferior and postero inferior quadrants,
Can also appreciate few white calcified plagues over TM
SLIDE OF TYMPANOSCLEROSIS
Can see TM
Cone of light, handle of malleus and umbo can be appreciated
Can appreciate white calcified plagues in antero superior quadrants,
Most probably diagnosis is tympanosclerosis.
Treatment is only required if there is hearing loss.
Hearing aids can be beneficial, as with any form of conductive hearing loss.
Surgery for tympanosclerosis involves excision of the sclerotic areas and reconstruction of
the ossicular chain.
SLIDE OF GROMMET
Can see TM
Can appreciate a foreign body in postero inferior quadrant, most probably a grommet.
Most probable diagnosis is grommet in TM.
A grommet is a very small tube that's inserted into ear during surgery. It can help drain
away fluid in the middle ear and maintain air pressure.It will help keep the eardrum open
P a g e | 442
for several months. As the eardrum starts to heal, the grommet will slowly be pushed out of
the eardrum and will eventually fall out.
SLIDE OF SECRETOARY OTITIS MEDIA
No air fluid level, bulge etc seen
Most probably diagnosis is secretory otitis media.
TURNING FORK TESTS

Check tuning fork 512Hz or 256 Hz
Do Rinne’s or modified Rinne’s test

Interpretation of tests
AC>BC Rinne’s Positive – Normal or sensori neuraldeafness
BC>AC Rinne’s Negative – Conductivedeafness
Do Weber’s
Interpretation
CSSO Conductive Same side Sensorineural Opposite side
Conductive lateralized to SAME side
Sensorineurallateralized to OPPOSITE side. Sensorineural
Hearing Loss – Acoustic neuroma

50 years old Mrs... presented to the hospital complaining of hearing loss for last 3
weeks. 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 losing hearing.
Dr: I am so sorry to hear about that. Can you tell me anything more about it?
Pt: It is there for quite some days now doctor. It is not getting any better.
Dr: Which ear are you loosing 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.
P a g e | 443
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 painor numbness on your face? (Acoustic Neuroma)Pt:
No
Dr: Have you been feeling any headaches lately? (Acoustic Neuroma)Pt: No.
Dr: Did you have injury to this ear or head recently? (Trauma)Pt: No.
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? (Barotraumas) 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 or salicylates or 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)

P a g e | 444
Tragus Test:( if positive – Contraindication to otoscopy).
I need to examine the inside of your ear now with a special instrument called an
Otoscope.
Right examination Left ear examination
Position : Sitting with head and neck slightly tilted to the other side .
Check Instrument - Check the Otoscope working

Use the large size speculum. Hold theOtoscope in pen holding position
External auditory Canal –Throw Light
Comment on – No discharge, bleeding, inflammation, wax, FB
Tympanic Membrane
Left hand on head, pull pinna upward +backwards with thumb and index finger.-
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:
P a g e | 445
Cone Of Light
Handle of Melleus
Umbo
Annulus
Pars Flaccida/Pars Tensa (Any Findings In Tympanic Membrane)
SLIDE OF TYMPANIC MEMBRANE (NORMAL)

Cone of Light- Directed downwards and anteriorly
Handle of Malleus- Antero superior
Umbo - Central portion which joins handle with cone of light
Upper 1/3rd Pars Flaccida
Lower 1/3rd Pars Tensa
Annulus Outer fibrous ring around TM joining TM to surrounding
bony
Structure
Pearly grey in colour, Semi transplantNormal Tissue

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, is Normal Tympanic Membrane.
I will now do Rinne’s and Weber’s test to check for any hearing loss.
Rinne Weber
AC > BC lateralizes to left no lateralizes to right

P a g e | 446
lateralization
left right left ear right ear both ears left ear right ear
Normal
Sensorineural Sensorineural
⊕ ⊕ Normal Normal
loss loss
Sensorineural
loss
Conductive Combined
⊖ ⊕ Normal Normal
loss loss
Combined Conductive
⊕ ⊖ Normal Normal
loss loss
Conductive Combined Conductive Combined Conductive

⊖ ⊖
loss loss loss loss loss
Combined loss = conductive and sensorineural loss
Patient will show following results:
Rinne's Test: AC>BCWeber'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).

P a g e | 447
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 conditioncalledAcoustic Neuroma. Do you know what
it is?Pt: No doctor.
Dr: Well, it is 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 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 need 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
P a g e | 448
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 regards 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.
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 regards 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

P a g e | 449
 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
1. Introduce yourself to Patient – (GRIPS – Greet, Rapport, Introduce and Identify and Explain
Procedure) and wash your hands
2. Ask the patient whether they are experiencing any symptoms and explain the purpose of the
examination
3. Explain that it will involve undressing fully from the lower half and the examination may be
a bit uncomfortable but should not be painful
4. Gain consent and offer a chaperone
5. Before the patient undresses, perform a general examination, looking for signs of hormonal
disorders for example hirsutism and acne
6. 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.
7. Prepare trolley and equipment: flexible light source, gloves, lubricating jelly, speculum.
8. Allow the patient to become comfortable before starting
Inspection
1. Begin with a general abdominal examination

2. Inspect the external genitalia for hair distribution, swelling, scarring, signs of infection for
example warts or ulcers
3. Ask the patient to cough looking for signs of prolapse.
Speculum Examination
1. Think about the size of the speculum needed and use lubrication
2. Explain to the patient what you are going to do before proceeding
3. Expose the introitus by spreading the labia from below using the index and middle finger
4. Gently insert the speculum at a 45 degree angle and pointing slightly downward
P a g e | 450
5. 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)
6. Secure the speculum by turning the thumb
nut
7. Visualise the cervix and vaginal walls for
any abnormalities, such as ectopy, cysts or
polyps
8. Comment on whether the cervical os is
open or closed? (parous or nulliparous)
9. Perform any necessary tests, obtaining
samples for culture and cytology (below)
10. Withdraw the speculum slightly to clear the
cervix and gently loosen the speculum to close the blades
11. Continue to withdraw whilst rotating the speculum to 45 degrees, avoiding contact with the
vaginal walls
12. Tell the patient that you have finished, give a towel to the patient to wipe herself.
Cervical ( Pap) Smear

Info: All women who are registered with the GP are invited for cervical screening:
Aged : 25 to 49 – every 3 years.
P a g e | 451
Aged 50 to 64 – every 5 years

Over 65 – only women who have recently had abnormal cells.
Before proceeding rule out any contraindications like:

1. Pregnancy
2. Active menstruation
3. Active Vaginal bleeding
4. Recent Sexual intercourse
5. Recent use of spermicidal gel
Question:
You are FY2 doctor in the GP clinic.

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.
43
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 doctor.!
Dr: Mrs....... can you please confirm your age for me? Pt: I’m 43 doctor
Dr: Alright! When was the last time you had the smear sampling?
Pt: It was 3 years ago. 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 is 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
doctor!
Dr: Is 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 got two children. Elder one is 13 and the other one is 10.
Dr: So your last child birth was 10 years back .is that right? Pt: yes!
P a g e | 452
Dr: Were both of the deliveries were 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 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.
44
Check the trolley for:
1. Pair of gloves
2. Cusco’s speculum
3. Cervical brush
4. Sure Path
5. Few wipes
6. Lubricating Jelly
7. Clinical waste bin
8. Good source light
Wear Gloves
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.
Tell the patient about the procedure before we begin.

P a g e | 453
1. Warm the speculum and add lubricating jelly to it.

2. Warn the patient that 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.
3. Insert the brush deep enough to allow full contact with the cervix
4. Verbalise: “I can see the cervix, the os is closed and there is no cervical erosion, no
bleeding, discharge or any growth
5. Push gently the brush and rotate 5 times in a clock wise direction
6. Gently remove the brush and dip it 10 times in the Thin Prep Bottle, and then
shake it well.
7. Inspect for any remaining cells then discard the brush in the clinical waste bin.
8. Tighten the cap of the bottle and send it to the lab after recording patient’s details
on it.
9. If the bottle is sure path, drop the brush in the container.
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.
look for any bleeding or any discharge, and then send it for sterilization.( DOSPOSABLE
SPECULUM- DISCARD, METTALIC 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 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 below only if the patient ask any thing :
The types of screening result you may get depends on how your screening sample was
tested.
P a g e | 454
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
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.
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
46
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 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.
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 simpke procedure used to look at cervix, the lower part of the wombat
the top of the vagina. It is often done if cervical screening finds abnormal cells in your
cervix.
P a g e | 455

P a g e | 456
Breast Examination
You are the FY2 doctor in the surgical department.
Mrs .. Moulton 44 year lady presented to the hospital because she is concerned
about lump in her breast.
Take 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 some 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 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 ( Fibro adenosis – 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
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 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. Ask for exposure by saying ]
“May I ask you to sit down please.”
Patient will go and sit on the edge of couch. Begin examination with Inspection
P a g e | 457
• Both the breasts aresymmetrical.

• The level of nipples is on the sameline.
• There are no skin changes or anypigmentation.
• I cannot see any obviouslump.
• There is no redness, scar, swelling orsinuses
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 bendingforward.
3. Sitting, Inframammary region. Ask “Can you lift your breasts with two
fingers?”
• There is no eczema or fungal infection in infra-mammaryregion.
4. Nipples. Ask “Can you squeeze your nipple with your two fingers?”
( You (doctor) must not squeeze).
• There is no bleeding or discharge expressed from the nipples.
P a g e | 458
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 lying position and 45 degree. If it is not 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.”
P a g e | 459
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.”
Deep palpation: Warn the patient: “this time I am going to touch your breast deeper.”
• Palpate axillary tail ofspence

• Check for peri-areolar region for anyswelling.
• Then check all the quadrants movinganti-clockwise.
If a lump present, describe the lump.

• Site: e.g. upper outer quadrant of rightbreast
• Size: e.g. 2X2cms
• Surface: smooth /irregular
• Consistency: soft / firm /hard
• Margins: well defines/illdefined
• Relation to overlying skin and underlyingstructures
• Mobility
• Tenderness
Summarise your findings: eg-

“In deep palpation, there is a mass of about 2cm in 2 cm, present in right upper outer
quadrant, which is not tenderness in palpation, not attached to over lying skin,
attached to deep structure and it is mobile.”
C. Axillary Lymph nodes: In standing position

Inform the patient that: “I will be examining the few 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
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 finish my examination by examining supraclavicular lymph nodes.” Thank the
patient. “Thank you very much, you can dress up now.”
Talk to the patient:

P a g e | 460
Mrs Moulton, I have found a ( one or two) swelling 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 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 what 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: 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. Breast lump
will be more prominent if the patient had breast augmentation because the breast implant
will be inserted behind the breast tissue.

Testicular swelling ( new station on 22/03/2018)
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 my testicle. I am very worried whether 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. How many swellings did you notice ? One
Does it comes and goes ( like does it disappear on lying and appears on standing up ? or is
it present all the time ( hernia) ? No difference. Does it come out when you cough
( hernia) ? No
Dr: Ok. Do you have any pain ( torsion, epididymitis) ? No
Fever ( epididymitis) ? No Any discharge from the urethra ? No.
Any other swellings anywhere else ? No Any swellings in your groin area ? No
47
Did you hurt yourself on the testicle recently ( hematoma) ? No
Weight loss ? No
Did you have any such swellings in the testicle before ?
Any operations on testicle previously ( undescended testis) ? No
P a g e | 461
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 do 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 privacy and have
chaperone with me. Is that Ok ? Pt: Ok doctor.
Examine on 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”.
Feel the right side scrotum :
Non tender. No lumps felt. Feel the superior pole – can get above the swelling.
Epididimis ( 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. Epididimis and spermatic cord feels
normal.
48
Cough impulse: ask patient to cough and check for any swelling in the groin area : No
swelling.
P a g e | 462
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. ( 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 Ultra sound scan of the testicle, and also the 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 to your question at the moment. Specialist doctor will tell you that after all the
investigations.
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 what I mentioned earlier suggests that the chance of cancer is
very high then we need to remove the whole testicle by doing operation and send it to
the lab to confirm the diagnosis.
Pt: why remove the whole testicle ?why can’t you take 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 father if you remove my testicle?
Dr: Yes, surely you can as long as the other testicle is fine. Other option is 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 slight chance that it may recur.
49
P a g e | 463
Pt: Will I get cancer in the other testicle?

Dr: Unfortunately, there is slight 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.
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

Inguinal swelling teaching medical student(12th April 2018 )
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
(Inside the station – mannikin, student, and examiner)
D- Hello, I am John.
Ross- hello I’m Ross, third year medical student
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
P a g e | 464
and passes through inguinal canal then comes out through superficial ring.
50
D- Now thank the patient for his cooperation and then take his permission for examination.
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 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
( 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 –scrotal swelling
If not possible – inguino - scrotal swelling ( hernia extending into the scrotum)
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 cms 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
P a g e | 465
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
51
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.
CPR
You are the FY2 doctor.
You have organised BLS workshop for medical students.
Teach BLS to the first year medical student and check his understanding.
You: Hello I am Dr … What is your name? Are you the medical student? How are you
doing?
Do you want to learn about CPR ?
Student: Yes.
You: Do you know anything about CPR.
Student :No
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.
First of all before you approach near to 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.
P a g e | 466
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 check the
carotid pulse at the same time.
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. Keep two
fingers on his carotid pulse.
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 themyourself
52
 Stay with the victim when making the call ifpossible
Send someone to get an AED if available
Then start CPR.

Start with chest compressions
 Kneel by the side of thevictim
 Place the heel of one hand in the centre of the victim’s chest - which is the
lower half of the victim’ssternum.
 Place the heel of your other hand on top of the firsthand
 Interlock the fingers of your hands and ensure that pressure is not applied over
the victim'sribs
 Keep your arms straight, elbowlocked
 Do not apply any pressure over the upper abdomenorXiphisternum.
 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 thesternum;
Repeat at a rate of 100–120 min-1
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 thumbof
your hand on theforehead
 Allow the mouth to open, but maintain chinlift
P a g e | 467
Take a normal breath and place your lips around his mouth, making surethat you have a
goodseal
 Blow steadily into the mouth while watching for the chest to rise, takingabout 1
second as in normal breathing; this is an effective rescuebreath
 Maintaining head tilt and chin lift, take your mouth away from the victimand
watch for the chest to fall as air comesout
 Take another normal breath and blow into the victim’s mouth once more to
achieve a total of two effective rescue breaths. Do not interruptcompressions 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
chestcompressions
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 andbreathing
normally
 The helparrives
 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.
Teach Paediatric BLS to medical student (17/4 /2019)
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.
P a g e | 468
54
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:
o Place your hand on his forehead and gently tilt his head back.
o With your fingertip(s) under the point of the child’s chin, lift the chin.
P a g e | 469
o Do not push on the soft tissues under the chin as this may block the airway.
o 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.

 Give 5 initial rescue breaths.
 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:
55
 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
P a g e | 470
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).
 If you check the pulse take no more than 10 seconds:
o In a child aged over 1 year – feel for the carotid pulse in the neck.
o In an infant – feel for the brachial pulse on the inner aspect of the upper arm.
o 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.
56
 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.
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,
P a g e | 471
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, cough, 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.

Aero chamber
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 focussed history and assess whether the spacer technique mother is using is right
or not.
Ask her the details of the problems
Since when ?how bad he will be 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
P a g e | 472
particular seasons ? Does he has frequent infections ?

Aske 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.
Spacer the salbutamol inhaler, spirit swabs may be kept inside the cubicle.
2 puffs of salbutamol. Each puff child should breath 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 may 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.
SPACERS ARE AVAILABLE ON NHS PRESCRIPTION
AEROCHAMBER® PLUS ABLE SPACER®
POCKET CHAMBER® OPTICHAMBER®
NEBUHALER VOLUMATIC®
P a g e | 473
FAMILY OF AEROCHAMBER PLUS* VALVED HOLDING CHAMBERS
ORANGE Small Mask (0 - 18 months) Anatomically shaped facemask

creates a secure seal using minimal effort
– critical for parents and caregivers administering aerosol
medications to infants.
P a g e | 474
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).
Counsel /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 ask 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 you about it. If you have any question, 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 facemask 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.
P a g e | 475
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
If the child is with the mask on their face, let them breathe in
and out slowly five times – known as ‘tidal breathing’.
61
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.
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.

[should not be whistle sound- it means breathing faster]
. 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.
P a g e | 476
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 When they demonstrate they should be using the
demonstrate the technique aerochamber touching their face.
back to you
62
CLEANING- BEFORE FIRST USE THEN AT WEEKLY INTERVALS:
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 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 frequency of use.
P a g e | 477
Replace 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 facemask 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.
63
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 encourage your child to slow their breathing
rate down.
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 is 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 baby’s breathing.
To hold a protesting baby Prepare the Aerochamber and Inahler. 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.
P a g e | 478

ABDOMINAL DISTENSION – Alcoholic cirrhosis
Exam question
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, Herat failure)
/ fat (obesity) / faeces (constipation) / flatus / fetus (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 bloated. I feel heavy as if I am carrying some weight. I am really worried
about it.
Dr: Can you tell me for how long have you been feeling like that?
Pt: For about 4 to 6 weeks.
Dr: Can you tell me did 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 blood in vomitus.(hematemesis) ]
Dr: Any yellowish discoloration of your skin? Pt: No
Dr: Have you have itchiness ? Pt: No
Dr: Any bowel problems like diarrhoea or constipation (intestinal obstruction)? Pt : No
Dr: Any change in stool colour (malaena)? Pt: No
Dr: Have you lost any weight? Pt: No
Dr: Have you been diagnosed with any medical conditions in the past ? No
Dr: DM/HTN? Pt: No Dr: Have you ever had any liver problem before ? 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 tell 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:
Do General physical examination and abdominal examination

I need to examine you 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
Hands
No Clubbing, No nail changes or Palmar erythema,
No flapping tremor ( hepatic encephalopathy / uraemia / CO2 retention )
P a g e | 479
Eyes: No jaundice, No pallor

Chest - No Spider naevi ( chronic liver disease) and no gynaecomastia
( liver cirrhosis / digoxin/ spironolactone),
No Pedal edema
Detailed abdominal inspection
( Do this on the mannikin).
Inspection of abdomen
No operation Scars, 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 2 intercostal space
nd
downwards ( normal liver span is between 5 rib to costal margin which is 9 rib) for upper
th th
border of liver. Liver is 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)
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 ultrasound and 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 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.
P a g e | 480
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 what 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.
BACK PAIN - ABDOMINAL AORTIC ANEURYSM

DD
1. IVDP and SCIATICA
2.AAA
3. CAUDA EQUINA
4 SECONDARIES { PROSATE}
5. MUSCLOSKELETEL BACK PAIN
6. TRAUMA
Question:
You are an FY2 doctor in the A&E department
55 year old man presented with back pain since yesterday evening
Your task: Address his concerns and plan on INITIAL MANAGEMENT.
Hello, I am Dr .... one of the junior doctor in the A&E Department. How can I help you ?
Pt: doctor I am having back pain since yesterday
Dr: I'm sorry to hear that. Are you ok to talk or do you need any medications for your pain
Pt:I am alright doctor
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 back 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
Dr: Is it going to your loin area? Pt: no [RENAL PATHOLOGY]
Dr: Alright. Do you feel tired? Pt: no doctor
P a g e | 481
Dr: Do you have any bowel or bladder problems? [ CAUDA EQUINA] Pt: no doctor
Any numbness around your back passage? Pt: no doctor
Dr: Do you feel thirsty or do you want to pass urine more than the usual? Pt: No[secondaries]
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, playing or
lifting weight [MUSCULOSKELETEL BACK PAIN] Pt; No
Dr: Any chance you may have injured your back? Any fall? Pt: no doctor
Dr: Do you have fever ? No

Dr: Did you feel any pulsating mass in your tummy (AAA) ?
Dr: have you ever had any type of scans done on your tummy ( AAA)?

Dr: Did you have 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
EXAMINATION
I would like to examine your back, your back passage and your tummy is that okay?
Also I need to measure your heart rate, blood pressure and 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 until the mid thigh? Pt: ok doctor
examiner gives NEWS chart PR: 94 BP: 120/80 SPO2 97%
Examiner may say - back passage and back examination is normal.
Proceed to abdominal examination MANNEQUIN kept on the table

Start examining the abdomen but examiner gives the findings :
Tenderness above the umbilical region and pulsations felt all over the abdomen.
Dr: Mr.... from what you have told me and after the examination, I suspect you have a
condition called ABDOMINAL AORTIC ANEURYSM. 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 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 ( A part of the Aorta becomes swollen). This can
sometime result in bursting of the blood vessel and blood will start leaking,which is a life
threatening condition. If that happens patient will feel dizzy,short of breath and experience
severe pain the tummy or back. Are you following me? Pt: yes doctor.
P a g e | 482
Dr: We need to admit you. At this moment it doesn’t look like the blood is leaking from the
vessel. However, I will talk to my seniors and will arrange for anUSG scan of your tummy
to confirm this. We would like to run some baseline blood test 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
Treatment:
Dr: We will refer you to the Vascular surgeon ( Specialist). Treatment depends on the size
of the aneurysmand also whether it is leaking or not.
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 size increases and risk of rupture is there,then we have to surgically repair that.
There are two types of surgeries

1. Open aneurysm repair– A graft ( artificial tbe) is placed in the Aorta through cut in your
tummy.
2. Endovascualr aneurysm repair. A graft is inserted through a blood vessel in the grpin
and then passed up into the Aorta.
The type of surgery is decided by the surgical consultants.
Advise: Diet, Smoking, Exercise. Reducing weight if over weight.
Medications for BP if hypertensive.
If already ruptured: Immediate surgical repair to control the bleeding
Abdominal aortic aneurysm
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.
Some people with an AAA have:

a pulsing sensation in the tummy (like a heartbeat)
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.

P a g e | 483
Treatment isn't always needed straight away if the risk of an AAA bursting is low.
Treatment for a:
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 – read stop smoking advice and find out about Smokefree, the NHS stop smoking service
eating healthily – eat a balanced diet and cut down on fatty food
exercising regularly – aim to do at least 150 minutes of exercise a week; read about how to get started with
some common activities
maintaining a healthy weight – use the healthy weight calculator to see if you might need to lose weight, and
find out how to lose weight safely
cutting down on alcohol – read some tips on cutting down and general advice about 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.

PLAB 2 Notes Part 1

Uploaded by

Copyright:

Available Formats

You might also like

PLAB 2 Notes Part 1

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

PLAB 2 Notes Part 1

Uploaded by

Copyright:

Available Formats

Page |1

Dr Swamy PLAB 2 Course

Sl .No Video Page

44 2099 Tonsillitis Not available

87 2292 Urine dipstick – teaching Not available

132 2420 Statin Therapy Video available

170 2506 Neurological examination - ataxia Video available

206 Mother concerned about child taking Not available

242 Not available

278 2885 Post cyst removal wound infection Video available

Dr Swamy PLAB 2 Course

Introduction to the PLAB 2 exam has 16 parts of videos.

15 OSCE stations plus 3 rest stations. Total 18 stations.

Start bell Begin 2 minutes Move on to

Read question Task

Candidates standing outside the cubicles when reading the question

Competency, SAFE doctor

1. Simple ( Avoid medical jargon )

Type of questions in the PLAB 2 exam

How do they mark ?

How to start a station ?

How to Approach a station ?

Examination – Examine the Patient ( actor or simulator or manikin)

How to tell the diagnosis ?

Explain the investigations –

How to talk about the treatment ?

Safety netting when sending a patient home

 New symptoms ( may be the patient developed complications)

Reasons for taking History

Pneumonic for taking history

Doctor grade in the NHS ( National Health service) Hospital

Where are you

2. About the patient

Disorganized/unstructured consultation. Includes illogical and disordered approach

Id numbers 2021, 2022, 2023 and 2024 Video available

ETHICAL ISSUES for PLAB

Principles of the Act

Assessing lack of capacity

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

 Understand the information relevant to the decision.

Advance care planning

Lasting powers of attorney

Independent Mental Capacity Advocate (IMCA)

- If a judge or court requested the information

- In situations where another individual, or a community, is at risk of serious

DNAR ( DNACPR) Do not attempt resuscitation)

Gillick competency and Fraser guidelines

What do 'Gillick competency' and 'Fraser guidelines' refer to?

How are the Fraser Guidelines applied?

"provided he is satisfied in the following criteria:

How is Gillick competency assessed?

He also commented more generally on parents’ versus children’s rights:

What are the implications for child protection?

TIA and DVLA

When you need to tell DVLA ?

Epilepsy and Driving

Car drivers and motorcycle riders

Group 2 includes large lorries (category C) and buses (category D)