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ASPIRE: THE QUEST FOR EXCELLENCE
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Aspire Education 2
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Table of Contents
Acute Tonsillitis............................................................................................................................................ 4
Recurrent Tonsillitis ..................................................................................................................................... 7
Cataract ........................................................................................................................................................ 9
Age Related Macular Degeneration .......................................................................................................... 11
Colleague Confidentiality Issue (Facebook Post) ...................................................................................... 17
Leukaemia .................................................................................................................................................. 19
ITP .............................................................................................................................................................. 20
Analgesic Nephropathy ............................................................................................................................. 22
Carpal Tunnel Syndrome ........................................................................................................................... 24
De Quervain’s Tenosynovitis ..................................................................................................................... 26
Hand & Wrist Examination ........................................................................................................................ 27
Respiratory Examination ........................................................................................................................... 29
Syphilis ....................................................................................................................................................... 31
PSA Test- Demanding Patient.................................................................................................................... 33
8th Nerve Examination Teaching ............................................................................................................... 35
Cervical Screening (Lesbian) ...................................................................................................................... 37
8 Weeks Vaccination ................................................................................................................................. 39
Levothyroxine Dose Adjustment ............................................................................................................... 45
Cerebral Palsy ............................................................................................................................................ 47
Chest Pain (Mastectomy) .......................................................................................................................... 48
Chest Pain (Transgender) .......................................................................................................................... 49
Haematuria – Lab Results .......................................................................................................................... 51
Allergic Rhinitis .......................................................................................................................................... 53
Prescription Writing (DVT Apixaban) ........................................................................................................ 55
Prescription Writing (Nosebleed Apixaban) ............................................................................................. 58
Urticaria ..................................................................................................................................................... 59
Primary Enuresis ........................................................................................................................................ 61
Meningitis Prophylaxis .............................................................................................................................. 63
Cholesteatoma ........................................................................................................................................... 64
Chicken Pox (Pregnancy) ........................................................................................................................... 66
Post Herpetic Neuralgia ............................................................................................................................. 68
Preconception Counselling ........................................................................................................................ 70
Nipple Discharge ........................................................................................................................................ 71
Pregnancy (Hypertension on Ramipril) ..................................................................................................... 73
Concerned Daughter MMSE ...................................................................................................................... 74
Scabies ....................................................................................................................................................... 75
Discuss Blood Results ................................................................................................................................ 78
Inguino - Scrotal Examination ................................................................................................................... 79
Intestinal Obstruction................................................................................................................................ 83
Eczema ....................................................................................................................................................... 85
Elbow ......................................................................................................................................................... 87
Acute Cholecystitis .................................................................................................................................... 90
Twin Delay ................................................................................................................................................. 92
Depression ................................................................................................................................................. 93
Oxybutynin Urinary Symptoms ................................................................................................................. 94
Aspire Education 3
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Acute Tonsillitis
You are an F2 in GP. Samaira aged, 34 came to the clinic with sore throat. Please talk to
the patient, discuss plan of management with the patient and address her concerns.
D: What brought you to the hospital today? P: I have sore throat

D: Could you tell me more about it? P: like what
D: When did it start? P: 7 days ago
D: Was it sudden or gradual? P: Gradual
D: Is it continuous or comes and goes? P: Continuous
D: What type of pain is it? P: Dull pain
D: Is there anything that makes it better? P: No
D: Is there anything that makes it worse? P: When I swallow
D: Has it changed since started? P: It’s getting worse
D: Could you rate the pain on a scale of o to 10, where 0 being no pain and 10 being the
worst you have ever experienced? P: 7
D: Do you have any other symptoms? P: I feel feverish

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

D: Any ear pain or hearing problems? D: No
D: Any neck stiffness? D: No
D: Any problem with voice? P: No
D: Any nausea or vomiting? P: No
D: Any tiredness? D: No
D: Any headache? (Infectious mononucleosis) D: No
D: Any tummy pain? (Infectious mononucleosis) D: No
D: Any diarrhoea? (HIV) D: No
D: Did you have similar condition in the past?

D: Yes, I had it 6 months back and was given antibiotics.
D: Have you been diagnosed with any medical condition in the past? P: No
D: Are you taking any medications including OTC or supplements? P: No
D: Any allergies from any food or medications? P: Yes, I am allergic to penicillin
D: Any previous hospital stays or surgeries? P: No.
D: Has anyone in the family been diagnosed with any medical condition? P: No
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D: Do you smoke? P: No
D: Do you drink Alcohol? P: No
D: Tell me about your diet? P: Healthy
D: Are you physically active? P: I try to be.
D: Are you currently sexually active? P: Yes

D: Are you in a stable relationship? P: Yes
D: Do you use practice safe sex? P: Yes
I would like to do a GPE, check the vitals and Examine your tummy, neck and throat.
From our assessment we suspect you are having a condition called tonsillitis. It is an infection
and inflammation of the tonsils caused by a bug or virus. For your condition we will be giving
you painkiller and we will start you on antibiotics. As you are allergic to penicillin, we will be
giving you something else (Erythromycin or Clarithromycin).
Also, you can take Lozenges, throat spray and antiseptic solutions to ease the symptoms.
To help ease the symptoms:

• get plenty of rest
• drink cool drinks to soothe the throat
• gargle with warm salty water
Aspire Education 5
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If you get difficulty speaking, difficulty swallowing, difficulty breathing, difficulty opening
your mouth please come to the hospital.
An antibiotic may be advised in certain situations.
For example:
• If the infection is severe (Systemic features)
• If it is not easing after a few days. (3-5 days)
• A history of rheumatic fever
• Unilateral Peri tonsillitis
• If your immune system is not working properly (for example, if you have had your
spleen removed, if you are taking chemotherapy, etc).
• Acute tonsillitis with three or more Centor criteria present
There are four Centor Criteria that may be used:

a. History of Fever.
b. Tonsillar Exudates
c. No Cough.
d. Tender Anterior Cervical Lymphadenopathy.
Aspire Education 6
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Recurrent Tonsillitis
You are F2 working in GP. Anne, mother of 6-year-old boy, who is diagnosed with Tonsillitis
has come to you to talk about her son’s referral to ENT surgery that was rejected. The child
previously 5 episodes of infections over 6 months. Talk to the mother and address her
concerns. On request of the mother, GP made the referral to the ENT Surgery.
D: How can I help you today?

P: I am here for my son. He had recently been referred to ENT surgery from GP and the referral
got rejected.
D: I am really sorry for your experience. Would you mind if I ask you a few questions regarding
your son to have better understanding of your son’s health.
P: Ok
D: Could you tell me why he had been referred to the ENT surgery?
P: He had 5 episodes of tonsillitis in the last 1 year
D: Could you give a brief recap of the episodes?

P: The first episode was about 10 months ago. He had sore throat and fever and was advised
to have steam inhalation. The 2nd and 3rd episodes the symptoms were more severe, and he
was given antibiotics. And the last 2 episodes was like the first episode and it got better with
steam inhalation as well.
D: I can understand It must be very tough for him.

P: Yes, so why did the referral get rejected?
D: As you already know the referral was made upon your request. But to be honest with you
your son doesn’t meet the criteria to have the surgery for the tonsil removal.
P: What criteria are you talking about?
D: I do understand your concern. Let explain this to you further. There are few criteria’s that
has been set to decide which patients need tonsil removal surgery. One of those criteria is
having at least 7 attacks in a year. You mentioned your son had 5 attacks. Possibly that’s why
the referral got rejected.
P: Dr forget about the criteria. I can’t see him suffer like that. Please arrange the surgery
anyhow.
D: I can really see you are worried about son. But let me tell you the criteria are made in a
way to avoid unnecessary surgery and ensure better care for the patients. And every surgery
has a lot of complications. We don’t want your son to go through the unnecessary stress of
the surgery without any strong reason. Another thing is that tonsils are very important part
of the defence mechanism of our body that fight against infection. That is why we don’t want
to remove them unless it’s necessary.
P: Dr I just thing NHS is doing it for budget cutting. Don’t you think so Dr?
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D: I am really sorry you felt this way. But NHS has planned those surgery and set those criteria
for delivering the best possible care to the patients.
P: Alright
D: For now, we will give him painkillers to relieve the pain. Please ensure he is taking plenty
of rest. And gurgling with warm salty water can be helpful. By any chance if your son’s
condition gets worse or he develop neck stiffness or he can’t even swallow, please bring him
back to us.
If you have repeated (recurring) tonsillitis you may wonder about having your tonsils
removed. Guidelines suggest it may be an option to have your tonsils removed (tonsillectomy)
if you:
• Have had seven or more episodes of tonsillitis in the preceding year; or

• Five or more such episodes in each of the preceding two years; or
• Three or more such episodes in each of the preceding three years.
• And ...
• The bouts of tonsillitis affect normal functioning. For example, they are severe
enough to make you need time off from work or from school.
Aspire Education 8
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Cataract
You are an F2 working in Medicine. Evelyn Addison 65 years old has some concerns. She
went to her GP last week who advised her not to drive. Talk to her and address her concerns.

P: I have some problem with my vision and my GP advised me not to drive.
D: Can you tell me more about the vision problem? P: I don’t know.
D: Ok let me ask you few questions to have a better understanding of your vision.
D: Any pain in the eyes? P: No
D: Do you have any blurry vision? P: No
D: Any loss of vision? P: No
D: Any double vision? P: No
D: Do you find it harder to see in low light? P: Yes
D: For how long is that going on? P: 1 year
D: Do you see too bright or any glaring? P: No
D: Any faded colour in vision? P: No
D: Do you have any pain at the back of the eye? (Glaucoma) P: No
D: Do you have any coloured haloes around light? (Glaucoma) P: No
D: Any headache? (Glaucoma/ ICSOL) P: No
D: any nausea or vomiting? (Glaucoma/ ICSOL) P: No
D: Any discharge or redness in the eye? (Conjunctivitis) P: No
D: Any trauma to the eye? P: No
D: Do you see objects smaller? (ARMD) P: No
D: Do you see colours less bright? (ARMD) P: No
D: Do you have any trouble with the central vision? (ARMD) P: No
D: Do you see wavy lines instead of straight lines? (ARMD) P: No
D: Do you wear glasses or contact lenses? P: No
D: Have you had similar kind of problems in the past? P: No
D: Any DM, HTN, Glaucoma or visual problems in the past? P: No
D: Are you taking any medications including OTC or supplements? P: No.
D: Any allergies from any food or medications? P: No
D: Has anyone in the family been diagnosed with any medical condition?
D: Do you smoke? P: Yes/No

D: Do you drink Alcohol? P: Yes/No
D: Tell meat about your diet? N: Healthy
D: What you do for living? P:
D: Whom do you live with? P: My husband
I would like to examine you, do GPE, check vitals and I would like to examine your eyes.
Examiner: Bilateral cataract
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From our assessment it seems that you are having a condition called Cataract. A cataract is a
condition in which the lens of an eye becomes cloudy and affects vision.
P: Why did I have it?

D: There could be reasons for it. But in your case, it looks like due to age.
P: What’s the treatment?

D: Cataracts can usually be treated with a day-case operation, where the cloudy lens is
removed and is replaced with an artificial plastic lens. Day case surgery means you can come
to the hospital on the day of the surgery and leave the hospital on the same day if everything
goes on smoothly after the surgery.
P: Tell me about the surgery please?

D: A typical cataract operation takes about an hour and requires local anaesthesia only.
Surgeons will make a small cut and take the cloudy lens out and put an artificial lens in.
P: Dr It sounds very scary! They will operate in my eye without putting me on sleep! Please is
there any other way that the surgeons can take care of my anxiety?
D: I can see you are worried. I will be referring you to an eye specialist and they will be in a
better position to explain about the surgery. And they might give some medication during the
operation to sedate you or relieve your anxiety.
P: Will they operate both eyes at the same time?

D: Usually the surgeries of both eyes are done 6-12 weeks apart.
P: Thank You
D: Do you have any other concerns?

P: No
You don't need to tell the DVLA if you have cataracts in only one eye, unless you:
- also have a medical condition in the other eye
- drive for a living
If you drive a bus, coach or lorry, you must inform the DVLA if you have cataracts in one or
both eyes.
Aspire Education 10
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Age Related Macular Degeneration
You are FY2 in Medicine. Monica Ball aged 85 came with vision problem. Talk to her and
address her concerns.

P: I have got problem with my vision. Now I can’t see properly with my spectacles.
D: Tell me more about it?

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

D: Do you feel the objects looking smaller than the normal? P: No
D: Do you see colours seems to be less bright than they used to be? P: No
D: Any black or Grey Patch Affecting your vision? P: No
D: Any pain in your eyes? P: No
D: Any fleshing light? P: No
D: Any blurry vision? (Glaucoma) P: No

D: Any nausea and vomiting? P: No
D: Do you see any rings around lights? P: No
D: Have you noticed any redness in your eyes? P: No
D: Any burning sensation, any gritty sensation or any sticky discharge? (Conjunctivitis) P: No
D: Did you notice any weight loss? P: No
D: How is your appetite these days? P: Good
D: Any dizziness or heart racing? P: No
D: Do you feel tired these days? P: No
D: Has it happened before? P: No
D: Have you been diagnosed with any medical condition in the past? P: Yes, I have DM
D: Since when? P: From last 20 years
D: How is it managed? P: I am taking Insulin for that
D: Are you taking the medication regularly? P: Yes
D: Do you check it regularly? P: Yes
D: By any chance any HTN, Heart problem? P: No
D: Are you taking any other medications including OTC or supplements? P: No
D: Any previous hospital stays or surgeries? P: No
D: Do you smoke? P: Yes/ No

D: Do you drink alcohol? P: Yes/ No
D: Tell me about your diet? P: Good
D: Do you do physical exercise? P: Yes/ No
D: What do you do for a living? P: I am retired
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D: Whom do you live with? P: I live alone
I would like to check your vitals, examine your eye and would like to do fundoscopy.
Examiner: Fundus examination reveals drusen in the macular area.
Drusen = Discrete Yellow Deposits
Age-related macular degeneration is the most common cause of sight impairment in those
aged over 50. It causes a gradual loss of central vision, which we need for detailed work and
for things like reading and driving. Peripheral vision is usually intact.
Ocular coherence tomography is becoming more commonly used. This is a non-invasive test
that uses special light rays to scan the retina. It can give very detailed information about the
macula and can show if it is abnormal. This test is useful when there is doubt about whether
AMD is the wet or dry form, and to monitor treatment.
If wet AMD is diagnosed or suspected, then a further test called fluorescein

angiography may be done. For this test a dye is injected into a vein in your arm. Then, by
looking into your eyes with a magnifier the ophthalmologist can see where any dye leaks
into the macula from the abnormal leaky blood vessels. This can give an indication of the
severity of the condition.
You'll be seen by a specialist called an optometrist for the scan of the back of your eyes.
Dry AMD:
There's no treatment, but vision aids can help reduce the effect on your life. Read
about living with AMD.
Wet AMD:
Eye Injections (Anti-VEGF medicines – ranibizumab and aflibercept) (Every 1-2 month).
Injections given directly into the eyes, 9 out of 10 people and improves vision in 3 out of 10
people.
S/E:
Redness, irritation in eye, bleeding in the eye, foreign body sensation.
Photodynamic therapy (Every few months alongside eye injection): A light is shined at the
back of the eyes to destroy the abnormal blood vessels that cause wet AMD.
S/E:
Temporary vision problems, and the eyes and skin being sensitive to light for a few days or
weeks.
Intraocular lens is a new approach may eventually benefit patients with end-stage AMD of
either type.
Supplement of vitamin and mineral supplements can slow down the progression of AMD.
Aspire Education 12
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Advice about Smoking, Alcohol, Diet, Frequent eye checkup.
You're required by law to tell DVLA about your condition if it affects both eyes and if it only
affects one eye, but your remaining vision is below the minimum standards of vision for
driving.
Dry AMD Wet AMD

Caused by a Buildup of Fatty Substance Caused by the growth of abnormal Blood
called Drusen at the back of the eyes. Vessels at the back of the eyes.
Common Less Common
Gets worse gradually (usually over several Can get worse quickly (sometimes in days
years) or weeks)
No Treatment (Unless it develops into wet Treatment can help stop vision getting
AMD worse
Aspire Education 13
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IBS
You are an F2 working in GP. David Lloyd aged 50 has come in with some abdominal
discomfort.
D: How can I help you today? P: I have some discomfort in my tummy

D: Could you tell me more about it? P: like what?
D: Where exactly is it? P: It’s in all around my tummy
D: When did it start? P: More than a year
D: Is it continuous or comes and goes? P: Comes and goes
D: What type of pain is it? P: Colicky
D: Is there anything that makes it better? P: Yes, after I pass stool
D: Is there anything that makes it worse? P: No
D: Could you rate the discomfort on a scale of 1 to 10, where 0 being no pain and 10 being
the worst you have ever experienced? P: 5
D: Do you have any other problems? P: I have a feeling of bloating in my tummy
D: Could you tell me more about it? P: It’s been more than a year and it comes and goes
D: Anything else?
P: I have been having episodes of diarrhoea and constipation every now the then.
D: For how long is that? P: Same, about a year
D: Have you noticed any weight loss recently? P: No
D: Any change your appetite? P: No
D: Any tiredness? P: No
D: Any shortness of breath? P: No
D: Any bleeding from the back passage or blood in stool? P: No
D: Any change in the colour of urine and stool? P: No
D: Any lumps and bumps anywhere in the body? P: No
D: Did you have similar problems in the past? P: No

D: Have you been diagnosed with any medical condition in the past or any bowel
problems? P: No
D: Are you currently on any medication? P: No
D: Are you allergic to any foods or medication? P: No
D: Any family history of any significant health issues or bowel problems? P: No
D: Tell me about your diet? P: I eat healthy
D: Do you drink tea or coffee? P: Yes 5-6 cups of coffee a day
D: What about physical exercise? P: Quite active
D: Do you have any kind of stress? P: I am really stressed about my work
D: What you do for living? P: I work as an accountant
D: Whom do you live with? P: I live with my wife
Aspire Education 14
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I would like to do a GPE, check the vitals and Examine your abdomen and back passage. I
will be having a chaperone with me.
I will order initial investigation like routine blood test and stool test.
All patients meeting the symptomatic criteria for IBS should have the following
investigations:
- FBC.
- ESR.
- CRP.
- Coeliac screen.
- CA 125 for women with symptoms which could be ovarian cancer
- Faecal calprotectin for those with symptoms which could be IBD
Examiner: Everything is Normal
From our assessment we suspect you are having a condition called Irritable bowel
syndrome. It is a common condition that affects the digestive system.
There's no single diet or medicine that works for everyone with IBS. But there are lots of
things that can help if you have been diagnosed with it.
Do
§ cook homemade meals using fresh ingredients when you can
§ keep a diary of what you eat and any symptoms you get – try to avoid things that trigger
your IBS
§ try to find ways to relax
§ get plenty of exercise
§ try probiotics for a month to see if they help
Don't
§ do not delay or skip meals
§ do not eat too quickly
§ do not eat lots of fatty, spicy or processed foods
§ do not eat more than 3 portions of fresh fruit a day (a portion is 80g)
§ do not drink more than 3 cups of tea or coffee a day
§ do not drink lots of alcohol or fizzy drinks
How to ease bloating, cramps and farting:

• eat oats (such as porridge) regularly
• eat up to 1 tablespoon of linseeds a day
• avoid foods that are hard to digest (like cabbage, broccoli, cauliflower, brussels
sprouts, beans, onions and dried fruit)
• avoid products containing a sweetener called sorbitol
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• ask a pharmacist about medicines that can help, like Buscopan or peppermint oil
How to reduce diarrhoea:

• cut down on high-fibre foods like wholegrain foods (such as brown bread and brown
rice), nuts and seeds
• avoid products containing a sweetener called sorbitol
• ask a pharmacist about medicines that can help, like Imodium (loperamide)
How to relieve constipation:

• Drink plenty of water to help make your poo softer
• Increase how much soluble fibre you eat – good foods include oats, pulses, carrots,
peeled potatoes and linseeds
• Ask a pharmacist about medicines that can help (laxatives), like Fybogel or Celevac
You mentioned you are under stress and it can be a triggering factor for IBS.
We can refer you for a talking therapy, such as cognitive behavioural therapy (CBT).
This can help if stress or anxiety is triggering your symptoms. It can also help you cope with
your condition better.
Aspire Education 16
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Colleague Confidentiality Issue (Facebook Post)
You are F2 working in A&E. You colleague Peter an FY1 doctor made a post on Facebook
about an elderly lady in the emergency department with confusion who considered herself
to be the queen of England.
D: Hello Peter. Thank you for meeting with me on such a short notice.
P: That’s okay.
D: How’s your day going so far?

P: Great. Thank you.
D: Peter do you know what I am going to talk about?

P: No
D: Did you recently make a post on social media regarding one of our patients?
P: Oh yes doctor. You know I could not stop laughing while seeing the patient. Her name was
Diana. She was confused and she was thinking herself to be the Queen of England. Hilarious.
She was making funny comments like she lost her crowns and she was looking for it. So, I
made a video of her and posted it.
D: Ok. Where did you put in on Social Media?

P: I posted it on my Facebook profile.
D: Did you post her name and other details as well on Facebook?
P: No, I just posted the video.
D: Peter I don’t think you did the right thing. Posting patient information on social media is a
breach of confidentiality. Being a medical professional, we must obey the rules and
regulations of NHS. Before putting patient information online, think about why you are doing
it. You should definitely take the consent of your patient if you want to post something. Don’t
you think so?
P: Yes. But I didn’t mean to break the rules. It was just for fun
D: I do understand what you are trying to say. Many people are unaware that how easily this
information can spread on Facebook. Even if using the most stringent privacy setting,
information on social networking sites may still be widely available in search engines. Deleting
information is not sure-fire protection. It is almost stored in cyberspace and theoretically
permanently accessible.
P: To be honest I didn’t think that much before posting it.

D: Yes, I know. You wouldn’t have done it if you had thought about the consequence.
Breaching confidentiality can result in complaint to GMC and legal actions. Moreover, it can
erode public trust on the medical professionals, and it can hinder us getting the information
from the patients to treat them better.
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P: Yes, you are right. I am so sorry for what I have done. What should I do now?
D: I highly encourage you to delete the post immediately. I sincerely advice you not to do it
in future. How’s she doing now?
P: She is much better and fully conscious.

D: I am really happy to hear that. I would request you to talk to her and apologise to her for
the incident.
P: Ok. I will talk to her.

D: And It is very important to inform our seniors specially our consultant about the incident.
It will be bad if he gets to know about it from others. To be honest, he is the best person to
help us if we are in trouble. If you want, I can be there with you while you talk with our
consultant and we both can explain him a better way.
P: Thank you
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Leukaemia
You are an F2 in GP. John Bernard aged, 55 came to the clinic with gum bleeding/Wellman
check-up. Please talk to the patient, discuss plan of management with the patient and
address his concerns.
D: What brought you to the hospital today? P: I had gum bleeding today morning
D: I am sorry to hear that. Do you have any idea how much blood did you lose? P: No
D: Is it the first time you had this? P: Yes
D: How did the bleeding start? P: On its own
D: By any chance did you hurt yourself? P: No
D: Do you have any other symptoms? P: No
D: do you feel tired these days? P: No
D: any dizziness or heart racing? P: No
D: Any rash or bruise anywhere in the body? P: No
D: Any fever or flu like illness recently? P: No
D: Any bleeding from anywhere? P: No
D: Any change in the colour of stool that you noticed? P: No
D: Any lumps or bumps anywhere in the body? P: No
D: Any weight loss recently you noticed? P: No
D: has anyone told you that you are losing weight? P: No
D: How’s your appetite? P: Its good
D: Have you been diagnosed with any medical condition in the past or any blood disorder?
P: No
D: By any chance any blood thinners? P: No
D: Any family history of any significant health issues or any blood disorder in the family?
P: No
D: Tell meat about your diet? P: Healthy
I would like to do a GPE, check the vitals and Examine your tummy. I would like to order
initial investigation routine blood test.
Examiner: Abdomen: Splenomegaly. WBC count: >100,000
From our assessment we suspect you are having a condition called Leukaemia. Leukaemia is
a cancer of the white blood cells of our body. We will be referring you to a specialist and a
team of doctors within 2 weeks’ time and they will do further investigations like taking some
sample from your bone marrow to confirm the diagnosis. The treatment depends on the type
of leukaemia. There are chemotherapy and radiotherapy available for leukaemia. In some
cases, intensive chemotherapy and radiotherapy may be needed, in combination with a bone
marrow or stem cell transplant.
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ITP
You are an F2 in GP. Mark Anthony aged, feeling tired for last 1-2 weeks came to the clinic.
Please talk to the patient, discuss plan of management with the patient and address his
concerns.
D: What brought you to the hospital today? P: I am feeling tired for last couple of weeks
D: I am sorry to hear that. Can you tell me more about it? P: I just feel tired.
D: Is there any particular time of the day you feel tired? P: It’s throughout the day
D: Anything that makes it better? P: No
D: Anything that makes it worse? P: No
D: Is it the first time you had this? P: Yes
D: Do you feel cold when others around feeling normal? (Hypothyroid) P: No
D: Any change in your bowel habit recently? (Hypothyroid) P: No
D: How’s your mood been recently? P: My mood is fine
D: How did the bleeding start? P: It started on its own
D: Any fever or flu like illness recently?
P: Yes. I had some cough and fever 3 weeks ago. It got better on its own.
D: Any rash or bruise anywhere in the body? P: Yes. I have lots of bruises in my body
D: By any chance did you hurt yourself? P: I don’t exactly know
D: Any bleeding from anywhere? P: No
D: Any change in weight you recently noticed? P: No
D: Have you been diagnosed with any medical condition in the past or any blood disorder?
P: No
D: By any chance any blood thinners? P: No
D: Any family history of any significant health issues or any blood disorder in the family?
P: No
D: Tell meat about your diet? P: Balanced
I would like to do a GPE, check the vitals and Examine your tummy.
I would like to order initial investigation routine blood test.
Examiner: Abdomen: Splenomegaly; Bloods: Thrombocytopenia
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From our assessment we suspect you are having a condition called Idiopathic
thrombocytopenic purpura. It is a bleeding disorder in which the blood doesn't clot normally
because of the shortage of the tiny cells in the blood called platelet. We will be referring you
to a blood specialist and further investigations like taking some sample from your bone
marrow will be done to confirm the diagnosis.
P: It is serious?
D: I can see you are worried. But fortunately, there may treatment options available for it.
P: What is the treatment?

D: Sometimes no treatment is needed if the blood cells are not too low. If your condition
needs treating, usually steroid is the most widely used treatment for ITP. A short course of
steroid is good enough to tackle the symptoms.
There are other treatment options like some medicines that act on our body’s defence
mechanism (Immunosuppressive, Immunoglobulin, biological therapies). Another option
could be removal of the spleen by a surgery. The specialist will be in a better position to tell
you which kind of treatment would be most suitable for you.
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Analgesic Nephropathy
You are an F2 in GP. James Anderson aged, 30 came to the clinic with a new problem. His
eGFR low and Creatinine is High. Please talk to the patient, discuss plan of management
with the patient and address his concerns.
D: What brought you to the hospital today? P: I am losing blood in my urine

D: Could you tell me more about it?
P: It’s been happening for the last couple of days when I pass urine.
How much blood did you notice? P: I don’t know
D: Any blood clots in urine? P: No
D: Any pain while passing urine? P: No
D: Is there anything else bothering you?

P: Dr I have this back pain for around 2 years, but it’s not something new. I have been
referred to the specialist for that and they could not find out any cause for it.
D: How are you managing It?

P: I have been taking Ibuprofen almost every day for more than a year now.
D: How are you doing in terms of the pain now?

P: Its under control as I am taking the painkillers.
D: Any other symptoms? P: No

D: Any change in your urine colour or smell? P: No
D: Any fever or flu like illness? P: No
D: Do you have to rush to the loo? P: No
D: Any burning sensation while passing urine? P: No
D: Are you going to the loo more often? P: No
D: By any chance have you hurt yourself anywhere? P: No
D: Any pain in your pelvic area? P: No
D: Any bony pain? P: No
D: do you feel tired these days? P: No
D: Any rash or bruise anywhere in the body? P: No
D: Any bleeding from anywhere else? P: No
D: Any swelling in the ankles? P: No
D: Any tingling or numbness in your arms or legs? P: No
D: Any nausea or vomiting? P: No
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D: Did you have similar condition in the past? P: No
D: have you been diagnosed with any medical condition in the past? P: No
D: By any chance any kidney or bladder problems? P: No
D: Are you currently on any medication except the painkillers? P: No
D: Are you allergic to any medication? P: No
D: Any family history of any significant health issues or kidney problems? P: No
D: Have you travelled anywhere recently? P: Yes/No
D: Have you ever worked in Aniline, Dyes, Textiles, rubber, plastic or paint industries in the
past? P:
I would like to do a GPE, check the vitals and Examine your back. I would like to order initial
investigation like routine blood test, Renal function test and Urine dip.
Examiner: Urine Dip: Protein +; blood+, sediment+, FBC: Anaemia
From our assessment we suspect you are having a condition called Analgesics nephropathy.
It is a condition that happens due to long term consumption of painkillers resulting in kidney
damage. The mainstay of treatment is to stop taking all the painkillers right away to prevent
further damage to the kidneys. We will be referring you to a Kidney specialist for further
investigation and treating existing kidney problems.
The aims of treatment are to prevent further damage and to treat any existing kidney failure
- e.g., with dietary changes, fluid restriction, dialysis or kidney transplant.
Some behavioural changes or counselling can help to control chronic pain. We will also be
referring you to the pain management team who will help you tackling the long-term pain
that you are having.
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Carpal Tunnel Syndrome
You are an F2 in GP. Lucy aged, 34 came to the clinic with pain in both the wrist and hand.
Please talk to the patient, discuss plan of management with the patient and address her
concerns.
D: What brought you to the hospital today? P: I have pain in my hands and wrists
D: Could you tell me more about it? P: Like what
D: When did it start? P: 7 days ago
D: Is it continuous or comes and goes? P: Continuous
D: What type of pain is it? P: Electric shock like pain
D: Does it move to any anywhere else? P: It’s moving from my wrists to hands
D: Is there anything that makes it better? P: Changing hand posture or shaking the wrist
D: Is there anything that makes it worse?
P: Gets worse at night/repetitive movements of hand or wrist
D: Could you rate the pain on a a scale of o to 10, where 0 being no pain and 10 being the
worst you have ever experienced? P: 7
D: Any pain in other joints in the body? P: No

D: By any chance did you hurt yourself? P: No
D: Any redness or swelling in the joints? P: No
D: Do have any tingling or numbness in your Hands? P: No
D: Do you have any difficulty gripping things by your hand? P: No
D: Any nausea, vomiting or swelling in the ankles? P: No
D: Do you feel cold when others around feeling normal? (Hypothyroid) P: No
D: Any change in your bowel habit recently? (Hypothyroid) P: No
D: Do you feel more tired? (Hypothyroid) P: No
D: Did you have similar condition in the past? P: No

D: Any joint problems? P: No
D: Any family history of any significant health issues or joint problems? P: No
D: Tell me about your diet? P: Balanced
D: What you do for living? P: I worked as a typist in an office.
D: When was your LMP? P: I delivered the baby one month back.
D: Whom do you live with? P: With my husband
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I would like to do a GPE, check the vitals and Examine your hand and wrist.
Examiner: Examine doctor
• Tinel’s sign. In this test, the physician taps over the median nerve at the wrist to see if it
produces a tingling sensation in the fingers.
• Wrist flexion test (or Phalen test). The doctor will tell you to press the backs of your hands
and fingers together with your wrists flexed and your fingers pointed down. You'll stay that
way for 1-2 minutes. If your fingers tingle or get numb, you have carpal tunnel syndrome.
From our assessment we suspect you are having a condition called Carpal tunnel syndrome.
It occurs due to pressure on a nerve in your wrist. It causes tingling, numbness and pain in
your hand and fingers.
P: Why did I have it?

D: There could be many reasons for it. But as it seems in your case it could be due to your
pregnancy or your job.
P: What’s the treatment?
CTS sometimes clears up by itself in a few months, particularly if you have it because you're
pregnant.
Wear a wrist splint

A wrist splint is something you wear on your hand to keep your wrist straight. It helps to
relieve pressure on the nerve. You wear it at night while you sleep. You'll have to wear a splint
for at least 4 weeks before you start to feel better. You can buy wrist splints online or from
pharmacies. If a wrist splint does not help, your GP might recommend a steroid injection into
your wrist. This brings down swelling around the nerve, easing the symptoms of CTS.
Stop or cut down on things that may be causing it. Stop or cut down on anything that causes
you to frequently bend your wrist or grip hard, such as using vibrating tools for work or playing
an instrument.
Painkillers like paracetamol or ibuprofen may offer short-term relief from carpal tunnel pain.
Surgery
If your CTS is getting worse and other treatments have not worked, your GP might refer you
to a specialist to discuss surgery. Surgery usually cures CTS. You and your specialist will decide
together if it's the right treatment for you. An injection numbs your wrist, so you do not feel
pain (local anaesthetic) and a small cut is made in your hand. The carpal tunnel inside your
wrist is cut so it no longer puts pressure on the nerve. The operation takes around 20 minutes
and you do not have to stay in hospital overnight. It can take a month after the operation to
get back to normal activities.
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De Quervain’s Tenosynovitis
You are an FY2 in GP. Patient
D: How can I help you? P: Pain in the thumb.
S/S
1. pain or tenderness at the base of your thumb.
2. Swelling near the base of your thumb.
3. Numbness along the back of your thumb and index finger.
4. A catching or snapping feeling when you move your thumb.
Risk Factors:
• You are a woman.
• You are 40 years of age or older.
• Your hobby or job involves repetitive hand and wrist motions. This is a very common
cause.
• You have injured your wrist. Scar tissue can restrict the movement of your tendons.
• You are pregnant. Hormonal changes during pregnancy can cause it.
• You have arthritis.
To diagnose de Quervain’s tenosynovitis, your doctor may do a simple test. It is called the
Finkelstein test.
Treatment for de Quervain’s tenosynovitis focuses on reducing pain and swelling. It

includes:
• Applying heat or ice to the affected area.
• Taking a nonsteroidal anti-inflammatory drug (NSAID). These include ibuprofen (Advil,
Motrin) or naproxen (Aleve).
• Avoiding activities that cause pain and swelling. Especially avoid those that involve
repetitive hand and wrist motions.
• Wearing a splint 24 hours a day for 4 to 6 weeks to rest your thumb and wrist.
Getting injections of steroids or a local anesthetic (numbing medicine) into

the tendon sheath. These injections are very effective and are used regularly.
A physical therapist or occupational therapist can show you how to change the way you
move. This can reduce stress on your wrist. He or she can also teach you exercises to
strengthen your muscles.
Most people notice improvement after 4 to 6 weeks of treatment. They are able to use their
hands and wrists without pain once the swelling is gone.
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Hand & Wrist Examination
Rapport
Assess his knowledge.
GIPPEEC
Look:
Inspect hands from Dorsum:
There are no skin, nail changes, scar marks, swelling, deformities or muscle wasting.
Palms up:
There are no scars and swelling, Dupuytren’s contracture or thenar and hypothenar muscle
wasting.
Elbows:
There are no evidence of psoriatic plaques or rheumatoid nodules
Feel:
Palms up
Temperature:
Assess and compare the temperature of the wrists and small joints of the hand.
Radial and ulnar pulse:

Palpate the radial and ulnar pulse to confirm there is adequate blood supply to the hand
Thenar/hypothenar eminence bulk:

The muscle bulk of the thenar and hypothenar eminences is normal. There is no
palmar thickening
Median, ulnar and radial nerve nerve sensation:

median nerve sensation over the thenar eminence and indexfinger
ulnar nerve sensation over the hypothenar eminence and little finger
Radial nerve sensation over the first dorsal web space
Dorsum:
Assess and compare temperature using the back of your hand:

Wrist and MCP joint.
Gently squeeze across the metacarpophalangeal (MCP) joints, Bimanually palpate the joints
of the hand (MCPJ/PIPJ/DIPJ/CMCJ)
Assess and compare joints for tenderness, irregularities and warmth:

Metacarpophalangeal joint (MCPJ), Proximal interphalangeal joint (PIPJ), Distal
interphalangeal joint (DIPJ), Carpometacarpal joint (CMCJ) of the thumb (squaring of the
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joint is associated with OA). Palpate the wrists for evidence of joint
line irregularities or tenderness
Palpate the anatomical snuffbox: Tenderness may suggest scaphoid fracture.
Palpate the elbow: Along the ulnar border to the elbow feel for any rheumatoid nodules or
psoriatic plaques (extensor surface).
Move:
Active movements:
Finger flexion – Make a fist.
Finger extension – Open your fist and splay your fingers
Wrist extension – Put the palms of your hands together and extend your wrists fully.
Wrist flexion – Put the backs of your hands together and flex your wrists fully
Passive movement:
Assess movements passively, feeling for crepitus and noting any pain.
Motor assessment
Wrist/finger extension – radial nerve
Finger ABduction of the index finger – ulnar nerve
Thumb ABduction – median nerve
Function
Assess the patient’s hand function using the following screening tests:
Power grip – “Squeeze my fingers with your hands”
Pincer grip – “Squeeze my finger between your thumb and index finger “
Pick up a small object or undo a shirt button – “Can you pick up this small coin out of my
hand?”
Special tests
Tinel’s test:
Tinel’s test is used to identify nerve irritation and can be useful in the diagnosis
of carpal tunnel syndrome.
Tap over the carpal tunnel with your finger. If the patient develops tingling in
the thumb and radial two and a half fingers this is suggestive
of median nerve irritation and compression.
Phalen’s test:
Ask the patient to hold their wrist in complete and forced flexion (pushing the dorsal
surfaces of both hands together) for 60 seconds.
patient’s symptoms of carpal tunnel syndrome are reproduced then the test
is positive (e.g burning, tingling or numb sensation in the thumb, index, middle and ring
fingers)
To finish the examination, I will do full neurological examination, I will examine one joint
above.
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Respiratory Examination
You are an FY2 in Medicine. Danial James is a 2nd year medical student. Teach him
Respiratory Examination. Patient came with ankle sprain surgery and is about to leave the
hospital. Patient has agreed to be the surrogate in this teaching.
Rapport
Assess his knowledge.
Which patient we should do chest examination.
GIPPEEC
Look at the patient from foot end:

Patient is not coughing, no expiratory wheeze, no stridor.
Hands
Inspect the hands:

We are looking for Nicotine tar staining, Clubbing, Peripheral cyanosis, Skin changes or any
rheumatological diseases.
Palpate pulse – rate and rhythm

I will check for the respiratory rate as well.
There is no fine or flapping tremor.
Head and neck:
There is no conjunctival Pallor.

Central cyanosis – bluish discolouration of the lips / inferior aspect of tongue
Jugular venous pressure (JVP): At 45°. Measure the JVP – number of centimetres measured
vertically from the sternal angle to the upper border of pulsation
Inspection:
Chest is moving bilateral symmetrical, no scars or skin changes and no deformities.
Palpation:
There are no Engorged neck veins.
Trachea is central in position.
Chest expansion is normal.
Apex beat: Normal position is 5th intercostal space – mid-clavicular line
Percussion
Percuss the following areas, comparing side to side:
1. Supraclavicular (lung apices)
2. Infraclavicular
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3. Chest wall (3-4 locations bilaterally)
4. Axilla
Auscultation
Ask the patient to take deep breaths in and out through their mouth.
Assess quality:
Vesicular (normal)
Bronchial (harsh sounding – similar to auscultating over the trachea – inspiration and
expiration are equal and there is a pause between) – associated with consolidation
Added sounds:
Wheeze – asthma / COPD
Coarse crackles – pneumonia / bronchiectasis / fluid overload
Fine crackles – pulmonary fibrosis
Vocal resonance:
• Ask patient to say “99” repeatedly and auscultate the chest again
• Increased volume over an area suggests increased tissue density (especially if there is a
dull percussion note over the same area) – consolidation / tumour / lobar collapse
• Decreased volume over an area (especially if there is an associated dull percussion note)
suggests fluid outside of the lung (pleural effusion)
Ask patient to sit forwards
Lymph nodes:
Palpate the following areas:

Anterior and posterior triangles, Supraclavicular region and Axillary region
Assess the posterior chest:

Repeat inspection, chest expansion, percussion and auscultation on the posterior aspect of
the chest.
We will Examine the sacrum for oedema and Examine the legs Pitting oedema.
Assess the calves for signs of deep vein thrombosis
Thank you
Concerns:
What is abnormal breath sound?
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Syphilis
You are an F2 working in GP. Ben Stokes 24 years old has come with a skin lesion on private
part. He is concerned about it. Talk to him, discuss management and address his concerns.
D: How can I help you today? P: Dr I feel so embarrassed

D: I can really see you are embarrassed. Can you tell me what’s going on?
P: I have a small ulcer on my penis.
D: Can you tell me more about that? P: Like what?
D: How long it’s been there? P: For the last 1 week
D: What is the size of the ulcer? P: Like a coin
D: What is the shape of the ulcer? P: I don’t know
D: What is the colour of the rash? P: Red
D: Is there any discharge from the rashes? P: No
D: Is there itching in the ulcer? P: No
D: is it painful? P: No
D: any other skin lesions in the body? P: No
D: any fever or flu like illness recently? P: No
D: Any lumps or bumps in the body? P: Yes, I have some around my groin for a week
D: Does those hurt? P: No
D: Any weight loss? P: No
D: Any loss of appetite? P: No
D: Any headache? P: No
D: Any joint pain? P: No
D: Any tiredness? P: No
D: Any rash on the palms or soles? P: No
D: Any white patches in the mouth? P: No
D: Any long-term exposure under the sun or skin tanning sessions? P: No
D: Have you been exposed to someone having similar skin lesions? P: No
D: Did you have similar health condition in the past? P: No

D: Are you allergic to any foods or medication? P: No
D: Any family history of any significant health issues or skin problems? P: No
D: tell me about your diet? P: Balanced
D: Are you currently sexually active? P: Yes
D: Are you in a stable relationship? P: No. I have many partners
D: May I ask about your sexual orientation? P: Bisexual
D: Do you use any contraception? P: No
D: Any pain during or after sex? P: No
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I would like to do a GPE, check the vitals and Examine the ulcer.
From our assessment we suspect you are having a condition called syphilis. It is a kind of
sexually transmitted infection caused by a bacteria. We will be doing further investigation
like an antibody test (treponemal serology test) in GP practice to confirm the diagnosis and
we will refer you to the GUM clinic. They might take a swab from the lesion and some more
blood work up.
Syphilis is usually treated with either:

• an injection of antibiotics into your buttocks – most people will only need 1 dose,
although 3 injections given at weekly intervals may be recommended if you have had
syphilis for a long time
• a course of antibiotics tablets if you cannot have the injection – this will usually last 2
or 4 weeks, depending on how long you have had syphilis
You should avoid any kind of sexual activity or close sexual contact with another person
until at least 2 weeks after your treatment finishes. It is very important to complete the
treatment by bringing in your partners and treating them as well if they have got the
infection. If you are not able to bring your partners, we can contact them through partner
notification programme. We usually offer HIV test to those who have any kind of sexually
transmitted infections.
D: Do you wish to have one? P: No
If you develop any sore throat, white patches in the mouth, any tingling or numbness in
your hands or feet, any vision problems please come back to us.
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PSA Test- Demanding Patient
You are an F2 in GP. Jason Roy aged, 55 came to the clinic requesting PSA. Please talk to
the patient and address his concerns.
D: What brought you to the hospital today? P: I want to have the PSA test done
D: May I know why? P: Dr one of my friend is having prostate cancer
D: I am sorry to hear about your friend. How’s he doing now? P: He is under treatment
D: Let me ask you few questions to assess your health better.
D: Do you have any kind of symptoms? P: Like what
D: Are you going to the loo more often these days? P: Yes
D: Can you tell me more about it. P: I have to go to the loo 10-12 times a day now.
D: Do you have to rush to the loo? P: No
D: Any burning sensation while passing urine? P: No
D: Any fever or flu like illness recently? P: No
D: Do you have to wake up at the middle of the night to go the loo? P: No
D: Do you have to strain while passing urine? P: Yes/No
D: Do you have difficulty in starting urination? P: Yes/No
D: Are you able to hold your urine before going to the loo? P: Yes/No
D: Do you feel like you are not completely able to empty your bladder? P: Yes/No
D: Have you noticed any dribbling at the end of urination? P: Yes/No
D: Do you have weak urine stream or stream that stops and starts? P: No
D: By any chance any blood in your urine? P: No
D: Has anyone told you that you are losing weight? P: No
D: Any dizziness or heart racing? P: No
D: Did you have similar symptoms in the past? D: No

D: have you been diagnosed with any medical condition in the past or any prostate
problems? P: No
D: By any chance any kidney or bladder problems? P: No
D: Any family history of any significant health issues or prostate problems? P: No
I would like to do a GPE, check vitals and examine your back passage. I will be having a
chaperone with me.
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D: Can you tell me how much you know about the test?
P: I know it indicates prostate cancer
D: PSA is a protein produces by normal and cancerous cells of the prostate. PSA is an
inaccurate marker for prostate cancer. Because cancer can be present without increased
PSA levels and there are many other causes of increased PSA levels (BPH, Prostatitis, UTI).
1. So, before you make a decision about PSA testing you need to consider benefits and
risks:
- Benefits can be early detection and early treatment of Prostate cancer
- Limitations and risks could be false positive results about (85%) and false negative
results (about 15%). False positive result can further lead to invasive investigation such
as taking sample from your prostate (biopsy) and there may be adverse event like
infection or bleeding after the procedure.
2. We can offer PSA testing to Men>50 years old as long as they are symptomatic
3. Routine screening for prostate cancer is not in the national policy because the benefits
have not been shown to clearly outweigh the harms. Therefore, we don’t offer it to
those who doesn’t have symptoms.
4. we can provide you with some leaflets before you decide from the Prostate cancer UK
organization.
P: Dr I want to have the test done please.

D: Yes, in that case we can do it for you.
v Before doing PSA, test men should not have-
§ Active urine infection
§ Ejaculated in previous 48 hours
§ Exercised vigorously in previous 48 hours
§ Had a prostate biopsy in previous 6 weeks.
Inform choice programme
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8th Nerve Examination Teaching
You are an F2 working in neurology. David your colleague wants to learn 8 th cranial
nerve examination. Talk to him and teach him
Ø
Build rapport with colleague
Ø
Assess his knowledge about the nerve and give him knowledge about the
function of 8th nerve
Ø
Greetings with the patient (Both mannequin and patient are there)
Ø
Parts of 8th nerve examination:
•
Inspection of ear
•
Palpation of ear: temperature, tenderness, Tragus test
•
Otoscopy on mannequin
•
Hearing test: Rinne and weber
•
Vertical and horizontal nystagmus
•
Romberg test
•
Marching test
•
Gait and tandem gait
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Cervical Screening (Lesbian)
You are an FY2 in GP. Sarah, 26-year-old female presented to you with a new concern. She
has recently been sent a letter to undergo cervical screening tests. Please talk to her and

P: I have been sent a letter to come for the cervical screening test. I was wandering why?
D: Cervical screening (a smear test) checks the health of your cervix. The cervix is the opening
to your womb from your vagina. It's not a test for cancer, it's a test to help prevent cancer.
We recommend having the test done as long as they are within 25-64 years old.
P: But doctor I don’t think I need to go for the test.
D: May I ask why do you think so? P: Dr I am a lesbian

D: Ok let me explain you further. But before that may I ask you few questions to assess your
overall health P: Ok
D: Do you have any discharge from your front passage? P: No
D: When was your last Menstrual period? P: 2 weeks ago
D: Are your periods regular? P: No
D: Any bleeding between your periods? P: No
D: Any problem with your urine or bowel? P: No
D: Any bleeding during or after sex? P: No
D: Any pain in your lower back or pelvis? P: No
D: Have you had any cervical screening test in the past? P: No
D: Has anyone told you that you are losing weight? P: No
D: Any family history of any significant health issues? P: No
D: Do you smoke? P: Yes

D: What and how much do you smoke? P: 10 cigarettes per day for the last 3 years
D: Do you drink alcohol? P: No
D: Are you in a stable relationship? P: Yes

D: For how long? P: 2 years
D: Any previous partners? P: No
D: Which route of sex do you prefer? P: All
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D: Thanks for answering all my questions. Let me tell you women should be offered screening
and consider attending regardless of their sexual orientation.
P: Why is that? I don’t have a male partner.
D: Research suggest that although the virus responsible for cervical cancer (HPV) is more
easily transmitted through heterosexual intercourse. It can also be transmitted through
lesbian intercourse. As with other sexually transmitted infections HPV is passed on through
body fluids. This means that oral sex transferring vaginal fluids on hands and fingers can be
all ways of being exposed to HPV. As well as sexual behaviour, smoking is also a risk factor for
cervical cancer
P: How long does it take to have the test done?

D: During cervical screening a small sample of cells is taken from your cervix for testing. The
test itself should take less than 5 minutes. The whole appointment should take about 10
minutes. It’s usually done by a female nurse or doctor. You should get your results within 14
days.
P: Thank you
Lifestyle counselling regarding smoking
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8 Weeks Vaccination
You are an FY2 in GP. Evana, 30-year-old female presented to your clinic with her 8 weeks
old boy. She wants to know about the vaccines that can be given to her baby. Please talk
to her, explain to her about the vaccines that can be given at 8 weeks of birth and address
her concerns.
Vaccine Side Effects

6 in 1 This vaccine is given as a single injection into your Redness, swelling
baby’s thigh. This protects against 6 childhood at injection site,
diseases. Such as Diphtheria, Tetanus, Pertussis, Fever
Hepatitis B, Hemophilus Influenzae B and Polio
Pneumococcal Injection in your baby’s arm or leg muscle. Protects Redness, swelling
against pneumococcus at injection site,
Fever
Rotavirus Oral vaccine against rotavirus infection. Common Irritable/ Mild
cause of diarrhoea and sickness diarrhoea
MenB Single injection into your baby’s thigh to protect Redness, swelling
against infection by meningococcal group B at injection site,
Fever
Please refer to Immunisation Table in Introduction Booklet.
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Hip Examination Combined Station
You are an FY2 in GP. 44 year old lady has come to your clinic with pain in both hip joints
for 3 weeks. Please talk to her, do relevant examination, discuss the management plan
and address her concerns.
D: What brought you to the hospital today? P: I have pain in my hip

D: May I know which side? P: Right side
D: SOCRATES
P: For 3 weeks. Pain just started. Getting worse with time. Continuous. Dull pain. Doing
some activities makes pain worse.
D: Did you hurt yourself? P: No

D: Any previous medical diagnosis? P: No
D: Any regular medications? P: No
D: Any allergies? P: No
Ex: I am going to examine your hip.
D: Any surgeries to the hip? P: No

D: Are you able to stand and walk? P: Yes
Joint examination: LOOK (Standing)/ FEEL (Lying flat)/ MOVE (Lying flat) & Special Tests
Look (Inspection):
Anatomical position: Joint symmetry
Front: Skin changes/ scars/ swelling/ level of ASIS/ Quadriceps muscle wasting
Side: Lumbar lordosis (Normal or Hyper lordosis)
Back: Scoliosis / gluteal wasting / pelvic tilt
Gait: Normal/ Antalgic/ Trendelenburg
Trendelenburg Test
Fell (Palpation):
Temperature
Tenderness: Around the joint/ Greater trochanter (Tenderness on palpation of greater
trochanter suggests greater trochanteric bursitis).
Leg length: True/ Apparent
True: Umbilicus to the tip of medial malleolus.
Apparent: ASIS to the tip of medial malleolus
Move (Movements):
Active: Flexion: Bring your right knee towards the chest and relax. Bring your left knee
towards the chest and relax.
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Abduction/Adduction: Bring your right leg at the edge of the couch. Bring your right leg and
cross it over the left leg.
Bring your left leg at the edge of the couch. Bring your left leg and cross it over the left leg.
Internal and external rotation: Join your toes and keep your heel apart. Join your heel and
keep the toes apart.
Special Tests:
Thomas Test:
1. Place the hand on the patient spine.
2. Flex the unaffected leg as far as you are able to and your hand should detect the lumber
lordosis is now flattened.
3. The test is positive if the affected thigh raises off the bed indicating a loss of extension in
the hip. This would suggest a fixed flexion deformity in the affected hip.
(NOTE: Don’t do if hip replacement)
Trendelenburg Test:
1. Place your hands on the iliac crest on either side of the pelvis.
2. Ask the patient to stand on the affected side for 30 second and observe your hands to see
which moves up and down.
3. Normally the iliac crest on the side with the foot off (Unaffected) the ground should rise
up.
4. The test would be positive if the pelvis falls on the side with the foot off the ground
(Unaffected). The abnormal result suggests weak hip abductors on the contralateral side.
I would like to finish my examination by examining a joint above (lumbar spine) and a joint
below (Knee).
I would also like to do a full neurological examination of lower limbs including checking for
distal pulses.
Management:
From my assessment, you seem to be having a condition called Greater Trochanteric
Bursitis. This means, inflammation of bursa on the bony bump called greater trochanter, on
the outside of your hip. (Bursa is a fluid filled sac that provides cushion around bony
prominences).
Do PRICE avoid HARM
Rest – try not to move the joint too much and avoid activities that'll put pressure on it.
Ice – gently hold an ice pack (or a bag of frozen peas) wrapped in a tea towel on the area for
around 10 minutes at a time and repeat every few hours during the day.
Anti-inflammatory medication
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Avoid aggravating positions
Stretches
Physiotherapy
In persistent cases steroid injection may be helpful.
P: What causes GTPS (Greater Trochanteric Pain Syndrome?

D: It is most common in middle aged females. The most cases of greater trochanteric pain
syndrome are due to minor tears or damage to the nearby muscles, tendons or fascia, so that
an inflamed bursa is an uncommon cause. So, rather than the term trochanteric bursitis, the
more general term, greater trochanteric pain syndrome, is now preferred.
The exact causes of GTPS are not fully understood, but there are many factors that can
contribute to it, including: direct fall on outside edge of hip
• excessive load, for example prolonged walking or running. Poor running style can also lead
to increased load on this area of the hip.
• prolonged or excessive pressure to your hip area (for example, sitting in bucket car seats,
or sleeping on your affected side, may aggravate the problem)
• weakness of the muscles surrounding the hip, called the gluteus Medius and minimus.
P: How long does it take to get better?

D: Everybody will improve differently, but for most people it will take six to nine months of
focused rehabilitation to make a return to full normal activities without pain.
If you have a very high temperature, cannot move the affected joint and you have very
severe, sharp or shooting pains in the joint come back to the GP.
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Bullying at Workplace (Lesbian)
You are an FY2 in GP. 34-year-old Lucy presented to you with some new symptoms. She is a
lesbian and her colleagues at work place are bullying her for that. Please talk to her and
D: How can I help you today? P: Dr I am feeling anxious for the last 3 weeks
D: I am sorry to hear that. Could you please elaborate what do you mean by anxious?
P: Dr I get shortness of breath and a feeling of being unwell when I go to my office.
D: Could you tell me more about the shortness of breath?

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

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

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

P: Do you have any other friends or family members living nearby? P: No
P: Whom do you live with? P: My partner
P: How do you get along with her? P: Really well. She is the one who supports me a lot.
P: For how long have you been in a relationship? D: 3 years
P: Have you been ever been diagnosed with any medical condition in the past? P: No
D: Any allergies to anything? P: No
D: Any family history of any significant health issues? P: No
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From my assessment it seems you are having a condition what we call Panic attack. A panic
attack is a rush of intense anxiety and physical symptoms. They can be frightening and happen
suddenly. It’s happening probably due the stress that you are going through at your
workplace.
Treatment aims to reduce the number of panic attacks you have and ease your symptoms.
Psychological (talking) therapies and medicine are the main treatments for panic disorder.
If you prefer, we can refer you for talking therapy. You might discuss with your therapist how
you react and what you think about when you're experiencing a panic attack. Your therapist
can teach you ways of changing your behaviour, such as breathing techniques to help you
keep calm during an attack.
We may prescribe some medication (Antidepressant) as well to control your symptoms.
D: Did you talk with anyone in your HR department or your supervisor regarding this issue?
P: No
D: You should inform them about what’s happening with you. They would be the best person
to help you in your office.
You should inform them about what’s happening with you. They would be the best person to
help you in your office. Poor levels of mental health among lesbian, gay, bisexual and trans
(LGBT) people have often been linked to experiences of discrimination and bullying.
It might not be easy but getting help with issues you may be struggling to deal with on your
own is one of the most important things you can do.
Talking with a therapist trained to work with LGBT people may help you deal with issues such
as:
• difficulty accepting your sexual orientation
• coping with other people's reactions
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Levothyroxine Dose Adjustment
You are an FY2 in GP. Daughter of a 65 year old lady living in care home presented to you
to know why she has not been informed about the dose reduction of her mother’s thyroid
medication. Daughter should have been informed about it as her mother doesn’t have the
capacity. Thyroid function tests were normal and Thyroid function test will be done again
after 6 weeks to check her mother’s thyroid hormone levels. Please talk to her and address
her concerns.

P: Dr I am Lucy. I am the daughter of your patient Mrs Smith. I am here to talk about her Dr
(Patient seems angry)
D: I can see you are angry, and I am here to address all your concern. Can you tell me what
exactly happened?
P: Dr I went to the nursing home and I came to know your colleague has changed my mother’s
thyroid medication without informing me.
D: I am extremely sorry for your experience. I came to know from your mother’s note that
you should have been informed regarding that. I am really sorry. I will definitely talk with my
colleague and try to find out what went wrong and why you had not been informed. Can I ask
you few questions to have a better understanding of your mother’s health?
P: Yes Dr
D Can you please tell me about your mother’s thyroid problem.

P: Dr she is doing fine. She has been taking the thyroid medication for 6 years now. She
doesn’t have any symptoms of thyroid now.
D: Has she been diagnosed with any other medical condition in the past?
P: Yes. She has dementia for the last 10 years.
D: Is she on any kind other medication except the thyroid one?

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

P: Dr it was getting difficult for me to take care of her alone as I am working full time. So, I
decided to send her to care home. She has been there for 8 years now. They keep me updated
about my mother’s health time to time. And the doctors always inform me about my mother’s
health and medications. But I don’t know what happened this time. I think your colleague
neglected my mother’s care.
D: I am really sorry that we made you feel bad. I will surely look into the matter. We will take
further actions to prevent this from happening in future.
P: How would you prevent?
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D: We will document everything. We will escalate this issue to the consultant and seniors. If
there is any further change in your mother’s treatment plan in future, we will make sure you
are the first person to be informed.
P: Alright. But I don’t know why her medication has been reduced.
D: I can understand your frustration. Let me explain it to you further. Your mother was having
a condition what we call hypothyroidism that means her thyroid gland was underactive and
was not secreting enough hormone. So, we gave hormone replacement medication to make
up for it. Now her hormones have come to back to normal. If we continue giving the
medication at the same dose there is a chance of overactivity of the hormones. That’s why
we had to reduce the dose of the medication.
P: Ok.
D: We will be checking your mother’s thyroid hormone levels after 6 weeks. And decide how
the treatment will progress. We will update you as soon as we get the results.
P: Ok. Thank you.
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Cerebral Palsy
You are an FY2 in Paediatrics. Teddy aged 5 was admitted to the hospital with Pneumonia.
Teddy has Cerebral Palsy. Mother Ann does not want a Cannula attached to her son.
Talk to the mother and address her concerns.
Ask about Pneumonia.

Explain why we need to give the antibiotics through vein.
Ask about CP.
PMH: NAD
Paedatrics Questions: NAD
Mothers Concerns:
1. Is It painful?
2. Why not Oral?
3. You have to prick him so many times. I can’t see him in pain.
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Chest Pain (Mastectomy)
You are an FY2 in A&E

Maria aged 60 presented with SOB and chest pain.
Take history and discuss management.
PC:
Chest pain
SOB
PMH: DM, breast cancer and mastectomy. OCP.
Life-style: Negative.
Examination:
GPE, Vitals. Sats: 90% PR 110 Temp: 37. BP: 120/80

ABG: respiratory alkalosis
CXR normal.
People with cancer may have a higher number of platelets and clotting factors in the blood
which in turn help clotting and stop bleeding.
Management:
Admit and do CTPA along with d-dimer. Begin LMWH immediately and monitor.
Inform the senior and discuss regarding the and long-term anticoagulants
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Chest Pain (Transgender)
You are and FY2 in A & E. Chanella Oliver, 28 Years Old, has come to the hospital with
Chest Pain. He is under transition from Male to Female.
Talk to her and address her concerns.
D: How can I help you? P: I have Chest Pain

D: Where is it exactly? P: Left Side
D: Does it go anywhere? P: No
Pain gets worse on inspiration.
(Complete SOCRATES)
D: Any other symptoms? P: No

D: Any Fever? P: No
D: Any Leg Pain? P: Yes, 2 days ago.
(Elaborate)
D: Do you feel out of breath? P: No
Any Cough, Dizziness, Trauma, Skin Lesion.
PMH: Oestrogen from 6 months taking more than prescribed.

Spironolactone the same time.
Personal:
D: Have you travelled anywhere recently? P: No
D: Are you currently sexually active? P: No
D: Who do you live with? P: Alone
Examination: Examiner said it is normal. BP: 120/80, Sats: 99%.
Mention the treatment and review the medication Oestrogen and spironolactone by the
specialist.
Risk factors: Prolonged Immobilisation, Pregnancy, Pills, HRT, Previous PE/DVT, Malignancy
à Thrombophilia
Investigation: FBC, Urine (Pregnancy), ABG, D-Dimer, CXR, ECG, CTPA
Treatment:
O2.
Morphine & Metoclopramide
Anticoagulation Heparin 5 Days
Warfarin à 3-6 Months
Prevention (Compression Stockings, Stop HRT/Pills, Anticoagulation administered to
Immobile patient)
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Risks
There's some uncertainty about the possible risks of long-term masculinising and feminising
hormone treatment. You should be made aware of the potential risks and the importance of
regular monitoring before treatment begins.
Some of the potential problems most closely associated with hormone therapy include:
• blood clots
• gallstones
• weight gain
• acne
• hair loss from the scalp
• sleep apnoea – a condition that causes interrupted breathing during sleep
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Haematuria – Lab Results
You are an F2 in GP. Mrs Maria Aged 62 has come to the clinic for her lab reports. She was
asked to see a doctor by the nurse. She went to well woman clinic for a regular check-up
2weeks back. A urine dip was done which showed +RBC. Another urine dip was repeated
yesterday which showed +RBC. Her blood pressure is 120/80. She was diagnosed with AF 5
years ago and is on Bisoprolol and Warfarin. Her Warfarin dose is managed according to
her INR. Her last INR is 2.0. Please talk to the patient, explain the test results and address
her concerns.
D: How can I help you?

P: I have come for my test results.
D: I understand, I have your test results. Before I tell you your results, could you briefly tell
me why you got this test done?
P: I usually go for regular check-up in well women clinic. They have done my urine test and
asked me to see a doctor.
D: Did you have any symptoms that made you go to the well women clinic?
P: No, I regularly go to general health check-ups.
D: Okay, I understand that they have tested your urine 2 weeks back and also yesterday.
P: Yes.
D: Unfortunately, we found microscopic traces of blood in your urine. We call it Microscopic

Haematuria.
P: What do you mean by that?

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

D: That’s a very valid concern. Let me ask you few questions to see why this is happening
and to address all your concerns. P: Okay
D: Could you please tell me how has your health been? P:

D: Any fever? P: No
D: Any pain anywhere in your body? P: No
D: Any tummy pain or discomfort? P: No
D: Did you have any urinary problems? P: No
P: Like what? P: No
D: Any pain or burning sensation while passing urine? P: No
D: Any change in colour of your urine? P: No
D: Any cloudy or smelly urine? P: No
D: Any change in your weight recently? P: No
D: How is your appetite these days? P: No
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D: Any dizziness or shortness of breath? P: No
D: Any blood in your stool? P: No
D; Any bruising? P: No
D: Have you been diagnosed with any medical condition in the past?
P: Yes. I was diagnosed with atrial fibrillation.
D: May I know when were you diagnosed with AF? P: 5 years now
D: May I know how is it managed? P: I take Bisoprolol and Warfarin
D: Are you taking them regularly? P: Yes
D: Any missed dose? P: No
D: Any other medical conditions DM, Heart/Kidney disease or high cholesterol? P: No
D: Are you taking any other regular medications including OTC or supplements? P: No

D: Do you drink alcohol? P: Yes/No
D: Tell me about your diet? P: Good/Bad
D: Are you physically active? P: Yes/No
D: What do you do for a living? P:
D: Whom do you live with? P:
D: I would like to examine you. Check your vitals and perform a GPE.
NEWS chart:
RR 18
Sats 99%
BP 110/80
HR 96
Temp 37.6
P: Why did I have this blood in my urine doctor?

D: From my assessment, I did not find any obvious cause for this. But do not worry we are
going to do some investigations to see why this happened.
D: There are many causes like infection or stones in your urinary system. We are going to
send urine for investigation to see if there is any infection. We may also consider doing
some scans and a procedure called cystoscopy to see inside of your bladder for any
abnormality.
P: Is this because of warfarin?

D: One of the side effects of warfarin is bleeding. But we have checked your blood tests and
your INR is with in normal range.
D: If this bleeding is not severe and not going to affect your health, then we don’t have to
stop warfarin. In the meanwhile, if we find any other cause then we will treat it.
D: Please come back to the hospital if you experience any severe bleeding or any urinary
symptoms (frequency/urgency/pain).
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Allergic Rhinitis
You are an FY2 in GP. Luke aged 25 has come with complaints of runny nose from the past
2 days. Take history and address his concerns.
D: How can I help you? P: I have got runny nose.

D: Tell me more about it? P: IT has been 2 days I am having this, and it is getting worse.
D: What is the colour of the fluid? P: Clear watery fluid
D: Anything makes it better or worse? P: It gets worse in the winter season.
D: Anything else? P: No
D: Any itching? P: No
D: Any swelling or redness? P: No
D: Any fever and flu like symptoms? P: No (Infective rhinitis)

D: Any pain or discharge from ear? (Ear Infection) P: No
D: Any numbness or tingling on the face? P: No (Cranial Nerve Tumours)
D: Have you had similar kind of problem in the past? P: No
P: I have got skin allergy (Atophy)
D: Any DM, history eczema or asthma? P: No.

D: Are you taking any medications including OTC or supplements? P: No.
D: Any allergies from any food or medications? P: No.
D: Any allergy to the pollens or dusts? P: No
P: Siblings have Eczema and Asthma
D: Do you smoke? P: Yes/no

D: Tell me about your diet? P: I don’t eat healthy.
D: Do you do physical exercise? P: I don’t have much time.
D: Do you have any kind of stress? P: No.
D: What do you do for the living? P: I am a driver.
I would like to check your vitals and examine your eye, ear, nose, throat.
The main lines of treatment are education, allergy avoidance, antihistamines and topical
steroids.
Please regularly rinse your nasal passages with a saltwater solution to keep your nose free
of irritants.
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I may send for some initial investigations including routine blood test (IgE), skin prick test.
Nasal Endoscopy might be done in case we suspect any Polyp.
As the patient is driver so we will make sure we will prescribe non-drowsy antihistamines.
There are many types of antihistamine.

They're usually divided into two main groups:
• older antihistamines that make you feel sleepy – such as chlorphenamine,
hydroxyzine and promethazine
• newer, non-drowsy antihistamines that are less likely to make you feel sleepy – such
as cetirizine, loratadine and fexofenadine
We can prescribe a stronger medication, such as a nasal spray containing corticosteroids.

Inhalers and nasal sprays such as beclomethasone and fluticasone can be used.
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Prescription Writing (DVT Apixaban)
Amelia May, aged 50, was admitted to the hospital with DVT. This is her third admission
with DVT. She is prescribed with Apixaban. Please talk to the patient, explain her about
the medication, prescribe Apixaban and address her concerns.
D: Hello, how are you feeling today?

P: I am feeling fine. Could you please tell me about my medication?
D: Yes, I am going to talk to you about your medication and address all your concerns. But
before that let me ask you few questions.
P: Okay
D: May I know why were you admitted to the hospital?

P: I had leg swelling
D: May I know since when?

P: For 2 days.
D: Do you know about your diagnosis?

P: Yes. Clot in my legs. This is the third time I am having this condition.
D: How are you feeling now?

P: I am okay now.
D: Any pain or swelling?

P: No
D: Have you been diagnosed with any other medical condition in the past? P: No
D: Any other medical conditions DM, Heart/Kidney disease or high cholesterol? P: No
D: Are you taking any regular medications including OTC or supplements? P: No
D: Any allergies from any food or medications? P: Penicillin

D: Tell me about your diet? P: Good/Bad
D: Are you physically active? P: Yes/No
D: What do you do for a living? P:
D: Whom do you live with? P:
D: Thank you for answering all my questions.
We are going to prescribe you a medication called Apixaban, which is a blood thinner.
This will prevent from future clot formation in the legs.
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Prescribe APIXABAN on the drug chart in the section for anticoagulation.
Apixaban – Treatment dose 10 mg BD for Days 1-7
Apixaban – Maintenance 5 mg BD for long term from day 8 (for recurrent DVT).
(Also write about Penicillin allergy on the drug chart on the front in allergy column)
You have to take this medication twice a day preferably at the same time, regularly and as
prescribed without missing any dose. As you had this condition for three times, you have to
take this medication for a long time (possibly lifelong).
Tips to prevent DVT:
Do
- stay a healthy weight
- stay active – taking regular walks can help
- drink plenty of fluids to avoid dehydration – DVT is more likely if you're dehydrated
Don'ts
- do not sit still for long periods of time – get up and move around every hour or so
- do not cross your legs while you're sitting, it can restrict blood flow
- do not smoke – get support to stop smoking
- do not drink lots of alcohol
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Prescription Writing (Nosebleed Apixaban)
James Carter, aged 25, has had a nosebleed. He is on Apixaban. Talk to him
and complete the prescription.
Patient had a clot 3 years ago. Was prescribed Apixaban.

Concern was: What do I do when I get bleeding?
Assess the patient and compliance of Warfarin.
Go to the A&E:
- your nosebleed lasts longer than 10 to 15 minutes

- the bleeding seems excessive
- you’re swallowing a large amount of blood that makes you vomit
- the bleeding started after a blow to your head
- you’re feeling weak or dizzy
- you’re having difficulty breathing
How to stop a nosebleed yourself
You should:
- sit or stand upright (don't lie down)
- pinch your nose just above your nostrils for 10 to 15 minutes
- lean forward and breathe through your mouth
- place an icepack (or a bag of frozen peas wrapped in a teatowel) at the top of your nose
Hospital Treatment
If doctors can see where the blood is coming from, they may seal it by pressing a stick with a
chemical on it to stop the bleeding.
If this isn't possible, doctors might pack your nose with sponges to stop the bleeding. You
may need to stay in hospital for a day or two.
When a nosebleed stops:

After a nosebleed, for 24 hours try not to:
- blow your nose
- pick your nose
- drink hot drinks or alcohol
- do any heavy lifting or strenuous exercise
- pick any scabs
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Urticaria
You are an FY2 in GP. Mother of 5-year-old Daniel has got some concerns. Talk to her and
PC: He has rash. Whole body. It is itchy.

It has happened 2-3 times. Once, after shower and the other time after playing sports with
friends.
Disappears after few minutes to hours.
PMH: Negative. Fam Hx of Asthma or Allergy: Negative.

Lifestyle: All Good
Ex: Image was given when asked to examine. (Lateral view of head with rash all over face).
Urticaria (possibly cholinergic)
Mx: In many cases, treatment isn't needed for urticaria, because the rash often gets better
within a few days.
If the itchiness is causing discomfort, antihistamines can help.
A short course of steroid tablets (oral corticosteroids) may occasionally be needed for more
severe cases of urticaria.
For persistent urticaria, refer to a skin specialist (dermatologist). Treatment usually involves
medication to relieve the symptoms, while identifying and avoiding potential triggers.
Certain triggers for Urticaria:
• drinking alcohol or caffeine

• emotional stress
• warm temperature
Causes of Urticaria:
• an allergic reaction – such as a food allergy or a reaction to an insect bite or sting

• cold or heat exposure
• infection – such as a cold
• certain medications – such as non-steroidal anti-inflammatory drugs
(NSAIDs)or antibiotics
Concerns: The school is worried if the Rash is contagious. Whether son can go to school or
not.
Return to School:
o Hives cannot be spread to others.
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o Your child can go back to school once feeling better. The hives shouldn't keep him from
normal activities.
o For hives from an infection, can go back after the fever is gone. Your child should feel well
enough to join in normal activities
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Primary Enuresis
You are an FY2 in GP Surgery. Rachel Williams, mother of 4-year-old David Williams, has
brought him in to the clinic because of Bed Wetting. Talk to her and address her concerns.
D: What brought you to the hospital? P: My child is not dry at night.

D: Tell me more about the it? P: Dr he is 4 years old but still he wets the bed in the night.
D: Did you child use to be dry at night before? P: my child has never been dry before.
D: Is it daily or off and on? P: It is daily doctor.

D: Have you noticed any dry nights before or in between? P: No
D: Did anything significant happen before the onset that led to this condition? P: No
D: What is bathroom routine of child before going to bed.
D: Anything else? P: No
D: Any fever? P: Yes/No

D: Any daytime wetting? P: Yes/No
D: Excessive crying? P: Yes/No

D: Any burning while passing urine? P: Yes/No
D: Any cloudy/smelly urine? P: Yes/No
D: Any lethargy? P: Yes/No
D: Loss of appetite? P: Yes/No
D: Weight loss? P: Yes/No
D: Any abnormal swellings in tummy? P: Yes/No
D: Has he been diagnosed with any medical condition in the past? P: No

D: Is she taking any medications including OTC or supplements? P: No
D: How was the birth of your baby? P: It was normal vaginal delivery.
D: Are you happy with the red book? P: Yes.
D: Is she up to date with all her jabs? P: Yes.
D: Has she received any recent jab? P: No
D: Is she feeding well? P: Yes. She is feeding very well.
D: Does she have any problems with her wee and poo? P: No.
D: Who looks after her? P: It’s me.
D: who else lives with the child P: Me and my husband.

D: Any other child? P: No
D: Is he going to school? P: Yes.
D: Any problem at school? P: No
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I would like to check the vitals, general physical examination and abdominal examination.
Bedwetting is common in young children and children usually grow out of it. We can devise
a plan to help your child with this.
Plan:
Plenty of water during the day. It's best to avoid drinks for an hour before bedtime.
Avoid drinks that contain caffeine, such as cola, tea, coffee or hot chocolate, because they
increase the urge to wee.
Encourage your child to go to the toilet regularly during the day.
• If the child wakes up at night, encourage them to go to toilet.

• Make a habit of asking your child to go to toilet before going to bed.
Reward your child for having plenty of drinks during the day and remembering to have a
wee before bed
We will be following your child up and if these measures did not help, or your child developed
daytime wetting, or your child did not outgrow of this after 5 years of age, then we will further
test your child.
Further plan of action:

• referral to enuresis clinic/ specialist.
• Urine test
• Alarm clock for encouraging the child to visit the loo
GP may suggest a medicine called desmopressin.
Please Come for the follow up and come back to the hospital with your child if he develops
fever, lethargy, tummy swelling, daytime symptoms and your child has suddenly started
wetting the bed after they've been dry at night for a while.
We will give you leaflet.
Note: if child is above 5 years, then you have to make referral, offer general advice same as
above and also include alarm clock and positive reward system. If child is of any age and has
daytime symptoms as well, make referral to enuresis clinic. If child was dry before and now
started wetting the bed, make referral.
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Meningitis Prophylaxis
You are an FY2 in GP/A&E. Olivia, aged 50, has some concerns. Talk to her and address her
concerns.
D: How can I help you? P: I am worried I might get Meningitis.

D: May I know why? P: My niece was diagnosed with meningitis one week ago.
D: Have you been in contact with your niece? P: No
D: When was the last time you were in contact with her? P: 1 months ago, I saw her.
Preventing the spread of Infection
The risk of someone with meningitis spreading the infection to others is generally low. But if
someone is thought to be at high risk of infection, they may be given a dose of antibiotics as
a precautionary measure.
Meningococcal Infection Chemoprophylaxis
The decision to initiate contact tracing in respect of meningococcal infection will be made
by the Consultant in Public Health Medicine (CPHM) in conjunction with relevant clinicians.
Responsibility for contact tracing and organising the administration of chemoprophylaxis
also lies with the CPHM. Chemoprophylaxis must ONLY be prescribed on the instruction of
the CPHM. It should be given as soon as possible (ideally within 24 hours) after diagnosis of
the index case.
CPHM will establish a list of close contacts; who may include:

• Those who have had prolonged close contact with the case in a household type setting
during the seven days before onset of illness. Examples of such contacts would be those
living and / or sleeping in the same household (including extended household), pupils in the
same dormitory, boy/girlfriends, or university students sharing a kitchen in a hall of
residence.
• Those who have had transient close contact with a case only if they have been directly
exposed to large particle droplets / secretions from the respiratory tract of a case around
the time of admission to hospital.
The use of single dose ciprofloxacin is recommended by a Cochrane Review and included in
the Public Health England’s Guidance for public health management of meningococcal
disease in the UK’. Ciprofloxacin is licensed in adults for the prophylaxis of invasive
infections due to Neisseria meningitidis; however, its use in children and adolescents
remains ‘off label’.
If further cases occur within a group of close contacts in the four weeks after receiving
prophylaxis, an alternative agent should be used for repeat prophylaxis. Rifampicin may be
used as outlined in Table 2 below (except in pregnancy). Azithromycin as a single dose of
500mg may be used as an alternative in pregnancy.
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Cholesteatoma
You are FY2 in GP. Patient came to the clinic complaining of pain in the ear. Talk to the
patient and discuss the management with the patient.
D: How can I help? P: I have pain in my right ear.

D: Can you tell me more about it? P: I have been having this pain for 1 month, I took
paracetamol, but it is not improving. It is getting worse. (SOCRATES)
D: Anything else? P: I can’t hear properly with my right ear.
D: How about the other ear? P: It is fine
D: Any Fever (OM, Meningitis)
D: Vertigo, Tinnitus, Numbness or tingling in the face? (Cranial Nerve Involvement)
D: Aural fullness?
D: Any trouble with the vision? (Blurring)
D: Any recent travel? (Flight)
D: Have you been swimming recently? (OE)
Ask Past Medical History

Ask Lifestyle
Symptoms:
Ear infection sometimes can lead to brain abscess or meningitis,
Hearing loss,
Vertigo,
Tinnitus,
Facial nerve damage.
Risk Factors:
Trauma, Otitis media, Tympanic membrane perforation.
Differentials Diagnosis:
Otitis media with effusion,
Otitis externa,
Tympanosclerosis (Seen after grommet insertion),
Osteonecrosis
Examination:
GPE, Vitals, Ear examination, Otoscopy, Hearing Test and Balance Test.
Examiner: Conductive Hearing Loss, Otoscopy: Perforation in the Middle Ear usually Pars
Flacida
Investigation:
Routine blood test, CT, MRI
Treatment:
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Surgery followed by topical antibiotics and topical steroids. After the cholesteatoma has been
taken out, your ear may be packed with a dressing. This will need to be removed a few weeks
later. The surgeon may be able to improve your hearing by a tiny artificial hearing bone
(prosthesis) In some cases, it may not be possible to reconstruct the hearing, or a further
operation may be needed.
The benefits of removing a cholesteatoma usually far outweigh the complications. However,
as with any type of surgery, there's a small risk of facial nerve damage resulting in weakness
of the side of the face. Medical treatment where surgery is not possible, that will be
antibiotics and regular ear cleaning.
Prognosis:
It can recur again in 5-30% cases.
Around 10% can get it in another ear as well.
If you develop discharge or significant bleeding from your ear or wound, fever, and severe
pain come to the
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Chicken Pox (Pregnancy)
You are an FY2 in GP. Sophia Jenkins, 30-year-old female came to you with some concerns.
Talk to her and discuss the plan of management.
Complications for the unborn baby:
Complications that can affect the unborn baby vary, depending on how many weeks
pregnant you are. If you catch chickenpox:
- Before 28 weeks pregnant: there's no evidence you are at increased risk of suffering a
miscarriage. However, there's a small risk your baby could develop foetal varicella
syndrome (FVS). FVS can damage the baby's skin, eyes, legs, arms, brain, bladder or
bowel.
- Between weeks 28 and 36 of pregnancy: the virus stays in the baby's body but doesn't
cause any symptoms. However, it may become active again in the first few years of the
baby's life, causing shingles.
- After 36 weeks of pregnancy: your baby may be infected and could be born with
chickenpox.
Antiviral Medicine:
You may be offered acyclovir, an antiviral medicine, which should be given within 24 hours
of the chickenpox rash appearing. Acyclovir doesn't cure chickenpox, but it can make the
symptoms, such as fever, less severe and help prevent complications. Acyclovir is usually
only recommended if you're more than 20 weeks pregnant, but in some cases your doctor
may suggest it if you're less than 20 weeks pregnant. Discuss the risks and benefits with
your doctor.
Self help
To help relieve your symptoms, you can try the following:
• drink plenty of fluids
• take paracetamol to lower a temperature or help with pain
• use cooling creams or gels from your pharmacy
Will my baby need to be treated?

Once you have chickenpox, there's no treatment that can prevent your baby getting
chickenpox in the uterus.
After the birth, your GP may consider treating your baby with chickenpox antibodies called
varicella zoster immune globulin (VZIG) if:
Ø your baby's born within 7 days of you developing a chickenpox rash
Ø you develop a chickenpox rash within 7 days of giving birth
Ø your baby's exposed to chickenpox or shingles within 7 days of birth and they aren't
immune to the chickenpox virus
If your new born baby develops chickenpox, your GP may treat them with acyclovir.
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Complications for pregnant women:
You have a higher risk of complications from chickenpox if you're pregnant and smoke, have
a lung condition, such as bronchitis or emphysema, are taking or have taken steroids during
the last three months and are more than 20 weeks pregnant.
There is a small risk of complications in pregnant women with chickenpox. These are rare
and include: pneumonia, encephalitis, and hepatitis. Complications that arise from catching
chickenpox during pregnancy can be fatal. However, with antiviral therapy and improved
intensive care, this is very rare.
Complications for the newborn baby:

Your baby may develop severe chickenpox and will need treatment if you catch it:
Ø around the time of birth and the baby is born within seven days of your rash developing
Ø up to seven days after giving birth
If you're pregnant, have chickenpox and develop chest and breathing problems, headache,
drowsiness, vomiting or feeling sick, vaginal bleeding, a rash that's bleeding , a severe rash
you should be admitted to hospital.
These symptoms are a sign that you may be developing complications of chickenpox and
need specialist care.
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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.
D: How can I help you? P: I am still in pain.

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

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

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

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

D: Yes, I had it 6 months back and was given antibiotics.
D: Are you physically active? P: I try
D: Do you get any help looking after your wife? P: Yes, Nurse comes Twice a week.
Ask about Sleep, depression, rule out Cancer (As age is 72) and other causes of Tiredness.
Treatment:
To help reduce the pain and irritation of post-herpetic neuralgia wear comfortable
clothing and use cold packs – some people find cooling the affected area with an ice pack
helps.
We can give you Lidocaine plasters and Capsaicin cream (Capsaicin is the substance that
makes chilli peppers hot. It's thought to work for nerve pain by stopping the nerves sending
pain messages to the brain).
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Antidepressants:
Amitriptyline and duloxetine are the two main antidepressants prescribed for post-herpetic
neuralgia.
Anticonvulsants: Gabapentin and pregabalin are the two main anticonvulsants prescribed
for post-herpetic neuralgia.
We can also prescribe Tramadol or Morphine if symptoms are not relieved.
Follow the pain ladder.
Living with post-herpetic neuralgia can be very difficult because it can affect your ability to
carry out simple daily activities, such as dressing and bathing. It can also lead to further
problems, including extreme tiredness, sleeping difficulties and depression.
Concerns:
P: How to get rid of this Pain?
P: How to manage tiredness?
P: Can you give something else other than tablets?
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Preconception Counselling
You are an FY2 in GP. Meghan, aged 29, is planning to become pregnant. She has come in
for preconception counselling. Talk to her and address her concerns.
Ø Previous Obstetrics History;

Ø 4 P’s Questions
Ø PMH:
o Diabetes
o Thyroid
o Hypertension
o Epilepsy & Mental Health Issues
o Kidney
o Cardiac
o Asthma
o Previous Clots or Blood Disorders
o Inflammatory Bowel Disease
o Rheumatological Conditions
o Genetic Disorders
• Usage of Prescription Medications including OTC & Herbal
Ø Personal:
o Smoking
o Alcohol
o Drugs
o Dietary Habits & BMI
o Any plans to travel anywhere (Epidemic Area)
The association between increasing maternal age and subfertility and found an increased risk
of miscarriage, chromosomal abnormalities, congenital abnormalities, gestational diabetes,
placenta praevia, and caesarian delivery in women aged over 35 years, with women over 40
years experiencing an increased risk of abruption, preterm delivery, low birth weight and
perinatal mortality.
Ø Immunity to Infections: Chicken Pox & Rubella

Ø Use of Folic Acid to reduce the risk of Neural Tube Defect
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Nipple Discharge
You are an FY2 in GP. Yara White, aged 29, has come to you because of Nipple Discharge.
Talk to her and address her concerns.
D: How can I help? P: I have some discharge coming from my nipples. (Single or Both)
D: Elaborate: When? How long? Colour? Consistency? Blood stained?
D: Do you have anything else? P: No

D: Any change in shape and size of the breast? P: No
D: Any change in the skin of the breast? P: No
D: Any swelling or mass? P: No
D: Any lumps and bumps in the body? P: No
D: Any weight loss? P: No
D: Any loss of appetite? P: No
D: Any SOB or tiredness? P: No
D: Any fever or flu like symptoms? P: No
D: Tell me about your periods, when was tour last menstrual period? P: 2 weeks ago
D: Is it regular? P: Yes
D: Any heavy periods or bleeding in between the periods? P: No
D: Any pregnancy? If yes how many kids?
D: Are you sexually active now? P: Yes
D: Are you using any method of contraception? P: Yes/No

D: Any breast problem in the past? P: No
D: Any hormonal therapy? P: No
D: Has anyone in the family been diagnosed with any medical condition? P: Yes/No
D: Do you drink alcohol? P: No
I would like to do a GPE, check the vitals and examine your breasts.
We may refer you to a hospital or breast clinic for further tests. At the hospital or breast
clinic, you may have a:
• breast examination
• scan – usually a breast X-ray (mammogram) or ultrasound
• biopsy – where a needle is inserted into your breast to remove some cells for testing
The tests are often done during the same visit.
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You'll usually be told the results on the same day, although biopsy results can take longer –
you should get them in a week or two.
See a GP if you have nipple discharge and any of these:

• it happens regularly and isn't just a one-off
• it only comes from 1 breast
• it's bloodstained or smelly
• you're not breastfeeding, and it leaks out without any pressure on your breast
• you're over 50
• you have other symptoms – such as a lump, pain, redness or swelling in your breast
• you're a man
Causes:
• breastfeeding or pregnancy – see leaking nipples in pregnancy
• a blocked or enlarged milk duct
• a small, non-cancerous lump in the breast
• a breast infection (mastitis)
• a side effect of a medicine – including the contraceptive pill
Nipple Discharge
• Nipple discharge isn't usually a sign of anything serious, but sometimes it's a good idea
to get it checked just in case.
• Nipple discharge is often normal
• Lots of women have nipple discharge from time to time. It may just be normal for you.
• It's also not unusual for babies (boys and girls) to have milky nipple 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.
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Pregnancy (Hypertension on Ramipril)
You are an FY2 in the GP Surgery. Mrs Amy Travis, aged 42, has come to see you. She is on
Ramipril for her hypertension. Talk to her and address her concerns.
D: How can I help you? P: I am trying to get pregnant.

D: Let me ask you few questions to make sure everything is fine. P: Ok
D: Have you been pregnant before? P: No
D: Ask 4 P’s?
D: How long have you been trying to get pregnant? P:
P: Yes, I have been diagnosed with hypertension for the last 5 years.
D: How is it managed? P: I’m on Ramipril
D: Are you taking it regularly as prescribed? P: Yes
D: Have you been diagnosed with any other medical condition in the past like Diabetes,
Kidney Diseases and STI?
P: No
D: Are you taking any other medications including OTC or supplements? P: No
D: Who do you live with? P: My partner

D: How long have you been living with your partner? P: 2 years
I would like to do a GPE, check the vitals including blood pressure.
ACE inhibitors are not given in pregnancy, they should be stopped, and patient must be
started on some other medication. Ramipril should be stopped as she is pregnant. We have
to aim for blood pressure lower than 140/90 and always try to keep it 135/85.
We may Consider giving Labetalol, Nifedipine, Methydopa. ACEi can cause adverse effect for
the woman, fetus, and newborn infant. Give lifestyle advice to the patient.
We may give you folic acid supplements and other medications. We may refer you to the
OBG department. They will run some blood tests and urine tests too.
It's is important that you are monitored throughout your pregnancy to make sure your high
blood pressure is not affecting the growth of your baby (pre-eclampsia). Please make sure
you go to all your antenatal appointments.
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Concerned Daughter MMSE
You are an FY2 in GP. Mariah Smith, aged 55, came to the clinic with some concern. Talk
to her and address her concerns.
D: How can I help you? P: My daughter wanted me to see you.

D: Why? P: She said I keep forgetting things.
D: Do you think there has been any changes in you? P: No
D: Are you able to remember things? P: Yes, I remember most of the things.
Rule out vascular dementia.

Ask PMH and personal history.
Examiner: MMSE 26, Routine Test – Normal
Examiner: Which investigation you want to do:
These include some laboratory tests such as FBC, U&Es, LFT, calcium, vitamin B12, thyroid
function tests and random or fasting blood sugar, CT scan or MRI of the brain.
Differential Diagnosis:
1. Neurodegenerative disorders for example Multiple sclerosis.
2. Other CNS disorders for example Brain tumours, Epilepsy and Trauma.
3. Infectious disease such as HIV.
4. Metabolic disorders such as Hypercalcemia, Hyponatremia.
5. Endocrine disorders such as Addison disease, Cushing syndrome and thyroid problems.
6. Vitamin deficiencies such as vitamin B12, folate, thiamine, niacin deficiency.
7. Medications such as anabolic steroids, corticosteroids, cimetidine and some antibiotics
such as penicillin.
8. Substance abuse such as Amphetamines, Cocaine, Alcohol, Cannabis.
9. Related psychiatric disorders such as Schizophrenia, delirium, Mood disorders with
delusional symptoms (manic or depressive type), Obsessive-compulsive disorder.
According to the NICE guidelines,
25-30 - Normal.
21-24 - Mild Cognitive Impairment
10-20 - Moderate Cognitive Impairment
< 10 - Severe Cognitive Impairment.
Patient concern:
What Investigation will you do Doctor?
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Scabies
You are an FY2 in GP. Parents of Sacha aged 2 have come to you with some complaint.
Sacha had gone for a pit walk with her father. Talk to the mother and address her
concerns.
D: How can I help you? P: Sacha is scratching all over.

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

D: How was the birth of Sacha? P: It was normal vaginal delivery.
D: Are you happy with the red book? P: Yes.
D: Is she up to date with all her jabs? P: Yes.
D: Has she received any recent jab? P: No
D: Is she feeding well? P: Yes. She is feeding very well.
D: Does she have any problems with her wee? P: No.
D: Is Sacha a playful child? P: Yes
D: Is Sacha playing well? P: Does not go out to play
D: Has Sacha come in contact with anyone with same complaint? P: No
D: I need to have a look at Sacha. P: I have a picture of the rash.
(Red rashes on knuckles and web spaces)
Investigation:
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1. Diagnosis is clinically mainly. A magnifying lens may help in identification of burrows or
even occasionally mites.
2.The ink burrow test can be helpful in confirming burrows. Ink is rubbed over a burrow (for
example, with the surface of a fountain pen nib) then wiped off with an alcohol swab. Ink
will track into a burrow, outlining it.
3.Skin Biopsy - presence of mite, eosinophilic infiltrate; rarely eggs and mite faecal material.
Treatment:
Symptomatic Treatment:
1. Anti-histaminics
2. Low dose steroid cream.
Non-crusted scabies – Permethrin Topical (5%)

Crusted (Norwegian) Scabies – Combination therapy with Permethrin + Ivermectin (As an
adjunct
All members of the household, close contacts, and sexual contacts should be treated
simultaneously with the index patient. It is important that all contacts apply treatment on
the same day to reduce the risk of re-infestation from an untreated contact.
The primary method of treatment for scabies is by topical application of a parasiticidal

preparation overnight to the whole body from head to toe.Apply treatment to the whole
body, including the scalp, neck, face, and ears, and especially between the fingers and toes
and under the nails. Treatment should not be applied after a hot bath (as this increases
systemic absorption and removes the drug from its treatment site). If the hands are washed,
the liquid or cream must be reapplied. This should be repeated a week later.
Complication:
1. Scabies can cause flaring or reactivation of eczema or psoriasis.
2. Secondary bacterial infection.
Do
- wash all bedding and clothing in the house at 50C or higher on the first day of treatment
- put clothing that cannot be washed in a sealed bag for 3 days until the mites die
- stop babies and children sucking treatment from their hands by putting socks or mittens
on them
Don't
- do not have sex or close physical contact until you have completed the full course of
treatment
- do not share bedding, clothing or towels with someone with scabies
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Risk factors:
Overcrowding, Poverty, poor nutritional status, Homelessness, Poor hygiene, Institutions.
Residential care homes in the UK, refugee camps in some parts of the world, Sexual contact,
Children, especially in developing countries, Immune suppression.
Concerns:
P: How many days will it take to go away?
P: What will you do for her?
P: What happens if it gets worse?
Differentials
Impetigo
Tinea
Dermatitis herpetiformis
Psoriasis
SLE
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Discuss Blood Results
You are an FY2 in GP. Dorothy Perkins, aged 81, has come to you for medication review.
She has been on Amlodipine 10mg for 2 months. Other medications she is on are
Atorvastatin 20 mg and Levothyroxine 125mcg.
Bloods: TSH - <0.02
T4: 24
Lipid Profile, U & E’s, LFT’s - Normal
Talk to her and review the Medications and Blood Results.

P: I am here for review of medications.
Assess the patient

Ask for thyroid symptoms.
Ask for High blood pressure symptoms.
PMH: Hypertension, Hypercholesterolemia and Hypothyroid.
Hypercholesterolemia and Hypothyroid: For many years.
Hypertension: For last 2 months.

She took Amlodipine for 2 Months. After that she stopped.
Why?
P: Because GP gave me only 2 months stock.
Life style history:

I would like to do examination:
Examiner: BP 160/90 in last 3 readings.
Explain the blood reports to the patient.
We have to review your medication.

Be complaint with the medication of HTN, Take it regularly.
Lifestyle advices.
Warning sign and follow up.
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Inguino - Scrotal Examination
Examination:
a. Exposure
b. Chaperone
c. Being gentle
d. Consent
Assessment of a suspected hernia:
An inguinal hernia is a protrusion, or movement of abdominal contents, from within the

abdominal cavity. This tissue then protrudes, or emerges, at the exit point, the superficial
inguinal ring. Inguinal hernias are most commonly found superomedial to
the pubic tubercle.
Femoral hernias occur just below the inguinal ligament, when abdominal contents pass
through a naturally occurring weakness in the abdominal wall called the femoral canal.
It is important to note that the space a femoral hernia protrudes through is quite tight, and
it is bordered medially by the sharp edge of the lacunar ligament. Therefore, femoral
hernias are at high risk of strangulation and obstruction. Femoral hernias are
typically found infero-lateral to the pubic tubercle (and medial to the femoral pulse).
Position of Hernia
• Above and medial to the pubic tubercle: Inguinal hernia

• Below and lateral to the pubic tubercle: Femoral hernia
Direct vs Indirect Inguinal Hernia
• Locate the deep inguinal ring (midway between the anterior superior iliac spine and
pubic tubercle)
• Ask the patient to reduce their hernia (if able) or alternatively reduce it yourself by
starting inferiorly compressing the lump towards the deep inguinal ring
• Once reduced, apply pressure over the deep inguinal ring
• Ask the patient to cough
• If a hernia reappears it is more likely to be a direct inguinal hernia whereas if it does
not, it is more likely to be an indirect inguinal hernia
• In the latter case, release the pressure from the deep inguinal ring and observe for
the hernia reappearing (further supporting the diagnosis of an indirect inguinal
hernia)
• It should be noted that this clinical test is unreliable and further imaging (e.g.
ultrasound scan) would be required before any management decisions were made
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1. The mid-inguinal point: It is halfway between the anterior superior iliac spine and the
pubic symphysis.
2. The midpoint of the inguinal ligament: It is halfway between the anterior superior
iliac spine and pubic tubercle.
3. The two openings to the inguinal canal are known as rings:
a) The deep (internal) ring is found above the midpoint of the inguinal ligament
which is lateral to the epigastric vessels.
b) The superficial (external) ring marks the end of the inguinal canal, and lies just
superior to the pubic tubercle.
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Scrotal Examination
Inguinal hernias can extend into the scrotum, so if you note swelling or suspect an inguinal
hernia, palpation of the scrotum can be performed (with consent)
Typically, an inguinal hernia will present as a testicular lump that you can not get above.
Testicular Examination:
Inspection:
Inspection of Genital region and the surrounding areas (Penis, Groin & Lower Abdomen)
There are no skin changes (rash, bruising, erythema, swelling), Scars and any obvious
masses.
Inspection of the Scrotum: ask the patient to hold their penis out of the way to allow easier
inspection of the scrotum. Inspect the scrotum from the front and posterior sides.
There are normal scrotal rugosities, no skin changes, scar, obvious masses, swelling, sinuses
and necrotic tissue.
Palpation:
Temperature: compare both the testicles with the thigh.
Phren’s Test: If testicular pain is relieved by elevating the testes, this is suggestive of
Epididymitis.
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Testicular Torsion (if pain is not relieved).
Palpation: (Palpate with thumb and index finger)

Superficial: check for tenderness in both the testicles.
Deep: palpate for spermatic cord, epididymis
Feel for any mass (site, size, shape, surface, consistency, contour, tenderness, mobile,
attached to underlying structure or not).
Special Tests
Cough Impulse:
Presence of cough impulse suggests hernia/varicocele.
Fluctuation Test:
Cystic, fluid filled masses fluctuate. Fluctuation is elicited by holding the mass firmly with
thumb and two fingers of both hands. Firmly press the mass with one finger while observing
for displacement of the other finger.
Trans illumination Test:

Place a pen torch behind the scrotal swelling. (Trans-illumination suggests the mass is fluid
filled where there will be red glow – Hydrocele)
Cremasteric Reflex:
Stroke the patient’s medial thigh which leads to stimulation to cremaster reflex and elevate
the testicles. (Loss of Cremaster reflex may suggest Testicular Torsion).
Aspire Education 82
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Intestinal Obstruction
D: How can I help you? P: I am tummy pain. (Generalized abdominal pain). SOCRATES
D: Anything else? P: Didn’t pass stool.
S/S:
- Nausea, vomiting, dysphagia, abdominal pain and failure to pass bowel movements.
- Clinical signs include abdominal distention, tympanic sound on the percussion of the
abdomen due to an air-filled stomach and High-pitched bowel sounds.
DD:
1. Gastroenteritis.
2. Acute Pancreatitis.
3. Peptic Ulcer Disease.
4. Perforated Diverticular disease.
Examination:
I would like to do GPE, Vitals and abdominal examination.
Look for signs of dehydration.

Abdominal Distension.
If strangulation or perforation occurs there will be features of an acute abdomen with
peritonism.
The patient may be generally toxic and unwell because ischaemia of the bowel allows
bacteria and toxins to enter the circulation.
Investigations
• Fluid intake and output monitoring.
• NG tube.
• Plain abdominal X-ray is an important investigation. Multiple fluid levels and distension of
the bowel are abnormal. Gas under the diaphragm suggests perforation.
• FBC, U&Es and creatinine and group and crossmatch in case major surgery is required.
• A water-soluble contrast enema X-ray may be helpful.
• CT (NCCT), USG, MRI.
Treatment:
1. Uncomplicated obstruction: management is conservative, including fluid resuscitation,
electrolyte replacement, intestinal decompression and bowel rest.
Aspire Education 83
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2. When gastrointestinal obstruction results in ischaemia, perforation or peritonitis, then
emergency surgery is required. Laparotomy may be required.
In view of the risk of perforation and absorption of toxins from ischaemic bowel,
prophylactic antibiotics for gut surgery are advised.
Aspire Education 84
#GotAspirEd
Eczema
You are an F2 in GP. John Smith, aged 15, came to the hospital with his mother with some
concerns. He is a diagnosed case of Asthma. Please talk to them, take history, discuss your
plan of management with them and address their concerns.
Present Complaint: I have got rash on the back of my legs.

Elaborate: From last 7 days.
Elbow flexors.
Back of the knee.
Back of the neck.
It is itchy.
Any Pain, Discharge, ulcer, bleeding, discharge: No
Any other lesion: No

Any fever: No
D: Have you had similar kind of problem in the past? P: yes, when I was a kid.
Mother: He had some rash on his hand, and we put some cream E45 and he was fine.
P: Asthma. Since childhood. No triggers, sometimes getting worse when playing. On
salbutamol inhaler and it is well controlled. (Rule out all triggers for Asthma)
D: any DM, HTN, Heart disease or high cholesterol? P: No

D: Any previous hospital stay or surgeries? P: No
P: Father and sister has asthma.

D: Tell me about your diet? P: I try to eat healthy.
D: Do you have any kind of stress? P: No Dr
I would like to check your vitals and examine your lesion.

I would like to send for some initial investigations including Routine Blood Test.
Management:
1. Self-care techniques, such as reducing scratching and avoiding triggers

2. Emollients (moisturising treatments) – used on a daily basis for dry skin
Aspire Education 85
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3. Topical Steroids – used to reduce swelling, redness and itching during flare-ups
Allergy test: are not usually needed, although they're sometimes helpful in identifying
whether a food allergy may be triggering symptoms.
Aspire Education 86
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Elbow
You are an F2 in GP. Diana Whales, aged 53, came to the clinic with some concerns. Please
talk to her, assess her and discuss your plan of management with her and address her
concerns.
Present Complaint: I have got pain in my right elbow. SOCRATES

From last 1 month, PCM helps, Score 5-6.
Assistant in Kitchen.
Anything else? No
Any stiffness? No


D: Do you have any kind of stress? P: No Dr.
I would like to check your vitals and examine your elbow.

I would like to send for some initial investigations including Routine Blood Test, XRay.
• playing racquet sports – such as tennis, badminton or squash.

• throwing sports – such as the javelin or discus
• using shears while gardening
• using a paintbrush or roller while decorating
• manual work – such as plumbing or bricklaying
• activities that involve fine, repetitive hand and wrist movements – such as using
scissors or typing
• other activities that involve repeatedly bending the elbow – such as playing the
violin
Treatment:
PRICE
HARM.
Steroid injetions
PRP injections.
Aspire Education 87
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1. Avoid the activities responsible for the condition.
2. wear a tennis elbow splint when you are using your arm
3. Increasing the strength of your forearm muscles can help prevent tennis elbow.
Look
Inspect from the front
There are no Scars, Swelling, erythema of the joint. Carrying angle is normal.
Inspect from the back:

There are no Scars, Swelling, erythema of the joint. There are no Rheumatoid nodules and
Psoriatic plaques.
Feel
Temperature: Compare the elbow joint with the other elbow and the forearm.
Palpate around the elbow to elicit any localised tenderness:
1. Lateral epicondyle
2. Olecranon
3. Medial epicondyle
4. Biceps tendon.
Move
1. Elbow flexion.
2. Elbow extension.
3. Pronation.
4. Supination.
Special tests
Medial epicondylitis – “Golfer’s elbow”
Active wrist flexion against resistance

1. The patient should be seated for this assessment, with their elbow flexed at 90º
2. Stabilise the patient’s elbow by supporting the forearm with one hand and firmly
palpating the patient’s medial epicondyle
3. Hold the patient’s wrist with your other hand
4. Ask the patient to make a fist and actively flex the wrist
5. Ask the patient to hold the wrist in flexion while you try to passively extend it
Lateral epicondylitis “Tennis elbow”
Active wrist extension against resistance

1. Stabilise the patient’s elbow by supporting the forearm with one hand and firmly
palpating the patient’s lateral epicondyle
2. Hold the patient’s wrist with your other hand
3. Ask the patient to make a fist and extend their wrist
4. Ask the patient to hold the wrist in extension while you try to passively flex it by pushing
down on the dorsum of the hand
Aspire Education 88
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Patient concern:
I want a sick note.
Aspire Education 89
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Acute Cholecystitis
You are an F2 in A&E. John Smith, aged 57, came to the hospital with pain in the
abdomen. Please talk to him, assess and discuss your plan of management with him and
address his concerns.

P: I am having pain (Right Hypochondrium) SOCRATES.
P: Radiates to shoulder
Anything else: No
Any fever, N/V, Loss of appetite, sweating, Jaundice and abdominal mass. — No

D: Have you been diagnosed with any medical condition in the past? P: HTN for
last 10 years and taking Amlodipine.
D: any DM, Heart disease or high cholesterol? P: No


D: Do you drink alcohol? P: Yes
Social: Living with wife.

I would like to check your vitals and examine your Abdomen..
Examiner: Temperature- 38.5

Do abdominal examination.
CRP-Very high (100)
Examination: Extremely Painful in Right Hypochondrium.
Further scans:
USG, X-ray, CT and MRI scan.
Management:
1. NPO
2. IV fluids.
Aspire Education 90
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3. Pain killer.
4. Antibiotics if needed.
5. Surgery Referral (Cholecystectomy can be planned after initial treatment)
CAUSES:
1. Gallstones.
2. Bile duct Block (Kinking or tumour)
3. Infections.
4. Alcohol
Aspire Education 91
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Twin Delay
You are an F2 in GP. Diana Whales, mother of 15 months old boy and a girl came to the
clinic because of some concern. Please talk to her and discuss your plan of management
with her and address her concerns. Children are not in the cubicle.
She is saying many words, but he only speaks 2 words Dada and mama.
Both are twins and other milestones are fine.
BIRD is fine.
Reassurance to the mother.
Aspire Education 92
#GotAspirEd
Depression
You are an F2 in GP. Diana Whales, aged 30 came to the clinic because of concern of
weight loss. Please talk to her and discuss your plan of management with her and address
her concerns.
Presenting Complaint:
I am losing weight, people around me telling about it and I have lost half stone.
Husband left one year ago and since then feeling this way.
She has got 2 years old child and that is the reason she has to leave the job.
she is on benefits at the moment.
R/O other causes of weight loss.
Also, the safeguarding of the child.
Aspire Education 93
#GotAspirEd
Oxybutynin Urinary Symptoms
You are an F2 in GP. Peter Smith, aged 72 came to the clinic 2 weeks ago for urinary
symptoms and was prescribed oxybutynin 5 mg for that. After one week his symptoms were
not relieved and the dose was doubled. Now he has booked for the urgent appointment.
Please talk to him, assess him and discuss your plan of management with him and address
his concerns.

P: 2 days ago, I had funny sensation.
D: What do you mean by it?

P: I was not myself. I was out with my friends and I was confused for few mins. We were
playing cards and I suddenly didn’t know that how to play game. I didn’t know where I was.
Everything started after I doubled the dose.
D: Why did you come to the hospital 2 weeks ago?

P: I was going to the loo more often and it was very difficult for me to hold the urine. I was
prescribed oxybutynin and I was told if symptoms didn’t improve you can double the dose.
R/O UTI, BPH, Cancer, Stone, Dehydration.


I would like to check your vitals and examine your urinary system.
Side effects of Oxybutynin:

anxiety; arrhythmia; cognitive disorder; depressive symptom; drug dependence;
gastrointestinal disorders; glaucoma; hallucination; heat stroke; hypohidrosis; mydriasis;
nightmare; paranoia; photosensitivity reaction; seizure; urinary tract infection.
Aspire Education 94
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It remains popular despite several studies linking oxybutynin use to cognitive side effects
and increased dementia risk. This is troubling because elderly patients are already more at
risk for dementia, and oxybutynin may worsen the situation.
Patient concern:
Is it dementia?
Aspire Education 95
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Aspire Education 96
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ASPIRE: THE QUEST FOR EXCELLENCE

Facebook Page: Aspire Education

Facebook Group: PLAB2 by Dr Ankur Garg

D: What brought you to the hospital today? P: I have sore throat

D: Do you have any other symptoms? P: I feel feverish

D: Any other symptoms? D: No

D: Did you have similar condition in the past?

D: Are you currently sexually active? P: Yes

To help ease the symptoms:

An antibiotic may be advised in certain situations.

There are four Centor Criteria that may be used:

D: How can I help you today?

D: Could you give a brief recap of the episodes?

D: I can understand It must be very tough for him.

• Have had seven or more episodes of tonsillitis in the preceding year; or

D: How can I help you today?

D: Do you smoke? P: Yes/No

P: Why did I have it?

P: What’s the treatment?

P: Tell me about the surgery please?

P: Will they operate both eyes at the same time?

D: Do you have any other concerns?

D: How can I help you today?

D: Tell me more about it?

D: Anything else with this problem? P: No

D: Any blurry vision? (Glaucoma) P: No

D: Has it happened before? P: No

D: Do you smoke? P: Yes/ No

If wet AMD is diagnosed or suspected, then a further test called fluorescein

Dry AMD Wet AMD

D: How can I help you today? P: I have some discomfort in my tummy

D: Did you have similar problems in the past? P: No

Examiner: Everything is Normal

How to ease bloating, cramps and farting:

How to reduce diarrhoea:

How to relieve constipation:

D: How’s your day going so far?

D: Peter do you know what I am going to talk about?

D: Ok. Where did you put in on Social Media?

P: To be honest I didn’t think that much before posting it.

P: She is much better and fully conscious.

P: Ok. I will talk to her.

Examiner: Abdomen: Splenomegaly. WBC count: >100,000

Examiner: Abdomen: Splenomegaly; Bloods: Thrombocytopenia

P: What is the treatment?

D: What brought you to the hospital today? P: I am losing blood in my urine

D: Is there anything else bothering you?

D: How are you managing It?

D: How are you doing in terms of the pain now?

D: Any other symptoms? P: No

Examiner: Urine Dip: Protein +; blood+, sediment+, FBC: Anaemia

D: Do you have any other symptoms? P: No

D: Any pain in other joints in the body? P: No

D: Did you have similar condition in the past? P: No

P: Why did I have it?

Wear a wrist splint

You are an FY2 in GP. Patient

D: How can I help you? P: Pain in the thumb.

Treatment for de Quervain’s tenosynovitis focuses on reducing pain and swelling. It

Getting injections of steroids or a local anesthetic (numbing medicine) into

Radial and ulnar pulse:

Thenar/hypothenar eminence bulk: