OSA (188):

You are FY2 in the GP surgery, patient 58 YO man, presented with some concerns, have sleeping
problems in the past, assess the patient

Patient info:

sleeping problem for the last 4 months, snore a lot, gasping during sleep, during day time feel sleepy,
sleep 7-8 hours a day, no medical conditions, feel tired all the time during the day, Taxi driver, feel
sleepy while driving.

Q: is it something dangerous? Ask are you worry about anything in particular? It is potentially
dangerous, people with this condition might develop some complications like HTN, heart problems, the
most dangerous thing is if you fall asleep while driving which might cause accidents.

what do you mean by sleeping problem? do you have problem falling asleep?

how many times do you wake up at night? what do you think could be the cause of your sleep problem?

any other medical problems like COPD? obesity, weight? nocturia? anxiety? stress in your life?

Systemic review:

MAFTOSA: Occupation? Driving sleepy?

Examination:

Observation, Check heart, lungs and tummy, weight and height (BMI).

You most likely have a condition called OSA, this a condition in which the muscles of your throat become
over relaxed which leads to narrowing of the airways, this usually causes difficulties in breathing and
snoring as you mentioned. Because of this you may feel sleepy and tired during the day.

Management

Routine bloods, TFTs

Aim at helping to improve breathing during night. Will refer you to the specialist. He might need to do
sleeping study (which involve monitoring your sleep and checking O2 levels during sleep).

Advice not to sleep on the back

Elevate the head side of the bed

Reduce the number of pillows

Ask to lose weight

Avoid alcohol in the evening

Explain the main Rx: you will be giving a device called CPAP, you will be connected to this device in the
night which will prevent your airway from closing while you are sleeping. Sometimes you might be given
a device to put it in the mouth during your sleep (mandibular advancement).

Refer urgently (since he is a professional Taxi driver)

Advice not to drive and after the diagnosis has been confirmed he has to inform DVLA.

RA (191):

F2 in GP, 42 Y/O lady presented with pain in her hands, she is a smoker. Take history, assess the patient
and discuss the management.

Patient info:

Pain in hands, both sides, been there for last 2-4 weeks, secretary in a hospital, pain worse when typing,
have morning stiffness in both hands, smoke 10 cigarettes a day, tried paracetamol but didn’t work.

SOCRATES

Ask about the other joints

Swelling, redness, pain, fever (septic arthritis), steroid use, OA worse by the end of the day, changes in
the shape of your hands (deformities), stiffness improve as the day progress, tingling numbness or pain
in the wrist.

Since you are having these symptoms for a quite long time, how it has affected your life?

Examination:

Pic with squeeze test positive

You are most likely having a condition called RA, inflammation of the joints particularly in the hands and
feet. We need to do some blood tests (routine bloods and some markers specifically RF, ESR, CRP).

Urgent referral to the specialist (within 3-4 days).. usually for this condition we need to refer you
urgently to the rheumatologist.

He will assess you again and may stay you on medications to control your inflammation and halt the
progression of this condition.
Arrange occupational therapist

Ibuprofen to easy your pain but it can cause some ulcers in your stomach + PPI (to protect your tummy
we will give you another medication called omeprazole)

Safety netting: Fever, redness, symptoms getting worse

Post-herpetic neuralgia (280):

You are FY2 in GP, 61 y/o come for follow-up, came 2 months ago with chest pain, was diagnosed with
shingles and treated with acyclovir. 1 week ago he came back with chest pain and was given
paracetamol and codeine and was asked to come for follow up after 1 week time and today he is here
for the follow-up.

Patient info:

Shingles initially 8/10, now it is 2/10, it is burning pain, pain is annoying, and feel like paracetamol and
codeine are not helping.

I understand you are here for a follow-up today, how the things now? Do you still have rash? Pain?
SOCRATS for the pain, previous treatment? Has the medication helped? What was the pain score when
you were diagnosed for the 1st time and what is it today? Do you take the medication as prescribed? Any
side effects of the medication (nausea, vomiting, drowsiness, constipation). How this pain has affected
you?

Examination:

Had a look at the rash,

It seems like you have a condition called post-herpetic neuralgia, neuralgia means nerve pain, because
shingles can affect the nerve even after shingles has dissolved it can leave you with long-term pain.

Management:

If pain is increasing and medication not working (uncontrolled)  give amitriptyline and review in 1
week time

Pain is OK and getting better (controlled)  give topical cream (capsaicin cream or lidocaine plaster)

Advices:

Avoid sharing clothes and towels

Wear loose fitting clothes

Avoid putting other creams (other than prescribed)

If you still have rash, keep it clean and dry

Try to apply cool pads

Protect the sensitive area by applying protective layer from the pharmacy or plastic wound dressing

If the pain is not controlled you need to come back to us to refer you to the specialist.

UTI in young woman (237):

You are FY2 in GP, 30 y/o female made an appointment to see you. Talk to the patient and address her
concerns.

Patient info:

Tummy pain (points toward both sides of the back), burning sensation, frequency, came 2 days ago to
the GP but were offered no medications. Have RA for 5 years treated with methotrexate. Allergic to
penicillin, menstruation was 2 weeks ago.

Nitrates and leukocytes are positive.

Diagnosis is urinary infection. You may have a complication of urinary infection called pyelonephritis; it
means the inflammation may have gone up into your kidneys. The medication you are taking for RA can
lower down your immune system, so simple infections like urine infection can cause complications.

Send to the hospital. They will admit you. Antibiotics through your blood vessels. They might do a scan
to your tummy and some tests to analyze your urine.

They will give nitrofurantoin as you are allergic to penicillin.

Gout (247):

You are FY2 in GP, 54 y/o female presented with pain in the right big toe, patient was diagnosed with
Hay fever 5 years ago and taken cetirizine, 4 months ago diagnosed with HTN and taken thiazides.
Assess her and outline the management plan.

Patient info:

Pain in right big toe, becoming worse, stated 1 week ago, toe is red and swollen. Work as a Taxi driver.
She also drinks 4 pints of peer daily.
SOCRATS, DDx (RA, septic arthritis, trauma, gout, OA, hemarthrosis). Ask about the medical conditions
(how long diagnosed, take any medications, it is controlled?). Allergic to anything? (If yes, what
happens?). Occupation and effect of symptoms.

Examination: observation and have a loot at your legs.

Diagnosis: a condition called gout; it is a type of arthritis (meaning inflammation of your small joints
caused by crystal formation in your joints due to increased levels of urine acid in the blood).

Management:

To control the pain and settle down the inflammation we will give you colchicine. We will do some
routine bloods. It would take 2 days for the pain to resolve.

Change thiazide into amlodipine.

Lifestyle advice (dietary, alcohol… explain the risk factors and its association with gout).

Arrange X-ray and offer leaflet (more info about gout, how to avoid triggering factors).

Advice about driving (advice the patient to inform DVLA himself).

Safety netting for septic arthritis (fever, increasing pain, symptoms getting worse).

Seizure in a middle-aged man (262):

Same scenario of viral encephalitis.

Findings: CSF appears cloudy, CSF Neutrophils in abundance, Rash, neck stiffness positive.

Diagnosis: meningitis; means inflammation of the covering of your brain.

Management: We need to promptly give strong antibiotics through his blood vessels (ceftriaxone).
There is vaccination available.

It is quite serious condition; however, most patients respond very well to the treatment so we will try
our best.

Talk about contact tracing and inform the authorities (since meningitis is a notifiable disease).

Polycystic ovarian syndrome (257):

FY2 in GP, 22 y/o female came for test results review. Blood test done after she initially presented with
acne and irregular periods.

LH is high, FSH is normal, LH: FSH ratio is 3:1.

Explain the results, take the history, and discuss the management with her.
Patient info:

Gain weight wight, hair grown on her face, pimples, periods stopped 6 months ago before that it was
irregular. I don’t like taking hormone treatment.

Do you why these tests have been done? Did anyone tell you why these tests were done?

The test we have done are to check female hormones. Unfortunately, one hormone which is the LH
came back to be quite high but the other hormone which is FSH came back normal. We have also
checked the ratio between these hormones which also came back quite high.

Do you have any symptoms? Since when? Getting worse?

Menstrual history?

Brown pigmentations in your armpit, elbow or anywhere.

Psychological issues (feeling low, sleep problems, OSA).

Examination: observation, weight and height (BMI), BP, blood sugar level.

Diagnosis: from the information you have told and considering your blood tests you most likely have a
condition called PCOS. It is a condition in which you develop cysts (fluid filled cavities) in your ovaries.
These cysts affect how your ovaries work which usually affects your periods and lead to imbalance of
your hormones. Testosterone levels become high leading to excessive hair growth and acne. It has no
specific cause.

Management:

Hormones  if not willing go for Mirena

Encourage lifestyle changes (weight loss is the most important).

For acne: weight loss will help, take OCP, and take Roaccutane.

For hair: you can shave or use wax.

Pregnancy: can get pregnant but might be a bit difficult. If you decided to get pregnant you can come to
us in which we will give you some advices and may give you some medications to help you conceive.

Analgesic nephropathy (290)

FY in GP, 50 y/o come for follow-up.

Blood tests: Hb= 10, urea= 4.6, creatinine 80, eGFR= 52, LFT normal, glucose normal.

Take to the patient and discuss the management.

Patient info:
Came for routine blood test (well man follow-up). Past medical Hx: OA for 5 years for which he takes co-
codamol and NSAID.

These parameters test the filtering ability of your kidneys. The optimal level of eGFR is +60,
unfortunately in your case it is 52 (a bit reduced), so I need to ask you few questions regarding
symptoms of kidney problems.

Swelling in legs, face, feeling tired, changes in water work, itchiness, …

Any medical condition: DM, HTN, UTIs, kidney problems before.

Medications: NSAIDs, ACEI, ..

Examination: observations, abdominal, heart, legs.

Diagnosis: analgesic nephropathy. It means kidney damage due to chronic use of painkillers. If you take
painkillers like what you said for long time it can affect your kidneys in the long run.

Management:

Stop NSAID and take codeine only if there is persistent pain.

Refer to specialist.

Repeat blood test after 2 weeks (after stopping the offending medication).

Do complete urine analysis.

Physiotherapy for OA.

Offer leaflet (about kidney damage and analgesic use).

Nose bleed (340):

You are FY2 in GP, 55-year-old presented with some concerns. 3 years ago, have DVT and he is on
apixaban.

Patient info:

2 episodes of nosebleed, 1st was 1 week ago while picking the nose, 2nd was yesterday spontanesoly
while rub the nose. 1st one stopped when you squeezed the nose.

Qs:

What is the cause of this?

Do I need to stop apixaban?

Examination: scar formation in the little’s area of the nose.

When? What were doing? 1st time? 2nd time? What did you do for that? Any bleeding anywhere? Blood
in the urine, vomit, stool? Any bruises?
Any medications (specially blood thinners)? Since when? Dose? Any dose changes? Any chance you
could have taken too much accidently?

Any medica problem? Liver problems, bleeding conditions? trauma to the nose?

Diagnosis: bleeding is due to nose picking; you are on blood thinner medication which makes you bleed
easily when you pick your nose.

Prevention: avoid picking, blowing the nose, avoid drinking too much alcohol, avoid over the counter
medications such as ibuprofen.

In case you had a bleed, lean forward and pinch the soft part of your nose and hold it for 10-15 minutes
while you breathe through your mouth. Don’t press on the bony part of the nose as it will not stop the
bleeding. If the bleeding didn’t stop within 10-15 minutes, please call the ambulance and they will bring
you to the hospital. In the hospital they can ceil the bleeding vessels or pack your nose to stop the
bleeding.

We can also prescribe you a cream called NASEPTIN which can be applied.

If you notice any blood in your urine, stools or any bruises please seek medical advice.

No need to stop apixaban as the cause of this bleeding is trauma.

Gilbert syndrome (245):

FY2 in GP, 25 y/o male has some blood tests done and came to check it.

LFTs are all normal except for bilirubin (unconjugated and total are high).

Patient info:

Blood tests done 3 time and all come the same. Not expecting anything serious but father have some
liver problems. Drink a bottle of wine daily.

Diagnosis: gilbert syndrome; usually runs in families in which bilirubin (blood pigments) are not
processed properly in the liver.

Management:

Urgent referral to the specialist to confirm the diagnosis. (Genetic testing)

Arrange for US scan of the tummy.

No specific treatment for this condition, however we can give some advices to avoid any worsening.

Advice:

Avoid conditions leading to dehydration, stress.

Avoid drastic changes in your diet/exercise.

Taking certain medications can affect the liver, so consult your GP before initiating any medication.
Alcoholic liver disease (250):

FY in GP, male come for follow-up for tests done last week.

FBC normal, ALT & AST slightly elevated, MCV elevated.

Patient info:

Heavy drinker (bottle of vodka daily).

Diagnosis: alcohol hepatitis, excessive intake of alcohol has affected your liver.

Management:

Do some more specific blood markers (GGT).

Check blood vitamin levels.

Arrange for a liver scan.

Hepatitis screening.

Alcohol counselling. Cutting down alcohol is the main way to treat this condition. We can help you with
this but also you will need to have the desire to do so by motivating yourself and engaging in other
things to keep you away from alcohol.

Alcohol misuse (327):

64 y/o female. come for follow-up for tests done last week.

FBC normal, ALT & AST slightly elevated, MCV elevated.

Patient info:

Drink about half a bottle of wine every day and on weekends for the last 15 years. Because of drinking
habits have some problems with partner and worried about the relationship. Mood is good.

Management the same as above.

Regarding alcohol: there are thing we can do and thing you can do.. and go on with alcohol counselling.

Leukemia 1 (201):

FY 2 in GP, man presented with tiredness. Take history and discuss the initial management.

Patient info:
Feel tired for the last 1 weeks, noticed after participating in a football competition. Getting worse, got 2
bruises on the arm (can’t understand why), gum bleeding when brushing.

Q: I got my friend’s wedding in 5 days; will I be able to go to that wedding? It is a bit difficult for us to tell
now, you need further tests to assess if it is safe to you to go without any complication or affecting your
condition. Once you are in the hospital, they will be in a better position to discuss this with you.

Examination: observations, head to toe examination (check for the bruises), examine the mouth (pic
with gum bleeding), tummy exam, check for the glands.

I’m concerned regarding your symptoms. Unfortunately, leukemia also presents in this way. It is a type
of blood cancer.

We need to do blood tests immediately. You will need to be referred to the specialist within 2 weeks’
time. He will have a chat with you and he may need to do further investigations (other scans and bone
marrow biopsy).

Treatment: chemotherapy & or radiotherapy.

We need to assess you in the hospital setup to check your body’s function more comprehensively.

Leukemia 2 (281):

FY2 in GP: 65 y/o man come for follow up.

Hb: 10, MCV: low, lymphocytes: high, WBC: high. Take history and discuss the initial management.

Patient info:

Feel tired for the last 2-3 months. Using to play golf but can’t play anymore because of the tiredness.

Examination: splenomegaly, observations are normal, cervical lymphadenopathy.

So mainly we checked your blood. It showed you are anemic; this means your blood level is low. They
type of cells which protect us from infections which called white blood cells are on the higher side. We
are concerned about these findings. The reason about this concern is that cancer of the blood can
present in the way. We are worried you might be having a condition called leukemia.

Papilloma (54e):

FY2 in outpatient surgery, 30 y/o female presented with a skin lesion on the shoulder. Take focused
history and discuss the treatment options with her.

Patient info:

What the lesion to be removed because she is going to get married.

Q: will I have a scar? Unfortunately, you may have a scar.

Q: what are my options?

Topical cream salicylic acid up to 3 months

Liquid nitrogen is commonly used (freezing), use need about 4-6 treatment sessions.

Surgical removal.

Laser therapy (not offered by NHS)  leave you with the least scar.

In rheumatoid arthritis patient (232):

FY2 in GP, 55 y/o lady has RA on methotrexate for 5 years.

Patient info:

Noticed a lump on the forearm below the elbow few months ago. Size increasing, itchy, color changed.
Works in construction company as a supervisor and travel for vacation. She thinks its an infection which
needs antibiotics.

Examination: observations, look at the lesion (squamous cell carcinoma).

It is a type of skin cancer which can spread.

Urgent referral to dermatologist (2 weeks), biopsy, might need further tests to look for spread.

It would be sensible to do blood tests today so they are ready when you see the dermatologist.

Melanoma (54b):

55 y/o lady presented with skin lesion. Assess the patient and discuss the management.

Lesion location: female (shoulder), male (behind the ear).

Lipoma (54d):

25 y/o male have shoulder swelling slowly growing for many months.

Usually doesn’t require any treatment, but if it is bothersome, it can be removed under local anesthesia.

It doesn’t look like a cancer.

Seborrheic keratosis (352):

F2 in GP, 72 y/o lady presented with some concerns. Lesion in the breast. Father & mother had skin
cancer.

Q: do you think it is skin cancer?

Q: what are the treatment options?

It doesn’t look like a cancer, but will refer urgently to the dermatologist (as she has positive family
history of skin cancer).

They might remove it by surgical curettage or cryotherapy if it is bothersome to you.

Advise not to scratch it or try to remove it manually.

Acne (183):

F2 in GP, 18 y/o female made appointment to see you. She would like to ask about ROACCUTANE.

Patient info:

Got acne, skin doesn’t look nice, have been using OTC cream and its not working. Have migraine and
take ibuprofen. Wants to see if you can prescribe her ROACCUTANE as her friend use it and got
improved.

Rule out (criteria for specialist referral): fever, painful skin upon touch, poor response to topical
treatment, psychological issues.

Ask for PSCO, contraceptives, implants.

How this affected your studies, confidence, performance, mood, …

There will be a paper inside with medical info on ROACCUTANE.

Refer her to dermatologist.

Advices:

Wash with soap and warm water daily.

Don’t scrub or scratch the acne.

If the skin is dry, use water-based emollients.

Safety netting: If you develop any fever, joint pain (arthritis), or excessive discharge please seek medical
help.

Infective rash (ringworm) (197):

FY2 in GP, 50 y/o male made an appointment to see you. Talk to him, take history, and address his
concerns.

Patient info:

Lesion in the arm for the last 1 month. Gradually progressing, round in shape, red in color, and itchy.
Wife is pregnant in 38 weeks (worried about her and the baby).

Examination: observations (important) + looking at the rash.

Treatment: will give you antifungal cream, apply 2-3 times a day for at least 4 weeks.

Don’t share towels. Don’t scratch the rash as it may spread the infection.

Unfortunately, yes you may pass it to your wife.

Impetigo (283):

FY2 in GP, 28 y/o lady come with rash on her face. Talk to him, take history, and address her concerns.

Patient info:

Rash on the upper lip, started 2 weeks ago. Few days starting getting swollen and turning into blisters.
Tried some OTC creams but didn’t help. Not painful to touch. Married and got a 6 months old baby.
Practice oral sex. Works as a teacher.

Diagnosis: it is a skin infection caused by bacterial bugs.

Treatment: antibiotic cream called Fucidin.

Avoid going to work until 48 hours after starting the treatment (it is infectious for 48 hours after
applying the cream), or until the blisters go/get crusted oral.

Avoid oral sex as well as it may spread to your partner.

Normally it doesn’t leave a scar.

Wash your hands with soap and water after touching the lesion, avoid kissing your child/husband, avoid
sharing clothes or appliances. You can cover the lesion with a loose clothing.

Urticaria in a 5-year-old (329):

FY2 in GP, 5 y/o child brought by her mother.

Developed rash 2 days ago after taking a hot shower but the rash went away after few hours. It was all
over the body. Pinkish in color. Today, 3 hours ago she developed a rash again after comping back from
playing outside which disappeared now.

Q: is it meningitis (the school is asking)?

Q: is it contagious?

Ask about insect bite, any allergy, medications

Diagnosis: condition called cholinergic urticaria (also called heat bumps).

Treatment: we can you some antihistamines. But the main stay in this condition is prevention by
avoiding triggering factors (heat, …)

We need to send the child to do allergy test, and blood test.

It doesn’t seem like a meningitis, doesn’t seem to be contagious.

Scabies (343):

FY2 in GP, 4 y/o brought by the mother. Take focused history and address her concerns.

Went for a camping for a week and while there started to have a rash mainly between the fingers.

Q: can he pass this to others?

Anyone has similar lesion? Visited anyone recently? Any discharge? Itchy specially at night? Been to any
overcrowded places?

Fever, feeling unwell (chickenpox)?

Diagnosis: scabies, type of parasite infestation.

Treatment: cream called permethrin that has to be applied for the whole body (should be left for at
least 8-12 hours on the body before washing).

The whole family members and their sexual partners need to be treated as well.

Beddings, clothing and towels  all should be decontaminated by washing using high temperature.

Offer leaflets.

Chickenpox (353):
FY2 in GP, 3 y/o child was brought by his mother who wants to get advice about his condition.

Rash for the last 2 days on the face and then spread to the rest of the body. Have fever, cough and
runny nose. He was at the nursery who called the mother to come and pick up the child. Up to date with
immunizations including MMR.

Q: when he can go back to nursery?

Chickenpox is caused by a virus. Common in children but can be in any age. It usually gets better on its
own.

Treatment: paracetamol, antihistamine (to relive the itching).

Advise: Cut the nails of the baby to avoid damaging the skin when scratching, avoid contact with other
children and infants less than 4 weeks, drink plenty of fluids, wear smooth cotton clothing.

Most infectious period is 1-2 days before the rash appears, but it continuous until all the lesions have
crusted (which takes usually about 5 days after the onset of the rash). The crusting of the lesions usually
follows within 2-3 days.

Avoid the nursery until all the vesicles have crusted.

Safety netting (bacterial infection): sudden high fever, pus formation, or getting worse.

Hemangioma:

FY2 in GP, 1 week old boy brought by his mother. Take to the mother and address her concerns.

2 days ago, noticed a lesion on his back, red in color. Child is doing well with no medical problems.
Q: is it cancer? Something serious?

Q: will it stuck on his clothes? Can it bleed?

Ask about trauma? Fever? Infection?

Examination: inspection of the lesion.

Diagnosis: harmless growth of the blood vessels. It will stop growing on its own. Usually common in
premature babies (relate with the history).

It usually shrinks without leaving any scans, so most of the time no treatment is required. However, if it
become an ulcer or getting larger then it can be removed by surgery, laser or beta blockers injection.

Offer leaflets about this condition.

It usually doesn’t bleed but if it started to bleed or ulcerate, please bring your child back to the hospital.

Measles:
FY2 in student health center, 25 y/o visited the center 30 minutes ago and couldn’t wait but the nurse
has taken a picture of his lesion.

Rash started behind the ear and spread to the rest of the body 2 days ago. Has fever, cough and runny
nose. Not sure about the immunizations. Nurse checked temperature it is 39 C.

Bilateral cervical lymphadenopathy.

It is a viral infection. Very contagious. However, it is a self-limiting condition.

Drink adequate fluids and take paracetamol for fever. Aspirin should be avoided in children (younger
than 6 y/o).

Stay from school or work for at least 4 days after the onset of rash.

Avoid contact with susceptible people (like pregnant)

It needs to be notified to the local health protection team.

Offer leaflet.

Safety netting:
Diabetes:

9 y/o was admitted with DKA. Talk to the mother.

Has DM-I. The nurse has explained how to use insulin and about DKA. Tomorrow going for a holiday.
Address her concerns.

Optic neuritis:

FY2 in GP, 28 y/o female made an appointment to see you.

Have eye pain started yesterday. Has similar symptoms 3 months ago which resolved after 1 week.
Didn’t see any doctor yet. Have noticed problem differentiating different colors. Work as IT project
developer. Mother has MS and similar eye problems.
Q: can I go for my presentation?

Q: will I lose my vision? (if the condition gets worse, you may have serious impairment on your vision so
we need to sort this urgently and start the treatment ASAP).

Examination:

Fundoscopy  optic disc partially not visible.

Light reflex  sluggish on the left, normal on the right.

Painful eye movement

Visual acuity  right: 6/6, left 6/18

Difficulties in waking? Bladder problems? Numbness or tingling? Muscle stiffness/spasm? Balance

problems?

Diagnosis: inflammation of the nerve responsible for the vision, you may have multiple sclerosis which
affects the nerves. It is caused by your immune system mistakenly attacking your own nerves.

Treatment: urgent referral to neurology and eye specialist. (Eye immediately today, neurology routine)>

Main stay is steroids to speed off the recovery and reduce the inflammation.

There are variety of disease-modifying therapies and treatment for individual symptoms once you see
the neurologist.

Advise not to go to the presentation (not advisable), you may be able to manage or may not be able.

Cellulitis (353):

FY2, 36 y/o lady thinks she had insect bite yesterday and now has a rash on the leg which has been
increasing. Has fever, tachycardia, red and swollen legs.

Check for DVT

Tell examination findings: you are running a temperature and your heart beats fast.

Diagnosis: skin infection called cellulitis probably due to the insect bite.

Immediate referral to the hospital.

Give painkillers for now.

In the hospital: admission with IV antibiotics.