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PAIN
Have you ever smoked before? Do you smoke cigarettes? How long? How many?
Do you drink alcohol? How long? How much?
By any chance do you take any recreational drugs.
MAFTOSA
Medication: Are you taking any long term medications? Including over the counter medication for any particular condition
Allergy: Are you allergic to any medication?
END OF STATION
Thank you very much Mr. You have been cooperative.
I would like to speak the examiner now.
Examiner: My most probable diagnosis is .......
I have ruled out ..........
Dysphagia
D/D:
Ca Esophagus.
Achalasia
Oesophageal stricture
Pharyngeal pouch
Myasthenia Gravis
Globus Histericus
Post-procedural
CA Eosophagus: Difficulty on solid >liquid. Weight loss. Appetite loss. Anaemia. Smoking History.
Achalasia Cardia: Difficulty on liquid >Solid.
Oesophageal Stricture: Due to esophagitis. Drinking hot liquid (Corrosive material: Bleach, househo
cleaner).
Is it possible that accidentally you swallowed something corrosive or hot?
Pharyngeal pouch:
How much do you feel about your mouth odour recently?
Have you noticed food stuff left on pillow when you get up in the morning?
Have people told you that your odour is offensive?
Myasthenia Gravis: Do you feel tired most of the day?
Globus Histericus: Female patient. Do you have a sensation of lump in your throat?
Do you have to clear your throat repetidly? Do you feel the need to clear your throat repetidly?
Post-operative Endosocopy: Have you undergone a procedure recently in which a instrument is
passed from your mouth to your tummy?
ABDOMINAL PAIN
Main diagnosis:
Burning sensation
Fever
Increase frequency
Abdominal Pain
RECTUM
D/D:
Hemorrhoids
Anal Fissure
Rectal Prolapse
Ulcerative Colitis
Acute Diverticulitis
Post-Procedural
Drug Induced
Bleeding disorder
Liver disease
Type of Blood
Assess Anaemia: SOB, racing of heart. Fatigue.
Bleeding Questions:
Post surgery.
Blood thinners.
Post-procedural bleeding.
Colorectal Carcinoma
Family History:
Family History of Medical Problem
Family History of Bowel Problems
Family History of Bowel Carcinoma
Haemorrhoid: Painless. Bright red splash.
Anal Fissure: Painful + History of constipation. Streak of blood.
Ulcerative Colitis: Diarrhea and Blood. Skin and Eye changes.
Acute Diverticulitis:
Rule out Anaemia:
Shortness of breath
Racing of heart
Feeling tired, fatigue, dizziness, light headness
Have you done recently any procedure?
Have you been diagnosed with a condition called Polyp?
Is there any history of bleeding disorder? Are you taking any medication
regularly for a long time?
Have you been diagnosed with a Liver condition?
HEMATURIA
D/D:
Renal Calculi
Ureteric Calculi
Bladder Calculi
Urinary Tract Infection
Renal Carcinoma
Bladder Carcinoma
Schistosomiasis
Drug Induced (Warfarin/Cyclophosphamide )
Renal Calculi: Pain Back.
Ureteric Calculi: Travels far side of tumour, deep down the private parts.
Bladder Calculi: Urine stream.
Urinary Tract Infection : Burning Sensation.
Renal Carcinoma:
Have you noticed any swelling in your groin area?
Weight loss. Fever. Night Sweats.
Bladder Carcinoma:
History of working in Dye Industry.
Smoking.
Schistosomiasis:
Any chance of excessive swimming in lake?
Any friend you joint you is having a similar complaint?
Drug Induced:
Cyclophosphamide: Are you taking medication for a sinister problem?
Urinary Bladder Carcinoma: Occupation: DYE INDUSTRY
Schistosomiasis:
Travel outside the UK?
Where?
Did you by any chance swim in any lake?
Trauma: Is it possible that you accidentally may have hurt yourself in your private area?
URINARY OBSTRUCTION
BPH
Carcinoma Prostate
Carcinoma Bladder
Bladder Calculi
Urinary Tract Infection
Drug Induced
Post-procedural.
Frequency
Urgency
Hesitancy
Dribbling
Nocturia
BPH
Urine stream
Incomplete sense of evacuation
Frequency:
Do you need to go to the toilet most of the time now?
Do you feel you have to go the toilet more often than you used to do before?
Urgency:
Are you able to hold it when you go to the toilet?
Are you able to hold your urine or you feel you have to rush to the toilet?
Hesitancy:
Do you have to wait a long time to go out of bathroom?
Do you find it difficult to pass urine?
Nocturia : Do you wake up at night frequently to pass urine?
Urine Stream : How is your urine stream?
Incomplete sense of evacuation:
Do you feel you cannot empty completely your bladder?
CA Prostate: Systemic Symptoms: Back Pain/Bone Pain. Hematuria. Symptoms of
BPH.
CA Bladder: Smoking. Dye Exposure.
Drug Induced:
Anticholinergic drugs: Eye problems. Mood Elevation (AD-Tryciclics).
Are you taking any medication for a long term medical condition such as ...
(Eye problems, Mood problems).
Are you on any long term medication?
Dysuria + UO (Urinary Obstruction).
Management:BPH + UTI
Investigations:
Blood test: PSA Urine: Dip M/C &
Treatment: Antibiotics. Surgery
TESTICULAR PAIN
D/D:
Trauma
Testicular Torsion
Acute Epidediomyositis-Orchitis
Urinary Tract Infection
Obstructive Hernia
Bladder Calculi
Blood tests.
Urine tests.
Swab of discharge.
USG Testis.
Treatment:
Torsion of Testis: Urgent surgery.
Acute Epidemiocistitis: Analgesia. ATB. Rest.
COUNSELLING
Listen + Address Patients Concerns
1. Opening sentence GRIPS
Dx- Given.
Not Given Dx: Focus History, Establish Dx and then Counsel.
GOUT
History Taking: SOCRATES.
OEDIPARA.
Questions of pain.
Medication:
Iron tablets.
Folic Acid tablets.
Vitamin B injection.
Iron Injection.
Anaemia: Is a condition in which Red Blood Cells carrying O2 to tissues has gone down unexpectedly and the
needs to be thoroughly investigated.
There are risks:
Poor wound healing
Risk of infection
Interference with sleep medication
We dont want these to happen to you. These is why we need to defer surgery.
Causes:
Are you on any long term medication?
Have you noticed any recent change in the colour of your stools?
Have you noticed anything with your urine lately?
Malignancy questions: Weight loss, fatigue.
We will need to run some further investigations to find/determine the cause.
Do you have any religious restriction regarding blood transfusion?
We respect your beliefs, let my consultant know.
Well be monitoring you regularly, and once you are fit we will program you for surgery immediately.
WOUND INFECTION.
Im very sorry that are you in pain & Do you need any painkillers?
My consultant is busy at the moment give me chance, I will see you now, and later arrange an appointment with
a consultant.
As you undergo surgery 7 days ago, this is wound infection, I am very sorry.
Patient is suffering from a wound infection from surgery.
We need to run some tests. We will take a swab from your wound. We need to find out wha
exactly is causing the problem.
We will give you regular painkillers, start ATB immediately.
My consultant will see you later and guide you.
However. As we told you earlier, before doing the surgery, there is a possibility of having some
complications after surgery, I am sorry, but it is one of those complications.
Patient: Give some medication, I want to go home.
We need to keep you in the hospital, because we have to give you ATB which most probably will be
given by blood channels, which cant be given at home.
If you go outside, there is a probability that you will get more infections.
Worry about wages: WORK & PENSION DEPARTMENT will compensate.
I am going to inform my seniors & Infection Control Team: INFECTION CONTROL TEAM.
Cure by proper Antibiotics, but everyone responds differently to medication.
I am sure my colleage might have explain these unforeseen complication. But is best to focus on
getting you better.We have informed the Infection Control Team and notify your consultant and are
looking at this with the outmost priority.
Patient: Will it be cured?
It is a treatable condition with the right ATB, along with your patience and cooperation.
Patient: How long will it take?
As soon as your infection is cleared up, and your wound healed.
ABDOMINAL PAIN
GRIPS. Explain Dx: Results all normal. No abnormality.
There is no chance, we ran many cross-check to each other. So taking it in consideration will not be beneficial.
Painkillers: Pain
Healthy diet.
Surgery.
Stress: Yoga, exercise.
Morphine.
Hospital environment is not good for your health, why do want to put your life at risk.
Sending Patient HOME:
WARNING SIGNS: Come back to the hospital for study if any:
Any change in bowel habits.
Any weight loss.
Any appetite loss.
NHS DIRECT NUMBER: Advice you according to the problem. Advice to go to the hospital if necessary.
We do respect and regard your concern. And we will treat the symptom.
Asks for admission:
Action Plan:
1.
2.
3.
4.
We will not admit you, but we will keep a close eye on your symptoms with your GP.
Follow-up regularly with your GP.
We will prescribe you painkillers if you need some.
Encourage participation in physical activities (physiotherapy).
5.
6.
7.
8.
Ask has anyone in your family been treated with similar problems/complaints?
Answer Yes:Give warning signs of Bowel Ca:
Weight loss
Appetite loss
Fatigue
New Symptoms
Please come back.
Have you noticed any change in the character of pain?
Whatever you have is not serious. It could be Irritable Bowel syndrome, or Abdominal migraine, but we are not
sure. But we will manage it accordingly.
ULCER. SKIN
Where is it?
How did you notice it?
How long has it been there?
What is the colour?
Is it painful?
Has the ulcer change it size?
Any bleeding from discharge?
How is the skin around the ulcer?
Bleeding or discharge?
Is this the first time you have an ulcer?
Malignant Melanoma
D/D:
Main Features:
A Asymmetrical
B Border Irregular
C Colour Malignant
D Diameter >6 cm
E Evolving change in size
Squamous Cell Carcinoma: Border rugosity
Pressure Sores: Have you been immobilized for a long time?
According to my clinical opinion you could have a skin problem. It may be a sinister growth. We
will remove the ulcer with a few mm of surrounding normal skin. We will send the specimen for
laboratory. Results will come 3-4 weeks time. Once we have the results we will know if there is
normal or abnormal tissue, we will treat it according to the problem.
Ulcer:
Colour
Site
Size
Shape
Pain
Bleed
Discharge
Surrounding structure
Smell/odour
Duration
Itching sensation
Differential:
Malignant melanoma
Squamous carcinoma
Basal Cell Carcinoma
Diabetic ulcers
Venous ulcers
Tuberculous ulcers
Pressure sores
Traumatic ulcers
Venous ulcer:
Have you noticed any change in size, colour on your legs?
We have a condition called Malignant melanoma. It could be sinister but we manage it.
We would like to remove the ulcer.
We will remove it with surrounding 5 mm of normal skin.
We will send the ulcer to the lab for further investigations.
Results will come back in 2-4 weeks.
Once we have the results, we would know whether it contains normal or abnormal tissue and treat
it accordingly.
Hopefully it would not be serious.
If results are not very encouraging we will do some more tests.
Please dont worry, you are in safe hands.
It ALWAYS BE MALIGNANT MELANOMA.
ANKLE SPRAIN
Injury to ligament (strong band of tissue, around joints, these help to keep bone together and stable?
P - Painkillers
R Rest
TESTICULAR LUMP
Testicular implants are available, after removal of testis. So they can restore normal appearance after
surgery.
Cant affect fertility if other testis is normal.
Do not say its cancer.
Concerns: Sex life: Doesnt affect your sex life.
Fertility: As long as your other testis is healthy should not affect your fertility.
Cosmetic: We can provide a prostetic testis.
Talk to my consultant and alleviate your concern.
BREAST LUMP
Post-operative Options:
1. Mastectomy Bra
2. Reconstructive surgery:
Lip Modeling
Silicon Implant
Muscular Flap
3. Excessive Regime: Actions:
3.
4.
5.
6.
Bony pain
Yellow discolouration
Headache
Visual disturbances
SURGICAL PROCEDURE
1.
2.
3.
4.
5.
Opening statement.
Admit patient:
Nill by mouth
Operation threatre.
Anaesthesia.
Procedure (durational incision).
Recovery room.
Ward
Discharge
Recovery at home
Special Care
Rest
Light work
Hard work
Driving
Sex.
Complications:
Pain: Painkillers.
Infection: ATB
Bleeding
Damage to surrounding structures:
Gastrointestinal: Nausea, vomiting, diarrhea.
Consent form.
UPPER GI ENDOSCOPY
APPENDICECTOMY
CHOLESCYSTECTOMY
NEPHRECTOMY
Breaking bad news
Just say hello.
Are you Mr. Smith, husband of ..... I am Dr....
How much do you know about the condition of your wife?
Unfortunately I dont have good news, your wife has a condition called ....
Observe reaction: Crying offer tissues. Not crying: give time.
We need to remove it immediately to save the patients life and before it moves to other
organs.
Breaking bad news: Dont give Leaflets or websites. Consent form to the patient.
RADICAL NEPHRECTOMY Procedure to remove kidney and surrounding structures.
There is a possibility that when we open your tummy the surrounding structures are involved
by cancer. In such case we have to remove surrounding structures. It is called RADICAL
NEPHRECTOMY.
Nephrectomy
Counsel patient husband.
How much do you know about your wifes condition?
Mr.---- Lets not think about that now. Lets think about how to help her. My consultant has
decided to do this surgery/procedure. Do you know anything about this procedure
Nephrectomy?
Dont give time frame.
Cancer society
McMillan Nurses
Instead of Risk of Death: Say Slight risk to life during operation.
Radical Nephrectomy
Remove surrounding structures.
We are uncertain about the future regarding its recurrence.
Monitoring her regulary.
HEMICOLECTOMY
Our team has decided to remove the portion around portions of bowel by a procedure called hemicolectomy.
Admit you.
However, in case abnormality has spread and we will have to take large part of bowels. My consultant will
create a hole in your tummy, also known as stoma, and join first part of bubble so that he can pass stools
through his back passage.
Specialist Stoma Nurse: Will teach you about it.
Take to Recovery room.
Complications of Stoma:
Herniation
Redness
Bleeding
Stoma can be seek in or out.
Any problem with stoma: CALL STOMA NURSE.
Avoid:
Spy food
Baked beans
Brocoli
Coliflor
Colostomy nurse
Diet
General activities.
Travel.
PROSTATECTOMY
Waterpipe
Waterbag
Watertablets
VASECTOMY
Is a permanent procedure.
Have you informed your partner about it?
Have you completed your family?
If asked for reversal later NHS will not pay it.
Explain procedure.