Fever

1. Meningitis
2. OTM
3. Pneumonia
4. URTI
5. TB
6. Hepatitis
7. GE
8. UTI
9. PID
10. Epidedymo orchitis
11. Malaria

25 years old lady presents to the hospital because of fever. You

are SHO in A&E department. Take a relevant history and discuss
about differentials with examiner.

- Think about covering the patient. Ask the patient if she is fine.
[MALARIA PATIENT SO WILL NOT GIVE FEVER HISTORY] If Reactive
arthiris, they have knee pain

- Patient says I m feeling terrible.

- Why, my dear? I have a headache last few days. Pain all over,
vomited once since last night.
- What else do you have? Any fever by any chance? Yes but fever
comes and goes. I feel chilly.
- Have you travelled recently? Yes to Ghana or Kenya sometimes.
- When did you come back? (Incubation period 1week to 1 month)
- How long you have been there?
- Have you received any medication for malaria? ( Yes, I took some
medication and I am still taking medication, My GP told me to take
some thing. I bought the cheap one.
- I did not take medication regularly.
- NHS does not pay for prophylaxis.
- 1 week before and during and 4 weeks after.

Dry cough
28 years old patient presents to the hospital because of dry cough. You
are SHO. Please talk to the patient and discuss about diagnosis and
investigations to examiner. [PILOT STATION]

Differentials For Dry cough

Respiratory
1. Pneumonia
2. Asthma
3. Atypical pneumonia (PCP)
4. URTI
5. Tuberculosis

1
Cardiac causes

1. Cardiac asthma
Medications ACE Inhibitor

I have got the weight loss and night sweat.

Travel history no travel history
Close contact no close contact
Ask question of asthma, hay fever, and rule out all Df/Dx.

I suspect my patient has tuberculosis so I want to do.

Investigations
1. Blood test
2. CXR
3. Bronchoscopy and lavage
Tuberculosis
Active when you have the symptoms. CXR, AFB, blood test.
Latent _ manthoux test, Blood test Interferon Gamma essay, if close
contact

Hepatitis (jaundice , fever and abdominal pain)

1. Viral Hepatits Hep B and C (sexual history , blood
transfusion,tattoos, IV drugs ) IP 1 to 6 months
Hepatitis A similar condition in family, eating , drink
water (IP 5 to 50 days)
Nausea, vomiting (GE symptoms, LOA)
2. Alcoholic hepatitis alcohol drinking
3. Obstructive hepatitis gall stones (history of surgery)
_ Ca head of pancreas

45 years old patient refer to the hospital because of pain, you

are SHO in clinic, please take a relevant history and look at your
LFT, lab report and suggest and likely diagnosis to the examiner.
(not asked in last 35 exam yet)

ALT viral 5-35 200

AST viral 5-35 200
ALP obstructive 30-150 100
GGT alcohol 5-40 20
bilirubin 3-17 30

1. I have a pain in right upper tummy.

2.
3. I have a low grade fever as well.
4. I have yellow discoloration in my skin and eye.
5. Rule out from past medical history.
6. Blood transfusion + 2 weeks ago. GB operation + in the past.

2
 7. Just say Dx is viral hepatitis ( if asked it is Hep A since few
weeks ago it is Hep A)
47years old patient presents to the hospital with right upper
quadrant pain. Please talk to the patient, look at LFT and
discuss with the patient about the lab report. (4th of sept ,
PILOT)
ALT viral 5-35 200
AST viral 5-35 200
ALP obstructive 30-150 100
GGT alcohol 5-40 200 *
Bilirubin 3-17 30

Diagnosis Hepatitis
Findings RUQ pain, sick for few weeks, flu like symptoms, loss his
appetite, yellowish discoloration of skin and eye.
History live with boyfriend. not safe sex.
Alcohol history one or two glass per week.
Tell the patient from what you told me, and from your abnormal
blood test, you have the condition called hepatitis which is
inflammation or swelling of the liver. This can happen as a result of
drinking too much alcohol, or bug. Sometimes obstruction like gullet
stone also causes this condition. When bug causes hepatitis, these 2
enzymes increases (ALT and AST) as it is now same as your results.
When an obstruction causes hepatitis, ALP will increases however
your ALP is normal, also you have had removed your gall bladder.
When excessive alcohol consumption cause hepatisis. GGT will rise as
it is in your blood. However, you told me you drink in moderation. So
that in order to find out what can be the cause of your abnormal
result, we should do further investigation. (blood test or serology)

21 years old patient, present to the hospital , refer by GP

because of jaundice. Talk to the patient, take history , discuss
about your diagnosis with the examiner. (4 times in couple of
month) can be real station.

Lab report

ALT viral 5-35 510

AST viral 5-35 Not given
ALP obstructive 30-150 160
GGT alcohol 5-40 Not given
bilirubin 3-17 40

-Patient is tinted yellow.

-Will tell you I have jaundice in last 2 weeks, patient will have RU
tummy pain recently.

3
 -Vomiting + , diahorrea + in last few days, Low grade fever +
-Travel history did you eat out in your holidays? Yes
-Sexual history had unprotected sex with 3 different girls, any
protected sex in the back days.
-Alcohol history every weekend, usually as the Sunday, not a lot
enjoying his drink.
I m suspecting viral hepatitis. If he is responding sexual history for about
1 to 6 months, it will be 6months.
If no sexual activity in before time, it is Hep A

Case. 28 years old patient presents to the hospital because of

having wheeze. Please talk to the patient and take only history.
(Pilot)

Can I have puffer? Why you want? I have got the wheeze and I cannot
breathe. `I had the same condition two years ago and My GP give me
inhaler.
Do you have any allergy that you have? Yes I have hay fever.
Phlegm, chest pain.
Smoker? Drinker? - Drink in moderation.

Headache
Differentials
Life threatening SAH, meningitis, SOL
SOL headache in the morning, vomiting, tingling in the hands
Elderly - GCA, glaucoma
Glaucoma any pain in the back of your eye? Do you see any halos or line
around the light?
Typical Migrane, cluster and tension
Cluster - Watery eye and watery nose? Pain starts in specific time of day and
night.

Case: 70 years old patient has been refered to the hospital because
of the headache. You are SHO in the A & E department. Talk to the
patient. Differential with examiner. (PILOT) GCA

Where is the pain? Temporal area.

Since when Since 3 weeks ago.
When pain increased? combing
When chewing does it hurt? Yes
Rule out differential as much as you can.

First rule out life threatening.

4
25 years old patient presents to A & E because of headache. Male /
Female, take relevant history and discuss management with patient.
(1 min for management, history is 4 mins) SAH

Do you want to dim the light? Do you want pain killer? all yes
SOCRATES where is the pain? back of the head( could be anywhere)
When it started? 2 hours ago. Suddenly.
Where were you? I was in the university lecture.
Pain all over the head when we asked about radiation
Scale is 5 mins. It is the worst experience in my life.
Vomiting? Dont ask photophobia because already dimmed the light.
In PMH, when we ask about any similar episode, I had a migrane.
Is it like the previous mirgrane? No
Ask about medication? (zolmitrypten)

Management
From what you told me, I suspect SAH, it is uncommon type of stroke cause by
bleeding on the surface of your brain which is a serious condition and it is an
emergency.
To confirm, we will do CT scan, to check the sign of bleeding in your brain. If
there is bleeding, we will find out how much and where?
CT is normal we have to do another test, we have to take some fluid out of
your spine to see if there is blood in there or not.
If we confirm our diagnosis, we will refer you to the specialist to do surgery.

18 years old girl present to the hospital with headache, take history
and discuss about your differential about your diagnosis to your
examiner. (MIGRANE)

Covering eye and hand and had severe headache, when you make sure
pain is comfortable you can start talking to the patient.
Show me the pain?
When this pain is start, since this morning I have this pain which is
coming so bad but this is last 2 to 3 months. So the patient has
headache in the last few months but the headache become severe.
What makes it better and what makes it worse? Lie down and feel better
but this time is not feeling better.
Score 7 -8
PMH
family history -mother got migrane
Not smoker or alcohol drinker.

55 years old patient presents to the hospital with pain in the right
eye. Please talk to the patient and please discuss about your
management with examiner.

Finding wearing sunglasses to cover the red eyes. (Dont ask the patient to
remove glasses)

5
 Offer painkiller.
I have painful eye and red eyes.
When you asked about pain? The first thing you ask is S site- pain here (near
eyebrow)
When the pain has started? 2 hours ago.
What were you doing at the moment? I was in the kitchen and cutting
kitchen. Having breakfast.
Vomiting had vomiting once before coming here.
Associating symptoms - when I m looking at the light I can see light around
the light.
What about the other eye? To rule out systemic or local. Only one eye.
Local causes of eye pain
1- Conjuntivitis (sticky discharge)
2- Watery eye (cluster headache)
3- Trauma

Systemic causes of eye pain

1- Uveitis
2- SLE
3- RA

Depression diagnosed 6 months ago and taking amytryptlline,

Management with the examiner
Based on my history, my most probable diagnosis is Acute close angle
glaucoma.
I will start my initial treatment based on patient symptoms and history.
I will give my patient 3 drugs, 1.Pilocarpine (constrict pupils)
2. Timolol (reduced the eye fluid)
3. Steriod(reduced inflammation)

Both Acetazoamide and IV Mannitol of the drug reduce eye inflammation.

Probably anti-emetic if needed.
To stop Amytryplline, and contact the GP immediately.
And I will refer the patient to eye specialist.

Knee pain
40 years old patient present to hospital with haemoptysis. SHO in
medicine dept. talk to patient and give D/d to examiner.

Can you pls tell me about ur pain? 2- 3 months ago coughing blood.
Could u pls tell me more about it.

Do you smoke? Have you ever smoke?

Do you drink? Have you ever drink?
Are you having any phlegm? (to rule out COPD)

6
30 years smoking 40 cigars a day. Coughing blood D/D 1. Lung cancer

Diahorrea : 35 years old patient present to the hospital because of

diahorrea. You are SHO in A & E department. Your nurse check
temperature and is 38.5. no dehydration. Has 2 kids. Take a relevant
history and discuss management with patient. (1 min with patient?)

Patient hand is on tummy.

Pain killer.
Elaborate diahorrea.
When it start? Yesterday
How many times? Six times?
Any blood? No blood
Nature -Watery stool.

Any vomiting 3 times since last night.

Any tummy pain yes
odour
Temperature any fever, any temp? high fever now better.

Eating out? Staying in hotel with 2 kids and hotel restaurant

Anyone having the same symptoms ? other people in hotel.
Any medication are you taking? (antibiotics) psudomenbraneous colitis

Dehydration status
Are u feeling any drowsiness?
Can you eat and drink well? (yes good to go home) if no admit the patient.

Management with the patient

You are having tummy bug. Gastroenteritis. It is self limiting in nature and
will improve by itself. Please have plenty of fluid.
Please wash you hands after going to toilet and before your little one can
easily catch condition.
Dietery advice
Avoid spicy food.
Travel history E-coli [ blood in stool ]
Investigation
We may take some sample from your stool.
Warning sign
Drowsiness
Note if patient cannot eat well, admit the patient.

40 years old patient presents to the hospital because of diahorrea.

Please talk to the patient and discuss about your differential
diagnosis. ( Pilot station but chance of having as real station)

7
Symptoms 4 weeks ago.
Frequency start 2-3 times a day but 6 times a day.
Type watery loose stool

D/D
Gastric causes
1- IBD
2- IBS
3- Coeliac disease
4- Bowel CA

Endocrine cause of chronic diahorrea

1- Hyperthyroidism
2- DM
Rule out IBD
Any fever?
Fever and Tummy pain + in IBD
diahorrea with blood.
No fever and tummy pain.
Wt loss one stone weight loss.
Blood in the stool as well.
Family history of bowel cancer.
Loss of appetite.
Sometimes no family of cancer.

When you are suspecting for IBD, chronic diahorrea and bloody diahorrea.
Weight loss.
Ask about ulcer in the mouth, skin change, eye changes.

70 years old patient presents to the hospital with constipation.

Please talk to the patient and talk to the examiner about the
diagnosis.

Make the patient comfortable.

If you see Constipation rule out bowel cancer!! If not it is morphine drug.

What can I help you?

Two weeks go I started having constipation.
When someone has constipation, ask for medication
Codeine may be present.
They dont give any history? Any codeine over the counter?
I was travelling and I got ankle sprain.

9 questions of bowel cancer

dehydration?
Other differential is not that necessary since we dont have time
Hypothyroid,

8
50 years old patient, presents with constipation. Talk to the patient
and discuss about differential with the examiner.

1. Constipation from last 3 to 4 months.

2. Last few days getting severe recently. Toilet ( 3 to 4 days)
3. I have noticed streak of blood in tissue.
4. Colour red
5. Diet will not eating that much fruit and vegetable.
6. Family history + for bowel cancer.

Elderly patient presents to hospital with constipation for a few

months for constipation. You are SHO in department. Talk to the
nurse and discuss about differential to examiner.

The patient is not able to talk.

Findings from your nurse collegue family history of bowel caner/ PR bleeding/
no weight loss

CA bowel cancer
All the differentials should be talked about.

Weight loss
20 years old girl came to the hospital with weight loss, you are SHO
in OPD . Talk to the patient and talk about D/D to the examiner.

8kg weight loss in last 2 months

Are you trying to lose weight? (Intentional or not)
I eat a lot, full lunch, full breakfast.
I do not do exercise.
Are you taking any medication? No
Patient will tell you heart racing, hand shaking.
Rule out HIV. Stable relationship / no other any positive history.
Family history of hyperthyroid +/- my sister has got the same
symptoms.
When everyone feels normal, do you feel hot?
GIT cause of weight loss
1. IBD
2. CA bowel
Infective cause for weight loss
1.HIV
2. TB
Two endocrine.
1.DM
2.Hyperthyroid
Psychiatry cause

9
 Depression and anorexia nervosa

Calf pain (2 stations) one station is pilot

62 years old patient has been referred to the hospital because I am
having pain. SHO in medicine department and discuss about
differential to the examiner.

Vascular cause
1. PAD
2. Acute limb ischemia
3. Burgur disease
4. DVT
Mechanical cause
Trauma
Rupture baker cyst (do you have any fullness behind your knee?)
Neurological
1. Siatica ( shooting pain , history of heavy lifting, from back to your leg)

Calf pain presents in last 10 days?

Any redness or hotness?
Any travel history?
Acute limb ischaemia ? sudden onset of pain.
Coldness, numbness, pain.
How can we differentiate between PAD and Acute limb ischaemia?
PAD life style question (smoking, alcohol, exercise, diet, stress)
PMH DM, H/T

62 years old patient, calf pain in last 10 days. Dx - PAD

After 100 yards, walking pain.
PAD, lifestyle, smoking, how much smoke, how much?
Exercise? Golf. But no physical activity recently
Sensible diet, but dont like fatty food.
No hotness, swelling.
Shortness of breath + DVT
No surgery.

Calf pain 35 years old patient presents with calf/ leg pain. You are
SHO in A & E department. Discuss about 2 differentials diagnosis
with examiner.

- Patient lying on the bed.

- Blanket on the leg too.
- Pain 2 days ago in my calf.
- Walking pain becomes worse.
- Smoker for 15 -20years.
- PAD no ulcer, no paleness
- Nothing wrong in examination question.
Calf.
1. Hotness +

10
2. Chest pain _
3. OC pill +
4. PMH diabetes, H/T

2 Differential
PAD and DVT

Dizziness
59 years old patient presents to the hospital with dizziness. You are
SHO talk to the patient. Discuss about differential with the
examiner.

Dizziness few months ago

Why are you here now? Seen my GP and some medication prescribed.
Stemitil is taken.
Sometimes I take medicine but sometimes I dont take.
If not taking, side effects.
Tell me more about your dizziness.
When I feel dizzy, early morning, when I woke up move my head and neck,
I have this dizziness when I sit up and stand up (Benign postural vertigo)
Rule out other causes
1. Meniers disease. Any problem with hearing? Fullness in ear? Ringing in
the ear?
2. Acoustic neuroma - weakness in face? Problem with hearing?
3. MS - have u diagnose with MS before
Any fever?
Any discharge?
Any vomiting?
By any chance you have DM?
How long have you had this condition?
Have u seen with anyone for that?
What does he done for you?

82 year old was brought to the hospital by 60 years old

daughter. Some bruises were found on arms, fore arm, tummy
and flank area. You are SHO. In A & E department
A. Please talk to the daughter and discuss about management
with the examiner.

11
 B. Please talk to the daughter and take history for NAI and
discuss about management with the daughter.
I was changing my mother clothes and she fell down and hit the radiator.
Sometimes my mother was living room and hit with the radiator. Ask
about with whom your mother live. My mother lives with me.
My and my two kids take care of my mother.
My mother has dementia sometimes.
How is relationship with grandchildren? They are not talking because my
mother has dementia.
Any other medical illness my mother has urinary incontinence as well.
I am suspecting NAI, I will admit my patient, I will do investigation like
Xray to see fracture, and other investigation.
Will talk to consultant, elderly care consultant and
If they confirm, social services will involve.
To daughter, we are going to have to admit your mother because we need
to do some investigations and tests to find out what is wrong with your
mother.
What can cause fall in elderly people?
A. Postural hypotension
B. Mechanical causes
Osteroarthritis
Oesteroporosis.

C. Cardiac causes.
Arrhythmia, DM,

80 years old patient,was admitted to hospital 2 days ago. On

examination, temperature is 34. Discuss management and address
concern with son. (HYPOTHERMIA)

I went to mother house and saw my mother lying down on the floor.

59 years old patient presents with recurrent history of fall. Please

talk to the patient take history and discuss about the your
investigations and diagnosis with the examiner. (Postural
hypotension due to blood pressure)

What happened? Recently, I have a few falls. The last one was yesterday. I
was in shopping centre.
I am taking medication for blood pressure.
How long many years ago.
Have you gone to GP, changed dose and medication colour change.
7 8 weeks ago.

Investigation
- Sitting and standing blood pressure.
- 24 hour BP because patient is taking medication

12
Loss of consciousness(Pilot)
30 years old patient, in front of the park fell down and brought
to the hospital by ambulance. From ambulance notes, LOC for 2
minutes, SHO in A & E department, please talk to the patient
and discuss about your management with the examiner.
Dx head injury

Patient got drunk and fell down.

D/f of fall
D/D for LOC
Findings when you ask what happened? two pints of larger.
Patient fell down and hit the head and hit the floor and after that he
cannot remember anything.
By any chance, did you get any fits or jerky movment?
Any rash or any fever? No fever no rash
Any strange feeling?
Any drowsiness? No doctor.
Vomiting- once.
Any pain no pain.
Heart disease / dm (-) (Arrthymia can cause fall)
GCS 15/15
Pupils are reactive and normal. All motor reflexes are normal. BP 120/ 80
PR 75
Management
From the history the reason for LOC is head injury and then tell the
examiner. I will keep the patient in the hospital for neurological
observation.
I will do CT scan if necessary.

Chronic fatigue syndrome (Real station)

CFS causes long-term fatigue and other symptoms. Fatigue will be at

least 6 months and this tiredness should not improve by tiredness.
- Pain (muscle, joint, headache, sore throat)
- Psychological (sleep disturbance, poor concentration,
forgetfulness, depression)
- Other (hot flash, postural hypotension)
Triggers factor
A. Infection
B. Low exercise
C. Bad diet
D. Stress
E. Depression
F. Social isolation
Management of CFS
A. General management

13
 Manage your sleep.
Manage your rest. Do some relaxation.
Well balance diet
B. Specific treatment.
1. CBT(will talk to you and improve your mood)
2. Graded exercise therapy ( gradually increases the level of
exercise)

47 years old child, tiredness and fatigue in few month. Talk to

the patient and take history only.
What happened? I had a fatigue. 6-7 months.
I m feeling tired all the time. Even if I m sleeping it does not improved.
Could you remember first time you have this symptom.
Go to GP. But did not go away.
What is your job? office job
Do you have many things to do? I cant do these
Did you have to bring job to home? No.
Feeling very guilty. I work with my kids and help them to do homework
and we went out and played and I am just tired .
I am very sorry to hear that.
Pain all over my body. (depression could be one factor)
How is your mood? Mood is fine.
-Anaemia ( lightheadness, heartracing, tiredness)
-Hypothyroid. Constipation, cold intorlarance.
- Any lump and bump.
-chronice condition like CRF and DM
Any medical illness, like kidney, renal problem?

All investion done.. difficult. ( ma may dot bu )

3rd CFS station : 66 years old patient has been referred to the
hospital with history of feeling tired all the time in last few
months. You are SHO in OPD, please talk to the patient and
dicuss about differential with the examiner.
Dx - hypothyroid
1.i have been feeling tired.
How long? In the last 12 month. I feel dizzy and weak.
Feel cold n normal.
Weight very good diet but still I am gaining weight.

47 years old patient present to the hospital with diplopia. You

are SHO in medicine department. Please talk to the patient
and discuss about differential diagnosis with the examiner.
Finding seeing double for objects.
I am a teacher, my right side seen double. A few weeks ago notice
that. Wheni m writing on board right side is double.

14
Few months ago. I was driving and reversing and I was going out from
car park. I was looking at my side mirror the right one and I hit the car
bumper.

GMC4 SHIRT
Giant cell arteritis
Muscle palsy. Myasthenia Gravis. Malignancy. Multiple sclerosis.
Cateract, SOL, hypothyroidism,inflammatory myositis, (inflammation
of orbit muscle) GLASSES, TRAUMA.

20 years old patient presents to the hospital with the sore

throat. Talk to the patient and discuss about your differential
with the examiner.

Sore throat in last 3 days.

Fever +
Too hot did not measure myself.
I did not have running nose. No cough.
Glandular fever rash itchy?
Where on my chest, it went away now.
What else did u have? Swelling in my neck
Recently to rome 5 days ago.
Any upper respiratory tract infection.
Vocal abuse.
Smoking.
Instrumentation.
Tonsillitis (severe pain, redness, swelling)
To diagnose as Glandular fever,
Rash
Fever
Sore throat and lymphadenopathy.
Have u got any medical history?
DD >> URTI, pneumonia, tonsillitis. Instrumentation.

73 years old patient present with musculoskeletal pain. You

are SHO in medicine department. Take history and suggest a
likely diagnosis. (Pilot station)

I have a muscle pain, since when my dear. 6 months ago. Right chest
and right arm. Now it is all over my body. I used to be so active, now I
feel so weak. And I have got difficulty from getting out of bed.
Nowaday , I have to do work in mid afternoon cause I cannot get out
of bed.
I have high cholesterol.
What are you taking for high cholesterol? Statin.
Drug induced due to s tovastatin.

Weakness

15
 60 years old patient present to the hospital with weakness in
her limp. Left arm and left hand. Talk to the patient and
discuss with patient take history and discuss D/d with the
examiner.

Left arm and left hand pain +

Could you please tell me when was the last time?
What happened?
Weakness in my hand.
My husband was with me at my home I have difficulty in talking to
him. he said
A few minutes only and it is gone by itself.
I have numbness and tingling in my arm as well.
When was it 2 weeks ago. While I was doing shopping I have the same
problem.
In bank exactly same thing happened to me. I came back
home with taxi.
Any medical illness- any heart problem? Any blood pressure?
Any family history? Stroke, heart?
Smoking. 1 packet since I was very young

SOL headache?

38 years old patient present to the hospital with palpitation.

You are SHO in medicine department. Take history and discuss
about your differential diagnosis with the examiner.

I have a heart racing.

Do you have any idea do you think you have this heart racing?
It started by itself.
Differential diagnosis.
1.Hyperthyroid.
2.Heart disease. Family heart disease. Have u been diagnosis
3.Pheochromocytoma any headache. Shaking of the hands.
4.Insulin any diabetes or using insulin.
You can ask psychiatric question. How is your mood?

Banker working the bank and stressing.

Coffee, recreational drug.
Dx. I think this patient has palpitation because of coffee.
And I rule out.

GUM clinic
Taking History from GUM
Presenting complaint
Elaborate

16
 (1)Symptoms (fever, burning sensation, joint pain, eye
changes)
(2)Examination findings (genital area redness, ulcer, swelling,
lump, discharge)
Sexual history - Are u in a stable relationship? Are you practising
safe sex? Route /any other partners.
PMH any previous STI, any medical illness, any medication and
any allergy.
Investigation discharge (swab)
Urine Clymadia
Swab Clymadia, gonorrhoea or trichomoniasis
Blood offer such as HIV, HBs Ag. HCV Ab
Treatment Clymadia doxycycline
Azithromycin 1 tab single dose
Advice going to be given
1) If you start medication, please ask the patient. Do not have sexual
intercourse until you finished your treatment.
If patient using single dose, one week after single dose.
2) It is so important to bring your partner and treat your partner is
needed. Your infection will not clean up and you will end up with
many complications.
3) In the future please use condom.
4) It is important to complete your medication. If not you can end up
with many complications.

1.55 years old patient has been refered to you with discharge
from private part. You are SHO in gum clinic, talk to the
patient and discuss with the patient address the patient
concern. (sometimes investion) (h/0 and counselling)
I have got burning sensation. No other symptoms. No ulcer, no redness. I
got the yellowish creamy discharge.
Sexual history I travelled to London two weeks ago and I met a girl we
have un-protective girl with the girl. Oral or vaginal route. No previous
STI.
From what you told me, STI sexual transmitted disease which is an
infection that passed from person to person when they have unprotected
sex. We are going to do some investigation. Urine test and swab from
your discharge.
And we can offer you blood tests if you agree .
Ask about allergy.
It is very important to complete the dose even your symptoms is
resolved. If your condition left untreated. It may cause some serious
complication like narrowing of the tube that connects the bladder to your
penis which can cause obstruction

It may also cause infection in the prostate.

Sometimes it can cause infection around the testis and surrounding
organ.
Did you have any sex after that unprotected sex.

17
Could you pls bring the partner.
Please practise safe sex in the future.

2.24 Year old patient presents to GUM clinic. Vagina swab

has been taken and result shows girl has gonorrhoea.
Patient is using OCP.
I met my bf 3 weeks ago and unprotected sex and discharged. Done
blood test and waiting for blood results.
From what we have done, you have sexual transmitted infection
which we called gonorrhoea. We will give you single dose injection.
Offer patient blood test.
No sex for 1 week and check patient again. And recheck again and if
okay , she can have sex again.
Complications
Pain during sex.
Miscarriage

Please practise safe sex with condom.

50 year old man present to GUM clinic because he had

unprotected . You are SHO in the gum clinic. Please take
sexual history. (please do not advise about HIV) PILOT but
real station phyit naing tal.

I had unprotected sex two weeks ago. I went to Berlin. And had some
sexual activity. Fever, burning sensation, knee pain, eye pain.
Any discharge?
Redness + in the private area.
Any lump in groin area.
Where did you meet your partner? In hotel or red light district.
Route- sexual partner male or female?
No medical history?
I am really worried. Do not worry. We are going to do some tests. And
test.

(Honest husband) 27 years old lady presents to the hospital

because she is worried about STI. Take history only and talk to
the patient.

My husband had sex with someone else last month. Why are you here
now?
The husband told me this morning.
Ask if it was protective or un-protective.
He told me it was protective but he was drunk.
Did you have sex with your husband afterwards? Yes, that is why she
is worried.
Have you been having any discharge? No.

18
 Do you have any other partner or not? He was my only husband.

Epilepsy
21 year old patient present to the hospital two weeks ago
and disgnosed as epilepsy. Was prescribed with
carbamazipine with 400 mg bd. This patient still have some
few fits after starting medication. Please address the patient
concern.

Doctor gave me some medication and still I have fit.

Have you noticed any change in nature of the fits? (the same)
Are you taking irregularly?
Honestly speaking, in first 5 days I took regularly. I had one fits in the
fifth days and after that I took medication and I have got the feeling I
may have fit.
Are you taking regularly? Are you taking as we prescribed? Medication
takes time to build up best effect.

Previously this patient do not take medication regularly because of the

side effects (in previous exam)
Side effect headache and drowsiness.
Are you drinking alcohol?
Diet?
Cinema?
Water intake?
Any stress? Any exam if it is young patient? Anything bothering you?
Working as waiter? Do you have enough sleep?

A girl diagnosed with epilepsy recently moved to new town to

start university. She came to the clinic regarding her condition. I
have this medication will hurt my liver.
Your medication is one of the safest medications. We will check your LFT,
liver function tests. Sodium valproate is safe.
Can I use OC pill? Yes it is safe to use with OC pill.
If you are pregnant, please tell the GP.
You may need to take supplement.
It is advisable to use electric cook in stead of gas cook.
You can talk to your friends about the epilepsy. Wear the bracelet all the
time.
Driving DVLA after stopping medication, one year later, she can drive
again.

26 years old patient presents to the hospital because of the fits.

You are SHO in A& E department. Please talk to the patient and
take relevant history. Discuss about differentials with the
examiner [Real station]

19
In situation like epilepsy, loss of consciousness, who was witness? Who
saw you?
The girlfriend was witness. What happened before? Strange feeling
before event.
What happened? Jerky movement 2 minutes, wet himself, up-rolling of
the eyes.
I have some headache afterwards.
It is not the first time.
Family history yes.

Life style
1. Diet (please have a well balance diet which contain a large amount
of food and vegetable, green food rather than fried food) please
try to have more fish and chicken rather than red meat.
2. Exercise ( to fit physical activity into his or her daily life, we dont
have to go to gym, WHO recommend should have 30 mins walk .
You dont have to run. Use the stairs in stead of lift. Shopping
dont drive. Walk to there.
3. Alcohol (male = 3 unit female = 2unit / 3 times 7 days)
Every shot is 25 ml. every glass of wine 3unit. Shot of whisky 1
unit. Beer is 2unit.
4. Smoking cut down or stop according to the situation. Smoking
cessation clinic.
5. Stress work, wife- you should refer to carrier advisor. New job.

Risk factors for stroke

Non-modifiable age 55, gender, family history and previous history
Modifiable Risk factor life style
Hypertension
DM
High cholesterol
Arrthymia
Kidney diease

Next thing we should think is why we should do rehab after stroke.

Increased the level of activity.
Increased the quality of life.
Physiotherapy
Occupational therapy(access environment and facility if you can
go to job or not)
Speech therapy

20
 Psychotherapy
Special nurses
Any facial problems, arm weakness, speech problem and ask for
ambulance 999.
60 years old patient come to hospital for follow up. This man
had for stroke 4 weeks ago. Left side of limb has weakness.
Assess risk of any further stroke. Discuss about management
and prognosis.

NOTE: all the station of life style modification are history and
counselling station . Take history and give advice immediately
after any item. Immediately advice according to the finding.
It means
Assess risk factor.

Above55 is a risk factor.

Male are more prone to stroke than female.
Dont worry we cannot do anything we can make change to many things.
Do you smoke? Yes doctor. Last 2 years. Immediately advise to stop.
8-10 pints of beer per week. Ask to cut down.
My wife look after me keep that.
Exercise it was so bad when I was discharge. Now becoming better. I
cannot grab a cup before but still sometimes I have some weakness.
Good. My dear, are you going for physiotherapy.
Nope I will refer you to physiotherapy.
Medication
Are you having any medication? I am on cholesterol. So taking statin so
keep taking that.
Other medical condition. Hypertiension taking medicine. So keep
continue.

65 years old patient present to the hospital referred by GP, GP

asked please assess the risk factors of stroke in this patient
SHO in medicine department. Please talk to the patient and
access risk factor.

Few weeks ago, my uncle died of a stroke. Sympathy empathy show.

Granddad died of a stroke as well.
My GP did blood pressure, and awaiting cholesterol is fat in blood. Risk
factor for stroke.
Hopefully you are fine. You have family history of stroke.
You dont have so far. It is good. You are female. Less prone to stroke. 30
cigars a day.
Give advise.
Alcohol. Pls cut down
Diet
Warning signs- FAST
Stress-

21
60 year old patient present to the hospital, Female, 3 weeks ago
have MI. got discharged after admission patient now have
shortness of breath plus ankle swelling. Echo has been done-
left ventricular failure shown. Please talk to the patient and
please advice about medication.

Post MI heart failure- common complication after MI

How can I help you? I had MI 3 weeks ago. I cannot breathe. I have to
put 4 or 5 pillow. Look at my leg. Swollen.
Are you taking your medication? Which medication?
Taking only aspirin
Beta blocker decreased overload.
ACEI
Statin to stabilze the cholesterol
Explain one by one about the importance of the drug.
You should talk all of your medication life long. We gave you some tablet
which strengthen your heart. As I explained to you, it is not strong as
before. Also we gae you some medication to reduce amount of fat in
your blood.
You must take all of the medication life long . You should ask GP to
prescribe.

How to take
Alarm
Tell partaner to remind you
Use medication box.
To conclude. Explain to the patient how important it is to continue. Which
method you can take to remember and

60 year old patient had an MI few weeks ago and angioplasty

has been done. Left coronary artery stent has been place. Obese
patient. Talk to the patient and discuss about life style
modification.

One by one about life style.

Diet you can enjoy the food but it is not that healthy more salt and
more butter so you should make your food at home.
Exercise I cannot because I do not have the time. Fit exercise in day to
day life
Smoking still +so advise.
I am taking full glass of wine every night. You are taking a lot . please cut
down your wine.
1st week after MI short walk
6th to 8th week after MI to do 30 mins walking
you should not have shortness of breath. It is good to be a little bit hot.
When you can go back to work is 2- 3 months after MI
Sex as long as no shortness of breathe

22
Diabetic retinopathy
45 years old patient present to the hospital because known case
of diabetes. Diagnose 12 years ago. Recently some investigation
has been done and this patient is having diabetic retinopathy.
Patient is a smoker, smoking for last 20 years. This patient drink
alcohol. Please talk to the patient.

If patient did not ask, you disclose the condition. What is diabetes
retinopathy. One of the complication of DM is DR. blood vessels will be
damaged. Damaging blood vessels will result in MI , kidney problems
and damaging small blood vessel at the back of your eyes will cause
diabetic retinopathy. First this condition has not gotten any symptoms
yet. After a few year, flashing may come and if you dont control this
may affect your vision. Sometimes the situation may get work
Can you treat DR? will I get blind?
Slower the progess of the disease as long as we can control your blood
sugar. Is it your blood sugar well controlled? Complicance of insulin
advise accordingly
No glucometere. No insulin regularly
Start asking life style question and advise accordingly.
Ask question about diet, alcohol, smoking and accordingly manage 2
mins should be spent.
Follow up eye check up.
Last 12 years diabetic annual check for eye check up.. so you need to
attend. We can check your eye and stop or slower.

50 years old patient present to the hospital with painful and

swelling big toe. He has been diagnosed with gout. Please talk
to the patient and explain the patient condition and talk about
contributing factor and talk about management.
Gout is a condition which cause pain and swelling in your joint. What
causes this joint? Gout is cause by high level of substance called uric
acid in your blood. Sometimes your body produce too much uric acid.
Sometimes ur body cannot pass uric acid. In this case your body collect
uric acid in joint and cause pain.

What is the most important thing for cut down alcohol. What u drink?
Beer, - cut down stop. One of the most im[ortant reason u will have too
much urine acid. Sugary drink is killer . I love coke. sugary drink can
increase too much uric acid. You should not drink.
Tell the patient it is one of the cause of your gout is thiazide.
Steak lover so it is adviseable to cut down red meat.
What are u going to do for me? Swelling put ice under towel and towel
put on joint 20 mins.
Ibuprofen to relieve pain for acute setting.( contraindication asthma
and gastric)
3 question before medication.
Any medication, allergy, any medical condition?

23
Non medical advice has been already done.
Prevention.
Allopurinol it is for acute attack.

32 years old. Procedure turned down after anesthesia

assessment,her bmi is 35 please talk to the patient and advise
accordingly,

We should put you to sleep. Your weight is above the normal . it is

dangerous since it will put you risk. You need to lose weight.
Diet everything at night time, chips
We should break the cycle. Dietician and reduce weight.

55 years old patient present to the hospital planned for lap

chole.
What happened is your collegue done inves for pre op and BP is
160/110 BMI 29. Talk to patient and management of
hypertension. ( Real station)

Ask about smoking.

Diet.
Advise according.
We will try our best but if we couldnt do we will consider medication
(after 4.30 mins)

PILOT 65 years old with type 2 DM and this guy was admitted to
the hospital because of blood sugar was not control. Discharge
the patient with metformin. Talk to the patient about diabetes

Start with diet. healthy but steak

Trouble with my joint
Smoking 50 cigars
Alcohol
To check glucometer and fasting blood sugar.

Will I go blind? You will be fine.

Please go to food clinic regularly

28 years old patient presents to hospital with 3 blood pressure

recorded all of high. ( pilot)

24
25