I.

Manikin
2 minutes Hist – 4 minutes Ex – 2 minutes MGx (only if the question tells it)
Keep the conversation with the person not the manikin.
Verbalize like commentary on every finding you find and you did not find.
I need to look at the paitnet beside the manikin. Not the manikin.

1. Paracetamol overdose and blood sampling

Ms Victoria Jones has taken over dose of some tablets. Take history from her and do the necessary
investigation and then talk to her about the further management.
OD is >24 tablets  NAC immediately, <24 t  wait for 4 hours then do paracetamol blood level:
check the graph  below the limits I will follow up till the consultant discharges /: if above at any
point  I start NAC
A.
1. Dr -Hello Ms Victoria Jones. I am Dr .. one of the junior doctor in the Emergency department. I understand you
took some tablets today, is that right?
Pt - Yes doc. ( If denies - offer confidentiality say – Ms Jones Whatever you say we will keep that
information confidential. We are here to help you).
2. Dr -What did you take ? ---- Pt - Paracetamol tablets. Dr - How may did you take ? - -- Pt - About 40 tab. Dr
- When did you take them –--- Pt - 6 hours ago. (usually >24 tablets and after 4 hours)
3. Dr - Did you take anything else with that like Alcohol, other Medication of rec drugs? – Pt - No.
4. Dr - Did you throw up ( Vomit) after this ? Pt - Yes or no. Dr - Any pain in tummy? Pt - No. |Dr – Any chance
are you pregnant ? Pt - No.
5. Dr - Ms Jones you have taken too much of Paracetamol which can be dangerous to your health as it can damage
your liver and kidneys. We need to do some blood tests on you to check how your liver and kidneys are
functioning as well as the level of Paracetamol in the blood to see if you need any treatment. Is that OK?
Pt – OK

B. Explain the procedure: For the purpose of investigations, I need to draw some blood from your vein. For
that I would introduce a needle in your forearm, you will feel a sharp scratch but I would be as gentle as
possible.
C. Consent: Will that be okay with you?

D. Risk : The procedure can sometimes result in bruising but again it is very
rare, so please do not worry about it:
1. Have you got any pain anywhere in your arms?
2. Have you got any blood disorders that you are aware of?
3. Do you use any medications like, warfarin/blood thinners? etc
4. From which arm, would you like me to take blood?

E. PROCEDURE
1. Clean the tray with wipe you are going to use.
2. Collect the equipment in tray : Tourniquet, Gloves, alcohol wipe, gauze pieces, Vacutainer (Search for the
yellow one. If it is not present there, I search well. IF I did not find anything, I need to ask the examiner about
it), vacutainer holder and vacutainer needle, Sharps bin (yellow -sharps bin are small and if not present, I
need to search for it and if not there, I can ask for it. I need to check it in the first place before checking
anything else, before I wear gloves), Waste bin (but keep both outside the sterile area). Pair of non-sterile
 disposable gloves, Blood request form
 Use yellow cap vacutainer for Paracetamol level, LFT and U&Es. If the examiner say color does not matter
then use any color vacutainer given.
4. I’d like to scrub my hands and wear gloves. (even if they are not there – examiner will say proceed)
5. Check tourniquet (anyone that I am comfortable with - the pink tourniquet: I put the flat part of the tourniquet
on the side of the arm and the button piece on the front... then I stretch it as much as I possible that is when
the opening fits in the button) and place it on the arm. (if sleeves of the patient are long, I need to ask her to
pull it up) – If I used a rubber tourniquet then I need to place it into the medical bin after using it – I will find
pink rubber with a button.
6. Remove the correct end (smaller, white) of the needle and load vacutainer holder with needle. Throw the
cap in clinical waste bin.
Tip: if you open the wrong end of the needle or touch it discard it in the sharps bin and take a new one.
7. Palpate the vein. (above Y junction)
8. Fasten tourniquet.
9. Palpate the vein again.
10. Wipe the alcohol sterets, one stroke only, (circle outward) then discard it in the waste
bin. (I cannot palpate the vein now)
11. I will give alcohol few seconds to dry.
12. Unsheathe the needle (green end) and throw cap in clinical waste bin.
13. Warn the patient before inserting needle “you will feel a sharp scratch”.
14. Stretch the skin (by your thumb) and introduce needle (rest the inserting hand on the patient hand).
Tip: Don’t try to insert the whole needle inside. The moment the resistance has gone, you’re inside the vein
(mostly 2-3 cm).
15. When you get blood, stabilize vacutainer holder with left hand (The not inserting hand – because it will want
to get back) and insert vacutainer one by one for collecting blood samples.
16. Shake the bottle and put it inside the kidney tray.
17. Loosen the tourniquet.
18. Take gauze piece and press on needle and withdraw the needle. Ask the patient to
keep it pressed to attain adequate hemostasis.
19. Discard the vacutainer holder in sharp’s bin with the needle.
20. If I failed:
• If I miss the first time, I throw everything in the sharps bin and say I am sorry I need to do it again.
• If I failed , I said that I’ll get my seniors and will wait results
21. Label the samples (patient’s name, DOB and hospital number, procedure, date and signature) and mention I
will send them to lab along with the blood request form.”
22. Remove the gloves and discard in clinical waste bin.
23. Enquire how the patient feels and thank the patient for his cooperation and ask her to roll down sleeves”
24. Once you take the blood, examiner gives the paracetamol level as 94 mg at 6 hours. (he will aslo give
paracetamol chart) Plot the level on the below chart. 94
mg is above the treatment line at 6 hours. (it is always
above the treatment line)
25. If the patient is close to me, I can show her and explain
what is the chart to her.
26. We will start NAC. If we already started, I am glad that
we already started it. Is it okay? Once you are okay, we
need to refer you to a psychiatry department.
27. She will be upset mostly  sympathy and empathy
 2. Post appendicectomy – IV cannulation
 I can try cannula many times. If failed I can say I will call my seniors. Once I have done the right technique, results
are not so important.
 If there is a chair beside the patient, Do not say or sit till he offer the chair.
 It is very similar to blood sampling.

Mrs Stevens had appendicectomy operation few hours ago. His IV cannula has been blocked.
Take a brief history and do the necessary procedure and talk to the examiner about the further management.
A.
1. Dr: Hello Mrs Stevens I am Dr …one of the junior doctor in the surgical department. How are you doing ?
Pt: I am OK doc
2. Dr: Do you have any problem like pain? Pt: Yes I still have pain over the operation area. Dr: Ok we will
give you some pain killers
The station may be appendectomy (pain over the appendinx wound) or appendix rupture (more dangerous – There will
be pain in tummy all over). Deal with the pain.
3. Dr: Any vomiting - Pt: yes doctor If she says nausea, vomiting, I can give metoclopramide - do not take much
detailed history Dr: Any pain in Calf or Shortness of breath Pt: - No Dr: Any fever? Pt: - No

4. Dr: Mrs Stevens I need to put a cannula to your hand now because the one what you have now is blocked. Then
I can give medications through your vein. Is that Ok (only say cannula is blocked, I need to insert a new cannula.
Do not talk too much about it) Ok doctor

B. Explain procedure: It will be a little uncomfortable and you will feel a sharp scratch but I would be as gentle
as possible. Also, I would need to repeat the procedure again, if I do not get blood in the first attempt.
C. Consent:
1.Are you happy for me to go ahead with this procedure?
2.Are you allergic to anything?
3.Have you got any pain anywhere in your arms?
4.Which arm would you like me to do the procedure on?
D. Complications: This procedure also carries a risk of infection (phlebitis) and swelling (hematoma) but please
do not worry about it, we take great care to prevent this from happening.

A. PROCEDURE
1. ,Wash hands. (Do not wear apron)
2. Clean the tray with wipe you are going to use.
3. Collect equipment in tray:
o 1 Pair of gloves
o Cannula (pink or blue)
o Alcohol sterets
o Gauze piece
o Tegaderm
o Tourniquet
o 2cc syringes filled with normal saline or syringe and saline vial
o Clinical waste bin
o Sharp bin – yellow
4. Make sure sharps bin is close by and open the sharps bin.
5. Check tourniquet and place it on arm. (loose, don’t tie it yet)
6. Check the site and the vein. (below Y junction if the mannequin has Y junction)
7. Wear gloves. Remove cannula from the sheath with no touch technique and place it back in clean tray. Take
out stopper (the white part); place it on clean area facing upwards.
8. Fasten tourniquet. Palpate the vein again.
9. Clean the area with alcohol sterets in one direction with single stroke. Leave it to dry. Discard it into clinical waste
bin. Do not palpate the vein again after that point.
10. Take a three point grip of the cannula, with your thumb on the white cap or the projecting part of the stylet,
index finger on the coloured cap, and middle finger on the wing (hold only the wings). Apply counter-traction
to the overlying skin with your other hand to help anchor the vein during insertion.
11. Before introducing needle you should warn the patient, so say “you will feel a sharp scratch now”.
12. Stretch the skin and insert cannula with bevel end upwards at 30 to 40 degree. Then reduce to a 15° angle to
advance the needle inside the vein.
13. When blood gushes back, change your grip, so the thumb and middle finger are on the white cap to withdraw
the needle about 5 mm to produce the second flashback. Importantly the index finger provides counter-
traction on the wing so that cannula will stay inside and only needle is withdrawn out, but not fully.
14. If no blood gushes/The cannula failed:
• Never recap it
• Throw it in the sharp bin
• Try another cannula
15. With just the index finger remaining in place at the wing, advance the cannula along the vein.
16. Release the tourniquet. Place a gauze between cannula and underlying skin. Press over the vein around the
tip of cannula with the index finger of left hand so that blood does not leak out. Remove the needle and discard
into sharps bin.
17. Position and stabilise the cannula with left thumb. Put the stopper at the end of
cannula.
18. Take 2cc syringe with normal saline (if it is present there) and flush through third
opening (opening in upwards), go slowly, feel for the flow and see for patient’s
comfort and say “I would check any resistance or swelling or reports of pain from the
patient”. Then push all the remaining normal saline in the syringe and close the
opening.
19. Apply tegaderm: mentioning date and time on the tegaderm. Inform the patient
to please not move his arm.
 I remove the outer layer and as I remove I check it is tight
 Then I remove the inner layer
 Do not throw the outer layer into clinical bin. I will say I need to type name,
etc, and place it on the white site of the cannula

A. Information written on a paper on the table

Thank you M. I need to talk to my seniors to discuss painkillers to give you.
Examiner will show you pain chart which shoes  Patient has been prescribed Morphine 5mg every 4 hours.
Last dose given one hour ago.
Talk to the examiner about the further management.
1. Since patient was given morphine just one hour ago I cannot give Morphine for the next 3 hours. Since the
patient has pain now – I will give him Paracetamol -1gm IV (if appending rupture  I will give diclofenac)
and
2. Metoclopramide –10 mg IV for vomiting and also IV fluids – Normal saline. I will give her IV antibiotics
3. Since the patient is complaining of pain in her abdomen. I need to check her NEWs. I will examine her abdomen
and check for any signs of intra-abdominal bleeding. I will check her Haemoglobin for bleeding.

B. Aftercare advice:
1. Inform patient the cannula will be checked and flushed 3 times a day and will be removed after 72 hours.
2. Inform patient to alert staff if:
 The cannula site becomes painful/sore/hot.
 The insertion site looks infected/red/swollen.
 The cannula is knocked
 The dressing is coming loose or is wet
 They feel the cannula is limiting their self-care.

C. IV cannulation Post operation ( ruptured appendix)

2. Stop at 6th minute bell if you did not get the blood.
3. Check on the table for any paper, which may be written – 5 mg Morphine to be given every 4 hours. Last dose
was given one hour ago.
4. Management – talk to the examiner
a. Check NEWS chart – there may be Hypoxia, Check the pulse and blood pressure also.
b. I will give her pain killer – Diclofenac 75mg IV for pain ( if she complains of pain abdomen) since the last dose
of Morphine just given one hour ago.
c. I will give her Cyclizine for vomiting – 50mg IV
d. I will examiner her for any signs of bleeding because she has hypoxia like pallor and abdomen for distension
generalized tenderness.
e. I will do blood tests like FBC, U& Es, Group and cross match and clotting screen
f. I will also examine her chest for any signs of Atelectasis and PE.
g. I will inform my senior about this.

3. Breech (baby presented with leg not head) Antenatal examination

You are FY2 doctor in the OBG department
Mrs Catherine Anderson, 20 years old lady has come to the hospital with gestational amenorrhea of 36
weeks. Midwife suspected breech presentation. Midwife has checked the vitals and they are normal.
Take a brief history, do the examination – confirm the diagnosis and talk to the patient about further
management.
A.
1. Dr: Hello Mrs Catherine Anderson, I am Dr … one of the junior doctors in the OBG department. How are you
doing? Pt: I am OK doctor.
2. Dr: How is your pregnancy? any problem at all ? Pt: No problems  Pregnancy raport
3. Dr: I was told that Midwife has examined you and she was bit concerned about the position of the baby. Is that
right ? Pt: Yes that is right.
4. Dr: How many weeks pregnancy now? Pt: 36 weeks doctor Dr: Do you feel your baby kicking ? Pt: Yes
5. Dr: Did you have any problem before in this pregnancy at all? Pt: No Dr: Were you pregnant before ? Pt:
Yes, twice before.
6. Dr: How are the children now? Pt: They are fine
7. Dr: Was it normal delivery or caesarean section ? Pt: Both were normal delivery
8. Dr: Was there any problems with the position of the babies during delivery in your previous pregnancy?
Pt: No
B. Dr: Mrs Anderson Can I examine your tummy now. This examination involves inspecting and touching your
tummy to feel for the structures and position of baby. The reason it is performed is to ensure yours and your
baby’s wellbeing.
C. Exposure/ position, privacy and Chaperone: “for the sake of examination I would like you to lie down and
undress/get undressed below your breasts (till mid thigh), keeping your underwear on. For which I will ensure
adequate privacy and have a chaperone.”
D. Consent: “can I proceed?” (Verbal consent). Is there any question you would like to ask me or have you got
any concerns? Thank you very much for your cooperation, I will continue the examination on mannequin.
E. Undress/uncover gently/slowly from the down side till below breats (the foot end is not flat – the head/head
end is flat and has a tube with pump). Do not say anything while uncovering the manikin. Only if you cannot
make out which is head or foot end,  Ask the examiner: “Where is the head end?”
Tip: never expose the breast. If examiner didn’t show the head end (he did not answer), undress manikin
gently. If you expose the breast, say sorry and roll down and go back the other side.
F. Inspection:
1. On inspection of abdomen there is a distended abdomen consistent with the days of amenorrhea. (or I can
say: I can see ..
2. I can’t see any cutaneous signs of pregnancy, such as striae gravidarum and linea nigra. (do not say signs of
pregnancy)
3. There are no visible scars, veins peristalsis, bruises; umbilicus seems to be inverted inside.
4. There are no obvious fetal movements.
G. Palpation: Tell the patient not the manikin: Now I am going to touch your abdomen. Is it okay?  Then ask
her if she is tender anywhere on abdomen before touching, and also ask if she feels discomfort or pain to let
me know. Keep your hand fingers close and attached to each other (Even the thumb)
1. Temperature: Warm your hands (back of your hand) and compare temperature with the other side (or
random areas but do not forget to touch umbilicus). “There is no local rise in temperature.”
2. Tenderness: same as temperature (Cover the 9 queadrents in S- shaped --start from any place) but at the
same time look at the patient face. (not the manikin face)
3. Deep palpation: For palpation, start from the middle to up and come back to down. Have consent: Now I am
going to touch more deeper. Is it okay?
 Baby in vertex - or 'head' down position.

1. Assessing the height of the fundus (lower area of 2. Assessing the size of baby and feeling for the
the baby) - seeing how many finger breadths below baby's back and limbs.
the xiphisternum (bottom of the woman’s sternum
bone).

3. Pawlik's grip - the lower part of the uterus is

grasped by the midwife to determine the 4. Pelvic palpation to determine the position of the
presenting part. baby's head.

6. Listen to the baby heartbeats

5. Measuring the height of the fundus which

generally corresponds to the number of weeks of
gestation
Baby in breech position - or 'bottom' down position

5. Assessing the baby's position and size. Feeling

1. Checking the height of the fundus (the highest point for the baby's head, back and limbs.
of the uterus). At 20 weeks this measurement is taken
from the belly button. When the pregnancy is at term
(37-40 weeks), it's taken from the lower end of the
woman's sternum bone (the xiphisternum).

4. Listening to the baby's heartbeat.

3. Using ‘Pawlik's grip’ to check that the baby's
buttocks are in the pelvis.
4. Fundal Grip: Upper pole, hard and globular head
Back of the fetus: (either left or right) One side you will feel irregular structure limbs on the left/right,
The other side you will feel a curved structure - back on the right/left,
5. Pelvic Grip: Lower pole, round and soft buttocks “on the lower pole, I can feel
soft round structure; most likely it is buttock of fetus.” [ in the new exam – it will
be breach presentation – there will not be any engagement]
6. Comment:
a. “on the upper pole, I can feel hard globular structure, most likely it is
head.”
b. “On one side, I can feel irregular structures, most likely the limbs.”
c. “On the other side, I can feel a curved structure, most likely is back of fetus.”
d. “on the lower pole, I can feel soft round structure; most likely it is
buttock of fetus.”
e. That is why I believe that baby is lying in longitudinal direction and the
presntion is breech.
7. Height:
a. Take consent: M anderson Now I would like to measure your tummy to
see how well your baby is growing
 b. Measure the symphysio-fundal height from pubic symphysis (which I need to feel) to the maximum of
the fundus (just belwo the xiphestrnum) passing through the umbilicus with the help of measuring
tape.
c. The measurement in centimeters and should closely match the fetus gestational age in weeks, within
1 or 2 cm, e.g., a pregnant woman's uterus at 22 weeks should measure 20 to 24 cm. (x wk prengnacy
 hight is x+/-2: 36 wk pregnancy  36 cm +/- 2 cm = 34-38 cm)
d. Look at the meter then remove it slowly. Then tell it to the examiner.
e. Fetus is clinically normal/ small/ large of dates
f. If the fundal height is high: Polyhydramnios Multiple pregnancies Wrong date of LMP. Large baby

H. Auscultation:
1. M. I would like to use stethoscope to heat your fetal pulse ..
2. The fetal heart is best heard in the back of the fetus
3. In cephalic or normal fetus, it is on either sides of the umbilicus (below and lateral to umbilicus)
along the back of the fetus.
4. In the GMC manikin, there is actual heart sounds that means you should try to hear any sound on the tummy of
the manikin with the help of the fetal stethoscope provided to you. Wider part of fetal stethoscope should be on
the tummy and smaller part to your ear to listen to the heart of the fetus. Do not have agap between stethoscope
and the patient tummy. Put your ear direct on the stethoscope and take hands off 4-5 seconds.
5. Let the examiner know if you can hear fetal heart sound.  I can hear fetal sounds around the shoulders ( the
upper RT quadrent of patient tummy)
E. Thank the patient and ask her to dress up. (I then cover the manikin without sayin anything)
F.
1. Dr: Mrs Anderson – I think your baby is in a breech position? Do you know anything about it ? Pt: No
Dr: Breech means your baby is lying in a bottom first i.e. bottom of the baby is facing down instead of usual
head first position. Usually by 36 to 37 weeks of pregnancy babies are ready to be born in the head down
position.
2. Pt: Is there any problem with this ?
a. Dr: Unfortunately sometimes this can cause serious problem during delivery because head of the baby can
get caught inside the birth canal and the delivery can be very difficult.
b. Sometimes we may need to use the instruments to deliver the baby if the head gets caught inside the birth
canal.
3. Pt: Why is this happening doctor? (if she panicked I need to let her panic)
Dr: Sometimes it is just a matter of chance but sometimes it may be due to excessive or less fluid in the womb
or the position of the placenta causing this.
4. Pt: What will happen now ?
a. Dr: We need to do ultrasound scan of your tummy to check the type of breech and also we need to check
the size of the baby and the size of your birth canal. We can do several things.
b. Sometimes we may wait for few more days and see whether the baby will turn on its own to the normal
position because most of the times babies do turn to normal position by 37 weeks.
c. Otherwise my seniors may try to change the position to normal position by manually turning the baby by
moving it over the tummy.
d. If that is not possible then we may do caesarean section. If the scan shows it is safe to deliver through the
vagina then we may deliver the baby through vaginal route.
e. However if we decide to deliver through the vagina sometimes we may need to use some instruments to
deliver the head of the baby. Caesarean section is safer than vaginal delivery.
5. My seniors will discuss with you and you can decide which way you can have the delivery. Are you following
me? Pt: Yes doctor
Dr: Any questions ? Pt; No doctor. Thank you very much.

4. Catheter
You are the FY 2 doctor in surgery department.
Mr. Graham Martin a 55 year old male patient presented to the hospital with pain abdomen and unable to
pass urine.
Take brief history
Do the relevant procedure and talk to him about the further management. (it is a station for urine retention
– a urine problem + manikin = cath.
A. A long history
1. Dr : How can I help you. Pt: Doctor I have pain in my tummy --> pain lines Dr : Since when Pt: Since yesterday.
Dr : Where is the pain ? Pt: Lower part of my tummy  I offer pain killers (the examiner will only say proceed.
He won’t ask for details) – I need to look at this area (be bold and look at the patient)
2. Dr : Any other problem other than pain? Pt: I could not pass urine since yesterday it is almost 24 hours now
Dr : I am sorry to hear that.
3. Dr : Did you have this problem before Pt: No
4. Dr : Did you have any problem passing urine before like burning sensation while passing urine Pt: No Dr : Did
you have any surgery recently Pt: No
5. Dr : Were you going to loo more times than usual especially in the night ? Pt: Yes since last few months Dr :
Any dribbling of urine ? Pt: yes
6. Pt: Any fever – Pt: No Dr : Do you have back pain ( for secondaries in the vertebra) ? Pt: No Dr: Weight loss
(for cancer prostate)? No
7. Dr : Did you have any injury to or instrumentation done on urethra Pt: No Dr: Any kidney stones before ? Pt:
No Dr : How is bowel habits - Pt: That is fine.
8. Dr : Are you taking any medications ( opioids, antipsychotics CCB)? - Pt: No Dr: Any medical conditions ( MS,
DM, Parkinson) Pt: No
B. Examination it will be short because no time - I need to examine your tummy and back passage to see
what is causing this problem.
Examiner says – Bladder is distended and prostate is smooth surface and enlarged. Thank you.
C. Management:
1. Dr: Mr Martin, Your urine bladder is enlarged because the urine is collected in the bladder. I think you had
this problem because a gland called Prostate which is present at the base or the urine bladder which surrounds
the urine passage is enlarged and making the urine passage narrow.
2. We need to do further test to see what type of enlargement is this whether it is cancerous or non-cancerous.
On examination it looks like non-cancerous type of enlargement.
3. We need to do some blood tests which is specific for prostate gland and also do the scan for the gland and
take some tissue sample from the gland and treat the condition either with medication or we may need to
some surgery to widen the urine passage. We will keep you in the hospital for all this. Dr: Do you follow me?
4. Pt: Yes what will happen to me now ?
Dr: For now I am going to pass a tube to your urine bladder through the penis and drain the urine out. Take
Consent: would that be okay with you? Pt: OK doctor.
 D. Short history to rule out contraindications: 1.Any injury to the urethra? No 2.Any bleeding from the
urethra? No
E. Exposure / chaperone: For the purpose of this procedure I would like you to get undressed below
your waist please, lie comfortably on your back. I will ensure your privacy and request for a
chaperone.
F. PROCEDURE (MGx and History in this station are more important – the most
important here and time will end with me at sterilization part mostly)
Catheter set is kept open and ready – catheter will be kept inside bag opened at the
top.
1. Wash hands, put on apron, clean the trolley you are going to use with wipe. Ask the
examiner --> May i know if is this sterlie area?
2. Collect equipment.
• Catheter pack: it includes ( drape, forceps, gauze (3 to clean penile opening and 1 to hold penis),
cotton wool, fluid container (empty but It will be labled sterilizer and I
need to verbalize it) , kidney tray “will be thrown into clinical waste if
paper or metal which I need to send to sterlization)
• Cleaning solution
• 2 pairs of sterile gloves (disposal only there –
use the medium size)
• Prefilled syringe with anaesthetic gel
• Catheter ( this comes double packed and
includes a syringe of water to inflate the balloon.
• Urinary bag (I won’t be able to use it
because I won’t be able to reach such step)
• Clinical waste bin
3. Make sure the clinical waste bin is near you before starting
4. Open the catheter pack without touching the contents and place the inner pack on clean surface
5. Wash your hands. Now open the catheter pack by just touching the edges and underside. This creates your sterile
field. Everything in this is sterile and shouldn’t be touched unless you are wearing sterile gloves. Check gauzes if
there is missing I need to tell the examiner.
6. Open the urinary catheter outer packaging and lubricant without touching the contents. Place them carefully in
your sterile field.
7. Open the urinary drainage bag and place it between the patients leg for easy access when
needed.
8. Pour cleaning solution into the container. Open a pair of sterile gloves to the side of your
sterile field.
9. Wash your hands, put on your gloves, take care not to contaminate them by touching
the outside of the gloves with your hands. I really need to scrub my hands thoourouhly
and then wear the gloves .. the examiner will say ok. I then wear gloves.
10. Place the drape over your patient to create a clean area. It should be around the penis .. press it inside between
thighs and pull it inwards.
11. Look and comment on presence of blood on meatus. I can see no blood over the external meatus.
12. One hand ( right ) is now going to be your clean hand, which can be used to pick things out of the sterile field.
The other hand (left ) will be your dirty hand, which will be used to hold the penis using gauze. This hand cannot
enter the sterile field.
13. Retract the prepuce ( if the mannequin has it and only if it is possible to retract, most of the mannequins you
won’t be able to retract it, then you will have to clean over the prepuce) for adequate
exposure of the glans and meatus.
14. Pick up a swab with the help of forceps, dip it in cleaning solution 3 times and clean
the glans from centre to periphery in a circumferential manner with single stroke
counterclock wise – around the tip only. Repeat the procedure to clean area around
glans also. Discard the swab and plastic forceps in clinical waste bin. If it is metal I need to
send it for sterilization latter
15. I then talk to the examiner --> Ideally, I would like to wait for a few seconds for the
sterlizer to dry off.
16. Take the lubricant anesthetic gel and inject it down the urethra after raising the penis a
little bit.
17. Then I talk to the examiner --> I d like to wait for few seconds for the anesthetic gel to work
18. Change your gloves, clean hands in between. No change of gloves here. Remove the outer packaging from
syringe of water, so it is ready to be used, place the kidney tray between the patient’s legs.
19. Explain and cocnent for inserintg catheter.
20. Tear off the tip of the bag covering the catheter. Hold the catheter by the bag in your
clean hand and use your dirty hand to hold the penis (hold the penis tightly to make the
cathther inserted tightly and does not slip backward). Push catheter with no-touch-
technique ( don’t touch catheter or glans with hand nor make the bag touch of the catheter
touch the penis – the rest of the catheter will be in the kidney). Push up to Y junction.
21. Inflate the bulb with distilled water. Inject in about 5ml of it slowly, looking at the
patient’s face. Then inject the rest of distilled water. Give a slight tug to make sure catheter
is properly placed inside. Discard the syringe to clinical waste bin.
22. Replace the retracted prepuce if possible and Discard the shaft holding gauze piece to clinical
bin and hold Y junction with left hand.
23. With the right hand I inflate the catheter with 10 cc saline then pull it backward to check if
it is in the place. Then throw the syringe into the medical waste
24. Connect the urine bag. (You can leave the bag on the floor, place it below the mannequin
level).
25. Tear the drape (to the side and pull it to the side). Discard it to clinical waste bin.
26. Stick the catheter on the thigh with the help of tape. I would like to attach the bag to your thigh using tight strips ..
27. Make sure that the patient is left clean, tidy up equipment (I say to the examiner, would like to clean up the
table and tidy up equipment), Remove gloves and throw it into the clinical waste. explain
the patient that procedure is over and if they have any pain or discomfort with catheter, to
inform the member of staff.
G.
1. Record findings: “I would like to record the volume and color of urine, size of
catheter, and time and date and put my signature”
2. Ask the patient to redress: “ thank the patient and ask him to dress up.”
3. Dr :Urine is drained out now How do you feel. Pt: Much better doctor
4. Pt: How long should I be in the hospital?
Dr : It may take few days to do the tests and also we need to remove the
catheter to see whether you can pass the urine without the catheter [Trial
without catheter (TWOC)] . After that we can discharge you.
5. Pt: How long should I have this catheter ?
Dr : Most probably for few days only until we find the cause of the retention and treat it. Very rare chance that
you need it for long time.
6. Usually, the bill will ring  I am sorry M. I cannot complete the procedure. Examiner would you like me to clean the
place up? (Even if I finish the station) .. Remove the gloves = thanks you to both examiner and the patient -- and run to
the other station
 5. Breast Examination
You are the FY2 doctor in the surgical department.
Mrs .. Moulton 44 year lady presented to the hospital because she is concerned about lump in her breast.
Take history examine the patient and talk to her about the further management.
A. There will be a male wearing breast manikin and he will be sleeping. I am going to talk to the woman not
the patient on the bed..
1. Dr: Hello Mrs… Moulton, Pt: Hello
Dr: I am Dr … one of the junior doctor in the surgical department. How can I help you Mrs Moulton?
2. Pt: Doctor I noticed some lump in my breast. I am really worried doctor. (patient ussually notice one
lump and I willl find 2 lumps on both sides.)
Dr: Mrs Moulton, Do not worry about it because most of the lumps are not any serious condition.
3. Dr: Can you tell me anything more about it please ? Reassuring is very important in this station. 10 -15 seconds
Pt: I noticed it today morning when I was having shower. Dr: Anything more can you tell me about it?
Pt: like what doctor?
4. Dr: Is it painful at all ( mastitis) ? Pt: No Dr: Which side breast is that ? Pt: Right side doctor.
5. Dr: Have you noticed any swelling on the left side ? Pt: No DR: How many lumps have you felt? Pt: One/two
doctor. Dr: Do you have fever ( mastitis) ? Pt: No
6. Dr: Did you notice any discharge ( intra ductal papilloma), or blood discharge ( cancer) from the nipple ? Pt:
No
7. Dr: Do you get your menstrual period now? Pt: Yes / No
8. Dr: If yes - Do you have your menstrual period now ( Fibroadenosis – lumps are felt during the menstrual
period)? Pt: No
9. Dr: Have you noticed any lumps on your arm pits? Pt: No Dr: Have you injured your breast? Pt: No
10. Dr: Are you currently breastfeeding, or have done in the past? Pt: Yes/ No Dr: Did you have any such swellings
in the breast before ? Pt: No
11. Dr: Any of your family members had breast lumps ? Pt: No/ Yes.
12. Mrs Moulton I need to examine your breasts now. Is it okay? Pt : Ok doctor.

B. Examine the breast.

1. Explain the procedure “ while examining, I will be asking you to do some maneuvers and will be looking at
you and touching your breast and arm pits to feel for any lumps. If you feel uncomfortable on any point please
let me know I will stop the examination.”

2. Exposure: Can you please undress above your waist.

I will ensure privacy and have a chaperone with me. Is that OK?
[Position: 3 different position will be used during examination. Sitting, Lying down at 45 degrees and Standing.
Ask for exposure by saying ]
When the examiner says proceed to the couch .. I will find the person on the couch rises up .. And I will start to
examine him ...
Check if the couch is 45 degree -- if the patient is flat (i wont be able to illicit the lamps) I need to make the couch
is 45 .. There is couches which i need to rotate to raise the couch ..
“May I ask you to sit down please.”
*When the patient with the manikin does nto answer or reply or do requests  i need to talk to the female patient.
Patient will go and sit on the edge of couch. Begin examination with Inspection

3. Inspection: all in sitting position, and examine both the breasts at the same time. Do it in 5 different positions,
all sitting (Inspection: I need to look all around the patient .. from every side ( I wont see any lumps or dimblings
in the GMC) -There are 4 positions and in each time I need to move around the patient and in each position I
 tell my comment during my inspection. Do not ever do hand gestures - alwasy keep hand gestures with your
body box - keep elbows beside your body):-
a) Sitting straight, hands on thighs. Ask “Could you please rest your hand on your thighs?
• Both the breasts are symmetrical.
• The level of nipples is on the same line.
• There are no skin changes or any pigmentation.
• I cannot see any obvious lump.
• There is no redness, scar, swelling or sinuses
4. Sitting, hands on sides and bending forward. Ask “Could please place your hands
on your hips/around your waist and lean a bit forward?” Could you please put
your hands around your waist and lean a little bit forward .. ?

I cannot see any lump or swelling becoming obvious on bending forward.

b) Sitting, Inframammary region. Ask “Can you lift your breasts with two fingers?”
There is no eczema or fungal infection in infra-mammary region.
c) Nipples. Ask “Can you squeeze your nipple with your two fingers?” (You (doctor)
must not squeeze). There is no bleeding or discharge expressed from the nipples.
d) Lymph Nodes. Ask “Please raise your hands and put behind the head please?” I
cannot see Axillary fullness or supra clavicular fullness.

5. Palpation:
a) Palpation is in lying position and 45 degree. If it is not 45 degrees ask the examiner.
b) Tell the patient: “Could you please lie down on the couch?”
c) Warn the patient: “I am going to touch your breasts now. If you feel discomfort or
tenderness please let me know.”
d) During palpation you should not poke with fingers. Feel with the fingers kept close
together, providing a flat surface. Never touch the nipple - I touch the 4 quadrants in
every breasat by the back of my hands and compare between. I need to look at the patient
face not the manikin face.
e) Temperature: Warm your hands and check for the local rise of temperature comparing
with the opposite breast of each quadrant and say: “There is no rise in temperature.”
f) Tenderness: Start with the superficial palpation. Do an anti clockwise palpation. Check the patient’s face for
tenderness. “There is no tenderness in superficial palpation.”
g) Deep palpation: Warn the patient: “this time I am going to touch your breast
deeper.” (same as superficial palpation but i do not grap or pinch it)
• Palpate axillary tail of spence. by 2 hands I feel until the
arm pit.
• Check for peri-areolar region for any swelling. By thumb
anti-clockwise but never touch the nipple.
• Then check all the quadrants moving anti-clockwise.
h) If a lump present, describe the lump.(once I find the lump I
comment)
• Site: e.g. upper outer quadrant of right breast
• Size: e.g. 2X2 cms (keep it integers)
• Surface: smooth / irregular
• Consistency: soft / firm / hard
• Margins: well defines/ill defined
• Relation to overlying skin and underlying structures
 • Mobility
• Tenderness
i) After that I ask the patient: Could you exacty point to me where is the lump you felt?
j) Summarise your findings: eg-
“In deep palpation, there is a mass of about 2cm in 2 cm, present in right upper outer quadrant, which is not
tenderness in palpation, not attached to over lying skin, attached to deep structure and it is mobile.”

C. Axillary Lymph nodes:

a) In standing position
b) Inform the patient that: “I will be examining the few nodes or swellings in your
arm pit. Could you stand up for me please? ”
c) For checking patient’s right side, say: “Can you please put your right hand on my
right shoulder? Put your right hand on her right shoulder and examine axilla with
left hand. Examine all groups of Axillary lymph nodes; apical, medial, anterior
d) Ask the patient: “can you please cross your hands in front of you?”
e) Go to the back with permission and examine lateral and posterior lymph nodes.
You can examine both sides together.
f) I say I could not find any masses.

“Ideally I finish my examination by examining supraclavicular lymph nodes. (if examiner wanted me to examine
it  I need to keep hand behind the back very official. I can check it below the clavicle and then above the
clavicle” Thank the patient. “Thank you very much, you can dress up now. ”
If ,any point, the 6 minute bell rang, I just thank the patient .. and shift to management.
D. Talk to the patient:
1. Mrs Moulton, I have found a ( one or two) swelling on your right/left breast. Do you have any idea what it
could be ?
Pt : Is it cancer doctor ?
a. Dr: Mrs Moulton, please do not be worried now because as I already told you before most of the time
lumps in the breast are non cancerous type.
b. Very rarely only they can be cancerous. At this moment we cannot say what exactly it is.
c. We will refer you to the breast specialist. They may do investigations like what we call triple
assessment – that the specialist will examine you and then he may do some tests like Ultra sound scan
( type of gel test what they do on pregnant ladies) or Mammography a type of special X Ray of the
breasts.
d. Thirdly they may do another test where they take a small tissue sample with the needle from the breast.
2. Pt: What is the treatment doctor?
a. Dr: Specialist will tell you depending on the investigation result. Is that OK? Pt : OK.
b. Dr: Once again Mrs please do not be worried too much about it.
------------------------------------------------------------------------------------------------------------
3. Do not give the diagnosis of cancer or fibroadenoma even if you are sure of Fibroadenoma.
4. Breast Examination is the same even if the patient had breast augmentation. Breast lump will be more
prominent if the patient had breast augmentation because the breast implant will be inserted behind the
breast tissue.

6. Earache
Exam question
21 year old Mr …. Presented to the hospital complaining of earache.
Take history, examine the patient and discuss the further management with the patient.
 Hearing loss in otitis media: Slide no 5 (no cone of light - no handle of mallous + completly red)
A.
1. Dr: Hello Mr …. I am Dr…. How can I help you ? Pt: Doctor I am having pain in my ear.
Dr: Can you tell me anything more about it?
Pt: It is there for few days now doctor. I took some pain killers it is not going.
B.
1. Dr: Which ear you have the pain? Pt: Right ear.
2. Dr: Do you have any discharge from that ear? Pt: No
3. Dr: Do you have any fever ? ( Otitis media may or may not have fever) Pt: Yes since the last few days.
4. Dr: Are able to hear in that ear properly ? Pt: Yes Dr: Do you hear any sound or noise in the ear ( tinnitus –
meniere’s disease) Pt: No
5. Dr: Do you feel your head is spinning ( meniere’s disease, labyrinthitis) Pt: No
6. Dr: Do you have any balance problem while walking ( labyrinthitis) Pt: No
7. Dr: Did you have any injury to the ear? Pt: No
8. Dr: Any rashes around the ear or face ( Ramsay hunt syndrome) ? Pt: No
9. Dr: Did you go for swimming recently ( trauma, furunculosis ) Pt: No
10. Dr: Any recent flight travel ( Barotrauma) ? Pt: No
11. Pt: Any headache ( GCA, Meningitis, Migraine ) ? Pt: No
12. Dr: Any problem in the other ear at all? Pt: No
13. Dr: Did you have any problems in the ear before ? Pt: No
14. Dr: Do you have any medical conditions ? Pt: No
15. Dr: Ae you on any medications ? Pt: No
16. Dr: Are you allergic to anything ? Pt : Yes Penicillin
C. Examination:
I need to examine your ear. During the examination I will be coming very close to you and will be touching your
ear, cheek and face.
1. Examine the affected ear first ( In real life, I will examine the healthy ear first but for the purpose of the exam
I will start by the right *the one that ptn told me of coplaint* ear. If I do not remember which ear, I can ask
him clearly what ear that you complain off).
1. Inspection : ( on the patient) 3 areas (pre-auricular - auricular - post auricular area)
- Pre auricular : There are no scars, sinus, discharge , redness, swelling , previous marks of surgery
- Auricular : No swelling, obvious haemotoma, deformity , vesicles, bleeding discharge
- Post Auricular : Same as pre auricular + no mastoid bruises / discolouration.
2. Palpation : ( On the patient) Temperature
a. Temprature: 2 regions in each area (up and down)
b. Superficial = Tenderness -> looking at patient’s face 3 areas (pre-auricular - auricular - post auricular
area)
Now M. I wil press gently .. thumb in periauricualr ,,, thumb and index auricular around the helix .. thumb in
post auricular. While palpating, I need to always ask any pain M. Then I comment by saying no obvious
swelling or tenderness

Right ear examination Left ear examination

 c.Deep palpation = Tragus Test:( if positive – Contraindication to otoscopy). Gently press on the tragus
one time .. and release .. (it is never positive because if it is positive I won’t do the otoscope)

3. Otoscope
a) Since tragus test is negative, I would like to proceed to examine the inside of your ear now with a special
instrument called an Otoscope. (I can rotate the manikin to make the ear I want to examine towards me)
b) Check Instrument - Check the Otoscope working -> rotate it from the bottom, open a button or turn it up and
down. Shine it on my hand.
c) Use the large size speculum. Hold the Otoscope in pen holding position.
1. If the otoscope is complete with a speculeum  I will remove the old speculum , I will ask the examiner
for a new speculum and then throw it into the cilinical speculum (do not throw it before it)
2. If the otoscope is not complete ( no speculum)  I Ask the examiner for a new speculum
d) I kneel on my 2 knees on the floor. I hold it in the right hand, like a pen with the left hand 3 fingers on the skull
.. and 2 figners on the ear (thumb and index) to pull the pinna upwrd and bacward
e) M. May you kindly tilt your head --> Then I tilt his head ...
f) Throw Light on the external auditory canal and look at the slide
g) I start looking --> then I get far form the patient ear .. a little bit back and then comment
h) Comment on:
i. External auditory Canal: No discharge, bleeding, inflammation, wax, FB
ii. Tympanic Membrane: comment on THE SLIDE:
DESCRIPTION OF SLIDE:
Comment on:
- Cone Of Light
- Handle of Melleus
- Umbo
- Annulus
- Pars Flaccida/Pars Tensa (Any Findings In Tympanic Membrane)
SLIDE OF AOM WITHOUT EFFUSION
 I can see the TM which is red, inflamed, congested, edematous and tense There is no air fluid level.
 Cone of light, handle of malleus and umbo cannot be appreciated Annulus can be appreciated.
 Therefore diagnosis is AOM without effusion.

i) Withdraw the instrument, Look at speculum, comment on bleeding, discharge or wax over speculum. Remove
and dispose it in clinical waste bin. (if she told me in the early station to assume that it is a new speculum, i
will say i will throw it into medical bin and i will place it on the table)
j) I then ask him to get him back to the normal positon from tilt .. and thank the patient

4. Ideally, I will do Rinne’s and Weber’s test to check for any hearing loss. (no need to do these test in the exam
as the tuning forks were not kept in the cubicle - I want to do renniw and weeber test but for the puispose of
 exam I will shift to lymph nodes examination is it ok?). Check the hearing with finger clicking sound.
5. Examine the Lymph nodes ( if you have time)
Take his consent to examine from back .. Then i rotate the ptn .. I start palpating all LNs groups.
• Sub mental
• Submandibular
• Pre – auricular
• Post Auricular
• Cervical
• Occipital [ stop the examination by 6 minutes]

b) DIAGNOSIS
Mr… You have infection in the right ear. This could be due to Bacteria type of
bugs. Pt: Ok
c) TREATMENT:
1. We will give you antibiotic called Erythromycin (since the patient allergic to
Penicillin) which you need to take for 5 days.
2. We will also give you some pain killer medication. Usually this condition subsides
in about 5 to 7 days.
3. Pt: Any complications doctors?
Dr: Rarely this can cause infection in the nearby ear area like infection in the bone (mastoiditis) and also infection
of the covering layer of the brain called meningitis.
d) WARNING SIGNS:
1. You can take this medication at home. If the condition is getting worse, or if you develop headache, rashes on the
body – these signs of meningitis - please call the ambulance and come to the hospital.
2. [ No need to do – Rhombergs and Marching test because there is no hearing loss and balance problem].
 7. Hearing Loss – Acoustic neuroma
50 years old Mrs... presented to the hospital complaining of hearing loss for last 3 weeks. Take history, examine
the patient and discuss the further management with the patient.

Hearing loss in acoustic neuroma: Slide no 1- hearing loss for 3 weeks continously .. (in meniier disaese it comes
and goes). Otoscope examination + Rennie and webber test + Balance test (romberg test If I have time) but LN
examination is not very important. It will be normal tympanic membrance

A.
1. Dr: Hello Mr …. I am Dr…. How can I help you ?Pt: Doctor I am losing hearing.
Dr: I am so sorry to hear about that. Can you tell me anything more about it?
Pt: It is there for quite some days now doctor. It is not getting any better.
2. Dr: Which ear are you loosing the hearing from?Pt: Left ear. Dr: Any problem in the right ear ? No
Dr: When did it start? Pt: Almost 3 weeks doctor.
3. Dr: How did it start? Was it sudden or gradual?Pt: (Sudden/gradual?) Dr: Do you have pain in this ear?Pt: No
doctor. Dr: Do you have any fever ?(Otitis Media)Pt: No.
4. Dr: Do you have any discharge from that ear? (Otitis Media)Pt: No.
5. Dr: Do you hear any hissing or ringing sounds in the ear? (Tinnitus - Meniere’s disease/Acoustic Neuroma
)Pt: No.
6. Dr: Have you been feeling dizzy lately? (Meniere’s disease)Pt: Yes doctor.
7. Dr: Do you feel that your head is spinning? (Vertigo - Meniere’s disease)Pt: Yes.
8. Dr: How long do these episodes last? (>20 min in Vertigo - Meniere’s disease)
9. Dr: Do you have any balance problem while walking? (Balance Problems - Meniere’s disease/Acoustic
Neuroma)Pt: (No )
10. Dr: Do you feel any fullness in your ear (Aural Fullness-Meniere's Disease)? No
11. Dr: Have you been feeling any painor numbness on your face? (Acoustic Neuroma)Pt: No
12. Dr: Have you been feeling any headaches lately? (Acoustic Neuroma)Pt: No.
13. Dr: Did you have injury to this ear or head recently? (Trauma)Pt: No.
14. Dr: Were you exposed to any sudden loud noise when it start? (Noise induced)No.
15. Dr: Did you go for swimming recently? ( Trauma) Pt: No.
16. Dr: Any recent flight travel? (Barotraumas) Pt: No.
17. Dr: Did you have any medical conditions in the past ?Pt: No
18. Dr: Are you taking any medications now? Pt: No
19. Dr: Have you received any IV antibiotics or salicylates or diuretics or chemotherapy? (Ototoxic HL)Pt: No.
B. Examination:
Same as above +
1. DESCRIPTION OF SLIDE only if the examiner wants you to Comment on:
a) Cone Of Light
b) Handle of Melleus
c) Umbo
d) Annulus
e) Pars Flaccida/Pars Tensa (Any Findings In Tympanic Membrane)

1
2. SLIDE OF TYMPANIC MEMBRANE (NORMAL)
a) Cone of Light- Directed downwards and anteriorly
b) Handle of Malleus- Antero superior
c) Umbo - Central portion which joins handle with cone of light
rd
d) Upper 1/3 Pars Flaccida
rd
e) Lower 1/3 Pars Tensa
f) Annulus Outer fibrous ring around TM joining TM to surrounding bony

3. Structure
a) Pearly grey in colour, Semi transplantNormal Tissue
b) Can appreciate cone of light in antero inferior quadrant, handle of malleus in antero superior quadrant and
umbo at the junction of cone of light and handle of malleus.
c) Pars flaccida, Pars tensa and annulus appear normal
d) No retraction, no bulging, no air fluid level, no per formation, no bleeding, no discharge, no wax over TM
e) Therefore, is Normal Tympanic Membrane.

C. I will now do Rinne’s and Weber’s test to check for any hearing loss.

Rinne Weber

AC > BC lateralizes to left no lateralization lateralizes to right

Left right left ear right ear both ears left ear right ear

Normal
Sensorineural Sensorineural
⊕ ⊕ Normal Normal
loss Sensorineural loss
loss

Conductive
⊖ ⊕ Normal Combined loss Normal
loss

Conductive
⊕ ⊖ Normal Combined loss Normal
loss

Conductive Conductive
⊖ ⊖ Combined loss Conductive loss Combined loss
loss loss

Combined loss = conductive and sensorineural loss

1. Check tuning fork 512Hz or 256 Hz

2. Rinne’s test:

2
 i. How to do:
1- Explain and consent.
2- i strike the tuning fork with my elbow
3- I place the fork beside the ear --> when voice stops --> i place it back the ear on the bone (mastoid
process ---> he still hears it
ii. Interpretation of tests:
Normal people and snesironeuornal (AC>BC) but conductive hearing loss (BC>AC) ..
AC>BC Rinne’s Positive – Normal or sensori neural deafness
BC>AC Rinne’s Negative – Conductive deafness

3. Then do Weber’s
i. How to do:
1- Explain adn consent
2- Strike on the elbow
3- Place the fork on the forehead .. if it laterlaizes ( heard better in one ear) --> SNHL
ii. Interpretation: CSSO: Conductive Same side. Sensorineural  Opposite side. Conductive: lateralized to
SAME side. Sensorineural: lateralized to OPPOSITE side.
4. Patient will show following results: Rinne's Test: AC>BCWeber's Test: Lateralization to Right Ear.
(Indicating that patient has SNHL in Left Ear.)
b. Examine the Lymph nodes (if you have time otherwise verbalise) as above
c. Do Rhomberg's Test ( only if you have time).
[ stop the examination by 6 minutes]
I want to stand with your feet beside each other (shoulder apart). outstreach your arms and close your eyes.
If there is any imbalance, do not worry i will be beside you. Are you ok M.? Do not hug . hold by toucihng
the back and the shoulders ..

D. Diagnosis:
1. Dr: From the information I have gathered, I suspect you have a problem called Sensorineural Hearing Loss.
This is actually a problem of the inner ear and the nerves that supply this part of the ear. Are you following?
Pt: Yes doctor.
2. Dr: This problem could be due to condition called Acoustic Neuroma. Do you know what it is? Pt: No doctor.
3. Dr: Well, it is a harmless type of growth (tumour) in the brain. This is a non - cancerous type of growth. This
tumour grows on a nerve in the brain near to the ear. It can cause problems with hearing and balance.
4. Pt: Are you sure that I have it doctor?
a) Doctor: This what I am suspecting now. We need to do some tests like MRI scan of the brain to confirm
that.Pt: Okay
b) Dr: Another test is Audiometry. This is a test which will enable precise understanding of the degree of
hearing loss.
5. Pt: Why did I get it doctor? Dr: In most cases, the cause is unknown.
6. Management:
1. Dr: We will refer you to Ear Nose and Throat specialist.
Pt: How are you going to treat me?
a) Dr: If tests show that you have a very small acoustic neuroma, then it does not require any treatment but we
will monitor it closely by regular scans. This is because these growths are very slow-growing and may not
cause any problems for a long time. If it is big then we may do surgery or radiotherapy.

3
b) Dr: Also, for the hearing loss we can give you Hearing aids. Is that OK? Pt: OK [Patient need to inform the
DVLA if they drive]
2. Pt: Will I never get my hearing back?
Dr: I am sorry to tell you that even if the tumour is removed with surgery or destroyed with radiotherapy
unfortunately a degree of hearing loss will be permanent.
3. Dr: Do you have any concerns? Pt: No, you have been very kind. Dr: Thank you

8. Teach a final year medical student about Per Speculum Examination

(TEach = np HX no INV no MX. I just teach the procedure only ..)
A.
1. Introduce yourself to the medical student; build a rapport with him/her. Ask
how his/her studies are going, offer any help with regards to studies.
2. Assess his/her knowledge about Per Speculum Examination, Remember
to make sure that the student is following what you are teaching and
praise the student.
Certainly david ,, i d liek to teach you that: befoe we jump in .. could you
tell me hou much you know about it ..
3. Explain why we do PS examination.
• Bivalve (cusco) speculum is the instrument most commonly used to
inspect the vagina.
• The purpose of the examination is to look at the size and shape of
external and internal reproductive organs.
The external examination will involve:
• Examination of anatomy
• Looking for any lesions, ulcers, discharge or other signs of disease
• Palpation of the abdomen
The internal examination will involve:
• Palpation of the vulva and vaginal walls
• Examination of the cervix
• Assessing the size and position of the uterus.
• Palpating for any adnexal tenderness
• Location of the cervix using the speculum
• Performing any appropriate swabs or smears using the speculum
Preparation and Introduction

4
1. Introduce yourself to Patient – (GRIPS – Greet, Rapport, Introduce and
Identify and Explain Procedure) and wash your hands then wear gloves
2. Ask the patient whether they are experiencing any symptoms and explain
the purpose of the examination
4. Explain that it will involve undressing fully from the lower half and the
examination may be a bit uncomfortable but should not be painful
5. Gain consent and offer a chaperone
6. Before the patient undresses, perform a general examination, looking for
signs of hormonal disorders for example hirsutism and acne
7. Explain to the patient that the position they should be lying in is supine,
with knees bent, heels brought up towards bottom, and then letting legs
fall to either side of the bed (modified lithotomy position). Let the patient
undress in privacy behind the curtain and provide them with a blanket to
maintain their dignity.
8. Prepare trolley and equipment: flexible light source, gloves, lubricating
jelly, speculum.
9. Allow the patient to become comfortable before starting

Inspection
1. Begin with a general abdominal examination
Chair will be infront of the manikin. I tell the student: “I am sorry we do not
have another chair. .. I really do not mind to be standing but i really should be
seated ..”
2. Inspect the external genitalia for hair distribution, swelling, scarring, signs
of infection for example warts or ulcers
3. Ask the patient to cough looking for signs of prolapse.

Speculum Examination
I bring the flexible light source close to me (even if I am gloved) and I might
ask student to help me bring it and focusing on the speculum.
1. Think about the size of the speculum needed and use lubrication
There is rotating speculunm (usually the one) other one with up and down
open and close ..

5
Hold the 2 blades between index and middle finger like cigerate (but do not
tell the student with that) --> to keep it closed with thumb behind the handle
2. Explain to the patient what you are going to do before proceeding
3. Expose the introitus by spreading the labia from below using the index and
middle finger
I keep the labia away gently from outside by the thumb and index finger to
seperate them by th other hand (not the inserting hand)
4. Gently insert the speculum at a 45 degree angle and pointing slightly
downward
I get in with blades vertical then rotate it horizontally (keeping the handl
above) as I am getting in and keep it going as much as it allows me while
and then i open it as much as inside allows me
5. Gently rotate the speculum to a horizontal position and gently open the
blades until the cervix is in view (the blades may not need to be fully
opened)
6. Secure the speculum by turning the thumb nut (the screw - use one finger
to roll the screw by one finger to make it fast ...)
7. Visualise the cervix and vaginal walls for any abnormalities, such as
ectopy, cysts or polyps
Once looked in .. i need to get off the seat .. I then ask the candidate: x
(the student) would you like to have aseat and look inside?
8. Comment on whether the cervical os is open or closed? (parous or
nulliparous)
Do you think it is mutliparous or nullipoorus cervix?
This could be nulliparous --> because the internal os is narrow
it is multiparous --> because the internal os is wide
9. Perform any necessary tests, obtaining samples for culture and cytology
like pap smear. We take the pap smear brush and get into insdie. Trying
not to touch vaginal walls. We do 5 rotations and then get it back.
10. Before I withdraw:
Always tell david .. you see david .. Before removing the speculum I need
to tell the patient .. it is always important to keep the patient informed by
telling her that we are about to complete the procedure .. if she should feel

6
 any pain or discomfort at all she needs to tell you and you should stop
immeditaely
11. Withdraw the speculum slightly to clear the cervix and gently loosen the
speculum to close the blades
Slightly pull the speculum backward 
unscrew it  then I pull it turning it vertical
whil I am keeping the blades closed with my
fingers ..
12. Continue to withdraw whilst rotating the
speculum to 45 degrees, avoiding contact
with the vaginal walls
13. Examine the speculum after you remove for any discharge
14. I then get rid of the speculum:
 I tell the student: It is really important ater I finsish to remember to:
 If the speculum is metal  place it in warm sterile saline and need to
be sterilzed
 If the speculum is plastic  throw it into the medical clinical bin.
15. Tell the patient that you have finished, give a towel to the patient to wipe
herself.

II. Trauma and Emergency

1. CPR
You are the FY2 doctor.
You have organised BLS workshop for medical students.
Teach BLS to the first year medical student and check his understanding.

You: Hello I am Dr … What is your name? Are you the medical student? How are you doing? Do you want to learn
about CPR?
Student: Yes.
You: Do you know anything about CPR.
Student :No
Let me demonstrate on the manikin here. Please watch me and then you can repeat it and show me how you will
do it. Is it OK ?
Student: Ok

1-
You: Let us imagine this is an adult collapsed and lying on the floor.
First of all before you approach near to him – make sure the area is safe to approach. If the patient is not in a safe
area – then you move him to a safe area.

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2-
Then you check the victim for a response.
Gently shake his shoulders and ask loudly: “Are you all right?" If no response.
Turn the victim onto his back.
If the pateint is lying on its side  I need to get him on his back (Turn the manikin to show the student)
Place your hand on his forehead and gently tilt his head back; with your fingertips under the point of the victim's
chin, lift the chin to open the airway.
Head tilt and chin lift only if there are no sings of trauma
If there is any foreign body in the airway remove it carefully without pushing it down to his throat.

3-
Then Look, listen and feel for normal breathing for no more than 10 seconds and check the carotid pulse at
the same time.
Keep your chin near to the patient’s mouth and check chest movement while breathing and listen to his breath
sounds and feel for breathing hitting on your cheeks. Keep two fingers on his carotid pulse.
I can show the student .. the pulse ony my neck how to do it before getting to the manikin
If patient not breathing then you call for help.
If you are in the hospital you can call the cardiac arrest team but if you are outside the hospital call the Ambulance.
 Ask a helper to call if possible otherwise call them yourself
 Stay with the victim when making the call if possible

4-
Send someone to get an AED if available
Then start CPR.
Start with chest compressions
 Kneel by the side of the victim
 Place the heel of one hand in the center of the victim’s chest - which is the lower half of the victim’s sternum.
 Place the heel of your other hand on top of the firsthand
 Interlock the fingers of your hands and ensure that pressure is not applied over the victim’s ribs
When doing chest compressions, I need to not touch with my fingers on the chest ..
 Keep your arms straight, elbow locked
 Do not apply any pressure over the upper abdomen or Xiphisternum.
 Position your shoulders vertically above the victim's chest and press down on the sternum to a depth of 5–6cm
 After each compression, release all the pressure on the chest without losing contact between your hands and the
sternum;
 Repeat at a rate of 100–120 min-1

5-
After 30 compressions open the airway again using head tilt and chin lift and give 2 rescue breaths
In the exam  pick up the facial from a roll  place the facial on the manikin ... I need also to read (this
side up) the white part on the mouth
 Pinch the soft part of the nose closed, using the index finger and thumb of your hand on the forehead
 Allow the mouth to open, but maintain chin lift
Head tild and chin lift ... with the head tilt hand .. close the nose with some fingers ..
 Take a normal breath and place your lips around his mouth, making sure that you have a good seal
Take your mouth tight seal around the patient lips .. then blow very hard .. in 1 second ..
 Blow steadily into the mouth while watching for the chest to rise, taking about 1 second as in normal breathing;
this is an effective rescue breath

8
 Maintaining head tilt and chin lift, take your mouth away from the victim and watch for the chest to fall as air
comes out
Look at the chest --> when it gets back i give the other breath ..
 Take another normal breath and blow into the victim’s mouth once more to achieve a total of two effective
rescue breaths. Do not interrupt compressions by more than 10 seconds to deliver two breaths. Then return your
hands without delay to the correct position on the sternum and give a further 30 chest compressions
Continue with chest compressions and rescue breaths in a ratio of 30:2

6-
Do not interrupt resuscitation until:
 The victim shows signs of life like moving, opening eyes and breathing normally
 The help arrives
 You become exhausted.

You: Did you follow me ? Can you please show me how will you do it. Correct him if he does any mistake.
This is the only teachng station that he will repeat and will repaet wrongly is the CPR station
when he make mistakes --. i say you are almost right david but it is importat to do x

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 10

2. Advanced Trauma and Life Support – Primary Survey (initial assessment

after trauma)
You are the FY 2 doctor in the A& E department. Mr Robinson is a 30 year old man fell from 5 meter
height onto concrete floor from a building while painting the building just about half an hour ago. He was
brought into the hospital A&E Department.
His pulse is 100/min and BP is 90/40.
Do the systematic assessment for trauma. Stop the assessment at 6 th min bell and discuss the further
management with the examiner.
In plab exam --> there will be some injuries ..
1. Greet the examiner.
Tell the examiner – I assume I have taken all Universal precautions (gloves, gown and goggles) and I assume the
Trauma team is with me.
2. Airway (30 second)
Airways are always patent - (if the patient producing incomprehnsible sounds --> airway s patetn)
Patient lying down with collar.
1. Check response. Hello Mr Robinson, I am Dr… one of the junior doctor in the A&E department. I am here
to examine you. Is that OK ?
Patient - OK.
2. Tell the examiner - he is conscious and airway is patent since he is speaking.
3. His neck is already stabilized with collar. I will give him high flow oxygen.
a. If not stabilizied: How to immobilize the head? --> tripple immoblization
1) collar: Slide the collar beneath the head then applying the collar.
2) Head blocks and sand bacgs --> I left the head slightly then place the sand bag below it
3) Then strips one on the forehead and the other on the chin.
4) Now they leave only the collar
b. If the patinet is sitting --> apply the collar then ask him to lie down and then aply the head blocks
c. All major trauma  FFH - Car accident  do neck collar (Assume they have neck injuries) until I
remove it in the secondary survey.
4. I will tell the nurses to connect all the monitors.
5. Mr Robinson – can please tell me what happened?
Pt: I fell from a building while painting.
6. Dr – Do you have any pain anywhere at all?
Pt: Yes I have pain on my legs.
7. Tell the patient about the exposure - Mr Robinson, I need to examine now, for that we need to undress you
by cutting all the clothes. I will ensure privacy and have chaperone with me. Is that OK ?
Pt – OK doctor.
8. Ask the examiner – what shall I do ?
Examiner says – assume he is exposed.
3. Breathing
 keep taking during examiantion of chest :
o I am going to check neck
o I will check chest for deformities .. etc.
o Can you take a deep brreath please?during palaption and auscultation
o You say what you see and you then say what you think is that I can see plastr on the heel i think
this is a bed sore

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 11
1. Inspection – I will check for Breathlessness,
Neck –engorged neck veins, tracheal shift.
Chest – Bruises, open wound, flail chest, asymmetry of movement.
2. Palpation – Expansion is equal
3. Percussion – I will check for hyper resonance or dullness.
4. Auscultation- I will check for absent or diminished breath sounds and muffled heart
sounds.
a) If anything positive give your diagnosis and management.
At the end of the auscultation, I tell my diagnsois and MGX (if no fidnings -> chest is fine)
a. Mgx of Tension pneumthorax: I tell the examiner: I will insert thoracocentesis needle to relieve the
tension pneumothorax  then inform seniors for chest tube insertion
b. Mgx of oprn pneumohtrax: cover the wound with 3 way bandage
c. Mgx of Msv hemothorax: Resuccitate (Give oxygen and fluids)
b) If nothing, I assume the chest is fine.
4. Circulation
Pelvic strapping --> it is like a belt around the pelvis. and then I will refer to orthopedic for external pelvic
fixator and further managment.
If there is no bruises or bleeding aroudn the meautus --> I do the spring test
When I do the spirng test --> Pain (and i keep looing on patient face) --> + spring test
In the exam I need to do spring test
if the spiring test is - --> Go to thigh (fracture of the femur --> Fracture shaft of the femur which causes
bleeding)
Swelling can be there in the exam
Do not check for tendernreess
I need to check for pulses according to the the site of the swelling
I need to check the dorsalis pedis pulse
If no swelling -- i assume there is no fracture in the femur.
1. There are no signs of external bleeding. If there is then MGx Wound  Pressure bandage
Look at the manikin and comment there is no signs of external bleeding
2. I will check for pallor and cold peripheries.
Tachycardia and cold periphires are the most important signs for the hypovolemia.
3. Pulse and BP (either it is mentioned in the task or may be put on the wall as a chart – mention the reading
to the examiner. If it is not seen on the wall or not given in the task then ask the examiner for the vital
signs)
4. I will send the blood testing (FBC, U/E, Group and X-match 4 units, sugar, ABG, clotting screen)
5. I will give him IV Fluids - 2 litres of warm Hartman’s solution.
I should always assume that patient in aTLS are hypovolemic despite the vitals ..
6. Check for internal Bleeding--
Abdomen-: Inspection - bruises, distension, wounds,
Palpation – Tenderness, rigidity, Guarding
Percussion- Flank dullness
Auscultation – Sluggish or absent bowel sounds
Examine abdomin  they can show tenderness in abdomen - Blue colored marks as bruises
a) If signs of intra - abdominal bleeding – I think he has intra - abdominal bleeding, I will resuscitate, inform the
surgeons and shift him to the theatre for urgent laparotomy.
b) If no signs – I assume the abdomen is fine.
Pelvis: Inspection – I will check for bruises, deformity, scrotal or perineal hematoma or blood at the external
urethral meatus.

11
 12
Since there is not any bruises, deformity, scrotal or perineal hematoma or blood at the external urethral meatus,
Then I will do the spring test. - First warn the patient - I will be pressing your hips and if it hurts please let me
know. Gently press on his pelvis either trying to open it or to close it.
a) In the exam if they keep Pelvic fracture as the diagnosis patient will scream with pain.
When I do the spirng test --> Pain (and i keep looing on patient face) --> + spring test
In the exam I need to do spring test
i.Tell the patient - I am sorry to hurt you.
ii.Then tell the examiner - since the patient has pain in pelvis he may be having pelvic fracture, so I will stabilize
the pelvis with pelvic strapping and inform the Orthopaedicians for external pelvic fixator and for
further management.
Pelvic strapping --> it is like a belt around the pelvis. and then I will refer to orthopedic for external pelvic
fixator and further managment.
b) If no signs – Pelvis is fine. if the spiring test is - --> Go to thigh. (fracture of the femur --> Fracture shaft
of the femur which causes bleeding)
Thigh - Inspection – There are no bruises, swelling and deformity
Palpation – I will check distal pulses.
Movement – Do not check.
a) If there is swelling of thigh – I can see swelling of thigh, I will check distal pulse, I think he has fracture femur,
I will resuscitate, apply Thomas splint, and inform Orthopaedicians for further management.
Swelling can be there in the exam. Do not check for tendernreess. I need to check for pulses according to
the the site of the swelling. I need to check the dorsalis pedis pulse
b) If there is no swelling of the thigh – I assume there is no fracture femur both sides.
5. Disability
1. Do the GCS. Use the GCS chart on the wall. GCS may be 15.
In this station, the GCS chart will be pinned on the wall for use

-I this station it is crucial to calculate GCS accurately.

-The difference in real life and examination is that you have to give instruction to the dear simulator which
means that you are requesting him to give you findings.
-Pt will not show any response on insufficient painful stimuli. PLEASE apply painful stimulus on the nailbed of pt
until he shows response by moving his arm (might be withdrawal or localization of pain)
-While applying painful stimulus look at the eyes of pt(sometime pt opens eye and close it immediately. If you
miss that thing your GCS calculation will be wrong.
-GCS chart is available in the exam. Don’t worry about it. The most important thing is that you interpret it
accurately.
-Eye opening response is easy to calculate (that would be 2 or 3 on verbal command or on painful stimuli) ppl
make mistakes in calculation of verbal and motor response. So, I am going to explain these two component.
1. After greeting the examiner
2. Say to examiner: I will take universal precautions before approaching the patient
3. Look silently to the pt and check either eyes are open or not.
- If someobody is alive and eyes are open ... ( i wont ask him to open it)
- If not than say: Hello are you ok? If no response...Tap on both the shoulder gently and ask again
are you ok? No response
4. Now introduce yourself and tell the pt I am here to examine you. (Hello M. … I am here to examine you)
- Sir could you plz open your eyes?
i. If eyes are closed and when you call him, he open his eyes and stays open (like he was
asleep) --> Then it is a spontenous eyes opening.
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 13
ii. If I need to tell him open his eyes more than once, he always close it and opens it only when
i call him (please open your eyes and keep it open) then close it again --> this GCS 3
iii. If the patiant is not responding verbally (verbal stimulus)--> tap the person (before doing
pain) --> if he awaks - --> do your questions.
iv. If no response --> do pain stimulus
- Can you plz tell me your name?
- person (ASk him --> What is your name? or hello M.smith if he says hello -- then he knows his name)
- Can you plz tell me where you are?
i. Orientation *answers right* to the place (If he said hospital in the exam then it means he is
oriented to the place)
ii. Where are you?:
1. - If he tells i am at home/bath/cinema --> confused
2. - if he says Pizza --> Inappropriate
3. - if hs procudes sounsds --> incomprehiblme sounds
4. - no sound at all --> no
- Can you plz tell me what time is now? Time (around/maybe does not mean confused - do not ask
about time –morning/afternoon - Ask him can you tell me is it daytime or nighttime? always
daytime)
- Can you plz raise your arm, leg, take your tongue out?
i. Left your hand?  (Does not need to raise above the shoulder) - (Do not ask him about the
pain)
ii. if he did not I ask him to left his right hand  right leg  left leg ---> if not tell him to stick
out his tongue?
5. If the patiant is not responding verbally (verbal stimulus)--> tap the person (before doing pain) --> if
he awaks - --> do your questions.
If no response --> do pain stimulus
I need to tell the examiner ... "my patient is not showing a response, so I am going to give him pain
on his right index finger and focus to give the pain on the same index you were telling"
Now I am going to apply some pain on your finger plz bear with me (Apply pain on index finger only
and look at the face of pt for eye response if pt has not opened on verbal command. No need to give
pain above the eye. Learn to calculate GCS with single painful stimuli.
o I need to do pain on the nail bed ..
o Pushes my hand away ---> localizing the pain
o Pulls his hand away (at any direction)--> withdraw
o Flexing BOTH his elbows Towads his body --> Flextion
o Extend his whole body (like a mummy) --> Extension
o If I have to give pain to a patient --> do not give them real pain (pretend only give pressure)
o When I am giving the patient pain --> I need to look at his eyes and arms mainly movement (orget
leg movmement to focus) - keep your ears open (if he is producing any sound)
6. Interpret:

Glasgow Coma Scale

Response Scale Score
Spontaneously 4 Points

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 14
To verbal command, speech, or shout. 3 points'
EYE OPENING
RESPONSE (E4) To pain (Not applied to face) 2 points
No response 1 point

Oriented to time, place and person or (Oriented

x 3) 5 points
Confused conversation, but able to answer
questions 4 points
VERBAL Inappropriate response or speech, words
RESPONSE (V5) discernible 3 points
Incomprehensive sound or sound 2 points
No Verbal response 1 point

Obeys commands for movement 6 points

Moves to localised pain or
Purposeful movement to painful stimulus or
Localises pain
5 points
Flexion withdrawal from pain or
MOTOR Normal flexion 4 points
RESPONSE (M6)
Abnormal (spastic) flexion, decorticate posture 3 points
Abnormal extension or
Extensor(Rigid) response or
Decerebate posture or
Extension to pain 2 points
No Motor response or
Flaccid 1 point
Minor Brain Injury = 13-15 points;
Moderate Brain Injury = 9-12 points;
Severe Brain Injury = 3-8 points
1, 2

Eye Opening – 4 points in total

Spontaneous eye opening – 4 points
Eye opening on verbal command – 3 points
Eye opening on pain stimulus – 2 points
No eye opening – 1 point
Verbal Response – 5 points in total Orientated – 5 points
Confused – 4 points
Inappropriate words – 3 points
Incomprehensible words – 2 points
No response – 1 point
Motor Response – 6 points in total
Lift up your arm. Obeys commands – 6 points
Localize to pain – 5 points

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 15
Withdraw from pain – 4 points
Flexes to pain (decorticate) – 3 points
Extends to pain (decerebrate) – 2 points
No response to pain – 1 point

CALCULATE YOUR GCS AND TELL THE EXAMINER LIKE THIS:

Always in the exam, I need to analyze my GCS grading
I give the score for the best response (if he opened hus eyes for verbal and not for pain --> i pick up the best)
Remember the score not the movemnt ,,,
GCS usually i need to do it in 20 seconds .. (it is usually part of the station)
-Best eye opening response is on painful stimuli that is 2
-Best verbal response is incomprehensible sounds that is 2
-Best motor response is withdrawl from the pain that is 4
-So, the GCS of my pt is 8.
I need full exposure for the purpose of examination. I will maintain the privacy of my pt and request for
chaperon.(assume)

7. I will check for head injury signs like swelling laceration and any bruises on head and forehead. Any
bleeding from nose and ears.
8. Check the pupils – pupils are equal in size and reacting to light.
9. I will check the sugar
6. Exposure
1. I will cover him with warm blankets to prevent hypothermia
E: in real life, i will cut clothes  what should I do here ? ask the exmainer
If the examienr said okay assume he is exposed
I just say: I look for ,,, and keep talking
IF any part of the manikin is exposed --> I still say I need to have the patient full exposed and I go comment
Privacy and chaperone: If the paitent is the cosncous  I need to have the cosnent (privacy and chaperon)
from the patient not the manikin nor the examiner. Then I shift to the examienr and ask him what to do now?
I need to meneiont that I cover the patient with blanket to prevent hypothermia.
2. To examine the back  I cannot move the patient.
3. I will tell the nurses to arrange for Chest and Pelvic X Rays.
I need to do this x-rays (must) after 1ry survery and before second survey
7. Tubes: I will insert urinary catheter and Nasogastric tube.
I insert 2 tubes .. NG tube + Catheter (urethro catheter- Suprapubic catheter)
8. Once he is stable I will do secondary survey. Thank the patient and the Examiner.
9. At 6th Min – stop the assessment if you have completed and discuss further management with the examiner.
1. Tell you diagnosis and management – Fracture pelvis, Resuscitation with IV fluids (Rush the fluids
Normal saline or Hartman’s solution – arrange blood transfusion immediately – may be O negative, Pelvis
strapping and inform Orthopedicians for further management.
2. Examiner may show a assessment form – where the patient details are written – what will you write in
this area ?
I will write – fall from 5 metre height onto concrete floor – half hour ago.
Airway – patent
Breathing- Normal
Circulation – No external bleeding
Tender over Pelvic area
Disability – GCS – 15/15
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 16
Diagnosis -? Fracture pelvis
3. Treatment given - Oxygen, IV fluids ( NS)
X Ray – fracture pelvis
Bloods – sent for FBC, U&Es, Group and cross match.

A man was found lying on the pavement. He has been brought into the hospital by the ambulance.

You are the FY2 doctor in the A& E department. Your Consultant and registrars are busy. A&E nurse has
taken the hand over from the Ambulance who brought him in. Nurse is with the patient in the resuscitation
room. She has checked his vitals and inserted IV cannula. She has checked his blood sugar which is 5.7
mmols.

Assess the patient and discuss your findings and the management with the examiner.

A. Greet the examiner and tell him “ I assume I have taken all the universal precautions
Talk to the nurse – Hello I am Dr ..What is your name?
Nurse: I am Sarah Doctor.
Dr: Hello Sarah can you please tell me what happened?
Nurse : We have a 30 year man Mr….met with trauma was found on the pavement by the ambulance
and they brought him in just now.
Dr: Do you know his vitals.
Nurse: Yes his BP is 130/80 and his pulse is 85.

Dr: OK, I can see on the monitor his O2 is 96 %. (Give O2 - if saturation is low). Resp Rate – 18/min. Patient is
already on collar. Sarah – Can you please call the trauma team.

B. Talk to the patient

1. “Hello Mr … , Are you OK” – ( He may make some incomprehensible sounds).
2. Tell the examiner – since he is making sound his airway is patent.
3. He is breathing and respiratory rate is 18/min
4. Dr: Sarah we need to cut all his clothes – do we have scissor ( examiner may say – assume he is exposed)
C. Examine for breathing :
1. He is not breathless, No neck vein engorgement or tracheal shift.
2. Chest examination :
Inspection –I will check for bruises, open wounds any flail segments on the chest.
Palpation : Expansion is equal.
Percussion : No hyper resonance or dullness.
Auscultation: No absent or diminished breath sounds or muffled heart sounds.

I assume the chest is fine.

D. Check for external and internal bleeding: No signs of any external bleeding.
1. Examine the abdomen:
Inspection : No distension, bruises or open wounds.
Palpation – No tenderness and rigidity or guarding.
Percussion – No flank dullness
Auscultation – No absent or sluggish bowel sounds.
I assume the abdomen is fine.

2. Examine the pelvis:

16
 17
I will check the pelvis for bruises, deformity and for any blood in the external urethral meatus.
Do Spring test – if patient did not show signs of tenderness – I assume the pelvis is fine.
3. Examine the thighs:
There are no swellings or deformities on both the thighs. I assume there is no femur fracture.

E. Check conscious level with GCS – patient is responsive to the verbal stimulus.
1. I will check the head for injuries – There are no swellings or lacerations on the head but I can see bruise on
the left side forehead.
2. There are no bleeding or CSF leakage in the ears and nose.
3. Check the pupils with torch – both pupils are equal in size and reacting to light.
4. Dr: Sarah, what is his blood sugar?
Nurse : It is 5.7 mmols doc.

F. Dr: Thank you. Can you please send his blood for group and cross match, FBC and U&E. Can you also ask the
radiographer to do chest and pelvic X Rays.
G. Do quick neurological examination.
1. If conscious level is low can’t do sensory and motor.
2. Bulk appears to be normal in all 4 limbs
3. Tone is normal in all 4 limbs.
4. Reflexes are normal in all 4 limbs including plantar reflex.
5. I will log roll the patient with the help of 3 other people and examine the back for any injuries, any spinal
injuries, I will do per rectal examination.
H. Talk to the examiner –
1. I think he has head injury because he has low conscious level and has bruise on the forehead.
2. I will inform the seniors immediately and start with IV fluids and arrange CT scan of his head.
Patient may need surgery if he has intracranial bleeding.
3. I will insert NG tube and urinary catheter.
4. I will do the secondary survey now.
a. If patient is responding take brief history
b. What happened, when happened, Any pain anywhere? Any medical conditions, Any medications,
Any allergies? When did you eat or drink last?
c. I have already examined his head neck and trunk.
d. I will examine the upper limbs
e. There are no swellings or deformities in the upper limbs. Radial pulse is present both sides.
f. There are no swellings or deformities in the lower limbs. Dorsalis pedis pulse is present both the
sides.
g. I will do neck X ray if there is cervical tenderness. I will remove the collar if there are no signs of
neck injury.I will cover the patient.
h. I did not see any other injuries apart from head injury signs.
5. I will keep monitoring the patient until the trauma team arrives.
6. Thank you Sarah. Thank the examiner.

3. Meningitis examination
25 year old man Mr Edwards came to the hospital c/o headache.
Assess the patient and tell your diagnosis and management to the examiner
A.
1. Greet the examiner.
2. Go to the patient Patient is lying down with hands over the eyes ( covering eyes).
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 18
3. Talk to the patient: Hello Mr Edwards, I am Dr ... one of the junior doctor in the emergency department, I am
here to examine you.
4. I understand you have headache “ Do you want any pain killers” - Pt – Yes doc.{Or Patient may make
incomprehensible sounds only}
5. Dr – Ok I will give you pain killers. Tell the examiner I would like to give pain killers to my patient. What
should I do ? Examiner says – Assume you have given.
6. Ask patient do you feel better.
7. Ask patient why are you covering your eyes. Pt – Doc the lights are too bright I can’t open my eyes. Dr –
Ok don’t worry I will dim the light. Tell the examiner I would to dim the light what should I do ? Examiner
may say – assume or may tell you to dim the light. Tell the patient – the is dim now – can you please open your
eyes – can you please put your hand down ( remove hand from over the yes)

B. Take history if the patient is talking. [ If the patient is making incomprehensible sounds – then you cannot
take history]
1. Dr: How can I help you Mr Edwards ? Pt: I am having Headache doctor.
2. Dr: Since when ? Pt: Since last few hours.
3. Dr: How severe is your headache Can you please rate your pain in the scale of one to ten one being the mildest
and 10 being the most severe pain. 8 out of 10. ( SAH)
4. Dr: Where is the headache ? ( SAH, Migraine) Pt: All over the head,
5. Dr: Do you have any fever? ( Meningitis) Pt: Yes.
6. Dr: Do you have vomiting?( Meningitis, SOL) Pt: No
7. Dr: Do you have any pain in the eye ( glaucoma) ? Pt: No
8. Dr: Did you have any injury to your head recently ? Pt: No
9. Dr: Did you feel weakness in any arms or legs ? (SOL) Pt: No
10. Dr: Did you have headaches like this before ? Pt: No
11. Dr: Are you taking any medications ? Pt: No
12. Dr: Are you allergic to any thing ? Pt: No
13. Dr: Did you come into contact with any one with similar symptoms ? Pt: No

C. Dr: I need to examine you now.

1- Then do the GCS : ( In this station GCS can be anything between 6 to 15. Most of the time it was 9). It will
take 20 seconds.
2- Tell the GCS to the examiner
3- Then check for Meningism signs:-
a. Neck Stiffness:
 Support patient’s head with your fingers at the occiput and flex the head gently until chin touches the chest.
 If neck stiffness is present then neck cannot be passively flexed and you will feel spasm in neck muscles.
b. Brudzinski’s sign: while trying to touch chin to chest, look at the flexion of knees in response to
neck flexion which indicates +ve Brudzinski’s sign.

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c. Kernig’s Sign
 Flex one of patient’s legs at the hip and knee, with your other hand placed over the medial hamstrings.
 Use one hand to extend the knee while the hip is maintained in flexion.
 Kernig’s sign is positive when
a) Extension is resisted by spasm in the hamstring.
b) The other limb may flex at the hip and knee.
c) Complains of pain at the back
d) Bends his head
4- Exposure : - If the GCS is 15 tell the patient – Can you please undress I will ensure privacy and have a
chaperone with me.
If the GCS is low tell the examiner – in real life I will undress him completely – what shall I do here. Examiner
says – assume

5- Look for rash - The check for rashes all over the exposed area including face neck back, arms and legs ( you
can use the pen torch to look for rashes).
If you find any rashes tell the examiner – I will check whether it is blanching or not.
Get a glass and press it on the the rash to see if it is blanching or not  usually not blanching (a sign of
menigococla menitngiits)
If there is rash  it will be not blanching ..
(If there is no rash – say there is no rash over the exposed areas, however I will check all over the body for the
rashes). Cover the patient. *if he is unconscious .. tell the examiner i am going to cover the patient*
6- I need to look into eyes but theeexaminer wont allow me nor the patient becaue of Photophobia
D. Thank the patient. Tell your diagnosis and management to the examiner

Diagnosis – I think he has meningitis( Reasons for diagnosis – He has headache, photophobia, Low
GCS, Neck stiffness, Kernigs sign and Brudzuski sign positive and also has rashes ( if there are any rashes).

Management
Investigations
1) Blood – FBC, U&Es, CRP, Blood culture,
2) CT scan of brain
3) Lumbar Puncture
Treatment
1) Admit
2) Inform seniors

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3) IV antibiotics ( ceftriaxone, vancomycin – according to hospital protocol)
Manage infection
1) Isolate the patient
2) Inform Infection Control team.
3) Trace all close contacts and give prophylactic medication. ( Ciprofloxacin or Rifampicin)

4. SIMMAN-Anaphylaxis due to Blood transfusion/ Antibiotic

Scenario- Middle aged patient had undergone surgery on the abdomen and was given one unit of blood. He
was given an another unit of blood and experienced shortness of breath. (Inside the cubicle, there is a
Simman. He has got a wrist band that stated penicillin allergy. There is a bag of blood that is connected-
transfusion is taking place at the moment. There is also a bag of IV fluid,adrenalne,colloid on the table
nearby.)
Monitor findings - ECG-normal Oxygen- 80-85% BP- Low
A.
S- “Dr, I have shortness of breath”
D- “I am really sorry to hear about that”
S-“Dr, I can’t speak properly. My lips and tongue have swollen up, hands are itchy”
Check the monitor for vitals and tell the fin dings to the examiner.
D – Mr.. Please don’t worry I am going to give you some Oxygen now. You should feel better.
Mention high flow Oxygen( with reservoir bag) to the examiner. Oxygen saturation may increase
Mention to the examiner – I would like to stop the blood transfusion immediately – examiner may say assume).
Tell the examiner : I would like to give
1) 0.5ml ( 500 micrograms) 1:1000 adrenaline (repeat after 5 min if no better)
2) IV fluid ( Normal saline - fluid challenge): Adult - 500 ml
3) Chlorphenamine (IM or slow IV) - 10 mg
4) Hydrocortisone (IM or slow IV) - 200mg
Examiner may say - Assume Doctor.
B.
The blood pressure may return to normal. Patient begins to speak properly
D _ can you please tell me more about what is happening to you ?
“Dr, I had a surgery done on my tummy. Since then, I am having the shortness of breath”
D- “Do you know if any antibiotics was given after the surgery?”
P - Yes ( Which antibiotic do you know) / No
D- “Do you know your blood group?” P- “I am sorry Doctor, I do not know”
D - Are you allergic to any thing you know of before ? P - Penicillin
C. Examination:
Check the wrist band – Band may show allergy to Penicillin
D- “Is it alright if I can examine you? I will ensure privacy and chaperone with me.”
Simman asks you to expose him on your own.
Examination findings- red spots all over the chest and dressing on the abdomen.
Cover the Simman
D. Diagnosis and management
D - From what you have told me and from what I have examined, it seems that you had an serious allergic
reaction what we call anaphylactic reaction. It happens when you are allergic to something. In your case, it could
be due to reaction to the blood transfusion or antibiotics.
I will check your notes as to see what kind of antibiotics were given to you after the surgery. If it belongs to the
penicillin group, then that could explain the symptoms. However, I need to check if there has been any mismatch
of blood as well.
I sincerely apologize for all you have been going through. I will talk to my seniors about this.
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E. Examiner asks about further management
- Blood bag to be sent to the lab for further investigation.
- Patients blood sample for Blood group incompatibility.
- Further investigations – Blood – FBC, U&Es, Creatinine, ABG, Clotting screen, LFT,
- Check for blood in the urine.
- Inform seniors and blood bank immediately. Contact allergy specialist heamatolgist immediately.

III. Examination

1. Visual field examination

You are the FY 2 doctor in the Medical department.
Mr Stephen George 45 year presented to the hospital with bumping into neighbouring objects
while driving and even walking. His wife advised him to go for check up with the doctor. Take a
brief history and do the relevant examination and discuss your findings and further management
plan with the patient.

A.
1. Hello Mr Stephen George, I am Dr.. How can I help you ?
Pt: Doctor, I keep bumping to the neighboring cars when I try to reverse park my car. Also I keep
bumping to the walls on the sides when I walk some times. My wife told me to go for a check up.
2. Dr: Sorry to hear about this. Since when are you having this problem? Pt: This has been happening for the
last few weeks
3. Dr: Do you have any problem in your vision? Pt: I am not sure Do you wear eye glasses? No. Are you
able to read books? Yes
4. Are you able to see the distant objects? Yes Do you have any blurring of vision? No
5. Do you see anything floating in your vision area ? No
6. Do you have any pain in the eye ( glaucoma, optic neuritis) ? No Do you see any coloured halos around the
light ( glaucoma) ? No
7. Do you have any headache ( Stroke, Brian tumour, pituitary tumour) ? No Did you have any injury to the eye
or head ? No
8. Did this happen suddenly ? No doctor
9. Did you feel like a curtain coming down suddenly and blocking your vision ( retinal detachment) ? No
10. Has your night vision different than before ( retinitis pigmentosa) ? No Do you have any weakness in any part
of the body ( stroke) ? No
11. Have noticed any milk discharge from your nipple ( pituitary adenoma) ? No Any vomiting ( brain tumour) ?
No
12. Do you have any medical conditions ? No Are you taking any medications ? No
13. Any of your blood relatives have such problems ( pituitary adenoma) ? No Mr George I need to examine your
eyes and check your vision. Is that OK OK doctor
A. Examination
Explain the procedure: M. this examination will invovle me cmoing close to your eyes .. and shine light into your
eyes ... It also invovles special tests checking .. I Will explain these tests as we move on ..
1. Inspection eyes – Normal Visual acuity – Normal
a. Ask: Before going on, Do you wear glasses? Can you please remove it for me?
b. Look for symmetry – discharge – swelling – redness
Patient will be sitting on the couch:
Be 1 arm distance from the patient shoulders (measure it only by your eyes) = when i bend my knee,
My knee does not touch the knee of the patient.
you look at the patient
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M. can you please focus on the door?
c. Go behind the patient and check for proptosis and ptosis
M. I need to get behind you to examine you, can you please focus on the wall for me please. Can you
please look up without moving your head. I Stand and get back the patient beside him. I cannot
appreciate ptosis. I ask him to look up without moving your head .. (If i am tall I need to sit) I cannot
appreciate proptosis.
d. Nystagmus
For nystagmus: midway between you and the patient. M. Focus on the tip of my finger and follow my
tip of finger without moving yuor head please-
Do not break the movement, Do not comment while you are doing the movement
e. Visual acuity: VA: Snellen or using fingers
 Snellen (if it is present inside the cubicle of the station):
o If the patient is wearing glases, I need to tell him to put on his glasses again.
o Ex can I assume that the distance between M. and snellen chart is 6 meters.
o Can you please read the last line that is clear to your eyes?
o I will verbalize I would like to check color vision using ishhara.
 IF no snellen chart 
o I would like to check vision acuity using snellen chart and color vision using ishhara But for
the purpose of examination, I will check visual acuiry using my fingers.
o Always 1 meter between you and the patient
o Can you cover left eye with left hand? can you tell me how many are these? -- repeate the
same with the right eye
 My comment is: I only say: I can appreciate normal visual acuity (with glasses on if he is wearing
glasses)
2. Reflexes:
a. Light reflex (pupillary reflex):
 M. I will shine again some light on your eyes. I would appreciate if you keep your hands on your
nose bridge.
 Please focus on the wall
 Bringthe light rom outside to inside .. and look at both pubils
b. Accommodation:
 Can you please focus on wall -- you wait 2-3 seconds till his vision is fixed on the wall -- Come
aside and then place your finger in his vision field and ask him to focus on the tip of your finger ..
 I need to look at the patient during bringing my finger close to her eyes.
c. Red reflex:
 I get my fundoscopy (i need to make sure that the patient removed his glasses)
 I change the ophtalscope light till i get full moon yellow light ..
 ... 1 meter check both eyes then check the reflex on both eyes from half a metter
 I need to warn the patient that I will shine light into his eyes ..
 Focus the light - I shine the light on the paitents eyes quickly - focus on his eyes .. Rt eye then the left
eye .. i will see the eye red like cameras .. swich it off
3. Visual field – Finding may be tunnel vision rarely bitemporal hemianopia.
a. Visual fild cannot be done if there is nystagmus or low visual acuity
b. I do peripheral  if no findings  do central visual field. but if it is not normal --> i only verbalize it.
c. )))) Periphery (((((
1. it is either normal - bitemporal - tunnel vision
2. This white pen head .. Close your right eyes .. focus on the tip of my nose .. I will bring it from
outside to inside .. please say yes when you see the tip of the pen tell me when you say it please
3. I will make the pen midway between me and the patient ..
4. When i check the nasal side i change my hands And i tell the patient )and tell him not to change
her hands
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5. in bitemporal: before i change my hands --> the patient will see much latter than me above and
below
6. I move diagnoal to the center ..
7. Tunnel vision: all the 4 sides ..
8. While testing vision field, I need to do it slowly.
d. )))) Central ((((
1. I need to be very very very slow ((that noone can catch I am moving it before)
2. I will start by the tip of the pin (V. thin) fro mthe center of the eye.
3. I need first to confirm the color of the pin with the paitnet
4. I rest my whole arm and elbow on my chest.
5. I then move from the center till it disappears and then appears again
6. I then return back to the point it disappears and move above till it appears.
7. If it takes much time to disappear it will be sctoma and it wil be pittuatry ademona as well.
4. Fundoscopy examiner says normal
B. Diagnosis, Investigations and treatment. (shift to it on 6 minutes alarm)
1. Mr George, after assessment I can see that you are not able to see especially outer part of your vison area. That
is the reason you may be bumping onto the things. This could be due to problem in the brain. I suspect there is
tumour ( growth) in a gland in the brain called Pituitary gland which is located at the base of your brain near
your nasal passages. This gland produces hormones. This gland is pressing on the nerves suppling the eyes.
2. Most likely this a non-cancerous growth. Do you follow me? Yes doctor.
3. We need to do some test to confirm it. We will do some blood tests check the hormones and also MRI scan of
the brain to look for this tumour. Is that OK? Ok doctor.
4. If the tests does show that you have this growth of the Pituitary gland then depending on what type of growth
it is we will treat with either medication or surgery or radiation therapy. Most likely your vision will come back
after the treatment. However, my seniors will come and discuss the mgx with you once we have confirmed the
diagnosis. Any questions ?

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2. Fundoscopy
A.
1. Explain Procedure :
a. I need to examine the back of your eye with a special instrument called opthalmoscope. For that I will be
shining a bright light on your eyes . During the examination I will be coming very close to you and will be
touching your cheek and face. I will be using some dilating drops which might dim or blur your vision;
therefore you are advised not to drive home alone or to sign any important legal documents during the day.
Are you comfortable with that?
2. Exposure / Position : You can blink normally during the procedure but don't move your head and sit
comfortably . I will be dimming the lights of the room and you should fix your vision at a distant object .
3. Check Instruments
4. Check power of lens.
5. Check light - BIG FULL MOON
6. Inspection - coming at eye level I bend down on my knees to be on the same level of the minikin eyes and
shine the light on the manikin
a. Both Eyes are at same level
b. No Ptosis
c. No signs of inflammation
d. Orbit and appendages are normal
7. Once I finish it, I shift to red reflex Do a Red Reflex - same level as the eye. Look through the fundoscope
for Red Reflex (seen in normal eye and it means media is clear) I can appreciate red reflex on my patient.
Media is clear therefore I proceed to Fundoscopy.
8. In real patient I would have examined with Fundoscope light on but in exam since there is a
bright light shining from back I may have reflection or glare so I would like to examine now
with Fundoscope light switched off . (speaking to the examiner) – turn off the light I f the examiner said yes
9. Mr anderson , can i place my hand on iyopr forehead to support ( but be careful to not press the button above)
(Ask the lady not the manikiin)
10. Do the procedure , approach at an angle of 30-450., and follow the red reflex .
a. Right eye of patient Left eye of patient
b. Right eye of examiner Left eye of examiner
c. Right hand of examiner Left hand of examiner
"The funduscopy kisses my eyes and barely touch the patient.."
"Do not left the mnaikin form its place or bend it..."
Put the fundoscopy on the table then I verbalize my findings to the examiner.

11. Description of Slide Comment on:

a. Optic disc Colour (2) Margins (3) Contour (4) Cup disc ration {CD Ratio }
b. Origin of Blood Vessels: shape of vessel and calibre of vessels.
c. Periphery and Rest of Retina
d. Macula
B.
1. NORMAL FUNDUS
a) Optic disc – Always nasal

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b) Colour - Pinkish pale or pinkish yellow
c) Margins – Well defined
d) Circular or Rounded in Contour
e) Cup disc Ratio - 0.3 -0.5
f) Blood Vessels -Originating from Optic disc, straight not tortuous
normal caliber of vessels-A :V2:3
g) Periphery and rest of retina - Healthy and Normal - no
exudates, no hemorrhage
h) Macula - Healthy and Normal
2. SLIDE OF NORMAL FUNDUS: SLIDE 9
a) I can see the OD, pinkish pale or pink yellow in colour, well-
defined margins, circular in contour CD ratio is normal.
b) Vessels are originating from the OD, Straight not tortuous, normal in caliber.
Periphery and rest of retina and macula appears healthy and normal.
c) Therefore, my diagnosis is NORMAL FUNDUS.

3. Sudden loss of vision ( GCA and fundoscopy)

You are the FY 2 doctor in the Medical department.
59 year old Mrs Jane Anderson presented to the hospital sudden loss of vision.
Take a detailed history from her and do the necessary examination and talk to her about the
further management.
Questions
1) When happened?
2) One eye or both eye? – which eye
3) Can you still see something with that eye or you can't see anything at all? = can you appreciate
something?
4) Has it lasted only for short time or you still have the problem?
5) Painful - Glaucoma, Optic neuritis
6) Headache - GCA ( combing hair, jaw claudication), Ocular migraine (wavy vision)
7) Medications? Cialis, Viagra, and Levitra.
8) Loss of speech and loss of feeling one side of body for short time (Amaurosis fugax)
9) Curtain coming in front of the eye ( Retinal detachment)
10) Blurry vision or the presence of spots in your visual field (Vitreous Heamorrhage)
11) Brain tumour, Stroke ( rare causes)

1. Take brief history as above.

a. Patient gives history of pain on head while combing hair and pain in jaw while chewing.
b. Sudden loss of vision left eye only
2. Candidates should say I need to examine your eyes
Mrs , After what we spoken , i would like to examine at your eyes now,
a. Do red reflex and fundoscopy on manikin
b. Fundoscopy slides were normal both the eyes.
3. Talk to the patient: You have condition called GCA - explain the diagnosis. This condition has affected
the eyes that is why you are having blindness. Serious life condition - autoimmune conditon (as IBD)
- Causing some symotoms ..
4. Investigations:  HOwever to confirm dagnsois .. Temporal artery biopsy -> My sneiors will take
small tissue sample and send it to the lab. However, we do not wait for results, we already have vision
loss we want to protect the other eye.

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5. Treat with high dose steroid to prevent blindness of other eye. Then investigation to confirm. Then
long term treatment with low dose steroid. IV steriods/prednsisolone for 3 days then start the patient
on tappering doses of oral steroid for 2 years once confirmed the diagnosis (in HDK station --> start
oral steroids/predinsolone)
Is the blindness permanent ? - unfortunately yes.

4. Diabetic foot examination

You are the FY 2 doctor in the Medical department.
45 year old Mr Henry Rickman is a known Diabetic patient on diet control diabetes came to the hospital for
routine follow up.
Take a brief history and do the necessary examination and talk to him about the further management.
A.
1. Hello Mr Henry Rickman I am Dr … one of the junior doctor in the medical department. How are you doing ?
Pt: I am fine doctor.
2. Dr: I understand you have diabetes ? How is your diabetes now – are you monitoring your sugar regularly? Is
it controlled well? Pt: I am monitoring the sugar. It is controlled well.
3. Dr: Are you taking any medications for diabetes? Pt: No
4. Dr: Do you have any concerns ?
Pt: My friend has diabetes and doctors have amputated his toes. I am worried whether I too will end up having
the same problem.
Dr: Mr Rickman, Don’t’ worry everyone who has diabetes will not end up having their toes amputated. These
things happens only if the sugar is not controlled well for long time. If you control your sugar well and take
care of your foot this problem will not happen.
5. Dr: Can I ask few questions to see whether the diabetes has affected any organs or your legs ? Pt: Yes doctor.
6. Dr: [Eye] Do you have blurry vision or any other problem with your vision? Pt : No Dr: [Kidney] Do you pass
more urine than normal – do you have to go to loo more times than usual recently ? Pt: No
7. Dr: [ Heart] Any chest pain or palpitation Shortness of breath? Pt – No Dr: [ Nerve] – Any tingling or
numbness in the hands or legs ? Pt – No Dr: Do you have any pain in your legs ? Pt - No
8. Dr: Any pain in your calf muscles after walking for some time? Pt – No
9. Dr : Do you have any other medical conditions like high blood pressure ? Pt – No Dr- Have you checked
your cholesterol recently ? Pt - No
10. D: Do you smoke ? Pt- No / Yes
B. Dr: Mr Rickman I need to examine your legs. Could you please undress below your mid-thigh area. .
Explain and consent. (if she/he are wearing short dresses  I can say I can see you are ideally exposed
thank you )Pt: Ok
1. Inspection of the legs
a) There is no Swelling, Redness, Pallor, Muscle wasting. MRDSSS (muslce wasting - redness - deformity -
sinus, scars and swellings)
b) Check for loss of hair (I will see it as foundation cream and shaved- usually I will see it on the shin or the foot
 I can appreciate patch of hair loss at x), shiny skin, nail changes (I will see always normal) and fungal
infections between the web spaces of toes (I need to spread between toes (all toes then comment). I will see
it as green marker. I can apreciate some skin changes between the x and y toes in the foot which I suspect as
fungal infections)
c) Check the heels for pressure sores by lifting the legs. (To check it I need to left the leg a little bit and bend to
see changes. Only comment after lefting the 2 legs. I can apreciate some skin changes in the pressure areas in
the foot which I suspect as pressure sores).
2. Palpation –.
a. Rub your hands and tell him I am just warming hands
b. Temperature both legs
i. Touch both siades at the same time ... go for 5 points ( foot - ankle - mid shin - shin - knee) do
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it like 5 touches not continous one
ii. once you finish the knee--> remove hands and comment.
iii. – normal [ cool (e.g. PVD) / hot (e.g. cellulitis)]
c. Calf muscles: Explain and consent ( use the word squeeze) -- Let both legs and squeeze the calf muscles
d. Dorsalis pedis artery – lateral to extensor hallucis longus tendon
e. Posterior tibial artery – posterior and inferior to medial malleolus *i only
check it if cannot feel dorsais pedis*
3. Sensation –
Do not move the tools to the patient couch
a. Fine touch with cotton wool (and monofilament)–
i. This is a cotton . i would like to show you how it would feel on your leg.. Where would you be
comfortable (FOREHEAD or CHEST)
ii. Touch his forehead or chest  can yo feel it. yes. that is what it feels M. if she says chest -> rub it
on the manibrium sterni
iii. Would you please close your eyes and tell me when you feel the cotton?
iv. Once he closes his eyes  touch the 5 areas in the same leg (Distal to proximal) WHILE KEEPING
QUIET - if he said yes at any zone  (usually above knee, i do not comment)
v. After I finish the 2 legs .. I throw the cotton into medical waste and then comment --> I can see that
my patient has lost fine sensations below knee
vi. Repeat with the filament (like the cotton) --> but say that is what it feels on your soles not the foot
vii. touch his forehead --> put pressure on the filament till it bend .. like l=shaped
on the skin
viii. I will touch the middle of the big toe - then i will touch base of each toe
ix. Then i will be threw into the medication bin.
x. I will comment --> lost fine snesations on the sole
b. Pain with neuropin – throw into sharp bin.
i. Pain (Neuropin and i need to check sharps bin before usng it) -
ii. I ask the examiner: which side of the neuropin i am going to use? we use the blunt end of the
neuropin
iii. If the blunt end is removed/neuropin falls on the floor  i remove it
into sharp bin
iv. I check the 5 regions
v. $$$$$$$$$ Usually station ends here $$$$$$$$$$$$$$ If alarm 6
minutes end here  i verbalize all the rest
c. Vibration (I use 128 tuning fork which give me th best frequency on the limbs)
i. Show him how it feels -
ii. Please tell me yes when you feel it ..
iii. I touch the bone at the base of the first toe - then on the medial malleolus
- then on the shin - then on the patella
iv. I strike it each time.
v. If he feels it at any level ,, i will stop here ( i do not need to go above)
d. Joint position sense
i. position: I will do big toe --> ankle --> knee
ii. Show him first with eyes open (in the knee when the leg is close to you it is down when it is far
away it is up)
iii. then Close your eyes - move the toe up then down
iv. proprioception is intact
e. Comment if there is any sensory loss and if there is sensory loss up to what level ?
4. Motor – Check the knee and ankle reflexes
 Ankle reflex: flext the knee  Put a finger on achilis tendon and then do one tap with the hammer
 Knee reflex: Can you bend your leg a little bit for me please  you left leg (not thigh) and you hold it by
one hand and then hit it by the other hand.
5. Check the gait (normally i do not reach that step but if i examiner pushed me it will be for a finding there)
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Observe the patient walking whilst assessing:
 Ask the patient to get up and dress up .. Can you take few steps for me?
 Can you turn and walk back?
 Comment:
o Symmetry / balance
o Turning – quick / slow / staggered
o Abnormalities – broad based gait / foot drop / antalgia
6. Examine footwear:
 M. would you mind me take a quick look at your shoes?
 I need to take the shoes, left it and check its soles (is it metal or hard)
 Note pattern of wear on soles – asymmetrical wearing – gait abnormality
 Ensure the shoes are the correct size for the patient
 Note holes and material inside the shoes that could cause foot injury
7. Findings – usually there will be loss of sensation either below mid shin or below the knee.
[Stop the examination at 6th minute bell if you have at least finished the sensory part of fine
touch and pain – if not finish sensory]

C. Management:
1. Diagnosis : Mr Rickman, you have loss of sensation on your legs. This is because the diabetes has had affected
the nerves supplying the legs. Do you follow me?
Pt: Yes doctor.
2. Investigations –
We need to do blood test to check your sugar control (Hg A1c )
We also need to check your cholesterol, kidney function tests and liver function tests. Do not say Nerve conduction
(only in alcoholic)
3. Treatment
a) We may need to start you on medications to control your sugar. I will discuss this with my seniors and let you
know.
b) It is very important to control your sugar properly. Eat healthy balanced diet. Check your sugar regularly.
c) It is very important to take care of your feet.
 Avoid going barefoot, test water temperature before stepping into a bath.

 Trim toe nails to shape of the toe; remove sharp edges.

 Wash and check feet daily for any injuries or infections.
d) Stop smoking because it can worsen the condition if he is a smoker. 5.Do regular exercises.
Unfortunately the sensations what you have lost in your legs may not come back. However we can stop it from
getting worse if you follow all our advise.
e) We do not talk about alcohol (since his alcohol consumption is reasonable)
Thank you very much.

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 5. Alcoholic foot Examination
You are the FY 2 doctor in the medical department.
50 year old lady Mrs Sarah Boyer presented with burning sensation on feet. She is chronic alcoholic. She
was on alcoholic rehabilitation programme 5 years ago. Take focussed history, do the relevant examination
and discuss the management with her.
A.
1. Hello Mrs Sarah Boyer I am Dr … one of the junior doctor in the medical department. How are you doing ?
Pt : I am Ok
2. Dr: How can I help you Mrs Boyer ? Pt: I am having burning sensation in my feet.
3. Dr: Since when are you having this problem? Pt: Since the last few weeks. Dr: Do you have burning sensation
in hands also? Pt: No
4. Dr: Are you able to walk properly? Pt: Yes
5. Dr: Any tingling numbness in hands and feet ? Pt: No Dr: Do you have any medical conditions ? Pt: No
6. Dr: Like - Diabetes, High blood pressure ? High cholesterol? Kidney or Thyroid disease? Pt - No
7. Dr: Do you smoke ? ( can cause PVD) Pt: No / Yes Dr: Do you drink alcohol ? Pt: Yes
8. Dr: What do you drink ? How much ? how long ? Pt – I drink …
9. Dr: Have tried to cut down drinking alcohol? Pt: I tried 5 years ago. I was in the rehabilitation program for
that.
10. Dr: How is tour diet – do you eat healthy diet fruits and vegetables in your diet ? ( vitamin deficiency) ? Pt:
Yes
11. Dr: Are you taking any medications ? Pt : No
12. Dr: Mrs Boyer I need to examine your kegs now. Can you please undress below your mid-thigh area. Pt: Ok
doctor.

B. Examination: Same as diabetic foot examination. [Stop examination at 6th Minute bell ].

C. Management
1. Mrs Boyer, I think you have a condition what we call as Alcoholic neuropathy – that is alcohol has affected the
nerves in your legs.
2. If you are okay with it, Can I ask you to/Would you be comfortable with consider cutting drinking alcohol? The
reason for me asking that I do beleive that your drinking habit caused your sensation loss. If she refuses becuase
of old experience? (YOu do not have time to explore her worries and bad old expeirence)
3. We will do some tests to check whether you have any other causes – like diabetes and blood circulatory
problems. Also we will do some nerve conduction tests.

Treatment – unfortunately there is no cure for this condition.

 However we can give you some medications to relive your pain like amitriptyline,
 carbamazepine, gabapentin.
 We will give you some vitamin tablets.
 You must cut down drinking alcohol to prevent progression of this condition. Also eat healthy diet.

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 6. Knee examination
Teach the medical student about Knee Examination. Do not tell the medical student to examine the
patient after teaching.

1. David will be very active -- > do not forget to GRIPS. I do GTIPS with david not the patient.
1. Dr: Hello I am Dr …. How are you doing today David? Student: I am doing fine. How are you?
2. Dr: I am good too how are your studies going? Student: They are going alright. I actually need your help
regarding examination of Mr Smith’s knee.
3. Dr: Yes sure I will help you. It’s a very good thing that you are keen to learn. Do you have any prior knowledge
about the topic? Student: No.
4. Dr: That’s alright David, I will tell you. Now if you don’t understand anything just tell me. I will try to explain it
in a better way. Is that alright? Student: Okay.
5. Dr: So first of all whenever you are about to examine any patient you need to first identify and take consent
from the patient. Have you taken consent from the patient? Student: Yes/ No
Tell him what you are going to do (Take the consent form M. x --- Take history -- Explain the examination --
then go to M x). If he told you I already took the consent then thank him and tell him you made my job easier.
6. Dr: Okay I will show you. Lets start.
2.
7. Dr: Hello I am Dr … I am one of the junior doctors in the department. He is david he is a medical student. How
may I call you? (I introduce him to the patient as my colleague doctor David.)
Pt: You can call me Mr Smith
If the question says history, do it (if not do not do it) and it is a trauma history usually (if he does not know, i will
do full knee hisotry). But if there is no history, ask the foloowing 2/3 questions:
M. Can you please tell me What happened?
Are you able to walk?
(Which knee? if he did not mention)
Then I need to address david: This is how we take history david,
V.IMP keep talking to david and the patient (the only patient with student and the patient)
8. Dr: okay Mr Smith how are you doing today? Pt: I am doing alright. I just have some pain in my knee.
9. Dr: oh I am really sorry about that. Dr: May I please know which side is it? Pt: lt or Rt.
10. Would that be alright if we examine your knee joint? we will try to be as gentle as possible. Pt: Yes its fine.
I am here to examine your knee. (I adress the patient by me not we)
 I am going to do some special tests that may ilicit some pain, we cannot give pain killers because we
might miss some injuries +++++ are you comfortable with to bear with us till we fnish the examination
and then give you pain killer?
 (((( if he asked any pain killer aat any step? I am sorry that i cannot give you, we can stop for few
moments before we proceed. is it okay with you))
 Return back to david --> that is how you explain the examination and take consent , Am I clear?
 M. Goerge, Since David is very keen on learning the knee examination, would you be comfortable to
explain it to david as I do my test on you? Thank you.
 Turn back to David, DAvid in case something is not clear, let me know i will explain it to you (not to
repeat it) because the test may illicit pain on m. george so, you miht do it next time with senior
supervision.

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  I need to examine the normal knee then shift to the diseased knee. but for the pusporse of the exam i
will examine the right knee only.
11. This examination involves inspecting your knee joint, touching it and performing few movements. (talk to
student : So after the consent David, we just explained our purpose of examination, next we need to ask about
the exposure)
12. Exposure: Dr: For the purpose of this examination I would like you to get undressed below your waist please
but you can remain in you briefs.I will ensure your privacy and request for a chaperone. Mr Smith: okay.
1. (talk to David) Sometimes patient is in the bed and knees are already exposed, in that case don't ask for
exposure but say, thank you for adequate exposure.
2. Check student understanding also by asking him to perform few tests like drawer’s test
3. Position: Standing and lying flat. (Sometimes in exam, examiner might not allow you to make patient stand. In
that case, do everything in lying position only but don’t comment on level of joints)
4. Inspection:
1. Line UP: Axis and Gait
• Ask patient to stand up. ( most of examiners tell you do not make my patient stand up = no axis nor gait)
• Make patient stand in anatomical position with arms tucked in by sides, feet together and palms facing towards
you.
• M. Goerge can you please stand straight with your palms facing me (and show him)?
• If M. can stand it --> then I can say ASIS knee and medial malleoulus are on the same line.
• Then I say to him to walk few steps for me. --> usually i will find antalgic gait (limbing)
o Ask patient to take a few steps. Observe the gait and comment on either normal
(smooth & symmetrical) or antalgic (limp to avoid pain) gait.
• IF Patient is not standing striaght --> I ask him again to stand straight
• if he cannt and says his knee is hurting --> Isay i am sorry M. , please get back to the
couchand you can lie down (AND DO NOT comment on the line up)
• I verablize my indings --> Tell david --> AS you can see..
• Ask patient to lie down on couch which must be flat.
2. MRDSSS (no) + " Muslce wasting + Redness or erythema + D stands for deformity +
sinuses, cares"
I go to back and bend below behin the knees *or* if he s lying down I raise his leg and bend to see what is behing
the knee --> and say i cannot appreciate politeal fullness (I see it from the back - and it is mostly NO)
5. Palpation:
a) Warm up your hands (warm back hand with one hand and then the other)
b) Temperature: Assess temp, compare on both sides.
a. Touch also the back of knee and mid of thigh
b. Turn to David and tell him that is how we check the temparatue of the affected knee --> Is it clear
David?
c. I cannot appreciate ...
c) Pulsations (first)  like before ..
d) Tenderness: Joint lines: Ask patient to flex knee slightly. Feel both tibial and femoral joint lines and look for
any tenderness. Palpate above (Quadriceps tendon) & below (Patellar tendon) patella and look for
tenderness.
a. Look at patient’s face for tenderness.
b. Can you bend your leg a little bit or me (90 degree)?

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 c. Hold your grip around the knee with thumbs over the quadricpes tendons. The middle or index
fingers are in the popliteal fossa. (Tell David all of that )
d. Start pressing with the thumb on the latteral side (do not ask every time) after you finish the lateral
side by reaching the patellar tendon --> i ask does it hurt you
e. Start pressing on the medial side --
f. IF he has tenderness and dAvid asks to repeat it again 0--> i ask M. George --> Would it be okay to
repeat it again> -> i he agreed, I will repeat it again and repeat explaining it.
g. Thanks M. you can straighten your knees. Are yo comfortable M to go ahead?
6. Move (Both legs)
1. Flexion:
a. With patient supine, ask to “Can you bend knees/your legs up and bring foot as close to hip as possible/as
much as you can”  “ can you please ben your legs as much as you can?”
b. Turn to david.
2. Extension:
a. Tell patient to extend (straighten) the leg back down to couch.  “Thank you M., Can you please straighten
your legs now”
b. Thank you M. George. Return to DAvid, tel him: this isn ot only the type of the extensions. There is 2 types
of extension one from flexed position and the other from neutral postion.
3. Ask patient to lift one leg from couch and look at full knee extension. Do it on both sides.  Can you please
raise your leg (not both your legs) as high as you can without bending your knees?
4. I turn to David and i say as you can see, extension of knees in this patient is normal on the patient
5. Then I do it on the other leg...
6. In the station, The paitnet will not extend it fully from the neutral position .. --> i will say to dAvid that extension
is limmitted on that side

7. Tests of stability:
a) Patellar Tap:
• With patient knee extended, empty the supra patellar pouch by sliding your left hand down the thigh until you
reach the upper edge of the patella.

32
• Keep your one hand there and with the fingertips of other hand, press down briskly over the patella. You may feel
a fluid impulse in your left hand.
• 2-3 cm above the knee joint - use 2 thumbs from both sides .. squeez the muscles down ... leave the midal thumb
on the superio part of the patella with a firm grip on the knee --> then tap the patella
• No effusion

b) Collateral ligament (Stretch tests):

• I will be gently lefting you leg and supporting it between side of my body and my hand.
• I left the leg between my elbow and the side of my body. suppot the calf by my hand.
• I will pull the leg towards me and push the knee medially (or outside) --> is there pain? where is it> if it is in medial
--> then it is on the medial collateral injury
• if no pain or pain not in the medial side ... Are you comfortable to proceed? --> Change hands ..
• I will push the leg away from me , and pull knees laterally /// for the lateral collatarl injury etc ...
• Extend patient’s knee fully and hold the ankle between your elbow and side.
• Valgus: Apply force laterally on knee with one hand to feel for laxity or pain. It suggests medical collateral ligament
injury.
• Varus: Apply force medially on knee with one hand to feel for laxity or pain. It suggests lateral collateral ligament
injury. (Give your findings)

c) McMurray’s Test (meniscus)

i. Medial Meniscus
• Passively flex the knee fully.
• Externally rotate the foot, heel facing medially, abduct the upper leg at hip.
• Extend the knee smoothly. In medial meniscus tear a click/clunk is heard or pain is felt.
• Can you bend your knees a little bit for me. (90 degrees)
• I will be gently supporting your leg and left it.
• hand on the heel and hand on the knee
• Rotate the heel medially a little bit .. The leg will get out... I push it a little bit --> then I need to stretch the leg.
• It s very painful.
ii. Lateral Meniscus
• Then do it lateral meniscus by rotating heal out.
• Passively flex the knee fully.
• Internally rotate the foot, heel facing laterally, adduct the leg at hip.
• Extend the knee smoothly. In lateral meniscus tear, a click/clunk is heard or pain is felt.
iii. (Give your findings)

d) Drawer’s Test (for cruciate ligaments)

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 Can you please bend your knees a little bit for me? If he did not bend it fully --> M. do u mind if i position it for
you?
 Then --> would you mind me sitting on the tips of your toes .it is just to support your leg? yes --> talk to david -
-> then sit on the couch slightly touching the toes of the patient
 Do the grip of the tenderness --> M. Goerg are you comfortable --> M. George this will hurt you --> Pull the
patell tendon towards you --> M. George this wil hurt you --> Push the patella tendon towards the patient. ( do
not move while pusihg and pulling)
 WE check for the laxity and the pain.
 Explain it to David ...
 Okay M. George you can straighten your legs, ARe you cmortale to proceed or do you need to rest for few
moments?
e) Anterior drawer sign
• Place your hands behind the tibia and both thumbs over tibial tuberosity, pull the tibia anteriorly. Significant
movement suggests anterior cruciate ligament rupture.
f) Posterior drawer sign
• Push backwards on tibia. Significant movement of tibia suggests posterior cruciate ligament injury. (Give your
findings)
8. Thank the patient and ask to dress up. Finish your station by saying “I will examine joint above and below”.
Summarize to david my findings ..
9. General advice:
p: protection: Avoid activity which causes pain to allow the inflammation to heal.
R: Rest
I: Ice packs
C: Compression
E: Elevation
NSAID: we will give you some pain killers to relieve the pain
Physiotherapy: an appointment with physiotherapist
Follow up appointment: we will see you in the follow up appointment to see, how well you are doing.
Surgical treatment: if the above measures fail then we can refer you to a specialist doctor, who can consider an
operation.

7. ABDOMINAL DISTENSION – Alcoholic cirrhosis

Exam question: 40 year old man Mr Hutchinson presented with abdominal distension for past 4-6 weeks. Assess
him and discuss the further management with the patient.

A.
1. Dr: Hello my name is Dr … I am one of the junior doctors in the department. How can I help you today? Pt:
Doctor my tummy bloated. I feel heavy as if I am carrying some weight. I am really worried about it.
2. Dr: Can you tell me for how long have you been feeling like that? Pt: For about 4 to 6 weeks.
3. Dr: Can you tell me did the swelling develop suddenly or gradually? Pt: It developed gradually.
4. Dr: Any pain in your tummy? Pt: No
5. Dr: Any particular type of food makes it worse? Pt: No
6. Dr: Any nausea or vomiting? Pt: No. [ if yes ask blood in vomitus.(hematemesis) ]
7. Dr: Any yellowish discoloration of your skin? Pt: No
8. Dr: Have you have itchiness ? Pt: No

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9. Dr: Any bowel problems like diarrhoea or constipation (intestinal obstruction)? Pt : No
10. Dr: Any change in stool colour (malaena)? Pt: No
11. Dr: Have you lost any weight? Pt: No
12. Dr: Have you been diagnosed with any medical conditions in the past ? No
13. Dr: DM/HTN? Pt: No Dr: Have you ever had any liver problem before ? Pt : No
14. Dr: Any previous surgeries? Blood transfusion? Pt: No
15. Dr: Do you drink Alcohol? Pt: Yes
16. Dr: How much and for how long? ….. ( Pt will tell that he drinks a lot)
17. Dr: do you smoke? Pt: No/Yes
18. Dr: Do you use recreational drugs (IV Drug abuse)? Pt: No.
19. Dr: Have you travelled anywhere recently? Pt : No
20. Dr: Are you on any medication? Pt No
21. Dr: Any of your family members has any medical conditions ? Pt : No
22. Dr: Is there anything else you think is important that we need to know ? Pt : No
B. EXAMINATION:
1. Do General physical examination and abdominal examination
2. I need to examine you tummy, eyes and hands Mr Hutchinson,
3. Can you please undress above your waist. ( exposure to abdominal examination is from mid chest to mid
thigh)
4. Position patient – on the bed, sit upright for the first part of the examination
5. Ask if patient currently has any pain before you begin

General inspection :
1. Hands
No Clubbing, No nail changes or Palmar erythema,
No flapping tremor ( hepatic encephalopathy / uraemia / CO2
retention )
2. Eyes: No jaundice, No pallor
3. Chest - No Spider naevi ( chronic liver disease) and no
gynaecomastia (liver cirrhosis / digoxin/ spironolactone),
4. No Pedal edema

Detailed abdominal inspection( Patient may be wearing a manikin on the abdomen).

• Explain - consent - Epxosure:
• Position the patient supine, with their arms by their side and legs uncrossed, Look and move around the
abdomen all around the abdomen.:
o No operation Scars, No visible Masses or Pulsation
o No – bruising surrounding umbilicus [Cullen’s sign– retroperitoneal bleed (pancreatitis/ruptured
AAA)],
o No bruising in the flanks [Grey-Turner’s sign – retroperitoneal bleed (pancreatitis/ruptured
AAA)]
o Abdomin appears to be distended – [ fluid (ascites) / fat (obesity) / faeces (constipation)
/ flatus / fetus (pregnancy)]
o No Caput medusae

Palpation (always make the pain site the last one to examine)

35
• Explain and consent
• Kneel so that you are level with the patient. Observe the patient’s face throughout for signs of discomfort.
• Light palpation: No Tenderness, No Guarding  Temprature and superfical palpation: same as before with back
of the hand --> there is no tenderness and there is no local rise in temprature but tenderness in the left iliac
fossa
• Deep palpation - do not raise your hands keep it in wave motion from RILv- Deep --> Check for muasses .. This
time I’ m going to do it a little bit deeper .. No masses felt  but tenderness in the left iliac fossa.
• Liver – Palpate over abdomen for lower and percuss the chest from 2nd intercostal space downwards ( normal
liver span is between 5th rib to costal margin) for upper border of liver. Liver is enlarged
• Palpate for Spleen and Kidneys - not enlarged

Percussion:

 All you have to percuss is shifitng dullness (DO THE ACTUAL SHIFTING DULLNESS - no fluid thrill)
 Percuss from the middle of the umblicus till the Left side where you find dullnees --> keep your hand there -
-> ask the patient to turn to right.
 then I get my hand to the umbilic and percuss again to the LIF

Auscultation - Bowel sounds are normal,  keep it for 15 seconds. I can appreciate bowel sounds..

Verbally mention - I will examine the groin area for hernia. I will examine the genitalia and perform a digital
rectal examination (PR)  M. x ,, I d like to examine your back passage now

C. Provisional Diagnosis:
• Dr: Mr Hutchinson - From the information you have given me and from the examination I suspect that you have
Alcohol-related liver disease (ARLD) what we call as cirrhosis. Do you know anything about it? Pt: No.
• Dr: I am really sorry to tell you that excessive intake of alcohol might have damaged your liver that is what we
call cirrhosis. It may have caused fluid to accumulate in your tummy causing it to bulge.
• We need to do certain blood tests to check your liver functioning to make sure that you do not have any other
causes for distension of your tummy. Also we need to do ultrasound and CT scan of your tummy. We also might
need to take a fluid from your tummy and test in the lab.
D. MANAGEMENT:
1. Dr: I am really sorry to tell you that there's currently no specific medical treatment for this condition. The
main treatment is to stop drinking for the rest of your life. This reduces the risk of further damage to your
liver and gives it the best chance of recovering.
Pt: But I have been drinking all my life Doctor.
2. Dr: Mr … if one is dependent on alcohol, stopping drinking can be very difficult. We can help you to stop
drinking alcohol if you wish to do so.
3. But if you don’t stop - the condition can progress and lead to failure of your liver.
4. A liver transplant may be required in severe cases if the liver has stopped functioning.
5. We will admit you now to do the tests.
6. We will give you some medications what we call diuretics to reduce the fluid in your tummy. If too much fluid
gets collected in your tummy then we need to drain the fluid.
7. You can get malnourished due to this condition. So it's important to eat a balanced diet to get all the nutrients
you need. Our dietician will advise you on the diet.
8. Reducing salt in your food can reduce your risk of developing swelling in your legs, feet and tummy caused by
a build-up of fluid.

36
9. Also if you vomit blood or feel unusually drowsy and confused you should come to hospital.

8. Lady with pain abdomen - Appendicitis.

42 year old lady presented with abdominal pain. Take history and then do the relevant examination and
discuss the further management with her.
C.
Patient was complaining of pain abdomen for the last 5 days. Initially the pain was coming and going. Now it is
constant in the lower part of tummy.
She was feeling feverish for the last few days.
She was also complaining of constipation for the last 3 days. ( sometimes she may start her story with constipation
– do not confuse this station with constipation station).She was able to pass wind. No vomiting. Had nausea.
No urinary symptoms like burning sensation, increased frequency, haematuria, No previous bowel problems.
LMP was 3 weeks ago.( check when was her period before that), No vaginal bleeding now. No vaginal discharge.
No unprotected sex.
No diarrhoea, No previous medical conditions, No previous history of kidney stones, no history of previous
surgery.
A.
1. Ask where exactly was the pain when it started?
2. Ask was she on any medications ?
3. Ask family history, how many children she has?
4. Anything else important ?

B. Examination:
I want to examine your tummy. I will ensure your privacy and have chaperone with me. Can you please undress
above your waist and lie on the bed. Examine abdomen:
1. Inspection – No distension, No visible masses
2. Palpation - had tenderness all over lower abdomen, right iliac fossa, supra pubic area and left iliac fossa.
3. Percussion – normal
4. Bowel sounds – examiner said no bowel sounds ( for some candidates examiner said bowel sounds normal)
5. Per rectal examination – examiner said normal.
6. Check NEWS chart – temp – 38.9°C, Pulse – 106bpm, BP -130/80mmHg, PO2 was 97%.

C. Investigations:
1. We need to do blood tests to check for any infection markers. Also we need to do X Ray of your tummy and
chest, and Ultra sound scan of your tummy. ( examiner did not give any findings).
2. We need to test your urine also to check for any blood or infection markers and also do pregnancy test to make
sure that you are not pregnant. Is it OK?
D. Definitive diagnosis
1. I think you may have a condition called Appendicitis. Do you know any thing abiut this ? Pt : No
2. Dr: Let em explain ( draw if possible).
3. We all have an organ in our tummy called Appendix which looks like a small finger attached the beginning of
the large bowel located at the right lower part of the tummy.
4. That organ has become inflamed ( it is sore / swollen) This is what we call Appendicits.
5. Sometimes it is due to some bugs in that organ. If the condition is not treated urgently then this organ can
perforate and can cause serious infection within the tummy.

37
Treatment.
1. The only way to treat this condition is doing an operation and removing that organ.
2. Pt: Won’t there be any problem if you remove that organ.?
Dr: This organ has no important function in our body, so even if we remove there will not be ant problem. You
can live a normal life.
3. Pt: How long will be operation ? DR: 30 min to 45 min
4. Pt: How long should I be in the hospital? Dr : two to three days.
5. Pt: Any complications – Dr: very rarely there could be bleeding or infections but we can manage that.
6. Dr: Is that OK to go ahead with surgery ? Pt: OK Do you have any other questions ?Pt: No
7. Thank you.

9. Suspected Cerebellar Ataxia - Referred by GP

Exam question
60 year Lady Mrs Cathleen Nelson presented to the GP with unsteady feet.
GP referred her to you for suspected “Cerebellar ataxia”.
Take focused history from the patient, examine and talk to her about the management.
A. (no diagnsois - it could be cervical spondylosis/hypochondriasis - but it is not there yet)

1. Dr: Hello Mrs Cathleen Nelson… I am Dr… Can you please tell me what brings you to the hospital?
Pt: Doctor, My hands are very clumsy. I can’t knit sweater. I keep dropping things from my hands. ( patient may
or may not give history of unsteady feet)
2. Dr: Is it one hand or both hands? Pt: Both hands.
3. Dr: Since when this problems started? Pt: Since last few weeks. Dr: Did this happen suddenly or gradually you
noticed this problem? Pt: Suddenly / sometimes she may say gradually.
4. Dr: Did you have any other symptom when you developed this problem?
5. Dr: Do you have any pain in your neck ? Pt; Yes/ No
6. Dr: If there is pain – does the pain go any where ? ( to the arms – radiation? Pt – Yes/ No
7. Dr: Any stiffness in the neck ? Pt: Yes/ No [ Pain and stiffness in the neck are symptoms of cervical spondylosis]
8. Dr: Any tingling numbness in your hands? Pt: No Dr: Do you have any tremors in hands ?Pt: Yes/No Dr: Are you
able to eat with the help of spoon? Pt: Yes
9. Dr: Do you have balance problem while walking ? Pt: Yes / sometimes she may say no [ If she say no – ask her -
did you see your GP before for any balance problems because GP has mentioned in his notes – she may then
admit it ]
10. Dr: Any vision problem ( MS) ? Pt : No Dr: Any bowel or urine incontinence ( MS, Cervical spondylosis) ? Pt –
No. Dr: Do you have headache ( stroke, brain tumours) ? Pt: No
11. Dr: Did you have such problems any time before this last few weeks? Pt: No Dr: When these symptoms started
– at that time did you have headache, fever, vomiting? Any skin rashes? Head injury? ( Stroke, brain infections,
chicken pox – all risk factors for cerebellar ataxia).
12. Dr: Do you have any medical conditions? Pt : I have diabetes.
13. Dr: Are you taking medications for that? Pt: Yes I am taking Insulin.
14. Dr: Do you keep checking the sugar level - Is the sugar controlled well do you know ? Pt : Yes/No. Dr: Any
thyroid problems ( risk factor for cerebellar ataxia) ? Pt: No
15. Dr: Do you drink alcohol? ( Risk factor for Cerebellar ataxia) Pt : Not much. Dr: Thank you very much. I need
to examine you now. Is that OK? Pt: Yes doctor

B. Examination

38
1. Exposure: neck and above shoulders. If the patient is wearing jumpers --> I ask him to undress it.
2. Explain, privacy chaperone and Consent.
3. Check the neck :
a. Inspection –
i. Come behind the neck
ii. And comment on Muscle wasting – Redness - deforimty -scars - swelling
iii. No swelling - redness,
b. Palpate
i. For tenderness over the spine, (Spinal and paraspinal tenderness)
ii. Warm your hands --> by index click below the hair line up to T2
iii. in the center --> Spinal tndenrness  with thumbs of both hands --> do the same 0.5-1 cm
from the midline
c. Check for movements (6 movemnets)
i. Can you look up for me?
ii. Look down? Rt/lt - make your head to the side left and then to side right.
4. Neurological examination of the upper limbs
a. Can you please sit stretch your hands out? WE always stand infront of the patient not the side
b. Inspection – No muscle wasting, Tremors, No deformity of joints. MRDSS  usually nothing
c. Co ordination – Finger nose test, Disdiadokokinesia, Heel to Shin test.
d. Sensations (same as LL) –
i. Fine touch (no monofilament)- C4 shoulders -- C5 medial side of hte arm - C6 medial side of
hte forearm - C7 tip of the middle finger - C8 little finger - T1 the lateral side of the forearm - T2
lateral side of arm
ii. Pain (At least reach there)  Please tell me yes as you feel it. Neuropin (for pain)
iii. Vibration (do not do tuning forks even if it is present)
e. Tone: (only wrest and elbow) I will just move your hands - just relax 00 move her wrist and then elbow
--> comment.
f. Power:
i. Shoulder – abduction and adduction, elbow –flexion and extension, finger extension at wrist.
Finger abduction and grip.
ii. Bring your hands infront othe chest for me .. i will push your hands down and pull your hands
up please do not allow me to do it.--> the power in the shoulders is normal
iii. Pull your elbows towrds your body for me --> i will pull your hands awy and will push your hands
towards your body.  The power in the elbows are normal
iv. Can you please hold your fingers like this for me - will pull your fingers towards me , please do
not allow me to do it
v. Can you please fan your fingers do not allow me to bring them together -->
vi. Can you hold m finger as tight as yo ucan by your hand grip ,..
vii. c, d , e --> the power of both hands are normal
viii. Examiner may say – power is normal.
g. Reflexes – Biceps, triceps and supinator. - Examiner may say normal.
i. All on the fingers
ii. Supinator: hold patient hand and relax it .. hold the brachiioradialis and tap the hammer on yoru
finger (not hers)
iii. Biceps: hold the cubital fossa --> keep your index on the biceps tendon and then tap it with
hammer (without support)
iv. Tricepts: keep your hand on the triceps tendon and give it a tap wit hthe hammer.
39
5. Cerebellum examinations:
a. Slurred speach --> ask the patient to repeat the words of the british constitiuion --> scannig speach she
will break the consitituion
b. Check for Nystagmus --> like visual feild
c. Finger to nose test: *please touch my finger and then touch your (not mine) nose
d. Dysdiadokinesis:*can you please repeat this as fast as you can ..
e. Hail to shin
i. She needs to lie down the couch ..
ii. can you take your heel of the right leg and slide it below the knee of the left leg and the other
side..
iii. if she cannto do it --> Mrs can I show it to you ..
f. Rhomberg’s test:
i. Can you please stand up staright for me --> Do not worry I will support you to make sure you do
not fall down --> if she is tanding straight just say close your eyes.
ii. if she lean --> I say I am sorry .. let 's sit on the couch
iii. keep your hands just behind her not touching her.
g. Check the Gait ( broad based gait in Cerebellar ataxia)  *Ataxic gait - normal gait
6. [Stop examination at 6 minutes  Before the 6 min alarm (if not -> Ideally i will complete the exmaination
chekcing the tone, power, reflexes for the upper limb and cerebllar signs)].

C. Management:
2. Mrs. Nelson on examination I do not see anything abnormal. However, since you are having these symptoms –
we need to evaluate it further to why you are having these symptoms. We will refer you to Neurologist who is
a specialist in this type of problems. They may do tests like X Rays of your neck, CT and MRI scans of your head
and neck, Also some nerve conduction tests. They may also do some blood tests like liver function and thyroid
function and tests for any vitamin deficiencies. Is that OK?
3. Pt: Do you think I have a brian tumour or Stroke? Dr: Mrs. Nelson, with the examination findings it does look like
you have any such condition. However after the investigations Neurologists may be able to say what exactly
may be the problem.
4. Pt – Ok Is this a serious condition ? Dr: Mrs. Please do not be worried. Most of the time this type of
problems are not serious at all. However, only after the investigations we will be able to tell you properly.
5. Pt: Any treatment?Dr: Mrs Nelson treatment depends on the diagnosis. However, specialist may arrange for
physiotherapy and also he may refer you to Occupational therapists if you need any kind of aids. Also please
keep checking your sugar and keep it under control.
6. If the patient gives the history of neck pain and stiffness – give the diagnosis of cervical spondylosis
a. Mrs – Nelson, I think you may be having condition called cervical spondylosis. This is due to degeneration
mean wear and tear of the bones and the discs ( soft cushions betweens the bones) at the neck.
b. In this condition there will be some extra bony lumps develops in the bones of the neck which presses on
the spinal cord and the nerves and causes these type of muscle weakness in the hands and sometimes
balance problems when walking. Do you follow me ? Pt : Yes.
c. Dr: We will refer you to the Orthopaedician who are bone specialist who may investigations like X Ray and
CT and MRI scans of your neck and also nerve conduction tests to check whether this is the problem. Do you
follow me?
d. Pt : Yes. How will treat me doctor.
40
 Dr: Treatment depends on the diagnosis. If it is cervical spondylosis - then the specialist may give pain killers
– if you have pain and arrange physiotherapy, and the investigations that there is pressure on the spinal cord
they may advise surgery to relieve pressure on the spinal cord. Do you follow me ? Pt : Is that OK? Pt : Yes.
Dr Any other questions ? No

10. Shoulder and thigh pain – Polymyalgia Rheumatica

Exam question
Elderly lady
C/o shoulder and thigh pains – 3 weeks
History and management.
A.
1. Shoulder and thigh ( may show around pelvis also) pains since 3 weeks.
2. Onset – Sudden or gradual [ in PMR – it is usually sudden but can be gradual too]. Worse in the morning.
[in PMR it is worse in the morning].
3. Any swelling in shoulders - ? No
4. Any other joint pains ? No, Other joint swellings ( osteo arthritis) ? No, Swelling and pains in the hand joints
( rheumatoid arthritis) ? No
5. Any changes in the bowel habits like loose stools diarrhoea ? No
6. Fever – No, Trauma ? No
7. Soreness in eyes?– No, Skin rashes ( SLE) – No
8. Difficulty using shoulder ? can she lift weight? Difficulty in walking ?
9. Pain on the side of the head ? Any vision problems? Any pain in jaw while chewing? [ to r/o GCA] – No
10. PMHx – GORD on Omeprazole for 20 years
11. Any other medications
12. Allergy?
13. Family history
14. Anything else important?
B. Examination
1. I want to examine your shoulder joints and other joints and also examine your thighs Examiner may say –
shoulder movements restricted( abduction limited).
2. I want to examine for any swellings or muscle wastings ? Examiner may say – No [ In PMR – joints
movements may be restricted]

C. Provisional diagnosis
1. Mrs,,, I need to check whether the medication Omeprazole what you are taking is causing this problem. Is it
OK? check BNF for side effects – it may show long term use of Omeprazole causes Vit D and B 12 deficiencies
which may cause body aches).
2. Mrs.. If one takes Omeprazole for long term it may cause vit deficiencies which in turn can cause body pains
but they usually do not cause the pains to be worse in the morning and restriction movements of the joints.
3. I think you have a condition what we call as Polymyalgia Rheumatica. Do you know anything about this? No
4. Polymyalgia rheumatica is a form of arthritis – joint condition. It causes pain in the joints and muscles of the
lower back, thighs, hips, neck, shoulder and upper arms, and other parts of the body.
5. The condition occurs when the lining surrounding the joints and tendons near the shoulders and hips becomes
inflamed.
6. The disease is centered on the joints (especially the shoulders and hips). But the discomfort is felt in the upper
arms and thighs. This type of pain is called referred pain. It arises in one area but causes symptoms in another.
Do you follow me? Yes

41
7. Typically, polymyalgia rheumatica affects people older than 55. If not treated, it can lead to stiffness and
significant disability. In some cases, symptoms do not get worse. They may even lessen in a few years.
8. In a minority of cases, polymyalgia rheumatica is associated with another condition called giant cell arteritis
(temporal arteritis). This is a condition in which blood vessels are inflamed, especially in the neck and head. If
not treated giant cell arteritis can cause blindness or stroke.
D. Do you follow me ? Yes
1. We need to do some blood tests called ESR and CRP to check whether there are any possibilities of this
condition.
2. {The ESR and CRP tests may be used both to diagnose the condition and to check whether treatment is
working}.
E. Treatment
1. We will refer you to the specialist called Rheumatologists.
2. We can give you pain killer medication like NSAIDS but they are not very helpful.
3. We can give you medications called Corticosteroids, such as prednisolone. We will give you low doses of that
like 10 mg to 20 mg per day and they are highly effective.
4. Long term use of steroids can cause Osteoporosis that is thinning of bones. We can give you medications to
prevent osteoporosis like calcium, vitamin D and alendronate (Fosamax).
5. If you have serious side effects of steroids and if we cannot just treat with low doses of steroids then we may
give some other medications called methotrexate
6. We will also refer you to Physiotherapists. Physical therapy may help to control discomfort. It can also help
maintain the ability to move the joints and function.
F. Prognosis: Treatment may be required for years. But the outlook for people with polymyalgia rheumatica
is excellent.
G. Warning signs:
If you develop any headaches on the sides of the head or vision problems or jaw pain while chewing please
come to us immediately because these are the signs of serious condition called Gaint cell arteritis as I mentioned
earlier. We may need to treat to you urgently with high dose steroids.

42
 11. Vertigo
You are FY2 doctor in Emergency Department.

25 years old female has been brought to emergency room with complaint of Vertigo.

Take history from the patient, talk to her and discuss further management with her.

A.
1. Dr: Hello Miss I am Dr…. How may I call you? Pt: You can call me ....
2. Dr: What brings you to hospital Miss..? Pt: I am having vertigo doctor.
3. Dr: I am sorry to hear that. Could you please tell me what exactly do you mean to as vertigo?
Pt: Doctor every time I turn my head, I feel like my head is spinning.
4. Dr: It must be very distressing for you. Can you tell me more about it?
Pt: I was shopping in the market doctor and I just turned my head to have a look at something and it felt
like the whole world just spun around me. I fell down suddenly doctor. Could you imagine?
5. Dr: I can understand, it must be very upsetting for you. Pt: It is. I was brought by ambulance to the hospital.
6. Dr: Could you please tell me if this feeling is being provoked by any specific movements of head or your body?
(Like sitting up or leaning forward or turning the head in a horizontal plane?) Pt: Yes, doctor my symptoms
are worsened when I tilt my head to a side. (Patient might describe the position) (BPPV)
7. Dr: Can you tell me whether the feeling of head spinning is triggered by the head movement or is
exacerbated by movement? (Labrynthitis is not triggered by movement but may be exacerbated by it vs.
BPPV which is triggered by movement).
8. Pt: ? Doctor I get the feeling only when I move my head. (BPPV)
Dr: Could you please tell me how long do these episodes last? (20-30 seconds in BPPV vs. >20 min in
Meniere’s disease)
Pt: It lasts for a few seconds doctor but it is unbearable.
9. Dr: It must be. Does anything relieve it? Pt: Yes doctor, it resolves if I keep my head stable. (BPPV)
10. Dr: Is there any other symptoms other than head spinning? Pt: Yes doctor, I have been feeling sick. (Patient
is holding a cup in her hand as if about to vomit)
11. Dr: Have you vomited? Pt: No doctor. But I am afraid I might vomit any time.
12. Dr: Please do not worry. We mightbe giving you some medicine for this complaint. Are you comfortable to
talk to me? Pt: (Yes, I can bear it/No?)
I am so sorry that you are feeling that .. would you like to give you some medication that can help you wit hthis
vomting but it might take a bit.. ? Exmainer can you plz give the patinet antimetic. Once you are feeling better
I would like to ask mroe questions. Are you feeling okay and comfortable now?
13. Dr: Did you lose consciousness during this time period? (Syncope/TIA/Vertebrobasilar Ischemia))
Pt: No, I didn't lose consciousness but I fell down doctor.
14. Dr: Did you stand up suddenly from the sitting position at the moment you fell down in the market?
(Orthostatic Hypotension) Pt: No.
15. Dr: Did you experience any weakness in arms or legs during this time period? (TIA/Vertebrobasilar Ischemia)
Pt: No.
16. Dr: Did you lose hearing from one or both ears? (Labrynthitis/Meniere's Disease/Vestibular Neuroma) Pt:
No.
17. Dr: Do you have pain in this ear? Pt: No. Dr: Do you have any fever ? (Otitis Media) Pt: No.
18. Dr: Do you hear any hissing or ringing sounds in the ear? (Tinnitus - Labrynthitis/Meniere’s
disease/Acoustic Neuroma) Pt: No.
19. Dr: Do you have any balance problem while walking? (Balance Problems - Meniere’s disease/Acoustic
Neuroma) Pt: No.
20. Dr: Do you feel any fullness in your ear? (Aural Fullness-Meniere's Disease) Pt: No.
43
21. Dr: Have you been feeling unsteadiness in walking and/or hand movement? (Ataxia - Acoustic Neuroma) Pt:
No.
22. Dr: Have you been feeling any one sided headaches lately? (Vestibular Migraine/Acoustic Neuroma) Pt:
No.
23. Dr: Did you have injury to the ears or head recently? (Trauma) Pt: No.
24. Dr: Is it the first time it is happening? (Multiple Sclerosis) Pt: Yes.
25. Dr: Did you have any infections like flu in the recent past? Pt: Yes, doctor I have had a flu like illness a few
days before. (Viral Post-viral illness (Viral Neuronitis) a cause of BPPV)
26. Dr: How long ago was that? Pt: Almost ten days ago doctor. Dr: Have been diagnosed with any
medical conditions in past? Pt: No Dr: Are you taking any medications now? Pt: (No/Yes?)
B. Examination:
 I need to examine your ear. Examiner may say: Ear examination is normal.
 I will like to perform a test called Dix-Hallpike Test.
 [ Do the test unless the examiner stops you or gives the findings]
1. This will involve you sitting on the couch. I will have to ask you to lie back and move your head in certain
directions. These set movements will usually trigger an episode of vertigo. It will help us confirm the diagnosis
of what we are suspecting in you. Are you following? Pt: Yes.
2. (Rule out contraindications of performing the test)
i. Dr: could you please tell me if you have any neck or back related disease or injury? No.
ii. Dr: Any bone problems like Rhumatoid Arthritis? Pt: No.
a) Procedure of Hallpike Test:
The patinet will rest on the bed and I will suddenly move the head but only if you are comfortable with it?
The examiner It will +p (BBP) , it will -n (ecept if he did not open his mouth) (Vestibular neuiritis)
That is what will differntiae the station for me
1. Warn the patient that transient vertigo may occur in any position.
2. Ask the patient to keep their eyes open and stare at your nose.
3. Prepare the couch so the headrest is down and the patient's head will overhang the end.
4. Begin with the patient sitting with their head turned 45° to the left to test the left posterior canal. With their
head in this position, quickly lay the patient down until the head is dependent 30° below the level of the couch.
5. Observe for nystagmus in each position (30 seconds) and then return the patient to the upright position.
6. Repeat with the head turned to the right to test the right posterior canal.
7. If positive:
a. The patient experiences vertigo and rotary nystagmus in posterior canal BPPV. Purely horizontal
nystagmus suggests horizontal canal BPPV.
b. Nystagmus (fast component) will be upbeat and in the direction of the most affected ear. This has a
limited duration, lasting <30 seconds (adaption).
c. On sitting, there is more vertigo, experienced as the room spinning in the opposite direction (with
reversal of the nystagmus).
b) Rhomberg's Test - this is used to identify instability of either peripheral or central cause of vertigo:
Do it while she is standing ..
That might induce your
Do not worry --> I will hold you.
1. The patient stands up straight with feet together (or at a distance for them to be steady) with arms outstretched.
Then ask them to shut their eyes.
2. If they are unable to maintain their balance with their eyes closed, the test is positive (usually fall to the side of
the lesion so stay close by to prevent them falling).
3. A positive test suggests a problem with proprioception or vestibular function. Romberg's test can also be
positive in neuromuscular disorders and may not be reliable in very elderly people.
44
4. [ stop the examination by 6 minutes]
C. Diagnosis:
1. Dr: From the information I have gathered, I suspect that you might be suffering from a condition called as
BPPV. Do you know anything about it? Pt: No doctor.

a. Dr: BPPV is a condition of the inner ear. It is a common cause of intense dizziness or vertigo. I will tell
you what it means. It is short for Benign Paroxysmal Positional Vertigo.
b. Benign means that it is not due to serious cause. Paroxysmal means symptoms comes in episodes,
Positional means that the symptoms are triggered by certain positions. In the case of BPPV, it is certain
positions of the head that trigger symptoms.
c. Vertigo is dizziness with a sensation of movement. Are you following?
2. Pt: Yes doctor but why has it happened to me?
a. Dr: Our inner ear has some fluid filled structures called semi circular canals which maintains balance of
our body.
b. If any broken off fragments of the inner ear structures gets inside that fluid it causes vertigo when we move
the head in certain directions.
c. Sometimes this problem can be triggered if there is any injury or infections in the head or ear previously.
Are you following?
3. Pt: Yes doctor. Are you going to do any tests ?
Dr: There is no need to do any investigations to diagnose this condition. However if the condition does not
resolve or gets worse then we may need to do some tests like CT scan or MRI scan to exclude any other
conditions. However, I would like to refer you to Ear Nose and Throat specialist. Is that alright? Pt:
Alright.
4. Pt: Yes doctor. But how are you going to treat me?
a. Dr: This condition usually resolves itself in few days or in few weeks. There is no need for hospital
admission.
b. We have a special technique called The Epley manoeuvre. This manoeuvre is usually very successful in
stopping symptoms with just one treatment. If the first treatment does not work, there is still a good chance
that it will work in a repeated treatment session a week or so later.
c. We will give you medication called Proclorperazine and antihitamines this will help to improve your
symptoms of nausea vomiting and vertigo.
d. Dr: Can I ask if you drive? Pt: Yes doctor. Dr: Please do not drive until this problem is resolved
and please inform the DVLA.
5. Pt: Do I need to be careful about anything?
Dr: [ warning signs]However if you have any symptoms like hearing loss, hearing any abnormal hissing
sounds in the ear, headache vision problem please do come back because these could be due to some other
serious conditions. Pt: Yes doctor.
6. Dr: Do you have any concerns? Pt: No, you have been very kind.

12. Vertigo – Vestibular neuronitis

A. Diagnosis:
1. You have a condition called Vestibular neuronitis.This is an inner ear condition that causes inflammation (
swelling) of the nerve connecting the labyrinth ( an organ which helps maintaining our body balance) to the
brain.
2. The condition is usually caused by a viral infection. It usually comes on suddenly. Are you following me ?
Pt : Yes Is this a serious condition ?
Dr: This is not a serious condition. It will subside by itself in few weeks time.

45
 B. Treating vestibular neuronitis.
1. This condition subsides on its own in about 3 to 6 week time without any treatment.
2. There is no need to be admitted to the hospital for treatment.
3. We can give you medications to reduce the severity of your symptoms but they do not speed up recovery.
4. We will also give you anti- sickness medication called Prochlorperazine – which can help with symptoms of
nausea and vomiting.
5. [Antibiotics – if it is caused by a bacterial infection ( do not mention in the exam because patient did not have
fever so not bacterial infection)]
6. However, there are some self-help measures you can take to reduce the severity of your symptoms and help
your recovery.
C. Self-help for vestibular neuronitis
1. If you're feeling nauseous, drink plenty of water to avoid becoming dehydrated. It's best to drink little and
often.
2. If you have quite severe vertigo and dizziness, you should rest in bed to avoid falling and injuring yourself.
After a few days, the worst of these symptoms will go away and you will not feel dizzy all the time.
3. You can do several things to minimise any remaining feelings of dizziness by
 Avoiding drinking alcohol ( if the patient drinking)
 avoiding bright lights
 try to cut out noise and anything that causes stress from your surroundings
4. You should also avoid driving, using tools and machinery, or working at heights if you're feeling dizzy and
unbalanced.
5. Once the dizziness is starting to settle, you should gradually increase your activities around your home. You
should start to have walks outside as soon as possible. It may help to be accompanied by someone, who may
even hold your arm until you become confident.
6. You won't make your condition worse by trying to be active, although it may make you feel dizzy. While you're
recovering, it may help to avoid visually distracting environments such as:
 supermarkets
 shopping centres
 busy roads
1. Pt: Will there be any problem in the future ?
a. Dr: A small number of people experience dizziness and vertigo for months or even years.This is called
chronic vestibular neuronitis.
b. It happens when the vestibular nerve fails to recover and the balance organs can't get messages through to
your brain properly.
c. The symptoms aren’t usually as severe as when you first get the condition, although even mild dizziness can
have a considerable impact on your quality of life, employment and other daily activities.
d. If this happens then we have something called vestibular rehabilitation therapy (VRT) to treat this
condition.
e. VRT attempts to "retrain" your brain and nervous system to compensate for the abnormal signals coming
from your vestibular system.
f. VRT is usually carried out under the supervision of a physiotherapist.
g. Are you following me ? Pt Yes. Any other questions – No
D. Warning signs

46
Dr: Miss. You can go home now. However if you develop headache, hearing loss, double vision, slurred speech,
balance problem while walking or weakness or numbness in arms or legs you should come back because these are
the signs that it could be some other serious conditions.

13. Aero chamber

Child with Asthma - explain inhaler to the mother.
3 year child known to have asthma was admitted to the hospital multiple times in the past for exacerbations but he
improves when he is in the hospital but he deteriorates when sent home. Take a focussed history and assess whether
the spacer technique mother is using is right or not.
1. GRIPS  cross identity check
2. Ask her the details of the problems
a. Since when ?how bad he will be when he becomes short of breath ?
b. How does he improve ? When was the last time he was admitted ? How many times admitted in how
many years?
c. Any other medical conditions ? Allergy? Family history of asthma ?
d. Any triggering factors at home ? Pets, dust mites, exposure to pollens ? Is it worse in any particular
seasons ? Does he has frequent infections ?
e. Ask her whether she knows why her son gets this attack frequently ?
Normally x, there are triggers that might cause aggrevations at home, but sicne we rule out the trigger factors
would you be comfotrable if we go through the medication / medicine technique once again
3. Does she know how to use the inhalers ?she may say yes. Ask her to demonstrate. She will show wrong
technique.
4. Ask her does she know anything about asthma and the medications – she may say she knows everything about
it.
5. If there is no other reason for his frequent exacerbations – tell her that it could be due to wrong inhaler
technique.
6. Teach her the correct technique.
a. Spacer the salbutamol inhaler, spirit swabs may be kept inside the cubicle.
b. 2 puffs of salbutamol. Each puff child should breath for 6 to 10 breaths
c. She may ask how to count the number of breaths when the child is crying ?tell her use the mask with the
spacer to look and count the movement of the exhalation valve at the spacer.
d. She may say the spacers gets dirty can you give more spacers to take home. Tell her there is no need to
keep too may spacers at home. Teach her the cleaning technique. She can just keep 2 or 3 spacers at
home when she is washing and drying one – she can use the other one.
7. Check the age of the child properly and advise her which colour spacer to use according to the age of the child.

SPACERS ARE AVAILABLE ON NHS PRESCRIPTION

AEROCHAMBER® PLUS ABLE SPACER®

47
 POCKET CHAMBER® OPTICHAMBER®

NEBUHALER VOLUMATIC®

FAMILY OF AEROCHAMBER PLUS* VALVED HOLDING CHAMBERS

ORANGE Small Mask (0 - 18 months) Anatomically shaped facemask

creates a secure seal using minimal effort
– critical for parents and caregivers administering aerosol
medications to infants.

48
 YELLOW Medium Mask (1 - 5 years)
Slightly larger mask will provide a secure seal as the child
grows.

BLUE Mouthpiece (5 years+). Guidelines recommend patients be

transitioned to a mouthpiece product as soon as they are
able – usually around 5 years of age.

BLUE Large Mask (5 years+).

Suitable for patients who may have difficulty with a
mouthpiece, or who prefer the security a mask provides
(e.g. elderly or older youth).

Counsel /dad of the child who suffers with asthma about how to use the spacer.
1. (Do initial approach, assess knowledge, introduce the spacer, explain the purpose of use, explain how to use,
check the understanding by ask to perform, correct mistakes, Advice further and answer the question)
2. Greet and Introduce: Good morning I am Dr…..
3. Ask Mum: “How is your little John doing? I have come through notes that your little one is suffering from
asthma… She says: Yes
4. Purpose: I am very sorry to hear that. Because of his condition he will have to take certain medications through
a device called Aerochamber, on a regular basis and I am here to tell you about it and how to use it. Have you
ever heard about it? She says: No
5. (yellow one inhaler or blue inhaler) 3 years old .. yellow *if it is not there I ask the examiner for it*. 2 inhalers one
or me and one for isabelle
6. “I am here to talk you about it. If you have any question, stop me whenever you want.”Hold the Aerochamber
in your hand and say:“This is aerospacer. it is used to deliver medicine efectively into the lung. This device has
two openings on each side, at one end there is a mouthpiece and at the other end there is a hole for the inhaler
to fit into.”
[ SPACER WITH FACEMASK (USUALLY FOR CHILDREN <3 YEARS -The spacer with facemask is only for young children
who cannot manage the spacer with mouthpiece ].
Technique

Prepare your child by reducing anxiety in your normal way (for example cuddles, favourite music or story.)
Position your child so they are comfortable - sitting position or lying down.

Remove the cap of the inhaler.

Look inside Aerochamber to check there is nothing inside.

Shake the inhaler and insert in the end of Aerochamber. Place

the mask on the child’s face making sure that it is well sealed
around their mouth and nose

49
If the child is with the mask on their face, let them breathe in and
out slowly five times – known as ‘tidal breathing’.

Shake the inhaler well to mix the medicine before each puff.

Attach the inhaler to the non mouth-end and press the inhaler
top to give one puff only. Your child will not get all of their
medicine if more than one puff is put in the spacer at the same
time.
Once the child’s breathing pattern is well established, press the
inhaler down once and leave it in the Aerochamber as the child
continues to breathe in and out 6 times. 5:1:6
You will see the exhalation valve moving.

There should be minimal time delay between Inhaler actuation

and inhalation

Count out loud (one, two, three four, five and six ) at the same
time as the child is breathing.

Remove the Aerochamber from the child’s face.

[should not be whistle sound- it means breathing faster]

. If your child needs more than one puff, remove the spacer and
allow your child to breathe normally for 20-30 seconds between
puffs and repeat the procedure.
Put the cap back on the inhaler
If your child is using a steroid preventer inhaler e.g.
Beclomethasone, wash your child's face with warm water after
use. This will remove any unwanted traces of steroid from the
skin.

50
Ask the mom/dad to demonstrate the When they demonstrate they should be using the aerochamber
technique back to you. Give it to them .. touching their face.
Could you repeat it for me? Their mistakes:

 Sometimes they do not secure it.

 Someitmes the drug down.
 Any mistake --> Let her do it. --> say: x, There is a bit of
misunderstnading. Can I just show it to you once again?
Give it back and ask her to show you once again.
 (do not snatch or get angry)
 "if there is alcohol swab .. i can clean mine and tell her
you do not need to do it"

CLEANING- BEFORE FIRST USE THEN AT WEEKLY INTERVALS:

Remove metered dose inhaler from the back of the

Aerochamber.

Remove inhaler port from the back of the Aerochamber, do

not remove the mask.

Soak both parts for 15 minutes in lukewarm water with a mild

liquid detergent.

Agitate gently.
DO NOT RINSE. Do not scrub its inside to prevent any
scratches

Drying Allow dripping dry. Do not rub dry.

Do not dry spacers with a cloth as this can increase the static
charge; increasing the amount of drug that sticks to the inside
of the spacer.
The mouthpiece should be wiped clean of detergent before
use.
It should be cleaned at least once or twice a week and more
depending on frequency of use.

Replace It needs to be replaced when there is obvious breakage, any

staining inside.

Ask: Does little one go to school? If yes, the school nurse

should have a spacer too.

51
SPACER WITH MOUTHPIECE ( without mask). (FOR MOST CHILDREN OVER 3 YEARS)

1. The spacer works better without the facemask and should be used with the mouthpiece where possible.
2. Your child can sit or stand whilst using the spacer. Their breathing should be as relaxed as possible. Slow deep
inspirations are best.
3. Ensure your child does not push their tongue through the mouthpiece as this may reduce the amount of
medicine they get.
4. If a whistle sound is heard whilst breathing in encourage your child to slow their breathing rate down.

STORAGE AND DISPOSAL OF YOUR CHILD'S INHALER

1. Store your child's inhaler at room temperature, away from direct light.
2. Replace your child's spacer every 12 months.
3. Do not leave baby/infant with the Aerochamber - it is not a toy.

What is my baby objects to use aerochamber ?

1. If baby/infant objects to using the Aerochamber and cries, he/she will still inhale the medication you are giving
as he/she will be opening his/her mouth to take big breaths in order to protest – so persevere if you can, it only
takes a few minutes - followed by a cuddle, it can make all the difference to baby’s breathing.
2. To hold a protesting baby Prepare the Aerochamber and Inahler. Sit baby with his/her back to your front. Hold
his/her arms down by wrapping one arm around his/her front. Use your other arm to administer the
medication.

She will ask for 3 or 4 (normally she will take 2 maybe one more fo school) --> as a a rule i can only give you ,, we
will consider it next time. If she said Anna is busy --> Show her favourit cartoon, watch her favourite music, calm
her down.

14. Asthma discharge medication and PEFR ( new exam question)

Mr George Harrison was admitted to the hospital 2 days with shortness of breath. He was diagnosed as
Asthma and was treated.
Assess whether he is fit to be discharged and explain him about the medication he has to take at home.
( You will have to do PEFR also and tell him how to plot the reading s on the chart – however this part may
not be mentioned in the question).
I will find many medications like 50 or something
Yuo will find stethoscope but you wont use it when it comes to the examination  Examine the chest

A.
1. Greet the examiner.
2. Dr: Hello Mr George Harrison, I am Dr ..... How are you doing today. Pt: I am OK.
3. Dr:We are thinking of discharging you today if you are fine. I here to check whether you are fit enough to go
back home. Is that OK? Pt: Yes Doctor.
4. Dr: How is your shortness of breath now ? Pt : It is much better doctor.
5. Dr: Any chest pain ? No
6. Dr: I need to examine yourchest? ( examiner says – chest isclear).
7. Dr:I need you to do a test called PEFR to see how well your lungs are functioning now.How you done this test
before? Pt: No doctor.
8. Dr: Let me explain this to you.
B.

52
1. Explain PEFR : This is a device called PEFR meter which has 2 parts – one cylindrical part with readings in
litres /min which has a pointer which moves along the reader to show the reading and the other one mouth
piece.
2. You need to stand or sit straight but not lying down to do the test.
3. Attach the mouth piece to the devise, make sure the pointer is zero. hold it in both the hands horizontally
without blocking the pointer in the reader, take few breaths in and out, take deep breath in, keep the mouth
piece in your mouth, make tight seal of your lips around the mouth piece and blow though that as hard and as
fast as possible at one go and the check the reading and note it down.
4. Repeat the test 3 times and record the highest of
the 3 readings on a chart which will give you later.
5. Demonstrate the test and ask him to do the test and
correct if he makes mistakes. Check the readings,
ask his normal readings.
6. If he does not know his normal reading then ask
his/her height and age and determine what should
have been normal using the chart for them and tell
the patient this should have been your normal
readings but this is your readings now.
I need to check for which chart: is it male or
female chart?
(His PEFR readings may be almost equal to
predicted normal readings. PEFR should be at
least 75% of his normal to discharge him)
7. Dr: Mr Harrison, You are doing fine now. Test shows that your lungs are functions well now. Congratulations
-you are fit to go home now. But you need to do this test at home and record it in the chart which I will explain
later.

C.
8. You should take the medications also at home.
a. [Check - a) prescription chart for patient identity and for all the medications . b) Medicines for expiry date
and strength of tablets - it might be exppired .. and then I tell the examiner I cnanot give that meication to
the patient]
b. Salbutamol inhaler 2 puffs PRN Beclometasone BD ( 400 micrograms)
c. Tab Prednisolone 30mg PO OD for 3 days.
Do not worry about the dose
Explain medications
1.
a. Dr: This is called as Salbutamol inhaler which widens your airways. This is blue coloured. They are called
relievers because they relieve Asthma symptoms.
b. You need take 2 puffs of spray into your mouth whenever you have shortness of breath. Maximum 4 times
in a day.
c. Dr: Do you know how to use this inhaler ? Pt: No doctor. Dr: Let me explain the inhaler techinque
i. Remove the cap and shakewell
ii. Take few breaths in and out. Then take a deep breathout
iii. Put mouth peice in mouth (but do not put it into your mouth) and make tight seal of your lips around
the mouth peice , (make sure it is horizontal) and take a deep breath in. As you begin to breath in -
press this canister down once for one puff and continue to inhale deeply. Then take it out of
yourmouth.

53
 iv. Hold breath for 10 seconds and then breathout.
v. For second dose ( Puff) wait for approximately 30 seconds before repeating thewhole procedureagain.
vi. Can you please show me how you are going to use it !
vii. [ make him repeat – correct if he does any mistakes]
viii. Dr: Make sure that you keep your salbutamol inhaler with you all the time in case you need to use it.
d. Like any other medications this can also give some side effects but they are not serious. You may feel your
hands shaking, you may get palpitations and headache but they all will go away after some time on their
own. Are you following me? Pt: Yes.
2.
a. Dr: Next medicne is Beclometasone inhaler. This is steriod inhaler which is brown in colour, this prevents
asthma attack.
b. You should take it regularly 2 puffs in the morning and 2 puffs in the evening for two weeks. ( if the strength
of each puff is 200micrograms).
c. The way to use it is the same as the Salbutamol inhaler. You should wash your mouth after using this inhaler
otherwise it will cause fungal infection in the mouth. Are you following me ? Pt: Yes
3.
a. Dr: Next one is Prednisolone tablets ( eg 30mg once day PO for 3 days in the morning) (If one tab is 5mg -
take 6 tablets)
b. You should take 6 tablets once a day for 3 days by mouth in the morning after food. This also helps to prevent
Asthma.
c. This may cause pain in the tummy especially if you take it on empty stomch. Usually there is no other serious
side effects since you are taking these for a short period.
4. Are you with me. Pt: Yes doctor
D. Explain Asthma Dairy
1. Please keep takings medicines at home as prescribed and do this PEFR test home every day twice ( each time
3 times) and plot the highest of the three readings on this chart.

2. In this chart – please write the dates – at the bottom, and mark it properly for each day morning or evening line
corresponding to the readings. (Am is the lower point --> Pm is the hight point (better) in the PEFR chart.)
Check patient understanding by giving him the example reading an asking him to show where will you mark it.
3. If the readings are going up you are improving, please bring the chart with you in your next visit which will be
after 2 weeks.
4. If the readings are not going up –you are not improving. Please see your GP or come back her if you do not see
improvement in the next 3 to 4 days.

54
5. If the readings are going down that means you are getting worse. If you are severely short of breath and if the
medicines do not help please call the ambulance and come to the hospital A&E department.

15. Patient on carbimazole for hyperthyroidism

You are an FY2 in the GP clinic. Lucy Talbot was diagnosed with Thyrotoxicosis and started on carbimazole
a year back. She has come now for her annual follow-up. Discuss and agree a management plan with her.

Inside the cubicle, there may be knee hammer and BNF on the table. The simulator sitting on a chair and there was
no couch or any other equipment inside the cubicle.

A.
1. How can I help you ?
I had overactive thyroid. I am on medication. I have come for follow up.
2. I am glad that you came for the follow up. Is it Ok to ask few questions to see everything is OK with your
condition ?
3. Do you have any problems with that now ?
4. May I know what medications are you taking now ? Carbimazole .
5. How much ? Pt: 5 mg once a day. Check BNF for the correct dose ?
6. Are you taking it regularly ? Yes
7. Since how long you had this problem ? since – One year / ? ...
8. Do you have any other medical conditions at all ? No
9. Are you taking any other medications ? No
10. How are the symptoms you had before we started taking the medications ? They are all gone now.
11. Ask about hyper and hypo - thyroid symptoms

Hyperthyroid Hypothyroid

 Do you feel any irregular or unusually  tiredness

fast heart rate (palpitations)
 weight gain
 Any problems in vision ( double vision)
 Constipation
 Any twitching or trembling in hands
 depression
 Loose stools
 being sensitive to the cold
 Change in Voice ?
 dry skin and hair
 weight loss
 muscle aches
 Any problem in the periods ?
 Do you feel nervous, anxious.
 Do you feel your mood keeps changing
frequently
 Any difficulty sleeping
 Any persistent tiredness and weakness
 Any sensitivity to heat
 Any swelling in your neck from
an enlarged thyroid gland (goitre)

1. Ask about Side-effects of carbimazole;

a. Any joint pains, headaches, jaundice, Itching, Rash, taste disturbance.

55
 b. Rare side effect: agranulocytosis ( ask about recurrent infections)
c. Patient may say no for all the symptoms.
2. Are you pregnant at all? No
3. Any plans for pregnancy ? No my husband had vasectomy.
4. Is there anything else you want to tell me
5. That is good that you do not have any symptoms.
6. I need to examine you now. I need to examine your hands eyes and your neck – is that Okay?
7. Can you please undress that area.
B. Thyroid Examination (youtube
www.youtube.com/watch?v=ziaYBkgEZNU )

Position: Sitting
Inspection:
1. Hands:
• Dryness (hypothyroid), Sweatiness (Hyperthyroid)
• Clubbing
• Thyroid acropachy: Periosteal hypertrophy of distal phalanges.
• Palmar Erythema (Hyperthyroid)
• Tremor: Ask patient to outstretch arms and place a paper on back of hands
and observe the tremor. (Hyperthyroid)
• Pulse: Tachycardia (Hyper), Bradycardia (hypo), Irregular- AF (Hyper)
check the NEWS chart if present – if not ask for it.
2. Eyes:
• Exopthalmos (Inspect from front and side)
• Check for diplopia with ‘H’ test.
• Lid lag: Ask patient to look at your moving finger without moving head. Move it from upper to lower part of
visual field and note for delay in descent of upper eyelid to that of eyeball.
• Lid retraction: It is present if sclera is visible above the iris.
3. Thyroid:
Inspect the midline of neck: Ask patient to move chin up a bit.
Comment on:
• Swelling
• Skin changes
• Scar
4. Swallow Test:
• Ask patient to swallow some water.
• Observe any movement of mass. Most swellings move upwards on
swallowing.
5. Tongue Protrusion:
• Look at neck and ask patient to bring out the tongue.
• Thryoglossal cysts will move upwards.
Palpation:
• Inform patient that you are going to feel neck from behind.
• Stand behind the patient and ask patient to bend neck. (To relax the sternocleidomastoid muscle)
• Place your hands on either side of neck.
6. Thyroid:
• Place 3 fingers along the midline of neck below the chin and slide downwards until the area of thyroid gland,
which is just located below the thyroid cartilage.
• With 1 hand fix one side of thyroid and palpate the other side with help of 3 fingers. Do same on the other side.
• Feel for the gland and ask patient to swallow some more water and feel for any swelling moving with your hands.
56
• Verbalise that there is no abnormality noted.
7. Lymph Nodes:
Check all groups of lymph nodes
i) Submental
ii) Submandibular
iii) Anterior cervical chain (Tonsillar and deep cervical lymph nodes)
iv) Posterior cervical chain
v) Pre auricular
vi) Post auricular
vii) Occipital
viii) Supraclavicular
Percussion: Percuss down starting from sternal notch to listen for retrosternal dullness.
Auscultation: Auscultate both lobes of thyroid. (Thyroid bruit in Grave’s disease)
Pretibial myxoedema:
• Ask patient to roll up trouser.
• Note for the raised, discoloured appearance over legs.
Upper limb reflexes: Biceps, triceps and supinator.
Thank the patient.

C.
1. Mrs.. With the information you have given me and after the examination everything looks normal. However
we need to do blood tests to check Thyroid function. ( examiner may not give results).
2. I will let you know once we get the blood results.
3. Do you have any concerns ? No
D.
1. You are doing fine now. Usually we give medications for about 18 months and stop it if everything is fine. You
may be able to continue the medication with the same dose.
2. I will discuss with my seniors about you and get back to you.
3. [ If patient is already on Carbimazole for 18 months - We need to consider stopping the Carbimazole as you
may not need it any more – I will discuss with my seniors and get back to you about it ].

IV. OBS and GYNA

1. Preeclampsia
Case Scenario
You are F2 in the maternity clinic.39 year old lady is at her first pregnancy. She has come
for her regular ANC follow-up.
On examination, midwife found a BP of 150/100 and protein 3+ in her
urine. Her BP during her first ANC checkup was 110/60.
Take focused history, discuss management and address patient's
concerns.
A.
1. Dr: Hello Mrs.. My name is Dr .... I'm one of the junior doctors here in the maternity clinic..
How are you doing today?
P: Hello doctor, I'm okay. I came in for a routine check up
I undersratnd you are expecting .. You must be very excited (I need to be happy about it) ..

57
2. Dr: How far along in the pregnancy are you Mrs....? P: 36 weeks Too much time for the
delivery now?
3. Dr: That's great Mrs... Do you have any concerns that you would like me to
address first?
That is very good - that is very reassuring - I know that mom are so worried about their
pegnancies .. Do you have any problem?
P: Doctor.. The midwife examined me.. And she said that my BP was a little high..
That a doctor would come in to talk to me about it.
4. Dr: Ooooh I am sorry to hear that ..That's correct Mrs.. I am here to talk to you about that.
Would you mind if I asked you a few questions first? P: No doctor. Sure.
B.
1. Dr: This is your first pregnancy correct? P: Yes Dr: Ok. Have you had any issues with this
pregnancy? P: No
2. Dr: Were you told to have a high BP earlier in this pregnancy? P: No
3. Dr: Have you been following up with the ANC regularly? P: Yes
4. Dr: That's very good Mrs.... We do advice regular ANC visits. Do you have any
headache? P: No
5. Dr: Any visual disturbances?P:No Dr: Any pain in your tummy? P: No
6. Dr: Have you noticed any swelling of your face, hands or your feet? P: Yes my
shoes feel a little tighter
7. Dr: Any decrease in urine output? P: No Dr: Are you able to appreciate your baby's kicks? P:
Yes Dr: Have you noticed any change? P: No
8. Dr: Ok that is very reassuring Mrs... That indicates that your baby is well.. Were
you found to have any medical conditions prior to this pregnancy? HTN? P: No
9. Dr: Diabetes? P: No Dr: Are you on any medications? P: No
10. Dr: Do you have any family history of a similar condition.. High BP during
pregnancy? P: Not that I'm aware of doctor
11. Dr: Mrs.. I have a few questions about your lifestyle.. Do you smoke? P: No
Dr: Do you consume alcohol? P: No
C.
1. Dr: Ok Mrs.. The midwife did note that your BP was high.. It was 150/100. Your
BP during your first visit was 110/60. Additionally, your urine analysis showed
proteins.
This is a condition called preeclampsia. Do you have any idea what that is Mrs...?
2. P: I think I've heard of it doctor.. But I don't know what it is.
Dr: Mrs.. Preeclampsia is a condition that manifests after 20 weeks of pregnancy.
It is characterised by high BP and the presence of protein in your urine.
3. P: Why did this happen doctor?
Dr: There are many reasons why this can occur Mrs... but usually this is because
of some problem with the placenta.
4. P: Is it serious?

58
 a. Dr: Mrs... at the moment, it does not appear to be serious. But preeclampsia can
be a fairly serious condition if not managed at the right moment.
b. Itcanprogress to a more life threatening condition called eclampsia if left untreated,where you
could develop fits and that could be critical for both you and your baby.Are you following me
Mrs...? P: Yes doctor
c. Dr: For this reason Mrs... it is important that we admit you right away.
d. We have to monitor your BP every two hours and do serial urine tests. We will do a ultrasound
scan of your abdomen to check your baby.
e. We will also do a CTG scan, where we can make sure that your baby's movements and
heartbeat are ok.
5. P: Oh but doctor, I don't know if I can take the time off work.. I am not scheduled
for my maternity leave yet..
Dr: I can understand your concern Mrs... but as I mentioned, if your BP is not
controlled right away, it could progress to something more severe and that could
be dangerous for your baby. It is important that we admit you right away and
manage your situation.
6. P: How long will I have to be in the hospital doctor?
Dr: Mrs... in preeclampsia, we usually attempt delivery at around 37 weeks. Since
you are already at 36 weeks, we would keep you in the hospital until that time.
We will control your BP with a medication called Labetalol and consider
delivering after 37 weeks.
7. P: I was very much hoping for a normal delivery.. If possible a water birth?
a. Dr: Mrs... you have every chance of having a normal delivery. If your BP is
controlled and everything is fine with your baby, we can try and induce a normal delivery.
b. However if before that, there is a sign of any complication or distress for your baby, we might
have to go ahead with an emergency C-section operation.
c. As for a water birth, we do not advise that Mrs... It is risky in this condition and we need to
continuously monitor you and your baby.
8. P: Ok doctor..
9. Dr: Do you have any other concerns Mrs...?
P: No doctor.. Thank you..
Dr: Ok Mrs... I will get all the paperwork in order and have you admitted right
away..

2. Ectopic Pregnancy (needs proper time management)

18 year Miss Chloe Jones came to the hospital with lower abdominal pain.
Her pregnancy test is positive. Pregnancy test positive. As per hospital protocol she needs to be admitted for the
treatment and USG should be done the following day.
Talk to her and explain about the further management.
A.
1. Hello Miss Chloe Jones, I am Dr... one of the junior doctor in the Obstetrics and Gynaecology department.
How can I help you? Pt: Doctor I am having pain in my left lower tummy.
2. Dr: Can you please tell me anything more about it ? Pt: Doctor, It started few hours ago.

59
3. Dr: How severe is the pain - in the scale of 1 to 10 one being the mildest and 10 being
the most severe pain.? Pt: It is about 5 out of 10.
4. Dr: When was your last menstrual period ? Pt: 6 weeks ago. Dr: Are you sexually active? Pt: Yes
5. Dr: Any chance that you are pregnant ? Pt: I did the pregnancy test today. It is
positive.
6. Dr: Do you have any bleeding from vagina? Pt : Yes.
7. Dr: Since when and how severe is that? Pt: It just started few hours ago. It is just
spotting not very severe.
8. Dr: Do you feel dizzy or feel like fainting (ruptured ectopic) ? Pt No
9. Dr: Do you have fever ? Pt: No
10. Dr: Do you have burning sensation while passing urine ( UTI)? Pt: No
11. Dr: Do you have any discharge from the vagina ( STI) ? Pt: No
12. Dr: Did you see any blood in your urine ( ureteric stone) ? Pt -No
13. Dr: Do you have diarrheoa or vomiting ( gastroenteritis)? Pt : No
14. Dr Were you ever pregnant before ? Pt - No ( If yes ask - any previous ectopic, miscarriage)
15. Dr: Do you use any sort of contraception ( IUD or IUS are risk factors for ectopic)? Pt: No
16. Dr: Did you have any infections in your pelvic area before ( risk factor for ectopic) Pt : No
17. Dr: Did you have any operations in your tummy before ( previous surgery on fallopian
tube is a risk factor for ectopic) ? Pt : No
B. Examination: Miss Jones I need to examine your tummy and also check your pulse
and blood pressure. ( examiner may give the finding as mild tenderness over left iliac
fossa and pulse and BP are stable).
C. Diagnosis: Miss Jones with you told me and with the examination findings you have a
condition what we call as ectopic pregnancy. Do you have any idea about this? Pt : No
From what you told me and from the symotms you are experiencing, it is quiet likely thar you have what we
call ectopic pregnancy.
1. Dr: Normally pregnancy happens within the womb as you know. In this condition pregnancy is not in the
womb it is in the fallopian tube which is a tube which connects ovary to the womb.
2. In this condition pregnancy cannot continue. Sometimes this condition can be dangerous because the fallopian
tube can rupture and cause heavy bleeding inside the tummy. Are you following me?
3. Pt : Yes. What is going to happen now ?
Dr: We need to do an ultra sound scan of your tummy to confirm this condition.
However this test can be done only tomorrow morning. ( If she ask why not now - you
can say the expert doctor who does the scan can come only tomorrow morning ). Since
at this moment we are not suspecting you are bleeding heavily inside your tummy we
will keep you in the hospital and keep monitoring you and we will do the scan
tomorrow.
I understand that this is big news to digest.Would you like to take a minute?
4. Pt: Doctor I can't stay in the hospital. Dr: Why?
Pt: If I stay in the hospital my parents will come to know that I am in the hospital and
they will come to know that I am pregnant. I don't want them to know that I am
pregnant.
Dr: Miss Jones, if you go home now - sometimes it can bleed heavily and you may not
be able to come back to the hospital in safe time. We will not tell your parents unless
you want us to tell them. However we strongly advise you to tell your parents because
you may need their support now.

60
 {sometimes she may agree. If she does not agree - tell her that it is important that
some one knows that you are in the hospital as may need support - she may she I will
ask my friend to come).
So for the sake of your health and safety ..
It is a very difficult situation to be in .. but we strongly recommend
We understand  but still we want someone to be with you .. so can you calll smoene to be with you?
5. Pt: what are you going to do to treat this condition?
a. Dr: If the test confirm that it is ectopic pregnancy then there are several ways we can
manage it.
b. We will do another blood test to check a pregnancy hormone called Beta HCG which we will do now and
again after 48 hours.
c. Depending on the level we can decide the treatment options. If the symptoms do not get worse and the
hormone level is decreasing after 48 hours - we can just wait and watch because sometimes the pregnant
gets dissolved by itself.
d. If the hormone level is high then we will give you an injection ( one injection to the buttock) called
Methotrexate. This medication will stop the pregnancy from growing.
e. You do not need to stay in the hospital after that but we will keep monitoring you to
check the treatment is working.
f. If these treatment do not work then we may need to do an operation to remove the pregnancy.
g. In this procedure we will do a key hole surgery on your tummy and remove the fallopian tube of that side
along with the pregnancy if the other tube is healthy or remove only the pregnancy if the other tube is not
healthy. If we do operation -you may need to stay in the hospital for few days.
h. If it all it starts bleeding heavily then we need to do an open operation immediately to stop the bleeding.
Are you following me? Any questions?
6. Pt: Will there be any complications in the future?
Dr: Sometimes you can have ectopic pregnancy again or it can cause miscarriage or
very rarely it can cause infertility. Pt: OK
I need to talk to your seniors?
Of course, you can talk to seniors, At the moment the counseler is busy at the moment with the paitnets, But
the moment the consutlatnt is free I will let you know so you can speak to him
7. Dr: Any other question. Pt - No
Dr: We strongly advise you to practice safe sex and effective contraception until you want to become
pregnant again and if you become pregnant again and if you have any pain in your tummy - which is a sign of
ectopic pregnancy again- please come to us immediately. Thank you very much.

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 3. Antenatal assessment - lady had miscarriage previously.
28 year lady Mrs... (P 0+2) presented to the antenatal care unit. Nurse has checked BP and tested urine for infection
and protein which are normal. She is registered first time for the antenatal care.
Do the initial antenatal assessment and address here concerns.
P0+2 G = she is pregnant now. 2 --> abortions (lost kids efore 28 weeks)
A.
1. Hello Mrs..... I am Dr... How are you doing? Pt: I am fine.
Dr: how can I help you Mrs. Pt: Doctor, I am pregnant.
Dr: Congratulations. May I know how many weeks pregnant are you ? Pt -6 weeks
2. Dr: Do you know what we do here in the antenatal care unit ? Pt - No
a. Dr: Don’t worry, let me explain. First of all I am very glad that you have come here. We assess the
pregnant ladies to see if they have any health or other issues which can affect the pregnancy and the
baby and manage them so that they that they will not have problems during pregnancy and ultimately
have a healthy baby.
b. We also educate the parents about how to cope with pregnancy and delivery and address any concerns
you have. We have Obstetrics doctors, midwife and the whole team to help you to go through this
process. Do you follow me? Pt - Yes doctor.
3. Dr: I need to ask few questions about your health and other things for that. Before that do you have any
concerns which you like to ask me?
Pt: Doctor, I was pregnant twice before and I had miscarriage.
Dr: I am very sorry to hear that. Can I know when this happened ?
Pt : One miscarriage was about 3 years and the other one year ago.
4. Dr: At what week of pregnancy you had these miscarriages? Pt - Both were at 8 weeks.
5. Dr: Did you come for antenatal visits at that time ? Pt - No / Yes ( If no – May I know why ?) also praise her for
coming this time
6. Dr: Do you know why you had these miscarriages ? Pt - No ( ? Intentional abortion)
7. Dr: Is this the third time you are pregnant then ? Pt - Yes
8. Dr: Do you have any concerns now ? Pt - Yes doctor. I worried whether the same thing will happen again.
9. Dr: I can understand your worries. But don’t worry. I will explain about it. Before I explain about the
miscarriage, I need to ask you few questions -
a. Do you have any bleeding from the vagina now at all? ( r/o- miscarriage now)? No
b. Dr : Any pain in tummy ( ectopic pregnancy) ? Pt - No
c. Dr: Do you have a stable partner ? Pt - Yes.
d. Dr: Is this a planned pregnancy ? Pt - Yes
e. Dr: Is your partner also happy with this pregnancy ? Pt - Yes ( r/o abuse)
f. Dr: Was he the father both times previously when you were pregnant? Yes.
g. Dr: Do you smoke ? Pt - I stopped one year ago.
h. Dr: Do you drink alcohol ? Pt - No
i. Dr: Do you use any recreational drugs? Pt - No
j. Dr: Do you drink too much coffee ? Pt - No
B.
1. Dr: Mrs.... Most of the time people do have one two miscarriages before they have normal deliveries. This is
quite common. Sometimes the risk of miscarriage is high in those mothers who smoke, drink alcohol, use
recreational drugs or drink too much coffee.

62
2. Anyway, just because you had miscarriage twice before it does not mean you will have the same problem
again. There is a good chance that you have normal delivery this time.
3. However, if it happens more than 3 times then we call it recurrent miscarriage and then we start investigating
for the causes of miscarriage. One of the common causes of miscarriage in early pregnancy is chromosome
abnormality in the baby means there is problem in the gene of the baby. If miscarriage happens more than 3
times then we check for any gene problems in the parents. Other cause of miscarriage is development of some
antibodies in the mother called antiphospholipid antibody which causes thickening of the blood.
4. Again we test for this condition if the miscarriage happens more then 3 times and we give medications like
Aspirin and some heparin injections to thin the blood which helps in normal delivery.
5. Also we look for other causes like any problem in the mother womb or any infections which may cause
recurrent infections.
6. So for now please do not worry about the miscarriage. Hopefully you will have normal delivery. Is that OK? Pt -
Yes
7. Dr: Do you have any other concerns ? Pt - No
 Why inv. was not done in the revious miscarriages?
 Miscarraiges are so freqeunt we do not need to do
 investiagtions each time
C. Dr: I need to ask few questions about your health now. How is your general health now? Pt - I am fine
now.
1. Dr: Do you have any other symptoms like fever pains any where? Pt - No
2. Dr: Do you have any medical conditions ? Pt - No
3. Dr: Like high blood pressure, diabetes, any blood disorders like thalassemia, sickle cell disease, blood clots or
bleeding disorders ? Pt - No
4. Dr: Did you have any kind of infections before? Pt - No
5. Dr: Did you have any problems in your womb or ovaries were you told of ? Pt - No
6. Dr: Did you have any surgeries to your tummy or pelvis before ? Pt - No
7. DR: Are you taking any medications ? Pt: No
8. Dr : Are you taking folic acid? Pt: Yes/ No
9. Dr: Are you allergic to any thing ? Pt : No
10. Dr: Does your partner have any medical conditions ? Pt - No
11. Dr: Do you and your partner get along well with each other? Pt - Yes. ( ? Abuse)
12. Dr: Any mental health issues with you, your partner or both of your families ? Pt - No
13. Dr: Any medical conditions running in your family or in your partner’s family ? Pt - No
14. Dr: Anyone else in your or partners family had miscarriages or abnormalities in the babies or twins ? Pt - No
15. Dr: Have you planned where you want to deliver – at hospital or home?
16. Dr: Is there anything else you like to tell me ? Pt - No

D. Examination
Dr: Mrs.. I will be examining your heart, lungs and tummy to check everything is fine with you. Our nurse has
already checked your blood pressure – that is normal. [if there is NEWS chart – look at it.] Also she has tested your
urine for infections and some substance called protein. They are all normal. We will check your height and weight
also.

E. Investigations

63
1. We will do some blood tests to check blood group, sugar, infections like rubella syphilis, hepatitis and HIV ? Is
that OK? Pt - Yes.
2. We will do tests to check for abnormality in the baby like Downs syndrome, also we will do ultrasound scan
when you are 8 to 10 week pregnant. Pt: OK
3. Dr: Any questions so far? Pt - No
A. Advise:
1. Dr: I advise you to eat a healthy diet. Have good life style. It is good that you stopped smoking. We advise you
not to restart the smoking habit. Also do not drink alcohol use recreational drugs and drink too much coffee.
2. We will prescribe some Folic acid tablets for you.
3. You can join some parentcraft classes where they will teach you about coping at home with pregnancy, labour
feeding and caring of baby and other things. I also advise you to join some exercise classes. Have proper dental
check up. Avoid travelling to malaria prone countries. Is that Ok ? Pt - Ok
4. Any other questions? Pt - No
Dr: I will talk to my Consultant and arrange the date for your next visit. However if you have any problem like
bleeding or pain abdomen or any other problem, please come back.
Thank you very much.

4. Pelvic Inflammatory Disease (PID)

Task
25 year old Mrs Sarah boyer was diagnosed with pelvic inflammatory disease as she
presented with discharge from front passage 4 days ago. She is already on antibiotics
and taking OCP as well. US Scan has been done which shows Hydrosalphinx. Talk to
Mrs Sarah Boyer and explain about possible complications of PID.

A.
1. Dr: hello Mrs Sarah Boyer. I am one of doctor in Gynae/Obs department. How can I help you?
Pt: doctor I was diagnosed with PID and I am on antibiotics but I am still
worried about this condition.
2. Dr: Mrs Sarah I am here for this to address your concerns today regarding your condition. I
will try my best to answer your questions. So do you know what it is? Pt: No/yes
3. Dr: if No: it is infection (bugs) spreading from vagina or cervix (entrance of the womb) into the womb and
Fallopian tubes and ovaries. If yes: That is right. May I know why you are worried?
4. Pt: doc, how it's possible, do you think my Partner is cheating on me?
Dr: I am sorry if you misunderstood me, I did not mean that as there could be other causes
also as I told you. And also sometimes these types of bugs persist for longer period of time and
symptoms develop later in life if not treated immediately. Usually only one fourth of the time
it is due to sexually transmitted infection.
5. Pt: What should I do?
Dr: Do not worry; as long as you complete your treatment everything will be fine. It is very
important for you to complete your treatment.
6. Pt: is there anything which can happen to me?
Dr: I am afraid if you do not get proper treatment or do not follow proper instructions which
we will give to you, there are chances to get complications like;
a. You may not be able to become pregnant, called infertility
b. If you become pregnant
c. You can lose your pregnancy called Miscarriage.
d. It can be on abnormal place called ectopic pregnancy

64
 e. Your baby can be premature baby.
f. You can get pain during intercourse
g. Most importantly this infection can spread to other parts of body which is dangerous.
7. Pt: what can you do for me?
Dr: I just want to tell you please don't worry as you are already on antibiotics so please
continue your treatment as advised to you. Hopefully you will be alright but few things are
very important for you:
a. Please do not stop treatment early even if your symptoms disappear.
b. You should avoid even safe sex till you finish complete treatment. (National Chlamydia
Screening Programme: Do not have any sex with your partner(s) until seven days after you have both
completed your treatment.)
c. Your partner should also get treated.
8. Pt: why partner?
Dr: I am afraid if he is not treated then you can get infection back and can get complications
what we discussed and I am sure you don't want that. Can you bring your partner in?
Pt: Yes. (If patient says No)
Dr: It's fine. We have something called partner notification program in which we will call
your partner anonymously and treat him without revealing your identity.
9. Pt: Will it happen again?
Dr: 1 in 5 women can have it again but if you and your partner both get proper treatment and follow advice
hopefully you will not get it.
10. Would you like me to give you some advice? Pt: yes doc, sure
Dr: 1: Please avoid multiple sexual partners. 2: Practice safe sex in future. 3: If anytime you are suspicious of
getting this infection please come to GUM clinic immediately
{If the patient has IUD- it needs to be removed}

65
 5. Gonorrhea information
25 year old lady Mrs. Laura Thompson presented with vaginal discharge and
lower abdominal pain. You have diagnosed Gonorrhoea. Take a brief history and
tell her the diagnosis and treatment.
A.
1. Hello Mrs Thomson I am Dr How are you doing ? Pt - I am OK.
2. Dr - Do you know why you are here today? Pt - I came for test result.
3. Dr - I have the test results with me. Can you please tell me what problems you had ?
Pt: Doctor I had pain in my lower tummy and I had discharge from my front passage.
4. Dr - Test result shows that you have infection with some bugs in your lower tummy and front passage. This
bug is called Gonorrhoea.
5. Pt - How did I get this bug?
Dr - It is a sexually transmitted infection (STI) caused by bacteria called Gonococcus. Gonorrhoea is easily
passed between people through unprotected sex.
6. Pt : Does that mean that my boyfriend gave this infection to me? Dr: Since when re you having this
relationship? Pt: Since last three weeks.
7. Dr - Do you practice safe sex with your boyfriend ? Pt: No
8. Dr: Does your boyfriend have any symptoms like discharge from his penis or has he
got burning sensation while passing urine do you know? Pt: No
9. Dr: Do you use any sexual toys? Pt: No
10. Dr: Did you have sex with anyone else or did you have any partners before ? Pt: I had two partners before
this relationship.
11. DR: How long ago was that? Pt: Just before I started relationship with my current boyfriend>
12. Dr: Did any of them had symptoms like discharge from their penis or burning sensation
while passing urine - do you know? Pt : I don't know.
13. Dr: Were you practicing safe sex with them? Pt: No
14. Dr: You would have got this infection from any of them because this bug can stay in
the body for long time without having any symptoms. It is important that we need to treat you now.
B.
1. Pt - How will you treat me?
a. Dr - We will treat you with a single antibiotic injection (Ceftriaxone 500mg IM) and a
single antibiotic tablet (Azithromycin 1g oral) . With effective treatment, most of your
symptoms should improve within a few days.
b. We will see you again in a week and do the test again to see whether you have cleared
the infection.
c. Can you please tell your boyfriend to come here so that we can check
whether he also has any such infection and we can treat him ( treatment should be
given to the partner even if the tests are negative because sometimes the tests can be
false negative). Pt: OK, I will tell him.
d. [ if she had unprotected sex with others within the last 3 months - they also need to
informed about the possibility of infection and they should be asked to come to the
clinic and tested and treated - contact tracing].
e. Dr: Please do not have sex until the infection is cleared ( at least one week) and also
practice safe sex ( use condoms) after that.
2. Pt: Will there be any complications?
Dr: Usually if the infection is cleared and if it has not spread to other areas there will
not be any complications. However if the infection is not treated then the infection can

66
 spread to the womb and then it can cause serious problems sometimes like infertility,
miscarriage , pregnancy happening outside the womb etc. Pt: Ok Doctor.
3. Dr: Any other questions Pt : NoThank you very much.

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 6. OCP History and counselling
Mrs Claire Godwin 22 year old lady came to the hospital requesting combined pill for
contraception. Talk to her and advise her about the contraception.
(Very important in this station is to rule out contra indication - patient had DVT one year ago
and was on warfarin at that time. So Combined pill cannot be given to her. However all other
options are available to her because she is not on warfarin now). Female condoms ae only 95% effective.
A.
1. Dr: How can I help you? Pt: I need combined pills for contraception ?
2. Dr: Good. Why do you specifically asking for combined pill?
Pt: My friend is using that and she said it is good.
3. Dr: Are you using any contraception now? Pt: I am using female condom ?
4. Dr: Why do you want to change it ?
Pt: It is not good because I became pregnant last time because the condom tore. I want
something more reliable this time.
5. Dr: Ok do not worry we have several options for contraception also more reliable ones. But I need to ask you
few questions to see which type is suitable to you.
B. Rule out contraindications:
1. Dr: Have you ever had any clots in your lungs or legs? Pt: Yes I had it one year ago.
2. Dr: Were you given any blood thinner medication for that? Pt: Yes I was given warfarin.
3. Dr: Are you still taking warfarin? Pt: No I finished taking the warfarin many months ago.
4. Any family history of clots in legs or lungs? Sorry to ask you this but have you or any family member been
diagnosed with cancer of the breast?
5. Have you ever experienced a migraine or a one-sided severe headache?
6. Do you have any liver disease? Do you smoke? Are you on any medication?
C.
7. Dr: Do you have a partner? Pt: Yes, I have husband ( married)
8. Dr: Do you have children? Pt: Yes 2 children
9. Dr: Have you taken combined pill before any time ? Pt: No
a. Dr: Mrs Godwin, unfortunately the combined pill is not good for you because you had blood clot in your
leg before.
b. If you take the combined pill the blood clot can happen again because one of the complication of combined
pill is that it can give rise to blood clots. Combined pill has two types of hormone oestrogen and
progesterone. It is the oestrogen part which causes blood clots.
c. However we have plenty of other options - one of that is male condom - advantage is that is 98% reliable
and also it is the only contraception which prevents sexually transmitted infections also.
d. Pt: I do not want it because it can also slip.
10. That is true. We have other option which is Progesterone only pill (POP).
a. PROGESTOGEN ONLY PILL - Sometimes called the 'mini-pill'. It contains just a progestogen hormone
(it does not contain oestrogen) which works mainly by causing a plug of mucus in the cervix that blocks
sperm, and by thinning the lining of the uterus. Also prevents ovulation.
b. Advantages - It is very reliable success rate is 99% with that if taken correctly. It is easily reversible and
convenient. It does not cause clots like oestrogen and it can be used during breast feeding.
c. Disadvantages - It can cause irregular periods. Some women have side-effects like headaches, mood
swings and weight gain these are common though). They are not quite as reliable as the combined pill.
Also need to remember to take at the same time every day.
11. Contraceptive implant - This is a small flexible tube containing progestogen that's inserted under the skin of
your upper arm and lasts for three years.
a. It is 99% effective.
68
 b. The implant stops the release of an egg from the ovary by slowly releasing progestogen
into your body.
c. Progestogen also thickens the cervical mucus and thins the womb lining. This makes it harder for sperm to
move through your cervix, and less likely for your womb to accept a fertilised egg.
d. Advantage is that you do not need to remember to take it every day.
12. Other option is INTRAUTERINE DEVICE (IUD) - A plastic and copper device is put into the uterus.
a. It works mainly by stopping the egg and sperm from meeting. The copper also has a Spermicidal effect
(means it kills sperms).
b. Advantages: It is more than 99% effective. Don't have to remember to take pills and it lasts 5 or more
years.
c. Disadvantages - Periods may get heavier or more painful. It carries small risk of serious problems
including damage to the uterus and infection.
13. Other option is - HORMONE RELEASING INTRAUTERINE DEVICE (eg Mirena) - This is a plastic
device that contains a progestogen hormone is put into the uterus.
a. The progestogen is released at a slow but constant rate. It Works in a similar way to the POP.
b. Advantages: This is also more than 99% effective. Don't have to remember to take pills. It can remain in
place for 5 years. Periods become light or stop altogether.
c. Disadvantages: Side-effects may occur as with other progestogen methods. However, they are much less
likely as the hormone is mainly confined to the uterus.
14. If you have finished family ie do not want to have any ore children - then we have Permanent method -
Female sterilisation - this is a procedure where we block the part of the fallopian tubes connecting the ovary
and uterus. 99% effective. Disadvantage - very difficult to reverse and NHS may not fund.
15. Dr:- So Mrs Godwin which one do you prefer ?

69
 7. Emergency Contraception
Exam question (with uti only , the stations I need to write a presciption)
You are a junior doctor in GP clinic. 14 yr old girl, Miss... has come to clinic with unprotected sexual
intercourse. She is requesting for morning after pill. She is worried. Talk to her and address her concerns.
A.
1. Dr: Hello. My name is Dr.... I'm one of the junior doctors here in the GP Clinic.. How may I call you? P: Hello
doctor. You can call me...
2. Dr: How can I help you? Pt: Doctor I need morning after pills.
3. Dr: Can you please tell me why do you want those pills ?
Pt: Doctor I had sex with my partner and we did not use protection and I am afraid I might get pregnant.
4. Dr: Please do not worry. Let me ask you a few questions and I will tell you what I can do.
Pt: But doctor will you give me the pill?
5. Dr: Can you please confirm your age ? Pt: I am 14 year old.
6. Dr: Yes we can give you the pills if that is suitable to you. Can I ask you few more questions to decide about it
? Pt: Alright.
7. Dr: When did you last have unprotected sex? Pt: last night about 12 hours ago.
8. Dr: Alright. Was it for the first time that you had unprotected sex or did you have any unprotected sex before
that ? Pt: This was the first time doctor.
9. Dr: Before this incident, have you been sexually active? Pt: Yes doctor.
10. Dr: And for how long? Pt: For about a year now doctor.
11. Dr: And were you using any kind of contraception ?
Pt: Yes doctor, we have been using condoms but last night we didn’t have the condoms.
12. Dr: Could you please tell me the age of your partner? Pt: He is a year older than me.
13. Dr: Did you have any sexual encounter with adult (that is anyone having age more 18 years)?
Pt: No doctor.
14. Dr: Do your parents know about this? Pt: No doctor. My parents do not know. Please do not tell them. Will you
tell my parents?
Dr: Respecting patient confidentiality is an essential part of good care and this applies whether the patient is a
child or an adult. Please do not worry. Pt: Alright doctor.
B. Assess mental capacity
1. Dr: Can you please tell me why did you specifically ask for pills? Pt: My friend has used that and she said
it will work.
2. Dr: Alright. And what do you know about pills? Pt: Well, I have been told that it works in emergency cases
if one doesn't use any condoms for protection.
3. Dr: Do you know what can happen if you do not use contraception? Pt: Yes doctor, I know that if I not use
any protection, I will become pregnant. I do not want that doctor. Please help me.
4. Dr: Yes, we will help you, but do you know that if you do not use any condoms, one might get sexually
transmitted infections as well?
Pt: Yes doctor. But would you prescribe me the pills? I am really tense. I do not want to become pregnant.
5. Dr: Do not worry, we have some options to deal with such cases. I think that you have capacity to understand
the benefits and the risks of contraception so we might be giving you some morning after pill. But in addition
to this, my seniors will talk to you and will assess your situation a bit further. Are you following?
C.
1. Pt: Yes doctor. What will you give me?
Dr: We have two types of pills. Levonelle and EllaOne. It works mainly by preventing or delaying the release
of an egg from your ovary, which normally happens each month (ovulation). It does not interfere with your
regular method of contraception. Are you following me?
2. Pt: Yes doctor. But when do I take it ?
70
 Dr: You will have to take either one of the pill as soon as possible. It has to be taken in a single dose. The earlier
you take the pill, the more effective it is. And I have to tell you this that if you throw up within two hours after
taking the pill, you will have to take it again.
3. Pt: How effective are these pills?
Dr: It is difficult for us to say exactly how effective it is. However, there is a good chance of preventing
pregnancy if it is taken within few hours after unprotected sex. (<72 Hours in Levonelle and <120 hours in
ellaOne)
4. Pt: Are there any side-effects with these pills doctor?
a. Dr: Side-effects are usually uncommon. However, some women feel sick for some hours after taking the
pill. This may be less likely to happen if the pill is taken with food.
b. But as I have told you, if you vomit within two hours of taking the pill then take another pill as soon as
possible.
c. Other mild side-effects occur in some women for a short time, such as diarrhoea, dizziness and breast
tenderness.
5. Pt: Will it work doctor? Will I not get pregnant?
Dr: Hopefully it works. However, these pills do not continue to protect you against pregnancy. This means that
if you have unprotected sex at any time after taking the emergency pill you can become pregnant.
6. Pt: Do I need to be careful about anything doctor?
a. Dr: Yes, sometimes the pill may not work and you may become pregnant. So if your period is more than 7
days due please do pregnancy test or come back we will check whether you are pregnant.
b. Also there is a serious condition which can happen rarely is what we call as ectopic pregnancy where the
pregnancy happens outside the womb. The signs of it are having pain in lower tummy and bleeding from
vagina. So if do not have your period within one week of expected period and having these symptoms please
do come back. Are you following me? Pt - Yes
c. Dr: Also this is not a regular contraception. It is not good to use morning after pill as a regular way to prevent
pregnancy. It is better to follow a proper regular contraception.
7. Do you want me to tell you the other ways of contraception ?
Pt: No doctor not now. I will make another appointment for that.
D.
1. Dr: There are some things that we need to know before prescribing you the pill. Can you please tell me if you
have any medical condition? Pt: Like what doctor?
a. Dr: Any liver disease? Pt: No doctor. Dr: Asthmatic problems? Pt: No doctor.
b. Dr: Epilepsy? Pt: No doctor.
c. Dr: Alright. Are you using any medicines at the moment? (Antiepileptics - Phenytoin and carbamazepine.
Antibiotics like rifampicin and rifabutin. Antacids, omeprazole or ranitidine) Pt: No doctor.
d. Dr: Alright. Any allergies? Pt: No doctor.
2. Dr: Okay. Do you have any concerns?
Pt: Doctor will you tell my mother?
Dr: We highly encourage you to tell your parents but keeping patient confidentiality is very important for us.
Though you are a child, because you have mental capacity to understand the consequences of your actions and
mistakes, we cannot divulge your information to anyone else inclusive of your parents, without your permission.
We have to ask for your consent before disclosing this information. We normally keep disclosures to the
minimum necessary. Is that okay? Pt: Okay.
3. Dr: Do you have any other questions? Pt: No doctor.
Dr: My senior will talk to you shortly. And in future, you can come back to us if you have any other concerns
or questions. Pt: Thank you doctor.

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 8. OVARIAN CYSTECTOMY

Q. 23 years old lady presented with abdominal pain. USG has been done and it shows dermoid cyst in the
right ovary. You consultant has decided to do open ovarian cystectomy (pfannensteil incision). Talk to
patient and address her concerns. Consultant has planned to keep the patient in the hospital for 2 days after
the operation. Assess knowledge

1. Dr: How much do you know about your condition? Pt:

2. Dr: Certainly, I am here to discuss the result with you. As you know that you came with severe pain and we did
TV scan on your tummy. In which we have found that there is a fluid filled sac on your right ovary (egg
producing gland), known as ovarian cyst.
3. Pt: What is ovarian cyst?
Dr: An ovarian cyst is a fluid filled sac which develops in an ovary. They are very common and do not usually
cause any symptoms. In most cases, they are harmless and usually disappear without the need for treatment.
However, if the cyst is large or causing symptoms, it may need to be surgically removed.
4. Pt: What’s going to happen now?
Dr: My consultant has planned for an operation to remove this cyst.
5. Pt: Why do you have to do an operation, what happens if not removed?
Dr: The sac is a potentially dangerous, if it is not removed now then it can continue to grow in that case it might
rupture, bleed or twist on itself creating a situation in which we will have to remove it by an emergency
operation. Since you are here now we can plan ahead to avoid that situation.
6. Pt: What will you do?
Dr: My consultant has decided to do an operation called laparotomy in which an incision will be given on the
bikini line (Pfannenstiel incision: also called “bikini line incision”). This is an open operation means we have
to open the tummy through this bikini line incision and then remove the ovary.
Sometimes, in case of larger cyst, my consultant/ the surgeon might decide to remove the whole ovary.
7. Pt: How long will the surgery be? Dr: 45 minutes to 1 hour.
8. Pt: How big will the scar be? Will it not look bad when I wear bikini?
Dr: Incision will be about 8 inches long. However the scar will be very thin and it will not be visible even if
you wear bikini because it will be covered by the bikini.
9. Pt: When Can I go back home?
Dr: It depends on your operation and recovery. We are hoping that you will be able to go home in about 2 days
if everything goes well.
10. Pt: Is it cancerous or benign?
Dr: Most of the ovarian cysts are non cancerous. However we will be sending the cyst once removed to the
laboratory to confirm that.
11. Pt: Will I be able to conceive after removal of ovary? / Can I become a mother?
Dr: You have the problem in only one ovary so we will be removing the cyst from only one side. The other
ovary is fine. So you will be able to have babies.
12. Pt: What will happen to my sex life? When can I resume sex?
Dr: You can start having sex after 4-6 weeks after the surgery ( laparotomy). (2-3 weeks in laparoscopy)
13. Pt: When can I go back to work?
Dr: If only cyst is removed, you may be able to return to work within 2 weeks. However, if whole ovary is
removed then 5-6 weeks rest is essential.
14. Pt: When can I drive? After about 4 to 6 weeks you may be able to drive.
15. Pt: Are there any complications?
a. Dr: Pain: You might experience some pain after the operation but do not worry we have very good pain
control team who will take care of you.
72
 b. Bleeding: Do not worry, in case it does happen, we keep matched blood which can be given to you if
needed.
c. Infection: Again, do not worry. We will give you antibiotics
d. Damage to surrounding organs: Very rare. We have an excellent team. If anything happens we will manage
accordingly.
16. Dr: Do you have any other concern? Pt: No Dr: Can I ask you few questions jut to make sure that you are
fit for surgery ? Pt : Yes
17. Dr: Do you have any medical conditions ? No Dr: Are you taking any medications? No
18. Dr: Have you undergone any surgeries previously? No
19. DR: That is good. We will be doing some blood tests and other tests to make you that you are fine and then we
will do the surgery. Is that Ok ? Pt: Ok Thank you.

If task says laparoscopic surgery has been planned.

1. Smaller cysts can sometimes be removed using a procedure known as a laparoscopy. This is a type of keyhole
surgery where small cuts are made in your lower abdomen and gas is blown into the pelvis to lift the wall of
your abdomen away from the organs inside.
2. A laparoscope, which is a small, tube-shaped microscope with a light on the end, will be passed into your
abdomen so the surgeon can see your internal organs. Using tiny surgical tools, the surgeon will remove the
cyst through the small cut in your skin.
3. After the cyst has been removed, the cuts will be closed using dissolvable stitches. Depending on the type and
size of cyst, the operation usually takes about an hour. Most women are able to go home later on the same day
or the following day.
4. A laparoscopy is the preferred surgical method because it causes less pain and allows you to resume normal
activity sooner

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 9. Gillick Competence (Mother concerned about her minor daughter taking OCPs)
Mrs. Jordan has scheduled an urgent appointment with a doctor to discuss her daughter, 15 year old Katy
Jordan.
Mr and Mrs. Jordan and their daughter are regular registered patients at the clinic and visits are logged
into medical records, but you have not seen them. Talk to the mother and address her concerns.

A.
1. Dr: Hello Mrs Jordan.. My name is Dr... I am one of the junior doctors here in the clinic.
How can I help you ?
M: I want to know if my daughter Katy has come to the clinic for a visit.
2. Dr: May I ask why, Mrs. Jordan?
M: I was cleaning her room and I found some oral contraceptive pills under her bed. I want to know if
you have prescribed them.
3. Dr: Did you ask her about the pills, Mrs. Jordan?
4. M: I did. She said they were her friend Sara's and slammed the door shut. She wouldn't tell
me anything more. Can you please tell me if she has been here?
Dr: I can see that you are concerned Mrs. Jordan, but I'm sorry. We are not at liberty to
divulge that information.
5. M: Why not?! I'm her mother. I deserve to know!
Dr: I can see that you are a very concerned mother, Mrs. Jordan.. But as I said... I'm sorry.
I'm legally bound to keep any patient visits confidential. I can't specifically discuss your
daughter's records with you without her consent.
6. M: Doctor she is only 15! She is a minor. She is a child. I have the right to know about my
child. I have parental responsibility.
a. Dr: Mrs Jordan, I can completely understand that you are upset and you feel you need an
explanation. I recognise that she is 15 and that she is a minor, but to maintain the trust with
our patients we need to preserve that level of confidentiality regardless of their age.
b. This is exactly in the same way I would never discuss your record with anyone else without your consent.
c. As doctors we do have guidelines on dealing with patients who are under 16. I can't say
that we have or have not seen your daughter but I can explain the process we go through as
doctors if a girl of your daughter's age request contraception.
7. Mother: What is that process ?
a. If a 15 years old girl came to ask for the pill, we are trained to assess their level of
maturity. We talk at great lengths about risks and benefit and we also encourage them to
talk to their parents.
b. However, if we do feel that they are mature enough to take the pill and they will continue to be sexually
active with pill or without the pill and would therefore put themselves at risk of becoming pregnant, we do
prescribe it to them. In other words, we act in their best interest. Does that make sense?
8. M: Doctor she won't talk to me. Can't you just give me some peace of mind and just tell me?
Dr: I'm sorry Mrs Jordan... I have not seen your daughter. Medical records might have
details if she has visited the clinic, but even if that were the case, I am legally obligated to
keep that information.
9. Mother: She may be having sex. No one should have sex with a child. It is illegal.
Dr: I understand what you are saying. Mrs. Jordan... As per the law, sex is not illegal above the age of 13 if it
is with consent and with a partner of the same age.
10. Mother: She may be having sex with a 20 year old man.
a. Dr: Mrs Jordan, first of all we cannot tell you whether your daughter has come here or not.

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 b. However, I can reassure you that if any minor girl comes here asking for contraceptive
pills, we do advise that no adult should be having sex with them and if we come to know
about it we do take appropriate action on that.
11. Mother: I'm worried she could be even pregnant. What if she is your daughter how would
you feel?
Dr: Mrs Jordan, I can't even imagine how you may be feeling. Unfortunately we cannot reveal any
information about her.
12. Mother: We are Catholics. It is against our culture. She should not be having sex.
a) Dr: I completely understand you. I sincerely advise you to talk to your daughter directly. It often does help
when parents discuss the matter with their daughter, in a safe environment where she does not feel
threatened. You should create the environment for her where she feel safe and discuss openly with you.
b) Mother: But she would not tell me anything. Dr: May be her father can talk to her !
c) Mother: I have not told this to her father. He will be very furious if he comes to know
about it.
d) Dr: If you like we can have a meeting with you and your daughter together if she agrees and we can
discuss these things.
e) Mother: OK, so if we have a meeting will you tell me whether you gave the pills to her?
f) Dr: Mrs Jordan, we can discuss about it if she agrees for that. But as of now we cannot
even say whether she even came here.
13. Mother: Ok then, I will try to talk to her.
Dr: Thank you very much. I am sorry that I was not much helpful. If we can be any help in
the future please do let us know.

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 V. Legal and ethical situations

1. NAI in child
Actually in every child station I need to exclude NAI

A. History
1. What brings you to the hospital?
2. Elaborate the event:-
a. When did it happen? (if delay in presentation -What time did you come to the hospital - consider the time
she was waiting to see the doctor. Usually how much time does it take for you to come to the hospital
from that place, If there is still delay - Find out the cause of delay in presentation - what did you do after
the incident – till she brought the child to the hospital.)
b. What happened? Where it happened?
I am so sorry that happpened can you please tell me What happened after that?
c. When this happened were you with the child, - if not who was there at that time, any one witnessed at all?
Where were you? What did you do immediately?
3. Background
a. Who looks after the child? Who brought? Person who looks after are they biological father or mother?
Who else is at home? Any other children at home (probably they too may be abused)
b. Other unexplained injury We noticed .................... [Bruises]on [-e.g. arm]do you know about this? If
yes take full details
4. Past incidence –
a. Any injury in the past? If yes-did you get medical help?
Unplanned pregnancy - Was it a planned pregnancy? Any problem during or after birth? (to know if she is
his mother or a step mother)
b. Late presentation: Is there any problem because you could not bring immediately?
c. Economic status: What do you do for living?
B. INVESTIGATIONS IN CASE OF SUSPECTED NAI
 If there is bruise - R/O medical cause - FBC (Platelet count for ITP ) and clotting screen for bleeding disorders.
 Skeletal survey [fracture Hx]
 X Ray of the affected part if signs of fracture.
 Fundoscopy [for rocked/ shaken baby]
 Brain imaging if necessary 9 all children under the age one of year irrespective of signs of head injury - in older
children if there are signs of head injury.

C. MANAGEMENT
 Admit [inform parent about admission]
 Symptom relief [ pain killer , fluid- burn ]
 Inform : senior
 Medical photography of affected area
 Assess growth
 Check for History of previous admission
 Inform Orthopaedic surgeon if fracture
 Consider checking child protection list and involve social services [senior does]

You are the FY 2 doctor in the Paediatric department.

Miss Henna Smith brought in her 4 month old son Mitchell with swelling on his
left arm.
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X Ray shows spiral fracture of left humerus.
Take history from her and discuss management with the mother.

A.
1. Dr: Hello Miss Henna Collins, I am Dr .... How are you doing ?
Mother: I am fine thank you.
2. Dr: Can you please tell me what brings you to the hospital ? Mother: In the morning, when I came home, I noticed
swelling on Mitchell's arm.
B.
1. Dr: I am sorry to hear that. Do you know how this happened ? Mother: I don't know.
2. Dr: Were you not with Mitchell last night? Mother: No. I was at work.
3. Dr: Who was looking after Mitchell at that time? Mother: I asked my boyfriend Connor to look after Mitchell.
4. Dr: Did you ask your boyfriend about this swelling? Mother: I could not ask him because he was sleeping. /I asked
him but he said he did not know anything / I could not ask him because as soon as I reached home he left for his
work.
5. Dr: What time did you notice this? Mother: In the morning at .
6. Dr: Did he have that swelling before you went for your work ? Mother: No he didn't have that swelling.
7. Dr: OK. Has he got any other injuries ? Mother: I don't think so. I saw only swelling in his arm.
8. Dr: What did you do immediately after you saw the swelling? Mother: I brought him here. Dr: Mrs Collins. You have
done very good thing. We will definitely help him.
C.
1. Dr: Did Mitchell have any injuries in the past at all? Mother: No
2. Dr: Has he got any medical conditions at all? Mother: No
3. Dr: Is he taking any medications? Mother: No
4. Dr: Is he allergic to anything ? Mother: No
5. Dr: Did you have any problem when you were pregnant with him? Mother: No
6. Dr: Any problem during birth ? Mother: No
7. Dr: Was it a planned pregnancy ? Mother: Yes
8. Dr: Any problem with his development ? Mother: No
9. Dr: Where is his father ? Mother: I don't know.
10. Dr: Do you mean your boyfriend is not Mitchells father? Mother: Yes that is right.
11. Dr: Do you have any other children ? Mother: No
12. Dr: What work do you do? Mother: I work in an Off license shop
13. Dr: How is your finance - any problem with that at all ? Mother: No
14. Dr: What does your boyfriend do ? Mother: He works as ..
15. Dr: Does anyone of you use drugs or drink alcohol ? Mother: No
16. Dr: Is there anything else you think you want to tell me ? Mother: No
D.
1. Dr: Miss Smith, We have done the X ray. Unfortunately it shows that he has fracture in his left arm bone. Mother:
OK. What are you going to do?

2. Dr: We will have to keep him in the hospital and treat him. We will inform the Orthopaedic doctors. They will manage
him for the fracture. Mother: OK.

3. Dr: Also we may need to do the X Ray of his whole body and also CT scan of his head. I will inform my seniors and we
need to involve social services. Mother: Why involve social services ?

E.

1. Dr: I am very sorry to say this. This fracture looks very suspicious. This type of fracture usually do not happen due to
injuries. It usually happens if someone has twisted his arm. So we need to involve the social services. They will look

77
 into this. Mother: Do you mean to say I am hurting my child. I am going to take my son back. I
am the mother you can't stop me.

If the patient stand up  I need to stand up - Please calm. I am so sorry that I made feel you like this.
What is the problem? What are you concerns about the social service?
Whatever you do, I will never use social service?  We are legally bound to call social service.
Abuse --> I am not saying you are abusing your .. I see how caring you are as a x to you y. But I am saying there is an
abuse.
2. Dr: I am sorry if I made you feel that way. I didn't mean that. You have brought your son immediately here. It shows
you are very caring mother. I am very sorry if I hurt your feelings. I mean there are chances that someone has done this
to your son. Mother: Do you mean to say my boyfriend has done this?

3. Dr: We do not know who done that. You said you were not there when this happened. So it is for your son's benefit that
we need to involve the social services to see how this would have happened ? Don't you think it is good to involve the
social services so that these things may not happen to him again? What do you say? Mother: OK doctor.

4. Thank you very much

2. NAI in adult
You are the FY 2 doctor in the surgery department.
Ms Caroline Anderson is a 35 years old female who is 12weeks pregnant presented to the OBG department
with the history of bleeding per vagina. On examination midwife did not find any blood in the vagina but
she noticed multiple bruises which looked like finger marking on her wrists and on their parts of body.
Midwife asked you to talk to the patient. USG done and her baby is fine. Talk to the patient.DO NOT
EXAMINE HER.
I need to not talk much in that station. I keep looking at her even if she is looking away ..

1. Dr: Hello Mrs Anderson, I am Dr …. One of the junior doctor in the Obstetrics and Gynaecology department.
How are you doing ?

2. Can you please tell me what brings here to the hospital ? Pt: I had some bleeding from my front passage.
3. Dr: Ok. Did you have any other problem? Pt: No
4. Dr: Mrs Anderson Midwife examined you and she said there is no blood in the front passage and you are fine
and your baby is also fine.Is there anything else I can help with? Pt: No doctor I want go home.
She might say I want to go home now ..
I understand that you need to go home but therea re couple of questions i need to ask you before that
I have to be very polite and talk very slowly
Do not drift into asking about her child.

A.
1. Dr: Mrs Anderson midwife told us that she noticed some bruises on your wrists.Would you like to tell us about
it? Be assured that we will keep the information confidential unless you want us to disclose it toanyone
Pt: No doctor I am fine I just want to go home.
If she says it is door -->
I can say if i saw it that they do not look like
If i did not --> I can say the midwife has seen them and she says they do not look like
2. Dr: Mrs Anderson we are here to help you and your baby and any oneelse you areclose to if needed. You
seem to be in some danger. Please do not be worried. If you talk to us we may be able to help you. Can I have
a look at your wrists please? I can see bruises, can you please tell me how did you get this bruises? Pt: I just
banged the door that is how it happened?
Can I look at your wrist please? Offering confidnitiliy --> we wont tell anybody except if you want us to tell other
I need to comment on wrist marks even if there are not there ..
if she showed if to me fast i need to see it once ///
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3. Dr: Your bruise does not look like it happened because of banging the door. It looks as if some has pressed
with the fingers. Mrs Anderson, don’t be worried. We are here to help you. You can feel free to talk to me. Pt:
Doctor my partner Derek beats me some times but he is otherwise OK.
B.
1. Dr: How long this is happening ? Pt: Since my first child was born?
2. Dr: You mean you have a child ? Pt: Yes doctor. I have 3 year daughter Lacy.
3. Dr: Did you try to stop him in any way ? Did you try to take help from any one about this? Pt: No doctor?
4. Dr: Can I ask why you didn’t ? Pt: I don’t want to put him in any trouble. I don’t want anything bad to
happen to my daughter.
5. Dr: Has he hurt her also? Pt: No he does not hit her. He loves her. Dr: Is he the biological father ofyour
daughter? Pt:Yes
6. Dr: Is he the father of the baby inyour womb? Pt:Yes
7. Dr: Is this a planned pregnancy? Pt:Yes.
8. Dr: Is your first daughter was a planned pregnancy ? Pt : Yes.
9. Dr: Is there anyone else at home apart from your daughter ? Pt: No
10. Dr: Do you know why does he beat you ? Pt: Sometimes he gets too stressed and he beats me. Sometimes
it is my fault. I do not do the work at home properly.
11. Dr: Is he under the influence of alcohol or drugs when he beats you. ? Pt:No Dr: Does he hurt
you in any other ways like sexually oremotionally Pt:No Dr: Do you work ?
Pt: No.
12. Dr: Does he work ? Pt: Yes he is a plumber.( mechanic)
13. Dr: Mrs Anderson does this problem affect you in any way ? Do you feel low because of this ? Pt: yes
I feel low ( Mood may be5)
14. Dr: Did you ever think of harming yourself ? Pt: No
15. Dr: Do you have any emergency plans if something serious happens ? Pt: No
16. Dr: Have you spoken about this to your family members or friends ? They may be able to helpyou. Pt: I
haven’t told anyone. He has barred me from telling any of them.

C.
1. Dr: Mrs Anderson I am very sorry that this is happening to you. You do not deserve this. There are lot of help
is available for such problems in the community.
2. There is national domestic helpline and women’s Aid group. You can talk to them. We can involve
the Police and social services to help you.
3. Pt: I do not want to inform the police or anyone? Social services may take away my child. I don’t want
them to know. If I inform them then where will I go ? I don’t have any other place to live.
4. Dr: I can imagine your problems. However, Mrs Anderson this is for your own safety and child’s safety that
social services must get involved. Also if you are not safe to go back home they can make some arrangements
for you and your child to stay in a safe place. I am sure they will take care of everything. Is that OK?
5. Pt: Ok Thank you doctor. I will talk to my mother.
6. Dr: Please do let us know if you need any kind of help in the future. Thank you.

3. Insomnia and NAI

Scenario 34 year old female complains of insomnia. She has visited GP clinic 6 months ago for follow up of
OCP. Assess the patient and discuss appropriate management.

A. History
- Ask her the primary complaint and how long she has been having this problem.
She complains of insomnia for a period of 2 months. Ask her about sleep hygiene, medical conditions, medications
that she might be consuming.
She is completely anxious throughout the station. Ask her what is bothering her.
Later on after repeated probing ( offering confidentiality), she gives a history of domestic violence by her husband.
Her husband is a businessman and is very stressed. He comes home and hurts her by pulling her hair.
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NAI questions-
1. How long has this been going on?
2. Who else lives at home?
3. Do you have children? If yes, ask the following questions-
-Does he hurt the children?
-Is he the biological father?
-Was it planned pregnancy?
4. Has she confided this to someone else?
5. Do you work?
6. Is he under the influence of alcohol when he beats you?
7. Does he hurt you like sexually or emotionally?
8. Ask about mood scale
Husband doesn't drink. Pulls hair and pushes her around.
B. Management
1. Offer national domestic helpline and women aids group
2. Police and inform social services

(Insomnia is due to the domestic violence. Explain to her that she should be able to sleep again as before once this
is sorted out. If she still complains of lack of sleep, advise her sleep hygiene methods.) (Patient is not interested to
discuss about OCP)

. Insomnia: Woman comes in with history of insomnia since 2 months. No positive history for coffee, bed comfort,
neighbors, loud noises, flashy lights, exercise. She asks for confidentiality and then talks about husband abuse.
Husband is stressed at work and hence the abuse. She feels scared to even have children with him. Her parents are
down south, so it is relatively difficult to visit them. She considers Women’s aid group and the hotline service and
a short period of stay with her parents eventually.

4. Elderly Abuse
You are the FY 2 doctor in the medical department.
Mrs Diana Roberts brought in her 85 year old mother Mrs Margaret Roberts with the history of falls. Nurse
noticed some bruises on her body including her axilla. Bruises were of different ages.
You are suspecting some fracture and mother is in the X Ray at the moment.
Take history from the daughter and discuss the further management with her.
A.

Dr: Hello Mrs Diana Roberts . I am Dr… one of the junior doctor in the medical department. How are you doing ?
Daughter : I am fine doctor.

Dr: How can I help you Mrs Roberts.? Daughter : My mother fell down today. I brought her in to have a check
up.

B. (Elaborate on presenting complaint )

1. Dr: I am sorry to hear that. Can I ask how did she fall ? Daughter : She is very old and frail. She keeps
falling?
2. Dr: Can you please elaborate about the fall today? Daughter : She was in the room and she fell on the
radiator.
3. Dr: What time did this happen? Daughter : Few hours ago.
4. Dr: What did you do immediately after that? Daughter : I brought her in here.
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5. Dr: That is really good. Can you please tell me was she standing when she fell Daughter : Yes
6. Dr: Did she lose consciousness and then she fell do you know? Daughter : No she was conscious
7. Dr: Did she lose consciousness after she fell? Daughter : No
8. Dr: Was she able to get up after she fell down? Daughter : Yes.
9. Dr: Did she slipped or tripped on anything ? Daughter : No
10. Dr: Was it dark and she could not see anything? Daughter : No
11. Dr: Does she have any problem with her vision? Daughter : No
12. Dr: Did she have dizziness just before she fell do you know? Daughter : No ( Past history of falls and
injuries)
13. Dr: Has it happened before ? Daughter : Yes few times/first time.
14. Dr: Was she brought into the hospital before for this? Daughter : No
15. Dr: May I know why ? Daughter : She was fine after she fell.
C. ( Past medical history)
1. Dr: Has she got any medical conditions ? Daughter : No
2. Dr: Is she on any medications ? Daughter : No
D. ( History for bruises - if it is mentioned in the question)
1. Dr: Have you noticed any injuries this time? Daughter : I am not sure.
2. Dr: Nurses noticed some bruises on her body do you know how she got this?
3. Daughter : I don’t know about that / She fell on the radiator that is how she got it.
4. Dr: Is she taking any blood thinner medication or steroid medication? Daughter : No
5. Dr: Has she got any bleeding disorders ? Daughter : No
E. ( NAI questions)
1. Dr: Can I ask where does she live ? Daughter : She lives with me in my house?
2. Dr: Who looks after her? Daughter : I look after her
3. Dr: Do you work? Daughter : Yes I work.
4. Dr: Who else lives at home ? Daughter : I have 2 teenage age daughters. They live with me.
5. Dr: Anyone else at home ? Daughter : No
6. Dr: Anyone else looks after your mother apart from you? Daughter : No
7. Dr: How do you and your daughters get along with your mother? Daughter : We are fine.
8. Dr: You seem to be very busy. Do you find it difficult to manage everything at home ? Daughter : Yes doctor
I have to work, look after my kids and my mother and I have to do house work also.
9. Dr: I can imagine it must very tiring. Have you thought of keeping her in the care home or do you think you
need any help to look after your mother at home ? Daughter : That will be very helpful doctor if I can get
help to look after her at my home.
F. Management:
1. Dr: Mrs Roberts, we need to keep your mother in the hospital and examine and treat her because she could be
having some fractures for any injuries and do some test to find out why does she keep falling and why does she
has bruises on her body. We may need to do some tests like blood tests to check her sugar, for anaemia ECG,
her blood pressure and other things. I will inform my seniors about this. Daughter : Ok
2. Dr: We will have to involve the social services also. Daughter : Why involve the social services?
3. Dr: We need to involve them because we need to check if there are any other reasons like any type of physical
abuse because we cannot explain the reasons for some type of bruises she has on her body like bruises under
her armpit. Daughter: That bruises is because I was holding her arms.
4. Dr: That may be possible. However Mrs. We need to involve the social services just to be on the safe side for
your mother. Daughter : Are you saying I am abusing my mother.

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5. Dr: I am not saying that Mrs Roberts. I can see that you work and look after your mother and daughters. That
shows that you are a very caring daughter and a caring mother to your daughters. Your mother may be having
fractures which is very serious type of injuries if it is physical abuse. So it is for your mothers own benefit we
need to involve them. They will look into this issue and they may talk to you and your mother also. They will
take further decisions about your mother. In fact they may even help you by arranging social cares to look after
your mother if you wish. Daughter : Can I take her home?
6. Dr: As I mentioned we need to admit her now do tests and treat her and then the social services will take further
decisions after talking to you and your mother.

------------------------------------------------------------------------------------------------------
Same question - another story.

A.
1. Dr: Hello Mrs Diana Roberts . I am Dr… one of the junior doctor in the medical department. How are you
doing ? Daughter : I am fine doctor.
2. Dr: How can I help you Mrs Roberts.? Daughter : My mother fell down today. I brought her in to have
a check up.
B. (Elaborate on presenting complaint )
1. Dr: I am sorry to hear that. Can I ask how did she fall ? Daughter : I hit her and she fell down.
2. Dr: Can you please elaborate about the whole incident please. Daughter : We had some argument and I just
hit her. She fell down on the radiator.
3. Dr: What time did this happen? Daughter : Few hours ago.
4. Dr: What did you do immediately after that? Daughter : I brought her in here.
5. Dr: Can you please tell me was she standing when she fell. Daughter : Yes
6. Dr: Did she lose consciousness after she fell? Daughter : No
7. Dr: Was she able to get up after she fell down? Daughter : Yes.
8. Dr: Has this incident happened before? Daughter: No/ Yes
9. Dr Has been brought into the hospital for such incidents before? Daughter : Yes/ No
10. Dr: How do you feel about it now ? Daughter : I should not have done that. / I feel bad about it / I have
been bit harsh on my mother.
C. ( Past medical history)
1. Dr: Has she got any medical conditions ? Daughter : No
2. Dr: Is she on any medications ? Daughter : No
D. ( History for bruises - if it is mentioned in the question)
1. Dr: Have you noticed any injuries this time? Daughter : I am not sure.
2. Dr: Nurses noticed some bruises on her body do you know how she got this? Daughter : I don’t know about
that / She fell on the radiator that is how she got it.
3. Dr: Is she taking any blood thinner medication or steroid medication? Daughter : No
4. Dr: Has she got any bleeding disorders ? Daughter : No
E. (NAI questions)
1. Dr: Can I ask where does she live ? Daughter : She lives with me in my house?
2. Dr: Who looks after her? Daughter : I look after her
3. Dr: Do you work? Daughter : Yes I work.
4. Dr: Who else lives at home ? Daughter : I have 2 teenage age daughters. They live with me.
5. Dr: Anyone else at home ? Daughter : No
6. Dr: Anyone else looks after your mother apart from you? Daughter : No
7. Dr: How do you and your daughters get along with your mother? Daughter : We are fine.

82
8. Dr: You seem to be very busy. Do you find it difficult to manage everything at home ?Daughter : Yes doctor
I have to work, look after my kids and my mother and I have to do house work also.
9. Dr: I can imagine it must very tiring. Have you thought of keeping her in the care home or do you think you
need any help to look after your mother at home ? Daughter : That will be very helpful doctor if I can get
help to look after her at my home.
F. Management:
1. Dr: Mrs Roberts, we need to keep your mother in the hospital and examine for any injuries and do some test to
find out whether she has any medical conditions. I will inform my seniors about this. Daughter : Ok
2. Dr: We will have to involve the social services also. Daughter : Why involve the social services?
3. Dr: Mrs… you said that you hurt your mother - I do appreciate your honesty . I can see that you work and look
after your mother and daughters. That shows that you are a very caring daughter and a caring mother to your
daughters. However we need to involve them in such incidents of physical abuse. Also if she has fractures
then this will be very serious type of physical hurt. This is for your mother’s own benefit we need to involve
the social services. We have to make sure that she is safe.
4. They will look into this issue and they may talk to you and your mother also. They will take further decisions
about your mother. In fact they may even help you by arranging social cares to look after your mother if you
wish.
5. Daughter : Can I take her home? Dr: As I mentioned we need to admit her now do tests and treat her and
then the social services will take further decisions after talking to you and your mother. Thank you.

5. Cerebral palsy patient. Father thinks unfairly treated.

20 year old man with cerebral palsy was brought into the A&E 5 days ago because he fell from a wheel chair.
He had footinjury. He was treated with just pain killers without doing any X Ray to rule out fracture. X
Ray was not needed at that time because there was no bony tenderness. He was treated with Paracetamol.
Father brought him again today requesting for X Ray.
Talk to the father and address his concerns.

1.
1. Dr: Hello I am one of the junior doctors in the department. How may I call you?
2. Father: You can call me Mr Fredrick.
3. Dr: How can I help you Mr Fredrick?
4. Father: My son was brought into the hospital few days ago. I am very disappointed with the treatment
given to him.
5. Dr: I am really sorry that you feel that way. Can you please tell me what happened to your son?
6. Father: He has Cerebral palsy. He fell down when I was shifting him from the wheel chair to his bed 5
days ago. He injured his foot. I brought him in here 5 days ago. Doctors did not even do any X ray and
said he has just muscle pain and gave just paracetamol. Instead of providing special care my son was
treated very unfairly. I am very upset about it. This is not how it should be.
2.
1. Dr: Why do you think that he was treated unfairly Mr Fredrick?
2. Father: He injured his foot and none of the doctors did X ray of his foot. They just gave him few medicines
and sent us away. That shouldn’t be the way in hospital.
3. Dr: Certainly you are right Mr Fredrick no patient should be ignored or neglected in any setting. We try our
level best to give the good l care to all our patients. Can you please tell me what were the symptoms he was
experiencing when you brought him to the hospital last time ?
4. Pt: He was having pain in the ankle and he was crying. Initially he could put weight on the foot. But later
on he couldn’t even put weight on the foot. He had swelling and bruise also on the ankle. I have been so
worried. They should have done an X ray to check if there was bone damage.
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5. Dr: Mr Fredrick I can understand why you are worried. We normally do the X Ray if there is suspicion of
fracture when we examine the patients. But if there is no suspicion of fracture then we do not do X Ray.
Sometimes it’s apparent from the history and assessment that there is no bone damage. It might have been the
case. Was he able to move his toes after the injury? Father....
6. Dr:. How is the swelling around the ankle now ?
7. Father: Swelling has subsided now but there is still a bruise.
8. Dr: That is a good sign that the swelling has decreased. It means that the injury is healing. The bruise will take
slightly longer to go away.
9. Dr: Has the pain been the same since injury or has it changed in intensity? Father:...
10. Dr: what did the doctor advise him in the last visit?
11. Father: Doctors said there is no fracture. May be he has a fracture. Isn't it still better to do an X Ray.
Don’t people have X Ray done for smallest of reasons my son actually had a fall. I feel as if he was treated
as a second grade citizen and deemed not worthy of equal care as others. He can't put weight on his feet
though in the beginning he could. It worries me I want to have an X Ray done for him now.
3.
12. Dr: I can understand how you feel Mr Fredrick. It is very difficult to see your child in pain. I want to assure you
that all our patients are equally dear to us. We try our best to provide all of them with best care possible. Also
we try to keep our patients safe and try not to give them unnecessary treatments. If at all the Xray was needed
we would have done it.
13. Father: What if he is having a fracture?
14. Dr: I can see that you are a very concerned father. I will definitely examine him again and see whether he
needs X Ray now and if he needs it we will definitely do that now.
15. (Talk about examination – examiner may say there is no bony tenderness and the swellinghas subsided just a
bruise seen – tell the father I examined him now and there is no pain over the bone and has gone down). With
the information what you are giving me that his swelling has reduced since the injury and after examining him
, I still do not think he has a fracture and I do not think we need to do X Ray.
16. Let me explain in detail about when we do the X Ray and when we avoid doing the X ray -
a. For ankle or foot injury we do preliminary assessment of the patient and see if he was able to put weight
initially.
b. If one can put weight on his foot, it is very unlikely that the bone is broken.
c. On examining the patient if there is pain when we press on the bony points which suggests there could be
fracture then we do the X Ray.
d. But if there is no pain when we press on the bony points which suggest the fracture is very unlikely then we
avoid doing the X Ray because doing unnecessary X ray can cause radiation which itself can cause cancers.
e. So we try to avoid doing unnecessary X Rays for patient’s own benefit.
17. I see that you are worried about him because of the bruise. It may take few more days for the bruise to go down.
Are you following me Mr Fredrick?
18. Father: Yes.
19. Dr: Mr Fredrick I want to reassure you again. There is a standard procedure we normally follow whether is
patient is a normal person or differently abled person. It is very unlikely that he was treated unfairly because of
his condition. However if you still want to escalate the matter you can make a formal complaint. We have a
separate department for this purpose called Patient Advisory Liaison Service (PALS). They will help you make
the complaint. Any complaint will be taken seriously and respective authorities will assess the matter and I
assure that if there is any sort of discrimination there will be action taken on the concerned person.
20. Father: Thank You Doctor I will see about that.I feel relieved after talking to you.
21. Dr: I am glad I could help Mr Fredrick. I hope your son recovers soon. If you have any problems please do not
hesitate to come to us. We are here for you.
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22. Father: Thank You Doctor.

6. Aorto - Femoral bypass surgery. BBN

You are the FY 2 doctor in the surgery department.
Mrs. … 64 year lady had right sided Aorto-femoral bypass surgery. She developed heavy bleeding in the brain
after the operation. She has been transfused with 6 units of blood.
She is taken to the theatre now. Your Consultant is in the theatre.
Talk to her husband Mr… and address his concerns.
This complication was not unexpected.
A.
1. Dr: Hello Mr I am Dr…. one of the junior doctor in the surgical department. How are you doing?
Pt: I am OK
2. Dr: I am one of the team of doctors looking after your wife Mrs. I am here to talk to you about her condition.
Do you know anything about how her condition is now? Pt: She had a surgery. I just came to see her now.
I don’t know doctor how she is now. How is she doctor?
3. Dr: I really wish I had a good news for you. But Mr..I am very sorry to say this she is in a very critical condition
now.
B.
1. Pt: Why doctor what happened ?
a. Dr: After the surgery she was moved to the ward then we noticed that she started bleeding heavily.
b. We already transfused her 6 bags of blood. Unfortunately bleeding has not stopped. So we have shifted
her to the operation theatre again to try to stop the bleeding.
c. My Consultant is with her in the theatre. Our whole team is trying our best to stop the bleeding.
2. Pt: OK. I need to go for my work now. Shall I come back after she is back from the theatre? Dr: Mr. I
am very sorry to say that this condition is very serious because we may not be able to stop the bleeding and it
is a life threatening situation now.
3. Pt: What do you mean ? Do you mean she may not make it ? Dr: I really wish to I could say she is not in
danger but unfortunately that is true Mr... We are trying our best to stop the bleeding but it is very difficult to
stop the bleeding in such situation and if we do not succeed in stopping the bleeding she will not survive.
4. Pt: But why this happened? Dr: Unfortunately sometimes this type of complications does happen after the
surgery.
5. Pt: Didn’t you know this problem can happen before the surgery? Dr: These types of problems are expected
to happen after this type of surgery. Usually we are prepared to handle this type of problems by operating again
but in your wife’s case it is very difficult to control the bleeding.
6. Pt: If you did expect this problem before then why did you do the surgery? Dr: Unfortunately her condition
was so serious that if we did not do the surgery she would have lost her leg. That is why we did the surgery.
7. Husband: If you did not do that surgery she would have just lost her leg but now you have put her life at
risk.
a. Dr: Mr… It is true that it is a life threatening condition now but the risk of bleeding was very low.
b. Usually more than 95% of the people recover from this operation without any complications at all.
c. We usually inform the patient all the benefits and the risks of the operation before we do any operation.
d. Since the risk was very low we did the surgery. It is very unfortunate that this problem happened to her.
8. Pt: I think you did the operation unnecessarily and you are giving me my wife’s dead body now. Dr: I am
really sorry if I made you feel that way. I can imagine why you are feeling that way. It was essential at that time
to do the surgery to save her leg.
C.
1. Pt: Why is that you say it is difficult to stop the bleeding? Where is she bleeding from?
a. Dr: Let me explain her condition and what operation we did on her and you can understand where she
is bleeding and why it is difficult to stop the bleeding.

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 b. We all have a big blood vessel in our tummy called Aorta which branches out into smaller branches and
it continues in to the leg as femoral artery which supplies blood to the leg. She had blockage in the
femoral artery in the top part of her thigh so the blood was not flowing into her leg.
c. We had to do an operation to restore the blood supply to her leg. So we connected an artificial tube from
the Aorta in her tummy to the femoral artery in the thigh so as to by pass the blockage.
d. We have succeeded in restoring the blood supply to the leg but unfortunately she has bleeding now.
e. Bleeding is happening where we joined the artificial tube to the original blood vessel. Because blood is
under heavy pressure in that area it is very difficult for us to stop the bleeding.
f. However my seniors are doing their best to stop the bleeding. Let us hope they will succeed.
2. Pt: Doctor I have two sons. Do you think I should inform them? Dr: Mr … Yes surely you can tell them
that she is in a serious situation.
3. Pt: Should I tell them to come here ? Dr: Yes, Unfortunately the condition is very serious Mr. I think you
should tell them to come here very soon.
4. Pt: One of my son is in London other one is in Australia. Dr: You can tell your sons to come here as soon
as possible as she is in a critical condition. I think they need to be informed about it.
5. [sometimes he may say one is in London and the other is in Somerset – both can come here soon] Pt:
OK. Thank you doctor.
6. Dr: Once again I am very sorry to give this bad news. Let us hope that she will be fine. If you need any kind of
help please do let me know. Thank you very much.

7. Septic Shock – telephone conversation

Exam question:
You are the FY2 doctor in the A& E department.
88 year old lady Mrs Olive Green was referred from a care home to the hospital. She is in the A & E
department. There is no referral note from the care home.
She is confused and agitated. She did not allow you to examine her.
Her Pulse is – 120, BP – 90/60, Oxygen saturation is 88%, Temperature is 38 C.
Talk to the care home over the telephone and take her details and then talk to the examiner about her further
management.
A.
1. Dr: Hello, Is it the care home ? Carer: Yes,
2. Dr: I am Dr … one of the junior doctor in the A& E department. May I speak to the person who was looking
after Mrs Olive Green.. please. Carer: Yes it is me. How can I help you ?
3. Dr: May I Know your name please: Carer : I am ….
B.
1. Dr: I need some information about Mrs Olive Green she was actually referred to our hospital today but there
was no referral note from the care home. Could you give me some information about her – why she was referred
to the hospital today ?
Carer: Well doctor I was on leave for the last 3 days. I just came back to work today. I can look at her
notes and tell you about her. In the records it says she was chesty in the last few days.
2. Dr: You mean she had cough. Carer : Yes
3. Dr:Any information about what happened today? Carer : No
4. Dr:How long was she chesty ? Carer: Last few days
5. Dr:Did she have chest pain ? Carer: Yes.
6. Dr: Did she have fever: Carer: Not sure.
7. Dr:Was she coughing up any phlegm or blood do you know? Carer: Yes she had some phlegm.
8. Dr:Did she have any burning sensation while passing urine ( UTI) ? Carer: No
9. Dr:Any urinary incontinence? Carer: No
10. Dr:Was the urine very smelly? Carer: No

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11. Dr: Was she complaining of headache ( meningitis) ? No
12. Dr: Did she have any rashes on her body ( meningitis) ? No
13. Dr:Did she have any diarrhea ( Gastro-enteritis) ? - No Vomiting ? Carer: No
14. Was she complaining of any pain abdomen ? Carer: No
15. Dr: You have been very helpful. Can you please tell me was she mobile or bed ridden ? Carer: She was
mostly bed ridden but we are trying to mobilize her as much as possible.
16. Dr: Did she have any bed sores ( infected bed sores ) ?Carer: No
17. Dr: Was she eating drinking well ? Carer: She has swallowing problem. She had choked on food few times
and 3 months ago she had this problem. ( sometimes - there is no swallowing problem).
18. Dr: Has she got any medical conditions ? Carer: Yes she has High blood pressure and she had stroke 3
years ago.
19. Dr: Did she have diabetes or any heart problem ?Carer: No
20. Dr: Does she smoke or drink alcohol ? Carer: No
21. Dr: Is she on any medication ? Carer: Yes she is taking Ramipril, Aspirin and Atorvastatin.
22. Dr: Is she allergic to any medication? Carer: Yes Penicillin.
23. Dr: Do you know whether any of her family members has any medication conditions ?Carer: I do not know
24. Dr: Is there anyone else who is not well at care home recently ? Carer : No
25. Dr: Can I know about her family members please – any one visiting her? Carer: No one has visited her for
the last 3 months…
26. Dr: Can I get the tell number of the next kin please ?Carer: Yes…..
27. Dr: Is there any information in her records about any decisions about what should be the treatment if she is not
well? Carer: DNAR decision was taken last time when she was in the hospital.
DNER in the station --> if the patient did ot sign the document .. and i see it , I still need and give CPR.
28. Dr: Any other information about any treatment to be given or not ? Carer: Nothing else is written. Dr:Ok
Thank you very much Miss …
29. Carer: Thank you. What is happening to her doctor?
Dr: I do appreciate your concerns about her. As you know she is not well. We are treating her. Unfortunately I
cannot give more information about her because we are supposed to keep the patient’s health information
confidential. You have been most helpful. Thank you very much for the information.
C. Talk to the examiner.
1. Dr: I think Mrs Olivia … is in Septic shock because of aspiration Pneumonia. (if she was not vomiting just
Pneumonia but do not mention aspiration Pneumonia)
2. Examiner: Why do you think so?
Dr: She has been choking on food and she was chesty in the last few days and she had cough and chest pain
and she has fever on examination. That is why I think she has aspiration Pneumonia. Because she is confused
and she has tachycardia and hypotension, I think she has septic shock.
3. Examiner: What will you do?
a. Dr: First of all I will check her medical notes for any decisions about advance care planning about treatment
and also check for Do not attempt CPR decisions. Will proceed according to that.
b. She did not allow me to examine her. I will try to examine her again.
c. I will give her Oxygen
d. Take blood for – FBC, U&Es, Sugar, Creatinine, CRP, Blood culture, LFT and Blood lactate. I will also
check the ABG.
e. Start her on IV fluids. ( Normal saline).
f. I will catheterise her and monitor urine output.
g. Test the urine – dipsticks and send the urine for culture and sensitivity.
h. I will arrange for Chest X Ray and sputum culture.
i. Will inform the seniors immediately

87
 j.
Start her on broad spectrum antibiotics as per hospital protocol bearing in mind that she is allergic to
Penicillin.
k. May start her on Vasopressors after consulting with seniors.
l. May shift her to ITU for further treatment.
m. Will contact her family members to inform about her and get further information about her.
4. Thank you.

8. Pre- operative assessment

Day case surgery – Pin (screw) removal [exam question]

Mr Alex Thomas 50 year old man had fracture ankle 18 months ago which was fixed with the pins. Now the fracture
has healed. He has come for pin removal.
Do the pre - operative assessment to check his suitability to bring him as day case surgery and also tell him the
preparation for the operation and post operative management.

As SHO my role is to asses and anesthesiologist role is to decide

1. Takes 5 minutes
1. Dr: Hello Mr Thomas. I am Dr ….. How are you doing ? -- Pt: I am fine doctor.
2. Dr: How is your ankle now ? Pt: It is good doc. I can walk on that without any problem.
2.
1. Dr: Good. It is time now to pull out the pins from your ankle.
2. We need to do a small operation to pull out the pins. You need to be fit in regards to your health as we may need to give
general Anaesthesia( put you to sleep during the time of the operation).
3. I am here to see whether you are fit to undergo this operation and well as to see whether this can be done as a day case
procedure.
4. Pt: Are you going me give me general Anaesthesia?
Dr: We may be able to do it under local anesthesia however if we find any problem during the procedure we may need to
give you general anaesthesia. So we need to prepare you for the general anesthesia also.
5. Dr: Do you know what is day case surgery? Pt: No doctor.
6. Dr: We will give you a date for the surgery. You need to come to the hospital on the same day of the surgery and after
the surgery we will discharge you on the very same day if everything is fine. Pt: OK
7. Dr: I need to ask you few questions regarding your health and I will be examining you later and also we may do some
tests on you. Is that Ok? - Pt: Yes doctor.
8. Dr: How is your general health at the moment? Pt: It is OK doc.
9. Dr: Do you have any symptoms like Fever? Shortness of breath? Diarrhoea? Pt: No
10. Dr: Do have any medical problems at all now or did have any medical problems in the past? Pt: Yes doctor I have
diabetes.
11. Dr: Do you take any medications for that? Pt: I take Insulin doc.
D  Fasting and no insulin on day the opration
12. DR: How many times do you take Insulin? Pt: I take short acting 3 times a day and long acting one at night (Lantus
or ultra lente ).
13. Dr: Do you keep checking your sugar regularly and is controlled well at least in the last few months? Pt: Yes doc.
14. Dr: Did you have any problems during or after the last surgery when we fixed the fracture. –Pt: No
15. Dr: Do you have any other medical conditions apart from diabetes? Pt : No
16. Dr: Do you smoke ? Pt: No
If he is smoker ... 1 month before the opration
If the oepration is 2 weeks from now --> At least for now please stop till the operation
Smoking (stop) Alcohol (cut down = gradual stop to not cause withdrawls)
17. Dr: That is good. Do you drink alcohol ? Pt : No
Alcohol: Do not drink alcohol the day before the oepration .. or the day of the operation

88
 If he is not smoking or drinking alcohol  Praise him.
I wish everyone was like you.
18. Dr: Good. Are you taking any other medications apart from Insulin ? Pt: No
19. Dr: Are you allergic to anything at all? Pt: No
20. Dr: Do you have any loose teeth or denture ? Pt: No
21. Dr: Any problems in the neck ? Pt : No
22. Dr: Do you have any one to look after you after the operation ? Pt: Yes, my neighbor will pick up and drop me
back to home after the operation.
23. Dr: You should have some adult to look after you at home at least for 24 hours after we send you home. They should stay
at your home to look after you. Do you have any one like that to look after you? Pt: Ok doctor I will ask my
neighbor. They will do that. ( If patient says he cannot arrange any one to stay at his home to look after him – tell
him that we may not be able to do it as day case surgery then we may need to keep you in the hospital for a day at
least before we can discharge)
if he says my neighbour is close, i need to tell him that he needs someone to stay with you at home
24. Dr: How far away do you live from the hospital ? Pt: It is about 10 minutes drive from the hospital doc.
25. Dr: Is there anything else which may be important that we need to know ? Pt: No

3. Counselling:-
1. Examination of all systems
2. Dr: Mr Thomas, with the information what you have given it seems that you are fit to undergo this operation and we can
bring you for day care surgery.
3. However, after I examine you, and check your height and weight and do some tests like Blood tests ( like your sugar and
other tests), ECG and Chest X Rays we will tell you whether you are definitely fit for this procedure and for day case
surgery.

4. Preparation :You need to come prepared properly for this surgery.

1. You should be on empty stomach at least for 6 hours before we do the operation.
2. So please do not have your breakfast and your morning Insulin on the day of the surgery.
3. When you come to the hospital we will check the sugar and give the Insulin if required.
4. DR: Do you have any concern?
Pt: Doctor last time after the surgery I was sick many times. Will it happen again after this surgery? In that case
can you still do this as day case surgery?
Feeling sick = nausea - Being sick = disease
Dr:
a) Mr Thomas, Sometimes people do vomit after the operation because of the effect of the Anaesthetic medication or
as a side effect of pain killer medication.
b) Just because it happened last time it does not necessary mean that it will happen this time also.
c) We can still post you for day case surgery.
d) However, if you do vomit this time we will give you anti-sickness medication and if it helps then we can send you
home but if you continuously keep vomiting even after the giving you the anti-sickness medication we will keep you
in the hospital. So we may not be able to send you home that evening.
5. Post – operative management :
1. After the operation once you recover from the Anaesthesia you can have some food and take your usual Insulin if you
take at that time and wait for some time and if everything is fine, we will discharge you on the same day.
2. After the procedure and do not sign any important documents or work near heavy machinery at least for 24 hours.
3. Please do not drive until you are able to apply emergency break without any problem which may take about 2 weeks.
4. Also make someone stay with you to look after you at least for 24 hours after the procedure. After the operation – when
you go home we will give you our telephone number – you can contact us if you need any help after the operation. Are
you ok with these ? Pt: Will there be any complications?

Dr: Very rarely there can be damage to the nerves when we remove the pins and infection in the operated area later. If
there is any redness, pain or pus discharge from the operated site these are the signs of infection – if you have these -
please come back. Pt: Ok
89
5. Dr: Any other questions? Pt: No Dr: Thank you.
6. If the patient says he had severe vomiting after the previous surgery – he may be worried whether he will have that
problem again and how can he go home on the same day.
a. Reassure that just because it happened last time it may not happen this time. He can still be posted for day case
surgery.
b. Vomiting usually happens due the effect of anaesthetic medication or as side effect of pain killer medications.
c. If it happens this time we can give him anti emetic medication and keep him in the hospital for sometime and if he is
better before night he can be discharged otherwise he will be kept in the hospital – so be prepared to be admitted].

9. Inguinal Hernia Pre-operative Assessment & Address concerns

You are FY2 Doctor in Surgical Department.
45 years old man has been admitted to the ward for the Hernia Operation.
On pre-operative assessment, nurse has found the blood pressure to be 155/88.
He has been assessed already. Your Surgery Consultant is due to come to take consent for the surgery.
Talk to the patient, describe the operation, and address his concerns.
A.
1. Dr: Hello. I am Dr...Junior doctor in the surgery department. How may I call you? Pt: You can call me...
2. Dr: How are you doing Mr...? Pt: I am fine doctor.
3. Dr: That is good. Mr. Do you know why you are here today ?
Pt: I have hernia doctor. Your Consultant told me I need to have an operation. They wanted to assess me
before the operation.
B.
1. Dr: That is right. Do you know about your condition and why we are planning to do the operation for that ? Pt:
No, doctor, I don't know much really but I know I have hernia.
2. Dr: OK. Do you want me to explain everything to you? Pt: Yes doctor, I will like that.
3. Dr: A hernia occurs when an internal part of the body like intestines in the tummy pushes through a weakness
or gap in the tummy wall and comes out like a swelling. Are you following me? Pt: Yes.
a. Dr: This usually happen if pressure inside the tummy is increased for example due to coughing or
straining while opening bowel.
b. Most of the time this swelling goes in and out because the contents of the hernia goes inside the tummy
when you lie down and comes out again while standing our coughing.
c. Let me draw it for you on this page and maybe you can understand it better.
d. (Examiner might give a piece of paper and a pen for you to
draw for making the patient figure it out better)
e. Dr: Are you following me? Pt: Yes, doctor.
f. Dr: If we do not treat this condition sometimes this hernia gets
obstructed means the contents do not go inside the tummy and
it can become a serious problem. So it is very important to treat the
condition now. Do you follow me? Pt -Yes.

4. Dr: Do you have any idea how we are going to treat you ? Pt: Yes doctor,
I was told that surgeon would operate on me.
5. Dr: Yes, that is right Mr... Unfortunately we cannot treat this condition with any medication. Only option we
have is to do the operation. Do you have any concerns at this stage? Pt – No
C.
1. Dr: I need to ask you few questions about your health because for this operation, you need to be fit in regards
to your health. Also after the operation, we might have to request you to make some lifestyle changes to prevent
similar problems from happening again in future. Is that fine? Pt: Yes doctor.
90
2. Dr: How is your general health at the moment? Pt: It is OK doc.
3. Dr Did you undergo any surgeries previously? Pt : No
4. Dr: Have you been diagnosed with any medical conditions at all? Pt: No doctor.
5. Dr: I see. Well, Mr... I would like to tell you that nurse examined your blood pressure and she found that it was
a bit on the higher side. Have you ever been diagnosed of high blood pressure before ? Pt: No doctor.
6. Dr: I see. Your blood pressure is mildly elevated so you do not need to worry. However, we might have to take
Opinion from Cardiology Consultant that is the specialized doctor for such problems. We will have to see
why you are having the high blood pressure and control the blood pressure before we can do the surgery. Is that
alright? Pt: Yes doctor. Thank you.
7. Dr: Do you have any symptoms like Cough? Constipation ? Straining on Urination? Pt: No
8. Dr: Do you smoke? Pt: Yes doctor.
9. Dr: Could you please tell me how much do you smoke and for how long? Pt: I smoke almost 20
cigarettes or more daily for 20 years.
10. Dr: Could you tell me what do you do for living? Pt: I work in a warehouse/construction company
11. Dr: Does your work involve lifting or pushing heavy weights or standing for long periods of time? Pt:
Yes.
D.
1. Dr: Okay, Mr... I would now like to explain you how we are going to do the operation. Let me tell you about
your options. Is that alright? Pt: Okay.
2. Dr: Surgery is the main treatment for hernias. It’s a very common operation and a highly successful procedure
when done by a well-trained surgeon so you do not need to worry about anything because we have the best
surgical team.
3. We have two types of surgeries either an Open Surgery or a Key-Hole Surgery.
4. Did my Consultant tell you what type of surgery we are going to do on you ? Pt: He said open type.
5. Dr: Do you want to know how we do the open surgery ? Pt – Yes.
6. Dr: Open repair involves making an incision or cut on the skin into the groin.
a. This incision is usually about 6-8cm long.
b. After this, surgeon will return the contents inside the hernia like intestines back to the tummy and then
he will repair the tummy wall defect.
c. A mesh is placed in the wall, at the weak spot where the hernia came through, to strengthen it. When
the repair is complete, your skin will be sealed with stitches.
d. These usually dissolve on their own over the course of a few days after the operation.
e. This might leave a bigger scar.
7. Pt: What is this mesh made up of? Dr: It is made up of a material called polypropylene a type of synthetic
plastic.
E.
8. Dr: I see. Do you have any concerns related to the surgery?
Pt: Yes, doctor. My Father had hernia too. Doctors gave him a truss to wear. Will you give me that as
well?
9. Dr: I see. Mr…hernia truss is a supportive undergarment for men designed to keep the hernia in place and
relieve discomfort. This is only a temporary procedure but it does not treat the hernia. It is used be used
temporarily until we do the surgery or for those people who are not fit to undergo surgery. Are you following
me?
Talk about truss only if the patient asks about it.
10. Pt: Will it hurt during or after the operation?
a. Dr: Unfortunately all surgical procedures are associated with pain more or less. But you do not need to
worry we will manage your pain very well.

91
 b. During the operation, we will be giving you local Anaesthesia where the anaesthetic medication is
injected to the swelling area, or spinal anaesthesia where the anaesthetic medication is injected to the
spine and the lower part of the body is made numb.
c. You will be awake during the procedure, but the area being operated on will be numb so you won't
experience any pain. In some cases, a general anaesthetic is used. This means you'll be asleep during
the procedure and won't feel any pain.
d. Are you following me ? Pt: Yes Dr: Any concerns so far ? Pt – No
e. Dr: After the operation as with any surgical procedure, there will be some pain during recovery.
f. Your pain will be most severe the first few days. Initially we will give you strong pain killer medicine
like morphine then we will give you pain killer tablets called Co-codamol when you are ready to go
home.
F.
1. Pt: How long will the operation last doctor?
Dr: The operation usually takes about 30-45 minutes to complete if there is no problems during the operation.
2. Pt: When will I be able to walk after the operation? Dr: After the surgery, you'll be encouraged to move
about as soon as possible immediately after the operation same day.
3. Pt: When can I return to normal activities? Dr: Most people are able to do light activities, such
as shopping, after 1-2 weeks, but you should avoid heavy lifting and strenuous exercises for about 4-6 weeks.
4. Pt: When will I be able to have sex? Dr: You may be able to have sex after about 2 weeks.
5. Pt: When can I drive doctor? Dr: It's usually advisable to avoid driving until you're able to perform an
emergency stop without feeling any pain or discomfort (you can practice this without starting your car). It will
usually be about 4 weeks after open surgery.
6. Pt: When will I be able to go back home?
a. Dr: You'll be able to go back home on the same day. Some people stay in the hospital overnight if they
have other medical problems or if they live alone.
b. Do you have any one to look after you after the operation ? Pt: Yes/No?
c. Dr: You should have someone to look after you at home at least for 24 hours. They should stay at your
home to look after you.
d. Avoid drinking alcohol, operating machinery or signing legal documents for at least 48 hours after any
operation if it involves general anaesthesia.
7. Pt: Ok doctor. Will there be any complications of the operation doctor? Dr: There can be infection,
bleeding or pain at the incision site. But we will be giving you antibiotics, and painkillers so the chances of
these problems are very less.
8. Pt: Can it happen again doctor?
a. Dr: Yes Mr.... Unfortunately, there is a very small risk of recurrence after surgery.
b. Although the risk is small, yet I would like you to make certain changes in your lifestyle that will prevent
this from happening again.
c. You have been smoking for many years now. Smoking can make the body tissues weak and also leads
you to coughing and that can make the hernia come back.
d. I'd request you to consider quitting the cigarette smoking and if you need any assistance for that then a
lot of help is available. Would you like that? Pt: Yes doctor.
e. Dr: In addition if you have to strain while opening bowel then also hernia can come back. I advise you
to eat high fibre diet and drink plenty of fluids to avoid having constipation. Pt: Yes doctor.
f. Dr: Also, you should Avoid Lifting Heavy Weights following the operation. As you have told me, your
work involves lifting/pushing heavy weights, it is very important that you do not do it because this could
result in reappearance of this or similar swelling on the opposite side or elsewhere. Is there a way you
could change your work type? Pt: I don't think so. It is my job doctor. I have done it all my life.

92
9. Dr: I can understand. I advise you to talk to Job Centre and see if you can get any other suitable job where you
won't have to do a physically straining work. Okay? Pt: Okay.
10. Dr: Also you must Maintain a healthy weight. Pt: Do I need to come back for a follow up after the
operation? Dr: You should make an appointment for your follow-up visit in two weeks.
G. Warning signs
1. Pt: Is there anything I need to be careful about after I go back home?
Dr: If you have fever, bleeding, increased swelling, pain in your abdomen, pain not relieved by painkillers,
persistent nausea or vomiting, coughing or shortness of breath, increasing redness surrounding your incisions
or difficulty passing urine you need to come back to see us. Is that alright? Pt: Yes, doctor.
2. Dr: Do you have any concerns? Pt: No, thank you doctor. You have been very kind.

10. Fluid infusion to child with Appendicitis.

Child diagnosed with Appendicitis. Planned for Appendicectomy.
Child kept nil by mouth. Consultant advised IV fluids.
Calculate and prescribe IV fluids.
Explain the father about the necessity of giving IV fluids to his child.
Do not explain about the operation. Child is 6 years, Weight – 25 kg

A. Formula
 Daily maintenance fluid requirement in paediatrics.
 Formula: 100mls/kg for the first 1 to 10kg; then 50mls/kg for the next 1 to 10kg; then 20mls/kg for the next 1 to 10kg.
( Max – 2 litres in females and 2.5 litres in males)
 Fluid bag contains 500ml.
B. Assess knowledge.
2- Explain condition if he is not aware – Child has appendicitis. We all have any organ in our tummy called appendix which
looks is like a finger attached to the beginning of the larger bowel ( gut). Normal it has no important function in the body.
In your child this organ in inflamed or become sore. Only treatment is operation and remove that organ. He will lead a
normal life afterwards.
3- Need to give him IV fluids  We cannot allow him to eat or drink at the moment until and after about one or two days
of the surgery.
a. If his tummy has food when we Anaesthesia for the operation sometimes the food comes back from the stomach to
the food pipe and then it can enter the wind pipe and can cause severe infections in the lungs. To prevent this
happening his stomach should be empty when we do the operation.
b. Also since we cannot feed him by mouth for his energy requirement and to prevent dehydration we need to give him
fluids through his veins.
4- What type of fluids
a. We will be giving him fluids which contains glucose for his energy and also salts to prevent dehydration.
b. Is that OK ? Any questions ?
C. I need to write up the fluid prescription for him is that OK ?
1- Then write prescription on the fluid chart provided. (The paper includes maintenance fluid replacement formula).
Calculator is kept in the cubicle. Use the Formula
a. 25kg child = 10kg + 10kg + 5kg
b. First 10kg = 100mls × 10kg = 1000mls
c. Next 10kg = 50mls × 10kg = 500mls
d. Next 5kg = 20mls × 5kg = 100mls
e. Total fluid = 1000mls + 500mls + 100mls = 1600mls/day.
f. 1600 divided by 24 hours = 67ml/hour.
2- Full name -- data put -- Allergy (i need to fil up after asking the patient - I need to write NKDA = now known drug
allergies)
3- There will be calculator in the plab station
4- I have to write nil  I need to sign - the next sign i do not do it

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 a. Date:
b. Fluid: Dextrose. Saline
c. volume: 1600 ml/24 hours
d. Rate: 67 ml/hour
e. Additives: Nil
f. AMount: Nil
g. Sign: My sign
5- Ask about Full name, DOB, past history of any medical conditions? Any medications? Allergy
6- Do not forget to date and sign.

Unlabeled blood Samples: Medical Error (tel conversation)

As part of pre-op assessment ( herniorrhaphy) of a patient, you took samples for FBC, EUCr. The laboratory denies the receipt
of the samples. It appears you were too busy in the clinic and you forgot to label the samples. Call the patient and tell the
patient to come back so you can re-collect the samples. Patient has been informed you will be calling. Patients name, address,
DOB and hospital number given.

11. Post herniorrhaphy wound infection

35 year old man underwent herniorrhaphy one week ago. Now he presents with discharge, swelling, oozing and
redness at the site of incision in the groin area.
Talk to the patient.
Infection rate in this hospital is not more than National infection rate.
A.
1- Dr - I am Dr… one of the junior doctor in the surgery department in the hospital. How can I help you?
2- Pt – You are a junior doctor. I don’t want to speak to you. I had surgery a week ago and see now what has happened?
Some dirty discharge is coming out of my wound, it is smelling horribly, my wife is not coming near to me, I can’t even
go to my work. My wound is healing. I want to talk to your consultant.
3- Dr – I can certainly imagine how you ae feeling. I’m sorry for what is happening to you. I do understand that you want
to speak to my consultant but my consultant is busy at the moment. Don’t worry I’m here for you. I will try to explain to
you what is happening and we will do our best to help you. My consultant will see you as soon as he gets free.
B.
1- Dr: Can I ask few questions about it? Pt: Yes
2- Dr: Fine when are you having this discharge from the wound ? Pt: Last few days
3- Dr: Do you have any pain there ?Pt: Yes / No
4- Dr: Do you have any fever? Pt : No
5- Dr: Do you have any other medical conditions ?Pt: No
6- Dr Do have diabetes ? No
7- Dr: Are you taking any medications? Pt: No
8- Dr: Are you allergic to any medications ? Pt : No
C.
1- Dr: I need to examine your tummy? [Patient will show a picture – doctor this is how it looks like]
Dr: I can see your wound is bit red and there is some pus discharge there.
2- Pt – Why has this happened to me?
Dr – This happens when there is an infection of the wound, which means there are
germs/bugs growing there.
3- Pt – How/From where did I get this infection?
Dr – It could be due to many reasons.
a. These bugs could be from inside or outside the hospital. We do take all the measures
to prevent people getting infections after the operations. We do the operation in a clean
theatre, we give antibiotics and keep cleaning and changing the dressing regularly to prevent infections. Unfortunately
sometimes people get infections despite all the measure what we take.

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 b. However sometimes this infection can happen from outside the hospital. If the dressing on the wound becomes dirty
and if it is not kept clean bugs can get into the wound.
c. Can I please ask you were you able to take care of the wound ? Who was changing the dressing for you?
d. Patient: Yes I was able to take care of the wound properly / I was not able to take care of the wound properly.
4- I am sorry this happened to you. You have done a good thing by coming to the hospital. Right now what’s important is
that we take care of you.
5- Pt – What will you do for me now?
Dr - We need to admit you now. We will clean the wound, change the dressing and give you pain killers & antibiotics
medications. We will also take a blood sample and sample from the wound to check which exact bugs causing this
infection and send it to lab.
6- Pt – What! Admit me again? I have to work! I have to look after my family.
Dr – We are trying to do best for you. If you wish we can give you a sick note.
7- Pt – But I am self - employed. I will lose my income.
Dr – I can imagine your problems. However your health is more important. If you go to work it might get worse because
you may catch other bugs which will be more difficult to treat then. We need to give antibiotics through your vein which
cannot be given at home.
You may be entitled to tax benefits and child tax credit. You can take advice from Citizen Advisory Bureau.
8- Pt – How long will I be admitted for?
Dr – It may be for few days. As soon as the infection is cleared you can go home
9- Pt: What will you do so that these things will not happen again?
Dr: We look into all these type of problems very seriously. We have something called as Root causeanalysis meeting
where we discuss these type of issues. If there is anything need to be changed in our practice we will do that.
10- Pt – I want to complain
Dr – Yes you can if you wish to do so. You can talk to the Patient Advisory Liaison Service (PALS) and they will help
you. Pt – OK
11- Dr – Any other concerns Pt – No
12- Dr – Thank you very much.

12. Wound infection after cyst removal.

25 year old lady underwent an operation to remove a cyst from her knee 2 weeks ago. She developed infection in her
wound after that. She was admitted and again treated with the IV antibiotics. Infection has cleared now. She wants
talk to a doctor.
Talk to her and address her concerns.
A.
1. Dr - I am Dr… one of the junior doctor in the surgery department in the hospital. I understand that you want to talk to a
doctor. Can I help you Miss… ?
Pt – Yes doctor. I had an operation to remove a cyst from my knee 2 weeks ago.I was sent home and then I had
infection in the operation site. I was admitted again here and they gave me some medicine. Infection has cleared
now. I want to know why did I get this infection ?
B.
1. Dr: I am very sorry that you have to go through this problem. Can I ask you little more details about it so that I can answer
your questions better ? Pt : Yes
2. Dr: Can I ask you did any doctor explain you about the operation properly to you before the operation? Pt : Yes
3. Dr : Did they mention what are the benefits and what problems you may have after the operation ?
Pt: Yes they told me something but I can’t remember everything now.
4. DR: No problem Miss… Can you please tell me what happened after the operation – how long you were in the hospital
? Pt : It was a day case surgery so I was sent home on the same day.
5. Dr: I see. What was told to you when you were discharged – did any one explained to you how to take care of the wound
like changing the dressing or how to keep the operation are clean ? Pt: Yes they told me to change the dressing ….
6. Dr: Were you given any medications to take at home like any pain killer medication or any antibiotic medications? Pt: I
was given pain killer medication but not the antibiotics.

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7. Dr: Ok Thank you for the information. You asked em why you got this infection - Let me answer your question now
Miss…
a. Usually after almost every operation there are chances of people getting infection.
b. We take lot of measures so that people do not get infection after the operation we do the operation in the operation
theatre which is very sterile and clean and we keep the hospital very clean to prevent getting infection from other
patients and we change the dressings on the wound fequently in a very clean manner to prevent the infection.
c. Also in some type of operations if the chances of infection is very high then we give antibiotics to prevent people
getting the infection.
d. However, despite all our efforts sometimes people do get infections for so many reasons.
e. We usually mention about the benefits and risks of operation including the risk of people getting infection after the
operation to the people before they undergo the operation. It is very unfortunate that you got this infection.
8. Pt: Why the antibiotics was not given to me ? May that is why I got this infection.
Dr: Miss. We usually give antibiotics to only such operations where the chances of people getting is very high.
a. We do not give antibiotics if the chances of people getting infection is very low, ecause if we give antibiotics to
everyone even when the chance of infection is very low then the bugs can develop resistance to these antibiotics.
b. In the future if the people get infections from similar bugs then these antibiotics do not work and the condition can
become very serious and it can even be life threatening.
c. That is why we avoid giving unnecessary antibiotics.
d. The type of operation what was done to you – the chance of people getting infection after the operation is very low.
That is why the antibiotics was not given to you.
9. Pt: But I got the infection.
Dr: It is unfortunate that you got it. We generally advise patients that there is slight chance of getting infection and we
advise them of the signs and symptoms of infection and ask them to come back if they have such symptoms. We are
usually able to treat the infection if it does develop. That is what was done in your case Miss…
10. Pt: I am not happy about this.
Dr: I can certainly imagine how you may be feeling about this.
a. I will be reporting about this incident. I can reassure that the concerned authorities will look at this and take appropriate
steps for this.
b. In the future if lot of patients get infections after this type of surgery may be we need to think of giving antibiotics to
prevent the infection.
c. Miss.. You have all the rights to put a formal complaint about this if you wish. We have a dedicated department for
this called PALS. They will help you with this.
11. Pt: Thank you I will think about that.
Dr Any other concerns Miss.. Pt: No
Dr: Thank you very much Miss. Once again I am sorry that you had this problem.

13. Clostridium difficile Infection - Talk to Son.

You are FY 2 doctor in the medical department.
Mr. Andrew Reece 65 year old man had been admitted to hospital for exacerbated COPD ( or Pneumonia)
10 days ago. He has been treated with the appropriate IV antibiotics and has now developed acute diarrhoea.
His stool samples are taken and revealed presence of C. difficile Toxin.
He has been shifted to a bay with other people with similar condition and been started on treatment.
His son is concerned about him.
Please talk to him and address his concerns.
A.
1. Dr: Hello. Are you Mr. Andrew Reece’s son? Son: Yes.
2. Dr: I am Dr. …. One of the junior doctors in the medical department. How can I call you? Son: (?)
3. Dr: How are you doing Mr...? Son: I am fine. I am worried about my father. I just came to see him. He
has been shifted to some other room. I can see doctors and nurses wearing aprons and gloves. What is
happening to him doctor?
B.
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1. Dr: I can see that you are very concerned, I will explain everything. Before that can you please tell me how
much you know about what is happening to him?
Son: I know that he has COPD. Now, he has developed diarrhoea. I think he has got food poisoning
because of the food that you give him in the hospital.
2. Dr: You are right that he had COPD and yes, he has developed diarrhoea but it is not food poisoning and neither
it is because of the food that we are giving him in the hospital. We actually did some tests on him and it showed
that he has got some bugs in his colon.
Son: What kind of bugs?
3. Dr: These are bacterial kind of bugs called C. Difficile. Do you know anything about these bugs?
Son: No doctor. I don't know about the bugs but I know that you are responsible for this. He was perfectly
fine before.
4. Dr: You are a very caring son. I can imagine why you are so anxious. But let me assure you, we take really
good care of all our patients. Son: Then from where did he get these bugs?
5. Dr: Please let me explain it to you why your father has developed diarrhoea. Son: Okay.
a. Dr: Infection with this bug most commonly occurs in people who are in hospital and recently had a course
of antibiotics like your father. Are you following me? Son: Yes.
b. Dr: Actually, this bug is normally present in gut of many people. But it lives harmlessly. The number of
these bugs that live in the gut of healthy people is kept in check by all the other harmless bugs that also live
in the gut.
c. So, in other words, some of us normally have small numbers of these bugs living in our guts, which do no
harm.
d. If someone takes antibiotics for any infection as in your father's case, this antibiotic that he took not only
killed the bacteria that caused the chest infection, but also killed many of the harmless bacteria that lived in
his gut. C. difficile type of bugs did not get killed by this antibiotic.
e. When other harmless bacteria are killed then this allowed C. difficile type of bug to multiply. This bug also
started to produce poisons which are called as toxins and these toxins caused him diarrhoea.
6. Son: But doctor many other patients have developed diarrhoea as well. It has to be because the dirty
hospital food.
a. Dr: I can see why you are thinking that it is because of the hospital food. But let me tell you that we do keep
the hospital very clean.
b. We take really good care of hospital hygiene. The food provided in our ward is prepared under strict aseptic
techniques.
c. Every member of the health care team wash their hands thoroughly and wear aprons and gloves to minimize
the chance of spread of any kind of the infection to patients.
7. Son: Well, other people get it. Why did they get this bug?
a. Dr: Despite the good medical care, sometimes, it can spread to other people. It can happen that the spores
produced by the bugs can spread from the faeces of infected person to a non-living surface and from there
can spread to the patients who are prone to this infection.
b. Sometimes people can get this infection because new patients keep coming into the hospital and they may
have this infection and it spreads to patients already admitted in the hospital.
c. These bugs also spread through contact with contaminated objects such towels, sheets, clothes, dressings,
surfaces, door handles and floors.
d. And so regretfully, sometimes further spread can occur via the hands of healthcare workers despite all the
caution.
8. Son: Are you sure that he had this bug?
Dr: Yes, as I have mentioned we have tested the blood of Mr. Herman. We have found C. Difficile type of bug
in his blood and it is risen because of the antibiotic that he used in order to treat his chest infection.
9. Son: But why did he get this bug?

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 Dr: Well, as I have told antibiotics are the main cause of this infection. And above 60 years, there is increased
threat of getting infected with this bug.
Also, in your father's case because he has COPD, his body resistance would be low. So there is a fair chance
that bugs got inside his body and caused this infection.
10. Son: How are you treating him doctor ?
a. Dr: Well, Mr. Herman is closely monitored. We have stopped the antibiotics that we were giving him
previously for his chest illness.
b. This will allow the normal harmless bugs to thrive again in the gut. The overgrowth of C. difficile should
then reduce and diarrhoea will stop.
c. However, we will be starting him on a different antibiotic that is known to kill C. difficile. This is
usually vancomycin or metronidazole. Symptoms then usually ease within 2-3 days.
d. As with any cause for diarrhoea, it is important that we replace the fluids that are lost in the diarrhoea. So,
we will be giving him fluids through a drip into his veins to keep him hydrated. Are you following me?
11. Son: Is it serious doctor?
a. Dr: At the moment these bugs are just present in his colon and it is not causing any problems to him. So it is
not a serious problem to him at the moment. However, in very rare cases if the infection is not treated at the
right time, it can become very serious.
b. Son: Can there be any complication?
c. Dr: In small number of cases, if not managed at the right time, it can progress into a serious illness in which
swelling of intestine develops and for that, surgery may be needed.
12. Son: Why he has been shifted to the other room?
a. Dr: I can imagine why you are so worried. As I explained, this infection can spread from one patient to
another patient easily if they are close to each other in the same room. We have to keep him in a separate
room so that the bugs will not spread. It is beneficial to him also because there are no other patients in that
room, so he may not get any other kind of bugs from others.
b. Son: Can't you give him any medicine to stop his diarrhoea?
c. Dr: Anti- diarrhoeal medicines are not recommended in this infection. This is because it is thought that they
may slow down the rate at which the poisons (toxins) produced by the bacteria are cleared from your gut.
13. Son: How long will he need to be in the hospital?
a. Dr: It may take few days to get rid of this bugs. We will keep checking that. Once he get rid of this bugs and
he has no other problem then we will discharge him.
b. Son: Can I see him doctor?
c. Dr: Surely you can see him if you yourself do not have any medical conditions because if you have any
medical conditions then you may catch this bugs easily. You can enter his room and see him.
d. However, we suggest you to wash your hands thoroughly before and after you enter the room also you should
wear apron and gloves and minimise touching him or anything else inside the room so that this bugs will not
spread. Is that alright? Son: Ok doctor.
14. Dr: Any other concerns? Son: No doctor.
15. Dr: Thank you very much, I hope Mr. Herman will recover soon. If you need any other help please let me
know.

14. Telephone conversation with mother about child button in x ray

You are FY2 doctor in A & E Department.
A mother brought her 2 year child to the A&E department for swallowing of foreign body.
You examined her and did the X Ray. You thought the X ray was normal and discharged the child.
Later on Radiologist called and said there is some button ( foreign body) in the Oesophagus of the child.
Call the mother over the telephone who is at her home and tell her to bring the child back to the hospital.
A.
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1. [ X Ray may be on the table – Look at the X Ray before you call the mother].
2. Mother’s and child information ( Name and address) may be written on the table – confirm that with the mother.
3. Dr: Hello I am Dr ... junior doctor from the accident and emergency department of the hospital. Are you Amie’s
mother speaking? Mother: yes Dr I am. What is the matter doctor?
4. Dr: Actually Ms Jane you brought your daughter to the emergency in the morning. Is that right? Mother:
yes
5. Dr: I am the same doctor who saw your child and did the X Ray. I told you that her X ray is normal and told
you that you can take her home. Mother: Okay.
6. Dr: How is she now ? Mother: She is fine now.
B.
1. Dr: That’s good. Ms Jane Our Radiologist had a look at Amie’s X ray again. He said that there is some foreign
body in her food pipe. It looks like a button. I am really sorry that I told you that the X Ray does not show any
foreign bodies.
Mother: OK.
2. Dr: Do you have any idea what she might have swallowed ? Any button from her dress or any other’s dress
missing ? Mother: yes Dr she was wearing a buttoned shirt today. I don’t know now whether any buttons
missing.
3. Dr: Alright. Is she having any sort of breathing difficulty? Mother : No
4. Dr: Is there any other problem like drooling from mouth? Mother: No doctor she is completely alright.
5. Dr: Is she eating and feeding well? Mother: She ate and drank after I brought her back and she is
fine.
6. Dr: okay That is good. Ms Jane can you please bring her to the hospital for further assessment. Would that be
alright? Mother: I don’t get it if she is alright why do I have to bring her to the hospital. I am getting
late for work.
C.
1. Dr: I am really sorry Ms Jane about the problems you have to go through because of the missed finding. But
as it is shown in the X ray that the foreign body is in the food pipe (oesophagus) so she requires observation
and reassessment. We may need to do some procedures to remove it if required. For that you have to please
bring her to the hospital immediately.
2. Mother: Is she in any danger?
a. Dr: I am really sorry to say this because sometimes the object which is in the food pipe can get stuck
there and may not go down or if it is some type of poisonous objects then it can cause damage to the
food pipe.
b. But as she is having no symptoms so hopefully there is nothing to worry about. When she will be here
we will assess her again. We will treat her depending on the level at which the foreign body is in the
food pipe.
c. If we think it may cause problems especially if it is still in the food pipe then we will try to remove it.
But if it has already gone down to the stomach then it may not cause any problem then you can take her
back because it will pass out on its own. Is that OK?
3. Mother: But why this mistake happen ?
a. Dr: Mrs .. Actually I made the mistake as I told you. I am a junior doctor here and I am not that
experienced in reading the X Ray. It was not easily visible in the X Ray. Only the expert doctor that is
Radiologist could see that.
b. However, I do apologize for the incident I will go for some courses and learn how to read the X Rays
very soon. I will reassure that such mistake will happen again Mrs…
4. Mother: I don’t want to complain but I don’t have a car. I don’t even have money to pay for the taxi. I
can’t come.
Dr: I am really sorry for the incident again. Mrs. We can send an ambulance. Can you please bring your child
in the ambulance ? Mother: Yes doctor.
[ sometimes she may say that she has not time at all – in that case
Is that ok if we send the social services – can you please send Amie with them ? Mother – Ok ]

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5. Doctor: Once again I am really sorry Ms Jane for causing you all the problem to come to hospital again. I am
really regretful and I apologize that it was missed in the morning. I am really glad to hear that Amie’s is doing
alright at the moment. We will see her again soon.
Mother: yes doctor.
6. Dr: If you want you can also make a formal complain about this. We have a special department called PALS (
Patient advisory liason service) who will assist you regarding this when you come to hospital. Mother: Okay
doctor.
7. Dr: do you have any other concern Ms Jane? Mother: No.
Dr: okay hope to see you and Ammie in the hospital again soon.

15. Medical error – Rash after Amoxycillin

Exam question
You are an FY 2 doctor in the A& E Department.
8 year child Amie was given oral amoxicillin for chest infection and was sent home from the A& E
department last night. She has developed rash.
Her mother Mrs Jenny Carr has some concerns talk to her.
A.
1. Dr: Hello I am Dr ... one of the junior doctors in the department. Are you Amie’s mother? Mother: Yes dr.
2. Dr: How can I help you?
Mother: Doctor, I brought my daughter last night because she had fever and cough. Doctors here told
me she had chest infection. They gave some medications to her to take at home. I gave the medicines to
her and now she has developed rashes.
B.
1. Dr: Oh I am really sorry about that Mrs .... Do you know what medications was that? Mother : Amoxycillin
2. Dr: How many times did you give this medicine to her ? Mother : Twice.
3. Dr: Which part of the body she has rashes ? Mother; all, over the body.
4. Dr: Is the rash spreading? / is it widespread? Mother: No
5. Dr: Is the rash painful? Mother: .No ( for Toxic epidermal necrolysis-Steven Johnson)
6. Dr: Is it itching ? Mother : Yes/ No
7. Dr: Does she have any SOB? Mother: No
8. Dr: Does she have sore throat ? Mother : No
9. Dr: Swelling anywhere in body especially face and lips? Mother: No
10. Dr: Does she have any fever ( meningitis, Pneumonia)? Mother: No
11. Dr Does she have any headache, Neck stiffness ( meningitis) ? Mother: No
12. Dr: Lumps or bumps anywhere in the body ? Mother:... (lymphadenopathy for Drug hypersensitivity
syndrome, infectious mononucleosis)
C. Sometime the mother may say that her child developed allergic rashes straight away and ask you - why are
you asking other questions ?
1. Dr: May I know why do you think it is allergic rashes ? Mother: she had this allergic rash before also.
2. Dr: May I know when? Mother: few months ago. She was given the same medicine and she developed rash. I
was told that she is allergic to amoxycillin.
D.
3. Dr: You may be right Mrs... It could be allergic rash. I still need to make sure that it is not due to any other
serious medical condition like meningitis because as you may know there could be rashes even in menigitis.
4. Dr: has it happened for the first time? Mother: No actually it happened a five months ago as well....
5. Dr: Was it the same medication? what problem was the medication given for back then? Symptoms at that
time? Mother : … She was given the same medication. She had rash that time also.
6. Dr: Were you told that she is allergic to amoxicillin. Mother: Yes
7. Dr: Has she been diagnosed with any medical conditions? Mother: No ...
8. Dr: Does any of her family members have any medical condition such allergies ? Mother : No

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 E. EXAMINE: Tell the examiner - I would do a general physical examination including BP and Pulse. Also
I need to examine her face for any swelling and also have a
look at the rash.
Mother shows the picture
1. Mother: what has happened to my daughter?
Dr: Mrs .... I think this is allergic rashes due to
Amoxicillin.
2. Mother: Is she going to be fine? Is it dangerous?
Dr: Mrs ... I can understand why you are so worried.
Sometimes medication allergies can be serious but
thankfully she is not in danger as the rash is localized with no other symptoms. She is in good hands we will
ensure that she is well treated and completely alright.
3. Mother: What will you do now?
Dr: We will be admitting her and keeping her under observation for some time. We will stop the drug
immediately. We will look for any worsening of symptoms. Is that alright?
4. Mother: Yes .
Dr: We will give her some medication known as antihistamine syrup by mouth and some medication to apply
locally on the rash which will be a mild steroid. The rash will take a week almost to clear out. We will also
give some other antibiotic for her chest infection..
5. Dr: Is she allergic to Erythromycin ? Mother : No
6. Dr May be we can give Erythromycin to her. I will talk to my seniors and then we will give that antibiotics for
her chest infection.
7. Dr: Were you asked about any allergies before giving the medication by the staff?
Mother: No one asked me about it.
8. Dr: Oh, I am really sorry about that. This question is one of the routine and important questions we should ask
before giving any medication.
Mother: Why no one asked me ? Why did they give that medicine to her ?
9. Dr: As I mentioned earlier, whoever gave the medicine should have asked for allergy before giving medicine.
This is a mistake on our part. I am really sorry for what happened.
10. Mother: Will it happen again to her Doctor?
Dr: Mrs... We need to be careful because it is likely to happen again if the medication amoxicillin or any
medication from the class penicillin is given to her. We will give you all the necessary information in written
form on discharge paper. In future if you take her to doctor or hospital you should mention about the allergy.
We will also update her electronic medical records. Also you should educate her as she grows up. Would that
be alright?
Mother: yes
11. Dr: We will also update drug allergy status in all the GP and hospital records. Is there anything You want to
ask?
Mother: Can this allergy be prevented any way?
Dr: Yes surely we will be documenting details of everything this incident and also the previous incident. You
should carry this document with you at all times. So that it can be shown to any health care professional to
prevent it from happening again.
We can give test dose before giving any new medicine that is known to cause allergy. If person is found allergic
to it we give an alternative medication. Are you following me?
12. Mother: yes doctor. What will you do in the future so that these things will not happen again to others?
Dr: I really appreciate your concerns. Your feedback is very important. We are constantly looking for ways to
improve our health system. I will inform my seniors about this. We have something called as root causes
analysis meeting where we discuss any such issues and we take all the steps to rectify any such problems and
prevent it from happening again. You can also help us by reporting the matter. We have a separate unit to deal
with such concerns known as PALS (Patient advisory liaison service)
Mother: okay
13. Mother: Will she have any scar because of this allergy ?
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 Dr: Allergic rashes will heal completely without leaving any scar. Please do not be worried about it.
14. Dr: is there any other way I can help you? Mother : No doctor thank You.
15. Dr: hopefully ... will get better soon. If you have any concerns later on don’t hesitate asking. Thank You.

16. Medical Error- Misdiagnosed Pneumonia and Antibiotics given

unnecessarily
You are FY2 Doctor.
65 years old Mr. Pat Harding was diagnosed with Pneumonia 4 weeks ago.
On looking at his notes, you noticed that at the time of his presentation in respiratory clinic, X-ray Chest
was done. He was told that his X-ray result showed chest infection and he was admitted for a week and was
given given IV antibiotics and then later oral antibiotics.
Today, you have received a call from the Radiology Department. You are informed about the mixing of X-
ray Reports. Mr. Pat Harding's X-ray report is reanalyzed and is found to be normal.
Your consultant believes that he was misdiagnosed with Pneumonia and unnecessary antibiotic treatment
was prescribed to him.
Mr. Pat is here with you today for the follow up. Talk to him, tell him about the error and address his
concerns.
A.
1. Dr: Hello Mr. Harding. I am Dr …. one of the junior doctors in the medical department. How are you doing
today? Pt: I am OK.
2. Dr: Can you please tell me in detail what happened last time ?
Pt: I had some chest symptoms. I came here about4 weeks ago and the doctors did the chest X ray and
they told me I have chest infection. I was admitted for a week. They gave me antibiotic through my veins.
I have improved now.
B.
1. Dr : Which antibiotic ? Pt : Amoxycillin.
2. Dr: Any chest symptoms at all now ? Pt : No
a. Dr: Mr Harding I need to tell you something. A mistake happened at that time of your previous presentation.
b. Doctors did your Chest X-ray at that time and they told you that you have infection in your chest because
they thought your chest X ray showed chest infection. But in real this was not the case.
c. Unfortunately, another patient's report was mixed with your X-ray report. The doctors misdiagnosed you
with pneumonia and you were started on antibiotic which was unnecessary.
d. Your test result was later on found to be completely normal. I am very sorry to say this. I sincerely apologise
on behalf of the hospital. This should never have happened.
3. Pt: What !!! But why did this mistake happen ?
Dr: Mr. Harding as I have told you another patient's test results got mistakenly mixed with your reports. I can
only apologise to you now.
4. Pt: You doctors are very irresponsible. Why did the X Rays gets mixed up ?
a. Dr: Mr Harding.. I can see that you are very upset. I can perfectly understand that.
b. Whenever we check any test results like blood test or X Rays we doctors are supposed the check the identity
on the X ray before we read the X Ray.
c. I guess whoever saw the X ray at that time, did not check the identity properly or some other problem has
happened.
d. I am really sorry about this Mr. Harding. We usually take the maximum caution to prevent such mistake
happening..
5. Pt: Who is responsible for this mistake ?
Dr: We do not know exactly who is responsible for this at this moment but we are going to look into all this.
6. Pt: You people do not care for other’s life.
Dr: I am really sorry for what happened. I can certainly imagine why you are feeling that way. We do care for
everyone but sometimes mistakes do happen. We do take all the measures so that mistakes do not happen. Mr…
did you have any problems because of this medication what we gave last time ?

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7. Pt: I had sickness and loose stools unnecessarily.
Dr: Mr… you had to go through all those problems unnecessarily. I sincerely apologize for what happened.
8. Pt: Will I develop any long term problems with this antibiotics?
Dr: I'd like to reassure you Mr. Harding that no serious complication will happen in long term. Very rarely bugs
can develop resistance to this antibiotic but other than that, there will be no potential threat to your health at all.
9. Pt: What will you do so that these mistakes will not happen again ?
a. Dr: We will investigate this matter further.
b. We have a procedure where we report such incidents to the appropriate authorities.
c. We have something what we call as “Root Cause Analysis meeting” where we discuss such matters and
take appropriate actions so that these mistakes do not happen again. Also some actions may be taken over
defaulting persons.
d. We will educate staff, provide better supervision for juniors in every department, We will instruct everyone
to check the identity properly on any test results and may be a mandatory training for staff about dealing
with such problems.
e. Mr Harding if you like to escalate the matter further you can do it. We have a dedicated department for this
what we call as “ Patient Advisory Liaison Service” – you can talk to them about it.
Pt: Thank you doctor I will consider that.
Dr: I will like to reassure again that everything is fine with you now. If you need any help please let us know.
Thank you very much.

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 17. Missed - hair line wrist fracture in child.
4 year old boy brought into the hospital by his father previously ( ? yesterday) with wrist injury. His X ray
was done.
He was told that the boy has only soft tissue injury and no bony injury and was discharged with pain killers.
Later on Radiologist saw the X Ray and thought the X Ray showed greenstick fracture in the wrist bone.
His father was asked to bring his son back. Talk to the father and address his concerns.
A.
1. Dr: Hello Mr … I am Dr… How are you doing?
Father: I am fine. I was told to come back. What happened doctor?
2. Dr: I was told that your son had wrist injury. Can you please tell me in detail how it happened and what happened here in
the hospital and what was told to you ?
Father: He fell down from sofa yesterday and he had pain and swelling in his wrist. I brought him in here. Doctors
did the X Ray and they told me that he had no bony injury and he has only injured his muscle. They gave some
pain killer medications to give it to him.
B.
1. Dr: Yes. Mr… That is what I understand from his notes. But Mr… I need to tell you something about it. After he was
discharged from the hospital Radiologist saw the X ray and that your son’s X Ray showed a small fracture in the wrist
bone what we call as hairline fracture. Unfortunately, the doctor who saw your son did not see that fracture and he thought
there is no fracture. I am very sorry to tell you that this mistake happened.
2. Father: what …mistake happened!!! How is that doctor did not see the fracture if the other doctor can see that.
Dr: Mr… I cannot tell you why exactly the mistake happened. That fracture is like what we call as hairline fracture
which is very difficult to see in the X Rays unless one is very experienced in reading the X rays. Radiologist is the expert
doctor in X Rays, so he could see that. The doctor who saw your son … is not that much experienced in reading X Rays.
May be that is why he missed the fracture in the X ray. Once again I am very sorry the mistake happened.
3. Father: This is ridiculous. How can you keep such inexperienced doctors to treat patients ?
Dr: Mr… I can see that you are very upset. You have all the reasons to be upset. We do have junior to senior doctors in
every department. Whenever junior doctors have any doubt about anything they are supposed to consult the senior doctors
before they treat the patients. May be the doctor who saw your son had no doubt in his mind about the X Ray. May be
that is why he would have missed the fracture. However, at the moment I cannot tell you for sure why this mistake would
have happened.
4. Father: So what will happen to my son now?
Dr: Mr… First of all thank you very much for bringing your son … back here. My seniors will see him now. Depending
on the degree of fracture and if the arm has bent then we may need to manipulate ( do some procedures) to straighten that
bone and then we may have to put a cast ( like a plaster or splint) to his wrist and arm to treat the fracture.
5. Father: How long he will be on cast?
Dr: Usually it takes about 3 to 4 weeks for the fracture to heal. So he may need to be on the cast for 3 to 4 weeks.
6. Father: These type of mistakes can keep happening again and again ?
Dr: I can imagine why you are feeling so upset about the incident. I would like to reassure you that I will report this
incident to my seniors. This incident will be taken very seriously. In fact we have something what we call as “Root cause
analysis meeting” where we discuss this type of issues and take necessary steps so that such incidents will not happen
again. Hopefully this type of mistakes won’t happen again.
7. Father: I want to complain about this.
Dr: Surely Mr..you have all the rights to complain. We have a dedicated department for this what we call as PALS( Patient
advisory Liaison service). You can talk to them and they will help you to put formal complaint.
As I said before, I will also talk to my seniors about this. I am sure appropriate action will be taken. Any other concerns
? Father - No
8. Dr: Again I am very sorry for what happened. I do sincerely apologize from the hospital’s behalf for the incident. Thank
you very much for bringing your son back to us. I am sure your son..will recover soon.

18. Medical error – missed renal biopsy sample.

Exam question
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21 year old presents with suspected post streptococcal glomerulonephritis. Renal biopsy was done 2 days
ago. Lab said they did not receive the specimen. Talk to the patient about the missed sample.
A.
1. Dr: Hello Mr.... I am Dr.... How are you doing? Pt : I am fine doctor.
Dr: How are your symptoms now are they same or getting worse ? Pt : Same.
2. Dr: Mr... We did a procedure on you to take sample what we call specimen from the kidney to test what
condition you have 2 days ago do you remember ? Pt : Yes doctor.
B.
1. Dr: Mr... I am extremely sorry to say this, the specimen what we took is missing. We are not able to trace it.
I sincerely apologize for this.
2. Pt : What ? How can this happen?
Dr: Mr... After the procedure we have send the specimen to the lab but the lab is now told us that they did
not receive the specimen. We have tried our best to trace the specimen but we could not trace it. I am very
sorry once again.
3. Pt : How can you people be so irresponsible?
Dr: Mr.. I can imagine how you may be feeling now. I am really sorry for what happened. Usually we are very
careful so that these mistakes do not happen. But unfortunately some mistake happened somewhere and the
specimen is missing.
4. Pt : I do not understand – if you are so careful how can the specimen go missing?
Dr: Mr... I can see that you are very upset. I can perfectly understand. You have all the reason to be upset.
Usually after we do the procedure we label the specimen and then someone takes the specimen to the lab.
So the mistake could have happened anywhere like labelling, or taking the specimen to the lab, or collection
at the lab or it could have lost in the lab. At the moment, I cannot tell you where exactly mistake happen. We
are trying to find out what really happened.
5. Pt : Who is responsible for this?
Dr: Mr.. At this moment we are not sure who is responsible for this. We have reported the matter to the
concerned department about this incident. They will look into this issue.
6. Pt : So what will happen now?
Dr: Mr.. I would like to reassure that there is no serious harm has happened. However since the specimen is
missing unfortunately we need to take the specimen again. Will that be OK Mr...?
7. Pt : Well I guess it is OK. What will you do so that this will not happen again ?
Dr: I will reassure that we will take utmost care this time so that this mistake will not happen again.
8. Pt : I want to complain about this.
Dr: I perfectly understand your feelings. You can surely put a formal complaint about this. We have dedicated
department called PALS that is patient advisory liaison service and they will help with the complaint
procedure. I can reassure that this complaint will be taken very seriously and appropriate action will be taken.
9. Pt : What will you do so that this mistake will not happen to others?
Dr: I really appreciate our concerns to others. We have something called as root cause analysis meeting where
we discuss this issue to find out why this happened and we take all the measures so that this kind of mistakes
do not happen again.
10. Any other concerns ? Pt : No
Dr: Once again I sincerely apologize for the mistake. I will do the procedure again now and I am sure you will
feel better after the treatment. I wish you a speedy recovery. Thank you again for listening to me.

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 19. Medical student comes late to the hospital. Talk to him
SPIES

1. Seek info – what is the problem?

1. How are you doing? How do you find medical school ? what about the hospital posting ? do you like it? Do
you talk to patients in the hospital ? do you enjoy that ? Any problems at all ? do you come regularly ? do
you come in time to the hospital?
2. He may or may not admit to coming late
3. We noticed that you are coming late to the hospital may I ask why?
4. He may say that he gets up late. But I am late only few minutes.
5. Why does he get up late ? any sleep problem?
6. Any medical conditions ?
7. Any travel problems ?
8. Anything else bothering him?
9. How is he in studies? – praise him if he says he is good in studies.

2. Patient safety – It is not a good habit to come late. We being doctors we should be very prompt in our work.
We should be very punctual in our job. It is better that you develop that habit now itself. If the habit of coming
late to the job continues – once you become a doctor and come late to the work it may affect patient safety.
GMC can take actions which is not good for you.
3. Initiate : Do you keep alarm? I suggest you do that? Make habit of going to the bed early and getting up early.
Once you do it for sometime then you will get used to it and you may even like it. So you can reach the
hospital in time. As doctors we need to set an example to others by being prompt and punctual in our work.
4. Escalate: Do you have educational supervisor? Have you talked to him about this? I think it is better you
inform him about what is happening. If he hears from others it is not good for you.
1. Support: Is there any way I can help you ? Do you have any other problems ? I am sure your educational
supervisor also will help you in any way possible.

20. Refusing active treatment. - Changed question

Patient has lung cancer, radiologist says responding to the chemotherapy, however since past 6 months he was
being admitted for neutropenic sepsis. This was his 3rd time admission, and doesn't want anymore treatment.

Similar to DNAR station, but here he says he doest want active treatment and he will discuss with his daughter. He
has not thought of DNAR, he said he will discuss with her daughter. Tell him he can always change his decision.

21. Lady wants to change counsellor ETHICS

Scenario- 40 year old lady who went through a divorce 2 years ago has been attending counselling sessions.
She was on medication but has discontinued it since past one year. She is seeing a male counsellor and is
requesting to change her counsellor. Talk to her and address her concerns.

A.

D- “Hello,I am Dr.-------- one of the junior doctors in the department. I was told that you wanted to speak to me.
How may I help you today?”
P- “Dr., I want to change my counsellor”
D: May I know the reason why you are seeing the counsellor ?
P: I had 2 failed relationship. I am having depression and on medication - I was seeing him for that purpose.
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D- “Alright. How long have you been taking counselling sessions?”
P-
D-“Were you seeing the same counsellor from the start?”
P- “Yes”
D- “May I know why do you want to change your counsellor?”
P- “I prefer a female counsellor”
D- “Alright. I will talk to my seniors and we can arrange that for you. But is there any other reason that you would
like to change your counsellor?”
P- “Well Dr.,sometimes, he touches and hugs me.”
D- “Is this happening against your will?”
P- “No, Dr. , this is not his fault. I have been encouraging it. We went out for few dates. But I came to know
he has a girlfriend. And I feel what we are doing is wrong. I have no complaints against him. I just want a
female counsellor.”
D- “Ok, I am glad that you have opened up to me. However, I must tell my seniors because we do not encourage
this as it is against our professional ethics.”It is unethical for a doctor to have relationship with a patient.
P- “Dr, I don’t have any complaints at all.”
D- “I understand that. Unfortunately, I must tell this to my seniors and will also discuss your wish to change the
counsellor”
P- “Ok, Dr.”
Offer PALS.

22. Noisy relatives at hospital

Scenario- 92 year old female was admitted to the hospital after a history of fall. She was breathless at the
time of admission and she is breathless now as well. She is terminally ill. Other patients have complained
that there are a lot of visitors and they make a lot of noise all the time. Your task is to talk to the grandson
and discuss this matter with him.

(No visitors allowed from 2-5pm and only 2 visitors allowed at a time)

Grandson gives a history of his grandmother being unwell at the time of admission. Her condition is deteriorating
and the doctors have decided not to resuscitate. Relatives have come from far away and wanted to see her and
perform the last rites. They are Christian and want to chant prayers and wants their priest to be there. And also
wants to keep a Bible on the bed.

Cover the following points-

1. Respect religion and understand their beliefs

2. State that other patients are disturbed because of the noise (can disturb their sleep and can also harm their
recovery) and offer solutions –
3. - allowing 2 people at a time
4. - visitors are not allowed from 2pm to 5pm according to hospital policy. The relatives can see her after that.

(In the exam, grandson repeatedly says that doctors do not respect religion and the only way that they can perform
the last rites is by praying together in front of the patient)

Offer shifting his grandmother to a private room where they can perform the last rites at peace.

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 23. Mother with premature child – upset with nursing care
Child born at 24 weeks ( premature birth) was in the hospital for 2 years. Mother is very uset with the
nursing care – because there is no regular nurses. Nurses are temporary so no one knows properly about the
child.

1. Explain that the nurses usually works in shifts. We will try our best to appoint regular nurses. However
sometimes we have difficulty in getting regular nurses.
2. I will take this matter to my seniors and I am sure they will look into this and do something about this problem.
3. How is the medical care by doctors ? are you happy or not ? - I am happy with the doctors.
4. Mother: Do you think I should take my child to the private hospital?
5. Dr: I am really sorry if you are not happy with the way we have treated you and your child here.
6. We will definitely try our best to improve the care.
7. However it is up to you to decide whether you want to take the child to the private hospital.
8. Any other problem?
9. Offer PALS

24. Lady had Angiogram and had conflict with Physiotherapist and
Nurses.
Old lady with MI who had angiography done today morning. Physiotherapist has advised her to walk but she is afraid.
Talk to her. Assess knowledge – Had angiogram and Physiotherapist told her to walk.

1. Ask concern: She does not want to walk because she is tired. Also nurses told her not to walk. She is
confused.
2. Ask her any other reason: she can’t walk ( like any pain and imbalance). Besides that Physiotherapist
was very rude. Does not want that Physiotherapist. Wants some other Physiotherapist.
3. Apologize for conflict of opinion. This should not have happened. I will talk to the Physiotherapist and
the nurses to find why did they say that to see is there any particular reason to say that.
4. Usually patients do walk after few hours of the procedure. However, I will talk to the Physiotherapist
and my seniors and let you know when you can walk.
5. Talk about PALS, incident report.
6. We will take appropriate action so that this will not happen again.

25. DNAR
You are the FY 2 doctor in medicine department. Mr James Walker 72 year old man recently been
admitted to the medical ward for Pneumonia and has been treated. He is about to be discharged.
He has some concerns. He wants to talk to a doctor. Talk to him and address his concerns.
DNAR = Only not CPR
A.
1. Dr: Hello Mr James Walker ? I am Dr…. Junior doctor in the medical department. How are you doing
today? Pt: I am OK.
2. Dr: How is your Pneumonia ? Pt: I am OK now.
3. Dr: I was told that you have some concerns and you want to talk to a doctor is that right? Pt: Yes
4. Dr: Can I help you? Pt: Doctor, I don’t want to take this medications anymore? Dr: Why is
that? Pt: They make mesleepy?
5. Dr: Can you please show me which medications ? Patient shows – Enalapril, Aspirin and
Simvastatin,

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6. Dr: Why are you taking these medications ? Pt: I was given those medications 12 years ago when
I had heart failure.
7. Dr: Did you have any other medical conditions? Pt: Yes I had bypass surgery to my heart 20
years ago.
8. Dr: OK. We will see which one of this medication is making you sleepy. We will change that
medication and give some other medication. Will you take them?
9. Pt: Doctor I am tired of taking these medications. I don’t want to take medications any more.
B.
1. Dr: Why do you say that? Pt: I had enough in my life. I just want to go without suffering?
2. Dr: Can I ask you why do you feel that way? Pt: Doctor,I already had whatever I need in this life.
I had enough. I have accomplished everything in my life.
3. Dr: Is there any medical problem you have which is making you feel this way? Pt: No doctor.
4. Dr: Is there any other reason making you feel this way like are you feeling low for any reason?
Pt: No - Not at all
5. Dr: Is there anything we can help you with if you want to change your decision? Pt: No nothing like
that.
6. Dr: Can you please tell me do you do any job? Pt: No I am retired now.
7. Dr: What about your family ? Pt: My wife died of cancer few years ago. I have a daughter but she
has Rheumatoid arthritis.
8. Dr: Do you live with any one at all ? Pt: I live on my own. My daughter has arranged someone to
take care of me.
9. Dr: She is very caring. What do you mean by you had enough ? What do you have in your mind?
Pt: Doctor I want to die in dignity.
10. Dr: What exactly do you mean by that ? Pt: I was told you doctors do CPR if the heart stops
beating. I don’t want that to be done on me.
11. Dr: I see. Do you understand what is the meaning of CPR ? Pt: Yes I was told you compress
the chest if the heart stops beating to make the heart beat again.
12. Dr: That is right. But do you understand what will happen if we do not doCPR? Pt:Yes I understand
then the patient will die.
13. Dr: Is that what you really want. Pt: Yes that is whatI want. Dr: Have you discussed this with your
family members at all? Pt: I don’t need to discuss with them
14. Dr: Is that you don’t want us not to CPR only or do want us not to give you any active treatment if you
fall ill like giving medications through your veins?
Pt: Well, I don’t mind having active treatment but I don’t want CPR to be done. Can you please
bring that form?
Dr: Surely, I do respect your views. However this the decision has to be taken between you and my
consultant. I will speak to my consultant and get back to you. I need to tell you one thing, even if you
decide not to have CPR now, you can always change your decision later on if you feel like it.
Pt: OK thank you doctor. Dr: Thank you very much

26. Post-mortem examination

Post-mortem exam question
You are the FY 2 doctor in the medical department.

Mr Peter Green 64 year old man was treated for Pneumonia by the GP with antibiotics because he had
shortness of breath for 2 weeks. He was hospitalised one week ago because it got worse. He died of suspected
Respiratory failure.

His wife Mrs Green want to talk to a doctor about this issue. Talk to his wife Mrs Green and address her
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concerns.
( post mortem may not be mentioned in the question ).
A.
1. Dr: Hello Mrs Green, I am Dr …. Junior doctor in the medical department? How are you doing ?
Wife: I am not feeling good doctor. I don’t know what happened to my husband suddenly he died.
2. Dr: I am very sorry about it. Please accept my condolences for the loss of your precious one. I can’t even
imagine how you are feeling. I was told that you want to talk to a doctor about it. Do you have any concerns?
Wife: I am just wondering doctor why this happened so suddenly. He was doing good.
3. Dr: We think it could be due to infection in his lungs which has led to failure of the lungs has led to this. But
we are not very sure about it. However we need to know more about this. Can you please tell me what
happened before he was brought into the hospital?
Wife: He was short of breath since last 2 weeks. We went to GP and he said he has chest infection and gave
him antibiotics. He was getting more ill since last one week and we brought him to the hospital and he was
admitted a week ago. Now suddenly this happened.
4. Dr: Did he have any medical conditions? Any operations done recently? Any medications ? Any allergies?
Wife: Doctor, He had no medical problems at all. He has never been to the hospitals or GP before this.
He was completely fit and well. Why this happened doctor.
Dr: As I mentioned before. We think it could be due to infection in the lungs. We are not sure. I think it is a
better idea to do the post-mortem and find out about it. What do you think ?
Wife: My niece works as a nurse – she also told me that it is good to have the post-mortem.
5. Dr: OK, surely we can request for that if you wish to. Do you know what we do in the post- mortem? Wife: I
don’t know ?
a. Dr: We do the post-mortem to find the exact cause of death when we are not sure about the exact cause
of death. We do that in an examination room that looks similar to an operating theatre.
b. Pathologists ( specialist doctor) does the post-mortem.
c. During the procedure, they open the body and remove the organs for examination. Sometimes they know
the cause of death by looking at the organs.
d. Some organs need to be examined in close detail during a post-mortem and these investigations can take
several weeks to complete. They also will take some tissue samples from the organs and keep it for
future testing.
e. The pathologist will return the organs to the body after the post-mortem has been completed.
6. Wife: Who decide to hold the post-mortem?
Dr: It can be requested by a coroner (judge) or hospital or the close relative in this case like you can request
for the post-mortem.
7. Wife: When will you do the post-mortem?
Dr: We usually do the post-mortem within two to three working days of a person's death.
8. Wife: Can I see him ?
Dr: Surely you can see him before we do the post-mortem if you wish to or you can see him after the post-
mortem also.
9. Wife: Will it delay the funeral ?
Dr: After the post-mortem they will give release papers and after that you can hold the funeral.
10. Wife: When will I get the death certificate?
Dr: They usually give the death certificate once they know the cause of death. However you do not need to
wait until you get the death certificate to hold the funeral for him.
11. Wife: Will they keep the organs?
Dr: Usually they return the organs back to the body after taking some tissue samples. If they need to retain
any organ they will ask your consent for that. Do you know what was your husband’s wishes about the organs-

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 did he mention any thing about what to do for the organs before he died? If he had mentioned anything like
that before he died - then his wishes will be respected.
12. Wife: We did not discuss about this issue because this happened unexpectedly. Which parts for the body
do you open ?
Dr: We open only head, chest and tummy area only. We do not touch face, arms and legs. We stitch it up once
the organs are returned to the body. Stitched areas are usually covered by the dressing of the body by the
mortician. So there will not be any disfigurement to the face and arms.
13. Wife: How will this post-mortem help us doctor? Dr: It will help you and others a lot in many ways.
i. First of all you will have a peace of mind and feeling of closure if you know the cause of hisdeath.
ii. If it all he died of some genetically inherited condition, we can check for that problem in his family
members or if you have children we can check your children also and maybe we will be able to
treatthem.
iii. Also if it all he died of contagious disease we can protect others who came in contact withhim.
iv. Also it helps us a lot in our studies and future training.
14. Wife: Will you request to do the post-mortem doctor?
Dr: Yes surely. I will talk to my Consultant and then we will request the concerned authorities to do that.
15. Dr: Is there anything else I can do for you? Wife: No doctor. You have been kind.
Doctor: Thank you very much. We will keep you informed at every stage. I am very sorry again for what
happened to your husband. If you need any support we have bereavement support team in Dr the hospital
you can contact them. They may be able to help you.
Wife: Ok thank you doctor. Dr: Thank you.

27. Needle stick injury in child

3 year old child brought in by Nanny. Child had needle stick injury while playing in the garden. Take history and talk about
management.

1. Take detailed history about the incident.

When, how, ( child was coming down the slide and got injured with the needle)
2. Ask about needle – was it attached to syringe, and blood in the needle or syringe, was it rusted,
3. What did she do immediately after that. [ she washed child’s finger – appreciate her]
4. Ask about the jabs specifically Hep B – she says she does not know anything other than that the child is up
to date with all the jabs. Ask about parents – they are far away. Ask whether you can talk to them over the
phone and take some history from them about the jabs and any other medical conditions. Tell her we can get
the jabs information from the GP.
5. Ask about other medical conditions, similar incidents in the past.
6. Ask her about her concerns.
7. Tell that usually people get worried about children getting any infections because of the needle stick injury if
the needle was used by some drug addicts
8. Reassure that the chances of child getting HIV infection is almost negligible because HIV bugs do not survive
outside human body. So usually we do not do any tests for HIV and we do not offer any medications to prevent
them getting HIV infection.
9. Hep B – there are slight chances of child getting hep B infection if the child is not vaccinated.
10. We will check from the GP whether the child had Hep B vaccine or not and if the child did not had Hep B
vaccine we will give Hep B vaccine and another medication called Hep B immunoglobulin to prevent child
getting Hep B infection.
11. She may ask – will you give antibiotics
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 We will have a look at the wound { examination} clean the wound thoroughly and if the wound is deep then
we will give antibiotics to prevent wound infection.
Usually they do not get any other infection.
12. No need of admission.
13. Nanny may be taking down notes – ask her why – she may say I need to tell child’s parents everything you
say now. – appreciate. Tell her to bring the parents later so that you can explain everything to them directly.
14. Warning signs – if the child develops redness, swelling discharge from the wound site – this is sign of wound
infection – you need to bring the child back.
15. Any other concerns.

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 28. Needle stick injury in the nurse
You are the FY2 doctor in the A& E department.
Mrs Andrea Jones 23 year nurse in your hospital came to the A& E department because she had a
needle stick injury while she was drawing blood from a patient.
Talk to her and address her concerns.
A.
1. Dr: Hell Mrs Andrea Jones I am Dr …. How are you doing ?
Nurse: I am not feeling good doctor. I pricked myself with the needle when I was taking blood from a
patient.
2. Dr: I am very sorry to hear that. Can you tell me anything more about it ?
Nurse: I was just taking the blood from a patient. After that I accidentally pricked myself with the needle. I
happened just half an hour ago.
3. Dr: Did you prick yourself after you used on the patient or was it a new needle ( not used on anyone)
Nurse: It is the same needle I used on the patient and then I pricked myself
4. Dr: Was it ahollow-boreneedle? Nurse: Yes Dr: Which part of your body did you prick yourself? Nurse: My
finger
5. Dr: What did you do afterthat?
Nurse: I washed in soap and water. My senior staff told me to come here.
6. Dr: Good that you washed it soap and water. You are not supposed to use any antiseptics to wash and also
you are not supposed to put the area in the mouth. Was the wound deep or superficial ?
Nurse: Just superficial / it is deep.
7. Dr: Were you wearing gloves at that time? Nurse: Yes Dr: When was your last hep B vaccine and tetanus
vaccine? Nurse: I had both about 2 years ago.
8. Dr: Do you have any medical condition? Nurse:No
9. Dr: Have tested for HIV or Hepatitisrecently? Nurse: No Dr: Are you taking anymedications? Nurse:No Dr: Are
you allergic to anything at all ? Any chance you are pregnant?
10. Dr: Do you practice safe sex?
Nurse: I am married, so don’t practice safe sex / sometimes she may say I have a partner and practice safe
sex.
11. Dr: Did you have any such incidentspreviously? Nurse:No Dr: Do you use any drugs and share needles with
others ? Nurse : No Dr: Do you know what is wrong with thepatient?
12. Nurse: He has Meningitis? Dr: OK. Is he conscious? Nurse:Yes/No
13. Dr: Do you know whether he has any infections other than meningitis like Hepatitis or HIV ? Nurse: I don’t
know.
14. Dr: Did you tell him about this incident? Nurse: No
B.
1. Dr: Mrs Jones, I am once again very sorry this happened to you. Do you have any concerns about this incident
?
Nurse: Yes doctor I am worried. Will I get HIV or Hepatitis or any other infections ?
2. Dr: I can certainly imagine your worries. However Mrs Jones, Regarding HIV- the chances people getting HIV
infections through the needle stick injury is very low compared to other routes like sexual route or drug
addicts sharing needle. The risk of getting HIV from a needle stick injury is 0.3%. That means only 3 people
out of 1000 people who had needle stick injury will get this infection.
3. We will inform the Occupational health department.

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4. Occupational health department will inform the patient about it and take his consent to do blood test on him
for any infections like HIV, hepatitis or others.
5. We will need to take your blood also to do tests.
6. We have post exposure prophylaxis against HIV. You need to take this as soon as possible that is within one
hour, the latest you can take this is 72 hours. The medication pack is called Truvuda. The treatment duration
is 28 days.
7. Side effects include: nausea, vomiting, diarrhoea, myalgia, headaches and fatigue. It is important to continue
treatment even if you have all these side effects.
8. You should practice safe sex and do not donate blood during this period.
9. You will be followed up by the Occupational health department. You may be retested at 6 weeks, 3 month, 6
months and 9 months.
10. Dr: Are you followingme? Nurse: yes Dr: Any questions about HIV? Nurse: No
11. Dr: Regarding Hep B – since you are already immunised against Hep B chances you are going to get Hep B
infection is almost negligible. Risk is 30% in those who are not immunised. However we need to do blood tests
and check the antibody level for Hep B. If you do not have enough antibody then we may give you
immunoglobulin and booster dose of the Hep B vaccine. Hep B booster dose can be given within one week
of the incident.
12. Dr: Any questions about HepB? Nurse:No
13. Dr: Unfortunately there is no pre or post exposure prophylaxis for Hep C. The risk is 1.8% so very low chance
again.
14. Dr: Since the patient is having meningitis – we will give prophylaxis for the meningitis also.
15. Dr: Occupational health department will follow you up. They will check for side effects and do blood tests:
FBC, Us and Es, LFTs, HIV, Hep B and Hep C at 3 months and 6 months.
Occupational Health can also provide you counselling and support if required. Any other concerns. Nurse: No
Thank you verymuch.

29. MMR
You are the FY 2 doctor in the Paediatric department. Rachel 13 month old child is scheduled for
the MMR Vaccine next week. Her mother Mrs Jennifer Anderson has some concerns about the
MMR vaccine. Talk to her and address her concerns.
6.
1. Hello I am Dr.... one of the junior doctor in the Paediatric department. Dr: Are you Mrs jennifer Anderson ?
Mother :Yes.
2. Dr: Are you the mother of Rachel Anderson ? Mother : Yes Dr: How are you doing? Mother: I am fine
doctor.
3. Dr: How can I help you Mrs Anderson ?
Mother: I was told that my daughter has to have a MMR vaccine next week. I am
concerned about it.
Dr: May I know what are you concerned about? Mother: I heard MMR vaccine causes Autism.
a. Dr: First of all I am very glad that you came to us with your concerns.
b. Yes it was true that such an article was written by one of the Paediatric Consultant
long time ago. He was found to have misconducts.
c. But then the article published was proven to be wrong and publishers withdrawn.
d. There are many study done after that and all shows it is safe.
e. The million peoples taking this vaccine around the world and they do not have any
problem.

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 f. MMR is given around 15 months of age and this is the same age around which
autism is diagnosed so there was a fake impression that autism is caused by MMR.
4. Mother: But why do you want to give the MMR vaccination because those diseases are not in UK
anymore!
a. Dr: The reason these illnesses are not seen in the UK is because we give this vaccination to almost everyone
here in UK. If we stopped giving this vaccination these illnesses would reappear in the UK.
b. Also Your child may come into contact with a foreigner who has entered the UK
and is infected with Measles, Mumps or Rubella and your child may get the
infections from them.
c. These infections are dangerous if at all your child gets this infections -
i. MEASLES is a very contagious infection and may cause complications such as diarrhoea, ear infections,
pneumonia.
ii. MUMPS is also a contagious infection. It may cause complications such as meningitis and deafness. In
girls, it may cause swelling of the ovaries. In boys, it may damage the testicles.
iii. RUBELLA (German measles) is usually a mid-infection; however, it can be harmful to pregnant women.
It may cause deafness, brain and heart damage, and eye defect in unborn babies.
d. By giving your child a vaccination it helps to lower the chances of them contracting a serious illness. It also
helps to prevent other children from contracting the disease as less people will have the disease to pass on.
5. Mother: I also heard that MMR vaccine can cause bowel problems ( Colitis) !
Dr: I would like to reassure you there is no link between bowel problems (Colitis) and the MMR vaccination.
6. Mother: Is there any alternative to MMR vaccine?
a. Dr: Unfortunately there is no alternative to MMR vaccine. The only alternative available is that – these
vaccine can be given as single doses rather than all three combined.
b. But the single doses are available only privately but not available in the NHS because the Studies have not
shown any advantage of giving MMR as separate vaccinations.
c. If given separately, we have to wait 4 weeks in between each vaccination.
d. We don't want to put the child through unnecessary pain by inj ecting the vaccination on three separate
occasions.
7. Mother: How will you give the vaccine?
a. Dr: I need to ask you few questions about your child to see whether it is suitable to give
vaccine now. Take a short history for contraindication:

□ Is your child currently unwell? No

□ Does your child has any long term illnesses? No
□ Have they ever had any immunizations before? Yes - usual jabs
□ Were there any problems afterwards? No
□ Are they on any regular medications? No
□ Any allergies? No
b. Dr: Your child is safe to receive this vaccination. We give 2 doses of MMR vaccine - first dose is given after
the child's first birthday, and the second the dose before pre-school (3 and half years)
c. The vaccination will be given as an injection into the muscles of thigh or upper
arm.
d. EMLA cream is a local anesthetic cream that can be applied to the skin to suppress
the pain of injections.
e. After, may be your child may develop Redness and Swelling around the site of the
injection or fever. But this is very common and not dangerous - you can give
Calpol ( Paracetamol syrup)

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 f. You should contact your GP if: very high temperature, fits, high pitched cry, huge
swelling anywhere on the body but especially around the site of injection or lips
and mouth.
g. MMR vaccine can cause mild reaction like indurations (thickness in the skin) and pain at
the site of injection
8. Mother : My child has egg allergy, is it safe to give vaccine?
Dr: Egg allergy is not a contraindication for giving the MMR vaccine. This vaccine is not made from yolk cell.
9. Dr: Do you have any other concerns? Mother : No
10. Dr: Are you happy to have MMR vaccine to your child now? Mother : Yes / I will think over it.
Dr: Once again, Mrs Anderson I am very glad that you came to us with your concerns
about the vaccine. I hope I was able to clear all your doubts. Hope everything goes well.
Thank you very much

30. IV cannula
A. IV cannula –Talk to FY 1
Your junior colleague (FY1 doctor) Dr Wilson did not insert IV cannula to Mrs Williams who supposed to
receive IV antibiotics. Talk to your colleague.
1. You – Hi Wilson I am Peter. How are you doing? Him- I am fine Peter
2. You – How’s the work going on? Him- it is good not bad.
3. You – was it very busy today? Him – Not so much. I could manage.
4. Do you remember one of your patients names Mrs william?
a. yes -->
b. if no --> i will confront him that she complained him
5. You – She has put a complaint saying that you didn’t insert a IV cannula and she is waiting for a long time.
Him – oh really. But there is 2 hours’ time for the next antibiotics. I don’t understand why she has to complain.
6. You – What did you tell her about the cannula.
Him – Well I told her that I will be back in about 15 min to insert cannula but then I saw an interesting X ray, I
went to the library to read about it.
7. You – It is good to know that you are interested in learning. But I think since you had already told her that you
will be back in 15 min to insert the cannula you should had done that first or you could have told her that you
will be back to insert the cannula before the next dose indue.
Him – Well yes, I think I should have done that.
Praise him: That is very good - excellent (always paraphrase) that you are keen on learning -- Then give him
options (But the patient safety is more important) --
8. You - Do you have any problem in prioritising, because when I started working I too had the problem of
prioritising, then I went to a course, it helped me a lot. May be you too can attend one course like that if you
want to.
Him – ok, I will surely try that.
9. You – I think you need to talk to Mrs Williams and explain to her and may be apologise to her if you think so.
Him – Yes, I will.
10. You - I think you can insert the cannula now and tell her that no harm has happened also I suggest you to fill up
a clinical incident form.
Him – yes, thank for your suggestion. Will you tell the consultant?
You – I guess he may come to know that from others. It may be better you that to him yourself rather than he
hearing it from others.
Him – yes, thank you. You – thank you
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11. Sometimes the colleague says he forgot to insert the cannula.
You can ask him to maintain a diary so that he will not forget the jobs.
12. Sometimes he says he was caught up in doing CPR.
You can tell him that he could have told you to insert the cannula or he could have informed the nurses in the
ward to tell the patient that he will be late.

B. IV cannula – talk to upset patient

Your junior colleague (FY1 doctor) Dr John David did not insert IV cannula to Mrs Williams who supposed to receive IV
antibiotics for insect bite. Talk to Mrs Williams.
1. Hello Mrs Williams I am doctor… How can I help you.
Pt - Doc your colleague told me that he is going to come back and inset cannula in my hand and he did not come
back since then. I am due for antibiotics through my veins. I am supposed to go home now. I have a meeting to
attend in the next one hour.
2. Dr - I am very sorry for what happened, but I will insert the cannula to you now.
Pt - Thank you for that, but why is that your colleague did not come back to insert the cannula.
Dr - I am not sure why he did not come to insert the cannula may be he is caught up in some other emergencies.
But as I told you I will insert the cannula now and I will ask him to come and tell you what happened. I would
like to reassure that nothing serious has happened to your health now. Is that OK?
3. Pt: What about him?
DR: I will ask him to come and explain to you about what happened.
4. Pt: I don’t’ want to see him. Will you take any action on him.
a) Dr: We do take all such incidents very seriously. We will all the measures so that these type of problems will
not happen again.
b) Pt - I don’t want such things to happen to me or anyone else again.
c) Dr - Yes, sure we will make sure that these things will not happen. I will inform my seniors about this.
d) Pt – I want to put a written complaint.
e) Dr – You can surely do that if you wish to. We have patient advice liaison service you can talk to them about
it and they will help you. Pt – Thankyou.

VI. Cancer

1. Lady with bowel cancer - Son does not want mother to know.
You are the FY 2 doctor in the medical department.
72 year old lady Mrs Ali was recently been diagnosed as bowel cancer. She had a short period of confusion.
Information was revealed to her daughter. Now Mrs Ali has recovered from the confusion and she has the
mental capacity.
Her son Mr. Mohammad Ali wants to talk to you. Talk to her son.
Mrs Ali has given consent to talk to him about her condition.
A.
1. Dr: Hello Mr. Mohammad Ali, I am Dr…. one of the junior doctor in the medical department. How are you
doing? Son: I am, fine doctor.
2. Dr: I am one the team of doctors looking after your mother Mrs Ali. I was told that you want to speak to me
about her. Is that right ? Son: Yes doctor.
B.
1. Dr: How can I help you Mr.. Son: How is my mother now doctor.
2. Dr: She has recovered from her confusion now and she is much better now. Son: I was told that she has bowel
cancer, is that right doctor?
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3. Dr: Yes that is right Mr. Ali. I am very sorry about that. Son: Have you told her that she has cancer?
4. Dr: No, not yet. We could not tell her because she was bit confused but she is fine now so we are just about to
tell her now.
5. Son: Doctor please don’t tell her that she has cancer. Dr: Why do say that Mr. Ali ?
6. Son: Doctor my dad also had cancer. She was looking after him for a long time and she has seen all the
suffering what my dad went through. My dad has died now. If she comes to know that she also has cancer
she will be very distressed.
Dr: Mr. Ali I am really sorry to hear about your dad. I can imagine how you are feeling. I do understand she
will be distressed to hear the news. However, Mr. Ali we need to tell her that she has a cancer because she needs
to know about her condition.
7. Son: Doctor please tell her some other condition other than cancer.
Dr: Mr Ali we need to tell her the truth we need to be honest with our patients. She has a right to know about
her condition.
8. Son: OK doctor - if you have to tell her then tell her that she has some abnormal growth.
Dr: I can certainly see how caring son you are. I do appreciate your concerns to your mother. Your opinion
really very important for us. However, Mr Ali she is in a right frame of mind to understand everything now.
She has a mental capacity to understand and to take decision for herself about her treatment. To give her the
right treatment we need her consent. We need to tell the name of her condition to offer the right treatment.
Unless we tell the name of the real condition we cannot get her consent to treat her.
9. Son: But why can’t tell her abnormal growth?
Dr: Mr abnormal growth has different meaning it can be cancerous or noncancerous growth. People usually
know the word cancer. People may not understand any other word for this condition other than the word
cancer.
10. Even if we tell her that she has abnormal growth she can ask us what is that abnormal growth and that time we
have tell her that it is cancer type of growth.
11. Son: Doctor, I am her eldest son. Now I am the eldest in the family. In our culture it is the elder person
who takes decisions. Doctor you don’t need her consent. I am telling you that you treat her without telling
her the word cancer. I am giving you permission. Anywayshe is going to ask me only about what todo.
Dr: We do respect all cultures and family relationships. However when we take medical decisions it has to be
person’s own decision if they have the mental capacity.
12. Son; You doctors are only care about your duty but you don’t understand our feelings. You don’t care
for our feelings at all?
Dr: Mr Ali I am really sorry if I made you feel that way that we don’t care about your feelings. We definitely
care for the feelings also. However if we don’t tell her the name of the condition then we may not be able to
offer her right treatment with which we may be able to prolong her life or if she is in pain we may not be able
to provide her right kind of medication and she will suffer more and she will be more distressed. I am sure you
don’t want her to be distressed a lot isn’t it ?
13. Son: Doctor I will tell her that she has cancer myself in private.
Dr: Mr Ali Unfortunately we have to tell the diagnosis to the patient our self. It is our duty. We are trying to do
the best for her and I am sure you also want the best for her.
What you say ? You tell me should we tell her or not ?
14. Son: Yes doctor I can understand. You do whatever you feel is right.
Dr: Thank you very much Mr Ali. As I said your input is very important for us to manage her condition. If she
agrees, you can also join us when we discuss with her about her condition and all the treatment options. I am
sure she needs your support to cope with this condition. Thank you very much.

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 2. Mother suspected of cancer bowel. Son ( surgeon) wants to talk to you.
Exam question: Lady had CT scan of abdomen showed growth in the ascending colon. Suspected of bowel
cancer. Talk to son.

Nothing mentioned about consent in the question. Son is a surgical Consultant. Wants to discuss about the test
results and further plans.

1. Enquire – are you working in this hospital or some other hospital? He may say he is working in Dublin ( not in
Manchester). If in the same hospital is he in the same team?
He will say no.
2. Ask him how much he knows about his mothers condition?
3. Apologize – I am sorry I cannot discuss about your mother with you at the moment because we have not yet
taken consent from his mother to talk to son. As you know we cannot divulge patient information to anyone
else unless we have consent from the patient.
4. You know this better than me.
5. I will talk to your mother soon and ask for consent to talk to you. If she gives consent I will surely come back
immediately and talk to him about it?
6. Son: Can I be there when you talk to my mom?
Dr: Let me get the consent first – if she agrees surely you can be there. I am sure she will be well supported if
you are there.
7. Son: Does she know about the result?
Dr: No not yet. We are just about to discuss the results with her.
8. Son: Is it a bad news ?
Dr: I am sorry I cannot discuss anything about the results now. As soon as we get th consent then we can
discuss the result and further plans for her.
9. Examiner may ask what will you do now?
I will talk to my senior about the test result and ask for further plans for the patient and inform the patient
about the test result and discuss further investigations like biopsy to confirm the diagnosis. I will also inform
my senior about her son that he is a surgical consultant and wants to know about his mother and discuss further
management with the team. I will also ask the patient for the consent to talk to her son about her condition.

3. Ca Lung (Modified old station)

60yr old man referred by GP on account of shortness of breath.

NB: Patient isn't coughing, only 6months history of breathlessness and weight loss with significant smoking history. Xray
showed cannon ball appearance on the apical lobe of the left lung(normal x ray for lung CA) I shift to the provisional diagnosis.

4. Neuroblastoma – Mother giving green liquid to child

SCENARIO- Nurses notice Mrs. Devoine(mother) giving green liquids to 19 month old child
diagnosed to have neuroblastoma and is currently being treated for sepsis. Talk to the mother and
address concerns

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First, get her to admit that she is giving green liquid to her child. Do not criticize her but
appreciate her concerns for the child. She might ask how did you know about this, be honest with
her and tell her politely nurses had noticed it and was concerned about the well-being of the child.

Secondly, ask the details of the green liquid (for example-contents, how long she has been
giving the herbal medication to the child, if it was given by a qualified practitioner).

In the exam she says that she heard it from a friend who is diagnosed with breast cancer and is
currently on the herbal medication.

Summary-

1. How long has the baby been on herbal medication?

2. Contents?
3. How did she know about it? Whether it was prescribed by a qualified doctor?
4. Is the baby on any other herbal medication/any other medication that has not been prescribed
by the hospital?
5. If she mentions her friend is taking it for her breast cancer, be concerned about her friend and
you can ask her hows her friend doing at the moment.
Thirdly, confront her about the harmful effects of the medication. Cover the following points-

1. The herbal medication might not be FDA approved, hence can invite a lot of adverse effects
and allergic reactions.
2. Herbal medication can interact with the medicines prescribed by the hospital. The
simulator might argue that herbal medication are natural, hence there will be no
interaction.
Explain to her that herbal medication contains potent chemicals as well. You can include an
example for better understanding-mushroom is a natural product but some species contains
poisonous chemicals which could prove fatal.
3. If the child is on radiotherapy/chemotherapy for neuroblastoma, the herbal medication can
interact with the treatment, halting the cancer-cell killing process and making the prognosis
worse.
4. Simulator might ask for examples of herbal-drug interaction
- Garlic extract + aspirin (thinning of blood)
- Green tea supplement + pseudoephedrine (nasal decongestant)
- Digoxin, warfarin (drugs of low therapeutic index)+ St. Johns wort
Offer a lot of support to the mother, explain that a team of doctors are looking after the child. She
should always consult with the doctor regarding additional medication.

Mother may say - “ I didn't know about these doctor it's good you told me now. So is my son going to die bcoz
of this remedy?

Q) don't worry we will continue to monitor your son. If needed we can involve more specialist drs in toxicology to
check whether that herbal medicine has interacted with any medicine what we are giving.

Use empathetic sentences lik “I can imagine that you are in pain to see your child in this situation.
I know this journey is challenging, but we are here to help you. You can call us anytime, if you
have any concerns and we will try our best to help you out.
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Ask if she has any other concerns.

VII. Derma and Muscloskeletal

1. Skin lesion: ? Squamous cell carcinoma

63 year old man presented with skin lesion in his head. Take history and discuss the further management
with the patient.

A.
1. Dr: Hello Mr… I am Dr…. How can I help you Mr…
Pt: Doctor I am having this swelling in my head. My wife noticed it first and she told me to come here.
2. Dr: Since how long have you had this swelling ? Pt: It is there since about four weeks now doctor.
3. Dr: Is it the same since it started or have notice any change in that. Pt: It is becoming little bigger in the
last one week.
4. Dr: Any other changes have you noticed ? Pt: Yes doctor it is little bit bleeding also since last one
week.
5. Dr: Is there discharge from that? Pt: No
6. Dr: What is the colour of that ?Pt: Pink/ Brown/ Dark
7. Dr: Is there any change in the colour ?Pt: No
8. Dr: Is it painful? Pt: No
9. Dr: Any itching?Pt: No
10. Dr: Do you have any other swelling anywhere else? Pt: No
11. Dr: Any swellings on your neck area ( lymphandenopathy)Pt: No
12. Dr: Have you exposed yourself to sun too much ?Pt: Doctor I lived in Australia for 10 years.Dr: When was
that? Pt: …
13. Dr: Have been using hats to cover your head during those time ?Pt: No
14. Dr: Have you used tanning beds ?Pt: No
15. Dr: Did you have similar problems before ?Pt: No
16. Dr: Do you have any medical conditions at all? Pt: No
17. Dr: Are you on any medications ?Pt: No
18. Dr: Do you smoke ? (If yes- what do you smoke, How much, How long)Pt: Yes/ No
19. Dr: Any of your family members has any such swellings ?Pt: No
20. Dr: Is there anything else you think is important we need to know about?Pt: No

Examination:

1. Dr: Mr…. I need to examine that and see how

it looks like. Also I need to check whether you
have any swellings around your neck.
Pt: Doctor this how it looks like ( he will
show a picture).

Diagnosis:
1. Dr: Thank you for that. Do you have any idea
what it could be ?Pt: No Doctor.
2. Dr: I afraid it could be a serious condition. Do
you want to know about it ?Pt: Yes doctor
please tell me.

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3. Dr: I am very sorry to say this could be a type of skin cancer what we call as squamous cell carcinoma.Pt:
Cancer !!!Ohh..really doctor!!
4. Dr: I am afraid it does look like that. However, we need to do some tests to confirm that.

Investigation:
We need to take some tissue sample from that and send it to the lab to test it. Is that OK?
Treatment :
1. Pt: Ok doctor. How will you treat that doctor?
a. Dr: We need to confirm what type of growth is that to decide what type of treatment we can offer.
b. If it is squamous carcinoma as I mentioned before, depending on how much it has grown or whether
it has spread to any other area then we can decide the type of treatment.
c. Usually we will be able to do some surgery and remove the whole growth and test the removed
growth in the lab to check whether the cancer cells has been removed.
a. However,if it has spread then we may not be able to remove it completely in that case we may have to
treat it with some medications[ Erivedge (vismodegib)] or Radiation therapy.
2. Pt: Is it dangerous doctor?
Dr: Mr… Though this is a cancer usually they do not spread so it is usually treatable. Very rarely only it can
spread to the other areas and then it can be dangerous or life threatening.
3. Pt: OK Dr: Any other concerns?Pt: No doctor. You have been very helpful

Warning signs:

1. Dr: However Mr… You need to be careful in the future. You should avoid too much exposure of your skin to
the sun. You can wear sun creams or wear proper protection clothes, wear broad brimmed hat to prevent
exposure to sun. If you develop any swellings again you should inform the doctor immediately. Pt: Ok.
2. Dr: Thank you very much Mr… I hope everything will be fine soon.

2. Skin lesion
25 year female presented with swelling on shoulder. Take relevant history and talk to her about the
management. Take informed consent for surgery. There is no need to fill up the consent form.
A.
1. Dr – How canIhelp? Pt- I have a swelling on my shoulder. Dr-Since when? Pt- many years.
2. Dr- what made you worry about it now? Pt- it looks ugly. I am getting married soon. It will be visible when
I wear my wedding dress. I want it to be removed.
3. Dr: Does the swelling bother you in any way. Pt: It keeps rubbing on my dress. It is very uncomfortable.
Dr – have you shown it to any doctor so far? Pt- No.
4. Dr- do you know how it started? Pt – I donotknow. Dr-anypain? Pt-No. Dr-itching?
Fever?Bleeding?Discharge? Pt-no
5. Dr-what colour? Pt-pinkish .Dr- any change in colour and size orborder? Pt-No.
6. Dr: Have you noticed any swelling in the arm pit or in the neck ( spread to lymph node in melanoma) ? Pt :
No
7. Dr- Is it on an exposed area is it usually covered with the dress ? Pt – it is covered with my dress but for
wedding I will be wearing a dress below my shoulder level so it will be visible.
8. Dr – Have you tried to treat it in any waysofar? Pt –No.
9. Dr – Do you have any such swelling anywhere else in body Pt–No Dr – Did you have any such swelling
before? Pt-No.
10. Dr – do you have any medical conditions? No Any surgery before? No

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11. Dr: Any medications ( immunosuppression is a risk factor for melanoma) ? Pt – No. Dr: Have gone on holidays
and exposed your skin to sun ? Pt: Yes/No
12. Dr: Have you used sun beds for skin tanning? Pt: Yes/No
13. Dr – Any of your family members had any such problems ( family history is a high risk factor for melanoma)?
Pt –No.
14. Dr- What do you do for living?
B.
1. Dr- I need to examine you to see what exactly it is?
Pt – OK. Doctor. I have a picture. [patient may show different types of
pictures to different candidates]
2. Dr- It looks like a growth in the skin. It looks more like a non
cancerous type of growth what we call as Mole or it could be another condition called as Papilloma. Moles
are due exposure of skin to the sun.
3. I also need to examine your neck and armpit for any swellings ( lymphadenopathy).
C.
1. Pt – what will happen now?
2. Dr – This type of growth does not need to be removed for medical reasons. However if you want it to be
removed we can remove that.
3. Pt: What will happen if I don’t remove it?
a. Dr:.Most of the time it can remain like that for the whole life without causing any problem. However if it
is mole it can rarely turn into cancerous type what we call Melanoma. If that happens then we need to
remove it.
b. So you need to keep an eye on that to watch for any changes like changes in size, colour, border, surface or
discharge or bleeding – then you need to come back to the hospital. Pt:Ok

D. Treatment options:
1. Dr: We have several treatment options. We can surgically remove it under local anaesthesia. (We just make the
area numb by giving anaesthetic injection to the site). We will then stitch it up.
2. We have other options like what we call as shave removal with a blade.
3. Other ways to remove it is by freezing with liquid nitrogen. This is like a spray. It does not require any
anaesthesia. The swelling will fall off after few days.
4. It can also be removed by Laser. This treatment uses intense bursts of light radiation to break down the
abnormal cells in the skin. This method usually takes two or three treatments to remove the swelling completely.
5. Can I remove this at home?
Some people do it on their own. But it is better if we do that to make sure everything is fine.
6. Pt – how long is theprocedure? Dr- 10 –15minutes.Pt – will it leave ascar?
7. Dr– We have expert doctors to do the operation. There will be small thin scar may not be noticeable.
8. Pt – will it come back?
Dr- Unfortunately sometimes they can come back. Any other concerns ?
9. Dr: Are you happy to go ahead with the procedure ? Pt: Yes.
10. Dr- OK. I will talk to my seniors and we will arrange further tests and the date for the procedure. Also please
take care of your skin.
11. You can go out in the sun; however, it is advised to wear proper sun protection like hats, protective clothing,
sun creams to prevent moles from forming in the future and to prevent removed moles from returning.
12. If it all you develop any swellings like this please come to us immediately. Good luck with your wedding.

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 1. Whiplash injury
30 year old Mr Morrison met with a road traffic accident 2 hours ago. He came to the hospital
today complaining of pain and stiffness in his neck. Take a brief history and do the necessary
examination and discuss the further management with the patient. Patient may be sitting on
the chair or couch.

A. History :

Dr: How can I help you ?

Pt : I met with the road accident about 2 hours ago. Now I have pain in my neck.

Dr. I am sorry to hear about the accident. Can you please tell me more about the accident.

Pt: I was driving my car. Another car hit the back of my car.

Dr: What happened after that ?

Pt: I was fine initially. I went to the office then I started to have pain in my neck.

1. Dr: Where in the neck you have this pain? –Pt: Back of the neck.
2. Dr: Since when? Pt: There was no pain immediately after the accident but then I went
to the office I started to have pain - almost one hour now.
3. Dr: Does the pain go anywhere from the neck ? Pt: No
4. Dr: Anything else? – My neck is stiff. Since when?- Pt: Since the last one hour.
5. Dr: Anything else? – Like what doctor?
a. Dr : Do you have headache? Pt : No
b. Dr Any dizziness ? Pt : No
c. Dr: Any problem in your vision? Pt : No
d. Dr: Any tingling or numbness in your hands? – Pt: No
e. Dr: Any problem in the neck before this accident? – Pt: No
f. Dr: where there anyone else in the car ? Anyone else had serious injuries? Pt : No (
sometimes he may say driver was driving the car but he is fine).
B. Examination :
1- I need to examine you now. [ patient may be adequately exposed. If not mention about the
exposure. We need to undress you above the waist to examine you – is that OK? Pt - Ok.
Patient may then remove the shirt]
2- Inspection of the neck :
a. Look all around the neck ( front sides and back)
b. No swelling, no bruise or wounds around the neck. No neck deformity.
3- Palpation :
a. I’m going to feel the back of your neck over the spine with my thumb. Please tell me if
it hurts. Just say yes or no but do not move your head too much. – Pt: Ok Doctor.
b. Then check for tenderness over the cervical spine up to about 2 nd thoracic vertebra : (there
may or may not be any tenderness over the spine)
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 c. Then check for tenderness over both the para-spinal areas : (Usually there is tenderness
there).
4- Then do neurological examination. –
a. Sensory –
i. fine touch (with wisp of cotton) on both the upper limbs.
ii. Then check for pain sensation with neuropin : [No sensory loss].
iii. C4 – top of shoulder, C5 – Outer aspect of upper arm, C6 – outer aspect of hand (
thumb area), C7 – middle finger, C8 – Little finger, T1 – Medial aspect of elbow.
b. Motor –
i. C5- Shoulder abduction and Elbow flexion, C6 - Elbow flexion and wrist
extension, C7 – Elbow extension and wrist flexion and finger extension, C8 –
finger flexion, T1 – Finger abduction ----- No motor deficits.
c. Check reflexes in upper limbs : Biceps reflex ( C5), Brachioradialis reflex ( C6), Triceps
reflex (C7). --- Normal
5- No need to do neck X Rays if there is no bony tenderness.
If there is bony tenderness - Tell the examiner I will make him lie down and stabilize his neck
and send him for X rays of his neck. Can I know the X-ray result please ?
( Examiner may say – X Ray – normal )
6- I will remove his collar and check for neck movements. Examiner may say assume you have
removed the collar.
Ask the patient - Please turn your head to right, left, up and down and both sides- flexion
movements. Movements are restricted ( which ever direction). Thank you.
C. Management with the patient:
1- You have a condition what we call us whiplash injury. It is due to sudden stretching of muscles
and ligaments at the back of your neck which happens due to excessive movements of the neck
during the accident. Usually there is tearing of muscles and ligaments at the back of the neck.
But you do not have any serious problems like fracture or spinal cord injuries.
2- The symptoms of whiplash injuries – that is pain and stiffness will subside on their own in
about 2 to 3 weeks.
3- Please take pain killers like Paracetamol and keep doing some neck exercises until then.
4- Sometimes it can last for months. If it does not subside in 2 to 3 weeks we will arrange
physiotherapy. Is it Ok? Any questions.
5- Pt: Can you please give me a collar to the neck
Dr: We used to give collar previously but we found out that the collar will only worsen the
stiffness of your neck. So nowadays we do not give collar. It is better that you keep moving
your neck.
6- Pt; Can I drive doctor?
Dr: It is better not to drive until your pain and stiffness in your neck subsides.
7- Pt; Why did I get pain in my neck after few hours not immediately?
Dr: This is what usually happens in whiplash injury because it takes some time for the
inflammation ( soreness) to start and then it becomes painful.

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 2. Back Pain
50 year old Mr … presented to the hospital complaining of back pain. Take a brief history
and talk to him about the management. [ Positive in history – back pain since 2 months, weight loss,
and increased frequency of urination ]

A.
1. Dr: Hello Mr ….. I am Dr …. How can I help you ? Pt: I am having pain in my back doctor.
2. Dr: Sorry to hear that. Are you comfortable to talk to me? Pt : Yes, I am Ok to talk doctor.
B.
1. Dr Anything more you can tell me about your pain ? Pt: It just started on its own. It is there since about 2
to 3 months doctor.
2. Dr: Anything more can you tell me about it Pt : Like what doctor?
3. Dr: Where exactly do you have pain? Pt: Here at my lower back. (Patient may show the pain at the lower
spine).
4. Dr: Does the pain go anywhere from the back ( sciatica) ? Pt No
5. Dr: Did it started suddenly or gradually. Pt; Gradually/ suddenly
6. Dr: Ay thing makes it better or worse ? Pt: It hurts me more when I turn around.
7. Dr : Do you have pain anywhere else other than back ? Pt : No
8. Dr : Any headache or pain at the hips ( MM)? Pt : No
9. Dr: Did you have any fracture of bones ( pathological fractures in MM)? Pt : No
10. Dr: Have you notice any change in your weight ( MM)> Pt: Yes, I have lost some weight. ( quantify - how
much in how much time)
11. Dr: Do you feel tired ( Anaemia in MM) ? Pt : No
12. Dr: Do you get repeated infections ( decreased white blood cells in MM) ? Pt : No
13. Dr: Do you get bruising ? Any unusual nose or gum bleeding ( decreased platelets in MM)? Pt : No
14. Dr: Do you have any pins and needles, numbness in the legs and feet ( Compression of the spinal cord due to
prolapsed disc or compression fracture of vertebra due to MM )? Pt:No
15. Dr: Do you have increased frequency of urination ( nocturia) ( hypercalcaemia due to MM, diabetes) ?
Pt: Yes.
16. Dr: Any pain in your tummy ( pancreatitis, cancer of the pancreas)? Pt : No
17. Dr: Did you have any injury to your back ( trauma)? Pt : No
18. Dr: Did the pain started after lifting anything heavy ( prolapsed disc)? Pt : No
19. Dr: Did it start after doing any exercise or sports? Pt : No
20. Dr: Do you feel that your back is stiff ( osteo arthritis, ankylosing spondylitis)? Pt: No
21. Dr: Do the urine dribble when you pass urine ( enlarged prostate)? Pt : No/yes
22. Dr : Any blood in the urine ( renal cancer)? Pt : No
23. Dr: Any urine or bowel incontinence ( cauda equine due to prolapsed disc or pathological fracture of vertebra
due to MM)? Pt : No
24. Dr: Do you have any cough ( TB) ? Pt : No
25. Dr: Any swelling in the front of neck (thyroid cancer)? Pt :No Dr: Any mass in your loin area ( renal cancer )
? Pt : No
C.
1. Dr :Do you have any medical conditions? Pt : No Dr: Do you smoke ? Pt : Yes/ No
2. Dr: Are you taking any medications? Pt : No
3. Dr: Any of your family members have any medical conditions? Pt : No
4. Dr: what job do you do? Pt: I work in the post office.
5. Dr : Do you lift heavy thing at your work place? Pt : Yes / No
6. Dr : Is there anything else important you think we may need to know? Pt : No
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 D. Examination:
4. Tell the patient – I need to examine your tummy, back and your back passage for prostate gland
Examiner may say – Prostate normal no other finding. [Or examiner may say prostate enlarged]
5. Tell the examiner : I also need to do neurological examination of the lower limb, do Straight leg raising test
(SLR) test for prolapsed disc causing any sciatica.
a) [ The straight leg raise, also called Lasègue's sign, Lasègue test or Lazarević's sign, is a test done
during the physical examination to determine whether a patient with low back pain has an
underlying herniated disk, often located at L5
(fifth lumbar spinal nerve).
b) Technique: With the patient lying down on his or her back on an
examination table or exam floor, the examiner lifts the
patient's leg while the knee is straight.
c) Interpretation: If the patient experiences sciatic pain when the
straight leg is at an angle of between 30 and 70 degrees, then the
test is positive and a herniated disc a possible cause of the pain.
A negative test suggests a likely different cause for back pain.
E. Diagnosis :
1. We need to do some investigations to check what exactly is causing your back pain.
2. We will do X ray and MRI scan of your back. Also we need to do some blood tests.
3. [If the examiner says prostate enlarged – On examination I found that one gland called prostate which is at the
neck of the urine bladder is enlarged. Sometimes if it is a cancer type of enlargement then it can cause pain at
the back because of the spread of cancer to the back bone. We will also do scan of the prostate gland and some
type of blood tests to check what type of enlargement it is)]
4. Dr: Mr... It s not very clear from the information what exactly is causing your back pain.
5. There are lot of conditions which can cause pain at the back like sometimes sinister conditions like cancers
which has spread to the back bones or sometimes slipped disc or sometimes it could be just a wear and tear of
back bones and many more things which can cause back pain.
6. However after we get the investigation result we may be able to tell you we what exactly is causing the pain at
your back.
7. Pt: My neighbour had Pancreatic cancer. Do I have that doctor ?
8. Dr: It is very unlikely you also have the same problem. However we need to check for all the possibilities.
F. Treatment:
1. We will give pain killers for your pain. We will give you stronger pain killer than Paracetamol what we call Co
–Codamol. Hopefully that will help your pain.
2. We can arrange physiotherapy for you. Usually most of the patients improve after physiotherapy.
3. If the investigation result shows any other problem we will treat accordingly.
4. [ If the examiner say prostate enlarged - - If the investigations show that you do have prostate cancer then
depending on the stage of the cancer we will treat you with either surgery or special cancer medicines].

3. Musculoskeletal back pain.

SCENARIO- A young man with back pain came to the emergency department, c/o back pain. Your task is to take
history and discuss management with the patien

Patient gives history of back pain after playing squash. He had not played squash for 5 years. No sciatica.

A. History-
1. Primary complaint?
2. Could you point out where exactly is the pain?
3. How did it happen?
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4. Since when?
5. Grade the pain on a scale of 1 to 10 (in the exam, scale was 5)
6. Is there anything that makes the pain better or worse? (IVDP-relieves on lying flat and worse on movement,
coughing or sneezing)
7. How will you describe the pain?
8. Does the pain radiate anywhere? (loin to groin, to the legs)
9. Is it the first time you are experiencing this kind of pain?
10. Any pain anywhere else ? Any joint pains ?
11. Any history of lifting heavy weight?
12. Any bowel or bladder incontinence ( leakage of urine, unable to control bowel movement) ( cauda equina
syndrome)
13. Any fever, cough Travel and contact history - for TB
14. Were you told to have any weak bones?
15. Any history of repeated bruises or infections?
16. Did you experience any weakness of the legs during this event?
17. Did you experience any difficulty while passing urine or motion?
18. Loss of weight?
19. MAFTOSA- specifically ask for history of cancers in family
B. Examination- (verbal)
1. Examine back and prostate
2. SLR test- explain. Do not perform.(If SLR positive-prolapsed disc)
3. Ensure privacy and chaperone
4. Tests to be done- X ray, MRI
5. Examiner may say – tenderness over paraspinal area, SLR negative.
C.
“From what you have told me and from what I have examined, it seems to me you have a muscle pain. It might
have occurred after sudden movement of the back after playing squash after a long period of time.
This is not a serious condition. We shall give you pain killers to ease with the pain. The pain should subside after
few days. If it did not subside after few day, please come back.
D.
{(if SLR TEST POSITIVE INDICATING PROLAPSED DISC, MANAGEMENT IS DIFFERENT)-
Continue with normal activities as far as possible. Initially, try doing simple activities that wont cause much of
pain. Set a new goal everyday-
For example- first day- walking around the house
Second day- walking to the next shop and so on..
You are likely to recover quickly when you do this.
We can give you painkillers to ease with the pain. If it doesn’t subside- refer to physiotherapist.
(Surgery-if symptoms persist for more than 6 weeks)}
(Explain warning signs-spinal cord compression-inability to pass urine, pain radiating to the legs. If there are
symptoms, advise to come to the hospital immediately)

4. Breast Cancer with Back Pain management

62 year old female, who is a known case of breast cancer presents with back pain.
Talk to her about the pain management.
Sympathy and empathy is very important in this station
A.
1. Dr: Hello I am Dr .... I am one of the junior doctors in the department. Are you Mrs ....? Pt: Yes doctor.
2. Dr: How can I help you? Pt: Dr I have pain in my back for the past four months. I don’t want to have this
pain. Please do something doctor.
B.

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3. Dr: I am really sorry about that Mrs ... it must be really distressing for you. We will definitely help you. Can
you tell me more about the pain?
Pt: Yes I have had it for the past four months. I am taking Paracetamol for it - two tablets in the morning
and evening. Now I have to attend this wedding in the next few days and the pain is very debilitating. I want
to get rid of it now.
4. Dr: That must be very difficult for you. Can you grade your pain for me? Like on a scale of one to ten how will
you grade your pain? Pt: …
5. Dr: Are you comfortable enough to talk to me now? Pt Yes
6. Dr: Do you have any idea why you have this back pain?
7. Pt: Patient may say that she had breast cancer 5 years ago and had an operation and radiotherapy
treatment for that and is told that the cancer has spread to her back bones now.
a. Dr: I am very sorry to hear that.
b. If the patient did not know the cause of back pain –
c. Dr: Mrs. Your back pain can be to cancer which would have spread to the spine. We will do
investigations to confirm that. However, we can still manage the pain while we wait for the
investigations and hopefully you will be able to attend the wedding pain free.
8. Dr: Since when are you having this pain? Pt: since … Doctor the Paracetamol tablets what I am taking are
not helping enough now.
9. Dr: I am very sorry to hear that. Do you have any other problem other than pain ? Pt : Like what? Dr: Any
problem passing urine or opening bowel ? ( bowel and bladder incontinence due to spontaneous fracture
vertebra). Pt : No
10. Dr: Did you have any sort of injuries to your back recently? Pt : No.
C.
1. Dr: Mrs.. Sometimes people can have fractures in the back bones very easily because the back bones are very
weak if it has cancer cells. Sometimes even minor trauma can cause fracture. I need to examine your
back to check whether you have any chance of having a fracture.
( examiner may or may not give any findings).
2. Also we will do some X Ray of your back to see if you have any broken bones? Is that ok Mrs ..? Pt : Yes.
D.
1. Dr: Mrs... please do not need to worry about the pain. We are going to do everything possible to control this
pain and help you to cope with this condition.
2. We have a whole special team here to help to control your pain.
3. I will tell you about the various options we have for pain control. Are you following me? Pt: yes doctor. What
are you going to do?
4. Dr: We are going to give you stronger pain killers than Paracetamol. First option are the weak Opioids such
as codeine. These are tablets which you can swallow. Like any medications these too have some side effects
however we will keep monitoring you all the time and we will sort out any problems if you develop.
E.
1. Do you want me to tell you the side effects ? Pt: Yes doc please tell me.
2. Dr: This can cause drowsiness. Pt: Doctor please do not give me any medicine which will make me feel
drowsy because I need to attend my niece’s wedding in the next 2 week time..
a. Dr: Mrs.. Unfortunately all the good pain killer medicines makes people feel drowsy. But most of the time
drowsiness wears off after few days of starting the treatment. Also we can add Paracetamol to the codeine
and reduce the content of codeine in the tablet which gives drowsiness. How do you feel about this ? Pt
: That sounds good.
b. Dr: In the initial few days so you should not drive, and work near any heavy machinery. However this
drowsiness will wear off after few days as I told you. You may be able to drive if you are not feeling drowsy
after few days.
c. Pt: How can I work if I feel drowsy?
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 Dr: What work do you do? Pt: ...
Dr: As I said drowsiness will wear off after few days you can take a break from your work if you wish to in
the first few days when you may feel drowsy. Pt: Ok doc
3. Dr: If you get dryness of mouth you can chew ice cubes or Pineapple slices or chew sugar free gums. If they
do not help we can give some artificial saliva. Pt: OK doc.
4. Dr: Constipation is another problem with this medication but if you eat lot of vegetables and fruits with high
fibre then this may not be a big problem. We can also give some laxatives. Sometimes we may be able to
adjust the dose to overcome this problem.
5. Are you comfortable with this medication? Pt: Yes
F.
1. Dr – As the condition progresses the pain can get worse and if your pain is not controlled by codeine we will
give you strong opioids such as morphine which can also be taken by mouth. It has the same side-effects as
codeine.
2. You can take this as an injection too what we call as patient controlled analgesia. There will be a small devise
which contains the medication ( morphine ) which you
need to keep it with you. That will be attached to your
vein with tube. You can press a button on the devise
and the medication will be delivered to your veins. The
advantage is that it works faster than taking this as a
tablet and more effective. This can be used at home
too.
3. Pt - Will I get addicted ?
Dr – Unfortunately all the opioid type of medicines causes
addiction. However if you if you take the
medications at the right dose and the right time then
there are less chances of addiction. Pt – Ok.
4. Dr – Hopefully your pain will be managed by this. If at all your pain gets worse, in that case we can change
morphine to even stronger pain killer what we call as Fentanyl which can be worn as patches over your arm.
Is that Ok ? Pt – OK doc.
5. Dr: Do you have any concerns? Pt: No.
6. Dr: One of the best things you can do to prevent back pain is to exercise regularly and keep your back muscles
strong.
7. Some people find complementary and holistic medicine like acupuncture, hypnosis, massage techniques
helpful to control the pain.
8. Other medications like bisphosphonates can relieve pain.
9. Other tips for managing back pain:
 Hot or cold packs, or a combination of the two, can soothe a sore back. Heat can help reduce muscle spasms
and cold can help reduce inflammation.
 Eat a healthy diet that includes enough calcium and vitamin D to keep your spine and bones as strong as they
can be.
 Maintain a healthy weight to ease stress and strain on your back.
 Practice good posture and support your back properly when you have to sit for a long time.
 Avoid lifting heavy items. If you do have to lift something, keep your back straight (don't bend over to pick
up the object). Instead, bend your knees and then lift the item. This puts the stress on your legs and hips
rather than your back.

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10.Keep a pain diary: Please keep a diary of your pain like when do you get pain how long it lasts, how severe
it is what type of pain, what medication you took – this will help us decide what is the best way to treat our
pain.
11. Dr: You should get urgent medical advice if you feel difficulty walking or difficulty controlling urine and/or
bowel movements (Warning sign of spinal cord compression common in breast secondaries)
12. Dr – Do you have any other question?
Pt – No doctor.
Dr –I wish you cope well with this. As I mentioned earlier there is a specialist team including Psychologists,
Macmillan nurses to help you to cope with the pain. We will make sure you will be comfortable. If you need any
help in the future please do contact us. Thank you very much.

5. Lady Fracture neck of femur – Vasovagal syncope

EXAM question
A 70 Year old lady fell at home few days back. She was brought to A and E. She was diagnosed with fracture neck of
femur. The fracture has been treated. Further decisions have to be made. She is vitally stable at the moment.
You are FY 2 doctor in the medicine department.
Take history to find the cause of the fall and discuss further management with her.

A.
1. Dr: Hello Mrs Hilda My name is Dr... I'm one of the junior doctors in the medical department. How are you doing ? P:
I am OK now.
2. Dr: I was told that you had a fall few days ago and you had a broken hip bone is that right? Pt: That is right.
3. Dr: I am really sorry to hear that. How are you feeling now? Are you comfortable talking to me? Pt: yes doctor I
am fine thank you.
B.
1. Dr: what was done for the broken hip bone? Pt: They did an operation.
2. Dr: I see, How is everything now? Pt : Everything is OK now.
3. Dr: That is good to know. Mrs Hilda it’s a bit concerning to us why you fell down and it led to such an unfortunate
incident. I am here to see why did you fall and if there is any medical causes for your fall then we may need to treat that
so that you don’t fall again. Is that OK ? Pt: Ok doctor.
4. Dr; Can you please tell me how did you fall and the whole incident?
P: Doctor, I was in the kitchen just had my meal and was talking to my husband. Next thing I know is that I was
on a floor and had severe pain in my leg.
5. Dr: Oh I am really sorry about that. Were you standing when this happened? Pt : Yes
6. Dr: Do you know anything about why you fell down? Pt: No doctor to be honest I don’t know anything.
7. Dr: Ok..did you lose consciousness before you fell? P: Yes few seconds / Don’t know really but I don’t remember
what happened.
8. Dr: Was there any one with you when you fell down? Pt: Yes/ No
9. Dr: Did anyone tell you that you had fits when this happened ? Pt : No one was there at that time.
10. Dr: Did you bite your tongue ( epilepsy)? Pt : No
11. Dr: Was there any urine incontinence ( epilepsy) ? Pt : No
12. Dr: Do you have visual problems? P: No doctor I had my glasses checked recently?
13. Dr: Do you keep slipping or tripping and then fall? P: No
14. Dr: Did you feel like the room was spinning? P: No
15. Dr: Do you have a feeling of fullness in your ear? P: No
16. Dr: Do you hear any high pitched noise in any ear? P: No
17. Dr: Do you have any balance problem while walking? P: No
18. Dr: Did you have palpitations ( racing of heart)? P: No
19. Dr: Did you feel that you may pass out before you fell down? Pt : No
20. Dr: Did you have any weakness of arms or legs when this happened ( stroke )?
21. Dr: Did anyone tell you that you went pale before you fell down ? Pt: Yes my husband told me / No
22. [ Pale /cyanosis – suggests epilepsy, very pale/ white – suggests syncope or arrhythmia]

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23. Dr: Has it happened before to you? Pt: Yes doctor I have fallen four to five times in the past one year.
24. Dr: Did anything significant happen that led to subsequent falling? Pt: Not that I can think of. Like what doctor? Dr:
Any change in medication? Or any incident in family or friends? Pt: ….
25. Dr: Did you visit any doctor for the frequent falling? Were any investigations done? Any possible cause identified?
26. Dr: Did anyone tell you that you went pale before you fell previously also ? Pt: Yes my husband told me that.
27. Dr: Did you notice that these falls happen after prolonged period of standing? Pt: No (orthostatic)
28. Dr: Did these falls occur after any unpleasant incident, unexpected sight, sound or smell? Pt: (Vasovagal syncope-
emotional stress)
29. Dr: Did these incidents happen after meals usually? Pt: (Post-prandial hypotension)
30. Dr: Did you notice that these falls happen usually when you turn your head? Pt: No
31. Dr: Was there any warning: light-headedness, nausea, sweating, weakness or visual disturbance? Pt : ……[Preceding
nausea, sweating and blurred vision have been shown to be predictive of non-cardiac syncope in the elderly]
32. Dr: Do you live alone or with someone? Pt: (assess NAI)
33. Dr: Have you ever been diagnosed with any medical conditions in the past? Pt: Yes I have high blood pressure .
34. Dr: Since when ? Pt: Since last 10 years.
35. Dr: Are you taking any medications? Pt: Yes I am taking medications for my blood pressure.
36. Dr: Since when are you taking medications? Pt : Since the last 10 years.
37. Dr: Has the medications been changed recently. Pt: No doctor.
38. Dr: I see. Can you please tell what medication you are on right now? P: I can't remember the name doctor
39. Dr: No problem Mrs... Do you have the medication with you? P: No Dr: Are you carrying the prescription given by your
GP? P: No
40. Dr: Ok that's fine Mrs...I will find that out from your notes.
41. Dr: Have ever been diagnosed with any heart conditions ? Pt : No
42. Dr: Do you have diabetes? P: No
43. Dr: Have you had any heart related problems in the past? P: No
44. Dr: Have you ever had a stroke? P: No
45. Dr: Do you have any bone pain or other bone related problems any fractures before ? Pt: No (osteoporosis)
46. Dr: Have you been diagnosed with Osteoporosis ? Pt No
47. Dr: Any of your family members have any medical conditions ? P: No
48. Dr: Any family history of osteoporosis? Pt: No
49. Dr: Do you consume alcohol? P: Yes/ No (Explore alcohol according to answer)

C. Examination and investigations:

1. Mrs. .. I need to do examine you some tests to find the cause of why you fell.
2. For that we need to I check your pulse and BP. I will have to check your BP while you are lying down and while you are
standing.[ Examiner may not give you standing and lying blood pressure].
3. I would also like to examine your chest to check your heart. [Start examining the patient – stop examining if the examiner
stops it] – check for irregular pulse, examine chest –try to auscultate).
4. We need to check your sugar, check whether you have anaemia and do heart tracing. Also we may need to check your
heart tracing for 24 hours to see if you have any abnormal heart rhythms. [examiner may not give any result]
5.
D. Diagnosis:
6. Dr: Mrs... based on the information you have told me and the findings on examination, I think you have a condition called
vaso- vagal syncope which is otherwise called simple faint.
7. Pt: why is this happening to me doctor ?
a. Dr: Fainting (syncope) is caused by a temporary reduction in blood flow to the brain.
b. Blood flow to the brain can be interrupted for a number of reasons like an unpleasant sight, heat, sudden
pain, coughing, sneezing
c. Laughing, sitting or standing up suddenly. Sometimes this can happen if you you stand for long time or if
there is any problems in the heart or if someone has Anaemia or Diabetes or narrowing of arteries ( blood
vessels) in the neck.
d. In your case it is most likely just a simple faint. It is unlikely that you have any problems in the heart or
you have anaemia or any other condition causing this.
8. However we need to make sure that you do not have any such problem by doing some tests like blood tests and
heart tracing. We may need to do 24 hour heart tracing too. We need to do some tests to check for narrowing
of blood vessels in the neck. Is that Okay?
Pt: Ok. when will you get the results?
Dr: It may take one or 2 more days for us to get the result for all these.
9. Pt: How will you treat me doctor?
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 Dr: If we find anything abnormal in the test we will treat accordingly. However if all the tests are normal it
could be just a simple faint. Unfortunately there is no treatment for this.
It can happen again so you need to be careful.
10. Please avoid standing for long time and avoid taking hot baths. Drink plenty of fluids and also drink strong tea or
coffee. Take small frequent meals because some people have large drops in blood pressure after meals. Avoid drinking
excess alcohol ( if she drinks).
11. If you feel that you are going to faint – please lie on the floor immediately with the legs up on chair or walls.
12. When you get up from the bed get up slowly.
Dr: Any other questions ? Pt: No
Dr: Let us hope this will not happen again. Thank you.

6. Fracture pelvis in child

You are the FY 2 doctor in the Paediatric department
10 year old boy Joshua Martin was brought into the hospital by the ambulance because he met with the Road
traffic accident.
Investigations revealed that he has fracture pelvis.
Pulse – high. BP – very low. He is not stable.
Talk to his parents and address their concern.

A.
1. Dr: Hello Mr and Mrs Martin ? ….. I am Dr ….. one of the junior doctor in the Paediatric department. Are you
the parents of Joshua ? Parents: Yes doc
2. Dr: I am one of the team of doctors looking after your son. Parent: Oh, How is he doctor ?
3. Dr: Joshua is in the resuscitation room now. Our team is taking care of him.
B.
4. I have come here to talk to you about him. Before that – Mr Martin, I was told that he met with an accident.
Can you please tell me more about it?
Parent: Doctor we were about to go to a restaurant and Joshua suddenly ran to cross the road and the
next thing I heard he was calling me Papa Papa. When we saw him he was under the car. We called the
ambulance immediately. They brought him here.
5. Dr: I am very sorry to hear that. When did this happen ? Parent: About half an hour ago.
6. Dr: Mr and Mrs Martin, I do have some news about him. I wish I could give you some good news but
unfortunately Joshua is in a very critical condition now.
Parent: What happened why do you say that?
7. Dr: Mr and Mrs Martin, we examined him and did some investigations. They show that he has broken his hip
bones. Because of that he is bleeding heavily inside in his hip area.
Parent: Is it serious ?
8. Dr: This is a very serious condition. I am very sorry to say this. Parent: Don’t you have any treatment for
this?
Dr: We can do surgery and try to fix the fracture. That is what our team is trying to do. We do have the best
surgical team to deal with such problems. We are doing our best to save him. Most of the time surgery is very
successful and they recover from the condition.
Usually that controls the bleeding. Also we may need to give him blood transfusion because he would have lost
lot of blood. Is that OK for us the give the blood transfusion ?

9. Parents: Yes doctor you can give blood transfusion.

Dr: Mr and Mrs Martin, As I told you before most of the time the operation is very successful and we will be
able to control the bleeding. However sometimes it is be very difficult to control the bleeding in that case it can
still be very serious and it can be even life threatening.

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10. Parent: Is he going to die doctor ?
Dr: As I mentioned our team will try to do the best for Joshua. As I told you before, most of the time children
do recover from the problem once we do the operation and fix the broken bones.
However, there is a very slight chance that he may not make it.

11. Mother may cry – console her and dad. ( tissues – glass of water to drink). Parent: Doctor I can’t believe
this !
Dr: I can’t even imagine how you are feeling now. We will do everything possible from our side.
12. Parent: Thank you doctor Can we see him?
Dr: I can understand you want to see him. As you know at the moment we are resuscitating him. You may not
be able to see him for long time because we need to operate on him as soon as possible. May be you can have
a quick look at him now and you can see him properly after the operation, is that OK Mr and Mrs Martin.
13. Dr: Any other concerns Mr and Mrs Martin ? Parents : No doctor.

14. Dr: Are you Ok for us to go ahead with the operation?

Parents: Sure doctor, if you think that it is necessary. Please do whatever is best for him.
15. Dr: Thank you. I need to ask you few questions about his health ? Is that OK? Parents : OK
16. Dr: Can I ask you how was Joshua’s health before this happened ? Parent: He was completely fine.
17. Dr: Did he have any medical conditions at all ? Parents: No
18. Dr: Is he on any medications? Parent: No
19. Dr: Is he allergic to anything you know? Parent: Strawberries doctor.
20. Dr: I see. It is good that you told me about it. I will make a note of this in his notes and let everyone know about
this so that no one gives him strawberries here. Can I ask is he allergic to any medications at all? Parents - No
21. Dr: Any medical conditions in the family members ? Parent: No
22. Dr: When did he last eat or drink? Parent: Just before this happened / in the morning. Dr: How many hours ago
is that? Parents … hours ago.
23. Dr: Thank you very much for the information. Is there any other questions? Parents: No
24. Dr: Thank you very much Mr and Mrs Pilmore, once again I am very sorry to give this news.
We will keep you informed about everything. I will be around if you need any other help. I hope to come back
with good news. Thank you very much.

7. Lady with fracture wrist – Talk to son.

Exam question:

You are the FY2 doctor in the Orthopaedic department.

84 year old lady Mrs Margaret Edwards had a simple fall at home and sustained fracture wrist on the non-
dominant hand.
She has been treated and the Multidisciplinary team consisting of doctors, Physiotherapists and
Occupational therapists have assessed her and decided to send her home with twice a day visit by the carers.
She is also been arranged for the follow up at the fracture clinic every week.
She was given walking stick.
She is Lucid. She also wants to go home. She has given consent to talk to her son.
Her son wants to talk to a doctor about her.
Talk to him and address his concerns.
Praise the son (for asking and caring for her mom - even if he is souhting because it means he really loves his
mom)  I see how much concerned you are about (your relative) -->

A.
1. Dr: Hello Mr Edwards ? Son: Yes
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2. Dr: I am Dr… junior doctor in the Orthopaedic department. Are you the son of Mrs Margaret Edwards? Son:
Yes
3. Dr: I am one of the team of doctors looking after your mother. I was told that you want to speak to a doctor
about your mother. Can I help you Mr Edwards ? Son: Yes doctor. How is she ?
B.
1. Dr: May I ask - do you know what has actually happened to her ? Son: I was told that she had a fracture in
her wrist.
Dr: That is right Mr Edwards. Fracture has been treated now. Our Multidisciplinary team consisting of doctors,
physiotherapists and occupational therapists have assessed her and decided to send her home. We have arranged
twice a day visits by the carers until she is better and also we have arranged follow up for her in our fracture
clinic every week until she completely recovered.
Twice a day is enough .. but i you r really worried about , then i will talk to m snerios and come back to yuo
about it
2. Son: Are you sure she can take care of herself at home.
Dr: Yes we think so. She has been fully assessed by our team including her home conditions and the team
believes she will be able to manage herself at home with the help of carers visiting her twice a day to help her.
Also her fracture was in a non-dominant hand. We have given her a walking stick also. So we are hoping it
should not be any problems.
3. Son: What will the carers do?
Dr: They will do everything help her daily activities like cooking, feeding, dressing, shower, shopping, giving
her medications and any other necessary things.
4. Son : why was she given walking stick?
Dr: Because she has a fracture in one hand she was given walking stick so that she can support herself if she
loses balance while walking. This is given temporarily until her fracture heals. She may not need it afterwards.
It is not permenant -- to suport her just in case she lost balance but latter she will not need it
5. Son: Doctor I live about 50 miles away from my mother’s house. It will be very difficult for me to visit
her and look after her. Can you please keep her in the hospital until she is completely fine.
Dr: I can understand your concerns. However, Mr Edwards, we have assessed her and we believe she will be
able to manage herself at home with carers help. We are not expecting you to take care of her on a daily basis.
Beside that she herself want to go home. We appreciate if you can visit her whenever you have time.
6. Son: She may say that she will manage herself, But I am sure she won’t be able to manage herself. What
if she falls again ?
Dr: May I ask why do you think she will fall again?
Son: She already fell once she may fall again? Are you sure she will not fall again at home?
Dr: I can understand why you are so worried. Mr Edwards, we have assessed her and we did not see any medical
causes for her fall. Our team has visited her home also and made sure everything is safe. We do not see any
medical reasons for her to fall again ?
Praise him -- Ask about why he has worries -- and reassure him that from our side we cannot see why she might
fall again
7. Son: Well, I don’t know. But if she falls again then the hospital will be responsible for that.
Dr: Mr Edwards as we have mentioned we have checked for all the medical causes and we do not see any
medical causes for her to fall. If you have any other reasons to believe she may fall again at home, please do let
us know. We will look into that again.

If he said he has no worries? I would liek to reassure you that we have cleared all reasons that she does not fall
again

8. Son: Doctor can you please tell her to go to a care home or residential home ?
Dr: May I ask - why do you want her to go to the care home ?
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 Son: She lives alone and I live so far away from her home. I have wife and children to look after. I am
too busy. It will be better for her to live in a care home or a nursing home.
Dr: Mr Edwards, I can see that you are a very caring son. I can imagine why you want her to be in the care
home. However, it is her decision because she has a mental capacity to decide for herself what she wants. Have
you discussed this with her ?
Praise (I can se you are concerneed bout your mother). it is better for her to stay in the hospital if there is a
reason to admit her .. at the moment she does nto have .. we have made all precautions .. we gave her walking
stick .. we are not expecting you to stay with her .. you can just visit her ..
Son: No doctor. It is embarrassing for the family members to suggest her this. It is better you doctors
suggest that to her.
Dr: If we have seen any medical reasons that it is not safe for her to live alone in her house then we could have
suggested for to live in the care home or nursing home. I sincerely advise you to discuss this matter with her.
I can see you are caring son.. She can stay there if there is any medical reason ..
we cannot see any medical reason for her to stay ..
9. Son: I believe she will not be safe at home.
Dr: Mr Edwards. I can see you are very concerned about her. We also want the best for her as much as you
want that for her. If you wish we can have a meeting again with the whole team and you can raise any concerns
and see if anything more we can do for her.
10. Son: But you already had a meeting !
Dr: That is right, but at that time you were not in the meeting. We can arrange the meeting again if your mother
agrees for that. Mr Edwards, please be reassured that we will do everything possible from our side to keep her
safe at home. If needed maybe we can increase the frequency of carer’s visits to her home. Son: Ok Doctor.
11. Dr: Thank you very much Mr Edwards. I will talk to my Consultant now and inform him about your
concerns. Thank you very much for coming here and sharing your concerns. We really appreciate that. Thank
you again.

8. Hemi-arthroplasty of Hip Joint

You are the FY 2 doctor in the Orthopaedic department.
A 70 year old lady Mrs Katherine Jones fell at home and could not walk after that. She was brought into the
hospital and the X Ray was done which showed fracture neck of femur. Your Consultant planned to do
hemiarthroplasty of hip joint.
Your colleague has already told her about the operation and Anaesthetic colleague has already explained
her about the pain management.
Talk to her about the post - operative management.
A.
1. Dr - Hello Mrs Katherine Jones I am Dr …one of the junior doctor in the Orthopaedic department. How are
you doing ? Pt: I am OK doctor.
2. Dr- I am sorry to hear about what happened to you. Are you in pain now ? Do you need any pain killers? Pt :
It is OK doctor. Nurse just gave me some pain killers.
3. Dr: Are comfortable to speak to me? Pt: Yes doctor.
B.
1. Dr: Mrs Jones -do you know what has happened to your hip ? Pt - Yes doc, I was told that I have a broken
bone in my hip.
2. Dr - That is right, I am sorry about that. Mrs. Jones do you know what we are going to do for that?
Pt - Yes, your consultant told me I need to have a surgery.
3. Dr - Yes that is right. We are going to put a new joint to your hip. I was told one my colleague has already told
you about the operation and how we are going to manage you pain. Is that right ? Pt - Yes doc.
4. Dr – Mrs. Jones do you have any concerns of what may happen after the surgery?
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 Pt – Doctor, I am worried because one of my friend had some surgery and she had some blood clot in her
lungs and she became very serious with that. Will the same thing happen to me also doctor?
Dr: I am really sorry to hear about your friend. Unfortunately people do get blood clots in the legs or lungs
after major surgeries like the one what we are planning do for you. However, not everyone has this type of
operation will get clots. Mrs Jones we take all types of precautions so that you will not get this problem. Even
if you get it we will try to manage that.
Pt: Thank you very much doctor.
5. Dr: Mrs Jones It is usually the blood clots which develops in the legs which travels to the lungs. There are lot
of risk factors why people get this type of problems. Can I ask few questions about your health to see if you
have any risk factors to develop this clot.
a. Dr: Can I ask you did you have any blood clots in your legs or lungs before ? Pt: No
b. Dr: Do you have any medical conditions? Pt: No
c. Dr: Are you taking any kind of medications? Pt: No
d. Dr: Do you have any kind of blood disorder? Pt: No
e. Dr: Any of your family members had blood clots ? Pt: No
6. Dr: OK. That is good. You do not have much risk factors to develop clots. The chances of you getting blood
clots are low. However, since this is a major operation around the hip there are still some chances of getting
blood clots. As I mentioned earlier we still take all precautions to prevent you having this problem.

7. Pt: What will you do so that I will not get clot doctor ?
Dr: We do take lot of measures so that this problem does not happen –
a. like we give some blood thinner injections to you every day before the surgery itself and also we continue
to give that after the surgery for few days to prevent you getting clots.
b. We will give you some special stocking ( T.E.D stocking) to wear on your legs – this improves blood
circulation in the legs and also we have some special types device which also improves the circulation in the
legs by changing air pressure ( intermittent pneumatic compression therapy).
c. If people lie down on the bed for long time they can get clots in the legs. We will try to mobilize you as soon
as possible after the surgery to prevent you getting clots.
8. Pt: Thank you very much doctor. How will I know if I get clots in my legs or lungs?
Dr: If you have blood clot in the legs you will have pain and swelling in your calf and if you get blood clot in
the lungs you will have pain in the chest and shortness of breath. If you develop any of this symptoms you need
to inform us immediately. If you develop this problem at home after we discharge you need to call the
ambulance and come to the hospital immediately.
9. Dr: Do you have any other concerns? Pt: When will I walk again?
Dr: As I mentioned earlier we will try to mobilize you as soon as possible either the same day after the surgery
if not the next day itself to prevent clots. However you will not be able to walk without any support. You will
use some type of crutches to support and also there will be physiotherapist supporting you.
10. Pt: When will I walk on my own without any support?
Dr: It usually takes about 6 weeks for the operation site to heal properly and the tissues around that to become
strong. So after about 6 weeks you may be able to walk on your own without any support.
11. Dr: Any other concerns? Pt: When will I go home ?
Dr: - If you are generally fit and well, we will discharge you within about three to five days. However we need
to make sure that you will be able to cope at home before we discharge you. Our Occupational therapist will
visit your home before we discharge you to check whether you can cope at home when we discharge you. They
will make any adjustments required so that you can cope at home. You may not be able to walk up and down
the stairs for some time if you have stairs at home. Do you have stairs at home ?

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 Pt: Yes, I have stairs at home. ( sometimes she may say no I live in a bungalow ( bungalow is one floor
house).
Dr: Occupational therapist will look at these problems. They may arrange everything to be in one floor ( like
bedroom kitchen and bathroom) so that you don’t have to go up and down the stairs until your joint becomes
strong ( may be about 3 months). Occupational therapist will also advise you on how to do daily activities, such
as washing yourself.
They will also advise about any equipment you may need to help you to be independent in your daily activities.
This may include a raised toilet seat and aids to help you dress.
12. Dr: Any other concerns?
Pt: Is there anything I need to be careful about?
Dr: One other problem after this hip surgery is that the joint can easily dislocate means the bones may pop out
of the joint. You should be very careful that this will not happen.
You should take care not to fall. Also physiotherapist will teach you some exercises after the operation so that
that hip becomes strong.
You should do take the joint will not dislocate like:

• avoid bending your hip more than 90° (a right angle) during any activity
• avoid twisting your hip
• do not swivel on the ball of your foot
• when you turn around, take small steps
• do not cross your legs over each other
• avoid sitting on low chairs and toilet seats.
13. Pt : When will I be completely be normal doctor ?
Dr - Generally, you should be able to stop using your crutches within four to six weeks and feel more or less
normal after three months, by which time you should be able to perform all your normal activities. It is best
to avoid extreme movements or sports where there is a risk of falling, such as skiing or riding.
14. Pt: Can I play ball game?
Dr: You can play ball game after your hip should become strong which may take about 3 months to 4 months.
[Sports which are allowed after hip surgery (but only after about 5 to 6 months) - low‐ impact activities such as
swimming, bowling, stationary biking, dancing, rowing and walking are allowed. Downhill and cross‐country
skiing, weightlifting, ice‐skating are activities that are allowed with experience.
Not allowed - racquetball/squash, jogging, contact sports, high‐impact aerobics, baseball/softball and
snowboarding].
15. Dr: Do you drive Pt: No
Dr – You should be careful while getting in and out of your car. It is best to ease yourself in backwards and
swing both legs round together. ( Driving is allowed after about 6 weeks).
16. Dr Any other concerns ? Pt : No doctor.
Dr: Mrs Jones there could be some other complications which may happen rarely like infections or bleeding
but again we take all care so that these things will not happen. Thank you very much. Hope you recover soon
and go home soon.
17. Say these only if the patient ask :
a. [ Pt - When can I go back to work? - After six and 12 weeks after your operation.
b. Pt: When can I have sex after this operation ? After about 6 weeks.
c. Pt - Will I need another new hip? - Nowadays, most hip implants last for 20 years or more. You may
need another operation after about 20 years.]

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 9. Reactive arthritis
25 years male, Mr Robert, C/O joint pains
Assess him and discuss the management with the patient.
Differentials for Joint pain. ( Pneumonic – GHRRROSS)
1. Gout
2. Heamarthrosis
3. Rheumatoid arthritis
4. Reactive arthritis ( Reiter’s syndrome – old name for reactive arthritis)
5. Osteo arthritis
6. Septic arthritis (Septic arthritis is so painful)
7. Sports injuries
A.
1. Dr: Hello I am Dr .... Are you Mr Robert ... Pt: Yes.
2. Dr: How can I help you? Pt: I am having pain in my knee and ankle joints.
3. Dr: Is it both the knees and both the ankles ? Pt: Yes
4. Dr: I am sorry to hear that. Can you tell me anything more about them? Pt: It started about 2 weeks ago
doctor
5. Dr: Do you know how it started? Pt: On its own doctor
B.
1. Dr: Do you have any other symptoms other than pain in your joints ? Pt: My eyes are bit sore since last few
days.
2. Dr: Did you have any injury to your knee or ankles at all? Pt: No
3. Dr: Are all those joints swollen ( heamarthrosis, reactive arthritis, septic arthritis, rheumatoid arthritis) ) ? Pt
: Yes
4. Dr: Do you have fever ( septic) ? Pt : No
5. Dr: Are you able to walk at all ( Can’t walk in septic arthritis because of severe pain) ? Pt: Yes I can walk.
6. Dr; You have pains in the small joints of your hands ( Rheumatoid arthritis affects small joints) ? Pt : No
7. Dr: Do you have stiffness in the joints ( Rheumatoid, reactive) ? Pt -Yes
8. Dr : Any pain in your back ( ankylosing spondilitis) ? Pt : No
9. Dr: Do you have any swelling and pain in the big toe ( Gout) ? Pt : No
10. Dr: Did you have this type of problem before? Pt : No
11. Dr : Do you have any medical conditions? Pt: No
12. Dr: Are you taking any medications at all? Pt : No
13. Dr : Any of your family members has this type of conditions? Pt : No
14. Dr: Have you travelled outside UK recently? Pt : I went to France about 3 months ago.
15. Dr: Did you have any health problems when you were there? Pt: I had diarrhoea for few days.
16. Dr: Did you take any treatment for that ? Pt: No it subsided on its own.
17. Dr: Did you have any unprotected sex with any one recently ? Pt : No
18. Dr: Do you have burning sensation while passing urine ? Pt: No
19. Dr: Any discharge from the urethra that is front opening of urine passage? Pt: No
20. Dr: Is there anything else you think important that we may need to know? Pt : No
C. Examination
1. Check NEWS chart for temperature
2. I need to examine your knee and ankle joints. I will be very gentle while examination. Is that OK if I examine
now ? Pt : Yes.
3. Can you please undress below your mid thigh.
4. Check Gait: Could you please take few steps (May have antalgic gait = limbing = painful gait)
5. Can you please stand now.
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 6. Inspection of knees and ankles : No swelling, redness, scars or sinuses.
7. Palpation: Knees
a. Can you please lie down on the couch.
b. Check for temperatures ( compare temperature over the
knees to thighs).
c. Check joint line tenderness – No joint line tenderness
d. Check for fluid collection – milk from thigh down
towards the knee and do patellar tap. – No fluid in the
joints.
e. Check movements ( Active and passive) – Flexion,
extension, Internal rotation external rotation – all
movements normal.
8. Ankles – Check for any bony tenderness – No bony
tenderness, No swelling
9. Check movements – plantar fexion, dorsi flexion: Movements normal
D. Investigations
Robert we need to do some investigations to find out what exactly is the problem. We will do some blood tests for
infection markers, Also we will do the X Rays of your knees and ankles. Also we need to do some tests to check
for some joint conditions like rheumatoid factors in the blood. Is that Ok? Pt : Ok doctor.

E. Diagnosis.
1. Robert with the information you have given me and after examination I think you have condition what we call
as Reactive arthritis. Do you know anything about this condition ? Pt : No
2. Dr : I will explain. If someone had any infections due to some bugs in other parts of body like bowel - sometimes
as reaction to that infection people develop inflammatory ( a type of reaction which causes swelling of joints)
reactions in the big joints like knees and ankles. Since you had diarrhoea few weeks ago which may be due to
bugs – that would have caused this condition in you. This condition causes pains in the knees and ankles and
also it causes soreness in the eyes. This condition is due to problem in the immune system.
3. Do you follow me ? Pt : yes doctor
4. Dr: Do you have any questions at this point ? Pt : No
F. Treatment
1. Dr: Unfortunately there is no cure for this condition. However, the good news is that it usually subsides on
its own but it may take up to six months or may be even up to a year to subside completely.
2. We advise you to take plenty of rest and avoid using the joints as much as possible initially.
3. As your symptoms improve, you should start doing exercise slowly to strengthen muscles. We will refer you
to the Physiotherapist for that.
4. We will give you medications called Ibuprofen – that also will help you reduce the pain.
5. If the Ibuprofen medication do not help then we can give you medications what we call steroids.
6. We will give you steroid drops to your eyes – that will help to reduce the soreness in your eyes.
7. If none of these medications help then we will give medications called DMARDs ( Disease-modifying anti-
rheumatic drugs ) such as sulfasalazine which may help.
8. Pt: Can it come back again? Unfortunately it can happen again if you develop any infection in parts of body
again.
9. Dr: Any other questions ? Pt : No Thank you.

10. Ankle sprain

You are the FY 2 doctor in the A&E department.
30 year Mrs Anna Henley presented to the hospital in the morning because she fell on grass while she was
140
going home from work. She had pain, swelling and bruise in her ankle. X Ray was done in the morning.
She has come back to get the X Ray result.
Take history and talk to her about the further management.
A.
1. Dr: Hello Mrs Henley I am Dr.. How can I help you ?
Pt: I came in the morning to the hospital because I had injury to my ankle. They did X Ray But I could not wait
for the X Ray result at that time. I have come now for the X Ray result.
2. Dr: Could you please tell me how did you injure your ankle?
Pt: I work as a cleaner in a school. I fell inside the school premises while working and that is how I injured my
ankle.
3. Dr: Mrs Henly it is written in our notes that you fell on the grass outside the school premises!
Pt: Oh Yes I made a mistake in the morning. I was not thinking properly that is why I told I fell outside the
school premises. Doctor can you please change what is written in the notes and write that I fell inside the school
premises.
4. Dr: Mrs Henly we cannot erase what we already wrote in our notes. However we can write that you have
requested us to change the story of how it happened.
Pt: No doctor don’t write like that. Please erase what you wrote in the morning and write what I told you now.
5. Dr: Can I ask you why do want us to do that?
Pt: If I mention that I fell inside the school premises I will be entitled for compensation for the injury happened
at the work place.
Dr: I can imagine why you
want to do that. Unfortunately
we cannot do that – we should
be honest
PRICE stands for:
• Protection – protect the affected
area from further injury by using a
supportor, wearingshoes.
• Rest – Avoid activity for the first
48 to 72 hours. We can give you
crutches tohelp you towalk.
• Ice – for the first 48 to 72 hours
after the injury; apply ice wrapped in a damp towel to the injured area for 15 to 20 minutes every two to three
hours during the day. Don't leave the ice on while you're asleep, and don't allow the ice to touch yourskin directly
because it could cause a coldburn.
• Compression – We will put elasticated bandage to the ankle to limit the swelling and movement that could damage
it further. You can use a simple elasticbandage or an elasticated tubular bandage. Remove the bandage before you
go tosleep.
• Elevation – keep the injured area raised and supported on a pillow to helpreduce swelling.

You should avoid ( HARM )

• Heat – such as hot baths, saunas or heatpacks.
• Alcohol – drinking alcohol will increase bleeding and swelling, and slowhealing.
• Running – or any other form of exercise that could cause moredamage.
• Massage – which may increase bleeding andswelling.

1. Generally, you should try to start moving a sprained joint as soon as it's not too painful to do so.
2. Pt: When can I walk properly doctor?

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 Dr: Usually you'll probably be able to walk one or 2 weeks after the injury. We can give you crutches to help
you walk until then. You will be able to use your ankle fully after 6 to 8 weeks,
3. Avoid driving until strength and mobility have returned which may take 6 to 8 weeks. You can return to
sporting activities after 8 to 12 weeks if you do any sports.
4. Contact your GP if your injury doesn't improve as expected or your symptoms get worse. Surgery – is not
needed to treat sprains unless the injury is very severe.

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 11. Osteoporosis
69 year old lady had fracture wrist one week ago.
DEXA scan showed Osteoporosis.
Explain the result to her and address her concerns.
A.
1. Hello Mrs .. I am Dr ..one of the junior doctor in the medical department.Dr - How are you doing? Pt – I am fine
doctor.
2. Dr: How is your wrist fracture ? Any pain now ? Pt: Not in pain now.
B.
3. DR: Can you please tell me how actually you injured your wrist. Pt: I was coming down the stairs holding the
railing. Suddenly I felt pain in my wrist.
4. Dr - We did special X Ray that is DEXA scan on you. The results of that test is back now. I am here to talk to you about
the result. Is that OK. Pt - Ok Doctor.
5. Dr – Test results shows that you have a condition called Osteoporosis or thinning of bones. Do you know anything about
it ? Pt – No Doctor
Dr - Osteoporosis is a condition where the bone loses minerals which makes the bones less dense and less strong. So the
bones becomes weak and fragile so they break very easily even with a minor injury.
6. Pt – Why did I get this doctor?
Dr –It is commoner after the age of 60 years. It sin seen more commonly in women compared to men. This is usually
due to lack of calcium and Vit D and lack of exposure to sunlight. There are lot reasons why people get this condition.
C.
7. Can I ask you few questions to see why you would have got this condition ? Pt – Yes doc
8. Dr- Sometimes people can get this condition if they have some types of medical conditions. Do you have any medical
conditions like thyroid problems, Joint problems ( rheumatoid arthritis), Bowel problems( crohn’s disease), Bronchitis (
COPD), kidney problems (CKD). Pt – No doctor
9. Dr – Sometimes this condition can run in Family. Any of your family members have this condition? Pt – My mother
had hip fracture.
10. Dr – Okay as I mentioned probably this is one of the reasons. Sometimes it can happen in those people who takes steroid
type of medications. Do You take any medications ? Pt – No
11. Dr: Can I ask what kind of food do you eat regularly ? Pt: I eat healthy balanced diet doctor.
Dr: Do you drink milk ?
Pt – I drink lot of milk. I use milk for cereals also.
Dr – It is very good that you drink lot of milk.
a) Milk contains calcium which strengthens bones. Calcium and vitamin D are important for bone health. Your body
needs adequate supplies of vitamin D in order to absorb the calcium that you eat or drink in your diet.
b) We advise you to drink a pint of milk every day.
c) Other sources of calcium are hard cheese such as Cheddar or yoghurt, Bread, calcium-fortified soya milk, some
vegetables (curly kale, okra, spinach, and watercress) and some fruits (dried apricots, dried figs, and mixed peel) are
also good sources of calcium.
d) Butter, cream, and soft cheeses do not contain much calcium. You can check how much calcium you eat with an
on-line dietary calcium calculator.
12. Pt: Can you give me some calcium supplements?
Dr: We can give you calcium and vit D supplements too.
Dr: Food which contain Vit D are cooked salmon or cooked mackerel or tuna fish or sardines (both canned in oil).
However Vitamin D is mainly made by your body after exposure to the sun. The ultraviolet rays in sunshine trigger your
skin to make vitamin D. So it is better to have sun exposure.
13. Dr – Do you do exercise.Pt – Yes I go for swimming and jogging.
a. Dr –That is really good to know that you do exercise. .
b. Doing exercise helps to stimulate bone-making cells and strengthens your bones. Regular weight-bearing exercise is
best.

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 c. This means exercise where your feet and legs bear your body's weight, such as brisk walking, aerobics, dancing,
running. For most benefit you should exercise regularly - aiming for at least 30 minutes of moderate exercise or
physical activity at least five times per week.
d. Unfortunately swimming is not weight-bearing exercise, this is not so helpful in preventing osteoporosis.
14. Dr – Do you smoke? Pt - No/Yes doctor ( 10 to 15/day since many years )
15. Dr – This one of the risk factors why people get this condition. ( If no – it is really good. Please do not start smoking, If
yes - I would strongly advise you to stop smoking. We can help you if you wish to stop smoking ).
16. Dr - Do you drink alcohol Pt – No/Yes doctor 1 to 2 glasses of wine every day.
17. Dr – This is also another risk factor. ( Please cut down drinking. Again we can help if you wish to cut down.
18. Dr - Did you have any operations ? Pt – No/ I had my womb removed when I was 35 year old.
19. Dr – Removal of the ovaries also can contribute to this problem. Have they removed your eggs? ( Oopherectomy is risk
factor) Pt – No
20. Dr – Did you attain menopause and when? ( early menopause is risk factor) ( can be treated with HRT if patient had early
menopause) Pt – when I was 45 years old.
21. Dr – You should take care not to fall because you can have fractures very easily because of weak bones.
D. Pt – Any medications to treat doctor
1. Dr: There are medicines called Bisphosphonates like alendronate can help. They can help to restore some lost bone and
help to prevent further bone loss. They may also help to reduce the chance of a second fracture if you have already had a
fragility fracture.
2. You need to take bisphosphonate tablets whilst you are sitting up and with plenty of water, as they can cause irritation of
your gullet (oesophagus).
3. Side effects: This can lead to indigestion-type symptoms such as heartburn or difficulty swallowing. Other side-effects
may include diarrhoea or constipation.
4. You should not eat or take other tablets for half an hour after taking your bisphosphonate tablet. Depending on which
medicine is used, you may need to take it daily, weekly, or sometimes less frequently.
5. A rare side-effect from bisphosphonates is a condition called osteonecrosis of the jaw. This condition can result in severe
damage to the jaw bone and jaw pain. You should have regular dental check-ups whilst taking a bisphosphonate. Tell
your dentist that you are taking a bisphosphonate. [ Note: the risk of osteonecrosis of the jaw is low in people taking
bisphosphonate tablets as a treatment for osteoporosis. It is greater in people who are being treated with bisphosphonates
by injections into the veins (intravenously)].
6. Pt: Can you give me HRT ?
Dr: Hormone replacement therapy (HRT) contains oestrogen. HRT was widely used few years ago to prevent
osteoporosis. However, the recent findings showed there are health risks of HRT like breast cancer, heart disease and
stroke. So it is not used nowadays. (except in women who have had an early menopause).

12. Tiredness –Fibromyalgia

A.
1. Dr: Hello Mr James Paterson. I am Dr…. one of the junior doctor in the clinic. How can I help you? Pt: Doctor,
I came to the GP surgery 6 weeks ago. I was told to come back again.
2. Dr: Mr Paterson, Unfortunately our computer system is crashed and your records are not available. Could you
please tell me again why did you come here last time ? Pt: I am feeling very tired for the last few months.
3. Dr: I am very sorry to hear that. Is there anything else you can tell me ? Pt: I am having body ache also. I
can’t do my work properly.
4. Dr: Since when exactly all these problems started? Pt: Almost 6 months now doctor.
5. Dr: Can you figure out what would have triggered these things at all? Pt: I do not know.
6. Dr: Were you completely well before this 6 months. Pt: I had some viral infection before these symptoms
started which lasted for few days.
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7. Dr: May I ask what job do you do? Pt: I work as an assistant in the Lawyers office.
8. Dr: Does it affect your work, I mean are you able to carry out your work? Pt: With difficulty I am managing
to work. I have taken few days off in the last few months because I was feeling very tired.
9. Dr: How about your daily activities – are you able to do them? Pt: Yes, but again I do get tired quickly.
10. Dr: You said you have body pain. Since when are you having this? Pt: Since again about 6 months.
11. Dr: Can you please tell me where all you have pain in your body - can you please point it ? Pt: …
12. Dr: Are you able to sleep properly? Pt: My sleep is very disturbed. I don’t feel refreshed when I get up in
the morning. Dr: Do you have headache ? Pt: No
13. Dr: How is your mood ? Pt: It is low because I am very tired and can’t do work.
14. Dr: Any worries and stress before these symptoms started ?Pt:No Dr: Do feel SOB? –No
15. Dr: Any constipation ? –No Dr: Weight gain or weight loss? – Pt: No
16. Dr: Do you have any joint swellings or joint pains ( rheumatoid arthritis) ? Pt: No Dr: Any balance problem
while walking ( Multiplesclerosis)? Pt :No
17. Dr: Any lumps and bumps in the body? –No Dr: Did you have this type of problems before? –No Dr: Any
medical conditions ?Pt:No Dr: Any heart kidney or liver problems? -No
18. Dr: Diabetes or High blood pressure? -No
19. Dr: Do you smoke?-No Dr: Do you drink Alcohol? – Pt:No
20. Dr: Do you use recreational drugs?-No Dr: Have tested for HIV ?-No Dr: Any medical conditions or any
cancers in the family members ? - No Dr: How much does this affects yourlife?
Pt: It affects a lot doctor. I can’t work properly My wife gets very annoyed with me. Dr: I am very sorry
to hear that. We will try our best you help you.
21. Dr: Can you please tell me whether any investigations like blood tests or urine tests done last time when you
came here? Pt: Yes/No
B. Diagnosis;
1. D: Mr Paterson, I think you have a condition what we call as Fibromyalgia, also called fibromyalgia
syndrome (FMS). It is a long-term condition that causes pain all over the body and tiredness.
2. Pt: Why did this happened doctor?
Dr: The exact cause why this happens to anyone is not known but it's thought to be related to abnormal levels
of certain chemicals in the brain. Sometimes it can happen after some infections or stressful event. Sometimes
it could be an inherited condition.
3. Pt:Is it serious doctor?
Dr: Unfortunately it is a serious condition because it is very disabling and affects people’s life in many ways.
However it is not life threatening.Pt: How can you help me doctor ?
C. Investigations:
1. Dr: First of all we need to do some tests to make sure it is not due to other medical conditions. (if they are not
already been done last time).
2. We will do some blood tests to check liver function. Thyroid function, kidney function, anaemia. Importantly
we will check the blood for any VitD deficiency because this can be due to Vit D deficiency too.
3. If they are all normal that means it is Fibromyalgia.
D. Prognosis: Unfortunately this condition may last forever.
E. Treatment:
1. If there is Vit D deficiency we will give you VitDsuppliments. You need to have more sun exposure which
helps Vit D production in the body.
2. If it is Fibromyalgia, unfortunately there is no cure for this condition, but there are treatments to help relieve
some of the symptoms and make the condition easier to live with.
3. Treatments are like we can give
 medications– such as antidepressants and painkillers for depression andpain.
 We have something what we call Cognitive behavioural therapy - a kind talking therapy which helps you
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 to cope withthat.
 Then our physiotherapists can teach you graded exercise where you gradually increase your body strength
by gradually increasing the exercise.
Are you following me ? Pt: Yes
4. Dr: Making some changes in life styles also can help.
 Life style changes – such as exercise programmes swimming, cycling can help, also relaxation techniques
canhelp.
 Pacing where you balance your period of activity and rest also canhelp.
 Better sleeping habits like trying to going to bed and getting up same timeevery day and relaxing before
going to bed can help. Also avoid drinking coffee or smoking before going to bed can alsohelp.
 Some people find alternative therapies like acupuncture and massagehelpful.
 You can join Fibromyalgia support group. That may be very helpful to you. Pt: Thank you doctor.
5. Dr: Anything else you want to ask me ? Pt: No doctor. You have been kind.
Dr: Thank you. We will keep following you up. Hope you recover soon Mr Paterso

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 13. Tiredness : Chronic fatigue syndrome
Exam question
You are the FY 2 in the GP clinic.
Mr John Paterson 35 year old man presented to the GP surgery 6 weeks ago with tiredness.
He has come for follow up. IT has been crashed and his records are not available.
Take history from him and talk to him about the further management.
[If the patient did not have body ache – give chronic fatigue syndrome as diagnosis]
A.
1. Dr: Hello Mr John Paterson. I am Dr…. one of the junior doctor in the clinic. How can I help you? Pt:
Doctor, I came to the GP surgery 6 weeks ago. I was told to come back again.
2. Dr: Mr Paterson, Unfortunately our computer system is crashed and your records are not available. Could you
please tell me again why did you come here last time ? Pt: I am feeling very tired for the last few months.
3. Dr: Since when exactly this problem started? Pt: Almost 6 months now doctor?
4. Dr: Can you figure out what would have triggered this thing at all? Pt: I do not know?
5. Dr: Were you completely well before this 6 months? Pt: I had some viral infection before these
symptoms started which lasted for few days.
6. Dr: May I ask what job do you do? Pt: I work as an assistant in the Lawyers office.
7. Dr: Does it affect your work, I mean are you able to carry out your work? Pt:With difficulty I am
managing to work. I have taken few days off in the last few months because I was feeling very tired.
8. Dr: How about your daily activities – are you able to do them? Pt: Yes, but again I do get tired quickly.
9. Dr: Do you have any body pain ?Pt: No
10. Dr: Any joint pain? Pt - No
11. Dr: Are you able to sleep properly? Pt: My sleep is very disturbed. I don’t feel refreshed when I get
up in the morning.
12. Dr: Do you have headache? Pt: No
13. Dr: Nausea or vomiting ? Pt: No
14. Dr: Any palpitations? Pt: No
15. Dr: How is your mood? Pt: It is low because I am very tired and can’t do work.
16. Dr: Any worries and stress before these symptoms started ?Pt: No
17. Dr: Do you have any swelling in the ankle? - No, Bloated tummy -No, Puffiness of face? - No
18. Dr: Do feel SOB? - No Dr: Any constipation ?- No Dr: Weight gain or weight loss?- No
19. Any lumps and bumps in the body? - No
20. Dr: Did you have this type of problems before? - No
21. Dr: Any medical conditions ? No heart kidney or liver problems? - No
22. Dr: Diabetes or High blood pressure? - No
23. Dr: Do you smoke? - No Dr: Do you drink Alcohol? - No
24. Dr: Do you use recreational drugs? - No Dr: Have tested for HIV ? - No
25. Dr: Any medical conditions or any cancers in the family members ? -No
26. Dr:How much does this affects your life? Pt: It affects a lot doctor. I can’t work properly My wife gets very
annoyed with me.
27. Dr:I am very sorry to hear that. We will try our best you help you.
28. Dr: Can you please tell me whether any investigations like blood tests or urine tests done last time when you
came here? Pt: Yes/No
B. Diagnosis:
1. D: Mr Paterson, Sometimes people have this type of problems due to some medical conditions like when heart
liver or kidney not working properly or due to thyroid disease or other medical conditions. But if none of these
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 medical conditions are causing this problem then we call this condition as Chronic fatigue syndrome which I
think is the case with you.
2. Pt:Why did this happened doctor?
Dr: There is no known reasons why this happens. Sometimes it can happen after some infections.
3. Pt: Is it serious doctor
Dr: Unfortunately it is a serious condition because it is very disabling and affects people’s life in many ways.
However it is not life threatening.
4. Pt: How can you help me doctor.
C. Investigations:
1. Dr: First of all we need to do some tests to make sure it is not due to other medical conditions. (if they are not
already been done last time).
2. We will do some blood tests to check liver function. Thyroid function, kidney function, anaemia. Importantly
we will check the blood for any VitD deficiency because this can be due to Vit D deficiency too.
3. If the investigations are all normal that means it is chronic fatigue syndrome. There is no specific medications
to treat this conditions.
D. Prognosis: This condition can last for many months or even for years but then it subsides on its own. There
are many things we can do to help you to cope with this condition.
E. Treatment:
1. If there is Vit D deficiency we will give you VitD suppliments. You need to have more sun exposure which
helps Vit D production in the body.
2. If it is chronic fatigue syndrome;
a. We have something what we call Cognitive behavioural therapy- a kind talking therapy which helps you to
accept this condition and cope with that. Then our physiotherapists can teachyou graded exercisewhere you
gradually increase your body strength by gradually increasing the exercise. Are you following me ?
b. Pt: Yes
c. Dr: Also we can give you medications like pain killers if you have pain, anti-depressant medications if you
feel low.
d.Also certain life style changes can help like pacing where you balance your period of activity and rest. Please
avoid smoking or drinking alcohol or too much coffee.
3. Pt: Thank you doctor.
Dr: Anything else you want to know
Pt: No doctor. You have been kind.
Dr: Thank you. We will keep following you up. Hope you recover soon Mr Paterson.

14. Tiredness - Hypothyroidism

Exam question : - 60 year old presents with tiredness. History and management with the patient. [Positive
symptoms- Tiredness, weight gain, constipation, prefers hot weather]
A.
1. Dr: Hello Mrs. .. I am Dr…. one of the junior doctor in the medical department. How can I help you?
Pt: I am feeling very tired for about 2 years.
2. Dr: I am very sorry to hear that. Is there anything else you can tell me ? Pt: Like what ?
3. Dr: Do you have any other symptoms like high temperature ( fever) ( TB) ? Pt : No
4. Dr: Any headache ? Pt: No
5. Dr: Body pain ( Fibromyalgia, CFS) ? Pt: No
6. Dr: Any changes in the bowel habit ( Hypothyroidism, cancer) ? Pt: I am constipated
7. Dr: Since when ?Pt: Since many months now.
8. Dr: Have you noticed any bleeding from the back passage ( Bowel cancer) ? Pt: No
9. Dr: What is the colour of the stool ( black colour – upper GI bleed – anaemia)? Pt: No

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10. Dr: Have you noticed bleeding from anywhere like nose, gums ( Anaemia) ? Pt: No
11. Dr: Do you have SOB ( Anaemia, heart failure) ?Pt: No
12. Dr: Palpitation ( anaemia) ? Pt: No
13. Dr: Do you have any preference to any particular weather ?Pt: Yes I prefer warm weather.
14. Dr: How about cold weather ( hypothyroidism) ? Pt: I don’t like it – I feel too cold can’t tolerate it.
15. Dr: Have you noticed any swelling in the front of your neck? Pt: No
16. Dr: Have you noticed any changes I your weight ( hypothyroidism, cancer) ?Pt: Yes I have gained weight
17. Dr: Can you please tell me how much weight did you gain in how much time? Pt :---
18. Dr: Have you noticed any changes in your voice (hoarseness in Hypothryroidism) ?Pt: No
19. Dr: Have you had any surgeries in the neck (thyroidectomy can cause hypothyroidism)? Pt: No
20. Dr: How is your mood ( hypothyroidism, depression) can you please rate in the scale of 1 to 10 one being very
low and 10 being very happy ? Pt: It is low about 6 to 7.
21. Dr: Any worries and stress making you feel low? Pt: I lost my husband about 2 years ago.
22. Dr: I am sorry to hear that. Do you think the tiredness started after that ? Pt : Yes / No
23. Dr: How is your sleep ? Pt: Sleep is fine but I don’t get refreshed properly I the morning.
24. Dr: Any lumps and bumps in the body? Pt: No
25. Do you feel your tummy distended ( heart, liver kidney failure) ? Pt: No
26. Dr: Any swelling of feet ( heart failure)?Pt: No
27. Dr: Did you have this type of problems before? Pt: No
28. Dr: Do you have any medical conditions ?Pt: No
29. Dr: Any heart kidney or liver problems? Pt: No
30. Dr: Diabetes or High blood pressure? Pt: No
31. Dr : Have you checked you cholesterol ( fat content in the blood) before ? Pt: No
32. Dr: Are you taking any medications ( excessive thyroxin can cause hypothyroidism) Pt: No
33. Dr: Do you smoke? Pt: No Dr: Do you drink Alcohol? Pt: No
34. Dr: Any medical conditions or any cancers in the family members ?Pt: No
35. Dr: Any of your family members has any thyroid related conditions ?No/yes
36. Dr: How much does this affects your life? Pt: It affects a lot doctor. I can’t work properly
37. Dr: Is there anything else you think is important that we need to know? Pt: No
B. Examination : Dr: Mrs. I need to examine now and check your neck for any swelling and also examine your
chest and tummy. (Examiner may not give any findings)
C. Investigations:
1. Dr: Mrs.. We need to do some tests to find out what exactly is causing these symptoms in you. There are lot of
conditions which can cause tiredness like anaemia, diabetes, heart and liver failure, Vit D deficiency. We will
do blood investigations to check whether you have any of these problems. Sometimes it could be due to
underactive thyroid.
2. So we need to do blood tests to check some hormones in called thyroid hormones. Do you follow me? Pt:Yes.
Dr: Is that OK. Pt: Ok
[Examiner may not give TFT result – In hypothyroidism TSH will be high and T4 will be low]
3. What is a normal TSH level in a woman?
Normal TSH levels for the average adult range from 0.4 - 4.0 mIU/L (milli-international units per liter).
However, many organisations agree that a reading of 2.5 or less is truly ideal, with anything 2.5 – 4.0 mIU/L
considered “at risk”. For those on thyroxine, goal TSH level is between 0.5 to 2.5 mU/L.
4. What is the normal range for T3? Typically, normal results range from 100 to 200 nanograms
per deciliter (ng/dL).
5. What is a normal t4 level? Normal results are generally from 4.5 to 11.2 micrograms per deciliter.

Diagnosis: Mrs... with the information you have given me, I think you have condition what we call as
Hypothroidism otherwise called underactive thyroid. Do you know anything about it? Pt: No
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1. Dr: We have a butter fly shaped gland in front of the neck called thyroid gland which normally produces some
hormones called thyroid hormones.
a. These hormonesregulate the body's metabolism - the process that turns food into energy.
b. An under-active thyroid gland (hypothyroidism) is where your thyroid gland doesn't produce enough
hormones. Many of the body's functions slow down when the thyroid doesn't produce enough of these
hormones. Are you following me ?
2. Pt : Yes. Why am I having this problem?
a. Dr: Most cases of an underactive thyroid are caused by the immune( body’s defence) system attacking the
thyroid gland and damaging it.
b. Sometimes it can be due to deficiency of Iodine in the diet or previous treatment for overactive thyroid or
sometimes it can be due to tumour ( growth) of the thyroid gland.Do you follow me ? Pt: Yes
c. If we do not treat this condition then it can lead to other complications – it can increase cholesterol( bad fat)
levels in the blood leading to heart problems. Sometimes it causes swelling in the front of the neck. So it is
very important to treat the condition.
3. Pt: How will you treat me doctor?
a. Dr: We will treat you with a medication called Levothyroxine. This replaces the thyroid hormones in the
body.
b. Initially we need to keep checking your blood levels of thyroid hormone regularly to find out the proper dose
of the medicine you require.
c. We will start with the low dose and increase it gradually until the proper required dose is reached. Usually you will
have to take one tablet per day either morning or night.
d. Some people start to feel better soon after the treatment, while in others it may take months to see the
improvement.Are you following me?

4. Pt: Yes, how long should I take this medicine?

Dr: An underactive thyroid is a lifelong condition, so you will usually need to take this medicine for the rest of
your life.
a. The effectiveness of the tablets can be changed by other medications, supplements or foods, so you should
swallow the tablet with water on an empty stomach, and you should avoid eating for 30 minutes afterwards.
b. [mention only if asked - If you're prescribed levothyroxine because you have an underactive thyroid, you're
entitled to a medical exemption certificate. This means you don't have to pay for your prescriptions].
5. Pt: Are there any side effects doctor ?
Dr: It doesn't usually cause any side effects.Side effects usually only occur if you're taking too much of this
medicine. This can cause problems including sweating, chest pain, headaches, diarrhoea and vomiting.Are
you following me ? Pt: Yes
6. Dr: Any other concerns ? Pt: No Dr:Thank you very much.

VIII. GIT and DM

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

A.
1. Ask her problems
She had tummy pain when she went to drop her children to school. Had nausea, had 2 loose stools.
2. Ask in detail about pain abdomen ( Socrates),
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3. Ask about fever, headache, chest pains
4. Ask about symptoms dehydration ( dehydration is complication of DKA) ( decreased urine output, drowsiness,
increased thirst)
5. No need to rule out differentials as the condition is already diagnosed. ( if the question say suspected then go through
differentials – Ruptured ectopic pregnancy, UTI, PID, Ureteric calculus, Gastroenteritis)
6. Past history – is it first time, Any medical conditions – she may say she has diabetes since she was 14 years old. She
taking insulin for that.
7. Ask more questions for triggers of DKA infections, chest symptoms, cough, dysuria, )
8. Main trigger factor is not taking insulin – ask her whether she is taking insulin regularly, has been checking sugar
regularly, if she is not taking insulin regularly why she is not taking regularly.
[ she may say that she was not eating well and also not taking insulin for the last few days because she was too busy]
9. Was she admitted previously for such problems
10. Smoking, alcohol,
11. Ask about - Family hX, allergy, any other medications,
B. I need to examine you – your tummy chest, I need to check your pulse, blood pressure and temperature. Check for
NEWS chart.
C. I need to do investigations to find the cause -
1. Blood sugar level, blood investigations to check for infection markers, blood gases, urine for sugar and ketones and
dipstix to check for infection and send for culture
2. Other investigations ( chest xray if she has cough and chest pain) , Abdomimal x ray.
3. Examiner may show blood test result- sugar – 30mmol, ABG shows – metabolic acidosis – ph low, CO2 may be high
or normal , HCO3 will be low) Urine – glucose+++, Ketone+++
4. Urine shows glycosuria,
D. Diagnosis
1. I think you have a condition called Diabetes keto acidosis. Do you know anything about it?
I do not know.
a. This is a complication of diabetes where the blood sugar is very high along with some other chemicals also very
high what we call as ketone bodies. This causes a problem called acidosis.This also causes severe dehydration.
b. Unfortunately, this is very serious condition. If we do not treat you immediately this can even be life threatening.
Fortunately we have good treatment.
c. We need to admit and treat you immediately. We will have to treat your dehydration immediately. We will give
you fluids through your veins.
d. We need to reduce your blood sugar too. For that we need to give you insulin injection into our veins continuously
like a drip. Also we need to check your sugar level hourly.
e. If you have any infections we need to treat with antibiotics.
2. To give you all these treatment we need to admit you to the hospital. Is that OK
a. No doctor, I do not want to be admitted. D: May I know why? P:I have children at home.
b. I can understand your problem. This condition as I said is very serious and can be even life threatening if we do not
admit and treat to you now in the hospital.
c. So it is very important that you need to stay in the hospital. Is there anyone who can take care of your children
until you get better and go back home.
3. How long will I need to be admitted?
a. It may take few days for you to recover completely and then ou can go home.
b. Ok doctor I will arrange someone to look after my children and stay in the hospital.
c. That is really good Mrs. We will do our best to treat you and hope you recover very soon.
d. If the patient does not agree for admission – say you will talk to seniors and may be they will convince her for the
admission. If she says there is no one to look after her children – say we will arrange social services to look after
your children.
e. If she still did not agree at all – tell her she has to sign a form for discharge against medical advice and then she
can go home.
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 2. Patient with Uncontrolled Diabetes
You are FY2 in a medical department.
Mr. George Tindal, 55 year old man has been a diagnosed case of type-1 Diabetes Mellitus since 14 years of
age. He came to the hospital 4 months ago. He was given Insulin for one month but he did not come back for
getting more Insulin. He has come now to the hospital.
Blood and Urine tests were sent to the laboratory. His urine test reveals Proteinuria and Glycosuria. His
blood has been collected for HbA1c, ESR, Cholesterol tests. In addition, the patient has been diagnosed with
Diabetic Nephropathy, Neuropathy and Retinopathy (Fundoscopy shows dot and blot hemorrhages).
Talk to the patient, explain him about the sugar control and discuss with him the further management.
A.
1. Dr: Hello, I am Dr…. I am one of the junior doctors in the medical department. Are you Mr. Tindal? Patient:
Yes, doctor.
2. Dr: How are you doing Mr. Tindal? Patient: I am doing fine doctor.
3. Dr: Well, Mr. Tindal I am here to talk to you about your condition. From the notes, I have gathered that you
have Diabetes. Is that right? Patient: Yes.
4. Dr: Well, Mr. Tindal, could you please tell me how long do you have this condition? Patient: Since I was 14
years old.
5. Dr: I see, and how much do you know about your condition? Patient: I only know that I have diabetes doctor.
6. Dr: I see. Well, Mr. Tindal, could you please tell me what medicines are you taking to treat your condition?
Patient: I was given insulin 4 months ago. But I stopped taking it.
7. Dr: Could you please tell me why did you stop taking insulin? Patient: I don’t think it was necessary.
8. Dr: I see. Well, Mr. Tindal, I would like to ask you some questions in order to see how much this disease has
progressed. Is that alright? Patient: Okay.
9. Dr: Could you please tell me if you have any symptoms now? Patient: Like what doctor?
10. Dr: Have you been noticing any change in your vision? Patient: Yes doctor, my vision has worsened over last
few months.
11. Dr: Have you ever had any heart problem, chest pain or shortness of breath? Patient: No
12. Dr: I see. Do you have any numbness, tingling, or pain in your hands, legs, or feet ? Pt: Yes/No
13. Dr: I am sorry to hear that. Have you had any kidney problems in the past? Patient: No.
14. Dr: Have you been diagnosed with high blood pressure, high cholesterol? Patient: No doctor.
15. Dr: Do you smoke? Patient: No/Yes
16. Dr: Do you take Alcohol? How often and how much do you drink? Patient: No/Yes
17. Dr: What is your typical diet? What are your eating habits and patterns? Patient: ..
18. Dr: Do you exercise regularly? Pt:…
19. Dr: Are you taking any other medicines at all? Patient: No doctor.

Management:
1. Dr: Well, Mr. Tindal, from the information I have gathered and from the investigations done on your blood and
urine, unfortunately the Diabetes has advanced quite a lot in your system and has developed certain
Complications due to the poor control of sugar. Are you following?
2. Patient: But why it happened doctor?
a. Dr: As you may know Insulin usually controls the blood sugar level. Diabetes occurs when the level of sugar
(glucose) in blood becomes higher than normal. This happens either when your body does not make enough
insulin, or if the insulin that you do make does not work properly on the body's cells.
b.Because you stopped taking Insulin since the last few months the blood glucose levels have begun to increase
and caused a lot of problems.
c. Now the diabetes has affected your kidneys, eyes and the nerves in your legs. That is why you may be having
poor vision and tingling numbness in your legs. Are you following me? Pt: Yes.
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 d.Dr: If the blood sugar level is not controlled it can cause other problems such as heart attacks, stroke. Do you
understand Mr. Tindal?
3. Pt: Yes. Is that serious doctor?
Dr: Unfortunately, it is serious if it the sugar is not controlled. Therefore, it is very important to keep the blood
sugar under control to prevent this complications progressing further.
4. Pt: What should I do doctor?
a. Dr: You will need Insulin injections for the rest of your life. You should take it regularly. You will need to
monitor your blood sugar levels by using a monitor at home and keep the sugar level under control. Pt:
Alright.
b.Dr: Also, you should eat a healthy diet. Basically, you should aim to eat a diet low in fat, salt and sugar
and high in fibre and with plenty of fruit and vegetables. We will refer you to a dietician for detailed advice.
c. Also, you should keep your blood pressure under control ( if he has high blood pressure).
d.We have taken your blood to check cholesterol levels. If the cholesterol level is high we will give some
medications to reduce the cholesterol levels but you need to cut down eating fatty food. Is that Ok ? Pt :
Okay doctor.
e. Dr: Smoking can worsen the condition. I sincerely advise you to stop smoking. We can help you for this if you
need. Would you consider doing that? Pt: Yes doctor.
f. Dr: Exercising regularly also helps in controlling the sugar. Pt: Ok
5. Pt: What happens to the complications what I already have doctor ?
a. Dr: If you take Insulin regularly and keep the sugar under control it will delay the complications from becoming
worse. Do you understand Mr. Tindal? Pt: Yes, doctor.
b.Dr: Mr. Tindal, our hospitals have special Diabetes Clinics. Doctors, nurses, dieticians, specialists in foot care
(podiatrists), specialists in eye health (optometrists), and other healthcare workers all play a role in giving
advice and checking on progress.
c. Regular checks may include Eye checks to detect problems which can often be prevented from becoming worse
and can usually be treated. Now because you have developed changes in your eye already, we can refer you
to Eye Specialist in order to treat your eyes.
d.Also, we can schedule Foot checks by referring you to a podiatrist- to help to prevent foot ulcers because the
nerves in your feet seem to be affected.
e. Urine tests, blood tests will be performed after a few weeks as well to see how well your kidneys are functioning
and to see the blood sugar control over months.
f. It is important to have regular checks, as some of these complications can be treated. Is that okay? Pt: Yes
doctor, thank you very much.
g.Dr: Also, you should be immunized against infection from pneumococcal germs. These infections can be
particularly unpleasant if you have diabetes. Pt: Alright.
6. Dr: Is there anything else that you need help with? Pt: No doctor, you are very kind. Dr: Thank you.
7. (Only if the patient asks Pt: Are there any no alternatives to injecting insulin?
a. Dr: There has been plenty of research done in recent years to develop ways to administer insulin other than by
injection.
b.These have included insulin nasal and oral sprays, patches, tablets and inhalers.
c. After many years of work, some of the methods being researched are showing a degree of success.
d.However, it will be some time before any of these devices will be available to people with diabetes in the UK.
Is that alright?

3. Uncontrolled Diabetes – Examination of legs

You are FY2 in a medical department.

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Mr. .. old man has been a diagnosed case of type-1 Diabetes Mellitus since 14 years of age. He came to the
hospital 4 months ago. He was given Insulin for one month but he did not come back for getting more Insulin.
He has come now to the hospital.
Blood and Urine tests were sent to the laboratory. His urine test reveals Proteinuria and Glycosuria. His
blood has been collected for HbA1c, ESR, Cholesterol tests. In addition, the patient has been diagnosed with
Diabetic Nephropathy, Neuropathy and Retinopathy (Fundoscopy shows dot and blot haemorrhages). Talk
to the patient, do the relevant examination discuss with him the further management.
Look inside the cubicle – if any cotton wisp, tuning fork neuropin are kept – then you have to examine the
legs

A.
1. Dr: Hello, I am Dr…. I am one of the junior doctors in the medical department. Are you Mr. ... ? Patient: Yes,
doctor.
2. Dr: How are you doing Mr. ? Patient: I am doing fine doctor.
3. Dr: Well, Mr.... I am here to talk to you about your condition. From the notes, I have gathered that you have
Diabetes. Is that right? Patient: Yes.
4. Dr: Well, Mr....., could you please tell me how long do you have this condition? Patient: Since I was 14 years
old.
5. Dr: I see. Well, Mr. .., could you please tell me what medicines are you taking to treat your condition?
Patient: I was given insulin 4 months ago. But I stopped taking it.
6. Dr: Could you please tell me why did you stop taking insulin? Patient: I don’t think it was necessary.
7. Dr: I see. Well, Mr...., I would like to ask you some questions in order to see how much this disease has
progressed. Is that alright? Patient: Okay.
8. Dr: Could you please tell me if you have any symptoms now? Patient: Like what doctor?
9. Dr: Have you been noticing any change in your vision? Patient: Yes doctor, my vision has worsened over last
few months.
10. Dr: Have you ever had any heart problem, chest pain ? Patient: No
11. Dr: I see. Do you have any numbness, tingling, or pain in your hands or legs ? Pt: Yes/No
12. Dr: Have you had any kidney problems in the past? Patient: No.
13. Dr: Do you smoke? Patient: No/Yes
14. Dr: What is your typical diet ? What are your eating habits and patterns? Patient: ..
15. Dr: Do you exercise regularly? Pt:…
B. Examine : Similar to diabetic foot examination
C. Management:
1. Dr: Well, Mr...., from the information you gave me and from the investigations done on your blood and urine,
unfortunately the Diabetes has advanced quite a lot in your system and has developed certain Complications
like it has affected your eyes, kidneys and your legs due to the poor control of sugar. Are you following?
2. Patient: But why it happened doctor?
a. Dr: Because you stopped taking Insulin since the last few months the blood glucose levels have begun
to increase and caused a lot of problems. Are you following me? Pt: Yes.
b. Dr: If the blood sugar level is not controlled it can cause other problems such as heart attacks, stroke.
Do you understand Mr....?
3. Pt: Yes. Is that serious doctor?
Dr: Unfortunately, it is serious if it the sugar is not controlled. Therefore, it is very important to keep the blood
sugar under control to prevent this complications progressing further. You will need Insulin injections for the
rest of your life. You should take it regularly. Pt: Alright.
4. Dr: Also, you should eat a healthy diet. Basically, you should aim to eat a diet low in fat, salt and sugar
and high in fibre and with plenty of fruit and vegetables. We will refer you to a dietician for detailed advice.

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5. Pt: What happens to the complications what I already have doctor ?
Dr: If you take Insulin regularly and keep the sugar under control it will delay the complications from becoming
worse. Do you understand Mr...? Pt: Yes, doctor.
6. Dr: We will refer you to the specialist like eye specialist, foot care specialist for further management of your
condition. We will monitor your kidney function also.
7. Dr: Smoking can worsen the condition. I sincerely advise you to stop smoking. We can help you for this if you
need. Would you consider doing that? Pt: Yes doctor.
8. Dr: Exercising regularly also helps in controlling the sugar. Pt: Ok
9. Dr: Is there anything else that you need help with? Pt: No doctor, you are very kind. Dr: Thank you.

4. Hypoglyceamia in Taxi driver

Exam question:

Young man taxi driver – known patient of Insulin dependent diabetes. Collapsed after injecting himself
large dose of Insulin. Came for follow up. His HbA1c is 61. Talk to him

A.
1. How are you doing?
2. Understand that you have diabetes ? How is everything about diabetes ? Any problems ?
3. He gives the story of being in a party and eating a lot of sweets and injected himself large dose of Insulin one
month ago. He almost passed out while driving. He stopped and ate chocolate and felt better.
4. Ask about any such incidents any other time?
5. Is he controlling sugar well?
6. Is he taking Insulin regularly?
7. Any other medical conditions like high blood pressure, Heart problems ?
8. Any problem in the vision, Any chest pains, any wounds in the legs?
B.
1. We have checked your blood sugar level what we call as HbA1c which tells us how was your sugar level in
your blood in the last 2 to 3 months. Normally it should be about 48 mmol/mol (6.5%) for diabetic patients. In
your case it is 61mmol/mol which is very high. This means your sugar level was very high in the last few
months.
2. Do you know the problems of not controlling the sugar
3. It can cause heart problems, can affect eyes and kidneys and nerves in the legs.
4. It is very dangerous to have low sugar – it can cause sudden death if the sugar in the body becomes very low. It
is better to have high blood sugar than sudden severe low blood sugar. So please do not inject large doses of
Insulin even if you eat lot of sugar.
5. So it is better to control sugar well.
Eat healthy balanced diet. Avoid eating too much sugar.
Stop smoking - if he is smoking.
Do regular exercise.
6. Warn about early symptoms of Hypoglycaemia;
Shakiness, Dizziness, Sweating, Hunger, Irritability or moodiness, Anxiety or nervousness, Headache. If any
such symptoms eat chocolate of sugary drinks. Keep sweets at all times with him.
7. Ask whether he has glucometer at home? Measure sugar at home.
Keep the sugar level Type 1 diabetes –

Upon waking - Before meals At least 90 minutes after meals

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 5 to 7 mmol/L 4 to 7 mmol/L 5 to 9 mmol/L

8. Record the readings in the diabetic diary.  How can I record it in the diary ?
Ask the examiner if there is any diabetic diary available? If so then show to the patient.
If not – I will show the diary later.
You need to enter the dose of Insulin taken and then measure the sugar level before and after the meal and
enter in the dairy. You can also enter any notes. I will tell the diabetes specialist nurse to explain that to you.
Explain if the diary is available - Blood glucose recording tips

a. Use the top ‘notes’ section to record the medication you are taking. If you record dosage info, use shorthand eg
‘5 H’ could stand for 5 units of Humalog and ‘10 L’ for 10 units of Levemir.
b.Make a note of exercise and illnesses as these can both have an effect on sugar levels. It can be helpful to
record any periods of stress during the day for this reason too.
c. Note down any periods where a meal has had to be delayed or missed out. If you do shift work or have less
regular sleeping times, you may want to change some of the headings or make extra notes. Test your blood
sugar at varying times of the day.
d.Spotting trends in your blood sugar levels
e. Test before and after meals (either 1 or 2 hours after).This will help you to see how well you and
your medication cope with different meals.
f. Make a note of the meals which make your blood sugar control more difficult.
g.Look to see if your numbers are high during certain parts of the day.
h.Look at how exercise, illness and stress affect your blood glucose levels. Try to see how much these events
affect your sugar levels and/or medication dosages.
i. If you keep notes going back over a number of years, you may be able to
spot seasonal trends. For example, you may notice that for three years
running your numbers have started to increase during October.
9. Since you are a Taxi driver – it is better to inform the DVLA
and your local council since they have some guidance for those who
are diabetic patients and drives taxis though you are not banned
from driving.
10. Please wear your diabetic bracelet at all times.

5. Dysphagia
50 year old man presents with dysphagia. Take history, examine and discuss relevant management with the
patient.

It is a cancer station. Dysphagia and hematuria --> i donot need to tell that here is cancer . Others I must say cancer

A.
1. Dr: Hello Mr.... My name is Dr... what brings you to the hospital today? P: I have had trouble swallowing
doctor.. I also have lot of discomfort in my lower chest
2. Dr: I am very sorry to hear that Mr... could you please tell me when this started? P: It has been few weeks
doctor
3. Dr: Has it worsened since then? P: Yes.. Initially it was mainly to solid food items. Now it is also to liquids
4. Dr: Did it start with liquids first or solids first ? P: solids first now it is liquids also doctor.
5. Dr: Is it worse towards the end of the day ( Myesthenia )? P: No
6. Dr: Have you had any vomiting? P: Yes/no
7. Dr: have you thrown up any blood? P: Yes/No
8. Dr: Difficulty in talking? ( Palsy, MS) P: No
9. Dr: Did you have any procedures or instrumentations done on you food pipe recently? P: No
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10. Dr: Belching? Heartburn, worse on lying?( GORD) ? P: No
11. Dr: Do you have a sensation of lump in your throat ( Globus hystericus) ? P: No
12. Dr: (Pharyngeal pouch) Any bad breath? Food on pillow in morning? Old food regurgitated? P: No
13. Dr: Long time heart burn ( GORD) ? P : No
14. Dr: Any ingestion of corrosives ? P: No
15. Dr: Any procedures/instrumentations done? P: No
16. Dr: ( spasm) Is it continuous problem or Intermittent? Cold or hot food makes it worse? P: Continous.
17. Dr: Fever ( tonsillitis) ? P: Yes/No
18. Dr: Have you had any trouble swallowing or any discomfort with the upper part of your throat? P: No
19. Dr: ( cancer) Have you noticed any change in your weight? P: Yes my belt has become lose. (quantify)
20. Dr: Have you noticed any lumps in your neck or your armpits? P: Yes/No
21. Dr: do you have any underlying medical condition? Diabetes? P: Yes/No
22. Dr: asthma? P: Yes/No (For inhalational steroid usage)
23. Dr: Are you on any medications? P: No
24. Dr: What was your diet like before? (assess spicy food/hot beverages/caffeine)
25. Dr: Do you smoke? P: Yes
26. Dr: Could you tell me what you smoke and how much? P: I smoke 15-20 cigarettes a day. I have been
smoking for >30 years
27. Dr: Do you consume alcohol? P: Yes/No
28. Dr: Do you have any family history of such problems? P: Yes/No
29. Dr: Any F/H of cancers?

Examination:
1. Mr.... I would like to examine your neck, chest abdomen and your armpits to look for any lumps or swellings.
2. Examiner might or might not give findings.

Diagnosis:

1. Dr: Mr... Do you have any idea what might be wrong with you? P: No doctor
2. Dr: Based on the information that you have given me and the examination findings, I'm sorry to say that you
might be having a serious condition. Would you like to know about it? P: Tell me doctor
3. Dr: Mr... I'm sorry to say that it is possible you might be having cancer of your food pipe... P: Are you sure
doctor?

Investigation:

1. Dr: To be sure we will have to run some more tests Mr.... we will have to do a CT scan of your chest and a
procedure called an endoscopy, where a specialist (gastroenterologist) will pass a tube with a camera through
your mouth to visualise your food pipe. If there is any growth or abnormality, we might take a tissue
sample/biopsy and send it for further analysis to confirm the diagnosis. Are you following me Mr...?
2. P: But why did this happen to me doctor?
Dr: Mr... there are a few risk factors that can result in this condition.. In your case, it appears to be because of
your smoking... It is an important risk factor for cancer of the food pipe. I'm sorry I don't have better news for
you Mr...

Treatment:

1. P: What will you do for me if it is cancer?

Dr: Unfortunately Mr... there is no cure for cancer of the food pipe... However we do have some treatment
options to relieve your symptoms and make life easier like surgery, chemotherapy or radiotherapy. Sometimes

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 a gastroenterologist may consider placing a stent in the lower part of the food pipe to enable swallowing... Are
you with me Mr...?
2. P: Yes doctor.. Dr: Do you have any questions for me Mr...? P: No
3. Dr: Once again, I am really sorry Mr... I will speak with my consultant and we will start the tests for you. I
sincerely hope that we have better news with the results. If you have any concerns, please feel free to contact
me at any time.

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 6. GORD
Scenario-54 year old man has come with complaints of indigestion. Address his concerns and discuss
management with the patient.

A.

D- “Hello, I am Dr.-------, one of the junior doctors in the department. How are you doing?”
P- “Dr, I have this burning sensation in the chest”
D- “I am sorry to hear that. Could you tell me how long have you been feeling this? P-
D- “Can you point it where exactly are you feeling this sensation?”
P- Points to epigastric region
D- “Is there anything that makes it better or worse?”
P- “Dr, I eat spicy food. Every time I have it, the sensation gets worse. Also, whenever I burp, there is some
sour fluid that comes up to my mouth and I have to swallow it. I just can’t take it anymore”
D-“ I can imagine that you must be in distress. We will try to help you as much as we can.
Did you have any other symptoms-
Fever-NO, Tummy pain-NO, Chest pain-NO, Vomiting ( Blood) -NO
Bowel problems-NO, Difficult in swallowing food/liquid-NO
MAFTOSA- He is a smoker since 15-20 years.
May gave history of consumption of alcohol. He gives history of over the
counter medications- Rennie tablets for 6 months.
(RENNIE TABLETS IS AN ANTACID BASED CALCIUM CARBONATE
AND MAGNESIUM CARBONATE FORMULA)
B. Examination:
D-“I would like to examine you now and will ensure privacy and chaperone. I will examine your neck, chest and
tummy. Ask for NEWS chart.
Examiner may say- All normal
C.
D-“From what you have told and from what I have examined, I suspect you have a condition called GORD-Gastro
Oesophaegeal reflux disease. Do you know anything about it?”
P- “No, Dr.”
D- “It is a condition where acid from the stomach leaks into the food pipe hence giving your typical symptoms-
burning sensation in your chest and unpleasant taste in your mouth.
This condition can be caused or made worse by-
Certain foods/drinks- such as coffee, alcohol, intake of spicy food, Smoking, Anxiety
D.
p- “ What are you going to do for me now?”
D- “We will do some blood tests - FBC as well as refer you to the gastroenterologist for endoscopy to see if there
is any damage to the stomach wall and to rule out any other problems.”
P-“Dr.. I don’t want endoscopy. One of my friends had the procedure and it as quite unpleasant. He was in
a lot of pain” (Patient is aware of what is endoscopy and says it is a camera test)
D- “I understand. But before the procedure, we will give you a local anaesthetic spray to numb that specific area. It
shouldn’t be painful after that. Will you consider that?”
P- “Alright Doctor. That sounds better.”
E.
D- “We will also give you medications to protect the stomach wall - PPI’s. They are medications like Omeprazole.
Hopefully, you should get better.
I can tell you some remedies that will help you relieve your symptoms-

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Eat smaller frequent meals. Eat well before your bed time to avoid indigestion.
Raise your head end of the bed by putting an extra pillow so that acid doesn’t travel up to your mouth.
Try to avoid all trigger factors-spicy food, smoking, alcohol. This will only worsen your condition.
Talk to your GP before taking any over the counter medications.
P – Will there be any problems because of this ?
D – Rarely it can cause narrowing of the food pipe causing difficulty in swallowing, sometimes it can cause
soreness of the food pipe causing pain. Very rarely it can cause serious problem that is cancer of the food pipe.
However if it is treated all these problem will not happen. Do not worry.
Is there anything Else I can help you with?”
P-“No, Doctor. Thank you”

7. Hematemesis
Young lady vomiting blood. History and management.

A.
1. Vomiting blood for three hours.
2. Ask which was first – vomiting food and then started vomiting blood or vomiting blood from the beginning itself. (
vomiting food first and the blood may be Mallory weis syndrome),
3. Ask about pain abdomen – no, dark stool, weight loss ( gastric carcinoma)
4. Alcohol – oesophageal varices), pt was drinking alcohol.
5. Any surgery or procedure done on the food pipe or stomach before, Any foreign body ingestion.
6. Medications – was taking Ibuprofen or indomethacin ( ask about over the counter medication) for headaches
for quite long time. Not prescribed by doctor. Not taken PPIs.
7. Ask about weakness, drowsiness,
8. Previous episodes, previous medical conditions family history, any bleeding disorders. Bleeding from nose gums, urine,
hemoptysis. LMP.
B. Examination –
1. I need to examine tour tummy and also I need to check your pulse, BP and temperature. Check for NEWS chart.
2. Examiner may say – tenderness in epigastric area.
3. Any other medications, allergy.
C. Diagnosis –
1. I think you are vomiting because you have some damage to the stomach walls which can happen due to the Ibuprofen
medication what you are taking for long time.
2. This can be serious if we do not treat you immediately
9. We will have to do investigations initially blood tests to check for anaemia to see how much blood you would have lost,
check whether you have any bleeding disorder or liver problems because sometimes alcohol can cause damage to the
liver which in turn can cause vomiting of blood,
10. We may need to give you fluids through your veins and also transfuse you blood. Is it OK?
11. We need to admit and do a special test called endoscopy which is a camera test. We pass a tube with a camera at its tip
through your mouth to the stomach. This test ill show us where exactly is the bleeding and what may be reason for
bleeding also sometimes we may be able to control the bleeding while we are doing this test.
12. We may also give you some medications called PPIs this is to heal the damage what would have happened to your
stomach walls.
13. I advise you in the future if you have to take pain killer medications like NSAIDS ( Brufen type medications) for long time,
please consult your GP. Otherwise same problem can happen again.
14. Is this OK ? Any other concerns.

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 8. Vomiting in New Born Child – Pyloric stenosis
Exam question
You are FY2 doctor in Paediatric Department.
6 weeks old boy, Rhys was brought in by his mother with history of persistent vomiting for last 2 days.
Take history from the mother Mrs Nicola Hampshire and talk to her about further management.
Vital signs are given in question.
A.
1. Hello I am Dr... one of the junior doctor in the Paediatric department. Are you the mother of Rhys?
Mother: Yes. I am
2. Dr: How may I call you? Mother: ? You can call me Nicola
3. Dr: How can I help you Miss/Mrs. . .? Mother: My son has been vomiting a lot since last 2 days.
4. Dr: I am really sorry to hear about that. Can you tell me more about that? Mother: Doctor he is
throwing everything out.
5. Dr: How did it start? Mother: Doctor it started almost suddenly.
6. Dr: What do you feed him? Mother: I breastfeed him.
7. Dr: Does the vomiting occur in immediately after ( pyloric stenosis, GER) you breastfeed him or later ?
Mother: Yes, doctor he vomits when I feed him.
8. Dr: Is it like throwing up or just dribbling of the food from the mouth (Regurgitation) ? Mother: He is
throwing up.
9. Dr: Does the vomit go far away like a fountain (Pyloric Stenosis)? Mother : yes
10. Dr: How many times does he vomit in the day? Mother: Every time I feed him, (almost instantly) he
throws up.
11. Dr: What is the content of the vomiting? Mother: It is just the milk.
12. Dr: Is it ever green coloured (bilious – duodenal atresia) or blood stained? Mother: No.
13. Dr: Do you think you are feeding him more than usual (Overfeeding) ? Mother : He is very hungry all the
time ( may be because of pyloric stenosis also)
14. Dr: Does your child shy away from light, Any Rashes ( meningitis) ? Mother : No
15. Dr: Has he got fever ( Meningitis, UTI, Pneumonia, Ear infection) ? Mother : No
16. Dr: Doe she cry a lot ( meningitis, Obstructed hernia, Intussusception) ? Mother : No
Consolable cry  cry only during eating episodes (pyloric stenosus)
17. Dr: Have felt any lump in his tummy ( Pyloric stenosis, Intussusception) ? Mother Yes/No

18. Dr: How is his poop? Is it normal or has he got diarrhoea( loose stool) (Gastroenteritis) ? Mother – Normal.
( may be less in quantity in Pyloric stenosis) .
19. D: Is the poop red coloured( Intussusception) ? Mother: No
20. Dr: Does his urine smell bad? (UTI) Mother: No.
21. Dr: Is there any recent change in his feed ( Milk allergy) ? Mother: No doctor.
22. Dr: Did he have any injury to the head? Mother : No
23. Dr: Is his mouth dry ( dehydration) ? Mother: Yes/No
24. Dr: How is he – is he active or drowsy (severe dehydration) ?Mother :He is not active bit drowsy.
25. Dr: How has been your child before? Has been diagnosed with any medical conditions? Has he ever been
admitted to hospital before? Mother: No.
26. Dr: Any medications that your child is on? Mother: No doctor.
27. Dr: Does your child have any allergies? Mother: No.
28. Dr: Does any child in your family now or in the past had similar problems as Rhys? [Family History risk
factor for Pyloric Stenosis, gastroenteritis (contagious)] Mother: Yes/No

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29. Dr: Is he your fist child or do you have any other children? Mother : He is my first child. ( First child –
risk factor for Pyloric stenosis)
30. Dr: When you delivered Rhys – was it normal birth or did you have any problems ? Mother: It was normal.
31. Dr: Any problems during development? Mother: No doctor.
32. Dr: Is there anything else you think that may be important that we may need to know ? Mother : No
B. Examination: Well, I need to examine your baby’s tummy. (Examiner may say there is no
abnormal finding)
C. Diagnosis:
1. Dr: From the information that I have gathered I think Rhys might be having a condition what we call as Pyloric
Stenosis. Do you know anything about it? Mother:No doctor.
2. Dr: It is a condition in the tummy that can sometime affect the new born children. Let me explain it to you. Our
stomach opens into the gut ( bowel). The outlet of the stomach into the gut is called the Pylorus. Stenosis means
a narrowing. Pyloric Stenosis means a narrowed outlet of the stomach. Because of the narrowing of the outlet
of the stomach food is not going to the gut. So the babies vomit the food out.
3. Mother: Is it serious doctor?
Dr: It is not a serious problem because we have a good treatment for this. This is not a worrying condition.
4. Mother: Why did this happen?
Dr: It is not known why this occurs. This condition is seen more in boys than in girls. And sometimes, it can
run in families.
5. Mother: What are you going to do?
a. Dr: We need to admit Rhys. First of all, we need to confirm whether this is the problem with Rhys.
b. I think Rhys is very drowsy because of severe dehydration which can happen when they vomit a lot.
We need to do some blood tests to check whether he has severe dehydration. We will do some blood
tests on him to check the blood gases.
6. [ Examiner may give the test result. Picture is as follows:
a. pH = High ( Normal 7.35 to 7.45 )
b. PaCO2= normal or high
c. HCO3- = high
7. Tell the mother - Blood test shows he has some problem called metabolic alkalosis this is due to vomiting. (If
asked then mention vomiting of acid from the tummy).
8. We also need to perform Ultrasound of his tummy to confirm whether this is the condition. Mother: Ok
doctor.

Treatment

1. Dr: We need to admit him and give some fluids through his veins for the hydration and nutrition. So, please
do not feed him until we tell you to do so. Is that Okay?
2. Mother: Okay. How will you treat him doctor ?
Dr: We can do a small operation to correct the narrowing of the stomach outlet and it normally cures the
problem. This operation is usually done by keyhole surgery. A small cut is made in the skin over tummy. The
operation allows the obstruction site to widen into a normal size. This means that milk and food can pass easily
out of the stomach into the bowel.
3. Mother: Will there be any complication?
Dr: Some complications from surgery include bleeding and infection. However, complications aren't common,
and the results of surgery are generally excellent.
4. Mother: Will he be normal after this?
Dr: Yes, he will be normal and he will grow normally without having any problems.
5. Dr: Any other concerns ? Mother: No Thank you.

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 9. ANOREXIA NERVOSA
You are the F2 in the psychiatric dept. 16/25yr old female referred by her GP on account of weight loss. BMI of 17.
Has no symptoms of depression. Take history and discuss further management with her. Patient doesn't believe she
has problems, losing weight intentionally and still believes she is overweight.

Miss Jessica Thompson, 20 years old girl was brought to the hospital by her parents. On her recent visit to
GP, GP noticed that Miss Jessica has lost some weight and he referred her to the hospital for this reason.
Her Parents are not with her now in the hospital. You are the SHO in psychiatry department, Take history
from Miss Thompson and discuss further management.

A.
1. Dr: Hello are you Miss Jessica Thomson ? Miss: Thompson: Yes
2. Dr: I am Dr… one of the junior doctor in the psychiatry department. Can you please tell me what brought you
to the hospital? Miss: Thompson: I am here because of my parents; they think that I have been losing too
much weight.
3. Dr: Can you please tell me, how much weight did you lose? Miss: Thompson I have lost about 15 pounds
( more than one stone, 6.8 kg) in the last 3 months.
4. Dr: Have you been trying to lose weight? Miss: Thompson: Yes
5. Dr: Could you please tell me, why are you losing weight? Miss: Thompson: Dr, I want to be like my friend.
6. Dr: Can you please tell me, why do you want to be like your friend? Miss: Thompson: She is slim and good
looking. My friend has found boyfriend.
7. Dr: Do you think that you are fat? Miss: Thompson Yes doctor.
8. Dr What do you do ? Do you work or you are a student ? Miss: Thompson: I am a university student.
9. Dr: Can we talk about your general life style? Miss: Thompson of course, Doctor.
10. Dr: What is your diet like? / What do you eat in breakfast/ lunch/ dinner? Miss: Thompson: In breakfast, I
eat ----. In lunch, generally I do eat ---- I take ---- at night.
11. Dr: Have you any time eating too much food and could not have any control on eating. (Binge eating)
12. Dr: Do you do any exercise? Miss: Thompson Yes, doctor. I enjoy running (doing exercise).
13. Dr: How often do you do exercise? Miss: Thompson I do it every day for about 2 hours.
14. Dr: Do you take any medications to lose weight ? Miss: Thompson No
15. Dr: Do you make yourself sick because you feel you are uncomfortably full? Miss: Thompson: No
16. Dr: Do you have any preference for clothes? Miss: Thompson: Yes, Doctor, I like to wear baggy clothes.
17. Dr: Do you have any role models? Miss: Thompson I am very big fan of -----
18. Dr: Can you please tell me, do you like looking yourself in the mirror repeatedly? Miss: Thompson : No
doctor.
19. Dr: Do you keep checking your weight frequently? Miss: Thompson: Yes doctor.
20. Dr: How has been your mood? Can you please grade it, 1 being the saddest and 10 being the happiest? Miss:
Thompson: It has not been good. (3/10)
21. Dr: Have you ever thought of harming yourself? Miss: Thompson: No
22. Dr: do you think that you have been losing too much weight? Miss: Thompson: No, dr. / I feel uncomfortable
when I do not follow my daily routine of diet and exercise.
23. Dr: How is your general health? Miss: Thompson Dr, I feel weak nowadays, I want to sleep most of the
time.
24. Dr: How you ever had any mental health problem before? Miss: Thompson: No.
25. Dr: Are the family members supportive? Miss: Thompson: Yes they are supportive.
26. Dr : Any problems with your colleagues in the university? ( Bullying ?) Miss: Thompson: No

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27. Dr How is your periods? Miss: Thompson: I am waiting for my periods; it has not come for last 8 weeks.
I am worried about it.
28. Dr: Do you have any health symptoms like palpitation, Feeling faint or any other symptoms? Miss: Thompson
No
29. Dr: Thank you very much for all the information.
B. Diagnosis
1. Miss .. We have measured your height and weight. Your weight is far lesser than what it should be for your
height. I think you have lost too much weight. This is not good for you. In medical terms we call this condition
as Anorexia Nervosa. Do you know anything about this at all? No
2. Anorexia nervosa is a serious mental health condition.
3. It's an eating disorder where a person keeps their body weight as low as possible.
4. If it continues like this it can lead to lot of other conditions like depression and medical problems like
Osteoporosis and sometimes people with this condition may not be able to conceive children. Do you
follow me? Yes
5. We can help you to treat this condition.
C. Treatment
1. We can help you by combination of psychological therapy and supervised weight gain. We have a team of
specialists like Psychiatrists, Psychologists, dieticians and specialist nurses here to help you
2. We as Psychiatrists can help you by Psychotherapy otherwise we call as Cognitive analytic therapy and
Cognitive behavioural therapy. We can involve your family members also if do not mind to help the treatment.
3. Our dieticians can teach you what type of food you can eat to gain weight.
4. We do not need to admit you at this moment. We can do all these as an outpatient and see how things goes. Is
that OK? What do you think about this?

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 10. Weight loss - Hyperthyroidism
You are FY2 Doctor in GP clinic.
40 year lady presented to GP clinic 2 weeks ago with weight loss and tremors. Thyroid function test was
done. She has come now for the blood results.
Talk to her, take history and manage her.
I will not do examination But I will od MGx
If they did not say discuss inv.  do not do it
A.
1. Dr: Hello, my name is Dr… one of the junior doctors in the GP clinic. How may I call you? Pt: You can
call me....
2. Dr: Miss/Mrs… I can see that you visited us a few days ago. Pt: Yes doctor, I am here for my test results.
Could you give me my test report?
3. Dr: Yes, I do have your test results with me. However before I go on to that, I would ask you a few questions.
This would help us know your condition better so that we can treat you appropriately. Okay? Pt: Okay.
4. Dr: Could you tell me what made you visit the hospital last time? Pt: Doctor I am losing weight.
5. Dr: I am sorry to hear that. For how long have you been experiencing these symptoms? Pt: (For a few months?)
6. Dr: How much weight have you lost? Pt: Two & half stones doctor.
7. Dr: Since how long ?Pt: …
8. Dr: Is there anything else that has been bothering you in any way? Pt: Doctor I am also experiencing shaky
movements in my hands.
9. Dr: It must be very distressing for you. Has there been any change in your appetite? Pt: Doctor, I am eating
more than usual nowadays and despite that I am losing weight.
10. Dr: I see. What about your bowel habits? Pt: Doctor I have been going to toilet more frequently than usual.
Also I am passing loose stools for some time now. Is there a problem doctor?
11. Dr: Well, I need to know a few more details and then I would let you know about the results. Is that alright?
Pt: Okay doctor.
12. Dr: Do you have a preference for weather? Pt: I don’t like summer doctor.
13. Dr: Why is that? Pt: Doctor I feel hot when others don’t really feel hot.
14. Dr: Do you sweat more than usual? Pt: No/Yes
15. Dr: Have you been experiencing your heart beating faster than usual? Pt: Yes.
16. Dr: Do you find it difficulty closing eyes or have you been noticing double vision? Pt: No.
17. Dr: Can you tell me when was your last menstrual period? Pt: Doctor, I have been having infrequent
menstrual periods for some time now.
18. Dr: Have you been noticing any fever? ( T.B) Pt: No doctor.
19. Dr: Any sweating at night time? Pt: No doctor.
20. Dr: Have you been having cough lately? Pt: No doctor.
21. Dr: And have you been noticing any lumps or bumps anywhere on your body? ( Cancers) Pt: No.
22. Dr: How has been your mood lately? (Depression) Pt: My mood is fine.
23. Dr: Are you intentionally trying losing weight by any chance ?( Anorexia Nervosa)? No
24. Dr: Do you think you have lost weight or only others are telling you this? (Anorexia Nervosa) Pt: Doctor, I
definitely think there’s something wrong with me. I eat a lot and despite that I am losing weight.
25. Dr: Do not worry. Tell me if you have been ever diagnosed with any medical conditions in the past? Pt: No
doctor.
26. Dr: Do you have Diabetes or High blood pressure or any gland problems in the neck? No
27. Dr: Do you smoke? Pt: No.
28. Dr: Do you take Alcohol? Pt: No.
29. Dr: Have you ever done any blood tests like HIV or Hepatitis? Pt: No
30. Dr: How are your dietary habits? Pt: My diet is fine doctor.
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31. Dr: Are you taking any medications? Pt: No doctor.
32. Dr: Any allergies? Pt: No doctor.
33. Dr: Has anybody in your family ever been diagnosed of any gland problems in the neck or thyroid diseases?
Pt: (Yes doctor, my mother and sister and my aunt has similar problems)
34. Dr: Have you travelled anywhere recently? Pt: No.
35. Dr: Have you recently come in contact with anyone who has T.B? Pt: No.
B. Examination:
Dr: I would like to perform Examination of your Hands, Eyes and Neck for any abnormal swelling. I would also
be checking your Pulse. Pt: Okay.
Examiner might give findings: Pulse is raised and rest of the examination is insignificant.
I tell  I would like to examine  Examiner  will tell you the findings are fine. If the examinerd did not give
me findings  Okay i will come back to examination latter
C. Diagnosis & Explanation of Report:
1. Dr: Well, Miss/Mrs… from information you have given me and from the examination and test results, I am
suspecting that you have a problem of a gland that is situated in the neck. We call this gland Thyroid Gland and
this illness is called Hyperthyroidism. Do you know what it is? Pt: No doctor.
2. Dr: Hyperthyroidism means an overactive thyroid gland. When your thyroid gland is overactive it makes too
much hormone. The extra hormone causes many of your body's functions to speed up. I would explain you
the test results and that would make you better understand the situation here. Pt: Okay.
Test Report:
TSH 0.2 mU/L ( Normal - 0.4 - 4.0 mU/l (milliunits per litre)
T4 - 35 pmol/l ( Normal - 9.0 - 25.0 pmol/l (picomoles per litre)
T3 - 6 pmol/l (Normal - 3.5 - 7.8 pmol/l (picomoles per litre)
3. Dr: As I have told you, thyroid gland produces some hormones. They are essential for normal body functioning.
4. T4 that is written here is actually short for Thyroxine. Thyroxine is a body chemical (hormone) made by your
thyroid gland. It is carried around your body in your bloodstream. It helps to keep your body's functions working
at the correct pace.
5. You see it is way above its normal range. A high level of T4 confirms hyperthyroidism.
6. Thyroid-stimulating hormone (TSH) is chemical made in another gland in the brain Pituitary gland. It is released
into the bloodstream. It stimulates the thyroid gland to make thyroxine. If the level of thyroxine in the blood is
high then the gland in brain releases less TSH.
7. Therefore, a low level of TSH means that your thyroid gland is overactive and is making too much thyroxine
which is true in your case. Are you following me? Pt: Yes doctor.
8. Dr: Well, we would like to see further what could be the cause that is leading you to this. One of the causes of
this overproduction of hormones by this gland is a disease called Grave’s Disease.
9. In order to confirm that, we would perform another blood test. This blood test may detect specific
Autoantibodies which are commonly raised. However, these can also be raised in some people without Graves'
disease so this is not a specific test for Graves' disease. Is that okay? Pt: Okay.
10. Dr: Also we might be performing a scan called an Isotope scan in which we would ask you to swallow a
radioactive substance in capsule or liquid form, and we later on would take images of your neck to see the
gland. It would help us better visualize the pathology of the gland.
D. Pt: Alright. How will you treat me doctor?
1. Dr: There are a number of treatment modalities available. Antithyroid medicines can reduce the amount of
thyroxine made by the overactive thyroid gland. The most common medicine used is Carbimazole.
2. Pt: Do I need to be careful about anything when I am taking this medication?
Dr: It has some side effects. It can, rarely, affect your white blood cells which fight infection. Whilst taking
carbimazole, you should see a doctor urgently for a blood test if you develop any of the following: A fever. A
sore throat. Mouth ulcers. Is that okay?
166
 (An alternative medication called Propylthiouracilis usually given instead of carbimazole if you are pregnant.
Carbimazole is safe to take if you are breast-feeding.
If she mentioned pregnancy .. do not give carbamizole
IF i did not ask that question --> I need to ask the question in the mangmanet
(Ask whether pt is pregnant or chance of becoming pregnant if pt. is young) Pt: Okay doctor.
3. Dr: Also for controlling your symptoms, we can give you medicines called Beta Blocker, those will relieve
your symptoms of thumping heart, shaky movements of hands, sweating. etc. Is that okay? Pt: Okay.
4. Dr: Other treatment modalities include Radio-iodine. This will shrink the size of thyroid gland.
5. The last option is Surgery, if other treatments don’t work. This involves removing a part of your thyroid gland.
It is usually a safe operation. However, as with all operations, there is a very small risk of complications. Are
you following me? Pt: Yes doctor.
6. Dr: Also we will be referring you to endocrinologist who is a specialist of diseases such as thyroid gland. He
will advise you further about it. Is that alright? Pt: Yes Doctor
7. Dr: Do you have any other concerns? Pt: No doctor… Thank you.

11. Middle aged lady Obesity talk to her.

Exam question: 55 year female came with complaints of over weight,talk to her and address her concerns

A.
1. How can I help you ? I am obese I want lose weight.
2. It is really good that you have come to us. Certainly we can help with that.
3. Take history to r/o hypothyroidism ( do you have problem tolerating hot or cold weather? Any constipation?)
4. Any medications ( steroids)
5. Lack of physical activity – do you do any exercise ? What is your job ( ? sedentary job)
6. Familial cause – any of your family members are overweight ? Yes
7. Diet – what do you eat on a regular basis – eats junk food and says can’t stop eating.
8. Have you tried losing weight yourself – by cutting down on eating fatty food exercising?
9. Have you taken any weight reducing medications ? any weight reduction surgeries in the past?
10. Do you have any problems because of overweight?
B.
1. Do you know what problems you can have because of over weight ?
It's very important to take steps to tackle obesity because, as well as causing obvious physical changes, it can
lead to a number of serious and potentially life-threatening conditions, such as: type 2 diabetes , coronary heart
disease , some types of cancer, such as breast cancer and bowel cancer , stroke
2. Obesity can also affect your quality of life and lead to psychological problems, such as depression and low
self-esteem.
3. Do you know your BMI ? - examiner may say 40.

C. Treating obesity

1. The best way to treat obesity is to eat a healthy, reduced-calorie diet and exercise regularly.
2. To do this you should:
a. eat a balanced, calorie-controlled diet. We can refer you to dietitian who can advise you on that.
b. join a local weight loss group
c. take up activities such as fast walking, jogging, swimming or tennis.
d. eat slowly and avoid situations where you know you could be tempted to overeat
3. We can refer you to Psychologists who can help change the way you think about food and eating.
167
4. If lifestyle changes alone don't help you lose weight, we can prescribe a medication called Orlistat. If taken
correctly, this medication works by reducing the amount of fat you absorb during digestion.
5. Since your BMI is 40 which is very high we may be able to do surgery to reduce your weight.
a. Weight loss surgery, also called bariatric or metabolic surgery, is sometimes used as a treatment
for people who are very obese.
b. It can lead to significant weight loss and help improve many obesity-related conditions, such as type 2
diabetes or high blood pressure.

12. Lady with abdominal cramps

Then we had that abdominal cramps station. Lady had c sec done 15 years ago, taking antidepressants for last 5
years. Now presented with abd pain for 1 yr/6 months. Pain comes and goes, sometimes 2 to 3 times in one day and
sometimes after 2 or 3 days.

A. All history negative.

B. Some people said – she had new relationship with a man since about 6 months and the symptoms started after that !
C. No vaginal discharge, Taking Mini pill, Had 2 children.
D. Check BNF for side effects.

In women, pain in the reproductive organs of the lower abdomen can be caused by:
• severe menstrual pain (called dysmenorrhea)
• ovarian cysts.
• miscarriage.
• fibroids.
• endometriosis.
• pelvic inflammatory disease.
• ectopic pregnancy.

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 13. Abnormal LFT
You are the FY 2 doctor in the GP clinic. 47 year old lady Miss Rachel Campbell came to the GP clinic few days ago
with abdominal discomfort. Some blood tests were done. She has come for the follow up. Talk to her about the further
management.
Liver Function Test ( given in the question) Miss Rachel Campbell
 Bilirubin – 25 ( Normal 3 – 17 micromols/L)
 ALT – 581 ( Normal 3 - 35 IU/L )
 AST – 110 ( Normal 3 - 35 IU/L )
 ALP – 50 ( Normal 3- - 150 IU/L)
A.
1. Dr: Hello Miss Rachel Campbell I am Dr… junior doctor here in the GP clinic. How can I help you?
Pt: I have come to collect my blood test report.
2. Dr: Yes it is here. We had done your Liver function test last time. Dr: Can you please tell me what is happening to you ?
Pt: Doctor I have pain in my tummy
B.
1. Dr: Can you please tell me more about it? Pt: It is here right side upper part.
2. Dr: Since when are you having this pain? Pt: Since the last two weeks.
3. Dr: What type of pain is that? Pt: It is like a dull pain sometimes it is just discomfort
4. Dr: Is it there all the time or come and go ? Pt: It is there all the time
5. Dr: Does the pain go anywhere else at all? Pt: No
6. Dr: To the back (pancreatitis, gall stones) Pt: No
7. Dr: Do you have any other problem other than pain? Pt: I feel bit tired. Dr: Since when ? Pt: Since last few weeks.
8. Dr: Any fever Pt: No
9. Dr: Any yellowish discolouration of skin or eye ( Jaundice) Pt: No
10. Dr: Nausea or Vomiting Pt:I feel sickly
11. Dr: Diarrhoea Pt: No Dr: Any itching? Pt: No
12. Dr: What is the colour of the stool ? Pt: Normal brown
13. Dr: What is the colour of the urine ? Pt: Normal
14. Dr: Do you keep eating outside in restaurants?
Pt. Yes .I like to eat uncooked shell fish ( oyster) in restaurants. I have been doing it for many months. Dr: Was it
in one particular restaurant or do you keep changing the restaurants ? Pt: One particular restaurant / different
restaurant.
C.
1. Dr: Have you travelled outside UK recently ? Pt: Not for the last one year.
2. Dr: Did you have any blood transfusion ? Pt: No Dr: Are you sexually active ? – Pt: Yes I am married. Dr: Do you
practice safe sex ? Pt: No.
3. Dr: Did you have Hep A or B vaccine ? Pt: No
4. Dr: Did you have any problem in your liver or gall bladder previously? Pt: No
5. Dr: Do you feel that your tummy is bloated or any ankle swelling ( liver failure) ? Pt: No
6. Dr: Did you have such problem before Pt:No
7. Dr: Do you have any medical conditions at all ? Pt: No
8. Dr: Do you have Diabetes or high blood pressure ? Pt: No Dr: Have you had any surgeries before ? Pt: No
9. Dr: Do you use any recreational drugs or share needle with others ? Pt: No
10. Dr: Do you drink alcohol ? Pt: No
11. Dr: Any chance that you are pregnant ? Pt: No
12. Dr: Are you taking any medications ? Pt: No
13. Dr: Any family members have such problem or liver problem in family members? Pt: No
14. Dr: Did you come into contact with anyone who had Jaundice Pt: No
15. Dr: What do you do for living ? Pt: …
D. Examination: Miss Campbell I need to examine your eyes for jaundice and your tummy. [examiner may say no
jaundice mild tenderness in right upper quadrant]

169
 E. Diagnosis:
1. Dr: Miss Campbell. We checked your blood test to see how your liver is functioning. It shows that something is abnormal
in your liver. Do you want to see the result ? Pt: Yes doctor.
2. Dr: Bilirubin is high – this means you have slight Jaundice. AST and ALT – these are some type of enzymes produced
by the liver when they are damaged, They are elevated and ALT is higher than AST – means it could be due to some type
of infections in the liver. ALP is normal means you do not have problems like gall stones etc.
3. It could be due to what we call as Hepatitis A. This is a liver infection caused by a virus that's spread in the stool of
an infected person. Sometimes it can happen due to uncooked shellfish. This could be due to the food you are having
in the restaurants.
4. Do you follow me ? Pt: Yes doctor.
5. Dr: We need to do some more blood tests to confirm this. As well as we may need to do scan of your tummy and liver to
exclude any other problems
6. Dr: This is not a serious condition because itwill normally subside on its own within a couple of months. So there is no
treatment required and no hospital admission required.
7. You can usually look after yourself at home.
 get plenty of rest
 take painkillers such as paracetamol if you have pain.
 eat smaller, lighter meals to help reduce nausea and vomiting
 stay off work
 practise good hygiene measures, such as washing your hands with soap and water regularly
F.
1. Hepatitis A can occasionally last for many months and, in rare cases, it can cause serious condition that the liver to stop
working properly (liver failure).
2. Once it subsides, you normally develop life-long immunity against the virus. However I still advise you not to eat
uncooked Oyster.
3. Dr: Any concerns ? Pt : No
4. Dr: I will inform my seniors about this and you can go home and follow the advise and we will keep following you
up.Thank you.

14. Diarrhoea? Inflammatory Bowel disease

50 year old man Mr… presented to the hospital with a history of passing lose stools for the last 2 months.
Take history and do the necessary examinations and discuss further management with him.
B.
1. Hello Mr. I am Dr.. Please tell me what brings you to the hospital ? Pt: I am having diarrhoea since about 2
months.
2. Dr: Any thing more you can tell me about it ? Pt: Like what?
3. Dr: Is it watery or loose stool ? Pt: It is loose stool
4. Dr: How many times in a day you get this diarrhoea? Pt; 5 to 6 times
5. Dr: Have you noticed any blood along with that ? Pt: No/ Yes once Dr Is the blood mixed with the stool or
separate from the stool ? Pt: It is mixed with the stool.
6. Dr: Any mucus in the stool? Pt: No
7. Dr: Is the stool difficult to flush in the toilet? Pt: No
8. Dr: Any pain in your tummy? Pt: Yes left lower part of my tummy.
9. Dr: Since how long ? Pt: Since almost 2 months.
10. Dr: Does the pain gets relieved on passing stool ? Pt: No Dr: Any fever ? Pt: No
11. Dr: Any vomiting ? Pt: No
12. Dr Have you lost weight recently ? Pt: Yes my belt has become loose. Dr: How is your diet? Pt: I eat
healthy diet – plenty of fruits and vegetables. Dr: Did you have this problem before this 2 months ? Pt: No
13. Dr: Do have any medical conditions ? Pt: No Dr: Diabetes or thyroid disease ? Pt : No
14. Dr: Have you undergone surgery on your tummy before ? Pt : No
170
15. Dr: Any of your family members have any medical conditions or bowel problems? Pt : No Dr: Have you
travelled outside UK recently? Pt : No
16. Dr: Is there anything else you think important that we need to know? Pt : No Tell the patient
C.
1. I need to examine your tummy and back passage.
2. Can you please undress above the waist and lie on the bed. [Ideal exposure for abdominal examination is from
mid chest to mid thigh]
3. Inspection – No abdominal distension, no visible peristalsis, mass or veins. Palpation – Superficial palpation –
mild tenderness on the left iliac fossa.
4. Deep palpation – no palpable mass.
5. Percussion – No fluid thrill. Auscultation – bowel sounds normal
6. Tell the examiner – I need to examine the back passage. Examiner says – no abnormal findings.
7. Tell the management to the patient.
D. Diagnosis:
1. Mr …. With the information what you have given and after examination I think you have a condition what we
call as Inflammatory bowel disease most likely a type called Ulcerative colitis.
2. This is a condition in the bowel. This condition can be due to genetic reasons or sometimes due to disruption
to the immune system (the body’s defence against infection). Are you following me? Yes
E. Investigations:
1. We need to do some tests to confirm the diagnosis as well as to make sure that there is no bowel cancer. .
2. We will be doing some test called colonoscopy where we pass a tube with camera through the back passage
into the colon - we can see the inside of the colon and also take some tissue samples. We will also do X Ray
of your tummy. We will do test on the stool to check for any bugs.
3. Pt: I don’t like colonoscopy. It may be very uncomfortable. Can you do any other test doctor?
Dr: Did you have colonoscopy before? Pt; Yes / No
Dr: We can another test what we call barium enema which is a special dye X Ray, But it is not as good as
colonoscopy because we can look properly inside of the colon during colonoscopy and also take tissue sample
which we cannot do in barium enema test. We can give you sedation during the colonoscopy so that you will
not be uncomfortable. Is that OK ? Pt - Ok doctor.
4. Dr; Are you following me? Pt: Yes.
E. Treatment
1. Dr: We will admit you to do the investigations and to treat. Unfortunately, there is currently no cure for this
condition. We can treat the symptoms and prevent them from returning.
2. We can give medications like Aminosalicylates, or corticosteroids – to reduce inflammation and immune-
suppressants – to reduce the activity of the immune system. If it does not respond to medications sometimes
we may have to surgically remove the affected part. Are you following me? Pt: Yes. Dr:Any concerns ? Pt :
No.
3. Thank you

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 15. Diarrheoa in elderly lady ? Bowel cancer
Scenario-65 year old lady presents with bowel problems. Take history and discuss management. Two
scenarios given in exam- 1. Diarrhoea lasting for 7 days
2. Diarrhoea lasting for 2 months along with constipation

A. HISTORY-
1. Primary complaint? (patient complains of change in bowel habits)
2. How long did it last? (2 months/7 days)
3. What was the colour of the stools?
4. What was the nature? Watery/loose/mucus?
5. Was there blood present? (1 episode of dark blood mixed with stools)
6. How many times did you pass in a day?
7. Did you experience constipation anytime during this time period? (altered bowel habits can signify colon
cancer)
8. Are you able to pass wind?
9. Did you feel any lumps on your back passage, Did you see the blood splashing in the toilet bowl ? (
haemorrhoids)?
10. Any associated factors-
-fever ( Gastro-enteritis)
-vomiting
-tummy pain
(patient gives negative history of pain, fever, vomiting or pain in the back passage ( anal fissure) while passing
stools)
11. Dark coloured and very foul smelling – diverticulitis
12. Do you get the sensation that you have not completely opened the bowel even after opening the bowel (
tenesmus – rectal carcinoma)
13. Assess dehydration status-
-are you passing reduced volume of urine ?
-did you experience dry mouth ?
-have you been feeling thirsty nowadays ?
14. Have you experienced any weight loss? (cancer) (patient may say no weight loss)
15. Have you experienced tremors/palpitations, weather preference ? (hyperthyroidism)
16. Have you travelled anywhere recently? (gastroenteritis)
17. Have you had food from outside recently?
MAFTOSA- ask specifically for medications [antibiotics (clostridium difficille) sometimes excessive use of
laxatives can cause diarrhoea] and family history of cancers/similar history of diarrhoea.
B.
Examination- I would like to examine your tummy and check vital signs. { examiner may say - examination is
normal)
C.
If diarrhoea lasts for 2 months-
We have to do tests to find out the exact cause.
We have to admit you and do some blood tests and stool to check for any bugs. We would also like to check if
you have dehydration.
We shall refer you to a Gastroenterologist who might do colonoscopy.
(Explain what is colonoscopy- a tube which has a camera attached to its end that we have to pass through the back
passage into the colon so that we can have a look inside the colon and take a tissue sample.)
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(In the exam, patient refuses colonoscopy and is persistent that nothing is wrong with her and would like to discuss
with her family. She does not want to be referred as well). (patient repeatedly says that she lives with her dog)
D.
Diagnosis : We need to check whether you have any sinister growth in the bowel. That is why colonoscopy is the
best test compared to other Dye X Ray test ( barium enema) because we cannot take tissue sample in the X Ray
test.
E.
It is very important to have this test because in- case if there is any growth and if it is in early stage we can treat it.
If we delay the test then the growth may spread and then it is difficult to treat.
Try to convince her to stay in the hospital. Ask her if she can arrange any one to look after the dog if not – we can
talk to the RSPCA and ask them to look after your dog until you are fine.
However, if she still disagrees, ask her to look out for the warning signs and come back to the hospital-
1. Sudden severe abdominal pain
2. Signs of dehydration
3. Blood in the stool
Treatment : treatment depends on what we find on the investigation. If at all it is growth then it depends on the
stage of the growth. We may need to do surgery or may be Radiation therapy.

Scenario change-
If diarrhoea lasts for a week-
Management differs-
I would also like to do some blood tests, check and stool culture. I would also like to check your dehydration
status. Depending on the tests, we shall treat you accordingly. Drink enough fluids to avoid dehydration.
If not severely dehydrated, able to eat and drink, no blood in the stool can go home and come back if the diarrhoea
persists more than a week.

16. Constipation
Question: 80 year old lady Mrs Edith Thompson had hip operation one week ago. Since
then she is having constipation. Take history and talk to her about the further
management.

Dr Hello Mrs… I amDr…. Howare you doing? Pt Doctor I am having

constipation ?
Dr Sorry to hear that. Can you please tell me what Pt Doctor It is both.
exactly you meant by constipation – do you mean
you did not open bowel for
long time or you have to strain more than usual to
open the bowel.
Dr Since when Pt Since about one week now. I
am having it sine this
operation I had on my hip.
Dr Are you passing any stool at all or not opened Pt I did not open bowel for the
bowel at all? last 4 to 5 days.

Dr Do you have any pain in your tummy (Intestinal Pt No but it is very

obstruction) uncomfortable

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Dr Have you vomited ( Intestinal obstruction) Pt No
Dr Are you able to pass wind (Intestinal obstruction) Yes
Dr Is there any bleeding from your back passage Pt No
( bowel cancer, anal fissure, haemorrhoids)
Dr Do you have any diarrhoea also along with Pt No
constipation
Dr Have you noticed any change in your weight Pt No
( bowel cancer)

Dr How is your appetite Pt I don’t feel like eating

Dr Do you get the feeling of opening the bowel but Pt No
nothing comes out when trying to open bowel
(tenesmus – rectal cancer)
Dr Any pain in the back passage while trying to open Pt No
the bowel ( anal fissure)
Dr Did you feel any lump in your back passage Pt No
( haemorrhoids)
Dr Did you see any mucus in the stool, any joint pains Pt No
? ( Inflammatory bowel disease)
Dr Do you have any medical conditions Pt No
Dr Like diabetes or thyroid problems any bowel Pt No
problems before
Dr Are you taking any medication Pt Yes I am taking Co codamol.
Dr Since when are you taking co-codamol ? Since after the operation –
one week
Dr Any of your family members have any kind of Pt No
bowel problems or bowel cancer at all?
Dr Do you eat enough of fruits and vegetables Pt Yes

Dr Do you drink enough fluids Pt Yes

Dr Have you been physically resting for long time Pt Well after this operation I am
not moving around that
much.

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Dr Examination:
I need to examine your tummy and your back passage. ( examiner may say hard stool
felt in the rectum).

Diagnosis:
Mrs Thompson, I think the Co -codamol medication what you are taking for pain is
causing this constipation because one of the side effects of co-codamol is constipation.
Treatment:
1. First of all we will stop giving this medication and we will give you some other
medication which will not cause constipation - maybe we will give you
Paracetamol if you are not in that much pain now.
2. We can give you some laxatives like senna, bisacodyl and sodium pico- sulphate to
help you to open your bowel.
3. You should drink plenty of fluids and eat high fibre diet like fruits and vegetable
or whole wheat bread. That will help you to open bowel.

Pt: What if the laxatives do not work.

Dr: We can give you some medication like Bisacodyl as Suppository – this type of
medicine is inserted into your back passage.
Pt: What if that also does not help ?
Dr: Then we can give enema where a medicine like Docusate andsodium
citrate in fluid form is injected through your back passage into your large bowel.
Pt: What if they do not help
Dr: We can evacuate the stool manually once then you should be able topass the
stool.
Dr: Any other concerns. Pt: No Dr: Thank you verymuch.

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 17. Elderly lady Constipation – talk to Nurse
87 year old lady was admitted to Orthopaedic ward 5 days ago with history of fall due to trip.
Patient is in physiotherapy. She is drowsy. Talk to the nurse looking after her and discuss the
management with the nurse. Patient also may be in the cubicle. ? Can’t take history from
patient because she is drowsy.

A.
1. Dr: Hello. I am Dr... I am one of the junior doctors in the Orthopaedic department. How may I call you?
Nurse: You can call me Elaine.
2. Dr: How are you Elaine? Nurse: I am fine thank you doctor.
3. Dr: How can I help you ? Nurse we have 87 year old lady in the ward who has constipation. I need to talk to
you about her.
4. Dr : Please tell me. Also may I know the name of the patient please?
Nurse: Mrs Thompson tripped and fell 5 days ago. She had a fracture of T8 vertebra. Doctors treated her with
bed rest. Now she is constipated.
5. Dr: Did she have any surgery for that? Nurse: No she didn't have any surgery.
6. Dr: what medications have been prescribed? Nurse: She is taking Aspirin, Dihydrocodiene and
Bisphosphonate.
7. Dr: Is she complaining of any other symptoms ? Nurse: Yes she complains of having constipation along with
bouts of diarrhoea since she came to hospital.
8. Dr: Could you please tell me what she meant by constipation. Like is she having difficulty defecating due to
hard stools or has she not opened her bowel at all?
Nurse: She has not opened her bowel for the last 4 to 5 days.
9. Dr: Does diarrhoea alternate with constipation? Nurse: Yes she has diarrhoea and constipation / No
10. Dr: Okay. So has she had constipation after she fell down or has she have constipation even before she fell
down ? (any chronic condition/Old age) Nurse: She didn’t have constipation before she fell down.
11. Dr: Is she having any pain in tummy ? Nurse : No.
12. Dr: Has she had any vomiting. Nurse: No vomiting doctor. (Intestinal Obstruction)
13. Dr: Is she passing wind? Nurse: Yes/ No
14. Dr: Did she tell you about any bleeding from back passage? Nurse: No / I don’t know about that.
(Haemorrhoids/Rectal CA)
15. Dr: Was there any mucus in the stool when she has diarrhoea? Nurse : No
16. Dr Was the stool colour dark or normal when she had diarrhoea ? Nurse : Normal
17. Dr: Its okay Elaine. You are providing valuable information. Thank you very much for that. I just need to ask a
few more things before we can discuss how to manage Mrs Thompson and relieve her problem. Is that alright?
Nurse: Yes doctor sure.
18. Dr: Do you know has she lost weight recently ? Nurse: Not sure about that too. (Bowel CA)
19. Dr: Does she have any pain on opening her bowel ? Nurse: No (Anal Fissure)
20. Dr : What about her diet and fluid intake? Nurse: Unfortunately she is not eating and drinking well.
21. Dr: Ok You said she is on bed rest now. Was she bed ridden even before the fall ? Is she been physically resting
for longer periods or has she been adequately mobile?
Nurse: I am not sure before the fall but now she is on bed rest She is on bed rest doctor.
22. Dr: OK, Dr: Has she got any other problem other than constipation and diarrhoea?
23. Nurse: She is bit drowsy. Dr- since when? Nurse….
24. Dr: Did you examine her by any chance Elaine? Nurse: Yes doctor. I did per rectal examination.
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25. Dr: That is very good of you Elaine. May I know what did you find on rectal examination?
Nurse: The examination was normal. No hard stools.
26. Dr: OK alright. Did you notice any lump? or any fissure? Nurse: No
27. Dr: okay Is she having any other medical condition? Nurse: No doctor.
28. Dr: Does any of her family members have any medical conditions such as colon cancer/IBD? Nurse: I don’t
know/ No
29. Dr: Has she got hypothyroidism ? Nurse: No. Dr: Does she have any intolerance to cold? Nurse: No
B.
1. Dr: I will go and examiner her and maybe we need to do X ray of her tummy if required.
a. You said she is on Dihydrocodiene and bisphosphonate. Opioids That is Codiene are known to cause
constipation.
b. We can switch her to paracetamol of she is not in much pain. I will assess her for that. One of the side
effects of bisphosphonate is also constipation.
c. I will discuss with my seniors about all the findings and we will manage her medications accordingly.
Nurse: okay doctor.
d. Dr: She may be feeling drowsy may because of the codeine - you know drowsiness is one of the side effect
of codeine. Hopefully she will become alert when we stop codeine. Nurse : Ok
2. Dr: Diarrhoea can be due to constipation called as Overflow diarrhoea.
a. So we need to treat constipation first. Dehydration and not having high fibre food also caused constipation.
We need to ensure that she is drinking and eating well. We need to provide her with fluids regularly.
b. Also we need to give her diet rich in fibre with lots of fruits and vegetables. This might relieve her bowel
problem. Nurse: Certainly doctor.
c. Then we can use laxatives after that. If constipation is not relieved we can use suppository. Our last resort
will be Enema. Are you following Elaine? Nurse: Yes Doctor.
d. Dr: I will talk to the Ortho team to see when we can start mobilising her because you know sometimes
immobility leads to constipation. Nurse : Ok
3. Dr: We need to rule out a few serious conditions like bowel cancer if the constipation does not settle. We
might need to do certain invasive procedures such as colonoscopy for that purpose. But hopefully it will be
relieved soon. Nurse: OK
4. Dr: We also need to do some blood tests including Full blood count, Urea and electrolytes, Thyroid function
tests and serum calcium levels. Nurse: Okay Doctor.
5. Dr: Elaine do you have any questions ? Nurse: No doctor.
6. Dr: Thank You so much Elaine for providing me with all the information. I am happy to see that you are so
dedicated to patient care. I will also go and check on Mrs Thompson now.

18. Coeliac Disease - Pt. Concerned about endoscopy.

Scenario -Middle aged lady is on Iron tablets as she is diagnosed to have iron deficiency anaemia. Despite
the medication, her condition isn’t improving. She had undergone some tests and found to have tissue
transglutaminase test to be positive. Endoscopy to be planned for the patient. Talk to her and address her
concerns.
A.
D- “Hello, I am Dr.------, one of the junior doctors in the department. I was told that you wanted to talk to me.
How can I help you?”
P-“Yes, I was told that I have Iron deficiency anaemia and some test is positive for Coeliac disease.

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D- “Did anyone explain to you regarding your condition?”
If patient says no,
“I understand from my notes that you have iron deficiency anemia and your condition wasn’t improving despite
the medication. Hence we tested for some antibodies in your blood- tissue transglutaminase. This is an indication
for coeliac disease.
“It is a condition of the bowel caused by an adverse reaction to gluten, which is a dietary protein found in cereals.
As a result, you might face some symptoms such as tummy pain, bowel problems and indigestion.”
B.
“We had tested for the antibodies in the blood which was found to be positive. However, to confirm the condition
and to manage you further, we need to do an endoscopy”
P- “Dr, why do you want to do an endoscopy? Isn’t the blood tests enough?”
D- “The blood tests showed you had antibodies present. However, it is quite a sensitive test and not necessarily
mean that you have this condition. We need to make sure with the help of an endoscopy so that we can give you
the proper treatment”
P – Endoscopy is uncomfortable. I am still concerned about this procedure. Could you tell me how it is
done?”
D- “Sure. I am glad that you asked.
An endoscopy is basically a camera test that will help us to visualise the inside of your body. This procedure is
performed with the help of an instrument called endoscope. An endoscope is a flexible tube that has a light source
and camera at one end. This is connected to a television screen which will give images.
However, before this procedure is performed, we ask the patient avoid eating and drinking for several hours
beforehand. The diet to be followed is gluten containing diet so that better results are obtained.
Sometimes we give antibiotics to reduce chances of infection
( Are you taking any blood thinner medications ? No ( it needs to be stopped few days before the procedure).
I can see that you might be concerned about the pain.
Before the procedure, we give a local anaesthetic in the form of a spray to numb the specific are of your body. You
may also be given a sedative to help you relax and make you less aware of what is going on around you.
After that, we shall carefully insert the tube from your mouth into the stomach and have a look inside the stomach
and take a tissue sample.
This procedure usually takes between 15 and 60 minutes. You will be allowed to leave on the same day if there are
no complications thereafter.
However, please make sure you have a friend or relative along with you to take you back home as it take time for
the sedation to wear off.
Complications are usually rare. However the possible one could be infection or bleeding.
C. Warning signs:
When you go back home, please do watch out for any signs of infection-
Fever, Shortness of breath, Vomiting /vomiting blood, Redness, pain or swelling, Chest pain
If you experience any of these symptoms, please do come back to us.
P- “Alright doctor, thank you. But the blood tests already shows that I have anaemia. Can’t you just treat
that rather than going for endoscopy?”
D- “Yes, you are right that you have anaemia. But we need to find out the cause behind it and treat it accordingly.
Most likely it is the Coeliac disease is causing the iron deficiency anaemia in your case.
P - Alright Doctor. Is there any risk of bowel cancer developing because of this condition ?
D – There is a very rare chance that bowel cancer may develop.
D- “Do you have any concerns? No.
D - Will you be happy to go ahead with the procedure? - Yes
D - I would like to tell you that there are some dietary restrictions for celiac disease
P- Yes, Dr, I know that. My cousins have the same condition and I cook for them.

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D- “Alright, would you like me to refer you to the dietician so that you have a better idea about the diet that you
can follow? P - Yes, I shall consider that
D - Do you have any concerns ? P- No, Dr. Thank you D - Thank you
--------------------------------------------------------------------------------------------------------
WHY IS ENDOSCOPY DONE FOR COELIAC DISEASE?
-Blood tests are helpful in diagnosing celiac disease but they aren’t perfect. False negatives and false positives are
possible.
- In the small intestine, there are finger like projections called villi that helps absorb nutrients. In celiac disease, the
gluten damages the villi and causes them to flatten. Hence endoscopy findings will show the following-
1. inflammation or damage to small intestine 2. flattened villi

19. Intussusception
GP referred a 20 month old child Andrew Collins because he was crying, lethargic, cold and pale,
but making enough urine.
Take history from child's mother Mrs Samantha Collins and talk to her about the further
management.
A.
I need to act like I am going in so oepn way .. that I do not know the diagnosis ..

1. Dr: Hello Mrs Sarah Collins. I am Dr ... junior doctor in the Paediatric department. How can I help you?
Mom: My son has been crying a lot since almost 10 hours.
Dr: I am very sorry to hear that.
2. Dr: Do you know why he crying at all? Mom: No doctor M. What do you think could be the reason
for his symptoms?
3. Dr: Did he fall or have any injuries ? Mom: No doctor NAI --> has Little x admitted to hosptial
with any history of injury or fall?
4. Dr: Has he got any symptoms? Mom: He has been passing loose stools since yesterday.
5. Dr: How many times ? Mom: May be 3 to 4 times
6. Dr: What is the colour of the stool ? Mom: It looks red doctor ( looks like red currant jelly) D: id you try
to change his nappies?
7. Dr: Has been vomiting ? Mom : Yes 3 to 4 times
8. Dr: What is in the vomit ? Mom: It is green colour liquid ( Bile)
9. Dr: Did you notice any lump or swelling in his tummy ? Mom: Yes his tummy looks bloated
10. Dr: Has he got high temperature? ( meningitis) Mom: No
11. Dr: Has he got any rash anywhere? Mom: No
12. Dr: Is the first time these things are happening to him? Mom: Yes
13. Dr: Does his urine smell bad ? ( UTI) Mom: No
14. Dr: Has he got any swelling in the groin ( obstructed hernia) ? Mom: No Dr: Any swelling or redness in the
scrotum? ( torsion testes)? Mom: No Dr: Do you give him breast milk or bottle milk ? Mom: Bottle milk /
breast milk
15. Dr: Any change in his diet ? ( milk allergy) Mom: No
16. Dr: Any change in your diet ( if she is breast feeding - intolerance to dairy products if mother is drinking too
much coffee tea, dairy products)
17. Dr: Does he have any other medical condition? Mom: No
18. Dr: Did he have any problem in the tummy before? Mom: No
19. Dr: Did he have any operations in the tummy? Mom: No
20. Dr: Is he on any medications ? Mom: No
21. Dr: Was there any problem during his birth or development ? Mom: No

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22. Dr: Do you have any other children? Mom: No
23. Dr: Any medical conditions in the family members ? Mom: No
B. Examination
Dr: Mrs Collins I need to examine your child's tummy. ( examiner may say there is mass in the abdomen)
C. Diagnosis:
1. With what you are telling me, I think your son has a condition what we call as Intussusception. Do you anything
about this? Mom: No
2. Dr: It is a condition in the tummy. As you know bowel looks like a tube. In this
condition a part of the bowel goes inside another part of the bowel like a telescope which
causes bowel obstruction. This quite a serious condition if we do not treat immediately.
This condition is usually seen in children between the age of 3 months to 24 months.
3. If she told me that I cannot understand? I turn to the examiner and ask him for a paper and pen to explain for
her what is intusspection is  Examier will say proceed
4. Mom: Why did this happen?
Dr: Sometimes this can happen for no known reason. Sometime if he had any other
medical condition affecting the bowel can cause this. ( Meckel's diverticulum (75%),
Polyps, Henoch-Schonlein purpura (3%), Lymphoma and other tumours (3%), Cystic
fibrosis, An inflamed appendix, Foreign body, Postoperative ).
5. Mom: What are you going to do doctor?
D. Investigation
4. Dr: First of all we need to do some tests to confirm whether this is the problem.
We will do X ray of his tummy (for perforation) and ultrasound scan of his tummy ( USG
- may show doughnut or target sign, pseudo kidney/sandwich appearance).
5. Also we will do some blood tests to check whether he is dehydrated because sometimes the children can be
very dehydrated with this condition. Is that OK ? Mom: OK
a. I will inform my seniors and discuss it with them and get back to you.
b.Dr: Please do not give him anything to eat or drink now until we tell you to do so. To treat him initially we will
give some fluids through his veins to hydrate him.
c. There are 2 different ways to treat the condition. One is by doing an operation other one without doing any
operation with a simple procedure.
d.First we will try with a simple procedure - Our Radiology specialist doctors may try to push the bowel back to
the original position by giving some type of air enema ( air and water double contrast enema) with high
pressure through the back passage of your child.
e. If it is not possible to correct with the enema or if there are any other problems in his tummy we may need to
do the operation and correct the condition.
f. (indications for laparotomy: Peritonitis, Perforation, Prolonged history (>24 hours), High likelihood of
pathological lead point, Failed enema.)
6. Mom: Can you leave it like that doctor ? Won't it become normal on its own ?
Dr: It is very rare that it will correct itself. Since he already has severe symptoms it is very unlikely it will
correct itself now. If we leave it like that for long time it can cause damage to the bowel wall and we may have
to do the operation.
7. Mom: When can I take him back home ?
Dr: If it corrected by enema, you can take him back home in a day or two. If we have to do the surgery to correct
the problem then we need to keep him in the hospital for about 3 to 4 days.
8. Mom: Will there be any problem after the treatment? Dr: Usually there is no problem after the treatment.
9. Mom: Will it happen again? Dr: Very rarely it can happen again ( recurrence rate : 5-15%)
10. Dr: Any other concerns ? Mom: No
Dr: Thank you very much. I will try to arrange the tests now and keep you informed.
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 20. Neonatal jaundice
SCENARIO - 15 day old baby was noticed to have jaundice by the midwife. Your task is to talk to the
mother- take history and discuss management with her.

A. History-
3. I was told by the midwife that your child has yellowish colour of the skin. Did you notice his skin turning
yellow? –NO
4. Is he active? Playful? YES
5. Did he have fever? Vomit? NO
6. Did you notice any rash? NO
7. Bowel movements- how is his poo? Any colour change? Blood in the poo? Any change in consistency?
(EVERYTHING NORMAL)
8. Any problems with the wee? Is he passing urine well? Any discolouration? Presence of blood in the urine
9. Is he feeding well ? YES
10. Do you breast feed your child? YES
11. Was there any recent change in your diet? Changes in his diet? NO
12. Did you notice any lump in the tummy? NO

B. DIFFERENTIAL DIAGNOSIS-
1. PHYSIOLOGICAL JAUNDICE
2. HEMOLYSIS (CAN ASK ABOUT FATHER’S AND MOTHER’S BLOOD GROUP)
3. BILIARY ATRESIA (PALE STOOLS AND DARK URINE)
4. SEPSIS (FEVER)
5. BREAST MILK JAUNDICE
MAFTOSA-
1. Does the baby have any medical conditions?
2. Does the mother have any medical conditions? ( diabetes has an increased risk of causing neonatal jaundice)
3. Is the baby/mother on any medications?
4. Does the baby have any allergies?
5. Any medical conditions in the family?
DELIVERY HISTORY-
1. Was it normal delivery or caesarean section?
2. Was there any complications with the pregnancy or delivery?
3. Were any instruments used during the delivery? (cephalohaematoma)
4. Is he your first child? (if not, ask for if there was any similar history of physiological jaundice in the
previous pregnancy)
C.
“Is it alright if I can examine your child? I will be doing a general physical examination, will ensure privacy and
chaperone. (check eyes for kernicterus, check for gums) ASK FOR NEWS CHART.
I shall be doing a couple of tests- FBC, LFT
Examiner gives findings- vitals normal
Icterus present
Abdomen examination-normal
Tests- fbc-normal, total bilirubin-150 (below treatment level), direct-10
D.
“From what you have told me and from what I have examined, it seems your baby has a condition called
physiological jaundice”
“What is that, Dr.?”
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Jaundice is a common and usually harmless condition in newborn babies that causes yellowing of the skin and the
whites of the eyes. The medical term for jaundice in babies is neonatal jaundice.
Blood has red blood cells which are broken down and replaced frequently. When it breaks down it produces a
yellow substance called Bilirubin. Jaundice is caused by the build-up of bilirubin in the blood. This bilirubin is
usually removed from the blood by Liver. The liver in newborn babies is also not fully developed, so it's less
effective at removing the bilirubin from the blood.
By the time a baby is about two weeks old, their liver is more effective at processing bilirubin, so jaundice often
corrects itself by this age without causing any harm.

This type of Jaundice usually happens after 2nd day of birth and usually resolves by 2 weeks, however sometimes it
can last longer time.
E.
Mother : So, Dr. what is the treatment
D: We have done a blood test to check the level of bilirubin. (Show the blood test to the simulator ) and explain
bilirubin is below treatment level.
IF BILIRUBIN IS BELOW TREATMENT LEVEL-
There is no need of any special treatment because it will resolve on its own may be in the next few days. However
we must keep the child hydrated. So continue breastfeeding. We shall be repeating the blood tests to make sure the
level of bilirubin has come down.
-------------------------------------------------------------------------------------------------------------
IF BILIRUBIN IS ABOVE TREATMENT LEVEL-
We need to start your baby on phototherapy treatment. This involves placing the baby in a cot under UV lamp. The
baby will be naked and eyes will be covered. However, you can take the baby out for feeds and nappy changes.
We will test his bilirubin levels every 4 to 6 hours and also check his temperature once the treatment starts and
once the bilirubin levels falls, we can stop the treatment. (S.E of phototherapy- rash, diarrhoea). The child must
continue feeding even during this treatment.
If the bilirubin levels hasn’t come down after the phototherapy treatment, exchange blood transfusion can be done-
where we have to replace the baby’s blood with new blood.

IX. Neurology

1. Brachial plexus injury

38 year old Mrs Sharon ... had Road Traffic Accident one year ago. She had brachial plexus injury. She
wants to go back to her work. Assess her condition to check whether she is fit to go back to work. At 6 th min
bell examiner will ask you questions.

A. Dr: Hello Mrs Sharon .. I am Dr.... one of the Junior doctor in the ... department. How can I help you ?
Pt: Doctor I met with a road traffic accident one year ago. Had injury to Brachial plexus on my right
side. I was undergoing physiotherapy for that. I was not working all this time since the accident. I want
to know whether I can go back to work now ?
1- Dr: First of all I am very sorry to hear about the accident and the injury you had.
2- You said you had brachial plexus injury – do you know what type of injury was that – were the nerves cut
or was the nerves just got stretched ? Pt: I do not know.
3- Dr: Were you told that you had any fracture in the neck bones or any disc prolapsed in the neck? Pt:
No /Yes
4- Dr: Ok. Did you have any wounds over the neck ? Pt: No

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 5- Dr: Ok, May I know what is your job ? Pt: I work on computers in the office/ I work as engineer at air
forse ( RAF). My work involves tightening screws ( rotational movements at wrist)
6- Dr: Did you have any problem working on computer or any other type of work before you had this accident
? Pt: No doctor. I was perfectly fine. I could do all the jobs properly.
7- Dr: May I know what functions in the hand you could not do after the accident ? Pt: Doctor I could not
.......
8- Dr: Have you tried doing those jobs now ? Pt: Yes, I can do all those now. Can I go back to work ?
9- Dr: Let me assess you completely and then I will tell you if that is OK with you ? Pt: Ok
10- Dr: Are you able to write with a pen on paper ? Pt: Yes I can now.
11- Dr: Can you type on the computer key board? Pt: Yes/ did not try.
12- Dr: Are you able to eat food with a spoon? Pt: Yes
13- Dr: Do you feel hot and cold sensations in your hands ? Pt: Yes
14- Dr: Do you have any other medical conditions ? Pt: No
15- Dr: Are you on any medications ? Pt: No
16- Dr: Mrs Sharon .. I need to examine your neck and hands now Is that OK? Could you please undress those
area. Pt: Yes doctor
B. Examination
1- Inspection of neck. : No scars over the neck, No deformity or swellings.
2- Do the upper limb neurological examination.
3- Sensory - fine touch and pain.
4- Don’t do Joint position and vibration ( even if tuning fork kept inside)
5- Check power – C 5 – shoulder abduction, C6 – elbow flexion, C7 – elbow extension. C8 – finger extension,
T1 – finger abduction.
6- Check the grip – ask the patient to hold your 2 fingers tight and you try to pull that out.
7- Ask the patient to write with a pen – if there is a paper.
8- Ask the patient to touch his thumb to tips of other fingers in the same hand.
9- Check the typing action movement of fingers.
10- Check reflexes

Everything will be normal.

Dr: Thank you Mrs Sharon ...

C. Talk to the examiner

I would to talk to the physiotherapist and the Occupational therapist and seniors and take their opinion about this.
We may need to do nerve conduction studies. However, so far with the information what Mrs Sharon gave me and
with the examination findings which were are normal, I think she is fit to go back to work.

2. Viral Encephalitis
23 /18 year old man was brought in by his father because he suddenly became unwell. Take history and discuss
management with him.

A.
1- Dr: Hello, I am Dr... Are you the father of ... Father: Yes
2- Dr: How can I call you please ? Father: You can call me ...
3- Dr: How can I help you Mr.. Father: Doctor, me and my son were sitting and watching
television just few hours ago. Suddenly he started talking rubbish, was not making any sense and had a fit ? I am
very worried doctor ?

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 B.
1- Dr: I am very sorry to hear that. Can you tell me anything more about it? Father: He was saying he had
headache and fever since yesterday. Otherwise he was OK until this suddenly happened?
2- Dr: Did he have any other symptoms other than headache and fever ? Father: I don’t know.
3- Dr : Was he complaining of headache for a long time or just for one day ? Father – Just since yesterday?
4- Dr: Did he have any weakness or arms or legs ( SOL) ( TIA, stroke) ? Father : No
5- Dr: Did he have vomiting ? Father : No
6- Dr: Did he have earache ? Father: No
7- Dr: Discharge from the ear ? Father: No
8- Dr: Did he have sore throat recently ? Father: Yes/ No
9- Dr: Did he cough ?Father : No Dr : Chest pain ? Father: No
10- Dr: Was he shying away from the lights ?Father : I do not know?
11- Dr: Did you notice an rashes on his body ? Father: No
12- Dr: Did he complain of burning sensation while passing urine recently ? Father: No
13- Dr: Did he have high temperature in the evening do you know ( TB) ? Father : No
14- Dr: Did he have any head injury recently ? Father: No
15- Dr: Did he had any similar problems in the past ? Father : No
16- Dr: Has been diagnosed with any medical conditions in the past ? Father : No
17- Dr: Did he ever had TB before ? Father : No
18- Dr : Did have fits like this before ? Father : No
19- Dr: Did he have any mental health illness ? Father : No
20- Dr: Does he smoke ? Father : No
21- Dr: Does he use any recreational drugs ? Father: No
22- Dr: Did he have any medical conditions like HIV infections ? Father No
23- Dr: Has he lost weight recently ( TB) ? Father : No
24- Dr: Is he on any medications ? Father : No
25- Dr: Is he allergic to any medications ? Father : No
26- Dr: Anyone in the family had similar problems or any medical conditions running in the family do you know? Father
: No
27- Dr: Did he travel outside UK recently ? Father: No
28- Dr: Did he come into contact with anyone who had similar problem recently? Father : No
29- Dr: Did he come into contact with anyone who has or had TB recently? Father : No
30- Dr: Does he work or is he a student ?Father : ....
31- Dr: Is there anything else you think is important that we may need to know? Father : I can’t think of anything else.

C. Examination and investigations

1- Dr: Mr I need to examine your son to check his pulse, BP, temperature, and I also need to check for any brain infection
signs, check his conscious level, and whether he has any rashes on his body.
2- Also I need to check whether he has any swellings in the neck. Then we may need to do investigations like blood tests,
CT and MRI scan of his brain and also we need to do a test called spinal tap where we take little bit of fluid from his
lower spine and test that. Examiner may give a paper with lot of information:
 In the paper it may be written
 Patient drowsy, NO neck stiffness, Brudzunski sign and Kernig’s sign negative, No rashes.
 He has cervical lympahdenopathy.
 CSF result- Pressure normal, sugar normal, protein high, lymphocytes 80%, Monocytes 10%.
3- We need do gram stain and ZN stain – examiner may that is normal. We will send it culture.
D. Talk to father about diagnosis and management
1. I think your son has a condition what we call as Encephalitis. Do you know anything about this ? Father : No

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2. Dr: In this condition there is infection of the brain by some kind of bugs. There are lot of different type of bugs can
cause serious brain infection. Different type of bugs like bacteria, virus and fungus type can cause this infection in
the brain.
3. However, the test results show it is more likely due to some kind of virus type of bugs. Brain infection due to virus
type of bugs can be dangerous some time but most of the time they resolve with treatment. Are you following me
? Father : what kind of virus doctor?
4. Dr: we will do some blood tests to find out what exactly the type of bugs. Father yes. What will happen to him
now?
5. Dr: We are going to admit him and treat him with Antibiotics through his veins this to be on the safer side because
if at all this is due to bacterial infection which can be very dangerous if we do not treat immediately. Also we may
give some antiviral medication ( Aciclovir) through his veins. Hopefully he recovers soon. We also be giving him
oxygen and fluids through his veins. I will be informing my seniors also immediately about him. Any other concerns
? Father : No. Thank you.

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 3. Extradural Heamatoma in child
You are the FY 2 doctor in the Paediatric department
10 year old boy Joshua Pilmore was brought into the hospital by the ambulance because he met with the
Road traffic accident.
CT scan of the head showed he had extra dural heamatoma.
Seniors are getting ready to take him to the theatre. He is in a critical condition. You have not seen the child.
Talk to his parents and address their concern.

1. Dr: Hello Mr and Mrs Pilmore ? ….. I am Dr ….. one of the junior doctor in the Paediatric department. Are you
the parents of Joshua ? Parents: Yes doc
2. Dr: I’m one of the team of doctors looking after your son. Parent: Oh, How is he doctor ?
3. Dr: Joshua is in the resuscitation room now. Our team is taking care of him.
I have come here to talk to you about him. Before that – Mr Pilmore, I was told that he met with an accident. Can
you please tell me more about it?
Parent: Doctor we were about to go to a restaurant and Joshua suddenly ran to cross the road and the next
thing I heard he was calling me Papa Papa. When we saw him he was under the car. We called the ambulance
immediately. They brought him here.
Dr: I am very sorry to hear that. When did this happen ? Parent: About half an hour ago.
Dr: Mr and Mrs Pilmore, I have not seen him as yet. I will be seeing him soon after I talk to you. I do have some
news about him. I wish I could give you some good news but unfortunately Joshua is in a very critical condition
now ?
Parent: What happened why do you say that?
Dr: Mr and Mrs Pilmore, we examined him and did a CT scan of his head which showed he had head injury and
has bleeding inside the head.
4. Parent: Is it serious ?
Dr: This is a very serious condition. I am very sorry to say this. Parent: Don’t you have any treatment for this?
Dr: We can do surgery and try to remove the blood clot from the brain. That is what our team is trying to do. We
do have the best surgical team to deal with such problems. We are doing our best to save him. Most of the time
surgery is very successful and they recover from the condition. However sometimes it can be very serious. In fact
sometimes it can be even life threatening.

5. Parent: Is he going to die doctor ?

Dr: As I mentioned our team will try to do the best for Joshua. As I told you before, most of the time children do
recover from the problem once we do the operation and remove the blood clot from inside his head. However,
there is slight chance that he may not make it. I am sorry to say this.

6. Mother may cry – console her and dad. ( tissues – glass of water to drink). Parent: Doctor I can’t believe
this !
Dr: I can’t even imagine how you are feeling now. We will do everything possible from our side.

7. Parent: Thank you doctor Parent: Can we see him?

Dr: I can understand you want to see him. As you know at the moment we are resuscitating him. You may not be
able to see him for long time because we need to operate on him as soon as possible. May be you can have a quick
look at him now and you can see him properly after the operation, is that OK Mr and Mrs Pilmore.

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8. Parent: Ok doctor. Will there be any damage to the brain after the operation ?
Dr: Hopefully he will not have any brain damages. However, we can’t say much about it now. We may know that
only after the surgery.
Dr: Any other concerns Mr and Mrs Pilmore? Parents : No doctor.
Dr: Are you Ok for us to go ahead with the operation?
Parents: Sure doctor, if you think that it is necessary. Please do whatever is best for him.
9. Dr: Thank you. I need to ask you few questions about his health ? Is that OK? Parents : OK
a) Dr: Can I ask you how was Joshua’s health before this happened ? Parent: He was completely fine.
b) Dr: Did he have any medical conditions at all ? Parents: No
c) Dr: Is he on any medications? Parent: No
d) Dr: Is he allergic to anything you know? Parent: Strawberries doctor.
e) Dr: I see. It is good that you told me about it. I will make a note of this in his notes and let everyone know
about this so that no one gives him strawberries here. Can I ask is he allergic to any medications at all?
Parents - No
f) Dr: Any medical conditions in the family members ? Parent: No
g) Dr: When did he last eat or drink? Parent: Just before this happened / in the morning. Dr:
How many hours ago is that? Parents … hours ago.
10. Dr: Thank you very much for the information. Is there any other questions? Parents: No
Dr: Thank you very much Mr and Mrs Pilmore, once again I am very sorry to give this news.
We will keep you informed about everything.
I will be around if you need any other help. I hope to come back with good news.
Thank you very much.

4. Intracranial bleed in adult. BBN

You are the FY 2 doctor in the medical department.
62 year old man Mr Ali presented to the hospital with headache and the CT scan of his head showed huge
intracranial bleed due to berry aneurysm.
He is unconscious but breathing on his own.
Neurosurgeon has decided that active intervention is not useful.
Your Consultant has decided for Palliative treatment.
Talk to his wife Mrs Ali and address her concerns.

1.
Dr: Hello Mrs….. I am Dr. …. How are you doing? Wife: I am OK.
Dr: I am one of the junior doctors in the medical department looking after your husband Mr Mohammed Ali. I am
here to talk to you about his condition.
Dr: Do you know anything about his condition? Wife: He had headache and he collapsed at home. Then we
brought him in here doctor.
Dr: I am sorry to hear about that.

2. Dr: Can I ask you few questions about his health? Wife: Yes doctor.
a) Dr : Did he have any medical conditions at all? Wife - No
b) Dr: Like High blood pressure ? Diabetes? Any heart conditions or kidney problems? Wife : No
c) Dr: Any stroke or mini strokes before ? Wife: No
187
d) Dr: How was he before ? Was he very active ? Was he working? Wife : He was very active.
e) Do you know what happened after you brought him to the hospital ? Wife : No doctor.

3. Dr: Mrs Ali, we did a CT scan of his head and we got the result. Did anyone discuss the CT scan result with
you ? Wife: No doctor ?
Dr: Before I tell you the result MRs Ali can you please tell me - Do you have any idea what may be happening to
him ?
Wife: No doctor.
Dr: I am very sorry to say this - it is not a good news. He has a very serious condition. Do you want to know about
it?
Wife: Yes doctor.
Dr: Do you want any of your family members to be with you when we discuss this? Wife: No it is OK doctor.
Dr: Mrs Ali, CT scan of his head showed there is massive bleeding inside his head. This is a very serious condition.
Wife: But don’t you have any treatment for that?
Dr: Sometimes we can do surgery to treat this condition. We have discussed his condition with the Neurosurgeon
but he thinks the surgery or any other treatment will not help for your husband’s condition because the bleeding
is very huge.
Unfortunately, we will not be able to treat his condition. He is in a very critical condition. In fact it is a life
threatening condition.

4. Wife: Do you mean to say he is going to die ?

Dr: I really wish I could say it is not true. But unfortunately Mrs Ali that is true. She may cry – Pause, offer
tissues and water.
Wife: Why did this happen doctor?
Dr: Mrs Ali There are various reasons this condition can happen. In his case he had some abnormal blood vessels
in his head which were kind of swollen and thin and that blood vessel suddenly ruptured and caused this heavy
bleeding. Also since he had high blood pressure sometimes the high blood pressure can contribute to this problem.
Sometimes this condition can run in the family members.

5. Wife: Are you not going to do anything?

Dr: I really wish we could do something to save his life. But Mrs Ali - unfortunately we will not be able to save his
life because the bleeding is very huge.
Wife: That means you are leaving him to die ?
Dr: I am really sorry if I made you feel that way. I can imagine why you are feeling that way. Mrs Ali - If at all we
could have done anything we would have definitely done that for him. But our hands are tied because there is no
such treatment available to save his life.
Wife: Are you going to keep him in the Intensive therapy unit ?
Dr: Sometimes if they are not breathing on their own we keep patients in the ITU and attach a machine which helps
them in breathing.
Mrs Ali as you may know he is still unconscious but breathing on his own at the moment.
I really wish we could keep him in the ITU and treat him. But we keep only such patients in the ITU to treat - with
whom we expect them to recover from the condition. Unfortunately, we are not expecting that Mr Ali will recover
from his condition.
Keeping him in the ITU even if he stops breathing is not going to help him.
My consultant will discuss these things with you because your opinion is also very important for us. What do you
think Mrs Ali ?
Wife: I can understand. Are you not going to do anything at all for him ?
Dr: Mrs Ali, However we are going to do everything possible from our side to keep him comfortable. We will

188
provide him palliative care – that is we will be providing all types of care to keep him comfortable.
6. Wife: When do you think he may die?
Dr: I really wish that I could say that he can live very long and healthy life but Mrs Ali he may not live very long.
He may die any day.
Wife: I have 2 sons. Should I tell them to come here ?
Dr: Mrs Ali I think you should tell them to come here because as I mentioned it is a very serious condition now.
Wife: Can I take him home doctor ?
Dr: Yes surely Mrs. Ali. We will make all the arrangements so that you can take him home and we will provide all
types of care and support you may need to look after him as long as he lives.
Dr: Is there any other concerns?
Wife: No doctor.
Dr: Once again I am very sorry to give you this bad news. Wife: Thank you doctor
Dr: Thank you very much Mrs. Ali. If you need any help please do let us know.

5. Head injury in adult

Criteria for performing a CT head scan in adults (NICE guideline). For adults who have sustained a head injury
and have any of the following risk factors:-
1. Perform a CT head scan within 1 hour of the risk factor being identified:
2. GCS less than 13 on initial assessment in the emergency department.
3. GCS less than 15 at 2 hours after the injury on assessment in the emergency department. Suspected open or
depressed skull fracture/
4. Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or
nose, Battle's sign).
5. Post-traumatic seizure. Focal neurological deficit
6. More than 1 episode of vomiting.
For adults with any of the following risk factors who have experienced some loss of consciousness or amnesia
since the injury, perform a CT head scan within 8 hours of the head injury:
• Age 65 years or older.
• Any history of bleeding or clotting disorders.
• Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a
motor vehicle or a fall from a height of greater than 1 metre or 5 stairs).
• More than 30 minutes' retrograde amnesia of events immediately before the head injury.

40 year old man Mr Andrew Robert collapsed outside a pub. Take history from the patient and discuss the
management with the patient.
A. Dr - What brings you to the hospital ? Pt - Doctor I passed out
Dr –When? Pt - I just came out of the restaurant and passed out
Dr – Was there any one with you ? Pt - yes my wife was with me.
B. Dr - How did this happen? Pt: We are in the restaurant, we came out and
suddenly I passed out.
1. Dr: Did you slipped or tripped ? Pt: I am not sure. ( sometimes he may say I
tripped on the pavement)
2. Dr - How long did you lose consciousness? Pt – I am not sure because when I was awake I
was in the ambulance.
3. Dr - Did you recover completely after this, or was there any drowsiness Pt – yes, I did recover
completely immediately after the incident
4. Dr - Any head injuries when fell down ? Pt – No/Yes
5. Dr: Did you had any head injury before you lost consciousness ? Pt: No
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6. Dr - Any headache …? Pt - no
7. Dr: Did you vomit after this ? Pt: Yes twice
8. Dr – Did anyone tell you that were jerking ( fit) at that time ? Pt - no
9. Did you wet your pants do you know ? Pt - no
10. Dr: Do you know whether you had any bleeding from ear nose ? Pt - no
11. Dr: How much do you remember before this incident ? ( any amnesia for 30 min before incident) Pt:
Sometimes he may say I remember everything until I just passed out / sometimes he may say I just
remember going into the restaurant and then my wife told me that when we came out I just passed out.
12. Dr: How much do you remember before this incident ? Pt. I remember when I was awake I was in the
ambulance and remember everything after that.
13. Dr - Is this the first time ….? Pt-Yes
14. Dr -Any medical problems like – DM, HTN, Heart conditions, Epilepsy, Stroke Pt – No
15. Dr -Did you drink alcohol just before this? Pt – Yes doctor but it is same type and same
amount as usual
16. Dr -Did you use any recreational drugs just before that? Pt - No doctor
17. Dr – Do you take any medications ? Any blood thinners ? Pt – No ( Any drug Overdose)
18. Dr – Any of your blood relatives have any medical conditions like DM, Heart conditions or epilepsy ?
Pt - No
19. Dr - Do you live with any one ? Pt – Yes, my wife

C. Dr: Mr Robert, I need to examine you ( Examiner may not give any findings).

1. With what you told me I think you have injured your head and probably you have some bleeding inside your
head. We need to admit you in the hospital and do CT scan of the head to check whether you have the bleeding.
Is that OK?
2. Pt: No Doctor I am fine now. I want to go home.
Dr: Mr Robert with the symptoms what you are telling me like that you have headache and vomiting, these are
the signs of bleeding inside the head. It will be very dangerous for you to go home. We need to admit you treat you
if you have bleeding inside your head. We may need to do operation on your head to remove the blood clot if at
all you have the bleeding in the brain. We will also do so me tests to see why did you fall–like we will do ECG
(heart tracing, check your blood sugar).
3. However if all these tests are normal then you can go home. Is that OK ? If we discharge you then you should
stay at home at least for 24 hours and your wife should take care of you. If you have any symptoms like (
warning signs) continued headache, continuously vomiting, Drowsiness or fits you should come back.
Pt: Ok doctor. Thank you very much.

6. Head injury in children

You are the FY 2 doctor in the Paediatric department.
9 Month old child Jane was brought in by her mother with a history of fall from sofa. Take
history from the mother and talk to her about further management.
History should include pre -incident - incident and post incident - also questions for Non-
accidental injuries)
Check for indications for CT scan of head and admission.
A.
Hello I am Dr ... one of the junior in the Paediatric department. Are you the mother of Jane
Anderson ? Mother : Yes:
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Dr: How can I call you please ?
Mother : You can call me Mrs Anderson. Dr: How can I help you Mrs Anderson?
Mother: My daughter Jane fell from the sofa today.
B. Dr: I am sorry to hear that. When did this happen? Mother : About an hour ago.
1. Dr: Can you please tell me what happened immediately after that?
Mother : She was quite for some time then she started crying.
2. Dr: Why did you worry about Jane to bring her to the hospital?
Moher: She has some bruise on her head.
3. Dr: What did you do immediately after that? Mother : I brought her here to the hospital.
4. Dr: It is really good that you brought her I immediately. Can you please tell me what was Jane
doing before she fell from the sofa? Mother: She was lying on the sofa and playing.
5. Dr: Was she well before this happened? Mother: She was completely fine before this
happened.
6. Dr: How did she fall from the sofa? Mother: She rolled over and fell down. I was changing
the nappy of my other child.
Dr: Ok. What type of floor was it? Carpeted or tiled floor? Mother: Carpet floor.
7. Dr: Did she lose consciousness after she fell down? Mother : She was limp for few seconds
but she did not lose consciousness. She started crying
immediately.
8. Dr: Has been fully conscious after that until you brought her in here? Mother - Yes
9. Dr: was she drowsy at all after the fall? Mother : No
10. Dr: Can you please show me in your finger how big is the bruise? Mother: This long doctor (
she may show in her finger ( may be lesser than or more than 5 cm).
11. Dr: Did you notice any other injury on her head apart from bruise like wound or swelling ?
Mother : No
12. Dr: Did she have any bleeding or fluid discharge from her ear or nose ? Mother : No
13. Dr: Did you notice any injury anywhere else in the body? Mother : No
14. Dr: Did she vomit after the fall? Mother: Yes twice/once.
15. Dr Did she have any fits? Mother : No
16. Dr: Did you notice any abnormal behaviour of your child after this incident? Mother: No
17. Dr: Was she completely fine and playful after this incident apart from vomiting? Mother : Yes
C.
1. Dr: Did Jane have any injuries in the past for which she was brought into the hospital or even
not brought into the hospital? Mother: No
2. Dr: May I ask who looks after Jane? Mother: I look after Jane - sometimes my sister looks
after Jane.
3. Dr: Do you mean your sister lives with you. Mother: Yes/ No. Sometimes when I have work
I drop Jane in my sister's house.
4. Dr: Does your sister like your child ? Mother : Yes, she likes her a lot.
5. Dr: What about Janes' Father? Mother: We are divorced.
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6. Dr: Does he look after Jane anytime? Mother - Sometimes yes.
7. Dr: Does he take her with him to look after her ? Mother : No
8. Dr: Did you have any problem when you were pregnant with Jane? [ to check whether she is
the biological mother] Mother : No
9. Dr: How was the delivery? Did you have normal delivery or caesarean section ? Mother:
Normal delivery
10. Dr: Was this a planned pregnancy? Mother : Yes
11. Dr: Has Jane been diagnosed with any medical conditions at all? Mother: No
12. Dr: Do you have any other children? Mother: Yes I have another 3 year old daughter.
13. Dr: Did she have any injuries any time? Mother: No
1 4 . Dr: Whom do you live with? Mother: I live on my own with my 2 children.
1 5 . Dr: Anyone else lives at your home? Mother – No
1 6 . Dr: What work do you do? Mother : I work as . . .
17. Dr: How does the father and the children get along with each other? Mother: They are Ok.
18. Dr: Sorry to ask you this Does the father or any one hurt your children at all? Mother : No
19. Dr: Is there anything else you think that we may need to know? Mother: I just feel guilty
doctor! Dr: Please don't feel guilty. Sometimes it does happen.
D.
Dr: Mrs Anderson. I need to examine your child for any signs of head injuries. [Examiner did not
give any findings - if the examiner asks - what you want to examine-I will check for head injuries
any other new or old injuries. Check the GCS and vital signs-examiner may say child is fine apart
from bruise]

E. Management:
1. I think your child has no serious head injury with the information what you have given me.

 If vominting 3 or 4 / 5 cm wound -->

o I need to admit
o The thing that you said that little .. and the wound ,,,
o WE need to admit him. becaue we have to run some tests . a tst called CT scan.
Once it confirms it is a bleeding , we wil lrefer him to a specialist from
neurosurgoun--> Do not worry we are going to admitt and do all needed as fast as
possible
2. Normally we do tests like CT scan of the head to look for any bleeding inside the head if the
child vomits more than 3 times or if the bruise is more than 5 cm or if they lose consciousness
and other things. You said she vomited only twice and her bruise is very small and she is
completely fine now - the chances she is having any bleeding inside the head very very low.
So we do not need to do CT scan of the head of your child. There is no need for any
treatment. There is no need to keep her in the hospital.

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3. If she insisted that he needs be admitted:

a. If the mother says there is something wrong with him? Do not you wrorry M . Thank
you so much for telling me. We can observe him for some more hours. until you feel
that your little x is completely okay M. Anything for your M.
b. If she insisted --> we can tell her that we do not see this necessary
4. You can take your child back home. It is very unlikely that she will have any further
problems.
5. You can give her some paracetamol if she keeps crying. Is that OK Mrs Anderson?
Mother: Ok doctor.

6. Would you be there to observe him for the next 24 hours? whatever her answer  That is
fine, but whoever will be with him, i will leave him a leaflet
Dr: You need to observe her at least for 24 hours at home. If she has any symptoms like
a. If she loses consciousness,
b. She is abnormally drowsy (feeling sleepy) that goes on for longer than 1 hour when they
would normally be wide awake,
c. you find difficulty in waking her up,
d. weakness in one or more arms or legs
e. vomiting (being sick)
f. seizures (also known as convulsions or fits)
g. clear fluid coming out of their ear or nose
h. bleeding from one or both ears
I suggest you call the ambulance and bring her back to the hospital emergency department as
soon as possible because these symptoms show there is bleeding inside the head. But I as I told
you before these are very rare to happen. Do make sure that there is a nearby telephone and you
should stay within easy reach of the hospital. Any other question? Mother: No
Dr: Thank you.

7. Headache – GCA
67 year old lady Mrs Melinda Jones presented to the hospital with headache. Take history from her and discuss
the management with her.

Differential Diagnosis
Imagine- put your finger on glabella and move to eye then to temple and dig deeper so
you will not miss the dd.
AACG ( acute angle Do you see coloured circles around light? Worse in
closure glaucoma) darkness? Redness of eye? Flashes

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 GCA [temporal artery] Jaw claudication-Do you get pain on chewing?
Temporal tenderness-pain while combing or touching
temple area? Any vision problems ( shade coming in front
of the eye, vision loss later)
Head injury [bone] By any chance you got hurt on your head?
Meningitis[meninges] Fever, vomiting, Photophobia-feel discomfort on bright
light? Rash-any rash in your body?
Neck stiffness-difficulty in moving your neck?
SAH[Below meninges] Sudden onset, meningeal signs but no fever.
SOL[brain] Early morning, vomiting Gradual worsening, limb
weakness
Migraine– pattern- one sided, aura, family Hx
Cluster headache- Comes in cluster – previous Hx of headaches, timing,
redeye, tearing
Tension head ache –band like, worse in evening, stress
Refractory error- long do you wear glasses? Any problem in reading or
vision? When did you last
visit optician?

C.
Patient gives Hx of Pain on the sides of head while combing hair and pain in the jaws while eating. No vision
problems. No - Family history. Ask about severity of pain ( if very severe – offer pain killers)

D. Management
1. Mrs Jones with what you told me I suspect you have a condition what we call as Giant cell arteritis. Do you
know anythingaboutthis? Pt – No
2. Dr: It is a condition in the blood vessels, usually in the head and neck, become inflamed. It is sometimes called
temporal arteritis because the arteries around the temples are usually affected.
3. Pt: What are going to do for me?
a.Dr: We will do some blood tests to check for the possibility of this condition. (ESR and CRP).
b. We need to do another test called temporal artery ( blood vessel on the side of the head) biopsy to confirm
the diagnosis. During the procedure, a small sample of your temporal artery is removed and checked in the
laboratory. It can take several days to get the results of a biopsy.
c. However, we need to treat you urgently before we can do the biopsy because if we delay the treatment
waiting for the test result sometimes people can lose their vision which can be permanent. To prevent the
loss of vision we need to treat you immediately. Do you follow me?
4. Pt: Yes. How will you treat me?
a.Dr: We will treat you medication called Prednisolone tablets which is a steroid. Initially we will give high dose
steroids ( 60mg ) which will gradually be reduced every two to four weeks, depending on how well you
respond to treatment.
b. If the diagnosis is confirmed with the biopsy - you may need to take prednisolone for up to two years to
prevent your symptoms returning. Your symptoms should improve significantly within a few days of starting
treatment. However, there is a chance they will return (relapse) once treatment stops.
c. Please don't suddenly stop taking steroid medication because it can make you feel very ill.
5. There are some side effects of steroids because you may need to take it for long time. Do you want to know
about them? Pt ; Yes doctor.
a.Dr: It can cause changes in mental state - you may feel very depressed and very anxious, or very confused.

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 b. It can also cause increased appetite, which often leads to weight gain
• increased blood pressure
• mood changes, such as becoming aggressive or irritable with people
• weakening of the bones(osteoporosis)
• stomach ulcers
• increased risk of infection
c. The risk of these side effects will be lesser as your dosage of prednisolone is decreased. We will also give you
another medication called Aspirin in low dose (75mg daily).
d. This prevents complications of giant cell arteritis, such as heart attacks or stroke.
e.We will give another medication called Omeprazole to protect your stomach from stomach ulcers.
f. We may also give some other medication called immune-suppressants, such as methotrexate to suppress
the immune system (the body's defence against infection and illness). This can help prevent the condition
recurring.
g.We will follow you up regularly to see how you are responding and to reduce the dose of prednisolone.
h. We will issue a steroid card which you need to carry with you at all times as it will explain that you are
regularly taking steroids.
6. Pt: Will there be any complications ?
a.Dr: Sometimes it can cause Visual loss or heart attacks or stroke. However Aspirin medication lowers the
chances of getting these problems.
b. Another complication sometimes can happen is a condition called Polymyalgia rheumatic which causes
inflammation of the muscles and joints and causes neck and hip pain, and stiffness of the affected muscles
(which is often most obvious after waking up).
7. Any other concerns ? Pt: No Dr: Thank you very much. Hope you will recover soon. 1

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8. Sub Arachnoid Haemorrhage (Headache - history and management)

54 year old lady Mrs Joan presented to the hospital with severe headache. Take history, examine her and
discuss the further management with her.
A.
1. Dr: Hello Mrs Joan, I am Dr…. one of the junior doctor in the medical department. Can you please tell me what
brings you to the hospital? Pt: I am having severe headache.
2. Dr: I am very sorry to hear that. Can you please tell me how severe is the pain – in the scale of one to ten one
being the mildest pain and ten being the most severe pain ?Pt: It is 10 out of 10 doctor.
3. Dr: Do you want me to give you some pain killers ? Pt: Yes please doctor. Offer pain killer.

B.
1. Dr: Can you please tell me more about your headache ?
Pt: Doctor this headache started suddenly. This is the worst headache of my life. I felt it like thunder clap
/ I thought someone hit the back of my head.
2. Dr: Do you mean to say you used to have headaches like this before ? Pt: Yes doctor, I have migraine.
3. Dr: Is this different than migraine headache ? Pt: Certainly doctor. I never had headache like this before.
4. Dr: Where exactly in the head you have this headache. Pt: Back of my head doctor.
5. Dr: Since when are you having this headache ? Pt: Almost 2 hours now.
6. Dr: What were you doing when you got this headache ? Pt: Doctor I was doing …. (subarachnoid haemorrhage
sometimes happens during physical effort or straining – such as coughing, going to the toilet, lifting something
heavy or having sex).
7. Dr: Did you take any medications for your headache ? Pt: Yes I took paracetamol but it didn’t help me at
all.
8. Dr: Do you have any other symptoms other than headache ? Pt: I feel sick doctor but not vomited.
9. Dr: Anything else? Pt: Like what? Dr: Any fever ? ( meningitis) Pt: No, Dr: Neck stiffness? Pt: No Dr: Rash
on the body? Pt: No
10. Dr: Any head injury recently? Pt: No
11. Dr: Any pain on the side of your head when combing hair ? ( GCA) Pt: No
12. Dr: Any pain in your jaw ? ( GCA) Pt: No
13. Dr: Any vision problem ? ( SAH, GCA)Pt: No Dr: Any colored halos in your vision? ( glaucoma) Pt: No
14. Dr: Any watering of the eyes ? ( cluster headache) Pt: No Dr: Do you get headaches in the morning ? ( SOL)
Pt:No
15. Dr: Any weakness on any part of your arms or legs ? ( SOL, stroke, SAH) Pt: No Dr: Any speech
problems ? ( Stroke SAH) Pt: No
16. Dr: Do you have any medical conditions? Pt: No
17. Dr: Have you ever had any medical conditions in the past? Pt: No Dr: Diabetes? Pt: No Dr: High blood
pressure ? Pt:No
18. Dr: Any strokes or mini strokes in thepast ? Pt: No Dr: Any kidney problem ? Pt: No
19. Dr: Do you smoke ? Pt: No Dr: Do you drink alcohol ? Pt: one bottle wine a day
20. Dr: Do you use any recreational drugs? Pt:No
21. Dr: Are you taking any regular medications ? Pt: No Dr: Are you allergic to any medications ? Pt: No
22. Dr: Any of your family members had headaches like this or had bleeding in their brain ? Pt: No
23. Dr: What do you do for living ? Pt: I am an accountant.
24. Dr: Is there anything else you think may be important that we need to know? Pt: I don’t think so doctor.

C. Examination:
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1. Dr: Mrs Joan I need to examine you now and check your pulse and Blood pressure.
2. Examiner says – examination is normal. Her BP is 150/90, Pulse normal

D. Diagnosis
1. Dr: Mrs Joan, I think you have a condition what we call as Subarachnoid haemorrhage -that is bleeding in
the brain. Are you following me?
2. Pt: Yes, but why do I have that doctor?
Dr: There are several reasons why this can happen. This usually happens because there is some abnormal blood
vessels in the brain which blood vessels becomes thin and they bulge out what we call as aneurysm. Sometimes
these blood vessels suddenly rupture and cause severe headache like what you had. Sometimes this condition
can run in the family. Unfortunately this is a very serious condition and sometimes this could be even life
threatening. Do you follow me?
3. Pt: Yes doctor. Are you sure that is what I have ?
Dr: We need to do some tests to confirm that. We will have to do CT scan of head.( CT scan is the first line
investigation – shows bleeding in 98% of cases but negative in 2% cases)
Examiner said – CT scan is normal. What will you do?
4. Dr: We will do Lumbar puncture which is usually done after 12 hours of onset of headache to look for
Xanthochromia ( Lumbar puncture should ideally take place over 12 hours after the onset of the headache
because if there are red cells in the CSF, sufficient lysis will have taken place during that time for bilirubin and
oxyhaemoglobin to have formed - xanthochromia (yellow discoloration of the spinal fluid ).
Examiner says : What will you do if the Lumbar puncture is positive for SAH ?
d. Dr: We will admit her in the ITU and transfer to the neurosurgical ward.
e. Do further investigations to find out the exact location shape and size of the abnormal blood vessels
like
CT Angiography
Magnetic Resonance Angiography(MRA)
ECG
E. Treatment: One of problem with SAH is Cerebral ischemia due to vasospasm.
1. Treat her with calcium channel blocker – Nimodipine ( 60 mg four-hourly - this is normally taken for three
weeks, until the risk of secondary cerebral ischaemia has passed ) to relax the blood vessels in the brain to
improve blood circulation to the brain.
2. Labetolol - to treat hypertension; the level should be low enough to prevent re-bleeding whilst high enough to
maintain cerebral perfusion.
3. Patients should not be given an anti-fibrinolytic agent or steroids.
4. She needs operation on the brain either clipping or coiling.
5. We can give her pain killers ( morphine, cocodamol, anti-emetics, and anticonvulsants - if she has fits)

F.
1. There is 50 % mortality even with the treatment.
2. Complications
Re-bleeding
Epilepsy ( 1 in20)
problems with certain mental functions, such as memory, planning and concentration
changes in mood, such as depression
Hydrocephalus,
Delayed cerebral ischaemia

Thank you very much to the patient and examiner.

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9. STROKE RISK ASSESSMENT

You are F2 in the GP clinic.
60 year old Mr. Zimmerman makes an appointment with the clinic because he is very concerned about
developing stroke. The nurse has found his BP to be 160/90.
Talk to him and address his concerns.
A.
1. Dr: Hello Mr. Zimmerman... I am Dr.... one of the junior doctors here in the GP clinic.. Pt: Hello doctor..
Very nice to meet you.
2. Dr: Nice to meet you too Mr. Zimmerman. I understand you made an appointment with the clinic
because you had some concerns. Is that correct? Pt: Yes doctor. I'm very worried that I might develop
stroke.
3. Dr: Could you please tell me why you are worried about it?
Pt: I had a health check by the Occupational health department 2 years ago and they told me that my
blood pressure is bit high at that time. But I was too busy and I didn’t bother much about it. But now
I am very worried it.
4. Dr: Can you please tell me why are you worried of getting stroke if your blood pressure is high ?
Pt: My father and elder brother had high blood pressure. My father died of stroke many years ago
and my brother had stroke few years ago. He has just recovered now.
5. Dr: I am very sorry to hear that Mr. Zimmerman. But don’t worry Mr Zimmerman we can help you to
reduce any risk of you getting stroke.
Mr Zimmerman, do you know what is stroke and why people get this condition ?
6. Pt: I know people can have paralysis if they have stroke.
a. Dr: That is right Mr Zimmerman. This condition happens either because there is bleeding in the brain
and blockage to the blood supply to the brain.
b. People who have this condition can have paralysis. Sometimes people do improve from this problem
but sometimes the paralysis can last forever.
c.Sometimes this condition can be even life threatening. Pt: I see.
d. Dr: Sometimes this condition can run in the family because of genetic reasons. However, there are
lot of others risk factors why people get stroke.
e. We may be able to reduce the chances of you getting stroke if you have any other risk factors and
if we can modify those factors.
f. I am really glad that you came to the hospital now. Let us see if you have any other risk factors and
try to sort out those. Is that OK Mr Zimmerman? Pt: Ok Doctor.
7. Dr: Did you have any strokes or mini strokes previously ? Pt: No Dr: Do you have any heartproblems?
Pt :No
8. Dr: Do you have any palpitations (Atrial fibrillation)? Pt : No Dr: Do you have diabetes? Pt:No
B.
1. Dr: You said your blood pressure was high before. Our nurse checked your blood pressure now which
is 160/90 which is quite high. High blood pressure is one of the major risk factor which can cause
rupture of the blood vessels in the brain and cause bleeding in the brain. It is very important to keep

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the blood pressure under control. We can give medications to keep the blood pressure under control.
I will talk to my seniors about it and get back to you.
2. However, apart from medications you may need to do lot of other things to keep the blood pressure
under control.
a) Pt: What is that doctor ? Dr: One important factor is diet. Can I ask you what type of food do you eat
usually?
b) Pt: You know doctor. I am a NHS manager. I'm usually busy. I don’t have time to cook food. So I eat
out most of the time. I have to eat fast food - I eat chips, burger, steaks etc.
c) Dr: Mr Zimmerman, the kind of food what you are eating is not good because they have very high bad
fat content that is cholesterol.
d) This can increase the blood pressure and contribute to stroke. I sincerely advise you to eat more of
white meat which has less bad fat like chicken and fish.
e) I also advise you to include plenty of fruits and vegetables also in your diet.
f) Also please reduce the salt content in your food because it can increase the blood pressure. I will
refer you to a dietician who will advise you in detail about the healthy diet. Is that OK ? Pt: That is
fine. Doctor.
3. Dr: That is good. Can I ask do you do exercise ? Pt: Not much doctor. As I said I don’t get time to do
exercise.
g) Dr: I understand you are very busy. However, I sincerely advise you to do some exercise like walking
for about 30 min every day at least 5 days a week.
h) If that is not possible may be you can have a treadmill at home and exercise on that while you are
watching TV.
i) Exercising regularly will keep you healthy and also helps to keep the blood pressure under control.
What do you say ? Pt: Yes doctor that seems to be a good idea.
4. Dr: Excellent. Do you smoke Mr Zimmerman?
j) Pt: Yes doctor I smoke about 10 to 15 cigarettes a day for the last 15 to 20 years doctor.
k) Dr: Again smoking is not good for health at all as you may know. Smoking also can increase the blood
pressure and also can cause lot of other health problems. I strongly advise you to stop smoking. We
can help you to stop smoking if you wish. Do like to consider that Mr Zimmerman.
l) Pt: Doctor you know my work is very stressful. In fact NHS is going through lot of financial crisis. I
have to do lot of work to prevent this financial problems. I might even lose my job. I have to smoke
to relieve my stress doctor.
m) Dr: I can surely understand your problem. However, there are many other ways to relieve stress.
May be you can take some break from work and go for relaxation classes and yoga classes which
might help you to relieve from stress. Remember stress also can increase the blood pressure. What
do you say?
n) Pt: Yes doctor you are right. I will try my best to do that.
5. Dr: Do you drink alcohol Mr Zimmerman? Pt: Yes doctor. I drink about 2 glasses of wine every day
and also whisky sometimes over the weekends.

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6. Dr: Mr Zimmerman, alcohol also is not good for the health. I sincerely advise you to cut down drinking
alcohol and drink within the recommended limits that is not more than 14 units per week. We can
help you to cut down if you wish. What do you think ? PT: Yes doctor I will surely think of that.
7. Dr: Excellent. Do you have any questions? Pt: Doctor if I follow all the advices what you gave then
will I not get stroke?
o) Dr: Mr Zimmerman. There is something called as modifiable and non- modifiable risk factors for
stroke.
p) Non modifiable factors are like age above 60 years, genetic cause means inherited risk which we can’t
do anything about these.
q) However there are lot other modifiable risk factors like all the factors what we discussed so far like
diet, exercise, smoking which you can modify and have a healthy life style. This can substantially
reduce the risk of you getting stroke.
r) Also there are other risk factors like abnormal heart rhythms and narrowing of the blood vessels in
the neck which supplies blood to the brain.
s) We can check whether you have any problems like these and we can treat them if you have. All these
things will greatly reduce the risk of getting stroke. Pt: Ok Thank you very much doctor.
8. Dr: I sincerely advise you to follow all the advices. We will keep following you up. Please be aware of
the symptoms of stroke like facial weakness, arm weakness or speech problems. If you have any of
the symptoms please call the ambulance and come to the hospital immediately because these are
the symptoms of stroke. Is that Ok Mr Zimmerman? Pt : Ok doctor.
9. Dr: Any other questions ? Pt : No doctor. You have been very kind.
Dr: Thank you very much Mr Zimmerman. Once again I really appreciate that you came here today. I
wish you a very long and healthy life.

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 10. Massive stroke – Palliative care BBN
60 year old man was admitted one week ago with ischemic stroke. He had another ischemic stroke now. GCS
is only 3. MDT decided for DNAR and not to ventilate. Planned for palliative care only. You talk to the
daughter who is pregnant.

1. Assess knowledge
2. Break the news. He has a massive stroke ( there is big blood clot in the brain – so there is no blood supply to
the part of the brain. He is unconscious now. Unfortunately he will not recover. Our team has planned not to
resuscitate if his heart stops beating. Also the team has decided not to put him on breathing machine if he stops
breathing because any of these procedures o not help him.
3. Address concerns
4. Her main concern “Can you please keep him alive until my baby is born which may be next week ?”
a. First of all congratulations on your pregnancy and having a baby soon.
b. I really wish we could keep your father alive until your baby is born. But unfortunately he is in a very critical
condition now. He may not survive. And as I mentioned our team has decided not to do resuscitation if his
heart stops beating or if he stops breathing also.
5. Ask – any other concerns – Any help required.

11. TIA
69 year old lady had presented to A&E with sudden onset facial weakness, unilateral limb weakness and
slurring of speech. On evaluation, found to have BP of 150/90.
Neurological examination was completely normal. She is worried and has given consent to talk to her husband.
Talk to him, take history, discuss management and address concerns.
A.
1. Dr: Hello Mr.... my name is Dr... Are you Mrs. X's husband? H: Yes doctor..
2. Dr: How are you doing Mr...? H: I'm fine doctor.. I was told someone would come by to talk to me about
my wife.
3. Dr: That's correct Mr... I am here to talk to you about your wife. Could you please tell me what exactly
happened? H: We were at home. She was just sitting and watching TV. And all of a sudden she wasn't
able to articulate words. I noticed some change in the right side of her face and she couldn't move her right
arm as well. So I just called an ambulance within 15 minutes they arrived her and brought her to the
hospital. But after we got here, within an hour, she was perfectly fine! ( sometimes he may say symptoms
lasted 2 hours)
4. Dr: Ok Mr... You did the right thing. It's very good that you called for an ambulance immediately and brought
her here. I do have a few more questions to ask you about your wife's condition prior to this incident. Would
that be all right? H: Yes
5. Dr: Did she complain of headache? H: No Dr: Did she lose consciousness? H: No
6. Dr: Has your wife had such attacks in the past? H: No
7. Dr: Does she have any underlying medical conditions like diabetes? H: Yes ( sometimes he may say - No)
Dr: High Blood pressure ? H: No
8. Dr: Was she ever found to have high cholesterol? H: No Dr: Has she had any heart related incidents in the
past? H: No Dr: Did she had abnormal heart beats? H: No
9. Dr: Ok.. Now Mr... I have a few questions about your wife's lifestyle.
10. What is her diet generally like? H: She eats a healthy balanced diet doctor. Plenty of fruits and vegetables.
11. Dr: Ok. That is very good Mr... Does she get exercise?` H: A little.. Yes.. Moving around the house..
Gardening etc.... ( sometimes he may say we go for brisk walking every day – so does good exercises)

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12. Dr: Does she smoke? H: No Dr: Does she consume alcohol? H: No Dr: Is she on any medications?
H: No Dr: Ok. Does she have any allergies? H: No
13. Dr: Does she have any family history of heart disease? H: No Dr: F/H of stroke? H: No
B. Examination and Diagnosis:
1. Dr: Mr... as you had mentioned, your wife's symptoms resolved within an hour.. And on examination, she had
no neurological problems. From the information we have gathered, it appears that she has had what we call
a Transient Ischemic Attack (TIA) or a mini-stroke. Do you have any idea what that is? H: No
2. Dr: A TIA is a medical condition where there is a momentary decrease or loss in blood supply to the brain. This
could either be because of some narrowing of the blood vessels in the neck that supply blood to the brain...
or because of some rhythm problems in the heart. Are you following me Mr...?
3. H: Yes doctor.. Is it serious?
Dr: Mr... A TIA as such is not serious as it usually resolves by itself within 24 hours. But we need to evaluate
and find out why it happened because if it happens again, it might not be a TIA, but something more serious,
like a complete stroke. Do you follow me?
4. H: Yes doctor. What are the chances that she may get stroke doctor ?
Dr: Unfortunately the risk of she getting the stroke in the next few days itself is very high.
We need to admit her and treat her immediately to reduce the chance of she getting the stroke in the next
few days.
C. Investigations
1. Dr: We need run some tests... to find out why this happened. H: What kind of tests doctor?
2. Dr: First we will have to do a CT scan of her head... to make sure that there is no evidence of a stroke. We will
then do an ECG or a heart tracing to look for any rhythm problems. We will also do some blood tests to check
her sugar and cholesterol levels.
3. Additionally, we will have to do a scan called a Doppler... of the blood vessels of her neck to see if they are
narrowed. Are you with me Mr...? H: Yes
D. Treatment:
1. Dr: Mr... on examination, we also found that your wife's BP was on the higher side. It was 150/90. We will
have to start her on a medication to control her BP. We will also start her on Aspirin, which can help prevent
such attacks in the future. We will also ask the Neurologist to evaluate your wife. Do you have any questions
for me Mr...?
2. H: When can I take her home?
Dr: If all the investigations are all right, you can take her home within a day or two Mr... If the scan of the
blood vessels in her neck show significant narrowing, we might have to consider a surgery to correct it. We
will let you know based on the findings.
Warning signs :
1. If you do take her home Mr... I would like to inform you about the warning signs of a stroke [FAST – Facial
weakness, Arm weakness, Speech problem – Time to call the ambulance]. If you ever notice any weakness
in her face or limbs... or any slurring of her speech, please call an ambulance and bring her to the hospital
immediately as the next time, it can be even stroke. Do you have any questions for me ?
H: No doctor.. Thank you.

12. FEBRILE CONVULSION

FEBRILE CONVULSION - exam question
You are the FY 2 doctor in the Paediatric department
Mrs Julia Robert has brought her 18 months old son Ben to the hospital with complaint
of an episode of fit which lasted for few minutes today. She is worried about her son.
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On examination - his ear drum was red and had high temperature.
Take history from the mother and talk to her about the further management.
A. (much history and little examination)
1. Did this happen before? What happened before ? what happended during? What hapend after it?
2. If she uses the word fits  I use that word. If she uses Seizures  I use the word siezures
3. Hello I am Dr... one of the junior doctor in the Paediatric department. Are Mrs Julia Robert?
Mother: Yes Dr: Are you the mother of Ben ? Mother: Yes
4. Dr:How can’t help you Mrs Robert? Mother: Dr, My child had fits
5. Dr: Could you please tell me in detail, what happened before that? Mother: He was sweating before fits
and he was pale as well.
6. Dr: Can you please confirm the duration of fits? Mother: 2 min You did say that he was jerking. I know it is
very difficult to notice. But I still need to ask --> how much did it last? USually she will answer <5 min
7. Dr: Is it the first time? Mother: Yes
8. Dr:How is your child after this fit? Mother:He seems to be fine now.
9. Dr: Did he have fever before this incident ?
Mother: Yes, He had flu and his nose was running. I gave him Paracetamol. But still he was
hot before fits.
10. Dr: Did Ben have any rash? High grade fever? Was he crying while moving his neck? (meningitis) Mother: No
11. Dr: Did he have his food today as usual ? ( hypoglycaemia) ? Mother : Yes
Dr: Ben diagnosed with any medical condition like Diabetes, Epilepsy? Mother: No
Dr: Does Ben feel sick in morning? Does he have any weakness in limbs? Mother: No
Dr: Did he have any head injury recently? Mother : No
12. Dr: Is he on any medication? Mother – No Dr: How was his birth - was there any problems during birth?
Mother : No Dr: Any problems with the development? Mother – No Dr: Any one in the family has fits ?
Mother: No.
13. Dr: Mrs Roberts we have examined the child and found that one of the ear drum of your
child's is red and also his temperature is high. Mother: Ok
B.

1. Diagnosis: I think your child has a condition what we call as febrile convulsions. Do you know anything
about this? Mother : No doctor Dr: This is condition where the children get fits when they have fever.
2. Mother : Is it a dangerous condition?
Dr: The vast of majority of febrile seizures are not serious. Children usually have full recovery with no
permanent damage. Most illness which cause fever and febrile convulsions are the common coughs, colds and
viral infections which are not usually serious. However, the illness that causes the fever sometimes can be
serious- for example, pneumonia or meningitis.

3. Mother: Why my child is having fever?

Dr: I think your child is fever because he has ear infection - we need to treat the ear infection with some
medications.

4. Mother: Will this fit happen again doctor ?

Dr: Febrile Convulsion is common in children aged between 6 months and 5 years, Generally, most of the
children grow out of this condition. So usually after the age of 5 years they will not get this condition.
However until they reach 5 years old they may get this fits again if they have fever.

5. Mother: What can I do if it happens again?

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 a. Dr: First of all you should make sure that your child will not get high fever to prevent him from getting the
fits. If he has fever- keep giving him regular Calpol (paracetamol) to keep the temperature under control.
Keep your child very lightly dressed. You can also give him plenty of fluids to prevent dehydration.
b. When he has a fit
i. Lay them on his side with his face turned to on the side. (This will stop them swallowing any vomit,
and prevent chocking )
ii. Don't put anything , including medication, in your child's mouth while they are having a fit. Do not
put any hard objects into the mouth to prevent tongue bite because it can break teeth and the broken
teeth can go into the wind pipe and cause choking. It is better to have tongue bite rather than broken
teeth because tongue bite will heal on its own in few days.
iii. Stay with your child and Note the time.
iv. Usually the fit will stop in about 5 minutes. There is no need to bring your child to the hospital. You
can tell to your GP about it.
v. If it lasts longer than five minutes, (or if it's your child's first seizure) call the ambulance.
6. Mother: Is febrile convulsion a type of epilepsy?
Dr: No, the cause of a febrile convulsion is related to the feverish illness and
epilepsy is because of abnormal electrical activity in brain.
7. Mother: Will it lead into epilepsy. Dr: It is very rare that this will lead into epilepsy.
8. Mother: Will it cause learning disability? Or brain damage ? Dr: There is no research that suggests
simple febrile convulsions cause long-term problems, for example brain damage or learning difficulties

9. Mother: Will you give me some medication?

Dr: There are no medications required to treat this condition. [ parents have been to taught to give per rectal
diazepam if the fits lasts longer than 5 minutes - but this is taught to only those people who live far away from
the hospital - more than 2 hours journey] (no need to tell this to the mother in exam)

10. Mother: What will you do now?

Dr: I will examine and admit your child, we will do some tests (Blood tests and urine tests). We will keep him
for observation for some time. If all investigations are normal, then it is Febrile convulsion. Then you can
take your child home.

11. Dr: Any other concerns Mother : No Thank you very much.

13. Epilepsy
You are the FY 2 doctor in the medical department.
Mr Sandeep Singh 28 year man was diagnosed with epilepsy few weeks ago. He has come for follow up.
Take history and address his concerns.
There may be medication box written as Sodium Valproate 300 mg BD and BNF
A.
1. Dr: Hello Mr Sandeep Singh, I a Dr… one of the junior doctor in the medical department. How are you doing?
Pt: I am OK doctor.
2. Dr: I understand you were diagnosed to have epilepsy. I am sorry about it. How is your condition now?
Pt: Doctor I had fits again after that.
3. Dr: I am sorry to hear about it. When exactly was that?
Pt:Once few days ago and once about a week ago when I was in the party.
B.
1. Pt: Why did that happen doctor ?
Dr: There could be many reasons why people still have fits even after treatment. Can I ask you few questions
to see why this would have happened to you? Pt: Yes doctor.
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 a) Dr: Have been given medications for that? Pt: Yes Dr: Can I ask you which medications?
Pt: I take this doctor. (Patient may show Sodium Valproate tablets).
b) It is written 300mg twice a day here. Are you taking the same dose? Pt: Yes.
c) Dr: Let me check the book whether the dose is right for you. ( check the BNF for dose and side effects).
Mr Singh – dose seems to be right for you. Are you taking these medications regularly? Pt: Yes I am.
d) Dr: Are you taking it as prescribed by us? Pt: Yes Dr: Please tell me when do you take it? Pt:
Whenever I have fit I take it doctor.
e) Dr: Does it mean that you do not take everyday. Pt: Yes that is right?
f) Dr: Can I ask you why you are not taking it daily? Pt: I forget to take it.
g) Dr: Mr Singh, It is very important to take these medications regularly every day even when you do not have
fits. There should be certain amount of medications in your blood all the time to prevent you from getting
fits. I advise you to keep alarm to remind you to take this medications regularly. Is that OK? Pt: OK doctor
I will do that.
h) [sometimes patient may say – I was told to take the medications only when I have fits. I am sorry if that is
what was told. There could be some misunderstanding]
2. Sometimes this problem can happen if the medications are not absorbed into the system if people have vomiting
or diarrhoea. Do you have vomiting or diarrhoea ? Pt: No doctor.
3. Dr: Do you have any other medical conditions at all? Pt:No Dr: Are taking any other medications? Pt: No
4. Dr: Sometimes people can get fits if the dose is not enough or the medications do not work for them. In that
case we need to change the medications. We will see that again after sometime if you still get fits after taking
the medications regularly. Pt: Ok doctor
5. Dr: There are reasons also why people can fits like if they are exposed to some triggering factors like exposure
to too much light in cinema, watching TV for long time ?
a) Do you go to cinema or watch TV for long time? Pt: Yes doctor. Dr: I advise you to avoid them
b) Dr: Do you work on the computers for long time? Pt: I am student doctor. I have to work nearly 5 to 6
hours every day on the computer.
c) Dr: Again I advise you to avoid looking at the computer continuously for long time. It is better to take
print outs and use them.
d) Dr: Do you go to pubs where there are flashing lights ? Pt: Yes doctor Dr: I advise you to avoid that because
flashing lights can trigger fits.
6. Also sometimes lack of sleep or starving for long time also trigger fits. I advise you to sleep well and have
food at regular intervals - do not starve for long time.
7. Dr: Do you drink alcohol? Pt: Yes
8. Dr: Alcohol also can trigger fits, please avoid drinking alcohol. Pt: Ok
9. Dr: You need to be careful when you have fits. Avoid going near the fire. Who cooks food for you? Pt: I live
with few other friends. I cook food.
Dr: May be your friends cook food for you and you can do some other work for them.
Also avoid using gas cookers. Electric cookers are better. When transferring the food to plate please take the
plate to the pan and not hot pan to the plate.
10. You should be careful when taking shower. Do not take bath in bath tub instead take a shower. Pt: OK
11. Do you swim ? Pt: Yes. Dr: If you are swimming in the swimming pool or sea or river please tell the
lifeguards that you have this condition. Swimming in the river or sea is more risky than swimming in the pool.
Pt: OK
12. Dr: Do you drive ? Pt: I am about to take a practical driving test next week.
Dr: I am afraid you should not drive may be for about a year now. Please inform the DVLA about it and they
will advise you when you can start driving.
13. Please inform your friends at your college if he is a student ( or colleagues at your work place if he is working)
that you have this condition and let them know how to help you. Please wear your bracelet all the time.
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14. Dr: Any other concerns? Pt: No doctor. Dr: Thank you very much. Hope you will not have the fit again.
15. If the patient is a young lady – ask about Contraception
[sodium valproate does not affect the combined pills - so she can continue. Carbamazepine reduces the effects
of combined pill so they should increase the dose 9double the dose) of oestrogen in the combined pill and also
use other forms of contraception.]

14. Newly diagnosed Epilepsy in child

Exam question
You are the FY 2 doctor in medical department.
12 year girl Anna had a fit for the second time and was diagnosed with Epilepsy. She was treated with
medications by the Paediatric Neurologist. She is about to be discharged.
Talk to her mother and address her concerns.
A.
1. Dr: Hello I am Dr… one of the junior doctor in the department. Are you Anna’s mother? Mother: Yes
2. Dr: How are you doing? Mother: I am Ok.
3. D: I am one of the junior doctor looking after your daughter Anna. I am here to talk to you about her. Is that
Ok? Mother: Yes.
4. Dr: I understand that Anna had a fit and was brought into the hospital. Can you please tell me bit more about
the fit? Mother: She had a fit. Her whole body was jerking.
5. Dr: Did she have fit like this before? Mother : Yes she had a fit few months ago.
6. Dr: Is this the second time she had a fit? Mother : That is right.
7. Dr; Was she diagnosed with any medical condition at all before this? Mother: No
8. DR: Does she has Diabetes ? No Dr: Did she have any headache or rashes on her body when she had fits ? No
Dr: Did she have fever when she had Fits ? No
9. Dr: Any of her family members had fits like this at all? Mother : No
10. Dr: Do you have any idea why Anna had that fit Mrs.. ? Mother : No / Yes
11. Dr: If she say no - Unfortunately it is not a good news. Do you want to know about it? Mother: Yes
12. Dr: Mrs… Our Paediatric Neurologist has seen her. We have done some tests on her and unfortunately she has
a condition called Epilepsy. Do you know anything about it ? Mother: No doctor.
B. Diagnosis:
1. Dr: I will explain everything to you. Epilepsy is a condition that affects the brain and causes repeated fits. It is
due to abnormal electrical activity in the brain. Sometimes there is no reason why this condition happens
although sometimes it could be an inherited condition.
2. Mother: Is it a serious condition ?
Dr: Unfortunately it is a serious condition because even if we treat she can have fits like this again for a long
time may be even for years.
3. Mother: What are you going to do now ?
a. Dr: Our specialist doctor has decided the treat her with some medications.
b.She has to take this mediations which are tablets regularly every day without forgetting.
c. It is important that she takes this medicines even when she does not have fits because there should be certain
amount of medicine in her blood all the time to prevent hr having fit. [ check whether the medication on the
table.
d.If there is medicine check the BNF for the dose and side effects] Mother: Ok
e. Dr: If she is going to take any medications she should tell her GP about it because other medications can
interact with the epilepsy medications. Mother : Ok
f. Dr: We will keep monitoring her. As she grows older we may need to increase the dose of her medication. If
she has diarrhoea and vomiting then the medications may not be absorbing into her system, in that case you
need to inform the GP.
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4. Dr: There are several factors which can trigger these fits like exposure to too much light in cinema, watching
TV for long time.
a. Does she happen go to cinema or watch TV for long time? Mother: Yes
b.Dr: It is better for her to avoid watching cinema or watching TV for long time.
c. Dr: Does she work on the computers for long time or does she play computer games?
Mother: Yes she does. Dr: Again I advise you to tell her to avoid looking at the computer continuously for
long time.
d.Dr: It’s better for her to avoid places with bright flashing lights like clubs because flashing lights can trigger
fits. Mother: OK
e. Dr: Also sometimes lack of sleep or starving for long time also trigger fits. Please tell her to sleep well and have
food at regular intervals – she should not starve for long time.
5. Dr: She should be careful when taking shower. It is better for her not take bath in bath tub instead she should
take a shower because if at all she has fit while taking bath in bath tub it can be dangerous to her. Mother:
OK
6. Dr: Does she swim ? Mother: Yes she loves to swim.
Dr: If she is swimming in the swimming pool or sea or river she should tell the lifeguards that she has this
condition. Swimming in the river or sea is more risky than swimming in the pool.
7. Mother: Can she dance doctor? She loves to dance.
Dr: She can certainly dance. But she should avoid dancing in the clubs where there are flashing lights. Also
someone should be there while she dances who knows her condition and what to do is she has the fits when she
dances. Mother : OK
8. Dr: She should not go near to the fire. If there is gas cooker at home it may be better to change to electric cooker
and it is better for her to avoid cooking.
9. Dr: In the future she may not be able to drive if she still has fits. You can take advise from the DVLA at that
time. Mother : OK
10. Dr: Please inform her school and friends about her condition and let them know how to help her. Please make
sure she wears her epilepsy bracelet all the time. Any other concerns ? Mother : What to do if she has a fit
?
Dr: When she has a fit
 Lay her on her side with her face turned to on the side. (This will stop them swallowing any vomit, and
prevent choking )
 Don’t put anything, including medication, in your her mouth while she is having a fit.
 Do not put any hard objects into the mouth to prevent tongue bite because it can break teeth and the broken
teeth can go into the wind pipe and cause choking.
 It is better to have tongue bite rather than broken teeth because tongue bite will heal on its own in few days.
 Stay with her. If it lasts longer than five minutes call the ambulance.
11. Mother: Ok. Dr : Any other concerns ? Mother : No. Thank you.

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 X. Urinary system

1. Ureteric calculus
Question :45 year old man presented to the hospital with abdominal pain. Take history and discuss the
management with the patient.

A. Offer pain killer.

B. Differentials of left sided abdominal pain:
1. Kidney or ureteric stone – loin groin pain, hematuria. Previous Hx of kidney stone. R/o UTI and Pyelonephritis
– Fever, burning sensation, increased frequency, smelly urine.
2. Diverticulitis – Diarrhoea, pain relieved on defecation.
3. Pancreatitis – pain from front to back. Alcohol.
4. Bowel cancer – change in bowel habit, weight loss.
5. Dissection of abdominal aortic aneurysm- did you ever had any scans of your tummy and was told that you
have abnormal blood vessels in your tummy.
C.
1. In the Hx include risk factors
2. In problem in kidney before ( stones, horseshoe kidney)
3. Any parathyroid gland problem ( bone pains, pathological fractures – fractures without trauma)
4. Any high blood pressure, Hx gout,
5. Family Hx of any kidney problems
6. Medications?
7. Any vomiting ? Are you able to drink? Are you able to pass urine?
D. I need to examine your tummy. (No response from the examiner)

Diagnosis: Mr… I think you have a stone in the ureter. Ureter is a tube which drains urine from the kidney to the
urine bladder.

Investigations: We need to do some tests like CT scan of your tummy area to confirm that. Also we need to test
your urine to check whether it shows any blood and any infection markers( examiner says – urine test shows
blood). We need the check your blood to check how your kidneys are functioning and also check some chemicals
like for calcium, phosphate and other things.
Treatment: If the tests confirm that it is stone we treat it. We have various options to treat it.

1. Sometimes this stone will pass out on its own if it is very small.
2. We will give you very good pain killer medication what we call as Diclofenac as a suppository through your
back passage.
3. If your pain is relieved and you are able to eat and drink and able to pass urine then you can go home. Drink
plenty of water and the stone may pass out on its own. If possible, you should pass urine into a container or
through a tea strainer or gauze to catch any identifiable calculus. We will give you an appointment for follow
up within a week.
4. However, if your pain is not relieved and if you keep vomiting continuously or if the scan shows some
abnormality in the kidney then we will keep you in the hospital and treat you.
5. We can give you some fluids through your veins or medications( tamsulosin or nifedipine) which will help to
flush out the stone in the urine.
6. If that does not work then we have something what we call as shock wave treatment where break the stone
into smaller pieces by giving some type of shock and then it will flush out easily.

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7. If these things do not work then either we can do a key hole surgery and remove it or rarely we may have to
do open operation to remove it.
8. If we get the stone we will send it to the lab for further analysis. Depending on the composition of the stone
we may give medication to prevent further stone formation. [eg, thiazide diuretics (for calcium
stones), allopurinol (for uric acid stones) and calcium citrate (for oxalate stones).
E. This condition can happen again. To prevent stones in the future
2. Drink plenty of fluid.
3. Reduce salt intake.
4. Reduce the amount of meat and animal protein eaten.
5. Reduce oxalate intake (foods rich in oxalate include chocolate, rhubarb, nuts) and urate-rich foods (eg, offal
and certain fish).
6. Drink regular cranberry juice: increases citrate excretion and reduces oxalate and phosphate excretion. Do
you follow me? Any concerns? Thank you.

2. UTI and BPH

Question :
Mr Mike Atherton, 75 years old man, came to the Surgery department with complaint of fever and lower
abdominal pain for the last 3 days.
You are the SHO in the Surgery department. Take a brief history for the patient and talk to him about the
further management and address his concerns.
A.
1. Dr: Hello Mr ……. I am Dr … junior doctor in the Urology department. How are you doing? Pt:I am OK.
2. Dr: How can I help you? Pt: Doctor I am having burning sensation when I pass urine.

B.

3. Dr: Can you tell me anything more about it ? Pt: Yes doctor it is happening since 3 days now.
4. Dr: Do you have fever? Pt: Yes since last 3days
5. Dr: What is the colour? Pt: Dark and cloudy it smells bad doctor Dr: Did you notice blood in the urine? Pt:No
6. Dr: Any pain intummy? Pt: yes my lower tummy Dr: Do you have pain in the loin area (Peylonephritis)? Pt:
No Dr: Did you have this problem before? Pt:No
7. Dr: Do you pass more times than usual? Pt:Yes doctor Dr: Do you have to get up in the night to go to loo? Pt:
Yes since few months Dr: Any dribbling? – Pt: Yes Is it poor stream? Pt:yes
8. Dr: Do you have any back pain (secondaries in the vertebra) ?- Pt:No Dr: Have you noticed any weight
loss(cancer)? - Pt: No Dr: Any problem opening bowel ? Pt: No
9. Dr: Do you have anymedical conditions? Pt: No Dr: Did you have any kidney stones before? Pt:No
10. Dr: Are you taking any medications? Pt:No Dr: Are you allergic to any medications ? Pt:Yes to Penicillin
11. Dr: Do you have any one to look after you ? on my own. Pt:yes, I live with my wife/ I live

C. Examination:
1. Dr: Mr Edwards I need to examine your tummy and back passage to see why this may be happening?
Examiner says – There is some tenderness in the supra pubic area and prostate is enlarged and smooth
surface.
D. Diagnosis:

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1. Dr: Mr Edwards I think you have a condition called as Urinary tract infection basically this this is infection in
the urine means there are some bugs in the urine.
2. Pt: Why do I have this infection doctor?
Dr: Sometimes bugs comes from the back passage. They get into the urine through the urethra (opening of
the urine passage). In your case there is one other problem which may be causing this infection.
3. Pt: What is that doctor?
Dr: While examining your back passage I noticed that one glad called prostate gland which is the base of the
urine bladder is enlarged. When this glad is enlarged it narrows the urine passage so the urine does not flow
out properly. Urine gets accumulated in the urine bladder and the bugs grows very easily in such situations.
Sometimes this condition causes recurrent urine infections.
4. Pt: What are you going to do for me doctor?

E. Investigations for UTI:

1. Dr: We need to confirm whether you have urine infection - for that we need to test your urine for bugs and
send it to the lab to see what type of bugs may be causing this infection?
Examiner shows a paper - Urine dipstick shows – nitrites and leucocytes and pus cells.
F.
1. Dr: Mr Edwards your urine tests does show that you have urine infection. We will treat you with antibiotic
medication. Since you said you are allergic to Penicillin we will give you some other type of antibiotics which
are called Trimethoprim (200mg twice a day for about a week) which are good for this kind of infection.
2. We will keep you in the hospitals to treat your urine infection. You can also take some Paracetamol tablets
for the pain and fever and drink plenty of fluids.
G. Investigations for Prostate gland:
1. Also we need to do some test to check your prostate gland to see what type of growth it is whether it is
cancerous type or non cancerous. It looks like non cancerous on examination. We need to do scans on the
gland and also we may take some tissue samples from that. We will also do some blood test specific for
Prostate gland.
H.
1. We will treat the gland according to the test result either with medications –
One of them shrinks the prostate gland (5 a – reductase inhibitor –Fenestaride) and the other relaxes the
water bag / bladder (its neck) alpha blockers –tamsulosin).
2. Pt: What if the medications don’t work ?
Dr: We may also consider doing a procedure ( TURP) where we pass some instruments through the urethra
and widen the urine passage or we may do an operation to remove the prostate gland.
3. Pt: Will I get this infection again.?
Dr: If the prostate gland has been treated then you may not get the infection again and again.
4. Dr: Any other concerns Pt: No doctor. Dr: Thank you very much.
5. If the patient lives with his wife –
a. There is no need to be admitted to the hospital for this you can take this medications at home. It may
take up to a week to clear this infection.
b. However if you become very unwell or if you becoming confused you need to come back to the
hospital. Please tell this to your wife.

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 3. UTI in Female.
Young lady presented with lower abdominal pain. Take history and discuss further management with
her and also write up a prescription.
A.
1. Dr: Hello I am Dr … one of the junior doctors in the department, Are you Ms ? Pt: Yes
2. Dr: How are you doing Ms…..Pt: I am OK.
3. Dr: How can I help you? Pt: Doctor I am having burning sensation when I pass urine.
4. Dr: Can you tell me anything more about it? Pt: Yes doctor it is happening since …. days now.
5. Dr: Do you have fever ?Pt: Yes/No since last …. Days
6. Dr: What is the colour of urine? – Pt: Dark and cloudy it smells bad doctor
7. Dr: Did you notice blood in the urine ?Pt: Yes/ No
8. Dr: Any pain in tummy ?Pt: yes/no (SOCRATES for pain if Yes)
9. Dr: Do you have pain in the loin area ( Pyelonephritis) ? Pt: No
10. Dr: Do you feel the need to pass urine despite having just done so (strangury)? Yes/No
11. Dr: Did you have this problem before ?Pt: Yes/ No
12. Dr: Do you pass urine more times than usual ?Pt: Yes doctor
13. Dr: Do you have any nausea or vomiting? Pt: Yes/No ( if unable to keep food down consider admission)
14. Dr: Do you have any back pain (upper UTI) ? - Pt: No
15. Dr: Do you have any discharge from your front passage ?Pt : No
16. Dr: Have you noticed any weight loss( cancer)? - Pt: Yes / No
17. Dr: Any problem opening bowel? Pt: Yes / No
18. Dr: Do you have similar problems in the past ?Pt: Yes/No (repeated UTI)
19. Dr: Do you have any medical conditions? Pt: Yes / No
20. Dr: do you have high blood sugar? Pt: Yes/No ( diabetes also risk factor)
21. Dr: Have you had any surgeries in the past? Related to urinary passage? Pt : Yes No
22. Dr: Did you have any kidney stones before ?Pt: Yes/ No
23. Dr: when was your Last menstrual period? Pt: … (ask to rule out pregnancy in young, menopause in old as
menopause causes increase risk for UTI)
24. Dr: Are you married or do you have any partner ?Pt: I am married.
25. Dr: Do you use any sort of contraception ? Pt: No I am trying to get pregnant. (spermicide causes increase
risk of UTI)
26. Dr: Are you taking any medications ? Pt: I am taking Folic acid because I am trying to get pregnant.
27. Dr: Have been told that you have Folate deficiency ?Pt : ….
28. Dr: Does your husband has any urinary symptoms or discharge from his penis do you know? Pt : No
29. Dr: Are you allergic to any medications ?Pt: Yes/No
B. Examination:
1. Dr: Miss …. I need to examine your tummy
Examiner may say – There is some tenderness supra pubic area
C. Diagnosis:
1. Dr: Miss …. I think you have a condition called as Urinary tract infection basically this is infection in the
urine means there are some bugs in the urine.
2. Pt: Why do I have this infection doctor?
Dr: Sometimes bugs comes from the back passage. They get into the urine through the urethra (opening of the
urine passage) or vagina.
3. Pt: What are you going to do for me doctor?
D. Investigations for UTI:

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1. Dr: We can do to test your urine called dipstick and then send it to the lab to see what type of bugs may be
causing this infection.
(Examiner may or may not show the test results. If he does explain the result if not continue to
management)
2. Dr: If the test shows that you have urine infection we will give you some antibiotic medications to treat this.
E.
1. Dr: Let me write the prescription for you.
2. Write the prescription on the paper provided. Use the BNF.
 Write the full name in the prescription note
 USE THE BNF - to write the dose
3. I will give you an antibiotic medication called Nitrofurantoin.
4. Dr: Are you allergic to this at all? Pt: No Dr: Have you taken this before ? No
5. Dr : Do you have any kidney disease ( should not be given in kidney disease) Pt : No

Title Forename Surname DOB

Tab. Nitrofurantoin 50mg QDS ( 4 times/ day) for 3 days.

Sign and write your name.

212
6. This is a 50 mg tablet you need to take one tablet 4 times in a day with food for the next 3 days. Hopefully your
symptoms will subside in the next 2 to 3 days.
7. Like any medication. this also can give some side effects like
 Headache, dizziness;
 Upset stomach;
 Mild diarrhoea; or
 Vaginal itching or discharge.
8. They usually subside after you finish the course but if it causes you problem then please call your GP and take
advise.
F.
Do
 Wipe from front to back when you go to the toilet
 Try to fully empty your bladder when you go for a pee
 Drink plenty of fluids
 Take showers instead of baths
 Wear loose, cotton underwear
 Pee as soon as possible after sex
Don’t
 Use perfumed bubble bath, soap or talcum powder
 Hold your pee in if you feel the urge to go
 Wear tight, synthetic underwear, such as nylon
 Wear tight jeans or trousers
 Use condoms or diaphragms with spermicidal lube on them - try non-spermicidal lube or a different type
of contraception
G. Warning signs.
1. However if the symptoms do not subside by the next 3 days if your fever gets worse, if you start having loin
pain, you are feeling very unwell and getting too tired please do come back. Pt: okay
2. Dr. Also you can take pain killer medications like Paracetamol for your pain. Pt: yes
3. Dr: Any other concerns Pt: No doctor. Dr: Thank you very much.

4. Heamaturia
Exam question
You are the FY2 doctor in the Urology department.
Middle age man presented to the hospital with the history of passing blood in the urine.
Take relevant history and discuss the further management with the patient.
B.
1. Dr: Hello Mr … I am Dr…. One of the junior doctor in the urology department. How can I help you ? Pt:
Doctor I am passing blood in the urine.
2. Dr: Can you tell me anything more aboutit? Pt: Likewhat? Dr: Since when did you noticethis? Pt: Since last
fewdays.
3. Dr: Is the bleeding at the beginning of urinating ( urethra or prostate) or at the end of urinating ( bladder or
prostate) or throughout ( bladder, kidney ureter) ? Pt: It is throughout.
4. Dr: Do you have any pain while passing urine (UTI)? Pt:No
5. Dr: Do you have fever (UTI)? Pt:No Dr : Increased frequency orurination? Pt : No/ Yes
6. Dr: When you pass urine does it flow properly or does it dribble ( Prostate symptoms) ? Pt: No/ Yes there is
dribbling.
7. Dr: Do you have to run to the loo when you get the sensation of passing urine (prostatism) Pt : Yes/ No

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8. Dr: Did you have any injury to the penis or totummy? Pt:No Dr : Did you ever had any kidney stones
before ? Pt :No
9. Dr: Did you have any kidney problems before (polycystickidney) ? Pt:NoDr: Any pain going from loin to
groin at all ( ureteric stone)? Pt :No
10. Dr: Any pain in your loin area ( renalcancer)? Pt:No Dr: Any mass in the loin area (renalcancer)? Pt:No Dr:
Have you noticed any change in your weight (Cancer)? PT: No / Yes ( how much in how much time?)
11. Dr : Do you cough (TB)? Pt:No Dr: Night sweats (TB)? Pt:No Dr:Do you smoke? Pt : Yes ( How many and
how long ?)
12. Dr : Have done any strenuous exercise recently ? Pt : No
13. Dr: Do you have any pain at the back ( secondary in the vertebra – primary in the kidney or prostate) ? Pt :
No
14. Dr: Any procedures or operations done recently on kidney, urine bladder or urethra ( front passage) ? Pt :
No
15. Dr: Do you have any bleeding disorders? Pt:No Dr: Did you have this problem before? Pt:No
16. Dr: Are you taking any kind of medication –blood thinners? Pt:No Dr: Are you allergic to any medications?
Pt : Yes .Penicillin.
17. Dr: Have you travelled to other countries recently (schistosomiasis)? Pt:No
C. Examination:
Mr… I need to examine your tummy and back passage to check the prostate gland.
[ Examiner may say prostate is enlarged and smooth and no other abnormal findings ]
D. Diagnosis :
1. Mr… While examining I found that your prostate gland ( a gland which is present at the base of the urine
bladder) is enlarged.
2. However Mr .. There is a possibility that you may be having some growth in the urine bladder causing this
problem. We need to do further tests to find out what exactly is causing the bleeding from the urethra. ( If
you are the FY 2 doctor in the Urology mention talking to seniors about the further investigations and
treatment, if you not in the Urology department – then mention referral to Urologists specialists in Kidney
and urine excreting organs for further investigations and treatment).
3. Pt: Do I have cancer doctor?
Dr: At the moment we cannot say anything. However there are many other reasons for the bleeding like this.
Specialist will tell you once they get all the investigation result. Pt : Ok
E. Investigations:
4. Mr… We will have to test your urine first to check for the blood or other things (protein) which may show any
problem in the kidney. We need to do investigations like cystoscopy to check inside the urine bladder. In this
procedure we pass a tube with the camera attached to that through the urethra ( front passage ) into the
urine bladder and we have a look inside the bladder and take any tissue samples if there is any growth there
and test that in the lab.
5. Also we may need to test the prostate gland to see what type of growth it is whether it is cancerous or non -
cancerous. We will have to do ultrasound scan and do some blood test specific for the prostate gland.
6. Also we need to do CT scan of the lower tummy area to check whether the cancer has spread if at all it is
cancer. Do you follow me? Pt : Yes doctor
F. Treatment:
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1. Dr: Depending on the test result we will treat you. If at it is bladder cancer, depending on whether it is spread
or not we will treat either by doing surgery – if possible we may remove just the growth or we may need to
remove the whole urine bladder and create an artificial urine bladder.
2. We may also need to treat with chemotherapy and radiotherapy.
3. If at all it is cancer of the prostate - again depending on the result we will treat either by surgery or
chemotherapy or radiotherapy.
4. Are you following me? Is that OK? Pt : Ok doctor. Thank you very much.

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 5. Lady with unexplained haematuria. Talk to relative.
Mrs Zainab ... was treated for heart failure after she had suffered with heart attack. Now she developed
haematuria while she was treated for heart failure. All investigations done to find the cause for haematuria
but no cause was found.
Her relative MrSanjay ... wants to talk to you. Talk to him and address his concerns.
A.
1. Dr: Hello Mr Sanjay … I am Dr…. How are you doing?
Relative: I am fine. I want to know what is happening to my mother ( Aunt).
2. Dr: Surely, I will tell you everything. Before I tell you about her, can you please tell me how much you know
about her so that I can explain better about her ?
Relative: I know that she has chest infection.
3. Dr: May I know how did you know about it ?
Relative: I know she has swelling of her feet and she is short of breath.
4. Dr: Mr Sanjay. She hasn’t got chest infection. In fact she has heart failure. Do you know anything about this ?
Relative: I know that she had heart failure. I was told that she has blood in her urine now. Is that true
doctor? Dr: That is true Mr Sanjay …
5. Relative: So why has she got the blood in the urine?
Dr: Mr Sanjay .. There are any reasons why one could have bleeding in the urine. For example one of the reason
is that it can happen after we insert urine catheter to drain the urine,
6. Relative: But she had the catheter 10 days ago. I was told that bleeding will stop in few days if it is due
to the catheter. Why does she have the bleeding even now?
a. Dr: You are right Mr Sanjay .. If the bleeding is due to catheterisation usually it will stop in few days.
However, sometimes it can last longer period if there is any other medical causes contributing to that. We
are doing investigations to find the exact cause of her bleeding.
b. Also there are many other reasons why the patient can have bleeding in the urine for example - if the patient
is taking any blood thinner medication or if they have any bleeding disorder. Sometimes if there is any
other medical conditions affecting kidney or urine tract also there could be bleeding in the urine.
c. We have looked into almost all the reasons but unfortunately so far we could not find the actual reason for
her bleeding.
7. Relative: You have been doing investigations for such a long time and still you do not know why she is
having bleeding. You doctors are very careless.
Dr: I am very sorry if you feel that way. I can imagine why you are so upset. But Mr…We do care for all the
patients. I can reassure that we are doing our best to find the cause. Hopefully we will know the cause soon and
we will be able to treat her soon.
8. Relative: You have been telling this for so many days. No one is telling me what is happening here.
Yesterday I called the nurse asking about my mother but the nurse told me she has many patients here
and she has no time to talk to the relatives.
Dr: I am really sorry if that has happened Mr Sanjay. Sometimes the nurses can’t give the patient’s information
over the phone to others because we are supposed to keep the patient information confidential. We have to be
sure about whom we are speaking to and also we need to make sure that we have patient’s consent to talk to
the relative about them before we can speak to the relatives about the patient over the phone. It could have been
for any of these reasons. However, if they had consent to talk to you and they were sure of whom they were
talking then they should have explained everything to you however busy they are. I do apologize for the

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 incident. I will certainly inform my seniors about it. I am sure they will enquire about this matter and appropriate
action will be taken.
9. Pt: Also, I came yesterday and asked a doctor, he said he does not know why she has bleeding. He told
me to come today and talk to you. You also do not know why she is bleeding. Is this how you take care of
her ?
Dr: I am really sorry to hear that. May be the doctor whom you spoke yesterday was not the one looking after
Mrs Zainab … Probably that is why he would have told you to come and speak to us today.
10. Relative: Are you the one looking after my mother/ Aunt ?
Dr: Yes, I am one of the team of doctor looking after Mrs Zainab …
11. Relative: How come you also do not know why she is having this bleeding ?
Dr: Mr… I can see that you are very caring son/ Nephew. I really appreciate your concerns for her. As I told
you we are doing our best to find the cause and hopefully we will be able to treat her soon.
12. Relative: I want to speak to your Consultant. Dr: Mr Sanjay … Surely you can speak to my Consultant. He
can explain to you everything in detail to you.
13. Relative: Is he also going to say the same thing that he also does not know why she is having bleeding?
Dr: Mr… I am afraid he too will say that we do not know the cause of the bleeding at the moment.
However, he may be able to answer you better if you have any other concerns about her.
14. Relative: What is the point of talking to him then? No one knows what is happening to her. No one tells
me what and why these things are happening to her.
Dr: Mr… I am very sorry if it is not informed you in time. I will make sure that we will keep you informed
about her condition at all the time.
Once again I am very glad that you came all the way up to here to talk to me about you mother/ Aunt. It shows
me how much caring son you are. I really appreciate that. We will give her the best possible care. I am sure she
will recover soon from all her problems. Thank you very much for talking to me.
15. Relative: I want to complain about this.
Dr: Mr Sanjay … Surely you can put a formal complaint if you are not happy with the care given to her. We
have a dedicated department what we call as PALS they can help you with this. I am sure all the necessary steps
will be taken to make sure that she is taken care of properly. Anything else I can help you with Mr… Relative:
Nothing else. Dr: Thank you Mr…

6. Elderly man with UTI – now presented with septic shock

Exam question: Elderly man was treated for UTI 3 days ago with Trimethoprim. Culture has shown Ecoli
sensitive to Trimethoprim. His wife brought him back today. Talk to her. Husband and wife both are inside
the cubicle.

A.
1. Talk to husband first – How are you – he is confused may say where am I ? who am I?
2. Then talk to his wife.
3. Ask details.
4. She may give the story of having fever, burning sensation of urine 3 days ago. Now he is confused,
vomiting and has blood in the urine.
5. Did he complain of severe pain in tummy ? Any loin pain? Loin to groin pain ( ureteric calculus)
6. Ask about whether he was taking the antibiotics regularly or not?
7. Any other medical conditions ? Any Diabetes? Any other medical conditions ( lowering body immunity) ?
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8. Was he having increased frequency ( getting up to go to loo in the night) poor stream, dribbling of urine
before ?
9. Any problems in the kidneys before and any kidney stones before ?
10. Any other medications ?
11. Any allergy?
B.
2. Check news chart Pulse – very high, BP - ?90/60. Temperature 38.5
3. I need to examiner his chest, tummy and back passage for prostate enlargement.
4. Examiner may or may not give findings.
C.
Mrs .. He has a condition what we call septic shock this is due the bugs which was in the urine has entered the
blood and caused blood poisoning. This is a very serious condition if we do not treat him immediately.
D.
We need to do some investigations to confirm it though like blood and urine tests to check for bugs and other
infection markers.
E.
We will have to admit him and give him very strong antibiotic medications through his veins. Also we need to
give him oxygen and give him fluids through his veins. We will keep him in the intensive therapy unit to treat
him now. I will inform my seniors immediately.
Any other concerns?

7. SIMMAN- POST-TURP INFECTION

Scenario- 80 year old man was brought in by wife, and he is feeling sick. Talk to him and address his concerns.
(Inside the cubicle, you may find a Simman in a hospital robe and connected to the monitors. Monitor reading- ECG-
Normal, Pulse- 100/mt(tachycardia), Blood Pressure- 100/70 mm hg, SPO2-97%, Temperature- 37 degree Celsius).
S=Simman D= Doctor

A.

D- “Hello, I am Dr.------, one of the junior doctors in the department.” How can I help you?
S- “Dr., I am feeling sick”
D- “Do not worry, I am here to help you. Could you tell me more about it?”
S- “I am feeling very tired. I haven’t peed for a day and it is quite uncomfortable.
D- “I am really sorry to hear about that. Is it alright if I can ask a few questions to know more about your
condition?” S “Yes”
D- “Did you have tummy pain?
Did you vomit?
Did you have fever? – I felt feverish
Were you able to pee well before this? No
Did you have to get up in the night many times to go to the loo? Yes
Dribbling? Pain while passing urine? - Yes there was dribbling.
Bowel movement-loose stools/constipation?

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D- Any back pain ? weight loss ( for cancer prostate?) - No
D – Any kidney stone before ? No
D- Any medical conditions ? No
D- Are you on any medications ? No
D- Are you allergic to anything ? No
D - Have you had any operations done on your tummy ?
S - Yes, Dr. I was operated for TURP 4 days ago”
D- Did you have any problems after the operation ?
B. Examination :
D- “I would like to examine you and will ensure privacy and chaperone. I would like to examine your chest and
tummy. S- doctor you do it.
(Remove the hospital robe as well as the shorts underneath.
Urine catheter attached to urine bag may show yellowish turbid urine with pus collection. No blood )
Examiner may say- chest is normal. Abdomen is normal except for suprapubic tenderness.
Cover the patient after examination.
C.
Talk to the examiner:
E- “Dr, what do you think this is?”
D- “I think this is urinary tract infection- probably after TURP. One of the most common complication after TURP
is infection.”
E - Alright, what would you like to do now ?
D-“I would like to take sample from the catheter bag- test for culture and sensitivity. I would also like to test for
urea and electrolytes as well as the FBC, blood culture and blood gases.
Examiner may show ABG
ABG shows metabolic acidosis. Ph - low, Low HCO3, Low or normal CO2.
D.
E – How do you manage ?
“I would like to involve my seniors. I will give him broad spectrum antibiotics according to the hospital protocol. I
would like to do a USG (both prostate and abdomen) as well as CXR
E- “Ok”
-------------------------------------------------------------------------------------------------------------
(Different scenario- Simman presents with enlarged prostate and did not pass urine since 2 days. He was
catheterised. He is posted for surgery 6 months later)
Similar to above except the operation was planned later.

XI. Eye and Ear

1. Diabetic Retinopathy
Exam question
You are the FY2 doctor in the GP clinic.
33 year old man was referred by Optometrist for early diabetic retinopathy. Talk to him and address his
concerns.
A.
1. Dr: Hello Mr…. I am Dr.How are you doing?

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 Pt: Doctor, I went to the Optometrist and she said I have diabetes in my eyes. She has given this letter to
you. Doctor will I lose my vision ?
2. Dr: Let me have a look at the letter. [ Letter says – early diabetic changes seen in the eye]
Mr…. Yes, the letter does say you have diabetic changes in your eye. However to say whether you lose vision
or not I need to ask you few questions and examine you. We may be able to reduce the chances of you becoming
blind even if diabetes has affected your eyes.
3. Can you please tell me why did you go to the Optometrist?
Pt: Doctor, I am a painter. I can’t see small things when I paint. That is why I went to the Optometrist.
4. Dr: I am sorry to hear the problem. Can I ask you since when are you having this problem? Pt: Since the last
few weeks doctor.
5. Dr: Do you have Diabetes? Pt:Yes doctor. Dr: Since when are you having diabetes? Pt: Since
many years.
6. Dr: Are you on medications for that? Pt: No, I was told to control it by diet. Dr: Do you keep checking your
sugar? Pt: Not very often.
7. Dr: Is it controlled well? Pt: Not really doctor.
8. Dr: Do you visit your GP here regularly for your diabetes? Pt: No.
9. Dr: You said you can’t see small things. Do you think it is one eye problem or both eyes? Pt: Both the eyes.
10. Dr: OK. Do you have any other problem in your vision ?Pt: No.
11. Dr: Do you see anything floating in your vision area ( floaters)? Pt: No
12. Dr: Any pain in the eye? Pt: No Dr: Anydouble vision? Pt:No
B.
1. Dr: I need to examine your eyes. [ examiner may say – it shows early diabetic retinopathy. Some examiners
may not say anything ]
2. Dr: Mr. as per the information what you have given me and the Optometrist letter probably you have a condition
called Diabetic Retinopathy. This means diabetes has affected your eyes.
3. If the blood sugar is very high, it causes the blood vessels which supplies blood to the back of the eye called
retina gets bulged out and it can start leaking blood.
4. Sometimes new tiny blood vessels get formed at the retina which easily gets damaged and starts bleeding. This
is called Diabetic retinopathy. This can cause vision problem. If the condition continues then it can cause loss
of vision. Are you following me Mr… ?
5. Pt: Yes, I can understand what you are saying, but I don’t want to lose my vision doctor.
Dr: I can understand how you are feeling. We can definitely try to help you so that the risk of losing vision will
be reduced.
a. This condition is mainly caused by high blood sugar and also there are other risk factors like high blood
pressure, high bad fat content in the body and smoking which can contribute to this problem.
b.If you control the blood sugar properly and also reducing other risk factors if there are any then the chances of
you losing vision will be greatly reduced.
6. I need to ask few questions to see why your blood sugar is not controlled well. Pt: OK doctor.
a.Dr: How is your diet? Do you eat healthy diet? Pt: Not really doctor. I eat fast food. (burger and chips)
b. Dr: Mr… It is very important to eat healthy balanced diet to keep your sugar under control. You should reduce
eating food with high sugar content and fat content. So you should reduce eating fast foods like burger and
chips – they have high bad fat content. Eat more of white meat like chicken and fish and also lots of fruits
and vegetables. This will help to keep the sugar under control. I can refer you to a dietician who can advise
in detail about it. What do you say Mr..Pt: Yes, surely I will consider that doctor.

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 c. Dr: Excellent. Do you do exercise at all?Pt: No doctor. Dr: I suggest you to do good exercise. That will reduce
the bad fat in your body. Pt: Ok doctor.
d.Dr: Do you smoke Mr…?Pt: Yes doctor. Dr: What do you smoke and how much do you smoke?
Pt: I smoke 10 to 15 cigarettes per day for many years now.
Dr: As I mentioned earlier this also can contribute to damage to the eye. I strongly advise you to stop smoking.
If you need we can help you to stop smoking. Would you like to consider that Mr… ? Pt: Yes doctor.
I will try my best.
e. Dr: Good. Do you have high blood pressure do you know ? Pt: I don’t know doctor.
Dr: We will check that and if you have it we will treat that also because high blood pressure also can contribute
to the eye damage. Pt: Ok.
f. Dr: We will also start you on some medications for your diabetes. I will talk to my seniors about it and let you
know.All these things what we discussed now will help to keep the sugar under control. Pt : OK doctor.
g.Dr: We will refer you to the Ophthalmologist ( eye specialist doctor). They will advise further about it. You
may need keep visiting them more frequently.
7. Do you have any questions?
8. Pt: How are you going to treat my condition doctor ?
a. Dr: Usually in early stages of Diabetic retinopathy - it does not require any treatment. Controlling sugar will
delay the condition getting worse. Whatever damages has already happened cannot be reversedunfortunately.
b.However if it gets worse means in advances stages of this condition we can treat it in many ways like Laser
treatment where we pass laser to the back of the eye that is retina and burn the new blood vessels which are
formed there and also seal the leaking blood vessels.
c. This will reduce it getting worse. Sometimes we may have to inject some type medications {( anti-VEGF -
ranibizumab (Lucentis) and aflibercept (Eylea)}to the back of the eye to prevent new blood vessels forming
there.
d.Very rarely we may do some surgery (Vitreoretinal surgery ) to remove some of the vitreous humour from the
eye. This is the transparent, jelly-like substance that fills the space behind the lens of the eye. Pt: Ok doctor.
C.
10. Dr: Any other questions ? Pt: If I do everything what you suggested, will I not lose my vision doctor ?
3. Dr: Mr.. If you do everything what I suggested the chances of you losing vision will be greatly be
reduced. So, I sincerely suggest you to follow everything we discussed. Pt: Ok doctor.
4. Dr: Any otherquestions Pt:No. Dr: Thank you very much Mr…

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 2. Painful Red Eye -Glaucoma
A AACG(acute angle closure Glaucoma) Pain worse in dark, haloes around light, DH

F Foreign body, chemical, complication of
Contact lens
A Allergy[hay fever or any gas]
S Sub conjunctival Haemorrhage
T Trauma
C Conjunctivitis[bacterial/viral/ulcer]
By any chance something has gone into your eyes? Occupation?
Gritty
Running nose, itchy eyes
Scratchy feeling on the surface of your eye, patches of redness,
no pain, no
By any chance you got hurt in your eye
Discharge, difficulty in opening eyes in morning

Contact glass irritation

A Autoimmune –Ankylosing spondylitis AS Back pain worse in morning

Systemic Lupus Erytheramatosis IBD SLE Butter fly rash
Rheumatoid Arthritis IBD Abd pain, diarrhea etc
RA Small joint pain

R Rieter’s syndrome Urethral discharge joint pain, Sex Hx

S Sarcoidosis Tender red bumps on skin, SOB, cough
You are F2 in Emergency Department.
56 year old lady presents with sudden onset severe pain in her left eye. Take history, examine and discuss
management with her. (Patient may be wearing sunglasses )
A.
1. Dr: Hello Mrs... My name is Dr... one of the junior doctors in the Emergency Department. P: Hello doctor
2. Dr: What brings you into the hospital today? P: I have this pain in my left eye doctor
3. Dr: Once again I am very sorry Mrs... Could you tell me when it started? P: It started suddenly around 2-3
hours ago
4. Dr: Do you have pain anywhere else ? P: I do have pain on my left side forehead as well.
5. Dr: Any redness of your eye? P: Yes doctor (She might show you the picture of the red eye) Dr: Any watering
from your eye? P: No
6. Dr: Have you noticed any coloured halos when you look at a light source? P: No
7. Dr: Do you have any problem with your vision? P: My left eye feels a little blurred.

8. Dr: I'm sorry to hear that Mrs... when did that start? P: Same time this morning doctor.
9. Dr: Do you have any discharge in the eye ( conjunctivitis) ? P: No Dr: Do you have any itching in the eye (
allergy) ? P- No
10. Dr: Did you sustain any injury to your eye? P: No Dr: Do you wear contact lenses ? P: No
11. Dr: Do you have any fever ( orbital cellulitis) ? P: No
12. Dr: Joint pains? P: No Dr: Any rashes on your body? P: No
13. Dr: Have you noticed any change in your bowel habits? P: No

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14. Dr: Do you have diabetes? P: No Dr: High BP? P : No
15. Dr: Are you on any medications? P: I'm taking amitriptyline for depression
16. Dr: Since when have you been taking that? P: 6 months
17. Dr: Has it helped with your depression Mrs...? P: Yes doctor! Dr: Do you have any allergies? P: No
18. Dr: Any family history of similar problems? P: No
19. [Patient may be wearing dark sun glasses] Dr: Can I ask why are you wearing this dark glasses? P: I feel
comfortable with that. [You can ask her to remove if it not comfortable]
B. Examination I would like to examine your eye Mrs... (Patient might show a picture of a red
eye)
C. Diagnosis:
1. Dr: Mrs... With the information that you have given me and after the examination, it seems you have a condition
called Glaucoma. Do you know whatthatis? P:No
2. Dr: In the eye there are two compartments filled with fluid... Sometimes when there is an increase in the
production of fluid or a blockage in the outflow, the pressure inside the eye can increase and that is what causes
the pain and the redness in the eye.
3. P: Oh.. Yes doctor.. I do feel like there is a lot of pressure in my eye
Dr: Mrs... This is a serious condition because if it is not treated quickly it can cause irreversible loss of vision.
4. P: But why did this happen to me doctor?
Dr: There are many reasons why this can happen Mrs... But in your situation, it appears to be because of the
amitriptyline that you are taking for your depression
5. P: (she might get upset_ console as needed) Oh.. It’s my fault then?
Dr: No Mrs.... it's not your fault.. It is an expected side effect of the medication and though not everyone on the
drug develops the S/E, some people might. Firstly, we have to stop this medication. We will give some other
medication for your depression.
P: Ok thank you doctor. What are you going to do for me now?
D. Investigation
Dr: We will have to run some tests to confirm the diagnosis. We will do a test called tonometry to check the
pressure inside your eye.
E. Treatment:
1. We will also have to start you on treatment immediately to prevent loss of vision. We have a number of
options.
11. We will give you some eye drops called Pilocarpine to reduce the pressure.
12. We also have drops called Timolol which will also help remove the excess fluid inside your eye.
13. We can also give you some medication called Acetazolamide into your vein to do that. We will refer you
immediately to the Ophthalmologist for the further treatment. Are you following me Mrs...?

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14. P: Yes doctor.. Will my vision become all right?
Dr: Unfortunately Mrs... I'm really sorry to say but any slight loss of vision that you may have sustained may
not be reversible... but we can prevent permanent loss of your vision if we start treatmentrightaway. P:Ok...
15. Dr: Do you have any questions for me Mrs...? P: No doctor. Thank you very much.
Dr: I will get in touch with the ophthalmologist and we'll start your treatment immediately Mrs... If you have
any concerns, please feel free to ask for me.

3. Ear infection in child

Earache in 9 month old child. Child had fever + pulling on his ear + can’t tolerate oral feeding. On
examination right eardrum pink (usually written), left ear drum is red. cappliary refil less than 2 sec. Child
was kept in the A& E for few hours. Given paracetamol. Temperature come down after the paracetamol.
[Vitals before and after pcm administration: Temp- 38.8/37celsius, RR- 40cpm/25cpm, PR-
130bpm/100bpm] All the blood tests – normal. Talk to the father. It is always ear infection in child
A. Take history
1. Fever – since when ?
2. Ear pulling, discharge from ear ? - No
3. Child has nasal discharge, not eating drinking properly. No fits.
4. Has he shown the child to GP before coming to hospital ( father said GP did not give antibiotic)
5. Any medication given
6. R/o meningitis ( shying away from light, rashes on body)
7. UTI ( crying on passing wee)
8. Past history – any medical conditions? Medications ? Allergy ? previous such incidents.
9. Tell the father
10. We have examined – child had high fever – now after Paracetamol - it has come down.
11. His left ear drum is red. He has not other problem. All the blood tests are also normal.
B. Diagnosis.
2. Looks like child has viral infection affecting the left ear.
3. They usually subside on its own in the new few days.
4. Antibiotic medications not required.
5. Admission not required.
6. Once he starts eating and drinking now - you can take him home.
7. Keep giving him regular paracetamol. Give him plenty of fluids to drink.
8. Hopefully he will completely improve in the next few days.
C. Warning signs
If he become very unwell, very lethargic and has discharge from his ear – these shows that he is may have developed
Bacterial infection which sometimes can happen – please bring him back to the hospital.

XII. Psychiatry
 Psychiatry --> always history. I can ask psychiatry questions. I can remove some questions. I can ask any quesions
and they won’t be offended.
 Do not be judgmental in your tone or appearance towards the psychiatry patient
 All psychaitry stations i do not need to reach the diagnsois --> except in psychosis station

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 ASTHMA SHIT
 A= Appearance and behaviour. No questions there. Just put it in your mind (shaving - age - gender - tattos -
Alcohol smell - dress - Ethnic group - profession - language - mood - /behavious) -- > I never act like i am
looking for appreaance.
 Speech --> pressure/ Fast/ Slow
 Mood --> I observe it ( how has your mood been these days/today? - what is your mood today? Can you 1
means lowest mood and 10 is normal - "Do not say: How is your spirit been lately or today?"
 Congition --> cannot understand me .. I do not need to ask it. If she is understanding. if the patient
understood mmy mood question --> then he/she has good cognition.
 Any changes in the cognition I need to ask: I need to see how this affected his life (The impact)-->
How this affected your perosnal /social life?
 Do you need to take additional precatuions?
 Suicide --> Have you ever had thought os harmong yourself (do not ask about killing yourself)?
 Hallucinations and Thoughts -->
 I need to signpost for these questions. There are few symtpoms that peopele can go through but
they are not comofortable in sharing with others. is it okay if i ask you those?
 Have you felt, smelt , seen or heard somethig that are not real to anyvody around you? Do you feel
people are putting/ taking thoughts from your mind? Do you feel people can see your thoughts?
 Do not rapport ..
 If he said it is a wierd question and i do not have those qierd symptoms:
 Be official --> I am really glad that you do not have it. But some people actually go through
it.
 If he laughed -->Actually some people go through it.
 Psychosis could be due to many causes: drugs, medication, space occupying lesion but I
cannot call it pschezophrenia.
 INSIGHT:
 Why do you think you are feeling like this? do you have any idea why this is happeening? why do
you think you are going through this?
 No --> I need to clarify it for you ---> well from what you told me, it could be (the Diagnosis)
 In suicide --> i do not need to tell insight (if he/she told or said the reason of her suicide)
 3F AMISH (ISH = Insight - Suicide - Halucinations and thoughts)
 Family and friends:
 DO you stay with your family or do you live alone? ARe you close to them? Does she/he know what
happened? No --> May be it is better for you to share this with her? I know sshe could really uspet.
But she will be there dfor you. This situation will be much better. We will e always for you. but it is
always good/better to have family and friends also for you to talk about this. They can help you
overcome this together with us
 (do not ask them do you have any friends? - Some friends is much better? Do you meet them
often?)
 Forensics: Have you had any problems/troubles with police or law? - if they tell yes, can yo utell me what
was it? if anything --> I can see you are btter man now. Praise him.
 Finances: How is your fnances? how do yu mancnage your fiannces?
 A and recrational drugs:
 Alcohol
 Smoking is not important

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  Mental condtion --> have you ever/has any body in your family been diagnosed by any mental condtion? or
Have you ever visisited a psychiatry before?
if he said yes --> Could you please tell me more about it?
 Never use words (problems- complaints -illness or disease )

1. The Mental Status Examination (asses cognition and memory)

Exam question :
Mr James Smith, 25 years old man was brought to the hospital by police. According to the police, Mr Smith
went to the police station and was convinced that he has done something wrong. After investigations, Police
found that it was a false claim.
You are the FY 2 doctor in Psychiatry department, talk to the patient and do Mental state examination and
talk to him about further management.
A.
1. Dr : Hello Mr Smith, I’m Dr …. One of the junior doctor in the Psych Dept. in this hospital. I’m here to talk to
you and help you. Can you please tell me what happened?
Mr Smith : Police are after me all the time…see they are standing by the door.
2. Dr : Do not worry Mr Smith they will not come inside. See I’m a doctor here and I’ll not allow them to come
inside. Please tell me why do you think they are after you?
Mr Smith : I did something wrong, So the police were after me.
Dr:I assure you that you are in safe place,and nobody will harm you.
If he is worried about police men  I Can see that you are worried that they after you. . But they are only
worried about you. That is why they brought you. not to catch you or anything. Also, you are in hospital is a
safe place. They are just worried about you.

Mr Simth: they have planted cameras in my room.

Dr:don’t worry mr smith,hospital is secure place,and nobody can see you outside this room.
3. Dr : Do you know where you are now? ( Cognition)
Mr Smith : This is hospital.
4. Dr : Do you know who brought you here? Mr Smith : The police brought me here.
5. Dr : Did the police catch you or did you go to them ?
Mr Smith : I was hiding from them for long time but I got tired and I turned myself in.
6. Dr: Have you been harmed in anyway? Mr Smith: NoDr: Since when are you feeling this way? Mr
smith: Since last few weeks Dr: were you alright before? Mr smith: yes
7. Dr: how do you feel in ur mood?can you please rate your mood on scale of 1-10,1 being sad,low,and 10 being
normal,happy? Mr smith:4-5
8. Dr: Are you able to eat/sleep well?carry out daily activities normally? Mr smith:No/Yes
9. Dr:Do you ever see or hear things that are not really there, such as voices or visions? (hallucination/perception)
Mr Smith : No
10. Dr : Do you feel that someone is plotting anything against you? Mr Smith : Yes.
11. Dr : Have people been interfering with your thoughts (thought insertion). Mr Smith : No.
12. Dr: Do you think someone or some group intend to harm you in some way? Mr Smith: yes,I feel Police will
punish me.
13. Dr:Do feel like hurting urself/doing harm to self? Mr smith:NO
14. FMAISH is not important but if I do have time i do Famish

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15. Dr : Do you live with family or alone? Mr Smith : I live on my own (sometimes he may say :I live with my
mother).
She lives with mom and brother? -> MAy be a good thing to think of is to sharing this with them because
their support for you is needed along with others.
They might be sad? It will be ctually good for you. But I am glad tahat you are considering it/open to
thinking about it
16. Dr : Do you have some (never any) friends? Mr Smith : No
Do you have some friends? That is good because you need to have friends around you.
17. Dr : Do you have any problem with finance? Mr Smith : No
18. Dr : Do you have any legal problems? Have you been in trouble with law anytime?(Forensic history) Mr Smith
: No.
a. Dr : Do you drink alcohol? Mr Smith : sometimes
b. Dr: do you smoke? Mr smith:yes/no
c. Dr:Do you use recreational drugs ? Mr smith:No
19. Dr:Do you think you have any problem, do you think you need any help? (Insight) Mr Smith:No
20. Dr:do you feel that this has affected your work/family life/social life?(Impact) Mr smith:No/Yes
21. Dr : Do you have any medical conditions? Mr Smith : No
22. Dr : Did you have any mental health conditions before? Mr Smith : No
23. Dr : Any of your family members have any mental health conditions? Mr Smith : No
24. Dr : Do you take any medications? Mr Smith : No
25. Dr: are you allergic to any medications? Mr smith:No
26. Dr : Do you have any medical problems at all? Mr Smith : No
27. Dr : Mr Smith why do you think all this is happening to you? Mr smith:I don’t know
28. Dr : Thank you very much Mr Smith, we will try our best to help you.
29.
C. DIAGNOSIS: (At 6 min -->)
Do you have any idea why yo could be feeling right that> --> I have done something wrong right? --> No, I
know you are feeling that. They have invistigated you thouroughly. They found u are a good person. You have
not caused anyone any harm at all. --> That is not possible --> I insist on what I have said. AS i said before
If he asks you why I have sich kind of thoughts?
 From what you have told me and from what I have gathered --> It could be for many resons but it could be
actually due to a codntiion we call psychosis.
 If he asked what is psychosis? --> I tell him (if not I need to stop)
 Whatever he asks I answer ,, do not push answers ..
 If he reacted to Psychosis = I am so sorry. Then explain it like a confusion state . Like when you think
somehting is true but it is not true.
1. From the information you have given me, you have a mental health condition called Psychosis. Psychosis is a
condition where in people loose touch with reality and start to see,hear and believe things that are not true. It
happens due to chemical imbalance in the brain. It is not an uncommon condition, 1 in 100 people are affected
by it.
2. There are many reasons why people can have this condition like life events, it runs in some families.
D. INVESTIGATIONS:We will admit you and do some tests to find the reason. This test would include
Blood tests and CT Scan of your brain.
E. MANAGEMENT:

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1. If the investigations are normal and symptoms persist for a long time it could be a condition called
Schizophrenia. We will treat that condition with medications to help restore the chemical imbalance in the
brain. (Risperidone or Olanzapine – no need to tell the names of medications to the patient).
2. We will provide all kinds of Psychological help and Social support.
3. [The treatment could be Bio-psycho-social model]
F. Investigations for Psychosis
1. Abnormal LFTs and macrocytosis on FBC are highly suggestive of alcohol abuse.
2. Serological tests for syphilis should not be forgotten.
3. Screening for AIDS should be preceded by counselling.
4. Urine screen for drugs of abuse. Light recreational use of cannabis can produce a positive test for
the subsequent fortnight. Heavy and chronic use can produce a positive result for months after the
last use.
5. CT brain scan may be contributory (eg, to exclude a space-occupying lesion or cerebral atrophy) if
focal signs are present but not otherwise.

2. Dementia
Scenario – 6 A 75 years old man has been brought to the hospital because he was found confused and
wandering. All blood investigations are done and results are normal. You are the doctor in the Psychiatric
department. Assess this patient and discuss the initial management with the examiner

A.
1. Dr. Hello Mr Adam Williams,Mynameis........ I am one of the doctors in the Psychiatry department.
2. Dr - Can you confirm your name for me Pt:- Mr Adam Williams
3. Dr - Do you know where you are now ? Pt: - Where am I ?
Do yo know where you are? = Do you know what is this place? Do you know where you are? --> you are at
hospital --> Do you know how did you get here? -->
4. Dr - You are in the hospital, Do you know who brought you here?
Pt: Who brought me here ?
5. Dr - The police brought you here Pt: Am I in trouble?
The police found you confused and wandering that is why they worried about you and brought you here.
6. Dr - You're not in trouble. Do you know where do you live? Pt: I don’t know.
7. Do you remember where you live?? do you remember where you are staying?
Do not worry M. it is okay. that is completely alright. Is it okay if I ask you a few question to see how you
rmemeber a few things?
8. Dr: Ok Don’t worry. You are in a safe place now. Pt: Sure.
9. Dr: - I would like to ask you a few questions to know how well you remember things, is that okay with you
 I need to remember enough questions to reach 6 minute --> i do not need to remember them in order ..
 I can know 10 questions of place and time .. then add some of them ..
 The only psychaitry station I need to talk about the Mgx  I need to stop at 6 minute alarm and do the
amangement
 Even if he said wrong answers to your questions-  praise him all the time but score nothing.
 You can write down marks on the paper sheets present in the station. with each question  type down the mark
,, 1 or zero  do small zero and say at the same time very good M. and smile  do not make it so big and do
not hide it from him.

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 He only remmber only his name and he only remmebers that he is from England.
 Is it my marks? You are doing very well.
 IF he is irritable  No it is just this question. it is just to check your memory to see how well you remember/
to help you remember is it okay?
 If he is stuck at any point give marks for what he acheived - and help him to finish the word *but do nt give
marks* If i helped him without him telling any then he rememebered--> that is zero
 I always respond by very good..

Orientation Time Year/Season/ Month/ Day M do you know what day today is? he will
/Date tell the date wrong (he may answer many
---/ 5 qeustuos at the same time) --> I say: very
(one score for each right good. I then mark 3 zeros or 1 zero (as much
answer) asnwers he has asnwered)
DO not ask what time now .. but you can ask
is it day or night?
Which day of the week?

Place Country/ County City/town 1. What country are we in now?

Street Building/ floor 2. What county are we in?
---/ 5 3. What city are we in?
(one score for each right 4. What building are we in?
answer) Where are we? police station (I need to
correct him the is the only question) I can
undesrtand M. tha you believe that this place
is a police station. but this is actually a
hospital.
5. What floor of the building are we in?
What floor> (The right answer is 2nd floor)

(When you ask which floor you are in – he

may step on the floor and say “ I am on this
floor” – give zero score)
Registration 3 objects Ask to repeat 3 words [allow I can use any 3 words - If he failed  I can
one second between each repaeat it 2 more times do you tink we can
(you will
word, repeat them up to 5 try one mroe time? I say the whole 3 words
find objets
times] again.
inthe
---/3 I then use the best score (if he got 2 right then
station)
(one score for each right i write 1 and 1 )
answer) Somtimes he says I forget the 3rd word  I
repeat it and help him but i give him marks
only on the 2.
Could you please = can you tell me = do you
hitnk you can do that = Are you okay with ..

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 ? Be polite ..
I can pick up any 3 words.
Can you please hang these words in your
memeory so that i can ask you latter can you
tell them?

“ I am going to name 3 objects, I want you

to repeat them. Please remember these
words, I am going to ask you to name then
again in a few minutes.
These three objects are : APPLE, TABLE,
PENNY”. Please repeat the 3 words for me.
(If the patient cannot say correctly then
repeat until learned or up to maximum 5
times).
Attention WORLD M. Wiliam do you know the Now Can you spell it backward?
and spelling of the word world (write it on your paper - to check him right)
Calculation (never choose any other I score 1 for each letter from the begining ..
word)? So DLwor = 2 marks only
IF he forget any letter (then i
give him zero) Could you spell the word “world”? Now
could you please spell backward?
Ask to spell the word “world” ( you should not spell backwards to help
and correct if wrong and ask to him)
spell it back ward which gives
score. Give one score for each
correct answer until the order
of the spelling is correct. Eg :
D,L,R,W,O (score is 3 here)
---/5
Recall 3 recall Ask to recall those 3 words Could you please repeat those 3 words I
--/3 asked you to remember?
One score for each correct ( do not remind him the words)
answer.
Language Name 2 Ask to name 2 objects I need show him 2 objects --> one by one?
objects --/2 what this is? then what this is?
One score for each correct if there are not 2 objects i use the paper and
answer. pen
Show 2 objects one by one, Could you please
name this object?
( eg – pen, paper)
Repeat Ask to repeat NO IFS, ANDS, Now M. I will tell you a sentence. Can you
sentence or BUTS please repeat it after me?

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 --/1 Now the first sentence: Nos IFs ands or buts
Give one score if the whole If he said it is hard --> repeat it
sentence is correct otherwise If he says it without Ss --> it is okay give
zero. them marks

I want you to repeat exactly what I say

NO IFS, ANDS, OR BUTS
3 step Ask to perform a 3 steps act  I need to ask if you are right handed or
command --/3 left handed?
One score for each right step.  Could you pleae take Now take paper
from the table (in the notes written floor)
with your non -domnant hand -- fold it
beteen 2 hands then move it your
dominant hand to leave it on the table
 Do not move your hands whie explaining
 do not move your head  Give
instruction with only your voice]
 I give marks until the order is missed up
(Even he did it right latter)
 Do not give him the paper you are
writing the marks on
Ask pt which is his dominant hand. Ask him
to do the following steps in non- dominant
hand.
Please take this paper with in your left hand
( if he is right handed), fold it in half once
with both the hands and put the paper down
on the floor .(don’t show any gesture)
Read Read and Write a command on the paper Please read this and do what it says.
carry out and ask him to do that Write on the paper - [Please close your eyes]
the --/1 If the patient just repeats but does not close
command Give one score if he closes his the eyes, you can repeat the instruction 3
eyes not for reading. times, but you do not close your eyes to show
him.
Write Write a Ask to write a sentence,look Could you please write a sentence in this
sentence for meaningful sentence paper?
please --/1
One score for a meaningful
sentence (ignore spelling
errors).
Copy Copy this Ask to copy 2 intersecting Draw 5 sided shapes
diagram pentagons where intersection show him and give him a pen and could you
box has 4 sides only. please look at it and copy it

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 --/1
Give one score if drawn Let him draw till he gives you eye contact --
correctly (Must have drawn 4 > praise him , let him stop and then he will
sided figure between two 5 give it to you.
sided figures). Can you please copy this design.
Allow multiple attempts until
Pt is finished and hands it back
to you.

Total Score :
24-30 : Normal cognition

20-23 : Mild cognitive impairment

10-19 : Moderate cognitive impairment

0 -9 : Severe cognitive impairment

B. At the 6th minute bell :- Stop the assessment and discuss the management with the examiner (SOMETIMES
EXAMINER SAYS TO COMPLETE THE ASSESMENT)
 Did I do well? You did very well.
 Can I show them to my seniors and come back? yeah yeah go show me doctor
 Do you have any concerns? Thank u
 Then sit and count the marks (Count what you marked usually you do not)
 Go to the examiner and stand --> I could not finish the mentals state examination, Ideally I would liek to
finish it. But from the questions I have aske, I think he got score of which means/shows that he has x
impairment in cognition and memory but because I still have more questions left so It can even be moderate
(usually severe or moderate (something between 0-19)
C. DIAGNOSIS: From the above history and cognitive assessment the patient has impaired cognition. He is able
to PERFORM/NOT PERFORM most of the instructions. My provisional diagnosis is dementia.(TELL THE
SCORE/TYPE OF COGNITIVE IMPAIRMENT)
D. INVESTIGATIONS& MANAGEMENT• I would like to admit the patient since he has dementia so it is not
safe to send him home and do investigations like CXR, urine test, A brain CT scan to check for any cause for
dementia and also find out more information from GP about past history and Family about onset and progression
of his condition. Also, I would like to refer to dementia clinic/dementia team. Thank you ..

3. Dementia - Palliative care

You are the FY 2 doctor the medical ward. Mrs Mary Black is an 88 years old female with a diagnosis of
advanced dementia. She was admitted to the hospital 4 weeks ago with general deterioration and poor
oral intake as she is refusing to eat or drink. She is losing weight and she is also agitated. Your consultant
thinks planned not to give any aggressive treatment. He has decided for palliative treatment. Speak to
the daughter, Mrs Sarah Black, about her condition and address her concerns.

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1. Dr: Hello Mrs Sarah Black. I am Dr …. One of the junior doctor in the medical department looking
after your mother Mrs Mary Black.
How are you doing?
2. Daughter: I am fine doctor ? How is my mother ?
Dr: She is OK now but can you please tell me how much do you about what is happening to her.
3. Daughter: I was told that she has dementia.
Dr: Do you know what is dementia ? Daughter: No
Dr: Dementia is a condition of the brain that causes gradual loss of mental ability. This can cause
memory loss, reduced interest in eating enough, Incontinence, Swallowing difficulty, inability to
communicate.
4. Did she have any other medical condition before ? Daughter: No
5. Dr: Do you have any concerns about her?
Daughter: Yes doctor. She is not eating properly. She is losing weight. I am very concerned.
She has looked after me a lot. She has done lot for me. I want to do the best for her.
6. Dr: I can imagine. How was she at home before she was brought in – was she eating well ? Was
she active in her life ? Was she mobile ?
Daughter: She was eating OK but she was not very active.
a. Dr: We have examined her and found out that she has no other medical problem apart from
Dementia.
b. Yes we have noticed that she is not eating well and losing weight. This is because of her dementia
which is in advanced stage now.
c. Because of all these my consultant thinks it is not good to give her any active or aggressive
treatment as her condition is not going to be any better. So he thinks it is better we give her only
palliative care.
7. Daughter: What is palliative care ?
a. Dr: Palliative care means we do not give active aggressive treatment or any invasive procedure
to the medical condition which is advanced and progressive but we give complete supportive care
for patients and their families.
b. We manage their pain and any other distressing symptoms. We provide all types of supports like
psychological, social and spiritual support.
c. We try to give the best quality of life for patients and their families. We offer a support system to
help patients live in dignity and as comfortable as possible as long as they live.
8. Daughter: Doctor Who Provides Palliative Care ?
a. Dr: We have a specialist team called Multidisciplinary palliative care team who provides this type
of care.
b. There are specialist consultants and nurses and also physiotherapists, occupational therapists,
dieticians, pharmacists, social workers and those who are able to give spiritual and psychological
support. Someone can even stay at patient’s home to give care at home.
9. Daughter: Does this mean it is the end of her life ?
Dr: Palliative care is not just given for end of life care it is also given to those who needs such help
early in the disease means well before many months of expected death.
10. Daughter: But she is not eating properly. She is losing weight.
Dr: In advanced stage dementia these things do happen. They lose appetite and they refuse to eat.
Also Dementia patients lose weight even if they eat normally.

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11. Daughter: Don’t you have any methods to feed her ?
a. Dr: We do have lot of methods to feed patients artificially. We can give fluids subcutaneously
that is under the skin and also we can pass a tube from her nose to stomach ( NG tube) and feed
her through that and we have another method what we call as PEG where we make a small hole
from the tummy and pass a tube directly from the tummy wall to the stomach and feed her through
that.
b. However all these methods are not good for her because she will only be distressed more with
these types of feeding.
c. Instead we allow them to eat and drink as they like though there are
some risks involved. This is what we call as comfort feeding. If
required she can be hand fed rather than tube feeding.
12. Daughter: Why it is better ?
a. Dr: Because dementia patients have reduced appetite and they
lose weight despite feeding artificially. Artificial feeding will not improve appetite.
b. Also even in artificial feeding there are risks that food may still go into the lungs. It does not
improve quality of life. Survival is not prolonged in artificially fed patients.
c. Feeding through the nose tube can be applied temporarily for few weeks in someone who’s
swallowing are likely to recover. In your mother’s case we are not expecting her to improve or
recover.
d. It cannot be put for long time and also it is distressing to the patient and can make them more
agitated.
e. PEG: Disadvantage is that it is invasive procedure, can be dislodged by an agitated patient, also
it needs training to carers or family.
f. It is better to feed her by hand. Feeding by hand improves the communication and interaction
with the patient by being close to them while feeding.
g. Also they require much less energy. She can be fed high energy foods or fortified food. Our
dietician can advise what types of food is better for her.
13. Daughter: Can you feed her forcibly?
Dr: It is not good to do that. As I mentioned she will not improve even if we force feed her. It will only
distress her more.
14. Daughter: Can I take her home?
Dr: Yes surely you can take her home if you wish to. Have you thought of keeping her in the hospice
– this is similar to home where only this type of patients are cared for.
15. Daughter: What is hospice ? What do they do there?
Dr: In Hospice there are doctors, nurses, social workers, therapists, counsellors, and trained
volunteers. Hospices aim to feel more like a home than hospitals do. They can provide individual care
more suited to the person who is approaching the end of life, in a gentler and calmer atmosphere
than a hospital.
16. Daughter: OK. I would like to take her home now and think about the hospice later.
Dr: Ok that is fine. We will make arrangements for that. Do you need any help to take care of her at
home ? If you need we can arrange nurses and social care workers to help you to look after her.
17. Daughter: Thank you doctor. Dr: Thank you.

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 4. PSORIASIS AND VASCULAR DEMENTIA
Scenario- Mrs Katherine is diagnosed with psoriasis for many years and she is taking skin emollients for a long
time as a part of her treatment. Her BMI is 32. Talk to her and address her concerns..
A.
D- Katherine I understand that you were diagnosed with some skin condition and you are on treatment. I'm here to
address any concerns you may have.
P- Skin condition?? No doctor I'm here to talk about vascular dementia.
(Patient shows disinterest in talking about psoriasis and wants to talk about vascular dementia)
P- Thank you Dr.. I am really worried about the chances of me getting vascular dementia..
D- Can you tell me how much you know about vascular dementia?
P- I know everything about the condition but I am worried if I would get it.
(if patient doesn’t know, explain vascular dementia. Vascular dementia is a common type of dementia that is
caused by reduced blood flow to the brain. As a result, you will have difficulty in remembering things, feel
confused and might experience some mood and personality changes as well.)
D- OK. Can you please tell me why are you worried about vascular dementia?
P- Dr one of my family member had stroke and diagnosed with vascular dementia and now one of my close
friends is suffering from the same problem.
D- I am really sorry to hear about your family member and your friend. Can you please tell me if that family
member is a blood relative?
P- yes Dr.
D- Unfortunately this condition sometimes run in families. But it's not the only risk factor.. There are many
reasons why someone could get this. Is it alright if I can ask you few questions to get to the bottom of this?
P- Sure
D- Do you have difficulty in remembering things?
Have you been experiencing any mood changes?
Do you have difficulty in walking or keeping balance?
Are you able to do your daily activities?
Have you experienced any difficulty while passing urine?
D- Have you been diagnosed with any medical conditions? DM? High BP? Bad fat? P- No
D- Are you taking any medications? P- No
D-Are you allergic to any medications? P-No
D-Have you been diagnosed before to have any heart conditions? P-No
D- we noticed that your BMI is too high. ( 32). (Show the BMI and explain what it is. Your weight is at a higher
level compared to your height.). Heavy body weight can increase the risk of vascular dementia.
D- May I know what medication you are using for your skin condition ?
P – ( may say – steroid cream)
D- ( This may be one of the cause of gaining weight)
D-Let's talk about your eating habit. Do you follow a healthy diet?
P- I have a busy life and I don't have time to cook and eat so mostly I eat out..
M- what kind of food you eat outside?
P- Due to insufficient time, I eat in fast food outlets
D- I can imagine that you must be a very busy person, but eating in fast food outlets can increase the chances of
building up bad fat called cholesterol in your body. Your BMI is high as well. This it self can increase the risk of
vascular dementia.

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P- WHAT IS THE CONNECTION BETWEEN CHOLESTEROL AND VASCULAR DEMENTIA?
D- High cholesterol can narrow the arteries that supplies blood to your heart as well as brain which may lead to
stroke then can contribute to dementia.
P- Ohh I will stop eating out.. What else Dr?
D- May I ask if you smoke or drink?
P- Dr I don't smoke but I drink a lot.
D- I really appreciate the fact that you don’t smoke. Could you tell me how much do you drink and for how long?
P- Strong alcohol sometimes wine.. 2 bottles a day.
D- Katherine, is it possible that you can cut down your drinking?
P-ok Dr I will try
D-Also you need to loose weight.. As your BMI is too high.. 32.
P- What can I do to loose weight?
M- You can adopt some lifestyles changes like modifying your diet and including exercise daily. You need to
include more fruits and vegetables in your diet and have more white meat like chicken and fish. Avoid fried items.
I can refer you to a dietician for your diet, cardiologist for further assessment and obesity clinic as well.
P- is there anything you would like to do now?
M- I shall be doing some blood tests to check your cholesterol level and Q risk assessment to see your risk of
having stroke..

5. Confusion in elderly
Scenario- 82 year old man was brought to hospital with sudden onset of confusion.
Talk to his daughter and discuss management plan with her. Blood tests are done and results are kept
inside cubicle. Results are kept on the table- Hb marginally low, rest of FBC is normal, Low Sodium, Urea
and Creatinine is raised.
(Level of sodium given in exam- 115 Level of creatinine- 9.3)

A. History-
1. Primary complaint?
2. When did it start?
(daughter says that her father has been forgetful since past 15 days and has now forgotten her name as
well)
3. Was he completely well before this?
4. R/O – Infection : Fever – no, cough, no, headache, rashes – no, burning sensation of urine – no
5. Any weakness of arms or legs, speech problem - No ( stroke, TIA ) – No
6. Past medical Hx of – diabetes, Thyroid problem – No
7. High blood pressure – yes
8. Which medication for HTN – daughter shows – Amlodipine and Atenolol ( or Enalapril and Atenelol)
9. Does he drink alcohol – no
10. Any diarrhoea, vomiting : No
11. Ask questions regarding renal function
- Is he passing enough urine?
- Any weight loss?
- Swollen ankles?

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 - Does he appear pale?
- Any history of repeated urine infections?
Check BNF- for SE of Amlodipine and Atenelol ( or Enalapril) [ Amlodipine and Enalapril causes low
sodium)
-ask for family history of cancers, family history of kidney diseases.

B. Examination- general examination, vital signs

C. Explain the results to the daughter-
We have done kidney function tests. It consists of urea and creatinine.
Urea is a waste product which is formed from the breakdown of proteins. A high level can indicate that your
kidneys may not be working properly or it can also mean that he is dehydrated.
However, creatinine is a waste product which is formed by the muscles. A high level of creatinine also shows that
your kidney isn’t working properly.
Sodium level is low which causes confusion.
He has kidney failure. His kidney is not functioning properly. His high blood pressure would have caused the
kidney failure. Kidney failure causes raised urea which in turn can cause confusion.
Also Amlodipine ( Enalapril) medication what he is taking for the high blood pressure causes low sodium level in
the body.
We need to do other tests to make sure that he has no other problems causing this confusion – like we need to
check whether he has any infections, Check his sugar levels, Thyroid function levels , vitamin B12 levels –
because all these things also can confusion.
D.
Treatment : We need to admit him. Stop the Amlodipine ( Enalapril) medication. We will some other medication
for his high blood pressure.
We will give him some fluids which contains sodium through his veins as drip. Hopefully he will recover soon. He
should drink less fluids.
He may require dialysis.
Daughter may ask – will he survive this ?
He may or may not survive because when elderly people have kidney failure it is very difficult to treat.

6. Alcohol assessment
You must assess the following 6 steps and if required discuss your findings with the patient or the examiner.

1. Step 1: Presenting Complaint

2. Step 2: History of Present Complaint
 Daily Drinking Pattern: What/How Much/When/Where/Alone/Progression
 CAGE Questions: CAGE SCREENING TOOL (Cut Down/Annoyed/Guilty/Eye Opener)
• “Have you ever felt that you should Cut down on your drinking?”
• “Have people Annoyed you by criticizing your drinking?”
• “Have you ever felt bad or Guilty about your drinking?”
• “Have you ever had a drink first thing in the morning to steady you nerves or get rid of a hangover (Eye-
opener)?”
• Scoring: Two or more positive responses correlate with substance abuse.

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3. Step 3: Features of Dependence: TDW - Tolerance/Dependence/Withdrawal/Previous Treatment
4. Step 4: Consequences: Friends/Family/Finances/Forensic
5. Step 5: Complications: Physical/Depression(Mood)/Psychosis/Self Harm
6. Step 6: Insight

Management
If station/task states present findings/management/counsel, then as a rule, you should discuss:

• Referral to Alcohol Support Worker

• Lifestyle changes
• Outpatient Counselling Groups such as Alcoholics Anonymous
• Outpatient medication management
• Inpatient Detoxification
• Change of occupation if required

Key Points

• Be honest and non-judgemental.

• Do not start station by discussing alcohol directly, mention that their test results may be due to alcohol intake
as well as many other causes and that you want to ask some questions to rule alcohol out as a cause.
• Many patients drink in secret and may not want to discuss the issue.
• If patient denying drinking alcohol – you can offer confidentiality. ( Mr… “Whatever you discuss with us will
be kept confidential”
• The patient needs to accept that there is a problem before therapy can start.
• Government Recommended Allowances: Male and Female:14 UNITS PER WEEK (There should be at least 3
days free days a week- IF i am taking a sip every day then I still have a problem)

Exam question: Mrs Tames Parker, 45 years old woman who had hysteroscopy. The nurse noticed she has
got a bad drinking habit and wants you to talk to her about it. You are the SHO in the Psychiatric
department. Take history for alcohol abuse from the patient and talk to her about the management.

a. (GRIPS Followed by CAGE,T/D/W)

1. Dr: Hello, Mrs Parker, I am Dr………., one of the doctors in Psychiatric department. I am here to talk to you
and help you.
Dr: Can you please tell me how are you doing?
Mrs Parker: I am much better just a bit sore but I guess it’s expected. Dr: I am sorry to hear that
Mrs Parker: I am OK now.
2. Dr: Mrs Parker I want to talk to you about alcohol, is that okay ?Mrs Parker: Yes, Doctor.
One of our medical team has noticed a problem and she was very concnerned/worried about you. She wa abit
worried aout your health that you might have alcohol dependence.
3. Dr: Do you drink alcohol Mrs Parker ? Mrs Parker: Yes
Alcohol lady  She does not admit it. She is not going to be happy abotu confrinting her with her alcohol
problem.
I am glad that you are not addicted ot alcohol. But just to be on the safe side, is it okay to ask you a few
questions? Because she was very worried That is the only reason I came here. I am reall so sorry.
4. Dr : For how long have you been drinking? Mrs Parker: I have been drinking for last 20 years.

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5. Dr: How much do you drink? (How frequently?)
Mrs Parker: Doctor, I drink 3 pints of beer and 1 shot whisky daily
(Then ask CAGETDW – cut down, annoyance, guilty, eye opener, tolerance, dependence, withdrawal
questions )
6. Dr:Have you ever felt you should try to cut down on your drinking?
Mrs Parker: Yes, Doctor, I went to Alcohol Anonymous (AA) Group 6 months ago to cut down alcohol.
But sometimes, I went for drinks because of my friends.
--> If she said yes and I have tried: She might talk about the W of withdrawl
7. Dr: Does it mean that you still keep drinking. Mrs Parker : Yes doctor
8. Dr: Can you please tell me why did you try to cut down drinking?(INSIGHT)
Mrs Parker : It is not good for health.
--> May I know was there a particular reason that you tried to cut down? --> whatever the answr i can
use it latter to convince her to cut down again
9. Dr: Have people annoyed you by criticizing your drinking?
Mrs Parker: Yes, My husband is really annoyed about it
Do you feel upset or annoyed if someone asked, talked you about your dirnking habbit?
10. Dr: Have you ever felt bad or guilty about your drinking?
Mrs Parker: Yes, Doctor, Sometimes
(With the lowest tone) Do you regret or feel regretful about consuming much alcohol?
11. Dr: Have you ever had a drink in the morning (eye-opener) to steady your nerves or get rid of a hangover?
Mrs Parker : Yes, Doctor.
(The big confirmation ) Do you have to consume/have alcohol the first thing in the morning when you wake
up?just to start your day?/just to beging any acitivity?
(Patients with two or more positive responses are likely to be alcohol dependent).
12. Dr: Do you think that you have to take more and more alcohol to get the same effect as before? (tolerance)
Mrs Parker: No, Doctor.
Do you have to keep increasing the amount of the alcohol you drink to get the same feeling/effect?
13. Dr : Do you feel you cannot do your daily activities without drinking alcohol? (dependence) Mrs Parker :
Yes
Do you have to consume alcohol just to go through your daily acitiviites/ daily tasks?
14. Dr: How do you feel when you do not drink alcohol for a long time ? ( withdrawal)
Mrs Parker: Doctor, when I do not drink, I feel restless, I start sweating and sometimes I feel that my
heart is racing. It happened to me 1 year ago.
(If she already did not tell you about it)  When you try to stay away off alcohol or when you stay away
offf alcohol  Do you go through some unpleasant symptoms or feelings?
15. Dr: What do you do for living? Mrs Parker: I own a winery ( a place where wine is made).
16. Dr: Do you live with your family? Mrs Parker: Yes, with my husband
17. Dr : Do you have any financial problems? Mrs Parker : No
18. Dr: How is your mood? How would you grade your mood in 1 to 10 scale where 1 being low and 10 being very
happiest mood? ( Mood) MrsParker: My mood is fine (7/10)
19. Dr: At any point, THOUGHT of harming yourself or ending your life? ( Suicidal) MrsParker: No, doctor.
20. Dr : Do you ever see or hear things that other people seem unable to see or hear?
(HALLUCINATION/PERCEPTION) Mrs Parker : No
21. Dr:DO you feel that this has affected your work/family life/social life?(IMPACT) Mrs parker:NO/YES

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22. Dr:DO you tend to drink alcohol to relieve ur stress?(STRESSOR) Mrs parker:No
23. Dr: Do you have any health problem at all apart from the problem for which you had the procedure now?
Mrs Parker : No
24. Dr:did you have any mental health problems in ur past? Mrs parker:NO
25. Dr:are you taking any medications?/are you allergic to any medications? Mrs parker:NO
26. Dr:do you have family history of any mental health conditions? Mrs parker:NO
27. Dr:Do you have any legal problems? Mrs parker:NO
28. Dr: Thank you very much for all the information. We will try our best to help you.
b. DIAGNOSIS:Mrs parker ,ur experiencing soreness and withdrawal symptoms because of ur
ALCOHOL use. From the information I think you have alcohol dependence.
Cause and effect : From what you told me Mrs Parker, You seem to be taking too much alcohol which is
dangerous to you. This can damage your liver and risk your life.
Thank you so much for answring my questions  I am really glad you were as honest as possible because that
helped me to annalyze your stiuation. From what you have told me it Seems like/I believe that the amount of alcohol
you are consuming is a bit more than the recommend amount per week.
c. MANAGEMENT:
1. Stop alcohol : If you stop drinking, it will not only help you in this problem, but also
in your overall health. We can help you on that.
2. Medications: We can give medications to prevent withdrawal effects (anti
withdrawals - chlordiazepoxide) and also to help you stop drinking alcohol (anti-
craving medications – disulfiram, Acamprosate).
Since she already tried to cut down before. There avery good mecidation and methods to help her cut down and
keep her free from alcohol. They have very good medication which is anticraving
3. Counselling : You can try to attend Alcohol anonymous, or we can help by
counselling sessions ( CBT) or
if she told about it  you tell her you can join back AA.
4. Rehabilitation: if needed we can admit for rehabilitation (Job, Finances and
accommodation)
5. Avoid going to the winery, triggers ( seeing other people drinking): may be you can
try to change your job ( if he is a bar tender ) or try to avoid going to the bar floor (If
he is a bar owner).
May be it s better or yo if you can change your work place to a place where alcohol is not served and cosnumed
so freely around you
6. If the reason that she relapsed that she were with her frieneds? you can suggest her:
Have you htought about telling them about your probelm with lachojl that they might
be of help and support you?
7. I cannot do it? You already done it once. I can see you want to try one more time. it
is just the first time that is hard one.
8. Thank you so much .. Do not shut up till the 8 minutes finish ...

Scenario – 8
A 60 year old man, Mr Smith, was admitted in the hospital because of ingrowing toe nail infection. Medical
Investigation has been done : MCV ↑, LFTs : deranged. Talk to the patient, take Hx and advice patient to
stop drinking. [ This is a history and counselling station]

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1. Dr : Mr Smith we have done some blood investigations because you have infection in your toe
nail. The results show there is some abnormalities in your blood picture. This could be due to
several reasons lack of some type of food in your diet or drinking alcohol.
2. Dr: Do you think that you eat a healthy balanced diet? (Vit B12 deficiency causes high MCV)
Mr Smith : Yes.
3. Dr: Do you drink alcohol? Mr Smith : Yes.
4. The rest is similar approach as previous Task.

7. Drug abuse assessment

You must assess the following 6 steps and if required discuss your findings with the patient or the examiner.

7. Step 1: Presenting Complaint

8. Step 2: History of Present Complaint
 Daily Drug Pattern: What/How Much/When/Where/Alone/Progression
 CAGE Questions: CAGE SCREENING TOOL (Cut Down/Annoyed/Guilty/Eye Opener)
• “Have you ever felt that you should Cut down on your drinking?”
• “Have people Annoyed you by criticizing your drinking?”
• “Have you ever felt bad or Guilty about your drinking?”
• “Have you ever had a drink first thing in the morning to steady you nerves or get rid of a hangover (Eye-
opener)?”
• Scoring: Two or more positive responses correlate with substance abuse.
9. Step 3: Features of Dependence: TDW - Tolerance/Dependence/Withdrawal/Previous Treatment (Hrp B)
10. Step 4: Consequences: Friends/Family/Finances/Forensic
11. Step 5: Complications: Physical/Depression(Mood)/Psychosis/Self Harm
12. Step 6: Insight

Management
If station/task states present findings/management/counsel, then as a rule, you should discuss:

• Referral to Narcotic Support Worker

• Lifestyle changes
• Outpatient Counselling Groups such as Narcotics Anonymous
• Outpatient medication management (Methadone/needle sharing)
• Inpatient Detoxification

Scenario – 9 You are the FY 2 doctor in the Psychiatry department.

30 year old, Mr Henry Williams, has been referred to the hospital from his GP because he is opioid dependent
and he wants to quit the habit. Take history from Mr Henry and discuss the further management with him.
A. {GRIPS-CAGE,T/D/W,Which DRUG,DOSAGE,ROUTE OF INJECTION}
1. Dr: Hello Mr Williams, I am Dr… one of the junior from the Psychiatry Dept. How can I help you Mr Williams?
Mr Williams: Dr I use drugs and I want to stop and I need help.
2. Dr: It is really good to know that you wish to quit drug habit. I am really glad that you have come to us. We can
surely help you with that.

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 Heroin guys --> need help --> so I praise him for coming here and asking for help.
3. Can you please tell me, which drugs doyou use? Mr Williams: Doctor, I use Heroin.
Weeds  it is beter for you to stay away from weed as well. (but do not try to talk about the weeds just there)
4. Dr: For how long have you been taking it? Mr Williams: It has been 10 years; I started taking it when I was
20 years old.
5. Dr: How much do you take it? Mr Williams: about 1 gram.
6. Dr: How often do you take it? Mr Williams: I take it two times daily.
7. Dr: How do you use it? Mr Williams: I inject in my blood channels nowadays, before I used to snort it.
8. Dr : Do you know of the needle exchange programme? Mr Williams: Yes, I am aware of it. Do not talk to
him about the neeedle exchange progra excpet at the end.
9. Have you ever shared or reused needles? Yes
10. Have you ever tested for HIV, HBV? If he says yes  After you tested have you ever shared or reused needles?
if no  Then it is better ffor us to test you latter on.
11. Dr: Apart from heroin, do you take anything? Mr Williams: No doctor ( sometimes he may say - I use
cocaine, marijuana and amphetamine).
B. (Ask CAGETDW questions)
1. Dr: Have you thought of Cutting down or quitting them?
Mr Williams: I tried to quit it two times before (5 months and 7 months before) , but it did not work as I
had serious withdrawal symptoms
2. Dr: Why did you try to Cut down before? I was having some health problems. I had some infections on my
arm where I used to inject myself.
3. Dr: Do you sometime get Annoyed when people talk about your habit? Mr Williams:No (sometimes yes,
because of my wife/ girlfriend)
4. Dr: Do you have any sort of Guilt feeling that you are using opioid?
Mr Williams: Yes, Doctor, Sometimes I feel guilty in front of my wife/ girlfriend.
5. Dr: Do you take them in the morning as well?(EYE OPENER) Mr Williams: Yes, Doctor. First thing I do in
the morning is to take these drugs.
6. Dr: Do you think that you have to take more and more drugs to get the same effect as before?(TOLERANCE)
Mr Williams: No, Doctor.
7. Dr : Do you feel you cannot do your daily activities without taking drugs? (Dependence) Mr Williams : Yes
8. Dr: How do you feel when you do not take these drugs?(WITHDRAWAL)
Mr Williams: Doctor, when I do not take these drugs, I feel restless, I start sweating and sometimes I feel
that my heart is racing. It happened to me 1 year ago.
9. Dr: What do you do for living? Mr Williams: I am on benefits  Do not give sympathy or empathy
10. Dr: Do you live with your family? Mr Williams: Yes girlfriend who also uses opioids.
11. Dr : Do you smoke or consume alcohol? Mr Williams: No
12. Dr: How is your mood? How would you grade your mood in 1 to 10 scale where 1 being low and 10 being very
happiest mood? Mr Williams: My mood is fine (8/10)
13. Dr:do you ever feel that someone is telling you to do things/or controlling your mind? Mr Wiliams:No
14. Dr: At any point, thought of harming yourself or ending your life? Mr Williams: No, doctor.
15. Dr: At any point, you have gone to wrong side of the law?(FORENSICS)
Mr Williams: No (sometimes he may say-I was arrested when I was young for pick pocketing).
I am really proud that you are here and tryint to be better.

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16. Dr : Do you ever see or hear things that other people seem unable to see or hear? (hallucination) Mr
Williams: No
17. Dr:Is there any Stress which is making you take this drug?(STRESSOR) Mr Williams:NO/Yes
18. Dr: Do you think this is affecting your health or social life /Family life?(Impact) Mr Williams: Yes doctor.
19. Dr : Do you think you need help? (Insight) Mr Williams: Yes Doctor.
Do not ask "Do you have a problem?" "Do not say are you willing to stop" "Do you really want to quit?"
20. Dr : How do you see your future? Mr Williams: Good if I can stop this habit
21. Dr:did you suffer from any mental health conditions in the past? Mr Williams:NO
22. Dr:do you have any other medical conditions? Mr Williams:No
23. Dr:Are you allergic to any medications?are you taking any medicines? Mr Williams:No
24. Dr:Do you have family history of any mental health conditions? Mr Williams:No
25. Dr : Thank you Mr Williams

C. Management: (6th minute Thank you for answering all my questions. it wil lactually
know better how to help you.)
1. As you know it is not good for health as well as for your social life. We can help you to quit the habit if you
are willing to do so.
2. We have a Drug de-addiction (DETOXIFICATION) programme which can help you where we can Admit and
rehabilitate. WE will Give you drug called LOFEXIDINE,TO HELP You with the withdrawal effects.
3. *We will also treat you symptomatically. For example: METACHLOPARAMIDE for Nausea
,LOPERAMIDE for Loose Motions, BENZODIAZEPAMS for Palpitations.
For your withdrawls symtoms , we have medication for each of them, (DO not tell the neames -except if he
asked a certain symtom)
4. *REPLACEMENT THERAPY:We have some medications called Methadone or Buprenorphine ( tell the
names of the medications to the patient) we can give you to help you.
IF he is worried about it  MEthdone is not as harmful as heroin. And we are going to bring it down and
tapper it down until you are ffree from that too. Because it is actualy going to be intolerable if we suddenly
take herion from your system. but if yo dont like it, we have other meidcations.
5. *We have talking therapies, such as counselling, can help you to understand and overcome your addiction and
plan for your future.

6. *We can refer you to a support group (self help group -Narcotics Anonymous ) where you can meet other
people with similar problems and share your experiences which can help you.
7. *Talk about NEEDLE EXCHANGE PROGRAM
Because yiou have mentioned you have shared or used needles it will be better for you if you get tested for HIV
AND HBV. Because people who are sharing needles have higher chances of getting those infection. IT is better
for treat this if you have it. And you need to avoid sharing after getting treated.
8. *Advise about his girlfriend – if your girlfriend wishes to stop her drug habit we can help her too. would u like
us to talk to her?
If you could convince your GF to come here to advice her .. it wuold be great,
If she does not want and as a last resort, please tell her to not share and use needles
9. Do you follow me? Any questions ?

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 8. Alcoholic Colleague
You are FY2 in the medical department. During ward rounds, you have come across your colleague, Dr.
Jonathan smelling of Alcohol. This is second time you have encountered him in this state. Take your
colleague to a private room and talk to him.

Follow the acronym

1. S = Seek information
2. P = Patient safety
3. I = Initiate
4. E = Escalate
5. S = Support
A.
1. Dr: Hello Jonathan, I am... How are you doing? Colleague: I am fine.
2. Dr: How’s the work going on? Colleague: It is going alright.
3. Dr: That sounds good. Have you been able to manage all the duties well? Colleague: Yes, I could manage.
4. Dr: I see. Well Jonathan, I'm a bit concerned about something. If you can take some time off of your ward work,
I'd like to talk to you privately about it.
Colleague: Yes, it's fine. I am free for now. We can talk now.
5. Dr: Well Jonathan, I have been noticing something for some time now. Is there anything you want to share with
me? Colleague: No, everything is alright.
B. (Seek Information)
1. Dr: Actually, today during ward rounds, I found you smelling of alcohol. Can we talk about it?
Colleague: No, you must be mistaken.
2. Dr: Well, Jonathan, I don't think it could be a mistake because it's the second time I've happened to notice this.
You know, you can share with me if something troubling is leading you to take Alcohol. Colleague: I might
have taken some last night but not today.
3. Dr: But Jonathan, I can still sense the smell of Alcohol. Colleague: I do not think I took too much of it.
4. Dr: I see. Did you drink in the morning? Colleague: I might have.
5. Dr: Could you please tell me since when have you been taking Alcohol? (Stressor & Duration)
Colleague: You see it's not that long. I started taking a few weeks ago when my girlfriend broke up with
me.
6. Dr: It must be distressing for you. Colleague: It is. I don't know what to do now when she's gone. I
am devastated.
7. Dr: I am so sorry Jonathan. Colleague: Thank you.
8. Dr: Could you please tell me how much do you drink daily Jonathan?
Colleague: (?) Just a bottle of whisky and few shots of gin.
9. Dr: Jonathan, I can understand that you are very gloomy but did you try to stop taking it or reduce the amount?
(Cut Down)
Colleague: Not really. I have been miserable you know. I miss my girlfriend.
10. Dr: Alright. I can realize that your mood is low Jonathan, could you grade it for me on the scale of 1 to 10?
Colleague: 8 out of 10.
11. Dr: Do you live with your family Jonathan?
Colleague: I live in the hospital accommodation. My parents live in some other part of UK.

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12. Dr: Have you got any friends in here? Colleague: I do hang out with my friends some times.
13. Dr: That is good. Could you tell me if you have noticed that drinking has been impacting your life and work?
Colleague: (No?)
14. Dr: Have you ever come to ward before like this? Colleague: No.
15. Dr: Have you encountered any similar problems before? Colleague: No.
C. (Patient Safety)
1. Dr: Could you please tell me what time did you start working in the ward today?
Colleague: I started in the morning.
2. Dr: Jonathan, I need to tell you that for the wellbeing of patients, it's important that we review all the patients
you have been seeing since morning. This is because under the effect of Alcohol, you might have missed some
necessary steps in providing the best possible care to patients. Are you following? Colleague: Yes.
3. Dr: Could you please tell me how many patients did you see Jonathan? Colleague: (?)
4. Dr: Did you happen to look after any patient who seemed to require an emergency care or immediate referral?
Colleague: (?)
5. Dr: You see Jonathan, all of us want what is the best for our patients, I feel you should stop working now and
take rest for the rest of the day, what do you say ?
Colleague: That is right. I can understand. What will happen with them?
Dr: Well, I think these patients need to be reviewed. Do not worry. I will take care of that for now. Colleague:
Thank you.
D. (Initiate)
1. Dr: I can see that you are having some troubles and that's why you're consuming alcohol. I would appreciate if
you can understand how it can impact our work place. Are you understanding? Colleague: Yes.
2. Dr: As you know, our patients could be very sensitive Jonathan and it is important that we are not under effect
of anything toxic that can affect our judgement while dealing with the patients. What do you think?
Colleague: I can understand.
3. Dr: I am pleased that you understand. I can see that you wish the best of health for your patients. So, I would
like to suggest you that it'd be better for you if you take some time off from your work. What do you say?
Colleague: I still don't think it is that big an issue. Also I have my annual leave starting after 2 weeks. I
am going to stay with my parents.
4. Dr: Jonathan, it is important to us that patients do not get affected by this. In such circumstances, any negligence,
although involuntary, can lead to a complaint against you. And NHS takes such complains very seriously. A
strict action could be taken against you if a patient gets harmed. It can even cost you your registration with
GMC. Now, I know you don't want that. Isn't that so? Colleague: Yes.

E. (Escalate)
1. Dr: Also, I would like to let you know that we need to inform the Consultant about this. It'd be better that you
do that. What do you say Jonathan? Colleague: Is it really necessary?
2. Dr: Yes, Jonathan it is really important that our senior know this.
Colleague: Will you tell the consultant?
3. Dr: If you don't I am afraid I have to because it is crucial for the safety of patients. I think you will agree with
me at this. Also he may come to know from others even if I don't tell him. It may be better that you tell this to
him yourself rather than others. Will you do that?
Colleague: Thank you for your suggestion.

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 F. (Support)
1. Dr: Jonathan, I must remind you that a range of help is available for you to cope with this difficult time. Would
you like me to tell you some options? Colleague: Yes.
2. Dr: First of all, you should consider taking your time off from work for some days. This will allow you to relax
and will help you deal with your situation with open mind. Would you consider that? Colleague: But what
about my duties?
3. Dr: I can see that you are really concerned about your work but you do not need to worry because I can provide
your replacement until the department makes necessary arrangements for it. Colleague: Thank you so
much for that.
4. Dr: Also Jonathan, I think you need support from your loved ones, I would suggest you that you let your family
and friends know about this. They might be able to assist you deal with this hard time. Also, you might be able
to go to your parent's place for some time. It might do you a great deal of good. What do you think?
Colleague: Yes, I would consider that.
5. Dr: Also, as you would be talking to consultant, he might also be able to assist you.. Okay?
Colleague: Yes.
6. Dr: You also know that we do have all kinds of psychiatric help available. Some talking therapy might help
you. Our consultant will be able to assess you for that. Is that okay? Colleague: Okay.
7. Dr: Do you have any concerns Jonathan? Colleague: No, thank you for your help.
8. Dr: You can totally rely on me. Let me know if there is anything troubling you. Colleague: Okay. Thank you.

9. Cocaine Abuser - Final Year medical Student

You are FY2 doctor in the ward.
You went to a birthday party last night. There was a final year medical student, Joan Halas whom you suspect
was drinking heavily and was snorting cocaine. In the morning at work, you have found the medical student
agitated and hyper excited. You overheard the nurses making fun of him, saying that he snorts cocaine at work.
Talk to the medical student, and assess whether or not it is safe for him to stay in the hospital.
A.
1. Dr: Hello Joan, I am... How are you doing? Student: I am fine.
2. Dr: How are the studies going on? Student: It is going alright.
3. Dr: That sounds good. Are you learning how to taking history or examining patients in the ward? Student:
yes I am.
4. Dr: I see. Well Joan, I'm a bit concerned about something. If you have some time, I'd like to talk to you.
Student: Yes, it's fine. I am free for now.
5. Dr: Well Joan, I happen to be at a birthday party last night. It seems that you also have been at the same party.
Isn't that so? Student: Yes, I was out with friends last night.
6. Dr: I see. Joan, don't mind me asking you this, did you take any drugs when you were hanging out with friends?
Student: No, I did not.
7. Dr: Well Joan, I myself saw you snorting drugs. Student: Oh! you were there?
8. Dr: Yes, Joan I was. Student: It must be someone else. Are you sure you saw me?
9. Dr: Yes, I am sure. Also, I saw you drinking heavily. Is that right Joan?
Student: Will you keep it confidential if I tell you?

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10. Dr: You see it is very important that we talk about this. I might be able to assess you once we talk and maybe
we can determine how we can solve it right here. Sometimes, we might need to get some help but in any
case, this issue will always remain inside the medical team.
Student: Okay. I might have taken some drugs. But I have never done drugs at the work.
11. Dr: I have come to know that nurses have been talking about you snorting cocaine at work place and that you
have been behaving a little different. Student: I don't think so.
12. Dr: Well, Joan, have you been feeling agitated or excited more than usual ?
Student: I am feeling completely normal. Besides that, everybody do drugs nowadays. I don't think it is that
big a deal. Don't you do drugs?
13. Dr: Well, Joan, I do not and also, I think that considering the environment we are working in, no health care
provider could afford to do anything like that. It would be wrong if we are not careful while being in the vicinity
of patients. It, in fact, is a very concerning matter.
Student: But I have never done anything wrong. I am doing very well in studies, you can confirm from my
supervisor too.
14. Dr: I really appreciate that you are studious about academics Joan but this matter is of a great ethical
importance. I would like to ask you some questions in order to get into the bottom of this. Student: But I
do not think I took too much of either of the two.
B.
1. Dr: I see. But did you take it in the morning? (Seek Info) Student: I might have.
2. Dr: Could you please tell me since when have you been doing drugs and taking Alcohol? (Duration) Student:
I have just done it. Not more than once or twice.
3. Dr: Was there any incident like sad or shocking or anything that might have lead you to start it? (Stressor)
Student: No. Everything is fine.
4. Dr: Could you please tell me what drugs do you take? Student: Cocaine.
5. Dr: How much are you taking daily? Student: (?)
6. Dr: I see. Could you please tell me how much do you drink daily Joan?
Student: Just a bottle of whisky and few shots of gin.
7. Dr: Joan, I can understand that you are not taking it for very long time but did you try to stop taking the
cocaine and alcohol or reduce the amount? (Cut Down)
Student: Not really. I don't think it is too much.
8. Dr: Alright. Could you tell me how has been your mood lately? Grade it for me on the scale of 1 to 10?
Student: 10 out of 10.
9. Dr: I can see that you have friends and you like hanging out with them. Do you live with your family Joan?
Student: Yes/No
10. Dr: Any trouble with the law? Student: No.
11. Dr: That is good. Could you tell me if you have noticed that drugs have been impacting your life and studies ?
Student: (No?)
12. Dr: Have you ever come to ward before like this? Student: No.
13. Dr: Could you please tell me what time did you come to the ward today? Student: I started some time ago.
14. Dr: Joan, I need to tell you that for wellbeing of patients, it's important that we review all the patients you
have been seeing since morning to check any trouble or harm has been caused to patients. Are you following?
(Patient Safety) Student: Yes.

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 Student: That is fine. But I still think I did not do anything wrong.
15. Dr: I can see that you have the notion that taking drugs is not that big an issue but I would appreciate if you
can understand how immensely it can impact our patients. Are you understanding? (Initiate) Student:
Yes.
16. Dr: As you know Joan, one day, you are going to get into the professional medical field. It is very crucial that
you learn about patient safety and medical ethics now. You must try to understand that medical professionals
should not be under effect of anything toxic that can affect their judgement while dealing with diseased
patients. What do you think?
Student: Yes, I can understand.
17. Dr: I am pleased that you understand. I think you also wish the best of health for the patients. So, I would like
to suggest you that it'd be better for you if you do not stay at hospital today because you are under the effect
of drugs and alcohol. What do you say?
Student: I am not harming anyone.
18. Dr: Well Joan, I understand but it is important that patients do not get affected by your behaviour in any way
whatsoever. Also if you do not rectify your mistakes now, it might lead you into some trouble later on. Your
negligence can lead to a complaint against you. And such complains could be taken very seriously by NHS. A
strict action could be taken against you if a patient gets harmed. Now, I know you will not want that. Isn't that
so? Student: Yes.
19. Dr: Also, it is essential that you inform your Education supervisor about this. It'd be better that you do that.
What do you say Joan? (Escalate) Student: Is it really necessary?
20. Dr: Yes, Joan it is really important that your education supervisor know about this. I think you will agree with
me at this. Also he may come to know from nurses even if I don't tell him. It may be better that you tell this
to him yourself rather than others. Will you do that?
Student: Okay, I will go straight to my supervisor. Thank you for your suggestion.
21. Dr: Joan, I must remind you that a range of help is available. Would you like me to tell you some options?
(Support)
Student: Yes. What kind of help are you talking about?
a. Dr: As I would sincerely advice you to quit this habit Joan, you might need to know that some medicines
are available that could help you if you have trouble dealing with you cravings and for your withdrawal
symptoms once you stop doing drugs. Also Psychiatrist can help you if you need. Is that okay? Student:
All right.
b. Dr: Joan, I also think you better avoid going out to places that will make you want to do drugs and
drink.
c. I would suggest you that you let your friends know about this and how important it is for you to not
involve in drugs.
d. They might be able to understand your situation or you might avoid going out to such pubs and parties.
This will do you a great deal of good. What do you think? Student: Yes, I would consider that.
e. Dr: As you would be talking to your supervisor, he might be able to tell you if you need some time off
from your ward duties or not. Is that alright? Student: Okay.
22. Dr: Do you have any concerns Joan? Student: No, thank you for your help.
Dr: Once again Joan, you can totally rely on me if you ever encounter any problem in future. Let me know if
there is anything troubling you. Student: Okay. Thank you.

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 10. Drug Addict wants a Self-Discharge
You are FY2 Doctor in acute medical care unit.
A 27 year old lady, Miss.… has been admitted to the acute medical care unit. Patient is a known drug addict
and a diagnosed case of Infective Endocarditis. Patient has been started on intravenous antibiotics. To
complete treatment, patient needs IV antibiotics for several weeks as an inpatient.
Nurse has come to you and informed you that patient wants self-discharge.
Talk to the patient, inquire why does she want self-discharge and address her concerns.
A.
1. Dr: Hello, I am Dr…. I am one of the junior doctors in the medical department. Are you Miss…? Patient:
Yes doctor.
2. Dr: How are you doing Miss…? Patient: I do not like this hospital doctor. I want to go home.
3. Dr: Miss… could you please tell me why you do not want to stay in the hospital?
4. Patient: The nurses are very rude to me.
Dr: I am really sorry if someone misbehaved with you. I will look into this matter. Please do not be upset. Could
you please tell me what really happened?
5. Patient: No doctor, I do not want to stay in this hospital any more. I want to get discharged. Please
discharge me.
Dr: Well, Miss… could you please explain to me why you do not want to stay in the hospital. If you tell me
what is bothering you, I will be able to help you.
6. Patient: No doctor, nurses have been very impolite with me. They are calling me drug abuser. I want to
go home.
Dr: Well, Miss… I can clearly understand that you are very much offended by what happened and I apologize
to you for such behavior but it is very important for you to stay admitted in the hospital as we need to give you
medicines through your veins. However, I want to reassure you that if you can tell me what happened, all the
information you give me will be kept confidential within our team. Could you please open up to me about the
matter?
7. Patient: Doctor, you see, it is also because nurses object that I cannot smoke cigarettes in the hospital.
Dr: I see. I can understand that you must be very troubled by all this. I apologize to you again. However, I
would like to tell you that it is important for you to stay admitted.
8. Could you please tell me how much do you know about your condition?
Patient: I have been told that I have infection in heart.
Dr: Yes, you have been told right Miss… You have a condition called Infective Endocarditis. This is an
infection that affects the tissue that lines the inside of the heart chambers. This results in significant damage to
heart valves. Also, it can cause other serious complications if it is not treated quickly with antibiotics. Are you
following me?
9. Patient: Yes, doctor. But I do not want to stay in the hospital. Why should I stay in the hospital?
Dr: You see, Miss… it is a very serious infection and can be even life-threatening if not treated in time. The
earlier the condition is treated, the better the likely outcome.
10. Patient: But you can give me antibiotic tablets doctor I can take them at home.
Dr: Miss…Unfortunately this condition cannot be treated with just antibiotic tablets. Tablets are not as effective
as injections into veins. That is why we want you to stay in the hospital so that we can give this antibiotics
through your veins.

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11. Pt: I can’t stay here. Nurses don’t let me smoke and it is not bearable for me to continue without it. Can’t
I just pop out and smoke ?
Dr: I can understand why you are so upset. It must really be very distressing for you.
Well you can pop out and smoke but it is not advisable at all.

B.
1. If you do not mind, I will be asking you some questions about your general health, if that alright with you.
Patient: Okay.
2. Dr: Could you please tell me how much do you smoke? Patient: 20 cigarettes per day.
3. Dr: I see, and for how many years? Patient: ?
4. Dr: Do you take any recreational drugs? Patient: I take heroin. Dr: How much? Patient:
5. Dr: For how long have you been taking it? Patient: Years/months
6. Dr: How do you take it? Patient: I inject it through my veins.
7. Dr: And do you exchange needles? Patient: No doctor.
8. Dr: That’s good. And have you ever tried to cut it down or stop it altogether? Patient: No doctor, I cannot.
9. Dr: I see. Could you please tell me how has been your mood lately? Patient: I feel very alone doctor/feel
very low
10. Dr: And why is that? Patient: I do not have any friends.
11. Dr: I am really sorry about that. Could you please tell me what work do you do? Patient: I am jobless.
12. Dr: And where do you live? Do you live with your family? Patient: I am homeless doctor. I have no
family.
13. Dr: It must be really upsetting for you Miss… I can recognize that you have a very stressful life. However, I’d
like to tell you that a lot of help is available for you to cope with this state of affairs. Do you know why this
condition would have happened to you ?
Patient: Why doctor?
Dr: Miss…. unfortunately, people who inject street drugs may also inject bugs/germs into their bloodstream if
they use dirty or contaminated needles. These bugs may then settle on a heart tissue. The infection can damage
heart valves and may spread to other areas of heart tissue. Unfortunately, this might have happened and lead
you to develop this infection in the heart.
14. Pt: But doctor I just want to go home.
Dr: Miss … If you do not get treated now serious complications usually develop -for example, it can lead to
problems such as heart failure. Sometimes the infection can spread to other organs and can cause damage to
the other organs too. It can life threatening too if you do not stay in the hospital and get treated. That is why it
is very important that you stay in the hospital and get treated.
15. Patient: But I can’t smoke can’t do anything here.
Dr: I would sincerely advice you to consider quitting smoking. Smoking is not only hazardous to your lungs
but to your heart also. It can worsen your condition in the heart. I know that it must be really unbearable for
you to not smoke. We can give you help to cut it down and quit it. However, for now if you really want it we
can give nicotine patches. Is that Ok? Pt: May be yes.
16. Dr: Also, I would like to tell you that we can provide you help to cut down on drugs. We have a lot of medicines
available to help you cope this.
Pt: You will only give Methadone!
Dr: Miss… We have many different options to help you cut down on using drugs. I will tell you what your
options are. In order to reduce the craving of the drug, we can give you medicines. Also, in order to decrease

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 withdrawal symptoms we can give you another medicine called Lofexidine. Also, we might later on refer you
to some support groups to help you quit drugs. Would you consider it? What do you think about it?
Patient: Well I will think about it.
17. Dr: So would you consider staying in the hospital for getting this infection cleared off from you? Patient:
Yes, doctor I would.
18. Dr: Is there anything else you want to know?
Patient: No doctor, you are very kind. Dr: Thank you very much Miss…

C. If the patient still not convinced.

1. Dr: I am sorry that I wasn’t able to convince you about the importance of you staying in the hospital for the
treatment. You do have the right to refuse any treatment what we advise.
2. However, I will talk to my seniors and may be they will be able to convince you about it. If you still do not
want to stay in the hospital you can sign a “self - discharge form” and then you can go home. Thank you very
much for talking to me. I really wish all the good health for you Miss..

11. Insomnia
Exam Scenario for Insomnia
You are the FY2 doctor in the Rhuematology clinic
Mrs Sarah Johnson, 60 years old lady, has come to the Rheumatology clinic for the follow up
because she was diagnosed with Rheumatoid arthritis. She is on Paracetamol and Methotrexate
and Folate for RA. She complains of unable to sleep.
Talk to her and address her concerns.
A.
1. Dr: Hello Mrs Johnson, I am Dr. … of the junior doctor in the medical department.
How are you doing today ? Mrs Johnson: I am Ok doctor
2. Dr: What brought you to the hospital? Mrs Johnson: I have difficulty in sleeping.
3. Dr: I am really sorry to hear that. When did it start? Mrs Johnson: It started 6 months before.
4. Dr: Can you please tell me about your difficulty in sleeping? Do you find it difficult to sleep when you
go to bed or difficulty in maintaining sleep or you wake up early in morning?
Mrs Johnson: I get into bed at 9 or 10 o’clock but I can sleep only after 3 o’clock.
5. Dr: Has anything happened recently which might be the cause of this problem - like any sad or
shocking news ? Mrs Johnson: Yes doctor, Mr Johnson died.
6. Dr: I am really sorry to hear that. How did he die? Mrs Johnson:He Died of heart attack
7. Dr: How was your mood after your husband died?
Mrs Johnson: I was depressed initially but now I am Ok. Only sometimes when I get into bed I think
about him and I miss the time which we spent together. My mood is very low if I don’t get sleep ( this
is not depression).
8. Dr: You keep thinking of him in the night ! Is this what is causing lack of sleep?
Mrs Johnson: No doctor.
9. Dr: Do you have any medical or mental health problems ?
Mrs Johnson: I am diagnosed with Rheumatoid Arthritis.
10. Dr: Are you in pain nowadays because of this condition?

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 Mrs Johnson: No doctor. Pain is well controlled with Paracetamol, methotrexate and Folate. ( non of
these drugs cause insomnia)  I can check BNF for methotrexate
11. Dr: Do you take any other medication apart from these medications?
Mrs Johnson: No doctor.
12. Dr: Do you have any other symptoms like – shortness of breath in the night, have to go to the loo
many times in the night ( incontinence)? Mrs Johnson: No doctor.
13. Dr: How is the sleeping condition at your home? Is there any noise? Too bright lights disturbing you
?
Mrs Johnson: No problem at all. ( Sometimes she may say neighbours are very noisy in the night.)
14. Dr: Is the bedroom too hot or cold? Mrs Johnson: it is fine.
15. Dr: Are you working? Mrs Johnson: No
16. Dr: Do you have any stress or worries ? Mrs Johnson: No
17. Dr: Do you drink alcohol? / Do you smoke/Use recreational drugs? Mrs Johnson: I do not drink
alcohol/NO
18. Dr: Do you drink tea/ coffee before going to bed?
Mrs Johnson: No. (sometimes she says - 2 cups of coffee in the morning), (sometimes she says she
drinks coffee in the night)
19. Dr: Is the bed or pillow uncomfortable? Mrs Johnson: No
20. Dr: Do you sleep in the day time ?
Mrs Johnson: No ( sometimes she may say -Yes because I do not get sleep in the night I take a short
nap in the afternoon).
21. Dr: Do you keep watching TV or computer until late in the night ?Mrs Johnson: No.
If she is doing somehting good in sleep hygien  praise her
B. ASK QUESTIONS RELATED TO THOUGHTS, PERCEPTION, IMPACT
(Work,Family,Social Life)
C. Diagnosis & Management:
D. Counselling:  if she does not say any reason for insomnia and it is 6th minute
alarm  you can ask "have you tried anthgin to help you sleep?"
1. Dr: Mrs Johnson - There are many reasons why people do not get sleep. In your case though the
cause is not very clear sometimes people who have Rheumatoid arthritis do have this problem -
sometimes due to pain, but sometimes it can happen without any known reasons in patients with
this condition.
2. However you can I improve my sleep by what we call sleep hygiene - use a sleep diary to keep
track of your sleeping habits
If you forget to write --> Write it on the early morning when you wake up
3. If she is doing any of the following then advise accordingly:-
• Avoid sleeping during the day ( sometimes she is sleeping in the day time)
• Avoid tea, coffee and any other products that contain caffeine after midday (sometimes she drinks
too much coffee in the night time)
• Don’t eat or drink large amounts just before bedtime
• Avoid drinking alcohol if your sleep is disturbed
o WEll you see I know that the warm milk is very good but mixing it with brandy is actually
contradicted. I actually want you to keep away from it. --> that is the cause "i need to keep
asking her till she tells me that"

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• Don’t smoke before bedtime or during the night
4. Sometimes she may say – her neighbours are too noisy – you can request them not to make too
much noise if they do not listen – you can report to the council)
• Exercise regularly (but not within three hours of going to bed)
• Keep the bedroom dark, quiet and at a comfortable temperature
• Check that your mattress and pillows are comfortable
• Set up a relaxing routine – try to go to bed and wake up at the same time each day
• Take a warm bath before going to bed.
5. Relaxation techniques and Talking therapy (CBT) may also be help you. We will refer you to the
Psychiatrists who are experts in this.
6. Mrs Johnson: Doctor will you give me sleeping pills ?
Dr: There are many sleeping pills but they have side effects and they may cause addiction and also
medications may not help in the long term. Medications are not recommended for more than four or
five weeks. However if nothing else helps we can consider giving you sleeping pills
If it is necessary to give you sleep meidication, Defenitely we will give you sleep medication. But first
my seniors will review your medicationa nd condiion. And can you try sleep hygien for few day and
see if it works you might not even need sleep medication. Now, the reason why we do not want to
start sleep medication is that you become very dpeendent on them to the point that you cannot fall
asleep except with the help of them.
But if another methods did not work, we might consider sleep medication, Are you okay with that?
7. Is it OK ? Mrs Johnson : Ok doctor I will try.
8. Dr: We will keep following you up. Thank you very much.

12. PANIC ATTACK

Scenario - 12
Miss Sarah Jones, 25 years old lady has been referred to the hospital by her GP. She went to GP because
she thinks that she is very anxious nowadays. All investigations have been done and are normal. You are
SHO in the hospital. Take history from Miss Jones.
[ This station is only history taking]
A.
1. Dr: Hello Mrs Jones, I am Dr… one of the junior doctor in the Psychiatry department. How are you doing ?
Miss Jones: I am very worried doctor.
2. Dr : What are you worried about ?
Miss Jones: Dr, I become anxious nowadays. I Feel like my heart is racing and mouth is dry. Sometimes,
I even have choking sensation.
3. Dr: When did it start? Miss Jones: It started few months ago.
4. Dr: When was the last time you had symptoms?
Miss Jones: I had these symptoms two weeks ago when I went to the party and I met my family members.
5. Dr: Can you please tell me, how did it start at first time?
Miss Jones: It started when I was at shopping centre. And I started having symptoms.
6. Dr: Do you have any idea what can be the cause of these symptoms, any recent change/incident in your life?
Miss Jones: Yes doctor. My husband left me 8 months ago, and I got divorced after that.
7. Dr: Is there any particular thing which makes you anxious?

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 Miss Jones: No doctor. However, it happens when I go out.
8. Dr: Does it affect your daily life? Miss Jones: Yes.
9. Dr: How does it affect your life? Miss Jones: I cannot go out nowadays as I am afraid that if I go out I
might get these symptoms.
10. Dr: Do you have any concerns about your life, any responsibility?
Miss Jones: Yes, Doctor, I am concerned about my three kids.
11. Dr: Do you have any family to support you? Miss Jones: Yes, Doctor my sister supports me.
12. Dr: What do you do for living?
Miss Jones: I am not working right now; I lost my job 4 months ago.
13. Dr: How has been your mood? Miss Jones: It has been good
14. Dr: Have you ever thought of harming yourself? Miss Jones: No
15. Dr: Do u drink alcohol? Miss Jones: doctor, I am really worried about my heart.
16. Dr: Don’t worry, my GP colleague did all the investigations and fortunately everything is fine and there is
nothing wrong with your heart. ( Mention this only if the patient ask you this question, otherwise just say “thank
you very much for all the information”).
17. [This is only history taking station]

13. SSRI Counselling ( Fluoxetine) ( Antidepressant)

Key Points: In this station, you must emphasise the importance of staying on the medications to achieve the best
beneficial effect.

Scenario – 13
Mr Jeremy Williams 30 years old man has been referred to you from GP. This man was prescribed
paroxetine. Talk to the patient and address patient’s concern.

1. Dr. Hello Mr Williams I am Dr… One of the junior doctor in the Psychiatry department. How are you doing
today? Pt: The medicine what you gave me is useless doctor.
2. Dr: Why do you say that? Pt: They are not at all helping me.
3. Dr: Which medication are you talking about ?
Pt: I was prescribed this medication 10 days ago because I was feeling very low.
4. Dr: Do you take it regularly? Pt: Yes.
5. Dr: Are you still taking the medication or have you stopped taking them.
Pt: I am still taking them.
6. Dr: Mr Williams, unfortunately you may not see the effect of this medication within 10 days. It takes 4-6 weeks
to build up its best effects so please continue your medication regularly. Please do not stop taking this
medication on your own. You will see the effect in the next few weeks.
7. Dr: Do you have any other concerns about this medication ?
Pt : I heard that it can cause problems with sex life. Is that true ?
8. Dr: It is true. It can very rarely cause sexual dysfunction like low sex drive or erectile problems. However we
will keep monitoring the medication. Any other concerns ?
9. Pt: Do they have any other side effects ?
Dr: Yes, Common ones are headache, vomiting, diarrhoea or constipation and sometimes stomach ache.It can
either make you very sleepy or you may not get good sleep at all. This medication might cause poor sleep. So
please don’t take it in night, take it early morning.
10. Pt: Doctor is it addictive?

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 Dr: It is not addictive. We will not stop this medication suddenly. We will gradually decrease the dose of
medication. So you will not experience any side effect.
11. Dr: Do you have the feeling of harming yourself or ending your life ?
Pt: No ( is he says yes – admit him)
12. Dr: If at all you get these feelings any time later please do come back to us. We will keep following you up.

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 14. Bipolar disorder
Scenario – 14 ( This station assesses your ability to take history in a patient with elevated mood).
Miss Sarah Collins 30 year lady was brought into the hospital with cuts on her wrists. Medical management
has been done and she is medically stable.While she was in the hospital nurse noticed strange behaviour.
You are the SHO in the Psychiatric department. Talk to the patient and tell your diagnosis to the examiner.

1. Dr: Hello Mrs Collins I am Dr… How can I help you ? Pt: I cut my wrists
2. Dr: I am sorry to hear that. How did this happen?
Pt : Doctor, I have a very nice dress and I wanted to buy a matching shoe. When I went for shopping for the
shoe shop was closed. I saw a pair of perfectly matching shoe on the glass window of the shop, so I smashed
the window to get the shoe and I got hurt on my wrist.
3. Dr: I am very sorry to hear that. But why did you smash the window?
Pt: Oh doctor I was in a very good mood.
4. Dr: Has this happened to you before. Pt: Doctor I am very happy since the last two weeks.
5. Dr: Is there any particular reason why you are so happy? Pt: Nothing special.
6. Dr: Has this happened to you before ?
Pt: No doctor in fact some time ago I was very depressed and I left going to the University.
7. Dr: When was that ? Pt: This happened about a month ago.
8. Dr: Why were you so depressed ?Pt: I do not know why.
9. Dr: How is your mood now in the scale of one to ten, one being lowest mood and 10 being the happiest mood
? Pt: 10 out of 10 doctor.
10. Dr: Have you ever had low mood ? Pt: I was feeling very low about a month ago.
11. Dr: Do have any thoughts of harming yourself or ending your life ?
Pt: No doctor. I used to have that feeling before but now I am very happy.
12. Dr: Have been treated for depression or any other mental health problems before? Pt: No
13. Dr: What do you do for living ? Pt: I work as a waitress in hotel.
14. Dr: Are you financially stable? Pt: No doc. I am almost bankrupt.
15. Dr; Have you ever been involved in any legal problems? Pt: No
16. Dr: Who do you live with? Pt : My parents but we don’t have good communication.
17. Dr: Do you hear any noises when no one else is around? Pt: No doctor
18. Dr: Do you think you have any mental health problem? Pt: No
19. Dr: Do you have any problems with the sexual life? Pt: No
20. D: Do you drink alcohol? Pt: No
21. Dr: Do you use any recreation drugs? Pt: No
22. Dr: Thank you very for all the information.
23. Tell you diagnosis to the examiner: Bipolar disorder.

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 15. Suicide attempt/self harm risk assessment – Depression (Suicidal
attempts)
Scenario - 2 . Mr Graeme Hick, 35 years old man was brought to the hospital because he had taken overdose
of Paracetamol Tablets. He was admitted and treated for this. His condition is stable medically. You are the
SHO in psychiatric department. Do Psychiatric Assessment and discuss the Suicidal Risk for Mr Graeme
with the examiner. (Question can be do mental state examination / Please do MSE “OR” please do
psychiatric assessment “OR” please take detailed psychiatric history). GRIPS ( Do ABS in your mind, Ask
about – present, past and future ( Suicidal risk)

A.
1) Dr: Hello Mr Hick. I am Dr ….. How are you feeling? Mr Hick: Doctor, I do not want to live.
2) Dr: Mr Hick, Why do you not want to live? Mr Hick: I have gone through a lot.
3) Dr: I am sorry to hear that. Did you try to harm yourself in any way ? Mr. Hick – I took some paracetamol
tablets
4) I am so sorry you went into that stiaution. Can you tell me ..?
I need to make sure that she is stable -- That she has been treated that she is medically stable. BEFORE
getting ino psychiatry history.
5) Dr - When did you do that? Mr Hick: Today morning.
I know this is so sstressful situation and such sad situation But When this happened Did you write anu letter or
suicide note to anyone? Did you send any goodbye letter to anyone at home?
6) Dr: How many tablets did you take? Mr Hick: I took about 40 tablets.
7) Dr: Was there anyone with you? Mr Hick: No, Doctor.
8) Dr: Who brought you to the hospital? Mr Hick: My wife
I am really glad you came to us and that you did not lose time
9) Dr: Have you done anything like this before? ( Past) Mr Hick: Yes / No
Before this happened, How has you ever thought of harming yourself?
10) Dr: Did you plan it? Mr Hick: Yes Dr: Did you write suicide note? Mr Hick: Yes
11) Dr: Did you inform anyone before doing it? Mr Hick: No
12) 1- I needto ask if anyone made you this? Did anyone ask you to do this?
13) Dr: Will you do it again? ( Future ) ( How do you see your future ?) Mr Hick: As I told you, I don’t want to
live. / I may do it again / I am not sure.
DO you think you could be inclined to harming yourself again/ that this might happen ggain?
I am very glad to hear that . it s good to know. I a mvery happy for you
14) Dr: How is your mood nowadays? Mr Hick: Not good.
15) Dr: How would grade your mood, 1 being the saddest and 10 being the happiest? Mr Hick: Very Sad, I would
say 3/ 10.
16) Dr: It might sound bit irrelevant but I need to ask you few questions, Can you please tell me what day is
today?/Where are you now? (Cognition) Mr Hick: (He will give you correct answers )
17) Dr: Do you live with family? Mr Hick: Yes. (But I do not like my family)
18) Dr: Do you have friends? Mr Hick – No
19) Dr: Are you currently in financial trouble, are you working?
20) Dr: Do you have any problem with the law ?
21) Dr: Do you know why you are in the hospital? Do you need any help (Insight) Mr Hick: Yes

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22) Do not ask insight in this station.
B.
1) Dr: 'I'd like to ask you a couple of questions about things sometimes people have but may find difficult to talk
about. I ask everyone these questions.
2) “Have you ever had experiences of hearing noises or voices when there was nobody around?” Mr Hick: No
3) Dr: “Are your thoughts actually taken out or sent out of your mind? / Do there seem to be thoughts in your
mind which are not your own; which seem to come from somewhere else?”
4) “Do your thoughts seem to be somehow public; not private to yourself, so that others can know what you are
thinking?” Mr Hick:No Dr: Thank you, Mr Hick.
C.
1) Give your inference to the examiner( stop Hx at 6 min bell  if she is tlaking or I am talking  continue that
till a pause and shift to the diagnsosi and the management): -
2) I will admit the patient. My patient very depressed and has high suicidal risk because 1) He planned to harm
himself 2) He made a suicide note 3) he may do the same again in the future and 4) His mood is very low. Do
not says poison infomration center in paraceamol because it is GP role..

Scenario – 3 28 years old Ms Isabella Jane was brought to the hospital because she has cut her wrist. She
was admitted and treated few hours ago. Her condition is medically stable. You are SHO in psychiatry
department. You have been asked to do suicidal risk assessment, and discuss your management (inference)
with the examiner.

B.
1) Dr: Hello Ms Jane. I am Dr … I am here you help you. Could you please tell me what really had happened ?
Isabella: Doctor I cut my wrist.(IF PATIENT DOESN’T SPEAK,OFFER CONFIDENTIALITY)
2) Dr: I am really sorry to hear that. How are you feeling now? Isabella: I am okay.
3) Dr: Why did you try to harm yourself?
Isabella: I did it because I had some misunderstanding with my boyfriend. ( sometimes she may say “ I
had a row with my boy friend )”
4) Dr: When did this happen ? Isabella: A few hours ago.
5) {DURING}Dr: Where were you when this happened ?
Isabella: I was in the bathroom when I cut my wrist. After that, I screamed. My boyfriend was watching
football downstairs. He heard me and then, he brought me to the hospital.
6) Dr: Was there any one with you at that time? Isabella: I was alone when I cut my wrist (sometimes she
may say - my boyfriend/ mother was present in the other room and came into the room after I cut my
wrist )
7) Dr: I am sorry to ask you, but do you drink alcohol? Isabella: Yes, Occasionally
8) Dr: Were you under the influence of alcohol when this happened? Isabella: I had couple of glasses of wine.
9) {BEFORE}Dr: Did you plan this? Isabella: No
10) Dr: Did you inform anyone about this? Isabella: No Dr: Did you write any suicide note? Isabella: No Dr: Was
the wound deep? Isabella: No, it was not deep.
11) Dr: How is your mood now? Can you please grade your mood in 1 to 10 scale where 1 being low and 10 being
very happy? Isabella: My mood is okay. I would say 8/10.
12) Dr:do you feel /see/hear noises when nobody is around? Issabella:NO
13) Dr: Do you feel that somebody is trying to tell you to do things/or Is reading your mind? Isabella:NO
14) Dr:do you smoke/do you use recreational drugs? Isabella:NO

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15) Dr:do you think that this will affect ur family life/work/social life? Isabella:NO
16) Dr: Have you ever tried to harm yourself before? Isabella: No
17) {AFTER}Dr: How do you see your future?
Isabella: Brilliant, I am very happy with my boyfriend, He is very helpful.
18) Dr: Are you going to do this again? Isabella: No, Doctor. I am not happy about what has happened.
19) Dr: Do you have any medical condition? / are you taking any medication?/Allergic to any medications Isabella:
No
20) Dr:did you have any mental conditions in the past? Isabella:NO
21) Dr:do you have any Family history of any mental conditions? Isabella:NO
22) Dr: Do you live alone? Isabella: No, I live with my boyfriend.
23) Dr: What do you do for living? Isabella: I work in a coffee shop.
24) Dr: Did you have any problem with law? Isabella: No.
25) Dr: Thank you very much for all the information you have given me. We will try our best to help you.
I need to contact poison information center ..After my seniors say it is ok for us to send you home --> we will
send you home. But i want yo to come after few weeks for a review
26) Tell your management to the examiner
From the history, Isabella has low suicidal risk (insight is present, mood is 8/10, regretful, happy with boyfriend,
has job). I will discharge her after discussing with my seniors and arrange for follow-ups. ( No admission)
If she wants to stay in hispital and do not return back home --> say to her it is ok

Scenario – 4 16 years old Ms Jessica Thompson was brought to the hospital because she cut her wrist and
took overdose of OCP pills. You are FY2 doctor in psychiatric department. Take history from the patient
and discuss the management with her.(OFFER CONFIDENTIALITY,IF PATIENT DOESN’T SPEAK).
START WITH ONSET, DURATION, THEN DO BEFORE,DURING,AFTER)

B.
1) Dr: Hello Ms Thompson, Can you please tell me, what brought you to the hospital?
Jessica: I took pills and cut my wrist.
2) Dr: I am really sorry to hear that. How are you feeling now? Jessica: I am okay.
3) Dr: can you please tell me why did you do this? Jessica: I was stressed because I missed my period and I was
worried that I am pregnant. So I took some OCP yesterday and I was hoping to have my periods today. Today
also I didn’t get the periods –so I told my boyfriend about it. He broke up with me because he didn’t want me
to be pregnant. I got upset and cut my wrist.
4) Dr: When was your last period? Jessica: It was 5 weeks ago.
5) Dr: How many OCP pills did you take? Jessica: I took 20 tablets.
6) Dr: Where did you take these tablets? Jessica: In my room.
7) Dr - Was there any one with you at that time. Jessica – No
8) Dr: Where were you when you cut your wrist this morning? Jessica: I cut my wrist in bathroom.
9) Dr: Was there any one with you at that time ? Jessica: I was alone when I cut my wrist
10) Dr: Who brought you to the hospital? Jessica: I came to the hospital myself
11) Dr: Were you under the influence of alcohol when this happened? Jessica: No
12) Dr: Did you plan to harm yourself ? Jessica: No
13) Dr: Did you inform anyone about this? Jessica: No
14) Dr: Did you write any suicide note? Jessica: No

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15) Dr: Was the wound deep? Jessica: No, it was not deep It is just a graze.
16) Dr: How do you see your future? Jessica: Very bright. I am going to university for further studies.
17) Dr: Are you going to do this again? Jessica: No, Doctor. I am not happy about what has happened. I am
regretting what I did.
18) Dr: Have you ever tried to harm yourself before? Jessica: No
19) Dr: Do you have any medical condition? Jessica : No
20) Dr: Are you taking any medication?Allergic to any medications? Jessica: No
21) DR:how do you feel in ur Mood?on scale of 1-10,1 being sad,gloomy and 10 being normal,happy? Jessica:7-
8
22) Dr:do you see/hear noises when nobody is around? Jessica:No
23) Dr:do you feel that someone is telling you to do things?/or reading ur mind?/making you do things? Jessica:No
24) Dr:do you smoke?/DRINK Alcohol?/use recreational Drugs? Jessica:NO
25) Dr:do you feel that this has affected your family life/social life/work?(ASK INDIVIDUAL QUESTIONS)
Jessica:YES/NO
26) Dr:Do you think you need any help from us for your stress or if you are feeling low? Jessica:I am OK Now
27) Dr: Do you have any mental health conditions? Jessica: No
28) Dr: Any of your family members have any mental health conditions? Jessica: No
29) Dr: were you ever in trouble with Law before? Jessica:NO
30) Dr: Do you live alone or with others? Jessica: I live with my mother and brother.
31) Dr: Have you told your mother or brother about this? Jessica : No
32) Dr: Do you have any financial problem? Jessica : No
33) Dr: Do you have friends? Jessica:Yes
34) Dr: Thank you very much for all the information.
35) MANAGEMENT –
a. Because you are at low risk to harm yourself, We would discharge you. We would offer support for you in the
community after discharge in 2 weeks time.
b.-We will refer you to a Gynecologist as regards the pregnancy
c. -We will also take a look at your wrist and treat accordingly
d.-We will also contact the poison information center if you need any treatment for the tablets you have taken
and would treat you accordingly

Scenario – 5 50 year old man Mr Adam Thompson had met with road traffic accident 5 days ago. He was
diagnosed with whiplash injury after the X Ray showed no fracture in his cervical bones. He was treated
with pain killers. He has come back now c/o pain in his neck. He has low mood. Take history from the patient
and discuss the management with the examiner.

F.
1) Dr: Hello Mr Thompson, Can you please tell me, what brought you to the hospital?
Adam: I had met with an accident 5 days ago. I still have pain in my neck.
2) Dr: I am really sorry to hear that. Yes we have seen the X Ray of your neck and there were no fracture in your
neck bones. This pain will go away after some time on its own. Just keep taking some pain killers until then.
3) Is there anything else bothering you ? Adam: Doctor, I am feeling very low nowadays.
4) Dr: Is this after the accident? Adam: No
5) Dr: Since when are you feeling low? Adam: Since about last 6 months.

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6) Dr: Any particular reason you are feeling low ? Adam: I am not earning well. My wife is spending her
money on me and our children.
7) I am feeling bad. ( Sometimes he may say he keeps having arguments with his wife).
8) Dr: Do you work ? Adam:Yes I am a fire fighter but I don’t go to my work all the time.
9) Dr –Is there any other problems ? Adam – No. It is just I have this financial problem.
10) Dr: How is your mood now? Can you please grade your mood in 1 to 10 scale where 1 being low and 10 being
very happiest mood? Adam: My mood is okay. I would say 3/10.
11) Dr: Some people get a feeling of harming themselves or ending their life when they feel very low. Has this type
of feeling crossed your mind? Adam: I do feel like killing myself ?
12) Dr:Have you tried to do anything to end your life? Adam: No
13) Dr: Have you ever had such low feeling before this 6 months? Adam: No
14) Dr: How do you see your future? Jessica: I am just living with my wife’s money. I don’t feel like living
anymore.
15) Dr: Do you have any medical or mental health problem at all ? Adam : No
16) Dr: Whom do you live with ? Adam: I live with my wife and children.
17) Dr:Are they supportive? Adam: Yes Dr; Do you have many good friends? Adam ; Not many.
18) Dr: Have you have any trouble with the law? Adam: No
19) Dr: I would like to ask you a couple of questions about sometimes people have but may find difficult to talk
about. I ask everyone these questions
20) Have you ever heard voices speaking when there seems to be no-one around ? Adam: No
21) Dr: Do you have personal beliefs that are not shared by others ? Adam : No
22) Dr: Do you get any feelings to harm others?Adam: No
23) Dr: Do you know where you are now? Adam : Yes doctor, I am in the hospital.
24) Dr: Do you drink alcohol? Adam : No
25) Dr: Thank you very much for all the information.
26) Management with the examiner: I will admit him. My patient is very depressed. He has suicidal thoughts.

16. Self Harm –OCP overdose and cut wrist

16 years old Ms Jessica Thompson was brought to the hospital because she cut her wrist and took overdose
of OCP pills. You are FY 2 doctor in psychiatric department. Take history from the patient and discuss the
management with her.

(OFFER CONFIDENTIALITY,IF PATIENT DOESN’T SPEAK)

START WITH ONSET, DURATION, THEN DO BEFORE, DURING, AFTER
1.
1. Dr: Hello Ms Thompson, I am Dr... one of the junior doctor in the Psychiatry department. How can call you?
Jessica: You can call me Jessica.
2. Dr: Jessica Can you please tell me, what brought you to the hospital? Jessica: I took pills and cut my wrist.
3. Dr: I am really sorry to hear that. How are you feeling now? Jessica: I am okay.
4. Dr: Alright... can you please tell me why did you do this ?
Jessica: I was stressed because I missed my period and I was worried that I am pregnant. So I took some
OCP yesterday and I was hoping to have my periods today. Today also I didn’t get the periods – so I told
my boyfriend about it. He broke up with me because he didn’t want me to be pregnant. I got upset and
cut my wrist.

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5. Dr: I am very sorry hear about this Jessica. When was your last period?
Jessica: It was 5 weeks ago.
6. Dr: How many OCP pills did you take? Jessica: I took 20 tablets.
7. Dr: Where did you get these tablets. Jessica: It is my mom’s pills.
8. Dr: Where did you take these tablets? Jessica: In my room.
9. Dr - Was there any one with you at that time. Jessica – No
10. Dr: Where were you when you cut your wrist this morning? Jessica: I cut my wrist in bathroom.
11. Dr: Was there any one with you at that time ? Jessica: I was alone when I cut my wrist
12. Dr: Who brought you to the hospital ? Jessica: I came to the hospital myself
13. Dr: I see. Were you under the influence of alcohol when this happened Jessica ? Jessica: No
14. Dr: Did you plan to harm yourself at all ?
Jessica: No. It just happened. I was not thinking properly at that time.
15. Dr: I am sorry to ask this - Did you think of ending your life at all ? Jessica : No
16. Dr: Okay Did you inform anyone about this? Jessica: No
17. Dr: Was the wound deep ? Jessica: No, it was not deep It is just a graze.
18. Dr: How do you see your future ?
Jessica: Very bright. I am going to university for further studies.
19. Dr: Are you going to do this again ?
Jessica: No, Doctor. I am not happy about what has happened. I am regretting what I did.

20. Dr: Have you ever tried to harm yourself before? Jessica: No
21. Dr: Do you have any medical condition? Jessica : No
22. Dr: Are you taking any medication? Allergic to any medications? Jessica: No
23. Dr: How do you feel in your Mood on scale of 1-10,1 being sad, gloomy and 10 being normal, happy?
Jessica:7-8
24. Dr: Do you see / hear noises when nobody is around ? Jessica: No
25. Dr: Do you feel that someone is telling you to do things? or reading your mind? / making you do things?
Jessica:No
26. Dr: Do you smoke? / Drink Alcohol? / use recreational Drugs ? Jessica:No
27. Dr: Do you feel that this has affected your family life/social life/work?(ASK INDIVIDUAL QUESTIONS)
Jessica: YES/NO
28. Dr: Is she student what is she studying, any financial problems, Any other worries.
29. Dr: Do you think you need any help from us for your stress or if you are feeling low?
Jessica: I am OK Now
30. Dr: Do you have any mental health conditions? Jessica: No
31. Dr: Any of your family members have any mental health conditions? Jessica: No
32. Dr: were you ever in trouble with Law before? Jessica: No
33. Dr: Do you live alone or with others? Jessica: I live with my mother and brother.
34. Dr: Have you told your mother or brother about this? Jessica : No
35. Dr: Do you have any financial problem? Jessica : No
36. Dr: Do you have friends? Jessica : Yes
37. Dr: Has any one looked at your wound ? Jessica : Yes / No
38. Dr: Did any specialist doctor talk to you about the chance of pregnancy to you ? Jessica: Yes/ No
39. Dr: Thank you very much for all the information.

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 2. MANAGEMENT –
1. Jessica, I am very sorry you have to go through this problem. Do not worry we are here to help you.?
a. We will refer you to a Gynecologist as regards the chance of pregnancy ( if not already sorted out)
b. We will also take a look at your wrist and treat accordingly ( if not already sorted out)
c. We will also contact the poison information center if you need any treatment for the tablets you have
taken and would treat you accordingly.
d. However since you said you are regretting for what you have done and you are sure that you are not
going to do this again, I don’t think we need to admit you for any Psychiatric reasons. I will talk to my
seniors and then you can go home.
2. I sincerely advise you to talk to your mother about this. I am sure she will understand your problem and support
you in the future. What do you say - will you talk to your mother ?
Jessica : Yes doctor. [ If she says no - ask her - Can we talk to your mother and explain about you. I am sure
she will understand your problem – what do you say? Jessica – OK. If she still says no – then mention that
your seniors will talk to her before we discharge her]
3. We are also here to support you if need any time. We will give the telephone number of a help line to call if
you feel very stressed out like this any time in the future and they will advise you of what you can do. Also
will have a follow up in the community clinic after 2 weeks. Is that OK ? Jessica : Ok
4. Dr: Thank you very much.

17. Self Harm – Gay man PCM OD

You are FY 2 doctor in Emergency department. 18/20 years old Mr..... was brought to the hospital because
he took over dose of Paracetamol tablets. Take history from the patient and discuss the management with
him.
(OFFER CONFIDENTIALITY,IF PATIENT DOESN’T SPEAK)
START WITH ONSET, DURATION, THEN DO BEFORE, DURING, AFTER
A.
1. He took 16 tablets of paracetamol 2 hours ago. Boy friend brought him to the hospital.
2. He had an argument with his mother because mother was very upset because she found out that he is gay. He
is regretting for that now. Not going to do it again. Sees future bright. Lives alone.
3. Dr: Is he working what is his job, any financial problems, Any other worries.
B. MANAGEMENT –
1. Mr.. I am very sorry you have to go through this problem. Do not worry we are here to help you.
4. Mr… Unfortunately overdose of Paracetamol can damage and kidneys.
5. First of all we need to do some blood tests to see if you have any damage to the liver and kidneys.
6. Also we need to check whether you need any treatment with antidote medicine for overdose of Paracetamol.
For that we need to test the level of Paracetamol in your blood after 2 hours ( 4 hours after the ingestion).
7. I will talk to my seniors about it. Also we will refer you to the Psychiatry specialist. They will help you further.
8. Pt: Do I need to be admitted.
Dr: At the moment yes you need to be in the hospital because we need to do the test to see whether you need
any treatment for the overdose of the tablets you have taken.
9. However if the level of paracetamol is not very high or if there is no damage to the organs then you do not need
to be admitted here.

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10. But the Psychiatrist has to see you and then they will tell you about the further management. However since
you are regretting for what you have done and you are sure you are not going to do such things again they may
not admit you. They may advise you about the help what they can provide and follow up with you later. Is that
OK ?
11. Pt : Ok Dr Any other concerns ? Pt : No
12. Dr: Thank you very much.

XIII. CVS

1. Postural Hypotension
EXAM question
You are FY2 in the medical department. 64 year old lady presents with complaints of few falls last week. Take
history, do relevant examination and discuss management with the patient.

A.
1. Dr: Hello Mrs.... My name is Dr... I'm one of the junior doctors in the GP clinic. What brings you in today?
P: Hello doctor... I have been falling suddenly for a couple of weeks now...
2. Dr: I'm sorry to hear that Mrs.... could you please tell me more about it?
P: Doctor, in the last two weeks.. I have fallen all of a sudden a few times. Especially when I have gone
out with my friends. When I'm standing, suddenly I feel a little dizzy and then I fall. Today also I was
doing window shopping in the town centre and I suddenly fell. Ambulance brought me here. I like to go
out with my friends. Now I am scared to go out with my friends.
3. Dr: I am very sorry to hear that. We will sort out the problem very soon.
4. Dr: Ok.. Have you lost consciousness before or after the falls ? P: No
5. Dr: Do you have visual disturbance? P: No
6. Dr: Do you keep slipping or tripping and then fall? P: No
7. Dr: You mentioned feeling a little dizzy prior to your fall. Did you feel like the room was spinning? P: No
8. Dr: Do you have a feeling of fullness in your ear? P: No
9. Dr: Do you hear any high pitched noise in any ear? P: No
10. Dr: Do you have any balance problem while walking ? P: No
11. Dr: Do you have palpitations? P: No
12. Dr: Have you been diagnosed with any medical conditions? Pt: Yes I have high blood pressure.
13. Dr: Do you have diabetes or any other conditions like Parkinsons ? Pt : No
14. Dr: Have you had any heart problems in the past? P: No
15. Dr: Have you ever had a stroke? P: No
16. Dr: Any of your family members have any medical conditions ? P: No
17. Dr: Can you think of something that happened two weeks ago that might have triggered this problem?
P: No I can’t think of anything.
18. Dr: Are you taking any medications? P: Yes I am taking medications for my blood pressure.
19. Dr: Can you please tell what medication you are on right now? P: I can't remember the name doctor
20. Dr: No problem Mrs... Do you have the medication with you? P: No
21. Dr: Are you carrying the prescription with you ? P: No

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22. Dr: Ok that's fine Mrs... We will get in touch with your GP to get the details. Can you please tell me for how
many years you have had high BP? P: > 10 years
23. Dr: Has the medications been changed recently.
P: Yes about 2 weeks ago GP changed my blood pressure medication.
24. Dr: Have been falling like this before the GP changed the medications? P: No. It started after that.
25. Dr: Do you smoke Mrs..? P: No
26. Dr: Do you consume alcohol? P: Yes, whenever I go out with my friends (Explore alcohol according to
answer)
B. Examination and investigations:
1. Dr: Ok Mrs... I need to check your pulse and BP. I will have to check your BP while you are lying down and
while you are standing.
(Examiner findings: Lying- 150/90; Standing- 110/70 ) ( postural hypotension if standing blood pressure
is drop is more than 20/10 compared to lying down).
2. I would also like to examine your chest to check your heart..
(Examiner findings: normal)
3. I would like to get an ECG or a heart tracing. (Examiner may hand over an ECG- usually normal)
4. And check your blood for the sugar levels and check for anaemia. (Examiner says – Normal).

C. Diagnosis:
1. Dr: Mrs... based on the information you have told me and the findings on examination, I think you have a
condition called postural hypotension. Do you know what that is? P: No
2. Dr: Postural hypotension is a condition where your BP tends to fall when you switch from a lying down or
sitting position to a standing posture. It is very common in people after the age of 70 years. It can also caused
by other medical conditions like Diabetes o Parkinson’s disease. However in your case it might be due to your
new BP medication. Certain blood pressure mediations can lower your BP too much while standing causing
you to feel weak/dizzy and fall. Are you following me Mrs...?
3. Pt: But Doctor I did not stand from a sitting position when I fell down.
Dr: Sometime this can happen if you stand for long time or even when you change your posture like bending
down. Pt: OK

D. Treatment:
1. Dr: We will admit you now to the hospital. We will get in touch with your GP to find out which medication
you are taking for your blood pressure. We will then have to stop it if it is the cause and start you on some
other medication for your BP. We will keep monitoring you and when we think you are safe to go home we
will discharge you.
2. Dr: Unfortunately, this condition can happen even after discharge, so you need to take some precautions to
reduce this problem happening again.
3. Take particular care in the morning because blood pressure tends to be lowest in the morning and the symptoms
are likely to be worst in the morning. Get out of beds in stages. Cross and uncross legs firmly before you sit up
and again before standing.
a. Avoid sudden changes in posture.
b. Avoid sitting or standing for long periods.
c. Raise the head of your bed with blocks.

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 d. Wear support stockings or tights. This helps return blood to the heart. But do not wear them when you go to
the bed.
e. Drink plenty of fluids and also drink strong tea or coffee. Take small frequent meals because some people
have large drops in blood pressure after meals.
4. Avoid drinking excess alcohol.
5. If none of these measures helps you then we can consider giving some medication
( although fludrocortisone is not licensed for the treatment of postural hypotension it is usually the drug of
choice. Its actions include volume expansion and the promotion of arteriole vasoconstriction) Are you
following me ?
6. Pt : Yes. Dr: Any other questions ? Pt : No Thank you

2. Hypertension – Losartan

Question: Mr Pat Brown 50 year old man was admitted to the hospital 4 weeks ago for cellulitis and was
noted to have high blood pressure and treated for HTN with medications. He was discharged 2 weeks ago
and he has come back for follow up of blood pressure.
He also has diet controlled diabetes. Measure his Blood pressure and Address his concerns.

A.
2. Dr: Hello Mr Pat Brown, I am Dr … How are you?
3. Dr: I understand you had high blood pressure last time when you were in the hospital ? Can I please check your
blood pressure now ? (examiner says – his blood pressure now is 165/95).
4. Dr: Mr Brown your blood pressure is still quite high ? Are you taking your blood pressure medications?
Pt: I stopped taking them few days ago. Dr: Why ?
Pt: They are giving me too much cough. I can’t sleep and my wife also can’t sleep because I keep coughing
too much
5. Dr: I am very sorry to hear that. Can you please tell me which medications are you taking?
Pt: I am taking these doctor ( he will show Aspirin, Enalapril and Simvastatin)
6. Dr: Do you have any other problem other thancough? Pt: No Dr: Any fever ?(Pneumonia) Pt:No
7. Dr: Any sweats in the night time ? (TB) Pt:No
8. Dr: Have you noticed any change in your weight? (TB) Pt:No Dr: Have been diagnosed with Asthma before?
Pt:No
9. Dr: Do you have any other medical condition? Pt: Yes I have diabetes .Dr: Do you take any mediation for
that? Pt:No Dr: Are you allergic anything including to any medications? Pt:No
10. Dr: OK let me check the book and let you know. Check the BNF
a. It is Enalapril medication is giving you cough. One of the side effect of this medication is cough.
b. Mr Parker it is very important to take this medication to control your blood pressure. Do you think you can
continue taking this medication. You may get used this cough after some time.
11. Pt: No doctor I don’t want this medication. It is causing me too much problem.
Dr: OK don’t worry. We have some other medication to treat what we call Losartan (Angiotensin receptor
blocker – ARB). That will help to control your high blood pressure as well as it is good for the kidneys also.
However if you have any problems in your heart or liver this medication may not be good.
Do you have any problem in the heart or liver? Dr: No doctor
Dr: Ok then this should be good for you.
12. Pt: How do I take it ?

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 Dr: It can be taken by moth with or without food. Dose will be 50mg once a day but then we will adjust the
dose according to your blood pressure.
13. Pt: Will there be any side effects for that.
a) Dr: Unfortunately one of the side effects of this medication is also cough but it is not as much as
Enalapril.
b) Very rarely it can cause allergic reaction – in that case you should stop it. It can also cause body pain –
please tell your GP if that happens.
c) Dr: It is very important to take medications regularly. You should not stop taking medications on your
own without talking to your doctor.
d) If you do not take medications regularly your blood pressure can shoot up and it can cause other serious
problems.
14. Dr: Any other concerns? Pt:No
Dr: Mr Parker – Do you want to know about your other medications ? Pt: No doctor
[ If he says he wants to know then talk about them –
a. ASPIRIN:- This is a blood thinner tablet. It reduces the risk of clots forming in your blood. This reduces
your risk of having a stroke or heart attack.
Dose as mentioned in the prescription. ( 75 mg one tablet, Once a day, by mouth, after food)SE - Can
cause tummy irritation, slight bleeding in stomach and youmaynotice dark stool if it happens please
inform yourGP.
b. SIMVASTATIN: 20 mgnocte. This lowers the cholesterol (bad fat). Take one dose of simvastatin
each day, in theevening.
You can take simvastatin before or after food.
SE – Can cause Muscle cramps - can be serious problem some times ( inform your GP). Can also cause
hair loss,Headache,Dizziness.
c. These medications are taken lifelong].
15. Dr: Mr Parker it is very important that you should keep your blood pressure under control. Otherwise it can
cause serious health problems like heart problems and even stroke.
16. Dr: Do you do exercise? Pt : No
17. Dr: You should go for regular exercise – jogging or at least brisk walk for 30 min at least every day for about
5 days a week. This helps to keep the blood pressure under control. Dr: How is your diet ? Pt: I eat fast
food/ healthy food .
18. Dr: You should eat less of foods which contains high fat like red meat. Instead you cna eat chicken and fish.
You should also eat more of fruits and vegetables. Pt: Ok
19. Dr: Since you have diabetes it is important to keep the sugar also under control otherwise high blood pressure
and diabetes combined together can cause serious health problems.
20. Dr: Do you smoke ?Pt: No Dr:Good
21. Dr: Do you drink alcohol ? Pt: Not much Dr:Good. Dr: Any otherconcerns ? Pt:No
22. Dr: Thank you very much. We will keep following you up. If you need any help any time please do come back.

3. ACS – ECG normal

You are the FY 2 doctor in the medical department. 44 year old Man Mr … presented to the hospital with
severe chest pain. Take history from him and discuss the further management with him.

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 A.
1. Dr: Hello Mr …. I am Dr … one of the junior doctor in the medical department. Can you please tell me what
is happening to you ? Pt: Doctor I am having severe chest pain.
2. Dr: I am very sorry to hear that. How severe is your pain – in the scale of 1 to 10 one being the mildest and 10
being the most severe pain? Pt: Doctor it is 10 out of 10.
3. Dr: I see, don’t worry, we will give you some strong pain killer medication and you will be better.
Ask examiner – I want to give pain killer to my patient what can I do ?
Examiner says – assume doctor. ( if the examiner ask which apin killer – you can say Morphine injection
5-10 mg)
4. Dr: Mr… We have given pain killer. Are you any better now? Pt: I am slightly better.
5. Dr: Are you comfortable to talk to me now? Pt: Yes doctor, I can talk to you now.
6. Dr: Can you please tell me more about your chest pain?
7. Pt: Doctor, I was just sitting on sofa and watching television. Suddenly the pain started. It is almost 3
hours now. I took paracetamol, it didn’t help me at all doctor.
8. Dr: Anything more can you tell me ? Pt: I don’t know what else to tell you.
9. Dr: OK. Can you please tell me where exactly is this pain in your chest ?
Pt: It is here over the central part of my chest doctor.
10. Dr: OK. What type of pain is that? Pt: I feel as if someone is crushing my chest.
11. Dr: Does the pain go anywhere else at all. Pt: Yes doctor I am having pain my left jaw also.
12. Dr: Does it go to your left hand? Pt: No
13. Dr: Does it go to your back between your shoulder blades ? Pt: No
14. Dr: Does the pain gets relieved on leaning forward ? Pt: No
15. Dr: Do you have any other symptoms other than pain? Pt: Like what ?
16. Dr: Any vomiting ? Pt: No Dr: Fever? Pt: No Dr: Cough ? Pt: No
17. Dr: Pain in your calf ? Pt: No Dr: Do you feel short of breath at all? Pt: No
18. Dr: Did you have a long journey flight just recently? Pt: No
19. Dr: Did you have any surgery recently? Pt: No Dr: Do you get heart burn? Pt: No
20. Dr: Did you have any injury on your chest ? Pt: No
21. Dr: Did you have this type of problem before ? Pt: No
22. Dr: Do you have any medical problems at all ? Pt: No
23. Dr: Like high blood pressure ? Pt: No Dr: Diabetes ? Pt: No
24. Dr: High cholesterol? Pt: I don’t know. Dr: Any heart problem ? Pt: No
25. Dr: Did you have any blood clots in your lungs or legs before ? Pt: No
26. Dr: Do you smoke ? No Dr: Do you drink Alcohol ? Pt: No
27. Dr: Do you use any recreational drugs ? Pt: No
28. Dr: Do you take any kind of medications at all ? Pt: No
29. Dr: Are you allergic to any medications? Pt: No
30. Dr: Any of your family members have any medical conditions? Pt: No
31. Dr: Any heart problems in family members ? Pt: No
32. Dr: Is there anything else you think that may be important that we need to know? Pt: I don’t know doctor.
B.
1. Dr: Mr… I need to examine your chest and heart and also need to check your pulse and blood pressure.
Examiner says – chest is clear. Pulse and BP stable. Thank the examiner.
C.

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1. Dr: Mr… I think you a serious condition in your heart. I am sorry to say that you could be having heart attack.
Pauce ……
2. However, I need to do your heart tracing (ECG) to confirm that.
3. ECG – examiner shows ECG. ECG – normal.
Usually normal ECG but if it is ST elevation  do not say it is normal
if you do not know how to read ECG  pretend that you are reading ECG. Take your time.
D.
1. Dr: Mr… Your heart tracing looks normal. However it still looks like heart attack. Do you know what heart
attack means? Pt: I heard of it but I don’t know what exactly it means.
Heart attack  Major: if there is ST elevation. Minor: there is no ST elevation.
a. Dr: Let me explain. Heart needs it’s own blood supply for its muscles to survive. This blood supply is
provided by some blood vessels called coronary arteries.
b. In heart attack this blood vessel gets blocked by a clot partially or totally suddenly, for various reasons ,
which stops the blood flow and oxygen supply to a part of your heart muscle.
c. This causes serious damage to the heart muscles. If the vessel is occluded totally heart muscle supplied by
the affected artery dies. Sometimes this condition is life threatening as you may know.
d. However, you don’t need to worry. You have come to the hospital in good time. You are in a safe place
now. We are going to look after you. You will be fine.
2. Pt: What are you going to do for me ?
a. Dr: We will admit you in the hospital and repeat the heart tracing and also we will do some blood tests to
check some heart attack markers. We will keep monitoring you.
b. For now we will give you Oxygen (if saturation low) and Aspirin tablet to chew. To relieve your pain we
will give some medication called GTN spray under your tongue and a strong pain killer medication called
Morphine as injection . Are you following me?Pt: Yes.
c. Dr: If your ECG changes in time, or blood tests comes positive for heart attack markers we will be able to
say this is a heart attack. If not this is a condition what we call unstable angina which is due to reduced blood
supply to the heart muscle.
d. Heart attack usually need urgent treatment to open the blockage in the heart muscles to restore the blood
supply to the heart muscles. For this we do a procedure called angioplasty.
3. Pt: what is angioplasty doctor ? (Try to reach this stage in the station)
a. Dr: This is a procedure where we pass a catheter (tube) with a balloon at its tip, from the artery in your groin
or arm to the heart into the blocked section of the coronary artery using special X-ray guidance.
b. The balloon is blown up inside the blocked part of the artery to open it wide again. A stent may be left in the
widened section of the artery.
c. A stent is like a wire mesh tube which gives support to the artery and helps to keep the artery wide. Are you
following me? Pt : Yes
d. Dr: However we may not need to do that procedure straight away because your ECG is normal. But we may
do it later after few days. Are you following me? Is that OK?
4. If this is a heart attack we will give you some blood thinner medications called clopidogrel 600 mg and some
injections called enoxaparine. These will help preventing the formation of new clots.
5. We will alse give you medication called metoprolol which is a beta blocker and cholesterol medicine called
atorvastatin (high dose), ACE inhibitor called ramipril which also protects your heart.
6. Dr: There might be some complications of heart attack. Do you want to know about them? Pt: Yes

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 Dr: It can cause abnormal heart rhythms, or it can cause heart failure, or a further heart attack may occur
sometime in the future. However we will try to prevent them and manage them if any of these problems do
happen.
7. Dr: Do you have any other questions? Pt: No doctor. Thank you very much.
Dr: Thank you very much. I hope you recover very soon without any problem. If you need any help please let
me know.

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 4. Chest pain – Pericarditis
Scenario -30 year man with chest pain

A. History and management

Had chest pain for 3 days. Spontaneous oncet.
Sharp, retro sterna area, No radiation, on and off, relieved on leaning forward.
No – fever, cough, SOB, palpitation,
No – trauma, smoking HTN, DM, Cholesterol, Cocaine, calf pain, travel, recent surgery, No previous blood clots.
No – family history.
No history of any viral illness, recently, TB, HIV,
No medications or allergy.
B. Examination
Vitals ( for fever, hypotension in cardiac tamponade) – examiner may say
normal
Neck ( for engorged veins – for cardiac tamponade), Chest – for pericardial
rub, murmur and heart sounds ( muffled in cardiac tamponade)
Examiner may say – all normal
C. Investigations –
Blood – FBC, U&Es ( uraemia – uremic pericarditis) , Cardiac enzymes, chest X Ray (for pericardial effusion)
Examiner may say all normal
ECG – May show – global saddle shaped ST elevation or electrical alternans wih sinus tachycardia
St elevation

Electrical alternans

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 D. Diagnosis:
I think you have condition what we call as Pericarditis – it an infection of the lining covering the heart. Sometimes
it is a serious serious condition.
There are several causes – like viral or bacterial type of bugs can cause this. Sometimes it can be due to injury or
medications. However in your case it could me most probably due to viral kind of bugs.
We need to do some other tests like scanning of the heart ( echocardiography) to check for any complications like
sometimes there could be fluid surrounding the heart ( pericardial effusion). Which may cause heart failure.
Treatment
Depends on what is causing this condition.
We will admit you. I will inform my seniors.
We will give medicines like Aspirin or NSAIDS like Colchicine if it is viral kind of bugs causing this.
If there is fluid filled around the heart then we may need to drain it.
This condition usually resolves on its own but it may take weeks or months.

5. Musculo - skeletal chest pain

SCENARIO- 25/35 year old man comes to the A and E with history of chest pain. Take history and discuss
management.
D- How can I help you. P- Dr I have bad chest pain.
D- Could you please tell me in detail about your chest pain.
P- Sure Doctor, this pain started 3days ago and still there without any changes. It's really bothering me.
D- I'm really sorry, would you like any pain killer now? Are you comfortable to talk to me? P- yes Dr I'm
OK to talk.
D- can you tell me where exactly the pain and how intense is that?
P- Its really bad Dr. (simulator pointed at the right axillary line)
D- what type of pain is that?
P- what do you mean by that Dr?
D- is it like stabbing pain, crushing or its just ache?
P- it's kind of mixed.
D- how severe the pain? 1-10 scale P- may be 3-4
D- Dose this pain goes anywhere else? P- No
D- Any other symptoms such as shortness of breath? Fever? Cough?Swelling of the ankles? P- no Dr.. Only
this ache.
D-, any cold sweat? P- no
D- do you know how did it start? P- it just started like that 3days ago.
D- did you have any flu like symptoms before this pain? P- no
D- Any injuries to your chest.
P- Yes Dr I forgot to tell you that I had a fall from bicycle few days ago.
D- Was this pain there before or after the accident? P- After.
D- any recent travel outside the UK P- no
D- do you smoke? P-yes Dr I have been smoking for many years..
D- what do you smoke and how much? P- cigarette and I smoke 5 a day.
D- have you noticed any change in your weight? P- maybe I put on some weight.

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D- what about alcohol? P- I don't drink
D- I would like to examine you. Is that OK? P- yes Dr.
A. EXAMINATION FINDINGS
INSPECTION- EVERYTHING NORMAL, ESPECIALLY CHEST MOVEMENTS VERY SYMMETRICAL
AND EXPANSION WAS EQUAL, NO NECK VEIN ENGORGED (NO PNEUMOTHORAX)
PALPATION- TRACHEA NOT SHIFTED (NO PNEUMOTHORAX). Pain in right anterior axillary line along
4th and 6th intercostal spaces.
Percussion- normal except patient didn't allow in the pain area.
AUSCULTATION - AIR ENTRY IS EQUAL AND NORMAL VESICULAR SOUNDS.
B.
D- Mr... Based on the information what you told me and examination findings I am suspecting it might be
musculoskeletal injury, but to rule out other serious conditions and confirm the diagnosis I would like to request
some investigations. P- ok
C. Examiner- what would you like to do doctor?
D- I would like to request ECG AND CARDIAC ENZYMES TO RULE OUT MI AND OTHER HEART
DISEASES. ALSO CHEST AND ABDOMINAL XRAYS TO RULE OUT PNEUMOTHORAX, RIB
FRACTURE AND ANY VISIBLE LUNG PATHOLOGIES. ALSO FBC AND U&E.
EXAMINER- EVERY INVESTIGATION CAME BACK NORMAL.
D.
D- Mr... Its a good news All investigations came back normal. So what you have is just musculoskeletal pain due
to your bicycle accident.
P- is it serious? What can you do now doctor?
D- it's not serious but the pain might take some time to go away. We can give you some good pain killers. Do you
drive frequently or work with any machineries? P- no
D- any medication allergy or stomach problems? P-no
D- We can give you some painkillers. It will take a few days for the pain to subside. P- OK thank you Dr.
D- do you have any other concerns?
P- doctor my father died because of heart attack and brother was recently diagnosed.. Are you sure I'm not
having that?
D- “At the moment, it doesn’t look like a heart attack. Your ECG is normal. However we shall test your blood for
cardiac markers to make sure it is not a heart attack. We shall repeat your ECG later on. I will ask my seniors for
expert opinion.”

DIFFERENTIALS- MI, PE, TRAUMA, PNEUMONIA, PERICARDITIS

6. Post MI Discharge & Lifestyle Modifications

You are medical FY2 in cardiology ward.
60 years old Mr.... was admitted with a chest pain a few days ago and was treated for Acute Myocardial
Infarction. Now, he is stable on medical therapy and is fit to be discharged. Your consultant has commenced
him on the medical therapy. Talk to the patient, assess him clinically, and speak to him about lifestyle
modifications.
A.
1. Dr: Good morining, Mr... I am Dr .... One of the junior doctor in the cardiology dept. How are you doing today?
Pt: I am well doctor. I am going home today.

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2. Dr: Congratualtions. My consultant has prescribed some medications. Do you have any questions about
them?Pt: No doctor, I know about the medicines.
3. Dr: Well that is fine. Could you please tell me how much do you know about your condition?
Pt: I was told there is some problem in my heart.
4. Dr: Yes, that is right. You had a heart attack. Do you know anything about it? Pt: No doctor, not really. Dr:
Okay, let me explain that to you.
a. Heart needs its own blood supply for it to survive. Blood supply is provided by some blood vessels specially
for the heart muscles.
b. Heart attacks are caused by the blood supply to the heart being suddenly interrupted.This can happen due to
narrowing or obstruction which results in reduced blood supply to heart leading to damage of the heart
muscle. Do you follow me? Pt: Yes doctor.
c. Dr: We have given you apropriate treatment to restore the blood supply to heart.
d. Though, you are doing well, sometimes this condition can be really serious and even life threatening. And
we want what is the best for you and we do not want this to happen to you again. Are you following me? Pt:
Yes doctor.
5. Dr: Do you know why people get this condition? Pt: No doctor.
6. Dr: Well, Mr... there are certain risk factors which can lead to heart attacks. Some of them are not modifiable
while most of them are. And if we are able to control the modifiable risk factors, we can maximally reduce the
risk of getting heart attack. Are you understanding?
7. Pt: Yes doctor. What are these risk factors?
Dr: There are lot of others risk factors why people get heart attack. I would like to ask you a few questions to
know if you have any of those risk factors so that we can address them and help you cope with this condition.
We may be able to reduce the risk if we can modify those factors. Pt: I see.
8. Dr: Do you have any heartproblems in the past? Pt : (No/Yes?)
9. Dr: Did you have any strokes or mini strokes previously ? Pt: (No/Yes?)
10. Dr: Do you have diabetes?Pt: (No/Yes?)
11. Dr: Do you have high levels of cholesterol in your blood?Pt: (No/yes?)
12. Dr: Cholesterol is involved in the formation of blood clot that can lead to blockade of artery supplying the heart.
Are you following?Pt: Yes doctor.
13. Dr: Do you have high blood pressure?Pt: (No/Yes?)
Dr: High blood pressure is one of the major risk factor which can cause lead to weakening of heart muscle. It
is very important to keep the blood pressure under control. However, as I have told you apart from medications
you may need to do lot of other things to keep the blood pressure under control. Pt: What is that doctor?
14. Dr: One important factor is diet. Can I ask you what type of food do you eat usually?
a. Pt: You know doctor. I don’t know how to cook food. So, I eat out most of the time. I have to eat fast
food - I eat chips, burger, steaks etc.,
b. Dr: Mr, the kind of food what you are eating is not good because they have very high bad fat content that is
cholesterol. This can increase the blood pressure and contribute to heart attack.
c. I sincerely advise you to eat more of white meat which has less bad fat like chicken and fish. I also advise
you to include plenty of fruits and vegetables also in your diet.
d. Also please reduce the salt content in your food because it can increase the blood pressure. I will refer you
to a dietician who will advise you in detail about the healthy diet. Is that OK ?Pt: That is fine. Doctor.
15. Dr: That is good. Can I ask do you do exercise ?
a. Pt: No doctor. I am an old man. I don't do much exercise.

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 b. Dr: I can understand. However, I sincerely advise you to do some exercise.
c. However at least for the first one month do minimal exercise like walking inside the house but later you can
do some exercise like brisk walking for about 30 min every day at least 5 days a week.
d. Exercising regularly will keep you healthy and also helps to keep the blood pressure and cholesterol under
control. What do you say ? Pt: Yes doctor that seems to be a good idea.
16. Dr: Excellent. Do you smoke Mr...?
a. Pt: Yes doctor I smoke about 10 to 15 cigarettes a day for the last 15 to 20 years doctor.
b. Dr: Again smoking is not good for health at all as you may know. Smoking also can increase the blood
pressure and also can cause lot of other health problems.
c. I strongly advise you to stop smoking. We can help you to stop smoking if you wish. Do like to consider that
Mr...?
17. Pt: Doctor you know my life is very lonely. I am going through lot of financial crisis and I get stressed
some times.
Dr: I can surely understand your problem. However, there are many other ways to relieve stress. May be you
can take some relaxation classes and yoga classes which might help you to relieve from stress. Remember stress
also can increase the blood pressure. What do you say? Pt: Yes doctor you are right. I will try my best to do
that.
18. Dr: Do you drink alcohol Mr....?
a. Pt: Yes doctor. I drink about 2 glasses of wine every day and also whisky sometimes over the weekends.
b. Dr: Mr. alcohol also is not good for the health. I sincerely advise you to cut down drinking alcohol and drink
within the recommended limits that is not more than 14 units per week. We can help you to cut down if you
wish. What do you think ?
c. PT: Yes doctor I will surely think of that.
19. Dr: Do you work? Pt: No (Following a heart attack, most people can go back to work within 2-3 months)
20. Dr: Could you tell me if you drive? Pt: Yes doctor.
a. Dr: You should not drive for at least four weeks after a heart attack. Could someone help you with that?
Pt: (Yes doctor, my wife can drive?)
b. Dr: That is good. It is always sensible to contact the Driver and Vehicle Licensing Agency (DVLA) to be
sure. Also I would like to tell you something about air flight travels.
c. You can usually fly as a passenger within two to three weeks of a heart attack, as long as you have no
complications.
d. This means that you have returned to your usual daily activities, your condition is stable and you don't have
any symptoms, or your symptoms are controlled. Are you following me? Pt: Yes.
21. Dr: Regarding your sex life, I would like to recommend you that for a 3 to 4 weeks it is probably best avoided.
If you are able to walk without discomfort then a return to sexual relationships should not cause any problems.
If sex causes angina chest pains then tell your doctor. Pt: Yes.
22. Dr: You should have the annual influenza jab and be immunised against the pneumococcal germ (bacterium).
Okay? Pt: Yes.
23. Dr: Excellent. Do you have any questions? Pt: Doctor if I follow all the advices what you gave then will I not
get heart attack again?
Dr: As I have told you that there are both modifiable and non- modifiable risk factors for developing heart
attack. Non modifiable factors are like age above 60 years, genetic cause means inherited risk which we can’t
do anything about these. However there are lot other modifiable risk factors like all the factors what we

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 discussed so far like diet, exercise, smoking which you can modify and have a healthy life style. This can
substantially reduce the risk of you getting heart attack.
Pt: Ok thank you very much doctor.
24. Dr: I sincerely advise you to follow all the advices. We will keep following you up. If at any time you develop
chest pain or breathlessness, immediately call 999. If you have any of the symptoms please call the ambulance
and come to the hospital immediately because these are the symptoms of serious condition. Is that okay Mr... ?
Pt : Ok doctor.
Dr: Any other questions ? Pt : No doctor. You have been very kind.

7. WARFARIN
Question: Mr/Mrs 48 year old lady/man has been diagnosed as DVT.
He/She is being discharged from the hospital today. Your consultant has commenced her on warfarin tablets.
Talk to the patient and address his/her concerns.
Patient is slow to understand and keeps forgetting.

Warfarin tab -BNF + Booklet is not there sometimes

If it s not there --> Do not ask for it now --> When you neeed it ask for it from the examiner
A.
1. Greet the examiner. ( Warfarin packet, BNF and INR book may be kept inside the cubicle)
2. Check the Warfarin dose ( usually 5mg OD) also check the BNF briefly for the side effects.
 I need to open BNF index then get to the warfarin and explore it with the patient
 TO check the dosage:
o Can you give me a couple of seconds i just need to check my book for the dosage and the side
efffects --> I open warffari (do not open the book again)
o Close it
o Tell the patient
 If there is prescription --> I only open the book for the side effcts
3. Dr - Good morining Mrs Jones. I am Dr .... One of the junior doctor in the medical dept.
4. Dr - How are you doing today. Pt - I am well doctor. I am going home today.
5. Dr - Congratualtions. My consultant has prescribed some medications which you need to take at home. I am
going to explain to you how to take them at home. If you do not understand any thing any time please do let
me know. Is that OK ? Pt – Ok doc.
6. Dr - I need to ask you few questions before I explain these medications to you.
a) Any allergy to any medications - Pt - no
b) Do you have any other medical conditions - Pt – No (CI for warfarin - Liver disease, Peptic Ulcer, Sever
HTN)
c) Are you taking any other medications – Pt – No ( Sometimes he may say I take mini Asprin).
d) Any chance of Pregnancy, breast feeding , or taking OCP – Pt – No ( warfarin should not be given in first
and third trimester pregnancy).
B. Explain medicines to the patient
1. Dr: This warfarin tablet is a blood thinning tablets. This stops blood from clotting. ( patient may say you are
using big words – then explain clotting means blood may become thick again like what you already had)

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2. This should be taken regularly, everyday same time for about six months. Better to take it in the evening. You
need to take it by mouth. It is important to take it every day without forgetting.
3. ( Can you remember to take the tablet. Can you keep an alarm to remind you to take it every day, or do you
have any one to remind you to take the medicine every day. If so I will explain everything to that person. If
no one to remind - then we will do something to remind you take it every day).
4. Warfarin can be taken with or without food.
5. Dosage will depend on the blood test what we do on you regularly. This is called as INR for which you will have
to come to the hospital every week or so and bring the INR booklet (yellow booklet) with you.
INR booklet --> 1st 2 pages are for patient --- then we wil lfill the rest -- now the main thing is there are 5
columns here -->
6. Pt: What will I do if I miss taking the tablets ?
o Dr: First of all - it is very important that you should take this every day without forgetting, otherwise
you may develop blood clot again which may travel up to the lungs which can be life threatening.
o If Keep a regular alarm to remind you every day.
o If you are taking evening dose and if you forget to take it in the evening but remember before midnight
on the same day, take the missed dose. If midnight has passed, leave that dose and take your normal
dose the next day at the usual time.
7. Pt - Doctor, what if I forget to take the medicines with me when I go on a holiday ?
Dr – If you forget to take the medicines with you when you go on a holiday you should go to the hospital there
and get the medicine and take it every day.

Side effects – (I need to study and rmemebr Warfarin SE.)

1. Bleeding - Since this a blood thinning medicine so you are prone for bleeding.
2. Be careful while handling sharp objects ( do not injure yourself). If you notice bleeding, black stool, bruising
on the skin, please report to your GP.
3. Other uncommon side effects are Skin rash, Jaundice, Hair loss, Diarrhoea - please inform your GP.
4. If you develop chest pain or shortness of breath (PE), please call the ambulance and come to the hospital
immediately.

Specific advise:-
1. If you need pain killer, you can take Paracetamol but not Aspirin. [ If patient is taking mini Aspirin – you will
have to stop it. I will inform my seniors about it].
2. If you are going to see a new doctor or dentist, please tell them that you are taking warfarin.
3. [ If the patient is sexually active lady taking combined pill – may be the pill itself has caused the clot and the
pill can interact with the warfarin and reduce the effect. Please stop taking combined pill and talk to your GP
for other suitable contraception.
4. For sexually active young lady not using any contraception – please use some contraception.
5. Do not become pregnant when you are taking this medicine].
6. Changing your diet suddenly can affect your INR, especially if you begin to eat more vegetables and salad. So
do not keep changing your diet frequently.
7. Drink Alcohol in moderation if she is drinking alcohol. Never binge drink.
8. It is best if you avoid cranberry juice altogether.

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 9. If you still have time left then tell the following :

Advice on illness
1. Wear pressure stockings
2. Avoid long journey flight

8. Statin Therapy
Exam question
Lady with BMI – 28. Blood pressure of 150/89. Blood cholesterol ( fasting ) is high. Other blood
tests – FBC, LFT, HbA1c all normal.
According to Q RISK score is fit to eb started on Statin therapy.
Talk to her about starting statin therapy and address her concerns.
A. Assess knowledge:
Do you why you are here today?
I am here to collect my blood result.
Mrs... Yes your blood results are here with me. Before we discuss the blood results can I ask few
questions about your health? Yes
How is your general health now ? I am OK
Do you get any chest pains or shortness of breath and any pains in legs ? No
Have you diagnosed with any medical conditions ? Yes / no
High blood pressure, Diabetes, Liver problems ( liver disease is a contra indication) ? No
Any medications? Any allergies?
Any chance of pregnancy ( if the lady is young) ? ( pregnancy is a contra indication) - No
Any medical conditions in family members?
B.
Do you have any concerns about your health ? My friend had stroke I am worried about it?
Sorry to hear about your friend. Please do not be worried about you getting stroke. I am glad that you
have come here. We can reduce the risk of you getting stroke or any such serious health problems.
Can we discuss about what we have checked about your health you already ? Yes
We have checked your Body mass index means we have checked your weight against your height
which is bit higher than what it should be. Your blood pressure is also bit on the higher side.
Also we have done blood tests - most of the blood tests are normal. However, some blood tests are not
normal.
It shows that your cholesterol content in the blood is quite high.
Do you anything about cholesterol ? No
Cholesterol is a fatty substance known as a lipid and is vital for the normal functioning of the body. It's
mainly made by the liver, but can also be found in some foods.
Having an excessively high level of lipids in your blood (hyperlipidemia) can have an effect on your
health.
High cholesterol itself doesn't usually cause any symptoms, but it increases your risk of serious health
conditions.
C. Why should I lower my cholesterol?
Evidence strongly indicates that high cholesterol can increase the risk of:
 narrowing of the arteries (atherosclerosis)

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 heart attack
 stroke
 transient ischaemic attack (TIA) – often known as a "mini stroke"
 peripheral arterial disease (PAD)
This is because cholesterol can build up in the artery wall, restricting the blood flow to your heart, brain
and the rest of your body. It also increases the risk of a blood clot developing somewhere in your
body.

Your risk of developing heart disease also rises as your blood's cholesterol level increases. This can
cause pain in your chest or arm during stress or physical activity (angina).
D. What causes high cholesterol?
 There are many reasons why the cholesterol can increase in the body.
 One of the main reason is eating an unhealthy diet – in particular, eating high levels of fat.
 Other reasons are – smoking, not doing exercises. Sometimes this problem runs in the family.
 Being overweight, having high blood pressure, diabetes, or some health conditions can also increase
cholesterol levels.
As I mentioned earlier your weight is higher than what it should be. I sincerely advise you to reduce
your weight. Also your blood pressure is high – we need to keep under control. I will discuss with
my senior to check whether we need to give ay medications to control your high blood pressure.
However generally this can be controlled with healthy life styles.
E. What should my cholesterol levels be?
As a general guide, total cholesterol levels should be:
 5mmol/L or less for healthy adults and 4mmol/L or less for those at high risk.
 In your case the cholesterol level is ---- which is quite high.
F. How can I lower my cholesterol level?
The first step in reducing your cholesterol is to maintain a healthy, balanced diet.
It's important to keep your diet low in fatty food.
You can swap food containing saturated fat for fruit, vegetables and wholegrain cereals. This will also
help prevent high cholesterol returning.
Other lifestyle changes, such as taking regular exercise and giving up smoking (if you smoke), can also
make a big difference in helping to lower your cholesterol.
Generally when these things do not help to reduce the cholesterol levels we prescribe medications to
reduce the cholesterol levels.
As per your test results and our guidelines you require these medications. Do you want to know about
these medications ? Yes
These medications are called statins.
[Is it ok if I just check the book about this medicines and let know about the medicines – check BNF].
There are many types of statins like atorvastatin, simvastatin and others. My Consultant will decide what
type may be suitable to you.
"Statins" is a class of medicines that lowers the level of cholesterol in the blood by reducing the
production of cholesterol by the liver.
Statins come as tablets that are taken once a day. The tablets should normally be taken at the same
time each day – most people take them just before going to bed.

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In most cases, treatment with statins continues for life, as stopping the medication causes your
cholesterol to return to a high level within a few weeks.
G. Side effects of statins
Many people who take statins experience no or very few side effects. Others experience some
troublesome – but usually minor – side effects, such as an upset stomach, headache or feeling sick.
Very rarely it can cause severe muscle pains. Also rarely it can damage liver and kidneys.
Once we start the medicines we will keep monitoring you. We need to keep doing blood tests to check
your liver function.
Any other concerns ? No. Thank you.
-------------------------------------------------
H. Cautions and interactions
Statins can sometimes interact with other medicines, increasing the risk of unpleasant side effects, such
as muscle damage. Some types of statin can also interact with grapefruit juice.
Caution - statins should be used with caution in those with a history of liver disease or high alcohol
intake; it is advised that liver function tests should be undertaken before and within 1-3 months of
starting treatment and thereafter at intervals of 6 months and 1 year, or sooner if clinical features
suggestive of hepatotoxicity. If serum transaminase concentration rises to, and persists at, 3 times the
upper limit of the reference range, then treatment should be discontinued
contra-indications include: Active liver disease - Pregnancy

9. Heart failure.
Mr McKenzie 58 year old man was diagnosed with myocardial infarction 7 years ago. He was not coming
for follow up. Now presented with Shortness of breath. GP referred him to the hospital. Address his
concerns. Patient was sitting on chair.

A.
1. Dr: Hello Mr McKenzie, I am Dr ... one of the junior doctor in the medical department. How can I help you ?
Pt: Doctor, I am feeling very short of breath.
2. Dr: I am sorry to hear that. Are you comfortable to talk to me? Pt: Yes.
3. Dr: Can you tell me more about your shortness of breath ?
Pt: I am having this problem since last 4 months and it is getting worse.
4. Dr: When do you feel short of breath – I mean you feel short of breath when you do some work or exercise or
even at rest you feel SOB ?
Pt: If I walk for about 100 feet I feel short of breath.
5. Dr: What happens when you lie down ? Pt: I feel more short of breath.
6. Dr: Are able to sleep properly or do you get disturbed due this problem?
Pt: It wakes me from sleep sometimes and I have to sit up for some time and I feel better.
7. Dr: Do you have any chest pain at all? Pt: No Dr: Any cough ? Pt: No
8. Dr: Do you have fever ? Pt: No Dr: Do have any swelling on your ankles? Pt: Yes
9. Dr: Any pain or swelling in the calf muscles ( PE) ? Pt: No
10. Dr: Did you have any surgery recently ( PE) ? Pt: No
11. Dr: Do you have any wheez ( Asthma, COPD)? Pt: No
12. Dr: Were you diagnosed with any medical conditions before ?

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 Pt: Yes I had heart attack about 7 years ago.
13. Dr: Ok Any other medical conditions like, High blood pressure, Diabetes, Asthma, Bronchitis ? Pt: No
14. Dr: Have you checked your cholesterol? Pt: Last time ( years ago) when I checked it was high.
15. Dr: Do you smoke ? Pt: Yes/ No (quantify if yes).
16. Dr: Do you drink alcohol ? Pt: Yes / No
17. Dr: Are you taking any medications ? Pt: Yes, Statins, Aspirin, Beta blocker
18. Dr: Are you taking them regularly? Pt: Yes
19. Dr: Are you going for proper follow up with your doctor after you had heart attack. Pt: No
20. Dr: May I know why? Pt: Doctor I was too busy and I did not have problem until 4 months ago anyway.
21. Dr: May I know what job do you do? Pt: I am an Accountant
22. Dr: Do you do exercise ? Pt: Not much
23. Dr: Is there anything else important you think we may need to know? Pt: I don’t know.
B. Examination
1. Dr: Mr McKenzie, I need to examine you now, I need to check your pulse and BP and also examine your chest.
Examiner may give NEWS chart. – P-100, BP-130/90, SpO2 -96%, Temp – 36.9, RR- 15, O/E – Bibasal
crepitations heard.
2. I will do ECG – Examiner may give ECG – May show ST depression in V2-3-4-5-6.

3. I need to do his chest X Ray – Examiner may give Chest X Ray – may show Pulmonary Oedema

4. Thank the examiner.

C. Talk to the patient.
2. Dr: Mr McKenzei, Do you have any idea what may be happening to you? Pt: No doctor.

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3. Dr: You have a condition what we call as heart failure. Your heart has become very weak and it is not pumping
the blood out of the heart properly. That is why the fluid has accumulated in your lungs which is causing
shortness of breath and the fluid had accumulated in the ankle area that is why you are having ankle swelling.
Do you follow me?
4. Pt: Yes but why I am having this ?
a. Dr: This is one of the complication which can happen to those people who had heart attack in the past.
b. During the heart attack there is damage to the muscle wall of the heart and eventually it becomes very weak
and will not work properly. There are other contributory factors like high blood pressure, or if you do not
take the medication properly or if you continue to smoke and not eating healthy diet and not exercising – lot
of these factors can contribute towards this problem.
c. That is why it is very important to have a proper follow up where we monitor all these things and reduce the
chance of having complication. Do you follow me?
5. Pt: Yes : What happen to me now?
a. Dr: Mr McKenzie. This is quite a serious problem now. We need to admit you to the hospital to treat you.
Is that OK? Pt : OK
b. Dr: We will be giving you Oxygen, and we will give some medications called diuretics which gets rid of the
fluid from the body. You may be passing more urine because of this.
c. We will have to do some more investigations on your heart called Echocardiography – a type of heart scan
and also we may need to do tests to check whether you have any narrowing of the blood vessels in your
heart. Are you following me ? Pt : Yes. Dr: Is that OK? Pt Yes.
6. Dr: We will be giving other medications called ACE inhibitors and beta blockers. We need to check some
chemicals in the blood and also check your cholesterol. Is that OK? Pt: Ok
7. Dr: I sincerely advise you to stop smoking, do good exercise and eat balanced diet in the future and also have
a proper follow up once we discharge you ? What do you say?
Pt: Yes doctor, I will follow your advice. Dr: Good. I will talk to my seniors about you and hope you recover
very soon. Thank you very much.

10. Heart Failure and Atrial fibrillation SimMan

Exam question
60 year old presented with Shortness of breath, feeling dizzy. History examination and management with
the examiner. At 6th minute discuss finding’s with the examiner.
( Positive findings – Dizziness, SOB and palpitations for about 2 weeks)
A.
1. Dr: Hello Mrs ... I am Dr ... junior doctor in the medical department. How can I help you ?
Pt: I am feeling dizzy and I get palpitations since the last 2 weeks.
2. Dr: I am sorry to hear that. Is there anything else you can tell me about it?
Pt: Doctor it just started on its own. I was perfectly fine before that.
3. Dr: You said you felt dizzy – is it like light headedness or you feel the room is spinning?
Pt: I feel like light headedness/ not like the room is spinning
4. Dr: Can you please tell me when do you get dizziness – all the time or it happens only some times? Pt : It
happens only some times
5. Dr: How many times it happened since it started? Pt: --
6. Dr: How long does it last ? Pt: ---
7. Dr: Did you lost consciousness any time at all ? Pt : No

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8. Dr Do you have any balance problem ? Pt: Ye I feel as if I don’t have balance when I feel dizzy
9. Dr: Any problem in your ears like – hearing problem, any ringing sound in ears ? Pt : No
10. Dr: You said palpitations – since how long you had this ? Pt : about 2 weeks.
11. Dr: Does it also comes once in a while or is it continuous ? Pt: -
12. Dr: How many times you think you had this problem since it started ? Pt :
13. Dr: Do you feel dizzy when you get palpitations or they occur at different times ? Pt –
14. Dr: How do you feel the palpitations – do you feel as if the heart is racing or missing heart beat ? Pt –
15. Dr: Do you have any chest pain or did you have any chest pain when all these symptoms started ? Pt : No
16. Dr: Do have shortness of breath? Pt : yes Dr: Since when? Pt: Since the same time.
17. Dr: When do you get SOB – all the time or when you lie down or when doing exercise ?
18. Dr: Any swelling in your ankle ( Heart failure) ? Pt : Yes / No
19. Dr: Did you have any recent surgery ( PE) ? Pt: No Dr: Recent travel ( PE) ? Pt: No
20. Dr: Do you get too tired ( Anaemia) ? Pt : No
21. Dr: Have noticed any bleeding from gums or back passage ( anaemia) ? Pt: No
22. Dr: Any changes in the bowel habits ( hyperthyroidism) ? Pt: No
23. Dr: Any weather preference ( Hyperthyroidism) ? Pt: No
24. Dr: Have you been diagnosed with any medical conditions ? Pt : No
25. Dr: Like high blood pressure ? Pt : No Dr: Diabetes ? Pt- No
26. Dr: Heart conditions ? Pt: No
27. Dr: Are you taking any kind of medications ? Pt: No
28. Dr: Are you allergic to any medications ? Pt: No
29. Dr: Do you live with any one ? Pt: Yes/No
30. Dr: Is there anything else you think is important that we may need to know? Pt: No
B. Examination :
2. Mrs. I need to examine your chest. Could you please undress above the waist ? I will ensure privacy and have
a chaperone with me.
Mannikin may say - Doctor you do it. Then undress the manikin ( do not undress if the examiner says
assume the patient is exposed)
3. Examine the hands – no clubbing, palmar erythema, no cyanosis.
4. Ankle – No pedal oedema
5. Ideally I will check for raised JVP ( can’t check JVP in Manikin)
6. Check the pulse ( for about 10 seconds) – may show irregular rhythm.
7. Examine the chest – No scars or deformities in the chest.
8. I will check for apex beat to see shift in the apex beat ( manikin has no apex beat)
9. No palpable thrill
10. No Para sternal heave
11. Auscultate all the areas – for heart sounds and murmurs ( may be Pan-systolic murmur = mitral regurge)
12. Auscultate for basal crepitations ( on the sides of the chest because can’t make the manikin sit up) ( there
may be basal crepitations)
13. Check the monitor for Pulse rate, BP, Respiratory rate, Temperature and tell the examiner your findings
14. Check the ECG on the monitor – may show Atrial fibrillation ( irregularly irregular rhythm, narrow QRS
complex, Abscent P wave) (Look at the ECG on the monitor for at least 15 seconds otherwise you may miss
AF because sometimes normal rhythm come in between irregular rhythm)

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15. Cover the patient. Thank the patient
16. Talk to the examiner
a. Patient has palpitations, dizziness and shortness of breath since last 2 weeks. Had no medical problems
previously. On examination, I found patient has pan-systolic murmur, basal crepitations and the ECG shows
Atrial fibrillation with the pulse of ... and BP ...
b. I think the patient has heart failure may be secondary to mitral valve regurgitation with Atrial fibrillation.
(Do not say Heart failure if it is not present ..)
c. I want to do further investigations like FBC, U&Es, Cardiac enzymes chest X Ray. (Examiner may not give
any results.)
d. I will admit the patient, Inform my seniors– give Oxygen, Insert IV cannula. If the chest X ray shows heart
failure I will give her diuretics ( frusemide start with 40mg IV) and Catheterise her.
e. We may need to do Echo cardiography. She may need to be treated with beta blockers and anticoagulation
for Atrial fibrillation. I will refer her to cardiology for further management.

11. AF patient and does not want warfarin

Exam question;
You are FY2 doctor in medical unit.
A middle aged man, Mr.… has been diagnosed with Atrial Fibrillation and Stroke. Consultant has
prescribed and patient has been started on warfarin. But patient has refused the treatment.
Talk to the patient and address patient’s concerns.

B.
1. Dr: Hello, I am Dr…. I am one of the junior doctor in the medical department. Are you Mr…?
Patient: Yes, doctor.
2. Dr: How are you doing Mr…? Patient: I am doing well doctor.
3. Dr: My Consultant has prescribed you some medications which you need to take. I am here to explain
to you about this medicine. If you do not understand anything at any time, please do let me know. Is
that OK? Pt: Ok.
4. Dr: Well, Mr.… From your notes, I have gathered that you have been diagnosed with a condition
called Atrial Fibrillation and you have suffered a stroke as well. I am really sorry about that. Has
anybody explained to you about your condition?
Patient: I am aware that I have clots in my heart and these can go to my brain. But I do not
want warfarin. That is a rat poison.
5. Dr: I am sorry that you are not happy with the warfarin medicine. Yes you are right that the rat poison
also has the same composition. But you need this medicine. Is there any reason you don’t like this
medicine ?

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 Patient: I just do not want this medicine doctor. My dad used this medicine and he fell down
and head injury and then he had too much bleeding in his brain and he died because of that.
I do not want the same thing to happen to me.
6. Dr: I am really sorry to hear about your father but you have to understand that this medicine is vital
for your health and safety.
Patient: I do not see the point of it doctor. My father was told the same thing. He was on
warfarin and look what it did to him.
7. Dr: I can understand why you are so reluctant to take this medicine. And I am really sorry that it
happened to him but do you have any idea why he was on warfarin? Patient: …..
8. Dr: I see. Well, Mr… there are many other factors which might have lead to massive bleeding in his
head. Sometimes it can happen if the blood is too thin. However, in your case, it is imperative that
you take this medicine. Please let me talk to you in detail so that we can address this together. Is that
Okay ? Patient: Okay doctor.
9. Dr: Mr….., could you please tell me how much do you know about your condition?
Patient: I just know that I had clots in my heart and these travelled to my brain.
10. Dr: Yes, you have been told right Mr…. You have a condition called Atrial Fibrillation. Do you know
what it is? Patient: No.
11. Dr: It’s alright. I will explain it to you. This is actually a condition which causes a fast and irregular
heartbeat.Are you following me?
Patient: Yes doctor. Can’t you give me any medicine to control my heart rate?
a. Dr: Yes, Mr.… Although medicines can be used to control this abnormality in heart rate, yet one
of the most important complications of this condition is that it can cause blood clots to form in the
heart.
b. This blood clot can then travel in the blood vessels until it becomes stuck in a smaller blood
vessel in the brain. Part of the blood supply to the brain may then be cut off, which causes an
injury to brain. This is what we call as stroke.
c. This is the reason why you suffered from the stroke. Ae you following me Mr…? Patient: Yes.
d. Dr: Warfarin tablet is a blood thinning tablets which means that it stops blood from clotting.
e. It is essential for you to take this medicine because if you don’t then blood clots might result in
obstruction to the blood supply to your brain and unfortunately, a stroke may happen again. You
know sometimes the stroke can even be life threatening. And I am sure, you wouldn’t want that
to happen to you isn’t it ?
12. Patient: Yes doctor. But if I take it then if I fall then I can bleeding in the brain and then I will
die like my father. So, why should I take this medicine?
a. Dr: I can certainly understand your concern. Unfortunately this is one of the known problem which
can happen to those people who take warfarin. The chances of bleeding becomes high if the
blood is too thin.
b. That is why we keep checking the patient’s blood regularly to make sure the blood is not too thin
or not too thick. This blood test is what we call INR.
c. Also the patients who are taking warfarin needs to be careful so that they don’t fall or injure
themselves when using any sharp instruments.
d. However despite keeping the blood not too thin, bleeding can still happen if someone falls and
has head injury.
13. Pt: So, then it can happen to me !

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 a. Dr: Yes Mr… That is true. But the chances of you getting a stroke again which can be even life
threatening as I mentioned earlier is much higher than you falling and having bleeding in the
brain.
b. If you do not taken this warfarin you are almost certain to get this stroke again.
c. I sincerely advise you to be careful not to fall and careful not to have any injures while using
sharp objects.
d. Also if you want we can send our Occupational therapists to your home to see if there is anything
which can make you fall and they can to rectify those things. However you need to be careful
whenever you go outside not to fall.
14. Pt: But doctor you can’t prevent me falling. That can happen to me any time any day. You
know the falls happens accidentally.
a. Dr: I do understand what you are saying. However, if there is any medical causes which makes
you fall then we can sort out those issues. But you need to be careful about accidental falls like
slipping and tripping.
b. Mr… I am saying this to you because this medicine is very important for you and for your own
benefit I am advising this to you. What do you think now? Would you like to take it.
15. Pr: Yes, doctor you have convinced me about it. Thank you very much. But doctor since I had
stroke last time my memory is not very good. What if I forget to take this medicine ?
16. Dr : It is good you told me about it. It is very important to take this medicine regularly every day. If
you do not take the medicine blood can become thick again an cause more strokes. I advise you to
make a habit to take it same time every day so that you do not forget. Also you can keep an alarm
which can ring same time every day to remind you to take this medicine. Also if you live with someone
you can tell them to remind you to take this medicine every day. Is that OK ?
17. Pt - Ok doctor. Thank you.
C. Warning signs
Dr: Thank you Mr.. I am sure you will be fine with this medicine. However, if at you fall please call the
ambulance immediately or tell someone else to call the ambulance immediately in case if you fall. Is that
Okay Mr..
Pt: Ok doctor. Thank you. You have been very kind.
Dr: Thank you very much for talking to me. I really wish all the good health for you Mr..
D. If the patient still not convinced.
Dr: I am sorry that I wasn’t able to convince you about the importance of taking this warfarin. You do
have the right to refuse any treatment what we advise. However, I will talk to my seniors and may be
they will be able to convince you about it. Thank you very much for talking to me. I really wish all the
good health for you Mr..

12. Hypertension-Doesn’t Want To Take Medication ( Amlodipine) -

Changed Station
Diabetic patient was admitted 2 weeks ago for cellulitis. During admission, she was diagnosed with hypertension.
Today she came for follow up. Address her concerns.
This time, the patient says that she does not want to take the medication because she noticed swelling of the ankles
after taking AMLODIPINE.
Check BNF-One of the common side effects of amlodipine is swelling of ankles.

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Tell her that you would discuss with your seniors and consider changing the medication.

13. Smoking
You are the FY 2 doctor in the medical department. Mrs Joan Thomas has been planned for angioplasty.
She is a chronic smoker.Talk to patient and advise her to quit smoking.
A.
1. Dr: Hello Mrs Joan Thomas ,I am Dr..... one of the junior doctors in the medical department. How are you
doing? Pt: I am OK.
2. Dr: I am here to talk to you about your condition. Pt: If you have come here to tell me not to smoke, please
don’t talk to me.
3. Dr: It seems that you have been annoyed by others, don’t worry I am not going to annoy you.I am here to talk
to about your health condition and to advise you how you can prevent that problem in the future. Is that OK?
Pt: OK
4. Dr: Mrs Thomas, Can you please tell me how much do you know about your condition? Pt: I was told there is
some problem in my heart.
a.Dr: That is right. You had some thing like a minor heart attack. Let me explain that to you.
b. Heart needs its own blood supply for it to survive. Blood supply is provided by some blood vessels specially
for the heart muscles. These blood vessels have become narrowed in your case which has caused reduced
blood supply to your heart muscle.
c. That is why you had this pain in your chest. We are doing a procedure called angioplasty where we are
widening this blood vessels in our heart to restore the blood supply to the heart muscles. Do you follow me?
Pt: Yes
5. Dr: Do you know why this blood vessels would have become narrowed? Pt: No
Dr: There several reasons why this blood vessels can become narrow. Sometimes this happens with those
people who do not eat healthy balanced diet or who do not do exercise or who have some medical conditions
like high blood pressure or diabetes.
6. Can I ask you how is your diet? Pt: I eat healthy diet doctor.
Dr: That is very good to know. Please continue eating healthy food. Praise him
7. Do you do exercise ? Pt: Yes doctor.
Dr: That is also very good.Please do continue doing execrcises.(If she said no–I advise you to do some good
exercises . That will be very good for your heart and your health). Pt:OK
8. Dr: Do you have any medical conditins like high blood pressure or diabetes? Pt: No
Dr: That is excellent. That means it is non of these problems which are causing the problem in your heart.One
other reason why people get this problem in the heart is smoking for long time.
9. Can I ask you do you smoke Mrs Thomas. Pt: Yes
10. Dr: Can I ask you what do you smoke and how much do you smoke ? Pt: 20 cigarettes a day.
Dr: For how Long? Pt: For about 20 years now.
Dr: Well Mrs. Thomas, there is very high chance that this smoking habit has caused the problem in your heart.
Cigarette contains harmful substances like - Tar: A substance that causes cancer, Nicotine: it is addictive and
increases bad fat cholesterol levels in your body and Carbon monoxide: which reduces oxygen in the body. I
sincerely advise you to stop smoking so that you do not get this problem again.

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11. Pt: Why do you say it is smoking caused this? My dad was smoking whole of his life he had no health
problem at all ? ( there are so many people smoke they do not have any health problem)
a.Dr: I am really glad to know that your dad had no health problem at all despite smoking for many years.
However, Mrs Thomas there is evidence that people who smoke for long time do get lot of health problmes
like stroke, cancers, high blood pressure and including heart attack. In some people skin becomes more
wrinkled. Also, people stay near to you get passive smoking which can hppen even to your children if you
have at home. You may be spending lot of money on smoking Iguess.
b. You already had some minor heart problem in your heart now. If you continue that you can get major heart
attack next time & it may be even life threatening. I’m sure you don‘t want that to happen to you isn’t it ?

12. Pt: You said you are going to widen the blood vessels in my heart. So why should I get this problem again?
a.Dr: Mrs Thomas we are treating this condition now, but if you continue smoking - blood vessels in your heart
will become narrow again and it can cause serious problem next time.
b. There are many benefits of stopping the smoking:
c. Carbon monoxide and nicotine will be eliminated from the body, blood circulation will improve. Lungs start to
clear out smoking debris. Skin becomes less wrinkled.Coughing and wheezing stop.
d. Excess risk of heart attack and lung cancers reduces by half. Also you could save lot of money which you
spend on buying cigarettes and you can use that money for something else.
13. Pt: But doctor I enjoy smoking? I can’t stop it.
a.Dr: Many people say that they enjoy it but that enjoyment comes at the expense of your health. If you want
to enjoy your life you need to remain healthy. You can try doing some other things to enjoy life which will be
good for your health–may be going for some exercise classes, relaxation therapy or yoga classes where you
meet lot of people and you may enjoy that.
b. If you wish we can help you in stopping smoking. We have some thing called as smoking cessation clinic. I
can refer you to them. There are support help groups. You may be benefitted from that.
c. We also have some medicines called Bupropion and Varenicline which can help in stopping the craving for
cigarettes, but at the end of the day it is your willpower that is the most important thing.
Insisted?
We cannot stop yo. we can only advise you. we are cocnerned .. Then stress on that it will be a risk on you life

14. What do you say Mrs Thomas? Do you want to consider this? Pt: I will think over it.
Dr: That is really good. Please do let us know and we will do every thing possible from our side to help you.
(if she said no I can’t stop smoking – I can understand that it is not easy to give up the habits. However,you
may need more time to think over that.I advise you to think about it seriously and let us know any time if you
need our help, we are always here to help you.
Thank you very much. [ do not mention - I will tell my seniors – they will come to talk to you]

XIV. Chest stations

1. Acute Asthma SimMan

Exam question
30 year old man came to the emergency department c/o SOB

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Take history, examine and discuss your diagnosis and management with the examiner.
Differentials for Shortness of breath
1) Acute Asthma
2) Acute exacerbation of COPD
3) Heart failure
4) PE
5) Pneumonia
6) Pneumothorax
7) Anaphylaxis
8) Arrhythmias ( SVT)
SIMWOMAN --> will have wig
SIMMAN
I can ask and the simman witll respond to me (because it is in another room)
A.
1. Dr - Hello Mr ... I am doctor ... How can I help you Mr... ? Pt - Doctor I can’t breath properly
2. Dr - Since when ? Pt - since last few hours.
3. Dr - Did you have this problem before? Pt – Yes, I have asthma ( Known Asthma patient)
[If patient says – no, ask do you have Asthma or smoker’s cough, then patient may say – I have asthma]
4. Dr - Did you take your medication ?
Pt - yes, it is not helping me. They are on the table. ( inhalers may be kept on the table – Look at the
medicines).
Sometimes it says I am dying -->
I am sorry that you are feelign that way --> Can you please tell me what is exactly the problem ?
So since when? did you have this problem before?
--> sometimes he say no --> I then ask him do you have asthma - smoke stop = copd?
Do yo take any medications? you wil find medications o nthe table ..
B.
1. Look at the monitor for Oxygen saturation, respiratory rate, pulse and BP, temperature, ECG rhythm and tell
the examiner.
There will be a monitor ..
HR - SO2 - BP- Temp - ECG
I then tell the examiner what is on the monitor ,, and say it is norrmal or not ..
2. Usually oxygen saturation is 82 to about 84%. Tell the examiner - I will give high flow oxygen 100%
concentration with flow rate of 15 litres/min.
I need to give the patient oxygen --> The examiner wil ask about it? ..100% 15 l/min
3. Tell the patient – I am going to give you some oxygen you will feel better. Put the Hudson mask with reservoir
bag on the mannequin face and tie properly.
Simple face mask without reservoir bag (Left)
Hudson mask with reservoir bag (Right)
I need to use the fface mask with the resivorir and connect it to the
face of simman and then say I will give 100 % oxygen ..
I need to make sure that the mask if fitting the nose and mouth
propeply .. and tight
I do not use the vitore oxygen mask  (used in COPD) and in that case the rate  will be
2 L.
Then i go checking the satuation

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4. Dr - Any chest pain ( MI leading to heart failure) ? Pt-No
5. Dr: Does SOB gets better or worse while lying down ( heart failure) ? No change doctor.
6. Dr: Did you have any heart problem before ? Pt - No
7. Dr: What were you doing when this started ( exercise induced) ? Pt: I was just resting
8. Dr - Any fever ( Pneumonia) Pt - No
C.
1. Keep looking at the monitor – Oxygen saturation should improve by this time. If not jump to treatment ( I will
give him Salbutamol 5mg as nebuliser and call my senior immediately)
When I use salbutamol, chamber with the oxygen flow not the bag .. i will remove the bag
2. Make sure the saturation improves. And then continue.
Keep looking at the monitor and the patient from time to time frequently --> to make sure that patient is ine
If the saturation drops -->
I need to examine quickly by auscultation ..
I need to shift ot he management quickly .. I will give (salbutamol) nebulizar 5 mg .. I will change the mask
with the room of the nebulizer.
I always look at the monitor at all steps after each step in the xamination ..
Then they will increase the sturaion again ..
3. Dr: Do you smoke ( COPD) ? Pt: yes / No If he is smoking --> do not change the diagnosis
4. Dr: Any pain or swelling in calf ( PE) ? Pt: No
5. Dr: Recent Travel or immobilisation ( Surgery ) (PE) ? Pt: No
6. Dr : Do you take any other medications other than Inhalers ? Pt – No
7. Check the monitor for oxygen saturation.
D. Examine.
2. Exposure - Dr - I need to examine your chest. Can you please undress above your waist ?
Patient ( mannikin) may say - you do it [and then you expose the mannikin].
When I examine --> The shirt I will need to ask him undress the shirt --> he will tell me to do it myself --> so
i underess it
The female there will be anothershirt that i need to have consent to remove also
3. Inspection- Appears severely breathless, No cyanosis in hands and lips
4. No neck vein engorgement, No tracheal shift ( to r/o tension pneumothorax)
5. Chest – Inspection – Movements symmetrical.
6. Palpation - Movements symmetrical,
7. Percussion – No hyper - resonance or dullness
8. Auscultation – Air entry bilaterally equal, Wheeze heard bilaterally all over the lung field. No crepitation.
Wheeze is a symtpom - ronchi is a sign
9. Cover the patient.
10. Tell the patient : It looks like your Asthma has come back. We will give you some medicine and you will feel
better soon.
11. Then talk to the examiner.
E. Diagnosis – Acute Severe Asthma
12. Tell the other management to the examiner.
a. I will admit the patient.
b. Salbutamol nebuliser – 5mg,
c. Ipratropium bromide 0.5mg Neb

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 d. Hydrocortisone 100 mg IV every 6 hours
e. Keep monitoring the oxygen saturation, respiratory rate, ABG
f. Do portable chest X Ray and ECG
g. If no improvement – repeat salbutamol nebuliser every 15 minutes.
h. I will call the seniors immediately.
13. If no improvement – IV Magnesium 2gm over 20 minutes
14. If no improvement talk to seniors and consider Aminophylline infusion
15. If still no improvement – needs intubation and ventilation so I will call the anaesthetist also.
16. [If the patient says I am dying – stop taking history or examination check the monitor reassure the patient that
you will give medicine and he will be better soon, and tell the management to the examiner and then continue.
17. Keep looking at the monitor at all times – jump to the treatment if the saturation did not go above 94% or if it
drops any time, or if the patient says I am dying or if the patient shows signs of respiratory distress].
F. Talk to the patient
1. Mr ... Your Asthma has come back. Your inhaler medication is not working. So we need to keep you in the
hospital and treat you with nebuliser medications – salbutamol to widen your airways. This medication will be
given like a steam inhalation. We will also be giving some steroid medication through your veins. Any
questions ?
2. We need to do some tests like chest X Ray to make sure that you do not have any other problems. Also we will
be doing some blood tests to check blood gases and other things. Once you have improved then we will
discharge you. Is that OK?
3. Any concerns?
If the patient did not know what is Asthma - then explain.
Dr: In this condition your airways become narrow which is causes breathing difficulty. Sometimes this
condition runs in the family. Most of the time it is due to allergy to dust, animal fur, pollens or sometimes it
may be due to exercise.

2. Exercise induced Asthma

Mr …. Presented to the hospital with shortness of breath.
Take history from him and discuss you further management with him.
C.
1. Dr: Hello Mr… I am Dr …. Can you please tell me what brings you to the hospital? Pt: I am feeling very short
of breath whenever I play football.
2. Dr: I am sorry to hear that. Are you short of breath now? Pt: No I am Ok now.
3. Dr: Anything more you can tell me about this problem. Pt: It just started last few weeks.
4. Dr: Do you feel short of breath when you are not doing exercise ? Pt : No
5. Dr: Do you feel short of breath when you lie down ( heart failure) ? Pt : No
6. Dr: Do you have any cough ? Pt: Yes whenever I feel short of breath I get cough also. Dr: Do you bring out
any sputum? Pt:No
7. Dr: Any fever ? Pt: No Dr: Chest pain ? Pt: No I feel my chest is tight. Dr: Are you allergic to
anything at all? Pt: No Dr: Do you have any pets at home ? Pt: No
8. Dr: Do you get SOB when you get exposed to plant pollens ? Pt: No Dr: Did you have any swelling or pain
in your calf muscles? Pt: No Dr: Did you travel anywhere recently? Pt: No
9. Dr: Did you have any operations recently ? Pt:No

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10. Dr: Any other problems like any skin rash. Pt: Yes I have skin rash ( eczema ).
11. Dr: Did you have this problem before ? Pt: Yes I used to feel short of breath whenever I do any exercise.
12. Dr: Do you have any medical conditions ? Pt: No
13. Dr: Like bronchitis? Asthma ? Heart problems ? Pt: No Dr: Do you smoke ? Pt: No
14. Dr: Are you taking any medications ? Pt: No
15. Dr: Any of your family members have any medical conditions? Pt: My dad has asthma and eczema.
16. Dr: Is there anything else important that we need to know? Pt: No
D.
1. Dr: Mr… I need to examine your chest.
[Examiner may say – there is rhonchi on both sides]. Dr: Mr… I think you have asthma.
2. I want you to do a test to check how your lung is functioning. This test is called PEFR.
3. Make him do PEFR. Check his predicted normal reading on the chart provided. PEFR may be normal. ( may
be low sometimes).
E.
1. Dr: Mr… Your reading is good now. Mr … you may be having a condition called Asthma. Do you know
what is asthma ? Pt: No doctor.
2. Dr: Asthma is a condition in the lung where the patient becomes short of breath because the wind pipe become
narrowed. This is usually happens to people who are allergic to something like pollens, animal fur or sometimes
this can be triggered due to exercise – probably the exercise is causing you this problem. Are you following me
? Pt: Yes.
3. Investigation: We will do chest X Ray to make sure that you do not have any other problem in the chest. ( rule
out – pneumothorax).
4. Also we need to do a test called Spirometry when you are exercising on a treadmill to see your lung function.
That will tell us whether it is exercise induced Asthma.
F. Management
6. Dr: At the moment since you ae not short of breath there is no need for admission to the hospital. However you
may get this problem again when you exercise.
A. Prevention
2. In the future to prevent getting this asthma attacks you need to take some steps.
3. You can do exercises. It is better to avoid football because it involves long period of activity. Instead short
duration sports may better for you. However you need to take some inhaler medications like salbutamol (
broncho dilators) about 20 minutes before you do any kind of exercise.
4. In addition to taking medications, warming up prior to exercising and cooling down after exercise can help in
asthma prevention.
5. If you have allergy to pollen then the exercise should be limited during high pollen days or when temperatures
are extremely low.
6. If the weather is cold, exercise indoors or wear a mask or scarf over your nose and mouth.
7. Infections can cause asthma (colds, flu, sinusitis) and increase asthma symptoms, so it's best to restrict your
exercise when you're sick.
8. Is that Ok ? Pt : Ok doctor Dr: Are you following me? Pt: Yes Dr: Any other questions ? Pt: No
Thank you.

Another scenario for exercise induced Asthma  On history patient may say he is short of breath now.

1. Ask him since when ?

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2. What was he doing when he became short of breath ? He may say he was playing foot ball.
3. Ask him if he is comfortable to talk.
4. Rest of the history is same.
5. Do PEFR – which may be normal or low.
6. Diagnosis and investigation are the same as above.
7. Treatment
a. We will admit you ow and treat with some medications called salbutamol nebuliser. They are called broncho
dilators. This will help to widen your wind pipe.
b. We will also give you some steroid tablets. This will help prevent asthma attacks. We will discharge you
once you are better which may be a day or two.
8. Then talk about prevention.Information
What Are the Best Exercises for Someone With Asthma?
a. For people with exercise-induced asthma, some activities are better than others. activities that involve short,
intermittent periods of exertion, such as volleyball, gymnastics, baseball, walking, and wrestling, are
generally well tolerated by people with exercise-induced asthma.
b. Activities that involve long periods of exertion, like football, distance running, basketball, and field hockey,
may be less well tolerated, as are cold weather sports like ice hockey, cross- country skiing, and ice skating.
However, many people with asthma are able to fully participate in these activities.
c. Swimming, which is a strong endurance sport, is generally better tolerated by those with asthma because it
is usually performed in a warm, moist air environment.
d. Maintaining an active lifestyle, even exercising with asthma, is important for both physical and mental
health. You should be able to actively participate in sports and activities

3. Patient requesting Antibiotics for a sore throat

Exam question:
You are the FY 2 doctor in the GP clinic.
22 year old Miss Chris Barns presented to the GP clinic 2 days ago with sore throat. Practitioner
nurse did the throat swab which showed no bacterial growth. Nurse advised her to take mild
pain killers and steam inhalation. She has come back again and wants to talk to the doctor.
Assess her current condition and address her concerns.
A.
2. Dr: Hello Miss Chris Barns I am Dr…. How can I help you Miss Barns ?
3. Pt: I am having sore throat doctor. I came here 2 days ago and the nurse told me to take pain killers and
steam inhalation. I am not getting any better. Can you please give me antibiotics.
4. Dr: Can I ask you why are you asking for antibiotics?
Pt: Last time I had some infection and I was given antibiotics and I improved very quickly. Please give
me antibiotics. I have to attend some function in the next few days. I want to get better before that.
5. Dr: I can understand your concerns. Do you know what infection you had last time? Pt : I can’t remember
now.
6. Dr: No problem. Can I ask you few questions to see whether you need antibiotics. If you need it we will
definitely give it. Pt: Yes doctor. Thank you.
7. Dr: Since when are you having this sore throat ? Pt: Almost 4 days now doctor.

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8. Dr: Do you have any pain while swallowing ? Pt:Yes slightly. Dr:Are you able to swallow food or drink ?
Pt: Yes
9. Dr: Do you have any breathing difficulties? Pt: No
10. Dr: Is your symptoms getting any better or the same or getting worse ?
Pt: It is the same doctor not getting better. I feel slightly better when I use steam inhalation.
11. Dr: Do you have any other problem apart from sore throat?
Pt: I am having pain all over the body.
12. Dr: Any other problems? Pt : Like what ?
13. Dr: Do you have fever ? Pt: No Dr: Do you have cough and cold ? Pt:Yes Dr: Do you bring out any
phlegm ? Pt: No Dr: Do you have pain in the ear ? Pt:No Dr:Any chest pain ( Pneumonia) ? Pt: No
Dr: Any discharge from the nose ? Pt:Yes Dr:Any headache ( meningitis) ? Pt: No
14. Dr: Any rashes on the body ( meningitis, glandular fever? Pt:No Dr:Any swellings on the neck or arm pit (
glandular fever) ? Pt: No Dr: Did you have similar problem before at all? Pt: No
15. Dr: Do you have any medical conditions? Pt: No
16. Dr: Are you taking any medications other than pain killers and steam inhalation? Pt: No Dr: Are you allergic
to any medications ? Pt: No
B. Examination:
Dr: Miss Barns , I need to examine your throat and chest. Examiner may say – Examination is normal.
C. Diagnosis:
2. Dr: Miss Barns with the information what you have given me and after the examination, I think you have sore
throat due to viral type of bugs. This type of virus infection will subside on its own without any special
treatment. Only treatment required are for the symptoms like pain killers and the steam inhalation which you
are already taking.
3. Pt: But I am not getting better doctor !
Dr: Miss Barns sometimes it may take about a week for the condition to subside. I advise you to continue taking
the pain killers and the steam inhalation for few more days and you will feel better in the next few days.
4. Pt: Doctor, I have to attend a function in the next few days. I want to feel better soon to attend that
function. Please give me antibiotics.
Dr: Miss Barns Antibiotics are given only for infections due to bacterial kind of bugs not for infection due to
virus type of bugs. They do not help for viral infections. Besides that antibiotics has its own side effects. So
you may develop unnecessary side effects.
5. Pt: Doctors last time I improved very quickly after taking the antibiotics !
a. Dr: I am not sure why the antibiotics were given to you last time. May be you had infection due to bacterial
type of bugs. This time it is not bacterial infection.
b. Nurse took a swab from your throat last time to check whether you have bacterial infection. That test also
shows this is not bacterial infection..
c. Miss Barns, if we give antibiotics unnecessarily, bugs may develop resistance to these antibiotics and next
time if at all you get bacterial infections these antibiotics may not work and it may lead to serious
complications.
d. If it all you needed antibiotics we would have definitely given that to you. Your condition does not require
it. You will feel better soon. Pt: Ok doctor.
D, Warning signs.
1. Dr: Thank you miss Barns. You can go home now and continue taking pain killers and the steam inhalation.

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2. However if you are getting very unwell, or start developing chest pain and high fever or if you see rashes on
the body these could be the signs that you are developing some complications like chest infection, so please do
come back.
3. Hope you recover soon and be able to attend the function.

4. MRSA – COPD patient

You are the FY 2 doctor in the medical department.
Mr Charles Roper 56 year old man has been admitted to the hospital for COPD. His nose swab showed
MRSA.
He has been isolated and been treated appropriately. His wife Mrs Helen Roper is concerned about him.
Please talk to her and address her concerns.

A.
1. Dr: Hello Mrs Helen Roper ! Wife: Yes.
2. Dr: I am Dr. …. One of the junior doctor in the medical department. How are you doing Mrs Roper?
Wife: I am OK. I am worried about my husband ! I just came to see him. He has been shifted to some
other room. I can see doctors and nurses wearing aprons and gloves. What is happening to him doctor?
3. Dr: I can see that you are very concerned, I will explain everything. Before that can you please tell me how
much you know about what is happening to him? Wife: I know he has COPD !
Dr: Yes, That is right Mrs Roper. He has COPD and was treated as you know. But we did some swab test on
his nose and it showed that he has some bugs in his nose.
4. Wife: What kind of bugs?
Dr: These bacterial kind of bugs are called MRSA in other words they are called super bugs. Do you anything
about these bugs MrsRoper ?
5. Wife: Super bugs ! I have heard of them. From where did he get this bugs ? Is it because the hospital is
dirty?
a. Dr: Sometimes the bacteria normally live on the people’s skin without causing any problem. Sometimes
these bugs are spread through skin-to-skin contact with someone who has an MRSA infection. These bugs
also spread through contact with contaminated objects such towels, sheets, clothes, dressings, surfaces, door
handles and floors.
b. Sometimes people may get this infection outside the hospital also.
c. We do keep the hospital very clean to minimise the spread of this infection. When doctors and nurses enter
the room of the patient’s with this of infection they wash their hands thoroughly and wear aprons and gloves
to minimise the chance of spreading the infection.
d. However, sometimes people can get this infection because new patients keep coming into the hospital and
they may have this bugs on their skin and it spreads to others.
6. Wife: Is it a serious problem doctor?
a. Dr: At the moment these bugs are just present in his body and it is not causing any problems to him. So it is
not a serious problem to him at the moment.
b. However, if the bugs gets inside the body and cause infection then it can become serious problem.
c. Sometimes the bugs can get inside the body and cause infection if their body resistance goes down or if they
have some break in their skin like operated wounds or it can enter inside the body through urine catheter or
IV cannulas ( the tubes through which we give medication into the veins).
d. In your husbands case because he has COPD, his body resistance would be low. So there is a chance that
bugs may get inside his body and cause infection.

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7. Wife: Do you mean to say he may die doctor?
Dr: Mrs Roper, As I told you at the moment there is no problem because the bugs are just present in is body. It
is not very common that people die because of this bugs. It can happen only if the people gets serious infection
with this bugs and bugs do not respond to any treatment.
8. Wife: How are you treating him doctor ?
a. At the moment bugs are just present on his body. So we are treating him appropriately to get rid of these
bugs. Usually we put some antibiotic cream to the nose and use antibacterial body wash products and
powders to get rid of these bugs from the body.
b. However, if the bugs get inside the body and cause infection it can cause problems because these bugs are
resistant to most of the antibiotics what we usually use to kill the bugs.
c. But they usually do respond to one type of antibiotics called Vancomycin. We will treat patients with
Vancomycin injections if they have infection with this kind of bugs.
9. Wife: Why he has been shifted to the other room?
a. Dr: Mrs Roper, I can imagine why you are so worried. As I explained, this infection can spread from one
patient to another patient easily if they are close to each other in the same room.
b. We have to keep him in a separate room so that the bugs will not spread. It is beneficial to him also because
there are no other patients in that room, so he may not get any other kind of bugs from others.
10. Wife: How long will he need to be in the hospital?
Dr: It may take few days to get rid of this bugs. We will keep checking that. Once he get rid of this bugs and
he has no other problem then we will discharge him.
11. Wife: Can I see him doctor?
Dr: Surely you can see him. However, we suggest you to wash your hands thoroughly before and after you
enter the room and minimise touching him or anything else inside the room so that this bugs will not spread. Is
that alright Mrs Roper? Wife: Ok doctor.
12. Dr: Any other concerns? Wife: No doctor.
Dr: Thank you very much Mrs Roper, I hope he will recover soon. If you need any other help please let me
know.

5. Chest infection – Atypical Pneumonia

You are FY 2 doctor
50 year old man presented with SOB and cough fir the last 2 weeks.
GP treated him with antibiotics but he did not improve.
GP ordered for the chest X Ray and referred him to the hospital.
Take history and discuss the management with the patient.

A.
2. Hello Mr …. I am Dr… Can you please tell me what brings you to the hospital ?
Pt: Doctor I am having shortness of breath for the last few weeks.
3. Dr: I am sorry to hear that. Are you comfortable to speak to me ? Pt: Yes doctor.
4. Dr: Can you please tell me more about your SOB ? Pt; It just started like that doctor.
5. Dr: Can you tell me when do you feel short of breath - while doing any work or do you feel short of breath even
just resting ? Pt: Even when I am resting I feel SOB.
6. Dr: What happens when you lie down – do you feel more ( Heart failure) or less SOB.

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 Pt: No difference doctor.
7. Dr: Does the weather make any difference ( asthma)? No
8. Dr: Do you have any other symptoms other than SOB?
Pt: Yes doctor I am coughing also since the last 2 weeks.
9. Dr: Does anything makes it better or worse? Pt : No
10. Dr: Do you bring out any phlegm when you cough? Pt -Yes
11. Dr : What colour is that ? Pt : Whitish. Dr : Any blood in that at all? Pt : No
12. Dr Any other symptoms? Pt: I have chest pain also.
13. Dr: Where is the chest pain ?Pt Almost all over my chest doctor.
14. Dr Since when ? Pt: Last few days
15. Dr: What type of pain is that? Pt: ..
16. Dr: Any other problems ?Pt: Like what ?
17. Dr: Do you have fever ?Pt : Yes doctor I feel hot since the last 2 weeks.
18. Dr: When do you get fever – morning evening or throughout day and night ( TB)?
Pt Throughout doctor. Dr: Have you measured your temperature ?Pt : Yes / No
19. Dr: Did you see any doctor for this? Pt : Yes I saw my GP he gave me some medicines.
20. Dr: Do you know which medicines ?Pt : Amoxycillin
21. Dr: Ok. How long have been on this medication? Pt…
22. Dr: Have been taking the medication properly ? Pt : Yes
23. Dr: Did you have any calf pain or calf swelling ( PE) ? No
24. Dr: Have come into contact with anyone who has similar problems ? Pt : No
25. Dr: Have come into contact with anyone who has TB ? Pt : No
26. Dr: Did you have this type of problem before ?No
27. Dr: Do you have any medical conditions at all? No
28. Dr: Like high blood pressure, Diabetes ?No
29. Dr: Have you ever been diagnosed with Asthma or bronchitis? No
30. Dr: Do you smoke ? Pt: Yes/ No
31. Dr: Do you drink Alcohol? Pt: Yes/ No
32. Dr: Do you use any recreational drugs ? Pt: No
33. Dr: Are you married or do you have any partners ?Pt : I am married for last 30 years.
34. Dr: Have ever done any tests for infections like Hepatitis or HIV? Pt : No
35. Dr: Have you noticed any change in your weight ( TB) ? No
36. Dr: Are you taking any medications ?Pt : No
37. Dr: Are you allergic to any medications? Pt: No
38. Dr: Have you travelled outside UKrecently (Legionnaires) ? Pt: Yes I went Spain ( When ) /No
39. Dr: Did you stay in hotel there (Legionnaires) ?Pt : Pt yes/ No
40. Dr: Did you use any SPA recently (Legionnaires) ?Pt: Yes/ No (Legionnaires)
41. Dr : Did you go for swimming recently (Legionnaires)? Pt : Yes/ No
42. Dr: Is there anything else you think is important that we need to know? Pt : No
B. Examination:
2. Dr: Mr… I need to examine your chest now and also I need to check your pulse blood pressure and temperature.
[ Examiner may say – there is bilateral crackles].
3. Look at the NEWS chart
4. Temperature – 38, Pulse – 90, BP – 110/80, RR- 25, Oxygen saturation – 91%.

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5. [ Explain the chart to the patient – Mr…Do you want to know about your pulse and blood pressure – Pt : Yes
doctor,
a. Dr: Our normal body temperature should be about 37 degree but your temperature is 38 which is high means
you have fever,
b. our normal pulse rate is usually about 75 but in your case it is 90 which is raised which can happen in fever,
c. our normal blood pressure is about 120 by 90 and yours is 110 by 90 which is almost normal,
d. our normal respiratory rate is about 15 and in your case it is 25 which is high means you are breathing very
fast which happen if there is problem in the lung
e. and also normal Oxygen saturation is about 96% but in your case it is 91% that means you have low
oxygenation of blood which again can happen if here is problem in the lung.
6. Look at the chest X Ray – may show bilateral/ unilateral consolidation –
7. Mr…. Your chest X ray shows white opacities here both sides of your lungs.
C.
8. Do you want to know what may be happening to you ?Pt: Yes
a. Dr: Looks like you have chest infection.
b. You may be having some type of Pneumonia what we call as Atypical Pneumonia.
c. This is due to infection by a bacterial kind of bugs. This type of bugs are slightly different than the bugs
which causes common Pneumonia. It is bit serious than usual type of Pneumonia which commonly people
get.
d. Common type of Pneumonia usually responds to medications like Amoxycillin which was given to you. This
kind of bugs do not respond to amoxicillin type of antibiotics.
9. Further investigation : We need to do test your blood, urine and sputum to check for this type of bugs.
D. Treatment.
1. We need to admit you to treat you. We will some other strong antibiotic called Clarithromycin through you
veins which usually works for these kind of bugs.
2. Also we will give some Paracetamol tablets for your fever and fluids through your veins. Is that Ok? Pt : Ok
doctor. Is this serious ?
3. Dr: Well it is a serious condition compared to common type of Pneumonia but the good news is that most of
the people do recover completely from this condition in about 2 to 3 weeks time. Any other questions ? Pt :
No Thank you.

6. Chest infection in child with asthma

Exam question:Child with SOB. History and management
A.
Child had Fever, cough and SOB for – 2 days.
Has eczema. Father has Asthma. Known asthma child, Mother gives blue inhalers.
Has pets at home and also has collection of flowers at home.
No dust. No carpet floor.
Check is she giving medications whenever required.
Any other past medical conditions
Past admissions
Any other medications?

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Allergy
B. Examination
NEWS chart
Chest examination – examiner may or may not give findings
C. Provisional diagnosis
I think your child has infection in the chest – means there are bugs in the chest which makes the asthma worst.
We need to do some test like blood tests and chest X Ray
D.
We need to admit the child for treatment
We will give him antibiotics and also paracetamol.
We may need to give him the salbutamol medicine as nebuliser ( like a steam inhalation through a machine) until
he improves.
We will also give some steroid medications.
I will talk to my seniors.
Once he improves then we will discharge our child.
Advise : It is better to avoid close contact with the pets and flowers because it can exacerbate asthma.
Do you know how to use the inhalers properly – check the technique if time permits.

7. Dry Cough and Hemoptysis

Differentials for cough for > 3 weeks :

1. Bronchial carcinoma
2. Smoking, weight loss. Haemoptysis.
3. Mesothelioma – exposure to asbestosis, building worker ( roofer, plumber, carpenter) wt loss.
4. Infection T.B – Haemoptysis, night sweat, wt loss, contact with any one with TB.
5. P.E – SOB, chest pain, haemoptysis, calf pain, travel, surgery. Recent immobilization.
6. Asthma – allergy to pets – wheeze, pollen, exercise.
7. COPD - > 3 month for 2 consecutive years, wheeze.
8. CCF – ankle swelling, orthophnoea, PND.
9. Diffuse parenchymal lung disease.
10. Drugs – ACE inhibitors, Beta blockers
11. Psychogenic
12. GORD – heart burn, regurgitation.

Acute < 3 weeks

1. Foreign body – sudden onset.
2. Infection. URTF/ Pneumonia/ Infective COPD
 Old age _ hemoptyesis and not plumber --> TB
 Young age - hemoptysis --> Lung cancer

Exam question
You are F2 in medicine. 60 y/o man presents with complaints of cough since few months. He has coughed up
blood few times in the last week. Take history, examine and discuss management with the patient

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 A.
2. Dr: Hello Mr... my name is Dr... I'm one of the junior doctors in the medicine department. What brings you to
the hospital today?
P: Doctor.. I have been having this bad cough for a few months now.. And for the last few days I have
coughed up some blood as well
3. Dr: I'm sorry to hear that Mr... Could you please tell me when this problem started?
P: It has been over 6 months now.
4. Dr: Is the cough associated with any sputum/phlegm? P: No it is a dry cough
5. Dr: Have you had any shortness of breath? P: Yes.
6. Dr: could you please tell me when that started? P: Around the same time
7. Dr: Has it worsened since then? P: Yes/No
8. Dr: You mentioned that you had coughed up some blood few times this week. Could you please tell me more
about it? How much of blood did you cough up? P: __
9. Dr: Do you have any chest pain? P: No (Might say yes if mesothelioma)
10. Dr: Fever? P: Yes/No
11. Dr: Have you noticed any swellings in your neck or your armpits? P: No
12. Dr: Do you have any trouble swallowing? P: No
13. Dr: Do you have any pain in your calves? P: No
14. Dr: Have you noticed any change in your weight? P: Yes (assess quantity)
15. Dr: Do you have any other complaints that you wish to report Mr...? P: No doctor
16. Dr: Do you have high BP? P: No Dr: Diabetes? P: No Dr: Thyroid related illnesses? P: No Dr: Are you on any
medications? P: No
17. Dr: What is your diet generally like? P: Balanced doctor
18. Dr: Do you smoke Mr...? P: Yes doctor.. I have been smoking for >20 years
19. Dr: Could you tell me what you smoke in a day? P: 1 pack of cigarettes/day
20. Dr: Do you consume alcohol? P: Yes/No Dr: Do you have any allergies? P: No
21. Dr: Do you have any family history of medical problems? P: No
Dr: F/H of cancers? P: No
22. Dr: What do you do for a living Mr...?
P: I work as a plumber/carpenter/roofer (or) Patient might not give a significant occupational history.
23. Dr: Have you travelled anywhere recently? P: Yes/No (look for travel to TB endemic areas)
B.
2. Dr: Ok Mr... I would like to examine your neck, chest and hands.
3. ( Examiner may give findings of clubbing and /or swelling in the supraclavicular area; and decreased or
reduced air entry in the left or right lung.)
4. Dr: Mr...Do you have any idea what may be happening to you ? Pt: No doctor.
5. D: Mr… It looks like you have some serious condition. Do you want to know about it? Pt : Yes doctor.
6. Dr: Based on the information what you told me it looks like you have cancer in your lungs or lining of the lung.
Pause
a. Pt: Oh …. Really … I didn’t expect doctor.
b. [Pt may say “ my friend who was working with me had been diagnosed with mesothelioma. Do I also
have the same doctor”.
Dr: I wish it was not true but unfortunately you are right that it is possible that you too may be having the
same problem. ]

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7. Dr: However we will need to do some tests to confirm that. First we will do a chest X ray.
8. Examiner might show you the chest x ray
a. Scenario 1 – Lung cancer
b. Scenario 2 – Mesothelioma
9. SHOW XRAY TO THE PATIENT

Scenario 1 Lung Cancer

2. Dr: Mr... I have your Chest Xray with me. Would you like to take a look
at it? P: Ok doctor
3. Dr: These are your lungs Mr.... and this is your heart. Can you see this
round opaque shadow at the top of your lung here? P: Yes
4. I am sorry to say that I do not have very good news for you. Mr...
Unfortunately this looks like cancer of the lung...
5. Dr: We will have to do further tests to confirm the diagnosis, like a CT
scan of your chest. We will also refer you to a specialist... a pulmonologist... who will do a procedure called a
bronchoscopy, where we will have to pass a flexible tube with a camera through your mouth into your airways
to get a better view of the problem. If needed, he might take a tissue sample and send it for further analysis. Are
you following me Mr....?
6. P: Yes doctor. Why did this happen to me?
Dr: There are few factors that can increase the risk of developing lung cancer. This condition is common in
those people who smoke for long time.
7. P: Is it treatable doctor?
Dr: Mr... the treatment depends upon the diagnosis. If it is cancer, then it will depend upon the stage of the
cancer.. how far it has progressed and also the type of cancer. If it is an early stage, we may be able to offer
surgical options to remove the growth. But if the cancer has advanced too much or if it is a more aggressive
type of cancer, I'm afraid there are no curative options. We might be able to offer treatment measures like
radiotherapy or chemotherapy to prolong life and relieve the symptoms. Are you with me Mr...?
8. P: Yes doctor I understand. You can go ahead with the tests..
Dr: Ok Mr... I will speak with my consultant and arrange for them right away. Do you have any other concerns?
P: No doctor
9. Dr: Once again, I'm sorry I don't have better news for you at the moment... If you have any doubts, please feel
free to ask for me.

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Scenario 2 Mesothelioma

2. Dr: Mr... I have your Chest Xray with me. Would you like to take a
look at it? P: Ok doctor
3. Dr: These are your lungs Mr.... and this is your heart. Can you see
this white opacity over this lung? P:Yes
4. I am sorry to say that I do not have very good news for you. Mr...
Unfortunately this looks like cancer of the lining of your lung...
called mesothelioma.
5. We will have to do further tests to confirm the diagnosis, like a CT
scan of your chest. We will also refer you to a specialist... a
pulmonologist... who might try to take a biopsy.... or a tissue sample
from the lining of your lung and send it for further analysis. Are you
following me Mr....?
6. P: Yes doctor. Why did this happen to me?
Dr: There are few factors that can increase the risk of developing mesothelioma. Exposure to elements like
asbestos which was used extensively in the construction of old houses and buildings can affect the lining of the
lung and cause this condition.
7. P: Is it treatable doctor?
Dr: Mr... Unfortunately this is a serious type of cancer. I'm afraid there are no definitive curative options. We
might be able to offer treatment measures like radiotherapy or chemotherapy to prolong life and relieve the
symptoms, but I am afraid there is no permanent cure if you are indeed diagnosed with mesothelioma. Are you
with me Mr...?
8. P: Yes doctor I understand. You can go ahead with the tests..
Dr: Ok Mr... I will speak with my consultant and arrange for them right away. Do you have any other concerns?
P: No doctor
9. Dr: Once again, I'm sorry I don't have better news for you at the moment.. If you have any doubts, please feel
free to ask for me.

8. Dry cough
Patient with dry cough – Take history for the patient and tell your differentials and
investigations to the examiner.
1. Pt will give the same story as above
2. Also he may say that his son lives in Tanzania and visited him few months ago and both of them started to
having cough at the same time.
3. Differentials
a. Mesothelioma – Investigations – Chest X Ray, CY scan , Bronchosopy and biopsy
b. Lung Cancer Investigations – Chest X Ray, CY scan , Bronchosopy and biopsy
c. TB – Chest X Ray, Sputum - AFB test, Gold quantiferon test, Mantoux test.

9. Dry cough - PCP

Exam question
You are the FY 2 doctor in the medical department.

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30 year old homeless man presented with cough and shortness of breath.
Take history and examine the patient.
[ Positive findings – dry cough, exertional dyspnoea, night sweat, bisexual, does not practice safe sex, shares
needles, homeless)

Homeless patient is HIV -- Cough young man is TB in TB (it will india or africa)

A.
2. Dr: Hello Mr… I am Dr … one of the junior doctor in the medical department. How can I help you Mr..
Pt: Doctor I have been having cough for the last few weeks.
3. Dr: I sorry to hear that. Can you please tell me anything more about it ?
Pt: Like what doctor?
4. Dr: Do you get it throughout the day or any particular time? Pt: Throughout doctor.
5. Dr: Anything makes it worse or better? Pt: No
6. Dr: I see. Do you bring out any phlegm when you cough? Pt: No
7. Dr: Do you cough up any blood ?Pt : No
8. Dr: Do you have fever? Pt: No, but I feel a bit hot in the evening and I get sweating.
9. Dr: Do you have any chest pain? Pt: No ( if yes – explore chest pain – since where, when, type)
10. Dr: Do you have shortness of breath ? Pt: Yes doctor
11. Dr: Since when? Pt: Since last few weeks?
12. Dr: When do you get breathlessness is it on exertion or even at rest do you feel short of breath?
PT: When I exert my shortness of breath gets worse doctor.
13. Dr: Do you have any pain or swelling in your calf (PE) ? Pt : No
14. Dr: Dr: Have you noticed any change in your weight recently ( Lung cancer, Mesothelioma)? Pt: No
15. Dr: Are you allergic to anything you know of ( Asthma)? Pt: No
16. Dr: Have you ever came in contact with anyone who has similar symptoms ( TB, Pneumonia)? Pt: No
17. Dr: Have you ever been contact with anyone who has TB do you know? Pt: No
18. Dr: Have you travelled outside UK recently ( TB) ? PT: No
19. Dr: Do you smoke? Pt: No Dr: Do you drink alcohol ?Pt: No/Yes
20. Dr: Do you do recreational drugs? Pt: Yes. Dr: What drug do you use ?Pt: I inject heroin.
21. Dr: Do you share needles with others? Pt: Yes. Dr: Are you sexually active ?Pt: Yes
22. Dr: Do you have a regular partner? Pt: No regular partner.
23. Dr: Whom do you have sex with - males or females or both? Pt: I have male and female partners. I am a
bisexual doctor.
24. Dr: Do you practice safe sex? Pt: No Dr: Do you have any other medical conditions ?Pt: No
25. Dr: Do you have diabetes or high blood pressure? Pt: No
26. Dr: Have been tested for HIV or Hepatitis infections anytime ? Pt : No
27. Dr: Are you on any medications? Pt: No Dr: Are you allergic to any medications ? Pt : No
28. Dr: Any of your family members has any medical conditions ?Pt: No
29. Dr: What job do you do? Pt: I am jobless doctor.
30. Dr: Where do you live ?Pt: I do not have a home doctor.
Dr: Sorry to hear that. We will try to help.
31. Dr : Is there anything else you think is important that we need to know? Pt: I do not know doctor.

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 B.
2. Dr: Mr .. I need to examine your chest and also check your pulse, Blood pressure and your temperature. (
examiner may or may not give any findings)
3. Dr: Mr… with what you told me I think you have a condition what we call as Pneumocystis Pneumonia. This
is infection of the lungs by some kind of fungus type of bugs. Do you follow me?
4. Pt: OK. But why did I get this doctor?
a. Dr: This type of infection happens in those kind of people whose body resistance is low for example people
who have HIV infection.
b. There could be chance of you having this infection because this type of infection common in those people
who do not practise safe sex or shares needles with others when they use drugs. This infection can spread
easily this way.
c. This is quite a serious condition if you have HIV infection also.Are you following me Mr…
5. Pt: Yes. So what will happen now?
Dr: We need to do some investigations to confirm whether you have this condition. We need to do some blood
test to check for infection markers and also do chest X Ray.
[ Examiner says – chest X Ray shows bilateral basal consolidation or fluffy shadows]. Thank you to the
examiner.
a. Dr: Mr… Your chest X Ray shows that you do have chest infection. We need to do some more tests to check
what kind of bugs may be causing this this.
b. For this we need to test your sputum( silver staining) if you can get some sputum – if not we do a procedure
called bronchoscopy where we put some fluid into the wind pipe and take it out with some instruemnts and
then we test that for the presence of the bugs.
c. We may also take some tissue sample from the lungs. We may do a test called PCR ( polymerase chain
reaction) to check for these bugs. Also we may do CT scan of the chest. Are you following me? Pt: Yes
doctor.
6. Dr: It is better to check whether you have HIV infection also. We can treat the HIV infection if you have it? Is
that OK / Pt : Ok doctor.
7. Dr: Any questions? Pt: How will you treat me doctor?
a. Dr: To treat we will admit you in the hospital. We will give medications called Co-trimoxazole through your
vein and another medication called Dapsone as a nebuliser - something like steam inhalation. We may also
give steroid medication to treat this bugs.
b. We may also need to treat the HIV infection if you have.
c. I sincerely advise you to practice safe sex in the future and also stop using recreational drugs. If not at least
do not share needles with others.
d. We have something called needle exchange programme. You can get new needles for free.
8. Are you following me? Pt: Yes. Dr: Is that OK? Pt : Ok doctor.
Dr Any other questions ?Pt : No.
Dr: We will talk to the social services and see if they can help you with shelter when we discharge you. Thank
you very much. Hope you recover soon.

10. Dry cough (TB)

Young man dry cough. History and management

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Dry cough since 3 months, has night sweats, has blood in sputum, has weight loss, Has been to south
Africa 3 months ago. No known contact with any one with TB or similar symptoms. Chronic smoker.
Had SOB, able to talk.

A.
2. Take Hx for other differentials like other dry cough stations.
3. Risk factor of immunosuppression HIV ( rec drugs and sexual Hx): Works in community group with many
people.
4. Examine the chest and hands, examiner may not give any findings. I need to check your pulse, BP and
temperature. Check for NEWS chart.
5. Investigations: Blood tests for infection markers, Sputum test for bugs and chest X Ray – there was chest X
Ray. May be normal or may show white shadows
6. Diagnosis: You may be having a condition called Tuberculosis. Do you know anything about it? I do not know
a. This is an infection of your lungs by bacterial kind of bugs called Mycobacterium Tuberculosis.
b. This condition is very common in Asian and African countries. This infection can spread from person to
person by droplets while coughing or sneezing. So since you went to Arica - may be you came into contact
with someone with TB and you would have got this from that person.
c. This condition can cause infection in the lung for long time including months and can damage the lungs.
Sometimes it can spread to other areas of body like brain and kidneys and cause serious dame to those organs.
Do you follow me?
7. Management
a. We will admit you now and treat you, We will give medication like rifampicin, ethambutol, Isoniazid, and
pyrazinamide.
b. These are like tablets which you need to take daily. Usually you need to take all these 4 medications for first
2 months and then take only isoniazid and rifampicin for further 4 months. My Consultant will decide how
long you may need to take this medicine.
c. We will discharge once you feel better. We may need to keep you in a separate room while we treat you
because this infection can spread to others if you are very close to others.
d. It may be better to check whether you have any other medical conditions like HIV because if someone has
HIV then they can easily get TB also. We can treat HIV also if you have it. Is that OK.

11. Pulmonary embolism

Scenario-37 year old female patient comes with shortness of breath and chest pain. Take
history and discuss management. Vital signs- BP- 90/50 MM HG, SPO2- 84% (If vital signs are
given in the question, then I think its best to start the station with stabilising the patient first,
by administering Oxygen and IV fluids.) (In the recent exam,patient was stable)
A. History-
1. Primary complaint?
2. Shortness of breath? Since when? Anything that makes it better or worser? Do you have SOB
while walking,sitting or lying down?
3. Chest pain- site,nature,duration, radiation

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4. Associated symptoms- chest pain? Cough-phlegm/blood? Pain in the calf? Swelling of the
ankles?Fever?
5. DIFFERENTIAL DIAGNOSIS-
a) PULMONARY EMBOLISM
b) MI
c) ASTHMA
d) COPD
e) HEART FAILURE
f) PNEUMONIA
6. MAFTOSA- ask specifically for-
a) Asthma
b) Smokers cough
c) Recent long flights
d) Surgeries?
e) Any previous history of blood clots in the lungs or legs?
f) Family history of blood clots in the lungs or legs?
g) Medication-blood thinner?
h) IN THE EXAM, PATIENT WAS A FEMALE WHO WAS ON ORAL CONTRACEPTIVES FOR 8
YEARS/20 YEARS
B.
Examination- examine chest,NEWS chart,will ensure privacy and chaperone(examination
findings-coarse crackles at left lower lung zone)
C.
Tests- FBC,U&E,LFT,CLOTTING SCREEN,D-DIMER,ECG,CXR (EXAMINER GIVES ECG THAT SHOWS
CHANGES)
D.
“From what you have told me and from what I have examined, it seems to me you have a
condition called pulmonary embolism.
“What is it?”
“It is the blockage in one of the blood vessel in the lungs usually due to a blood clot. “
“Why did I get it?”
“Usually, the cause is a blood clot that has originally formed in a deep vein(dvt). This clot travels
through the circulation and eventually gets stuck in one of the blood vessels in the lung.
Sometimes it could be due to immobility and major surgeries.”
“Is it serious?”
“Yes,it is a life threatening condition. It has chances of recurrence even after treatment.”
“What will you do now?”

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“We shall be doing some specific blood tests- D-dimer- that detects any blood clot. The higher
the level, the more likely that you have a blood clot. We need to do another test to confirm this
condition-CTPA-which is a type of CT scan that looks at the lung arteries.(patient asks for
explaination of ctpa)
We shall do ECG (might show S1Q3T3 strain) and chest Xray as well.
E.
“How will you treat me?”
“You will have to be admitted for this condition.
We will start you on anticoagulant treatment even before we conduct the tests. It stops the
blood from clotting. At the moment, we will start you on low molecular weight heparin injection
before the test.
If the test confirms that you have this condition, then we will switch to oral
medication(anticoagulants)- apixaban,rivoraxaban OR dabigatran
Once you are stable, we shall discharge you and will ask you to come visit us for follow-up.
Address that you will talk to your seniors regarding the contraceptive pills-might have to change
it.
Explain warning signs-
1. Avoid falls
2. Cuts while dealing with sharp objects

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