DR MO SOBHY ACADEMY drmohamedplab2@gmail.

com (0044)7743137345

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DR MO SOBHY ACADEMY [email protected] (0044)7743137345

This book is in memory of my late father Sobhy and my late sister Raghda. Please keep them both
in your prayers.

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DR MO SOBHY ACADEMY [email protected] (0044)7743137345

Preface
When I began teaching PLAB2 I could not have imagined the privileged position that I
would be in just a few years later, running my own PLAB academy and meeting the
most interesting and intelligent doctors from around the world. Each one has their own
story and their journey coming to the UK which is always different. Although we know
that after they pass, they will most likely get jobs and move to different towns or cities
and we may never meet again, for those few weeks that they attend my academy, I
consider them my family. I will try my best to accommodate them in any way I can,
being always aware that coming to a different country for the first time can be
overwhelming for some. One of the requests I have been getting a lot recently was for
me to compile all my notes into a book, which many prefer to revise from than PDF
files. For this reason, I decided to have this book published.
This book is not intended to be used as a source on its own, but in conjunction with my
Online and Academy courses. The management of each scenario is taken directly from
the NHS website or NICE Guidelines and is quite extensive, therefore it is not intended
that doctors regurgitate all the management in their exam. Rather the intention is that
they pick the most suitable points of management depending on how the consultation
goes with the patient. The stations are not the same as the ones that appear in the
PLAB2 exam, but they are examples of what could appear.
I pray that my fellow doctors who have purchased this book benefit from it immensely
and find success on their PLAB journeys and in their personal lives.
Yours,
Dr Mohamed Fathelbab

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VOLUME 1 CONTENTS

TIREDNESS 10
STRUCTURE 11
IRON DEFICIENCY ANAEMIA 14
OBSTRUCTIVE SLEEP APNOEA 19
VITAMIN B12 DEFICIENCY ANAEMIA 24
CHRONIC FATIGUE SYNDROME 30
FIBROMYALGIA 35
TIREDNESS DUE TO CITALOPRAM 41
THYROID 45
HYPOTHYROIDISM 46
HYPERTHYROIDISM 50
HYPERPARATHYROIDISM 53

RHEUMATOLOGY 58
STRUCTURE 59
REACTIVE ARTHRITIS 60
RHEUMATOID ARTHRITIS 65
GOUT 70
POLYMYALGIA RHEUMATICA 76
OSTEOARTHRITIS 82
DE QUERVAIN’S TENOSYNOVITIS 89
CARPAL TUNNEL SYNDROME 94
TENNIS ELBOW 100

NEUROLOGY 107
GUILLAIN-BARRÉ SYNDROME 108
TRIGEMINAL NEURALGIA 112
BELL’S PALSY 115
CONFUSION 118
CONFUSION (HYPONATRAEMIA & URAEMIA) 122
CONFUSION (UTI -SEPSIS) 124

HEADACHES 127
STRUCTURE 128
TENSION HEADACHE 130
PREMENSTRUAL SYNDROME 134
SUBARACHNOID HAEMORRHAGE 138
GIANT CELL ARTERITIS 141
MIGRAINE 144
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SINUSITIS 150
HANGOVER HEADACHE 154
MENINGITIS 157

FALLS 162
STRUCTURE 163
POSTURAL HYPOTENSION 165
EPILEPSY FIRST ATTACK 168
HEAD INJURY 172
FALL DUE TO STOCK-ADAM 175
FALLS STATIONS (NO LOC) 178
CENTRAL VERTIGO 179
TIA 179
CEREBELLAR ATAXIA 182

COUGH & HAEMOPTYSIS 186

STRUCTURE 187
TUBERCULOSIS 192
LUNG CANCER 196
PNEUMONIA 199
ASTHMA 203

PAEDIATRICS 210
STRUCTURE 211
PYLORIC STENOSIS 214
INTUSSUSCEPTION 217
BRONCHIOLITIS 222
DEHYDRATION 225
FEBRILE CONVULSIONS 228
HEAD INJURY (DEMANDING CT) 233
ACUTE OTITIS MEDIA 237
DELAYED WALKING & DEVELOPMENTAL ISSUES 241
DELAYED TALKING 246
NIGHT TERRORS 249
AUTISM 253
CHLAMYDIA EYE INFECTION IN NEONATE 258
CONSTIPATION IN A CHILD 261
PRIMARY ENURESIS 264
NEONATAL JAUNDICE 269
BREAST MILK JAUNDICE 272
NEUROBLASTOMA IN CHILD & GREEN LIQUID 275
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TANTRUMS 278
MALARIA 282

BACK-PAIN 288
STRUCTURE 289
BACK-PAIN (PROSTATE CANCER?) 291
BACK-PAIN AAA 296
BACK-PAIN DUE TO EXERCISE 301
BACK-PAIN DUE TO DISC PROLAPSE 305
BACK-PAIN WITH CAUDA EQUINA SYNDROME 309
BACK-PAIN DUE TO MULTIPLE MYELOMA 311

GYNAECOLOGY 313
STRUCTURE 314
BACTERIAL VAGINOSIS 315
PELVIC INFLAMMATORY DISEASE 320
GONORRHOEA 326
PREMATURE OVARIAN INSUFFICIENCY 330
POLYCYSTIC OVARIAN SYNDROME 335
PREMENSTRUAL SYNDROME 340
CYCLICAL BREAST PAIN 345
STRUCTURE FOR ANTENATAL CARE STATIONS 350
PRE-CONCEPTION COUNSELLING 352
CONTRACEPTION 356
COMBINED PILL PRESCRIPTION 365
GENITAL HERPES 369
VAGINAL DISCHARGE 374
EMERGENCY CONTRACEPTION 380
PRE-ECLAMPSIA 385
POST-PARTUM DEPRESSION 389
ECTOPIC PREGNANCY 393
PREGNANCY (HTN ON RAMIPRIL) 401
PREGNANCY (16-YEAR-OLD) VOMITING 404
RUBELLA RH NEGATIVE 408
UNKNOWN MISCARRIAGE 414
MISCARRIAGE CONCERNS 418

UROLOGY 423
STRUCTURE 424
BLOOD IN URINE 428
HAEMATURIA (TEST RESULTS) STRUCTURE 434
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HAEMATURIA (TEST RESULTS) SCENARIO 437

URINARY TRACT INFECTIONS 442
URINARY TRACT INFECTION (FEMALE) 443
URINARY TRACT INFECTION (PREGNANCY) 449
URINARY TRACT INFECTION (TRANSGENDER) 454
URINARY TRACT INFECTION (BPH) 460
RECURRING URINARY TRACT INFECTIONS 465
SEXUALLY TRANSMITTED INFECTION (MALE) 471
LOIN PAIN (RENAL COLIC) 476
ERECTILE DYSFUNCTION 481
URINARY INCONTINENCE 487
CONFUSION (OXYBUTYNIN) 493
PROSTATE SPECIFIC ANTIGEN TESTING 497

CARDIOVASCULAR 501
STRUCTURE 502
ACUTE CORONARY SYNDROME (MI) 504
PERICARDITIS 508
MUSCULO-SKELETAL CHEST-PAIN (COSTOCHONDRITIS ) 511
PULMONARY EMBOLISM PART 1 515
PULMONARY EMBOLISM PART 2 (AFTER MASTECTOMY) 519
PULMONARY EMBOLISM PART 3 (TRANSGENDER) 522

OPHTHALMOLOGY 526
STRUCTURE 527
CATARACT 594
AGE-RELATED MACULAR DEGENERATION (AMD) 532
DIABETIC RETINOPATHY 537
ANGLE CLOSURE GLAUCOMA 541
OPEN ANGLE GLAUCOMA 545
SUBCONJUNCTIVAL HAEMORRHAGE 547
OPTIC NEURITIS 550
CONJUNCTIVITIS 554
RETINAL DETACHMENT 558

EAR, NOSE AND THROAT 563

STRUCTURE 564
ALLERGIC RHINITIS 566
EAR WAX 570
BAROTRAUMA 573
OTITIS MEDIA 577
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CHOLESTEATOMA 580
RECURRENT TONSILLITIS 585
EPISTAXIS 587
LABYRINTHITIS 589
ACUTE TONSILLITIS 593
SINUSITIS 596
FACIAL DROOPING 599
MUMPS ORCHITIS 603
BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) 607
VESTIBULAR NEURITIS 611
MENIERE’S DISEASE (DIZZY SPELLS) 616
UNILATERAL TINNITUS 620
ACOUSTIC NEUROMA (CN VIII) 623

DERMATOLOGY 626
STRUCTURE 627
URTICARIA (HIVES) 630
CHICKEN POX 634
MOTHER WANTS SICK NOTE (CHICKEN POX) 641
SCABIES 645
HERPES ZOSTER 651
HERPES LABIALIS 657
GENITAL WARTS 661
FUNGAL INFECTION RING WORM 667
IMPETIGO 671
ACNE (ISOTRETINOIN) 675
MOLE 681
MELANOMA 687
NON-MELANOMA (BCC, SQCC) 692
SEBORRHEIC KERATOSIS 696
SYPHILIS 701
ECZEMA 706
HAEMANGIOMA 710
RAYNAUD’S 714
ANIMAL BITE 719
PSORIASIS 722
INTERTRIGO (RASH IN BODY FOLDS) 726

PSYCHIATRY 731
STRUCTURE 732
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DEPRESSION WITH LOW MOOD 734

DEPRESSION (WEIGHT LOSS) 739
DEPRESSION WITH CBT FAILED 744
SELF-HARM/ SUICIDE 750
SUICIDE SCENARIO WITH SELF-HARM 752
SELF-HARM/ SUICIDE SCENARIO (OVERDOSE) 757
DEPRESSION WITH SUICIDE ATTEMPTS 762
INSOMNIA SCENARIO 766
INSOMNIA (CANNABIS SMOKER) 772
POST-NATAL MOOD CHANGES 775
POST-PARTUM DEPRESSION (TELEPHONE CONSULTATION) 776
ALCOHOL ADDICTION 781
HEROIN ADDICTION 785
ANOREXIA NERVOSA 788
ACUTE CONFUSION 794
MINI MENTAL STATE EXAMINATION (MMSE) 794
CONCERNED DAUGHTER MMSE 803
SCHIZOPHRENIA AND PSYCHOSIS 806
SECOND PSYCHOSIS SCENARIO (DELUSIONAL PATIENT) 810

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TIREDNESS

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TIREDNESS
Tiredness Approach:

P1 (ODIPARA)
When did this tiredness start? (duration)
Was it sudden or gradual? (onset)
Is it getting worse? (progression)
Does anything make it better or worse?
Apart from this, anything else?
What's your main concern? (concern)

Differential diagnosis of tiredness

ABCDEF MO
Shortness of breath,
Anaemia
A (Iron – B12)
Noticeable heartbeat
Pale skin

Whilst you sleep. Making gasping, snorting or

Apnea choking noises, waking up a lot and loud snoring.
During the day, you may also:
find it hard to concentrate, have mood swings
and have a headache when you wake up.

A persistent cough with bloody phlegm.

T.B
B Weight loss
Night sweats
High temperature

FLAWS
Cancer
C (Fever – Loss of weight – loss of Appetite – lumps)

Extreme physical and mental tiredness (fatigue)

that does not go away with rest or sleep. This can
Chronic fatigue make it difficult to carry out everyday tasks and
syndrome activities.

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Citalopram
Drugs
D D.M
Steroids

Feeling very thirsty

Peeing more frequently than usual, particularly at
Diet night.

Vegetarian (vit B12 – iron).

Bowel (constipation)
Endocrine
E
Mood (feeling low)
(hypothyroidism) Weight gain
Weather preference (cold)

Muscle stiffness difficulty

Fibromyalgia

F Sleeping problems

Memory and concentration

Headaches

Exclude Depression
Mood
MO
P2 (Past Hx)
Have you had tiredness like this before? Any past hx of chronic medical condition?

DESA
Can you tell me more about your diet?
Do you exercise?
Do you smoke?
Do you drink alcohol?

MAFTOSA
Always ask about psycho-social impact
It sounds a little distressing, how is it affecting your life?
How is it affecting your daily activities?
What do you do for living?
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How is it affecting your job?

How do you feel mood-wise? (must)
Do you drive? If yes, consider if it’s necessary to advise him/her not to drive & inform
DVLA.

ICE (IDEA- CONCERN- EXPECTATIONS)

Examination Vitals and neurological

Provisional diagnosis, then Management.

7 steps:
1- Admit
2- Senior
3- Investigations

FBC: Anaemia
FBS/RBS: DM
LFT: Liver failure
KFT: Kidney failure
TFT: Hypothyroidism
Urea& electrolytes: Hyponatremia (Citalopram/ steroids)
Cholesterol: Bad diet
Vitamins: Vit D, B12
Infection markers
4- Symptomatic (PAIN KILLER) + lifestyle
5- Specialist
6- Safety net for the red flags
7- Follow up

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IRON DEFICIENCY ANAEMIA

Who you are:

You are an FY2 in the GP clinic.
Who the patient is:
Mr. Russell, 45-year-old has come to the clinic today to receive his test results.

He had a blood test done three weeks ago which showed:

Hb: 10 g/dl (11-15)
TLC: 4000/cmm Plt: 430,000
MCV: 75 (80-100).

He had blood tests done one week ago as well which show:
Hb: 10.2 g/dl (11-15)
TLC: 4300/cmm
Plt: 400,000
U&E: Normal
LFTs: Normal
Serum Iron: Low
Serum Ferritin: Low
MCV: 78 (80-100)
Test for coeliac disease: Negative.

What you should do:

Talk to the patient discuss the results with him.

Build Rapport:

Doctor: I can see from my notes that you are here today for your test results. I have
your results with me, but I'd like to have chat with you before that, is that ok?
Patient: Okay doctor no problem.
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D: May I know why you had these tests in the first place?
P: My wife advised me to have a check-up because she was diagnosed with
diabetes.
D: It sounds like you have a caring wife, how is she doing now?
P: She is fine, thank you.

Anaemia Symptoms:

D: Do you think you may have any symptoms of diabetes?

P: No, I am fine.
D: Do you feel tired or short of breath?
P: No.
D: Any heart racing?
P: No.
D: Any weight loss? (Cancer)
P: No.
D: Any constipation or diarrhoea?
P: No.
D: Any dark or black coloured stool?
P: No.
D: By any chance have you noticed any bleeding in your stool recently?
P: No +FLAWS
If it's an already diagnosed condition, no need to take differentials.

MAFTOSA:

D: Do you have any medical condition?

P: No
D: Are you taking any medications including OTC or herbal medications?
P: No
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D: Do you have any allergies from food or medicines?

P: No
D: Any previous surgery or hospitalisations?
P: No
D: Has anyone in your family suffered from a similar condition in the past?
P: No.

DESA:

D: How is your diet?

P: I stopped eating red meat recently because I heard it's not good for my health.
I eat chicken, a lot of vegetables and fruit. (Positive finding)
D: Apart from this, do you drink coffee or tea?
P: Yes, I drink 6 cups of coffee every day (Positive finding)
D: Do you smoke?
P: No
D: Do you drink alcohol?
P: No
D: Do you exercise?
P: Yes, I try to be physically active.
D: What do you do for a living?
P: I work in an office.
D: Have you travelled recently?
P: No

DISCUSSING THE RESULTS

Thank you for answering these questions, your results came back normal except for iron
level which is low. You told me you that you stopped eating red meat recently, so I

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suspect that you have Iron deficiency Anaemia-it's a condition in which you lack enough
healthy red blood cells to carry adequate oxygen to your body's tissues.

MANAGEMENT:

- Refer to gut specialist to do further tests to find out the reasons for the
anaemia. Bleeding in the stomach and intestines is the most common cause of
iron deficiency anaemia. Bleeding may be due to many reasons such as:
stomach ulcers or inflammation of the bowel or food pipe.

- Senior
- Lifestyle
• There are things you can do yourself.
• Your diet is partly causing your iron deficiency anaemia, I would like to tell you
which foods are rich in iron so you can eat more of them.

Eat and drink more:

o Dark-green leafy vegetables like watercress and curly kale ✓ cereals and
bread with extra iron in them (fortified)
o Meat.

o Dried fruit like apricots, prunes and raisins, pulses (beans, peas and lentils).

Eat and drink less:

 Tea

 Coffee

 Milk and dairy

 Foods with high levels of phytic acid, such as wholegrain cereals, which can
stop your body absorbing iron from other foods and pills.
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 Large amounts of these foods and drinks make it harder for your body to
absorb iron.

▪ Stop taking unnecessary painkillers without consultation.

Symptomatic:

▪ You'll be prescribed iron tablets to replace the iron that's missing from your body.

▪ The prescribed tablets are stronger than the supplements you can buy in
pharmacies and supermarkets.

▪ You’ll need to take them for about 6 months.

▪ Drinking orange juice after you've taken a tablet may help your body absorb the
iron.

▪ Some people get side effects when taking iron tablets like:
constipation or diarrhoea - tummy pain – heartburn - feeling sick - black poo.
▪ Try taking the tablets with or soon after food to reduce the chance of side effects.

▪ It's important to keep taking the tablets, even if you get side effects.
- Specialist
You might be referred to a specialist dietitian if you're finding it hard to include iron
in your diet.

- Follow up
We may carry out repeat blood tests over the next few months to check that your
iron level is getting back to normal.

- Safety netting
▪ FLAWS

▪ Bleeding anywhere in your body.

▪ Keep iron supplement tablets out of the reach of children. An overdose of iron in a
young child can be fatal.
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OBSTRUCTIVE SLEEP APNOEA

Who you are:

You are an FY2 in a GP Clinic.
Who the patient is:
Mr. Ethan Cruise, 50-year-old male, has come to the clinic today with tiredness for
the past 2 months. He has been diabetic for 10 years.
What you should do:
Talk to him, take a history and discuss appropriate management with him.
Symptoms of sleep apnoea mainly happen while you sleep.

Sleep apnoea symptoms

• Breathing stopping and starting.

• Making gasping, snorting or choking noises.
• Waking up a lot during night.
• Loud snoring.

During the day, you may also:

• Feel very tired.

• Find it hard to concentrate
• Have mood swings
• Have a headache when you wake up

DON'T FORGET TO ORDER BMI

ODIPARA
Doctor: I can see from my notes that you have tiredness, can you tell me more about it?

Patient: I feel tired and sleepy most of the time in the last 2 months.
D: I’m sorry about that; is there anything that makes it worse or better?
P: No.
D: Is there any specific time of day you feel more tired?
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P: No
D: Is it getting worse?
P: No
D: Do you have any other concerns?
P: No.

Sleep apnoea symptoms

D: Can you tell me more regarding your sleeping?

P: I sleep 8 hours every day, but I don't feel refreshed.
D: And how is your concentration during the day?
P: I find it difficult to concentrate.
D: How is your sleep?
P: Sometimes I wake up in the middle of my sleep. (Positive finding)
D: How is your sleeping environment? Is your bed comfortable?
P: Yes, very comfortable.
D: Do you have any trouble falling asleep?
P: No.
D: Do you take naps during the day?
P: Sometimes I doze off during the day yes. (Positive finding)
D: Has anyone told you that you snore during your sleep? P: Yes,
my wife complains of that. (Positive finding)
D: Do you have any difficulty in breathing?
P: No.
DIFFERENTIALS:

D: Any weight changes recently?

P: No
D: Any fever?
P: No.
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D: Do you feel hot when other people feel cold and vice versa?
P: No.
D: Do you go to the loo more often than normal?
P: No.
D: Any joint pain or stiffness?
P: No.

MAFTOSA
D: Do you have any medical conditions?
P: No.
D: Are you taking any medications including OTC or herbal medications?
P: No.
D: Do you have any allergies from food or medicines?
P: No.
D: Any previous surgery or hospitalisations?
P: No.
D: Has anyone in your family suffered from a similar condition in the past?
P: No.

DESA
D: How is your diet?
P: I like eating out a lot. (+ve finding)
D: Do you smoke?
P: No.
D: Do you take alcohol?
P: No.
D: Do you exercise?

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P: No, I don't have much time.

D: What do you do for a living?
P: I am a taxi driver.
PSYCHOSOCIAL
D: You told me that you have had this condition for 3 months now, how is this affecting
your life?
P: It's ok, I am trying to cope with it.
D: It must be difficult for you, is it affecting your work?
P: Yes, I am afraid of falling asleep while driving.
D: It’s a valid concern. How is your mood?
P: It's a difficult time for me, but I think I am ok.
D: On a scale from 1 to 10, 1 being the lowest mood and 10 being the happiest, can you
grade your mood for me?
P: It would be about 6.
DON'T FORGET ICE

PROVOSIONAL DIAGNOSIS:

From the chat we had you mentioned that you have some tiredness, a sleeping problem
and you snore, so I suspect you may have a condition called Obstructive sleep apnoea.
It is a clinical condition in which there is intermittent and repeated upper airway
collapse during sleep. This results in irregular breathing at night and excessive
sleepiness during the day.

Management

- Refer patient to a specialist sleep clinic for tests.

- Senior.
- Investigations.
▪ At the clinic, you may be given devices that check things like your breathing and
heartbeat while you sleep.
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▪ You'll be asked to wear these overnight so doctors can check for signs of sleep
apnoea. You can usually do this at home, but you may need to stay in the clinic
overnight.

▪ The test can show if you have sleep apnoea and how severe it is.
This is based on how often your breathing stops while you sleep.

▪ Other investigations: BMI -routine blood – cholesterol – Blood sugar.

- Symptomatic
Sleep apnoea does not always need to be treated if it's mild.

▪ You may need to use a device called a CPAP machine.

▪ It gently pumps air into a mask you wear over your mouth or nose while you sleep.

▪ It can help improve your breathing while you sleep, improve the quality of your
sleep and help you feel less tired.
▪ Using a CPAP machine may feel strange or awkward at first but try to keep using it.
It works best if you use it every night. Inform us if you find it uncomfortable or hard
to use.
Less common treatments for sleep apnoea are available but may not work as well as
a CPAP machine.

- Lifestyle
There are things you can do to help you manage your sleep apnoea.

These may be all you need to do if your sleep apnoea is mild:

Try to lose weight

Sleep on your side – try taping a tennis ball to the back of your
sleepwear or buy a special pillow or bed wedge to help keep you on your side.
- Please avoid

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 Smoking

 Drinking too much alcohol – especially shortly before going to sleep

 Taking sleeping pills (unless recommended by a doctor) – they can make sleep
apnoea worse.

- Safety netting

▪ You may need to tell the DVLA about your sleep apnoea. Sometimes you may need
to stop driving until your symptoms are under control.

▪ If you have a headache or weakness in any part of your body come back to see us
immediately as sleep apnoea can lead to other medical conditions as high blood
pressure and stroke if not treated.

Vitamin B12 Deficiency Anaemia

Who you are:

You are an FY2 in GP Clinic.
Who the patient is:
Mrs. Olivia Stone, 30 years old, presented a week ago to the clinic with a history
of tiredness for the past 2 months. She has come to the clinic today to receive
her test results done one week ago which show:
Hb: 10.2 g/dl (11-15)
TLC: 4300/cmm
PLT: 400,000 U&E: Normal
LFTs: Normal
Serum Iron: Normal
Serum Ferritin: Normal MCV: 120
(80-100) Vitamin B12: Low.
What should you do:
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Discuss the test results with her and address her concerns.

Symptoms of vitamin B12 deficiency

• A pale-yellow tinge to your skin.

• A sore and red tongue (glossitis).
• Mouth ulcers.
• Pins and needles (paraesthesia).
• Changes in the way that you walk and move around.
• Disturbed vision.
• Irritability.
• Depression.
• Changes in the way you think, feel and behave.
• A decline in your mental abilities, such as memory, understanding and judgement
(dementia).

Symptoms of folate deficiency

• Symptoms related to anaemia.

• Reduced sense of taste.
• Diarrhoea.
• Numbness and tingling in the feet and hands.
• Muscle weakness.
• Depression.

Build Rapport:

Doctor: I can see from my notes that are you here today for your test results, I have
your results with me, but I'd like to have chat with you before that, is that ok?
Patient: OK doctor no problem.
D: May I know why you had these tests in first place?
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P: I am always tired.
D: Can you tell me more about that?
P: I have had this tiredness for the last 4 weeks. (+ve finding)
D: Is there anything that makes it better or worse?
P: No.
D: Is there a specific time when you have it?
P: All day.
D: Apart from that is there anything else?
P: No.
D: Do you have any concern?
P: No.

Symptoms of Anaemia

D: Apart from this, do you have any other symptoms?

P: No, I am fine.
D: Do you feel tired or short of breath?
P: No.
D: Any heart racing?
P: No.
D: Any weight loss? (Cancer)
P: No.
D: Any alternate bowel habits?
P: No.
D: Any dark or black coloured stool?
P: No.
D: By any chance have you noticed any bleeding recently?
P: No

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P: Any numbness in your body?

D: Yes, I do feel numbness in my feet (+ve finding)
P: Any problems with your vision?
D: No.
+FLAWS
If it's an already diagnosed condition, no need to take differentials.

P2:

Doctor: Have you ever had this tiredness before?

Patient: No.
D: Do you have any medical condition?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or herbal medications?
P: No.
D: Do you have any allergies from food or medicines?
P: No.
D: Any previous surgery or hospitalizations?
P: No.
D: Has anyone in your family suffered from a similar condition in the past? P: No.

DESA
D: How is your diet?
P: I have been a vegan/vegetarian for the past 2 years; I stopped eating meat and/or
eggs etc. (+ve finding)
D: Do you smoke?
P: No.
D: Do you drink alcohol?
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P: No.
D: Do you exercise?
P: I try to be physically active.
D: What do you do for a living?
P: I am an accountant.
D: Who do you live with?
P: I live with my husband and 2 kids.

IMPACT ON LIIFE
D: You told me that you have had this for 4 weeks, how it's affecting your life?
P: I find it difficult to focus on my work and it's too hard to focus on my kids.
D: This must be difficult, by any chance is this affecting your mood?
P: No doctor.

EXAMINATION
Diagnosis
Thank you for answering my questions. You told me that you are vegetarian/vegan, and
you feel tired and have numbness in your feet. Also, your test results are showing that
your vitamin B12 level is low, so I suspect you may have a type of anaemia called
Vitamin b12 deficiency anaemia.

Management
- You may be referred to a specialist for further tests or treatment.
A specialist in conditions that affect the digestive system (gastroenterologist) – to
exclude conditions which prevent your digestive system from absorbing vitamin B12
properly (pernicious anaemia), which is not related to your diet.
A specialist in nutrition (a dietitian) – as a vitamin B12 deficiency is normally caused by
a poor diet and to devise a personalised eating plan for you to increase the amount of
vitamin B12 in your diet.
Senior.

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Symptomatic
Vitamin B12 deficiency anaemia is usually treated with injections of vitamin B12.
At first, you'll have these injections every other day for 2 weeks or until your symptoms
have started improving.
After this initial period, your treatment will depend on whether the cause of your
vitamin B12 deficiency is related to your diet or whether the deficiency is causing any
neurological problems, such as problems with thinking, memory and behaviour.

- If your vitamin B12 deficiency anaemia is diet-related

(Due to vegan or vegetarian diet)
You may need vitamin B12 tablets for life. You may be advised to stop taking the
tablets once your vitamin B12 levels have returned to normal and your diet has
improved.
Good sources of vitamin B12 include: (meat - salmon and cod - milk and other dairy
products – eggs)

You can look for alternatives to meat and dairy products, there are other foods that
contain vitamin B12, such as yeast extract (including Marmite), as well as some fortified
breakfast cereals and soy products. Check the nutrition labels while food shopping to
see how much vitamin B12 different foods contain.
If your vitamin B12 deficiency anaemia is not diet-related
You'll usually need to have an injection of vitamin B12 every 2 to 3 months for the rest
of your life.

Safety netting
If you continue to have neurological symptoms that affect your nervous system, such
as numbness feet, it could be caused by a vitamin B12 deficiency. You may also be
referred to a haematologist (blood specialist) and you may need to have injections
every 2 months.

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Follow up
To ensure your treatment is working, we may need to do further blood tests
10 to 14 days after starting treatment to assess whether treatment is working.
Another blood test may also be carried out after approximately 8 weeks to confirm
your treatment has been successful.
You may have to return for an annual blood test to see whether your condition has
returned.

Chronic fatigue syndrome

Who you are:
You are an FY2 in a GP clinic.
Who the patient is:
Mrs. Julia Andresen, 35-year-old, presented to the GP surgery 6 months ago with
tiredness. She has come for her follow up.
Special notes
IT has crashed and his records are not available.
What you should do:
Take a history from her and talk to her about further management.

Chronic fatigue syndrome: tiredness more than 6 months + flu like symptoms
before the tiredness + without joints pain.
It is a disease of exclusion.
Build Rapport:
D: I can see from my notes that you're here for your follow up, how are you doing so
far?
P: This tiredness is getting worse doctor.
ODIPARA:
D: I am sorry to hear that, can you tell me more about it?
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P: I came 6 months ago for tiredness; the doctor ran some investigations, but I don't
know the results. (+ve finding)
D: Unfortunately, our IT system has crashed which means I can't reach your profile right
now; I am really sorry about that.
P: Does this mean all my data’s gone?
D: No, it's just temporary. Has the other doctor told you what may be causing your
tiredness?
P: No, he didn't find any cause for it.
D: Is there anything making it worse or better?
P: No.
D: Apart from this, is there anything else?
P: No.
D: What's your main worry?
P: I want to know what's wrong with me.

PSYCHOSOCIAL
D: You told me that you have had this condition for 6 months now, how is this affecting
your life?
P: It started to affect my relations with my wife, I am too tired to have sex with
her and she thinks I am cheating on her. (+ve finding)
D: Oh no! That’s not good at all. And is this affecting your work?
P: I am a lawyer and I find it difficult to concentrate, I am afraid I could lose my job. (+ve
finding)
D: Sound like you’re going through a difficult time. Is it affecting your mood?
P: It's difficult, but I think I am ok mood-wise.
D: On a scale from 1 to 10, 1 being the lowest mood and 10 being the happiest, can you
grade your mood for me?
P: It would be 6.

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DIFFERENTIALS:
D: Any weight changes recently?
P: No.
D: Any fever?
P: I had flu like symptoms before getting this tiredness
D: OK, do you have any fever now?
P: No.
D: Do you feel hot when other people feel cold and vice versa?
P: No.
D: Do you go to the loo more often than usual?
P: No.
D: Any joint pain or stiffness?
P: No.
P2:
D: Have you had this tiredness before?
P: No.
D: Do you have any medical condition?
P: No.

MAFTOSA
D: Do you have any medical condition?
P: No.
D: Any allergies?
P: No.
D: Any family history of a similar condition?
P: No.
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DESA
D: Can you tell me about your diet?
P: I try to eat healthy.
D: Do you smoke?
P: No.
D: What about alcohol?
P: Just occasionally.

Examination

Provisional diagnosis:
The exact cause of your tiredness is unknown, especially seen as I’m not able to get into
the system to check your results right now. However, I think you may have chronic
fatigue syndrome. It's a chronic condition which causes your body and mind to feel
exhausted, without having done any physical activity.

Management
• Senior.
• Investigations.
• Blood (all tests for tiredness) and urine tests. To rule out other conditions that
could be causing your symptoms.

Lifestyle changes
• Diet -It's important that you eat regularly and have a healthy, balanced diet. If
you feel sick (nauseous), eating little and often, may help. If this does not work,
medicine can be prescribed. Diets that exclude certain food types are not
recommended.

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• Sleep, rest and relaxation. You may have sleep problems (unrefreshing or restless
sleep or excessive amount of sleep) that make your CFS symptoms worse. You
should be given advice about how to establish a normal sleeping pattern.
• Limiting rest period during the day to 30 minutes could help.
• Relaxation techniques, such as breathing exercises.

Symptomatic
Treatments for CFS aim to help relieve your symptoms.
Your treatment will be tailored to your symptoms.
CFS can last a long time, but most people's symptoms will improve with time.
We should discuss all the options with you and explain the benefits and risks of any
treatment taking into account your circumstances and preferences.
Medicine can be used to relieve some of the symptoms.
Over-the-counter painkillers can help ease headaches, as well as muscle and joint pain.
You may be referred to a pain management clinic if you have long-term pain.
Antidepressants can be useful for pain or having trouble sleeping.
Amitriptyline may be prescribed to help ease muscle pain.

- Specialist treatments
There are several specialist treatments for CFS.

1. Cognitive behavioural therapy (CBT) - For mild or moderate CFS.

CBT is a talking treatment that can help you manage CFS by changing the way you think
and behave.
It can help you to: accept your diagnosis and feel more in control of your symptoms.
Using CBT does not mean CFS is a psychological condition.
It's used to treat a variety of long-term conditions.

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2. Graded exercise therapy (GET)

It is a structured exercise program that aims to gradually increase how long you can
carry out a physical activity.
It usually involves exercise that raises your heart rate, such as swimming or walking.
Your exercise program will be adapted to your physical capabilities.
GET should only be carried out with the help of a trained specialist with experience in
treating CFS.

3. Activity management
It involves setting individual goals and gradually increasing your activity levels.
You may be asked to keep a diary of your current activity and rest periods to establish
your baseline. Activities can then be gradually increased in a way you find manageable.

4. Changes in your place of work, study or home.

Safety netting

If you have severe CFS and need to spend much of your time in bed, it can cause
problems, including pressure sores and blood clots. These problems, and how to avoid
them, should be explained to you and your carers.
If you feel low due to your symptoms, come to us immediately.
Follow up
Your treatment plan would be reviewed regularly.

Fibromyalgia

Who you are:

You are an FY 2 in a GP clinic.
Who the patient is:
Mr Tony Peter, 35-year-old presented to the GP with tiredness.

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What you should do:

Take a history from him and talk to him about the further management.

Symptoms of fibromyalgia

As well as widespread pain, people with fibromyalgia may also have:

• increased sensitivity to pain.
• extreme tiredness (fatigue).
• muscle stiffness.
• difficulty sleeping.
• problems with mental processes (known as "fibro-fog"), such as problems with
memory and concentration.
• Headaches.
• irritable bowel syndrome (IBS).

If the patient has body ache → consider Fibromyalgia as diagnosis.

If tiredness is more prominent → consider CFS as diagnosis.

ODIPARA:
Doctor: I can see from my notes that you're here for tiredness, can you tell me more
about it?
Patient: I’ve had tiredness for 8 weeks now and I think it's getting worse (+ve finding)
D: Are you tired all day or is there a specific time that you feel tired?
P: All day doctor.
D: Is there anything making it worse or better?
P: No.
D: Apart from this, anything else?
P: I have pain in my body and my movement is stiff. This started around the same time
also. (+ve finding)
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D: Anything else?
P: No.
D: What's your main worry?
P: I want to know what's wrong with me.

PSYCHOSOCIAL

D: You told me that you have had this condition for 8 weeks, how is it affecting your
life?
P: I find it difficult to move and I feel pain all the time. (+ve finding)
D: This must be difficult, is it affecting your work?
P: I am doing some office work and it's becoming hard for me to focus on it. (+ve
finding)
D: I can see you are going through a difficult time with this, how is your mood?
P: I am OK.
D: Do you mind telling me, on a scale of 1 to 10, 1 being the lowest mood and 10 being
the happiest, what would you grade your mood at for me?
P: It would be 6.

DIFFERENTIALS:

D: Any weight changes recently?

P: No.
D: Any fever recently or now?
P: No.
D: Do you feel hot when other people feel cold and vice versa?
P: No.
D: Do you go to the loo more than often than usual?
P: No.

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D: Any change of the bowel habits?

P: no
P2:
D: Have you ever had this tiredness before?
P: No.
D: Do you have any medical condition?
P: No.

MAFTOSA
D: Do you have any medical condition?
P: No.
D: Any allergies?
P: No.
D: Any family history of a similar condition?
P: No

DESA
D: Can you tell me about your diet?
P: I try to eat healthy.
D: Do you smoke?
P: No.
D: What about alcohol?
P: Just occasionally.

Examination Provisional diagnosis

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From the chat that we had, you told me that you have tiredness along with pain and
muscle stiffness, I suspect you may have a condition called fibromyalgia; it's a long-term
condition which causes widespread pain in the body and tiredness.

Management of Fibromyalgia
- Refer
Different healthcare professionals may also be involved in your care, such as a:
Rheumatologist – a specialist in conditions that affect muscles and joints.
Neurologist – a specialist in conditions of the central nervous system.
Psychologist – a specialist in mental health and psychological treatments.

Senior
Investigations
• To rule out all other conditions that could be causing your symptoms as
rheumatoid arthritis, and multiple sclerosis.
• Tests to check for some of these conditions include urine and blood tests,
although you may also have X-rays and other scans.

Symptomatic
You may need to take several different types of medicines for fibromyalgia.
Painkillers
If over-the-counter painkillers are not effective, we may prescribe a stronger painkiller
for you.
Antidepressants can also help relieve pain for some people with fibromyalgia such as
amitriptyline. Antidepressants can cause several side effects, including sickness – dry
mouth – drowsiness.
Medication to help you sleep as an over-the-counter remedy, or we may prescribe a
short course of a stronger medication.

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Muscle relaxants If you have muscle stiffness or spasms (when the muscles contract
painfully) as a result of fibromyalgia, we may prescribe a short course of a muscle
relaxant, such as diazepam.
Anticonvulsants (anti-seizure) medicine, as these can be effective for those with
fibromyalgia such as pregabalin and gabapentin. Some common side effects of them
include dizziness – drowsiness.
Antipsychotics used to help relieve long-term pain. Possible side effects include shaking
– drowsiness.
Treatment of other combined conditions as irritable bowel syndrome (IBS), you may
need to have separate treatment for it.
Support group

Many people also find support groups helpful. Just talking to someone who knows what
you're going though can make you feel better.
Fibromyalgia Action UK is a charity that offers information and support to anyone who
has fibromyalgia.

Specialist treatment

There are other treatment options that can be used to help cope with the pain of
fibromyalgia.

▪ Hydrotherapy or balneotherapy: swimming, sitting or exercising in a heated pool or

warm water.
▪ An individually tailored exercise program.
▪ Cognitive behavioural therapy (CBT) – a talking therapy that aims to change the
way you think about things, so you can tackle problems more positively
▪ Psychotherapy – a talking therapy that helps you understand and deal with your
thoughts and feelings.
▪ Relaxation techniques.
▪ Psychological support – any kind of counselling or support group that helps you

deal with issues caused by fibromyalgia.

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Alternative therapies such as acupuncture – massage.

- Safety netting
If you feel low, come back to us immediately.

Tiredness due to citalopram

Who you are:

You are an FY2 in a GP surgery.
Who the patient is:
Sarah Taylor, 55-year-old female, who has come for her follow up. She has had
depression for the last 4 months. She comes now with tiredness.

What you should do:

Talk to her and address her concerns.

ODIPARA:

D: I can see from my notes that you're here for tiredness, can you tell me more
about that?
P: Yes, I have been feeling so tired in the past 3 months. (+ve finding)
D: Are you tired all day or there a specific time that you feel tired?
P: All day doctor.
D: Is there anything making it worse or better?
P: No.
D: Apart from this, is there anything else?
P: No.
D: What's your main worry?
P: I want to know what's wrong with me.

PSYCHOSOCIAL
D: You told me that you have had this condition for 8 weeks, how is it affecting your
life?
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P: I can't do my daily activity doctor. (+ve finding) D: I see…

and who do you live with?
P: I live alone.
D: Is there any family member or friends that come to see you often?
P: No.
D: Sounds like you’re going through a difficult time, how is your mood?
P: I am ok.
D: On a scale from 1 to 10, 1 being the lowest mood and 10 being the
happiest, can you grade your mood for me?
P: It would be 7.

DIFFERENTIALS:

D: Any weight changes recently? (FLAWS)

P: No.
D: Any fever?
P: No.
D: Do you feel hot when other people feel cold and vice versa? (thyroid)
P: No.
D: Do you go to the loo more often than usual? (DM)
P: No.
P2:
D: Have you ever had this tiredness before?
P: No.
D: I can see from my notes that you have depression, can you tell me more about
that?
P: I had depression 4 months ago after my husband died. (+ve finding)
D: I am really sorry for your loss, please accept my condolences.
P: Thank you doctor.

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D: How are you now?

P: I am feeling better regarding my mood the doctor gave me some medication.
D: Do you know the name of this medication?
P: I think it's citalopram.
D: Are you taking it as prescribed?
P: Yes doctor.
D: Did you notice this tiredness before or after starting the medication?
P: I didn't have it before taking it (+ve finding).

MAFTOSA
D: Apart from citalopram, are you taking any other medications?
P: No.
D: Any allergies?
P: No.
D: Any family history of a similar condition?
P: No.
DESA
D: Can you tell me about your diet?
P: I try to eat healthy.
D: Do you smoke?
P: No.
D: What about alcohol?
P: Just occasionally.

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Examination and check for sodium level

Provisional diagnosis:

From the chat we just had you told me that you have had tiredness for 3 months
now and you are taking citalopram for depression, so I suspect the medication is
probably the cause of your tiredness.
(You should open the BNF and check the medication)

Management

- Admit

- Senior

▪ Causative medications may be stopped.

- Investigations

▪ Blood tests:
potassium - kidney function - Thyroid function tests – cortisol - Blood inflammatory
markers - random glucose - osmolality

▪ Urine sample: looking for sodium levels and osmolality which are useful in
determining the cause.

▪ Imaging: a chest X-ray may be required to exclude heart failure, or a computerized

tomography (CT) brain scan may be necessary in patients with confusion.

▪ Other investigations: some other tests which may be undertaken include a 12lead
heart tracing (electrocardiogram, or ECG), an ultrasound scan of the heart
(echocardiogram, or echo) in cardiac failure and, in kidney disease, a renal
ultrasound scan. - Symptomatic
▪ Intravenous fluids slowly or fluid restriction in lack of fluid in the body according to

your test results.

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▪ Continuous monitoring of your vitals and blood sodium levels.

▪ Medications for any associated symptoms as headache or nausea.

▪ Review medications (Citalopram - Steroids) which may have caused the low blood
sodium.
Support groups.
- Specialist

▪ Refer to Psychiatry after being stable to modify your medications (Citalopram).

▪ Refer to Respiratory after being stable to modify your medications (Steroid).

- Follow up
▪ Clear plan regarding medication and prevention of further hyponatraemia is
required.

Thyroid

Thyroid Key points:

1- Be careful thyroid is in your heart until you pass PLAB2
Thyroid:
- DDs of constipation (hypo)
- DDs of diarrhoea (hyper) - DDs of tiredness (hypo)
- DDs of mood disturbance (hypo +hyper)
- DDs of period irregularities (hypo – hyper)
- DDs of weight loss (hyper) - DDs of weight gain (hypo)

2- How to remember symptoms of thyroid BMW

- Bowel: diarrhoea or constipation
- Mood disturbance
- Weight (loss or gain) / weather preference (hot or cold)

3- Period: be careful, you must ask about it.

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Hypothyroidism
Who you are:
An FY2 in a GP clinic.
Who the patient is:
Eva Green, a 50-year-old lady, presenting with tiredness.
What you should do:
Talk to her and address her concerns.

Another scenario could be:

Who you are:

An FY2 in the GP clinic.
Who is the patient
Eva Green, a 50-year-old lady, came a week ago and had some investigations for
gaining weight in the past year. She feels cold when others are comfortable. She has
constipation and tiredness most of the time.
Tests results: TSH 10 (High)
T4 low T3 low
What you should do:
Talk to her, discuss the results and address her concerns.

ODIPARA:
Doctor: I can see from my notes that you're here for tiredness, can you tell me more
about it?
Patient: I have had tiredness for the past 6 months and it's there all the time.
(+ve finding)
D: Sorry to hear that. Is there anything making it worse or better?
P: No.
D: Apart from this, was there anything else you wanted to discuss with me today?
P: Yes, I feel cold a lot. (+ve finding)
D: Can you tell me more about that?
P: Around the same time, I feel cold even if I am wearing heavy clothes.
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D: What's your main worry?

P: Nothing really.

PSYCHOSOCIAL
D: You told me that you have had this condition for 6 months now, how is it
affecting your life?
P: My life has become difficult. I am not able to do anything.
D: Sounds distressing. What do you do for living?
P: I am retired.
D: Who do you live with?
P: I live alone, my husband died 10 months ago.
D: I am really sorry to hear that, please accept my condolences?
P: Thanks.
D: So, how is your mood?
P: I don't feel good
D: On a scale from 1 to 10, 1 being the lowest mood and 10 being the
happiest, can you grade your mood for me?
P: It would be 3. (+ve finding)
D: OK, I see (nodding), sorry to hear that.
DIFFERENTIALS:
D: Any weight changes recently?
P: Yes, I have gained like 4 kilos even though my appetite is poor. (+ve finding)
D: Any fever?
P: No.
D: Do you go to the loo more than often than usual?
P: No.
D: Any joint pain or stiffness?
P: No.

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D: Any constipation?
P: Sometimes (+ve finding)
D: How is your sleep?
P: I have poor sleep. (+ve finding)

P2:
D: Have you ever had this tiredness before?
P: No.
D: Do you have any medical condition? P: No.
Don't forget Period
MAFTOSA
D: Do you take any medications?
P: No.
D: Any allergies?
P: No.
D: Any family history of a similar condition?
P: No.

DESA
D: Can you tell me about your diet?
P: I try to eat healthy but recently I have a poor appetite.
D: Do you smoke?
P: No
D: What about alcohol?
P: Just occasionally.

Examination
• Observation
• Hand
• Eye

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• Neck

Provisional diagnosis:
From the chat we had I suspect that you have Hypothyroidism which is a gland in front
of the neck. It’s a butterfly gland that secretes hormones responsible for the
metabolism (a process that occurs in order to maintain life). In your condition this gland
is underactive.

Management:
1. Senior
2. Investigation
(blood: T3, T4, TSH high TFT/ autoantibodies grave’s ds)
3. Symptomatic

Replacement therapy

Levothyroxine replaces the thyroxine hormone, which your thyroid does not make
enough of.
You'll initially have regular blood tests until the correct dose of levothyroxine is
reached. This can take a little while to get right.
You may start on a low dose of levothyroxine, which may be increased gradually,
depending on how your body responds.
Once you're taking the correct dose, you'll usually have a blood test once a year to
monitor your hormone levels.

1- Specialist:
(Endocrinologist: gland specialist) for further investigations (to find the cause
(Isotope scan, where you will swallow radio-active substance in a capsule or liquid)
May consider: Radioactive iodine (to shrink the gland) Surgery
2- Safety netting:
- Infection, fever, sore throat
- If you decide on pregnancy
- If you get pregnant
- Continuation of symptoms

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Hyperthyroidism

Who you are:

You are an FY2 in the GP clinic.
Who the patient is:
Eva White, a 25-year-old lady, presented with some concerns.
What you should do:
Talk to her and address her concerns.

Another Scenario

Who you are:

You are an FY2 in the GP clinic.
Who the patient is:
A 27-year-old complaining of the shaking of her hands and sweating. One week ago she
had some blood tests:
TSH: 0.6 (0.5 – 4.5)
T4: High T3: High
What you should do:
Talk to her, discuss the results and address her concerns.

ODIPARA:
Doctor: I can see from my notes that you're here for your test results, I have the results
here with me, but I'd like to have a chat with you before explaining it to you.
Can you walk me through what happened?
Patient: I came because I’ve had tremors, and I’ve been sweating a lot (+ve finding)
D: Sorry to hear that, can you tell me more about it?
P: It started 3 months ago.
D: Is there anything that makes it better or worse?
P: It's getting worse with time.
D: Do you have this all the time or a specific time of the day?
P: All the time.
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D: Apart from that, anything else?

P: Like what?
D: Any weight loss?
P: Yes, I think I lost like 5 kgs in the last 3 months (+ve finding)
D: Was that intentional?
P: No.
D: Any change in your bowel habits?
P: I have diarrhoea more often (+ve finding)
D: And what's your main worry?
P: Nothing really.

PSYCHOSOCIAL
D: You told me that you have had this condition for 3 months now, how is this affecting
your life?
P: It's ok doctor.
D: What do you do for a living?
P: I am doing office work.
D: Does this affect your work?
P: No doctor it's fine.
D: How is your mood?
P: Good.
D: On a scale from 1 to 10, 1 being the lowest mood and 10 being the happiest, can you
grade your mood for me?
P: It would be 8.

P2:
D: Have you ever had this tiredness before?
P: No.
D: Do you have any medical condition?
P: No.

Don't forget Period

D: I need to ask you some sensitive questions, but they are part of my consultation, how
is your period?
P: It’s irregular doctor.
D: Any bleeding in-between periods?
P: No.

MAFTOSA
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D: Do you take any medications?

P: No.
D: Any allergies?
P: No.
D: Any family history of a similar condition?
P: No.

DESA
D: Can you tell me about your diet?
P: I try to eat healthy but recently I have poor appetite.
D: Do you smoke?
P: No.
D: What about alcohol?
P: Just occasionally.

Examination
• Observation
• Hand
• Eye
• Neck

Discuss the results:

Your results show that some markers from the thyroid, which is a gland in front of your
neck, these markers are high, plus you told me that you have been sweating, having
tremors and weight loss, so I suspect you may have a condition called Hyperthyroidism.
This means your thyroid is overactive.

Management:
1. Senior
2. Investigation
(blood: T3, T4, TSH high TFT/ autoantibodies grave’s ds)
3. Symptomatic

(Carbimazole):
Once you mention medication you must tell patient - Tab
Once a day
You’ll take it with water (18 month)

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It may cause unpleasant effects (rash/ joint pain/ repeated sore throat/ fever/
infection) so if any of these happen, please come back right away for a re-evaluation.

It’s not advisable to use it if you are pregnant

(Propylthiouracil) (B Blockers):
For heart racing
Tab
Take with water
It may cause (dry mouth/ dry skin/ dry eye/ dizziness)

Specialist:
(Endocrinologist: gland specialist) for further investigations (to find the cause (Isotope
scan, where you will swallow radio-active substance in a capsule or liquid)
May consider: Radioactive iodine (to shrink the gland)
Surgery

Safety netting:
Infection, fever, sore throat.
If you decide on pregnancy.
If you get pregnant.
Continuation of symptoms.

Hyperparathyroidism
Who you are:
You are an FY2 in the GP clinic.
Who the patient is:
Elena James, 45-year-old lady, coming for the test results she had week back.
FBC: Normal
Corrected calcium: High
PTH: High
Urea: Normal
Electrolytes: Normal
What you should do:
Talk to her, discuss the results and address her concerns.

Symptoms of Hypercalcemia:

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Moans (mood irritable), Groans (pain), Bones (bone pain), Stones, Sitting on king’s
throne (constipation)

Symptoms like these of DM it doesn’t cause DM but just to remember:

Polyuria
Polydipsia
Weight loss (FLAWS)
Tiredness

Don't forget to ask about patient’s history of surgeries (removal of thyroid glands).

Build rapport:

Doctor: I can see from my notes that you're here for your tests results, I have the
results with me, but I'd like to have a chat with you before explaining it to you. Can you
walk me through what happened?
Patient: I came because I have had tiredness for the last 3 months (+ve finding)
D: Sorry to hear that, can you tell me more about it?
P: I am tired all the time doctor.
D: Is there anything that makes it better or worse?
P: It's getting worse with time.
D: Do you have this all the time or a specific time of the day?
P: All the time.
D: Apart from this, is there anything else?
P: I noticed that I go to the toilet more than usual.
D: When did you notice this?
P: Well around the same time.
D: Any weight changes?
P: No.
D: Any change in your bowel habits?
P: I have constipation most of the time (+ve finding)
D: Any pain in your body?
P: No.
D: Have you had any vomiting?
P: No.
D: Any problems with your bones?
P: No.
D: What's your main worry?
P: Nothing really.

FLAWS
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PSYCHOSOCIAL

D: You told me that you have had this condition for 3 months now, how is it affecting
your life?
P: It's ok doctor.
D: What do you do for living?
P: I am a housewife
D: Who do you live with?
P: My wife and 2 kids.
D: Lovely, and how is everything at home?
P: Nice.
D: How is your mood?
P: Good.
D: On a scale from 1 to 10, 1 being the lowest mood and 10 being the happiest, can you
grade your mood for me?
P: It would be 8.
P2:
D: Have you ever had this tiredness before?
P: No.
D: Do you have any medical condition?
P: No.

Don't forget Period

D: I need to ask you some sensitive questions, but they are part of my consultation, how
is your period?
P: It's irregular doctor.
D: Any bleeding in-between your periods?
P: No.

MAFTOSA
D: Do you take any medications?
P: No.
D: Any allergies?
P: No.
D: Any family history of a similar condition?
P: No.

DESA
D: Can you tell me about your diet?
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P: I try to eat healthy but recently I have poor appetite.

D: Do you smoke?
P: No.
D: What about alcohol?
P: I drink occasionally.

Examination
• Observation
• Hand
• Eye
• Neck

Discuss the results:

From the information you have given me and according to my examination, I suspect
that you may have a condition called Hyperparathyroidism. There’s a gland in our neck
called the parathyroid gland that secretes a hormone that regulates Ca level, this gland
is overactive leading to high Ca levels causing these symptoms.

Management:
1. Senior

2. Investigations:
(oestrogen/ progesterone/ Vit D/ scans of your neck/ Dexa scan)

3. Symptomatic + lifestyle
Advise the patient to drink plenty of (oral fluids) - Life style (Diet):
eat healthy balanced diet, you don’t need to avoid Ca altogether, a lack of Ca in your
diet is more likely to cause a loss of Ca in your bones.

4. Refer:
Cardiologist: will review your blood pressure and make sure it’s controlled - Gland
specialist: Endocrinologist who may give you bisphosphonate or you may need surgery.

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5- Safety netting:
Tummy pain, feeling not yourself feeling low or confused come back to see us right
away.

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RHEUMATOLOGY

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Rheumatology

Structure of Rheumatology

P1: JOINT PAIN (SOCRATES)

Can you point to where it hurts the most? (site)
When did this pain start? (onset)
What does the pain feel like? (character)
Does this pain go anywhere else? (radiation) –
Is there anything that makes it better?
Is there anything that makes it worse?
On a scale from 1 to 10 can you score your pain? (score)

Then whenever you approach any patient with a joint problem you should ask early on:
Which joint?
What about the other joint?
Are you able to(…) (Function of joint)?

If the person has had the condition for long period:

How is this problem affecting your daily activities?

What do you do for living?
How is this problem affecting your job?
How is your mood? (If it is impairing his life or causing disabilities.)
Apart from the joint pain, anything else?
What's your main concern? (concern)

Differential diagnosis of all joint problems:

GHRROSS
Gout
Haemo-arthrosis
Reactive arthritis
Osteoarthitis
Septic arthritis
Sport/ accident/ fall/ trauma

The first question you ask in DDS is

Do you have any fever? → to exclude septic arthritis.

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Don't forget FLAWS

P2 (past hx)
Have you had this pain before?
Do you have any medical conditions?
P3: DESA, MAFTOSA
ICE (IDEA- CONCERN- EXPECTATIONS)
Examination, Provisional diagnosis, then Management.

7 steps:

1. Admit
2. Senior
3. Investigations to be done in all joint problems
Blood: (FBC/ RBS/ ESR/ CRP/ Rheumatoid factor/ uric acid/ vitamin D) X-ray joint

4. Symptomatic + lifestyle
Pain killer for his complaint
Occupational therapist: to give strategies to cope with his job
Physiotherapist: to advice about certain exercise to be able to relieve pain and
use joint
5. Specialist
6. Safety net for septic arthritis
7. Follow-up

Reactive Arthritis
Who you are:
You are an F2 in Orthopaedics.
Who the patient is:
John, aged 29, came to the hospital with pain in his joints.
What you should do:
Please take history, do relevant examination and discuss the management with the
patient.

Don't forget
Can't see: eye pain, redness, sticky discharge, conjunctivitis and, rarely, inflammation of
the eye (iritis)
Can't pee: pain when peeing, or discharge from the penis or vagina.

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Can't bend the Knee: pain, stiffness and swelling in the joints and tendons, most
commonly the knees, feet, toes, hips and ankles. it always follows viral infection (STI or
Food Poisoning)

P1 (SOCRATES)
Doctor: Hello, how can I help you today?
Patient: I have pain in my joints.
D: Which joints? (site)
P: In both my ankle and knee joint
D: Any other joints?
P: No.
D: Are you able to use the joints?
P: Yes.
D: Can you tell me more about this pain?
P: Like what?
D: When did it start? (onset)
P: 10 days ago.
D: How did it start?
P: Suddenly. (+ve finding)
D: Is the pain continuous or does it come and go?
P: It comes and goes.
D: Could you please describe the pain for me? (character)
P: It is mild.
D: Does it go anywhere else? (radiation)
P: No.
D: Is there anything making it worse?
P: No
D: Is there anything making it better?
P: No
D: On scale from 1 to 10, with 1 being mild pain and 10 being severe, can you rate the
pain for me?
P: 4
D: Apart from this pain, is there anything else?
P: No.
D: What concerns you the most? (concern)
P: Nothing doctor.

Can't see, Can't pee, Can't bend the knee + (recent infection)

D: Is there any stiffness or swelling in your joints?

P: No.
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D: Any pain your eyes?

P: Yes, I have pain in both eyes (+ve finding)
D: When did that start?
P: It started with joint pain.
D: Any redness or discharge in your eyes?
P: No.
D: Any pain while passing urine?
P: No.
D: Have you had any recent flu-like symptoms?
P: Yes, I had food poisoning 3 weeks ago (+ve finding)
D: How are you now?
P: I am fine thanks.

Differentials (Don't forget septic arthritis)

D: Any fever?
P: No.
D: Any trauma to the joints?
P: No
+FLAWS

P2
D: Have you ever had this pain before?
P: No.
D: Do you have any medical condition?
P: No.
DESA+ SEXUAL Hx
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: What about your diet?
P: I try to eat healthy
D: Do you exercise?
P: No.
D: I need to ask you some intrusive questions, but it's part of my consultation, are you
sexually active?
P: Yes.
D: Do you have stable partner?
P: Yes.
D: Do you practice safe sex?
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P: No. (+ve finding)

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DON'T FORGET ICE

Examination: general physical and observations.

Provisional diagnosis:
From the chat we had (mention the positive findings) you told me that you have joint-
pain and eye-pain. You also told me that you had a recent infection and you are not
practicing safe sex so I suspect that you may have a condition called Reactive arthritis.
This is a condition that causes redness and swelling (inflammation) in various joints in
the body, especially the knees, feet, toes, hips and ankles.
It usually develops after you've had an infection, particularly a sexually transmitted
infection, or food poisoning.

Management
Reactive arthritis is usually temporary, but treatment can help to relieve your
symptoms and clear any underlying infection.
Most people will make a full recovery within a year, but a small number of people
experience long-term joint problems.
Refer to a sexual health clinic for further genitourinary investigation in sexually active
patients (if STI is suspected.)

Senior
Investigations
Blood
ESR – CRP – FBC
HLA-B27: positive in most cases
ANA (antinuclear antibodies) – Rheumatoid factor: negative.
Serology for possible infectious triggers - eg, Yersinia,
Campylobacter, Salmonella
Urine analysis
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Stool analysis and culture

Joint
Xray
Aspiration (to exclude septic arthritis)

Symptomatic
Antibiotics
Antibiotics will not treat reactive arthritis itself, but are sometimes prescribed if you
have an ongoing infection – particularly if you have an STI.
Your recent sexual partner(s) may also need treatment.
Non-steroidal anti-inflammatory drugs such as ibuprofen, can be taken to reduce
inflammation and relieve pain.
Steroid medication
If NSAIDs didn't work for you or you could not take them, you may be prescribed
steroid medication to reduce inflammation.
Steroids may be given as tablets or injected directly into the affected joint or tendon or
eye drops if you have eye problem.
Disease-modifying anti-rheumatic drugs (DMARDs)
If your symptoms don't get better after a few weeks with other treatments or are very
severe, you may be prescribed a DMARD, which also work by reducing inflammation.
They may be prescribed on their own but can also be prescribed in combination with
steroids or NSAIDs, or with both.
The most commonly used DMARDs are methotrexate and sulfasalazine.
It can take a few months before you notice a DMARD is working, so it's important to
keep taking it even if you don't see immediate results.

Self-care
get plenty of rest and avoid using the affected joints.
As your symptoms improve, you should begin to do exercises to stretch and strengthen
the affected muscles and improve the range of movement in your affected joints.
Ice packs and heat pads can be useful in reducing joint pain and swelling. Wrap them in
a clean towel before putting them against your skin.
Place the pack against the affected area for up to 20 minutes.
Splints, heel pads and shoe inserts (insoles) may also help.
The most effective way of preventing STIs is to always use a barrier method of
contraception, such as a condom, during sex with a new or non-exclusive partner.
Ensuring good standards of hygiene when preparing and storing food can help to
prevent bowel infections.

Specialist
You may be referred for physiotherapy.
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Safety netting
If your symptoms do not improve despite treatment or you experience fever, redness or
swelling in your joints, come back to us immediately.

Follow up.

Rheumatoid Arthritis
Who you are:
You are an FY2 in a GP clinic.
Who the patient is:
Suzan Wilson, aged 55, has presented with the complaint of hand-pain.
What you should do:
Take history, assess her and discuss management with her.

Rheumatoid Arthritis:
It affects small joints in hands and feet in form of (pain, swelling, stiffness, and
nodules). + general symptoms.

Tiredness and a lack of energy, a high temperature, sweating, a poor appetite

And weight loss.

Always search for triggers like smoking and FHx.

Don't forget to ask about the impact of this pain on her life.

P1 (SOCRATES)
Doctor: Hello, how can I help you today?
Patient: I have pain in my joint.
D: Which joints? (site)
P: In my wrist and in the fingers of my both hands
D: Any other joints?
P: No.
D: Are you able to use the joints?
P: Yes.
D: Can you tell me more about this pain?
P: Like what?
D: When did it start? (onset)
P: 10 weeks ago.
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D: How did it start?

P: Suddenly.
D: Is the pain continuous or does it come and go?
P: Continuous.
D: Could you please describe the pain for me? (character)
P: Dull.
D: Does it go anywhere else? (radiation)
P: No.
D: Is there anything making it worse?
P: Yes, in the morning it's stiffer and it gets better later.
D: Is there anything making it better?
P: No.
D: On a scale from 1 to 10 with 1 being the mildest and 10 being the most severe pain,
can you rate the pain for me?
P: 5
D: Apart from this pain, is there anything else?
P: No.
D: What concerns you the most? (concern)
P: Nothing really doctor.

OTHER SYMPTOMS:
D: Any stiffness or swelling in your joints?
P: Yes, doctor specially in the morning (+ve finding)
D: Any tiredness?
P: Yes, I feel tired most of the time (+ve finding)
D: Have you had any recent flu-like symptoms?
P: No.

Differentials (Don't forget septic arthritis)

D: Any fever?
P: No.
D: Any trauma to the joints?
P: No
+FLAWS

P2
D: Have you had this pain before?
P: No.
D: Do you have any medical condition?
P: No.
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DESA+ SEXUAL Hx
D: Do you smoke?
P: Yes, 20 cigarettes a day for the past 20 years (+ve finding)
D: Do you drink alcohol?
P: No.
D: What about your diet?
P: I try to eat healthy.
D: Do you exercise?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family ever been diagnosed with any medical condition?
P: Yes, my mother had rheumatoid arthritis (+ve finding)
D: How is she now?
P: She's fine thanks.
D: You've mentioned you have had this pain in the last 10 weeks, how are you coping?
P: I find it difficult doctor I can't do my work properly.
D: It must be difficult for you, what do you do for a living?
P: I’m a typewriter.
D: And how's your mood?
P: It's fine doctor thanks.

DON'T FORGET ICE

Examination:
-Vitals
-Your hands and other joints

Provisional diagnosis

From the chat we had (mention the positive findings) you told me that you have had
joint-pain in your wrist and finger, with morning stiffness and you also smoke and your
mother has rheumatoid arthritis, so I am suspect you may have Rheumatoid arthritis
which is a long-term condition that causes pain, swelling and stiffness in the joints.
The condition usually affects the hands, feet and wrists.
There may be periods where symptoms become worse, known as flare-ups or flares.
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Management
Refer patient to a hospital specialist within three working days or urgently.
(Rheumatologist).
Senior.
Investigations:
Blood tests
No blood test can definitively prove or rule out a diagnosis of rheumatoid arthritis, but several tests can
show indications of the condition.
erythrocyte sedimentation rate (ESR) – which can help assess levels of inflammation in
the body
C-reactive protein (CRP) – another test that can help measure inflammation levels
Full blood count – this test can be used to help rule out other possible causes of your
symptoms as well as provide an indicator of your general health.
Rheumatoid factor and anti-CCP antibodies - Rheumatoid factors are proteins that the
immune system produces when it attacks healthy tissue.
Joint scans
To diagnose and monitor rheumatoid arthritis include:
X-rays
MRI scans (where strong magnetic fields and radio waves are used to produce detailed
images of your joints).
To decrease disease activity and prevent joint damage
Disease modifying antirheumatic drugs (DMARDs).
They work by blocking certain chemicals involved in the inflammation process.
DMARDs include methotrexate, sulfasalazine, and other drugs.
It is normal to start a DMARD as soon as possible after RA has been diagnosed.
It is important to keep taking DMARDs as prescribed, even if they do not seem to be
working at first as they take several weeks to work.
It is normal to have regular tests - usually blood tests - whilst you take DMARDs. The
tests look for some possible side effects before they become serious and assess disease
activity.

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Biological medicines
They're usually taken in combination with methotrexate or another DMARD, and are
usually only used if DMARDs have not been effective on their own.
Side effects from biological treatments are usually mild but include skin reactions at the
site of the injections – infections - feeling sick.
Biological medicines are given by injection. They work by stopping certain chemicals in your
blood from activating your immune system to attack your joints.

Medicine to relieve pain

Painkillers: such as paracetamol or a combination of paracetamol and codeine (co-
codamol), NSAID, such as ibuprofen, naproxen or diclofenac. to relieve the pain
associated with rheumatoid arthritis.
They may be recommended while you're waiting to see a specialist or when your
symptoms are particularly bad (flare-up.)
Although uncommon, taking NSAIDs can increase the risk of serious stomach problems.
This is because the medicines can break down the lining that protects the stomach
against damage from stomach acids.
If you're prescribed NSAID tablets, you'll often be given another medicine to take with
it, such as a proton pump inhibitor (PPI) to reduce the risk of damage to your stomach
lining.

Steroids:
They reduce pain, stiffness and inflammation.
They can be given as: a tablet - an injection directly into a painful joint - an injection into
a muscle (to help lots of joints.)
They're usually used to provide short-term pain relief – for example, while you're
waiting for DMARD medicines to take effect or during a flare-up.
Steroids are usually only taken for a short time because long-term use can have serious
side effects, such as: weight gain - muscle weakness.
People with RA develop inflammation in other parts of the body such as the lungs,
heart, blood vessels, or eyes. Also, anaemia may develop. Various treatments may be
needed to treat these problems if they occur.

Supportive treatments
You may be referred to other services that might be able to help you with your
rheumatoid arthritis symptoms.
Physiotherapy
A physiotherapist may help you improve your fitness and muscle strength, and make
your joints more flexible.
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Occupational therapy
An occupational therapist can provide training and advice that will help you to protect
your joints, both while you're at home and at work.

Lifestyle modifications
If you have RA, you have an increased risk of developing heart disease, osteoporosis
and infections. Therefore, you should consider doing what you can to reduce the risk of
these conditions by other means. For example, if possible you should try to have a
good, healthy diet and exercise regularly. But it's important to find a balance between
rest and exercise.
Lose weight if you are overweight.
Do not smoke.
If you have high blood pressure, diabetes, or a high cholesterol level, they should be
well controlled on treatment.

Safety netting.

Gout

Who you are:

You are an FY2 in GP clinic.
Who the patient is:
Jenson Horton, aged 45, has come to you with the complaint of pain in the big toe. He is
hypertensive and on Amlodipine and Bendroflumethiazide.
What you should do:
Talk to him, address his concerns and discuss the management with him.

Gout:
It affects the base of the big toe. Ask for triggers like alcohol.
Don't forget to ask about fever and trauma.
P1 (SOCRATES)
D: Hello, how can I help you today?

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P: I have pain in my big toe. (+ve finding)

D: Which joints? (site)
P: In my big, right toe.
D: What about the left side?
P: No.
D: Are you able to use the joints?
P: Yes.
D: Can you tell me more about this pain?
P: Like what?
D: When did it start? (onset)
P: 5 days ago.
D: How did it start?
P: Suddenly.
D: Is the pain continuous or does it come and go?
P: It comes in attacks, but it's continuous during the attack (+ve finding)
D: Could you please describe the pain for me? (character)
P: Sharp.
D: Does it go anywhere else? (radiation)
P: No.
D: Is there anything making it worse?
P: No.
D: Is there anything making it better?
P: When I raise my leg it feels better.
D: On a scale from 1 to 10, with 1 being the mildest and 10 being the most severe pain,
can you rate the pain for me?
P: 7
D: Apart from this pain, is there anything else?
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P: No.
D: What concerns you the most? (concern)
P: I want to know what’s causing the pain.

OTHER SYMPTOMS:
D: Any swelling or redness?
P: Yes, it's red and swollen (+ve finding)
D: Any vomiting?
P: No.
D: Have you had any recent flu-like symptoms?
P: No.

Differentials (don't forget septic arthritis)

D: Any fever?
P: No.
D: Any trauma to the joints?
P: No
+FLAWS

P2
D: Have you had this pain before?
P: No.
D: Do you have any medical condition?
P: Yes, I have high blood pressure.
D: Tell me more about it…
P: I have had it 6 years now.
D: What you are taking for it?
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P: Amlodipine and Bendroflumethiazide(+ve finding)

D: Are you taking it as prescribed?
P: Yes.
D: Did you start to have this pain after having thiazide medications?
P: Yes (+ve finding).

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: Yes, 3 cups of wine every day for the past 15 years. (+ve finding)
D: What about your diet?
P: I try to eat healthy.
D: Do you exercise?
P: No.
MAFTOSA
D: Are you taking any other medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.

DON'T FORGET ICE

Examination:
Vitals and examination of the big toe
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Provisional diagnosis
From the chat we had (mention the positive findings) you told me that you have had
pain in your big toe and you are taking thiazide for hypertension so I suspect you may
have a condition called gout, a type of arthritis that causes sudden, severe joint pain.

Management
Refer you to see a specialist (rheumatologist)
Senior -To review your medications + open BNF (Bendroflumethiazide.)
Investigations
Arrange a blood test (uric acid – RFTs – U&E) and scan. The blood test will find out how
much of a chemical called uric acid there is in your blood. Having too much uric acid in
your blood can lead to crystals forming around your joints, which causes pain.
Sometimes a thin needle is used to take a sample of fluid from inside the affected joint,
to test it.
Fasting glucose and lipids- as gout is commonly associated with elevated level of these.

- Treatment to reduce pain and swelling

Attacks of gout are usually treated with a non-steroidal anti-inflammatory (NSAID) like
ibuprofen and / or Colchicine.
If the pain and swelling does not improve you may be given steroids as tablets or an
injection.
Do
Take any medicine you've been prescribed as soon as possible. It should start to work
within 2 days.
Rest and raise the limb.
Keep the joint cool – apply an ice pack, or a bag of frozen peas wrapped in a towel, for
up to 20 minutes at a time.
Drink lots of water.

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Try to keep bedclothes off the affected joint at night.

Don’t
Do not put pressure on the joint.

- Treatment to prevent gout coming back

Gout can come back every few months or it may be years. It can come back more often
if it's not treated. If you have frequent attacks or high levels of uric acid in your blood,
you may need to take uric acid lowering medicine.
It's important to take uric acid-lowering medicine regularly, even when you no longer
have symptoms.
Making lifestyle changes: may mean you can stop or reduce further attacks.
Do
Get to a healthy weight, but avoid crash diets.
Have a healthy, balanced diet – we may give you a list of foods to include or limit
Have some alcohol-free days each week.
Drink plenty of fluids to avoid getting dehydrated.
Exercise regularly – but avoid intense exercise or putting lots of pressure on joints
Stop smoking
Don’t
Do not eat offal, such as kidneys or liver, or seafood.
Do not have lots of sugary drinks and snacks.
Do not eat lots of fatty foods.
Do not drink more than 14 units of alcohol a week, and spread your drinking over 3 or
more days if you drink as much as 14 units and sometimes drinking alcohol other than
beer also helps.
Safety netting
If you do not feel better after treatment, come back immediately.

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Follow-up
In 2 or 3 days.

Polymyalgia Rheumatica
Who you are:
You are an F2 in GP clinic.
Who the patient is:
Mrs. Margret Smith, aged 73, presents to the clinic with aches and pains She had been
diagnosed with GE reflux 20 years back and she has been taking Omeprazole.
What you should do:
Please talk to the patient, discuss your initial plan of management with her and address
her concerns.

Polymyalgia Rheumatica:
It affects shoulder and hip joint + morning stiffness that improves with activity.
Don't forget to ask about GCA arthritis symptoms.
Don't forget to ask about impact of this on life.

P1 (SOCRATES)
Doctor: Hello, how can I help you today?
Patient: I have pain around my shoulder. (+ve finding)
D: Which shoulder? (site)
P: In my right shoulder.
D: What about the left side?
P: That’s fine.
D: Any other joint?

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P: There’s also pain in my hip joints (+ve finding)

D: Are you able to use the joints?
P: Yes.
D: Can you tell me more about this pain? When did it start? (onset)
P: 5 weeks ago.
D: How did it start?
P: Gradually.
D: Is the pain continuous or does it come and go?
P: Continuous (+ve finding).
D: Could you please describe the pain for me? (character)
P: It’s a dull pain.
D: Does it go anywhere else? (radiation)
P: No.
D: Is there anything making it worse?
P: No.
D: Is there anything making it better?
P: No.
D: On scale from 1 to 10, with 1 being the mildest and 10 being the most severe, can
you rate the pain for me?
P: 4
D: Apart from this pain, anything else?
P: No.
D: What concerns you the most? (concern)
P: Nothing doctor.

OTHER SYMPTOMS:
D: Any swelling or redness?
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P: No.
D: Any stiffness?
P: Yes, in the morning, but it improves as the day goes on.
D: Any pain while combing your hair? (GCA)
P: No.
D: Any pain around your jaw while eating?
P: No.
D: Any eye-pain or redness?
P: No.
D: Have you had any recent flu-like symptoms?
P: No.

Differentials (don't forget septic arthritis)

D: Any fever?
P: No.
D: Any trauma to the joints?
P: No.
+FLAWS

- P2
D: Have you had this pain before?
P: No.
D: Do you have any medical condition?
P: Yes, I have reflux.
D: Tell me more about it?
P: I have had it 20 years now.
D: What you are taking for it?
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P: Omeprazole.
D: Are you taking it as prescribed?
P: Yes

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: What about your diet?
P: I try to eat healthy.
D: Do you exercise?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements other than
omeprazole?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: You have had this pain for 5 weeks now, how is it affecting your life?
P: It's difficult, but I try to cope with it.
DON'T FORGET ICE

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Examination:
Vitals and examination of the joints

Provisional diagnosis
From the chat we just had (mention the positive findings) you told me that you have
had pain in your shoulders and around the hip and stuffiness that improves towards the
end of the day. Given all that, I suspect you may have Polymyalgia rheumatica, a
condition that causes pain, stiffness and inflammation in the muscles around the
shoulders, neck and hips.

Management
Senior.
Investigations.
Blood
Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are to check the
levels of inflammation in your body.
Rheumatoid factor and anti-CCP antibodies may be done to rule out rheumatoid
arthritis.
Blood tests can also help determine whether you have a blood infection.
Blood tests can also help determine how well your organs, such as your kidneys, are
working.
If you have an overactive thyroid gland or an underactive thyroid gland – both
conditions can cause muscle pain.
A urine test to check how well your kidneys are functioning.
X-rays and ultrasound scans may also be used to look at the condition of your bones
and joints.

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- Medications
Steroid medicine (prednisolone) is the main treatment for polymyalgia rheumatica
(PMR). Prednisolone works by blocking the effects of certain chemicals that cause
inflammation inside your body. It is taken as a tablet.
Although your symptoms should improve within a few days of starting treatment,
you'll probably need to continue taking a low dose of prednisolone for about 2 years.
Do not suddenly stop taking steroid medicine unless your doctor tells you it's safe to
stop. Suddenly stopping treatment with steroids can make you very unwell.
Side effects of prednisolone:
changes to your mental state (depression – hallucination – suicide).
Weight gain
High blood pressure
Mood changes, such as becoming aggressive or irritable
with people.
Weakening of the bones
Stomach ulcers

Immunosuppressant medicine: Sometimes other medicines may be combined with

corticosteroids to help prevent relapses or allow your dose of Prednisolone to be
reduced.
Painkillers, such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs), to
help relieve your pain and stiffness while your dose of Prednisolone is reduced.
Steroid card
If you need to take steroids for longer than 3 weeks, your GP or pharmacist should
arrange for you to be given a steroid card.
The card explains that you're regularly taking steroids and your dose should not be
stopped suddenly. Always carry the card with you.

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Safety netting
Temporal arteritis
A severe headache that develops suddenly (your scalp may also feel sore or tender).
Pain in the jaw muscles when eating.
Problems with sight, such as double vision or loss of vision.
If you have any of these symptoms, contact a GP immediately, or go to your nearest
urgent care service.
Side effects of steroids: You may feel depressed and suicidal, anxious or confused.
Some people also have hallucinations, (seeing or hearing things that are not there).
Get immediate medical advice if you think you've been exposed to the varicella-zoster
virus or if a member of your household develops chickenpox or shingles as taking
steroids increases risk of infection.

Follow-up
You'll have regular follow-up appointments to check:
how well you're responding to treatment.
if your dose of prednisolone needs to be adjusted.
how well you're coping with any side effects.

You'll have blood tests to check the levels of inflammation inside your body.
Follow-up appointments are usually recommended every few weeks for the first 3
months, and then every 3 to 6 months after this time.

Osteoarthritis

Who you are: You are an FY2 doctor in GP clinic

Who the patient is: 50-year-old, Antonella came with pain in knee and hip.
What you should do: Talk to her address her concerns.

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Osteoarthritis:
Pain and stiffness in the joint that gets worse with the time and crackling sound while
moving the joint.

P1 (SOCRATES)
Doctor: Hello, how can I help you today?
Patient: I have pain around my knees.
D: Both knees? (site)
P: Yes, in both.
D: Any other painful joints?
P: No.
D: Are you able to use the joints?
P: I have movement limitations.
D: Can you tell me more about this pain? When did it start? (onset)
P: About 7 weeks ago.
D: How did it start?
P: Gradually.
D: Is the pain continuous or does it come and go?
P: Continuous.
D: Could you please describe the pain for me? (character)
P: Dull.
D: Does it go anywhere else? (radiation)
P: No.
D: Is there anything making it worse?
P: Yes, it gets worse by the end of the day (+ve finding)
D: Is there anything making it better?
P: Rest (+ve finding)
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D: On a scale from 1 to 10, with 1 being mild and 10 being extreme pain, can you rate
the pain for me?
P: 4
D: Apart from this pain, is there anything else?
P: No.
D: What concerns you the most? (concern)
P: Just want to see what is causing me pain.
OTHER SYMPTOMS:
D: Any swelling or redness?
P: No.
D: Any stiffness?
P: Yes, and it gets worse as the day goes on.
D: Any cracking sound while moving?
P: Yes.
D: Have you had any recent flu-like symptoms?
P: No.

Differentials (don't forget septic arthritis)

D: Any fever?
P: No.
D: Any trauma to the joints?
P: No.
+FLAWS

P2
D: Have you had this pain before?
P: No.
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D: Do you have any medical condition?

P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: What about your diet?
P: I eat everything.
D: Do you exercise?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: You have had this pain for 7 weeks now, how is this affecting your life? P: It’s
affecting my work doctor
D: What do you do for a living?
P: I work in an office, and I find it difficult to move.
D: It must be difficult for you, how is your mood?
P: It's fine.
DON'T FORGET ICE
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Examination:
Vitals, BMI and examination of the joints.
BMI: 40

Provisional diagnosis
From the chat we had (mention the positive findings) you told me that you have pain
and stiffness in both of your knees that gets worse throughout the day and your BMI is
high, so I suspect you may have a condition called osteoarthritis. Your joints are
exposed to a constant low level of damage. In most cases, your body repairs the
damage itself and you do not experience any symptoms.
But in osteoarthritis, the protective cartilage on the ends of your bones breaks down,
causing pain, swelling and problems moving the joint. Bony growths can develop, and
the area can become red and swollen.

Management
Refer to joint specialist.
Senior.
Lifestyle changes-
Exercise
Exercise is one of the most important treatments for people with osteoarthritis,
whatever your age or level of fitness. Regular exercise that keeps you active, builds up
muscle and strengthens the joints usually helps to improve symptoms. Exercise is also
good for losing weight, improving your posture and relieving stress, all of which will
ease symptoms.
Losing weight
Being overweight or obese often makes osteoarthritis worse, as it places extra strain on
some of your joints. If you're overweight or obese, try to lose weight by doing more
physical activity and eating a healthier diet.
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Pain relief medicines

Paracetamol:
It's better to take it regularly rather than waiting until your pain becomes unbearable.
When taking paracetamol, always use the dose that GP recommends and do not
exceed the maximum dose stated on the pack.
Non-steroidal anti-inflammatory drugs (NSAIDs):
If paracetamol does not effectively control the pain of osteoarthritis. They help to ease
pain and reduce any swelling in your joints.
Some NSAIDs are available as creams (topical NSAIDs) that you apply directly to the
affected joints or tablets.
If you take the tablet form, you will be prescribed a medicine called a proton pump
inhibitor (PPI) to take at the same time to protect your stomach from the effect of
NSAIDs.
Opioids: such as codeine, may ease your pain if paracetamol does not work.
▪ Side effects such as drowsiness, nausea and constipation.
Codeine is combined with paracetamol in common medicines such as co-codamol.
If you need to take an opioid regularly, you may prescribed a laxative to take alongside
it to prevent constipation.
Capsaicin cream works by blocking the nerves that send pain messages from the
treated area. It may take up to a month for the treatment to be fully effective. Apply a
pea-size amount of capsaicin cream to your affected joints up to 4 times a day, but not
more often than every 4 hours.
Do not use capsaicin cream on broken or inflamed skin or delicate areas as eyes,
mouth and genitalia and always wash your hands after applying it.
You may notice a burning sensation on your skin after applying capsaicin cream. This is
nothing to worry about, and the more you use it, the less it should happen. But avoid
using too much cream or having a hot bath or shower before or after applying it,
because it can make the burning sensation worse.

Steroid injections:
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The injection will be made directly into the affected area. You may be given a local
anaesthetic first to numb the area and reduce the pain.
Steroid injections work quickly and can ease pain for several weeks or months.

Supportive treatments that can help reduce your pain and make everyday tasks
easier.
Transcutaneous electrical nerve stimulation (TENS) usually arranged by a
physiotherapist or doctor, who can advise you on the strength of the pulses and how
long your treatment should last.
Hot or cold packs to relieve the pain and symptoms of osteoarthritis in some people.
Assistive devices such as:
Footwear with shock-absorbing soles
Special insoles
Leg braces and supports
A walking aid, such as a stick or cane.
A splint
Special devices, such as tap turners

Surgery is only needed in a small number of cases where other treatments haven't been
effective or where one of your joints is severely damaged.
There are several different types of surgery for osteoarthritis.
Joint replacement
Joint fusing
Adding or removing some bone around a joint
Specialist
If osteoarthritis is causing mobility problems or making it difficult to do everyday tasks,
several devices could help. You may be referred to a physiotherapist or an
occupational therapist for specialist help and advice.
Safety netting.
Follow up.
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De Quervain's tenosynovitis
Who you are:
You are an FY2 doctor in a GP surgery.
Who the patient is:
Nicole Morris, aged 44, presented with pain in her right hand.
What you should do:
Talk to her and address her concerns.
De Quervain’s tenosynovitis:
The typical symptom is swelling and pain over your wrist at the base of your thumb that
is made worse by activity and eased by rest.
The Nature of the Pain:
o It is constant.

o Affects your ability to work or exercise.

o Movements involving the wrist and thumb such as pinching – grasping –
wringing makes the pain worse.

Risk factors
Women after pregnancy.
Repetitive and overuse of tendons such as writing, typing, supermarket checkout
or use of a computer mouse.
Trauma.
Arthritis.

P1 (SOCRATES)
Doctor: Hello, how can I help you today?
Patient: I have pain in my right thumb.
D: What about the other thumb? (site)
P: Nothing.
D: Any other joint pains?
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P: No.
D: Are you able to use the joints?
P: Yes.
D: Can you tell me more about this pain? When did it start? (onset)
P: 3 days ago.
D: How did it start?
P: Gradually.
D: Is the pain continuous or does it come and go?
P: Continuous.
D: Could you please describe the pain for me? (character)
P: Dull.
D: Does it go anywhere else? (radiation)
P: No.
D: is there anything making it worse?
P: Yes, it gets worse when I type (+ve finding)
D: Is there anything making it better?
P: When I rest it, it gets better. (+ve finding)
D: On a scale from 1 to 10, with 1 being the mildest and 10 being the most severe, can
you rate the pain for me?
P: 4.
D: Apart from this pain, is there anything else?
P: No.
D: What concerns you the most? (concern)
P: I just want to know what is wrong with me.

OTHER SYMPTOMS:
D: Any swelling or redness?
P: No.
D: Any stiffness?

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P: No.
D: Have you had any recent flu-like symptoms?
P: No.

DIFFERENTIALS (Don't forget septic arthritis)

D: Any fever?
P: No.
D: Any trauma to the joints?
P: No
+FLAWS

P2
D: Have you had this pain before?
P: No.
D: Do you have any medical condition?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: What about your diet?
P: I eat everything.
D: Do you exercise?
P: No.
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MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: What do you for living?
P: I am a secretary and I type a lot (+ve finding)

DON'T FORGET ICE

- On examination
Finkelstein's test
By placing your thumb in the palm of your hand and making a fist around it, then
bending your wrist towards your little finger. If this makes the pain by the base of
your thumb worse, the test is considered positive.

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Provisional diagnosis
From the chat we had (mention the positive findings) you told me that you have pain in
your thumb that gets worse while typing so I suspect that you may have De
Quervain's tenosynovitis. This is a condition that affects the tendons in your
thumb.
Management
Senior.
Investigations.
Joint scan: an X-ray, an ultrasound scan or an MRI scan of the affected area but
this is usually to make sure it isn't something more serious.

Symptomatic:
Rest.
It is important to rest, or at least reduce the use of the affected area, to allow the
condition to settle.
Sick note (if job includes moving of the thumb.)
A splint, firm bandage or brace
This forces your hand and wrist to stay in the same position for a time to allow the
affected tendon to rest.
Ice packs
Over the affected area may ease swelling and pain.
A simple ice pack can be made by wrapping a pack of frozen peas in a tea towel. Apply it
to the affected area for 10 minutes twice a day to reduce pain.
Anti-inflammatory painkillers are often prescribed (for example, ibuprofen).
These ease pain and reduce inflammation.
Some anti-inflammatory painkillers also come as creams or gels which you can rub over
the painful area.
These tend to produce fewer side-effects than those taken by mouth.

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Other painkillers:
Other painkillers such as paracetamol, with or without codeine added, may be helpful.
Physiotherapy
This is recommended if the condition is not settling with the above measures.
A physiotherapist will give you a program of exercises to gradually make the muscles of
the affected tendon stronger.

A steroid injection into the affected area may be given if the above measures do not
work. Steroid injections may be helpful in easing pain in the short term but they don't
treat the underlying problem and pain tends to come back in many people.
Surgical release of a tendon is a rarely needed option.

Specialist.
A referral to Physiotherapist may be needed.
Occupational therapist to show you how to change the way you move.
Safety netting.
If you are not improving despite treatment, come back to us.
Follow up.

Carpal Tunnel Syndrome

Who you are: You are an FY2 in a GP clinic.

Who the patient is: Julia Ross, aged 33, presented to the clinic with pain in both wrists
and hand.
What you should do: Talk to her and address her concerns.

Carpal Tunnel Syndrome:

- You're more at risk if you: are overweight /pregnant /work or hobbies that mean
you repeatedly bend your wrist or grip hard, such as using vibrating tools /another
illness, such as arthritis or diabetes

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Have a parent, brother or sister with CTS /previously injured your wrist.
- The symptoms of carpal tunnel syndrome include:
an ache or pain in your fingers, hand (in the distribution of the median nerve - the
thumb, index, and middle fingers, and medial half the ring finger on the palmar aspect)
or arm /numb hands / tingling or pins and needles / a weak thumb or difficulty gripping.
These symptoms often start slowly and come and go. They're usually worse at night.

P1 (SOCRATES)
Doctor: Hello, how can I help you today?
Patient: I have pain in my right hand.
D: What about the other hand? (site)
P: Nothing.
D: Any other joint?
P: No.
D: Are you able to use the joints?
P: Yes.
D: can you tell me more about this pain? When did it start? (onset)
P: 3 days ago.
D: How did it start?
P: Gradually.
D: Is the pain continuous or does it come and go?
P: Comes and goes.
D: Could you please describe the pain for me? (character)
P: It feels like electric shock. (+ve finding)
D: Does it go anywhere else? (radiation)
P: No.
D: Is there anything making it worse?

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P: Yes, it gets worse when I use my hands.

D: Is there anything making it better?
P: When I rest it feels better.
D: On a scale from 1 to 10, with 1 being the mildest and 10 being the most severe, can
you rate the pain for me?
P: 5
D: Apart from this pain, is there anything else?
P: No.
D: What concerns you the most? (concern)
P: I want to know what’s wrong with my hand.

OTHER SYMPTOMS:
D: Any swelling or redness in the hand?
P: No.
D: Any numbness or tingling?
P: Yes, it happens with the pain. (+ve finding)
D: Any stiffness?
P: No.
D: Have you had any recent flu-like symptoms?
P: No.

DIFFERENTIALS (don't forget septic arthritis)

D: Any fever?
P: No.
D: Any trauma to the joints?
P: No.
+FLAWS
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P2
D: Have you had this pain before?
P: No.
D: Do you have any medical condition?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: What about your diet?
P: I eat everything.
D: Do you exercise?
P: No.
MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: What do you for a living?
P: I am a secretary. (+ve finding)

DON'T FORGET ICE

- On examination
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Positive Phalen test: flexing the wrist for 60 seconds causes pain or paraesthesia
in the median nerve distribution.
Positive Tinel's sign: tapping lightly over the median nerve at the wrist causes a
distal paraesthesia in the median nerve distribution.
Positive carpal tunnel compression test: pressure over the proximal edge of the
carpal ligament (proximal wrist crease) with thumbs causes paraesthesia to
develop or increase in the median nerve distribution.

Provisional diagnosis:
From the chat we had (mention the positive findings) you told me that you have pain in
your hands along with numbness and tingling that gets worse while you work, so I am
suspect you may have carpal tunnel syndrome which causes pressure on a nerve in
your wrist. It causes tingling, numbness and pain in your hand and fingers.
Management
Refer: you may be referred to hospital for tests if diagnosis is not clear.
Senior.
Investigations.
If the diagnosis is not clear, we may refer you to hospital for tests, such as:

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o an ultrasound scan.
o a test to measure the speed of the nerve impulse through the carpal tunnel
(nerve conduction test) may be advised.

Things to do yourself
CTS sometimes gets better by itself in a few months, particularly if you have it because
you're pregnant.
Wear a wrist splint
A wrist splint is something you wear on your hand to keep your wrist straight. It helps
to relieve pressure on the nerve.
You wear it at night while you sleep. You'll have to wear a splint for at least 4 weeks
before it starts to feel better.
You can buy wrist splints online or from pharmacies.
Stop or cut down on things that may be causing it
Stop or cut down on anything that causes you to frequently bend your wrist or grip
hard, such as using vibrating tools for work or playing an instrument.
Painkillers
Painkillers like paracetamol or ibuprofen may help carpal tunnel pain short-term.
Hand exercises
A steroid injection
If a wrist splint does not help, a steroid injection into your wrist may be
recommended.
This brings down swelling around the nerve, easing the symptoms of CTS.
Steroid injections are not always a cure. CTS can come back after a few months, and
you may need another injection.
Carpal tunnel syndrome surgery
If your CTS is getting worse and other treatments have not worked.
Specialist
We might refer you to a specialist to discuss surgery if your CTS is getting worse and
other treatments have not worked.

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Safety-netting.
Follow up.

Tennis elbow
Who you are:
You are an FY2 in GP clinic.
Who the patient is:
Wendy Stones, presented with some concerns.
What you should do:
Talk to her and address her concerns.

Causes of Tennis Elbow:

Tennis Elbow is not only caused by playing tennis. It can be caused by any activity that
involves repeatedly twisting your wrist and bending your elbow or using your forearm
muscles.
Symptoms:
Pain can be like burning and tenderness on the outside of your elbow that may travel to
your wrist. Pain starts out as an intermittent nuisance and then intensifies and
becomes more constant.

P1 (SOCRATES)
Doctor: Hello, how can I help you today?
Patient: I have pain around the outside of my left elbow.
D: What about the other hand? (site)
P: Nothing.
D: Any other joint pain?
P: No.
D: Are you able to use the joints?
P: Yes
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D: Can you tell me more about this pain? When did it start? (onset)
P: 5 days ago.
D: How did it start?
P: Gradually.
D: Is the pain continuous or does it come and go?
P: At first it was coming and going but now it’s constant.
D: Could you please describe the pain for me? (character)
P: It feels like a burning pain. (+ve finding)
D: Does it go anywhere else? (radiation)
P: The pain sometimes reaches my wrist too.
D: Is there anything making it worse?
P: Yes, it hurts more when I try to grip things like when I try to write with a pen, or I try
to open a jar of jam.
D: Is there anything making it better?
P: Taking Ibuprofen.
D: On scale from 1 to 10, with 1 being the mildest and 10 being the most severe pain,
can you rate the pain for me?
P: 7
D: Apart from this pain, is there anything else?
P: No.
D: What’s your main concern? (Concern)
P: I’m worried it won’t get better.

OTHER SYMPTOMS:
D: Any swelling or redness?
P: No.
D: Any numbness or tingling?

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P: No.
D: Any stiffness?
P: No.
D: Have you had any recent flu-like symptoms?
P: No.

DIFFERENTIALS (don't forget septic arthritis)

D: Any fever?
P: No.
D: Any trauma to the joints?
P: No.
+FLAWS
P2
D: Have you had this pain before?
P: No.
D: Do you have any medical condition?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: What about your diet?
P: I eat everything.
D: Do you exercise?
P: Yes, I play baseball.
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D: Do you have the pain after playing?

P: Yes, playing makes it worse.

MAFTOSA
D: Are you taking any medications including OTC or supplements, other than Ibuprofen?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DON'T FORGET ICE

Examination
Mills' test:
Straighten the patient's arm and palpate the lateral epicondyle.
Fully bend (flex) the wrist.
Pronate the patient's forearm.
If this is painful the test is positive.
Cozen's test:
Elbow in 90° of flexion, patient makes a fist and deviates wrist radially with forearm
pronated.
Resisted extension of the wrist.
Pain in the area of lateral epicondyle is a positive result.

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Provisional diagnosis:
From the chat we had (mention the positive findings) you told me that you have pain
around the outer side of your shoulder, which sometimes radiates to the wrist. You play
baseball also, so I am suspect that you may have tennis elbow due to overuse or
repeated action of the muscles of the forearm, near the elbow joint.
Management
Senior.
Investigations:
These are usually not required but may be indicated if the diagnosis is uncertain –
CRP, elbow X-ray, MRI.
Nerve conduction study and electromyography may be indicated if ulnar nerve
involvement is suspected in patients with golfer's elbow.

General advice
Tennis elbow will get better without treatment (known as a self-limiting condition).
The most important thing to do is to rest your injured arm and stop doing the activity
that caused the problem.
There are also simple treatments to help with the pain, like holding a cold compress,
such as a bag of frozen peas wrapped in a towel, against your elbow for a few minutes
several times a day.

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Avoiding or changing activities that strain the affected muscles and tendons.
If you use your arms at work to carry out manual tasks, such as lifting, you may need to
avoid these activities until the pain in your arm improves.
Alternatively, you may be able to change the way you do these types of movements, so
they do not place strain on your arm.
Talk to your employer about avoiding or changing activities that could aggravate your
arm and make the pain worse.
Painkillers and non-steroidal anti-inflammatory drugs (NSAIDs) such as paracetamol,
and NSAIDs, such as ibuprofen, may help ease mild pain and inflammation caused by
tennis elbow.
NSAIDs are available as tablets or creams and gels (topical NSAIDs), which are applied
directly to the area of your body where there is pain.
Steroid injections for tennis elbow
These are offered when other treatments have not worked.
The injection will be given directly into the painful area around the elbow.
Local anaesthetic may be given first to numb the area and reduce the pain.
These will only give short-term relief and their long-term effectiveness is poor.
Up to 3 injections in the same area, with at least a 3–6 month gap between them.
Shockwave therapy for tennis elbow
High-energy shockwaves are passed through the skin to help relieve pain and promote
movement in the affected area.
PRP injections for tennis elbow.
PRP is blood plasma containing concentrated platelets that your body uses to repair
damaged tissue.
Injections of PRP have been shown to speed up the healing process in some people, but
their long-term effectiveness is not yet known.
The surgeon will take a blood sample from you and place it in a machine. This separates
the healing platelets so they can be taken from the blood sample and injected into the
affected joints. The procedure usually takes about 30 minutes.

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Surgery for tennis elbow

This is only for severe and persistent pain.
The damaged part of the tendon will be removed to relieve the painful symptoms.

Self-care advice
The measures you can take that may stop tennis elbow from developing or coming back
include:
Stopping the activity that is causing pain or find another way of doing it that does
not cause pain or stress.
Avoid using your wrist and elbow more than the rest of your arm. It may also help
to spread the load to the larger muscles of your shoulder.
Get coaching advice to help you change or improve your technique if you play a
sport that involves repetitive movements, such as tennis or squash.
Warm up properly and gently stretch your arm muscles before playing a sport
that involves repetitive arm movements.
Use lightweight tools or racquets and make their grip size bigger, to avoid putting
extra strain on your tendons.
Wear a tennis elbow splint when you're using your arm (not while resting or
sleeping) to stop further damage to your tendons.

Specialist
We may refer you to a physiotherapist if your tennis elbow is causing more severe or
persistent pain. Physiotherapists are healthcare professionals who use a variety of
methods to restore movement to injured areas of the body. They also help you build up
strength in your arm muscles.

Safety netting.
Follow up.

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NEUROLOGY

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Neurology
Guillain-Barré Syndrome

Who you are:

You are an FY2 in GP surgery.
Who the patient is:
Nancy Bedford, 32-year-old lady, has some concerns.
What you should do:
Talk to her and address her concerns.

Guillain-Barré Syndrome
Symptoms: (ascending weakness)
History of viral infection.
Symptoms often start in your feet and hands before spreading to your arms and
legs. At first you may have: numbness/ pins and needles / muscle weakness/ pain
problems with balance and co-ordination
Red flags: difficulty moving, walking, breathing and/or swallowing.

On examination:
Examine nerves in hands and feet show numbness and reduced or no reflexes.

DIFFERENTIALS:
Myasthenia gravis: weakness increased towards the end of the day.
Multiple Sclerosis: comes in attacks (comes and goes)
Stroke: face and arm weakness- slurred speech.
TIA: temporary weakness.
Botulism: canned food + food poisoning.

P1(ODIPARA)
Doctor: Hello, how can I help you today?
Patient: I have weakness in my legs.
D: Sorry to hear that, can you tell me more about it?
P: Both of my legs and hands are weak and numb (+ve finding)
D: When did it start? (onset)
P: A few days ago.
D: Was it sudden or gradual? (progression)
P: Gradual. It started with my legs and now it’s also in my arms (+ve finding)
D: Is it continuous?
P: Yes, it's getting worse with time (+ve finding)
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D: Are you able to walk?

P: Not very well no.
D: Does anything make it worse or better?
P: Nothing seems to be helping.
D: Anything other concerns? (concern)
P: No.

Differentials:
D: Does this weakness come and go? (MS)
P: No.
D: Do you feel it is worse towards the end of the day? (Myasthenia)
P: No.
D: Any slurred speech or facial dropping? (stroke)
P: No.
D: Any flu-like symptoms recently?
P: Yes. I had flu 4 weeks ago. (+ve finding)
RED FLAGS
D: Any breathlessness?
P: No.
D: Any heart racing?
P: No.
D: Any problem in swallowing?
P: No.
D: Have you lost control of your bowel/bladder?
P: No.
D: Any problem with balance?
P: No.
P2 (PAST Hx)
D: Have you had any similar problems in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any DM, HTN. Heart disease or high cholesterol?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
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P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: I try to eat healthy.
D: Do you do physical exercise?
P: No.
D: Have you recently eaten out or had any canned food? (Botulism)
P: No.
D: What do you do for a living?
P: I’m an office clerk.
D: Who do you live with?
P: I live alone.
D: So, you don’t have anybody to help you when you feel weak? How are you coping?
P: I find so difficult to help myself at home.
D: How's your mood?
P: it's fine, thanks.

Examination:
General physical + neurological: numbness and reduced or no reflexes.

Provisional diagnosis:
From the chat that we had (mention the positive findings) you told me that you have
weakness that started with your legs and now is in your hands too. You also had flu 4
weeks ago, so I am suspect you may have a condition called Guillain-Barré.
Unfortunately, this is a serious condition that affects the nerves. It mainly affects the
feet, hands and limbs, causing problems such as numbness, weakness and pain.
It can be treated, and most people will eventually make a full recovery, although it can
occasionally be life-threatening and some people are left with long-term problems.

Management
Refer to hospital immediately (admit if you are in the hospital).
Senior.
Investigations:
Routine bloods.
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In hospital, 2 tests may be carried out to see how well your nerves are working.
Electromyography (EMG) – tiny needles are inserted into your muscles and electrical
recordings are taken to see how they react when nearby nerves are activated.
Nerve conduction studies – small discs (electrodes) are stuck on your skin and minor
electric shocks are used to activate the nerves and measure how quickly these signals
travel along them.
In people with Guillain-Barré syndrome, these tests will usually show that signals are
not travelling along the nerves properly.
A lumbar puncture is a procedure to remove some fluid from around the spinal cord
(the nerves running up the spine) using a needle inserted into the lower part of the
spine.
The sample of fluid will be checked for signs of problems that can cause similar
symptoms to Guillain-Barré syndrome, such as an infection.

Symptomatic
IVIG
Most people are treated in hospital and usually need to stay in hospital for a few weeks
to a few months.
IVIG is the most commonly used treatment for Guillain-Barre syndrome.
When you have Guillain-Barré syndrome, the immune system (the body's natural
defences) produces harmful antibodies that attack the nerves. IVIG is a treatment made
from donated blood that contains healthy antibodies. These are given to help stop the
harmful antibodies damaging your nerves.
IVIG is given directly into a vein.

Plasmapheresis.
A plasma exchange is sometimes used instead of IVIG.
This involves being attached to a machine that removes blood from a vein and filters
out the harmful antibodies that are attacking your nerves before returning the blood to
your body.
Most people need treatment over the course of around 5 days.
Other treatment:
Painkillers and/or special leg stockings to prevent blood clots
being gently moved around on a regular basis to avoid bed sores and keep your joints
healthy.
A feeding tube if you have swallowing problems.
A thin tube called a catheter in your urethra (the tube that carries urine out of the
body) if you have difficulty peeing. Laxatives if you have constipation.

Safety netting:
if you're having difficulty breathing, let us know immediately.
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Trigeminal Neuralgia
Who you are:
You are FY2 in GP surgery.
Who the patient is:
Mr. Harry Maguire, aged 63, has come to you with facial pain.
What you should do:
Talk to him and address his concerns.

Trigeminal Neuralgia Symptoms:

Sudden attacks of severe, sharp, shooting facial pain that last from a few seconds to
about 2 minutes.

Triggers:
Attacks of trigeminal neuralgia can be triggered by certain actions or
movements, such as:
talking
smiling
chewing
brushing your teeth
washing your face
a light touch
shaving or putting on make-up
swallowing
kissing
a cool breeze or air conditioning
head movements
vibrations, such as walking or travelling in a car
However, pain can happen spontaneously with no trigger whatsoever.

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Differentials:
Stroke: face and arm weakness- slurred speech.
Trauma: trauma to the face.
GCA: Pain while chewing or combing hair.
Migraine: headache confined to one half of the head.

P1 (SOCRATES)
Doctor: I can see from my notes that you have facial pain, can you tell me more about
it?
Patient: I have electric-shock-like pain on the left-side of my face (+ve finding) D: Tell
me more about it? When did it happen?
P: 3 days ago.
D: Was it sudden or gradual?
P: Sudden (+ve finding)
D: Does the pain go anywhere?
P: No.
D: How often do you get these pains?
P: It comes as attacks several times a day
D: How long do they last?
P: A few seconds. (+ve finding)
D: Is there anything that makes it better?
P: No, I took paracetamol but it didn’t help.
D: Is there anything that makes it worse?
P: Yes, when I shave it gets worse. (+ve finding)
D: Could you please score the pain on a scale of 1 to 10, with 1 being no pain and 10
being the most severe pain you have ever experienced?
P: 6 during the attack.
D: Anything else?
P: No.
D: Apart from this, anything else?
P: No.
D: What’s your main concern?
p: I just want painkillers for this pain.
D: I can help you with that, just a few more questions.

DDS
D: Any weakness in any part of the body? (STROKE)
P: No.
D: Any facial dropping or slurred speech?
P: No.
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D: Any facial trauma? (TRAUMA)

P: No.
D: Any headache? (migraine)
P: No.
D: Any pain while eating or combing your hair? (GCA)
P: No.
+FLAWS

P2(PAST Hx)
D: Have you had this condition before?
P: No.
D: Do you have any medical condition?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.

DESA
D: How's your diet?
P: I try to eat healthy.
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Do you do any physical exercise?
P: I don’t have much time.
D: Is anything causing you a lot of stress recently?
P: No.

EXAMINATION
Vitals + examination of the head and neck.

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Provisional diagnosis:
From the chat that we had (mention the positive findings) you told me that you have
electric-like pain in the left side of your face that lasts a few seconds and it gets worse
by shaving, so I am suspect you have trigeminal neuralgia. This is a type of nerve pain in
your face caused by pressure on the trigeminal nerve which is a nerve that carries
sensation from your face to your brain.

Management:
Senior.
Symptomatic:
Simple pain killers: paracetamol and ibuprofen
Carbamazepine: Anticonvulsants were not originally designed to treat pain, but they
can help to relieve nerve pain by slowing down electrical impulses in the nerves and
reducing their ability to send pain messages.
Other alternatives: Pregabalin- Gabapentin
Avoid triggers.
Safety netting-worsening of symptoms and any weakness in the body.

BELL'S PALSY
Who you are:
You are an FY2 in a GP surgery.
Who the patient is:
Halley smith is a 22-year-old woman who come with some concerns.
What you should do:
Talk to her and address her concerns.

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Differentials:
Stroke: face and arm weakness- slurred speech.
Trauma: trauma to the face.
GCA: Pain while chewing or combing hair.
Migraine: headache confined to one half of the head.

P1 (ODIPARA)
Doctor: How can I help you today?
Patient: I have facial weakness on the left side (+ve finding)
D: Tell me more about it? When did it start to happen?
P: Just this morning.
D: Was it sudden or gradual?
P: Gradual.
D: Is it getting worse?
P: I think it's getting worse as the day goes on yes.
D: Is there anything that makes it better or worse?
P: No.
D: Anything else?
P: I can't close my left eye, it happened around the same time of my facial weakness
(+ve finding)
D: Any gritting sensation in your eye?
P: Yes, it feels like there's something inside my eye (+ve finding)
D: Can you blink your eye?
P: No. (+ve finding)
D: Apart from this, anything else?
P: No.
D: Apart from that are you normally fit and well? Is this your main reason you came to
see me today?
P: Yes, I am worried that I’m having a stroke.
D: I understand that, is there a reason you are worried about stroke in particular?
P: My dad had a stroke.
D: I’m sorry to hear that, how is he doing now?
P: He's good doctor thanks.

Other symptoms
D: Any problem with eating?
P: Yes, the food was falling out of my mouth when I was having my breakfast. Also, the
food seemed tasteless to me. (+ve finding)
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D: Any mouth drooling?

P: Yes. (+ve finding)
D: Are you able to clench your teeth?
P: No. (+ve finding)

DDS
D: Any weakness in any part of the body? (STROKE)
P: No.
D: Any facial trauma? (TRAUMA)
P: No.
D: Any headache? (migraine)
P: No.
D: Any pain while eating or combing hair? (GCA)
P: No.
+FLAWS

P2(PAST Hx)
D: Have you had this condition before?
P: No.
D: Do you have any medical condition?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DESA
D: How's your diet?
P: I try to eat healthy.
D: Do you smoke
P: No.
D: Do you drink alcohol?
P: No.
D: Any physical exercise?
P: I don’t have much time.
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D: Do you have any kind of stress?

P: No.

EXAMINATION
Vitals + examination of facial nerve.

Provisional diagnosis:
From the chat that we had (mention the positive findings) you told me that you have
left sided facial weakness with an inability to close your eyes, clench your teeth, and
facial dropping so I am suspecting Bell’s palsy, which is temporary weakness or lack of
movement affecting 1 side of the face. Most people get better within 9 months.
Unlike a stroke, the facial weakness develops gradually.

Management:
Senior.
Routine investigation - Medications:
This is because treatment for Bell's palsy is more effective if started early (within 72
hours).

A 10-day course of steroid medicine:

Eyedrops and eye ointment to stop the affected eye drying out
Surgical tape to keep the eye closed at bedtime.
The GP might prescribe a type of steroid called prednisolone. Treatment with
prednisolone should begin within 3 days (72 hours) of the symptoms starting.
Bell's palsy is rare in children, and most children who are affected make a full
recovery without treatment.
Safety netting: Worsening of symptoms and any weakness in the body.

Confusion
Causes of confusion: HEAD TO TOE
HEAD
A stroke or TIA ("mini-stroke")
A head injury
Meningitis
Dementia (chronic)
Delirium (acute)
MOUTH
Low blood sugar level in people with diabetes.
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Some types of prescription medicine: Oxybutynin, hyponatremia

Alcohol poisoning or alcohol withdrawal.
Taking illegal drugs
Chest
A severe asthma attack – or other problems with the lungs or heart
Chest infection
GIT
Diarrhoea and constipation
Urinary tract
UTI
Uraemia
Symptoms of confusion:
Not able to think or speak clearly or quickly.
Not knowing where they are, feeling disorientated.
Struggling to pay attention or remember things.
See or hear things that aren't there (hallucinations).
Try asking the person their name, their age and today's date.

On examination:
Full examination.
Mini – mental state examination.

Confusion due to Oxybutynin

Who you are:

You are an FY2 in a GP surgery.

Who the patient is:

Farida Paterson, a 50-year-old lady, has some concerns.

What you should do:

Talk to her and address her concerns.

P1 (ODIPARA)
Doctor: How can I help you today?
Patient: I feel confused.
D: Tell me more about it?
P: Well, I feel am not myself recently.
D: When did you start feeling like this?
P: Last week.
D: Was it sudden or gradual?
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P: Gradual.
D: Is it getting worse?
P: I think it's getting worse with time.
D: Is there anything that makes it better or worse?
P: No.
D: Anything else?
P: No.
D: Apart from this, are you normally fit and well? Is this the main reason you came to
see me today?
P: Yes, I want to know if I have dementia.
D: I understand that. Is there a particular reason why you are worried about dementia?
P: I read about it online.
D: OK I understand. I will ask you some more questions to exclude that then.
+ Symptoms of confusion

DDS
D: Any fever?
P: No.
D: Any trauma to your head?
P: No.
D: Any cough or SOB?
P: No.
D: Any pain while passing urine?
P: No.
+FLAWS

P2(PAST Hx)
D: Have you had this condition before?
P: No.
D: Do you have any medical condition?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: Yes, I am taking Oxybutynin (+ve finding)
D: Can you tell me more about that?
P: I have urinary incontinence and I've been taking it in the last 2 weeks
D: Are you taking it as prescribed?
P: I was taking 1 tablet, but I am taking 2 now because my symptoms are not improving.
D: Did this confusion start before or after this medication?
P: After the medication, before that I was totally normal (+ve finding)
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D: Any allergies from any food or medications?

P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.

DESA
D: How's your diet?
P: I try to eat healthy.
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Any physical exercise?
P: I don’t have much time.
D: Do you have any kind of stress?
P: No.

EXAMINATION
Full examination + Mini mental state.

Provisional diagnosis:
From the chat that we had (mention the positive findings) you told me that you have
had confusion and you've been taking Oxybutynin for the past 2 weeks, so I suspect it's
a side effect from the medication. Let me reassure you, it's not dementia.

Management:
Senior.
Investigation: routine
Treatment: Stop taking Oxybutynin.
Referral to urologist to review the medication and reassess you.
Safety net: fever, cough, dysuria.

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Confusion due to Hyponatremia and Uraemia

Who you are:
You are an F2 in A&E.
Who the patient is:
Martin Patient, aged 82, admitted to the hospital because he is confused now.
What you should do:
Talk to his daughter and discuss management plan with her and address her concerns.
There are some blood tests inside the cubicle.
Results:
Hb Normal - WBC Normal
Na 115 (135 and 145) – Urea (raised) – Creatinine (raised).

P1 (ODIPARA)
Doctor: I can see from my notes that your father was admitted because of confusion?
Patient: Yes, that's right.
D: Can you tell me more about it?
P: He was ok yesterday, but when I visited him this morning, he wasn't himself at all.
D: Is it getting worse?
P: I don't know.
D: Anything else I should know?
P: No.
D: Apart from this, is he normally fit and well? Is this the main reason you came to see
me today?
P: Yes.
+ Symptoms of confusion

DDS
D: Any fever?
P: No.
D: Any trauma to his head?
P: No.
D: Any cough or SOB?
P: No.
D: Any pain while passing urine?
P: Not that I know of.
+FLAWS

P2(PAST Hx)
D: Has he ever been like this before?
P: No.
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D: Does he have any medical condition?

P: He has high blood pressure, and he had a stroke 2 years back. (+ve finding)

MAFTOSA
D: Is he taking any medications including OTC or supplements?
P: Yes, he is taking amlodipine, aspirin and statin. (+ve finding)
D: Is he taking them as prescribed?
P: Yes.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DESA
D: How's his diet?
P: It's ok.
D: Does he smoke?
P: No.
D: Does he drink alcohol?
P: No.
D: Any physical exercise?
P: No.

EXAMINATION
Full examination + Mini mental state.

Provisional diagnosis:
From the chat that we had (mention the positive findings) you told me that your father
has been confused this morning and he is taking aspirin, plus we have done some
investigations and we found that his sodium is low, so I suspect he may have a
condition called hyponatremia due to a problem with his kidney as his kidney function
is high.

Management

Admit.
Senior.
Investigation:
Routine investigation CXR, Glucose, KUB
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Specialist review:
Nephrologist to review medications and assess his condition.

Treatment:
IV fluids to correct hyponatremia, usually 3% solution.

Safety netting.

Confusion due to UTI = Sepsis

Who you are:

You are an F2 in A&E.
Who the patient is:
Henry, aged 75, brought to the hospital by his wife because of confusion. He was
diagnosed with a UTI 3 days ago.
What you should do:
Please talk to them and address their concerns.

P1 (ODIPARA)
Doctor: I can see from my notes that your husband has been confused?
Patient: Yes, that's right.
D: Can you tell me more about it?
P: He's not himself the past 2 days, he is not aware of anything and he is always asking
me where I am!
D: Is it getting worse?
P: Yes.
D: Anything else?
P: No.
D: Apart from this, is he normally fit and well? Is this the main reason you came to A&E
today?
P: Yes.
D: I can see also that he was diagnosed with a UTI 3 days ago, can you tell me more
about that?
P: He had a fever and he was having a burning sensation while passing urine, so we
came to the hospital and he was given some medication (+ve finding)
D: Do you know which medication?

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P: No.
D: Is he taking it as prescribed?
P: Yes.
+ Symptoms of confusion

DDS
D: Any trauma to his head?
P: No.
D: Any cough or SOB?
P: No.

+FLAWS

P2(PAST Hx)
D: Has he ever been like this before?
P: No.
D: Does he have any medical condition?
P: No.

MAFTOSA
D: Is he taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DESA
D: How's his diet?
P: He hasn’t been eating anything in the past 2 days. (+ve finding)
D: Does he smoke?
P: No.
D: Does he drink alcohol?
P: No.
D: Any physical exercise?
P: No.

EXAMINATION
Full examination + Mini mental state + urine culture.
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Provisional diagnosis:
From the chat that we had (mention the positive findings) you mentioned that your
husband has had some confusion and he was diagnosed with a UTI 3 days ago, so I am
suspect he’s been having confusion due to that infection (Sepsis). Sometimes older
people who get infections like UTI may show increased signs of confusion, agitation or
withdrawal.

Management of any Sepsis

Admit as Sepsis needs treatment in hospital in an intensive care unit straight away
because it can get worse quickly. You may need to stay in hospital for several weeks.
Senior.
Investigations:
Bloods - include FBC, U&Es and creatinine, glucose, calcium, magnesium, sodium, LFTs,
TFTs, cardiac enzymes, vitamin B12 levels, syphilis serology, autoantibody screen and
PSA. Creatinine is vital to obtain an estimated glomerular filtration rate (eGFR), as this
may indicate impaired renal function and affect the handling of medications.
Urine dipstick testing and microscopy.
Blood cultures and serology, if indicated.
ECG.
Pulse oximetry and arterial blood gas, if indicated.
imaging - egg, CXR and possibly abdominal X-ray, if indicated - CT scan of the brain.

Symptomatic:
Continuous monitoring of your observations.
You should get antibiotics within 1 hour of arriving at hospital.
You may require oxygen through a tube in the windpipe.
You may need fluids through a drip directly into a vein in your arm.
Other medicines can be given through the drip, including antibiotics and insulin.
If pus has collected anywhere in the body, a surgical operation may be needed to
drain it.
A thin tube called a catheter in your urethra (the tube that collects urine out of
the body) to know how well your kidneys work.

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HEADACHES

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Headaches
General approach:

P1: SOCRATES
Can you point with one finger to where the pain is? (Site)
How did this pain start? (Onset)
What type of pain is it? (Character)
Are you in pain right now?
Does the pain go anywhere else like the back of your neck? (Radiation)
Is there anything that makes it worse or better? (Relation)
How severe is your pain on a scale from 1 to 10? (Scoring)
Have you taken any pain killers? (Medications)
Apart from this, is there anything else?
What is your main concern? (Concern)

DIFFERENTIALS:

When you give DDS try to exclude what could be fatal to the patient first: SOL/ SAH /
meningitis.
Take head from outside to inside:
➢ Skull: any chance you had a sustained trauma to your head?
➢ Meningitis: Fever, vomiting, neck stiffness, shy away from light, rash.
➢ Subarachnoid haemorrhage: below meninges (meningitis without fever).
➢ Brain (space occupying lesion): early morning headache, early morning vomiting,
gradual worsening weakness in limbs.
➢ Sinusitis: headache increased by leaning forward/ runny stuffy nose
➢ Eye: Acute angle glaucoma: (pain in eyes/ redness in eyes/ coloured haloes
around light)/ vision problems: do you wear glasses / any problem in reading?

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Migraine Cluster headache Tension headache

One-sided headache. Comes in episodes. Band-like headache

You must ask about aura: Always has past hx of Worse in evening.
Just before you got the headache.
headache, what happened?
(Advise about it in
management)
Family hx. Tearing. Due to stress, you must
find cause of stress & try
to manage it.

Red eye.
GCA:
➢ Pain while chewing
➢ Pain while combing
➢ Painful eye + joint pain (polymyalgia Rheumatica)

- DON’T FORGET FLAWS

P2: PAST Hx
Have you ever had such pain before?
Any medical condition? (5 conditions)

P3: DESA
MAFTOSA
→ If patient is complaining of acute headache (meningitis/ subarachnoid
hge) → quick hx & examination + Management.
→ If patient is complaining of chronic headache, then psychosocial questions:
- How is it affecting your life?
- How is your daily activity?
- How is it affecting your mood?
- What do you do for living?
- How is it affecting your job?

ICE (IDEA- CONCERN- EXPECTATIONS)

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Examination: Vitals and neurological.

Provisional diagnosis, then Management.

7 steps:
1- Admit.
2- Senior.
3- Investigations.
4- Symptomatic (PAIN KILLER) + lifestyle.
5- Specialist.
6- Safety-net for the red flags.
7- Follow-up.

Tension headache

Who you are:

You are an FY2 in GP surgery.
Who the patient is:
Dave, aged 39, presented with headache.
What you should do:
Talk to the patient; take history, assess her and discuss the plan of management with
the patient.

(Don't forget to ask about stress in his life)

P1 (SOCRATES)
Doctor: How can I help you today?
Patient: I have a headache.
D: Tell me more about it? Where exactly do you have the pain? (site)
P: All over my head.
D: When did it start? (onset)
P: I have had it for the past 2 months.
D: What were you doing when you first began to feel this pain?
P: I was not doing anything. Usually, I have this headache after I come home from my
work. (+ve finding)
D: Was it continuous or comes and goes?
P: It is continuous in the evening.
D: What type of pain is it? (character)
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P: Dull.
D: Does the pain go anywhere? (radiation)
P: No.
D: Is there anything that makes the pain better?
P: After I rest it gets better.
D: Is there anything that makes the pain worse?
P: I don’t know.
D: Could you please score the pain on a scale of 1 to 10?
With 1 being no pain and 10 being the most severe pain you have ever experienced.
(score)
P: 5.
D: Apart from the headache, is there anything else?
P: No.
D: Anything else concerning you? (concern)
P: Nothing else.

DDs
D: Any problem with looking at light? (Meningitis, SAH)
P: No.
D: Would you consider this the worst headache of your life? (SAH)
P: No.
D: Any neck stiffness? (SAH)
P: No.
D: Any early morning vomiting or headache? (SOL)
P: No.
D: Any weakness in your body? (SOL)
P: No.
D: Any pain while chewing or combing hair? (GCA)
P: No.
D: Any history of any trauma to your head?
P: No.
D: Any red eye or watery eye? (Cluster headache)
P: No.
D: Do you see coloured haloes around light? (Glaucoma)
P: No.
+FLAWS

P2
D: Have you ever had this headache in the past?
P: No.
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D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any other medical conditions like HTN, migraine and kidney disease?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: What do you do for a living?
P: I am a lawyer.
D: I hear it’s a stressful job, how do you find work?
P: Yes, it's so stressful these days! I have a lot of cases. (+ve finding)
D: You mentioned that you have had this pain for the last 2 months, how this affecting
your life?
P: It's ok, I’m coping with it.
D: Does is it affect your work or daily activities?
P: No.
D: How's your mood?
P: It's fine thanks

DESA
D: Do you smoke?
P: Yes.
D: How much do you smoke?
P: I smoke 5 cigarettes a day on average. Been smoking for the past 3 years.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: It is fine, pretty healthy I think.
D: Do you do physical exercise?
P: I don't get time.

Don’t forget ICE

Examination
General physical and neurological examination.

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Provisional Diagnosis:
From the chat we had (mention the positive findings) you told me that you have had a
headache and the stress in your work is increasing, so I suspect you may be having a
tension headache. Tension-type headaches are not life-threatening and are usually
relieved by painkillers or lifestyle changes.

Management:

Senior.

Symptomatic.
- Painkillers
▪ Painkillers such as paracetamol or ibuprofen can be used to help relieve pain.
Aspirin may also sometimes be recommended. Children under 16 should not be
given aspirin.
▪ If you're taking these medicines, you should always follow the instructions on the
packet.
▪ Paracetamol is usually the best choice if you're pregnant. Do not take ibuprofen
during pregnancy without speaking to us first.
▪ Medicine should not be taken for more than a few days at a time.
▪ If you are not getting better, we may prescribe for you more potent painkillers
(such as medicines containing codeine, such as co-codamol).
▪ Taking painkillers over a long period (usually 10 days or more) may lead to
medicine-overuse headaches developing.
▪ In some cases, an antidepressant medication called amitriptyline may be
prescribed to help prevent chronic tension-type headaches. It does not treat a
headache instantly but must be taken daily for several months until the headaches
lessen.

- Lifestyle changes
Relaxation techniques can often help with stress-related headaches. This may include:
▪ yoga
▪ Massage
▪ exercise
▪ applying a cool flannel to your forehead or a warm flannel to the back of your
neck.

Preventing tension headaches

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• If you experience frequent tension-type headaches, you may wish to keep a diary
to try to identify what could be triggering them.
• It may then be possible to alter your diet or lifestyle to prevent them occurring as
often.
• Regular exercise and relaxation are also important measures to help reduce
stress and tension that may be causing headaches.
• Maintaining good posture and ensuring you're well rested and hydrated can also
help.
• Guidelines from the National Institute for Health and Care Excellence (NICE) state
that a course of up to 10 sessions of acupuncture over a 5- to 8-week period may
be beneficial in preventing chronic tension-type headaches.

Safety netting.
You should seek immediate medical advice for headaches that:

Come on suddenly and are unlike anything you have had before.
Are accompanied by a very stiff neck, fever, nausea, vomiting and confusion.
Follow an accident, especially if it involved a blow to your head.
Are accompanied by weakness, numbness, slurred speech or confusion.

These symptoms suggest there could be a more serious problem, which may require
further investigation and emergency treatment.

Follow up.

Premenstrual Syndrome
Who you are:
You are an FY2 in A&E
Who the patient is:
Rachel, a 33-year-old, presented with headache.
What you should do:
Talk to the patient and address her concerns.

(Don't forget P4)

P1 (SOCRATES)
Doctor: How can I help you today?
Patient: I have a headache.
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D: Tell me more about it? Where exactly do you have the pain? (site)
P: All over my head.
D: When did it start? (onset)
P: 2 days ago.
D: What were you doing when you had this pain?
P: Nothing.
D: Is it continuous or comes and goes?
P: It is continuous during the evening.
D: What type of pain is it? (character)
P: Dull.
D: Does the pain go anywhere else? (radiation)
P: No.
D: Is there anything that makes the pain better?
P: No.
D: Is there anything that makes the pain worse?
P: It always gets worse 3 to 4 days before my periods (+ve finding)
D: Could you please score the pain on a scale of 1 to 10 with 1 being no pain at all and
10 being the most severe pain you have ever experienced? (score)
P: 4.
D: Apart from the headache, anything else?
P: I am getting emotional and angry. I am shouting on my husband and children. I don’t
know what’s going on. (+ve finding)
D: That must be distressing for you. Please don’t worry, we will look into this matter,
how long have you been feeling like this?
P: The past 8 months.
D: That’s quite a long time, how's your mood?
P: I have mood swings a lot, doctor and I feel low sometimes. (+ve finding)
D: Can you grade your mood for me?
P: It's 5. (+ve finding)
D: When people feel low sometimes, they might think of hurting themselves or others,
has that been the case with you?
P: No.
D: Apart from this, what's your main concern? (concern)
P: The headaches and my mood swings, that’s all.

DDs
D: Any problem with light? (Meningitis, SAH)
P: No.
D: Any neck stiffness? (SAH)
P: No.
D: Any early morning vomiting or headache? (SOL)
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P: No.
D: Any weakness in your body? (SOL)
P: No.
D: Any pain while chewing or combing your hair? (GCA)
P: No.
D: Any history of any trauma to your head?
P: No.
D: Any red eye or watery eye? (Cluster headache)
P: No.
D: Do you see coloured haloes around light? (Glaucoma)
P: No.
PMS symptoms
D: Any breast tenderness?
P: No.
D: Any pain in your body?
p: No.
D: Any tummy bloating?
P: No.

+FLAWS

P2
D: Have you had this headache in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DESA
D: Do you smoke?
P: Yes.
D: Could you tell me more about that?
P: I have smoked 2 cigarettes a day for the past 4 years
D: Do you drink alcohol?
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P: No.
D: Tell me about your diet?
P: It is fine.
D: Do you do physical exercise?
P: I don't get time.

P4
D: When was your last menstrual period?
P: 3 weeks ago.
D: Are they regular?
P: Yes.
D: Any bleeding in-between your periods?
P: No.
D: Do you use any contraception?
P: Yes, I’m on the mini-pill.
D: When did you start it?
P: 5 months ago.
D: Are you taking it as prescribed?
P: Yes.
Don’t forget ICE.

Examination
General, physical and neurological examination.

Provisional Diagnosis
From the chat we had (mention the positive findings) you told me that you have had a
headache which gets worse before your period and also you are having mood swings.
Therefore, I suspect you may be suffering from premenstrual syndrome which is the
name for the symptoms women can experience in the weeks before their period. Most
women have PMS at some point in their lives. It may be because of changes in your
hormone levels during the menstrual cycle. Some women may be more affected by
these changes than others.

Management:
Senior
Lifestyle change
→ Regular exercise.
→ Eat a healthy, balanced diet.
→ Get plenty of sleep – 7 to 8 hours is recommended.
→ Try reducing your stress by doing yoga or meditation.
→ Take painkillers such as ibuprofen or paracetamol to ease the pain.
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→ Keep a diary of your symptoms for at least 2 to 3 menstrual cycles.

Medications and CBT

→ Hormonal medicine – such as the combined contraceptive pill.
→ Cognitive behavioural therapy – a talking therapy.
→ Antidepressants.
Please avoid:
→ Smoking.
→ Drinking too much alcohol.

Specialist.
→ If you still get symptoms after trying these treatments, you may be referred to a
specialist.
→ This could be a gynaecologist, psychiatrist or counsellor.

Safety netting.

Follow up.

Subarachnoid haemorrhage
Who you are:
You are an FY2 in A& E
Who the patient is:
Alicia, a 54-year-old, presented with severe headache.
What you should do:
Talk to the patient and address her concerns.

P1 (SOCRATES)
Doctor: How can I help you today?
Patient: I have a headache.
D: Tell me more about it? Where exactly do you have the pain? (site)
P: At the back of my head.
D: When did it start? (onset)
P: 2 hours ago.
D: What were you doing when you had this pain?
P: Watching tv.
D: Was it continuous or comes and goes?
P: It’s continuous during the evening.
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D: What type of pain is it? (character)

P: Severe, sharp pain.
D: Does the pain go anywhere else? (radiation)
P: To my neck. (+ve finding)
D: Is there anything that makes the pain better?
P: No.
D: Is there anything that makes the pain worse?
P: I don’t know.
D: Could you please score the pain on a scale of 1 to 10 with 1 being no pain and 10
being the most severe pain you have ever experienced? (score)
P: 10, this is the worst headache of my life (+ve finding)
D: Apart from the headache, is there anything else? (concern)
P: No.

DDs
D: Any problem with light? (Meningitis, SAH)
P: Yes (+ve finding)
D: Any neck stiffness? (SAH)
P: There's some neck pain, yes. (+ve finding)
D: Any early morning vomiting or headache? (SOL)
P: No.
D: Any weakness in your body? (SOL)
P: No.
D: Any pain while chewing or combing hair? (GCA)
P: No.
D: Any history of any trauma to your head?
P: No.
D: Any red eye or watery eye? (Cluster headache)
P: No.
D: Do you see coloured haloes around light? (Glaucoma)
P: No.
+FLAWS

P2
D: Have you ever had this headache in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: Yes, I have migraines, but this is totally different from a migraine.
D: Any other medical conditions like HTN or kidney disease?
P: No.

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MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: Yes, I’m taking sumatriptan for migraines.
D: Are you taking it as prescribed?
P: Yes.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DESA
D: Do you smoke?
P: Yes.
D: Could you tell me more about that?
P: I’ve been smoking 15 cigarettes a day, for the past 20 years (+ve finding)
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: It is fine.
D: Do you do physical exercise?
P: I don't get time.

Don’t forget ICE

Examination:
General, physical and neurological examination.

Provisional Diagnosis:
From the chat we had (mention the positive findings) you told me that you have a
headache considered the worst headache of your life. Plus you've been smoking for a
long time, so I suspect you may be having a condition called subarachnoid
haemorrhage. This is bleeding on the surface of the brain. I don’t want to worry you,
but it is a life-threatening condition that needs urgent admission.

Management:
1- Admit to ICU.
2- Senior
3- Investigations
➢ Blood (mainly clotting profile)
➢ CT (if normal)
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➢ LP (which is usually done often 12 hours to look for xanthochromia: yellow

discoloration of CSF (fluid around your brain)
4- Symptomatic:
➢ Morphine (antiemetic)
➢ Nimodipine (antiemetic if vomiting) 60 mg/ four hours/ 3 weeks
➢ Labetalol if HTN.
➢ Anti-convulsant if having fits.
5- Specialist (neuro- surgeon): surgery clipping or coiling of bleeding vessels
6- Safety netting: Here he is in ICU already, so no safety netting necessary.

Giant Cell Arteritis

Who you are:
You are a F2 in general medicine.
Who the patient is:
Maria, aged 55, came to the hospital with a headache.
What you should do:
Take a focused history, assess the patient, do examination and discuss further
management with the patient.

P1 (SOCRATES)
Doctor: How can I help you today?
Patient: I have a headache.
D: Tell me more about it? Where exactly do you have the pain? (site)
P: On the sides of my head.
D: When did it start? (onset)
P: 7 days ago.
D: Was it continuous or comes and goes?
P: It’s continuous in the evening.
D: What type of pain is it? (character)
P: A dull pain.
D: Does the pain go anywhere else? (radiation)
P: No.
D: Is there anything that makes the pain better?
P: No.
D: Is there anything that makes the pain worse?
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P: When I eat it gets worse. (+ve finding)

D: Could you please score the pain on a scale of 1 to 10 with 1 being no pain at all and
10 being the most severe pain you have ever experienced? (score)
P: 5.
D: Apart from the headache, is there anything else? (concern)
P: No.

DDs
D: Any problem with light? (Meningitis, SAH)
P: No.
D: Any neck stiffness? (SAH)
P: No.
D: Any early morning vomiting or headache? (SOL)
P: No.
D: Any weakness in your body? (SOL)
P: No.
D: Any pain while chewing or combing hair? (GCA)
P: Yes (+ve finding)
D: Any muscle stiffness or weakness? (PMR)
P: No.
D: Any history of any trauma to your head?
P: No.
D: Any red eye or watery eye? (Cluster headache)
P: No.
D: Do you see coloured haloes around light? (Glaucoma)
P: No.
+FLAWS

P2
D: Have you had this headache in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any other medical conditions like HTN, migraines or kidney disease?
P: No

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
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D: Has anyone in your family been diagnosed with any medical condition?
P: No.

DESA
D: Do you smoke?
P: Yes.
D: Could you tell me more about that?
P: I’ve been smoking 10 cigarettes a day for the past 10 years.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: It’s fine.
D: Do you do physical exercise?
P: I don't get time.
Don’t forget ICE

Examination:
General, physical and neurological examination.

Provisional Diagnosis:
From the chat we had (mention the positive findings) you told me that you have a
headache that increases with chewing and combing your hair, so I am suspecting a
condition called giant cell arteritis (temporal arteritis) which is inflammation in the
arteries on the side of your head.

Management

Refer.
→ If you have problems with your vision, a same-day appointment with an eye
specialist (ophthalmologist) at a hospital eye department and admit.

Investigations:
→ Routine blood and ESR.

Specialist:
After having some blood tests, you'll be referred to a specialist.
They may carry out further tests to help diagnose temporal arteritis.
1- An ultrasound scan of your temples.
2- a biopsy under local anaesthetic – where a small piece of the temporal artery is
removed and checked for signs of temporal arteritis.

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Medications:
Steroids usually prednisolone.
Treatment will be started before temporal arteritis is confirmed because of the risk of
vision loss if it's not dealt with quickly.
There are 2 stages of treatment:
1. An initial high dose of steroids for a few weeks to help bring your symptoms
under control.
2. A lower steroid dose (after your symptoms have improved) given over a longer
period of time, possibly several years.
→ Do not suddenly stop taking steroids unless your doctor tells you to. Stopping a
prescribed course of medicine could make you very ill.

Other treatments, you may need if you have temporal arteritis include:
→ Low-dose aspirin – to reduce the risk of a stroke or heart attack, which can happen if
the arteries to your heart are affected.
→ Proton pump inhibitors (PPIs) – to lower your risk of getting a stomach problem like
indigestion or a stomach ulcer, which can be a side effect of taking prednisolone
→ Bisphosphonate therapy – to reduce the risk of osteoporosis when taking
prednisolone.
→ Immunosuppressants – to allow steroid medicine to be reduced and help prevent
temporal arteritis coming back.

Safety netting:
→Whilst blood vessels are inflamed, they can send blood clots to the eyes, heart or
brain, causing vision loss, heart attacks, or strokes.
→ Also, if you feel pain in your joints, mainly shoulders & hips (come back right away)
(Polymyalgia Rheumatica)

Follow-up:
→ You'll have regular follow-ups to see how you're doing and check for any side affects
you may have.

Migraine
Who you are: You are a FY2 in GP surgery.
Who the patient is: Emily White aged, 30, presented with headache.
What you should do: Talk to the patient; take history, assess her and discuss the plan of
management with the patient.

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P1 (SOCRATES)
Doctor: How can I help you today?
Patient: I have a headache.
D: Tell me more about it? Where exactly do you have the pain? (site)
P: On one side of my head. (+ve finding)
D: When did it start? (onset)
P: I have had it for the last 2 months.
D: What were you doing when you had this pain?
P: I was watching TV, but it happens all the time.
D: Is it continuous or comes and goes?
P: It comes in attacks lasting about 4 hours. (+ve finding)
D: What type of pain is it? (character)
P: Throbbing. (+ve finding)
D: Does the pain go anywhere? (radiation)
P: No.
D: Is there anything that makes the pain better?
P: After resting it feels better.
D: Is there anything that makes the pain worse?
P: Noise. (+ve finding)
D: Could you please score the pain on a scale of 1 to 10 with 1 being no pain at all and
10 being the most severe pain you have ever experienced? (score)
P: 7.
D: Apart from the headache, is there anything else? (concern)
P: No.

DDs
D: Any problem with light? (Meningitis, SAH)
P: No.
D: Would you consider this the worst headache of your life? (SAH)
P: No.
D: Any neck stiffness? (SAH)
P: No.
D: Any early morning vomiting or headache? (SOL)
P: No.
D: Any weakness in your body? (SOL)
P: No.
D: Any pain while chewing or combing your hair? (GCA)
P: No.
D: Any history of any trauma to your head?
P: No.
D: Any red eye or watery eye? (Cluster headache)
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P: No.
D: Do you see coloured haloes around light? (Glaucoma)
P: No.
D: Do you have any warning symptoms before the headache like flashing of light or
noise? (AURA)
P: No.
+FLAWS

P2
D: Have you ever had this headache in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any other medical conditions like HTN, migraines and kidney disease?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: You mentioned that you have had this pain for the last 2 months, how is this
affecting your life?
P: Whenever I have this pain, it prevents me from carrying out my normal activities.
D: I am sorry to hear that, how are you coping?
P: It's difficult doctor.
D: How's your mood?
P: it's fine, thanks.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: It is fine.
D: Do you do physical exercise?
P: I don't get time to be honest
Don’t forget ICE
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Examination
General physical and neurological examination.

Provisional Diagnosis
From the chat we had (mention the positive findings) you told me that you have a
throbbing headache on one side of your head and it's severe enough to affect your daily
activity, so I suspect you are suffering from migraines.

Management
There's currently no cure for migraines, although a number of treatments are available
to help ease the symptoms.
Refer you to a neurologist for further assessment and treatment if
→ a diagnosis is unclear.
→ you experience migraines on 15 days or more a month (chronic
migraine).
→ treatment is not helping to control your symptoms.

Senior.
General advice:
→ Identifying and avoiding triggers is one of the best ways of preventing migraines.
Recognising the things that trigger an attack and trying to avoid them.
→ Migraine diary: to help with the diagnosis, it can be useful to
keep a diary of your migraine attacks for a few weeks.
Note down details including:
❖ The date
❖ Time
❖ What you were doing when the migraine began
❖ How long the attack lasted
❖ What symptoms you experienced
❖ What medicines you took

Medications:
1. Painkillers
→ Many people who have migraines find that over-the-counter painkillers, such as
paracetamol, aspirin and ibuprofen, can help to reduce their symptoms.
→ They tend to be most effective if taken at the first signs of a migraine attack, as this
gives them time to absorb into your bloodstream and ease your symptoms.
→ Tablets you dissolve in a glass of water (soluble painkillers) are a good alternative
because they're absorbed quickly by your body.
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→ Aspirin and ibuprofen are also not recommended for adults who have a history of
stomach problems, such as stomach ulcers, liver problems or kidney problems.
→ Taking any form of painkiller frequently can make migraines worse. This is
sometimes called a medication overuse headache or painkiller headache, in this case we
may recommend that you stop using them.
→ If you find you cannot manage your migraines using over-the- counter medicines, we
may prescribe something stronger or recommend using painkillers along with triptans.

2. Triptans
→ Triptan medicines are a specific painkiller for migraine headaches. They're thought to
work by reversing the changes in the brain that may cause migraine headaches.
→ They cause the blood vessels around the brain to narrow (contract). This reverses the
widening of blood vessels that's believed to be part of the migraine process.
→ Triptans are available as tablets, injections and nasal sprays.
→ Common side effects of triptans include warm sensations tightness – tingling –
flushing - feelings of heaviness in the face, limbs or chest. However, these side effects
are usually mild and improve on their own.

3. Anti-sickness medicines
→ These can successfully treat migraines in some people even if you do not experience
feeling or being sick.
→ They can be taken alongside painkillers and triptans.
→ As with painkillers, anti-sickness medicines work better if taken as soon as your
migraine symptoms begin.
→ They usually come in the form of a tablet but are also available as a suppository.
→ Side effects of anti-emetics include drowsiness and diarrhoea.

4. Combination medicines
→ These medicines contain both painkillers and anti-sickness medicines.
→ It can also be very effective to combine a triptan with another painkiller, such as
ibuprofen.
→ Many people find combination medicines convenient.
→ It may be better to take painkillers and anti-sickness medicines separately. This
allows you to easily control the doses of each.

During an attack:
→ Sleeping or lying in a darkened room is the best thing to do when having a migraine
attack.
→ Eating something helps, or they start to feel better once they have been sick.

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Other treatment (to prevent migraines)

1. Acupuncture
→ If medicines are unsuitable or do not help to prevent migraines, you can try
acupuncture.
→ A course of up to 10 sessions over a 5- to 8-week period may be beneficial.

2. Transcranial magnetic stimulation

→ TMS involves holding a small electrical device to your head that delivers magnetic
pulses through your skin.
→ It can also be used in combination with the medicines mentioned above without
interfering with them.
→ But TMS is not a cure for migraines and does not work for everyone.
→ Potential long-term effects of the treatment, these include:
slight dizziness - drowsiness and tiredness.

Headache specialists in specialist centres may prescribe:

1. Topiramate
→Prevents migraines and is usually taken every day in tablet form.
→Not given in kidney or liver problems or pregnancy.
→Can reduce the effectiveness of hormonal contraceptives.
→ Side effects of topiramate can include: decreased appetite - feeling sick.

2. Propranolol
→ Effectively prevents migraines. It's usually taken every day in tablet form.
→ Not suitable for people with asthma, chronic obstructive pulmonary disease (COPD)
and some heart problems.
→ Side effects of propranolol can include: cold hands and feet - pins and needles -
problems sleeping.

3. Amitriptyline
→ Helps prevent migraines. It's usually taken every day in tablet form.
→ Can make you feel sleepy, so it's best to take it in the evening or before you go to
bed.
→ Other side effects include: constipation – dizziness - a dry mouth It may take up to 6
weeks before you begin to feel the full benefit of the medicine.

4. Botulinum toxin type A

→ Prevents headaches in some adults with long-term migraines.

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→ Should be given by injection to between 31 and 39 sites around the head and back of
the neck.
→ A new course of treatment can be given every 12 weeks.
- Treatment for pregnant and breastfeeding women
→ Medicines should be limited as much as possible when you're pregnant or
breastfeeding.

Preventing menstrual-related migraines

→ Menstrual-related migraines usually occur from 2 days before the start of your
period to 3 days after.
→ As these migraines are relatively predictable, it may be possible to prevent them
using either non-hormonal or hormonal treatments.
→ Non-hormonal treatments as (NSAIDs) or triptans. These medicines are taken as
tablets 2 to 4 times a day from either the start of your period or 2 days before, until the
last day of bleeding.
→ Hormonal treatments as contraceptives.

Specialist
→ If the treatments above are not effectively controlling your migraines, we may refer
you to a specialist migraine clinic for further investigation and treatment.
→ In addition to the medicines mentioned above, a specialist may recommend other
treatments, such as transcranial magnetic stimulation.

Follow-up appointment once you have finished your first course of treatment with
triptans. This is so you can discuss their effectiveness and whether you had any side
effects.

Safety-netting for any weakness or slurred speech + Meningitis and SAH symptoms.

Sinusitis
Who you are:
You are a F2 in general medicine.
Who the patient is:
David, aged 25, came to the hospital with headache.
What you should do:
Take a focused history, assess the patient, do examination and discuss further
management with the patient

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P1 (SOCRATES)
Doctor: How can I help you today?
Patient: I have a headache.
D: Tell me more about it? Where exactly do you have the pain? (site)
P: On my forehead.
D: When did it start? (onset)
P: 3 weeks ago.
D: Was it continuous or comes and goes?
P: Comes and goes.
D: What type of pain is it? (character)
P: Dull.
D: Does the pain go anywhere else? (radiation)
P: Around my cheeks and eyes (+ve finding)
D: Can you relate this pain to anything?
P: No.
D: Is there anything that makes the pain better?
P: No.
D: Is there anything that makes the pain worse?
P: Leaning forward. (+ve finding)
D: Could you please score the pain on a scale of 1 to 10 with 1 being no pain at all and
10 being the most severe pain you have ever experienced? (score)
P: 5.
D: Apart from the headache, is there anything else you have come about today?
P: My nose is blocked.
D: Could you tell me more about it?
P: I had it for a while now and sometimes I have toothache.
D: What's concerning you the most? (concern)
P: The headache and my nose being blocked.

DDs
D: Any problem with light? (Meningitis, SAH)
P: No.
D: Any neck stiffness? (SAH)
P: No.
D: Any early morning vomiting or headache? (SOL)
P: No.
D: Any weakness in your body? (SOL)
P: No.
D: Any pain while chewing or combing hair? (GCA)
P: No.
D: Any muscle stiffness or weakness? (PMR)
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P: No.
D: Any history of any trauma to your head?
P: No.
D: Any red eye or watery eye? (Cluster headache)
P: No.
D: Do you see coloured haloes around light? (Glaucoma)
P: No.
D: Any recent infection?
P: I’ve had a cold for a few weeks now.
+FLAWS

P2
D: Have you ever had this headache in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any other medical conditions like HTN, migraines and kidney disease?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: It is fine, I try to eat healthy.
D: Do you do physical exercise?
P: Not really.
Don’t forget ICE

Examination
General, physical and neurological examination.

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Palpation of sinuses, head, neck and glands in your body may reveal tenderness over
sinuses and lymphadenopathy.

Provisional Diagnosis
From the chat we had (mention the positive findings) you told me that you have a
headache and pain in and around your cheeks that increases when you lean forward,
plus you have a blocked nose, so I suspect you have Sinusitis. This is a swelling of the
sinuses, usually caused by an infection.

Management
Refer to an ear, nose and throat (ENT) specialist if:
You still have sinusitis after 3 months of treatment
You keep getting sinusitis
Only have symptoms on 1 side of your face
They may also recommend surgery.

Senior.

General advice:
→ getting plenty of rest
→ drinking plenty of fluids
→avoiding allergic triggers
→not smoking
→cleaning your nose with a saltwater solution to ease congestion.

Medications:
→ Taking painkillers, such as paracetamol or ibuprofen (do not give aspirin to children
under 16)
→ Decongestant nasal sprays or drops to unblock your nose.
(Decongestants should not be taken by children under 6).
→ Saltwater nasal sprays or solutions to rinse out the inside of your nose. You can buy
nasal sprays without a prescription, but they should not be used for more than 1 week.
→ Steroid nasal sprays or drops – to reduce the swelling in your sinuses
(You might need to take steroid nasal sprays or drops for a few months. They
sometimes cause irritation, sore throats or nosebleeds.
→ Antihistamines – if an allergy is causing your symptoms.
→ Antibiotics – if a bacterial infection is causing your symptoms and you're very unwell
or at risk of complications (but antibiotics are often not needed, as sinusitis is usually
caused by a virus).

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Surgery for sinusitis:

→ Surgery to treat chronic sinusitis is called functional endoscopic sinus surgery (FESS).
→ FESS is carried out under general anaesthetic (where you're asleep).
→ You should be able to have FESS within 18 weeks of your GP appointment.
→ The surgeon can widen your sinuses by either: removing some of the blocked tissue
by inflating a tiny balloon in the blocked sinuses, then removing it.

Safety netting.
Follow up.

Hangover Headache
Who you are:
You are a F2 in general medicine.
Who the patient is:
Sam, aged 18, came to the hospital with headache.
What you should do:
Take a focused history, assess the patient, do examination and discuss further
management with the patient.

P1 (SOCRATES)
Doctor: How can I help you today?
Patient: I have headache.
D: Tell me more about it? Where exactly do you have the pain? (site)
P: In the back of my head.
D: When did it start? (onset)
P: This morning.
D: Is it continuous or comes and goes?
P: It’s been continuous since this morning.
D: What type of pain is it? (character)
P: Dull.
D: Does the pain go anywhere else? (radiation)
P: No.
D: Is there anything that makes the pain better?
P: No.
D: Is there anything that makes the pain worse?
P: No.
D: Could you please score the pain on a scale of 1 to 10 with 1 being no pain and 10
being the most severe pain you have ever experienced? (score)
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P: 5.
D: Apart from the headache, are you fit and well or is there anything else? (concern)
P: I have vomited twice this morning too. (+ve finding)
D: Could you tell me more about it?
P: It was around the same time that the headache started.

DDs
D: Any problem with light? (Meningitis, SAH)
P: No.
D: Any neck stiffness? (SAH)
P: No.
D: Any early morning vomiting or headache? (SOL)
P: Yes, as I said before, I threw-up this morning. (+ve finding)
D: Any weakness in your body? (SOL)
P: No.
D: Any pain while chewing or combing hair? (GCA)
P: No.
D: Any muscle stiffness or weakness? (PMR)
P: No.
D: Any history of any trauma to your head?
P: No
D: Any red eye or watery eye? (Cluster headache)
P: No.
D: Do you see coloured haloes around light? (Glaucoma)
P: No.
+FLAWS

P2
D: Have you ever had this headache in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any other medical conditions like HTN, migraine and kidney disease?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
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P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: Well last night I had alcohol for the first time.
D: Ok , how much did you drink?
P: I had 3 glasses of vodka with orange juice. (+ve finding)
D: Do you do physical exercise?
P: I try to exercise often yes.
Don’t forget ICE

Examination
General, physical and neurological examination.

Provisional Diagnosis
From the chat we had (mention the positive findings) you told me that you had a
headache this morning plus vomiting, and you had alcohol for the first time yesterday,
so I suspect you've got a hangover headache.

Management
There are no cures for a hangover, but there are things you can do to avoid one and, if
you do have one, ease the discomfort.
Senior: Only if patient is severely dehydrated.
Symptomatic:
→ Dealing with a hangover involves rehydrating your body to help you deal with the
symptoms. The best time to rehydrate is before going to sleep after a drinking session.
→ Painkillers can help with headaches and muscle cramps.
→ Sugary foods may help you feel less trembly. In some cases, an antacid may be
needed to settle your stomach first.
→ Bouillon soup (a thin, vegetable-based broth) is a good source of vitamins and
minerals, which can top-up depleted resources. It's also easy for a fragile stomach to
digest.
→ You can replace lost fluids by drinking bland liquids that are gentle on your digestive
system, such as water, soda water and isotonic drinks.

To avoid a hangover:
→ Do not drink more than you know your body can cope with. If you're not sure how
much that is, be careful.
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→ Do not drink on an empty stomach. Before you start drinking, have a meal that
includes carbohydrates (such as pasta or rice) or fats. The food will help to slow down
your body's absorption of alcohol.
→ Do not drink dark coloured drinks if you've found you're
sensitive to them. They contain natural chemicals called congeners, which irritate blood
vessels and tissue in the brain and can make a hangover worse.
→ Drink water or non-fizzy soft drinks in between each alcoholic drink. Fizzy drinks
speed up the absorption of alcohol into your body.
→ Drink a pint or so of water before you go to sleep. Keep a glass of water by your bed
to sip if you wake up during the night.
→ Drinking more alcohol does not help.
→ Drinking in the morning is a risky habit, and you may simply be delaying the
appearance of symptoms until the extra alcohol wears off.
→If you've been drinking heavily, please wait at least 48 hours before drinking any
more alcohol (even if you don't have a hangover), to give your body time to recover.

Advice for regular drinkers:

To keep the health risks from alcohol to a low level, if you drink most weeks:
→ do not drink more than 14 units a week on a regular basis.
→ spread your drinking over 3 or more days if you regularly drink as much as 14 units a
week.
→ if you want to cut down, try to have several alcohol-free days each week
→ 14 units is equivalent to 6 pints of average-strength beer or 10 small glasses of low-
strength wine.

Safety netting- If you don’t feel better within a couple of days, come back and see me.
Follow up- Not necessary unless patient doesn’t get better.

Meningitis
Who you are:
You are a F2 in general medicine.
Who the patient is:
Maria, aged 27, came to the hospital with a headache.
What you should do:
Take a focused history, assess the patient, do examination and discuss further
management with the patient.

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P1 (SOCRATES)
Doctor: How can I help you today?
Patient: I have a headache.
D: Tell me more about it? Where exactly do you have the pain? (site)
P: On the back of my head.
D: When did it start? (onset)
P: 3 days ago.
D: Was it continuous or comes and goes?
P: It is continuous.
D: What type of pain is it? (character)
P: Dull.
D: Does the pain go anywhere else? (radiation)
P: No.
D: Is there anything that makes the pain better?
P: No.
D: Is there anything that makes the pain worse?
P: Yes, light seems to make it worse. (+ve finding)
D: Could you please score the pain on a scale of 1 to 10
with 1 being no pain at all and 10 being the most severe pain you have ever
experienced. (score)
P:6.
D: Apart from the headache, is there anything else you want to discuss with me today?
(concern)
P: No.

DDs
D: So, you said when you look at light, the headache gets worse? (Meningitis, SAH)
P: Yes, light makes it worse. (+ve finding)
D: Any neck stiffness? (Meningitis, SAH)
P: Yes (+ve finding)
D: Any rash on your body? (Meningitis)
P: Yes, I actually noticed I have a rash whilst I was coming here. (+ve finding)
D: By any chance have you had any fits? (Meningitis)
P: No.
D: Any early morning vomiting or headache? (SOL)
P: No.
D: Any weakness in your body? (SOL)
P: No.
D: Any pain while chewing or combing hair? (GCA)
P: No.
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D: Any muscle stiffness or weakness? (PMR)

P: No.
D: Any history of any trauma to your head?
P: No.
D: Any red eye or watery eye? (Cluster headache)
P: No.
D: Do you see coloured haloes around light? (Glaucoma)
P: No.
D: Have you come in contact with anyone who has any infection?
P: No, I don’t think so.
+FLAWS
IF PATIENT HAS HIGH FEVER= (+ve finding)

P2
D: Have you ever had this headache in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any other medical conditions like HTN, migraines and kidney disease?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: It is good.
D: Do you do physical exercise?
P: Sometimes yes.
Don’t forget ICE

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Examination
- Vital signs - Full physical - rash
- Neurological - GCS
- Brudzinski and Kernig signs

Provisional Diagnosis:
From the chat we had (mention the positive findings) you told me that you have a
headache that gets worse with light, and you have a fever and a rash, so I suspect you
may have meningitis. It is an infection of the protective membranes that surround the
brain and spinal cord.

Management
People with suspected meningitis will usually need to have tests in hospital and need to
stay in hospital for treatment.

Admit:
→ Treatment in hospital is recommended in all cases of bacterial meningitis and severe
viral meningitis, as the condition can cause serious problems and requires close
monitoring. For a few days, and in certain cases, treatment may be needed for several
weeks.
→ Isolate and inform infection control.

Senior- Inform
Investigations:
→ Tests in hospital: Several tests may be carried out to confirm the diagnosis and check
whether the condition is the result of a viral or bacterial infection.
→These tests may include: a blood test (routine + culture) to check for bacteria or
viruses.
→ A lumbar puncture – where a sample of fluid is taken from the spine and checked for
bacteria or viruses
→ CT scan to check for any problems with the brain, such as swelling

Symptomatic: As bacterial meningitis can be very serious, treatment with antibiotics,

given directly into a vein, will usually start before the diagnosis is confirmed and will be
stopped later on if tests show the condition is being caused by a virus.
→ Fluids given directly into a vein to prevent dehydration.
→ Oxygen through a face mask if there are any breathing difficulties.
→ Steroid medication to help reduce any swelling around the brain, in some cases.
→ Additional treatment and long-term support may also be required if any
complications of meningitis occur, such as hearing loss.
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Preventing the spread of infection:

→ The risk of someone with meningitis spreading the infection to others is generally
low, but if someone is thought to be at high risk of infection, they may be given a dose
of antibiotics as a precautionary measure.
→This may include anyone who's been in prolonged close contact with someone who
developed meningitis, such as:
- people living in the same house.
- pupils sharing a dormitory.
- university students sharing a hall of residence.
- a boyfriend or girlfriend.
- People who have only had brief contact with someone who developed meningitis
will not usually need to take antibiotics.

Treatment of mild viral meningitis:

→ You'll usually be able to go home from hospital.
→ This type of meningitis will normally get better on its own without causing any
serious problems.
→ Most people feel better within 7 to 10 days. In the meantime, it can help to
- get plenty of rest
- take painkillers for a headache or general aches.
- take anti-sickness medicine for any vomiting.

Safety netting- Not necessary as patient will be admitted.

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FALLS

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Falls stations

P1(ODIPARA)
• Can you tell me more about the fall?

• Did anyone witness the fall?

Before the fall During the fall After the fall

• Did you LOC? • Fits? • Fit?

• Was your heart • Wet yourself? • Wet yourself?
racing? • Bite your tongue? • Bite your tongue?

• Did you have your

meal as usual?

• Did you have any

fits?

Anything else? (Concern)

DDs (causes of falls)

A. Non -MedicalCauses:
Slipping.
Tripping.
Poor light.
Alcohol.
NAI.

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B. Medical causes

+ve LOC -ve LOC

2 Causes start with Hypo 3 Causes in the Ear

1. Hypoglycemia 1.BPPV
• Hx of DM. Have you had the fall after a
• Sweating, hungry, dizzy, irritable. sudden change in the
• Taking insulin while fasting (cause). 2. position of your head?

2. Hypotension (most of the time no LOC) 2.Meniere's disease

• Hx of HTN & on medications • Room spinning.
• Fall when sudden change position. Fullness of ear.
• High pitched noise.
2 Causes are in the Heart
3.Vestibular neuritis.
3.↑↑ rate (A.F) ---------------------------------
• Hx of heart problem. 4. Ataxia.
• Chest pain.
5.Stroke or TIA.
• Heart racing.
• Thyroid. 6. Acoustic neuroma.
4. ↓↓ rate (Stock-Adam) 7. Multiple sclerosis.
• Looking pale before fainting.

5.Epilepsy
• Hx of epilepsy.
• Wet himself.
• up rolling eye.
• Bite tongue.

6. Vaso-vagal syncope
• Fall after smelling or seeing unpleasant
thing.
FLAWS.

P2: PAST HX
Have you ever had such pain before? Any medical condition? (5 conditions)
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P3:
• DESA
• MAFTOSA
• ICE (IDEA- CONCERN- EXPECTATIONS)

Examination in ALL cases of falls:

→ Observations: Measuring BP while lying down & standing, the difference between 2
positions should be more than 20 systolic or 10 diastolic (postural hypotension).
→ Chest: (examine heart).

Provisional diagnosis then Management

7 steps:
1. Admit
2. Senior
3. Investigations
→ Blood • FBC for anaemia.
RBS or FBS for DM.
→ Heart tracing (ECG)

4. Treatment for risk factors & advise prevention of the condition.

5. Specialist
6. Safety net
7. Follow up

Postural hypotension
Who you are:
You are a FY2 in A&E.
Who the patient is:
A 64-year-old lady, presented with complaints of few falls last week.
What you should do:
Please talk to the patient, take history, assess the patient and discuss your initial plan of
management with the patient.

P1(ODIPARA)
D: How can I help you today?
P: I fall a lot these days.
D: Can you please tell me more?

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P: It occurs more in the morning when I try to get up from the bed, I feel dizzy and then
I fall (+ve finding)
D: When did this start?
P: 3 weeks ago.
D: Anything specific happen before that?
P: Yes, the GP changed some of my high blood pressure medications. (+ve finding)
D: Do you know what the name of the medications?
p: No.
D: Was there any difference in all the falls?
P: No.
D: Apart from this is there anything else worrying you?
P: No.

BEFORE – DURING - AFTER

D: Any loss of consciousness?
P: No.
D: Any fits? (Epilepsy)
P: No.
D: Any heart racing? (AF)
P: No.
D: Did you have your meal as usual? (hypoglycaemia)
P: Yes.
D: Any balance problem while walking? (ataxia)
P: No.
D: Do you feel like the room is spinning? (Meniere's)
P: No.
D: Any trauma to your head?
P: No.
D: Any fever/flu like symptoms? (Confusion)
P: No.

P2 (PAST HX)
D: Have you have this problem before?
P: No.
D: Do you have any medical condition apart from high blood pressure?
P: No.

MAFTOSA
D: Are you taking any other medications away from your high blood pressure
medication?
P: No.
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D: Are you taking high blood pressure medication regularly?

P: Yes.
D: Did you have all the falls after he changed your medication? (+ve finding)
P: Yes.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: Who do you live with?
P: I live alone.
D: You’ve been having this for the past 3 weeks, how are you coping with that? P: It's
been difficult…I’m afraid to leave my bed.
D: I am really sorry to hear that.

DESA
D: Tell me about your diet?
P: I try to eat healthy
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Do you do physical exercise?
P: Yes, I walk.
D: Do you have any kind of stress?
P: No.

ICE

Examination:
→ Observations: Measuring BP while lying down & standing, the difference between 2
positions should be more than 20 systolic or 10 diastolic (postural hypotension).
BP standing: 100/60. BP lying: 140/90
→ Chest: (examine heart).

Provisional Diagnosis: From the chat we had (mention the positive findings) you told
me that you have this dizziness when you change your position, and also your blood
pressure medication was changed recently, so I am suspecting you have a condition
called Postural hypotension. It’s a condition when your BP tends to fall when you
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switch your position suddenly from lying down to standing. In your case, I am
suspecting that it was caused by changing your BP medications. It also can be caused by
standing for a long period of time.

Management:
1. Admit
2. Senior
3. Investigations → Blood (FBC – RBS). → ECG.
We will get in touch with your GP to find out which medications you are on & we may
stop your medication and speak to a heart specialist to start you on some other
medications. (Here, patient does not know anything about his medications).
4. Advise about posture (very important)
Take care especially when getting up in the morning, as BP is usually the lowest, so:
• Get up in stages.
• Cross & uncross your legs firmly before sitting and before standing.
• Avoid sudden change in position.
• Avoid standing for long periods.
• Raise your head of your bed with blocks.
• Wear support stockings or tights to ↑ blood return to heart.
• Drink plenty of fluids.
• Take small frequent meals.
• Avoid drinking excess alcohol.

Epilepsy -first attack

Who you are:

You are a FY2 in A&E.
Who the patient is:
Marcus Jones, 26 years old, booked an urgent appointment with you because he thinks
he had fit at home.
What you should do:
Please talk to the patient, take history, assess the patient and discuss your initial plan of
management with the patient.

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Don't forget DRIVING

Ask about HOBBIES
Differentials:
Trauma
Meningitis
Encephalitis
Stroke
Syncope
Brain tumour

Seizure triggers
For many people with epilepsy, seizures seem to happen randomly. But sometimes they
can have a trigger, such as:
Stress
A lack of sleep
Waking up drinking alcohol
Some medicines and illegal drugs

P1(ODIPARA)
Doctor: I can see from my notes that you booked an urgent appointment, is everything
ok?
Patient: I think I had a fit doctor.
D: I see, can you please tell me more about it?
P: Yesterday, I was watching tv with my wife when suddenly I lost consciousness, and I
wasn't responding to her for 2 mins (+ve finding)
D: That must have been a scary experience for you and your wife.

BEFORE – DURING - AFTER

D: Any heart racing? (AF)
P: No.
D: Did you have your meal as usual? (hypoglycemia)
P: Yes.
D: Any balance problem while walking? (ataxia)
P: No.
D: Did you feel like the room is spinning? (Meniere's)
P: No.
D: Any trauma to your head?
P: No.
D: Any visual or auditory symptoms?
D: No.
D: Any fever/flu-like symptoms? (Confusion)
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P: No.
D: Do you remember what happened during your fit or did your wife tell you about
what you were doing? (Epilepsy)
P: Yes, she told me I was shaking and making weird movements. (+ve finding) D: I am
going to ask you some questions that might be worrying but they are an important part
of my consultation. By any chance did you bite your tongue?
P: No.
D: Wet yourself?
P: Yes, I soiled myself doctor. (+ve finding)
D: Did you remember anything after the fits?
P: No.
D: Did you feel any headache after that?
P: Yes, I had a headache, and I was confused also. (+ve finding)
D: Did you notice any weakness in your body?
P: No.

FLAWS
P2 (PAST HX)
D: Have you ever had this problem before?
P: No.
D: Do you have any medical condition?
P: No.

DESA
D: Tell me about your diet?
P: I try to eat healthy
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Do you use any recreational drugs?
P: No.
D: Do you do physical exercise?
P: No.
D: Do you have any kind of stress?
P: No.

MAFTOSA
D: Are you taking any medications?
P: No.
D: Any family history of fits?
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P: No.
D: What do you do for living?
p: I am a taxi driver.
D: Whom do you live with?
P: I live with my wife.
D: Any activity or hobbies you like to spend your free time doing?
P: No

ICE

Examination:
→ Observations
→ Head to toe include Neurological: (examine heart).

Provisional Diagnosis:
From the chat we had (mention the positive findings) you told me that
you had a shaking fit and you soiled yourself after it. You couldn’t remember what
happened and you felt confused. So, I believe what you experienced was a seizure
attack, there are a lot of causes that can cause this but the most common one is called
Epilepsy.

Management:
1. SENIOR.
2. Urgent referral to specialist
He will examine and reassess you and carry out more investigations like:
EEG: examine electrical activity of the brain
CT scan
Start you on medications if epilepsy is confirmed.

3. General advice
Keeping a diary of when you have seizures and what happened before them can help
you identify and avoid some possible triggers.
Some people with epilepsy wear a special bracelet or carry a card to let medical
professionals and anyone witnessing a seizure know they have epilepsy.
Identify and avoid seizure triggers
Driving: You must stop driving and tell the Driving and Vehicle License Agency (DVLA) if
you've had a seizure. If you don’t you could end up in a serious fatal accident.

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Sports and leisure: avoid swimming or doing water sports on your own, wear a helmet
while cycling or horse riding, avoid using certain types of gym equipment; ask staff at
the gym for advice.

4-Support groups:
There are 2 main epilepsy support groups that you might find a useful source of
information and advice.
- Epilepsy Action - Epilepsy Society

5- What to do during the attack

If someone is with you while you’re having a seizure: they should only move you if
you're in danger, such as near a busy road or hot cooker.
They should cushion your head if it’s on the ground, loosen any tight clothing around
your neck, such as a collar or tie, to aid breathing and turn you on to your side after the
convulsions stop.
Your family should read more about the recovery position and learn how to put you in
it. They should stay with you and talk to you calmly until you recover. They should also
note the time the seizure starts and finishes.

Head injury
Who you are:
You are FY2 in A&E.
Who is the patient:
Randy smith, 46-year-old, brought to the hospital by the ambulance after having a fall.
What you should do:
Take history, assess the patient and discuss your initial plan of management with the
patient.

Criteria for performing a CT scan for adults:

CT head scan should be performed within 1 hour.
GCS less than 13 on initial assessment in A&E.
GCS less than 15 at 2 hours after head injury on assessment in A&E.
Suspected open or depressed skull fracture.
Any sign of basal skull fracture (hemotympanum, panda eyes, cerebrospinal fluid
leak from ears or nose, battle sign.)
Post-traumatic seizure.
Focal neurological deficit
More than 1 episode of vomiting.

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For patients who have sustained a head injury and the following risk factors.
CT head scan should be performed within 8 hours of the risk factors being identified.
Patient on warfarin.
LOC or amnesia and any of the following:
Age more than 65.
Any history of bleeding and clotting disorder.
Dangerous mechanism of injury e.g., Fall of more than 1 meter or 5 steps, RTA
either is:
>Pedestrian or Cyclist or vehicle occupant.
>More than 30 min retrograde amnesia of event "immediately before the
injury”.

Build rapport
Doctor: I can see from my notes that you had a fall, how are you right now? Patient: I
am fine now doctor thank you.
P1
D: I'd like to have chat with you about what happened, can you tell me more about it?
P: I was out with my friends at a restaurant when I had a fall and then I fainted D: Sorry
to hear that. How long did you remain unconscious?
P: I don't know but I regained my consciousness in the ambulance.

BEFORE – DURING - AFTER

D: Any fits before? (Epilepsy)
P: No.
D: Any heart racing? (AF)
P: No.
D: Did you have your meal as usual? (hypoglycemia)
P: Yes, and also, I was drinking alcohol.
D: How much did you drink?
P: Around 3-4 glasses of wine.
D: Any balance problem while walking? (ataxia)
P: No.
D: Did you feel like the room was spinning? (Meniere's)
P: No.
D: Any trauma to your head?
P: I think when I fell, I hit my head (+ve finding)
D: Any fever/flu-like symptoms? (Confusion)
P: No.
D: Any vomiting?
P: I vomited twice. (+ve finding)
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D: Sorry I have to ask you….by any chance did you bite your tongue or wet yourself after
the fall?
P: No.
D: Apart from this, is there anything else?
P: No
FLAWS +Ask about CT criteria

P2 (PAST HX)
D: Has this ever happened to you before?
P: No.
D: Do you have any medical condition?
P: No.
D: Are you taking any medications?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.

DESA
D: Tell me about your diet?
P: I try to eat healthy.
D: Do you smoke?
P: No.
D: Do you do physical exercise?
P: Not really.
D: Do you have any kind of stress?
P: No.
ICE

Examination:
→ Observations: Measuring BP while lying down & standing.
→ Chest: (examine heart).
→ Head: small bruise on forehead (+ve finding)

Provisional Diagnosis
From the chat we had (mention the positive findings) you told me that you had a head
injury and you fainted. After that you vomited twice, so I suspect that the head injury is
the cause for your loss of consciousness.

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Management:
1. Senior
2. Keep you under observation to monitor you
3. Investigations: you told me that you vomited twice so we will do CT scan to make
sure everything is OK with you. According to the result we will decide if we will
admit you or discharge you
4. Safety netting: if you notice any vomiting, LOC, dizziness or fit call 999.

Fall due to Stock-Adam

Who you are:
You are a FY2 in the orthopaedic department.
Who the patient is:
A 70 year old woman, fell at home a few days ago. She was brought to A & E; she was
diagnosed with fracture neck of femur. The fracture was treated & she is stable.
What you should do:
Talk to her, assess her to find out the cause of the fall.

Build rapport
Doctor: I can see from my notes, that you had fx in your leg few days ago, how are you
now?
Patient: Yes, I am fine now doctor thank you.
D: How did the operation go?
P: It was ok.
D: Any pain?
P: No.
D: How is your hospital stay?
P: It's fine doctor I think you're doing a great job.

P1
D: I'd like to have chat with you about what happened, can you tell me more about
what caused your fracture?
P: I can't remember but my husband said that yesterday, I went pale, then I collapsed.
(+ve finding)
D: How long did this collapse last?
P: About 30 seconds.
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BEFORE – DURING - AFTER

D: So, you lost consciousness?
P: Yes. (+ve finding)
D: Did you have any fit? (Epilepsy)
P: No.
D: Any heart racing? (AF)
P: No.
D: Did you have your meal as usual? (hypoglycaemia)
P: Yes.
D: Any balance problem while walking? (ataxia)
P: No.
D: Did you feel like the room was spinning? (Meniere's)
P: No.
D: Any trauma to your head?
P: No.
D: Any fever/flu like symptoms? (Confusion)
P: No.
D: Sorry I need to ask you this, but by any chance did you bite your tongue or wet
yourself after the fall?
P: No.
D: Apart from this, is there anything else I should know?
P: No.
D: Any other concerns?
P: No.
FLAWS

P2 (PAST HX)
D: Has this ever happened to you before?
P: No.
D: Do you have any medical condition?
P: No.
D: Are you taking any other medications?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: Yes, my mother had a heart condition (+ve finding)
D: Do you know what the name of her condition is?
P: No.

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DESA
D: Tell me about your diet?
P: I try to eat healthy
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Do you do physical exercise?
P: No.
D: Do you have any kind of stress?
P: No.
D: Who do you live with?
P: I live with my husband.
ICE

Examination:
→ Observations: measuring BP while lying down & standing.
→ Chest: (examine heart).

Provisional Diagnosis
From the chat we had (mention the positive findings) you told me that you went pale,
then you fainted, and you have a family history of a heart condition. Taking all that into
consideration, I suspect that you may have a heart condition where the heart rate is
slow or the heart stops beating momentarily.
Many conditions can cause this to happen, one of them is called Stock- Adam's.

Management:
1. Senior
2. Investigations → Blood (All - FBC – RBS).
→ ECG (heart tracing).
3.Medications → Isoprenaline or Epinephrine.
4. Refer to heart specialist who will think of inserting a device called (Pacemaker) if its
confirmed and also do further investigations like Echo-cardiography.
5. Safety netting (Falls)
If she feels that she is dizzy and about to fall, try to be in a safe place.
If she drives → avoid and inform DVLA.

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Falls stations No LOC

(Peripheral – Central)

Peripheral (Ears problems) you will find more details in ENT chapter

BPPV Vestibular neuritis Meniere's

•Triggered by movement of •Triggered by viral infection •DVT (deafness – vertigo –

head. like flu. tinnitus).

•Last only for few seconds or •Have you had any viral •Do you feel fullness in
minutes. infection recently? your ears?

•Nausea without vomiting. •Last for hours. •Do feel any ringing sound
or hissing sound in your
•Nausea, vomiting, hearing ear?
loss (mix of •Do you have any hearing
BPPV & Meniere's). problem or hearing loss?

•Last > 20 min.

• Exclude any Ear infection:

Any pain in your ears?
Any fever?
Any discharge from ears?

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Central Vertigo
(Don’t forget to ask about Head injury)

TIA & Stroke Brain tumor Ataxia Multiple Sclerosis

F A S T 999 Early morning Have you been feeling Muscle spasm &
↓ ↓ ↓ vomiting. unsteady while walking? stiffness, episodic
Facial Arm Slurred Early morning symptoms come
weakness speech headache. Do you have any balance and go.
Weakness problems? Problems with
balance &
Any facial coordination.
weakness or one Vision problems
side headache?

Note:
Meniere's → Bilateral DVT.
Acoustic neuroma → Unilateral DVT.

TIA
Who you are:
You are a FY2 in A&E
Who the patient is:
Lydia Scar 67-year-old lady has been brought to the hospital by her husband due to
weakness on one side of her body, facial dropping and slurred speech 3 hours ago.
Symptoms lasted for 15 mins. General and neurological examination is normal.
Her blood pressure is 150/90. Ct is normal.
Special note
A referral to TIA clinic has been arranged.
What you should do:
Talk to her husband, address his concerns and discuss management plan with him.

- Take DESA in detail - don't forget driving.

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Build rapport
Doctor: I can see from my notes, that your wife had some weakness in her body.
Patient family member: Yes, doctor it was a horrible experience.
D: It must be worrying for you, do you know her condition now?
P: She is ok now.

BEFORE – DURING - AFTER

D: Any loss of consciousness?
P: No.
D: Any fits? (Epilepsy)
P: No.
D: Any heart racing? (AF)
P: No.
D: Did she have your meal as usual? (hypoglycaemia)
P: Yes.
D: Any balance problem while walking? (ataxia)
P: No.
D: Did she feel like the room was spinning? (Meniere's)
P: No.
D: Any trauma to her head?
P: No.
D: Any fever/flu-like symptoms? (Confusion)
P: No.
D: Did she by any chance bite her tongue or wet herself after the fall? Sorry, I have to
ask that…
P: No.
D: Apart from this, is there anything else I should know?
P: No.
D: Any other concern?
P: I am worried if this was a stroke.
D: Is there a reason why you are worried about it being a stroke in particular?
P: I just read about it before.
D: I see where you’re coming from. Just a few more questions and I will address your
concern.
FLAWS

P2 (PAST HX)
D: Has she ever had this problem before?
P: No.
D: Does she have any medical condition like DM, HTN, Cholesterol, or thyroid? P: No.
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MAFTOSA
D: Is she taking any medications?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DESA
D: Tell me about her diet?
P: We eat healthy, home-cooked food.
D: What do you mean by that?
P: We eat plenty of fruit and vegetables and we love to cook.
D: Does she smoke?
P: No.
D: Does she drink alcohol?
P: No.
D: Any physical exercise?
P: Yes, we walk 30mins everyday
D: Do you think she may be stressed about anything?
P: No.

ICE

Examination:
→ Observations: measuring BP: 150/90
→ Chest: (examine heart).

Provisional Diagnosis
From the chat we had (mention the positive findings) you told me that your wife had
arm weakness and slurred speech that lasted for 15 mins and when measured her
blood pressure it was on the higher side. So I suspect she may have a condition called
TIA (mini stroke). This is a momentary decrease in the blood supply to the brain and it’s
either due to narrowing in the blood vessels in the neck or due to some rhythm
problems in the heart and let me assure you it's not stroke.

P: What is the chance of her getting stroke?

D: Unfortunately, the risk of her getting stroke is high.

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Management
1.Senior.
2.Refer to TIA clinic
3. Investigations:
Blood
→ FBC – FBS → Clotting profile.
→ U & E.
→ ECG (heart tracing).
→ CT brain.
→ Doppler on blood vessels of the neck.

•Don’t forget Thyroid in Hx and investigations as a cause AF.

4. Symptomatic
→ Aspirin + BP medications.

5. DESA
You already told me that you are leading a healthy lifestyle, so keep on doing that.

6. Safety netting
If you do take her home, I'd like to inform you about the warning signs of stroke…

Cerebellar ataxia

Who you are:

You are a FY2 in a medical ward.
Who the patient is:
Georgina Dante, 60 years old, has been referred by her GP because of suspicion of
Cerebellar ataxia.
What you should do:
Take history, do relevant examination and discuss a management plan with your
patient.

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P1(ODIPARA)
Doctor: I can see from my notes, that you have been referred from the GP due to some
issues, can you tell me more about that?
Patient: Yes, I am having some problems with balance doctor.
D: Can you tell me more about it?
P: Whenever I walk, I feel like I’m falling.
D: When did it start?
P: 4 months ago.
D: Is it getting worse?
P: No, it's the same.
D: Is anything making it worse or better?
P: No.
D: Apart from this is there anything else worrying you?
P: No.

CEREBELLAR ATAXIA SYMPTOMS

D: Any tremours in your hands?
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P: Yes, I’ve had them about 4 months now too.

D: Any problem with speech?
P: No.
D: Any problem with swallowing?
P: No.
D: Any problem with vision?
P: No.

BEFORE – DURING - AFTER

D: Any loss of consciousness?
P: No.
D: Any fits? (Epilepsy)
P: No.
D: Any heart racing? (AF)
P: No.
D: Have you been having your meals as usual? (Hypoglycaemia)
P: Yes.
D: Do you feel like the room is spinning? (Meniere's)
P: No.
D: Any trauma to your head?
P: No.
D: Any fever/flu-like symptoms? (Confusion)
P: No.
FLAWS

P2 (PAST HX)
D: Have you ever had this problem before?
P: No.
D: Do you have any medical condition?
P: No.
D: Are you taking any other medications?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: Who do you live with?
P: I live with my husband.
D: How is this balance problem you are having affecting your life?
P: It's difficult doctor but I am trying to cope with it.
D: How is your mood?
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P: it's fine

DESA
D: Tell me about your diet?
P: I try to eat healthy.
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Do you do physical exercise?
P: No.
D: Are you under any kind of stress?
P: No.
ICE

Examination:
→ Observations: measuring BP while lying down & standing.
→ Complete neurological examinations.

Provisional Diagnosis
From the chat we had (mention the positive findings) you told me that you have
problems with balance and tremors in your hands. Therefore, I suspect you may have a
problem called ataxia. Ataxia is a term for a group of disorders that affect coordination,
balance and speech.

Management
1.Senior.
2.Neurological review by specialist, then MDT.
3.Routine investigation
4. Occupational therapy: To teach you how to adapt to your gradual loss of mobility
and develop new skills you can use to carry out daily activities.
5. Physiotherapy: This can help you maintain the use of your arms and legs and prevent
your muscles weakening or getting stuck in one position (contractures).
6- Leaflets
7- Support groups: Ataxia UK
8- Safety netting about worsening of the symptoms and epilepsy

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COUGH & HAEMOPTYSIS

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COUGH & HEAMOPTYSIS APPROACH

Exploring any cough:
P1 ODIPARA
❖ When did this cough start? (onset)
❖ Is it continuous? (duration)
❖ Is it a wet or dry cough?
If wet use TRAC (Timing-Relation-Amount-Content)
❖ Is it getting worse or better? (progression)
❖ Have you taken anything for it? (medications)
❖ Apart from this is there anything else?
❖ Is this your main concern?

Then:
5 Symptoms all the time;

SOB-Cough-Fever-Heart Racing-Trauma

Lung cancer: Smoking- gradual onset, progressive.

Mesothelioma: Occupation-asbestos
TB: Travel
PCP: HIV. (Sexual contact- sharing needles in drug use)- If the patient does not know
about his/her HIV status- offer HIV/Hep B testing

Less than 2 weeks:

Pneumonia- PE- Pneumothorax (3Ps)
F.B- Bronchiolitis (for children) (sudden onset of SOB+
localised wheeze)—Fever, blocked nose, chest wheeze,
crepitations.
Asthma (intermittent attacks of cough, wheezes, SOB)

Other causes of a cough include:

- Medications like ACEIs
- Smoker’ cough (heavy smoker+ 3 months of morning wet
cough/year+ Lung function tests showing obstructive pattern+
repeated attacks of chest infections)
- Bronchiectasis (positional, wet, large amount of yellowish/greenish mucus in morning
cough) + / cystic fibrosis (PMHx).

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- Heart failure (cardiac asthma, SOB on laying down+ LL swelling- frothy pinkish
sputum)
- GORD (heartburn- difficulty swallowing/chest pain)
- Asthma

HEMOPTYSIS
DDs:
- Pulmonary embolism (Discussed in the chest pain notes)
- Pneumonia (Discussed in the shortness of breath notes)
- Tuberculosis (Discussed in the shortness of breath notes)
- Bronchiectasis
- Lung cancer: Bronchogenic Carcinoma and Mesothelioma -
Bleeding disorders.
- Use of blood thinners.
- Instrumentation/ bronchoscopy
- False haemoptysis (exclude post. Epistaxis and hematemesis).
N.B: Make sure to differentiate between blood-streaked sputum and frank
haemoptysis and assess hemodynamic stability. Look for symptoms such as
dizziness and drowsiness and assess the number of attacks and volume
of blood loss. Do not forget to check for bleeding elsewhere, including skin
bruises and petechiae.
- DON’T FORGET FLAWS
P2: PAST HX
Have you ever had such pain before?
Any medical condition? (5 conditions)
P3: DESA+SEXUAL HX
MAFTOSA
ICE (IDEA- CONCERN- EXPECTATIONS)

Examination – chest x-ray – routine blood tests- sputum culture.

Provisional diagnosis then Management

7 steps:
1- Admit
2- Senior
3- Investigations
4- Symptomatic + lifestyle
5- Specialist
6- Safety net
7- Follow-up

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PCP

Who you are:

You are a F2 in medicine.
Who the patient is:
Michael, aged 28, presented to the hospital with a cough and shortness of breath for
the past few weeks. Patient is homeless and he is losing weight.
What you should do:
Please talk to the patient, assess the patient, do relevant examination and do
initial management with patient.

IMPORTANT: Ask about sexual and drug history.

P1 (ODIPARA)
Doctor: How can I help you today?
Patient: I have a cough and difficulty in breathing.
D: Tell me more about your cough, how long have you had it?
P: For the past 9 weeks (+ve finding)
D: Do you have this cough all the time or is it on and off?
P: It was on and off when it started, but now it is becoming worse.
D: Do you get any phlegm when you cough?
P: No.
D: Any blood?
P: No.

FIVE SYMPTOMS
D: Any fever?
P: Yes, I’ve a mild temperature but I haven’t measure it.
D: Any flu-like symptoms?
P: Yes, I have runny nose also.
D: Any chest pain?
P: No.
D: Any SOB?
P: Yes (+ve finding)
D: When did your breathing difficulty start?
P: The last few weeks.
D: Is it the same or getting worse with time?
P: It’s worse now.
D: Does anything make it worse?
P: Walking up the stairs, I even have to stop and rest sometimes.
D: Any heart racing?
P: No.
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D: Any trauma to your chest?

P: No.
D: Anything else concerning you? (concern)
P: No.
FLAWS
D: Have you lost any weight?
P: Yes, a few kgs
D: Was it intentional?
P: No.
D: Do you have night sweats?
P: Yes, in the last few weeks.

DDs OF COUGH > 3WKS

P2
D: Have you had this cough before?
P: No.
D: Do you have any chronic condition?
P: No.

DESA+SEXUAL HX
D: Tell me about your diet?
P: I eat everything.
D: Do you do physical exercise?
P: I try to be active.
D: Do you smoke?
P: Yes, 20 cigarettes a day for the past 10 years (+ve finding)
D: Do you drink alcohol?
P: No.
D: Sorry, I need to ask you some questions that might sound a bit intrusive. Have you
been taking any recreational drugs?
P: Yes, heroine for the past few years. (+ve finding)
D: How do you take it?
P: I inject.
D: Do you share needles?
P: Yes, sometimes. (+ve finding)
D: Some questions about your private life, are you sexually active?
P: Yes.
D: Do you have a stable partner?
P: No, I have many partners. (+ve finding)
D: Do you practice safe sex?
P: Sometimes.
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D: When was the last time you had unprotected sex?

P: A few days ago.
D: What is your sexual orientation?
P: I am gay / bisexual.
D: Sorry I have to ask you, do you engage in oral, anal or vaginal sex, or all three?
P: All three.
D: Have you been tested for any HIV or HepB?
P: No.

MAFTOSA
D: Are you currently taking any medications, over-the-counter
drugs or supplements?
P: No.
D: Any long-term steroids, antibiotics or chemotherapy?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical
condition?
P: No.
D: Any family member with similar symptoms or any lung
problems?
P: No.
D: What do you do for a living?
P: I am unemployed.
D: Could you please tell me about your home situation?
P: I don’t have home; I’ve been living on the streets for the past 2 years.
D: Have you travelled overseas recently?
P: No.
DON'T FORGET ICE

EXAMINATION
I would like to check your vitals and examine your chest.
I would like to send for some initial investigations including routine
blood tests. ABG and CXR.

PROVISIONAL DIAGNOSIS
From the chat we had (mention the positive findings) I have come to know that you’ve
had a cough for 9 weeks and you are sexually active with multiple
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partners. You are also taking heroin and sharing needles, so I am suspecting you have a
lung infection caused by a type of fungus called PCP. This infection mostly occurs in
people who have low immunity, so we need to do further investigations to exclude
other causes like HIV.

Management:
1- Admit
2- Senior
3- Investigations
→ offer HIV, Hep B and other STIs tests.
4- Medication
→ O2 and IV fluids if needed
→ antibiotics through your veins Co-trimoxazole
→ Steroids maybe given to reduce the inflammation.
→ avoid needle sharing and offer needle exchange program if he is
willing to quit, offer rehabilitation admission.
→ practice safe sex, offer partner screening, if refused, partner
notification anonymously after explaining the benefits of it.
→ offer social services support and accommodation.
5- Specialist
6- Safety net
→ worsening of symptoms.
7- Follow up

Tuberculosis
Who you are:
You are a F2 in A&E.
Who the patient is:
Thomas aged, 29, presented with a cough and SOB.
What you should do:
Talk to the patient, take relevant history, assess the patient and outline the plan of
management with him.

Important: Ask about travel hx

P1 (ODIPARA)
Doctor: How can I help you today?
Patient: I have a cough and difficulty in breathing.
D: I am sorry to hear that, can you tell me more about the cough? How long have you
had it?
P: For the past 7 weeks (+ve finding)
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D: Do you have this cough all the time or is it on and off?

P: It was on and off when it started, but now it is becoming worse.
D: Is anything making it worse?
P: No.
D: Do you get any phlegm when you cough?
P: Yes (TRAC)
D: Can you tell me more about it?
P: It started at the same time. It’s green with streaks of blood and not
too much in amount.
D: Anything else?

FIVE SYMPTOMS
D: Any fever?
P: Yes, mild temperature but I haven’t measured it.
D: Any flu-like symptoms?
P: Yes, I have runny nose also.
D: Any chest pain?
P: No.
D: Any SOB?
P: Yes (+ve finding)
D: When did your breathing difficulty start?
P: In the last few weeks.
D: Is it the same or getting worse with time?
P: It is worse now.
D: Does anything make it worse?
P: Walking up the stairs, I even have a rest sometimes halfway.
D: Any heart racing?
P: No.
D: Any trauma to your chest?
P: No.
D: Anything else concerning you? (concern)
P: No.

FLAWS
D: Have you lost any weight?
P: Yes, a few kgs.
D: Was it intentional?
P: No.
D: Do you have night sweats?
P: Yes, in last few weeks.

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DDs OF COUGH > 3WKS

P2
D: Have you had this cough before?
P: No.
D: Do you have any chronic condition?
P: No.
DESA+SEXUAL Hx
D: Tell me about your diet?
P: I try to eat healthy.
D: Do you do physical exercise?
P: I try to be active.
D: Do you smoke?
P: Yes, 20 cigarettes a day for the past 10 years (+ve finding)
D: Do you drink alcohol?
P: No.
D: Sorry, I need to ask you questions that sound a bit intrusive. Have you
been taking any recreational drugs?
P: No.
D: Some questions about your private life also, are you sexually active?
P: Yes.
D: Do you have a stable partner?
P: Yes.
D: Do you practice safe sex?
P: Yes.

MAFTOSA
D: Are you currently taking any medications, over-the-counter
drugs or supplements?
P: No.
D: Any long-term steroids, antibiotics or chemotherapy?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical
condition?
P: No.
D: Any family member with similar symptoms or any lung
problems?
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P: No.
D: What do you do for a living?
P: I am an accountant.
D: Have you travelled overseas recently?
P: Yes, I went to India 3 months ago.
D: How long did you stay there?
P: 4 weeks.
DON'T FORGET ICE

EXAMINATION
I would like to check your vitals and examine your chest.
I would also like to send for some initial investigations including routine
blood tests. ABG and CXR.
PROVISIONAL DIAGNOSIS
From the chat we had (mention the positive findings) I understand that you have had a
cough with sputum for 7 weeks and you’ve travelled to India recently, so I suspect that
you have a lung infection caused by bacteria,
called tuberculosis.

Management:
1- Admit
2- Senior
3- Investigations
4- Medication
→ give 6 months of anti-TB drugs (INH+ Rifampicin+ Pyrazinamide+
Ethambutol). The last two are only given for the first two months
(PE).

Advice and precautions:

→ Stay off work/University/school, etc. until you are told you’re safe to
return.
→ Self-isolation for the first three weeks until the antibiotics start
working. (As you are infectious during this period, until the
antibiotics work)
→ Stay in well-ventilated places and away from people. Sleep in
another room. Cover your mouth with disposable tissue if you cough.
→ You will feel better in several weeks. You must continue to take it
for whole duration of 6 months as you might relapse and even get
more severe serious wide-spread symptoms. Your body you might
become resistant to the bacteria and it will be difficult to find other
antibiotics to manage it.
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→ Watch out for bone pain, fits, lumps or swollen glands, diarrhoea,
change in urine color, blood in urine or sputum, worsening of
symptoms.
5- Specialist
Chest specialist for CT chest or further testing (for example:
BAL/Bronchoscopy) and management if complicated, atypical, or
underlying cancer is suspected.
6- Safety net
→ Worsening of symptoms: persistent fever, SOB or chest pain. If he/she becomes
drowsy, dizzy, or noticed to be confused (septic shock).
7- Follow-up.

Lung Cancer
Who you are:
You are a F2 in GP clinic.
Who the patient is:
Jack, aged 70, presented with a cough and SOB.
What you should do:
Talk to the patient, take relevant history, assess the patient and
outline the plan of management with him.

Important:
Carcinoma → +ve fhx and smoking
Mesothelioma → working with asbestos + only palliative treatment.

P1 (ODIPARA)
Doctor: How can I help you today?
Patient: I have a cough.
D: Sorry to hear that, can you tell me more about the cough? How long have you had it?
P: For the past 2 months (+ve finding)
D: Do you have this cough all the time or is it on and off?
P: It was on and off when it started, but now it is becoming worse.
D: Is anything making it worse?
P: I don’t know.
D: Do you get any phlegm when you cough?
P: No.
D: Any blood?
P: Yes, I coughed blood a few times this week. (Any bleeding, ask about
blood disorder, blood thinner, fhx, trauma, bleeding anywhere else)

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D: Could you tell me more about?

P: It was like a small amount of bright red (frank) blood.
D: Anything else?

FIVE SYMPTOMS
D: Any fever?
P: No.
D: Any chest pain?
P: No.
D: Any SOB?
P: Yes. (+ve finding)
D: No.
D: Any heart racing?
P: No.
D: Any trauma to your chest?
P: No.
D: Anything else concerning you? (concern)
P: I am worried it might be lung cancer.
D: May I know why?
P: Because my father had it before. (+ve finding)
D: I am really sorry about that, how's he doing?
P: He's dead.
D: I am really sorry, please accept my condolences.
FLAWS
D: Have you lost any weight?
P: Yes, few kgs in the last few weeks. (+ve finding)
D: Was it intentional?
P: No.
D: Do you have night sweats?
P: Yes, in the last few weeks. (+ve finding)

DDs OF COUGH > 3WKS

P2
D: Have you had this cough before?
P: No.
D: Do you have any chronic condition?
P: No.

DESA+SEXUAL HX
D: Tell me about your diet?
P: I try to eat healthy.
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D: Do you do physical exercise?

P: I try to be active.
D: Do you smoke?
P: Yes, 20 cigarettes a day for the past 10 years (+ve finding)
D: Do you drink alcohol?
P: No.
D: Sorry, I need to ask you questions that sound a bit intrusive. Have you
been taking any recreational drugs?
P: No.
D: Also, some questions about your private life, are you sexually active?
P: No.

MAFTOSA
D: Are you currently taking any medications, over-the-counter
drugs or supplements?
P: No.
D: Any long-term steroids, antibiotics or chemotherapy?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical
condition, other than your father’s cancer diagnosis?
P: No.
D: Any family member with similar symptoms or any lung problems
other than your father?
P: No.
D: What do you do for a living?
P: I am retired.
D: Have you travelled overseas recently?
P: No.
DON'T FORGET ICE

EXAMINATION
I would like to check your vitals and examine your chest.
Also, I would like to send for some initial investigations including routine
blood tests, ABG and CXR.

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PROVISIONAL DIAGNOSIS
From the chat we had (mention the positive findings) I have come to know that you
have had a cough and sometimes you’ve been coughing blood and you told me that you
smoke and the fact that your father had lung cancer: Best-case scenario it might be an
infection and worst-case scenario it might
be something serious like cancer.

Management:
1- Fast track referral within two weeks to a specialist.
2- Senior
3- Investigations
→ FBC- Infection markers- LFT/KFT/U&E-urine analysis and
osmolarity- CXR- ECG- Heart attack markers (smoker, old age)- Lung
Function Test- US on Liver is suspected metastasis.
→ Symptomatic: O2 if short of breath, antibiotics are complicated by
pneumonia.
4- Medication
The specialist will be in a better position to discuss the options with
you which can be surgical, chemotherapy, radiotherapy.

5- Specialist
→ CT scan chest, abdomen, brain. Bone scans. Bronchoscopy and
biopsy.
→ Pleural biopsy in mesothelioma. MDT (chest, oncology,
cardiologist) for plan of management
→ Don’t forget to offer support to the patient (family, friends, support
groups)
6- Safety net
→ Worsening of symptoms, being drowsy, confused, low mood.
7- Follow-up

Pneumonia

Who you are:

You are an F2 in A&E.
Who the patient is:
Daniel, aged 53, presented with a cough.
What you should do:
Talk to the patient, take relevant history, assess the patient and
outline the plan of management with him.

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P1 (ODIPARA)
D: How can I help you today?
P: I have a cough.
D: Sorry to hear that, can you tell me more about your cough? How long have you had
this cough?
P: For the past 10 days. (+ve finding)
D: Do you have this cough all the time or is it on and off?
P: On and off when it started.
D: Is anything making it worse?
P: No.
D: Do you get any phlegm when you cough?
P: Yes.
D: Tell me more about it? (TRAC)
P: It's green in colour and started 3 days ago, not too much in
amount.
D: Any blood?
P: No.
D: Anything else?

FIVE SYMPTOMS
D: Any fever?
P: Yes, it started at the same time as cough. (+ve finding)
D: Any chest pain?
P: No.
D: Any SOB?
P: Yes, I think it's related to the cough. (+ve finding)
D: Any heart racing?
P: No.
D: Any trauma to your chest?
P: No.
D: Anything else concerning you? (concern)
P: No.
FLAWS
D: Have you lost any weight?
P: No.
D: Do you have night sweats?
P: No.

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DDs OF COUGH < 2 WKS

P2
D: Have you had this cough before?
P: No.
D: Do you have any chronic condition?
P: No.

DESA
D: Tell me about your diet?
P: I try to eat healthy.
D: Do you do physical exercise?
P: I try to be active.
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.

MAFTOSA
D: Are you currently taking any medications, over-the-counter
drugs or supplements?
P: No.
D: Any long-term steroids, antibiotics or chemotherapy?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical
condition?
P: No.
D: Any family member with similar symptoms or any lung
problems?
P: No.
D: What do you do for a living?
P: I am a lawyer.
D: Have you travelled overseas recently?
P: No.
DON'T FORGET ICE
EXAMINATION
I would like to check your vitals and examine your chest.
I also would like to send for some initial investigations including routine
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blood tests, ABG and CXR.

Findings
Temperature 39
02 Sat 94%
CXR Prominent hilar markings in central area.

PROVISIONAL DIAGNOSIS
From the chat we had (mention the positive findings) I know that you have had a cough
with sputum and a fever. Also, the chest x-ray showed
some changes, so I suspect that you have a lung infection called pneumonia.

Management:
1- Admission
Indications for admission in pneumonia
→ CURB 65 (Confusion- Urea- RR- Bp low- age 65)
* Urea: 7 or more
* RR: 30 or more
* BP: Systolic <90, Diastolic < 60.
→ Each one is equal to 1 point. Admission If score is 3 or more.
→ Clinical judgement is used in admission rather than sticking to
these criteria.
→ Anytime the patient is homeless, elderly, with lack of social
support, admission should be offered.
2- Senior
3- Investigations
→ FBC- Infection markers- LFT/KFT/U&E-urine analysis and
osmolarity- CXR- ECG- Heart attack markers (smoker, old age)- Lung
Function Test- US on Liver is suspected metastasis.
4- Medication
→ Symptomatic
* O2 &IV fluids if needed
* Antibiotics according to the hospital protocol (usually CoAmoxiclav 1.2 TDS IV+
Clarithromycin 500 BD PO/IV for 5-10 days
* Painkiller.
6- Safety net
→ worsening of symptoms being drowsy, confused, low mood.
7- Follow-up
→ Continuous monitoring of observations and symptoms.

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ASTHMA
Who you are:
You are a F2 in a GP surgery.
Who the patient is:
Randy, aged 18, presented to the hospital with chest tightness.
What you should do:
Take a focused history, assess the patient, discuss diagnosis and about
management plan.
Don't forget to ask about triggers, any type of allergies and FHX.

P1 (ODIPARA)
Doctor: How can I help you today?
Patient: I have chest tightness
D: Tell me more about it?
P: It started few months ago. I get it when I’m cycling.
D: What about at other times?
P: I am fine.
D: Is it the same since it started?
P: It is getting worse.
D: Is there any thing that makes it worse or better?
P: Gets better when I rest.
D: Apart from this, is there anything else?
P: I have noisy breathing (+ve finding)
D: Tell me more about it?
P: It happens every time I have the tightness.
D: Anything else?

FIVE SYMPTOMS
D: Any fever?
P: No.
D: Any chest pain?
P: No.
D: Any SOB?
P: Yes, at the same time as the tightness. (+ve finding)
D: Any heart racing?
P: No.
D: Any trauma to your chest?
P: No.
D: Any cough? (+ve finding)
P: Only when I have the chest tightness.
D: Anything else concerning you? (concern)
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P: No.
FLAWS

D: Have you lost any weight?

P: No.
D: Do you have night sweats?
P: No.

Important: Uncontrolled asthma signs and symptoms drowsy, blue lips, unable to talk.
P2
D: Have you had this cough before?
P: No.
D: Do you have any chronic condition?
P: Yes, I have eczema, and I take steroids for it. (+ve finding)
Triggers
D: Do you have any pets in the house?
P: No.
D: Is there anything that triggers the tightness other than cycling?
P: No.

DESA
D: Tell me about your diet?
P: I try to eat healthy.
D: Do you do any physical exercise?
P: Yes, I cycle.
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
MAFTOSA
D: Are you currently taking any medications, over-the-counter drugs or
supplements other than steroid creams?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: Yes, my sister has asthma. (+ve finding)
D: How is she doing?
P: She is ok, thanks.
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D: What do you do for a living?

P: I am a student.
D: Have you travelled overseas recently?
P: No.
DON'T FORGET ICE

EXAMINATION
I would like to check your vitals and examine your chest.
I would also like to send for some initial investigations including routine blood
tests, ABG and CXR.

PROVISIONAL DIAGNOSIS
From the chat we had (mention the positive findings) I know you have had some chest
tightness and noisy breathing, plus your sister has asthma and you have eczema, so I
am suspect that you may have asthma, which is the narrowing of your airways.

ASTHMA MANAGEMENT (3 Presentations)

1) MANAGEMENT OF ACUTE SEVERE ASTHMA, NOW STABLE AND GETTING
DISCHARGED
1. Check for control: Monitor with PEFR measurement/ recording on
asthma diary.
2. Do the PEFR:
3. Explain how it is done at home:
• This is a device we use in such situations in order to assess that
you are fit to go home.
• Parts: pointer- mouth part- cylindrical part.
• Make sure the pointer is on Zero and hand is not blocking it.
• Instructions to the patients:
a) We will need you sit straight upright/ or standing.
b) Take a deep breath in.
c) Make a tight a seal around the mouth part.
d) Blow as hard and as fast as you can.
e) We will need to do this 3 times and get the highest reading. Then
plot it on the chart.
f) When you go home: do it at twice a day, for a week. Every time,
do it 3 times and record the highest reading.
g) Plot it on the chart.

Interpretation
- The normal PEFR is 75% of what is normal for his age, gender and height.
- Example: a patient’s normal reading for age/height is 600- patient’s
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reading now is 450. To calculate the appropriateness for age,

height and gender as compared to normal: 450/600= When
plotting it:
If line is going up: IMPROVING—come at your next scheduled appointment.
If it’s the same: NOT IMPROVING—then make a follow-up appointment before that.
If it is going down: GETTING WORSE- come to the hospital immediately.

Explain the medications:

• When getting discharged after acute asthma, you will need these three
medications:
- Salbutamol inhaler (blue reliever)- used when needed. 2 puffs/maximum 4 times a
day.
- Beclomethasone inhaler (brown controller= 2X2X2) 2 puffs twice
a day for 2 weeks.
- Prednisolone tablets (1X 3). 1 tablet 30 mg for 3 days.
• Mechanism of action: reliever and a controller.
• Explain how to use the inhalers in detail:
- Check the expiry date (open it to check)
- Shake it.
- Remove the cap.
- Exhale
- Make a tight seal around mouth part.
- While you press the canister, take a deep breath in - Repeat as
required.
- Rinse your mouth and gargle.
• Dose & form: inhaler—tablet.
• Side effects:
- Salbutamol: heart racing & shaky hands.
- Beclomethasone: fungal infection- gargle after the dose.
- Oral prednisolone: short-term low dose does not cause side
effects. (Do not take it on empty stomach)
• Precautions/contraindications/ interactions:
- expiry date- suitable in pregnancy.
- Do not take it on empty stomach for prednisolone (Peptic
Ulcer).
- Gargle after brown inhaler.

Safety netting:
- Not improving (severe SOB& chest pain).
- Signs of lack of control: Night symptoms- affecting your
everyday activities, more than 3 times a week use of inhaler,
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come back.
Action plan to act when you have an attack:
- Take blue reliever 2 puffs/repeat again if not improving until
10 puffs.
- Call 999 if not improving/ blue/unable to talk

Follow up: after two weeks: At GP clinic, discuss triggers to be avoided (smoking, pet,
pollens, pollutants). Use the asthma diary to record the symptoms to make sure you
asthma is well controlled.

2) MANAGEMENT OF EXERCISE INDUCED ASTHMA

- Investigations: PEFR----run on treadmill then spirometry.
- Symptomatic: blue reliever for home+ advice about exercise:
Exercise indoors
Use the inhaler before exercise.
Warm up and cool down.
Cover your nose in cold weather.
Do short duration exercise.
Use humidifier for dry air.
Avoid cold air.
Safety net: for SOB if not relieved, drowsy, blue lips, unable to talk. Uncontrolled
asthma signs and symptoms as above.
Give acute severe asthma (action plan)— (puffs up to 10- call
ambulance if not improving).
- F.UP. (diary- PEFR- symptoms).

3) MANGEMENT OF ACUTE SEVERE ASTHMA (SIMMAN)—COVERED IN DR MO SOBHY

ACADEMY.

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PEFR CHART

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ASTHMA DIARY

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PAEDIATRICS

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Paediatrics
Structure

N.B: In paediatrics you must confirm identity (Relationship to child, child’s name and DOB). If
it’s a new-born, ask if it was a planned pregnancy, and congratulate her on having the baby.
P1:

Presenting complaint (explore) SOCRATES (in pain) or ODIPARA

Anything else (explore)
Concern: ICE (Idea – Concern – Expectations)
What’s your main concern apart from….
DDs:
All paediatrics stations head to toe
Ears:
Fever
Pulling his ears
Discharge
When you speak to him, he doesn’t respond.

Trauma:
Any injuries?
Any trauma?

Meningitis:
Fever, vomiting?
Shy away from light?
Pain (crying) when you carry him?
Contact?

SOL:
Early morning vomiting?
Crying in the morning?

Nose:
Any discharge from nose (TRAC) Timing Relation Amount Content

Mouth:
Vomiting
Diet question

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Eye:
Discharge
Inability to open his eyes in the morning?

Lungs:
Difficulty in breathing?
Cough (TRAC)
Sputum?

Gastro-intestinal:
Vomiting
Diarrhoea, how is his poo?(Stool)
Fever
Contact
Diet in details
Over feeding
Or any problems with his poo?

UTI:
Fever
Smelly urine
Crying while passing urine
Does he cry while having a wee? (urine)
Or any problems with his wee?
You will explore all symptoms about your station but quick check on each system (2
questions max)

P2:
Past hx of presenting complaint
Past medical conditions?
BIRD DDD
B: Birth
Is he full term or preterm?
How was his birth?
Any problems during or after birth?
I: Immunisation
Is he up to date with his jabs?
When was his last jab? / What?
R: Red book
Does he have a red book?
When you take him to the doctor any concerns about his red book?
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D: Development
How is his development?
Is it okay in comparison to others of his age?
D: Diet
What do you feed him?
Any change to his diet?
If he is breast feeding? So, any changes to your diet?
Is he gaining weight?
Any lactose intolerance?

D: Dehydration
GENERAL QUESTION: Is your baby active and playful?
Mild:
Dry mouth
Crying without tears?
Not wetting his nappies as often? (Not passing enough urine)
Severe:
Not himself?
Drowsy?
Sleeping a lot?
Not active and playful?

D: NAI (Damage- ‫)ضب‬ ‫ر‬

Do you have a social worker involved?
Who do you and Adam live with?
How are things at home?

MAF
Medications
Allergies
Family history of any conditions?
Do you have other children?
Do you have any health conditions that run in family?
Examination
Provisional Diagnosis
Management: 7 steps

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Pyloric stenosis

Who you are:

You are an FY2 in a paediatric department.
Who the patient is:
5-week-old, Adam, was brought by his mother for persistent vomiting for the past 2
days.
What you should do:
Talk to the mother and address her concerns.

NB: DON’T FORGET Dehydration, ABG.

Pyloric stenosis:
1- Projectile vomiting goes far, not dribbling, soon after food (milk).
2- Baby is always hungry.
3- No pain (intussusception), no fever DDs (meningitis).
4- Risk Factors:
• Strong family hx?
• The fact that he is 6 weeks old.
• The fact that he is a boy and the first child.

P1 (ODIPARA)+ (TRAC)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: I Can see from my notes that you’re here today because of your son, can you
tell me more about him?
Patient’s Relative: My baby has been vomiting for 2 days, every time I feed him.
D: How long does he take to vomit after you have fed him? (onset)
PR: Usually 15 minutes after feeding.
D: Could you describe the vomiting?
PR: It’s projectile and goes far across the room. (+ve finding)
D: How much is it in amount?
PR: The whole amount I breastfed him.
D: What’s the content?
PR: It’s just the milk
D: Any blood in there?
PR: No.
D: Have you noticed anything else?
PR: No.
Concern
D: Apart from this, do you have any other concern?
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PR: I just want to know what’s wrong with my baby

DDS:
Mainly pain for intussusception, head trauma for vomiting and over
feeding + 3 more DDs from head to toe.
D: Does he pull his knees toward his chest OR cry a lot?
PR: No.
D: By any chance, has he had any trauma to his head?
PR: No.
D: Any fever?
PR: No.
D: Any rash?
PR: No.

P2
D: Has he had this problem before?
PR: No.
D: Has your baby been diagnosed with any medical condition?
PR: No.

BIRD DDD
Don’t forget DEHYDRATION.
D: Is your baby active and playful?
PR: He hasn’t been himself in the last 2 days doctor. (+ve finding)
D: Doe he wet his nappies as usual?
PR: Yes.
D: Is he drowsy or floppy?
PR: No.
DIET:
D: What do you feed him?
PR: He is only breastfed.
D: Any changes to your diet?
PR: No.
NAI
D: Who do you live with other than Adam?
PR: My husband.
D: And is he Adam’s dad?
PR: Yes.

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D: Do you have any other children.

PR: No.
D: Is everything ok at home?
PR: Yes, we are a lovely family.
MAF
D: Any medication including OTC medicines?
PR: No.
D: Any allergies?
PR: No.
D: Any family history of a similar problem?
PR: No.

Examination:
• Observations: to exclude dehydration
• Tummy
• Head to toe
• ABG

Provisional dx:
From the information you have given me (vomiting is projectile/ only
son/ the fact he is a boy/ age 6-8 weeks) and according to my
examination I suspect he may have a condition called pyloric stenosis. It
is a condition of the tummy. You see, usually our tummy (gut, or
stomach) is connected to the bowel, the outlet is called pylorus, any
narrowing in the opening is called pyloric stenosis.

PR: Dr, is it serious?

D: It is not serious, and we can rectify it, but I am afraid he will require
surgery.
Management

1- Admit

2- Senior

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3- Investigations:

• Blood (all) mainly ABG, blood gases metabolic alkalosis (low

HCO3)
• Us: to confirm Dx we need to do gel scan.

4- Symptomatic:
Fluids through his veins (vvimp)

5- Specialist:

Paediatric surgeon: It will be corrected by keyhole surgery, which is

small cut in his tummy to widen the narrowing.

6- Complications of surgery must be mentioned:

Well, there are some complications for the surgery, like any surgery,
such as getting an infection. However, it’s not common.

Intussusception

Who you are:

You are an FY2 in an emergency department.
Who the patient is:
GP referred 20-month-old Andrew, he was crying, vomiting, lethargic.
What you should do:
Take hx, manage the patient and address the mother’s concerns.

Symptoms of intussusception:
Crying (i.e., in pain)
Vomiting (address concerns)
Lethargic (i.e., may be dehydrated))
Red currant jelly stool.

Complications (risk factors):

1. You must ask about dehydration
2. Ask about family
3. Diet: all diet questions
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4. Overfeeding: important as child is vomiting

5. Intolerance to dairy product

P1 (ODIPARA)+ (TRAC)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: I can see from my notes that your son was referred to us by your GP, can you
tell me more about him?
Patient’s Relative: He has been crying and vomiting all morning.
D: Did the GP discuss anything with you?
PR: No.
D: Is he pulling his legs towards his tummy?
PR: Yes.
D: Is there anything that makes it better or worse?
PR: Whenever I try to touch his tummy, he cries a lot.
D: Is it getting worse?
PR: He is crying more now.
D: Could you describe the vomiting?
PR: it’s green, he vomited 3 times.
D: How much is it in amount?
PR: Not too much.
D: Does the vomiting go far across the room?
PR: No.
D: What’s the content?
PR: It seems to be the milk I give him.
D: Any blood in there?
PR: No.
D: Have you noticed anything else?
PR: When I was changing his nappies, I noticed some red jelly like poo.
D: How many times did you notice this?
PR: Twice.
Concern
D: Apart from this do you have any other concern?
PR: I just want to know what’s wrong with my baby.
DDs:
Mainly Swelling in the groin (obstructed hernia) Swelling & redness in scrotum (torsion
tests) Fever (meningitis) Head trauma
D: Did you notice any swelling in his tummy or groin?
PR: No.
D: By any chance, any trauma to his head?
PR: No.
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D: Any fever?
PR: No.
D: Any rash around his scrotum?
PR: No.

P2
D: Has he ever had this problem before?
PR: No.
D: Has your baby been diagnosed with any medical condition?
PR: No.

BIRD DDD
Don’t forget DEHYDRATION.
D: Is your baby active and playful?
PR: He hasn’t been himself all morning. (+ve finding)
D: Does he wet his nappies as usual?
PR: Yes.
D: Is he drowsy or floppy?
PR: No.
DIET:
D: What do you feed him?
PR: He has what we eat, homecooked food.
D: Any changes to your diet?
PR: No.
NAI
D: Who do you live with other than Andrew?
PR: My husband.
D: And is he Andrew’s dad.
PR: Yes.
D: Any other children?
PR: No.
D: Is everything ok?
PR: Yes, we are a lovely family.
MAF
D: Any medication including OTC medicines?
PR: No
D: Any allergies?
PR: No.

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D: Any family history of a similar problem?

PR: No.

Examination:
➢ Observations (dehydration)
➢ Tummy (examine, there may be a mass)
Provisional DX:
From the chat we had you mentioned that your son is crying a lot and
you noticed red jelly stool in his nappy, so I am suspecting a condition
called Intussusception. This is a condition of the tummy. As you know
our bowel is like a tube, when a part of it goes inside another part like a
telescope, then this causes an obstruction. I’m afraid it’s serious if we
don’t treat it immediately.

Management:
1- Admit
2- Senior
3- Investigations:
➢ Blood (all +ABG blood gases)
➢ Us (doughnut or target sign)
➢ X-ray erect (perforation)
4- Symptomatic:
➢ Fluids through veins
➢ Painkillers
5- Specialist:
2 types of treatment, interventional radiology or surgery.
We have two ways of managing this condition:

1- We’ll try a simple procedure, where our radiology specialist will try to
push air and water through the bowel. This is called an enema, with the
hope that it will rectify the problem.

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2- Operation- Surgery to correct this if we fail with the enema, if > 24

hours & had perforated & has caused peritonitis. (Generalized
tenderness)

When can I take him home? It depends if it’s corrected.

➢ Through enema (day or two)
➢ Surgery (within 4 days if no complications)

In the meantime, we will be keeping an eye on:

➢ His symptoms
➢ Bleeding
➢ Fever or signs of infection.
Dr, can it happen again?

Answer: Very rarely 5-15%

Comparison between (vvimp):

- Pyloric stenosis:
1- Vomiting only + dehydration
2- ABG + Us
3- Only surgery
- Intussusceptions:
1- Vomiting
2- Pain
3- Diarrhoea
4- Dehydration
5- ABG+ US+ x-ray for perforation
6- Enema or surgery exclude cause of pain (torsion testis/ hernia)

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Bronchiolitis
Who you are:
You are an FY2 in paediatric department.
Who the patient is:
9-month-old, Adam Yank, was brought in by his mum with a fever,
crying & poor feeding.
What you should do:
Talk to the mother, address her concerns, and discuss the management
with her.

Don’t forget it’s viral, self-limited - Don’t forget to ask about dehydration

Symptoms:
• Rapid breathing.
• Finding it difficult to feed.
• Noisy breathing (wheezing).
• Becoming irritable.
• Symptoms are usually worst between days 3 and 5, and the cough usually gets
better within 3 weeks.

Red Flags:

• Your child is having difficulty breathing – you may notice grunting noises or
their tummy sucking under their ribs.
• There are pauses in your child’s breathing.
• Your child's skin, tongue or lips are blue.
• Your child is floppy and will not wake up or stay awake.

Risk factors:
• Passive smoker: Ask about any smoker(s) in the house.
• Premature (birth)< 37 weeks.
• Chronic lung conditions.
• Nursery (attending crowded places).
• Family hx of asthma.
P1 (ODIPARA)+ (TRAC)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: I can see from my notes that your son is here because he is not feeling very
well, can you tell me more about it?
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PR: He is crying a lot, has some difficulty in breathing and I think he is feverish.
D: When did you notice that?
PR: 2 days ago, and I gave him some paracetamol syrup but he is not improving.
D: Is there anything making it better or worse?
PR: No.
D: Have you noticed any cough?
PR: No.
D: Have you noticed anything else?
PR: No.
Concern
D: Apart from this do you have any other concern?
PR: I just want to know what’s wrong with my baby.
ASK ABOUT THE REST OF THE SYMPTOMS
DDS:
Head to Toe but Mainly MENINGITIS and UTI.
D: Did you notice any rash?
PR: No.
D: By any chance, any trauma to his head?
PR: No.
D: Does he cry when he pees?
PR: No.
D: Any offensive smell coming from his urine?
PR: No.

P2
D: Has he ever had this problem before?
PR: No.
D: Has your baby been diagnosed with any medical condition?
PR: No.

BIRD DDD
Don’t forget DEHYDRATION.
D: Is your baby active and playful?
PR: He’s not been himself the past 2 days (+ve finding)
D: Does he wet his nappies as usual?

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PR: Yes.
D: Is he drowsy or floppy?
PR: No.

DIET:
D: What do you feed him?
PR: He is mostly breastfed, but he has little bits of baby food too.
D: Any changes to your diet?
PR: No.
D: Is he feeding well?
PR: He hasn’t been feeding well the past two days.

NAI
D: Who do you live with other than Adam?
PR: My husband.
D: And is he Adam’s dad?
PR: Yes.
D: Any other children?
PR: No.
D: Is everything ok at home?
PR: Yes, we are a happy family.
MAF
D: Any medication including OTC medicines?
PR: No.
D: Any allergies?
PR: No.
D: Any family history of a similar problem?
PR: No.

Examination:
• Observations (dehydration)
• Vitals
• Chest: (fever/ crackles or wheeze / spO2 92%)

Provisional DX:
From the chat we had, I am suspecting a condition called bronchiolitis,
which is an infection of the lungs by a virus-kind of organism (called
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respiratory syncytial virus). It’s self-limited and there’s no need for

Abx, however we need to stabilize the child so we will:

Management:
1- Admit.
2- Senior.
3- Investigations
➢ Blood: all blood ABG + blood gases
➢ Sample of discharge (nasopharyngeal aspiration)
➢ Chest x-ray
4- Symptomatic
➢ I.V fluids
➢ O2 + paracetamol
➢ Nebulization with salbutamol
5- Safety netting:
➢ Fever
➢ Fit
➢ Rash (meningitis)
➢ Persisting of the condition

Dehydration
Who you are:
You are an FY2 in paediatrics.
Who the patient is:
10-month-old Rayan has been sick for 2 days and he is in the triage call
care, his mother Sharon is concerned about him.
What you should do:
Talk to the mother and address her concerns.

P1 (ODIPARA)+ (TRAC)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: How can I help you?
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Patient’s Relative: Well, my son has been sick for the last 2 days.
D: Can you tell me more about that?
PR: He is sleepy most of the time and I think he has a fever.
D: Have you measured it?
PR: No.
D: Is there anything that makes it better or worse?
PR: I gave him paracetamol syrup, but he is not improving.
D: Have you noticed anything else?
PR: No.
Concern
D: Other than this, do you have any other concern?
PR: I just want to know what’s wrong with my baby.

DDS:
Head to toe: Don’t forget contact hx with any infectious illness has he been
in contact with
D: Did you notice any rash?
PR: No.
D: Has he, by any chance, had any trauma to his head?
PR: No.
D: Does he cry when he pees?
PR: No.
D: Any discharge from his nose?
PR: No.
P2
D: Has he had this problem before?
PR: No.
D: Has your baby been diagnosed with any medical condition?
PR: No.

BIRD DDD
Don’t forget DEHYDRATION.
D: Is your baby active and playful?
PR: No, he’s not himself in the last 2 days he’s just sleeping a lot. (+ve
finding)
D: Does he wet his nappies as usual?
PR: Not really as often as usual. (+ve finding)
D: Is he drowsy or floppy?
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P: Yes, he is floppy. (+ve finding)

DIET:
D: What do you feed him?
PR: He is mostly only breastfed, but he eats a little of our food too.
D: Any changes to your diet?
PR: No.
D: Is he feeding well?
PR: He is not feeding well the past two days.
NAI
D: Who do you live with apart from your baby?
PR: My husband.
D: Is that Rayan’s dad.
PR: Yes.
D: Any other children?
PR: No.
D: Is everything ok at home?
PR: Yes, we are a happy family.
MAF
D: Any medication including OTC medicines?
PR: No.
D: Any allergies?
PR: No.
D: Any family history of a similar problem?
PR: No.

Provisional Dx:
From what you have told me, Rayan is floppy and sleeping a lot and he
isn’t wetting his nappy much. I suspect that Ryan is severely
dehydrated.

Management:
So, we’ll need to see your child immediately:

➢ Do you drive?
➢ Can you bring him as soon as possible?
➢ Advise her to try and have someone else drive them if it’s possible.

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➢ Send ambulance (but explore first)

1- Admit.
2- Examine him.
3- Senior.
4- Investigations: (Blood All +ABG/ Urine/ CXR)
5- Symptomatic:
➢ I.V fluids
➢ O2
➢ Paracetamol
➢ May be ABX if bacterial infection

Febrile convulsions

Who you are:

You are a FY2 in paediatrics.
Who the patient is:
Sari Knowles has brought her 2-year-old son Alex Knowles. Alex had a fit
at home which lasted for 2 mins.
Additional information
His temperature is 38.5
Examination: redness of the left eardrum. Rest of the ENT investigations
are normal.
What you should do:
Talk to the mum, take focused hx and address her concerns.

Before:
➢ Can you please tell me what happenned in detail?
➢ What happened just before the fit?
➢ Did he have his food as usual? (hypoglycaemia)
During:
➢ How long ago did he have the fit?
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➢ How long did at last?

➢ Did he (LOC/ wet himself/ bite his tongue)
➢ Has he ever had such a fit before?
➢ How is he in general? Is he normally fit and well?

DDs for convulsions: Head from outside to inside

• Head injury
• Meningitis (fever + rash)
• SOL (early morning vomiting + limb weakness)
• Hypoglycemia (drowsy + sweating)
• Epilepsy (jerky movement + LOC)
• Febrile convulsion: FEVER +Discharge from (ear – nose – eye)
P1 (BEFORE – DURING – AFTER)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: How can I help you?
Patient’s Relative: My son had a fit.
D: Can you tell me more about that?
PR: I was in the kitchen when his older brother called me because his brother was
having a fit; he was jerking and moving all of his limbs and he fainted.
D: Did he bite his tongue?
PR: No.
D: How long did this last?
PR: 2 mins.
D: Did he hurt his head by any chance?
PR: No.
D: Has he been eating as normal?
PR: Not really
D: Have you noticed anything else wrong with him?
PR: Well, In the last 24h he was touching his left ear a lot, and I noticed there’s some discharge coming out of it.
(+ve finding)
D: Have you noticed any fever?
PR: I am not sure.
D: After the fit, did he regain his consciousness?
PR: He was floppy and pale.
Concern
D: Other than this, is there anything else worrying you?

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PR: I am worried if it’s meningitis.

D: Is there any specific reason for that?
PR: My neighbor’s daughter had meningitis 5 weeks ago. (Exclude
meningitis symptoms + contact hx)
D: I am sorry to hear that, how is she doing right now?
P: I think she is better.
DDS:
Head to toe
D: Did you notice any rash? (meningitis)
PR: No.
D: Any early morning vomiting? (sol)
PR: No.
D: Any family history of epilepsy?
PR: No.
D: Have any of you come into contact with your neighbor’s girl?
PR: No.

P2
D: Has he had this problem before?
PR: No.
D: Has your baby been diagnosed with any medical condition?
PR: No.

BIRD DDD
Don’t forget IMMUNIZATION HERE.
Dehydration
D: is your baby active and playful?
PR: He is not himself the last 24 hours (+ve finding)
D: Does he wet his nappies as usual?
PR: Yes.
DIET:
D: What do you feed him?
PR: Everything we eat as a family he eats with us.
D: Any changes to your diet?
PR: No.
D: So, you said he’s not feeding well?

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PR: No, he is not feeding well in the last two days.

NAI
D: Who do you live with other than Alex?
PR: My husband and my other 2 children.
D: Is your husband, Alex’s dad?
PR: Yes.
D: And is everything ok at home?
PR: Yes, everything is fine.
MAF
D: Is he on any medication including OTC medicines?
PR: No.
D: Any allergies?
PR: No.
D: Any family history of a similar problem?
PR: No.

Examination:
➢ Observations: Temp 39
➢ Ear: red inflamed tympanic membrane
➢ Head to toe

Provisional Dx:
Firstly, let me assure you Alex does not have meningitis, but I do
suspect he has a condition called febrile convulsions; It’s a type of fit
that happens when the child gets a high temperature.

Q: Is it serious?

Well, most cases of febrile convulsions are not serious, children usually
have full recovery without permanent damage. However, the illness
that’s causing the fever can be serious.

Q2: What’s causing the fever?

I suspecting the fever is due to an ear infection as we examined his ear,

and we found his ear drum to be swollen inflamed.

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Management:

1. We’ll put child under observation.

2. Senior.
3. Investigations
a. Blood: all + infection markers
b. Urine: dipstick
4. Symptomatic (fever)

i. Calpol (paracetamol)
ii. Keep him lightly dressed.
iii. Plenty of fluids
5. Prevention:
To prevent this from happening in future:
Make sure that your child doesn’t get a high fever.
If he gets feverish:
Calpol (paracetamol)
Keep him cool and lightly dressed.
➢ Plenty of fluids
When he has a fit:

➢ Lay him on his side with face turned to the side.

➢ Don’t put anything in his mouth, including medications Sit &
watch:
< 5 minutes no need to bring him
>5 minutes call the ambulance

Q1: Dr, is febrile convulsions a type of epilepsy?

Well, no, febrile convulsions are due to infection, whereas epilepsy

is due to abnormal electrical activity in the brain.

Q2: Dr, will it lead to epilepsy?

It’s very rare for it to lead to epilepsy.

Q3: Dr, will you give me some medication for him?

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Well, there’s no medication to treat this condition.

Note- if parents live more than 2 hours away & fit lasts for more than 5
minutes then a/9 MPO\7
\.
@?0P Z09/11/2022

6- Safety netting:
➢ Continuous fever
➢ Fit> 5 minutes
➢ Rash & neck stiffness

Head injury (Demanding CT)

Who you are:

You are an FY2 in the paediatric department.
Who the patient is:
Alicia, 9-month-old, brought by her mum with hx of fall from the sofa.
She has a bruise on her head. The child is well and actively playing in the
department.
What you should do:
Take hx, address concern and manage.

In any station of a head injury, exclude indications of CT scan and NAI.

NICE recommendations for when to request a CT immediately if < 16 years

• Witnessed loss of consciousness lasting > 5 minutes
• Amnesia (antegrade or retrograde) lasting > 5 minutes
• Abnormal drowsiness
• Three or more discrete episodes of vomiting
• Clinical suspicion of non-accidental injury (NAI)
• Post-traumatic seizure, but no history of epilepsy.
• Age > 1 year: GCS < 14 on assessment in the emergency department.
• Age < 1 year: GCS (paediatric) < 15 on assessment in the emergency department
• Suspicion of open or depressed skull injury or tense fontanelle.
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• Any sign of basal skull fracture.

• Focal neurological deficit.
• Age < 1 year: presence of bruise, swelling or laceration > 5cm on head.
• Dangerous mechanism of injury (high-speed road traffic accident either as
pedestrian, cyclist, or vehicle occupant, fall from > 3m, high-speed injury from a
projectile or an object).

Questions to ask in any in head injury station

• When did it happen?
• What time did you bring him?
• How did it happen?
• What made you worry about him enough to bring him in?
(Concern)
• What type of floor is it?
• What was he/she doing just before he/she fell?
• How high was the couch?

Questions/ indications of CT:

• Did she LOC?
• Did she have any fits?
• Can she remember what happened (if she is old).
• Any vomiting?
• How big is the bruise?
• Any bleeding or discharge (nose/ ears/ mouth)?
• Do you feel that she is drowsy?
• Did you notice any abnormal behaviour?

• Was she completely fine & playful before.

Don’t forget NAI (if there’s a delay in presentation, suspect NAI)

• Who looks after him/her?
• How do you get on with him/her?
• Any other children at home?

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• How do they get along together?

• Was it a planned pregnancy?
• Where is his/her dad?
• Does he look after him/her? How do they get along?

P1 (BEFORE – DURING – AFTER)

First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: I understand that your daughter had a fall on her head, can you tell me about
that?
Patient’s Relative: I was changing my daughter’s nappy when she fell off the sofa and
got a bruise on her head.
D: Oh dear, when did this happen?
P: An hour ago.
D: How far is the sofa from the floor?
P: Not too high.
D: Did she faint or anything?
P: No.
D: Any jerky movements?
P: No.
D: Any vomiting?
P: No.
D: Any bleeding from her nose or ears?
P: No.
D: Have you noticed her looking drowsy?
P: No.
D: How is she right now?
P: She is fine right now

Concern
D: Other than this, is there anything else concerning you?
P: I just want to run a CT scan on her head to make sure she is ok.
D: Is there any specific reason for that?
P: I am just worried about her.
D: Just a few more questions and I will address all of your concerns.
DDs:
Head to toe
D: Did you notice any rash?
P: No.
D: Any fever?
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P: No.
D: Any discharge from ears?
P: No.
P2
D: Has she ever fallen from anywhere before?
P: No.
D: Has your baby been diagnosed with any medical condition?
P: No.
BIRD DDD
Don’t forget Dehydration & NAI
D: Is your baby active and playful?
P: Yes.
D: Does she wet his nappies as usual?
P: Yes.
DIET:
D: What do you feed her?
P: She is mostly breastfed, but she eats a little baby food too.
D: Any changes to your diet?
P: No.
D: Is she feeding well?
P: Yes, she is feeding well.
NAI
D: Does anyone else live with you both?
P: Yes, my husband and my other older child.
D: Is that Alicia’s biological dad?
P: Yes.
D: Is everything OK at home?
P: Yes, we are a happy family.
MAF
D: Any medication including OTC medicines?
P: No.
D: Any allergies?
P: No.
D: Any family history of a similar problem?
P: No.
Examination:
➢ Vitals
➢ GCS
➢ Head injury: 2 cm bruise
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➢ Head to toe
Provisional Dx:
From the chat we had, let me reassure you that everything is OK with
Alicia. As you mentioned you didn’t notice any vomiting, jerky
movements or drowsiness. At the moment we don’t need to do any CT
scan; If we did, we would be unnecessarily exposing her to harmful
radiation.

Management:
➢ If there is indication of CT (admit + CT)
➢ If there is no indication of CT (observe 24 hours, don’t discharge)
➢ Symptomatic treatment:
- painkillers
- observe 24 hrs

➢ Safety netting: if any of these symptoms happen, bring her back

right away:
• LOC
• Fit
• Drowsy
• Difficulty in waking her up
• Weakness
• Vomiting
• Clear fluid nose/ ear

Acute Otitis Media

Who you are:
You are an FY2 in paediatrics.
Who the patient is:
Alex, 9-month-old, was brought in by his mum with a fever. He has been
examined and findings are:
t: 39 BP: 90/70
HR: 140 TM: pink tm on left ear
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Nose and throat are normal.

What you should do:
Talk to the mother and address her concerns.

When to give Antibiotics in AOM in Pediatrics?

P1 (ODIPARA)+ (TRAC)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: I can see from my notes that your son has a fever, can you tell me more about
how he’s been?
Patient’s Relative: Well, my son has been unwell for the last 2 days, he has had a fever
and he is pulling his left ear all the time
D: Regarding the fever, did you measure it?
P: Yes and it was 39, I gave him paracetamol but he didn’t seem better after.
D: Regarding the ear, when did you notice that?
P: Around the same time.
D: What about the other ear?
P: It’s fine.
D: Did you notice any discharge from the ear?
P: No.
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D: Is there anything that makes it better or worse?

P: No.
D: Have you noticed anything else?
P: No.
Concern
D: Other than the fever and ear, do you have any other concern?
P: I just want to know what’s wrong with my baby

DDs:
Head to toe: don’t forget meningitis - UTI
D: Did you notice any rash?
P: No.
D: Does he cry when he pees?
P: No.
D: Any discharge from his nose?
P: No.

P2
D: Has he ever had this problem before?
P: No.
D: Has your baby been diagnosed with any medical condition?
P: No.

BIRD DDD
Don’t forget DEHYDRATION.
D: Is your baby active and playful?
P: No, he is not himself the last 2 days (+ve finding).
D: Does he wet his nappies as usual?
P: Not really.
D: Is he drowsy or floppy?
P: Yes, he is floppy.

DIET:
D: What do you feed him?
P: He is mostly breastfed but he also eats a little baby food.
D: Any changes to your diet?
P: No.
D: Is he feeding well?

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P: He is not feeding well the past two days.

NAI
D: Who do you live with apart from your baby?
P: My husband.
D: Is that his biological dad?
P: Yes.
D: Any other children?
P: No.
D: Is everything OK at home?
P: Yes, we are a lovely family.
MAF
D: Any medication including OTC medicines?
P: No.
D: Any allergies?
P: No.
D: Any family history of a similar problem?
P: No.

Provisional Dx:
From the chat we had and from the examination I found you’re your
son has a fever and he’s pulling his ear, I am suspecting he has a
condition called Acute otitis media, which is inflammation in his middle
ear. It usually takes few days to resolve.

Management:

1- Observe (keep an eye on him)

2- Senior
3- Investigations
• Routine blood
• Ear discharge: swab
4- Symptomatic
• Paracetamol
• Plenty of fluids

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5- Safety netting: If he is still unwell or has any of these bring him back
right away
• Unwell
• Lethargic
• Sleepy
• Rash

Delayed walking and developmental issues

Who you are:

You are FY2 in the GP surgery.
Who the patient is:
Jade Anderson, the mother of 14-month-old, Adam. She has some
concerns regarding her son.
What you should do:
Talk to her and address her concerns.

Key points:
The problem here is in D (development) so your presenting complain
here is (D)
DDs: (causes of delayed walking)
• Head injury
• Malnutrition so diet here is important
• Overprotective environment is when parents tend to keep their
children in a confined area in order to keep them safe.
• Duchene Muscular atrophy (DMP)
Baby boys, often normal at birth and delayed walking may be
found retrospectively with symptoms appearing between 4-6
years.

• Severe learning disability: associated with language, social, fine

motor skills
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Red Flags
• poor hand control or floppy (6 month)
• unable to sit unsupported (9 month)
• no weight bearing (12 month)
• not walking (18 months)
• not running 2 years
• not climbing stairs 3 years
• no single word 18 months
• not saying 2 – 3 words (30 months)

In any case of developmental delay, check:

• Gross motor development:
▪ 3 months: support neck
▪ 6-9 month: 6 months can sit with support only/ 9 months can
sit without support
▪ 10 months: pulls object to stand
▪ 12 months: stand, walk, with one hand held
▪ 18 months: start walking well
▪ 2 years: goes up/ down stairs
▪ 3 years: ride tricycle

• Fine development:
2 years:
▪ unbutton large button
▪ undress easily
▪ open door (turn door knob)
3 years:
▪ Grasp marker with thumb & index fingers
▪ Dresses self
▪ Draws simple design

4 years:
▪ Holds pencil in adult fashion
▪ Draw recognizable person

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5 years:
▪ Write
▪ Print own name
▪ Cut with scissors

Family history is a must

A child is only considered delayed walking after 18 months, so if child was

brought in before 18 months, then make sure to exclude other causes of
delayed walking (then reassure).

P1 (Gross developments)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: How can I help you?
Patient: My son is not walking doctor
D: Can you tell me more about that?
P: His older brother was walking at 12 months, but he’s 14 and still can’t.
D: Was he able to walk then suddenly stopped?
P: No.
D: Is he able to walk with support?
P: No, I tried with him but he kept falling.
D: Is he able to crawl?
P: Yes.
D: Have you noticed anything else?
P: No.
OTHER DEVELOPMENTS QUESTIONS: FINE AND SPEAKING QUESTIONS
Concern
D: Other than him not walking, do you have any other concern?
P: I just want to know what’s wrong with my baby.

DDs:
Head to toe + causes of delayed walking
D: Any trauma to his head?
P: No.
D: Any bowing or abnormality in his legs?
P: No.
D: Any fever?
P: No.

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D: Do you feel that you are overprotective?

P: Not really no.
D: Does he mix with other kids?
P: Yes, he is very sociable.

P2
D: Has he ever had any other developmental issues in the past?
P: No.
D: Has your baby been diagnosed with any medical condition?
P: No.

BIRD DDD
D: Was he full or preterm?
P: Full term.
D: Any problem during labour?
P: No.

Dehydration
D: Is he active and playful?
P: Yes.
D: Does he wet his nappies as usual?
P: Yes.
D: Is he drowsy or floppy?
P: no.
DIET:
D: Are you happy with his eating?
P: Yes, I’m satisfied with his appetite.
NAI
D: Who do you live with apart from your baby?
P: My husband and 4-year-old brother.
D: Is that Adam’s biological dad?
P: Yes.
D: Is everything ok?
P: Yes, we are a happy family.

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MAF
D: Any medication including OTC medicines?
P: No.
D: Any allergies?
P: No.
D: Does anyone from your side or his father’s side have any condition
which has caused them developmental delay?
P: No.
Examination: (Neurological examination of lower limb):

▪ Movement
▪ Reflexes
▪ Muscle tone
Provisional Dx:
From the chat that we had I am not yet worried about Adam’s
development. This is because, every child develops at their own pace,
and he is still only 14 months old. We only become worried if he is still
not walking after 18 months.

Management:
1- Reassure the mother.
2- Senior
3- Investigations:

a. routine blood
b. creatinine phosphate kinase
4- Review in one month and avoid using child walkers/ encourage child
to walk by holding hands/ discourage isolation of the child.
5- If he has any of the red flags mentioned before you may consider
referring child to:
• pediatrician
• physiotherapist

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Delayed Talking
Who you are:
You are FY2 in the GP clinic.
Who the patient is:
Laila Ahmed the mother of 15 month old, Adam. She has some concerns
regarding her son.
What you should do:
Talk to her and address her concerns.
Same station exactly as the previous one + exclude autism
P1 (language + Gross developments)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: How can I help you?
Patient: I am worried about my son who is 15 months old, and he can only say ‘mama’
and ‘papa’, however his twin Sally can say 8 to 10 words.
D: Can you tell me more about it? Does he respond when you call him?
P: Yes.
D: Does he make eye contact?
P: Yes.
D: Is he able to hold things?
P: Yes.
D: Is he able to walk?
P: Yes
D: When did he start sitting up?
P: Around 7 months.
D: When did he start crawling?
P: Around 9 months.
D: Does he smile?
P: Yes, he is very happy.
D: Does he point to things?
P: Yes.
D: Any repetitive movements?
P: No.
D: Does he mix well with the other kids.
P: Yes, no problem with that.
D: Have you noticed anything else?
P: No.

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D: how about Sally, is she developing OK?

P: She is very good.
OTHER DEVELOPMENTS QUESTIONS: FINE AND SPEAKING QUESTIONS
Concern
D: Other than speaking, do you have any other concern?
P: I just want to know what’s wrong with my baby.

DDs:
Head to toe + causes of delayed development
D: Any trauma to his head?
P: No.
D: Any bowing or abnormality in his legs?
P: No.
D: Any fever?
P: No.
D: Do you feel that you are overprotective?
P: Not at all.
D: Does he mix with other kids?
P: Yes, he is very sociable.
D: Are you satisfied with the other aspects of his development?
P: Yes, I think he is doing fine.

P2
D: Has he ever had any delays in other aspects of his development in the
past?
P: No.
D: Has your baby been diagnosed with any medical condition?
P: No.

BIRD DDD
D: Was he full term?
P: Yes, full term, he and his sister were born at 38 weeks by vaginal
delivery.
D: Any problem during labour?
P: No.
Dehydration

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D: Is your baby active and playful?

P: Yes.
D: Does he wet his nappies as usual?
P: No.
D: Is he drowsy or floppy?
P: No.
DIET:
D: Is he feeding well?
P: Yes, I am happy with his appetite.
NAI
D: Who else do you live with other than Adam and Sally?
P: My husband.
D: Is that their biological dad?
P: Yes.
D: Any other children?
P: No.
D: Is everything OK at home?
P: Yes, we are a happy family.
MAF
D: Any medication including OTC medicines?
P: No.
D: Any allergies?
P: No.
D: Has anyone in the family been diagnosed with any condition which has
caused them any developmental delay?
P: No.
Examination:

▪ Observation
▪ Head to toe
Provisional Dx:
From the chat that we had I am not yet worried about Adam’s
development. This is because, every child develops at their own pace,
and he is still only 15 months old. we only become worried if he can’t
say 2 words after 18 months.

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Management:
1. Let him mix with other children in his age.
2. Encourage him to talk.
3. Don't isolate him.
4. Keep repeating for him simple words over and over again.
5. I think there is nothing to worry about for now, as many children are
late talking until 18 months old, so monitoring him is important.
6. Refer to speech and language therapist to try to help him (Not suitable
if he has appropriate level of understanding and normal development).
So, please keep an eye on him and if you notice that there is no
improvement or any other issues, you can bring him back right away.
7. If he has any of the red flags mentioned before you may consider
referring the child to a:
• pediatrician
• physiotherapist

Night terrors

Who you are:

You are an FY2 in paediatrics.
Who the patient is:
Alicia, 5 years old. Her mother is concerned as she wakes up in the
middle of night screaming.
What you should do:
Talk to her mother, child is not with her mum.

I) One word to remember here is the Environment around the

child
1-Home:
How are things at home?
Who looks after him/her?
Any financial stress?
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How does the child get on with whoever is looking after him/her or his/her brothers or
sisters if there are any? (NAI)

2- Nursery:
If he/she goes to nursery, ask about how he/she likes it?
Is he/she happy there?

3- Changed home / nursery / school recently?

Night terrors:
It is a condition which is common between 3-12 years old. It is a type of sleeping
disorder, in which the child wakes up in the middle of night screaming, shouting, they
could be even jumping out of bed, they can have their eyes opened but not fully awake,
they can’t remember or recall it the next day (unlike a nightmare).

Differentials:
Epilepsy:
Moves his/her limbs abnormally? (Fit or epilepsy)
His/her eyes roll up during the episode? (epilepsy)
Poo or wee during the episode?
Asthma
Gets breathless during episode?
Congenital heart
Skin looks blue during the episode?
Infection
Any fever?
UTI

Risk factors:

▪ Did anything significant happen before this started

happening?
▪ Death of family member?
▪ Death of pet that child was attached to?
▪ Change in the environment? School? Nursery? Home?
▪ New birth or younger sibling?
▪ Has he started new school?

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P1 (ODIPARA)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: How can I help you?
Patient’s Relative: My daughter keeps waking up in the middle of the night screaming,
this has happened 3 to 4 times in the last 4 months.
D: Can you tell me more about it? How long does it last?
P: Just for a few minutes.
D: Can you think of anything that may be causing it?
P: No.
D: Is there anything that makes it better or worse?
P: I don’t know.
D: Is she alert and responsive when she wakes up? (So important)
P: Not really.
D: Does she remember her dreams after? (So important)
P: No.
D: Away from this, is there anything else?
P: No.
Causes:
D: How are things at home?
P: Everything is OK.
D: Who takes care of her?
P: Me and her dad.
D: Any financial stress?
P: No.
D: Is she normally a happy child?
P: Yes.
D: Is there any change in his environment like a new school or new house?
P: No, everything is the same.
D: Does she play or watch violent games?
P: No.
DDs:
D: Any jerky movements of her body during the episodes?
P: No.
D: Any bluish discoloration of her face?
P: No.
D: Does she get breathless during the episodes?
P: No.
D: Any fever?
P: No.
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D: Any rash on her body?

P: No.

P2
D: Has she ever had this problem before?
P: No.
D: Has she ever been diagnosed with any medical condition?
P: No.

BIRD DDD
Dehydration
D: Is she active and playful?
P: Yes.
D: Is she going for a wee as usual?
P: Yes.
D: Is she drowsy or floppy?
P: No.
DIET:
D: What do you feed her?
P: Homecooked food, a bit of everything.
D: Are you satisfied with her diet?
P: Yes
D: Does she eat well?
P: Yes.
NAI
D: Does anyone else live with you both?
P: My husband and her 4-year-old brother.
D: Is everything ok at home?
P: Yes, we are happy.
MAF
D: Any medication including OTC medicines?
P: No.
D: Any allergies?
P: No.
D: Any family history of the same condition?
P: Her father told me that he had similar episodes at her age, but he grew
out of it.

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Examination:
Ideally, I would like you to bring her in for a basic head to toe examination.
Provisional diagnosis:
Don’t worry about it, she seems to be having what we call night terrors.
It is quite common between 3-12 years old, it’s a type of sleeping
disorder, in which a child wakes up in the middle of night screaming,
shouting, they could be even jumping out of bed. They can have their
eyes open but not fully awake, they can’t remember or recall it next day
(unlike nightmare).

Management:
▪ Reassure the mother
▪ Routine investigations
▪ Try to establish a time frame within which the episodes occur and then
wake the child 15 minutes before the expected time for 7 days (to break
the cycle).
▪ Stay calm, don’t approach the child during the episode, wait until they
calm down.
▪ Communicate with the child and try to discuss any stressors or if there is
anything upsetting in their life.
▪ Relaxing night routine, sleep with a lamp on & good sleep hygiene.
▪ Empty bladder before they go to bed.
▪ Leaflets.
▪ Safety netting.

Autism
Who are you:
You are an FY2 in GP surgery.
Who the patient is:
Mother of Jason, 3 years old, is concerned.
What you should do:
Talk to her and address her concerns.

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Signs of autism in young children include:

• Not responding to their name.

• Avoiding eye contact.
• Not smiling when you smile at them.
• Getting very upset if they do not like a certain taste, smell, or sound.
• Repetitive movements, such as flapping their hands, flicking their fingers or rocking
their body.
• Not talking as much as other children and repeating the same phrases.

P1 (odipara)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: How can I help you?
Patient: My 3-year-old son is still not speaking.
D: Can you tell me more about it?
P: I don’t know the age when kids should talk, but I think this is not normal. Also, he is
sits alone all day and he doesn’t interact with people.
D: Does he say any words at all?
P: No, he just makes sounds.
D: When did you notice that?
P: When he started kindergarten, I started to notice that he is different from the other
kids.
D: When you call him does he respond to you?
P: I think he hears me, but he doesn’t respond.
D: Does he make any eye contact?
P: He does but he can’t maintain eye contact.
D: Have you noticed any repetitive behaviour?
P: Yes, all the time, he is always flipping his hands.
D: Does he do that at specific times throughout the day, or randomly?
P: I don’t know, it seems random.
D: Does he share his toys?
P: No.
D: Does he like to place his toys in a straight line?
P: Yes! He does that a lot.
D: Apart from these things, is there anything else?
P: No.

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DDs:
Normal head to toe.
D: Any fever?
P: No.
D: Any rash on his body?
P: No.

P2
D: Has he ever had any delays in his development in the past?
P: No.
D: Has he been diagnosed with any medical condition?
P: No.

BIRD DDD
Birth is important
D: Was he born preterm or full-term?
P: Full term
D: Any problem during pregnancy?
P: No.
D: What about during delivery?
P: No.

Dehydration
D: Is he active and playful?
P: Yes
D: Is he going for a wee as usual?
P: Yes
D: Is he drowsy or floppy?
P: No.
DIET:
D: Are you satisfied with his diet?
P: Yes.
D: Is he feeding well?
P: Yes.
NAI

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D: Who do you live with other than Jason?

P: My husband and his 4-year-old brother.
D: Is your husband Jason’s dad?
P: Yes.
D: Is everything OK at home?
P: Yes, we are great.
Other development
D: Are you happy with the other aspects of his development?
P: Yes, he is well developed otherwise.
D: Any problems with walking?
P: No.
MAF
D: Any medication including OTC medicines?
P: No.
D: Any allergies?
P: No.
D: Any family history of delayed speech?
P: Well, my niece has autism and she had delayed speech.

Examination:
Head to toe examination.

Provisional Dx:

OK, so from the things you have told me about Jason, it sounds like he may have
autism. However, it’s not possible for me to give you a definite diagnosis right now, for
a definite diagnosis I would have to refer him to a team of autism specialists. They
would assess him over a period of time before confirming it is autism.

- Being autistic does not mean you have an illness or disease. It means your brain
works in a different way from other people.
- It's something you're born with or first appears when you're very young.
- If you're autistic, you're autistic your whole life.
- Autism is not a medical condition with treatments or a "cure". But some people
need support to help them with certain things.

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- Don’t think of this as a problem that needs fixing, instead accept that this is the
way your child is and try to understand all aspects of his personality.

Autistic people may:

• Find it hard to communicate and interact with other people.
• Find it hard to understand how other people think or feel.
• Find things like bright lights or loud noises overwhelming, stressful or
uncomfortable.
• Get anxious or upset about unfamiliar situations and social events.
• Take longer to understand information.
• Do or think the same things repeatedly.

Management:
I will talk to my senior as:
➢ We will need a 6-month assessment.
➢ We will refer him to a specialist (Autism team or health care
professional).
➢ The specialist will make a more in-depth assessment which should be
started within 3 months of referral with MDT which will include:

• Language therapist
• Behavioural therapist
• Occupational therapist
• Psychologist
School will need some guidance.

Any concerns??

Q: Does he have this because of the MMR vaccine?

A: Well, there have been rumours on the internet that the MMR
vaccine was causing autism, because autism is usually diagnosed at
around the same age that MMR vaccine was given. So, a small
number of people linked the two together and concluded falsely that

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the MMR vaccine was causing autism. HOWEVER, this theory has
long since been refuted by many doctors and studies.

Q: Why does he have this then?

The exact cause is unknown; however, it could be caused by:

Genetics:
Many researchers found that Autism is known to run in families.
Environmental triggers:
Being premature child before 35 weeks.
Being exposed to alcohol in womb.
Being exposed to certain medicine (Na valproate) in the womb.

Chlamydia eye infection in neonate

Who you are:

You are an FY2 in the GP surgery.
Who the patient is:
Sarah, 18 years old, made an appointment to see you. She delivered a
baby 10 days ago, who had red sticky eyes for the last 3 days, swab has
been taken from the eye, it shows (chlamydia). Chloramphenicol was
given 3 days ago.
What you should do:
Talk to mother and address her concerns.

You have here 2 patients: the mother and the baby so make sure that
you will ask about both.

It’s an STI so please don’t forget to ask both partners to attend the
Gum clinic.
Advice about stopping sex until both are cured + using condom.
P1
First confirm identity, name of child, relationship to child and child’s D.O.B.
Baby questions:
Doctor: I can see from my notes that your son had some discharge coming from his
eyes, can you tell me more about it?

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Patient: It was 3 days ago when I started to notice this sticky discharge from his eyes, it
was red and inflamed and they told they will examine it.
D: Which eye?
P: Both.
D: Has anyone discussed the results with you?
P: Yes, they updated me that he has an eye infection.
D: How is he doing right now?
P: He is taking the antibiotics and he is getting better now.
D: Any fever?
P: No.
D: Any rash?
P: No.
D: Do you have any other concern?
P: I just want to know if he will be OK now.

Mom questions
1st PID questions:
D: Sorry, I need to ask you some sensitive questions, but it’s important as it
could be linked to your son’s infection?
P: OK.
D: Have you noticed any abnormal vaginal discharge recently?
P: No.
D: Any lower tummy pain?
P: No.
D: Any pain while urinating?
P: No.

Sexual history: Don’t forget to sign post

D: Are you in a stable relationship?
P: Yes, I have been with my partner for the last 3 years.
D: As you have just had a baby, obviously you won’t have been using
condoms, have you and your partner ever been tested for STIs?
P: No.
D: Have you had any other partners in the last 6 months?
P: No.
D: Does your partner have any symptoms of an infection?
P: No, he is fine.

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DDs: No DDs as it’s already been diagnosed.

P2
D: Have you ever been diagnosed with any medical condition?
P: No.
D: Any history of Pelvic Inflammatory Disease or sexually transmitted
infections?
P: No.

MAFTOSA + DESA

Examination:

• Observation
• Abdominal examination
• PV + Speculum

Provisional Dx:
As you know, we have taken a swab from your baby’s eye which
showed a type of eye infection called Ophthalmia Neonatorum, which is
caused by a type of bacteria called Chlamydia. We have given him an
antibiotic called Chloramphenicol already. This type of infection can
only sexually transmitted which means unfortunately that you probably
have it also and it was passed to your baby during labour.

P: But I haven’t been sleeping with anyone else other than my

boyfriend. Does that mean he has been cheating on me?
D: I am sorry there is no way of me knowing that. It doesn’t necessarily
mean he has cheated; he could have had this from before he was with
you and he didn’t know he had it. The thing is with Chlamydia a lot of
the time it doesn’t have any symptoms, so you don’t always know you
have it.

Management:

1- I’ll speak to my senior.

2- Give Azithromycin eye drops.

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3- Refer to GUM clinic for both her and her partner

They will assess you and screen for other sexually transmitted
infections.
4- Advice on stop sexual activity until both are free from any
infections. ( Although they have probably already stopped as she has
just given birth and typically a woman is advised to wait 6 weeks after
giving birth before resuming sexual activity.)
5- Leaflets.
6- Safety netting.

Constipation in a child
Who you are:
You are an FY2, in GP clinic.
Who the patient is:
The mother of 2-year-old, Harry, came for a follow-up for him as he is
constipated.
She visited the GP 2 weeks ago, and the examination was normal – PR:
no faecal mass.
Additional information:
She was advised on dietary changes.
What you should do:
Talk to her and address her concerns.

It’s important to ask about:

• Diet, in detail.
• Exclude anal fissure, intestinal obstruction, blood in the stool.
• Potty training.
• NAI.
Constipation diagnosis:
• Frequency < 3 times/week.
• Rabbit dropping stool.
• Overflow diarrhoea.
• Hard, large stool.

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P1 (ODIPARA)
First confirm identity, name of child, relationship to child and child’s D.O.B.
D: I can see from my notes that you are here for a follow-up?
P: Ye, my son is still constipated.
D: Can you tell me more about that?
P: He had flu like symptoms 4 weeks ago, then he has been like that ever since, and the
doctor gave us some advice on his diet.
D: OK, so what do you mean by constipated? Do you mean he’s struggling
to poo or he’s not pooing at all?
P: He is only managing to poo 2 times a week.
D: I see, and what about the advice, did you follow the dietary advice you
were given?
P: Well, he doesn’t want to eat vegetables or fruit.
D: Is it getting worse?
P: He was going to the bathroom 3 times a week but right now only 2.
D: Can you tell me about the nature of the stool?
P: It’s large.
D: Any diarrhoea?
P: No.
D: Does he have any pain when he poos?
P: No.
D: Any blood?
P: No.
D: Any vomiting?
P: No.
D: Any tummy distention?
P: No.
D: Apart from this, is there anything else?
P: No.
D: Is he potty trained?
P: Yes.
D: Anything else concerning you?
P: No.

DDs: Normal Head to toe

D: Any fever?
P: No.
D: Any rash on his body?
P: No.
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P2
D: Has he had this problem before?
P: No.
D: Has your baby been diagnosed with any medical condition?
P: No.

BIRD DDD
Dehydration
D: Is he active and playful?
P: Yes.
DIET:
D: Can you tell me about his diet in detail please?
P: He has cereals for breakfast, toast for lunch, pasta for dinner.
D: Is he drinking enough water?
P: Yes.
NAI
D: Who else do you live with other than Harry?
P: My husband and his 6-year-old sister.
P: Is he your Harry’s dad?
D: Yes.
D: Is everything ok at home?
P: Yes, we are a happy family.
Other development
D: Are you happy with the other aspects of his development?
P: Yes, he is developing well.
D: Any problems with walking?
P: No.
MAF
D: Any medication including OTC medicines?
P: No.
D: Any allergies?
P: No.
Examination:
• Observation
• Abdominal examination
• PR

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Provisional Diagnosis:
I believe your Harry’s constipation might have been triggered by the flu like
symptoms he had, but also, you’ve described his diet to me which doesn’t
sound like it consists of much fiber, which isn’t helping the matter.

Management:

1- Senior
2- Dietary advice
High fiber food like fruit + veg
Plenty of fluids
Physical activity
3- Potty training:
Make sure child can rest their feet on the floor while using potty.
Ask if they feel worried about the potty or toilet.
4- Stay calm & reassuring:
So that your child doesn’t see going to the toilet as stressful or pooing
something to be something to be ashamed of.

5- Get the child into a routine of regularly sitting on the potty or toilet.
6- Laxatives are often recommended for children who are eating solid
foods and are constipated, alongside diet and lifestyle changes. It
may take several months for treatment to work & remember that
laxative treatment may cause overflow soiling (side effects).
Once constipation is dealt with in your GP may advice you to continue
using laxatives for a while to make sure the stool is soft enough before
stopping.

Primary enuresis
Who you are:
You are FY2 in the GP clinic.
Who the patient is:
Alicia is the mother of 4-year-old David, and she has some concerns.
What you should do:
Talk to her and address her concerns.
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Questions on any bedwetting?

• Was he dry before then he started wetting himself, or has he always
been like this?
• Does he wet himself during the day? Or only night?
• Any stress – abuse?
• UTI
• Constipation
• Toilet trained?
• Any problem with development?

NICE state with respect to nocturnal enuresis:

Consider assessment, investigation and/or referral when nocturnal enuresis is
associated with:

• severe daytime symptoms

• a history of recurrent urinary infections
• known or suspected physical or neurological problems
• comorbidities or other factors
• constipation and/or soiling
• developmental, attention or learning difficulties
• diabetes mellitus
• behavioural or emotional problems
• family problems or a vulnerable child or young person or family
• investigate and treat children and young people with suspected urinary tract
infection
• investigate and treat children and young people with soiling or constipation
• children and young people with suspected type 1 diabetes should be offered
immediate (same day) referral to a multidisciplinary paediatric diabetes care
team that has the competencies needed to confirm diagnosis and to provide
immediate care
P1 (ODIPARA)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: How can I help you?
Patient: My son still wets the bed.

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D: Can you tell me more about that? Like for example, when did it start?
P: He has been always like that, he has never been dry.
D: Does he use the toilet for a wee at all?
P: Yes, during the day.
D: Anything else concerning you?
P: No.

DDs:
D: Has he complained of any pain while passing urine?
P: No.
D: Any offensive odour while passing urine?
P: No.
D: Any straining?
P: No.
D: Have you noticed any abnormality in his genital area?
P: No.
D: Is he fully toilet trained?
P: Yes, he goes to the toilet during the day.
D: Any constipation?
P: No.
D: Is he in the kindergarten?
P: Yes.
D: Any stress in his life? Any bullying in the kindergarten?
P: No.
D: Is he active and playful?
P: Yes
D: Any fever?
P: No.
D: Any rash?
P: No.
D: Any discharge from his nose or ears?
P: No.
P2
D: Any previous concerns with his development?
P: No.
D: Has he been diagnosed with any medical condition?
P: No.

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BIRD DDD
Birth
D: Was he born preterm or full term?
P: Full term.
D: Any problem during pregnancy?
P: No.
Dehydration
D: Is he active and playful?
P: Yes.
D: Are you satisfied with his development?
P: Yes.
DIET:
D: What do you feed him?
P: He eats a bit of everything.
D: Are you satisfied with his diet?
P: Yes.
NAI
D: Who do you live other than David?
P: My husband and his 7-year-old brother.
D: Is that David’s dad?
P: Yes.
D: Is everything OK at home?
P: Yes, there are no problems.
MAF
D: Any medication including OTC medicines?
P: No.
D: Any allergies?
P: No.
D: Any family history of any bladder issues?
P: No.
Examination → Observations.

→ Abdomen.

→ General physical.

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Provisional diagnosis:
Firstly, let me reassure you that David is fine so don’t worry. We expect children to
achieve dry nights by the age of 5. It’s quite common for young children to have this
problem, and they mostly grow out of it eventually.

Management: (Lifestyle advice)

1. Encourage
• Plenty of fluid during the day.
• Going to the toilet regularly during day.
• Going to toilet to urinate before going to bed.
• If they wake up in the night, encourage to go to toilet.

2. Discourage
→ Drinks before bed, mainly drinks like (coke – Pepsi – hot chocolate).
3. Reward
→ For following your new rules well.
4. Environment:
→ Make sure, you speak to them in case they have any problems or
stress or bullying at school or if there is anything upsetting them.
5. We will book a follow-up for the child:
→ If all these measures fail and the issue continues till age of 5:
Further assessment.
Refer to specialist or enuresis clinic.
We may consider alarm to encourage going to toilet.
You can give him desmopressin for a short period: if he is going camping or to a
sleepover.
6. Safety netting:
→ Fever – tummy pain – tummy swelling – having symptoms during the
day, bring him.

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Neonatal Jaundice
Overview:

1. Common and usually harmless condition.

2. Develops 2 – 3 days after birth & tends to get better when the baby is 2
weeks old, so, duration at which mother noticed jaundice is important.
3. Jaundice is common in newborns as babies have a high level of red
blood cells that are broken and replaced frequently (bilirubin) → the
breakdown of red cells is removed by liver. Newborn's liver is not fully
developed until 2 weeks.
4. Jaundice is considered pathological if:

• Appears in the first 24 hours.

• Total bilirubin rises by > 5 mg /dl per day.
• Total bilirubin > 17 mg/dl (290 mmol/L).
• If there are signs and symptoms of infection or severe illness.

5. Premature babies are more prone to jaundice, it takes 5 – 7 days to

appear and 3 weeks to go (Prematurity).
6. Physiological Jaundice tends to last longer in breastfed babies, so it’s
important to ask about (Diet).
7. Jaundice starts (head – face) then chest & abdomen & legs.
8. Jaundice is pathological if baby:
Is floppy.
Is sleepy
Has poor feeding.
Is making a high-pitched sound.
Has dark urine (should be colourless).
Has pale stool (should be yellow or orange).
Causes for pathological Jaundice:
1. Under – active thyroid (Congenital)

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• Any medical condition that runs in family?

• Any other children?
• When baby was born, were you told he has under – active thyroid?
2. Blood group in compatibility

• Were you told that your blood group & baby blood group don’t match
(Ask about Mom & Dad).

• Rhesus factor disease?

• Mother – ve & baby + ve?
• Any blood disease that runs in the family?
• Ask about father blood group?
3. Infections

• Any infections?
• Fever & quick head to toe?
4. Any inherited medical conditions or conditions that run-in family from both
sides (Glucose 6 phosphate dehydrogenase).
5. Biliary atresia

• Dark urine?
• Pale stool?
• Family Hx?

Management:

1. No need for treatment for physiological jaundice, you should continue

breast feeding or bottle feeding.

• Monitor at home
• Safety netting → If continuous >14 days or baby's condition gets worse,
go to GP or mid-wife.
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2. Premature or Solely breast feeding it will improve without treatment,

but investigations needed to exclude other conditions (12 weeks).

• Monitor at home.
• Safety netting (as before).
3. If jaundice persists or signs of kernicterus or bilirubin above treatment
level 150, then treat.

• Phototherapy (hospital – home) Baby in his cot under UV lamp naked

with eyes covered for one- or two-days nappies to be changed, feeding
is given.

• Monitor → Temperature – Dehydration – Bilirubin.

(Every 4 – 6 hrs.).

• If bilirubin has not come down, then → blood transfusion.

• Safety netting→ Poor feeding.
→Not himself.
→Fever.
Note:

• Kernicterus is a condition in which bilirubin level is above treatment

level which is 150 → can cause brain damage.

• Must be treated.
C/P :
• Fever.
• Trouble feeding.
• Stiffness of whole body and spasm.
• High – pitched cry.
• Unusual eye movement.

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Breast Milk Jaundice

Who you are:
You are FY2 in the GP clinic.
Who the patient is:
A 15-day old baby, Joshua, has been refereed by the midwife because of
jaundice.
What you should do:
Talk to the mother and address her concerns.

Don’t forget to exclude:

1. Kernicterus or infection:

• Is he active – playful.?
• Fever – Rash – Stiff – Shy away?
• Vomiting?
2. Obstructive jaundice:

• Poo → colour? Blood?

• Wee → colour? crying? amount?
3. Pathological jaundice:

• Jaundice in the first 24hs of life.

4. Infection:

• Discharge from eye, ears, nose?

5. Pain in abdomen:

• Bringing legs towards tummy?

P1 (ODIPARA)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: I can see from my notes that you have been referred by the midwife, can you
tell me more about that?
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Patient: She said my son has jaundice.

D: When did this happen?
P: 2 days ago.
D: Is it getting worse?
P: No.
D: Have you noticed his eyes or skin becoming yellow?
P: I didn’t notice anything, but the midwife told me it is.
D: Apart from this, is there anything else concerning you?
P: No.

DDs:
D: Had you noticed any yellowish discoloration in the first 24hs of his life?
(Important to exclude pathological jaundice)
P: No.
D: Have you noticed any dark urine or pale stool? (Obstructive jaundice)
P: No.
D: Any fever?
P: No.
D: Any rashes?
P: No.
D: Any discharge from his nose or ears?
P: No.
P2
D: Has your baby been diagnosed with any medical condition?
P: No.

BIRD DDD
Birth
D: Was he born preterm or full term?
P: Full term.
D: Any problem during pregnancy or labour?
P: No.
Dehydration
D: Is he looking quite alert and happy?
P: Yes.
D: Is he wetting his nappies as usual?
P: Yes.
D: Is he floppy?
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P: No.
DIET:
D: What do you feed him?
P: He is only breastfed (+ve)
D: Is he feeding well?
P: Yes, he’s gaining weight.
NAI
D: Who do you live with other than Joshua?
P: My boyfriend and Joshua’s 4-year-old sister.
D: Is that Joshua’s dad?
P: Yes.
D: Is everything OK at home?
P: Yes, we are all happy.
MAF
D: Any medication including OTC medicines?
P: No.
D: Any allergies?
P: No.
D: Any family history of the same condition?
P: No.

Examination
• Observations (fever).
• Eye.
• Skin (head to toe)
• Bilirubin level

Provisional diagnosis:
Firstly, let me reassure you that what Joshua has is nothing to worry
about. He has breast milk jaundice, because he is still young and his
liver is not mature enough yet to clear all the pigment that causes the
discolouration of his skin and eyes.

Management:

Investigations:
→ Blood (FBC –LFT). + Bilirubinometer.

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For now, there is no treatment → continue breast feeding + visiting the midwife.

Safety netting → All for kernicterus.

Neuroblastoma in child & green liquid

Who you are:

You are an FY2 in paediatrics.
Who the patient is:
19-month-old Luke was diagnosed with neuroblastoma and has been
having chemotherapy treatment.
He has been feeling ill frequently and he was admitted 3 days ago due to
neutropenic sepsis. Initially when he was admitted, he was very unwell.
At the moment he is doing well and has started feeding.
Additional information
The child is responding well to the treatment. Neuroblastoma has
reduced in the size. The nurses have noticed that his mother is giving
him green juice.
What you should do:
Talk to the mother about the incident and address her concerns.

This is counselling station so use your IPS

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• Approach:
• You have 2 patients here:
Mom Child

• How are you doing? • P1 → Sepsis (assess knowledge).

• I can see from my notes, Adam was • P2 → Neuroblastoma.
admitted 7 days ago. • BIRD DDD

• How is the hospital stay? ↓

Diet
• How is the care by doctors?
→What do you give him?
• How is the care by nurses?
→Who looks after him?
• Who do you live with?
→Any supplements?
• Any other children?
• MAF
• Who looks after them?
• Convince her
• Any challenges?
→Assess her knowledge about sepsis.
→Assess her knowledge about
Neuroblastoma.
→Drug interaction.

• Don’t accuse her always praise.

• While asking about diet, then green liquid will come, → What is it?

→ Since when?

→ How did you know about it?

→Do you know its ingredients?

→Have you noticed any improvements?

• I totally understand that it’s out of care and fear about your child.

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Build a rapport
First confirm identity, name of child, relationship to child and child’s D.O.B.
D: I can see from my notes that your son was admitted 3 days ago because he was
unwell. How is he doing right now?
P: I think he is getting better doctor, thank you.
D: How is your hospital stay?
P: It’s fine
D: Are you satisfied by the support provided by the team?
P: Yes, I am very happy thank you.
D: Can you please tell me how much you know about your son’s condition?
P: Well doctor he has neuroblastoma and he was admitted due to repeated
infection.
D: That’s right he is having these infections due to chemotherapy, which
unfortunately causes low immunity, but he is improving on the treatment
right now.
P: Thanks for explaining that.
D: And the great news is that the cancer is responding to the chemo and is
reducing in size.
Then QUICK PEDIATRIC HX
Then, bring up the topic of the juice
D: Is it OK if we have a chat about something that the nurses noticed
earlier?
P: Yes, what is it?
D: Well actually some of the nurses told me that you’re giving your son
some sort of green fluid, is that right?
P: Yes, it’s green juice my friend had it and it helped her with her breast
cancer.
D: I’m sorry to hear about your friend’s cancer, how is she right now?
P: She is much better.
D: I assume she was on other treatments also, not just the juice? P: Yes,
she was on chemo and radiotherapy.
D: Can you tell me more about the juice?
P: Well, it’s pure, herbal juice so it wouldn’t cause any harm to my son,
only good.
D: Where did you get it from?
P: A friend of mine prepares it in her home and I get it from her.
D: Do you know its contents?
P: No I am not sure but I think it’s mostly herbs.

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D: And when did you start giving him that juice?

P: Yesterday.
D: Have you noticed any change in his bowel habits the last 2 days?
P: No.
D: What do you think about the other treatment we are giving to your
child; do you think it’s helping?
P: Yes but I think the juice is helping too.
D: I can understand that you are doing this out of love and care for your
child and I can see that you are caring and loving mother, but I am a bit
concerned about this juice.
P: What’s concerning you doctor?
D: Well:
• herbal medications can cause some side effects and we don’t want
Luke to end up experiencing any of them.
• we are not sure about the content of this juice and this might pose a
risk of interaction between any of its components and the
medications we are giving him.
• there’s no scientific research to prove the effectiveness of this juice.
• If it’s OK with you I would like to examine Luke to make sure the
juice hasn’t affected him in a negative way.
• I highly advise you to stop giving him this juice to be on the safe side.
• (If she refuses, respect her decision and inform senior.)
• Arrange some tests to examine the content of the juice and
interaction with the medications.

Tantrums
Who you are:
You are FY2 in the GP clinic.
Who the patient is:
A 35-year-old lady made an appointment because her 3-year-old child Jack is acting
strangely.
What you should do:
Talk to her and address her concerns.

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Temper tantrums
Usually start at around 18 months and are very common in toddlers. Hitting and
biting are common, too. One reason for this is that toddlers want to express
themselves but find it difficult to know how to do that appropriately. They feel
frustrated, and the frustration comes out as a tantrum.

Exclude:

Autism,

ADHD (unable to sit still, unable to concentrate on one task, excessive talking)

Other developmental aspects.

P1 (odipara)
First confirm identity, name of child, relationship to child and child’s D.O.B.
Doctor: How can I help you today?
Patient: My son is acting weird whenever I give him food he throws it away, and
whenever I put him to sleep, he just runs out of bed and plays around.
D: When did he start acting like this?
P: He has been like that the last 2 months.
D: Has anything happened in the last 2 months that may be causing him to
act like this?
P: Nothing specific no.
D: Is there anything that makes this better or worse?
P: No, he is just like this all the time.
D: Apart from this, is there anything else concerning you?
P: No.

DDs:
D: When you call him does he respond to you?
P: Yes, but sometimes he ignores me.
D: Can he maintain eye contact?
p: Yes.
D: Does he interact and socialise with other kids?
P: Yes.
D: Is he active and playful?
P: Yes.
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D: Any repetitive movements?

P: No.
D: You said he threw his food away, does that mean his appetite is not
good?
P: No, I am satisfied with his appetite.
D: Does he sleep enough?
P: Yes, he sleeps very well.
D: Any stress or new change in his life?
P: No.
D: Does he do this with you or with other people?
P: Most of the time with me.
D: And what do you do in response to him?
P: I try to ignore him but sometimes I shout at him.
P2
D: Has he had this problem before?
P: No.
D: Has he been diagnosed with any medical condition?
P: No.

BIRD DDD
Development is important
D: Are you satisfied with his development?
P: Yes
D: Is he able to walk?
P: Yes.
D: Are you happy with his speech so far?
P: He can talk very well.
Birth
D: Was he born preterm or full term?
P: Full term.
D: Any problem during pregnancy or labour?
P: No.
Dehydration
D: Is he normally active and playful?
P: Yes.

DIET:

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D: Are you satisfied with his appetite?

P: Yes.
NAI
D: Who do you live with other than Jack?
P: My husband.
D: Is that his dad?
P: Yes
D: No other children?
P: No.
D: Is everything OK at home?
P: Yes, we are a happy, little family.
MAF
D: Any medication including OTC medicines?
P: No.
D: Any allergies?
P: No.
D: Any family history of similar behaviour?
P: No.

Examination
Observation
Head to toe

Provisional diagnosis

From the chat that we had it seems to me that Jack is just having some
temper tantrums. It’s perfectly normal behavior for many children.
Sometimes the reason for this is that toddlers want to express themselves
and their feelings but find it difficult to know how to do that appropriately.
They have not yet learnt how to manage their emotions, so they feel
frustrated, and the frustration comes out as a tantrum.

Management:
Find out why the tantrum is happening
Your child may be tired or hungry, in which case the solution is simple. They could be
feeling frustrated or jealous, maybe of another child. They may want more of your
time, attention and love, even though they're not being very loveable.
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Understand and manage your child's anger by diffusing the situation.

Find a distraction.
Don't change your mind about things: Giving in to his demands won't help
you in the long term. If you've said no, don't change your mind and say yes
just to end the tantrum.

Talk to them: Children often go through phases of being upset or insecure

and express their feelings by being aggressive. Finding out what's worrying
them is the first step to being able to help.

Show them you love them, but not their behaviour Don’t beat them.

Encourage them to let their feelings out in healthier ways: Find a big space,
such as a park, and encourage your child to run and shout.
Involve him/her in tasks that could be done easily.
Spend more time with him to show him your love.
Read stories to him before he/she sleeps.
Letting your child know that you recognise their feelings will make it easier for
them to express themselves without hurting anyone else.

Safety net.

Malaria
Where you are:
FY2 in the Emergency Department.
Who the patient is:
15-year-old Samantha Green came to the clinic with a fever.
What you should do:
Talk to the patient, assess, and address her concerns

Malaria (Positive Findings):

● A high temperature, sweats and chills
● Headaches and feeling confused

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● Feeling very tired and sleepy (especially in children)

● Feeling and being sick, tummy pain and diarrhoea
● Loss of appetite
● Muscle pains
● Yellow skin or whites of the eyes
● A sore throat, cough and difficulty breathing
● Cerebral Malaria – Impaired Conscious level, or seizures.
● Oliguria, acidotic breathing
● Haemoglobinuria - Dark urine

Presenting complaint (P1) (ODIPARA):

D: Hello I am one of the doctors in this Emergency department. You must be Samantha
Green?
P: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 15.
D: So, Samantha, I can see that you have been having some fever?
P: Yes, doctor.
D: Tell me more about this fever (Open question)
D: When exactly did it start?
P: Well, doctor, it started 3 days ago. (Onset)
D: Is it continuous or does it come and go? (Duration)
P: It comes and goes.
D: Have you measured it? (Intensity)
P: Yes, doctor, I have been measuring it, the last time I checked it was 39.7℃.
D: Do you think it has been increasing since it started? (Progression)
P: Yes, doctor, I think it is getting worse.
D: Anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: It just comes and goes on its own. I did try taking some paracetamol and that helps a
little.
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D: Anything else apart from the fever?

P: Yes, doctor, I have also been feeling a bit sick since this started and I get these body
aches that are really bad. When I have this fever, I also get sweats and chills.
D: Tell me more about these problems, did they start with the fever?
P: Yes.
D: Anything else?
P: I also get these headaches since this has started.

Concern
D: Apart from this, is there anything else that's worrying you?
P: No doctor, this is just what's bothering me. It doesn't seem to get better.

D.D’s
Rule out
● Lower respiratory tract infection (Any cough, chest pain)
● Urinary tract infections (Any problems with the water works)
● Gastroenteritis (Any problems with your bowels)
● RED FLAGS : Meningitis/Encephalitis (Any neck stiffness, Rash, Problem with light,
Any weakness anywhere in the body)

Past medical conditions (P2)

D: Has this ever happened before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: No, doctor.

D.E.S.A:
Any smoking ?
What about alcohol?

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M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: No, doctor.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in the family with similar problems or other medical conditions?
P: No, doctor.
D: Did you travel outside the UK in the past couple of weeks?
P: Yes, doctor, I went with my parents to South Africa 2 weeks ago, we came back 5
days ago. It was for my dad’s business.
D: Did you have any contact with anyone there, who was having a similar problem?
P: No doctor, I can't remember having met anyone with a similar problem.
Anything else?

Expectations?
D: Do you have anything specific in mind that you are expecting from us?
P: I just went to feel better, doctor.

Examination:
● Observation (Check vitals)
● General Physical Examination: head-to-toe examination, pallor, jaundice.
● GCS assessment
● Abdominal Examination: Hepatomegaly and Splenomegaly

Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea what is happening with me. I have never had anything like
this happen to me before.

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Suspected diagnosis:
D: So, Samantha, you told me that you have been having this fever and chills, and you
have been feeling sick along with body pain for the past couple of days. Also you told
me that you travelled recently to South Africa 2 weeks ago and through my
examination, I did, indeed, notice that you are still running a fever. I suspect that you
might have contracted an infection during your trip. I suspect it could be something like
malaria but we will need to run some tests to find the exact cause.
P: Ok, doctor. So what can you do about it and what tests are you going to do?

Management:

1. Admit/Referral:
● Malaria is a medical emergency so the patient should be admitted in the hospital
to be reviewed by a specialist.
2. Senior:
● Involve senior
3. Investigations:
● Routine blood investigations including full blood count, and inflammatory
markers.
● Specific Investigations: Microscopy of thick and thin blood films (Gold Standard) –
If first blood films are negative further blood testing to be done in 12-24 hours
later. Antigen detection test.
4. Symptomatic:
● Painkillers
● Antipyretics
● Anti-sickness medication
● Hydration
●
DOs to prevent malaria.
● If you're travelling to an area where malaria is found, get advice from a GP, nurse,
pharmacist or travel clinic before you go.
● It's best to do this at least 4 to 6 weeks before you travel, but you can still get
advice at the last minute if you need to.

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● Take any antimalarial medicine you're prescribed – you usually need to start
taking it a few days or weeks before you go, until a few weeks after you get back.
● Use insect repellent on your skin – make sure it's 50% DEET-based.
● Sleep under mosquito nets treated with insecticide.
● Wear long-sleeved clothing and trousers to cover your arms and legs in the
evening, when mosquitoes are most active.

5. Definitive management:
● Arrange immediate admission for specialist assessment and review if the
patient is: Suspected to have severe or complicated malaria, a pregnant woman,
a child or above 65 years.
● Urgently discuss all other people suspected of having malaria with an infectious
disease specialist: People with non-falciparum malaria may be admitted or
observed for at least 8 hours after starting anti-malarial therapy.
● Ensure that all cases of malaria have been notified to Public Health England.
● Medications to treat Malaria
● Artesunate.
● Artemisinin combination therapy (ACT) Atovaquone-proguanil.
● Quinine plus doxycycline.
● Primaquine.

6. Specialist:
Discuss the case with infectious disease specialist

7. Complication:
● Severe anaemia: where red blood cells are unable to carry enough oxygen around
the body, leading to drowsiness and weakness
● Cerebral malaria: in rare cases, the small blood vessels leading to the brain can
become blocked, causing seizures, brain damage and coma
8. Safety net

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BACK-PAIN

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Back Pain

Overview for Back Pain structure:

I. P1 Back pain: S-O-C-R-A-T-E-S:

− Site: Where is the pain exactly/ Can you point with your finger?
− Onset: How did it start? Course: continuous or comes and goes?
− Character: Can you describe that pain for me?
− Radiation: Does the pain go anywhere else?
− Duration (time): When did it start exactly?
− Alleviating factors: Does anything make it better ?
− Exacerbating Factors: Does anything make it worse?
− Severity: Can you score the pain for me on a scale from 1 to 10, with 1
being the least and 10 being the highest pain possible?
− Have you tried anything for the pain?
− BEFORE: What were you doing before the pain started?
− Any other symptoms with the pain? Open Q before asking about DDx.

II. Any back pain stations if not acute then: psychosocial questions will be a
crucial point in the structure, and you can start after with it P1 (SOCRATES)

− How is it affecting your life?

− How is it affecting your daily activities?
− What do you do for a living?
− How is it affecting your job?
− How is your mood?

ICE is extremely important and will help guide you to take shorter history.

IDEA: Any idea how the pain started? / Were you doing anything specific before the
pain started?
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CONCERN: Do you have any specific concern regarding this pain?

EXPECTATION: Are you expecting anything today in particular from us?

III. DDs of back pain:

1-AAA (abdominal aortic aneurysm): Pulsatile mass in the abdomen? Tummy pain?
Haemorrhage complication/ fainting/ dizziness/ light headedness?
2- Cauda Equina syndrome: Unable to control urine, bowel & pain, and numbness
around the back passage.
3- Multiple Myeloma: DM (polyuria, polydipsia, weight loss) dt increase Ca Decrease
blood (RBCs: anaemia/ platelets: bleeding, bruises/ WBCs: repeated infections)
4- Trauma / fall / accident
5- Disc prolapse: Pain after lifting heavy objects hearing a popping or clicking sound
immediately or during.
IV. Always consider:
• FLAWS (to exclude cancer)
• BPH: If it is a male & old age, back pain, ask about prostate:
− Difficulty in starting urination
− Weak stream
− Terminal dribbling

V. In examination:
− Observation:
− Back
− Back passage (PR)/ prostate)
− Tummy (AAA)
− SLRT (disc prolapse)

VI. In management:
− Explain provisional
− Admit/ discharge/ refer
− Senior
− Investigations (x-ray back)
− Medication: Don’t forget pain killers
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− Specialist
− Safety netting always (Cauda equina): if unable to control urine/ bowel/ pain
around the anus, come back.
− Follow up.

Back Pain (Prostate Cancer?)

Who you are: You are F2 in GP surgery.

Who the patient is: Samuel Frey, aged 61 years presents to the clinic complaining of
back pain.
Special note:
Additional information:
What you should do: Talk to the patient, take history, assess patient, and discuss
further management with patient and address patient’s concerns.

Doctor: What brought you to the hospital today?

Patient: I have pain here (Pointing towards lower back).
D: Tell me more about your pain? Open Question
P: I’ve had it for the past 3 months.
D: Onset: You mentioned it is in the lower back and started 3 months ago, can you tell
me how it started?
P: Gradually.
D: Was it continuous or comes and goes?
P: Continuous.
D: Character: Can you describe that pain for me?
P: Dull.
D: Radiation: Does it go anywhere else like the back or legs? (Disc prolapse)
P: No.
D: Alleviating factors: Is there anything that makes it better?
P: No.
D: Exacerbating Factors: Is there anything that makes it worse?
P: No.
D: Severity: Can you score the pain for me on a scale from 1 to 10, 1 being the least
and 10 being the highest pain possible?
P: 6.s
D: Have you tried anything for the pain?
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P: I tried paracetamol, but it didn't help that much.

D: How much did you take?
P: I took 2 tablets every 6 hours?
D: Is there anything else with the pain? (Open Q before asking about DDx)
P: Yes, in past few months I have been going to loo more often than usual/No.

BPH sx:
D: Do you have increased frequency of urine at night?
P: Yes/No (Nocturia)
D: Do you have to rush to the loo?
P: No (Urgency)
D: Do you have difficulty in starting urination?
P: No (Hesitancy)
D: Are you able to hold your urine before going to toilet? (Incontinence)
P: No.
D: Do you have a weak urine stream or a stream that stops and starts?
P: No.
D: Do you feel like you are not able to completely empty your bladder?
P: No.
D: Have you noticed any dribbling at the end of urination?
P: No (Dribbling).
D: Any blood in urine?
P: No, or I am not sure doctor but I might have had 2 or 3 times in the last month.

FLAWS
D: Do you have any fever? Pyelonephritis
P: No.
D: Lumps or bumps anywhere? Loin mass (renal cancer)
P: No.
D: Have you noticed any weight loss?
P: Yes, 1 stone in the last few months./ No (if no ask closed question)
D: How is your appetite?
P: I am not eating as before.
D: Do you feel tired or short of breath?
P: Yes/ No.
D: Any pain in upper back or pain in your tummy? (Pancreatic cancer)
P: No.
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D: Any heart burn or indigestion? (Gastric cancer)

P: No.
D: Any yellowish discolouration of skin or eyes? (Hepatobiliary cancer)
P: No.
D: Any persistent cough? (Lung cancer)
P: No doctor.
D: Any trauma to your back?
P: No.

Cauda Equina:
D: Some people with similar pain may have problems controlling urine or bowel have
you had anything similar?
P: (Yes/No)
D: Do you ever experience pain, and numbness around the back passage?
P: (Yes/No)

Multiple Myeloma:
D: Do you ever feel like you are more thirsty or drinking water more than usual?
P: (Yes/No)
D: Do you feel you are going to loo more often?
P: (Yes/No)
D: Do you ever feel unusually tired / breathless / heart-racing ?
P: (Yes/No)
D: Do you have any bleeding anywhere or easy skin bruising?
P: (Yes/No)
D: Do you easily get repeated infections ?
P: (Yes/No)

IDEA
D: Any idea how the pain started? / Were you doing anything specific before the pain
started?
P: Nothing.
CONCERN
D: Do you have any specific concern regarding this pain?
P: What do you think is wrong with me doctor? Is it a serious condition? Could it be
cancer?
D: I can a see that you are worried about the problem I will be doing my best to get to
the bottom of this, but may I ask you why you are thinking of cancer in particular?
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P: (May give a reason, explore)

EXPECTATION:
D: Are you expecting anything today in particular from us?
P: I want something for the pain doctor?

P2+MAFTOSA
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any enlarged prostate?
P: No.
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: Family history' of prostate problem?
P: No.
D: What you do for a living?
P: I’m a builder.

Psychosocial:
How is it affecting your life?
How is it affecting your daily activities?
D: What do you do for a living?
D: How is it affecting your job?
D: How is your mood?

DESA:
D: Tell me about your diet?
P: It’s good.
D: Do you do physical exercise?
P: I’m quite active.
D: Do you smoke?
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P: Yes/No.
D: Do you drink alcohol?
P: Yes/No.
D: Do you have any kind of stress?
P: No.

Examination:
D: I would like to check your vitals and examine your back, your tummy, your back
passage and perform a special test called a straight leg raise test.
Management:
Explain provisional:
From our assessment and from the information you have given us you mentioned that
you have (mention positive symptoms). This leads me to suspect you have a condition
in your prostate, which is a small gland which lies beneath the neck of your bladder.
P: Could it be serious doctor?
D: Go for “best case, worst case scenario”. Well, it’s still too early to know that. It
might be something as simple as an infection or back sprain, however you mentioned
some worrisome symptoms such as (mention symptoms), so there is a chance it could
be something serious. But it is very difficult for us to confirm that at this stage, before
doing all the necessary tests. (PAUSE… When he opens up start discussing the
management plan.)
Senior.
Investigations:
I would like to send for some initial investigations including routine blood tests, liver
and kidney functions. We will do a urine dip and a urine analysis as well to check if
there is any blood or infection in the urine.
CXR and X-Ray of your back.
We will check do a special blood test to see the amount of some prostrate markers
called PSA.
Medication:
We will give you some painkillers because you mentioned you are in pain. As you are
already taking paracetamol and it doesn’t help, we will prescribe you another stronger
medication called Co-codamol (paracetamol + codeine).

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Specialist:
Based on the results we might need to do a fast track referral to a urine specialist (IF
there’s blood in urine, refer anyway, tests will done there), would you like to me to
discuss more about what to expect there ?
They will do some scans.
− US scan of your prostate and may have to take a sample if necessary.
− A bone scan of your back to look for any abnormality.
− A CT or an MRI scan.

If it turns out to be something sinister, the specialist will have another discussion
about other treatment options which may be medications or surgery but it’s too
early to say for sure.
P: If it turns out to be cancer doctor what are my options:
D: it’s the specialist who will give you your options based on the size, type and spread
of the cancer. It’s still too soon to decide, however the options may be: medication ,
chemo , radio , surgery.
Safety netting always (Cauda equina):
While waiting for the referral to happen (2 weeks) come back if:
− Unable to control urine/ bowel/ pain around the anus.
− Pain gets really worse
− Bleeding anywhere

Follow up
We will arrange for follow ups later but if you have any inquiries please feel free to
contact us again.
If he is smoking advise about it.

Back pain (AAA)

Who you are: You are an FY2 in A&E department.
Who the patient is: Adam, 55 years old, came complaining of back pain since yesterday.
Additional information: Patient has been diagnosed with HTN for last 10 years.
What you should do: Talk to him, manage him, and address his concern.

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D: Hello! What brings you to the hospital today?

P: Doctor I have had back pain since yesterday. Severe pain.
D: Tell me more about your pain? Open Qs
P: It came all of a sudden (Don’t repeat the symptom already given show active
listening)
D: Site: Where is it the pain exactly/ Can you point with your finger?
P: It’s in my back I can’t say where exactly.
D: Character: Can you describe the pain for me?
P: It’s a throbbing pain.
D: Was it continuous or comes and goes?
P: It was continuous.
D: Radiation: Does it go anywhere else?
P: No/ To my abdomen.
D: Alleviating factors: Is there anything that makes it better?
P: I took ibuprofen it didn’t help.
D: Exacerbating Factors: Anything that makes it worse?
P: No/ Any movement.
D: Severity: Can you score the pain for me on a scale from 1 to 10, with 1 being the
least and 10 being the worst pain possible?
P: 7.
D: Anything else accompanying the pain? Open Q before asking about DDx
P: No.
D: What were you doing when the pain started? BEFORE the Pain.
P: I was just sitting when the pain started.

Cauda Equina:
D: Some people with similar pain may have problems controlling urine or bowel have
you had anything similar?
P: No.
D: Do you ever experience pain, and numbness around the back passage?
P: No.
ICE
IDEA
D: Any idea what might be the cause of the pain?
P: Not really.
CONCERN
D: Do you have any specific concern regarding this pain?
P: (If reason is given, you may need to explore)

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EXPECTATION:
D: Are you expecting anything today in particular from us?
P: (Address expectation)

AAA
D: Do you have any pulsatile mass in the abdomen? Any tummy pain?
P: No.
D: Any Fainting/ dizziness/ light headedness? Haemorrhage complications?
P: Yes/No
D: Have you hurt yourself by any chance or have you been doing any sort of heavy
lifting? Trauma
P: No.
Pyelonephritis/UTI:
D: Any fever?
P: No.
D: Any nausea or vomiting?
P: No.
D: Any burning during urination?
P: No.
D: Do you feel that you have to go to the loo more often, especially at night?
P: No.
Enteritis:
D: How are your bowel movements? any Diarrhoea or constipation?
P: Fine nothing.
D: How’s your appetite?
P: It’s fine.
D: Have you experienced any weight loss recently, appetite change or any lumps or
bumps FLAWS? cancer
P: No.
P2+MAFTOSA
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: I have had HTN for the last 10 years. EXPLORE
D: How are you managing this?
P: I am taking medicine for it.
D: Are you compliant with your medicine and follow ups?

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P: Yes.
D: So it is properly controlled?
P: I believe so.
D: Any DM, heart disease, high cholesterol, kidney problem?
P: No.
D: Any bone or joint problem?
P: No.
D: Are you taking any medications apart from ibuprofen including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries? Have you ever had any scans done on your
tummy for any reason?
P: No.
D: Has anyone in the family been diagnosed with any medical condition or unusual
blood vessel problem in their tummy?
P: No.
D: What do you do for a living?
P: I am working in an office.

DESA: Not in detail it’s an acute condition

D: Tell me about your diet?
P: It’s good.
D: Do you do physical exercise?
P: I’m quite active.
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Do you have any kind of stress?
P: No.
Examination:
D: I would like to check your vitals and examine your back, your tummy, your back
passage and perform a special test called a straight leg raise test. We will do some
initial investigations including FBC. ESR. CRP, LFT, ECG and chest.

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Examiner will hand you findings on a piece of paper: Pulsating and expansile mass in the
abdomen.
Management:
Explain provisional
From our assessment and from the information you have given us, you mentioned that
you have (mention positive symptoms), and from our investigations we have found
that (mention findings). Therefore, I suspect you have a condition which involves the
swelling of the main artery in your abdomen called the aorta, it is the main blood
supply of all organs. When it gets bigger it causes pressure onto the surrounding
organs, that's why you’re feeling the pain in your back. Sometimes when blood pressure
is too high, there is a risk of it bursting, which can be a life-threatening condition.
P: Why did I get it doctor?
D: Mostly it has no identifiable cause. There are some risk factors like in your case,
hypertension, however other factors may include smoking, getting older (especially
males), high cholesterol or family history.
Admit for monitoring and performing important investigations.
Senior.
Investigations
− Blood (CBC/ blood group/ cross matching) vvvimp + routine blood
− US scan on tummy

Medication:
O2 + fluids IV + Painkillers.
Specialist
We would like to refer you to a blood vessels specialist (vascular surgeon) depending
on the size of the aneurysm and whether there is leaking or not. Would you like to
know more about the management options?
− Open aneurysm repair: a cut in tummy & graft will be placed.
− Endovascular repair: a graft will be inserted through the blood vessels in your
groin.

Safety netting always (Cauda equina): if you feel any of these please ring this bell and a
staff member will be here at once.
− Dizziness or feeling you are about to faint inform us immediately
− if unable to control urine/ bowel/ pain around the anus come back.

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Follow up
We will arrange for follow ups later to discuss some lifestyle advice.
General advice: Give general advice about smoking, alcohol, diet, BP control physical
exercise and maintaining a healthy weight.
AAA Screening: ultrasound is feasible to allow early diagnosis. The idea is to
offer a single scan in men aged 65. If negative, this effectively rules out AAA
for life.

Back-pain due to Exercise

Who you are: You are an F2 in A&E.
Who the patient is: Janet Jackson aged, 30, came to you with acute back pain.
What you should do: Talk to the patient, assess him and give the further plan of
management.

D: Hello my name is Dr (name). I am one the doctors here in A&E. How can I help you?
P: I have back pain.
D: Are you comfortable to talk?
P: Yes, I can manage.
P1
D: Tell me more about your pain? Open Q
P: What you want to know?
D: Site: Where is the pain exactly/ Can you point to it with your finger?
P: In my lower back.
D: Onset: How did it start? Suddenly or gradually?
P: It was sudden.
D: Character: Can you describe the pain for me?
P: It is a dull pain.
D: Is it continuous or comes and goes?
P: It is continuous.
D: Radiation: Does it go anywhere else?
P: No.
D: Duration (time): When did it start exactly?
P: I have had this pain since yesterday.
D: Alleviating factors: Is there anything that makes it better ?

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P: I felt a little better when I was lying down.

D: Exacerbating Factors: Anything that makes it worse?
P: No.
D: Severity: Can you score the pain for me on a scale from 1 to 10, with 1 being the
least and 10 being the highest pain possible?
P: 4.
D: Have you tried anything for the pain?
P: A nurse gave me diclofenac. I am feeling better now.
D: How many did she give you?
P: I took 2 tablets.
D: Anything else accompanying the pain? Open Q before asking about DDx
P: No.

D: What were you doing when you had this pain?

P: I was playing squash and after the game finished it started. Explore
D: Any idea why you might have this pain? IDEA
P: No, this time I was playing squash for a longer time so maybe that is why I have this
pain.
D: Any swelling?
P: No.
D: Have you sustained trauma while playing ?
P: No.
D: Did you hear any clicking sound at any point? Disc prolapse
P: No doctor.
D: Any history of lifting heavy weights?
P: No.
Cauda Equina:
D: Some people with similar pain may have problems controlling urine or bowel, have
you had anything similar ?
P: Nothing like that doctor.
D: Do you ever experience pain, and numbness around the back passage or anywhere
on your legs?
P: No.
Multiple Myeloma:
D: Do you ever feel like you are more thirsty or drinking water more than usual?
P: No.
D: Do you ever feel unusually tired / breathless / heart-racing ?
P: No.
D: Do you have any bleeding anywhere or easy skin bruising?
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P: No.
D: Any fever, flu-like symptoms or cough?
P: No.
D: Any loss of weight?
P: No.
D: Any loss of appetite?
P: No.

P2+MAFTOSA
D: Has it happened before?
P: No.
D: Have you ever had any muscle cramps or spasms before ?
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: By any chance do you have DM, HTN or a bone problem?
P: No.
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any use of steroids?
P: Yes/No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DESA
D: Tell me about your diet?
P: It’s good.
D: Do you do physical exercise?
P: I’m quite active as I mentioned, I play squash.
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: Only occasionally.
D: Do you have any kind of stress?
P: No.
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CONCERN
D: Do you have any specific concern regarding this pain?
P: When can I resume playing squash?
EXPECTATION:
D: Are you expecting anything in particular from us today?
P: I would like something to help me with pain doctor because it’s quite irritating
doctor to be honest.

Examination:
I would like to check your vitals and examine your back your tummy, your back
passage and perform a special test called a straight leg raise test.

Management:
Explain provisional diagnosis:
From our assessment and from the information you have given us, I know that you have
(mention positive symptoms), and from our examination we have found that (mention
findings). Therefore, I suspect you have a form of muscle sprain, its simply when your
muscles are overstretched while playing any sport, in your case squash. No need to
worry as it’s self-limited, it will subside on its own. Are you following so far?
Senior.

Investigations (x-ray back)

Treatment:

− Medical: We will keep giving you some painkillers like Diclofenac as it helped you
with the pain.
− Non-medical Lifestyle advice : I advise you to rest for a while and avoid playing
squash or any vigorous sports, if not relieved after two weeks I can refer you to a
physiotherapist.

Specialist
Safety netting always (Cauda equina):
If unable to control urine/ bowel/ pain around the anus come back or if pain is not
relieved.
Follow up
We will arrange for follow ups later (after 2 weeks) but if you have any inquiries, please
feel free to contact GP.
D: Do you have any other concerns?
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P: Will you give me physiotherapy?

D: If you are taking longer than usual to get better, your GP may be able to refer you to
a physiotherapist.
P: When can I resume my exercise?
D: For now having a good rest will help you improve your symptoms and boost recovery
as there is risk of further damage. It is advisable to avoid vigorous exercise for a few
weeks.
P: Can I play squash?
D: I can see that you’re very keen on your sports and that’s a very good habit that I
would like to encourage. However, as I mentioned, it is better not to play any kind of
sport until your injury heals and it might take a few weeks.

IN A NUTSHELL:
1) ACUTE PAIN AFTER EXERCISE
2) ALL NEGATIVE
3) REASSURE
4) X-RAY BACK
5) REST AND PAIN KILLERS

Back pain due to disc prolapse

Who you are: You are an FY2 in emergency department.
Who the patient is: Scott Saunders, 30 years old came with back pain.
What you should do: Take hx and manage him.
D: What brings you to the hospital today?
P: Doctor, I have pain in my lower back.
D: Tell me more? Open Q
P1
P: I have had this pain the last 2 weeks on and off, but it has become very painful
since yesterday.
D: Site: Where is it the pain exactly/ Can you point to it with your finger?
P: It’s in my lower back doctor.
D: Onset: How did it start?
P: All of a sudden.
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D: Character: Can you describe the pain for me?

P: Sharp.
D: Radiation: Does it go anywhere else?
P: Yes, it goes to my both thighs & legs till the tip of my big toe.
D: Any weakness in the lower limb? Any unusual sensation like numbness in
your feet or legs? RED FLAG
P: No.
D: Is it continuous or comes and goes?
P: It is mostly continuous.
D: Alleviating factors: Does anything make it better ?
P: Yes, it gets better when I take diclofenac.
D: How many tablets did you take?
P: Two.
D: Exacerbating Factors: Anything that makes it worse?
P: Yes when I try to bend.
D: Severity: Can you score the pain for me on a scale from 1 to 10, with 1 being the
least and 10 being the worst pain possible?
P: 7/8.
D: Have tried anything else for the pain?
P: No.
D: What were you doing when you had this pain?
P: I was at my job, moving heavy boxes, and then the pain started.
D: Are there any other symptoms with the pain ? open Q before asking about DDx
P: No or like what?
D: Have u sustained any trauma to your back before?
P: No.
D: Have you noticed any redness or swelling in your back or feet?
P: No.
D: Have you experienced any nausea or vomiting with the pain?
P: No.
AAA:
D: Do you have any pulsatile mass in the abdomen? Any tummy pain? Fainting/
dizziness/ light headedness?
P: No.
Cauda Equina:
D: Some people with similar pain may have problems controlling urine or bowel have
you had anything similar?
P: No.
D: Do you ever experience pain, and numbness around the back passage?
P: No.
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Multiple Myeloma:
D: Do you ever feel like you are more thirsty or drinking water more than usual?
P: No.
D: Do you feel ever feel unusually tired / breathless / heart racing ?
P: No.
D: Do you feel you are going to loo more often?
P: No.
D: Do you have any bleeding anywhere or easy skin bruising?
P: No
D: Do you easily get repeated infections? Any fever, flu-like symptoms, or cough?
P: No.
D: How has your health been recently?
P: Fine.

FLAWS
D: Have you had any lumps or bumps anywhere in your body recently.
P: No.
D: How has your appetite been recently?
P: It’s been fine.
D: Have you by any chance noticed that you’ve lost any weight recently?
P: No.
D: Any tiredness or dizziness?
P: No.
D: Have you noticed any discolouration of your eyes or skin?
P: No.

P2+MAFTOSA
D: Have you ever had similar problems in the past before?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Have you been diagnosed with any medical condition such as enlarged prostate, IBD,
AS or RA?
P: No.
D: Are you taking any medication regularly?
P: No.
D: Are you taking any other medications other than Diclofenac including OTC or
supplements?
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P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: What you do for a living?
P: Office work.

DESA:
D: Tell me about your diet?
P: It’s pretty good.
D: Do you do physical exercise?
P: I’m quite active.
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Do you have any kind of stress?
P: No.

Examination:
I would like to check your vitals and examine your back your tummy, your back
passage and perform a special test called a straight leg raise test.

Findings will be handed to you:

− Local Tenderness in the Lower Back
− Straight Leg Raise Test: Positive
Management:
Explain provisional
From our assessment and from the information you have given us, you mentioned that
you have (mention positive symptoms), and from our examination we have found that
(mention findings). We are suspecting you have a condition in which some of the jelly
cartilage-like substance in between the back vertebra bulges or when a spine vertebra
slides over another compressing the nerves in the spinal canal causing the symptoms
you described.

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Admit/ discharge/ refer.

Senior.
Investigations
− Blood routine
− X-ray back
− MRI by orthopaedic
− US tummy
Symptomatic Treatment:
Painkillers: add paracetamol to diclofinac, muscle relaxant creams, if pain is too severe,
give nerve painkillers.
Lifestyle:
− Make sure to advise about lifestyle modifications and to avoid lifting heavy
objects or change their job if it is the cause.
− Offer sick note if needed.
− Unlike muscle sprain, advise them to slowly increase activity and keep mobility as
much as possible.

Specialist
− Physiotherapist (if the pain and Sx do not improve however, most improve)
− Nerve specialist (if pain persists after 6 weeks or cauda equine Sx)

Safety netting always (Cauda equina):

If unable to control urine/ bowel/ pain around the anus come back or worse Sx or no
improvement.
Follow up
We will arrange for follow ups later but if u have any inquiries, please feel free to
contact your GP.

Back pain with CAUDA EQUINA SYNDROME

Same approach, same scenario more or less but with positive Cauda equine red flags.
Cauda Equina:
Doctor: Some people with similar pain may have problems controlling urine or bowel
have you had anything similar ?
P: I have not been able to pass urine since morning.
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D: Any tummy pain?

P: Yes, I have some discomfort here (patient points towards suprapubic).

Other Cauda equina Sx

• Lower Back Pain
• Bowel Problem (constipation)
• Bladder Problem (Urine Retention)
• Sexual Problems may also occur (impotence in men).
• Numbness in the saddle area, which is around the back passage (anus), and
weakness in one or both legs.

Investigation:
o MRI
o Myelography and CT some time needed.
o Urodynamic studies: may be required to monitor recovery of bladder function
following surgery.

Management:
− Neurosurgical Referral for Urgent Surgical Decompression to prevent permanent
neurological damage.
− Surgery is indicated to remove bone fragments, tumors, herniated disc.
− If surgery cannot be performed, radiotherapy may relieve cord compression
caused by malignant disease.
− Anti-Inflammatory agents.
− Post-operative care including physiotherapy, occupational therapy and
addressing lifestyle issues.

IN A NUTSHELL:
1) PAIN AFTER HEAVING LEAFTING / MAY HAVE HEARD A POPPING OR SNAPPING SOUND
2) CAUDA EQUINE
3) REASSURE
4) ADVICE + PAIN KILLER +KEEP ACTIVE
5) SAFETY NET.

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Back pain due to Multiple Myeloma

Who you are: You are an FY2 in GP surgery.
Who the patient is: 65 years old James came with back pain for long time
Special note: He had blood tests that showed (anaemia decrease RBC/ blood
electrophoresis increases IgG / urine Bence jones protein/ decrease platelets)
What you are supposed to do: Talk to the patient discuss results and plan of
management.

This is already covered in Test Results scenarios so please check there aswell.

My approach, I can see from my notes that you are coming for the test results Is it okay
if we have a chat in order to be able to explain things in a better way? What made you
come for these tests in the first place?
P1: Back pain SOCRATES
DDS:
Multiple myeloma:
DM (It doesn’t cause DM , but it causes DM symptoms dt increase Ca so easy to
remember : polyuria- polydipsia- weight loss ) Bones/ moans/ groans/ stones/
sitting on the king throne.
Blood components: (RBCS: anaemia: tiredness/ SOB/ heart racing)
Symptoms of decrease WBCS (recurring sore throat/ fever/ cough)
Symptoms of decrease platelet (bleeding easily and bruises)
FLAWS
2- Trauma / accident/ fall / sport
3- Disc prolapse questions (2 questions)
4- AAA
5- Cauda equina
P2:
Back pain before?
Past medical conditions?
P3:
DESA
MAFTOSA Family hx of cancer.

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Examination: I would like to check your vitals and examine your back, your
tummy for (hepatomegaly / splenomegaly/ Lymphadenopathy), your back
passage and perform a special test called a straight leg raise test. vvvimp

Management:
Senior (As you are in GP clinic)
Investigations (Have been done in GP clinic)
Symptomatic (Painkillers) Morphine
Referral urgent to haematologist (blood specialist)
− Bone marrow biopsy (sample of your bone marrow)
− MRI

Multidisciplinary team:
− Psychologist
− Physio therapist
− Occupational therapist
− Dietitian
− Clinical and palliative physicians

Dr, what are my options of treatment?

1- Anti- myeloma medicine: to destroy myeloma cells & control cancer if it comes back.
2- Medicine & procedures to prevent problems caused by MM such as bone pain, bone
fracture.
IN A NUTSHELL NB : YOUR JOB IN THIS STATION IS PAINKILLER

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GYNAECOLOGY

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Gynaecology

Overview of gynaecology structure:

Very important notes:

1. With any female, you must ask (P4)

• Period
o How is your period?
o When was your last menstrual period?
o Is it regular?
o Is it heavy?
o Any bleeding in between?
• Pregnancy
o Is there any chance, you could be pregnant?
• Pills
o Are you using any contraceptive pills?
• Pap smear
o Are you up to date with your pap smear? (If she is > 25 years old).

2. (P5) (Partner)

• How is your partner's health in general?

• How are things at home?
• Does he have any medical condition or do any run in his family?
• Are you related to your partner in any way?

3. In any case , you must ask about discharge.

• Do you have any abnormal discharge from your front passage?

4. Sexual history
• Are you sexually active?
(If yes)

• Do you have a stable partner?

(If no)

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• How many partners do you have?

• Do you practice safe sex, by that I mean do you use condoms?
• Have you been tested for HIV or STIs?

(If yes)

• When was your last test?

• What was the result?

5. Two questions, you only ask in HIV case or PCP (pneumocystis carinii pneumonia )
• Have you ever had anal sex?
• Would you describe yourself as homosexual, heterosexual or something else?

Bacterial vaginosis
Where you are: You are FY2 in General practice.
Who the patient is: Ms Isabel Clarke, 34 years old, presented a week ago with vaginal
discharge. A swab from her vagina was taken and it came back positive for Gardnerella
vaginalis but negative for Chlamydia and Gonorrhoea.
What you must do: Discuss results with her and discuss further management.

Don't forget to ask about (bubble baths, perfumed products, new partner and IUD)
D: I can see from my notes that you are coming for your results. How are you doing
today?
P: I am fine doctor, just want to know about my results.
D: Sure, do you have any expectations regarding your results?
P: No doctor.
D: Alright Isabel, is it ok if I can discuss few things with you so that I can explain your
results in a better way?
P: Yes doctor.
(Take history)
D: So, why did you come to the GP clinic in the first place?
P: I was having vaginal discharge. (P1) (Explore)
D: Please tell me more about it?
P: Like what doctor?
TRAC
D: How long have you been having this discharge?
P: For the last 2 months.
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(Psychosocial)
D: How this is affecting your life?
P: I haven’t been able to have sex for the last 2 months because of the embarrassing
smell.
D: I am really sorry about that. We’ll do our best to help you, don’t worry.
P: Thank you.
D: How does it smell?
P: It has a fishy odour. (+ve finding)
D: What is the colour of the discharge?
P: Its greyish white in colour.
D: What about the amount?
P: It is copious in amount.
D: Anything else?
P: No doctor.

DDs
D: Any fever? (PID)
P: No.
D: Any tummy pain? (PID)
P: No.
D: Any bleeding from the vagina? (Ectopic pregnancy)
P: No.
D: Do you use bubble bath or perfumed products down there?
P: Yes, doctor I started using bubble bath in the last 2 months. (+ve finding)

FLAWS
D: Any weight loss? (Malignancy)
P: No.
D: Any lumps or bumps anywhere on your body?
P: No.
D: Any change in appetite?
P: No.
D: Any night sweating?
P: No.

(P2)
D: Is it the first time to have a condition like this?
P: Yes.
D: Do you have any health problems? Like DM or HTN?
P: No.

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DESA
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Tell me about your diet.
P: I eat healthy.
D: Are you physically active?
P: Yes/No

MAFTOSA
D: Are you using any medication?
P: No.
D: Any allergies?
P: No.
D: Any family history of a similar or a significant condition?
P: No.

(P4)
D: Is your period regular?
P: Yes.
D: Is it heavy?
P: No.
D: Any bleeding in between?
P: No.
D: When was your LMP?
P: 3 weeks ago.
D: Is there any chance you might be pregnant?
P: No.
D: Are you using any contraception?
P: I have an IUCD (+ve finding) (Explore)
D: For how long have you had it?
P: About one year.
D: Any problems with IUCD?
P: No.
D: Are you up to date with your pap smear?
P: Yes.

Sexual history
D: Sorry I need to ask you some sensitive questions is that OK?
P: Ok doctor.
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D: Are you sexually active?

P: Yes.
D: Are you in a stable relationship?
P: Yes.
D: For how long you have been in this relationship? (To know if she has a new partner)
P: About 6 months.
D: Do you practice safe sex?
P: Yes.
D: Any other sexual partner other than this partner?
P: No.
(Ask about partner's symptoms)
D: Does your partner have any symptoms?
P: No.

Examination:
D: Now I need check your vitals i.e. your BP, pulse, temperature and respiratory rate
plus your tummy and vagina examination, is that ok?
P: Ok doctor.

Diagnosis:
D: Alright, Isabel we have your results with us. The good news is that you don’t have
any sexual transmitted infection like chlamydia or gonorrhoea. However, your swab is
positive for a bug called Gardnerella vaginalis.
It’s a bug which can disrupt normal flora of the vagina causing a condition called
bacterial vaginosis, which is bacterial infection of vagina.

Concerns:
P: How did I get it doctor?
D: You told me that you started using bubble bath 2 months ago, that can be one of the
causes. Moreover, as you are using IUCD, that can also be one of the causes of this
infection.

P: Did I get it from my boyfriend?

D: No, it is not a sexually transmitted infection, so you didn’t acquire it from your
boyfriend.

Management:
You're more likely to get an STI if you have BV. This may be because BV makes
your vagina less acidic and reduces your natural defences against infection.
Senior

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Symptomatic:
• Bacterial vaginosis is usually treated with antibiotic tablets or gels or creams.
• If you have a same-sex partner, they may also need treatment.
General advice:
• Things you can do yourself to help relieve symptoms and prevent bacterial
vaginosis returning:
Do:
o Use only water and appropriate emollients such as Dermol 500 to wash
your genital area.
o Have showers instead of baths.
Don’t

o Do not use perfumed soaps, bubble bath, shampoo, or shower gel in the
bath.
o Do not use vaginal deodorants, washes or douches.
o Do not put antiseptic liquids in the bath.
o Do not use strong detergents to wash your underwear.
o Do not smoke.

Specialist:
One more thing which is concerning me is your IUCD. So, we will refer you to a
gynaecologist so that we can make sure that everything is fine with it.

Safety netting:
If you develop any fever, tummy pains or increased discharge please let us know.

Follow up:
We will arrange your follow-up in a week.

Notes:
Recurring bacterial vaginosis
• It's common for BV to come back, usually within 3 months.
• You'll need to take treatment for longer (up to 6 months) if you keep getting BV
(you get it more than twice in 6 months).

Bacterial vaginosis in pregnancy

• If you develop bacterial vaginosis in pregnancy, there's a small chance of
complications, such as premature birth or miscarriage.

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Risk factors
Bacterial vaginosis is caused by a change in the natural balance of bacteria in your
vagina.
You're more likely to get it if:
• You're sexually active (but women who have not had sex can also get BV).
• You have had a change of partner.
• You have an IUD (contraception device).
• You use perfumed products in or around your vagina.
• BV is not an STI, even though it can be triggered by sex.
• A woman can pass it to another woman during sex

Pelvic Inflammatory Disease (PID)

Where you are: You are F2 in A&E.
Who the patient is: Tanya Morris, 30 years old, presented to the hospital complaining
of right lower abdominal pain (RIF).
What you must do: Talk to the patient, discuss initial management and address her
concerns.

D: What brought you to the hospital?

P: I have tummy pain. (P1)
SOCRATES
D: May I know where the pain is exactly?
P: It’s here doctor. In my right lower tummy.
D: When did the pain start?
P: It started 2-3 days ago.
D: What were you doing when the pain started?
P: I was sitting at home when it started doctor.
D: Is it continuous or comes and goes?
P: The pain is always there since it started.
D: Has it been the same?
P: It is getting worse.
D: What type of pain is it?
P: It is a dull pain.
D: Does it go anywhere?
P: No.
D: Have you taken any medication for it?
P: I took paracetamol, but it didn't work.
D: How many tablets have you taken?

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P: Just two tablets whenever I had pain.

D: Is there anything that makes it better or worse?
P: No.
D: Could you please score the pain on a scale of 1 to 10, with 1 being no pain and 10
being the most severe pain you have ever experienced.
P: Around 5.
D: Anything else?
P: I have discharge from my front passage. (P1)
TRAC
D: When did the discharge start?
P: 2-3 days ago.
D: What is the colour of discharge?
P: Yellowy, green.
D: Is there any blood in it?
P: No.
D: Is there any smell?
P: Yes doctor, it smells bad.
D: How much was the discharge?
P: Not too much.

D: Anything else?
P: No.

DDs
D: Did you have any fever or flu-like symptoms?
P: No/Yes I had a temperature. (+ve finding)
D: Were you feeling sick?
P: Yes for the past 2-3 days (+ve finding)
D: Did you vomit?
P: No.
D: Any pain or burning sensation while passing urine?
P: No.

FLAWS
D: Any weight loss? (Malignancy)
P: No.
D: Any lumps or bumps in body?
P: No.
D: Any change in appetite?
P: No.
D: Any night sweating?
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P: No.

(P2)
D: Have you had any of these symptoms before?
P: No.
D: Have you been diagnosed with any medical condition in the past.
P: No.
D: Do you know if you have any cyst in your ovaries or any sexually transmitted
infections before?
P: No.
DESA
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Tell me about your diet.
P: I eat healthy.
D: Are you physically active?
P: Yes/No

MAFTOSA
D: Are you currently taking any medications, over-the-counter drugs, or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous surgeries or procedures?
P: No.
D: Any family history of health-related condition?
P: No.

(P4)
D: When was your last menstrual period?
P: 2/3 weeks ago.
D: Are they regular?
P: Yes.
D: Any bleeding or spotting in-between your periods?
P: No.
D: Any painful or heavy periods?
P: No.
D: Have you been pregnant before?
P: No.
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D: Do you use any method of contraception?

P: Yes, I have coil inserted. (Risk factor)
D: Since when?
P: About three years now.
D: Is it in place?
P: Yes.
D: Were there any issues with the contraception used?
P: No.
D: Are you up to date with your pap smear?
P: Yes.

Sexual history
D: Sorry I need to ask you some sensitive questions is that OK?
P: Ok doctor.
D: Are you currently sexually active?
P: Yes.
D: When did you last have sexual activity?
P: Me and my boyfriend tried yesterday but I was in too much pain.
D: Do you have a stable partner?
P: Yes.
D: For how long you have been in this relationship?
P: I met my partner 2 weeks ago. (New partner <6 months, ask about previous
partners).
D: Have you had any other partners recently?
P: Yes, I had two other partners before him recently.
D: What kind of sexual contact do you have, vaginal, anal, oral?
P: Vaginal/Oral.
D: Do you practice safe sex, by that I mean do you use condoms?
P: No. (Advise on having safe sex in management)
D: When was the last time you had unprotected sex?
P: Yesterday when we were trying…
D: And you already said you are feeling pain during or after sex?
P: Yes.
D: Any bleeding after sex?
P: No.

Examination
D: If it’s OK with you I would like to check your vitals and examine your tummy and
take some swabs through a speculum examination.
I would also like to send for some initial investigations including routine blood test and
urine test.
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Examiner: Right adnexal tenderness and cervical excitation.

Provisional diagnosis:
D: From our assessment, I suspect you have a condition called Pelvic Inflammatory
Disease in short (PID). This is an infection around your womb and surrounding
structures including the ovaries and the tubes connecting your ovaries to your womb.
This is caused by some bacteria that has travelled up into your womb.

Management
Urgent admission if :
• pregnant (to exclude ectopic pregnancy)
• symptoms are severe (such as nausea, vomiting and a high fever)
• signs of pelvic peritonitis
• an abscess is suspected
• unable to take oral antibiotics and need to be given them through a drip
(intravenously)
• Suspected appendicitis

Senior
Investigations:
• Swabs are usually taken from the inside of your vagina and cervix. These are sent
to a laboratory to look for signs of a bacterial infection and identify the bacteria
responsible.
• Urine test
• Blood test
• Pregnancy test
• An ultrasound scan, which is usually carried out using a probe passed through the
vagina (transvaginal ultrasound).
• In some cases, laparoscopy (keyhole surgery) may be used to diagnose PID. A
laparoscopy is a minor operation where 2 small cuts are made in the abdomen. A thin
camera is inserted so the doctor can look at your internal organs and, if necessary, take
tissue samples. This is usually only done in more severe cases where there may be other
possible causes of the symptoms, such as appendicitis.

Symptomatic:
• Antibiotics needs to be started quickly, before the results of the swabs are
available.
o PID is usually caused by a variety of different bacteria. This means you'll be given
a mixture of antibiotics to cover the most likely infections.

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o You'll usually have to take the antibiotic tablets for 14 days, sometimes beginning
with a single antibiotic injection.
o It's very important to complete the entire course of antibiotics, even if you're
feeling better, to help ensure the infection is properly cleared.
o In severe cases, you may have to be admitted to hospital to receive antibiotics
through a drip in your arm (intravenously).
• If you have pain around your pelvis or tummy, you can take painkillers such as
paracetamol or ibuprofen while you're being treated with antibiotics.

Treating risk factors

• If you have an intrauterine device (IUD) fitted, you may be advised to have it
removed if your symptoms haven't improved within a few days, as it may be the cause
of the infection.
• Treating sexual partners any sexual partners you have been with in the 6 months
before your symptoms started should be tested and treated to stop the infection
recurring or being spread to others, even if no specific cause is identified.
o PID can occur in long-term relationships where neither partner has had sex with
anyone else.
o It's more likely to return if both partners aren't treated at the same time.
o We can help you contact your previous partners. This can usually be done
anonymously if you prefer.
• You should avoid having sex until both you and your partner have completed the
course of treatment.
• You can reduce your risk of PID by always using condoms with a new sexual
partner until they have had a sexual health check.
• It is recommended to do screening for STIs regularly.

Follow-up
• A follow-up appointment 3 days after starting treatment to check if the
antibiotics are working.
• If the antibiotics seem to be working, another follow-up appointment is given at
the end of the course to check if treatment has been successful.

Safety netting
• If your symptoms haven't started to improve within 3 days, you may be advised
to attend hospital for further tests and treatment.
• If you develop any fever or redness, heat, swelling around your private parts or
groin area, any burning sensation while passing urine, any cloudy or smelly urine
please come back to us.
• We usually offer HIV test for those who have sexually transmitted infections. Do
you wish to have one?
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Concerns:
P: Why do I have this?
D: It has many causes, the coil can be one of the causes, one of the commonest causes
of PID is sexually transmitted infections.

P: Is my partner cheating on me?

D: It does not mean that your partner is cheating on you. These bacteria can stay in
your body for many months before causing any symptoms. You/He might have got this
infection from your/his previous relationships.

P: What are the complications of it?

D: This condition can lead to some complications in pregnancy and can also lead to
infertility.

Gonorrhoea

Where you are: You are F2 in GUM clinic.

Who the patient is: Maria, aged 24, has come to the clinic for her investigation results.
Swab has been taken and the result shows gonorrhoea.
What you must do: Please talk to patient, take sexual history, inform patient about the
results, discuss further management and advise the patient.

D: I can see from my notes that you are coming for the swab results, right?
P: Yes, I got a sexual check-up done as I got to know about sexually transmitted
infections and I am here for my results.
D: Yes, I have your results with me, would you like me to explain the results first or shall
we have a chat about your health in order to be able to explain the results in a better
way?
P: Ok doctor, we can have a chat first.

Take history
D: Did you have any symptoms that made you have the check-up done?
P: No, I just read somewhere about STIs and thought about getting screened.
D: That was really wise of you.

Symptoms
D: Have you got any fever or flu-like symptoms?

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P: No.
D: Do you have any bleeding or discharge from your vagina?
P: No.
D: Any pain or discomfort in your lower tummy or your private parts?
P: No.
D: Any pain or burning sensation while passing urine?
P: No.
D: Any cloudy or smelly urine?
P: No.
D: Do you frequently go to the loo?
P: No.
D: Any blood with urine or incontinence?
P: No.
D: Any redness, heat or swelling around your private parts or groin area?
P: No.
D: Any eye problem or joint problem?
P: No.

(P2)
D: Have you ever had any of these symptoms at anytime?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Have you had any sexually transmitted infections before?
P: No.

DESA
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Tell me about your diet.
P: I eat healthy.
D: Are you physically active?
P: Yes/No

MAFTOSA
D: Are you currently taking any medications, over-the-counter drugs or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
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D: Any previous surgeries or procedures?

P: No.
D: Any family history of a health-related condition?
P: No.

(P4)
D: When was your last menstrual period?
P: 2/3 weeks ago.
D: Are they regular?
P: Yes.
D: Any bleeding or spotting between your periods?
P: No.
D: Any painful or heavy periods?
P: No.
D: Have you been pregnant before?
P: No.
D: Do you use any method of contraception?
P: Yes/No
(Don't ask about pap smear if the patient is <25 years old)

Sexual history
D: Sorry I need to ask you some sensitive questions is that OK?
P: Ok doctor.
D: Are you currently sexually active?
P: Yes.
D: When did you last have sexual activity?
P: Yesterday.
D: Do you have a stable partner?
P: Yes.
D: Since when have you been together?
P: (If <6 months ask about previous partners)
D: Have you had any other partners previously?
P: Yes, I had two other partners previously.
D: What kind of sexual contact do you have, vaginal, anal, oral?
P: Vaginal/Oral
D: Do you practice safe sex, by that I mean do you use condoms?
P: Sometimes. (Risk factor)
D: Any pain during or after sex?
P: No.

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Diagnosis (Explain the results)

D: Unfortunately, Maria, your results have come back positive for Gonorrhoea. This is
a sexually transmitted infection which is usually transmitted by having unprotected sex.
I’m so glad you came in despite the fact you had no symptoms, because now we can
treat it, so thank you for coming today.

Management
Senior.
Symptomatic:
• Gonorrhoea is usually treated with a short course of antibiotics.
o In most cases, treatment involves having an antibiotic injection (usually in the
buttocks or thigh) followed by 1 antibiotic tablet.
o It's sometimes possible to have another antibiotic tablet instead of an injection, if
you prefer.
o If you have any symptoms of gonorrhoea, these will usually improve within a few
days, although it may take up to 2 weeks for any pain in your pelvis to disappear
completely.
o Bleeding between periods or heavy periods should improve by the time of your
next period.

General advice
You should avoid having sex until you, and your partner, have been treated and given
the all-clear, to prevent re-infection or passing the infection on to anyone else.
It is advisable to practice safe sex all the time by using condoms. Pills cannot protect
you from sexually transmitted infections. Using condoms is the only way to protect
yourself from getting these infections.

Sexual partners
• Gonorrhoea is easily passed on through intimate, sexual contact. If you're
diagnosed with it, anyone you've recently had sex with may have it too.
• It's important that your current partner and any other recent sexual partners are
tested and treated.
• We may be able to help by notifying any of your previous partners on your behalf
anonymously.
• A contact slip can be sent to them explaining that they may have been exposed to
a sexually transmitted infection (STI) and suggesting they go for a check-up. The
slip will not have your name on it, so your confidentiality is protected.

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Safety netting:
If your symptoms do not improve after treatment or you think you've been infected
again, come to us. You may need to repeat treatment or further tests to check for other
problems.
If you develop any fever or redness, heat, swelling around your private parts or groin
area, any burning sensation while passing urine, any cloudy or smelly urine please
come back to us.
We usually offer HIV test for those who have sexually transmitted infections. Do you
wish to have one?

Follow up
• Attending a follow-up appointment, a week or two after treatment is usually
recommended, so another test can be carried out to see if you're clear of infection.

Concerns:
P: But doctor I don't have any symptoms.
D: These bacteria can stay in our body for months without causing any symptoms. You
might have got this condition from your partner or from your previous relationships.

P: Is my partner cheating on me?

D: It does not mean that your partner is cheating on you, as I told you earlier these
bacteria can stay in your body for many months before causing any symptoms. You/He
might have got this infection from your/his previous relationships.

P: What are the complications of Gonorrhoea?

D: The complications of this condition are Pelvic Inflammatory Disease (PID) which is
an infection around your womb and surrounding structures including the ovaries and
the tubes connecting your ovaries to your womb. This can also lead to some
complications in pregnancy (like causing ectopic pregnancy) This can also lead to
infertility.

Premature Ovarian Insufficiency

Where you are: You are FY2 doctor in Obstetrics and Gynaecology department.
Who the patient is: Mrs Maria Taylor, 26 years old, presented a week ago with
amenorrhea. Blood tests were done and show: Estrogen = Low, FSH &LH = High.
Diagnosis of premature ovarian insufficiency was made. She came today for the results.
What you must do: Talk to her, explain the results and address her concerns.

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D: I can see from my notes that you are coming for your blood tests results, right?
P: Yes doctor.
D: Alright Maria, I have your results with me, would you like me to explain the results
first, or shall we have a chat about your health in order to be able to explain the results
in a better way?
P: Ok doctor, we can have a chat first.

Take history
D: What made you do these tests in the first place?
P: I am not having periods. (P1) (Explore)
D: For how long?
P: For the last 2 years.
D: Sorry to hear about that. So you mean you haven’t had any periods at all in the last 2
years?
P: Yes.
D: Did you do anything about it?
P: No.

Symptoms
D: Do you have hot flushes?
P: Yes/No
D: Do you have night sweats?
P: Yes/No
D: Any vaginal dryness?
P: Yes/No
D: Do you have reduced libido?
P: Yes/No
D: Any problems with concentration?
P: Yes/No
D: How is your mood?
P: It is low (Explore/ Ask about self-harm)
D: Some people when they have a low mood they may have some thoughts of harming
themselves, have you ever experienced such thoughts?
P: No.
D: How is your sleep?
P: Fine.

Complications
D: Did you have any fractures? (Osteoporosis)
P: No.
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D: Any chest pain or SOB? (Cardiovascular complications)

P: No.

(P2)
D: Have you ever had a condition like this before?
P: No.
D: Do you have any health problems?
P: No.
D: Do you have any immune problems, tuberculosis, or any infection?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: Occasionally.
D: Tell me about your diet.
P: I try to eat healthy
D: With whom do you live?
P: My partner.

(P4)
D: How were your periods before 2 years ago?
P: They were regular.
D: Have you been pregnant before?
P: No, I am trying to get pregnant.
D: So you don’t use any contraception?
P: No.

MAFTOSA
D: Are you using any medication?
P: No.
D: Do you have any allergies?
P: No.
D: Any one in your family had a condition like this or a significant health problem? (Risk
factor)
P: I don’t know
D: Have you had any surgery of your ovaries or womb? (One of the causes)
P: No.

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Examination
I would like to check your vitals, i.e., your BP, pulse, temperature and respiratory rate. I
will also do general examination of your whole body if that’s OK with you.

Diagnosis (Explain the results)

D: From what we have discussed and from your blood results it shows that you are
unfortunately having a condition called premature ovarian failure. It means that your
ovaries have stopped working and that’s why you are not getting periods.

Management
Women with POI may have complex physical and psychological needs; therefore, a
multidisciplinary approach is very important.

Senior
Investigations
• Blood tests (hormones)
TFTs and prolactin levels should be performed to exclude alternative pathology.
Screening for autoimmune diseases
Testing for adrenal antibodies, karyotype and the FMR1 gene premutation are the main
diagnostic tests currently available to determine an underlying aetiology
• Imaging
A dual-energy X-ray absorptiometry (DXA) bone scan may be undertaken at diagnosis
and then every two years to assess bone mineral density.
Transvaginal ultrasound scan to identify any underlying cause for the diagnosis.
• Fragile X testing should be performed in those presenting at a young age or those
with a family history of POI or learning difficulties.
• Relatives of women with spontaneous POI should be referred for
genetic counselling.

General lifestyle and dietary measures

• To reduce the risk of cardiovascular disease and osteoporosis
Adequate dietary intake or supplementation of calcium (1000 mg) and vitamin D (800
IU) is recommended.

Replacement
• Women with POI should be given replacement until at least the average age of
the menopause (51 years). This is not just for symptom control but also to maintain
their long-term health.
• Replacement may be with HRT or the combined oral contraceptive.
• Treatment with HRT can be given sequentially to induce a regular withdrawal
bleed or as a continuous combined preparation to achieve amenorrhoea.
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• HRT will maintain age-appropriate bone density and also significantly reduce the
risk of fracture.
• The regimen of transdermal estradiol and medroxyprogesterone acetate has
been shown to restore bone mineral density to a level equal to women with normal
ovarian function.
• If using combined hormonal contraception for sex hormone replacement, it
should be noted that:
 They may be less effective than HRT in the prevention of osteoporosis.
 The combined oral contraceptive pill is associated with an increased risk of
thromboembolism.

Specialist
• It is recommended that referral be considered to healthcare professionals with
the relevant experience to help women manage all aspects of physical and
psychological health related to their condition.
• A specialist menopause centre.
• Some women may need referral to a psychologist or psychiatrist.
• Any associated depression or anxiety needs to be addressed and managed
appropriately.

Conception
• Permanent early menopause will affect your ability to have children naturally.
You may still be able to have children by using IVF and donated eggs from another
woman or using your own eggs if you had some stored. Surrogacy and adoption may
also be options for you.
• Egg donation is the main treatment of choice for women who wish to attempt
conception. This is sometimes from a family member.
• Spontaneous pregnancies can occur in 5-10% of women with POI, as a result of
intermittent ovarian function.

Support groups
• Going through the menopause early can be difficult and upsetting.
• Counselling and support groups may be helpful. Here are some you may want to
try:
The Daisy Network – a support group for women with premature ovarian failure
Fertility friends – a support network for people with fertility problems
Human Fertilisation and Embryology Authority (HFEA) – provides information on
all types of fertility treatment
Adoption UK – a charity for people who are adopting children
Surrogacy UK – a charity that supports both surrogates and parents through the
process
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Safety netting
• If you experience any chest pain, weakness in any part of your body, come to us
immediately.

Polycystic Ovarian Syndrome

Where you are: You are FY2 doctor in GP clinic.

Who the patient is: Mrs Sandra Scott, 29 years old, presented a week ago with acne
and irregular period. Blood tests were done and results show: LH = High, LH/FSH ratio =
3:1, BMI = 32, FSH= normal, Pregnancy test = negative. She has come today for her
results.
What you must do: Discuss these test results with her, take appropriate history, discuss
management, and address her concerns.

Doctor: I can see from my notes that you are coming for your tests results, right?
Patient: Yes doctor.
D: Alright Sandra, I have your results with me, would you like me to explain the results
first or shall we have a chat about your health in order to be able to explain results in a
better way?
P: Ok doctor, we can have a chat first.

Take history
D: Alright Sandra, please tell me why you had these tests done?
P: I haven’t been getting my periods and also my acne was troubling me. (P1)(Explore
both)
D: I see, it was a good idea to have these tests then. Let me ask you few questions first.

D: For how long have you not been getting your periods?
P: 3 months.
D: Were they regular before 3 months?
P: Yes.
D: Did anything happen before your periods stopped?
P: Yes/No
D: Do you have any pain around your pelvis?
P: Yes/No
D: Any pain in your breasts or discharge from your nipples?
P: Yes/No

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D: Tell me about your acne?

P: What do you want to know?
D: Since when have you had acne?
P: 3 months.
D: Have you done anything for it?
P: I am using emollients.
D: Has it improved?
P: A little.

D: Anything else?
P: No.

Symptoms
D: Any changes in your weight?
P: Yes, I gained weight. (+ve finding)(Explore)
D: How much in how much time?
P: In the last 3 months I gained about 5 pounds.
D: Any excess hair anywhere?
P: Yes/no
D: How is your mood?
P: Good/Bad

DDs
D: Do you feel tired
P: Yes/No
D: Any bowel problem?
P: Yes/No
D: Do you feel cold when others are feeling normal?
P: Yes/No

(P2)
D: Have you ever had a condition like this before?
P: No.
D: Have you ever been diagnosed with any medical condition in the past?
P: No.
D: Any diabetes or high blood pressure?
P: No.

DESA
D: Do you smoke?
P: No.
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D: Do you drink alcohol?

P: Wine on weekends.
D: Are you physically active?
P: Yes/No
D: Tell me about your diet?
P: I love burgers and chips. (Advise on having a healthy diet in your management)
D: Any stress in your life?
P: Yes, at work sometimes.
D: Who do you live with?
P: I live with my partner.

MAFTOSA
D: Are you taking any other medications including OTC or herbal medications?
P: No.
D: Do you have any allergies from food or medicines?
P: No
D: Any previous surgery or hospitalisations?
P: No.
D: Any surgeries around your womb or ovaries?
P: No.
D: Has anyone in your family suffered from a similar issue in the past?
P: Yes, my sister had a similar problem. (+ve finding)
D: Did she go to the doctor about it.
P: No, I don’t think she did.

(P4)
(Period has been explored in P1)
D: Have you been pregnant before?
P: No, I am not keen on having children yet. I will think about it after I get married in a
year’s time.
D: Do you use any contraception?
P: Yes/No
D: Are you up to date with your pap smear?
P: Yes.

Examination
D: I would like to check your vitals and do GPE.

Provisional diagnosis
D: From my assessment and from your test results, I suspect that you have a condition
called Polycystic ovarian syndrome (PCOS). It is a condition that affects how your
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ovaries work. You mentioned you have not had periods for the last 3 months and you
also have acne which is getting better. Your BMI is also on the higher side which also
suggests PCOS.

Management
Refer to a specialist, either a gynaecologist (a specialist in treating conditions of the
female reproductive system) or an endocrinologist (a specialist in treating hormone
problems).

Senior.
Investigations:
• An ultrasound scan, which can show whether you have a high number of follicles
in your ovaries (polycystic ovaries). The follicles are fluid-filled sacs in which eggs
develop.
• A blood test to screen for diabetes or high cholesterol.

Lifestyle changes
• The symptoms and overall risk of developing long-term health problems from
PCOS can be greatly improved by losing excess weight.
• Weight loss of just 5% can lead to a significant improvement in PCOS.
• A normal BMI (a measure to know whether you're in a healthy weight) is
between 18.5 and 24.9. Your BMI is 32.
• You can lose weight by exercising regularly and eating a healthy, balanced diet.
• Your diet should include plenty of fruit and vegetables, (at least 5 portions a day),
whole foods (such as wholemeal bread, wholegrain cereals and brown rice), lean meats,
fish and chicken.
• We can refer you to a dietitian if you need specific dietary advice.

Medicines
• A number of medicines are available to treat different symptoms associated with
PCOS.
1. For irregular periods: The contraceptive pill may be recommended to induce
regular periods, or periods may be induced using an intermittent course of progestogen
tablets (which are usually given every 3 to 4 months but can be given monthly.

2. Fertility problems: With treatment, most women with PCOS are able to get
pregnant. The majority of women can be successfully treated with a short course of
tablets taken at the beginning of each cycle for several cycles A medicine called
clomiphene is usually the first treatment recommended for women with PCOS who are
trying to get pregnant. Other available treatments include metformin.

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3. Unwanted hair growth and hair loss:

Medicines to control excessive hair growth (hirsutism) and hair loss (alopecia)
include: particular types of combined oral contraceptive tablets (such as co-cyprindiol,
Dianette, Marvelon and Yasmin).
A cream called eflornithine can also be used to slow down the growth of
unwanted facial hair. But eflornithine cream is not always available on the NHS because
some local NHS authorities have decided it's not effective enough to justify NHS
prescription.

4. Laser removal of facial hair may be available on the NHS in some parts of the UK.

5. Other symptoms associated with PCOS as:

Weight-loss medicine, such as orlistat, if you're overweight

Cholesterol- lowering medicine (statins), if you have high levels of cholesterol in
your blood.
Acne treatments

Surgery:
• A minor surgical procedure called laparoscopic ovarian drilling (LOD) may be a
treatment option for fertility problems associated with PCOS that do not respond to
medicine.
• Under general anaesthetic we will make a small cut in your lower tummy and
pass a long, thin microscope called a laparoscope through into your abdomen.
• The ovaries will then be surgically treated using heat or a laser to destroy the
tissue that's producing androgens (male hormones).
• This corrects your hormone imbalance and can restore the normal function of
your ovaries.

Follow up:
• Annual checks of your blood pressure and screening for diabetes if you're
diagnosed with PCOS.
Note
• If you have PCOS, you have a higher risk of pregnancy complications, such as high
blood pressure (hypertension), pre- eclampsia, gestational diabetes, and miscarriage.
• These risks are particularly high if you're obese. If you're overweight or obese,
you can lower your risk by losing weight before trying for a baby.

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Premenstrual syndrome (PMS)

Where you are: You are FY2 in General practice.
Who the patient is: Sarah, a 32-year-old lady, wants to talk to you.
What you must do: Talk to her and address her concerns.

Doctor: How can I help you?

Patient: Doctor, my husband wants me to talk to you. Actually, I am not feeling myself
lately.
D: Can you elaborate on that?
P: I am getting emotional and angry. I am shouting at my husband and children. I don’t
know what’s going on. (P1)
D: I am sorry to hear about that. That must be distressing for you. Please don’t worry
we will look into this matter.
P: Thank you doctor.
(Explore P1)
D: So, for how long have you been feeling like this?
P: For the past 8 months. (Psychosocial)
D: That’s quite a long time. And how is it affecting your life?
P: I am becoming distant from family because of these mood swings.
D: I understand that. Please don’t worry, we will try our best to help you.
P: Thank you.
D: Have you tried to do anything to make your situation better?
P: No.
D: Is there anything that makes it worse?
P: 3 to 4 days before my periods, my mood swings get worse and 1 to 2 days into my
periods, I get a lot better. (+ve finding)
D: Alright, is it becoming worse or is it the same?
P: It is the same.
D: Anything else?

Symptoms
D: Any headaches?
P: No. (If yes do SOCRATES and DDs of headache)
D: Any breast tenderness?
P: No.
D: Any body aches?
P: No.
D: Any tummy bloating?
P: No.
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D: How is your mood today?

P: It is low (Explore)
D: Can you please score your mood on a scale of 1 to 10, where 1 is the lowest and 10 is
the happiest?
P: Around 4 to 5.
D: Some people, when they have a low mood they think about harming themselves or
others. By any chance have you ever experienced thoughts like these?
P: No doctor.
D: Do you feel sad, hopeless, or irritable most of the time?
P: No.
D: Do you have loss of interest in everyday activities?
P: No.
D: Do you have feelings of emptiness or worthlessness?
P: No.
D: Do you have episodes of feeling very happy or overjoyed?
P: No.
D: How is your concentration nowadays?
P: It is low.
D: How is your sleep?
P: It is fine/not fine.
D: How is your appetite?
P: Fine.

DDs
D: Do you feel cold when others are feeling comfortable? (Hypothyroidism)
P: No.

FLAWS
D: Any fever or flu-like symptoms?
P: No.
D: Any weight loss?
P: No.
D: Any lumps or bumps?
P: No.

(P2)
D: Is it the first time it is happening to you?
P: Yes.
D: Do you have any health problems?
P: No.

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DESA
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: No.
D: Any sort of recreational drugs?
P: No.
D: How is your diet?
P: Good.
D: Any stress in your life?
P: No.
D: What you do for your living?
P: I am a teacher.
D: Is this affecting your teaching?
P: No, I try to control it.
D: Who do you live with?
P: With my husband and 2 children.

MAFTOSA
D: Are you using any medications?
P: No.
D: Any allergies?
P: No.
D: Anyone in your family with a similar problem?
P: No.

(P4)
D: When was your LMP?
P: 3 weeks ago.
D: Are they regular?
P: Yes.
D: By any chance could you be pregnant?
P: I don't think so.
D: Do you use any contraception?
P: No, my husband has had a vasectomy.
D: Are you up to date with your pap smear?
P: Yes.

Examination: I would like to check your vitals, by that I mean your BP, pulse,
temperature, and respiratory rate. If it’s OK with you, I also need to do a general

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physical examination of your whole body including your thyroid gland and glands in
body.

Provisional diagnosis
D: So I suspect you may have a condition called Premenstrual syndrome (PMS). It is a
common condition in women in which due to hormonal fluctuations, women tend to
experience mood swings and angry outbursts especially before their periods. PMS
(premenstrual syndrome) is the name of the symptoms women can experience in the
weeks before their period. Most women have PMS at some point in their lives. Each
woman’s symptoms are different and can vary from month to month.

Management:
Senior.

Investigations: We will take some blood samples to check if you have anaemia and to
make sure everything is fine with your liver, kidneys, and thyroid.

Symptomatic and lifestyle measures:

Things you can do to help:
Do
• Exercise regularly
• Eat a healthy, balanced diet – you may find that eating frequent smaller meals
(every 2-3 hours) suits you better than eating 3 larger meals a day.
• Get plenty of sleep – 7 to 8 hours is recommended.
• Try reducing your stress by doing yoga or meditation.
• Take painkillers such as ibuprofen or paracetamol to ease the pain.
• Keep a diary of your symptoms for at least 2 to 3 menstrual cycles – you can take
this to a GP appointment.
Don’t
• Do not smoke.
• Do not drink too much alcohol.

See a GP if:
Things you can do to help are not working.
Your symptoms are continuing to affect your daily life.

Medications:
A GP can recommend treatments including:
• Hormonal medicine – such as the combined contraceptive pill.
• Cognitive behavioural therapy – a talking therapy.
• Antidepressants.
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• Dietary supplements.

Specialist
If you still get symptoms after trying these treatments, you may be referred to a
specialist. This could be a gynaecologist, psychiatrist, or counsellor.

Complimentary therapies and dietary supplements

This may help with PMS, but the evidence of their effectiveness is limited.
They can include:
• Acupuncture
• Reflexology
• Supplements such as vitamin B6, calcium and vitamin D and magnesium (check
with a GP or pharmacist if you are also taking medicines before starting to take regular
supplements).

Follow up:
We will arrange a follow up in a month

Safety netting:
If you experience more mood swings, anxiety, thoughts of harming yourself or others,
please let us know.

Notes
Causes of PMS:
It's not fully understood why women get PMS. But it may be because of changes in
their hormone levels during the menstrual cycle. Some women may be more affected
by these changes than others.

Premenstrual dysphoric disorder (PMDD):

A small number of women may experience more severe symptoms of PMS known as
premenstrual dysphoric disorder (PMDD).
Symptoms of PMDD are similar to PMS but are much more intense and can have a
much greater negative impact on your daily activities and quality of life.
Symptoms can include:
o physical symptoms such as cramps, headaches and joint and muscle pain.
o behavioural symptoms such as binge eating and problems sleeping.
o mental and emotional symptoms, such as feeling very anxious, angry,
depressed or, in some cases, even suicidal.
If you need urgent advice you can:
call a GP and ask for an emergency appointment
call 111 out of hours (they will help you find the support and help you need)
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call a helpline, such as the Samaritans (call free on 116 123)

if you feel that you may be about to harm yourself, call 999 for an ambulance or
go straight to A&E. Or you can ask someone else to call 999 or take you to A&E.
The exact causes of PMDD are unknown but it has been linked to sensitivity to changes
in hormones or certain genetic variations (differences in genes) you can inherit from
your parents.

The most common symptoms of PMS include:

• Mood swings
• Feeling upset, anxious, or irritable
• Tiredness or trouble sleeping
• Bloating or tummy pain
• Breast tenderness
• Headaches
• Spotty skin or greasy hair
• Changes in appetite and sex drive

Cyclical breast pain

Where you are: You are F2 in GP clinic.

Who the patient is: Jenny aged 40 booked an urgent appointment to discuss her
problem.
What you must do: Talk to the patient, take history, assess her, and discuss the plan of
management and address her concerns.

Doctor: How can I help you?

Patient: My breasts are lumpy and sore. (P1) (Explore both)

D: Could you please tell me more about the soreness? (Explore P1)
P: It’s in both the breasts.
D: For how long have you had this soreness?
P: It’s been there for the last few months.
D: Is it all the time or comes and goes?
P: It comes and goes.
D: How many episodes have you had till now.
P: I have this soreness whenever I am about to have my periods.
D: So how long before your periods would you say?
P: It starts a few days before my period. Then when my period comes, the pain goes
away.

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D: Is it the same or getting worse?

P: It is the same.
D: Is there anything that makes it better?
P: I tried paracetamol; it didn't help much.
D: Is there anything that makes it worse?
P: When I touch my breasts, they become even more sore.

D: Tell me more about the lumps in your breast? (Explore P1)

P: It is also same as the soreness. I feel lumps before the start of my periods. But when
my periods start, they disappear.

D: Anything else?
P: No.

DDs
D: Any change in shape and size of the breast?
P: No.
D: Any change in the skin of the breast.
P: No.
D: Any discharge from the nipples?
P: No.
D: Any SOB or tiredness?
P: No.

FLAWS
D: Any fever or flu like symptoms?
P: No.
D: Any lumps and bumps in the body?
P: No.
D: Any weight loss?
P: No.
D: Any loss of appetite?
P: No.

(P2)
D: Have you had similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any breast problem in the past?
P: No.
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DESA
D: How is your diet?
P: Good.
D: Are you physically active?
P: Yes/No
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: No.
D: Any stress in your life?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any hormonal therapy?
P: No.
D: Any kind of allergy?
P: No.
D: Has anyone in your family been diagnosed with any medical condition or breast
problem?
P: Yes/No

(P4)
D: Tell me about your periods, when was your last menstrual period?
P: 2 weeks ago.
D: Is it regular?
P: Yes.
D: Any heavy periods or bleeding in between the periods?
P: No.
D: Have you been pregnant before? (If yes explore how many kids?)
P: No.
D: Are you sexually active?
P: Yes.
D: Are you using any method of contraception?
P: Yes/No

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Examination (PPCCE)
• Explain the procedure: Is it OK with you if I examine your breasts to check the
lumps that you have? For the examination I will be looking at your breasts, touching
them for the lump and checking the lymph nodes of your breasts.
I will examine you in sitting position, lying down and in standing position.
• Privacy: I will ensure your privacy
• Chaperone: I will have a chaperone with me during my examination.
• Consent: Is that alright? May I proceed?
• Exposure: for the purpose of examination, you will need to undress above your
waist.

Inspection: While sitting:

1) Sit upright and put your hands on your thigh:

Both breasts are symmetrical, nipples are at the same level.
There is no redness, swelling, visible mass, bruises and scars for any surgery.
There is no discharge, bleeding from the nipples. There is no peau d'orange.
2) Put your hands on your waist and bend forward: There is no visible mass on
bending forward.
3) Put your hands on the back of your head: There is no fullness in supraclavicular
and axillary area.
4) Lift your breast with two fingers: There is no fungal infection in infra-mammary
area.
5) Squeeze your nipples with two fingers: There is no discharge or bleeding from the
nipples.

Palpation: While lying down at 45.

I will be touching your breasts, at any time if you feel pain or discomfort please let me
know.
Temperature: with the back of your hand.
Compare all four quadrants of one breast with all the quadrants with the other breast.
(Upper inner, upper outer, Lower inner and Lower outer)
Superficial Palpation:
Go anti-clockwise and check for any tenderness. (Look at patient's face)
Deep palpation:
Again, go anti-clockwise and find the mass and comment on the mass.
(Size, shape, surface, regular or irregular, attached to underlying structures and
attached to overlying skin or not).
Peri areolar Palpation:
Go anti-clockwise and use your thumb to find out the mass.
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Lymph nodes: While standing

Check for axillary lymph nodes:
o From the front (Stand in front of the patient): check for Anterior, Medial and
apical.
o From the back (Stand behind the patient): check for Posterior and lateral.
o Then check for supra clavicular lymph nodes.

(Examination will be normal in this case)

Provisional diagnosis
From my assessment, I suspect you have a condition called Cyclical breast pain. This
pain is related to periods. Typically, it occurs in the second half of the monthly cycle,
becoming worse in the days just before a period.
It is thought that women with cyclical breast pain have breast tissue which is more
sensitive than usual to the normal hormonal changes that occur each month. It is not
due to any hormone disease or to any problem in the breast itself. It is not related to
any other breast conditions.
Although it is not serious, it can be a nuisance.

Management
No treatment may be needed if the symptoms are mild. Many women are reassured by
knowing that cyclical breast pain is not a symptom of cancer or serious breast disease.
The problem may settle by itself within a few months. However, sometimes this pain
may come and go over the years.

Senior.

Symptomatic and lifestyle

1) Support your breasts with a well-supporting bra when you have pain.
2) Painkillers and anti-inflammatory medications (Oral and topical) like paracetamol
or ibuprofen can be taken on the days when the breasts are painful.
3) Medicines such as danazol, tamoxifen and goserelin injections can ease pain in
most cases. They are only prescribed by specialists only in severe condition.
4) Evening primrose oil might be helpful.

Safety netting
If you have breast pain with a lump in your breast or under your arms, or discharge
from a lump or nipple come right away.
See your GP if:
• painkillers are not helping.
• you have a very high temperature or feel hot and shivery.
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• any part of your breast is red, hot or swollen.

• there's a history of breast cancer in your family.
• you have any signs of pregnancy – you could do a pregnancy test first.

Ask for an urgent GP appointment or call 111 if:

• there's a hard lump in your breast that does not move around.
• you get nipple discharge, which may be streaked with blood.
• one or both breasts change shape.
• the skin on your breast is dimpled (like orange peel).
• you have a rash on or around your nipple, or the nipple has sunk into your breast.
These can be signs of something more serious.

Note:
Medicines which may worsen cyclical breast pain:
1. The contraceptive pill or hormone replacement therapy (HRT)
2. Some antidepressants and some blood pressure medications

Structure for ante-natal care stations

(P1)
1. Recent pregnancy

How is your pregnancy?

How many weeks?

2. Rapport pregnancy

Congratulations ( after making sure that there are no problems so far )

I can see from my notes that you are (….) weeks, will you be finding out the
gender of the baby?
Have you chosen a name yet?
Will you be having a baby shower?

3. Any kids

How many?
How are they?

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(P2)

1) How many times have you been pregnant?

2) Any medical conditions?
3) Any previous procedures through your front passages or lower tummy?

(P3)

• Smoking – Alcohol – Recreational drugs

(P4)

• Pap smear (only if >25 years old) and its results.

MAFTOSA

• Medications (folic acid )

• Family history (Does anybody in your family have any medical issues?)

(P5) (Partner)

1. How is your partner's health in general?

2. How are things at home?
3. Do any medical conditions run in his family?
4. Are you related to your partner in any way?
5. Was it a planned pregnancy?

Examination (verbalize):

• Observation
• BMI
• Foetus (if > 34 weeks )

Management

ARMMS

Advice about DESA

Risk factors
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• Avoid unnecessary OTC

• Undercooked meats
Medications and investigations
• Folic acid
• Blood
CBC – FBS – U&E
Infection markers – inflammation markers
Liver and kidney functions
Blood grouping
Virology ( HIV – HBV – HCV – syphilis – rubella – STIs – toxoplasma )
• Urine
Proteins and sugar
• Gel scan
8 – 10 weeks → dating
11 – 14 weeks → nuchal translucency (Down’s )
18 – 20 weeks → sex of baby

Multidisciplinary team

• Heart specialist: if chronic hypertension

• Diabetic clinic: if DM
• Parents craft classes: classes to teach you how to deal with vomiting during
pregnancy and labour and how to cope with the baby.
Safety netting

• Travel to malaria countries

• Pain – bleeding – baby kicking
• Dental follow up

Pre-conception Counselling

Where you are: You are FY2 in GP clinic.

Who the patient is: Mrs Maria Thomas, 34 years old, presented for conception advice.
She wants to become pregnant and is here for advice regarding that.
What you must do: Talk to her and address her concerns.

Doctor: How may I help you?

Patient: Doctor I'm planning to get pregnant and asking for your advice to increase my
chances of getting pregnant and having a healthy baby.
D: Oh that’s wonderful news! Of course, we will do our best to help you out.

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P: Thank you.
D: Alright Maria, may I ask you a few questions about your health in order to be in a
better position to give you advice?
P: Yes doctor.
D: When did you decide to try to become pregnant?
P: A few months ago.
D: Will it be your first pregnancy?
P: Yes.

(P2)
D: Do you have any health problems?
P: No.
D: Any diabetes, high blood pressure, heart problem or thyroid problem?
P: No.

MAFTOSA
D: Are you using any medications?
P: No.
D: Any allergies?
P: No.
D: Does anyone in your family have a significant health problem?
P: No.
D: Any surgical procedures around your private parts or womb?
P: No.
D: Any previous hospital admissions?
P: No.

FLAWS

DESA
D: Tell me about your diet?
P: I eat everything. (Advise on having a healthy diet in management)
D: Do you smoke?
P: Yes (Explore)
D: What do you smoke and how much?
P: I smoke 10 cigarettes a day.
D: For how long you have been smoking?
P: 10 years.
D: Do you drink alcohol?
P: Occasionally.
D: Any sort of recreational drugs by any chance?
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P: No.
D: Any stress in your life?
P: No.
D: What do you do for your living?
P: I work in an office.

(P4)
D: When was your LMP?
P: 2 weeks ago.
D: Are they regular?
P: Yes.
D: Is there any chance you may already be pregnant?
P: I don't think so.
D: Obviously you are not using any contraception now?
P: No.
D: Had you been on any contraception at all, up until you decided to try for a baby?
P: Yes, I was on the contraceptive pill.
D: When did you stop it?
P: A few months back.
D: Are you up to date with your pap smear?
P: Yes.

(P5)
D: How is your partner's health in general?
P: He is fine.
D: How are things at home?
P: Good.
D: Do any medical conditions run in his family?
P: No.
D: Are you related to your partner in any way?
P: No.

Examination
If it’s OK with you I would like to check your vitals, by that I mean your BP, pulse,
temperature, and respiratory rate. I will also check your BMI.

Management
You can improve your chances of getting pregnant and having a healthy pregnancy by
following this advice:

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Take a folic acid supplement:

• You should take a 400 microgram supplement of folic acid every day before you
get pregnant, and every day afterwards, up until you're 12 weeks pregnant.
• Folic acid reduces the risk of your baby having a neural tube defect, when the
foetus's spinal cord (part of the body's nervous system) does not form normally.
• A higher dose supplement of 5 milligram (5mg) every day, recommended if: your
baby's other biological parent has a neural tube defect or family history of neural
tube defects. Or if you have diabetes or take anti-epilepsy medicine.

Stop smoking:
• Smoking during pregnancy has been linked to a variety of health problems,
including premature birth and low birth weight.

• Quitting can be difficult, but support is available.

• NHS Smoke free offers free help, support, and advice on stopping smoking,
including when you're pregnant, and can give you details of local support
services.
• Smoke from other people's cigarettes can damage your baby, so ask your
partner, friends and family not to smoke near you.

Cut out alcohol:

• Do not drink alcohol if you're pregnant or trying to get pregnant. Alcohol can be
passed to your unborn baby.
• Drinking in pregnancy can lead to long-term harm to your baby, and the more
you drink, the greater the risk.

Keep to a healthy weight:

• If you're overweight, you may have problems getting pregnant and fertility
treatment is less likely to work.
• Being overweight (having a BMI over 25) or obese (having a BMI over 30) also
raises the risk of some pregnancy problems, such as high blood pressure, deep
vein thrombosis, miscarriage and gestational diabetes.
• Having a healthy diet and doing moderate exercise are advised in pregnancy, and
it's important not to gain too much weight.

Know which medicines you can take:

• Not all medicines are safe to take when you're pregnant or planning a pregnancy,
whether they're on prescription or medicines you can buy in a pharmacy or shop.
• If you take prescribed medicine let me know so I can check if it’s safe to use in
pregnancy.

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Get flu and whooping cough vaccinations:

• Some infections, such as rubella (German measles), can harm your baby if you
catch them during pregnancy.
• Most people in the UK are immune to rubella, thanks to the uptake of the
measles, mumps and rubella (MMR) vaccination.
• If you have not had both doses or there's no record available, you can have the
vaccinations at your GP surgery.
• You should avoid getting pregnant for 1 month after having the MMR
vaccination, which means you'll need a reliable method of contraception.

Testing for sickle cell and thalassaemia:

• Sickle cell disease (SCD) and thalassaemia are inherited blood disorders that
mainly affect people whose ancestors come from Africa, the Caribbean, the
Mediterranean, India, Pakistan, south and Southeast Asia, and the Middle East.
• If you are pregnant and live in England you will be offered screening tests for
these disorders, but you do not have to wait until you're pregnant before you have a
test.
• If you or your partner are concerned you may be a carrier for one of these
disorders, perhaps because someone in your family has a blood disorder or is a carrier,
it's a good idea to get tested before starting a family.
• You get a free blood test from either a GP or a local sickle cell and thalassaemia
centre.

Note
• Options for conception if you are LGBTQ+,
o Donor insemination
o Surrogacy

Contraception

Where you are: You are F2 in GP clinic.

Who the patient is: Emma, a 29-year-old patient, presents to the GP clinic to get some
advice about contraception.
What you must do: Talk to the patient, take relevant history, and discuss different
methods of contraception.

Doctor: How can I help you?

Patient: I want to discuss my options for contraception.

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D: OK. I can help you with that. Are you on any contraception now?
P: No. I just met a new partner and he said doesn’t like condoms.
D: Okay, we have many types of contraception which we can offer you. There are 15
different methods of contraception currently available in the UK. The type that works
best for you will depend on your health and circumstances. But before that, do you
have any particular type of contraception in mind that you want me to talk about?
P: I want to know about the contraceptive pill.
D: No problem, before offering you any type of contraception I would like to ask you
few questions to see which type of contraception is better for you.
P: Ok doctor.

(If she doesn't use condoms offer STI screening)

D: Have you used any kind of contraception before?
P: Yes doctor I used the diaphragm before but I got pregnant.
D: Do you have any children?
P: Two kids aged 2 and 5.

(P2)
D: Have you been diagnosed with any medical condition in the past?
P: I had a blood clot in my leg after a long flight 2 years ago. (+ve finding) (Explore)
D: May I know what was done for that?
P: I went to the hospital and I was given warfarin for 6 months.
D: Any other medical condition?
P: No.
D: Any high blood pressure or diabetes?
P: No.
D: Any stroke, heart or liver disease or any ovarian cyst?
P: No.
D: Any STI, PID or ectopic pregnancy?
P: No.
D: Any migraine?
P: No.

DESA
D: Tell me about your diet.
P: I eat everything.
D: Are you physically active?
P: Yes/No
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
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P: Yes/No

MAFTOSA
D: Are you currently taking any medications, over-the-counter drugs or supplements?
P: No.
D: Any blood thinner?
P: No.
D: Do you have any allergy?
P: No.
D: Have you had any procedure or operation?
P: No.
D: Any previous hospital stays?
P: No.
D: Has any member of your family ever been diagnosed with any medical condition?
P: No.
D: Any deep vein thrombosis in the family?
P: No.

(P4)
D: When was your last menstrual period?
P: I am on my period now.
D: Are they regular?
P: Yes.
D: Any bleeding or spotting between your periods?
P: No.
D: Any painful or heavy periods?
P: No.
D: Any pain or bleeding during or after sex?
P: No.

Explain suitable methods

D: From my assessment I’m afraid you cannot have the contraceptive pill as you have
had a blood clot in your legs before. And taking these pills can cause you to have a
blood clot again. But don’t worry we have many other types of contraception which we
can offer you.

There is temporary, short term, long term and permanent methods of contraception.
Other than the contraceptive pill, you can have an injection, a patch on your skin, an
implant under your skin, a device (a “coil”) inserted into your womb and sterilisation,
which is permanent and irreversible.

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Progestogen-only pill (mini pill):

Advantages:
• It's useful if you cannot take the hormone oestrogen, which is in the combined
pill, contraceptive patch, and vaginal ring.
• You can use it at any age - even if you smoke and are over 35
• It can reduce the symptoms of premenstrual syndrome (PMS) and painful
periods.

Disadvantages:
• Your periods may be lighter, more frequent, or may stop altogether, and you may
get spotting between periods.
• It does not protect you against STIs.
• You need to remember to take it at or around the same time every day.
• Medications, like certain types of antibiotics, can make it less effective.

Side effects:
• acne
• breast tenderness and breast enlargement
• an increased or decreased sex drive
• mood changes
• headache and migraine
• nausea or vomiting
• small fluid-filled sacs called cysts on your ovaries - these are usually harmless and
disappear without treatment
• weight gain

These side effects are most likely to occur during the first few months of taking the
progestogen only pill, but they generally improve over time and should stop within a
few months.

Contraceptive Injection (Depo-Provera)

There are three types of contraceptive injections in the UK: Depo-Provera, which lasts
for 12 weeks, Sayana Press, which lasts for 13 weeks, and Noristerat, which lasts for
eight weeks.
The most popular is Depo-Provera.

Advantages:
The main advantages of the contraceptive injection are:
• each injection lasts for either eight, 12 or 13 weeks.
• the injection does not interrupt sex.

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• the injection is an option if you cannot use oestrogen-based contraception, such

as the combined pill, contraceptive patch or vaginal ring.
• you do not have to remember to take a pill every day.
• the injection is safe to use while you are breastfeeding.
• the injection is not affected by other medicines.
• the injection may reduce heavy, painful periods and help with premenstrual
symptoms for some women.
• the injection offers some protection from pelvic inflammatory disease (the mucus
from the cervix may stop bacteria entering the womb) and may also give some
protection against cancer of the womb.

Disadvantages:
• Disrupted periods
• Weight gain
• Headaches
• Acne
• Tender breasts
• Changes in mood
• Loss of sex drive

Risks:
There is a small risk of infection at the site of the injection. In very rare cases, some
people may have an allergic reaction to the injection.

Contraceptive Implant
Advantages:
• It works for three years.
• The implant does not interrupt sex.
• It is an option if you cannot use oestrogen-based contraception, such as the
combined contraceptive pill, contraceptive patch or vaginal ring.
• You do not have to remember to take a pill every day.
• The implant is safe to use while you are breastfeeding.
• Your fertility should return to normal as soon as the implant is removed.
• Implants offer some protection against pelvic inflammatory disease (the mucus
from the cervix may stop bacteria entering the womb) and may also give some
protection against cancer of the womb.
• The implant may reduce heavy periods or painful periods after the first year of
use.

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• After the contraceptive implant has been inserted, you should be able to carry
out normal activities.

Disadvantages:
• Disrupted periods

Side effects:
• headaches
• acne
• nausea
• breast tenderness
• changes in mood
• loss of sex drive.

Intrauterine Device:
Advantages:
• Most women can use an IUD, including women who have never been pregnant.
• Once an IUD is fitted, it works straight away and lasts for up to 10 years or until it's
removed.
• It doesn't interrupt sex.
• It can be used if you're breastfeeding.
• Your normal fertility returns as soon as the IUD is taken out
• It's not affected by other medicines.

There's no evidence that having an IUD fitted will increase the risk of cancer of the
cervix, endometrial cancer (cancer of the lining of the womb) or ovarian cancer. Some
women experience changes in mood and libido, but these changes are very small. There
is no evidence that the IUD affects weight.

Disadvantages:
• Your periods may become heavier, longer, or more painful, though this may
improve after a few months.
• An IUD doesn't protect against STIs, so you may have to use condoms as well. If
you get an STI while you have an IUD, it could lead to a pelvic infection if not
treated.
• The most common reasons that women stop using an IUD are vaginal bleeding
and pain.

Risks:
• Damage to the womb
• Pelvic infections
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• Rejection
• Ectopic Pregnancy.

Intrauterine system (Mirena):

Advantages:
• It works for five years (Mirena) or three years (Jaydess).
• It's one of the most effective forms of contraception available in the UK.
• It doesn't interrupt sex.
• An IUS may be useful if you have heavy or painful periods because your periods
usually become much lighter and shorter, and sometimes less painful – they may
stop completely after the first year of use.
• It can be used safely if you're breastfeeding.
• It's not affected by other medicines.
• It may be a good option if you can't take the hormone oestrogen, which is used in
the combined contraceptive pill.
• Your fertility will return to normal when the IUS is removed.

There's no evidence that an IUS will affect your weight or that having an IUS fitted will
increase the risk of cervical cancer, cancer of the uterus or ovarian cancer. Some
women experience changes in mood and libido, but these changes are minor.

Disadvantages:
• Some women won't be happy with the way that their periods may change. For
example, periods may become lighter and more irregular or, in some cases, stop
completely. Your periods are more likely to stop completely with Mirena than with
Jaydess.
• Irregular bleeding and spotting are common in the first six months after having
an IUS fitted. This is not harmful and usually decreases with time.
• Some women experience headaches, acne, and breast tenderness after having
the IUS fitted. An uncommon side effect of the IUS is the appearance of small fluid-filled
cysts on the ovaries - these usually disappear without treatment.
• An IUS doesn't protect you against STIs, so you may also have to use condoms
when having sex. If you get an STI while you have an IUS fitted, it could lead to pelvic
infection if it's not treated.
• Most women who stop using an IUS do so because of vaginal bleeding and pain,
although this is uncommon. Hormonal problems can also occur, but these are even less
common.

Risks:
• Damage to the womb
• Pelvic infections
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• Rejection
• Ectopic Pregnancy.

Female sterilisation:
• Female sterilisation is usually carried out under general anaesthetic, but can be
carried out under local anaesthetic, depending on the method used. The surgery
involves blocking or sealing the fallopian tubes, which link the ovaries to the womb
(uterus).
• This prevents the woman’s eggs from reaching sperm and becoming fertilised.
Eggs will still be released from the ovaries as normal, but they will be absorbed
naturally into the woman's body.

There are two main types of female sterilisation:

• when your fallopian tubes are blocked - for example, with clips or rings (tubal
occlusion)
• when implants are used to block your fallopian tubes (hysteroscopic sterilisation
or HS).
• Removing the tubes (salpingectomy):
If blocking the fallopian tubes has been unsuccessful, the tubes may be completely
removed. Removal of the tubes is called salpingectomy.

Advantages:
• Female sterilisation can be more than 99% effective at preventing pregnancy.
• Tubal occlusion (blocking the fallopian tubes) and removal of the tubes
(salpingectomy) should be effective immediately - however, doctors strongly
recommend that you continue to use contraception until your next period.
• Hysteroscopic sterilisation is usually effective after around three months –
research collected by NICE found that the fallopian tubes were blocked after
three months in 96% of sterilised women.
Other advantages of female sterilisation are that:
o There are rarely any long-term effects on your sexual health.
o It will not affect your sex drive.
o It will not affect the spontaneity of sexual intercourse or interfere with
sex (as other forms of contraception can).
o It will not affect your hormone levels.

Disadvantages:
• Female sterilisation does not protect you against STIs, so you should still use a
condom if you are unsure about your partner's sexual health.

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• It is very difficult to reverse a tubal occlusion - this involves removing the blocked
part of the fallopian tube and re-joining the ends, and reversal operations are
rarely funded by the NHS.
• a 2015 US study found that around 1 in 50 women who had a hysteroscopic
sterilisation required further surgery due to complications such as persistent
pain.

Risks:
• There is a very small risk of complications, including internal bleeding and
infection or damage to other organs.
• It is possible for sterilisation to fail - the fallopian tubes can re-join and make you
fertile again, although this is rare (about one in 200 women become pregnant in their
lifetime after being sterilised)
• If you do get pregnant after the operation, there is an increased risk that it will be
an ectopic pregnancy (when the fertilised egg grows outside the womb, usually in the
fallopian tubes). If you miss a period, take a pregnancy test immediately. If the
pregnancy test is positive, you must see your GP so that you can be referred for a scan
to check if the pregnancy is inside or outside your womb.

Notes:
D: Remember, the only way to protect yourself against sexually transmitted infections
(STIs) is to use a condom every time you have sex. Other methods of contraception
prevent pregnancy, but they don't protect against STIs.

If you miss a period, take a pregnancy test immediately and see your GP.
P: Thank you Doctor. I will consult my partner and get back to you.

D: Can you make contraception part of your daily routine? Or would you prefer
contraception that you don't have to remember every day?

Not all contraceptives have to be taken every day or each time you have sex.
You don't have to think about some contraceptives for months or years.

Methods that are used each time you have sex:

• male condoms and female condoms:
• diaphragm or cap

Methods that are taken every day:

• the pill (the combined pill)

Methods that are replaced every week:

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• contraceptive patch

Methods that are replaced every month:

• vaginal ring

Methods that are renewed every two to three months:

• contraceptive injection

Methods that are renewed up to every three years:

• contraceptive implant

Methods that are renewed up to every five to 10 years:

• intrauterine device (IUD)
• intrauterine system (IUS)

Combined pill prescription

Where you are: You are an FY2 in OB/GYN.
Who the patient is: Avery Smith, aged 22, has come to you asking for a 6 months'
prescription of OCP.
Other information: She was not using condoms for 5 months.
What you must do: Talk to her and address her concern.

Doctor: How may I help you?

Patient: Doctor, I'm going on a holiday with my partner, and I want to avoid having my
periods during whilst I’m away.
Build rapport
D: Sounds lovely! Where are you going?
P: Thank you. We are going to Australia.
D: So you have planned for this. How long will your vacation will be?
P: About 6 months.
(Ask if she prefers a specific method of contraception)
D: Do you have any specific method or medication in mind?
P: I'm thinking about taking oral contraceptive pills.

Take history
D: Have you used the pill before?
P: No.
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D: Do you use any kind of contraception?

P: We were using condoms but stopped 5 months ago. (Offer STI screening, pregnancy
test and advise on having safe sex in your management)
D: Is there any specific reason for which you stopped using the condoms?
P: We just don’t like them.

(Rule out contraindications)

(P2)
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any high blood pressure, heart disease or diabetes?
P: No.
D: Any history of stroke, blood clots or liver disease?
P: No.
D: Any migraine?
P: No.
D: Any breast problem?
P: No.

DESA
D: Tell me about your diet.
P: I eat everything. (Measure BMI to rule out being very overweight)
D: Are you physically active?
P: Yes/No
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: Occasionally.

MAFTOSA
D: Are you currently taking any medications, over-the-counter drugs or supplements?
P: No.
D: Do you have any allergy?
P: No.
D: Any previous hospital stays?
P: No.
D: Has any member of your family ever been diagnosed with any medical condition like
blood clots?
P: No.

(P4)
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D: When was your last menstrual period?

P: 3 weeks ago.
D: Are they regular?
P: Yes.
D: Any bleeding or spotting between your periods?
P: No.
D: Any painful or heavy periods?
P: No.
D: Do you realise as you haven’t been using any contraception for the past 5 months
there’s a chance you be pregnant now?
P: I haven’t thought about it to be honest. (Do pregnancy test for her)

Sexual history
D: How long have you been with your partner?
P: (If <6 months ask about previous partners)
D: Any other casual partners?
P: No.

Examination:
Thank you, Avery, for the information you have given to me. Now I would like to
examine you if that’s OK. I will take your observations, measure your BMI and ask you
to pop into the toilet here to do a quick pregnancy test for me to be on the safe side.

Management:
OK Avery, after the chat we had I am happy to prescribe to you the combined pill (as
long as the pregnancy test is negative, and observations are OK). I would also like to
offer you some free condoms and encourage you to use them at least until you know
you are covered by the pill.
Also, Avery, as you told me that you and your partner have been having unprotected
sex for the past 5 months, I highly advise you to go to your nearest sexual health clinic
with your partner to have a general STI screening check.

Starting the combined pill:

You may need to use additional contraception during your first days on the pill – this
depends on when in your menstrual cycle you start taking it.

Starting on the first day of your period:

If you start the combined pill on the first day of your period (day one of your menstrual
cycle) you will be protected from pregnancy straight away. You will not need additional
contraception.
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Starting on the fifth day of your cycle or before:

If you start the pill on the fifth day of your period or before, you will still be protected
from pregnancy straight away, unless you have a short menstrual cycle (your period is
every 23 days or less). If you have a short menstrual cycle, you will need additional
contraception, such as condoms, until you have taken the pill for seven days.

Starting after the fifth day of your cycle:

You will not be protected from pregnancy straight away and will need additional
contraception until you have taken the pill for seven days.
If you start the pill after the fifth day of your cycle, make sure you have not put yourself
at risk of pregnancy since your last period. If you're worried you're pregnant when you
start the pill, take a pregnancy test three weeks after the last time you had unprotected
sex.

Delaying periods:
If you take a combined contraceptive pill, you can delay your period by taking 2 packets
back-to-back.
How you do this will depend on which pill you take.
Examples are:
• Monophasic 21-day pills, such as Microgynon and Cilest – you take a combined
pill for 21 days, followed by 7 days without pills, when you have a bleed (period). To
delay your period, start a new packet of pills straight after you finish the last pill and
miss out the 7-day break.
• Everyday (ED) pills, such as Microgynon ED and Lorynon ED – you take a
combined pill every day. The first 21 pills are active pills and the next 7 pills are inactive
or dummy pills, when you have your period. To delay your period, miss out and throw
away the dummy pills, and start the active pills in a new packet straight away.
• Phasic 21-day pills, such as Binovium, Qlaira and Logynon – the mix of hormones
in each pill is different, depending on which phase you're in. You need to take these pills
in the correct order to have effective contraception.

Follow up:
Pill checks:
If you are taking the contraceptive pill then, for your safety, you will need check-ups
every 6-12 months with the nurse, before your repeat prescriptions can be continued.

Safety netting:

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• If at any time if you feel that you have leg pain or calf muscle swelling, seek
medical advice right away.
• Advise on having safe sex, follow up regularly and offer STI screening.
(Finally wish the patient a good trip)
Notes:
You should not take the pill if you:
• Are pregnant
• Smoke and are 35 years or older
• Stopped smoking less than a year ago and are 35 or older
• Are very overweight
• Take certain medicines (ask your GP or a health professional at a contraception
clinic about this)
You should also not take the pill if you have (or have had):
• Thrombosis (a blood clot) in a vein, for example in your leg or lungs
• Stroke or any other disease that narrows the arteries
• Anyone in your family having a blood clot under the age of 45
• A heart abnormality or heart disease, including high blood pressure
• Severe migraines, especially with aura (warning symptoms)
• Breast cancer
• Disease of the gallbladder or liver
• Diabetes with complications or diabetes for the past 20 years

Genital herpes
Who you are: FY2 in the GP clinic.
Who the patient is: 30-year-old, Alice Brown came to the clinic with a rash.
What you should do: Talk to the patient, assess, and address her concerns.

Genital herpes (Positive Findings):

● Multiple painful blisters, which quickly burst to leave erosions and ulcers, on the
external genitalia.
● Lesions are usually bilateral and develop 4–7 days after exposure.
● Headache, fever, malaise, dysuria, or tender inguinal lymphadenopathy.

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● Vaginal or urethral discharge.

● Local oedema.
● Tingling/neuropathic pain in the genital area, lower back, buttocks or legs.

Presenting complaint (P1) (ODIPARA):

D: Hello, I am one of the doctors in the GP clinic. Are you Alice?
P: Yes.
D: Can I get your full name and date of birth please, before we begin the consultation?
P: (Confirms details)
D: So, Alice, what can I do for you today?
P: I have some lesions/blisters.
D: Tell me more about these lesions. (Open question)
P: Well, it’s a bit embarrassing, they are down there on my privates.
D: When exactly did it start?
P: Well, doctor, it started 3 days ago (Onset)
D: Is it continuous or does it come and go? (Duration)
P: They are there all the time.
D: Can you tell me exactly where they are? (Site)
P: It's around my front passage, doctor.
D: The size, shape and colour of the lesions?
D: Any discharge, bleeding, pain?
D: Have you noticed any fever along with it?
D: Do you think it has been increasing since it started? (Progression)
P: Yes, doctor, I think it is getting worse.

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D: Is there anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: No doctor, I took some paracetamol for the pain but that doesn't seem to help. Also,
I used a cream on them but that is also not very helpful.
D: Anything else apart from the fever?
P: I also get this headache sometimes along with some pain while urinating.
D: Tell me more about these problems, did they start with the rash?
P: Yes.
D: Any history of cold sores?
P: Not with me, but my partner gets cold sores.
D: Anything else?

DDs
● Herpes zoster
● Scabies
● Candida.

Concern
D: Apart from this, do you have anything else that's concerning you?
P: No doctor, this is the only thing that’s bothering me. It doesn't seem to get better.

Past medical conditions (P2)

D: Has this ever happened to you before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: No, doctor.

P4
D: Any contraceptive use?
D: Any possibility that you might be pregnant?

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P: Yes doctor, I am pregnant.

D: How many weeks?
P: 28 weeks.
D: Did you have your last pap smear?
P: Yes.

(P3)D.E.S.A + Sexual history:

Do you smoke?
What about alcohol?
Are you sexually active?
Do you have a stable partner?
Sorry to ask you this but it’s part of my consultation. Do you practice oral sex? (Yes)
Do you use protection?

M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: I am taking folic acid doctor.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in the family with similar problems or other medical conditions?
P: No, doctor.
D: Have you had any contact with anyone that might have had something similar going
on?
P: No, doctor.

Expectation
D: Anything specific on your mind that you are expecting from us today?
P: I just want something for this pain.

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Examination:
● Observations (Check vitals)
● General physical examination
● Examination of the lesion
● Lymph nodes

Idea
D: Do you have any idea what might be causing this?
P: No, doctor.

Suspected diagnosis:
D: So, Alice, you have these blisters around your front passage that rupture as well and
for the past 5 days now that are also very painful. After examining these lesions, I am
suspecting it to be something called Herpes simplex. Have you heard about it?
P: Yes, doctor, it's an STI, right?
D: Yes, Alice, it is an infection caused by a virus which is similar to the virus that can
sometimes cause cold sores on your lips.
P: What can I do about it, doctor?
Management:
1. Senior
Discuss with senior
2. Investigations
STI screening
3. Symptomatic management
Dos and Don’ts
Dos
● Keep the area clean using plain or salty water to prevent blisters becoming
infected.
● Apply an ice pack wrapped in a flannel to soothe pain.
● Apply petroleum jelly (such as Vaseline) or painkilling cream (such as 5%
lidocaine) to reduce pain when you pee.

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● Wash your hands before and after applying cream or jelly.

● Pee while pouring water over your genitals to ease the pain.
● Keep yourself hydrated.

Don’t
● Do not wear tight clothing that may irritate blisters or sores.
● Do not put ice directly on the skin.
● Do not touch your blisters or sores unless you're applying cream.
● Do not have vaginal, anal or oral sex until the sores have gone away.

4. Definitive management
● Oral antivirals are the primary treatment for genital herpes simplex
infection — treatment should commence within 5 days of the start of the
episode, or while new lesions are forming for people with a first clinical episode
of genital herpes simplex virus (HSV).
● Prescribe oral acyclovir 400 mg three times a day for 5–10 days, or 200 mg five
times a day for 5–10 days, or alternatively:
● Valaciclovir 500 mg orally twice a day for 5–10 days.
● Famciclovir 250 mg orally three times a day for 5–10 days.

5. Specialist
Referral to Genitourinary medicine clinic for screening

6. Safety net
● Bladder problems
● Other sexually transmitted diseases

Vaginal discharge (Candidiasis)

Who you are: FY2 in the GP Surgery.
Who the patient is: 25-year-old Betty Ruth came to the clinic with complaints of vaginal
discharge.
What you should do: Talk to the patient, assess, and address her concerns.
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Candidiasis (Positive Findings):

Symptoms in women
● White vaginal discharge (often like cottage cheese), which does not usually smell.
● Itching and irritation around the vagina.
● Soreness and stinging during sex or when you pee.
Symptoms in men
● Irritation, burning and redness around the head of the penis and under the
foreskin.
● A white discharge (like cottage cheese).
● An unpleasant smell.
● Difficulty pulling back the foreskin.

Presenting complaint (P1) (ODIPARA)(T.R.A.C):

D: Hello, I am one of the doctors in this GP clinic. Are you Betty?
P: Yes.
D: Can I get your full name and date of birth please, before we begin the consultation?
P: (Confirms details)
D: So, Betty, I can see that you have been having some discharge from the front
passage?
P: Yes, doctor.
D: Tell me more about it (Open question)
P: Yes, doctor. I have had this problem for a few weeks now.
D: When exactly did it start?
P: I don’t know it started a few weeks ago, I don’t know what brought it on. (Onset)
D: Is it continuous or does it come and go? (Duration)
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P: It is continuous.
D: Is it related to something?
P: I also have this intense itching and irritation around my front passage.
D: Can you tell me about the colour and smell of the discharge?
P: Its white in colour but it is odourless.
D: Do you think it has been increasing since it started? (Progression)
P: No doctor, it's the same since it started.
D: Is there anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: No doctor.
D: Anything else?
P: Yes, I also feel soreness and stinging during sex and it gets really embarrassing for
me.

DDs
● Candidiasis (White cheesy discharge, no itching, use of local irritants such as
soaps, shampoos, shower gels/douching, history of uncontrolled diabetes)
● Bacterial vaginosis (Itching not prominent, white, homogenous, malodorous
discharge)
● Trichomoniasis (Itching, foul-smelling, frothy, grey-green discharge)
● Chlamydia (No itching, dysuria)
● Gonorrhoea ( No itching, purulent discharge)

Concern
D: Apart from this, do you have anything else that's concerning you?
P: It is very embarrassing doctor.
D: I see it's been bothering you but don't worry we’ll look into it and see what can be
done to make it better.

Past medical conditions (P2)

D: Has this ever happened in the past?
P: No, doctor, I have never had anything like this before.
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D: Do you have any medical conditions that I should be aware of? (Uncontrolled
diabetes)
P: No.

P3 D.E.S.A + Sexual history:

Do you smoke?
What about alcohol?
Are you sexually active?
Do you have a stable partner?
Any other partner?
Any oral sex?
Do you use protection?

P4
D: Any contraceptive use? (COCP’s, IUCD)
P: No, doctor.
D: Any possibility that you might be pregnant?
P: No, doctor.
D: When was your last period?
P: 2 weeks ago.
D: Did you have your last pap smear?
P: Yes.
D: What were the results?
P: It was normal, doctor.
D: Have you had STI screening?
P: No, doctor.

M.A.F.T.O.S.A
D: Are you on any long term medication?
P: No.

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D: What about any known allergies to any food or drugs?

P: I don’t have any known allergies.
D: Anyone in your family with similar problems or other medical conditions?
P: No, doctor
D: Did you have any contact with anyone with a similar problem?
P: No, doctor
D: How has it been impacting you?
P: It makes me feel really embarrassed because it causes soreness during sex.
D: Anything else?

Expectations?
D: Anything specific on your mind that you are expecting from us today?
P: Something to get rid of it, doctor, it’s very embarrassing for me.

Examination:
● Observations (Check vitals)
● General physical examination
● Front passage

Ideas?
D: Do you have any idea what might be causing this?
P: No, doctor.

Suspected diagnosis:
D: So, Betty, you have been having this white discharge from the front passage and it's
also causing itching around your front passage. Also you told me that you also
experience some pain while peeing and you are diabetic as well. All these things are
making me suspect something called vaginal candidiasis which is basically a fungal
infection of the front passage. It’s also commonly known as ‘thrush’.
P: Is it an STI?
D: No, it's not an STI.

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Management:
1. Senior
2. Investigations
● Full blood count and ferritin levels
● High vaginal swab
● Vaginal PH testing
● Mid-stream urine testing (If suspecting UTI)
● HbA1c
● STI screening

3. Symptomatic management
● Use simple emollients as a soap substitute to wash and/or moisturise the vulval
area.
● Avoid contact with potentially irritant soap, shampoo, bubble bath, or shower
gels, wipes, and daily or intermenstrual 'feminine hygiene' pad products.
● Avoid vaginal douching.
● Avoid wearing tight-fitting and/or non-absorbent clothing, which may irritate the
area.
● Avoid use of complementary therapies such as application of yoghurt, topical or
oral probiotics, and tea tree or other essential oils.
4. Definitive management
● Antifungal medication (Tablets, Vaginal Pessary, Cream – 7 to 14 Days)
● You might need to take longer treatment up to 6 months if you have got
recurring thrush (>4 times in a year).
● You can buy antifungal medication from a pharmacy. You should not use
antifungal medication more than twice in 6 months without speaking to your
doctor.
● 4. Avoid anti thrush tablets if you are pregnant, trying to pregnant or
breastfeeding.
● Only use cream or a vaginal pessary that contains clotrimazole. Normally, thrust
is treated with fluconazole tablets.

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5. Specialist:
Arrange specialist referral or seek specialist advice, depending on clinical judgement,
if:
● An affected young person is aged 12–15 years.
● There is uncertainty about the diagnosis.
● Symptoms are not improving and treatment failure is unexplained.
● Symptoms persist after a second course of antifungal treatment.
● The woman has uncontrolled diabetes and treatment failure.

6. Safety net
● Recurrent infections.

Emergency contraception
Where you are: You are F2 in GP clinic.
Who the patient is: 14-year-old Julia, came to the clinic. She had unprotected sex and
she has some concerns.
What you must do: Please talk to the patient, assess the situation and address her
concerns.

Doctor: May I know what brought you to the clinic today?

Patient: I am here for morning after pill/ emergency contraception.
D: OK, could you please tell me the reason you are asking for emergency contraception?
P: I had unprotected sex with my boyfriend last night. I’m scared of getting pregnant.
D: OK, can we have a chat about your health and then we can see if you are suitable for
taking emergency contraception?
P: Ok doctor.

Sexual history
D: Sorry I have to ask you some private questions, Julia. May I know how long you have
been sexually active?
P: A few weeks.
D: Do you have a stable partner?
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P: Yes, my boyfriend.
D: Any other sexual partners?
P: No.
D: Do you use any type of contraception?
P: Yes we always use condoms, but last night we forgot.
D: I see. Has this ever happened before, or have you used emergency contraction
before?
P: No.

Partner (You should ask about age of the partner and their relationship to rule out
abusive relationship)
D: Could you tell me about your boyfriend?
P: He is my schoolmate.
D: May I know his age?
P: 15.
D: How long have you been in a relationship with him?
P: A few weeks.
D: How is your relationship?
P: Fine.
D: Have you ever been forced to have sex when you didn’t want to?
P: No.

(P4)
D: When was your last menstrual period?
P: 2 weeks ago.
D: Are your periods regular?
P: Yes.
D: Any bleeding or discharge between periods?
P: No.
D: Any pain or bleeding during or after sex?
P: No.

Mental capacity (Assess her capacity as she is only 14 years old)

D: Do you know that if you have unprotected sexual activity you could be putting
yourself at risk?
P: Yes.
D: Could you tell me how?
P: Pregnancy.
D: You are absolutely right. Do you know you are also at risk of sexually transmitted
infections, HIV, physical and emotional stress?
P: Yes I know.
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D: And do you know that emergency contraception/ morning after pill does not provide
protection against STIs or HIV?
P: Yes. It only prevents pregnancy after unprotected sex.
D: Yes you are right. How did you come to know about morning after pill?
P: Magazine, newspaper, internet, school told us about it.

(Family and support)

D: Who do you live with?
P: My parents.
D: How is your relationship with them?
P: Fine.
D: Do they know about your relationship?
P: No.
D: That’s OK, but we always like to advise young people under the age of 16 who are
sexually active to try to discuss this with your parents. They are still your legal guardians
and would be able to support you better if they knew what was going on in your life.
P: That is ok doctor. I don't want them to know.
(Remind her that she has patient confidentiality if she is not comfortable and she is not
answering questions.)

(P2)
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any sexually transmitted infections or pelvic inflammatory disease?
P: No.

MAFTOSA
D: Are you currently taking any medications, over-the-counter drugs or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Any recreational drug use?
P: No.
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Management
(Establish a good rapport and support)
Thank you very much for coming to us and answering all my questions. You did the right
thing by coming here to get emergency contraception.

Senior
Emergency contraception
• There are two types of emergency contraception: Morning after pill or
Intrauterine device/ coil which can be inserted into your uterus at a sexual health
centre. These can be given within 72hrs and 120hrs after having unprotected sex.
Which one would you prefer?

P: The Morning after pill.

• Please make sure you take this pill before 72hrs of having intercourse. You might
have some side effects like nausea, vomiting, dizziness, fatigue, headache, breast
tenderness, bleeding between periods or heavier menstrual bleeding, lower abdominal
pain or cramps.

• This is an emergency contraceptive pill and should only be taken after you have
had unprotected sex or if the condom broke. It is not a regular contraceptive pill so will
not protect you against future acts of sexual intercourse.
• If you want to have sex, make sure you’re protected. Use a reliable barrier
contraceptive method such as condoms until your next period, even if you use a regular
contraceptive pill.

• If you are sick (vomit) within three hours of taking morning after pill tablet,
come back to us we may have to give another tablet to take.

Discuss regular contraception

D: There are different types of contraception available for you if you are having sex
regularly. Do you want me to discuss them with you?
P: No doctor that’s okay.

Advice on safe sex

D: I sincerely advice you to practice safe sex, especially with condoms, because other
types of contraception cannot protect you from STIs and HIV. I can give you some free
condoms before you leave here today.

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Advice to discuss relationship with parents

Please think about discussing your relationship with your parents, so they can give you
support.

Safety netting
If you miss your next period or you feel that you might be pregnant, please do a
pregnancy test and come back to us.

As mentioned, if you throw up within the next 3 hours come back.

If you develop any lower tummy pain, burning sensation during passing urine, any
discharge or any lump or swelling around your private parts please come back to us.

Note
Gillick competency:
Lord Fraser stated that a doctor could proceed to give advice and treatment:
"provided he is satisfied in the following criteria:
• that the girl (although under the age of 16 years of age) will understand his
advice;
• that he cannot persuade her to inform her parents or to allow him to inform the
parents.
• that she is seeking contraceptive advice;
• that she is very likely to continue having sexual intercourse with or without
contraceptive treatment.
• that unless she receives contraceptive advice or treatment her physical or mental
health or both are likely to suffer;
• that her best interests require him to give her contraceptive advice, treatment or
both without the parental consent.

What are the implications for child protection?

• Professionals working with children need to consider how to balance children’s
rights and wishes with their responsibility to keep children safe from harm.
• Underage sexual activity should always be seen as a possible indicator of child
sexual exploitation.
• Sexual activity with a child under 13 is a criminal offence and should always result
in a child protection referral.

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Pre-Eclampsia

Where you are: You are F2 in OBG.

Who the patient is: Laila, aged 29, who is 36 weeks pregnant, has been referred to the
hospital. The mid-wife has seen the lady and made a note. Vitals: BP 160/110, Urine
protein (+++). This must be reviewed by a doctor.
Other information: The patient’s BP in her first booking was 110/70.
What you must do: Please talk to the patient, assess her condition, discuss your further
management with the patient and address her concerns.

Doctor: I can see from my notes that you are referred by the mid-wife. Could you please
tell me why you went to the mid-wife at the first place?
Patient: I went for my check up and I was sent here by the midwife because of my blood
pressure and protein in my urine.
D: Could you confirm the age of your pregnancy?
P: 36/38 weeks.
D: Is this your first pregnancy?
P: Yes. (Risk factor)
D: Have you attended all your antenatal check-ups?
P: Yes.
D: How has your pregnancy been so far?
P: Fine.
D: Have you developed any complications?
P: No.
D: Have you got any symptoms now?
P: No.
D: Have you had any scans done?
P: Yes.
D: Are you having twins in this pregnancy? (Risk factor)
P: No.
D: Can you feel the movements of your baby?
P: Yes.

(Ask about symptoms of pre-eclampsia and pregnancy complications)

D: Any headache?
P: No.
D: Any vision problems such as blurring?
P: No.
D: Any swelling of feet, ankles or face?
P: No.

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D: Do you feel sick?

P: No.
D: Any vomiting?
P: No.
D: Any excessive weight gain?
P: No.
D: Any tummy pain?
P: No.
D: Any vaginal bleeding?
P: No.
D: Any pain or burning sensation during urination?
P: No.
D: Do you go to the loo frequently?
P: No.
D: Do you feel tired?
P: No.

(P2)
D: Have you got any medical illness during pregnancy?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any high blood pressure, diabetes, or kidney problems?
P: No.

DESA
D: Tell me about your diet.
P: I eat healthy food.
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Have you been taking any recreational drugs?
P: No.
D: What do you do for a living?
P: Office job.
D: May I know who you live with?
P: My partner.

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MAFTOSA
D: Are you currently taking any regular medications, over-the-counter drugs or
supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Any surgical procedures?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: Did your mother or sister have any complications during their pregnancies? (Risk
factor)
P: No.

Examination
D: I would like to check your vitals including blood pressure and do an Antenatal
Examination if that’s OK with you? I would like to send for some initial investigations
including routine blood test and urine test.

Provisional diagnosis
From my assessment you seem to have developed a condition called pre-
eclampsia. It is a condition that affects some pregnant women, usually during the
second half of pregnancy (from around 20 weeks) or soon after their baby is delivered.
Early signs of preeclampsia include having high blood pressure and protein in
your urine. We checked your blood pressure and its high and your urine test shows
there is protein in your urine.
This condition can be serious if not treated.

Management
Pre-eclampsia can only be cured by delivering the baby. If you have pre-eclampsia,
you'll be closely monitored until it's possible to deliver the baby.

Admit, you need to stay in hospital until your baby can be delivered.

Senior.

Monitoring in hospital:
While you're in hospital, you and your baby will be monitored by:
o regular blood pressure checks to identify any abnormal increases.
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o regular urine samples taken to measure protein levels.

o various blood tests – for example, to check your kidney and liver health.
o ultrasound scans to check blood flow through the placenta, measure the
growth of the baby, and observe the baby's breathing and movements
o electronically monitoring the baby's heart rate using a process called
cardiotocography, which can detect any stress or distress in the baby.

Medication for high blood pressure:

• To lower your blood pressure. These medications reduce the likelihood of
serious complications, such as stroke.
Labetalol is specifically licensed for use in pregnant women with high blood pressure.
Possible alternatives to labetalol (methyldopa and nifedipine ) we may recommend one
of them if we think it's the most suitable medication for you. You should be made
aware that the medication is unlicensed in pregnancy and any risks should be explained
before you agree to treatment, unless immediate treatment is needed in an emergency.

Other medications:
• Anticonvulsant medication may be prescribed to prevent fits if you have severe
pre-eclampsia and your baby is due within 24 hours, or if you have had convulsions
(fits).
• They can also be used to treat fits if they occur.
Delivering your baby:
• In most cases of pre-eclampsia, having your baby at about the
37th to 38th week of pregnancy is recommended.
• Labour needs to be started artificially (known as induced labour) or you may need
to have a caesarean section.
• This is recommended because there's no benefit in waiting for labour to start by
itself after this point and delivering the baby early can also reduce the risk of
complications from pre- eclampsia.
• If your condition becomes more severe before 37 weeks and there are serious
concerns about the health of you or your baby, earlier delivery (premature births) may
be necessary and babies born before this point may not be fully developed.

Safety netting:
Please inform us if you have any tummy pain or you feel drowsy or confused.

Note:
Pre-eclampsia is thought to be caused by the placenta not developing properly due to
a problem with the blood vessels supplying it. The exact cause isn't fully understood.

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Some factors have been identified that could increase your chances of developing pre-
eclampsia. These include:
• having an existing medical problem - such as diabetes, kidney disease, high blood
pressure, lupus or antiphospholipid syndrome.
• previously having pre-eclampsia.
• it's your first pregnancy.
• it's been at least 10 years since your last pregnancy.
• you have a family history of the condition.
• you're over the age of 40.
• you were obese at the start of your pregnancy.
• you're expecting multiple babies, such as twins or triplets.

Post-partum Depression

Where you are: You are an FY2 in GP.

Who the patient is: Miss Amanda Lowe, aged 31, came to you with complaint of
insomnia.
What you must do: Talk to her and address her concerns.

(Don't forget to ask about mood in any case of insomnia)

D: How can I help you?
P: I have trouble sleeping. (P1)
D: Please tell me more about it?

(Explore insomnia)
D: What do you mean exactly by ‘trouble sleeping’? Do you have trouble falling asleep
or do you wake up in the middle of the night?
P: I have trouble staying asleep, I keep waking up.
D: What time do you go to bed?
P: I go to bed around 10 pm
D: What time do you usually go to sleep?
P: I go to sleep around midnight.
D: What time do you usually wake up?
P: I wake up around 5am.
D: Do you wake up in between?
P: Yes.
D: How often?

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P: At least 3 to 4 times.
D: Are you able to fall asleep afterwards?
P: Yes/No
D: How was your sleep before this problem started?
P: It was fine.
D: Do you take any naps during the day?
P: Yes/No
D: Tell me more about your sleeping environment. Do you have a comfortable pillow
and mattress?
P: Yes.
D: Any bright lights or noise around you?
P: No, it's dark and quiet.
D: Tell me, what you do before you go to bed?
P: I finish my chores.
D: Do you use any digital screens just before bed? Phone? Tablet?
P: No
D: When did this problem start?
P: It started 5 months ago.
(Long period>>Psychosocial and mood)
D: How are you coping? Does this affect your life?
P: Yes, it makes me feel tired.
D: Let me ask you a few questions to be in a better position to help you out.
P: Alright doctor.
D: Can you think of anything which might be the cause of your problem?
Or
D: Had anything specific happened just before having these symptoms 5 months ago?
P: I gave birth 5 months ago. (Build rapport)
D: And was everything OK with the birth and the baby?
P: Yes.
D: How is your mood?
P: It is low.
D: Could you please score your mood on a scale of 1 to 10, where 1 is low and 10 is the
highest.
P: It is 2/3.
D: Some people when they go through difficult times they think about harming
themselves or others. Have you experienced any similar thoughts?
P: No.
D: Have you had any difficulty bonding with your baby?
P: Yes/No
D: Some people, can hear or see things that others can't hear or see, have you
experienced anything like this?
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P: No.
D: Do you feel sad, hopeless or irritable most of the time?
P: No.
D: Do you have a loss of interest in everyday activities?
P: No.
D: Do you have feelings of emptiness or worthlessness?
P: No.
(Ask about support)
D: Who do you live with?
P: With my husband.
D: How is your relationship with him?
P: Good, he is supportive.
D: Do you have any relatives close by?
P: Yes, my mother.
D: Have you talked to her about how you feel?
P: Yes. My mum thinks that it’s normal to feel low.
D: How about any friends.
P: I don’t have any.

(P2)
D: Have you ever had a condition like this before?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.

DESA
D: Tell me about your diet, any heavy or fatty meals?
P: Yes/No
D: Do you drink a lot of caffeinated drinks?
P: No.
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Are you physically active?
P: Yes/No
D: What do you do for a living?
P: I stay at home.
D: Any stress in your life?
P: Yes/No

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MAFTOSA
D: Are you currently taking any medications, OTC drugs or supplements?
P: No.
D: Are you taking any birth control pills?
P: No.
D: Any allergies from any food or medication?
P: No.
D: Any previous surgeries or procedures done?
P: No.
D: Any family history of a similar condition?
P: No.

Examination
D: If it’s OK with you I would like to check your vitals and do some routine
investigations such as checking your iron levels in case you have become anaemic after
giving birth or checking your thyroid. These things tend to add to feelings of depression.

Provisional diagnosis
From the history you have given me, it seems that you may be having postnatal
depression. It is a type of depression that many parents experience after having a
baby.

Management
Postnatal depression can be lonely, distressing and frightening, but support and
effective treatments are available.
These include:

• Self-help – Things you can try yourself including talking to your family and friends
about your feelings and what they can do to help, making time for yourself to do things
you enjoy, resting whenever you get the chance, getting as much sleep as you can at
night, exercising regularly, and eating a healthy diet.

• Psychological therapy – GP may be able to recommend a self-help course or may

refer you for a course of therapy, such as cognitive behavioural therapy (CBT)
o Cognitive behavioural therapy (CBT) is a type of therapy based on the idea that
unhelpful and unrealistic thinking leads to negative behaviour.
o CBT aims to break this cycle and find new ways of thinking that can help you
behave in a more positive way.

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o For example, some women have unrealistic expectations about what being a
mum is like and feel they should never make mistakes.
o As part of CBT, you’ll be encouraged to see that these thoughts are unhelpful and
discuss ways to think more positively.

• Antidepressants – these may be recommended if your depression is more severe

or other treatments have not helped; I can prescribe an antidepressant that’s safe to
take while breastfeeding, (if you’re breastfeeding.)

Local and national organizations, such as the Association for Post Natal Illness (APNI)
and Pre and Postnatal Depression Advice and Support (PANDAS), can also be useful
sources of help and advice.

Notes:
Symptoms of postnatal depression:
Many women feel a bit down, tearful or anxious in the first week after giving birth. This
is often called the “baby blues” and is so common that it’s considered normal. The
“baby blues” do not last for more than 2 weeks after giving birth.
If your symptoms last longer or start later, you could have postnatal depression.
Postnatal depression can start at any time in the first year after giving birth.

Signs that you or someone you know might be depressed include:

• A persistent feeling of sadness and low mood.
• Lack of enjoyment and loss of interest in the wider world.
• Lack of energy and feeling tired all the time.
• Trouble sleeping at night and feeling sleepy during the day.
• Difficulty bonding with your baby.
• Withdrawing from contact with other people.
• Problems concentrating and making decisions.
• Frightening thoughts – for example, about hurting your baby.

Follow-up:
Please come back in a week to discuss your anaemia and thyroid results and to see
how you are getting on.

Ectopic pregnancy
Where you are: You are an F2 in OBG Department.
Who the patient is: Jenny, aged 18, presented to the hospital complaining of left iliac
fossa pain. Patient has come with six weeks of amenorrhea. Pregnancy test has been
done and is positive.
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What you must do: Please talk to the patient, take relevant history, and discuss about
different steps of management with the patient.
OR:
Where you are: You are FY2 in Emergency department.
Who the patient is: Julia Harrison, 29 years old, presented with abdominal pain.
What you must do: Talk to her and address her concerns.

D: What brought you to the hospital?

P: I have got pain here (Patient points at LIF). (P1)
D: Are you comfortable to talk?
P: Yes doctor.
SOCRATES:
D: When did the pain start?
P: It started last night.
D: Was it sudden or gradual?
P: It started suddenly.
D: What were you doing when the pain started?
P: I was not doing anything.
D: Is it continuous or comes and goes?
P: It is always there.
D: Is it the same or getting worse?
P: It is getting worse with time.
D: What type of pain is it?
P: It is a dull/sharp pain doctor.
D: Does it go anywhere else?
P: No doctor.
D: Is there anything that makes it worse?
P: No doctor, it is becoming worse on its own.
D: Is there anything that makes it better?
P: I tried paracetamol, but it didn't work. (Explore)
D: When and how many tablets did you take?
P: 2 tablets a few hours back.
D: On a scale from 0 to 10 when 10 is the most severe pain you have ever had. How do
you score your pain?
P: Around 6-8.

D: Anything else?
P: I’m bleeding from down there. (P1)
TRAC
D: When did the bleeding start?
P: It started around a few hours back.
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D: What is the colour of the bleeding?

P: I didn’t notice doctor.
D: Have you noticed any clots in it?
P: No.
D: How many pads have you changed since the bleeding started?
P: Only one pad. It is more like spotting doctor.
D: Was there any discharge present?
P: No.

D: Anything else?
P: I have been feeling sick since last night. (P1)
D: Did you vomit?
P: No doctor.

D: Anything else?
P: No.

Associated symptoms
D: Any pain around the tip of your shoulder?
P: No.
D: Any bowel problems?
P: No.
D: Any problem with your urination?
P: No.
D: Do you feel dizzy or about to faint?
P: No.
D: Any heart racing?
P: No.
D: Have you had any fever or flu-like symptoms?
P: No.
D: Any breast tenderness?
P: No.
D: Do you feel tired these days?
P: No.

(P4)
D: When was your last menstrual period?
P: 6 weeks ago.
D: Are they regular?
P: Yes.
D: Any bleeding or spotting between your periods?
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P: No.
D: Any painful or heavy periods?
P: No.
D: Are you pregnant by any chance?
P: Yes.
D: Did you do a test to confirm?
P: I did an over-the-counter pregnancy test, and it was positive.
D: Is this your first pregnancy?
P: Yes.
D: Was it a planned pregnancy? (It affects the way you will tell her that the pregnancy
will be terminated)
P: No.
D: Did you use any type of contraception before?
P: Yes/No
D: Have you ever used IUCD or coil? (Risk factor)
P: No.

Sexual history
D: Are you currently sexually active?
P: No, I broke up with my partner 2 weeks back.
D: When did you last have sexual activity?
P: 2 weeks back.
D: Have you had any other partners in the past 6 months?
P: Yes, I have.
D: Have you always used condoms for protection against STIs?
P: Not always no.
D: When was the last time you had unprotected sex?
P: 2 weeks back.
(If she is <16 years old) add 2 questions:
D: How old is your partner?
P: (If the same age group= do nothing)/ (If not the same age group= inform social
services after telling her)
D: Have you ever been forced into having sex? (To exclude sexual abuse/rape/coercion)
P: No

FLAWS
(P2)
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Have you ever been diagnosed with a condition called ectopic pregnancy? (Risk
factor) (If not her first pregnancy)
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P: No.
D: Any sexually transmitted infections or pelvic inflammatory disease (PID)? (Risk
factor)
P: Yes, I was diagnosed with Chlamydia. (Explore)
D: When was that?
P: When I was 15.
D: May I know how was it treated?
P: The sexual health clinic gave me antibiotics.

MAFTOSA
D: Are you currently taking any medications, over-the-counter drugs, or supplements?
P: No.
D: Any medications to increase fertility? (Risk factor)
P: No.
D: Any blood thinner?
P: No.
D: Do you have any allergy to any food or drugs?
P: No.
D: Any procedures or operations? (Risk factor)
P: No.
D: Any previous hospital stays?
P: No.
D: Has any member of your family ever been diagnosed with any medical condition?
P: No.

DESA
D: Do you smoke? (Risk factor)
P: Yes/No

Examination
D: If it’s OK with you, I would like to check your vitals and examine your tummy and do
a pelvic and speculum examination.
I would like to send for some initial investigations including routine blood test and
urine test.
Examiner: Tenderness in LIF.

Provisional diagnosis
From my assessment, I suspect you have a condition called Ectopic Pregnancy. This
means that the egg has implanted itself outside the womb, probably in one of your
fallopian tubes.

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It is a serious condition and unfortunately the pregnancy will have to be terminated as

it poses a risk to your own life.

Management
Unfortunately, the foetus (the developing embryo) cannot be saved in an ectopic
pregnancy. Treatment is usually needed to remove the pregnancy before it grows too
large.
Admit (if in OBG department) or Urgent refer to OBG (if in A & E)
Senior.
Investigations:
• Vaginal ultrasound : An ectopic pregnancy is usually diagnosed by carrying out a
trans-vaginal ultrasound scan.
o This involves inserting a small probe into your vagina. The probe is so small that
it's easy to insert and you won't need a local anaesthetic.
o The probe emits sound waves that bounce back to create a close-up image of
your reproductive system on a monitor.
o This will often show whether a fertilised egg has become implanted in one of
your fallopian tubes, although occasionally it may be very difficult to spot.
• Blood tests
o To measure the pregnancy hormone human chorionic gonadotropin (hCG) may
also be carried out twice, 48 hours apart, to see how the level changes over time. The
level of hCG tends to be lower and rise more slowly over time than in a normal
pregnancy.
• Keyhole surgery
o If it's still not clear whether you have an ectopic pregnancy or the location
of the pregnancy is unknown, a laparoscopy may be carried out.
o This is a type of keyhole surgery carried out under general anaesthetic (where
you're asleep) that involves making a small cut (incision) in your tummy and inserting a
viewing tube called a laparoscope to examine the womb and fallopian tubes directly.
o If an ectopic pregnancy is found during the procedure, small surgical instruments
may be used to remove it to avoid the possible need for a second operation later on.

Symptomatic
The main treatment options are:
• Expectant management – your condition is carefully monitored to see whether
treatment is necessary.
• Medication – a medicine called methotrexate is used to stop the pregnancy
growing.
• Surgery –used to remove the pregnancy, usually along with the affected fallopian
tube.

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Medication
• If an ectopic pregnancy is diagnosed early but active monitoring isn't suitable,
treatment with a medicine called methotrexate may be recommended.
• This works by stopping the pregnancy from growing. It's given as a single injection
into your buttocks.
• You won't need to stay in hospital after treatment, but regular blood tests will be
carried out to check if the treatment is working.
• A second dose is sometimes needed and surgery may be necessary if it doesn't
work.
• You need to use reliable contraception for at least 3 months after treatment. This
is because methotrexate can be harmful for a baby if you become pregnant during this
time.
• It's also important to avoid alcohol until you're told it's safe, as drinking soon
after receiving a dose of methotrexate can damage your liver.
• Other side effects of methotrexate include: tummy pain – this is usually mild and
should pass within a day or 2 – dizziness - feeling and being sick – diarrhoea.

Surgery
• In most cases, keyhole surgery (laparoscopy) will be carried out to remove the
pregnancy before it becomes too large.
• During a laparoscopy:
o you're given general anaesthetic, so you're asleep while it's carried out.
o small cuts (incisions) are made in your tummy.
o a thin viewing tube (laparoscope) and small surgical instruments are inserted
through the incisions.
o the entire fallopian tube containing the pregnancy is removed if your other
fallopian tube looks healthy – otherwise, removing the pregnancy without removing the
whole tube may be attempted.
o Removing the affected fallopian tube is the most effective treatment and isn't
thought to reduce your chances of becoming pregnant again. You'll be asked whether
you consent to having the tube removed.
o You can leave hospital a few days after surgery, although it can take 4 to 6 weeks
to fully recover.

• If your fallopian tube has already ruptured, you'll need

emergency surgery.
o The surgeon will make a larger incision in your tummy (laparotomy) to stop the
bleeding and repair your fallopian tube, if that's possible.
• After either type of surgery, a treatment called anti-D rhesus prophylaxis will be
given if your blood type is RhD negative. This involves an injection of a medicine that
helps to prevent rhesus disease in future pregnancies.
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Safety netting
• If you experience a combination of sharp, sudden and intense pain in your
tummy - feeling very dizzy or fainting - feeling sick - looking very pale please inform us
immediately.

Support groups
• Losing a pregnancy can be devastating, and many women feel the same sense of
grief as if they had lost a family member or partner.
• It's not uncommon for these feelings to last several months, although they
usually improve with time. Make sure you give yourself and your partner time to
grieve.
• If you or your partner are struggling to come to terms with your loss, you may
benefit from professional support or counselling.
• Support groups for people who have been affected by loss of a pregnancy can
also help. These include:
o The Ectopic Pregnancy Trust
o The Ectopic Pregnancy Foundation
o The Miscarriage Association
o Cruse Bereavement Care

Note
• If the patient has no symptoms or mild symptoms and the pregnancy is very small
or can't be found, you may only need to be closely monitored, as there's a good chance
the pregnancy will dissolve by itself. This is known as expectant management.
• The following is likely to happen:
o You'll have regular blood tests to check that the level of hCG in your blood is
going down – these will be needed until the hormone is no longer found.
o You may need further treatment if your hormone level doesn't go down or it
increases.
o You'll usually have some vaginal bleeding – use sanitary pads or towels, rather
than tampons, until this stops.
o You may experience some tummy pain – take paracetamol to relieve this.

Concerns:
P: I don't want to stay in the hospital.
D: Is there a reason you don’t want to stay?
P: I don't want my parents to know about this.
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D: I do understand your concern, but it is very important for you to stay in the hospital
and undergo all the investigations. And if the pregnancy is confirmed to be outside the
womb, then we must put you under observation.
P: I can come back for the tests tomorrow?
D: As I told you earlier, we need to observe you, as this condition may cause some
severe complications. The pregnancy may rupture, and you may go into shock and
collapse, which is a serious condition. If this happens, we need to treat you
immediately, by giving you fluids through a drip and taking you to theatre for
emergency surgery to remove the ruptured pregnancy.

Pregnancy (HTN on Ramipril)

Where you are: You are an FY2 in the GP Surgery.

Who the patient is: Mrs Amy Travis, aged 42, has come to see you. She is on Ramipril
for her hypertension.
What you must do: Talk to her and address her concerns.

Doctor: How can I help you?

Patient: I am trying to get pregnant and I want some advice. (Build rapport)
D: Let me ask you few questions to make sure everything is fine.
P: Ok.
D: Have you been pregnant before?
P: No.
D: How long have you been trying to get pregnant?
P: (Gives time period).

(P2)
D: Have you been diagnosed with any medical condition in the past?
P: Yes, I have been diagnosed with hypertension for the last 5 years. (Explore)
D: How is it managed?
P: I’m on Ramipril.
D: Are you taking it regularly as prescribed?
P: Yes.
D: Have you been diagnosed with any other medical condition in the past like Diabetes,
Kidney Diseases and STI?
P: No.

MAFTOSA
D: Are you taking any other medications including OTC or supplements?

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P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink Alcohol?
P: No.
D: Tell me about your diet?
P: Healthy.
D: Are you physically active?
P: I try to be.
D: Who do you live with?
P: My partner.
D: How long have you been living with your partner?
P: 2 years.

(P4)
D: When was your LMP?
P: 2 weeks ago.
D: Are they regular?
P: Yes.
D: Is there any chance you may already be pregnant?
P: I don't think so.
D: Obviously you aren’t on contraception?
P: No.
D: What contraceptive method were you on before you decided you wanted to get
pregnant?
P: We had been using condoms, then we stopped.
D: Are you up to date with your pap smear?
P: Yes.

(P5)
D: How is your partner's health in general?
P: He is fine.
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D: How are things at home?

P: Good.
D: Any medical conditions in your partner’s family?
P: No.
D: Are you related to your partner in any way?
P: No.

Examination
If it’s OK with you, I would like to check your vitals and ask you to take a quick
pregnancy test now.

(Pregnancy test comes back POSITIVE).

Management
(ACE inhibitors are not given in pregnancy, they should be stopped, and patient must be
started on some other medication).
Senior
Review the medication
• Ramipril should be stopped as she is pregnant. We have to aim for blood
pressure lower than 140/90 and always try to keep it 135/85.
• We may Consider giving Labetalol, Nifedipine, Methyldopa.
• ACE can cause adverse effects for the woman, foetus, and new-born infant.

Lifestyle
We may give you folic acid supplements and other medications.

Specialist
We may refer you to the OBG department. They will run some blood tests and urine
tests too.
It's important that you are monitored throughout your pregnancy to make sure your
high blood pressure is not affecting the growth of your baby. You are also at high risk
of pre-eclampsia.

Safety netting.
Follow up
Please make sure you go to all your antenatal appointments and allow us to monitor
you closely.

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Pregnancy (16 year old) vomiting

Where you are: You are an FY2 in GP surgery.

Who the patient is: Miss Leanne Bailey, aged 16, has booked an emergency
appointment.
What you must do: Talk to her, assess, and manage her concerns.

Doctor: How can I help you?

Patient: I'm feeling sick, and I have vomited a few times. (P1)
D: Can you tell me more?

ODIPARA
D: When did it start?
P: In the last couple of days.
D: What were you doing when it started?
P: I wasn’t doing anything special.
D: Is it there all the time or does it come and go?
P: I have nausea from time to time.
D: How often do you have nausea and vomiting?
P: I have had 4 episodes so far.
D: Is there anything which makes it better?
P: Not really.
D: Is there anything which makes it worse?
P: No.

D: Anything else?
P: No.

(Exclude dehydration)
D: Do you feel thirsty all the time?
P: No.
D: Is your urine dark yellow?
P: No.
D: Do your mouth and lips feel dry?
P: No.

DDs
D: Do you have any tummy pain?
P: No.
D: Do you have fever?

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P: No.
D: Do you have loose stools?
P: No.
D: Have you hurt yourself recently? (trauma)
P: No.
D: Do you have a headache?
P: No.

(P2)
D: Have you been diagnosed with any medical condition in the past?
P: No.

MAFTOSA
D: Are you currently taking any medications, OTC drugs or supplements?
P: No.
D: Are you taking any birth control pills?
P: No.
D: Any allergies from any food or medication?
P: No.
D: Any previous surgeries or procedures done?
P: No.

(P4)
D: When was your last menstrual period?
P: It’s a week late, I’m waiting to come on.
D: Are they regular otherwise?
P: Yes.
D: How long does your period last?
P: 5 days.
D: Any bleeding or spotting between your periods?
P: No.
D: Any painful or heavy periods?
P: No.
D: Have you been pregnant before?
P: No.

Sexual history
D: Sorry I have to ask you some private questions. Are you currently sexually active?
P: Yes.
D: Do you have a partner?
P: Yes, my boyfriend.
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D: How old is your partner?

(Although the age of consent in the UK is 16 and the patient is 16, it’s still important
to ask the age of her boyfriend as she is still under 18, and you are exploring her
circumstances to exclude any abuse or coercion.)
P: He is 17 years old.
D: Do you and your partner use any contraception or protection against STIs?
P: No, he just pulls out (coitus interruptus).
D: Do you use condoms?
P: No, we don’t like them.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: Good/Bad.
D: Are you physically active?
P: Yes/No.
D: Who do you live with?
P: I live with my mother.
D: How is your relationship with her?
P: We have a good relationship.

Examination
If it’s OK with you, I would like to check your vitals, and ask you to take a quick urine
pregnancy test for me.

Vitals found to be normal and UPT is POSITIVE.

Provisional diagnosis
From the history you have given me, and the tests we have done, it appears that you
are currently pregnant. That’s why you have not been feeling well and you have
vomiting and nausea.

Management and concerns

Senior
Investigations: US
Medications: Antiemetics if needed for nausea.
Lifestyle: Advise her to increase fluid intake.

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Finding out you’re pregnant when you’re a teenager can be daunting, especially if the
pregnancy wasn’t planned, but help and support is available.
As your pregnancy test is positive, it’s understandable to feel mixed emotions:
excitement about having a child, worry about telling your parents, and anxiety about
pregnancy and childbirth.
You may also be feeling worried or frightened if you’re not sure that you want to be
pregnant.
Make sure to talk through your options and think carefully before you make any
decisions.
Try talking to a family member, friend or someone you trust. I would like to advise you
to discuss your pregnancy with your mother for support and understanding.

P: Don’t tell my mum I am pregnant.

D: Of course, as this conversation is confidential, we will not be discussing this with your
mother without your consent.

P: What are my options?

D: Your options are:
1. Continuing with the pregnancy and keeping the baby.
2. Having an abortion.
3. Continuing with the pregnancy and having the baby adopted.

If you decide to continue your pregnancy, the next step is to start your antenatal care.
If you decide not to continue with your pregnancy, I can refer you to an abortion clinic.
Although I realise this is all very dauting and you have an important decision to make, I
advise you not to take too long making it. This is because if you do decide on the
abortion, the sooner it’s done the better. At this stage if we book you in before you’re
10 weeks pregnant you will just be given some tablets and can avoid an intrusive
operation. How about you take a week to decide, and I book you in for a follow-up
with me next week, so we can discuss what happens next?
Also if you decide on the abortion, we can discuss your contraception options next
week, as the ‘pulling out’ method doesn’t work a lot of the time as you can see and it
also doesn’t protect against STIs.
Follow-up. Appointment made in a week’s time.

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Rubella RH Negative
Where you are: You are an FY2 in the antenatal care clinic.
Who the patient is: Clare, 28 years old, is 14 weeks pregnant and has come to the
hospital for her results. She came to the antenatal clinic when she was 12 weeks
pregnant for routine antenatal check-up.
Reports:
Rubella = nonimmune
RH= -ve or O Rhesus antibodies were negative
Blood and urine = normal
What you must do: Talk to her and address her concerns.

Doctor: I can see from my notes that you are here for your blood tests report, Is that
right?
Patient: Yes doctor.
D: Alright, I have the results with me. Do you want me to discuss the results first or shall
we have a chat in order to explain the results in a better way?
P: OK.

(Ask about pregnancy and build rapport)

D: How far along are you in your pregnancy, Clare?
P: 14 weeks doctor.
D: Was this a planned pregnancy?
P: No.
D: Are you happy about it now though?
P: Yes, after I got over the shock.
D: Is this your first pregnancy?
P: Yes.
D: How has the pregnancy been so far?
P: It’s been okay.
D: Any complications so far?
P: No.
D: Any bleeding, spotting or discharge from your front passage?
P: No.
D: Any tummy pain?
P: No.
D: Any vomiting?
P: No.
D: Have you been feeling sick?
P: Not much.
D: Any pain in the breast?
P: No.
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D: Any fever or rash?

P: No.

(P2)
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Do you have any health problems like high blood pressure, diabetes or clots in lungs
or legs?
P: No.

MAFTOSA
D: Are you currently taking any medications, OTC drugs or supplements?
P: No.
D: Any allergies from any food or medication?
P: No.
D: Any previous surgeries or procedures done?
P: No.
D: Any family history of complications during pregnancy?
P: No.

Sexual history
D: Sorry I need to ask you some private questions which may seem intrusive. Are you
sexually active?
P: Yes.
D: Are you in a stable relationship?
P: No.
D: How many partners have you had in last 6 months?
P: 2, 3.
D: Do you practice safe sex?
P: No (Advise on having safe sex in your management)
D: Do you know the biological father of the baby?
P: No.
D: Have you ever been diagnosed with any STI?
P: No (Offer STI screening in your management)

DESA
D: Do you smoke?
P: Yes (Explore and advise on in your management)
D: How much a day and for how long?
P: 10 cigarettes a day for 10 years.
D: Do you drink alcohol?
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P: Yes (Explore and address in your management)

D: How much a day?
P: 2 glasses of wine.
D: By any chance do you use any recreational drugs?
P: Yes (Explore and address in your management)
D: What do you use?
P: Heroin (Do CAGE and ask about needle exchange)
D: Anything else?
P: Yes, I smoke cannabis. (Explore and address in your management)
D: Tell me about your diet?
P: Good/Bad
D: Are you physically active?
P: Yes/No
D: What you do for your living?
P: I’m unemployed.
D: Who do you live with?
P: I live alone.

Examination
If it’s OK with you I would like to check your vitals i.e. your BP, pulse, temperature and
respiratory rate.
P: Ok.

Discuss test results

D: The good news is your blood tests are normal. However, your blood group is O
negative, which means that we have to be a bit careful if baby is O positive. I will
explain everything to you in a minute.
P: OK.
D: Also, your results are showing that you are not immune to Rubella. Have you ever
had this infection in your life? Maybe as a child?
P: No.

Management
Rubella:
• The blood test showed that you are not immune to rubella. This means that you
may have missed out on your MMR vaccination and you could spread rubella. So you
need to be aware of this risk.
• If you develop rubella in the first 4 months of pregnancy, it can lead to serious
problems, including birth defects and miscarriage.
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• If a pregnant woman has rubella, the virus is likely to cause serious damage to the
unborn child. Rubella can cause damage to the heart, brain, hearing and sight. The baby
is likely to be born with a very serious condition called the congenital rubella syndrome.
• Contact us immediately if:
o you come into contact with someone who has rubella.
o you have a rash or come into contact with anyone who does.
o you have symptoms of rubella.
• You are unlikely you contract rubella, but you may need a blood test to check just
in case.
• MMR vaccine cannot be given during pregnancy.
• You should ask for the vaccine when you go for your 6-week postnatal check after
the birth. This will protect you in any future pregnancies.

RH negative
• Blood is known as RhD positive when it has a molecule called the RhD antigen on
the surface of the red blood cells.
• When the mother has rhesus negative blood (RhD negative) and the baby in her
womb has rhesus positive blood (RhD positive), the woman’s body responds to the RhD
positive blood by producing antibodies (infection-fighting molecules) that recognise the
foreign blood cells and destroy them and this could result in rhesus disease. Rhesus
disease doesn't harm the mother, but it can cause the baby to become anaemic and
destroy the baby's blood.
• Rhesus disease can largely be prevented by having an injection of a medication
called anti-D immunoglobulin.
• The anti-D immunoglobulin neutralises any RhD positive antigens that may have
entered the mother's blood during pregnancy. If the antigens have been neutralised,
the mother's blood won't produce antibodies.
• You'll be offered anti-D immunoglobulin if it's thought there's a risk that RhD
antigens from your baby have entered your blood –for example, if you experience any
bleeding, if you have an invasive procedure or if you experience any abdominal injury.
• This routine administration of anti-D immunoglobulin is called routine antenatal
anti-D prophylaxis, or RAADP (prophylaxis means a step taken to prevent something
from happening).
• There are currently two ways you can receive RAADP:
o a 1-dose treatment: where you receive an injection of immunoglobulin at some
point during weeks 28 to 30 of your pregnancy
o a 2-dose treatment: where you receive 2 injections; one during the 28th week
and the other during the 34th week of your pregnancy.

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• Anti-D immunoglobulin is also administered routinely during the third trimester

of your pregnancy if your blood type is RhD negative. This is because it's likely that small
amounts of blood from your baby will pass into your blood during this time.

• RAADP is recommended for all pregnant RhD negative women who haven't been
sensitised to the RhD antigen, even if you previously had an injection of anti-D
immunoglobulin.
• As RAADP doesn't offer lifelong protection against rhesus disease, it will be
offered every time you become pregnant if you meet these criteria.
• RAADP won't work if you've already been sensitised. In these cases, you'll be
closely monitored so treatment can begin as soon as possible if problems develop.
After giving birth a sample of your baby's blood will be taken from the umbilical cord. If
you're RhD negative and your baby is RhD positive, and you haven't already been
sensitised, you'll be offered an injection of anti-D immunoglobulin within 72 hours of
giving birth.
• The injection will destroy any RhD positive blood cells that may have crossed over
into your bloodstream during the delivery. This means your blood won't have a chance
to produce antibodies and
will significantly decrease the risk of your next baby having rhesus disease.
• Complications from anti-D immunoglobulin is a slight short- term allergic reaction
to anti-D immunoglobulin, which can include a rash or flu-like symptoms.
Smoking cigarettes and cannabis:
• Protecting your baby from smoke is one of the best things you can do to give your
child a healthy start in life. It can be difficult to stop smoking, but it’s never too late to
quit.
• Using cannabis while pregnant may harm the unborn baby. Cannabis smoke
contains many of the same harmful chemicals found in cigarette smoke.
• Regularly smoking cannabis with tobacco increases the risk of a baby being born
small or premature.
• Smoke can reduce your baby’s birth weight and increase the risk of sudden infant
death syndrome (SIDS), also known as “cot death”. Babies whose parents smoke are
more likely to be admitted to hospital for bronchitis and pneumonia during their first
year.
• The main reason that people smoke is because they are addicted to nicotine. We
can offer you nicotine replacement therapy.
o Nicotine replacement therapy is a medication that provides you with a low level
of nicotine poisonous chemicals present in tobacco smoke.
o These can be given in the form of patch, spray or chewing gum.
o It can help reduce unpleasant withdrawal effects such as bad mood and craving
which may happen when you stop smoking.

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• You could also consider trying E cigarettes. Although they are not risk free, they
are very much safer than cigarettes and can help people stop smoking.
• The NHS Smoke free helpline offers free help, support and advice on stopping
smoking and can give you details of local support services.
You can also sign up to receive ongoing advice and support at a time that suits you.

Alcohol:
• Drinking in pregnancy can lead to long-term harm to the baby, with the more you
drink, the greater the risk. The safest approach is not to drink alcohol at all to keep risks
to your baby to a minimum.
• When you drink, alcohol passes from your blood through the placenta and to
your baby.
• A baby’s liver is one of the last organs to develop and does not mature until the
later stages of pregnancy.
• Your baby cannot process alcohol as well as you can, and too much exposure to
alcohol can seriously affect their development.
• Drinking alcohol, especially in the first 3 months of pregnancy, increases the risk
of miscarriage, premature birth and your baby having a low birth weight.
• Drinking after the first 3 months of your pregnancy could affect your baby after
they’re born.
• The risks are greater the more you drink. The effects include learning difficulties
and behavioural problems.
• Drinking heavily throughout pregnancy can cause your baby to develop a serious
condition called foetal alcohol syndrome (FAS).

Heroin
(Advise her to stop using it as it can also affect her baby.) Offer support via CBT and
Narcotic anonymous support group.

Advise her on having safe sex:

Offer STI screening test.

Follow up: We will arrange your next follow up in a month.

Safety netting: if you feel unwell in anyway like fever, tummy pains or bleeding
through vagina, please let us know.

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Unknown Miscarriage

Where you are: You are an FY2 in the Antenatal clinic.

Who the patient is: Rachel, aged 32, has come for her antenatal result. Transvaginal
ultrasound scan was done which shows 5 weeks of gestation. Foetal pole was found but
no foetal heartbeat was detected.
What you must do: Talk to her about her reports and address her concerns.

Doctor: I can see from my notes that you are here for your scan report.
Patient: Yes doctor.
D: Rachel, I do have your reports with me, but before we discuss them I just need to ask
you few questions so that I can address your concerns better. Will that be okay with
you?
P: Yes.
D: Can you tell me why had the tests in the first place?
P: Just for a regular check-up.
D: Okay, That's great.

(Take pregnancy history)

D: Is this your first pregnancy?
P: Yes.
D: Was this a planned pregnancy? (Important question because it will affect the way
you break the bad news)
P: Yes.
D: How far along are you with your pregnancy?
P: 5 weeks.
D: How has the pregnancy been so far?
P: Fine, I think.
D: Any discharge from your front passage?
P: Yes, brown coloured discharge. (Explore)
TRAC
D: When did it start?
P: A day ago
D: How much discharge have you noticed?
P: Not much.

(Other symptoms)
D: Any bleeding that you noticed besides the discharge?
P: No.
D: Any tummy pain?

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P: No.
D: Any nausea?
P: No.
D: Any vomiting?
P: No.
D: Any fever or flu-like symptoms?
P: No.

(P4)
D: When was your last period?
P: 5 weeks ago.
D: Were they regular?
P: Yes.
D: Any bleeding between the cycles or after sexual intercourse?
P: No.
D: Were you on any kind of contraception before you got pregnant?
P: No.

(P2)
D: Have you ever been diagnosed with any medical conditions?
P: No.
D: Any gynaecological problem or PCOS?
P: No.

MAFTOSA
D: Do you take any medications including OTC or vitamin supplements?
P: No.
D: Are you allergic to any medications or food?
P: No.
D: Anyone diagnosed with any other medical conditions in the family?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Any kind of recreational drugs?
P: No.
D: How is your diet?
P: Good.
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Sexual history
D: Are you in a stable relationship?
P: Yes, I have been married for 7 years.
D: That’s great. How is your relationship with your husband?
P: It’s fine doctor.

Examination
I would like to take your vitals if that’s OK.

Provisional diagnosis
(Break the bad news)
D: Well Rachel, I have your ultrasound result with me and I am really sorry to say this
but I do not have a good news for you. (Warning shot 1)
P: What is it?
D: Would you like me to call someone for you? Or is there someone you would like to
be with you at this moment? (Warning shot 2)
P: No, my husband is working so it’s fine. What is it?
D: Well Rachel, as I said I don’t have good news, you said that you were 5 weeks
pregnant, and you have had brown coloured discharge from your front passage. And
from the ultrasound here it appears that the baby’s heartbeat was undetectable on
the scan. I am really sorry to tell you this but you’ve had a miscarriage. Do you know
what that is? (Pause)
P: Yes. You mean my baby is no more alive.
D: I can’t even imagine what you must be feeling right now. I wish I had better news for
you Rachel. Would you like me to ring your husband?

Management
Senior.
According to weeks of gestation
• If you're more than 18 weeks pregnant, you'll usually be referred to the
maternity unit at the hospital.
• If you're less than 6 weeks pregnant, you may not be referred for tests straight
away. This is because it's very hard to confirm a miscarriage this early on.
• If there's no pregnancy tissue left in your womb, no treatment is required.
• However, if there's still some pregnancy tissue in your womb, your options are:
o Expectant management – wait for the tissue to pass out of your womb
naturally
o Medical management – take medicine that causes the tissue to pass out of
your womb
o Surgical management – have the tissue surgically removed
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Expectant management
• If you have a miscarriage in your first trimester, you may choose to wait 7 to 14
days after a miscarriage for the tissue to pass out naturally. This is called expectant
management.
• If the pain and bleeding have lessened or stopped completely during this time,
this usually means the miscarriage has finished. You should be advised to take a home
pregnancy test after 3 weeks. If the test shows you're still pregnant, you may need to
have further tests.
• If the pain and bleeding have not started within 7 to 14 days or are continuing or
getting worse, this could mean the miscarriage has not begun or has not finished. In this
case, you should be offered another scan. After this scan, you may decide to either
continue waiting for the miscarriage to occur naturally, or have drug treatment or
surgery. If you choose to continue to wait, we should check your condition again up to
14 days later.

Medicine
• You may choose to have medicine to remove the tissue if you do not want to
wait, or if it does not pass out naturally within 2 weeks. This involves taking tablets that
cause the cervix to open, allowing the tissue to pass out.
• In most cases, you'll be offered tablets called pessaries that are inserted directly
into your vagina, where they dissolve.
• The tablets usually begin to work within a few hours. You'll experience symptoms
similar to a heavy period, such as cramping and heavy vaginal bleeding. You may also
experience vaginal bleeding for up to 3 weeks.
• In most cases, you'll be sent home for the miscarriage to complete. This is safe
but ring your hospital if the bleeding becomes very heavy.
• You should be advised to take a home pregnancy test 3 weeks after taking this
medicine. If the pregnancy test shows you're still pregnant, you may need to have
further tests.
• You may be advised to contact us to discuss your options if bleeding has not
started within 24 hours of taking the medicine.

Surgery
• In some cases, surgery is used to remove any remaining pregnancy tissue.
• You may be advised to have immediate surgery if:
o you experience continuous heavy bleeding.
o there's evidence the pregnancy tissue has become infected.
o medicine or waiting for the tissue to pass out naturally has been
unsuccessful.

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• Surgery involves removing any remaining tissue in your womb with a suction
device. You should be offered a choice of general anaesthetic or local anaesthetic if
both are suitable.

Safety netting
• Contact your hospital immediately if the bleeding becomes particularly heavy,
you develop a high temperature (fever) or you experience severe pain.

N.B In case you think patient is too depressed you can advise her to have talking
therapy.

Notes:
• The most common sign of miscarriage is vaginal bleeding.
• This can vary from light spotting or brownish discharge to heavy bleeding and
bright-red blood or clots. The bleeding may come and go over several days.
Other symptoms of a miscarriage include:
• cramping and pain in your lower tummy.
• a discharge of fluid from your vagina.
• a discharge of tissue from your vagina.
• no longer experiencing the symptoms of pregnancy, such as feeling sick and
breast tenderness.

MISCARRIAGE CONCERNS

Where you are: You are F2 in Antenatal Clinic.

Who the patient is: Emma, aged 28, is referred by her GP for her first ANC check-up.
She is 6 weeks pregnant.
Other information: Nurse has examined the patient. Urine test has been done. Vitals
have been checked:
BP: 130/80, Pulse: 70, Urine Test Negative (infection <& protein)
What you must do: Talk to the patient, take relevant history, do the initial assessment
and address her concerns.
Doctor: I can see from my notes that you were sent by your GP for an antenatal check-
up.
Patient: Yes doctor.
(Pregnancy history)
D: Could you confirm how far along you are in your pregnancy?
P: 6 weeks doctor.
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D: How has the pregnancy been so far?

P: It’s okay Doctor.
D: Any complications so far?
P: No.
D: Any bleeding, spotting or discharge from your front passage?
P: No.
D: Any tummy pain?
P: No.
D: Any pain in the breast?
P: No.
D: Have you been feeling sick?
P: No.
D: Is it a planned pregnancy?
P: Yes.
D: Any pregnancies before?
P: Yes (Explore)
D: How many pregnancies?
P: 2
D: When was that?
P: The first pregnancy was 3 years back and the second was 1 year ago.
D: What was the outcome?
P: Both ended in miscarriage.
D: I’m sorry to hear that (Sympathy). May I know how far along you were?
P: One at 6 weeks and the other at 8 weeks.
D: How were they managed?
P: First time, I went to the hospital as I had some bleeding. They checked and confirmed
miscarriage. I was discharged and advised rest. Second time, I had bleeding again and
went to the hospital. They asked me to wait and watch. I came back some time later
and they confirmed the miscarriage.
D: Did you have any other symptoms apart from the bleeding?
P: No.
D: Any sort of pain anywhere?
P: No.
D: Any fever?
P: No.
D: Did they tell you why you had the miscarriage?
P: No, they did some tests but they didn't give any reason for the miscarriage.
D: Are you concerned about anything? (CONCERN)
P: I’m really worried about having a third miscarriage.
D: I understand, your concern is very valid. Just let me finish asking you some questions
and we can have a chat about it.
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(P2)
D: Have you been diagnosed with any medical condition?
P: No.
D: Any DM, HTN, kidney problem, thyroid problem, PCOS, Fibroids, STDs or HIV?
P: No.

MAFTOSA
D: Are you on any medications or supplements such as folic acid?
P: Yes, I have been taking folic acid for the past month. (If she says no, advise her to
take it in management.)
D: Any allergies to medication or food?
P: No.
D: Any surgical procedures or operations?
P: No.
D: Any family members diagnosed with any medical conditions or family history of
complicated pregnancy?
P: No.

(P4)
D: How were your periods before you were pregnant? Were they regular?
P: Yes /No
D: Are they painful?
P: Yes/ No
D: How long does the bleeding last?
P: 6 days.
D: Any bleeding between your periods?
P: Yes/No
D: Any usage of contraception before you were pregnant?
P: No.

DESA
D: Do you smoke?
P: I stopped when I planned for pregnancy. I have been smoking a pack of cigarettes per
day since I was a teen.
D: Do you drink alcohol?
P: No. I stopped drinking when I knew I was pregnant.
D: How is your diet?
P: Good.
D: Do you drink coffee or tea?
P: Yes/No
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D: How is your physical activity?

P: I’m quite active.
D: Any usage of recreational drugs?
P: No.
D: Are you in a stable relationship?
P: Yes doctor, I am married.
D: What do you do for living?
P: Office job.
D: Who do you live with?
P: With my husband.

Examination
D: I would like to do some general examinations if that’s OK with you: Blood Pressure,
Pulse. Temperature and Breathing Rate; Measure your height and weight etc.

Examination results: Everything normal

Management
Senior.
Investigations: Blood tests for blood group, sugar, infections
(rubella/syphilis/hepatitis/HIV) and US.

Regarding your concerns about having another miscarriage:

In many cases, the cause of miscarriage is not known.
However, you can lower the risk of miscarriage by:
• Not smoking during pregnancy.
• Not drinking alcohol or using illegal drugs during pregnancy eating a healthy,
balanced diet with at least five portions of fruit and vegetables a day.
• Making attempts to avoid certain infections during pregnancy, such as rubella.
• Avoiding certain foods during pregnancy, which could make you ill or harm your
baby.
• Being a healthy weight before getting pregnant.
From the chat we had, it sounds like you are already doing everything you should be
doing to avoid a miscarriage.
For most women, it’s a one-off event and they go on to have a successful pregnancy in
the future. Most women are able to have a healthy pregnancy after a miscarriage, even
in cases of recurrent miscarriages.

Follow up:
We will keep monitoring you and your baby. Hopefully everything will be fine.
Attend all your antenatal check-ups.
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Safety netting: Please contact your GP, maternity team, or early pregnancy unit at your
local hospital in case of vaginal bleeding immediately.

Notes:
Recurrent miscarriages
If you've had 3 or more miscarriages in a row (recurrent miscarriages), further tests are
often used to check for any underlying cause. However, no cause is found in about half
of cases. Tests include abnormalities in the chromosomes,
abnormalities in the womb and further blood tests.

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UROLOGY

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Urology
Haematuria (Structure)

Presenting complaint (P1 O.D.I.P.A.R.A. + T.R.A.C.):

● Bleeding at the beginning of urination (urethra/prostate) or at the end of
urination (bladder/prostate) or throughout (kidney/ ureter).
O.D.I.P.A.R.A
● Onset (How did it start? Gradual/Sudden)
● Duration (When did it start?)
● Intensity (Can you score the pain from 1-10?)
● Progression (Has it been increasing since it started?)
● Aggravating factors (Is there anything that makes it worse?)
● Relieving factors (Is there anything that makes it better?)
● Anything else (Other than the blood in urine, anything else?)

T.R.A.C.
● Timing (since when?)
● Relation (Is it related to anything? Trauma/Procedures/Fever/Is it painful?)
● Amount (Can you quantify the amount of blood for me? Half teaspoon/Full
teaspoon)
● Colour and odour

Bleeding questions
● Any bleeding from anywhere else?
● Any bleeding disorders?
● Any blood thinners that you might be using?
● Any trauma?
● Any recent instrumentations or procedures?

Bleeding complications:
● Any heart racing?
● Any dizziness?
● Fainting?

Red flag symptoms:

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● Painless macroscopic haematuria

● Symptomatic macroscopic haematuria
● Symptomatic microscopic in absence of UTI
● Age > 50 years
● Abdominal mass

Concern
Apart from this, is there anything else that's concerning you?

DDs
Rule out
● F.L.A.W.S (Fatigue, Lumps and bumps, Appetite change, Weight change, Night
sweats) (FLAWS IS A MUST TO RULE OUT CANCER)
Kidney:
● Cancer (Adenocarcinoma)
● Glomerulonephritis
● Kidney stones
● Trauma (biopsy)
Ureter:
● Ureteric stones
● Infection
● Cancer
Bladder:
● Bladder cancer
● Cystitis (Tuberculosis)
● Bladder stone
● Trauma
Prostate:
● Benign prostatic hyperplasia (BPH)
● Prostate cancer
Urethra:
● Cancer
● Stone
● Infection
● Trauma

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Past medical conditions (P2)

Has this ever happened to you in the past?
Do you have any medical conditions that I should be aware of?

D.E.S.A:
Do you smoke?
What about alcohol?

M.A.F.T.O.S.A
Are you on any long-term medication? (Blood thinners)
What about any known allergies to any food or drugs?
Anyone in the family with similar problems or other medical conditions? (Kidney stones,
Polycystic kidney disease, Cancer)
Have you travelled outside the UK in the past couple of weeks? (Schistosomiasis)
What do you do for a living? (Occupational exposure: Aniline dye)
Anything else?

Expectations
Do you have anything specific in mind that you are expecting from us?

Examination:
● Observation (Check vitals)
● General Physical Examination: head-to-toe examination, pallor
● Abdominal Examination
● Back passage examination
● Front passage examination

Idea
Do you have any idea what might be causing the problem?

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Suspected diagnosis:
D: So, _______, you told me that you have been having blood in your urine along with
other symptoms (according to the history) I suspect you may
have____________________. We will need to run some tests to find the exact cause.

Management:

1. Admit/Referral:

2. Senior:

3. Investigations:
● Routine blood investigations (Full blood count/ U&E/ Renal function tests/ Liver
function tests/ clotting profile/ Prostate specific antigen)
● Urine: dipstick / MSUC
● Imaging: US KUB/ CT KUB
● Invasive: Cystoscopy (Camera test)
● TrPB : trans rectal prostate biopsy

4. Symptomatic:

5. Definitive management

6. Specialist:
● Urology referral

7. Complication:
● Dizziness
● Heart racing
● Fainting

8. Safety-net
● FLAWS
● New or increased bleeding.

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Blood in urine

Who you are:

You are an FY2 in the Emergency Department.
Who the patient is:
Simon Clark, 70 years old, came to the clinic with some concerns.
What you should do:
Talk to the patient, assess, and address his concerns.

Red flag symptoms:

● Painless macroscopic haematuria
● Symptomatic macroscopic haematuria
● Symptomatic microscopic in absence of UTI
● Age > 50 years
● Abdominal mass

Presenting complaint (P1 O.D.I.P.A.R.A. + T.R.A.C.):

Doctor: Hello this I’m Doctor (name). I am one of the doctors here in the Emergency
department. You must be Simon Clark?
P: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 70.
D: So, Simon, I understand that you have some concerns?
P: Yes, doctor.
D: Tell me more about it. (Open question)
P: Doctor, I have noticed some blood in my urine. It has been happening for some time
now but this morning it was more than usual so I got worried.
D: Tell me how did it start? (Onset)
P: It just started one day out of the blue.
D: When did it start? (Duration)
P: It started a month ago, doctor.
D: How often does it happen? (Intensity)

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P: Maybe once or twice a week.

D: Has it been increasing since it started? (Progression)
P: Yes doctor, at first it was minimal, but it has been increasing.
D: Is there anything that makes it worse? (Aggravating factors)
P: No doctor.
D: Is there anything that makes it better? (Relieving factors)
P: No doctor.
D: Is there anything else other than the blood in your urine?
P: No doctor.
D: Does it happen at specific times? (Timing)
P: No doctor.
D: Is it related to anything? Procedures/Pain (Relation)
P: No doctor, I did not have any procedures and there is no pain anywhere.
D: Can you give me an estimate of how much blood there is? (Amount)
P: At first it was minimal but then it has been increasing and this morning I think it was
about a spoonful.
D: What was the colour of the blood and did it have any odour?
P: It was bright red and no there is no odour doctor.
D: Is the bleeding at the beginning of urination (urethra/prostate) or at the end of
urination (bladder/prostate) or throughout (kidney/ ureter)?
P: Well doctor, it happens right at the end of urination.

Bleeding questions
D: Any bleeding from anywhere else?
P: No doctor.
D: Any bleeding disorders?
P: No doctor.
D: Any blood thinners that you might be using?
P: No doctor.
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D: Any trauma?
P: No doctor.
D: Any recent instrumentations or procedures?
P: No doctor.

Bleeding complications:
D: Any heart racing?
P: No
D: Any dizziness?
P: No
D: Fainting?
P: No.

Concern
D: Apart from this, is there anything else that's concerning you?
P: No doctor, I am just concerned about this, I was scared this morning when it
happened.
OR
P: Could it be something serious, like cancer?
D: Why do you think it could be cancer?
P: I don't know, doctor, I think having blood in my urine sounds like something serious
to me.
D: Don’t worry Simon, I will look into it and discuss with you what it might be.

DDs
Rule out:
(FLAWS IS A MUST TO RULE OUT CANCER, IT CAN BE AT ANY SITE)
● F (Have you been feeling fatigued lately? Yes)
● L (Any lumps or bumps around your body? No doctor)
● A (Any changes in your appetite that you might have noticed? No)
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● W (Any weight changes? My wife thinks I have lost some weight, I have not
checked it though.)
● S (Any excessive sweating especially at night? No)

Kidney:
● Any mass in the flank region? (Cancer)
● Any history of kidney problems (Polycystic kidney disease)
● Any pain in the flanks or any history of kidney stones? (Renal stones)
● Any history of trauma or procedures? (Biopsy)
Ureter:
● Any pain radiating from loin to groin? (Ureteric stones)
● Any fever, nausea or vomiting, any burning sensation while urinating? (Infection)
Bladder:
● Any history of lower tummy pain or problems with urination? Any night sweats?
(Cystitis, Tuberculosis)
● Bladder stone?
● Trauma?

Prostate:
● Any history of urinary symptoms including straining, increased frequency, post
void dribbling? (Benign prostatic hyperplasia)
● Prostate cancer?
Urethra:
● Cancer?
● Pain at the tip of penis? (Stone)
● Infection?
● Trauma?

Past medical conditions (P2)

D: Has this ever happened to you in the past?
P: No doctor. It started a month ago and before that it has never happened to me.
D: Do you have any medical conditions that I should be aware of?
P: No, doctor.

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D.E.S.A:
D: Do you smoke?
P: Yes doctor.
D: Tell me more about it.
P: I have been smoking cigarettes for the last 25 years. 1 pack every day.
D: What about alcohol?
P: Occasionally.

M.A.F.T.O.S.A
D: Are you on any long-term medication? (Blood thinners?)
P: No doctor.
D: What about any known allergies to any food or drugs?
P: No doctor.
D: Anyone in the family with similar problems or other medical conditions? (Kidney
stones, Polycystic kidney disease, Cancer)
P: No doctor.
D: Have you travelled outside the UK in the past couple of weeks? (Schistosomiasis)
P: No doctor.
D: Are you working or are you retired Simon? (Occupational exposure: Aniline dye)
P: I am currently retired, but I have worked in a Tyre factory for 40 years.
D: Anything else?
P: I think that's it, doctor.

Expectation
D: Do you have anything specific in mind that you are expecting from us?
P: I just want to figure out what’s wrong with me. And is it something serious?
D: Surely, I understand that this is troubling you, but I am here to help you and I will be
discussing what it could be in a moment after I have examined you if that’s OK.
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Examination:
● Observation (Check vitals)
● General Physical Examination: head-to-toe examination, pallor
● Abdominal Examination
● Back passage examination
● Front passage examination
● BMI

Idea
D: I know you are worried about the situation, but do you have any idea what might be
causing the problem?
P: I have no clue, doctor.

Suspected diagnosis:
D: So, Simon, you told me that you have been having this blood in your urine for a
month and it has been increasing. Along with this you also told me that you have been
tired lately and you lost some weight. So, best case scenario, it could be something
benign going on with your water works. Worse case scenario, as you told me that you
have been a smoker for a while now and you worked in a tyre factory for a long time, it
could also be something serious which we will have to rule out. But we will need to run
some tests to find the exact cause.

Management:

1. Admit
● Admit the patient in the hospital.

2. Senior:
● Talk to senior.

3. Investigations:
● Routine blood investigations (Full blood count/ U&E/ Renal function tests/ Liver
function tests/ clotting profile/ Prostate specific antigen)
● Urine: dipstick / MSUC
● Imaging: US KUB/ CT KUB
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● Invasive: Cystoscopy (Camera test)

● TrPB : trans rectal prostate biopsy

4. Symptomatic Management:
● Advice about smoking cessation.
● Lifestyle modification including diet exercise

5. Definitive Management:
● If the test results show that it is something serious like cancer, there are a few
options that may be offered to you depending on its size and spread:
1.Surgery
2.Chemotherapy
3.Radiotherapy

6. Specialist:
● Urology referral

7. Complication:
● Dizziness
● Heart racing
● Fainting

8. Safety-net
● FLAWS
● New or increased bleeding.

Haematuria (Test Results) Scenarios Structure:

Presenting complaint (P1)

I can see that you are here for your test results. Can you tell me why you had the tests
done in the first place?
I have the test results with me. Would you like to have a chat before I explain the
results to you?

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How is your health in general?

Explore any known medical conditions
- Since when?
- How is it managed?
- What medication are you taking?
- Are you taking it as prescribed?
- Any symptoms?
- Any bleeding since you have taken it?

Bleeding questions:
Have you seen any blood in your urine?
Bleeding anywhere else in your body?
Are you on any blood thinners?
Any known bleeding disorders?
Any trauma or instrumentation?

DDs of haematuria (Risk factors)

Any burning sensation while you are passing urine? (UTI)
By any chance have you hurt yourself? (Trauma)
FLAWS (Cancer)
Any back or groin pain? (stones)
Renal red flag:
When was your last time you passed urine?
NOTE
If the haematuria is microscopic, do not ask haematuria questions.

Complications:
Any heart racing?
Any dizziness?
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Any fainting?

Past medical history (P2)

Apart from _________ (Above mentioned) medical conditions do you have any other
medical conditions?
Have you had this condition before?
Previous surgeries?

DESA
Any recent changes to your diet? (Beetroots?)
Do you do any regular exercise?
Do you smoke?
Do you drink alcohol?

MAFTOSA
Are you on any medications apart from the _________ (Above mentioned)
Any allergies?
Any family history of medical conditions?
How is that affecting your life?
Who do you live with at home?

Examination:
Observations
Tummy
Pelvis
Per Speculum examination

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Explain test results:

Your urine test contained blood cells which normally should not be there. This is called
microscopic haematuria, but otherwise everything else is normal.
For now, we are not sure of the reason why these blood cells are in your urine; it might
be nothing at all. However, we need to exclude other reasons such as infection or
stones or more serious reasons by doing further investigations.
Any concerns so far?

Management :

1. Advise

2. Risk Factors
Explain risk factors if any and advise regarding them.
3. Management
● Refer/Admit/Observe
● Involve senior
● Medication
● Investigations
4. Multidisciplinary team
● If patient is suspected to have something sinister, they might need
management by a multidisciplinary team.
5. Safety-net
● FLAWS
● New or increased bleeding
● Bleeding from anywhere else

Haematuria Test Results Scenario

Who you are: An FY2 in General practice.

Who the patient is: 65-year-old, Angela Stark, has come to the clinic for the results of
the tests that she had a week ago. 2 weeks ago, she came for a well woman check-up
and had her tests done. Her urine dipstick was positive for microscopic haematuria

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showing +++ RBC’s and the test was repeated again. You have the test results now
which are again positive for haematuria showing +++ RBC’s.
Additional Information: She has been diagnosed with atrial fibrillation and is on regular
medication including Bisoprolol and Warfarin.
What you should do: Talk to the patient, explain test results and discuss further
management.

Presenting complaint (P1)

Doctor: Hello this I am Dr (name). I am one of the doctors in General practice here. You
must be Angela Stark.
Patient: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 65.
D: I can see that you are here for your test results. Can you tell me why you had the
tests done in the first place?
P: I came for a routine check-up 2 weeks ago and had a few tests. One of the tests at
that time showed that there was some blood in my urine, so this test was repeated.
D: Yes, sure I have the test results with me. Would you like to have a chat before I
explain the results to you?
P: Sure, doctor.
D: How is your health in general?
P: I was recently diagnosed with atrial fibrillation, doctor, other than that I have been
well.
D: Since when?
P: It has been a few months, maybe 6 or 7.
D: How is it managed?
P: I am taking regular medication for it.
D: What medication are you taking?
P: Bisoprolol and Warfarin.
D: Are you taking it as prescribed?

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P: Yes, doctor.
D: Any symptoms?
P: No.
D: Any bleeding since you have taken it?
P: No, doctor. I have not noticed any bleeding.
D: Do you visit the doctor regularly for follow ups?
P: Yes, doctor.

Bleeding questions:
D: Have you seen any blood in your urine? (If microscopic)
P: No.
D: Bleeding anywhere else in your body?
P: No.
D: Are you on any other medication apart from Warfarin? (Blood thinners)
P: No, doctor.
D: Any known bleeding disorders?
P: No, doctor.
D: Any trauma or instrumentation through the front passage?
P: No, doctor.

DDs of haematuria (Risk factors)

D: Any burning sensation while you are passing urine? (UTI)
P: No, doctor.
D: By any chance have you hurt yourself? (Trauma)
P: No. doctor.
D: Any Fatigue, Lumps and bumps, appetite change, weight change that you noticed?
(Cancer)
P: No, doctor.
D: Any back or groin pain? (stones)
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P: No doctor.

Renal red flag:

D: When did you last pass urine ?
P: It was just this morning, doctor.
Complications:
D: Any heart racing?
P: No.
D: Any dizziness?
P: No.
D: Any fainting?
P: No.

Past medical history (P2)

D: Apart from atrial fibrillation do you have any other medical conditions?
P: No doctor.
D: Have you had this condition before?
P: No, doctor.
D: Previous surgeries?
P: No, doctor.

DESA
D: Any recent changes to your diet? (Beetroot?)
P: Nothing as such, no.
D: Do you do any regular exercise?
P: I try my best, doctor.
D: Do you smoke?
P: No.
D: Do you drink alcohol?
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P: Occasionally.

MAFTOSA
D: Are you on any medications apart from the ones you mentioned?
P: No.
D: Any allergies?
P: None that I know of.
D: Any family history of medical conditions?
P: No.

Examination:
● Observations
● Tummy
● Pelvis
● Per Speculum examination

Explain test results:

D: Angela, thank you for bearing with me and answering all those questions. We
repeated your urine test and it indeed shows that you have blood cells in your urine
which is called microscopic haematuria. Normally, there shouldn’t be blood cells in
your urine, but otherwise everything is else is normal.
P: So what are we going to do about it?
D: For now, we are not sure about the reasons for the blood being there; it might be
nothing at all. However, we need to exclude other reasons such as infection or stones
or more serious conditions with further investigations.
Any concerns so far?

Management:
• Refer to specialist for further testing and assessment to see if the medication is
causing the bleeding or there is another cause for that.
• I will also discuss this with my senior for his input regarding this.

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• For now, you should continue taking your medication for atrial fibrillation as
prescribed.
• We might also need to run some further investigations to check for any problem
in your blood clotting mechanism to see if the warfarin dose is appropriate or it
needs to be reduced but this is something that your heart doctor will be deciding
after assessing you.

Multidisciplinary team
If after further assessment something sinister is found, you might need management
by a multidisciplinary team.

Safety-net
● FLAWS
● New or increased bleeding
● Bleeding from anywhere else

Urinary tract Infections:

Urinary tract infection (Positive Findings):
● Pain or a burning sensation when peeing (dysuria)
● Needing to pee more often than usual during the night (nocturia)
● Pee that looks cloudy, dark or has a strong smell.
● Needing to pee suddenly or more urgently than usual.
● Needing to pee more often than usual.
● Blood in your pee.
● Lower tummy pain or pain in your back, just under the ribs.
● A high temperature or feeling hot and shivery.
● A very low temperature below 36C.

Risk factors
● Having sex
● Pregnancy
● Conditions that block the urinary tract – such as kidney stones
● Conditions that make it difficult to fully empty the bladder – such as an enlarged
prostate in men and constipation in children
● Urinary catheters
● Having a weakened immune system
● Not drinking enough fluids
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● Not keeping the genital area clean and dry

● Holding urine for a long time
● Wearing tight undergarments
● Wiping from back to front
● Testosterone use (Female to male transitioning)

Urinary tract Infection (Female)

Who you are:
An FY2 in General Practice.
Who the patient is:
35 year old, Olivia Quagmire, came to the clinic with some concerns.
What you should do:
Talk to the patient, assess, and address his concerns.

Presenting complaint (P1) (SOCRATES):

Doctor: Hello, I am one of the doctors here. You must be Olivia Quagmire.
Patient: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 35.
D: So, Olivia, I can see that you have been having some problems with your tummy?
P: Yes, doctor.
D: Tell me more about this pain. (Open question)
P: It started a few days ago, and it is not improving.
D: Where exactly is the pain? (Site)
P: It's in my lower tummy.
D: When exactly did it start?
P: Well, doctor, it started 3 days ago (Onset)
D: What type of pain is it? (Character)
P: It's like a dull pain, doctor.

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D: Does this pain go anywhere else apart from the tummy? (Radiation)
P: No doctor, it's just my tummy.
D: Is there anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: I did try taking some paracetamol and that helps a little.
D: Do you think it has been increasing since it started? (Progression)
P: Yes, doctor, I think it is getting worse.
D: Can you scale the pain on a scale of 0-10, 0 being no pain and 10 being the worst
pain? (Scale)
P: I would say it's like a 5.
D: Anything else apart from the discomfort?
P: Yes, doctor, I have also been having some problems with my wee. It burns.
D: Tell me more about this problem?
P: It started 3 days ago as well and it burns whenever I go to the loo.
D: Has it been increasing?
P: Yes doctor.
D: Any changes in your urine? (Colour, smell, frothy, blood?)
P: I think it seems a bit cloudy.
D: Any nausea or vomiting?
P: I feel a bit sick sometimes.
D: Any pain in the loin?
P: No doctor.
D: Any fever?
P: I feel a bit feverish at times, but I have not checked it.
D: Do you by any chance wipe from back to front when you are on the loo?
P: I think yes, sometimes I do, am I not meant to?
D: It is better to wipe front to back to avoid infection. Is there anything else?
P: No doctor.

Concern
D: Apart from this, is there anything else that's concerning you?
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P: No doctor, nothing else. It doesn't seem to be getting better.

DDs
Rule out:
● UTI (Burning micturition, increased urinary frequency, smelly or frothy urine,
fever, lower tummy pain)
● Pyelonephritis (Flank or lower back pain, high temperature, shivering and chills,
feeling sick, loss of appetite)
● PID (Lower tummy pain, vaginal discharge, heavy or painful periods, pain while
peeing, pain while having sex)
● Ectopic pregnancy (Vaginal bleeding, shoulder tip pain, lower tummy pain)
● Appendicitis (Right sided lower tummy pain, feeling sick, loss of appetite,
constipation or diarrhoea, a high temperature and flushed face)

Past medical conditions (P2)

D: Has this ever happened to you before?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: No, doctor.

D.E.S.A (P3) + Sexual history:

D: Do you smoke?
P: I don't smoke, doctor.
D: What about alcohol?
P: Occasionally.
D: Sorry, I need to ask you a few questions about your sexual health. Are you sexually
active?
P: Yes, doctor.
D: Do you have a stable partner?
P: Yes, doctor.
D: Do you practice safe sex?
P: Yes doctor.

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P4
D: Tell me about your periods?
P: They seem to be fine, doctor, I was on last week.
D: Could you be pregnant by any chance?
P: No, doctor, I don't think so.
D: Have you had a Pap smear recently?
P: Yes doctor. It was normal.
D: When was that?
P: 6 months ago.
D: Are you on any kind of contraception?
P: I am using the oral contraceptive pill.

M.A.F.T.O.S.A
D: Are you on any long-term medication apart from the contraceptives?
P: No, doctor.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Does anyone in your family have similar problems or other medical conditions?
P: No, doctor.
D: Has your partner been having something similar?
P: No, doctor.
D: Anything else?
P: No, doctor.

Expectations
D: Do you have anything specific in mind that you are expecting from us?
P: I just want this to get better.
Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea.

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Examination:
● Observation (Check vitals)
● Abdominal examination
● Urine dipstick test to be done straight away (sample preferably to be collected
midstream.)

Diagnosis:
If urine dipstick is positive: So, Olivia, you told me that you have been having this lower
tummy pain for the past three days along with burning while urinating and you also told
me you noticed that your urine is frothy and you have been feeling feverish as well. On
examination, I also noticed some tenderness and your urine dipstick test is indicating
that you have a urinary tract infection. It’s quite common so I wouldn’t worry about it. I
can give you some antibiotics and some advice on how to try to avoid these types of
infections in the future.

If urine dipstick is unclear: Although you are showing signs of a UTI, your urine test isn’t
clear so I would like to it send it off for further analysis.
Management:

Senior:
● Involve senior

Investigations:
● Routine blood investigations including full blood count, U&E, RFT, and LFT
● Urine dipstick test and culture
● USG abdomen

Symptomatic:
● Pain killers
● Antipyretics
● Hydration

Treatment:
● Antibiotics (Nitrofurantoin, Trimethoprim)
Nitrofurantoin :
● 100 mg x 2 times a day for 3 days
● Side effects (N/V/D + vaginal itching)
● Contraindicated in kidney disease

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Note: if the patient is allergic to nitrofurantoin or has kidney disease then give
Trimethoprim
200 mg twice for 3 days
Side effects: N/V/D + pruritus + skin rash
Contraindication: pregnancy / bleeding

Specialist:
Refer to specialists if symptoms are not improving, or if they are worsening even after
antibiotic use.

Safety net
● If symptoms are worsening
● Pyelonephritis (loin pain/ fever & chills/ vomiting)
● Sepsis (lethargic/ drowsy/ tired)

Advice for avoiding UTI in future:

DO
● Wipe from front to back when you go to the toilet.
● Keep the genital area clean and dry.
● Drink plenty of fluids, particularly water – so that you regularly pee during the
day and do not feel thirsty.
● Wash the skin around the vagina with water before and after sex.
● Pee as soon as possible after sex.
● Promptly change adult nappies or incontinence pads if they're soiled.

DONT
● Do not use scented soap.
● Do not hold your pee in if you feel the urge to go.
● Do not rush when going for a pee – try to fully empty your bladder.
● Do not wear tight, synthetic underwear, such as nylon.
● Do not drink lots of alcoholic drinks, as they may irritate your bladder.
● Do not have lots of sugary food or drinks, as they may encourage bacteria to
grow.
● Do not use condoms or a diaphragm or cap with spermicidal lube on them – try
non-spermicidal lube or a different type of contraception.

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Urinary tract infection (Pregnancy)

Who you are:
An FY2 in the Emergency department.
Who the patient is:
35-year-old, Masha Rostova, came to the clinic with some concerns.
What you should do:
Talk to the patient, assess, and address his concerns.

Presenting complaint (P1) (SOCRATES):

D: Hello, I am one of the doctors here. You must be Masha Rostova.
P: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 35.
D: So, Masha, I can see that you have been having some problems with your tummy?
P: Yes, doctor.
D: Tell me more about this pain. (Open question)
P: It started a few days ago, and it is not improving.
D: Where exactly is the pain? (Site)
P: It's in my lower tummy.
D: When exactly did it start?
P: Well, doctor, it started 5 days ago (Onset)
D: What type of pain is it? (Character)
P: It's like a dull pain, doctor.
D: Does this pain go anywhere else apart from the tummy? (Radiation)
P: No doctor, it's just my tummy.
D: Anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: I did try taking some paracetamol and that helps a little.
D: Do you think it has been increasing since it started? (Progression)
P: Yes, doctor, I think it is getting worse.
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D: Can you scale the pain on a scale of 0-10, 0 being no pain and 10 being the worst
pain? (Scale)
P: I would say it's like a 5.
D: Anything else apart from the pain?
P: Yes, doctor, I have also been having some problems with my wee. It burns.
D: Tell me more about this problem?
P: It started 5 days ago as well and it burns whenever I go to the loo.
D: Has it been getting more and more painful by the day?
P: Yes doctor.
D: Any changes in your urine? (Colour, smell, frothy, blood)
P: I think it is a bit cloudy.
D: Any nausea or vomiting?
P: I feel a bit sick sometimes.
D: Any pain in the loin?
P: No doctor.
D: Any fever?
P: I feel a bit feverish at times, but I have not checked it.
D: Do you by any chance wipe from back to front when you are in the loo?
P: I’m not sure, maybe.
D: Anything else?
P: No doctor.

Concern
D: Apart from this, is there anything else concerning you?
P: No doctor.

DDs
Rule out
● UTI (Burning micturition, increased urinary frequency, smelly or frothy urine,
fever, lower tummy pain)
● Pyelonephritis (Flank or lower back pain, high temperature, shivering and chills,
feeling sick, loss of appetite)
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● PID (Lower tummy pain, vaginal discharge, heavy or painful periods, pain while
peeing, pain while having sex)
● Ectopic pregnancy (Vaginal bleeding, shoulder tip pain, lower tummy pain)
● Appendicitis (Right sided lower tummy pain, feeling sick, loss of appetite,
constipation or diarrhoea, a high temperature and flushed face)

Past medical conditions (P2)

D: Has this ever happened before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: No, doctor.

D.E.S.A (P3) + Sexual history:

D: Do you smoke?
P: I don't smoke, doctor.
D: What about alcohol?
P: No, doctor. I don't drink.
D: I would like to ask a few questions about your sexual health.
D: Are you sexually active?
P: Yes, doctor.
D: Do you have a stable partner?
P: Yes, doctor.
D: Do you practice safe sex?
P: Yes doctor.
D: That’s good.

P4
D: Tell me about your periods?
P: I don’t have periods at the moment, I’m pregnant.
D: Tell me about the pregnancy?
P: I am 15 weeks pregnant, doctor.
D: Was it a planned pregnancy?
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P: Yes, we are really happy about it.

D: Congratulations! Have you had your Pap smear?
P: Yes doctor. It was normal.
D: When was that?
P: A year ago.

M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: I am taking folic acid, doctor.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in your family with similar problems or other medical conditions?
P: No.
D: Has your partner been having something similar?
P: No.
D: Anything else?
P: No.

Expectations
D: Do you have anything specific in mind that you are expecting from us?
P: I just don’t want the baby to be affected.
Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea.

Examination:
● Observation (Check vitals)
● Abdominal examination
● Urine dipstick test to be done straight away (sample preferably to be collected
midstream.)

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Provisional diagnosis:
If dipstick test is positive:
So, Masha, you told me that you have been having this lower tummy pain for the past
few days along with burning while urinating and you have also noticed that your urine is
frothy and you have been feeling a little feverish as well. On examination, I also noticed
some tenderness in your lower tummy and your urine dipstick test is showing that you
have a urine infection (UTI).
A UTI can be harmful to the baby if left untreated but thankfully you have come in
early, and we can begin treatment today to avoid any harm to the baby. Don’t worry.
If urine dipstick is unclear: Although you are showing signs of a UTI, your urine test isn’t
clear so I would like to it send it off for further analysis.

Management:
Senior:
● Involve senior, especially as she is pregnant.

Investigations:
● As she is pregnant, routine blood investigations including full blood count, U&E,
RFT, and LFT
● Urine dipstick test and culture to be sent off also.
● USG abdomen

Symptomatic:
● Painkillers
● Antipyretics
● Hydration

Treatment:
● Antibiotics (Nitrofurantoin, Amoxicillin, Cefalexin)
Nitrofurantoin :
● 50 mg x 4 times a day for 7 days
● Side effects (N/V/D + vaginal itching)
● Contraindicated in kidney disease/ Pregnancy (Avoid in last trimester)
Note: if the patient is allergic to nitrofurantoin or has kidney disease or is near term
then give Amoxicillin
Amoxicillin (250-1000mg QDS) usually 500mg 3 times daily for 7 Days.

Specialist:
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If the woman has fever (you should know from taking her vitals) or loin tenderness,
suspect upper urinary tract infection, and admit or seek urgent specialist opinion.

Safety-net:
● If symptoms are worsening
● Pyelonephritis (loin pain/ fever & chills/ vomiting)
● Sepsis (lethargic/ drowsy/ tired)

Advice for avoiding UTI in future:

DO
● Wipe from front to back when you go to the toilet.
● Keep the genital area clean and dry.
● Drink plenty of fluids, particularly water – so that you regularly pee during the
day and do not feel thirsty.
● Wash the skin around the vagina with water before and after sex.
● Pee as soon as possible after sex.
● Promptly change adult nappies or incontinence pads if they're soiled.

DONT
● Do not use scented soap.
● Do not hold your pee in if you feel the urge to go.
● Do not rush when going for a pee – try to fully empty your bladder.
● Do not wear tight, synthetic underwear, such as nylon.
● Do not drink lots of alcoholic drinks, as they may irritate your bladder.
● Do not have lots of sugary food or drinks, as they may encourage bacteria to
grow.
● Do not use condoms or a diaphragm or cap with spermicidal lube on them – try
non-spermicidal lube or a different type of contraception.

Urinary tract infection (Transgender)

Who you are: An FY2 in General Practice.
Who the patient is: 25-year-old Allison McKenzie, came to the clinic with some burning
sensation while passing urine.
What you should do: Talk to the patient, assess, and address concerns.

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Presenting complaint (P1) (SOCRATES):

D: Hello I am one of the doctors here. You must be Allison.
P: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 25.
D: So, Allison, I can see that you have been having some problems when urinating?
P: Yes, doctor.
D: Tell me more about it (Open question)
P: It hurts when I go for a wee.
D: How exactly did it start? (Onset)
P: Well, doctor, initially I started feeling a bit of discomfort while peeing and then it
started increasing and the discomfort turned into pain.
D: When did it start? (Duration)
P: It started 4 days ago.
D: So the pain has been increasing since it started? (Progression)
P: Yes, doctor, I think it is getting worse.
D: Is there anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: No, doctor.
D: Anything else apart from this?
P: Yes, doctor, I have also been feeling a bit feverish as well.
D: Tell me more about this fever?
P: It started 4 days ago as well, however, I did not check it.
D: Any changes in the urine? (Colour, smell, frothy, blood)
P: I think it seems a bit cloudy.
D: Any nausea or vomiting?
P: I feel a bit sick sometimes.
D: Anything pain in your loin?
P: No doctor.
D: Do you by any chance wipe from back to front when you are on the loo?
P: I think yes, sometimes I do.
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D: Anything else?
P: No doctor.

Concerns?
D: Apart from this, is there anything else that's concerning you?
P: No doctor.

DDs
Rule out
● UTI (Burning micturition, increased urinary frequency, Smelly or frothy urine,
fever, Lower tummy pain)
● Pyelonephritis (Flank or lower back pain, High temperature, Shivering and chills,
feeling sick, loss of appetite)
● PID (Lower tummy pain, vaginal discharge, heavy or painful periods, pain while
peeing, pain while having sex)
● Appendicitis (Right sided lower tummy pain, feeling sick, loss of appetite,
constipation or diarrhoea, a high temperature and flushed face)

Past medical conditions (P2)

D: Has this ever happened before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: Well, doctor, I am actually transitioning right now.
D: Do you mean from female to male?
P: Yes.
D: What stage are you in?
P: I am on hormone therapy right now. I am taking testosterone at this point.
D: Have you had top or bottom surgery at all?
P: No, not yet doctor.
D: Would you like to tell me which pronouns you want to be referred by and I will make
a note of your wishes on our system?
P: Yes, my new pronouns are he/him, thank you.
D: Are you regularly following up at the clinic?
P: Yes, doctor.
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D: Any challenges so far?

P: I do have some issues at my office, as we don't have any gender-neutral toilets, so I
have to hold my wee in sometimes.

D.E.S.A (P3) + Sexual history:

D: Do you smoke?
P: I don't.
D: What about alcohol?
P: Occasionally.
D: Sorry I need to ask you a few questions about your sexual health.
D: Are you sexually active?
P: Yes, doctor.
D: Do you have a stable partner?
P: Yes, doctor.
D: Do you practice safe sex?
P: Yes doctor.

P4
D: Tell me about your periods, do you get them?
P: Yes doctor, I was on 2 weeks ago.

M.A.F.T.O.S.A
D: Are you on any long-term medication apart from testosterone?
P: No, doctor.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in your family with similar problems or other medical conditions?
P: No, doctor.
D: Has your partner been having something similar?
P: No, doctor.
D: Anything else?
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P: No, doctor.

Expectations
D: Do you have anything specific in mind that you are expecting from us?
P: I just want this to get better.

Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea.
Examination:
● Observation (Check vitals)
● Abdominal examination
● Urine dipstick test to be done straight away (preferably to be collected
midstream.)

Diagnosis:
If dipstick test is positive:
D: So, Allison, you told me that you have been having this burning sensation while
peeing for the past 4 days and you also told me you noticed that your urine is frothy
and you have been feeling feverish as well. Additionally, you told me that you are using
testosterone for transitioning, and you have to hold your urine sometimes as well. On
examination, I also noticed some tenderness in your lower tummy and your urine
dipstick test is positive, confirming the signs that you have a urine infection (UTI).
If urine dipstick is unclear: Although you are showing signs of a UTI, your urine test isn’t
clear so I would like to it send it off for further analysis.

Management:
Senior:
● Involve senior

Investigations:
● Routine blood investigations including full blood count, U&E, RFT, and LFT
● Urine dipstick test and culture
● USG abdomen

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Symptomatic:
● Pain killers
● Antipyretics
● Hydration
● Cranberry juice

Treatment:
● Antibiotics (Nitrofurantoin, Trimethoprim)
Nitrofurantoin :
● 100 mg x 2 times a day for 3 days
● Side effects (N/V/D + vaginal itching)
● Contraindicated in kidney disease
Note: if the patient is allergic to nitrofurantoin or has kidney disease then give
Trimethoprim
200 mg twice for 3 days
Side effects: N/V/D + pruritus + skin rash
Contraindication: pregnancy / bleeding

Specialist:
● Refer to specialist if symptoms are not improving, or if they are worsening even
after antibiotic use.
● Refer to the gender clinic for follow-up.

Safety-net
● If symptoms are worsening
● Pyelonephritis (loin pain/ fever & chills/ vomiting)
● Sepsis (lethargic/ drowsy/ tired)

Advice for avoiding UTI in future:

DO
● Wipe from front to back when you go to the toilet.
● Keep the genital area clean and dry.
● Drink plenty of fluids, particularly water – so that you regularly pee during the
day and do not feel thirsty.
● Wash the skin around the vagina with water before and after sex.
● Pee as soon as possible after sex.
● Promptly change adult nappies or incontinence pads if they're soiled.

DONT
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● Do not use scented soap.

● Do not hold your pee in if you feel the urge to go.
● Do not rush when going for a pee – try to fully empty your bladder.
● Do not wear tight, synthetic underwear, such as nylon.
● Do not drink lots of alcoholic drinks, as they may irritate your bladder.
● Do not have lots of sugary food or drinks, as they may encourage bacteria to
grow.
● Do not use condoms or a diaphragm or cap with spermicidal lube on them – try
non-spermicidal lube or a different type of contraception.

Urinary tract infection (BPH)

Who you are:
An FY2 in General Practice.
Who the patient is:
70 years old Morgan Paxman came to the clinic with some burning sensation while
passing urine.
What you should do:
Talk to the patient, assess, and address his concerns.

Presenting complaint (P1) (SOCRATES):

D: Hello I am one of the doctors here. You must be Morgan Paxman.
P: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 70.
D: So, Morgan, I can see that you have been having some problems when going for a
wee?
P: Yes, doctor.
D: Tell me more about it. (Open question)
P: When I go for a wee it burns.
D: How exactly did it start? (Onset)
P: Well, doctor, initially I started feeling a bit of discomfort while peeing and then it
started increasing and becoming more and more painful.
D: When did it start? (Duration)
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P: It started 5 days ago.

D: You say it has been increasing since it started? (Progression)
P: Yes, doctor, I think it is getting worse.
D: Is there anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: I have been drinking a lot of water, but it doesn't help much.
D: Anything else apart from that?
P: Yes, doctor, I have also been a bit feverish as well.
D: Tell me more about this fever?
P: It started 4 days ago as well, however, I did not check it.
D: Any changes in the urine? (Colour, smell, frothy, blood)
P: I think it seems a bit cloudy.
D: Any nausea or vomiting?
P: I feel a bit sick sometimes.
D: Any pain in the loin?
P: No doctor.
D: Did you have any problems with weeing before this started ? (Frequency, difficulty in
starting, nocturia, post-void dribbling)
P: I haven’t felt right for weeks.

Concern
D: Apart from this, is there anything else that's concerning you?
P: No doctor

DDs
Rule out
● UTI (Burning micturition, increased urinary frequency, Smelly or frothy urine,
fever, Lower tummy pain) + BPH + Prostate cancer. (FLAWS)
● Pyelonephritis (Flank or lower back pain, High temperature, Shivering and chills,
feeling sick, loss of appetite)
● STI (Discharge, Lower abdominal pain, fever)
● Appendicitis (Right sided lower tummy pain, feeling sick, loss of appetite,
constipation or diarrhoea, a high temperature and flushed face)

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Past medical conditions (P2)

D: Has this ever happened before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: I have been diagnosed with high blood pressure in the last few years.

D.E.S.A (P3) + Sexual history:

D: Do you smoke?
P: Yes, doctor, I smoke occasionally.
D: What about alcohol?
P: Yes, occasionally.
D: Sorry, I need to ask a few questions about your sexual health. Are you sexually
active?
P: Yes, doctor.
D: Do you have a stable partner?
P: Yes, doctor.
D: Do you practice safe sex?
P: Yes doctor.

M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: I am taking some medication for my blood pressure problem (Ramipril)
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in the family with similar problems or other medical conditions?
P: No, doctor.

Expectation
D: Do you have anything specific in mind that you are expecting from us?
P: I just want this to get better.

462 | P a g e
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Examination:
● Observation (Check vitals)
● Abdominal examination
● Back passage examination
● Urine dipstick test to be done straight away (sample preferably to be collected
mid-stream)

Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea.

Suspected diagnosis:
So, Morgan, you told me that you have been having this burning sensation while
urinating for the past 5 days and you have also noticed that your urine is frothy and you
have been feeling feverish as well. On examination, I also noticed some tenderness in
your lower tummy and your prostate is enlarged as well. Your urine dipstick test is also
confirming you have a urinary tract infection (if test was positive). This could be due to
the enlarged prostate that is not letting your bladder empty completely. We will run
some tests to find out exactly what is happening with you.

Management:

Senior:
● Involve senior

Investigations:
● Routine blood investigations including full blood count, U&E, RFT, and LFT and
PSA
● Urine dipstick test and culture
● USG abdomen

Symptomatic:
● Pain killers
● Antipyretics
● Hydration
● Cranberry products

Treatment:
● Medication to relax the prostate gland: Tamsulosin
463 | P a g e
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● Antibiotics (Nitrofurantoin, Trimethoprim)

Nitrofurantoin :
● 100 mg x 2 times a day for 3 days
● Side effects (N/V/D + vaginal itching)
● Contraindicated in kidney disease
Note: if the patient is allergic to nitrofurantoin or has kidney disease then give
Trimethoprim
200 mg twice for 3 days
Side effects: N/V/D + pruritus + skin rash
Contraindication: bleeding

Specialist:
Refer to urologist for further assessment and investigations for prostate symptoms.

Safety-net
● If symptoms are worsening
● Pyelonephritis (loin pain/ fever & chills/ vomiting)
● Sepsis (lethargic/ drowsy/ tired)

Advice for avoiding UTI in future:

DO
● Wipe from front to back when you go to the toilet.
● Keep the genital area clean and dry.
● Drink plenty of fluids, particularly water – so that you regularly pee during the
day and do not feel thirsty.
● Wash the skin around the vagina with water before and after sex.
● Pee as soon as possible after sex.
● Promptly change adult nappies or incontinence pads if they're soiled.

DONT
● Do not use scented soap.
● Do not hold your pee in if you feel the urge to go.
● Do not rush when going for a pee – try to fully empty your bladder.
● Do not wear tight, synthetic underwear, such as nylon.
● Do not drink lots of alcoholic drinks, as they may irritate your bladder.
● Do not have lots of sugary food or drinks, as they may encourage bacteria to
grow.

464 | P a g e
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● Do not use condoms or a diaphragm or cap with spermicidal lube on them – try
non-spermicidal lube or a different type of contraception.

Recurring urinary tract infections

Who you are:
An FY2 in the GP Surgery.
Who the patient is:
25-year-old Stella Morris came to the clinic with some concerns.
Additional Information:
She had dysuria 2 weeks ago and was diagnosed with a UTI. She has been taking
antibiotics for the past 2 weeks.
What you should do:
Talk to the patient, assess, and address her concerns.

Presenting complaint (P1) (SOCRATES):

Doctor: Hello I am one of the doctors here. You must be Stella Morris.
Patient: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 25.
D: So, Stella, I can see that you are here with some concerns?
P: Yes, doctor.
D: Tell me more about what’s going on. (Open question)
P: I have been using the medication for my UTI symptoms for the last two weeks, but
they are not getting better.
D: Can you tell me about your symptoms?
P: I have this pain in my lower tummy along with this burning feeling while urinating.
D: What has been done for you so far?
P: I came here with this problem and they diagnosed me with a UTI and started me on
antibiotics. I took them for 7 days but they did not help and so I came back again, they
changed my antibiotics but that medication is not helping me either even after I used it
for 7 days.
D: Have you been taking the medication regularly and as prescribed?
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P: Yes doctor.
D: Have you noticed any improvement in your symptoms at all?
P: No, doctor.
D: Where exactly is the pain? (Site)
P: It's in my lower tummy.
D: When exactly did it start?
P: Well, doctor, it started 2 weeks ago (Onset)
D: What type of pain is it? (Character)
P: It's like a dull pain, doctor.
D: Does this pain go anywhere else apart from your tummy? (Radiation)
P: No, doctor, it's just my tummy.
D: Is there anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: No, doctor.
D: Do you think it has been increasing since it started? (Progression)
P: Yes, doctor, I think it is getting worse.
D: Can you scale the pain on a scale of 0-10, 0 being no pain and 10 being the worst
pain? (Scale)
P: I would say it's like a 5.
D: Tell me about the urine problem?
P: Yes, doctor, I have to go to the loo very frequently these days and I get this burning
sensation while urinating.
D: How many times are you going to the loo these days?
P: Around 5 or 6 times a day.
D: Any changes in your urine? (Colour, smell, frothy, blood)
P: I think it seems a bit cloudy.
D: Any nausea or vomiting?
P: I feel a bit sick sometimes.
D: Any pain in the loin?
P: No doctor.
D: Any fever?

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P: I feel a bit feverish at times, but I have not checked it.

D: Do you by any chance wipe from back to front when you are in the loo?
P: No.
D: Anything else?
P: No doctor.

Concern
D: Apart from this, is there anything else that's concerning you?
P: I just want this to get better, doctor. I have been taking medication for the last 2
weeks, but it is still not improving.

Past medical conditions (P2)

D: Has this ever happened before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: No, doctor.

D.E.S.A (P3) + Sexual history:

D: Do you smoke at all?
P: No.
D: What about alcohol?
P: Occasionally.
D: Sorry I need to ask a few questions about your sexual health.
D: Are you sexually active?
P: Yes, doctor.
D: Do you have a stable partner?
P: Yes, doctor.
D: Do you practice safe sex?
P: Not, always.

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P4
D: Tell me about your periods?
P: They seem to be fine, doctor, I was on 3 weeks ago.
D: Could you be pregnant by any chance?
P: No, doctor, I don't think so.
D: Have you had a Pap smear recently?
P: Yes doctor. It was normal.
D: Are you on any kind of contraception?
P: I’m on the pill.

M.A.F.T.O.S.A
D: Are you on any long-term medication apart from the pill?
P: No, doctor.
D: What about any known allergies to any food or drugs?
P: I don’t have any allergies.
D: Anyone in your family with similar problems or other medical conditions?
P: No, doctor.
D: Has your partner been having something similar?
P: No, doctor.
D: Anything else?
P: No, doctor.

Expectations
D: Do you have anything specific in mind that you are expecting from us?
P: I just want this to get better.
Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea.

Examination:
● Observation (Check vitals)
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● Abdominal examination
● Urine dipstick test to be done straight away (sample preferably to be collected
mid-stream)

Diagnosis:
Stella, after our chat and my examination and your positive urine sample it does seem
that you still have a UTI. I think what is happening here is that you are suffering from
recurrent urinary tract infections. That could be due to multiple reasons and
unfortunately it can be caused by unprotected sex which you told me you are having
sometimes.
We will need to run some further tests to be sure about what is causing this.

Management:
Refer:
● Referral to specialist for further testing and assessment to find out the cause of
recurrent UTIs.
● Advise her to attend sexual health clinic with her boyfriend for STI/HIV testing as
they are having unprotected sex.

Senior:
● Involve senior.

Investigations:
● Routine blood investigations including full blood count, U&E, RFT, and LFT
● Urine dipstick test and culture
● USG abdomen

Symptomatic:
● Pain killers
● Antipyretics
● Hydration
● Cranberry juice

Treatment:

● Antibiotics to treat infection (Nitrofurantoin, Trimethoprim)

Nitrofurantoin :
● 100 mg x 2 times a day for 3 days
● Side effects (N/V/D + vaginal itching)
● Contraindicated in kidney disease
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Note: if the patient is allergic to nitrofurantoin or has kidney disease then give
Trimethoprim
200 mg twice for 3 days
Side effects: N/V/D + pruritus + skin rash
Contraindication: pregnancy / bleeding

● Prophylactic antibiotics:
Trimethoprim:
● 200 mg as a single dose when exposed to a trigger, or 100 mg at night
● There is a teratogenic risk in first trimester of pregnancy

Nitrofurantoin (if estimated glomerular filtration rate is 45 ml/minute or more):

● 100 mg as a single dose when exposed to a trigger, or 50 mg to 100 mg at night

Advise her to avoid sexual contact for a week or 2 till symptoms get better.

Specialist:
Specialist assessment to investigate and find out triggers and causes.

Safety net
● If symptoms are worsening
● Pyelonephritis (loin pain/ fever & chills/ vomiting)
● Sepsis (lethargic/ drowsy/ tired)

Advice for avoiding UTI in future:

DO
● Wipe from front to back when you go to the toilet.
● Keep the genital area clean and dry.
● Drink plenty of fluids, particularly water – so that you regularly pee during the
day and do not feel thirsty.
● Wash the skin around the vagina with water before and after sex.
● Pee as soon as possible after sex.
● Promptly change adult nappies or incontinence pads if they're soiled.

DONT
● Do not use scented soap.
● Do not hold your pee in if you feel the urge to go.
● Do not rush when going for a pee – try to fully empty your bladder.
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● Do not wear tight, synthetic underwear, such as nylon.

● Do not drink lots of alcoholic drinks, as they may irritate your bladder.
● Do not have lots of sugary food or drinks, as they may encourage bacteria to
grow.
● Do not use condoms or a diaphragm or cap with spermicidal lube on them – try
non-spermicidal lube or a different type of contraception.

Sexually transmitted infection (Male)

Who you are:
An FY2 in the GP Surgery.
Who the patient is:
25-year-old Barney Stinson, came to the clinic with some concerns.
What you should do:
Talk to the patient, assess, and address his concerns.

Sexually transmitted infections (Positive Findings):

● An unusual discharge from the penis or anus
● Pain when peeing.
● Lumps or skin growths around the genitals or bottom (anus).
● A rash.
● Itchy genitals or anus.
● Blisters and sores around your genitals or anus.
● Warts around your genitals or anus.

Presenting complaint (P1) (SOCRATES):

Doctor: Hello I am one of the doctors here. You must be Barney Stinson.
Patient: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 25.
D: So, Barney, I can see that you have been having some concerns?
P: Yes, doctor.

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D: Tell me more about it. (Open question)

P: I have been having some problems with my pee. It burns.
D: How exactly did it start? (Onset)
P: Well, doctor, initially I started feeling a bit of discomfort while peeing and then it
started increasing.
D: When did it start? (Duration)
P: It started 5 days ago.
D: Do you think it has been increasing since it started? (Progression)
P: Yes, doctor, I think it is getting worse.
D: Is there anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: No doctor.
D: Anything else other than this?
P: Yes, doctor, I have noticed some discharge from my penis.
D: Tell me more about this discharge?
P: It started 5 days ago as well.
D: What is the colour of this discharge?
P: It's yellowish green in colour.
D: Does it have a foul smell?
P: Yes doctor.
D: Any fever?
P: Yes, doctor.
D: Any lumps around the genitals?
P: No doctor.
D: Any rash around genitals?
P: No doctor.
D: Any pain in the loin?
P: No doctor.
D: Any nausea, vomiting?
P: No.
D: Any problems weeing previously?
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P: No.

Concern
D: Apart from this, is there anything else that's concerning you?
P: No doctor.

DDs
Rule out
● STI (Discharge, lower abdominal pain, fever, burning urination)
● UTI (Burning urination, increased urinary frequency, smelly or frothy urine, fever,
lower tummy pain)
● Pyelonephritis (Flank or lower back pain, high temperature, shivering and chills,
feeling sick, loss of appetite)
● Appendicitis (Right sided lower tummy pain, feeling sick, loss of appetite,
constipation or diarrhoea, a high temperature and flushed face)

Past medical conditions (P2)

D: Has this ever happened before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: No, doctor.

D.E.S.A (P3) + Sexual history:

D: Do you smoke ?
P: Yes, doctor, I smoke occasionally.
D: What about alcohol?
P: Yes, occasionally.
D: Sorry I have to ask you a few questions about your sexual health. Are you sexually
active?
P: Yes, doctor.
D: Do you have a stable partner?
P: I have a few girlfriends at the same time.
D: Do you practice safe sex?
P: Sometimes, yes, but sometimes I don't.
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M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: No.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in your family with similar problems or other medical conditions?
P: No, doctor.

Expectations
D: Do you have anything specific in mind that you are expecting from us?
P: I just want this to get better.
Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea.

Examination:
● Observation (Check vitals)
● Abdominal examination
● Genital examination
● Urine dipstick test to be done straight away (sample to be preferably taken
midstream.)

Diagnosis:
Barney, you told me that you have been having this burning sensation while urinating
for the past 5 days and you have also noticed some foul-smelling greenish discharge
from your penis. Additionally, you also told me that you have multiple girlfriends, and
you don’t always practice safe sex. On examination, I indeed noticed the discharge and I
suspect you may have a sexually transmitted infection.

Management:
Refer:
● I will need to refer you to a sexual health clinic for further testing and
assessment.
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Senior:
● Involve senior.

Investigations:
● Routine blood investigations including full blood count, U&E, RFT, and LFT
● Urine dipstick test and culture
● Swabs for culture and sensitivity

Symptomatic:
● Painkillers
● Antipyretics
● Hydration

Treatment:
● Broad spectrum antibiotics would be started once the swab test results have
come in, you will be started on specific antibiotics to treat the infection.
● You will have to bring all your current partners in to be tested for STIs as it is
highly likely that they also have it as well and they will also need to be treated at
the same time, to avoid the infection being passed back and forth.
● Anonymous partner notification program is available if they are not willing to
talk and bring in their partners.

Specialist:
Refer to Sexual health clinic or GUM clinic.

Safety net
● If symptoms are worsening
● Sepsis (lethargic/ drowsy/ tired)
● Do not have sex until you and your partners have been treated completely.

Advice on avoiding STIs in future:

DO
● Use a condom when you have vaginal or anal sex.
● Use a condom to cover the penis or a latex or plastic square (dam) to cover the
vagina if you have oral sex.
● Make sure you complete treatment course.

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DONT
● Do not share sex toys (or wash and cover them with a new condom before
anyone else uses them).
● Do not share needles if you inject drugs.
Note:
Do not have sex (vaginal, anal or oral) until you and your partner have finished
treatment and tests have shown treatment has worked.

Loin pain (Renal colic)

Who you are:
An FY2 in Accident and Emergency.
Who the patient is:
40-year-old George Santos came to the hospital with some loin pain.

Additional Information:
The nurse has given him diclofenac.
What you should do:
Talk to the patient, assess, and address his concerns.

Renal stones (Positive Findings):

● Pain on the side of your tummy (abdomen) or groin – men may have pain in their
testicles.
● A high temperature.
● Feeling sweaty.
● Severe pain that comes and goes.
● Feeling sick or vomiting.
● Blood in your urine.
● Urine infection.

Presenting complaint (P1) (ODIPARA):

D: Hello I am one of the doctors in the Emergency Department. Are you George Santos.
P: Yes.
D: Can you confirm your age please before we begin the consultation?

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P: I am 40.
D: So, George, I can see that you have been having some loin pain?
P: Yes, doctor.
D: Tell me more about it. (Open question)
P: I don’t know, doctor, it started half an hour ago.
D: Where exactly is the pain? (Site)
P: Its right around here on the left side (Points at the left loin region)
D: How did it start, was it sudden or gradual? (Onset)
P: It started suddenly, half an hour ago, while I was having my lunch.
D: What type of pain is it? (Character)
P: It is a very sharp pain.
D: Is it radiating anywhere else? (Radiation)
P: It’s going to my groin region as well.
D: Is there anything that you think makes it better or worse? (Aggravating and
elevating factors)
P: The nurse gave me some painkillers and that helped a bit.
D: Is it continuous? (Timing)
P: It comes and goes doctor.
D: On a scale of 0 - 10, 0 being no pain and 10 being the worst pain, how would you rate
it?
P: I think it is a 7 or 8.
D: Anything else apart from the pain?
P: No.
D: Any fever?
P: Yes.
D: Any nausea, vomiting?
P: I am feeling a bit sick as well, doctor.
D: Any burning urination?
P: No.
D: Any changes in urine colour or any blood in urine?
P: No.
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D: Anything else?
P: No.

Concern
D: Apart from this, is there anything else that's concerning you?
P: No. It's the pain, it's really bad.

DDs
Rule out
● Renal stone (Pain in loin, sometimes radiating to groin, high temperature, severe
pain that comes and goes, feeling sick or vomiting, blood in your urine)
● Pyelonephritis (Flank or lower back pain, high temperature, shivering and chills,
feeling sick, loss of appetite)
● Pancreatitis (Pain radiating to back, vomiting, nausea, excessive alcohol intake)
● Diverticulitis (Pain relieved on defecation, per rectal bleeding)

Past medical conditions (P2)

D: Has this ever happened before in the past?
P: No, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of? (Gout, Joint problem,
Hyperparathyroidism - Risk factor)
P: No.

D.E.S.A (P3) + Sexual history:

D: How is your diet? (For gout - Risk factor for kidney stones) + Do you drink enough
fluids?
P: My diet is good and my fluid intake is alright, doctor.
D: Are you physically active? (Immobilisation - risk factor)
P: I try to be physically active, doctor.
D: Do you smoke ?
P: Yes, doctor, I smoke occasionally.
D: What about alcohol?
P: Yes, occasionally.
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D: I would like to ask a few questions about your sexual health.

D: Are you sexually active?
P: Yes, doctor.
D: Do you have a stable partner?
P: Yes, doctor.
D: Do you practice safe sex?
P: Yes, doctor.

M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: No.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in your family with similar problems or other medical conditions? (Kidney
stones - risk factor)
P: No, doctor.

Expectation
D: Do you have anything specific in mind that you are expecting from us?
P: I just want this to get better.

Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea.

Examination:
● Observation (Check vitals)
● Abdominal & genital examination
● Urine dipstick test to be done straight away (sample to be collected preferably
midstream).

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Provisional diagnosis:
George, you told me that you have been having this pain in your left loin that suddenly
started half an hour ago and it also radiates to the groin as well. It comes and goes and
is 8 on the pain scale, right? You also told me that you have been feeling sick since this
pain started. I have done an examination and you have some tenderness in your left
flank and all these things point me towards a renal stone that is causing this colicky
pain. We will need to give you some medications, do some further tests and observe
you here for a while.

Management:
Observe:
● Retain the patient in emergency department for observation, initial
management, and further investigations.
Senior:
● Involve senior.

Investigations:
● Routine blood investigations including full blood count, U&E, RFT, LFT, ESR, CRP,
Uric acid, RBS.
● Urine dipstick test and culture.
● Non - contrast CT KUB.

Symptomatic:
● Painkillers (NSAIDs, Paracetamol)
● Hydration

Treatment:
Definitive management depends on the size of the stone:
For smaller stones:
● Drinking plenty of fluids throughout the day.
● Anti-sickness medicine.
● Alpha-blockers (medicines to help stones pass).
● You might be advised to drink up to 3 litres (5.2 pints) of fluid throughout the
day, every day, until the stones have cleared.
● Drink water, but drinks like tea and coffee also count.
● Add fresh lemon juice to your water.
● Avoid fizzy drinks.
● Do not eat too much salt.
● Make sure you're drinking enough fluid. If your pee is dark, it means you're not
drinking enough. Your pee should be pale in colour.
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● You should try to collect the stone from your urine. You can do this by filtering
your urine through gauze or a stocking and then give to stone to your GP so that
he can have it analysed to help determine any further treatment you may need.

Treating large kidney stones:

If your kidney stones are too big to be passed naturally, they're usually removed by
surgery.
Surgery for treating kidney stone:
● Shockwave lithotripsy (SWL)
● Ureteroscopy
● Percutaneous nephrolithotomy (PCNL)
The type of surgery will depend on the size and location of your stones.

Specialist:
Refer to urologist for further investigations including imaging to find the location and
size of the stone to decide further management.

Safety-net
● If symptoms are worsening
● Sepsis (lethargic/ drowsy/ tired)
● Severe pain
● Pyelonephritis (loin pain/ fever & chills/ vomiting)

Advice on avoiding renal colic in future:

● Drink plenty of fluid.
● Reduce salt intake and red meat.
● Reduce oxalate intake (chocolate, nuts etc.)

Erectile Dysfunction
Who you are:
An FY2 in General practice.
Who the patient is:
60-year-old Nicolas Tesla came to the hospital with some loin pain.
What you should do:
Talk to the patient, assess, and address his concerns.

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Erectile dysfunction (Causes):

There are two main causes of ED: physical and psychological.
Physical causes:
● Diabetes.
● Inadequate blood flow to the penis because arteries have got furred-up (a
condition called atherosclerosis) or damaged.
● Regular heavy drinking.
● The side-effects of prescribed drugs, particularly those used to treat high blood
pressure, heart disease, depression, peptic ulcers and cancer.
● Spinal cord injury.
● Prostate gland surgery (or other surgery around the pelvis).

Psychological causes:
● Relationship conflicts.
● Stress and anxiety.
● Depression (90% of men affected by depression also have complete or moderate
ED)
● Unresolved sexual orientation.
● Sexual boredom.

Presenting complaint (P1) (ODIPARA):

Doctor: Hello I am one of the doctors here in the surgery. Are you Nicolas Tesla?
Patient: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 60.
D: So, Nicolas, I can see that you have been having some concerns that you want to talk
about.
P: Yes, doctor. I am having some trouble performing, doctor.
D: Tell me more about it. (Open question)
P: Every time I try to have sex with my wife, I can’t keep it up.
D: When did it start?
P: Around 4 months ago.
D: Has it gotten worse since it started?
P: No doctor.
D: Is there anything that makes it better?
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P: No, doctor.
D: Can you elaborate? Is it that you can't get an erection, or you can't maintain it?
P: I have difficulty in getting an erection, Sometimes, I do get it, but I can't maintain it
for long.
D: When you are able to get an erection, is it sufficient for penetration?
P: Yes, doctor, but I can't maintain it.
D: Do you get morning erections?
P: Yes, doctor.
D: Tell me about your sexual drive/libido?
P: That seems to be normal.
D: Have you ever had a problem with ejaculating in the past?
P: No doctor.
D: Have you ever had a problem with completing sexual activity (achieving orgasm)?
P: No, doctor.
D: Any problems with your penis, other than the erection problem?
P: No, doctor.
D: Any pain during sex?
P: No, doctor.
D: When was the last time you had sex?
P: We tried yesterday.
D: How is your relationship with your partner, any challenges?
P: Our relationship is good; I have discussed this problem with her and she understands
the situation she advised me to come and talk to you.
D: Any recent stressors?
P: No, doctor.

Concern
D: Apart from this, is there anything else that's concerning you?
P: It is really embarrassing for me, doctor. I just want to get rid of this problem.
D: There’s really no need to feel embarrassed it’s a very common problem.

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Past medical conditions (P2)

D: Has this ever happened to you in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: I have a blood pressure (Hypertension) problem and I had a heart attack 5 months
ago.
D: Are you using any medication for these issues?
P: Yes doctor. I have been using amlodipine for my blood pressure problem for the last
5 years. For the heart problem, I had an angioplasty and I am taking Bisoprolol,
Atorvastatin, and clopidogrel.

D.E.S.A (P3) + Sexual history:

D: How is your diet?
P: My diet is good.
D: Are you physically active?
P: I try to be physically active, doctor.
D: Do you smoke?
P: I used to smoke before, but I stopped it since I had the heart attack.
D: What about alcohol?
P: Yes, occasionally.
D: Did you mention you are married?
P: Yes, doctor, 20 years now.

M.A.F.T.O.S.A
D: Are you on any other long-term medication apart from the ones that you mentioned
earlier?
P: No.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in your family with similar problems or other medical conditions?
P: No, doctor.

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D: What do you do for a living?

P: I am working as a recruitment officer, doctor.
D: Any stress related to your job?
P: No, doctor.
D: Who else do you live with, apart from your wife?
P: It's just the two of us.

Expectation
D: Do you have anything specific in mind that you are expecting from us?
P: Maybe some medication for the problem.

Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea.
Examination:
● Observation (Check vitals)
● Genital examination to check for any obvious physical cause

Diagnosis:
Nicolas, you told me that you have been having problems with achieving and
maintaining your erection for a couple of months now. There can be many reasons for
this but in your case, you told me that you had a heart attack and are now using
medications for that. One of the medications (Bisoprolol - Beta-blocker) can cause
erectile dysfunction. Everything else seems to be fine with you.
P: Ok, doctor. Should I just stop taking the medication then?
D: Well we need to consult your heart doctor regarding the medication before we can
switch it or stop it.

Management:
Refer:
● Referral to heart doctor for medication review for possible side effect to either
switch or stop the causative medication.

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Senior:
● Involve senior.

Investigations:
● Routine blood investigations including full blood count, U&E, RFT, LFT, ESR, CRP,
Uric acid, RBS, Testosterone.

Treatment: There are also specific treatments for some of the causes of erectile
dysfunction.
Treatments for some causes of erectile dysfunction

Possible cause Treatment

Narrowing of penis blood vessels, high Medicine to lower blood pressure,

blood pressure, high cholesterol statins to lower cholesterol

Hormone problems Hormone replacement (for example,

testosterone)

Side effects of prescribed medicine Change medication

Medicine such as sildenafil (sold as Viagra) is also often used by doctors to treat erectile
dysfunction. It's also available from pharmacies. (Rule out any contraindications of
using Viagra before prescribing)

Specialist:
Refer to heart specialist for medication review and If medication change does not help,
a urologist referral for further investigations including to find out the cause and manage
it.

Safety-net
● For heart conditions
● Symptoms not improving.

486 | P a g e
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Advice for Erectile Dysfunction:

DO
● Lose weight if you're overweight
● Stop smoking
● Eat a healthy diet
● Exercise daily
● Try to reduce stress and anxiety
DONT
● Do not cycle for a while (if you cycle for more than 3 hours a week)
● Do not drink more than 14 units of alcohol a week

Urinary incontinence
Urinary Incontinence:
1. Stress incontinence:
Stress incontinence is when you leak urine when your bladder is put under sudden extra
pressure – for example, when you cough, sneeze, laugh, lift heavy weight, or do
exercise. It's not related to feeling stressed.
Causes of stress incontinence
● Damage during childbirth – particularly if your baby was born vaginally, rather
than by caesarean section.
● Increased pressure on your tummy – for example, pregnancy or obesity.
● Damage to the bladder or nearby area during surgery – such as the
hysterectomy, or removal of the prostate gland.
● Neurological conditions, such as Parkinson's disease or multiple sclerosis.
● Connective tissue disorders such as Ehlers-Danlos syndrome.
● Certain medicines (ACE inhibitors, Antidepressants, HRT, Diuretics, Sedatives.)

2. Urge incontinence
Urge incontinence, or urgency incontinence, is when you feel a sudden and very intense
need to pass urine and you're unable to delay going to the toilet. It may be triggered by
a sudden change of position, or even by the sound of running water. This type of
incontinence often occurs as part of a group of symptoms called overactive bladder
syndrome, which is when the bladder muscle is more active than usual.
Causes of urge Incontinence:
● Drinking too much alcohol or caffeine.
● Not drinking enough fluids.
● Constipation.
● Urinary tract infections (UTIs) or tumours in the bladder.
● Neurological conditions.

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● Certain medicines (ACE inhibitors, Antidepressants, HRT, Diuretics, Sedatives. )

Who you are:

An FY2 in General practice.
Who the patient is:
46-year-old Daphne Winston came to the hospital with some concerns.
What you should do:
Talk to the patient, assess, and address his concerns

Presenting complaint (P1) (ODIPARA):

Doctor: Hello I am one of the doctors here. You must be Daphne Winston.
Patient: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 46.
D: So, Daphne, I can see that you have been having some concerns?
P: Yes, doctor. I have been having some problems with peeing. It leaks out sometimes
and wets my clothes. Which is very embarrassing.
D: Tell me more about it. (Open question)
P: It has been going on for a few months now.
D: How did it start, was it sudden or gradual? (Onset)
P: It was gradual, doctor.
D: When exactly did it start? (Duration)
P: I first noticed it 6 months ago.
D: Has it been getting worse since then? (Progression)
P: Yes, I’d say so.
D: Is there anything that you think makes it better or worse? (Aggravating and
elevating factors)
P: No, but it usually happens when I cough or sneeze or maybe lift something heavy.
D: Is there anything else apart from this?
P: No doctor.

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D: Any problems with your urine (Burning, frequency,)?

P: No, doctor.
D: Any fever?
P: No, doctor.
D: Any nausea, vomiting?
P: No, doctor.
D: Any changes in urine colour or any blood in the urine?
P: No, doctor.
D: Anything else?
P: No, doctor.

Concern
D: Apart from this, is there anything else that's concerning you?
P: It's just this problem, doctor. It gets embarrassing for me when it happens in public.

Past medical conditions (P2)

D: Has this ever happened before?
P: No.
D: Do you have any medical conditions that I should be aware of?
P: No.

D.E.S.A (P3) + Sexual history:

D: How is your diet? Do you take any stimulants like coffee or energy drinks?
P: My diet is good, and I drink a cup of coffee every day.
D: Are you physically active?
P: I try to be physically active, doctor.
D: Do you smoke?
P: No, doctor.
D: What about alcohol?
P: No, doctor.

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D: If you don’t mind, I would like to ask you a few questions about your sexual health.
Are you sexually active?
P: Yes, doctor.
D: Do you have a stable partner?
P: Yes, doctor.
D: Do you practice safe sex?
P: Yes, doctor.

P4
D: Tell me about your periods?
P: They seem to be fine, doctor, I had them 2 weeks ago.
D: Could you be pregnant by any chance, or have you been pregnant in the past?
P: No, doctor, I don't think that I am pregnant, but yes I have been pregnant in the past.
I have 5 children.
D: Tell me about the deliveries, normal, vaginal deliveries or caesarean sections?
P: All normal, vaginal deliveries, doctor.
D: When was your last delivery?
P: It was 7 years ago.
D: Any instrumentations during any of the deliveries?
P: Yes doctor, In the last 2 deliveries they had to use some instruments.
D: Have you had a Pap smear recently?
P: Yes, last year. It was normal.
D: Are you on any kind of contraception?
P: I am on the pill.

M.A.F.T.O.S.A
D: Are you on any long-term medication? (ACE inhibitors, Antidepressants, HRT,
Diuretics, Sedatives. )
P: No.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.

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D: Anyone in your family with similar problems or other medical conditions?

P: No, doctor.
D: How has this been affecting your life, you told me it has been going on for a few
months now?
P: It's just that it gets really embarrassing for me at instances when I am out in public,
and this happens.

Expectation
D: Do you have anything specific in mind that you are expecting from us?
P: Maybe some medicine to stop this.

Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea.

Examination:
● Observation (Check vitals + BMI)
● Genital and pelvic examination

Provisional diagnosis:
Daphne, you told me that you have been having this problem for the past 6 months.
Your urine leaks out unintentionally at instances when you cough or sneeze. Also, you
told me you have had 5 normal deliveries in the past. I have done an examination and I
suspect you have stress incontinence. It basically means that whenever you cough,
sneeze or strain the pressure inside your tummy increases and that causes your bladder
to leak. It could be due to multiple reasons but in your case it could be due to multiple
pregnancies and instrumentations that can lead to weak pelvic muscles causing this to
happen.

Management:
Senior:
● Involve senior

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Investigations:
● FBC, RFT, LFT, U&E
● Urine dipstick

Non-surgical management:
● Maintain a bladder diary.
● Lifestyle changes including reducing your intake of caffeine, losing weight (if
overweight).
● Pelvic floor muscle training (Kegel exercises).
● Bladder training.

Incontinence products that can be used to counter the leakage:

● Absorbent products, such as pants or pads.
● Handheld urinals.
● A catheter.
● Devices that are placed into the vagina or urethra to prevent urine leakage.
Medication:
Stress Incontinence : Duloxetine
Urge Incontinence : Oxybutynin, Tolterodine, Darifenacin

Surgical management:
Stress Incontinence : Colposuspension, sling surgery.
Urge Incontinence: Botulinum toxin A injection, Sacral nerve stimulation.

Specialist:
Refer to urologist for further management if initial measures are not helpful.
Safety net
● If symptoms are worsening
● UTI (lethargic/ drowsy/ tired)
● Pyelonephritis (loin pain/ fever & chills/ vomiting)

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Confusion (Oxybutynin)
Who you are:
An FY2 in General practice.
Who the patient is:
75-year-old Steve Austin came to the hospital with some concerns.
Additional Information:
He came to the clinic 2 weeks ago and was started on oxybutynin for stress
incontinence. He used it for a week but that did not help, and the dose was doubled
after a week. The patient has now booked an urgent appointment.
What you should do:
Talk to the patient, assess, and address his concerns.

Presenting complaint (P1) (ODIPARA):

D: Hello Steve I am one of the doctors in general practice here. Is your full name Steve
Austin.
P: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 75.
D: So, Steve, I can see that you have been having some concerns?
P: Yes, doctor, I was playing golf with my friend yesterday and I had a very odd
sensation at that time, I don't know what it was.
D: Tell me more about this sensation?
P: I don’t know but I felt a bit confused for a few moments and I didn’t know where I
was or what I was doing. I have been having this feeling for a week now and I think it
happened because of the drug I’ve been put on.
D: Can you tell me about the drug, what drug is it and why are you taking it?
P: 2 weeks ago I went to the doctor as I was going to the loo more often and it was very
difficult for me to hold my urine in. I was prescribed oxybutynin 2 weeks ago, but the
symptoms did not go away, so my dose was doubled a week ago.
D: Did your symptoms improve after doubling the dose?
P: Yes doctor, they did improve but then this happened and I stopped taking it
yesterday.

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D: Do you have any other symptoms apart from the confusion?

P: No.
D: Any fever?
P: No.
D: Any changes in your urine (cloudy, frothy, blood)?
P: No.
D: Any nausea and vomiting?
P: No.
D: Do you have any pain while passing urine?
P: No.
D: Do you have to go to the loo more frequently at night?
P: Yes.
D: How many times do you have to wake up during the night?
P: Twice, I think.
D: Any other problems with urinating, like straining or having difficulty in passing urine
or dribbling at the end?
P: No, doctor.
D: Are you able to hold your urine before going to the loo?
P: Well, that was the problem that I went to the doctor in the first place about and it
improved since I doubled the dose of medicine.
D: Do you feel like you are not able to completely empty your bladder?
P: No
D: Have you noticed any weight loss?
P: No doctor.
D: Any lumps and bumps anywhere?
P: No, doctor.
D: Any changes in appetite?
P: No.

Concern
D: Apart from this, is there anything else that's concerning you?
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P: Well, being confused was scary.

D: I can imagine it was.

Past medical conditions (P2)

D: Has this ever happened before?
P: No.
D: Do you have any medical conditions that I should be aware of?
P: Just this problem with the urine, nothing else.

D.E.S.A (P3) + Sexual history:

D: Are you physically active?
P: I try to be physically active, doctor.
D: Do you smoke?
P: No, doctor.
D: What about alcohol?
P: No, doctor.

M.A.F.T.O.S.A
D: Are you on any long-term medication apart from oxybutynin?
P: No.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in your family with similar problems or other medical conditions?
P: No, doctor.

Expectation
D: Do you have anything specific in mind that you are expecting from us?
P: I just want this to get better.
Idea
D: Do you have any idea what might be causing the problem?
P: No doctor, I have no idea.
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Examination:
● Observation (Check vitals + BMI)
● Abdominal Examination
● Per rectal examination

Provisional diagnosis:
Steve, from what you told me, I understand that you had a feeling of being confused
yesterday and you have been having this urge incontinence problem for which you have
been taking oxybutynin with a double dose since last week. I suspect that you are
correct in thinking this was caused by doubling the drug dose, as it is a known side
effect of this drug.

Management:
Refer:
● Specialist referral to review the medication and dosage.
Senior:
● Involve senior.

Investigations:
● FBC, RFT, LFT, U&E
● Urine dipstick

Symptomatic management:
● Lifestyle modifications including reducing caffeine, drinking an optimal amount
of water, losing weight, to counter the incontinence problem to decrease the
drug dosage.
● Pelvic floor muscle training (Kegel exercises)
● Bladder training.
● NHS incontinence services which include special nurses and physiotherapists
who can help with the issue.

Surgical management:
Urge Incontinence: Botulinum toxin A injection, Sacral nerve stimulation.

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Specialist:
Refer to the specialist for medication review and further management of urge
incontinence.

Safety-net
● If symptoms are worsening
● If you are not feeling yourself.
● UTI (lethargic/ drowsy/ tired)
● Pyelonephritis (loin pain/ fever & chills/ vomiting)

Prostate specific antigen testing

(Demanding patient)
Who you are:
An FY2 in General practice.
Who the patient is:
60-year-old Mike Johnson came to the surgery with some concerns.
What you should do:
Talk to the patient, assess, and address his concerns.

Presenting complaint (P1) (ODIPARA):

Doctor: Hello I am one of the doctors in General practice here. Are you Mike Johnson?
Patient: Yes.
D: Can I get your age, please, before we begin the consultation?
P: I am 60.
D: So, Mike, I can see that you have been having some concerns?
P: I want to have the PSA test done.
D: Sure, we can most certainly do that for you, but would you mind telling me why?
P: One of my friends had this test done and later on he was diagnosed with prostate
cancer.
D: I am sorry to hear about your friend. How’s he doing now?

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P: He just had a surgery and is now under treatment.

D: I would like to ask you a few questions about your health in general. Do you have any
kind of symptoms? (Prostatism)
P: Like what, doctor?
D: Are you going to the loo more often these days? (Frequency)
P: No, doctor.
D: Do you have to rush to the loo? (Urgency)
P: No, doctor.
D: Do you have to strain while passing urine? (Hesitancy)
P: No, doctor.
D: Do you have difficulty in starting urination?
P: No, doctor.
D: Do you have to wake up in the middle of the night to go to the loo? (Nocturia)
P: No, doctor.
D: Any burning sensation while passing urine?
P: No, doctor.
D: Any changes in your urine (colour, smell, blood)?
P: No, doctor.
FLAWS
D: Do you feel tired these days?
P: No.
D: Any lumps or bumps anywhere on your body?
P: No.
D: Any appetite or weight change that you noticed recently?
P: No.
D: Any lower back pain?
P: No, doctor.

Concern
D: Any specific concerns that you might have?
P: I just want to get the test and be sure that I don't have the cancer.
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Past medical conditions (P2)

D: Do you have any medical conditions that I should be aware of?
P: No, doctor.

(P3)D.E.S.A + Sexual history:

D: Do you smoke?
P: No.
D: What about alcohol?
P: Occasionally.
D: Are you sexually active?
P: Yes, doctor.
D: Do you have a stable partner?
P: Yes, doctor.
D: Do you use protection?
P: Yes, doctor.

M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: No, doctor.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Any medical conditions that run in the family, especially cancer?
P: No, doctor.
Expectation
D: Apart from the PSA test, is there anything else that you are expecting from us today?
P: I just want the test done, doctor.

Idea
D: What do you understand about this test?
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P: I just know it can detect prostate cancer.

D: Yes, that is correct. I will just explain it for you now. So basically, this test actually
checks the level of something called the Prostate Specific Antigen, which is a chemical
produced by the prostate. High levels of PSA circulating in the blood can be indicative of
something going on with the prostate. However, it is not a very specific test to rule out
cancer, as it is only a screening test and it can give a false positive and a false negative
test result as well. Additionally, it can also be raised with other conditions such as an
infection of the prostate or even benign enlargement of the prostate which is called
Benign prostatic hyperplasia (BPH).
P: I would still want to go for the test doctor.
D: Sure, we can do the test for you if you want. There are a few things that I would
advise you about before we can do the test for you.
Examination:
● Observations (Check vitals)
● Abdominal examination
● Per rectal examination

Management:

● Involve senior and discuss the case.

● Offer PSA testing.
● Explain the prerequisites that include the following:
No signs of active urinary infection
No ejaculated in 48 hours before the sampling
No vigorous exercise in 48 hours before the sampling
No prostate biopsy in the previous 6 weeks.
● Book an appointment for the patient.

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CARDIOVASCULAR

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CARDIOVASCULAR

CHEST PAIN APPROACH:

Exploring any chest pain:

P1: SOCRATES
• Can you point with one finger where the pain is? (Site)
• How did this pain start? (Onset)
• What type of pain is it? (Character)
• Are you in pain right now? (Angina Vs MI)
• Does the pain go anywhere else in your body? (Radiation) Left jaw – Left hand –
neck – Left shoulder (MI).
• Between your shoulder blades (Dissection).
• Referred to your back (Epigastritis).
• Anything that makes it worse or better? (Relation)
• Relieved by leaning forward (Pericarditis).
• How severe is your pain on a scale from 1 to 10? (Scoring)
• Have you taken any pain killers? (Medications)
• Apart from this, is there anything else?
• What is your main concern? (Concern)
• 5 symptoms all the time
(SOB-cough-fever-heart racing-trauma)

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Differentials:

SKIN Herpes zoster (discussed before).

MUSCLE & BONES 1. Trauma: fall- sport-accident-injury

2. Costochondritis
HEART 1. MI • Radiation
• Family Hx
• Acute, severe pain
• DESA
2. Pericarditis • Fever
• Pain relieved by leaning
forward.
3.Stable Angina • Not in pain now
• Exercise triggers it
• Rest makes it better.
4.Aortic Dissection • Pain radiates to in-between
shoulder blades.

LUNGS 3Ps 1.Pneumonia • Fever

• Cough
• Sputum
2.P.E. • Travel Hx
• Recent surgery
• Calf muscle tenderness
3.Pneumothorax • Trauma
• Accident
ESOPHAGUS GORD (Discussed before) • Heartburn
• Sour taste in mouth

- DON’T FORGET FLAWS

P2: PAST HX
Have you ever had such pain before?
Any medical condition?
(5 conditions)

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P3: DESA
MAFTOSA
ICE (IDEA- CONCERN- EXPECTATIONS)
EXAMINATION +ECG (CHEST TRACING) +HEART ATTACK MARKERS
Provisional diagnosis then Management
7 steps:
1- Admit
2- Senior
3- Investigations
4- Symptomatic (PAIN KILLER) + lifestyle
5- Specialist
6- Safety net
7- Follow up

Acute Coronary Syndrome (MI)

Where you are:
You are an Fy2 in A&E.
Who the patient is:
John, aged 55, presented to the hospital with chest pain.
What you must do:
Please talk to the patient, take history, assess the patient and
discuss your initial plan of management with the patient.

Don't forget (Admission - radiation to jaw – Concern – red flags – FHx)

P1
Doctor: How I can help you today?
Patient: I have pain in my chest (Socrates)
D: Tell me more about your pain? Where exactly do you have the pain? (Site)
P: It is in middle of my chest (Pt. points towards the chest)
D: When did it start? (onset)
P: 2 hours ago.
D: What were you doing when you began to have this pain?
P: I was just sitting.
D: Was it sudden or gradual?
P: It was sudden.
D: Is it continuous or comes and goes?
P: It is continuous.
D: What type of pain is it? (character)
P: It is like a stabbing pain.
D: Does the pain go anywhere else? (radiation) (Important)
P: It is going to my left arm, shoulder, or jaw. (+ve finding)
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D: Is there anything that makes the pain better?

P: It is better now.
D: Is there anything that makes the pain worse?
P: No.
D: Could you please score the pain on a scale of 1 to 10, with 1 being
no pain and 10 being the most severe pain you have ever experienced?
P: It was 7, but now it is better.
D: Do you have any other problem?
P: No.
D: Anything else concerning you? (concern)
P: No.
FIVE SYMPTOMS
D: Any Fever?
P: No.
D: Any SOB?
P: No.
D: Any trauma?
P: No.
D: Cough?
P: No.
D: Heart racing?
P: No.
DDs
D: Any calf pain, redness or swelling? (PE)
P: No.
D: Does your pain get relieved on bending forward? (Pericarditis)
P: No.
+ FLAWS
P2
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any DM, HTN, Heart disease or high cholesterol?
P: No.

DESA (no need for it in emergencies)

D: Do you smoke?
P: Yes 20 cigarettes a day since I was 20. (+ve finding)
D: Do you drink alcohol?
P: Yes/No
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D: Tell me about your diet?

P: I don't eat healthy.
D: Do you do physical exercise?
P: I don't have much time.
MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: Yes, my dad had a heart attack when he was 50.
D: How's he doing right now?
P: He's dead.
D: Sorry for your loss, please accept my condolences.
ICE
D: Any idea what might be causing this?
P: No.
D: Any expectations today?
P: I want painkillers doctor.
D: No problem, I can help you with that, right now I'd like to examine you, if that’s OK.

Examination + ECG (heart tracing) +Heart attack markers.

↓
Observations & Chest.

• Examiner says → chest is clear

→ BP & Pulse normal/stable
→ ECG normal

Provisional Diagnosis:
From the chat we had (mention the positive findings) you told me that
your pain radiates to your left shoulder and you smoke, so I suspect
you may be having a heart attack.
The heart needs its own blood supply for the heart muscle to survive. During a
heart attack the blood flow to the heart stops because of a narrowing or
clot in the blood vessels.

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• Patient asks→ Is it serious?

↓
I am sorry to say that it is serious and can be life-threatening; however, you are in the
right place, and we will try our best to make sure you are stable.

Management:
1. Admit
2. Senior
3. Investigations → Blood • Repeat cardiac enzymes.
• Clotting profile.
• Other routine.
→ ECG (repeat) Minor changes → Normal
Major changes→ Heart attack.

4. M O N A
↓ ↓ ↓ ↓
Morphine- O2- Nitro-glycerine - Aspirin
(GTN Spray)
5. If major heart attack (i.e., ECG changes) → Heart Specialist,
procedure called Angioplasty.
Tube with a balloon and a camera on its tip & it will pass through an artery in your groin
to the blocked section, then the balloon will be blown up & stent will be left in the
blocked part.
A stent is like a wire mesh tube that keeps the artery patent.

6. Then patient will go home on:

A B C D E
↙ ↓ ↓ ↓ ↓
Atorvastatin B blockers Clopidogrel DESA advice Enoxaparin
ACE inhibitor 600mg (for some time)

7. Safety netting (MI again)

At any time, you feel central crushing chest pain radiating to left shoulder, left hand or
jaw → Call 999.

NOTE:
MI is an emergency, you can do ECG, Cardiac enzymes early & MONA early before
history.

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Pericarditis
Who you are:
You are an F2 in A&E.
Who the patient is:
Harry, aged 25, presented to the hospital with chest pain.
What you must do:
Please talk to the patient, take history, assess the patient and discuss your initial plan of
management with the patient.

DON’T FORGET IN HX:

1. Diagnose → Chest pain that’s relieved by leaning forward.
2. Causes (risk factors) →
• Complication of MI.
• Post viral infection.
• Post T.B.
• Uremic pericarditis.
• Side effects of medication (Hydralazine – Isoniazid – Warfarin).
P1
Doctor: How I can help you today?
Patient: I have pain in my chest. (SOCRATES)
D: Tell me more about your pain? Where exactly do you have the pain? (SITE)
P: It is in the middle of my chest (Pt. points towards the chest)
D: When did it start? (ONSET)
P: 1 day ago.
D: What were you doing when you began having this pain?
P: I was just sitting.
D: Was it sudden or gradual?
P: It was gradual.
D: Is it continuous or comes and goes?
P: It is continuous.
D: What type of pain is it? (CHARACTER)
P: It is a sharp pain.
D: Does the pain go anywhere else? Like your jaw or left shoulder? Or
between your shoulder blades? (RADIATION)
P: No. (MI and aortic dissection excluded)
D: Is there anything that makes it better?
P: When I lean forward. (+ve finding)
D: Is there anything that makes the pain worse?
P: When I lie down. (+ve finding)
D: Has it changed?
P: I think it’s getting worse.
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D: Could you please score the pain on a scale of 1 to 10, with 1 being
no pain and 10 being the most severe pain you have ever experienced.
P: 7.
D: It seems you are in severe pain, are you comfortable talking to me?
P: Yes thanks.
D: Apart from the pain, is there anything else?
P: No.
D: Anything concerning you? (concern)
P: Yes doctor, is it a heart attack?
D: Is there a reason you are particularly worried it’s a heart attack?
P: My dad had a heart attack before.
D: Sorry to hear that, now I understand why you are worried it’s a heart attack. How's
your dad doing now?
P: He's fine now doctor thanks.

FIVE SYMPTOMS
D: Any Fever?
P: Yes, I had flu-like symptoms 5 days ago. (+ve finding)
D: Did you have any other symptoms? (Explore it)
P: Yes, I had a sore throat.
D: Did you take anything for it?
P: I took paracetamol for that.
D: Any SOB?
P: No.
D: Any trauma? (Pneumothorax)
P: No.
D: Cough? (Pneumonia)
P: No.
D: Heart racing?
P: No.

DDs
D: Any calf pain, redness or swelling? (PE)
P: No.
D: Does your pain get relieved on bending forward? (Pericarditis)
P: No.
+ FLAWS
P2
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
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P: No.
D: Any DM, HTN, Heart disease or high cholesterol?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition other than your
dad?
P: No.

DESA
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Tell me about your diet?
P: I try to eat healthy.
D: Do you do physical exercise?
P: I don’t have much time.
D: Do you have any kind of stress?
P: No.

ICE
D: Any idea what might be causing this?
P: No.
D: Any expectations today?
P: I want painkillers doctor.
D: No problem, I can help you with that, right now I'd like to examine you if that’s OK.
Examination + ECG (heart tracing) +Heart attack markers
Observations- (for fever & hypotension).
Chest- (for pericardial rub, heart sounds muffled in cardiac tamponade).
Neck- (for engorged neck veins).

Provisional Diagnosis:
D: Since you told me (use the positive findings in the HX) that the pain
gets better when you lean forward, and you had flu like symptoms a few
days ago, I suspect you have a condition called pericarditis. Are you
familiar with the term?
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P: No doctor, can you explain it to me?

D: It is inflammation of the lining of the heart & it usually follows a viral
infection.

Management: DON’T FORGET PAINKILLER

1. Keep patient under observation till you get the ECG and heart attack markers results.
2. Senior
3. Investigations
→ Blood
• All bloods. • Urea & electrolytes (for uremic pericarditis).
• Cardiac enzymes. • Infection markers.
→ ECG:
• Electrical alternans.
• Global saddle shaped ST elevation.
→ CXR:
For pericardial effusion, may be globular heart.

4. Medications →
Aspirin or NSAIDs (Colchicine). → If fluid filled, we will drain it (pericardiocentesis).
5. Heart Specialist →
Although pericarditis is self-limited, we may wait to refer you to heart specialist to
check for complications & further investigations & some scans (Echocardiography) to
assess the walls of the heart.
6. Safety netting → MI, (Important) call 999.

Musculo-Skeletal Chest Pain

(Costochondritis)

Who you are:

You are an F2 in A&E.
Who the patient is:
John, aged 26, presented to the hospital with chest pain.
What you must do:
Please talk to the patient, take history, assess the patient, and discuss
your initial plan of management with the patient.
Always exclude MI and other red flags
P1
Doctor: How I can help you today?
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Patient: I have pain in my chest. (SOCRATES)

D: Tell me more about your pain? Where exactly do you have the pain? (SITE)
P: It is in here on my chest (Pt. points towards the shoulder)
D: When did it start? (ONSET)
P: 4 days ago.
D: What were you doing when you began to have this pain?
P: I am not sure but I had this pain when I was exercising. (+ve finding)
D: Was the pain before or after exercising?
P: After it doctor.
D: Was it sudden or gradual?
P: It was sudden.
D: Is it continuous or comes and goes?
P: It is continuous.
D: What type of pain is it? (CHARACTER)
P: It is a dull pain (+ve finding)
D: Does the pain go anywhere else? Like your jaw or left shoulder? Or between your
shoulder blades? (RADIATION)
P: No (MI and aortic dissection excluded)
D: Is there anything that makes it better?
P: No.
D: Is there anything that makes the pain worse?
P: When I take a deep breath in, it hurts or when I exercise. (+ve finding)
D: Do you feel pain when you move your arm or shoulder?
P: Yes, I do.
D: Could you please score the pain on a scale of 1 to 10, with 1 being
no pain and 10 being the most severe pain you have ever experienced?
P: 5.
D: It seems you are in pain, are you comfortable talking to me right now?
P: Yes doctor, thanks.
D: Apart from the pain, is there anything else?
P: No.
D: Anything else concerning you? (concern)
P: No.

FIVE SYMPTOMS
D: Any Fever?
P: No.
D: Do you have any other symptoms? (Explore it)
P: Yes, I have had a sore throat.
D: Did you take anything for it?
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P: I took paracetamol for that.

D: Any SOB?
P: No.
D: Any trauma? (Pneumothorax or Musculoskeletal pain)
P: I might have hurt myself when I was exercising.
D: Cough? (Pneumonia)
P: No.
D: Heart racing?
P: No.

DDs
D: Any calf pain, redness or swelling? (PE)
P: No.
D: Does your pain get relieved on bending forward? (Pericarditis)
P: No.
+ FLAWS

P2
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any DM, HTN, heart disease or high cholesterol?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: I try to eat healthy.
D: Tell me more about your exercise?
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P: I do a lot of exercise (explore it)

D: I’m really glad to hear that you are keeping healthy by exercising.

ICE
D: Any idea what might be causing this?
P: No.
D: What are your expectations from us today?
P: I want painkillers doctor.
D: That’s not a problem, I can help you with that, right now I'd like to examine you, if
that’s OK.

Examination + ECG (heart tracing) +Heart attack markers

Examination
- Observations→ Normal
- Chest
•Inspection
→ Chest is moving bilateral symmetrical.
→ There is no sign of any trauma or injury.
→ There is no flail chest.
→ No engorged neck veins.
•Palpation
→ Trachea not shifted.
→ Tenderness on both sides of chest
•Percussion→ Normal.
• Auscultation → equal air entry.

Provisional Diagnosis:
Since you told me (use the positive findings in the HX) that the pain
started suddenly while you were exercising, and it increases when you
take a deep breath, I suspect you have a Musculo-skeletal injury or
costochondritis. This is the inflammation of the cartilage that joins
your ribs to your breastbone (sternum). However, we would like to do further
investigations to exclude other serious conditions. (Be safe)

Management: DON’T FORGET PAINKILLERS

1. Keep patient under observation till you got the ECG and heart attack markers results.
2. Senior
3. Investigations → Bloods
• All bloods.
• Cardiac enzymes (If pain is on right side, you don’t need to mention cardiac enzymes)
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→ ECG: Normal.
→ CXR: Normal (tell patient that CXR is normal and no rib fracture)
4. Medications →painkillers and rest.
It’s a self-limited condition & the pain will go away on its own.
If not improving → specialist referral for steroid injections or TENS therapy.
5. Safety netting → MI, (Important) call 999.

Pulmonary Embolism PART 1

Who you are:
You are an F2 in GP clinic.
Who the patient is:
Amber aged 24, presented to the hospital with chest pain.
What you must do:
Please talk to the patient, take history, assess the patient, and discuss
your initial plan of management with the patient.

Risk factors for PE:

• Previous or current DVT (leg pain)
• FH of blood clot and bleeding disorders.
• Malignancy on treatment
• Recent immobilization: pelvic surgery/ recent long travel history
• Use of medications like/ OCP/ HRT/ blood thinners.
• Smoking

P1
Doctor: How I can help you today?
Patient: I have pain in my chest. (SOCRATES)
D: Tell me more about your pain? Where exactly do you have the pain? (SITE)
P: It is in here on my chest (Pt. points towards the shoulder)
D: When did it start? (ONSET)
P: 2 Hours ago.
D: What were you doing when you had this pain?
P: Watching Tv.
D: Was it sudden or gradual?
P: It was sudden.
D: Is it continuous or comes and goes?
P: It is continuous.
D: What type of pain is it? (CHARACTER)

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P: It is a dull pain.
D: Does the pain go anywhere else? Like your jaw or left shoulder? Or
between your shoulder blades? (RADIATION)
P: No. (MI and aortic dissection excluded)
D: Is there anything that makes it better?
P: No.
D: Is there anything that makes the pain worse?
P: No.
D: Could you please score the pain on a scale of 1 to 10, with 1 being
no pain and 10 being the most severe pain you have ever experienced.
P: 6.
D: It seems you are in pain, are you comfortable talking to me?
P: I’m OK carry on.
D: Apart from the pain, is there anything else?
P: No.
D: Anything else concerning you? (concern)
P: No.
FIVE SYMPTOMS
D: Any Fever?
P: No.
D: Any SOB?
P: Yes (+ve finding)
D: Can you tell me more about it?
P: It started at the same time as the chest pain.
D: Any trauma?
P: No.
D: Cough? (Pneumonia)
P: No.
D: Heart racing?
P: No.

DDs
D: Any calf pain, redness or swelling? (PE)
P: Yes (+ve finding)
D: Does your pain get relieved on bending forward? (Pericarditis)
P: No.
+ FLAWS

P2
D: Have you had a similar kind of problem in the past?
P: No.
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D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any DM, HTN, heart disease or high cholesterol?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any blood disorder
condition?
P: No.
D: Have you travelled recently?
P: No.

P4
D: Are you using any method of contraception at the moment?
P: Yes, I am taking Combined Oral Contraceptive Pills. (+ve finding)
D: How long have you been taking it?
P: 6 months.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: I try to eat healthy.

ICE
D: Any idea what might be causing this?
P: No.
D: Any expectations today?
P: I want painkillers.
D: No problem, I can help you with that, right now I'd like to examine you if that’s OK
with you.

Examination + ECG (heart tracing) +Heart attack markers

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Examination
- Observations→ SPO2: 88%
- Chest
•Inspection
→ Chest is moving bilateral symmetrical.
→ There is no sign of any trauma or injury.
→ There is no flail chest.
→ No engorged neck veins.
•Palpation
→ Trachea not shifted.
→ Tenderness on both sides of chest
•Percussion→ Normal.
• Auscultation → equal air entry.
- Leg
→Swollen and tender calf muscle.(+ve finding)

Provisional Diagnosis
Since you told me (use the positive findings in the Hx) that you have
chest pain and shortness of breath, plus the fact that you are using oral
contraceptive pills and we found swelling and tenderness in your leg, I
suspect a condition called Pulmonary Embolism. This is when a blood clot
forms in the veins of the lungs & blocks the veins, but we would like to
do further investigations to confirm it.

Management: DON’T FORGET PAINKILLER & OXYGEN.

1. Immediate referral to the hospital
2. Senior
3. Investigations:
Clotting profile D-Dimer (so imp)
CTPA - ABG - U&E Doppler US on the leg for the cause (DVT)
→ Blood
• All bloods.
4. Medications →
O2
IV fluids if in shock
Painkillers (morphine)
5. Specialist→ Heart specialist may give you blood thinner called heparin.
6. Safety netting → (Don’t forget)
• Persistence of symptoms
• Complications of the condition
• Prescribed medication: bleeding anywhere or falls.
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7. Follow up → (at anti-coagulation clinic/warfarin clinic).

Pulmonary embolism PART 2-After mastectomy

Who you are:
You are an F2 in A&E.
Who the patient is:
Sara, aged 55, presented to the hospital with chest pain.
What you must do:
Please talk to the patient, take history, assess the patient, and discuss your initial plan
of management with the patient.

P1
Doctor: How I can help you today?
Patient: I have pain in my chest. (SOCRATES)
D: Tell me more about your pain, where exactly do you have it? (SITE)
P: It’s in here on my chest (Pt. points towards the shoulder)
D: When did it start? (ONSET)
P: Two hours ago.
D: What were you doing when you began having this pain?
P: Just on my phone lying on the couch.
D: Was it sudden or gradual?
P: It was sudden.
D: Is it continuous or comes and goes?
P: It is continuous.
D: What type of pain is it? (CHARACTER)
P: It is a sharp pain.
D: Does the pain go anywhere else? Like your jaw or left shoulder? Or
between your shoulder blades? (RADIATION)
P: No. (MI and aortic dissection excluded)
D: Is there anything that makes it better?
P: No.
D: Is there anything that makes the pain worse?
P: No.
D: Could you please score the pain on a scale of 1 to 10, with 1 being
no pain and 10 being the most severe pain you have ever experienced?
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P: 5.
D: It sounds like you are in quite a bit of pain, are you comfortable talking to me right
now?
P: I’m OK.
D: Apart from the pain, is there anything else?
P: No.
D: Anything else concerning you? (concern)
P: No.

FIVE SYMPTOMS
D: Any Fever?
P: No.
D: Any SOB?
P: Yes. (+ve finding)
D: Can you tell me more about it?
P: It started at the same time as the chest pain.
D: Any trauma?
P: No.
D: Cough? (Pneumonia)
P: No.
D: Heart racing?
P: No.

DDs
D: Any calf pain, redness or swelling? (PE)
P: Yes (+ve finding)
D: Does your pain get relieved on bending forward? (Pericarditis)
P: No.
+ FLAWS
P2
D: Have you had similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: Yes, I had breast cancer and had a mastectomy for that. (+ve finding)
D: Sorry to hear that. And how are you doing now?
P: Thanks, doctor I’m ok.
D: Any DM, HTN, heart disease or high cholesterol?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
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P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any blood disorder
condition?
P: No.
D: Have you travelled recently?
P: No.

P4
D: Are you using any method of contraception at the moment?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: I try to eat healthy.
D: That’s good to hear.

ICE
D: Any idea what might be causing this?
P: No.
D: Any expectations today?
P: I want to know if it’s serious.
D: Well I’d like to examine you first if that’s OK with you and then I will tell you what I
think is going on here.

Examination + ECG (heart tracing) + Heart attack markers

Examination
- Observations→ SPO2: 88%
- Chest
•Inspection
→ Chest is moving bilateral symmetrical.
→ There is no sign of any trauma or injury.
→ There is no flail chest.
→ No engorged neck veins.
•Palpation
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→ Trachea not shifted.

→ Tenderness on both sides of chest
•Percussion→ Normal.
• Auscultation → equal air entry.
- Leg
→Swollen and tender calf muscle. (+ve finding)

Provisional Diagnosis
Since you told me (use the positive findings in the Hx) that you have
chest pain and shortness of breath plus the fact that you had a
mastectomy recently, I suspect you are having a Pulmonary
Embolism. That is where a blood clot forms in the veins of the lungs & blocks the veins,
but we would like to do further investigations to confirm it.
It is quite serious, but you are in the right place, you did the right thing coming in and
we will do our best to help you.

Same PE Management as previous stations

Pulmonary embolism PART 3 (Transgender)

Who you are:
You are an F2 in A&E.
Who the patient is:
Isla, aged 28, presented to the hospital with chest pain.
What you must do:
Please talk to the patient, take history, assess the patient, and discuss
your initial plan of management with the patient.

P1
Doctor: How I can help you today?
Patient: I have pain in my chest. (SOCRATES)
D: Tell me more about your pain? Where exactly do you have the pain? (SITE)
P: It is in here on my chest (Pt. points towards the shoulder)
D: When did it start? (ONSET)
P: An hour ago.
D: What were you doing when you had this pain?
P: Watching Tv.
D: Was it sudden or gradual?
P: It was sudden.
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D: Is it continuous or comes and goes?

P: It is continuous.
D: What type of pain is it? (CHARACTER)
P: It is a sharp pain.
D: Does the pain go anywhere else? Like your jaw or left shoulder? Or
between your shoulder blades? (RADIATION)
P: No. (MI and aortic dissection excluded)
D: Is there anything that makes it better?
P: No.
D: Is there anything that makes the pain worse?
P: No.
D: Could you please score the pain on a scale of 1 to 10, with 1 being
no pain and 10 being the most severe pain you have ever experienced?
P: 5.
D: Are you comfortable talking to me right now with the pain?
P: Yes thanks.
D: Apart from the pain, is there anything else?
P: No.
D: Anything else concerning you? (concern)
P: No.

FIVE SYMPTOMS
D: Any Fever?
P: No.
D: Any SOB?
P: No.
D: Any trauma?
P: No.
D: Cough? (Pneumonia)
P: No.
D: Heart racing?
P: No.

DDs
D: Any calf pain, redness or swelling? (PE)
P: Yes.
D: Does your pain get relieved on bending forward? (Pericarditis)
P: No.
+ FLAWS

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P2
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any DM, HTN, heart disease or high cholesterol?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: Yes, I am taking oestrogen.
D: May I know why?
P: I am transitioning. (From male to female)
D: Thanks for telling me that, can you tell me more about the oestrogen?
P: I've been taking it for the past 3 months. It was prescribed for me by doctor in the
gender identity clinic.
D: Are you taking it as prescribed?
P: Yes, doctor.
D: Apart from that how's transitioning going?
P: It’s going very well, I am really happy with the results so far.
D: I am glad to hear that, are you taking any other medications?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any blood disorder
condition?
P: No.
D: Have you travelled recently?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: I try to eat healthy.
D: Great.

ICE
D: Any idea what might be causing this?
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P: No.
D: Any expectations today?
P: I want painkillers doctor and I want to know what’s causing this.
D: Of course, I can help you with that. Firstly, if it’s OK with you, I'd like to examine you?
P: Sure.

Examination + ECG (heart tracing) +Heart attack markers

Examination:
- Observations→ SPO2: 96%
- Chest
•Inspection
→ Chest is moving bilateral symmetrical.
→ There is no sign of any trauma or injury.
→ There is no flail chest.
→ No engorged neck veins.
•Palpation
→ Trachea not shifted.
→ Tenderness on both sides of chest
•Percussion→ Normal.
• Auscultation → equal air entry.
- Leg
→Swollen and tender calf muscle. (+ve finding)

Provisional Diagnosis
Since you told me (use the positive findings in the Hx) that you have
chest pain and shortness of breath plus the fact that you are
transitioning and taking oestrogen, I suspect you are having a Pulmonary Embolism.
This is when a blood clot forms in the veins of the lungs &
blocks the veins, but we would like to do further investigations to
confirm it.

Same PE Management as previous station +If transgender patient taking oestrogen or

any HRT, can be reviewed by Gender Dysphoria Clinic, and possibly substituted for
patches rather than oral form as they have less risk for PE.
DON’T FORGET TO ASK ABOUT:
- Support- how are you coping with the changes?
- Offer him LGBTQ Support.

- Follow up (at anti-coagulation clinic/warfarin clinic).

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Ophthalmology

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Ophthalmology

STRUCTURE OF OPHTHALMOLOGY
In any eye condition case you must ask :

1. Which eye?
2. What about the other eye? (ANY PAIR COMPARE)
3. Are you able to see?
4. Is it painful?
5. Is it itchy?
6. Any bleeding / discharge?
7. Is it watery? (Lacrimation)
8. Have you sustained any trauma? (Injury)
9. Do you wear contact lenses?
10. Do you wear glasses?
11. Any fever?
12. Have you noticed anything going into your eyes? (Foreign body)

Psychosocial:
1. What do you do for a living?
2. How has this affected your life?
3. How has this affected your daily activities? Your job?

Examinations and tests in eye stations:

1. BMI
2. Eye examination
3. Visual acuity (cataract)
4. Capillary blood sugar (diabetic retinopathy)
5. Visual field (Open angle glaucoma)
6. Pressure inside eye (glaucoma).
7. Fundoscopy (back of the eye) by specialist

Differential diagnosis of red eye: A FAST CARS

A → Acute closed angle glaucoma.

F → Foreign body.

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A → Allergy.
S → Subconjunctival haemorrhage.
T → Trauma.
C → Conjunctivitis.
A → Autoimmune.
R → Reiter's disease.
S → Sarcoidosis.

Differential diagnosis of visual impairment:

1. Glaucoma
2. Cataract
3. Macular degeneration.
4. Optic neuritis.
5. Pituitary adenoma.
6. Diabetic retinopathy.
7. Retinal detachment.
8. Stroke
9. Giant cell arteritis.

Cataract
Who you are: You are an FY2 in Medicine.
Who the patient is: Emma Wilson 70 years old has some concerns. She went to her GP
last week who advised her not to drive.
What you should do: Talk to her and address her concerns.

Doctor: Hello my name is Dr…. I am one of the doctors here in the GP clinic can I
confirm your full name and date of birth please?
Patient: My name is Emma Wilson, I am 70 years old doctor.
D: How can I help you today?
P: I have a problem with my vision and my GP advised me not to drive. (P1)
D: Can you tell me more about the vision problem? (Open Question)
P: I feel like my eyes have gone cloudy.
D: Ok let me ask you few questions to have a better understanding of your vision.
P: Okay.
D: You mentioned you have problems with your vision? Can you tell me which eye?
P: Mostly the left, but they are both not right.
D: What about the other eye, any problems with it?
P: The other one is better but not 100%.
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D: Is it a complete loss of vision or are you able to see a little?

P: I can see but not very well.
D: Any double vision?
P: No.
D: Any pain/ itchiness/ discharge/ tearing in the eyes?
P: No.
D: Any trauma to the eye? Do you wear glasses or contact lenses?
P: No
D: For how long have your eyes been like this? (Duration)
P: 1 year

Cataract Questions:
Do you feel your eyesight is blurred or misty.
Do you feel the lights are too bright or glaring.
Is it harder to see in low light.
Do feel your lenses are dirty and need cleaning, even when they do not. (For
wearers of glasses/lenses only)
DDx
D: Any faded colour in vision? Optic neuritis
P: No.
D: Do you see any coloured haloes around light? (Glaucoma)
P: No.
D: Any headache? (Glaucoma/ ICSOL)
P: No.
D: Any nausea or vomiting? (Glaucoma/ ICSOL)
P: No.
D: Any discharge or redness in the eye? (Conjunctivitis)
P: No.
D: Do you see objects smaller? (ARMD)
P: No.
D: Do you see colours less bright? (ARMD)
P: No.
D: Do you see wavy lines instead of straight lines? (ARMD)
P: No.

P2+ MAFTOSA
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any DM, HTN, glaucoma or visual problems in the past?
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P: No.
D: Are you taking any medications (steroids) including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.

PSYCHOSOCIAL
D: What you do for a living?
P: I’m retired.
D: Who do you live with?
P: My husband.
D: How is it affecting your life?
P: I can’t drive to go and see my grandkids so that’s upsetting.

DESA
D: Tell me about your diet?
P: I always eat healthy.
D: Do you smoke?
P: No.
D: Do you drink Alcohol?
P: Rarely.

Examination:
Is it OK if I take your vitals and examine your eyes, your visual field and the back of
your eyes?
P: Yes that’s fine.

Examiner says: Bilateral cataract

Diagnosis & Management:

From my assessment it seems that you have Cataracts in your eyes. This is a condition
that affects the part of the eye which is called the lens. Usually this lens is extremely
clear, however, with this condition it becomes a bit cloudy and affects your vision. Does
that make sense to you?

P: Why do I have it?

D: There could be many reasons for it. But in your case, it looks like it’s due to age.
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Senior.

Refer to eye specialist for some other investigations and more thorough examinations
(explain if asked about what will be done there)

Investigations:
Routine blood – blood sugar.
Lifestyle advice: smoking – alcohol – control blood sugar.

Symptomatic:
According to patient’s condition.
If not too bad, stronger glasses and brighter reading lights may help for a while.
If it gets worse over time, you’ll eventually need surgery to remove and replace the
affected lens
Surgery is the only treatment that's proven to be effective for cataracts.
Probable cause of the cataracts would be considered by senior.

Safety netting:
You do not need to tell the DVLA if you have (or previously had) cataracts, and you still
meet the visual standards for driving.
If you drive a bus, coach or lorry, you do not need to tell the DVLA if you have (or
previously had) cataracts and :
-you still meet the visual standards for driving.
-you do not have an increased sensitivity to glare because of the cataract.

Other patient concerns:

P: Can you tell me about the surgery please?
D: This is usually a day-case operation, where the cloudy lens will be removed and
replaced with an artificial plastic lens through a small cut done under local anaesthesia.
Clear so far?
Day case surgery means you can come to the hospital on the day of the surgery and
leave the hospital on the same day if everything goes smoothly after the surgery.
Typically, these cataract operations only take about an hour.
P: It sounds very scary! They will operate on my eye without putting me to sleep! I’ll be
too anxious!
D: I can see you are worried. I will be referring you to an eye specialist and they will be
in a better position to explain about the surgery. And they might give you some
medication during the operation to sedate you or relieve your anxiety.
P: Will they operate both eyes at the same time?
D: Usually the surgeries of both eyes are done 6-12 weeks apart.
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P: Do I need to tell DVLA?

D: No, you don’t need to tell the DVLA if you are still able to see well enough to drive.
But if your vision is blurred as you said, then please don’t drive until you are treated by
the specialist and can see better again.

4 POINTS RECAP:
1. ONLY VISION PROBLEM
2. REFER
3. SURGERY
4. DRIVING

Age- related Macular degeneration (AMD)

Who you are: You are FY2 in Medicine.

Who the patient is: Sandra Green, aged 87, came with vision problem.
What you should do: Talk to her and address her concerns.

Doctor: How can I help you today?

Patient: I’m not seeing things clearly.
P1
D: Can you tell me more about your vision problem? Open Question
P: I see wavy lines instead of straight lines, even with my glasses on.
D: Ok let me ask you few questions to have a better understanding of your vision.
Which eye is affected by this problem?
P: The right mostly.
D: What about the other the eye?
P: It’s a little affected too.
D: Are you able to see?
P: I am struggling doctor; my vision is getting weaker and weaker?
D: (Reflect) I’m sorry to hear that, it must be really distressing. I’ll do my best to get to
the bottom of this. For how long has this been going on? (Duration)
P: 1 week

ARMD Questions
D: You mentioned that you are seeing straight lines as wavy or crooked.
Do you have a blurred or distorted area in your vision?

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Do you struggle to see anything in the middle of your vision or feel like there is a
black/grey patch affecting your central vision?
Do think objects are looking smaller than normal?
Do colours seem less bright than they used to.
Are you seeing things that are not there? (hallucinations)
Do you see any flashing lights?
P: (Whatever the patient will give you as a positive finding, use later while explaining
diagnosis.)

DDx
D: Do you find it harder to see in low light? (Cataract)

P: No doctor.
D: Do you see everything too bright or any glaring?
P: No.
D: Any faded colour in vision? (Optic neuritis)
P: No.
D: Do you have any pain at the back of the eye? (Glaucoma)
P: No.
D: Do you see any coloured haloes around light? (Glaucoma)
P: No.
D: Any headache? (Glaucoma, Intra cranial space occupying lesion)
P: No.
D: Any nausea or vomiting? (Glaucoma, Intra cranial space occupying lesion)
P: No.
D: Any discharge or redness in the eye? (Conjunctivitis)
P: No.
D: Any tearing or watery eye
P: No.
D: Any trauma to the eye? Do you think something might have fallen into your eye?
P: No.
D: Do you usually wear contact lenses or glasses?
P: Yes, reading glasses.
D: Do have any fever? (Pit adenoma)
P: No.
D: Ask FLAWS very briefly.

P2+ MAFTOSA
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you ever been diagnosed with any eye problems in the past?
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P: I’ve been told I need reading glasses, that’s it.

D: Have you been diagnosed with any medical condition in the past?
P: Yes, I have DM.
D: Tell me more about it. Explore DM one of the major risk factors for macular
disorders.
P: It’s been 20 years . It has been well controlled.
D: How are you managing it?
P: I am taking insulin mixtard 2 times a day. 20 in the morning and 10 in the evening.
D: Do you check your blood sugars regularly?
P: Yes, today in the morning it was 6 before my meal.
D: Any symptoms of DM?
P: No.
D: Any complications related to DM ? Maybe a foot problem?
P: No.
D: Any HTN, Glaucoma or visual problems in the past?
P: No.
D: Any family history of any significant health issues or visual problems?
P: No.
D: Are you currently on any medication other than Insulin?
P: No.

DESA
D: Tell me about your diet?
P: I try to eat healthy.
D : How about physical exercise?
P: I try to go for a walk every day.
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No
D: Do you drive? (IMPORTANT QUESTION)
P: No.

Psychosocial and mood

D: Are you retired?
P: Yes, I am.
D: Who do you live with?
P: I live alone.
D: How is it affecting your mood?
P: Well it’s upsetting but I try not to let it get me down.
D: (Always reflect on patient’s mood)
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Examine:
Is it OK if I check your vitals, examine your eyes and do a fundoscopy to look at the back
of your eyes as well?

Examiner- might hand you a finding of Drusen in macula.

If fundoscopy is done in the station, advise the patient that eye drops used in
fundoscopy can make your vision blurry for a few hours. Do not drive (if the patient
drives) until your vision goes back to normal. This may take 4 to 6 hours.

Diagnosis & Management:

You mentioned (positive findings) and from my assessment as well I found
(examination findings). I suspect you have a condition called macular degeneration. It
is the distortion or loss of sight of the middle part of a person's visual field and is caused
by damage or degeneration to the macula. The macula is the part of the retina that is
responsible for clear, sharp vision and acts as the body's natural sunglasses, absorbing
any excess light that enters. Are you following me?

P: Why do I have it though doctor?

D: Many factors might be involved, but in your case, it looks like it’s due to your
advancing age. It's the most common cause of visual problem in those over 50 years
old. You also mentioned you have DM which is one of the risk factors for this as well.

Senior.

Specialist referral: Eye specialist (referred within a day). You may have more tests, such
as a scan of the back of your eye.
Or other special investigations like Occular coherence tomography which is a non–
invasive test where a special light will be used to scan your retina. It will tell us which
form of macular degeneration you have.

Treatment
Lifestyle advice:
• AMD is often linked to an unhealthy lifestyle. Please, try to (eat a balanced diet -
exercise regularly - lose weight - stop smoking).
• Useful devices - such as magnifying lenses
• Consider making changes to your home - such as brighter lighting
• Use software and mobile apps that can make computers and phones easier to
use.

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• If you're considering taking supplements for AMD, please, speak to the specialist .
They're not suitable for everyone.

Symptomatic: Treatment depends on the type

Dry AMD – there's no treatment, but vision aids can help reduce the effect on your life.
Wet AMD – you may need regular eye injections (Anti VEGF or Ranibizumab inject.
every 2 months) and very occasionally, a light treatment called photodynamic therapy
or a combination of both.

EYE INJECTIONS:
Given directly into the eyes - stops vision getting worse and may improve vision, usually
given every 1, 2 or 3 months.
Drops numb the eyes before treatment – most people have minimal discomfort.
Side effects include bleeding in the eye, feeling like there's something in the eye, and
redness and irritation of the eye.

LIGHT TREATMENT:
A light is shone at the back of the eyes to destroy the abnormal blood vessels that cause
wet AMD.
Usually needs to be repeated every few months.
Side effects include temporary vision problems, and the eyes and skin being sensitive to
light for a few days or weeks.

Safety-net (DRIVING)
• Driving:
AMD can make it unsafe for you to drive. You may inform DVLA about your condition if:
it affects both eyes.
If it affects 1 eye but your remaining vision is below the minimum standards of vision
for driving.

• Contact us as soon as possible if your vision gets worse or you notice any new
symptoms.
• Keep having routine eye tests (usually every 2 years) to pick up other eye
problems that your check-ups do not look for.

• Support for AMD:

A referral to a low-vision clinic if you're having difficulty with daily activities.
Staff at the clinic can give useful advice and practical support. For example, they can
talk to you about: (useful devices – such as magnifying lenses - changes you can make
to your home – such as brighter lighting software and mobile apps that can make
computers and phones easier to use.)
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If you have poor vision in both eyes, the specialist may refer you for a type of training
called eccentric viewing training. This involves learning techniques that help make the
most of your remaining vision.

Living with AMD can be very difficult. you may find it useful to use support groups such
as Macular Society.

See a GP if you've been feeling low for more than 2 weeks. They can offer support and
treatment if you need it.

Follow-up

Wet AMD
Growth of abnormal blood vessels
Less common
Quickly worsening.
TTT to prevent or help vision from worsening

Dry AMD
Fatty deposition
Common.
get worse gradually.
No treatment.

Diabetic retinopathy

Who you are: You are an F2 in GP Surgery.

Who the patient is: Mr. David Smith, age 50, was referred by Optometrist for early
diabetic retinopathy.
Special note: A referral letter may be handed inside.
Additional Information: He is diagnosed with non-insulin dependent diabetes mellitus,
which is controlled with diet.
What you should do: Please talk to the patient and discuss plan of management with
the patient.

Doctor: Hello, can I get your full name and date of birth please ?
Patient: My name is David Smith, I am 50.
D: How can I help you today?
P: Doctor I went to the opticians to check my eyes and he gave me this note:

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Letter:
We examined the eyes of 50-year-old gentleman.
Patient has been diagnosed with Diabetes.
Patient visual acuity is normal and on examination there is diabetes in the retina.
Carry this letter when you see your GP.
Follow up is required.

D: Why did you go to the opticians?

P1
P: I just went to check my eyes to see if I need glasses, I am a painter and I'm having
trouble seeing fine lines while working.

ODIPARA + EYE STRUCTURE

D: This eye problem, when did it start? (Duration)
P: A few days ago.
D: How did it start? (Onset)
P: Slowly.
D: Any change since it started? (Progression/course)
P: It’s getting worse.
D: Is there anything that makes it better or worse?
P: I don’t know.
D: Is it affecting both eyes?
D: What about the other eye?
D: Are you able to see?
D: Any Pain/ Itching?
P: No.
D: Any bleeding/discharge/ watery eyes?
P: No.
D: Do you sometimes feel that there are shapes floating in your field of vision (floaters)
or like you have blurred or patchy vision?
P: No.
D: Has your optician told you what is going on? (Idea)
P: No doctor, he just gave me this letter and asked me to see you.
D: Do you have any particular expectations from us today?
P: I want to understand what’s wrong with me.

P2: Explore DM
D: How long have you been diagnosed with diabetes?
P: 2 years.
D: How has your Diabetes been managed?
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P: My condition is controlled by diet.

D: Do you take any medications?
P: No.
D: Is your diabetes well controlled?
P: I think so.
D: Do you check your blood sugars regularly?
P: No to be honest.
D: When did you last check your blood sugar?
P: 2 years ago.
D: Do you visit your GP regularly? (Follow up)
P: No. I don’t have any symptoms to go to the GP.
D: Do you go for your annual check-up?
P: No. I missed my last one.

D: Have you been diagnosed with any other medical condition in the past? HTN, heart
and kidney diseases?
P: No.
D: Are you taking any medications?
P: No.

DESA very important

D: Tell me about your diet?
P: I eat everything.
D: Do you do physical exercise?
P: I don't give much time.
D: Do you smoke?
P: Yes/no
D: Do you drink alcohol?
P: Yes/no
D: Do you have any kind of stress?
P: Yes. I am self-employed.

Examination:
Ideally, I would like to examine you now, check your observations, your blood sugar
levels and the back of your eyes, if that’s OK with you.

Management:
Provisional diagnosis:
You told me that you have been missing some of your follow ups at the GP clinic for
your DM and from the assessments we have done we found that your blood sugar was
a bit on the higher side. It seems that you have a condition called diabetic retinopathy.
539 | P a g e
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It is one of the complications of having diabetes for a long time, especially if blood sugar
is on the higher side. Does that make sense to you?
Diabetes can cause damage to small or large blood vessels. Damage to large blood
vessels will cause heart disease, kidney disease and stroke.
Damage to small blood vessels at the back of the eye causes retinopathy.

Refer to eye specialist.

Senior
Investigations:
Routine bloods – HbA1C (average blood sugar level over the past few weeks) –
cholesterol – random blood sugar.
Lifestyle:
You can reduce your risk of developing diabetic retinopathy, or help stop it getting
worse, by keeping your blood sugar levels, blood pressure and cholesterol levels under
control.
This can often be done by making healthy lifestyle choices, although some people
will also need to take medication.
Eating a healthy, balanced diet – in particular, try to cut down on salt, fat and
sugar
losing weight (if overweight ) –aim for a BMI of 18.5-24.9;
Exercising regularly – aim to do at least 150 minutes of moderate-intensity
activity, such as walking or cycling, a week; doing 10,000 steps a day can be a good way
to reach this target
Stopping smoking
Not exceeding the recommended alcohol limits – men and women are advised
not to regularly drink more than 14 alcohol units a week.
To keep your blood sugar levels, blood pressure and cholesterol levels under
control , it is important to monitor them regularly and know what level they are.
You might be prescribed medications to control your blood sugar, blood pressure
and cholesterol level.

Symptomatic:
In the early stages of diabetic retinopathy, controlling your diabetes can help
prevent vision problems developing.
Diabetic retinopathy usually only requires specific treatment when it reaches an
advanced stage and there's a risk to your vision.

The main treatments are: laser treatment – eye injections – eye surgery. (Same as
before ARMD)

540 | P a g e
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Safety netting:
Any problems in your eyes or your vision and DRIVING.
Follow up: Regular screening is still important to attend your annual diabetic eye
screening appointment, as this can detect signs of a problem before you notice
anything is wrong.

5 POINTS RECAP:
1. EXPLORE EYE AND DM
2. FUNDUSCOPY
3. BLOOD SUGAR AND HBA1C
4. LIFESTYLE
5. DRIVING

Angle closure glaucoma

Who you are: You are an FY2 in the Emergency Department.

Who the patient is: Mrs Jessica Charles, aged 58 years old, presents with sudden onset
of severe pain in her left eye.
What you should do: Assess the patient and address her concerns.

Symptoms of Acute closure angle glaucoma:

Intense eye pain (Red Flag)
Nausea and vomiting
A red eye
A headache
Tenderness around the eyes
Seeing rings around lights
Blurred vision

D: What brought you to the hospital today?

P: I have pain in my left eye.
P1
D: Tell me more about your pain? (Open question)
P: It just hurts.

SOCRATES
D: How did it start? (Onset)
P: Very suddenly doctor.
D: When did it start exactly? (Duration)

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P: It started few hours ago.

D: What were you doing when you had this pain?
P: I was doing nothing doctor I was just watching TV.
D: Can you describe the character of the pain?
P: It’s a very severe, dull pain in my eyes.
D: Is it in both eyes or only one eye? (Site)
P: Only in my left/right eye doctor.
D: What about the other eye
P: That one’s normal.
D: Any problem with your vision?
P: I have blurry vision; I can’t see properly with my left eye.
D: Does it come and go or is it continuous? (Course)
P: It is continuous and becoming worse.
D: Does the pain go anywhere? (Radiation)
P: No.
D: Is there anything that makes the pain better?
P: No doctor.
D: Is there anything that makes the pain worse?
P: No.
D: Have you tried anything for the pain?
P: I took PCM but didn’t help.
D: How much did you take?
P: I took two tablets.
D: Could you please score the pain on a scale of 1 to 10, with 1 being no pain and 10
being the most severe pain you have ever experienced?
P: It is 7.
D: Any other symptoms? (Open question)
P: I have headache in my left side of my head and eyebrow.
D: Since when? (Explore briefly)

SOCRATES
P: Since my eye pain started. DURATION
D: Was it continuous or comes and goes? COURSE
P: It is continuous.
D: Was it sudden or gradual? ONSET
P: It was sudden.
D: What type of pain is it? CHARACTER
P: It is a dull pain.
D: Does the pain go anywhere else? RADIATION
P: No.

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D: Could you please score the pain on a scale of 1 to 10, with 1 being no pain and 10
being the most severe pain you have ever experienced? GRADE
P: It is a 9.
D: Any other symptoms? OPEN Q
P: No.
D: Any fever or flu-like symptoms?
P: No.
D: Any nausea?
P: Yes, I feel nausea
D: Did you vomit?
P: Yes, I vomited two times.
D: Do you see any rings around lights?
P: No.
D: Have you noticed any redness in your eyes?
P: No.

DDx:
D: Any burning sensation, any gritty sensation, or any sticky discharge? (Conjunctivitis)
P: No.
D: Any joint pain? Wee problem? (Reiter’s)
P: No.

P2+ MAFTOSA
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: Yes. I have depression.
D: Since when?
P: 6 months
D: How is it managed?
P: I am taking Amitriptyline.
D: Are you taking the medication regularly?
P: Yes.
D: Any other medical condition such as IBD, AS or RA?
P: No.
D: Are you taking any other medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
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D: Has anyone in your family been diagnosed with any medical condition?
P: No.

DESA: NO NEED AS ACUTE SETTING

D: What you do for a living?

P: Office work.

EXAMINATION:
If it’s OK with you I would like to take your vitals and examine your eye.
YOU MAY BE HANDED A PICTURE OF THE PATIENT’S EYES: RED EYE AND DILATED PUPIL.

MANAGEMENT:
Explain diagnosis:
From what you have told me and our assessment as well (mention findings), I suspect
you have a condition called Acute Angle Closure Glaucoma. This is when a part of the
eye that drains fluid becomes blocked causing pressure to build up on the inside,
inflicting upon you this severe pain which you are having.

Senior
Specialist:
Refer to Ophthalmology Department IMMEDIATELY or ADMIT if you are in
Ophthalmology Department.

Investigations:
Explain that the specialist might need to do some specific investigations using special
equipment.
• Slit light Exam examining your eye using a special light and magnifier.
• Tonometry to measure the pressure inside the eye.
• Gonioscopy to look at the front part of your eye where fluid is drained.

Symptomatic:
Immediate treatment in hospital with medicine (topical and through your veins) to
reduce the pressure in the eye.
Followed by laser treatment, this is where a high-energy beam of light is carefully aimed
at part of your eye to stop fluid building up inside it.
The unaffected eye is usually also treated preventively with laser because it is at high
risk of developing acute angle closure in the future.

Treatments of other symptoms: analgesia and anti–emetic.

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Review medications, you should open the BNF and inform your senior to review
medications as they might be the cause. Refer to psychiatry.

Safety netting:
You will need advice from an eye specialist regarding driving.

Open angle glaucoma

Who you are : You are an FY2 in the Emergency Department.

Who the patient is: Mrs Monica Thomas, aged 55 years old, went to the optometrist
who told her that the pressure inside her eye is raised.
What you should do: Talk to her and address her concerns.

Symptoms of Open angle glaucoma:

Picked up during a routine eye test, often before it causes any noticeable symptoms.
Patchy blind spots in your side (peripheral) and reduced vision.
No eye pain but if it turns into acute glaucoma, it may present as angle-closure
glaucoma.

Otherwise Hx points are similar to the above case.

MANAGEMENT:
EXPLAIN DIAGNOSIS:
Based on what you have told me and from my assessment, I suspect you have open
angle glaucoma. It’s a condition in which the pressure in your eye is higher than normal
causing some damage in the peripheral part of the back of your eye. This part of the eye
is called the retina and it is responsible for your vision. That is why you’re struggling to
see at the peripheries of your visual field.

Senior.
Refer to a specialist eye doctor (ophthalmologist) for further tests.
(Routine referral)
Investigations:
Gonioscopy is an examination to look at the front part your eye, this is where the fluid
should drain out of your eye to determine whether this area (the "angle") is open or
closed (blocked), which can affect how fluid drains out of your eye.
Visual field test: checks for missing areas of vision.
Optic nerve assessment: The optic nerve, which connects your eye to your brain, can
become damaged in glaucoma, so an assessment may be carried out to see if it's
healthy.

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NB: For the test, eyedrops will be used to enlarge your pupils. The eyedrops used to
widen your pupils could temporarily affect your ability to drive, so you'll need to make
arrangements for getting home after your appointment.

Symptomatic:
Treatment can't reverse any loss of vision that has already occurred, but it can help stop
your vision getting any worse.
1. Eye drops: The main treatment. they work by reducing the pressure in your eyes.
They're normally used between 1 and 4 times a day. It's important to use them as
directed, even if you haven't noticed any problems with your vision. Your sight is at risk
if you don't stick to the recommended treatment.
You may need to try several types before you find the one that works best for
you. Sometimes you may need to use more than one type at a time.
Eye drops can cause unpleasant side effects, such as eye irritation.
3. Laser treatment or surgery may be offered if drops don't help.

Safety-netting:
You will need advice from your eye specialist and DVLA regarding driving.
If you experience any pain or redness in your eye, please come to the hospital
immediately. Acute angle closure glaucoma.
You'll also be advised to attend regular follow-up appointments to monitor your eyes
and check that treatment is working. It's important not to miss any of these
appointments.

5 POINT RECAP:
ACUTE ANGEL CLOSURE GLAUCOMA:
1. SEVERE PAIN (SOCRATES) HEADACHE AND VISION PROBLEMS (ODIPARA)
2. MEDICATIONS (AMYTRIPTALINE)
3. URGENT REFERRAL
4. SPECIALIST-MEDS - SURGERY
5. DRIVING

4 POINT RECAP:
OPEN ANGLE GLAUCOMA:
1. PAINLESS VISION PROBLEMS
2. EXCLUDE RED FLAGS DDX AND MEDICAL CONDITIONS (DM)
3. ROUTINE REFERRAL – SPECIALIST- MEDS
4. DRIVING AND AACG

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SUBCONJUCTIVAL HAEMORRHAGE
Who you are: You are an F2 in A&E.
Who the patient is: Roy Hunt, a 78-year-old has presented to the hospital with
complaint of red eye.,
What you should do: Take history, discuss the management with the patient and
address his concerns.

D: What brings you to the hospital today?

P: Doctor my eye has suddenly become red.
P1
D: Tell me more about your eye? Open Q
P: It's my left eye.

Eye Qs
D: What about the other eye?
P: That is fine.
D: Are you able to see?
P: Yes.

ODIPARA
D: When did you notice it? (Duration)
P: This morning.
D: What were you doing when you noticed it?
P: I was just washing my face and I looked in the mirror and saw that my eye was red.
D: Anything else?
P: No.
D: Do you have any pain/itching/ irritation?
P: Just some irritation doctor.
D: Do you have any discharge/is your eye watery?
P: No.
D: Have you hurt your eye by any chance? (Trauma)
P: I don't remember hurting my eye doctor.
D: Do you use contact lenses? (Foreign body)
P: No.

DDx
D: How have you been recently?
P: Fine.
D: Any headache?
P: No.
D: Any fever?
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P: No.
D: Any long-standing sneezing, cough or constipation urine retention or straining?
P: No.
D: Any burning sensation, any gritty sensation, or any sticky discharge? (Conjunctivitis)
P: No.
D: Any joint pain? Urine problem? (Reiter’s)
P: No.
D: Do you have any bleeding anywhere else from your body?
P: No.
D: Change in colour or smell of stool or urine?
P: No.

P2+ MAFTOSA
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any condition such as DM, HTN, Blood Disorder, Cholesterol or Heart Disease?
P: No.
D: Any other medical condition such as IBD, AS or RA?
P: No.
D: Are you taking any other medications including OTC or supplements?
P: No.
D: Any blood thinners or steroids?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.

DESA:
D: Do you smoke?
P: Yes/No
D: Who do you live with?
P: My wife died couple of years back. I’m ok. I spend my time playing bowling and golf.

EXAMINATIONS
If it’s OK with you I’d like to examine you now, take your observations including your
blood pressure and examine your eye.
548 | P a g e
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YOU MAY BE HANDED A PICTURE OF RED EYE.

Management
Explain provisional diagnosis:
From what you’ve told me and from my examination, I think you have a subconjunctival
haemorrhage. It is slight bleeding in one of the thin membranes of your eyes. I would
like to reassure you that it’s not serious.

This layer is called Conjunctiva and it covers part of the front surface of the eye.
Conjunctiva contains many small & fragile vessels. Sometimes it happens that these
vessels rupture or break and blood leaks in the space under the conjunctiva and the eye
appears red as in your case. Fortunately it doesn’t affect your eye or your vision in any
way.
A subconjunctival bleeding usually occurs without any reason or sometimes due to
strong coughing or sneezing or sometimes due to high blood pressure.

Fortunately it usually improves in a week or two on its own without any need for a
specific treatment and based on what you have told me you do not have any red flag
symptoms for any underlying sinister conditions.

Senior
Investigations:
CBC , PT , APTT , INR.
Swab test from eye (to exclude infection.)
Tonometry (pressure in eye).

Symptomatic and Lifestyle treatment

If everything comes back negative, no treatment is required. They usually fade and
disappear within two weeks. (Like any other bruise, the red colour will go a
yellow/brown colour before it fades away.)
1. Artificial tears can be used four times per day for mild irritation.
2. Not to touch or rub your eyes.
3. Not to use painkillers without consultation.
4. Not to wear your contact lenses.

Safety netting
If it becomes a persistent or unexplained recurrence or you experience pain or change
in your vision, come to the hospital immediately.

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If you ever have any bleeding anywhere from your body or you feel tired or sick or
dizzy come back to the GP.

4 POINTS RECAP:
1. EXCLUDE DANGEROUS SX HEADACHE, VISION , EYE PAIN BLEEDING TENDENCY.
2. NOT SERIOUS
3. NO TREATMENT REQUIRED
4. REASSURE AND SAFETY NET

OPTIC NEURITIS

Who you are: You are an F2 in Emergency department.

Who the patient is: Mr. Jack Harries, aged 52, presents with a vision problem in the
right eye.
What you should do: Talk to him and address his concern.

Symptoms of Optic neuritis:

- Eye pain (particularly on eve movements)
- Loss of vision (temporary)
- Colours appearing faded or less vivid
- Weakness in the arms and legs
- History of autoimmune disease as multiple sclerosis.

Doctor: Hello, how can I help you?

Patient: I’ve had pain in my eye since yesterday.

P1
D: Sorry to hear about that, please tell me more about it? OPEN Qs
P: I can’t differentiate between colours as well.

SOCRATES
D: How did the pain start? ONSET
P: Suddenly.
D: From how long? DURATION
P: Since yesterday.
D: Where exactly is the pain? SITE
P: In my left eye.
D: How is your right eye? Any symptoms?

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P: No.
D: Are you able to see? FUNCTION
P: Yes, but I feel like colours are a bit faded somehow.
D: Does the pain go anywhere else ?
P: No/ I feel have headache as well doctor
D: Can you describe the character of the pain?
P: It’s a sharp pain.
D: Have you noticed anything that makes it better ?
P: No.
D: Is there anything that makes it worse?
P: Yes, doctor whenever I move my eyes it gets even more painful.
D: Can you score the pain for me from 1-10, 1 being the least pain and 10 being the
worst pain possible ?
P: It’s about 8.
D: Have you tried anything for the pain?
P: Yes, I’ve tried PCM but it did not help doctor.

Eye Sx:
D: Any discharge or bleeding or watery eyes?
P: No.
D: By any chance have you injured your eyes ? Foreign bodies / contact lenses?
(Trauma)
P: No doctor.
D: Do you have any fever?
P: No doctor.

DDx:
• Conjunctivitis Qs (fever/discharge)
• Trauma

P2+ MAFTOSA
D: Are you experiencing this for the first time?
P: It happened 3 months ago as well but it resolved on it is own after a week.

D: Ask all symptoms of MS:

o fatigue
o difficulty walking
o vision problems, such as blurred vision
o problems controlling the bladder
o numbness or tingling in different parts of the body
o muscle stiffness and spasms
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o problems with balance and coordination

o problems with thinking, learning and planning
o How is your mood?

D: Do you have any other health problems?

P: No.
D: Are you using any medicine?
P: No.
D: Any one in your family with MS?
P: My mum has it.
D: And how is she now?
P: She is taking lots of meds doctor.
D: What do you do for a living?
P: Homemaker.

D: Do you have any idea what might be going on?

D: Do you have any particular concerns?
D: Do you have any specific expectations from us today?

Examination:
If it’s OK with you, I would like to examine you, check your vitals, examine your eyes
and the back of your eyes using a special lens. I will send for some initial investigations
like infection and inflammatory markers.

Examiner may or may not give you findings, of decreased visual acuity and blurred optic
disc.

Management:
Explain Provisional Diagnosis:
From what you have said and based on what we have found through the assessment, I
think that you have a condition called optic neuritis. This involves the inflammation of
the optic nerve and unfortunately it means that your immune system is mistakenly
attacking the nerve of your eye.

Senior.
Specialist:
Refer to an eye specialist immediately. Usually, an ophthalmologist is involved in the
initial assessment, diagnosis and treatment.

Investigations:

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o MRI scan of your brain and spinal cord to give information about the risk of
developing MS.
o Blood tests.
o A lumbar puncture might be required, where a sample of the fluid
surrounding your spine is removed using a thin needle and tested.

Symptomatic treatment:
There's no cure for optic neuritis, but treatments can help to ease symptoms, prevent
future relapses, and slows down the condition's progression.
You may be prescribed:
o Steroids to reduce the inflammation
o Medicine to suppress your immune system and ease your symptoms, such
as azathioprine, mycophenolate or methotrexate rituximab, a newer type
of medicine to reduce inflammation
o Painkillers for pain.

Further management:
Regarding the risk of MS, I will refer you to a neurologist (a nerve specialist) for further
testing to confirm the diagnosis.
Rehabilitation techniques, such as physiotherapy, can also help if you have problems
with your mobility.
Therapies and support groups are available.

Safety netting:
Optic neuritis may affect your ability to drive. Please, inform the DVLA.
Also,
If you have nerve or muscle problems or pain, feel that you are tired more than usual or
if you develop a problem controlling your urine. These are signs for a more severe
condition so please come back to your GP.

Follow-up
We will have a follow up appointment after a few weeks to make sure you are
responding to medication and to prevent relapses.

6 POINTS RECAP:
1. SEVERE PAIN
2. MS
3. IMMEDIATE REFERRAL OPHTH
4. SENIOR AND START STEROIDS
5. LATER REFERRAL TO NEUROLOGY
6. SAFETY NET AND DRIVING
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Conjunctivitis
Who you are: FY2 in the GP clinic.
Who the patient is: 30 year old Hans Zimmer came to the clinic with some problems
with his eyes.
What you should do: Talk to the patient, assess, and address his concerns

Conjunctivitis (Positive Findings):

● Conjunctivitis is also known as red or pink eye. It usually affects both eyes and
makes them:
❖ Red
❖ Burn or feel gritty
❖ Produce pus that sticks to lashes
❖ Itch
❖ Water

Presenting complaint (P1) (ODIPARA):

D: Hello I am one of the doctors in the GP. You must be Hans?
P: Yes.
D: Can I get your full name and D.O.B., please, before we begin the consultation?
P: (Confirms details.)
D: So, Mr, Zimmer, I can see that you have been having some problems with your eyes?
P: Yes, doctor.
D: Tell me more about it (Open question)
P: I have been having this itching in my eyes and they are red as well.
D: Which eye?
P: Both the eyes.
D: When exactly did it start?
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P: Well, doctor, it has been going on for the past 3 days (Onset)
D: Is it continuous or does it come and go? (Duration)
P: It comes and goes.
D: Any discharge, bleeding, pain?
P: No, doctor, it's itchy and is watering.
D: Have you noticed any fever along with it?
P: No, doctor.
D: Do you think it has been increasing since it started? (Progression)
P: No, doctor. It's the same since it started.
D: Is there anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: No doctor, it comes and goes by itself.
D: You had any injury or has any foreign body fallen into your eyes?
P: No doctor.
D: Any headache?
P: No.
D: Any problem with your vision?
P: No, doctor.
D: Anything else?

D.Ds
● Allergic conjunctivitis
● Infective conjunctivitis (Pus)
● Acute glaucoma (Severe eye pain, Headache, Decreased visual acuity)
● Foreign body.

Concern
D: Apart from this, do you have anything else that's concerning you?
P: No.

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Past medical conditions (P2)

D: Has this ever happened to you before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: Yes, doctor, I have hay fever.

D.E.S.A:
Do you smoke?
What about alcohol?

M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: No, doctor.
D: Any allergies to any food or drugs other than hay fever?
P: I am not sure about that, doctor.
D: Anyone in the family with similar problems or other medical conditions?
P: No, doctor.

Expectation
D: Anything specific in your mind that you are expecting from us today?
P: Something to get rid of it, doctor.

Examination:
● Observations (Check vitals)
● General physical examination
● Eye examination

Idea
D: Do you have any idea what might be causing this?
P: No, doctor.
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Suspected diagnosis:
D: Mr. Zimmer, as you have been having this redness in the eye along with itching and
excessive watering and you also have a history of hay fever, I am suspecting it to be
allergic conjunctivitis, which is an allergic response of the eye to an allergen.

Management:
1. Senior
2. Investigations
● Not normally required.
3. Symptomatic management
● Avoidance of allergens, for example dust mite, mould, and animal dander control,
avoidance of pets and proper ventilation of home and office environments.
● Washing the hair before going to bed may help reduce allergen exposure.
● Avoidance of eye rubbing.
● Boil water and let it cool down before you gently wipe your eyelashes to clean off
crusts with a clean cotton wool pad (1 piece for each eye).
● Hold a cold flannel on your eyes for a few minutes to cool them down.
● Do not wear contact lenses until your eyes are better.
● Application of saline solution or artificial tears (Advise not to drive or perform
other skilled tasks until vision is clear).

Dos and Don'ts

Do
● Wash your hands regularly with warm soapy water.
● Wash your pillowcases and face cloths in hot water and detergent.
● Cover your mouth and nose when sneezing and put used tissues in the bin.
Don’t
● Do not share towels and pillows.
● Do not rub your eyes.

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4. Definitive management
● Topical antihistamine or dual action mast cell stabilisers/topical
antihistamine.
● Mast cell stabilisers can be used if symptoms are recurrent or persistent.
(Need to be applied routinely for at least 2 weeks to provide prophylactic
benefit.)
● Topical ocular diclofenac can be prescribed as adjunctive therapy if further
symptomatic relief is required.

5. Specialist
● Only required if suspecting a serious cause for red eye

6. Safety net
● Meningitis
● Decreased visual acuity
● Purulent discharge

Retinal detachment
Who you are: FY2 in the GP
Who the patient is: 40-year-old Michael Croft came to the clinic with some
complaints.
What you should do: Talk to the patient, assess, and address her concerns.

Retinal detachment (Positive Findings):

● Dots or lines (floaters) suddenly appear in vision or suddenly increase in number
● Flashes of light in your vision
● Dark "curtain" or shadow moving across your vision
● Sudden onset blurred vision
● Decreased visual acuity

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● Decreased visual field

Presenting complaint (P1) (ODIPARA):

D: Hello I am one of the doctors in this Emergency department. You must be Michael?
P: Yes.
D: Can I get your full name and D.O.B., please, before we begin the consultation?
P: (Confirms details)
D: So, Michael, I can see that you have been having some problems with your vision?
P: Yes, doctor.
D: Tell me more about it (Open question)
P: Doctor my vision has suddenly gone blurry in one of my eyes, I can’t see clearly.
D: Which eye?
P: Left eye, doctor.
D: What about the other eye?
P: That one is fine doctor.
D: When exactly did it happen?
P: Well, doctor, it happened half an hour ago (Onset)
D: Is it continuous or does it come and go? (Duration)
P: It is continuous.
D: Is it completely lost or partially? (Site)
P: It's just one half of my left eye vision, the side towards the nose.
D: Any pain in the eye?
P: No, doctor.
D: Any discharge, increased tearing, or bleeding from the eye?

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P: No, doctor.
D: Do you think it has been increasing since it started? (Progression)
P: No. doctor, it’s the same since it started.
D: Is there anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: No doctor.
D: Are you using any glasses or contact lenses?
P: No, doctor.
D: Anything else?
D: How did you come to the clinic? Do you drive?

DDs
● Retinal detachment (Any curtain falling? Dots or lines in your vision? Flashes of
light?)
● Stroke (Any weakness in the body? Slurred speech?)
● Central retinal artery occlusion (History of multiple episodes of momentary
sudden vision loss that returned after a few moments - Amaurosis Fugax)

Past medical conditions (P2)

D: Has this ever happened to you before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: I had a cataract, doctor.
D: In which eye?
P: The same eye, doctor. I had surgery on it 1 month ago.

D.E.S.A:
Do you smoke?
What about alcohol?

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M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: No, doctor.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in your family with similar problems or other medical conditions?
P: No, doctor.

Examination:
● Observations (Check vitals)
● General physical examination
● Visual acuity
● Colour vision
● Visual field
● Relative afferent pupillary reflex
● Neurological examination
● Fundoscopy

Idea
D: Do you have any idea what might be causing this?
P: No, doctor.

Suspected diagnosis:
D: Michael, from what you told me, you had this sudden painless loss of vision in your
left eye half an hour ago that was not associated with anything else in particular and
you noticed these dots in your vision with a curtain falling down in your vision. After
having examined you, I am suspecting it might be retinal detachment, which basically is
a condition in the back of the eye. The layer of the eye that is responsible for vision is
detached from the back of the eye and it leads to all these symptoms that you have just
stated.

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Concern
D: Apart from this, do you have anything else that's concerning you?
P: Will I get my vision back, doctor?
D: Well, your worry is quite understandable, Michael, we will do whatever we can to
make it better for you and there are some things that can be done for you, although,
I’m afraid a 100% recovery cannot be guaranteed.

Management:
1. Referral
● Immediate referral to the emergency department via an ambulance. Also, advice
to lay back while travelling to prevent any further detachment
2. Senior
3. Investigations - Fundoscopy
4. Definitive management
● Vitrectomy (Removing and replacing the jelly inside your eye)
● Scleral buckling (Attaching a small band around your eye to push the wall of your
eye and retina closer together)
● Pneumatic retinopexy (Injecting a bubble of gas into your eye to push the retina
against the back of your eye
● Cryotherapy (Sealing the tear in your retina with laser or freezing treatment)
5. Specialist
● Any patient with visual field loss or changes in visual acuity or fundoscopic
changes of retinal detachment or vitreous haemorrhage should be seen by an
ophthalmologist on the same day.
6. Safety net
● Advise to avoid flying.
● Advise to contact the Driver and Vehicle Licensing Authority (DVLA) if they have a
visual field defect and/or have had retinal treatment in both eyes.
● Advise on the early warning signs of possible future retinal tear or detachment
and the need for immediate ophthalmology assessment

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EAR, NOSE AND THROAT

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EAR, NOSE and THROAT

History of Ear conditions:

Key points:
P1
- Tell me more.
- Which ear?
- What about the other?
- Are you able to hear?

DDs (as discussed)

P2
- Have you had this before?
- Previous surgery?
- Medical condition?

P3 > DESA
MAFTOSA

Medication. M
Allergy (important, patient allergic A
to amoxicillin → Erythromycin)
Family history F
Travel or barotrauma (important) T
Occupation (important, as it could O
be a cause)
PSychosocial (if hearing loss) S
Anything else A

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Ear Problems

Inner Middle External

Ear Ear Ear
DVT 1. Pain 1. Trauma
1. Bilateral → 2. Fever - Noise.
Meniere's 3. Discharge - Mechanical trauma.
2. Unilateral + - Barotrauma (flight)
Face weakness → - Hurt your ear
Acoustic neuroma (Physical trauma)
2. Otitis Externa
- Redness – Swelling in external ear canal
- Exposure to water (swimmer’s ear)
3. Vesicles
- Ramsey – Hunt syndrome.

Any Dizziness
BPPV Vestibular neuritis Meniere's
- Precipitated by - Precipitated by - DVT bilateral
movement. Viral infection.
- Few seconds or - head move
minutes. exacerbate.
- Episodic - Hours or days
- Associated with - Nausea – vomiting –
nausea but not hearing loss
vomiting

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History of Nose Conditions

Nasal blockage - ODIPARA.

- One side or both sides.
- Dryness of nose and throat.
- Cause
▪ Foreign body - Trauma – polyp
▪ Allergic rhinitis
Nasal discharge - TRAC
- One side or both sides.
- Postnasal drip.

Nosebleed - TRAC
- One side or both sides
- Bleeding questions
- Foreign body - trauma
Other symptoms - Change in smell or voice
- Sneezing
- Headache or facial pain.
- Swelling or deformity.
- Snoring.

Allergic rhinitis

Where you are: You are an FY2 in GP.

Who the patient is: Luke, aged 25, has come with complaints of a runny nose
for the past 2 days.
What you should do: Take history and address his concerns.

Ask about other allergic conditions: asthma – eczema.

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Doctor: How can I help you?

Patient: I have got runny nose.
(P1)
D: Tell me more about it? (explore P1)
(TRAC)
P: I have been having this for 2 days and it is getting worse.
D: What is the colour of the fluid?
P: Clear watery fluid.
D: Is there anything that makes it better or worse?
P: It gets worse in the winter season.
D: Anything else?
P: No.

DDs
D: Any itching?
P: No.
D: Any swelling or redness?
P: No.
D: Any fever and flu-like symptoms? (Infective rhinitis)
P: No.
D: Any pain or discharge from ear? (Ear Infection)
P: No.
D: Any numbness or tingling on the face? (Cranial Nerve Tumours)
P: No

(P2)
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: I have got a skin allergy (Atopy) (+ve finding)
D: Any DM, history of eczema or asthma?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any allergy to pollens or dust?
P: No.
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D: Any previous hospital stays or surgeries?

P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: Siblings have Eczema and Asthma (+ve finding)

DESA
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Tell me about your diet?
P: I don’t eat healthy to be honest.
D: Do you do physical exercise?
P: I don’t have much time.
D: Do you have any kind of stress?
P: No.
D: What do you do for a living?
P: I am a driver. (Make sure you don't prescribe drowsy antihistamines)

Examination
If it’s OK with you I would like to check your vitals and examine your eyes, ears, nose
and throat.
I will examine the inside of your nose to check for nasal polyps which are
fleshy swellings that grow from the lining of your nose or sinuses, the small
cavities inside your nose.
I will also examine cranial nerves (to rule out rare tumours).

Provisional diagnosis:
I suspect a condition called Allergic rhinitis where your nose gets irritated
by something you are allergic to and causes cold like symptoms.

Management
Refer you to a hospital allergy clinic for allergy testing.
Senior.
Investigations:
Allergy testing: If the exact cause of allergic rhinitis is uncertain,

The 2 main allergy tests are:

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A skin prick test – where the allergen is placed on your arm and the surface of the skin
is pricked with a needle to introduce the allergen to your immune system; if you're
allergic to the substance, a small itchy spot (welt) will appear.

A blood test – to check for the immunoglobulin E (IgE) antibody in your blood; your
immune system produces this antibody in response to a suspected allergen.
Symptomatic:
Non-medical treatment:
If possible, try to reduce exposure to the allergen that triggers the condition.
Regularly cleaning your nasal passages with a salt water solution, known as nasal
douching or irrigation, can also help by keeping your nose free of irritants.

Medication
1. Antihistamines
They relieve symptoms of allergic rhinitis by blocking the action of a chemical called
histamine, which the body releases when it thinks it's under attack from an allergen.
Antihistamines can sometimes cause drowsiness. If you're taking them for the first
time, see how you react to them before driving or operating heavy machinery. (The
patient is a driver).
In particular, antihistamines can cause drowsiness if you drink alcohol while taking
them.

2. Corticosteroids
If you have frequent or persistent symptoms and you have a nasal blockage or nasal
polyps, we may recommend a nasal spray or drops containing corticosteroids.
Corticosteroids help reduce inflammation and swelling. They take longer to work than
antihistamines, but their effects last longer.
Side effects from inhaled corticosteroids are rare, but can include nasal dryness,
irritation and nosebleeds.
If you have a particularly severe bout of symptoms and need rapid relief, we may
prescribe a short course of corticosteroid tablets lasting 5 to 10 days.

3. Add-on treatments
If allergic rhinitis does not respond to treatment, we may choose to add to or increase
the dose of your original treatment.
Other medications include using a short-term course of a decongestant nasal spray –
ipratropium nasal spray - a leukotriene receptor antagonist medication.
If you do not respond to the add-on treatments, you may be referred to a specialist for
further assessment and treatment.

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4. Immunotherapy (hypo sensitisation or desensitisation)

It's only suitable for people with certain types of allergies, such as hay fever, and is
usually only considered if your symptoms are severe.
Immunotherapy involves gradually introducing more and more of the allergen into your
body to make your immune system less sensitive to it.
The allergen is often injected under the skin of your upper arm. Injections are given at
weekly intervals, with a slightly increased dose each time.
Immunotherapy can also be carried out using tablets that contain an allergen, such as
grass pollen, which are placed under your tongue. When a dose is reached that's
effective in reducing your allergic reaction (the maintenance dose), you'll need to
continue with the injections or tablets for up to 3 years.
Immunotherapy should only be carried out under the close supervision of a specially
trained doctor, as there's a risk it may cause a serious allergic reaction.

Safety netting
If your symptoms do not respond to medication after 2 weeks, come back.

Follow-up

Ear wax

Where you are: You are an FY2 in GP surgery.

Who the patient is: Mrs Nicole Harrop, 29 years old, presented with
intermittent ear pain and hearing difficulty for the past month.
What you should do: Take history and address her concerns.

Doctor: How can I help?

Patient: I have had pain in my ear for the past month.
(P1)
(SOCRATES)
D: Where is it exactly? (site) (which ear?)
P: Right side.
D: What were you doing when it started? (Onset)
P: I was just sitting.
D: What kind of pain? (character)
P: I feel like my ear is blocked (+ve finding)
D: Does it go anywhere? (radiation)
P: No.
D: Is it continuous or comes and go?

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P: It comes suddenly and goes on its own.

P: Anything makes your condition better?
P: No.
D: Is there anything that makes it worse?
P: Shower and swimming.
D: Could you please score the pain on a scale of 1 to 10, with 1 being no
pain and 10 being the most severe pain you have ever experienced?
(score)
P: 6.
D: How about the other ear?
P: It is fine.
D: Anything else? Are you able to hear?
P: I can’t hear properly with my right ear. (Hearing difficulty +ve finding)
D: Anything else?
P: No.

DDs
D: Any fever? (OM)
P: No.
D: Any discharge from the ear?
P: No.
D: Any vertigo, tinnitus, numbness or tingling in the face? (Cranial nerve
involvement)
P: No.
D: Does your ear feel stuffy?
P: Yes. (+ve finding)
D: Do you use cotton buds?
P: Yes (+ve finding)

P2
D: Have you experienced a similar pain before?
P: No.
D: Have you been diagnosed with any medical conditions?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Do you have any allergies from any food or medications?
P: No.
D: Any hospitalisations or surgeries?
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P: No.
D: Has anyone in your family been diagnosed with any medical
condition?
P: No.
D: Any recent travel? (flight)
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: I eat everything, its fine.
D: Do you do physical exercise?
P: I am active.
D: What do you do for a living?
P: Office job.

Examination
I would like to check your vitals and examine your ear if that’s OK. I will
be using an instrument called an otoscope – an instrument with a light
and magnifying glass - to look inside the ear, and I would also like to do
hearing tests and balance tests. We will also do some initial
investigations.

Provisional diagnosis
From my assessment I suspect that you have ear wax build-up in your ear. Sometimes
earwax can build up in your ears and block them.
This can be uncomfortable and annoying, but can usually be treated.

Management
Senior.
Symptomatic
General advice:
You cannot prevent earwax. It's there to protect your ears from dirt and germs.
Do not use your fingers or any objects like cotton buds to
remove earwax. This will push it in and make it worse.

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Medical:
Earwax usually falls out on its own. If it does not and blocks your ear, put 2 to 3 drops of
medical grade olive or almond oil in your ear twice a day for a few days to soften the
wax.
It is recommended you use a dropper while lying your head on one side for a few
minutes to let the oil work its way through your ear canal(s).
You may find it easier to do this first thing in the morning and then just before you go to
sleep.
Over about 2 weeks, lumps of earwax should fall out of your ear, especially at night
when you're lying down.

If your ears still blocked despite using of the drops, we can do:
Ear irrigation: flush the wax out with water.
Microsuction: to suck the wax out.
These treatments are usually painless. You might have to pay to have them done
privately.
There's no evidence that ear candles or ear vacuums get
Rid of earwax.

Safety netting
Do not use drops if you have a hole in your eardrum (a perforated
eardrum).
If your symptoms have not cleared after 5 days or your ear is badly blocked and you
cannot hear anything (you can get an infection if it has not cleared) come back to us.

Barotrauma

Where you are: You are an FY2 in GP surgery.

Who the patient is: Mr David Thomas, 33 years old, presented with ear
pain and hearing difficulty for a week.
What you must do: Talk to patient and address his concern.
Doctor: How can I help?
Patient: I have had pain in my ear for 1 week.
(P1)
(SOCRATES)
D: Where is it exactly? (site) (which ear?)
P: My right ear.
D: What were you doing when it started? (Onset)
P: I was just sitting.
D: What kind of pain is it? (character)
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P: Dull.
D: Does it go anywhere else? (radiation)
P: No.
P: Is there anything that makes your condition better?
P: No.
D: Anything that makes it worse?
P: No.
D: Could you please score the pain on a scale of 1 to 10, with 1 being no
pain and 10 being the most severe pain you have ever experienced?
(score)
P: 6.
D: Anything else with it? (Are you able to hear?)
P: I can’t hear properly.

DDs
D: Any fever? (OM)
P: No.
D: Any discharge from the ear?
P: No.
D: Any vertigo, tinnitus, numbness or tingling in the face? (Cranial nerve
involvement)
P: No.
D: Does your ear feel stuffy?
P: No.
D: Have you been swimming recently? (OE)
P: No.

P2
D: Have you experienced a similar pain before?
P: No.
D: Have you been diagnosed with any medical conditions?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Do you have any allergies from any food or medications?
P: No.
D: Any hospitalisations or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical
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condition?
P: No.
D: Any recent travel? (flight)
P: Yes, I flew back from Australia one week ago. (+ve
finding)

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: I eat everything, its fine.
D: Do you do physical exercise?
P: I am active.
D: What do you do for a living?
P: Office job.

Examination
Is it OK if I check your vitals, and examine your ear? I
would also like to do hearing tests and balance tests. Also, I would like to do
some initial investigations.
Examiner says: Conductive hearing loss.

Provisional diagnosis
From my assessment I suspect that you have a condition called
Barotrauma. It is a condition that happens when the ear drum becomes
stretched and tense. It causes ear pain and dull hearing.

Management
Refer to Ear specialist for more assessment (as audiometry, measure your hearing
acuity).
Senior
Symptomatic:
Most cases of ear barotrauma generally heal without medical intervention. There are
some self-care steps you can take for immediate relief.
You may help relieve the effects of air pressure on your ears by: yawning - chewing
gum - practicing breathing exercises - taking antihistamines or decongestants.
A decongestant nasal spray can dry up the mucus in the nose. For example, one
containing xylometazoline - available at pharmacies. Spray the nose about one hour
before the expected time of descent. Spray again five minutes later.
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Then spray every 20 minutes until landing. Decongestants are not suitable for young
children.
Air pressure-regulating ear plugs. These are cheap, reusable ear plugs that are often
sold at airports and in many pharmacies. These ear plugs may help slow the rate of air
pressure change on the eardrum.
The following may help people who develop ear pain when flying:
Suck sweets when the plane begins to descend. Air is more likely to flow up the
Eustachian tube if you swallow, yawn or chew. For babies, it is a good idea to feed them
or give them a drink at the time of descent to encourage them to swallow.
Try doing the following: take a breath in. Then, try to breathe out gently with your
mouth closed and pinching your nose (the Valsalva manoeuvre). In this way, no air is
blown out but you are gently pushing air into the Eustachian
tube. If you do this you may feel your ears go 'pop' as air is pushed into the middle ear.
This often cures the problem. Repeat this every few minutes until landing - whenever
you feel any discomfort in the ear.
Do not sleep when the plane is descending to land. (Ask the air steward to wake you
when the plane starts to descend.) If you are awake you can make sure that you suck
and swallow to encourage air to get into the middle ear.
If there is any complications as :
In severe cases, prescribe an antibiotic or a steroid to help in cases of infection or
inflammation.
In some cases, ear barotrauma results in a ruptured eardrum. A ruptured eardrum can
take up to two months to heal.

Occasionally, the eardrum will tear (perforate). However, if this occurs, the eardrum is
likely to heal by itself, without any treatment, within several weeks.

Symptoms that don’t respond to self-care may require surgery to prevent permanent
damage to the eardrum.
Surgery: In severe or chronic cases of barotrauma, surgery may be the best option for
treatment.
Tympanostomy tubes or grommets : for Chronic cases of ear barotrauma may be aided
with the help of ear tubes. These small cylinders are placed through the eardrum to
stimulate airflow into the middle of the ear. Ear tubes are
most commonly used in children and they can help prevent infections from ear
barotrauma. These are also commonly used in those with chronic barotrauma who
frequently change altitudes, like those who need to fly or travel often.
The ear tube will typically remain in place for six to 12 months.
The second surgical option involves a tiny slit being made into the eardrum to allow
pressure to equalise. This can also remove any fluid that’s present in the middle ear.
The slit will heal quickly, and may not be a permanent
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solution.
If you are a diver:
Normal practice of divers is to descend and ascend slowly which should give time for
the air pressures to equalise either side of the eardrum. Divers can do the Valsalva
manoeuvre (described above) too. You should not dive if
you have a condition that may cause a blocked Eustachian tube, as this may cause
severe barotrauma and severe ear pain.

Safety netting
If your condition worsens , come back to us.

Otitis media

Where you are: You are an F2 in A&E.

Who the patient is: Adam Willis, aged 22, presented to the hospital with
pain in the ear.
What you must do: Please take rapid history, do relevant assessment and
discuss management with the patient

Or,

Where you are: You are an F2 in Paediatrics.

Who the patient is: Lucy, 15 months old, was brought to the hospital by her father with
fever, shortness of breath and was pulling her left ear. They went to the GP and he gave
her PCM and referred her to the hospital. Her father is concerned about her condition.
On examination, there is redness over her left ear drum. Her right ear drum is pink.
NEWS chart:
Before : Temp - 38, HR -130 (80-130), RR-40 (25-35)
After : Temp -37, HR-100 (80-130), RR -30
What you must do: Please talk to her father, take history, discuss plan of
management with the father and address his concerns. Nurse colleagues
are looking after her in the next room.

Or,

Where you are: You are F2 in Paediatrics.

Who the patient is: Monica, aged 2 years old, has been brought to the hospital
by her mother because she had a fit. She has been managed in the A&E department
and has been referred to you. Her temperature is 38.9 C. On

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examination, there is redness over her left eardrum.

What you must do: Please talk to her mother, Mrs. Diana Julie, take
history, discuss your plan of management with the mother and address her
concerns. The mother is very concerned. The child is not in the cubicle.

Doctor: How can I help?

Patient: I have pain in my ear / Baby is crying and pulling her ear.
(P1)
(SOCRATES)
D: Where is it exactly? (site) (which ear?)
P: Left side.
D: What were you doing when it started? (Onset)
P: Nothing much.
D: What kind of pain? (character)
P: Sharp, sudden/ dull, continuous.
D: Does it go anywhere else? (radiation)
P: No.
D: Has it been the same or getting worse?
P: It is getting worse.
P: Does anything make your condition better?
P: I took paracetamol, but it is not improving.
D: Anything that makes it worse?
P: No.
D: Could you please score the pain on a scale of 1 to 10, with 1 being no
pain and 10 being the most severe pain you have ever experienced.
(score)
P: 6
(Ask about the other ear)
D: How about the other ear?
P: That one is fine.
D: Anything else?
P: Yes I have a temperature (Explore, have you taken anything for it? / have you
measured it?)
D: Anything else with it? (Are you able to hear?)
P: I can’t hear properly with my right ear.
D: Any discharge from the ear?
P: No /Yes (If yes explore > TRAC)

DDs
D: Any vertigo, tinnitus, numbness or tingling in the face? (Cranial nerve
involvement)
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P: No.
D: Does your ear feel stuffy?
P: Yes.
D: Have you been swimming recently? (OE)
P: No.

P2
D: Have you experienced a similar pain before?
P: No.
D: Have you been diagnosed with any medical conditions?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: PCM (Explore how many tablets? Did it help?)
D: Do you have any allergies from any food or medications?
P: No.
D: Any hospitalisations or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: Any recent travel? (flight)
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: I eat everything, its fine.
D: Do you do physical exercise?
P: I am active.
D: What do you do for a living?
P: Office job.

Examination
Is it alright if I check your vitals, and examine your ear? I will be using an instrument
called an otoscope – an instrument with a light and magnifying glass - to look inside the

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ear, and I would also like to do hearing tests and balance tests. We will also do some
initial investigations.

Examiner says: redness over right ear drum.

Provisional diagnosis
From my assessment I suspect a condition called otitis media which is an infection of
the middle ear that causes inflammation and a build-up of fluid behind the eardrum.

Management:
- Senior
- Symptomatic:
Painkillers such as paracetamol or ibuprofen (children under 16 should not take
aspirin).
Place a warm or cold flannel on the ear.
Remove any discharge by wiping the ear with cotton wool.
Antibiotics are not usually offered because infections inside the ear often clear up on
their own and antibiotics make little difference to symptoms, including pain.
Antibiotics might be prescribed if:
• An ear infection does not start to get better after 3 days.
• You or your child has any fluid coming out of their ear.
• You or your child has an illness that means there's a risk of complications, such as
cystic fibrosis.
• They may also be prescribed if your child is less than 2 years old and has an
infection in both ears.
General advice:
Do not put anything inside your ear to remove earwax, such as cotton buds or your
finger.
Do not let water or shampoo get in your ear.
Safety netting
If your symptoms do not improve despite treatment, discharge or ( jerky movement in
children ), come back to us.
Follow-up

Cholesteatoma

Where you are: You are FY2 in GP surgery.

Who the patient is: Mr. Josh Andrews, aged 26, came to the clinic complaining of pain
in the ear.
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What you must do: Talk to the patient and discuss the management with him.

(Don't forget foul smelling discharge)

D: How can I help?
P: I have had pain in my ear for 1 month.
(P1)
(SOCRATES)
D: Where is it exactly? (site) (which ear?)
P: Right side.
D: What were you doing when it started? (Onset)
P: I was just sitting.
D: What kind of pain? (character)
P: Dull.
D: Does it go anywhere? (radiation)
P: No.
D: Has it been the same?
P: It is getting worse.
P: Does anything make your condition better?
P: I have been having this pain for 1 month, I took paracetamol, but it is
not improving.
D: Anything that makes it worse?
P: No.
D: Could you please score the pain on a scale of 1 to 10, with 1 being no
pain and 10 being the most severe pain you have ever experienced?
(score)
P: 6.
(Ask about the other ear)
D: How about the other ear?
P: It is fine.
D: Anything else with it? (Are you able to hear?)
P: I can’t hear properly with my right ear.

DDs
D: Any fever? (OM, meningitis)
P: Yes/No
D: Any discharge from the ear?
P: Yes (explore) (TRAC)
D: Since when?
P: For 1 month, it comes and goes.
D: What kind of discharge?
P: It is watery and grey.
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D: How much is it?

P: A little.
D: Is it foul smelling?
P: Yes.
D: Any vertigo, tinnitus, numbness or tingling in the face? (cranial nerve
involvement)
P: No.
D: Does your ear feel stuffy?
P: No.
D: Any trouble with the vision? (blurring)
P: No.
D: Have you been swimming recently? (OE)
P: No.

P2
D: Have you experienced a similar pain before?
P: No.
D: Have you been diagnosed with any medical conditions?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: PCM (explore how many tablets? Did it help?)
D: Do you have any allergies from any food or medications?
P: No.
D: Any hospitalisations or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: Any recent travel? (flight)
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: I eat everything, its fine.
D: Do you do physical exercise?
P: I am active.
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D: What do you do for a living?

P: I work in an office.
D: Tell me about your home condition?
P: I live in a house.

Examination
If you don’t mind, I would like to check your vitals and examine your ear. I will
be using an instrument called an otoscope – an instrument with a light and magnifying
glass - to look inside the ear, and I would also like to do hearing tests and balance tests.
We will also do some initial investigations.

Examiner says: Conductive hearing loss.

Otoscopy: Perforation in the Middle Ear usually pars flaccida.

Provisional diagnosis
From what you’ve told me and from my examination, I suspect that you have a
condition called cholesteatoma. A cholesteatoma is an abnormal collection of skin cells
deep inside your ear. They’re rare, but if left untreated, they can damage the delicate
structures inside your ear that are essential for hearing and balance.

Management
Senior.
Investigations:
We need to do some investigations to confirm this.
We’ll do some routine blood tests, and we will probably do a CT scan to see whether
the cholesteatoma has spread, and which parts of your ear are affected or we may do
an MRI.

Symptomatic
Surgery
To remove a cholesteatoma, you usually need to have surgery under general
anaesthetic.
After the cholesteatoma has been taken out, your ear may be packed with a dressing.
This will need to be removed a few weeks later, and you'll be told how to look after it.
As well as removing the cholesteatoma, the surgeon may be able to improve your
hearing. This can be done in a number of ways. For example, a tiny artificial hearing
bone (prosthesis) can be inserted to bridge the gap between your eardrum and the
cochlea (hearing organ). In some cases, it may not be
possible to reconstruct the hearing or a further operation may be needed.

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The benefits of removing a cholesteatoma usually far outweigh the complications.

However, as with any type of surgery, there's a small risk associated with having
anaesthetic, and a very small chance of facial nerve damage resulting in weakness of
the side of the face.
Recovering from surgery
You may need to stay in hospital overnight after the operation, and you should plan to
take a week or so off work.
When you get home, you'll need to keep the affected ear dry. You should be able to
wash your hair after a week, provided you do not get water inside the ear. To avoid this,
you can plug the ear with Vaseline-coated cotton wool
You may be advised to avoid flying, swimming and doing strenuous activities or sports
for a few weeks after surgery. At your follow-up appointment, ask when it will be safe
to return to your usual activities.

Follow-up appointments
If your stitches are not dissolvable, they may need to be removed by your practice
nurse after a week or 2.
Most people have a follow-up appointment in a clinic within a few weeks of the
operation when any dressings in your ear will be removed.
A cholesteatoma can come back, and you could get one in your other ear, so you'll need
to attend regular follow-up appointments to monitor this.
Sometimes a second operation is needed after about a year to check for any skin cells
left behind. However, MRI scans are now often used instead of surgery to check for this.

Medical treatment
Where surgery is not possible, that will need antibiotics and regular ear cleaning.

Safety netting
If you have jerky movements, come back to us.
If you develop discharge or significant bleeding from your ear or wound, fever, and
severe pain, come to the hospital immediately.

Patient's concerns:
P: Why did I get it?
D: Well, it can happen because of trauma to the middle ear, or a chronic
ear infection. Some people are born with it. Since you have had an
earache only for the past month, it might be because of an infection.
P: Can it happen again?
D: Unfortunately, it can recur in 5-30% cases. Around 10% can get it in the other ear as
well. If you develop discharge or significant bleeding from your ear or wound, fever and
severe pain, come to the hospital immediately.
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Recurrent tonsillitis

Where you are: You are FY2 in GP surgery.

Who the patient is: Julia, mother of a 6 year old boy, who is diagnosed with
tonsillitis, has come to you to talk about her son's referral to ENT surgery
that was rejected.
The child had previously 5 episodes of infections over 6 months.
What you must do: Talk to the mother and address her concerns. On
request of the mother, GP made the referral to the ENT surgery.

Doctor: How can I help you today?

Patient: I am here for my son. He had recently been referred to ENT surgery
From the GP and the referral got rejected.
D: I see. Would you mind if I ask you a few questions regarding your son to have better
understanding of your son's health?
P: OK.
(Take history)
D: Could you tell me why he had been referred to ENT surgery?
P: He had 5 episodes of tonsillitis in the last 1 year
(Explore)
D: Could you give a brief recap of the episodes?
P: The first episode was about 10 months ago. He had a sore throat and
fever and was advised to have steam inhalation. The 2nd and 3rd episodes the
symptoms were more severe, and he was given antibiotics.
And the last 2 episodes was like the first episode, and it got better with
steam inhalation as well.
(Show sympathy)
D: I can understand it must be very tough on him and he’s only young.
P: Yes, so why did the referral get rejected? (Concern)
D: As you already know the referral was made upon your request. But to
be honest with you your son doesn't meet the criteria to have the surgery for tonsil
removal.
P: What criteria are you talking about? (Explain criteria)
D: Let me explain this to you further. There are some criteria that have been set to
decide which patients need tonsil removal surgery. One of those criteria is having at
least 7 attacks in a year. You mentioned your son had 5 attacks. So it’s possible that
that's why the referral got rejected.
P: Doctor, forget about the criteria. I can't see him suffer like that anymore. Please
arrange the surgery for him.
D: I can really see you are worried about your son. But let me tell you the

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criteria are made in a way to avoid unnecessary surgery and ensure better care for the
patients. And every surgery has a lot of complications.
We don't want your son to go through the unnecessary stress of the surgery without a
strong reason. Another thing is that tonsils are a very important part of the defence
mechanism of our body that fights against infection. That is why we don't want to
remove them unless it's absolutely necessary.
P: Doctor I just think the NHS is doing it for budget cutting. Don't you think so?
D: I am really sorry you feel that way, but the NHS has planned those surgeries and set
those criteria for delivering the best possible care to the patients.
P: Alright.

Management
D: For now, we will give him painkillers to relieve the pain. Please ensure he is taking
plenty of rest.

Safety netting
By any chance if your son's condition gets worse or he develops neck stiffness or he
can't even swallow, please bring him back to us.

Indications for tonsillectomy:

You may be advised to have your tonsils removed in certain situations. In particular:
1. If you have frequent and severe bouts of tonsillitis.
This usually means:
-Seven or more episodes of tonsillitis in the preceding year; or
-Five or more such episodes in each of the preceding two years; or
-Three or more such episodes in each of the preceding three years.

And
2. The bouts of tonsillitis affect normal functioning. For example, they are severe
enough to make you need time off from work or from school.

3. If you have large tonsils that are partially obstructing your airway, this may be a
contributing factor to a condition called obstructive sleep apnoea syndrome.

4. If you develop cancer of the tonsil.

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Epistaxis

Where you are: You are an FY2 in GP surgery.

Who the patient is: Jack Wilson, aged 25 , has had a nosebleed. He is on Apixaban.
What you must do: Talk to him and assess his concern.
(Don't forget HTN, bleeding disorders and blood thinners)

Doctor: How can I help?

Patient: I have had a nosebleed since this morning.
(P1)
(TRAC)
D: What were you doing when it started? (Onset)
P: I was just sitting.
D: Anything else with it?
P: No.
D: Any bleeding anywhere else?
P: Yes/No
D: Any trauma to your nose?
P: No.
D: Do you pick your nose or blow it too hard?
P: Yes/No

P2
D: Have you experienced a similar condition before?
P: No.
D: Have you been diagnosed with any medical conditions?
P: No.
D: HTN?
P: No.
D: Any bleeding disorder?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: I'm taking Apixaban. (+ve finding explore)
D: Why do you take it?
P: For DVT.
D: For how long you have been taking it?
P: 2 months.
D: Do you take it as prescribed?

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P: Yes/No
D: Do you follow up regularly with your GP?
P: Yes/No
D: Do you have any allergies from any food or medications?
P: No.
D: Any hospitalisations or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition
or bleeding disorder?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: I eat everything, it’s good.
D: Do you do physical exercise?
P: I try to.
D: What do you do for a living?
P: Window cleaner.
D: Tell me about your home condition?
P: I live in a bungalow.

Examination
Can I check your vitals and examine your nose? Also, I would like to do some initial
investigations including full blood count and bleeding profile.

Provisional diagnosis
Your nose bleeding is mostly due to the medication you are taking, Apixaban, which is a
blood thinner.

Management
Senior:
To review your medications and make sure everything is ok.

Investigations:
Routine bloods and bleeding profile including INR.

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Symptomatic:
To stop a nosebleed yourself: Sit down and lean forward, with your head tilted forward,
pinch your nose just above your nostrils for 10 to 15 minutes. Breathe through your
mouth.

Hospital treatment for nosebleeds:

If we can see where the blood is coming from, they may seal it by pressing a stick with a
chemical on it to stop the bleeding.
If this is not possible, we might pack your nose with sponges to stop the bleeding. You
may need to stay in hospital for a day or two.

When a nosebleed stops:

After a nosebleed, for 24 hours try not to (blow your nose -pick your nose - drink hot
drinks or alcohol - do any heavy lifting or strenuous exercise - pick any scabs )

Safety netting
Come to the A & E immediately if:
• Nosebleed lasts longer than 10 – 15 minutes.
• Excessive bleeding.
• If you swallow large amount of blood that makes you vomit.
• If bleeding started after a blow to your head.
• If you are weak or dizzy.
• If you have any difficulty in breathing.

Labyrinthitis

Where you are: You are an FY2 in GP surgery.

Who the patient is: Suzan James, 34 years old, presented with dizziness and hearing
problems.
What you must do: Talk to her and address her concerns.

Doctor: How can I help you?

Patient: I feel dizzy.
(P1)
D: What do you mean by feeling dizzy?
P: I feel everything around me is spinning.
D: Tell me more about it. (Explore P1)
P: What would you like to know?
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ODIPARA
D: Since when have you been feeling dizzy?
P: About 4 or 5 days.
D: Was it sudden or gradual?
P: Sudden
D: How many times has it happened?
P: I don’t know.
D: How long does an episode last?
P: Not sure.
D: Anything that triggers the dizziness?
P: I don’t know.
D: Anything else?
P: I feel sick.
D: Have you vomited?
P: No.
D: Do you feel unsteady, or do you have any balance problem?
P: I find it difficult to stay upright or walk in a straight line. (+ve finding).

DDs
D: Any fever or flu-like symptoms recently?
P: Yes/No
D: Any motion sickness?
P: No.
D: Any blurry vision or double vision? (Acoustic Neuroma)
P: No.
D: Any numbness on your face (Acoustic Neuroma)
P: No.
D: Any hearing loss?
P: No.
D: Any ringing sensation in your ears? (Meniere's/Acoustic Neuroma)
P: No.

(P2)
D: Have you had a similar condition before?
P: No.
D: Any other medical conditions?
P: No.

MAFTOSA
D: Are you taking any other medications including OTC or supplements?
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P: No.
D: Any allergies from any food or medications?
P: No.
D: Any surgeries or hospital admission?
P: No.
D: Any family history with similar conditions?
P: No.

DESA
D: Do you drink alcohol?
P: Yes/No
D: Do you smoke?
P: Yes/No
D: What about your diet?
P: My diet is very good.
D: What do you do for a living?
P: I am a salesperson.
D: Is it stressful?
P: Yes/No
D: Who do you live with?
P: I live with my kids.

Examination
I would like to check your vitals and do a neurological, ear examination, if that’s OK
with you. I would also like to send for some initial investigations including routine blood
tests.

Provisional diagnosis
From my assessment I suspect you have a condition called labyrinthitis. It
is a condition of inner ear infection that affects your balance.

Management
Senior.
Symptomatic and lifestyle:
Antihistamines or motion-sickness tablets for up to 3 days. Do not take them for any
longer, as they can slow down your recovery.
Labyrinthitis is usually caused by a viral infection, such as a cold or flu, so antibiotics will
not help. But I will confirm with my senior as we may prescribe antibiotics if they think
your infection is bacterial.

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General advice
Labyrinthitis usually gets better on its own. But there are things you can do to ease the
symptoms:
• Lie still in a dark room if you feel very dizzy.
• Drink plenty of water if you're being sick – it's best to drink little and often.
• Try to avoid noise and bright lights.
• Get enough sleep – tiredness can make symptoms worse.
• Start to go for walks outside as soon as possible – it may help to have someone
with you to steady you until you become confident.
• When you're out and about, keep your eyes focused on a fixed object, rather
than looking around all the time.

Please avoid:
Do not drive, cycle, or use tools or machinery if you feel dizzy.
Do not drink alcohol – it can make symptoms worse.

Specialist
Sometimes, balance problems can last for much longer – for many months even years.
Vestibular rehabilitation is a series of exercises that can help to restore balance. You
should only do the exercises under the supervision of a physiotherapist.
Refer you to a physiotherapist, or it may be possible to refer yourself directly.

Safety netting
If you have sudden hearing loss in 1 ear, symptoms do not get better after a few days,
or get worse , Please come back to us as you may be referred to a specialist for further
tests.

Follow up: After few days

Note
Labyrinthitis and Vestibular neuritis – what's the difference?
Labyrinthitis is inflammation of the labyrinth – a maze of fluid-filled channels in the
inner ear.
Vestibular neuritis is inflammation of the vestibular nerve –the nerve in the inner ear
that sends messages to the brain.
However, if your hearing is affected, then labyrinthitis is the cause. This is because
inflammation of the labyrinth affects hearing, while inflammation of the vestibular
nerve does not.

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Acute tonsillitis

Where you are: You are an FY2 in GP.

Who the patient is: Samira, aged 34, came to the clinic with a sore throat.
What you must do: Talk to the patient, discuss plan of management with the patient
and address her concerns.

Doctor: What brought you today?

Patient: I have a sore throat.
(P1)
D: Could you tell me more about it? (Explore P1)

SOCRATES
D: When did it start?
P: 7 days ago.
D: Was it sudden or gradual? (onset)
P: Gradual.
D: Is it continuous or comes and goes?
P: Continuous.
D: What type of pain is it? (character)
P: Dull pain.
D: Is there anything that makes it better?
P: No.
D: Is there anything that makes it worse?
P: When I swallow.
D: Has it changed since it started?
P: It's getting worse.
D: Could you rate the pain on a scale of o to 10, with 0 being no pain
and 10 being the worst you have ever experienced? (score)
P: 7.
D: Anything else?
P: I feel feverish (P1)
D: Tell me more about it. (explore)
P: It's been 7 days.
D: Did you measure the temp?
P: No.
D: Did you take anything for it?
P: I took paracetamol and it helped.
D: How much did you take?
P: 1 tab 3 times daily.

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D: Anything else?
P: Yes, I have some lumps and bumps on my neck. (Explore)
D: For how long have you had those?
P: 5 days.
D: Are those painful?
P: Yes, when I touch them.
D: Any lumps and bumps elsewhere on the body?
P: No.
D: Anything else?
P: No.

DDs
D: Any ear-pain or hearing problems?
P: No.
D: Any neck stiffness?
P: No.
D: Any tiredness? (Infectious mononucleosis)
P: No.
D: Any headache? (Infectious mononucleosis)
P: No.
D: Any tummy pain? (Infectious mononucleosis)
P: No.
D: Any diarrhoea? (HIV)
P: No.
(P2)
D: Have you had a similar condition in the past?
P: Yes, last time I had it 6 months back and was given antibiotics.
D: Have you been diagnosed with any medical condition in the past?
P: No.

MAFTOSA
D: Any family history of any significant health issues?
P: No.
D: Are you currently on any medication?
P: No.
D: Are you allergic to any medication?
P: Yes, I'm allergic to penicillin

DESA
D: Do you smoke?
P: No.
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D: Do you drink alcohol?

P: No.
D: Tell me about your diet?
P: Healthy diet.
D: Are you physically active?
P: Yes/No

Sexual history
D: Are you currently sexually active?
P: Yes.
D: Are you in a stable relationship?
P: Yes.
D: Do you practice safe sex?
P: Yes.

Examination
If it’s OK with you, I would like to do a GPE, check your vitals and examine your throat.

Provisional diagnosis
From my assessment I suspect you have tonsillitis. It is an infection and inflammation of
the tonsils caused by a bug or virus.

Management
Senior
For most patients, antibiotics have little effect on the duration of the condition or the
severity of symptoms ; however, I would like to confirm with my senior.

Investigations
A swab test to see if bacteria are causing your tonsillitis (a cotton bud is used to wipe
the back of your throat).
A blood test for glandular fever if symptoms are severe or will not go away.
You should get any test results back within 2 or 3 days.

Symptomatic
Tonsillitis usually gets better on its own after a few days, but to help treat the
symptoms:
get plenty of rest.
drink cool drinks to soothe the throat.
take paracetamol or ibuprofen (do not give aspirin to children under 16)
gargle with warm salty water (children should not try this)

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General advice: To stop these infections spreading:

Stay off work or keep your child at home until you or your child feel better.
Use tissues when you cough or sneeze and throw them away.
Wash your hands after coughing or sneezing.

Safety netting:
If you have a severe sore throat that quickly gets worse or swelling inside the mouth
and throat, difficulty speaking , difficulty swallowing, difficulty breathing , difficulty
opening your mouth come to us immediately.

Follow up.

Note
There are four Centor Criteria that may be used:
1. History of fever.
2. Tonsillar exudates.
3. No cough.
4. Tender anterior cervical lymphadenopathy.
(Consideration of antibiotic prescription should be limited to patients with three or
four criteria).

The National Institute for Health and Care Excellence (NICE) suggests that indications
for antibiotics include:
o Features of marked systemic upset secondary to the acute sore throat.
o Unilateral peri tonsillitis.
o A history of rheumatic fever.
o An increased risk from acute infection (such as a child with diabetes
mellitus or immunodeficiency).
o Acute tonsillitis with three or more Centor criteria present.

SINUSITIS

Where you are: You are FY2 in GP surgery.

Who the patient is: Mr. James Rickman presented with pain in forehead and
Cheeks which started a few days ago.
What you must do: Talk to him, take history and address his concerns.

Doctor: How may I help you today?

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Patient: Doctor I have pain in my forehead and my cheeks. (P1)

D: Tell me more about it? (Explore P1)

SOCRATES
D: Gradual pain or sudden pain?
P: Gradual onset.
D: Character of pain?
P: Dull pain.
D: Radiation of pain?
P: Forehead and cheeks only.
D: Scale the pain 0 to 10
P: 4 or 5.
D: Does anything make it better or worse?
P: No.
D: The pain is constantly present or on and off?
P: It’s constant.

Other symptoms
D: Any discharge from the nose?
P: No.
D: Do you find it difficult to breathe through your nose?
P: Yes.
D: Any loss of smell?
P: No.
D: Anything else?
P: No.

DDs
D: Any fever and flu-like symptoms? (Bacterial or viral)
D: Repeated respiratory infection? (Cystic fibrosis)
D: Repeated gastrointestinal infection?
D: Do you feel pressure in your ears?
D: Do you have throat pain? (Common cold and rhinitis)
D: Are you sneezing?
D: Any headache? (Cluster headache)
D: Any pain in your teeth? (Dental pain)
D: Any rashes, watery eyes? (Hay fever, eczema and atopy)
D: Any lumps and bumps in your body? (cancer)
D: Any weight loss?

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(P2)
D: Have you had a similar condition before?
P: Yes/No
D: Do you have any medical condition?
P: No.

MAFTOSA
D: Are you taking any medications?
P: No.
D: Are you allergic to any medications, OTC, steroids or food?
P: No.
D: Any family history of chronic illness?
P: No.

ICE
D: Do you have any idea of what’s going on with you?
D: Do you have any specific concern?
D: What are your expectations from today's consultation?

Examination
I would like to check your BP, pulse, RR, and temperature, if you don’t mind.
I will also examine your nose and mouth (pharynx for any discharge), any
facial tenderness and swelling. Also, I would like for us to perform an X RAY of your
sinuses.

(The diagnosis of sinusitis is solely based on the history, but examination is done in
case any other abnormality is found.)

Provisional diagnosis
From the information you have given me and from the assessment that we have done it
seems that you have a condition called Sinusitis. Sinusitis is a swelling of the sinuses,
usually caused by an infection. It's common and usually clears up on its own within 2 to
3 weeks. But medicines can help if it's taking a long time to go away.

Management
Senior
Symptomatic:
▪ Plenty of rest
▪ Plenty of fluids
▪ Painkillers, such as paracetamol or ibuprofen
▪ Avoid triggers and smoking

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▪ Clean your nose with a salt water solution to ease congestion

▪ Decongestant nasal sprays or drops to unblock your nose (decongestants should
not be taken by children under 6)
▪ Salt water nasal sprays or solutions to rinse out the inside of your nose.

If not improved after advice and pain killers for 1 week:

Steroid nasal sprays or drops – to reduce the swelling in your sinuses. You might need
to take steroid nasal sprays or drops for a few months. They sometimes cause irritation,
sore throats, or nosebleeds.
Antihistamines – if an allergy is causing your symptoms.
Antibiotics – AMOXICILLIN if a bacterial infection is causing your symptoms and you're
very unwell or at risk of complications (but antibiotics are often not needed, as sinusitis
is usually caused by a virus). If pregnant and allergic or intolerant to penicillin —
erythromycin.

(ENT) specialist
If patient:
• still has sinusitis after 3 months of treatment.
• keeps getting sinusitis.
• only has symptoms on 1 side of their face.

They may recommend surgery in some cases to treat chronic sinusitis which is called
functional endoscopic sinus surgery (FESS). FESS is carried out under general
anaesthetic.

Safety netting
• Severe headache
• Visual changes
• Periorbital oedema
• Altered mental status

Follow up
FACIAL DROOPING

Where you are: An FY2 in GP Surgery

Who the patient is: Mr. Alexander, aged 40 years old, presented to you with a
complaint of drooping of the mouth.
What you must do: Take a history and manage him accordingly.

Doctor: What brought you here today?

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Patient: Doctor I have a problem with my face.

D: Tell me more about it?
P: The right side of my face started drooping on one side.
(P1)
D: Can you tell me a bit more about it? (explore)
P: What do you want to know doctor?
D: When did it start?
P: It started about a day ago.
D Was it gradual or sudden? (onset)
P: Sudden.
D: How has it been since?
P: It’s getting worse doctor.
D: Has anything made it better or worse?
P: No doctor I just came here as it started worrying me.
D: Have you tried taking anything for it before coming here?
P: No.
D: Did you notice it on: one side or both sides of your face?
P: One side.
D: Right or left?
P: Right.

Other symptoms: (Chief complaints of Bell’s):

Any drooling?
Dry mouth?
Loss of taste?
Eye irritation, such as dryness or tears?

DDs
Any recent fever or flu? (ear infections can cause inflammation in the
nerves)
Any weakness in other parts of the body? (TIA)
Any slurred speech? (TIA, stroke)
Peripheral Limb weakness? (GB, Stroke, TIA)
Hearing loss? (cholesteatoma)
Painful ear and/or discharge from ear? (Otitis media)
Rash or joint pain? (Lyme disease and sarcoidosis)
Recurrent vision problem? (MS)
Recurrent weakness? (MS)
Dry mouth? (problem in parotid gland)
Is the weakness more prominent at specific time of the day? (MS)
Any trauma?
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P2
D: Have you had a similar condition before?
P: Yes/No
D: Any chronic illness like DM, HTN, sarcoidosis or cancer?
P: No.

MAFTOSA
D: Are you taking any medication?
P: No.
D: Are you allergic to any medication?
P: No.
D: Do you have family history of chronic illness (Bell’s palsy)?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: Sometimes.
D: How is your diet?
P: It’s a balanced diet.
ICE
D: Do you have any idea what is going on with you?
D: Do you have any specific concern?
D: What are your expectations from today's consultation?

Examination
If you don’t mind, I would like to check your BP, pulse rate, RR and temperature and
also do a neurological examination.
(The physical examination should include a careful inspection of the
ear canal, tympanic membrane, as well as evaluation of peripheral
nerve function in the extremities and palpation of the parotid gland.)

Laboratory testing is not usually indicated. However, because

diabetes mellitus is present in more than 10 percent of patients with
Bell's palsy, fasting glucose or A1c testing may be performed in
patients with additional risk factors (e.g., family history, obesity,
older than 30 years).

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Provisional diagnosis:
From what you have told me and what I have observed I suspect you have a condition
called Bell’s palsy.
Bell's palsy is a peripheral palsy of the facial nerve that results in muscle weakness on
one side of the face. Affected patients develop unilateral facial paralysis over one to
three days with forehead involvement and no other neurologic abnormalities.

Management: (Patients with Bell's palsy should be treated within three

days of the onset of the symptoms)
Senior
Symptomatic:
1. Oral acyclovir:
Because of the possible role of HSV-1 in the aetiology of Bell's palsy, the
antiviral drugs acyclovir and valacyclovir have been studied to determine if they have
any benefit in treatment.
Either, acyclovir 400 mg can be given five times per day for seven days
Or, valacyclovir 1 g can be given three times per day for seven days.
2. Oral prednisolone:
Oral corticosteroids have traditionally been prescribed to reduce facial nerve
inflammation in patients with Bell's palsy. Prednisolone is typically prescribed in a 10-
day tapering course starting at 60 mg per day.
Do not stop the medication on your own. In case you have any side effect of the
medication or worsening please come back to us immediately. We will keep a close
check and regular monitoring of your progress and decrease the dose accordingly.

If he throws a concern that steroids are dangerous- tell him yes they have
certain side effects, but that doesn’t necessarily mean he will have any of them.
Treating the condition at the moment outweighs the risk of side effects as he has come
within 72 hours. Also, it’s a short duration of steroid course and not a lifelong course so
he does not need to worry about long term
effects.

Specialist
o Patients should be monitored for eye irritation and be prescribed eye lubrication.
Patients with corneal abrasions should be referred to an ophthalmologist.
o Surgery In the past, surgical decompression within three weeks of onset has been
recommended for patients who have persistent loss of function (greater than 90
percent loss on electroneurography) at two weeks. The most common complication of
surgery is postoperative hearing loss.

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o Patients with complete paralysis who do not improve in two weeks on medication
should be referred to an otolaryngologist for evaluation for other causes of facial nerve
palsy.

Safety netting
Go back to see a GP if there are no signs of improvement after 3 weeks.
Some cases might need to be treated with surgery.
Living with Bell's palsy can make you feel depressed, stressed, or anxious.
Speak to a GP if it's affecting your mental health.
CALL 999 and come to EMERGENCY if you have:
- Slurred speech
- Weakness in your limbs
- Confusion.

Other Concerns:
P: Will I be alright after the treatment?
D: Approximately 70 to 80 percent of patients will recover spontaneously. However,
treatment with a seven-day course of acyclovir or valacyclovir and a tapering course of
prednisone, initiated within three days of the onset of symptoms, is recommended to
reduce the time to full recovery and increase the likelihood of complete recuperation.
P: How long Bell's palsy last?
D: Most people make a full recovery within 9 months, but it can take
longer. In a small number of cases, the facial weakness can be permanent.
P: How can I prevent Bell’s palsy?
D: Because it's probably caused by an infection, Bell's palsy cannot usually be
prevented. It may be linked to the herpes virus.
You'll usually only get Bell's palsy once, but it can sometimes come back. This is more
likely if you have a family history of the condition.

MUMPS ORCHITIS

Where you are: You are FY2 in GP clinic

Who the patient is: The mother of a 15-year-old boy is here with some
concerns.
What you must do: Talk to her, take history and manage him accordingly.

Doctor: What brought you here today?

Patient: Doctor I’m here for my son.

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D: Can you confirm his name and age please?

P: Yes doctor, his name is James, and he is 15 years old.
D: Is he with us today?
P: No doctor.
D: Okay. Could you please tell me what happened to James?
P: Doctor my son has swelling near and below his ear? (P1)
D: Could you please tell me more about it? (Explore P1)
P: Doctor it started a few days ago but it is now increased and I’m afraid it
might be something serious.
D: Is it the first time he’s had something like this?
P: Yes.
D: Could you please tell me which side it is on
P: Doctor it’s the left side only.
D: When did it was start?
P: A few days ago doctor.
D: Is it painful? (MUMPS)
P: Yes, it is painful.
D: How big is the swelling?
P: (She indicates with hand)
D: Has it changed since it started or is the same?
P: I’m not sure.
D: Any redness or rash over the swelling?
P: I don’t think so.
D: Any discharge from the swelling?
P: No.
D: Any breathing difficulty or swallowing difficulty due to the swelling?
P: I think he’s breathing OK but when he swallows it hurts.

Other symptoms:
D: Any swelling anywhere else?
P: Yes he was embarrassed to tell me but his testicles are also swollen. (MUMPS
ORCHITIS)
D: Any weakness in his face?
P: No.
D: Any hearing loss that he has complained of?
P: No.
D: Any headache?
P: No.
D: Any joint pain? (MUMPS)
P: Yes, I think so.
D: Any flu-like symptoms?
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P: Yes, he has a fever, it started a few days before the swelling.

(explore)
D: Any medications given for the fever or anything else?
P: Yes doctor, I am giving paracetamol twice a day.
D: Any improvement in his condition?
P: No doctor.
D: Has he come into contact with anyone who has similar symptoms?
P: Maybe, I’m not sure.

DDs
D: Any lumps and bumps in his body? (infection/cancer)
P: No.
D: Is he thirsty most of the time? (Sjogren syndrome – dry eyes, itchy eyes,
dry mouth)
P: No.
D: Any rash on the body? (meningitis)
P: No.
D: Any neck stiffness?
P: No.
D: Any lumps and bumps in his neck besides the swelling? Any white
patches over his tonsils? Has he had a sore throat recently? Any change in
voice? (tonsillitis)
P: No.

(P2)
D: Has he had a similar condition before?
P: No.
D: Any past medical condition?
P: No.

MAFTOSA
D: Is he taking any medications?
P: No, just paracetamol.
D: Is he allergic to any medications?
P: No.
D: Does he have any family history of a similar or a chronic condition?
P: No.
D: Has he travelled anywhere recently?
P: No.
D: Did he have all his vaccinations as a child?
P: No, I didn’t think he needed them.
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ICE
D: Do you have any idea of what is going on with your son?
D: Do you have any specific concern?
D What are your expectations from today's consultation?

Examination
Ideally, I would like to check your son’s vitals, I would do a GPE and would also
examine the swelling.

Provisional diagnosis:
From the information you have given us and what we have assessed I suspect your son
might have a condition called Mumps which has developed into Mumps Orchitis. This is
a complication of Mumps, which causes swelling in the testes in post-pubescent males.
Mumps is a contagious viral infection that used to be common in children
before the introduction of the MMR vaccine.
Mumps is most recognizable by the painful swellings in the side of the face
under the ears (the parotid glands), giving a person with mumps a distinctive "hamster
face" appearance.

Management:
There's currently no cure for mumps, but the infection should pass within 1 or 2 weeks.
Mumps is a notifiable condition which means I will have to notify your local health
protection team (HPT). The HPT will arrange for a sample of saliva to be tested to
confirm or rule out the diagnosis.

Senior.
Symptomatic:
• Getting plenty of bed rest and fluids.
• Using painkillers, such as ibuprofen and paracetamol (aspirin should not be
given to children under 16).
• Applying a warm or cool compress to the swollen glands to help relieve
pain.

Safety netting:
If you notice any neck stiffness, rash, high non-subsiding fever, difficulty
in breathing or swallowing due to the swelling come back right away.

Follow up

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Concerns:
P: How does mumps spread?
D: Mumps can spread in the same way as colds and flu: through infected droplets of
saliva that can be inhaled or picked up from surfaces and transferred into the mouth or
nose.
A person is most contagious 1 – 2 days before the symptoms develop and
for 9 days afterwards. During this time, it's important to prevent the infection spreading
to others, particularly teenagers and young adults who have not been vaccinated.

P: How can we prevent mumps?

D: We can prevent it by:
• regularly washing your hands with soap.
• using and disposing of tissues when you sneeze.
• avoiding school or work for at least 5 days after your symptoms first develop.
MMR vaccine: Your child should be given 1 dose when they're around 12 to 13 months
and a second booster dose at 3 years and 4 months.

P: What are the complications of mumps?

D: Meningitis / Swelling of testes and ovaries.

BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)

Where you are: You are an FY2 in GP clinic.
Who the patient is: Mr. Liam Jackson, aged 45, has come to you with
dizziness.
What you must do: Please talk to him, assess him, and address his concerns.
Don't forget > (Sudden change in head position, lasts from seconds to minutes, nausea,
no vomiting)
BPPV is a specific diagnosis, and each word describes the condition:
- Benign: this means it is not life-threatening, even though the symptoms can be very
intense and upsetting.
- Paroxysmal: It comes in sudden, short spells.
- Positional: Certain head positions or movements can trigger a spell.
- Vertigo: Feeling like you're spinning, or the world around you is spinning.

D: How can I help you?

P: I feel dizzy.
(P1)
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D: What do you mean by feeling dizzy?

P: I feel everything around me is spinning.
D: Tell me more about it. (Explore P1)
P: What would you like to know?

ODIPARA
D: Since when have you been feeling dizzy?
P: About 4 or 5 days.
D: Was it sudden or gradual?
P: Sudden.
D: How many times has it happened?
P: 3 times.
D: How long did the episode last?
P: About 30 seconds.
D: Is there anything that triggers the dizziness?
P: When I move my head right, left, or upwards, I feel dizzy.
D: Anything else?
P: I feel sick.
D: Have you vomited?
P: No.
D: Anything else?
P: No.

DDs
Before
D: Any fever or flu-like symptoms recently? (Vestibular neuritis)
P: No.
D: Any motion sickness?
P: No.
D: Any balance problem?
P: No.
D: Any blurry vision or double vision? (Acoustic Neuroma)
P: No.
D: Any numbness on your face. (Acoustic Neuroma)
P: No.
D: Any hearing loss?
P: No.
D: Any ringing sensation in your ears? (Meniere's/Acoustic Neuroma)
P: No.
D: Did you hurt yourself?
P: No.
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D: Any weight loss?

P: No.

During
D: Any jerky movements?
P: No.
D: Any loss of consciousness?
P: No.

After
D: How did you feel after the incident?
P: Fine.
D: Any confusion?
P: No.
D: Any drowsiness?
P: No.
D: Any nausea or vomiting right after?
P: I felt nauseous but didn't vomit.

(P2)
D: Have you had a similar condition before?
P: No.
D: Any other medical conditions?
P: No.

MAFTOSA
D: Are you taking any other medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any surgeries or hospitalisations?
P: No.
D: Any family history with similar conditions?
P: No.

DESA
D: Do you drink alcohol?
P: Yes/No
D: Do you smoke?
P: Yes/No
D: What about your diet?
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P: My diet is very good.

D: What do you do for a living?
P: Travel agent.
D: Is it stressful?
P: Yes/No
D: Who do you live with?
P: I live with my wife.

Examination
Is it OK with you if I check your vitals and do the neurological, ear examination
and perform DixHallpike maneuver?
I would also like to send for some initial investigations including routine blood
tests.

Examiner says: Ear examination is normal and Dix-Hallpike manoeuvre is

positive upward and left direction.

Provisional diagnosis:
From my assessment, you are experiencing something which we call Benign Paroxysmal
Positional Vertigo (BPPV). BPPV is a condition of the inner ear. It is a common cause of
intense dizziness (vertigo). It is unpleasant but it is not serious. It is triggered by certain
movements.

Management
BPPV is a condition that goes away on its own after several weeks or months.

Senior.

Symptomatic:
Epley Manoeuvre: This is done by a series of 4 movements of the head. After each
movement, the head is held in the same place for 30 seconds or so. Epley manoeuvre is
successful in controlling the symptoms in about 8/10 cases with just 1 treatment.
Otherwise, repeated treatment session in a week after may be recommended.
Brandt-Daroff Exercises: It is recommended if Epley manoeuvre does not work. These
exercises involve a different way of moving the head as compared to the Epley
manoeuvre.

Lifestyle
▪ Get out of bed slowly and avoid jobs around the house that involve looking
upwards.
▪ Take care in moving your head during daily activities.

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▪ Sit down immediately when you feel dizzy.

▪ Try to relax as anxiety can make vertigo worse.
▪ Do not bend over to pick things up, squat to lower yourself instead.

Safety netting
If you have sudden and unexpected attacks of dizziness, DVLA recommends that you
should stop driving.
If you use ladders, operate heavy machinery or drive, you should inform your employer
as it could pose a risk to you or others.

VESTIBULAR NEURITIS

Where you are: You are an F2 in A&E.

Who the patient is: Harlow, aged 22, was out shopping in a supermarket, she turned
her head and had a sudden episode of dizziness.
What you must do: Talk to the patient, assess her condition. Discuss the initial plan of
management with the patient.

Don't forget (viral infection few weeks before, lasts from hours to days, nausea,
vomiting and hearing loss)

Doctor: What brought you to the hospital?

Patient: I was at the supermarket and when I turned my head I felt dizzy, I
tripped and fell, someone helped me to get up and then she called the ambulance.
D: How are you feeling now?
P: I feel dizzy. (P1)
D: Are you comfortable speaking to me, would you prefer to lie down?
P: No, I am OK thank you.
D: So, what do you mean by dizziness exactly?
P: It feels like the room is spinning.

ODIPARA
D: When did this start?
P: 1-2 hours ago.
D: Is it continuous or does it come and go?
P: It is continuous.
D: Has it changed?
P: No.
D: Is anything making it better?

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P: No.
D: Anything making it worse?
P: No.
D: Does it change when you move your head and neck?
P: No.

Explore the fall

Before
D: Any other symptom before having the fall?
P: No.

During
D: Did you make any jerky movements?
P: No.

After
D: Did you go unconscious after having the fall?
P: No.
D: Did you feel sleepy or confused?
P: No.
D: By any chance did you injure yourself?
P: No.
D: Did you bang your head on the floor?
P: No.
D: Anything else?
P: I am feeling sick. (P1, explore)
D: When did that start?
P: It started with the dizziness.
D: Did you vomit?
P: No.
D: Anything else?
P: No.
DDs
D: Any fever or flu-like symptoms? (Vestibular neuritis)
P: Doctor. 10 days ago, I had a sore throat and I took Paracetamol for it.
(+ve finding)
D: Any ear pain? (Labyrinthitis)
P: No.
D: Any feeling of stuffiness in the ear?
P: No.
D: Any ringing sounds in the ear? (Meniere's Disease)
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P: No.
D: Any problem with hearing?
P: No.
D: Do you have a headache? (Meningitis, Migraine)
P: No.
D: Any rash by any chance? (Meningitis)
P: No.
D: Any numbness, pain, or weakness on one side of the face? SOL (Acoustic
Neuroma)
P: No.
D: Any visual problem such as blurry vision or double vision? SOL (Acoustic Neuroma)
P: No.
D: Any weakness in your arm or speech problem? (TIA)
P: No.

(P2)
D: Has anything like this happened before?
P: No.
D: Have you been diagnosed with any medical condition in the past? DM, Heart
diseases or ear problem?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any family history of a similar condition or chronic illness?
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: Occasionally.
D: How is your diet?
P: It’s fine.
D: Are you physically active?
P: Not much.
D: What you do for a living?
P: I work as state agent.
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D: With whom do you live?

P: I live with my family.

Examination
Is it OK with you if I check your vitals and examine your heart, ENT examination,
hearing test and central nervous system examination?
I’d also like to send for some initial investigations including routine blood test and ECG.

Examiner says: ECG is normal and blood test results are awaited.
Provisional diagnosis

Provisional Diagnosis:
From our assessment, it seems like you have a condition called vestibular neuritis. In
this condition one of the nerves in the brain, which sends signals from the inner ear to
the brain, is inflamed. This nerve is responsible for maintaining our balance and our
hearing.
You had the flu a few days ago. Sometimes the bug that causes the flu can affect this
nerve and that's why you may be experiencing these symptoms.

We did some examinations, and everything seems to be normal. We did an ECG and it
was normal also.

Management
We will keep you in A&E for a while to take a closer look at you and reassess your
symptoms.
Once your symptoms improve and you can tolerate fluids, we will be able
to send you home with medication as this condition can be managed at home.

Investigations:
We will do some blood tests to check anaemia or if there is any bug in your
blood.

Senior

Symptomatic
The symptoms of vestibular neuritis usually settle over a few weeks, even without
treatment. However, there are some self-help measures you can
take to reduce the severity of your symptoms and help your recovery.
Medication doesn't speed up your recovery, but may be prescribed to help
reduce the severity of your symptoms.

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Self-help for vestibular neuritis:

▪ If you're feeling nauseous, drink plenty of water to avoid becoming
dehydrated. It's best to drink little and often.
▪ 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 should have passed
and you should no longer feel dizzy all the time.
▪ You can do several things to minimise any remaining feelings of
dizziness and vertigo. For example:
▪ Avoid alcohol, avoid bright lights and try to cut out noise and
anything that causes stress from your surroundings.
▪ You should also avoid driving, using tools and machinery, or
working at heights if you're feeling dizzy and unbalanced.

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.
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 and busy roads etc. These can cause feelings of
dizziness, because you're moving your eyes around a lot It can help to keep your eyes
fixed on objects, rather than looking around all the time.

Medication for vestibular neuritis:

Medications for severe symptoms, such as:
Benzodiazepine - which reduces activity inside your central nervous system,
making your brain less likely to be affected by the abnormal signals coming from
your vestibular system.
Antiemetic - which can help with symptoms of nausea and vomiting.

Specialist
If your symptoms persist or you develop any other symptom, your GP can
refer you to the specialist and they may need to do some further investigations such as
CT Scan or MRI, to exclude other causes.

Safety netting:
D: Is there anyone who can pick you from the hospital and get you home
safely?

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D: If you develop double vision, slurred speech. you start walking funny, weakness or
numbness please come back to the hospital.

MENIERE'S DISEASE (DIZZY SPELLS)

Notes about Meniere's disease:
Symptoms:
Progressive episode of severe vertigo, tinnitus, hearing loss.
Feeling of fullness or congestion in the ear.
Usually, unilateral, comes on in middle age.
Stages:
Early-stage disease: vertigo attacks, which are sudden, unpredictable, and
accompanied by nausea, vomiting, and aural fullness lasting 20 mins to 24 hrs.
Middle-stage disease: vertigo and fluctuating hearing loss. Tinnitus may worsen.
Periods of remission are variable.
Late-stage disease: progressive hearing loss that is non-fluctuant. Balance issues
particularly in the dark. Tinnitus may be a significant symptom.
Causes:
The exact cause of Meniere’s disease is unknown, but it is associated with a
problem with pressure deep inside the ear.

Where you are: You are an FY2 in Medicine.

Who the patient is: Mr. Benjamin Rao, aged 30, has come to you with
complaint of dizziness.
What you must do: Talk to him, manage, and address his concerns.
Don't forget (pressure or fullness in ear, lasts from half to one hour, DVT)

Doctor: How can I help?

Patient: I have been feeling dizzy. (P1)
D: Tell me more about it? Explore
P: I’ve been like this for a few days?

ODIPARA
D: Did it start suddenly or gradually?
P: Suddenly.
D: Does it come and go?
P: Yes.
D: Is it becoming worse by anything?
P: It gets worse when I stand up suddenly.
D: Does anything make it better?

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P: It gets better when I lie down.

D: Anything else? Any nausea?
P: Yes.
D: Any hearing loss?
P: I had hearing loss couple of days back which lasted for few hours. (+ve
finding)
D: Was it in one ear or both?
P: In my left ear.
D: Any ringing in your ears?
P: Yes (+ve finding)
D: Any earache?
P: No.
D; Any discharge from your ear?
P: No.

(P2)
D: Has anything like this happened to you before?
P: Yes, 1 week ago.
D: How did it resolve?
P: It resolved on its own.
D: Have you been diagnosed with any medical conditions in the past?
P: No.
D: Any DM or HTN?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Do you have any allergies?
P: No.
D: Any hospitalisations or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: Have you travelled anywhere recently? (flight)
P: No.

DESA
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
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P: Yes/no
D: Do you take any caffeine?
P: Yes/No
D: Tell me about your diet?
P: I eat everything, its fine.
D: Do you do physical exercise?
P: I am active sometimes, but other times lazy.
D: What do you do for a living?
P: Office job.
D: Who do you live with?
P: I live alone.
D: Do you drive?
P: Yes/No

Examination
Is OK if I check your vitals, do GPE, and examine your ear? I will be using an instrument
called an otoscope to look inside the ear, and I would also like to do hearing tests and
balance tests along with a specialised test called audiometry. I would also like to do
blood tests.

Provisional diagnosis:
From my assessment I suspect a condition called Meniere’s disease. It is a
condition of the inner ear that causes sudden attacks of vertigo, tinnitus and hearing
loss.

Management
Senior.

Specialist:
Referral to (ENT) specialist to confirm diagnosis. He will check if you have:
1. Vertigo, with at least 2 attacks lasting 20 minutes within a short space of time.
2. Fluctuating hearing loss, which is confirmed by a hearing test
3. Tinnitus or a feeling of pressure in your ear.

Symptomatic and lifestyle

There is no cure for this disease. However, symptomatic treatment will be given.
The 2 medicines usually recommended by GPs are;
Prochlorperazine, which helps relive severe nausea and vomiting.
Antihistamines, which help relieve mild nausea, vomiting and vertigo.

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If symptoms are severe enough, people may require hospital admission for intravenous
(IV), labyrinthine sedatives and fluids to maintain hydration and nutrition.
A trial of Betahistine can be considered to reduce the frequency and severity of attacks
of hearing loss, tinnitus, and vertigo.

You may be offered:

Counselling – including cognitive behavioural therapy (CBT)
Relaxation therapy – including breathing techniques and yoga.

Lifestyle measures:
Meniere’s disease can cause you to lose balance. At the first sign of attack, you should:
Take your vertigo medicine if you have one.
Sit or lie down.
Close your eyes, or keep them fixed on a still object in front of you.
Do not turn your head quickly.
If you need to move, do so slowly and carefully.
Once the attack is over, try to move around to help your eyesight and other
senses compensate for the problems in your inner ear.
Things that help:
• Diet
• Eating a low-salt diet
• Avoiding alcohol
• Avoiding caffeine
• Stopping smoking
Consider the risks before doing activities such as:
• Driving
• Swimming
• Climbing ladders or scaffolding
• Operating heavy machinery
Safety netting:
You may also need to make sure someone is with you most of the time in
case you need help during an attack.
Driving: You should not drive when you feel dizzy or if you feel an attack
of vertigo coming on. You must inform DVLA.
Flying: Most people with Meniere’s disease have no difficulty with flying.

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UNILATERAL TINNITUS
Causes of tinnitus:
Some form of hearing loss
Meniere's disease
Chronic illness: diabetes, thyroid disorders or multiple sclerosis
Anxiety or depression
Taking certain medicines – tinnitus can be a side effect of some chemotherapy
medicines, antibiotics, NSAIDs and aspirin
Tinnitus in one ear:
A tumour called an acoustic neuroma occasionally causes tinnitus. This is usually
persistent and in one ear only. If you get the noise only in one ear, it is particularly
important that you consult a doctor, so this can be ruled out. ENT >Audiometry
>MRI/CT scan

Where you are: You are an FY2 in GP.

Who the patient is: Mr. Kieran Richards, aged 40, has come to you with complaint of
hearing noises.
What you must do: Talk to him and address his concerns.

Doctor: How can I help you?

Patient: I have been hearing noises in my ear. (P1)
D: Which ear?
P: the right ear.
D: Tell me more about it?
P: It’s like a ringing in my ear.

ODIPARA
D: When did it start?
P: It started 3 years ago.
D: Did it start suddenly or gradually?
P: Gradually.
P: Does it come and go?
P: No, it is present all the time.
D: What does the noise sound like?
P: Like a ringing sound.
P: Is it becoming worse by anything?
P: It gets worse when I go to sleep.
D: Does anything make it better?
P: Yes/No
D: Anything else?

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P: I don’t think so.

D: Any hearing loss?
P: No.
D: Any vertigo/dizziness?
P: No.
D: Any earache?
P: No.
D: Any discharge from the ear?
P: No.
D: Does the ringing sound coincide with your pulse?
P: No.

(P2)
D: Have you had a similar kind of problem in the past?
P: No.
D. Have you been diagnosed with any medical condition in the past?
P: No.

MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: Any recent travel? (flight)
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: I eat everything, its fine.
D; Tell me about your physical activity?
P: I am active.
D: What do you do for a living?
P: Office job.
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D: Do you listen to loud music or go to concerts a lot?

P: No.

Examination
I would like to check your vitals and examine your ear if you don’t mind. I will be using
an instrument called an otoscope to look inside the ear, and I would
also like to do hearing tests and balance tests. We will also do some initial
investigations.

Provisional diagnosis
From what you have told me and from my examination, I suspect that you have a
condition called tinnitus. Tinnitus is the name for hearing noises that are not caused by
sounds coming from the outside world. It is common and not usually a sign of anything
serious. It might get better by itself and there are treatments that can help.

Management
Specialist: You may be referred to a specialist as a precaution for further tests such as
an MRI/ CT scan to make sure your tinnitus is not caused by a tumour or anything
sinister. You may also be referred for a hearing test to see if your tinnitus is linked to
any hearing loss.

Medicine: When the cause for the tinnitus is unknown in a patient, there is no way to
treat it, so we can only treat the symptoms.

Things you can try to help cope with tinnitus:

DO
Try to relax – deep breathing or yoga may help.
Try to find ways to improve your sleep, such as sticking to a bedtime routine or cutting
down on caffeine.
Try to avoid things that can make tinnitus worse, such as stress or loud background
noises.
Try self-help books or self-help techniques to help you cope better from the British
Tinnitus Association (BTA).
Join a support group – talking to other people with tinnitus may help you cope.

DON’T
Do not have total silence – listening to soft music or sounds (called sound therapy) may
distract you from the tinnitus.
Do not focus on it, as this can make it worse – hobbies and activities may take your
mind off it

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If the cause of your tinnitus is unknown or cannot be treated, we may refer you for a
type of talking therapy.
This could be:
Tinnitus counselling – to help you learn about your tinnitus and find ways of coping
with it.
Cognitive behavioural therapy (CBT) – to change the way you think about your tinnitus
and reduce anxiety.
Tinnitus retraining therapy – using sound therapy to retrain your brain to tune out and
be less aware of the tinnitus.
Tinnitus retraining therapy may be available on the NHS for people with severe or
persistent tinnitus. It's unclear if tinnitus retraining therapy works for everyone. It's
widely available privately.
If tinnitus is causing you hearing loss, hearing aids may be recommended.

Safety netting:
Come back if your tinnitus is bothering you – for example, it's affecting your
sleep or concentration or is making you feel anxious and depressed.
You have tinnitus that beats in time with your pulse.

ACOUSTIC NEUROMA (CN VIII)

Where you are: You are an F2 in GP surgery.
Who the patient is: Mrs. Selina Richards, aged 50, presented with a problem
in her ear. She has come to you for the first time.
What you must do: Please talk to the patient, take focused history, do necessary
examination, and discuss your initial plan of management with the patient.

Doctor: What brought you today?

Patient: I can't hear properly from my ear. (P1)
D: Could you please tell me more? Explore
P: It’s my left ear.
D: Since when have you been having this problem?
P: The last few months.
D: Is it same or getting worse?
P: It is getting worse.
D: Did anything happen when it started?
P: No.
D: Any loud sound?
P: No.
D: What about your other ear?
P: The other ear is fine.
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D: Anything else? Any dizziness?

P: I feel unsteady when I am standing on the ground. I feel wobbly.
D: Do you feel sick?
P: No.
D: Any motion sickness?
P: No.
D: Do you often have to ask people to repeat themselves when they are talking to you?
P: No.

DDs
D: Do you have a sore throat, fever or flu-like symptoms?
P: No.
D: Do you have any pain or discharge from your ear? (Infection-otitis media or other
viral illness)
P: No.
D: Any numbness or weakness on one side of your face?
P: No.
D: Any blurry vision or double vision? (Acoustic neuroma)
P: Yes/ No
D: Any vertigo?
P: Yes/ No
D: Any ringing sounds in your ear? (Meniere’s disease)
P: No.
D: Have you been swimming recently?
P: No.

(P2)
D: Have you had a similar condition before?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any ear problem?
P: No.
MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Are you allergic to any type of food or medication?
P: No.
D: Any family history of chronic illness or ear condition?
P: No.
D: Have you undergone any surgical procedures in your ear?
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P: No.
D: Recent flight travel? (Barotrauma)
P: No.

Examination
D: I would like to check your vitals, examine your ear and do some
hearing tests. Is that, OK?

Provisional diagnosis
From my assessment it seems like you have a condition called sensorineural hearing
loss. It is a problem with your inner ear and the nerves that supplies this part of the ear.
There can be many reasons for it and one of them could be an Acoustic Neuroma.
An acoustic neuroma is a type of non-cancerous (benign) brain tumour. It
can cause problems with hearing and balance.

Management
Senior.
Investigations
We need to do some tests like MRI and CT scan of the brain to confirm
diagnosis.
Specialist
We will refer you to specialist. Small tumours often just need to be monitored with
regular MRI scans.
The treatments are generally only recommended if scans show it's getting
bigger. 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.
It is difficult for people with sensorineural hearing loss to regain their
hearing. But most people find sensorineural hearing aids very helpful. We
can offer you a large variety of hearing aids.

Safety netting: Patient needs to inform the DVLA if they drive.

Follow up.

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DERMATOLOGY

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Dermatology
Overview of Dermatology structure:

1. Always start any skin conditions with psychosocial aspect:

• How is it affecting your life?
• What do you do for a living?
• Any impact on your job?
• How is your mood? (Important to ask and assess suicidal risk if low mood).
2. History

➢ Skin lesion (P1)

− Since when? What made you come now?
− Site? Anywhere else?
− Size? Any change in size?
− Colour? Any change in colour?
− Shape? Any change in shape?
− Is it bleeding?
− Is it itchy? Painful?
− Any discharge?

➢ Related symptoms:

− Any fever?
− Have you shown it to any doctor?
− Have you used anything on it?
− Any joint pain? Eye problem?

➢ In any rash exclude:

− Meningitis
− Anaphylaxis

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➢ P2
• Same lesion before
• Medical conditions:
− DM & COPD (fungal infection)
− Asthma (eczema)

3. Always ask

• FLAWS
• STI:
− Sun exposure? Sun beds? If job involves sun exposure?
− Trauma
− Insect bite

• Family hx of skin conditions

• Contact hx
• Travel hx?

4. On examination always:

• Observations
• Skin lesion
• Lymph nodes (important)
• BMI if weight loss

5. Provisional diagnosis

• If cancer is suspected but not confirmed:

From the information you have given to me and according to my examinations (Always
briefly mention the positive findings you have found in Hx and Examinations), I suspect
that:
o Best case scenario, it could be something as simple as an infection.

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o Worst case scenario, it could be something sinister as you mentioned you

have…...… Suspicious Sx...…..so, I would like to make sure that we are not missing
something serious.
6. Management:

• Don’t forget urgent referral 2 weeks to dermatologist (cancer).

• Senior: if in dermatology department, I will talk to my senior to discuss taking a
biopsy.
• Investigations:
− Blood in all
− Scraping fungal
− Biopsy cancer
• Symptomatic (according to the lesion)
− DESA
− Smoking
− Sun exposure
• Specialist (skin specialist )
− Fungal → skin scraping
− Cancer → biopsy
− Benign → for removal by laser, cautery , freeze or simple surgery.

• Safety netting:
− Benign
> Asymmetry
> Bleeding
> Colour
> Discharge
− Malignant: There are already changes so safety for metastasis (lumps &
bleeding anywhere)
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> Bleeding anywhere

> Breathing difficulty
> Back pain
> Bone aches
− Fungal
> Contact
> Wash towels, hands, bed sheet
> Don’t share clothes
> Make sure if patient has pets at home to treat pets and wash
hand before and after touching.

Urticaria (Hives )
Where you are: You are an FY2 working in General Practice
Who the patient is: Mrs. Elaine Adams, mother of 5-year-old Colton has some concerns.
What you must do: Take focused history, address mother’s concerns and discuss the
appropriate management plan.

Doctor: Hello my name is Dr…, I am one of the junior doctors in this GP clinic. How can I
help you?
Patient: My son has rash on his whole body (P1)
Dr: I am sorry to hear about that. Please tell me more about it. (Reflect, open Qs) then
ODIPARA
Pt: It has happened 2-3 times. Once, after his shower and this time he was playing in
the garden. (When, What Inc.)
Dr: For how long does it stay? (Duration)
Pt: It disappears after a few minutes or an hour.
Dr: Can you describe where exactly they appear? Site
Dr: Do you remember the shape?
Pt: It was red patches.
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Dr: How about their size?

Pt: Not sure doctor they were of different sizes.
Dr: Is it itchy?
Pt: Yes.
Dr: Is it painful?
Pt: No.
Dr: Is it bleeding/any discharge?
Pt: No.
Dr: Any fever? (Meningitis)
Pt: No.
Dr: Any shortness of breath? (Anaphylaxis)
Pt: No.
Dr: Any wheeze?
Pt: No.
Dr: Any swelling of face?
Pt: No.
Dr: Any dizziness?
Pt: No.
Dr: Does he have any long-standing health problems? (Or ask specifically about
asthma.) (P2 medical conditions)
Pt: No.
MAFTOSA
Dr: Is he using any medication?
Pt: No.

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Dr: Any allergies to food or medicine?

Pt: No.
Dr: Family history of asthma or allergy?
Pt: No.
Dr: Any one in family with similar symptoms?
(Contact)
Pt: No.
(BIRDDD)
Dr: How was his birth?
Pt: Fine.
Dr: Is he up to date with his jabs?
Pt: Yes.
Dr: How is his development overall?
Pt: It is normal.

Examination

Image is given when asked to examine.

Diagnosis
Dr: (Explain positive findings in Hx and Examinations) From what you have told me you
mentioned a recurrent and itchy rash that usually happens after a shower or after
playing in the garden. We have assessed your little one and we found some raised, red
raised spots. We think that he got this rash due to a condition called urticaria. It is an
allergic rash that develops on exposure to some triggers, are you following so far? Do
you have any CONCERNS
Pt: Is it contagious?
Dr: No, it is not contagious
Pt: Can my child go to his school?
Dr: Absolutely once he feels better.

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Pt: So what can you do for him?

Management

Senior
General advice:
> In many cases, treatment isn't needed for urticaria, because the rash often gets
better within a few days.
> Try to find out what triggers hives for you, so you can avoid those triggers. This
may help prevent an episode of hives.
❖ Eating certain foods.
❖ Contact with certain plants, animals, chemicals and latex.
❖ Cold – such as cold water or wind.
❖ Hot, sweaty skin – from exercise, emotional stress or eating spicy food.
❖ A reaction to a medicine, insect bite or sting or some infections as
common cold.
> Non-specific aggravating factors should be minimised, such as overheating,
stress, and medication likely to cause urticaria (eg, non-steroidal anti-
inflammatory drugs (NSAIDs)).

Medications: Symptomatic

> Topical: Topical anti-pruritic agents such as calamine lotion or topical menthol
1% in aqueous cream may help ease symptoms.
> Systemic: Non-sedating antihistamines are the core treatment. (Cetirizine,
loratadine and fexofenadine) are usual choices.
> Where symptoms are severe, a short course of oral steroids may be appropriate.

Specialist
• If hives do not go away with treatment, you may be referred to a skin specialist
(dermatologist) for second-line treatment options ( as montelukast or
omeprazole ).
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• If urticaria is painful and persistent, refer for biopsy and histological diagnosis.

Follow up: We will arrange a follow up in a month.

Safety netting in the meantime Come to the A&E immediately if he feels anything like:
− Very high fever with rash and neck pain.
− Wheezes.
− Tightness in his chest or throat.
− Trouble breathing or talking or his mouth, face, lips, tongue or throat start
swelling.

NB: Urticarial Skin lesion:

− raised, red patches or raised spots.

− Hives can be different sizes and shapes and appear anywhere on the
body in both adults and children.

− The rash is often itchy and sometimes feels like it's stinging or burning

− May be associated with swelling of the soft tissues of the eyelids, lips
and tongue (angio-oedema).

− Duration, symptoms develop and resolve in hours and days (acute ),

rash persists for few weeks ( chronic ).

Chicken Pox

Where you are: You are an FY2 working in a GP clinic.

Who the patient is: Lippy Harrison, the mother of Robin Harrison aged 3 years old, has
come to the clinic as her son is not feeling well.
What you must do: Take focused history, address the patient’s concerns and discuss the
plan of management accordingly.

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Doctor: Hello my name is doctor (name)… Can I get your full name please—can I
confirm your little one’s full name and date of birth as well….. How can I help?
Patient: My child is unwell (fever and rash all over the body since yesterday)
2 complaints explore both
Dr: Can you please tell me what happened? Open Qs then ODIPARA
Pt: He was fine 3 days ago until he got a fever. Onset/Duration
Dr: Did you measure his temperature? Fever
Pt: No doctor.
Dr: What did you do to bring it down?
Pt: We went to the GP and he gave her Calpol and referred us to the hospital.
Dr: Does he have any cough? Sputum?
Pt : No
Dr: You mentioned he has rash as well?
Pt: Yes.
Dr: When did you notice it? Onset/duration
Pt: 3 days ago.
Dr: Where on his body did it start? Site
Pt: On his chest.
Dr: Did you notice its size or shape?
Pt: They were red spots.
Dr: Did they change afterwards? (Progression/any change)
Pt: They spread all over and some became blisters.
Dr: Do they emit any discharge? Bleeding?
Pt: No.
Dr: Is there any itching?
Pt: Yes.
Dr: Is he crying? (Painful)
Pt: Yes, a lot.

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Dr: Have you noticed if he is shying away from light or cries while moving his neck?
Meningitis
Pt: No.
Dr: Have you noticed any difficulty in breathing? Anaphylaxis
Pt: No.
Dr: Any vomiting?
Pt: No.
Dangerous Sx and Dehydration Sx:
Dr: Do you feel that his mouth is dry?
Pt: No.
Dr: Does he have any problems with his wee? Has he been weeing normally today?
Pt: He’s been weeing fine.
Dr: Have you noticed any tummy pain or change in his poo?
Pt: No.
Dr: Any diarrhoea?
Pt: No.

P2+MAFTOSA
Dr: Has this ever happened before?
Pr: No, this is the first time.
Dr: Has he been diagnosed with any medical condition in the past?
Pt: No.
Dr: Is he taking any medications including OTC or supplements?
Pt: No.
Dr: Any allergies from any food or medications?
Pt: No.
Dr: Any previous hospital stays or surgeries?

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Pt: No.
CONTACT
Dr: Has anyone in your family been diagnosed with any medical condition or developed
similar Sx?
Pt: No.
Dr: Who looks after him?
Pt: I do.
Dr: May I ask who lives with you at home?
Pt: Just his father and sister.
Dr: By any chance are you pregnant?
Pt: No.
BIRDDD
Dr: How was Colton’s birth?
Pt: It was a normal vaginal delivery.
Dr: Was he born full-term?
Pt: Yes.
Dr: How much was his birth weight?
Pt: I can’t remember but it was normal.
Dr: Are you happy with his red book?
Pt: Yes.
Dr: Is he up to date with all his jabs?
Pt: Yes.
Dr: Has he received any recent jabs?
Pt: No.
Dr: Is he feeding well? Diet
Pt: Yes/Not much
Dr: Since when?
Pt: Since his fever.

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On Examination
• Observation
• Rash
• Check signs meningism

1. Chickenpox starts with red spots. They can appear anywhere on the body and
might spread or stay in a small area.

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2. The spots fill with fluid and become blisters. The blisters may burst.

3. The spots scab over. New spots might appear while others are becoming blisters or
forming a scab.

Management:
Diagnosis:
From what you have told me and from my examinations as well (Explain briefly positive
findings) I am suspecting your child has Chickenpox. It’s a type of viral infection with
caused by a virus called varicella that as you mentioned starts with red spots that can
appear anywhere on the body and might spread or stay in a small area. The spots fill
with fluid and become blisters. The blisters may burst. The spots scab over. New spots
might appear while others are becoming blisters or forming a scab. It may take a few
weeks 1-3 to develop Sx after infection.
Senior
Symptomatic

• Medications:

− Paracetamol to help with pain, fever and discomfort.

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− A soothing cream (emollient) may help the itch. Calamine lotion is the most
popular one.
− Sedating antihistamine (liquid medicine) may help with sleep if itch is a problem.
This can be used in children over 1 year old. Give a dose at bedtime.
Chlorphenamine (Piriton®) is the one most commonly used.
− Extra treatment such as acyclovir is given for children have a higher risk of
developing complications from chickenpox (such as heart , lung disease , taking
steroids or less than 1 month ).

DO

− Drink plenty of fluids (try ice lollies if your child is not drinking) to avoid dehydration.
− Put socks on your child's hands at night to stop them scratching their spots and cut
your child's nails.
− Bathe in cool water and pat the skin dry (do not rub).
− Dress him in loose clothes.

DON’T
− Do not use ibuprofen unless advised to do so by a doctor, as it may cause serious
skin infections.
− DO NOT GIVE ASPIRIN TO CHILDREN UNDER 16
− Do not be around pregnant women, newborn babies and people with a
weakened immune system, as chickenpox can be dangerous for them.

Safety netting
You'll need to stay away from school, nursery or work until all the spots have crusted
over. This is usually 5 days after the spots appear. Chickenpox is infectious from 2 days
before the spots appear, until they have all crusted over – usually 5 days after they first
appear.
Although serious complications are rare, it is best to be watchful. See us if your child
develops any worrying symptoms that you are unsure about such as:
− Breathing problems.
− Weakness such as a child becoming wobbly on his/her feet.
− Drowsiness.
− Fits.

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− Pains or headaches which become worse despite paracetamol.

− Being unable to take fluids, due to a severe rash in the mouth.

Follow up after a 1 week

The following groups, should see a doctor urgently if they have been in
contact with chickenpox or have symptoms of chickenpox:

− Children (babies) less than 1 month old.

− Children with a poor immune system. For example, children with
leukemia, immune diseases or HIV/AIDS.
− Children taking certain medication such as steroids, immune-
suppressing medication, or chemotherapy.
− Children with severe heart or lung disease.
− Children with a severe skin condition.

4 POINT RECAP:

1) EXPLORE FEVER AND RASH

2) EXCLUDE DANGEROUS SX OF MENINGITIS AND ANAPHYLAXIS
3) CONTACT AND PREGNANCY
4) TTT SUPPORTIVE+ ADVICE (AVOID SCHOOL)

MOTHER WANTS SICK NOTE (CHICKENPOX)

Where you are: You are an FY2 in in General practice.

Who the patient is: Angela White, aged 31, has come to you with some concerns. Her
daughter Brianna has recently been diagnosed with chickenpox.
What you are required to do: Talk to her and negotiate with her.

Doctor: Hello my name is doctor (name)… Can I get your full name please and can I get
your daughter’s full name and date of birth as well? ………. How can I help?
Patient: I need a sick note.
Dr: Okay no problem, what do you need the sick-note for?
Pt: My daughter has had chickenpox for the past 3 days.
Dr: I see, and how is she doing?
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Pt: She is fine.

Dr: Does she still have any fever? ODIPARA
Pt: Yes.
Dr: Since when? Duration
Pt: 3 days.
Dr: How did it start? Onset
Pt: Suddenly.
Dr: Did you measure her temperature? (Is it getting worse or better) Course
Pt: Not really.
Dr: Have you given her anything for it?
Pt: No.

Anaphylaxis
Dr: Is she active and playful?
Pt: Yes.
Dr: Any breathing difficulty.
Pt: No.
Meningitis
Dr: Any rashes?
Pt: No
Dr: Is your daughter shy to light?
Pt: No

P2+MAFTOSA
Dr: Has she been diagnosed with any medical conditions in the past?
Pt: No.
Dr: Are you taking any other medications including OTC or supplements?
Pt: No.
Dr: Any allergies from any food or medications?
Pt: No.
Dr: Has anyone in the family been diagnosed with any medical condition?
Pt: No.
Dr: Has she come into contact with anyone having the same Sx? Contact
Pt: No.

BIRDDD
Dr: How was Brianna’s birth?
Pt: It was a normal vaginal delivery.
Dr: Was she delivered at full-term?
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Pt: Yes.
Dr: Are you happy with her red book?
Pt: Yes.
Dr: Is she up to date with all her jabs?
Pt: Yes.
Dr: Has she received any recent jab?
Pt: No.

Psychosocial (Core of the station try to find solutions)

Dr: Who looks after her?
Pt: Me and my husband, but my husband is away at the moment on business.
Dr: Does your daughter go to nursery/school?
Pt: Yes.
Dr: Do you have other kids?
Pt: No.
Dr: Is there anyone who can look after your daughter?
Pt: No.
Dr: Is there any friend or family nearby who can look after her?
Pt: No.
Dr: When will your husband be back?
Pt: After a week.
Dr: Can he come back early?
Pt: Yes/No
Dr: Is there anyone else who can look after your child?
Pt: Yes/No
Dr: Can you arrange a carer for your daughter?
Pt: Yes/No
Dr: What do you do for a living?
Pt: I am a lecturer in a university.
Dr: Have you spoken to the university for some time off?
Pt: Yes/No
Dr: Have you spoken to your employer regarding changing work environment? (Phased
work, amended duties, altered hours, workplace adaptations)
Pt: Yes/No

Dr: Apart from the Sick Note do you have any other concerns?
Pt:
− Will I get chickenpox?
− Can the students at the university get it also because of me?
− How long will the chickenpox last?

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Dr: Have you had chickenpox in the past or ever been immunised? (Important Qs to
address the mother’s concerns)
Pt: Yes.

Examination and Management Same as Previous case but you will have to address the
patient’s concerns more and offer solutions.
Pt: Will I get chicken pox?
Dr: It is highly unlikely that your daughter will give you chicken pox again because you
already had the infection so you are immunised but we will run some tests to make sure
that you are protected with sufficient antibodies. You can get another condition which
is called shingles. It is basically a reactivation of the old infection which sometimes
remains dormant inside your body but it is not triggered by exposure to chicken pox
again.
Pt: Can the students at the university get it also because of me?
Dr: As I mentioned you probably won’t get Chicken pox from your daughter because it is
very rare for a person to get chicken pox twice in their life, so I wouldn’t worry about
passing it on to your students. But if you develop shingles, you can infect others with
chicken pox if they have never had them before or were not immunised.

Pt: How long will chicken pox last?

Dr: Usually, your little one will start to recover after a few days to a week or two but she
will have to stay away from school, nursery until all the spots have crusted over. This is
usually 5 days after the spots appeared, as chickenpox is infectious from 2 days before
the spots appear, until they have all crusted over – usually 5 days after they first
appeared.
Pt: I need a sick note?
Dr: Unfortunately, I cannot write you a sick note because it’s not you who is sick, it’s
your daughter. But we can try to find other solution:
− Arrange for a caregiver or a family member to take care of her while you are at
work.
− Try talk to your boss explaining the situation, see if you can have a few days off
work.
− Ask your boss if you can work from home until your daughter is better.
− Take a few days from your annual leave.
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− You can go for Unpaid Parental leave

− We can always involve Citizen advice bureau

Pt: Am I allowed to take time off if my child is sick?

Dr: In short, yes. A child is technically your dependent which means you are allowed to
take time off work to cope with an emergency. Even if that emergency might just be a
horrible common cold. A day or two is considered sufficient to deal with a crisis, and
time off beyond this point may result in unpaid leave.

5 POINTS RECAP:

1) EXPLORE AS CHICKEN POX CASE

2) PSYCHOSOCIAL AND CONTACT
3) NO SICK NOTE
4) A FEW DAYS OF PARENTAL LEAVE.
5) CITIZEN ADVICE BUREAU

Scabies
Where you are: You are F2 working in General Practice.
Who the patient is: Sandra Peters, the mother of Samuel aged 2, has come to you with
a complaint.
Special Note: Samuel had gone for a pit walk with his father, he is not in the room.
What you must do: Take focused history, address patient’s concerns, and discuss
management plan with the mother.

P1
D: How can I help you?
P: Samuel is scratching all over.
D: How did it start? Onset
P: Suddenly doctor and it’s getting worse (Course)
D: Since when? Duration
P: 1 week.
D: Does anything make it better or worse?
P: I haven’t notice doctor OR maybe worse at night.
D: Where is he scratching exactly? Site
P: It started between his fingers and now it’s all over his body.
D: Any other symptoms? Open Qs

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P: Like what?
D: Is there any rash? Meningitis
P: Yes.
D: Have you placed a glass over the rash to see if it disappears? Meningitis
P: Yes, I have checked it and it does disappear.
D: Any Fever?
P: No.
D: Any Discharge?
P: No.

P2+ MAFTOSA
D: Has he been diagnosed with any medical condition in the past?
P: No.
D: Is he taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: Has he come into contact with anybody having the same itching? CONTACT very
important
P: No.
D: Is Samuel an only child? CONTACT
P: Yes.
D: Have you recently travelled abroad? Travel
P: Yes.

BIRDDD
D: How was Samuel’s birth?
P: It was a normal vaginal delivery.
D: Are you happy with his red book?
P: Yes.
D: Is he up to date with all his jabs?
P: Yes.
D: Has he received any recent jab?
P: No.
D: Is he feeding well?
P: Yes. he is feeding very well.
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D: Does he have any problems with his wee?

P: No.
D: Is Samuel an active and playful child?
P: Yes.
D: Is Samuel playing well with other children? If he is coming into contact with others
P: He does not go out to play much.

On examination
Observation and examine the lesion.
We may use a magnifying glass to examine the rash (for any burrows). We may also do
an ink burrow test where ink is rubbed over the rash and then wiped out with an
alcohol swab to outline the burrow track.

Tiny mites lay eggs in the skin, leaving lines with a dot at one end The rash can appear anywhere, but it
often starts between the fingers.

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The rash may then spread and turn into tiny spots. This may look red on lighter skin; The rash may
leave dark spots on the skin. This may look brown or black on darker skin.

Management:
Diagnosis:
From what you have told me and the rash that you have shown me, it appears that your
son has a skin infection caused by mites which is known as scabies. These bugs actually
burrow into the skin and can cause terrible itching and rashes.
Senior.
Symptomatic:

• Anti-Scabies creams:

− Permethrin cream (Main TTT) that kills the mites, applied to cool dry skin (not
wet) overnight to the whole body from head to toe, including the scalp and face
specially between the fingers, the front of the wrists and elbows, beneath the
breasts, the armpits and around the nipples in women.
− Malathion liquid. (If allergic to permethrin.).
− The cream or lotion should be left on for the full recommended time. Permethrin
cream should be left on for 8-12 hours. Malathion lotion should be left on for 24
hours.

> Children should stay off school until the first application of treatment has been
completed.
> Breast-feeding mothers should wash off the lotion or cream from the nipples before
breast-feeding, and re-apply treatment after the feed.

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> Permethrin cream is not usually used for babies under the age of 2 months, and
malathion is not usually used under the age of 6 months.

• Antibiotics: for a secondary skin infection may also be prescribed.

• For Itching: Topical treatments that you apply to the skin:

− Emollients
− Antihistamine medicine that makes you drowsy, such as chlorphenamine if
itching is a problem at night (particularly for children).
− Hydrocortisone cream. This is a mild steroid cream that may ease any
inflammation and help to ease itch. It can be applied once or twice per day, for
up to a week.

General advice:

• You'll need to repeat the treatment 1 week later to make sure all mites are killed.
• Scabies is very infectious, but it can take up to 8 weeks for the rash to appear.
• Everyone in your home and all close contacts need to be treated at the same
time, even if they do not have symptoms.
• Anyone you have had sexual contact with in the past 8 weeks should also be
treated.
• You or your child can go back to work or school 24 hours after the first treatment.

DO
− Wash all bedding and clothing in the house at 50C or higher on the first day of
treatment.
− Put clothing that cannot be washed in a sealed bag for 3 days until the mites die.
− Stop babies and children sucking treatment from their hands by putting socks or
mittens on them.
− Alternative options to kill any mites on clothes and linen are ironing the item with
a hot iron, dry cleaning, or putting items in a dryer on the hot cycle for 10-30
minutes.

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DON’T
− Do not have sex or close physical contact until you have completed the full course
of treatment.
− Do not share bedding, clothing or towels with someone with scabies.

Specialist:

Seek specialist advice for children under 2 months old - scabies is rare in this age group.
Notify Public Health in case of outbreaks.
Safety netting
− If the itch persists longer than 2-3 weeks after treatment. Sometimes the first
treatment does not work, and a different one is then needed.

− If the rash becomes sore, painful or you experience fever, come to us

immediately as it might be complicated by a secondary bacterial infection.

Follow up

Concerns:

P: How many days will it take to go away? 2 -3 weeks

P: What will you do for her? Management plus advice
P: What happens if it gets worse? Specialist, repeat treatment, try another treatment.

5 POINTS RECAP:
1) SEVERE ITCHING WORSE AT NIGHT
2) CONTACT
3) MAGNIFYING LENS AND INK BURROW TEST
4) TREAT ALL HOUSE MEMBERS
5) ADVICE

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Herpes Zoster

Who you are: You are an F2 in GP surgery.

Who the patient is: Tony Jameson, aged 40, has presented to the clinic with chest pain.
What you should do: Talk to the patient, assess him and discuss the plan of
management.

Doctor: How can I help you?

Patient: I’m in pain.
P1: Open Qs then SOCRATES
D: Tell me more about your pain?
P: It’s in my chest.
D: Where exactly do you have the pain can you point with one finger? Site
P: It is in right side of my chest (Pt. points towards the lower right side of the chest)
(If left side you will have to exclude angina by Hx and Inv -be a safe doctor).
D: Was it sudden or gradual? Onset
P: It was gradual.
D: When did it start? Duration
P: I have been having this since yesterday.
D: What were you doing when you started having this pain? before
P: I was just sitting.
D: Was it continuous or comes and goes? Course
P: It is continuous.
D: What type of pain is it? Character
P: It is a dull pain like a burning, tingling pain.
D: Does the pain go anywhere else? Radiation
P: It is going to my back.
D: Is there anything that makes the pain better?
P: No.
D: Is there anything that makes the pain worse?
P: No.
D: Could you please score the pain on a scale of 1-10, with 1 being no pain and 10
being the most severe pain you have ever experienced?
P: It is a 5.
D: Does your pain get relieved on bending forward? (Pericarditis)
P: No.

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D: Any calf pain, redness or swelling? (PE)

P: No.
D: Have you travelled anywhere recently? (PE)
P: No.
D: Is there anything else with pain? OPEN Q
P: I have skin lesions over my chest. RASH 2nd P1 ODIPARA
D: Where exactly on the chest? Site
P: On the right side.
D: Since when did you notice it? Duration
P: Since yesterday.
D: Does it have a specific shape?
P: Like lines of blisters.
D: Does it itch?
P: Yes /No
D: Is it painful?
P: Yes.
D: Any bleeding or discharge?
P: No or Yes some have ruptured and discharging clear fluid.
D: Is it spreading or changing in size or shape?
P: Yes, the lines are increasing doctor (Does not cross to the other side of the
midline)
D: Have you come into contact with anyone who had any type of skin lesions?
P: No.
D: Do you have skin lesions anywhere else?
P: No.
D: Any skin lesions on your face near the eyes or ears?
P: No.
D: Anything else?
P: No.
D: Any headache? Meningitis
P: No.
D: Any breathlessness or sweating? Angina
P: No.
D: Any fever or flu-like symptoms or cough? Pneumonia
P: No.

P2+MAFTOSA

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D: Have you ever had any chicken pox before? Very important, ask directly.
P: Yes / No
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any DM, HTN. Heart disease or high cholesterol? Causes of reactivation
P: No.
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.

Psychosocial:
D: Who do you live with at home?
P: I live with my wife.
D: Is she pregnant by any chance?
P: Yes, we are very happy about it, she is 24 weeks.
D: I’m happy for you, you seem excited (Reflect to anything your patient gives you a
chance to get IPS marks), has she ever had chicken pox before?
P: Not sure doctor.
D: What do you do for a living? occupation
P: I’m a teacher.

DESA
D: Tell me about your diet?
P: I don’t eat healthy to be honest.
D: Do you do physical exercise?
P: I don’t have much time
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
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D: Do you have any kind of stress?

P: No Dr.
Examination: Ideally, I would like to do GPE, take your vitals, and examine your skin
lesions.
− The shingles rash appears as red blotches on your skin, on 1 side of your body only.
A rash on both the left and right of your body is unlikely to be shingles.
− The blotches become itchy blisters that ooze fluid. A few days later, the blisters dry
out and scab.
− The rash can form a cluster that only appears on 1 side of your body. The skin
remains painful until after the rash has gone.
− The first signs of shingles can be:
> A tingling or painful feeling in
an area of skin.
> A headache or feeling
generally unwell.
> A rash will appear a few days
later.
− Usually, you get shingles on
your chest and tummy, but it can
appear on your face, eyes and
genitals.
− Most people have chickenpox
at some stage (usually as a child)

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NOTE: WHENEVER YOU ARE GIVEN PICTURES ,

EXPLAIN THEM TO THE PATIENT . ALWAYS
MENTION THE POSITIVE FINDINGS IN HX AND
EXAM TO SHOW YOU ARE ACTIVE LISTENING .

Management:

Diagnosis:
From our assessment, you might have this chest pain because of the skin lesions which
are called shingles. It is a painful, blistery rash in one specific area of your body.
Shingles is a reactivation of the chickenpox virus that you had as a child but only in one
nerve root. So instead of getting spots all over the place like the chickenpox, you get
them just in one area of your body.
Senior
Symptomatic: Mostly supportive treatment.
• Antiviral medicines for shingles
− Antiviral medicines used to treat shingles include aciclovir, famciclovir and
valaciclovir.
− An antiviral medicine does not kill the virus but works by stopping the virus from
multiplying. So, it may limit the severity of symptoms of the shingles episode.
− An antiviral medicine is most useful when started in the early stages of shingles
(within 72 hours of the rash appearing).
− However, in some cases your doctor may still advise you have an antiviral
medicine even if the rash is more than 72 hours old - particularly in elderly people
with severe shingles, or if shingles affects an eye.
− Antiviral medicines are not advised routinely for everybody with shingles. As a
general rule, the following groups of people who develop shingles will normally
be advised to take an antiviral medicine : over the age of 50 - any age and
Shingles that affects the eye or ear ,a poorly functioning immune system or
Shingles that affects any parts of the body apart from the trunk as an arm, leg,
neck, or genital area)
− If prescribed, a course of an antiviral medicine normally lasts seven days.

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DO
− Rest, plenty of fluids.
− Take paracetamol to ease pain.
− Keep the rash clean and dry to reduce the risk of infection.
− Wear loose-fitting clothing.
− Use a cool compress (a bag of frozen vegetables wrapped in a towel or a wet
cloth) a few times a day.

DON’T

− Do not let dressings or plasters stick to the rash.

− Do not use antibiotic cream – this slows healing.

Safety netting
Stay away from certain groups of people if you have shingles
TRY TO AVOID: VERY OLD, VERY YOUNG, VERY PREGNANT ☺
− PREGNANT WOMEN WHO HAVE NOT HAD CHICKENPOX BEFORE
− PEOPLE WITH A WEAKENED IMMUNE SYSTEM – LIKE SOMEONE HAVING CHEMOTHERAPY .
− BABIES LESS THAN 1 MONTH OLD – UNLESS YOU ARE THE MOTHER , AS THEY SHOULD BE
PROTECTED FROM THE VIRUS BY YOUR IMMUNE SYSTEM.

Stay off work or school if the rash is still oozing fluid (weeping) and cannot be covered,
or until the rash has dried out. You're only infectious to others while the rash oozes
fluid. You can cover the rash with loose clothing or a non-sticky dressing.
You cannot spread shingles to others. But people who have not had chickenpox before
could catch chickenpox from you. This is because shingles is caused by the chickenpox
virus.

SHINGLES VACCINATION
A shingles vaccine is available on the NHS for people in their 70s. It helps reduce your
risk of getting shingles. If you get shingles after being vaccinated, the symptoms can be
much milder.
Follow up

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5 POINTS RECAP:
1) TYPICAL ZOSTER SX PAIN AND LINES OF RASH ON ONE SIDE NOT CROSSING MIDLINE
2) EXCLUDE ANGINA IF LEFT SIDE
3) CHICKEN POX HX
4) CONTACT AND PREGNANCY
5) SUPPORTIVE TREATMENT

Herpes labialis
Who you are: You are an F2 in GP Clinic.
Who the patient is: Amber Wilson, a 24-year-old lady, came in with rashes on her lower
lip. She is concerned about it.
What you should Do: Please talk to the patient, take history and address her concerns.

Doctor: How can I help you today?

Patient: I have got a rash on my lip.
P1: ODIPARA
D: Can you show me? Site
P: Lower lip.
(Pt might show a picture of the rash when you try to ask questions to elaborate the
rash).

D: When did you notice the rash? Duration

P: 2 weeks back.
D: What is the colour?
P: Yellowy brown.
D: What is the size?
P: About the size of 5p piece.
D: Is the lesion painful?
P: Yes/No
D: Is the lesion itchy?
P: Yes, it is itchy sometimes.
D: Any discharge or bleeding?
P: No.
D: Is it getting worse in any way? Progression
P: I’m not sure.
D: Any other rashes/lesions anywhere else in the body?
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P: No.

FLAWS
D: Any change in your weight recently?
P: No.
Any lumps/bumps anywhere in the body?
P:Yes/No
Do you have any other symptoms?
P: No
Any fever?
P: Yes/No
P2+MAFTOSA
D: Have you had similar kind of rash in the past?
P: No.
D: Have you been diagnosed with any medical condition?
P: No.
D: Any skin condition or STI? Sun Exposure/Trauma/insect bite/infection ?
P: No.
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: Yes, I am allergic to Penicillin.
D: Any previous hospital stays or surgeries?
P: No.
D: Any family history of a similar condition?
P: No.
D: Have you travelled anywhere recently?
P: Yes/No

Sexual Hx
D: (Intrusive Qs signpost) Are you sexually active?
P: Yes/No
D: (If No) Were you sexually active before?
P: Yes.
D: When was the last time you had sexual activity?
P: (Gives indication of last time)
D: Do you practice safe sex? (Most important:- If safe, move on don’t go into much
details to save time).
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P: Yes/No
D: Which routes of sex do you practice? Oral? Vaginal? Anal? Everything?
P: Oral and vaginal.
D: Kissing?
P: Yes/No

DESA
D: Tell me about your diet?
P: Good/Bad
D: Do you do physical exercise?
P: Yes/No
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: What do you do for a living?
P: I work in a bar.
D: Whom do you live with?
P: Nobody.

D: Is it OK if I examine the lesion? (Picture).

P: Yes, that’s fine.

Management:
Diagnosis
D: From my assessment, it seems like you
have a cold sore. Cold sores are painful
blisters that form on or near the lips and
inside the mouth. They are caused by an
infection with a virus called "herpes simplex virus."

Senior
Symptomatic
P: Is there a treatment for it?
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D: Cold sores are usually mild and self-limiting and so can be managed
symptomatically. (Reassure the patient that lesions will heal without scarring). They
resolve on their own in 10-14 days.

D: I’ll give you Painkillers (main treatment)

− Paracetamol and ibuprofen, Gels for pain control of cold sores are also available.
− Antiviral medication:
Topical –may help the healing process. started ASAP.

P: Will I get this again?

D: Treatments can help ease the symptoms of cold sores, but no treatment can cure
cold sores for good. Once you have the virus that causes cold sores, you will have it for
the rest of your life. That means that cold sores can keep coming back.
P: Why did I get a cold sore?
D: The virus that causes cold sores spreads easily from person to person. You might
have caught it from an infected person if the 2 of you shared cutlery, kissed, or had
some other type of close contact. People who give oral sex to people with genital
herpes can also get cold sores on their mouth.
Cold sores are highly contagious. Cold sores are contagious from the moment you first
feel tingling or other signs of a cold sore coming on to when the cold sore has
completely healed.
DO:
− Rest and plenty of fluids.
− Eat cool soft foods.
− Avoid touching the lesions.
− Wash hands with soap and water immediately after touching the lesions, such as
after applying medication.
− Topical medications only dabbed not rubbed to avoid trauma.
DONT:
− Sharing Topical medications or other items that come into contact with a lesion
area – e.g., lipstick or lip gloss.
− Kissing until the lesions have completely healed.
− Oral sex until all lesions have completely healed.
− Eat acidic, spicy or salty food.

There is a risk of transmission to the eye if contact lenses are contaminated.

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Children with cold sores do not need to be excluded from nurseries and schools.

Consider admission to hospital if the person is:

− unable to swallow due to pain and is at risk of dehydration (especially in
children).
− Showing signs of a serious complication of oral herpes simplex infection - they
may need intravenous antiviral drug treatment.
− showing red flags suggesting oral cancer (2 weeks referral)
− NEWBORN BABIES, PREGNANT WOMEN AND PEOPLE WITH A WEAKENED IMMUNE SYSTEM MAY
BE REFERRED TO HOSPITAL FOR ADVICE OR TREATMENT .

Safety netting
Avoid kissing a baby if you have a cold sore as it can lead to neonatal herpes, which is
very dangerous to new-born babies.
If the cold sore is not resolved after 2 weeks , come back to us immediately.
Follow up
REMEMBER WITH ANY HERPES AVOID VERY OLD ,VERY YOUNG AND VERY PREGNANT ☺

GENITAL WARTS

Who you are: You are an FY2 in GP surgery.

Who the patient is: John Edwards, aged 22, has made an urgent appointment.
What you should do: Talk to him and address his concerns.

Doctor: What brought you to the hospital?

Patient: I have some skin lesions. P1—Open Qs then ODIPARA
D: Can you tell me more about the lesions please?
P: They are on my privates.
D: Have you got any idea how the lesion started? Onset
P: No.
D: When did you first notice it? Duration

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P: I noticed it a few days ago.

D: May I know the size of the lesion?
P: Like a 5p coin.
D: What shape is it?
P: I don’t know, different shapes.
D: What is the colour of the lesion?
P: Pink.
D: Any pain?
P: No.
D: Any itching?
P: Yes.
D: Any bleeding or discharge from the lesion?
P: No.
D: Have you noticed any change in its size, shape or colour since it started?
P: No.
D: Have you noticed any ulcer on the lesion?
P: No.
D: Do you have any other skin lesion anywhere else?
P: No.
D: Any other problem?
P: No.
FLAWS
D: Have you got any fever or flu-like symptoms?
P: No.
D: Any change in your weight recently?
P: No.
DDX—URINE AND STI Sx
D: Do you have any bleeding or discharge from your penis?
P: No.
D: Any pain or discomfort in your lower tummy or your private parts?
P: No.
D: Any pain or burning sensation while passing urine?
P: No.
D: Cloudy or smelly urine? Frequency? Haematuria? Incontinence?
P: No.
D: Any redness, heat or swelling around your private parts or groin area?
P: No.

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P2+MAFTOSA
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any previous skin condition?
P: No.
D: Are you currently taking any medications, OTC or supplements?
P: No.
D: Any long-term steroids or antibiotics?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.

Sexual history very important core of the station

Now I need to ask you a few questions that may sound a bit intrusive but it’s part of my
consultation. Some of these questions are quite in depth and personal. We ask these
questions to everyone so please don't take it personally. If you feel uncomfortable and
would prefer not to answer, just let me know.

D: Are you currently sexually active?

P: Yes.
D: When did you last have sexual activity?
P: Yesterday.
D: Do you and your partner(s) practice safe protected intercourse i.e. do you use
condoms?
P: Yes, we use condoms.
D: How often do you use this protection?
P: Most of the time.
D: Have you had any issues with the condoms used?
P: No.
D: Do you have a stable partner?
P: Yes.
D: Have you had any other partners previously?
P: Yes, I had two other partners previously.
D: What kind of sexual contact do you have? (Genital? Anal? Oral?)
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P: Genital/Oral.
D: What is your sexual preference?
P: I am bisexual.
D: Any pain during or after sex?
P: No.
D: How is your partner? Any similar kind of
symptoms?
P: No.

DESA+IV Drug
D: Tell me about your diet?
P: I eat everything.
D: Do you do physical exercise?
P: I try to be active.
D: Do you smoke?
P: Yes/no
D: Do you drink alcohol?
P: No.
D: Have you been taking any recreational
drugs?
P: No.

Examination:
I would like to check your vitals and examine
your private area.
I would like to send for some initial
investigations including routine blood tests.

Examination picture given with several bumps on the genital area, no scrotal
swelling…

Management:
Diagnosis
Based on what you have told me; you mentioned you don’t always practice safe
intercourse and from my examination we found some bumps around your genitals, I
suspect you might have Genital warts which is caused by aninfection with a virus called
HPV.

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Refer to a sexual health clinic. Sexual health clinics specialise in treating problems
with the genitals and urine system.
Senior.
Symptomatic
The type of treatment you'll be offered depends on what the warts look like and where
they are. The doctor or nurse will discuss this with you. Treatments include:
• Cream or liquid: can usually be applied to the lesions by yourself or by the doctor or
nurse.
• Sometimes the lesions can be removed by Surgery or Freezing them and then they
are left to fall off after.
• The warts may come back. In some people, the treatment does not work.
• There's no cure for genital warts, but it's possible for your body to fight the virus
over time.

General lifestyle Advice:

DO

− Tell us if you're thinking of becoming pregnant (for women with warts), as some
treatments may not be suitable.
− Avoid perfumed soap, shower gel or bath products during treatment because
these can irritate your skin.
− Ask the doctor or nurse if your treatment will affect condoms, diaphragms or
caps.

DON’T

− Smoke as it affects treatment.

❖ Your current sexual partners should get tested because they may have warts and
not know it. After you get the infection, it can take weeks to many months before
symptoms appear.

❖ You can stop genital warts from being passed on by:

− Using a condom every time you have vaginal, anal or oral sex – but if the virus is
in any in skin that's not protected by a condom, it can still be passed on.
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− Not having sex while you're having treatment for genital warts.
− Not sharing sex toys; if you do share them, wash them or cover them with a new
condom before anyone else uses them.
− The HPV vaccine can help prevent infection, usually offered to girls and boys
aged 12 to 13 also to men (up to the age of 45) who have sex with men (MSM).

Safety netting
SEXUAL INTERCOURSE : DO NOT HAVE VAGINAL , ANAL OR ORAL SEX UNTIL THE WARTS HAVE GONE ;
BUT IF YOU DO HAVE SEX , ALWAYS USE A CONDOM .

Patient Concerns:
• Is Genital warts a type of cancer? Genital warts are not cancer and do not
cause cancer.
• How does it spread?
U can get genital warts from:
− skin-to-skin contact, including vaginal and anal sex.
− sharing sex toys.
− oral sex, but this is rare.
− The virus can also be passed to a baby from its mother during birth,
but this is rare.

Follow up

CHERRY ON TOP :D :
• UTI SX, STI SX, FLAWS
• SEXUAL HX AND PARTNER
• GUM CLINIC
• ADVICE ABOUT SAFE SEX

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Fungal Infection Ring Worm

Who you are: You are an FY2 in GP.

Who the patient is: George Seaholm, aged 45, has come to you with some concerns.
What you should do: Talk to him & address his concerns.

Doctor: What brings you to the hospital today?

Patient: Doctor, I have this rash on my forearm. P1
D: Which arm? Site
P: Left.
D: Since when? Duration
P: For the past few weeks.
D: Can you please describe the rash for me?
P: It’s like a ring.
D: What colour is it?
P: Red.
D: Is it itchy?
P: Yes.
D: Any pain around it?
P: No.
D: Any bleeding or discharge?
P: No.
D: Has it increased in size?
P: Yes, it has become bigger.
D: Is there anything that makes it better?
P: No.
D: Is there anything that makes it worse?
P: No.
D: Have you used anything for/on it?
P: No.
D: Have you shown it to a doctor before?
P: No.
D: Any similar rash elsewhere in the body?
P: No.
D: Anything else with the rash? OPEN Qs always help
D: Any fever? (Meningitis, Infections)
P: No.
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STI +DDX only one or two Qs each is more than enough

D: What do you do for a living? Sun exposure and Contact sports
P: Office.
D: Have you hurt your forearm anywhere? Trauma
P: No.
D: Have you noticed any insect bite? (Lyme)
P: No.
D: Have you lost any weight? (FLAWS)
P: No.
D: Any pain in your joints? (Sarcoidosis, Psoriasis)
P: No.
D: Any bowel problems? (I.B.D)
P: No.

P2+ MAFTOSA
D: Has it ever occurred before?
P: No.
D: Have you ever been diagnosed with any medical conditions?
P: No.
D: By any chance DM, Lung ds, Liver ds or heart ds?
P: No.
D: Are you taking any medications including OTC or herbal medications?
P: No.
D: By any chance any steroids? (Immunosuppressants)
P: No.
D: Are you allergic to any food or medication?
P: No.
D: Family hx of skin problem? Eczema
P: No.
D: Do you by any chance have any pets in your house? (Skin infections)
P: No.
D: Have you travelled anywhere recently? (Warm, humid)
P: No.
D: Have you seen anyone around you with a similar rash? CONTACT very important
P: No.

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DESA+ Sexual Hx
D: Do you Smoke?
P: No.
D: Do you drink Alcohol?
P: No
D: Are you sexually active?
P: No.
D: Do you practice safe sex?
P: Yes (then no need to ask more Sexual Hx)

Examination
D: I would like to take your observations and examine your rash, if that’s OK?
P: Sure Doctor. (Pt. Shows picture)

Management:

Diagnosis
From what you have told me and the
rash that you have shown me, it
appears that you have a skin infection
caused by fungus. They produce a ring-
like pattern, so it’s called a ring worm. They are very common and can affect
different parts of the body. We would however need to confirm it for which we
would have to take some skin scrapings from the area of rash and send them off
for analysis.

Senior
Symptomatic
Antifungal medicine every day for up to 4 weeks. This might be a cream, gel or spray
depending on where the rash is. It's important to use it for the right amount of time,
even if the rash has gone away. You may be given tablets like, terbinafine, griseofulvin,
or itraconazole tablets. Prescribed by skin specialist.
DO
− Start treatment as soon as possible.
− Wash towels and bedsheets regularly.
− Keep your skin clean and wash your hands after touching animals or soil.

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− Regularly check your skin if you have been in contact with an infected person or
animal.
− Take your pet to the vet if they might have ringworm (for example, patches of
missing fur).

DON’T
− Do not share towels, combs or bedsheets with someone who has ringworm.
− Do not scratch a ringworm rash – this could spread it to other parts of your body.
− It's fine for your child to go to school or nursery once they have started
treatment. Let your child's teachers know they have ringworm.

- Note
• The patient may have the following concerns: THAT’S WHY IT’S ALWAYS IMPORTANT TO
ASK ABOUT ICE MORE THAN ONCE IN EVERY PLAB2 STATION .

1. My wife is pregnant, could she catch the infection from me ? Unfortunately, yes
as the infection can be passed on through close contact with: an infected person
or animal infected objects – such as bedsheets, combs or towels.
2. Could it harm the baby ? It should not harm the baby. It is limited to the skin.

Safety net:
If Sx get worse or doesn’t improve with treatment please come back.
Follow up
The rash is usually ring-shaped. The outer edge is more inflamed and scalier
than the paler center. So, it often looks like a ring that becomes gradually
larger - hence the name ringworm.

5 POINTS RECAP:
1. RING SHAPED RASH
2. CONTACT HX TRAVEL HX PETS
3. IMMUNE COMPROMISED
4. SKIN SCRAPINGS
5. ANTIFUNGAL

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Impetigo

Who you are: You are an F2 working in GP surgery.

Who the patient is: Samantha Reid, 27 years old, has come with a rash on her face.
She is concerned about it.
What you should do: Talk to her and address her concerns.

Doctor: How can I help you today?

Patient: Doctor I have a rash around my lips P1
D: Can you tell me more about the rash? Open Qs then ODIPARA
P: It’s been there for the past week. Duration
D: What is the size of the rash?
P: Its spreading.
D: What is the shape of the rash?
P: I don't know.
D: What is the colour of the rash?
P: Honey crusted.
D: Is there any discharge from the rash?
P: No.
D: Is it itchy?
P: Yes, sometimes.
D: Is it painful?
P: Yes sometimes.
D: Any other skin lesions in the body?
P : No.
D: Any fever or flu-like illness recently?
P: No.
D: Any neck stiffness? Meningitis
P: No.
FLAWS:
D: Any lumps or bumps in the body?
P: No.
D: Any weight loss?
P: No.
D: Any loss of appetite?
P: No.
D: Any tiredness?
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P: No.

STI
D: Any long-term exposure under the sun or skin tanning sessions?
P: No.
D: By any chance any insect bite?
P: No.

P2+MAFTOSA
D: Have you had a similar health condition in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any family history of any significant health issues?
P: No.
D: Are you currently on any medication?
P: No.
D: Are you allergic to any foods or medication?
P: Yes, I’m allergic to penicillin.
D: Have you been exposed to someone having similar skin lesions? Contact
P: No.

DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Have there been any recent changes in your diet?
P: No.

Examination
I would like to check your vitals and examine your skin rashes. Is that OK?

Management
Explain condition:
From my assessment, I suspect you have a condition called Impetigo. It is a skin
infection that's very contagious but not usually serious. It often gets better in 7 to
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10 days if you get treatment. Anyone can get it, but it's very common in young
children.

Senior
Investigations
Usually clinical diagnosis, but a swab for culture and sensitivity may be useful if:
− The impetigo is extensive or severe.
− MRSA is suspected.
− The impetigo is recurrent or failing to respond to treatment. (Take nasal
swabs if there is recurrent impetigo, to exclude nasal staphylococcal
colonisation. Use Naseptin® to eradicate it if found.)

Symptomatic
− Antibiotic cream (fusidic acid can be used first-line in localised infections,
three times a day for seven days. Mupirocin is reserved for MRSA cases, to
avoid resistance.)
− Oral antibiotics only if extensive or resistant or causing systemic symptoms. A
seven-day course is recommended. Make sure you finish treatment. Do not
stop early, even if the impetigo starts to clear up.

Lifestyle Advice
Do
− Stay away from school or work.
− Keep sores, blisters and crusty patches clean and dry.
− Cover them with loose clothing or gauze bandages.
− Wash your hands frequently.
− Wash flannels, sheets and towels at a high temperature.
− Wash or wipe down toys with detergent and warm water if your children have
impetigo.

Don’t
− Touch or scratch sores, blisters or crusty patches – increase scarring.
− Have close contact with immune compromised.
− Share flannels, sheets or towels.

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− Prepare food for other people.

− Go to the gym.
− Play contact sports like football.

❖ Impetigo can easily spread to other parts of your body or to other people until it
stops being contagious. It stops being contagious: 48 hours after antibiotic start
or when the patches dry out and crust over.

Safety netting
• Redness, swelling and tenderness ( cellulitis ).
• Fever or worsening of your symptoms despite treatment.

• Refer to hospital or seek specialist advice if:

− There is impetigo and any symptoms or signs suggesting a more serious illness
or condition (e.g., cellulitis).
− There is widespread impetigo in people who are immunocompromised.
− There is bullous impetigo, particularly in babies (aged 1 year and under).
− Impetigo is recurring frequently.
− The patient is systemically unwell.
− A high risk of complications exists.

Follow up

5 POINTS RECAP:
1. RASH WITH FEVER AND DISCHARGE
2. CONTACT HX
3. ISOLATE FOR A WHILE
4. ANTIBIOTIC
5. LIFESTYLE

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Acne (Isotretinoin)
Who you are: You are an F2 in GP clinic.
Who the patient is: Jumana Alby, aged 24, came to the clinic. She is having acne and
wants Isotretinoin medications for it.
What you should do: Talk to the patient and discuss the plan of management with
the patient.
NOTE: Instructions paper for retinoid is given in the cubicle. Retinoid - Gel for mild
to moderate acne treatment and Severe Acne require Oral meds. Start as early as
possible.

Doctor: What brings you to the hospital today?

Patient: I want Isotretinion (Roaccutane) for my acne.
D: May I know why? / May I ask you what you know about this treatment already ?
(When the patient demands a specific treatment, always explore what they
know about it, in case they are misinformed)
P: Yes, my friend has been taking it and her acne is much better now, she had a
similar problem as mine, I want mine to get better too.
D: Okay! Can I ask you a few questions before we get to that?
P: Yes sure.
D: Since when have you had it? P1: Acne
P: I’ve had it for a long time but it has become worse recently.
D: Any itching?
P: No.
D: Have you noticed any discharge coming out of your spots?
P: No.
D: Is it painful?
P: No.
D: Does it become better/worse with anything?
P: No.

Acne Risk Factors

D: How often do you wash your face?
P: I wash my face twice daily.
D: Do you use any cosmetic products on your face?
P: Yes, I use cosmetic pads & Clearasil face wash (benzoyl peroxide & salicylic acid)
D: How often do you use it?
P: Twice daily.
D: Did you notice your acne becoming worse after that?
P: I’m not sure.
D: Did you by any chance notice that it becomes worse near the time when you will
have your period?
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P: No.

P4-Period Pregnancy very important

D: When was your last LMP?
P: A week ago.
D: Any problem with your periods?
P: No.
D: By any chance are you pregnant?
P: No doctor, I'm taking the combined pill.
D: Have you noticed any weight gain or more facial hair recently? (PCOS)
P: No.

P2+Maftosa
D: Have you been diagnosed with any medical conditions?
P: No.
D: Any kidney, liver, Epilepsy or Depression problems? Very important to
explore as they are Isotretinoin medication side effects
P: No.
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any steroid use?
P: Yes/No
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Does anyone in your family have a similar problem?
P: No.

DESA
D: Tell me about your diet?
P: Good/Bad
D: Do you do physical exercise?
P: I don’t have much time
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Yes/No
D: Do you have any stress in your life?
P: Not really doctor.
D: What do you do for a living?
P: I work in a drama club and this ACNE bothers me a lot.
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D: How does it make you feel?

P: Well, it’s very distressing for me, all these spots on my face, I want clear skin, I
feel down because of it.
D: I’m sorry to hear that. I can see that it’s causing you a lot of stress. (Always try to
reflect to what the patient tells you)
P: Yes doctor.
D: Can you rate your MOOD for me please on a scale of 0-10, 1 being the lowest and
10 being happiest?
P: 5.
D: Are you sleeping alright these days?
P: Yes.
D: Is there anything else you would like to tell me about your condition?
P: No.
D: Apart from the acne affecting your life and drama club do you have any other
things in mind concerning you ?
P: No.
D: Do you have any expectations apart from the isotretinoin treatment?
P: I just want a treatment for my acne doctor.

Examination:
I would like to check your vitals and examine your chest if that’s OK. I will be
examining the skin on your face, chest and back for the different types of spots, such
as blackheads or sores or red nodules.

Patient shows picture of forehead with -red acne spots on it.

Management
Diagnosis
Acne is caused when tiny holes in the skin known as hair follicles become blocked. From
my examination, it seems that you have mild/moderate/severe acne.

• Grade 1 (Mild): Acne is mostly confined to whiteheads and blackheads, with just
a few papules and pustules.
• Grade 2 (Moderate): There are multiple papules and pustules, which are mostly
confined to the face.
• Grade 3 (Moderately Severe): There’s a large number of papules and pustules,
as well as the occasional inflamed nodule, and the back and chest are also
affected by acne.
• Grade 4 (Severe): There’s a large number of large, painful pustules and nodules.

NB: Isotretinoin treatment Side effects:

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1- Liver impairment
2- Renal impairment
3- Mood affection
4- Extremely teratogenic in pregnancy

Contra indications for Isotretinoin treatment:

1- Pregnancy or having plans to become pregnant

2- Breast feeding
3- Allergy SOY and FRUCTOSE intolerance
4- IBD Crohn’s or Ulcerative colitis

Isotretinoin is a treatment for severe acne that comes in capsules.

Refer: It must be prescribed and supervised by a specialist doctor ( Skin specialist.)

Senior
Investigations
You will a have a blood test before you start taking it and regularly while taking
isotretinoin and after stopping it.

− Routines: Liver functions – Kideny functions – Cholesterol

− Pregnancy test very important
− Hormone profile (ovarian markers): FSH – LH
− Vitamin A level

General Advice
How to cope with side effects:

• Dry skin or lips: apply a moisturiser and lip balm often (the best type of
moisturiser is an oil-free face moisturiser for sensitive skin).
• Try to keep your showers shorter than 2 minutes, using lukewarm water
rather than hot.
• Skin becoming more sensitive to sunlight: stay out of bright sun and use a
high factor, oil-free sun cream (SPF 15 or above) even on cloudy days.
• Dry eyes: eye drops, wear glasses instead of contact lenses while taking the
medicine
• Dry mouth or throat: try chewing sugar-free gum or sweets.

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• Dry nose and nosebleeds: thin layer of Vaseline to the inside edges of your
nose.
• Headaches and joint, muscle and back pain: painkiller.

Safety netting
• Avoid waxing, dermabrasion, or laser skin treatment while on medicine and
for at least 6 months after you stop, as this could cause scarring or skin
irritation.
• If you become depressed or think about harming yourself while taking
isotretinoin, stop taking the medicine and tell your doctor straight away.
• Diabetic patients require more monitoring.

Serious side effects

❖ RARE But Stop taking isotretinoin capsules and call a doctor straight away if you
get:

• Mood Changes, depression, anxiety, or suicidal thoughts.

• Skin colour turns yellow, difficulty peeing, or feeling very tired (liver or
kidney problems)
• Severe tummy pain may be pancreatitis.
• Bloody diarrhea (gastrointestinal bleeding).
• Muscle weakness as pain swelling or difficult movement of arms and legs.
• Bad headaches.
• Vision problems.

• Extremely teratogenic in PREGNANCY: VERY IMPORTANT

− Can harm the baby and increases the risk of miscarriage.

− Stop taking the capsules and tell your doctor as soon as possible if unexpectedly u
become pregnant.
− Should follow strict rules to prevent pregnancy during treatment and for 1
month afterwards using TWO reliable methods of contraception for 1 month
before starting isotretinoin capsules, and for 1 month after treatment has stopped
− Should do pregnancy test before, during, and 5 weeks after the end of treatment.
− Can go into breast milk so avoid breast feeding.
− Men can safely take isotretinoin capsules if they and their partner are trying for a
baby, or their partner is pregnant.

How and when to take it:

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Always as instructed by specialist doctor,

− It's best to take them straight after a meal or snack to make sure they work properly.
− Never take a double dose. Never take an extra dose to make up for a missed one.
− Later the dose is adjusted according to response and side effects.

Cautions with other medicines

Some medicines might increase the risk of having retinoids side effects so tell your doctor if you
are taking any of these:
− Supplements that contain vitamin A.
− Tetracycline antibiotics such as doxycycline, oxytetracycline, minocycline, and
lymecycline.
− Other acne medicines (using both together may make skin irritation worse).
− Mixing isotretinoin capsules with herbal remedies or supplements.

6 POINT RECAP ☺:

1- PSYCHOSOCIAL & MOOD

2- LIVER & KIDNEY
3- PREGNANCY & BREAST
FEEDING
4- SAFETY NET
5- FOLLOW UP
6- SPECIALIST WILL
PRESCRIBE

❖ Misconception about Acne:

1. Acne is caused by having

dirty skin or poor
hygiene.
2. Squeezing blackheads,
whiteheads and spots is
the best way to get rid of
Acne.
3. Acne is caused by poor
diet.
4. Having sex or
masturbating will make
acne better or worse.
5. Sunbathing, sunbeds and
sunlamps help improve the symptoms of acne.
6. Acne is infectious.

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Mole

Who you are: You are an FY2 in the Surgery clinic.

Who the patient is: Jasmine Jay, 26 year old female, presented with swelling on
shoulder. She has a letter from her GP. The letter states that patient has some
concerns about the lesion and wants to remove it from her shoulder.
What you should do: Take relevant history and discuss different management
options. Take informed consent for surgery.
Special note: There is no need to fill up the consent form. (Consent form is not
available inside the cubicle.)

Doctor: What brought you to the hospital?

Patient: I have a mole on my right shoulder. I want it to be removed. My GP referred
me here. P1 & Expectation
D: That’s fine. We will assess you first and see what can be done.
P: Okay.
D: Can you tell me more about the lesion please? Open question
P: I think it’s a mole.
D: Have you got any idea how the lesion started? Onset
P: No, I’ve had it a long time.
D: When did you first notice it? Duration
P: I had it for many years.
D: May I know the size of the lesion?
P: It’s about 1x1 cm.
D: What shape is it?
P: Round.
D: What is the colour of the lesion?
P: Brown.
D: Have you noticed any change in its size, shape or colour since it started?
P: No.
D: Any pain or itchiness?
P: Yes when it catches my clothes.
D: Any bleeding or discharge from the lesion?
P: No.
D: Did you notice any ulcer on the lesion?
P: No.
D: Do you have any other skin lesion anywhere else?
P: No.
D: You mention you had it for many years, may I ask if there was any particular
reason why you want it removed now?
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P: I have my wedding coming up and my wedding dress won't cover it. It looks ugly.
Also, sometimes it gets stuck in my dress and is quite uncomfortable.
D: Congratulations for your wedding, now I understand why you seem worried
about it. We can definitely give you some treatment options later on but can I ask
you a few more Qs about your general health before that?
P: Yes.

FLAWS very important

D: Any fever?
P: No.
D: Any lumps or swelling in your neck or armpit?
P: No.
D: Do you feel tired these days?
P: No.
D: Have you noticed any weight loss?
P: No.
D: How is your appetite these days?
P: Good.
D: Any other problem?
P: No.
D: Any dizziness or heart racing?
P: No.

P2 & MAFTOSA
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any previous skin conditions, diabetes?
P: No.
D: Are you currently taking any medications, over-the-counter drugs or
supplements?
P: No.
D: Any long-term steroids or antibiotics?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries
P: No.
D: Has anyone in your family been diagnosed with any medical condition? VERY
IMPORTANT
P: No.
D: Anyone with any skin problems or any skin cancer in the family?
P: No.

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DESA + SUN EXPOSURE

D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: Occasionally.
D: Tell me about your diet?
P: It’s healthy.
D: What do you do for a living?
P: Office job.
D: Any long-term exposure to sun or
tanning sessions?
P: No.
D: Have you got any idea what the lesion
could be?
P: A mole?
D: Yes you are right it looks like a mole to me.

Examination:
I would like to check your vitals and examine your lesion if you don’t mind and
send for some initial investigations including routine blood tests.

Management

Diagnosis
So, we can both agree that the lesion is a harmless mole. We wouldn’t normally
remove a healthy mole on the NHS but as you said it gets caught on your clothes and
causes you pain, I believe you may be able to have it removed.
Have you got any other particular concerns apart from wanting it removed
before the wedding?
P: Not really.
D: I understand you want this mole removed but were you expecting anything else
from today’s consultation?
P: I just want it to be removed doctor.
D: I will discuss it with my senior and we may be able to remove the lesion. Do you
want me to tell you how we would remove it?
P: Yes.

Senior
Refer to a dermatologist
A dermatologist may use an instrument called a dermatoscope to examine a mole
closely in more detail. It is a painless procedure. If there is any concern over the

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diagnosis your doctor will arrange for the mole to be removed and checked in the
laboratory.

Investigations:
Routine and Dermatoscope.
There are three main reasons for removing moles:

1. If there is doubt about the diagnosis then the mole needs to be cut out and
examined under the microscope.
2. If the mole is traumatised on a regular basis.
3. The patient is concerned about the lesion's cosmetic appearance (not available
on the NHS).

They can be removed surgically if necessary, but most are best left alone. There is
a risk of developing a scar or a skin graft may be required for large moles. It is not
recommended to have a mole removed with laser as it is not possible to have a
sample for histology.

❖ Options for removal

• Excision biopsy may be used for diagnostic purposes. Where there is any
doubt as to the diagnosis of the lesion, use ABCDE.
Asymmetry growing in size or changing in shape (becoming asymmetrical with
an irregular ragged edge)
Bleeding
Colour (an uneven colour with different shades of black, brown or pink).
Discharge ooze or scab
Elevation if a mole is very different from the other moles on the skin.

• Shave and cautery better cosmetic results than excision biopsy.

• Freezing with liquid nitrogen. This is like a spray. It does not require any
anaesthesia. The swelling will fall off after a few days.
• 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

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Safety net
Skin should be examined monthly for moles that are ABCDE
− Ask a family member or a friend to examine your back and taking a
photograph is helpful to monitor any change to a mole.
− Protect yourself and children from too much sun exposure. For example, be
careful to avoid sunbathing and burning, use sun protection creams of SPF 50
or above.
− Do not use sunbeds.

❖ ADDITIONAL CONCERNS THAT MAY ARISE :

P: Will the surgery leave a scar?

D: The procedure will be done by experts very carefully but however there will be a thin scar left
any the site.

P: Will the mole come back once it is removed?

D: There is a chance that the mole may come back unfortunately. However, we are
going to take all the precautions we can while performing the surgery to prevent it
from coming back. You can also take some measures like using sunscreens and
wearing protective clothing to cover yourself properly when you go out in the sun.
This can prevent your mole from coming back.

P: What if I decide to keep the mole as it is without any treatment?

D: As I told you, your mole looks harmless (benign) so it won’t be a problem if you
leave it without any treatment. It can stay as it is for the rest of your life. However,
there is a rare chance of moles becoming cancerous so you would still need to wear
sunscreen and cover it when in the sun.

P: How is the procedure done doctor?

D: A shave excision is a simple procedure used to remove growths, such as moles.
The primary tool used in this procedure is a sharp razor. We may also use an
electrode to feather the edges of the excision site to make the scar less noticeable.
Once they've removed the growth, your doctor may send it to a laboratory for
analysis. This can help them learn whether it’s cancerous.

P: Shave excision? Is the surgery painful? Local anaesthesia? Why not put me
to sleep?
D: Explain shave excision as above, local anaesthesia will help with pain, whereas
general anesthesia has complications.
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If the patient doesn’t say that it catches her clothes and her only concern is her
wedding dress.
Ask -D: Does it cause any kind of problem to you in any way?
P: No
D: Okay. Most moles are harmless. Harmless moles are not usually treated on the
NHS. The NHS wouldn’t be able to cover the expenses to remove it for cosmetic
reasons. But we can give other options for removal like going private.

P: Can I do it privately?
D: Yes of course. You can pay a private clinic to remove a mole, but it may be
expensive.

5 POINTS RECAP:
1) EXPLORE ABCDE & FLAWS & FAMILY
2) SUN EXPOSURE
3) DERMATOLOGIST
4) COSMETIC REASON : NHS=NO, BUT CAN BE DONE PRIVATELY , IF AFFECTING MOOD
OR SYMPTOMATIC: REMOVE
5) SAFETY NET ABCDE

➢ ABCDE CHECKLIST:

o ASYMMETRICAL – melanomas usually have 2 very different halves and are an

irregular shape.

o BORDER – melanomas usually have a notched or ragged border.

o COLOUR – melanomas will usually be a mix of 2 or more colours.

o DIAMETER – most melanomas are usually larger than 6mm in diameter.

o ENLARGEMENT OR ELEVATION – a mole that changes size over time is more likely to

be a melanoma.

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Melanoma

Who you are: You are an F2 in GP surgery.

Who the patient is: Mrs. Martha, aged 41, presented to the clinic with a skin lesion
on her shoulder.
What you are required to do: Please talk to the patient, take focused history,
discuss different options of management and address her concerns.

Doctor: What brought you to the hospital?

Patient: I have a lesion on my right shoulder. I want it to be removed. (P1)
D: That is fine. We will assess you first and see what can be done.
P: Ok.
D: Can you tell me more about the lesion please. OPEN Q
P: I’ve had it for years.
D: When did you first notice it? Duration
P: I can’t remember it was years ago.
D: May I know the size of the lesion?
P: It’s about 2 x 3 cm.
D: What shape is it?
P: Round.
D: Have you noticed any change in its size since it started?
P: Yes it's getting bigger.
D: Have you noticed any change in its shape since it started?
P: I am not sure.
D: Have you noticed any change in its colour since it started?
P: It’s been getting darker the past few months.
D: What is the colour of the lesion?
P: Brown/black.
D: Is it painful?
P: No/Yes, it has been recently.
D: Is it itchy?
P: It was not itchy before, but now it is.
D: Any bleeding or discharge from the lesion?
P: No/ Yes it’s been bleeding a little recently.
D: Have you noticed any ulcer on the lesion?
P: No.
D: Have you got any idea how the lesion started?
P: No.
D: Do you have any other skin lesion anywhere else?
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P: No.

FLAWS
D: Any fever recently?
P: yes / no
D: Any lumps or swelling in your neck or armpit?
P: No.
D: Have you noticed any weight loss recently?
P: No.
D: How is your appetite these days?
P: Good.
D: Do you feel tired these days?
P: No.
D: Any other problem?
P: No.
D: Any dizziness or heart racing?
P: No.
P2+maftosa
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any previous skin conditions?
P: No.
D: Are you currently taking any medications, over-the-counter drugs or
supplements?
P: No.
D: Any long-term steroids or antibiotics?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: No.
D: Anyone with any skin problems or any skin cancer in the family?
P: No.
D: What do you do for a living? Occupation
P: I’m a gardener and I also sell fruit and vegetables in the market.
D: Any long-term exposure to sun or tanning sessions? Sun exposure is Very
important
P: Yes, I’m in the sun all day for my work.

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DESAS
D: Do you smoke?
P: Yes/No.
D: Do you drink alcohol?
P: Occasionally.
D: Tell me about your diet?
P: It’s a good diet.
D: Could you please tell me about your home condition?
P: I live in a house with my partner.
D: Does the lesion affect your day-to-day activities?
P: No.
D: Have you got any particular concern for the lesion to be removed now?
P: I have my wedding coming up and my wedding dress won’t cover it. It looks ugly.
Also, it gets stuck in my dress and is quite uncomfortable.
D: Oh dear! That sounds horrible. I understand how it must be frustrating for you.
ALWAYS REFLECT ON THE PATIENT.
EXAMINATION

D: I would like to check your vitals and examine your lesion if that’s OK? I would
like to send for some initial investigations as well including routine blood tests.

D: Have you got any idea what the lesion could be?
P: Well I thought it was a mole but since it started changing I’m not sure any more.

Management:

Diagnosis:
Best case - Worst case scenario So far based on what you have told me it might be
something as benign as a mole. However, from my assessment we found out that
(mention any positive findings what so ever that are red flags). So I am a bit
worried that your lesion might be something more sinister like melanoma.
Unfortunately, this is a type of cancer of the skin, but it’s still too early to say for
sure. PAUSE

We will refer you to a dermatologist and team of doctors (multi-disciplinary team)

who will do the necessary tests and confirm the diagnosis and start treatment
depending upon the condition.
We will refer you to the specialist in 2 weeks time.

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Senior.
Investigation:
• Routine bloods
• Excisional biopsy: They may remove it and send it for testing to check whether
it's cancerous.
• Wide local excision: If cancer is confirmed, you'll usually need another
operation, most often carried out by a plastic surgeon, to remove a wider area of
skin. This is to make absolutely sure that no cancerous cells are left behind in the
skin. We call it WLE.
• Depending on the depth and the size. Other tests and scans might be needed to
find out if it has spread to another area of your body. CT, MRI or PET or taking
samples from nearby Lymph nodes (sentinel LN biopsy)
• If you don't have melanoma, you do not need any further tests or treatment.

Treatment
Surgery is the main treatment for melanoma. Other treatments include:
− Immunotherapy
− Chemotherapy
− Radiotherapy

Specialist
• Multidisciplinary team: If you have melanoma skin cancer you'll be cared for
by a team of specialists that should include a skin specialist (dermatologist), a
plastic surgeon, a specialist in radiotherapy and chemotherapy (oncologist),
an expert in tissue diseases (pathologist) and a specialist nurse.

• When helping you decide on your treatment, the team will consider:
− the type of cancer you have
− the stage of the cancer (its size and how far it has spread)
− your general health

• Your treatment team will recommend what they believe to be the best treatment
option, but the final decision will be yours.

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Safety netting
If you experience any bleeding, difficulty in breathing, come to us immediately.

RED FLAGS for MELANOMA are often a new mole or a change in the appearance of
an existing mole. Signs to look out for include a mole that's:

• getting bigger
• changing shape
• changing colour
• bleeding or becoming crusty
• itchy or sore

Follow up
After your treatment, you'll have regular follow-up appointments to check
whether:
− there are signs of the melanoma coming back.
− the melanoma has spread to your lymph nodes or other areas of your
body.
− there are signs of any new primary melanomas.

Help and support

Being diagnosed with melanoma can be difficult to deal with. You may feel
shocked, upset, numb, frightened, uncertain, and confused. These types of
feelings are natural. Some people prefer to talk to people outside their family.
There are several UK-based charities that have specially trained staff you can
speak to on a free helpline:
− Macmillan Cancer Support
− Melanoma UK

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NON MELANOMA (BCC,SqCC)

Who you are: You are F2 in GP.
Who the patient is: Mr. Ronald Giggs, aged 64 has some concerns about a skin problem
he has.
What you should do: Please talk to the patient, assess his condition, discuss your
management, and address his concerns.

D: What brought you to the hospital?

P: I have a lesion on top of my head. I want it to be checked as my wife is concerned
about it. (Patient shows left temporal or parietal area). (P1)
D: Oh I see you are a bit stressed out about it let me reassure you we will take a look at
it and see what can be done
P: Ok.
D: Can you tell me more about the lesion please. OPEN Q
P: It’s been there a few months.
D: When did you first notice it? Duration
P: 2-3 Months ago.
D: May I know the size of the lesion?
P: It’s not that big.
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D: What shape is it?

P: Irregular.
D: What is the colour of the lesion?
P: Pink/ Purple.
D: Have you noticed any change in its size since it started?
P: Yes it’s getting bigger.
D: Have you noticed any change in its shape since it started?
P: Yes, it was not like before.
D: Have you noticed any change in its colour since it started?
P: It is getting darker.
D: Is it painful?
P: No/ Yes, it became painful recently.
D: Is it itchy?
P: Yes/No
D: Any bleeding or discharge from the lesion?
P: Yes, it started bleeding a little in the last few days.
D: Have you noticed any ulcer on the lesion?
P: No.
D: Have you got any idea how the lesion started?
P: No.
D: Do you have any other skin lesion anywhere else?
P: No.

FLAWS
D: Any lumps or swelling in your neck or armpit?
P: No.
D: Have you noticed any weight loss?
P: I wish!
D: How is your appetite these days?
P: Good.
D: Any dizziness or heart racing?
P: No.
D: Do you feel tired these days?
P: No.

P2+ MAFTOSA
D: Have you had any skin lesion in the past?
P: Yes. I had a lesion on the right side of my head few years ago.
D: May I know what was done for that?
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P: I went to a doctor and he froze it.

D: Any other problem?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any previous skin conditions, diabetes?
P: No.
D: Are you currently taking any medications, over-the-counter drugs or supplements?
P: No.
D: Any long-term steroids or antibiotics?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: Anyone with any skin problems or any skin cancer in the family?
P: No.
DESA
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol?
P: Occasionally.
D: Tell me about your diet?
P: Good diet.
D: What do you do for a living?
P: I used to work in Australia but now I am doing an office job here in the UK.

D: Any long-term exposure to sun or tanning sessions?

P: Yes when I was in Australia.
D: Could you please tell me about your home condition?
P: I live in a house with my partner
D: Does the lesion affect your day to day activities?
P: I used to go swimming but now I don’t go because of this.
D: Oh that sounds really distressing. Well we will do our best to get to the bottom of
this and provide you with options. How has your mood been recently?
P: Alright not bad.

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Examination:
D: Is it OK if I check your vitals and examine your lesion; I would like to send for some
initial investigations including routine blood tests.
Have you got any idea what the lesion could be?
P: No.

Management: (Same as previous case)

Diagnosis: Best Case Worst Case scenario. So far based on what you have told me it
might be something as benign as a mole. However, from our assessment we found
out that(mention any positive findings what so ever that are red flags). So I’m a bit
worried that your lesion might be something more sinister like melanoma.
Unfortunately, this is a type of cancer of the skin, but it’s still too early to say for
sure. PAUSE

We will refer you to a dermatologist and team of doctors (multi-disciplinary team)

who will do the necessary tests and confirm the diagnosis and start treatment
depending upon the condition.
We will refer you to the specialist in 2 weeks’ time. Urgent Referral PATHWAY.
Senior
Investigations
• Bloods
• Skin biopsy: Excisional Biopsy or WLE Same as discussed above a minor surgical
procedure where either part or all of the lesion is removed so it can be studied
under a microscope to know type and risk of spread. Done by local anesthesia
while you are awake.
• Skin cancer can sometimes be diagnosed and treated at the same time. The
lesion can be removed and tested, and you may not need further treatment
because the cancer is unlikely to spread.
• It's usually several weeks before you receive the results of a biopsy.

Further tests

− SCANS: CT MRI PET

− Lymph nodes sampling. (Sentinel LN)
− If the dermatologist or plastic surgeon thinks there's a significant risk of the
cancer spreading, it may be necessary to do a biopsy on a lymph node. This is
called a fine-needle aspiration (FNA). During FNA, cells are removed using a
needle and syringe so they can be examined.

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Treating non-melanoma skin cancer:

• Surgery is the main treatment. Surgical excision is an operation to cut out the
cancer along with surrounding healthy tissue to ensure the cancer is completely
removed. In most cases,
• Non-surgical treatments:
− Freezing (cryotherapy),
− Photodynamic therapy (PDT),
− Radiotherapy
− Chemotherapy.
− Anticancer creams
Specialist
If you have skin cancer, your specialist care team may include a dermatologist, a plastic
surgeon, a radiotherapy and chemotherapy specialist (an oncologist), a pathologist (a
specialist in diseased tissue) and a specialist nurse. If you have non-melanoma skin
cancer, you may see several (or all) of these specialists as part of your treatment.
When deciding which treatment is best for you, doctors will consider:
− the type of cancer you have
− the stage of the cancer (its size and how far it's spread)
− your general health
−
Safety netting: Same as last case, plus Metastatic symptoms:
− FLAWS
− Bleeding,
− Brain: headaches, weakness
− Lungs: cough
− Liver: Tummy pain

Seborrheic Keratosis
Who you are: You are an FY2 doctor.
Who the patient is: Nina Callahan, a 70-year-old female, with some concerns regarding
a skin lesion has booked a phone consultation today.
Additional information: She has emailed you a picture of her lesion.
What u are supposed to do: Talk to her and address her concerns and discuss a plan of
management.

Dr: Hello, how can I help you?

Pt: I noticed a lesion on my chest P1
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Dr: Tell me more about it. OPEN Q

Pt: Well, I just want to get it checked out.
Dr: When did you notice it? Duration
Pt: 2 months ago.
Dr: Can you describe its Shape, Size, Color?
Pt: Reddish in colour, coin shaped, appears to be stuck on my skin. (Warty-looking
lesion in sun exposed areas)
Dr: Has it changed in shape, size or colour?
Pt: It has increased in size.
Dr: Has the lesion appeared anywhere else?
Pt: No.
Dr: Does anything make it better?
Pt: No.
Dr: Does anything make it worse?
Pt: No.
Dr: Any discharge?
Pt: No.
Dr: Any Pain/ itchiness?
Pt: No.
Dr: Any bleeding?
Pt: No.
Dr: Any other symptoms?
Dr: Do you go out in in the sun a lot? Sun Exposure is very important
Pt: No, I don’t
Dr: Any tanning beds?
Pt: No.

FLAWS
Dr: Any fever?
Pt: No.
Dr: Any recent weight loss?
Pt: No.
Dr: Any lumps or bumps?
Pt: No.
Dr: Loss of appetite?
Pt: No.
P2+ MAFTOSA
Dr: Have you been diagnosed with any medical condition in the past?
Pt: No.
Dr: Any DM, HTN, heart disease or high cholesterol?

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Pt: No.
Dr: Are you taking any medications including OTC or
supplements?
Pt: No.
Dr: Any allergies from any food or medications?
Pt: No.
Dr: Any previous hospital stays or surgeries?
Pt: No.
Dr: Has anyone in your family been diagnosed with
any medical condition?
Pt: My mother had skin cancer.
Dr: How is she now?
P: She passed away a few years ago.
D: Sorry about that please accept my condolences.

DESAS
D: Do you smoke?
Pt: Yes/No
Dr: Do you drink alcohol?
Pt: Yes/No
Dr: Tell me about your diet?
Pt: I try to eat healthy.
Dr: Do you do physical exercise?
Pt: I don’t have much time.
Dr: What you do for living?
Pt: I am retired.
Dr: With whom do you live?
Pt: My husband.
Dr: Do you have any kind of stress?
Pt: No.

Examination

If you could come in I would like to check your vitals, i.e., your BP, pulse, temperature
and respiratory rate. I would also like to examine your breasts for lesions (Picture is in
the cubicle)

ALWAYS ASK ABOUT ICE IDEAS/CONCERNS AND EXPECTATIONS

CONCERNS:
IS IT CANCER? NO, BUT IT RARELY MAY BECOME SOMETHING MORE SINISTER SO EDUCATE ABOUT THE
RED FLAGS.
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Management

Diagnosis:
From what you have told me & the picture you have emailed me, it appears that you
have a skin lesion called seborrheic keratosis. They are harmless growths on the skin
and can vary in colour from skin colour to almost black.

I would like for you to come visit the GP clinic for an examination of the lesion with a
special tool called a dermatoscope. If needed, we can refer you to the hospital for the
biopsy.
Senior
Investigations
Examine it with dermoscopy which is a tool to give more details about the lesion.
Treatment:
Seborrheic warts do not require treatment, as they are usually harmless, but you may
want them to be removed for cosmetic reasons or if they become large, irritated, itch,
or bleed easily (get stuck in clothes or jewelry), once removed they usually do not
return.
• Scraping the wart away under local anaesthetic (where the skin is made numb) or
by freezing it with liquid nitrogen.
• Cryosurgery: Liquid nitrogen, a very cold liquid gas, is applied to the growth the
lesion usually falls off within a few weeks. Occasionally, there will be a small dark
or light spot that usually fades over time.
• Curettage
• Electrosurgery
.
Lifestyle Advice:
it's important to avoid any further sun damage. This will stop you getting more skin
patches and will lower your chance of getting skin cancer.
− use sunscreen with a sun protection factor (30 SPF or more)
− wear a hat and clothing that fully covers your legs and arms when you're out in
the sunlight

• Don’t
− Use sunlamps or sunbeds.

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− Do not go into the sun between 11am and 3pm – this is when the sun is at its
strongest.

Skin specialist so that he can also assess you.

Safety netting
If you do notice a change in a seborrhoeic wart, it is worth asking your doctor to
examine it.
− ABCDE
− Grows rapidly
− Bleeds or scabs
− Red or irritable
Follow up:
In a month. In the meantime if you feel that your lesion is growing, changing its color,
any bleeding from it or any weight loss, please let us know. Thank you.

REFERENCE INFORMATION:
Seborrhoeic keratoses are often confused with warts or moles, but they are quite
different. Seborrhoeic keratoses are non-cancerous growths of the outer layer of skin.
They occur as a single lesion or clusters. They are usually brown, waxy with a stuck-on
appearance. More common in elderly with frequent sun exposure.

5 POINTS RECAP:
1) SUN EXPOSURE
2) TYPICAL DISC SHAPE LESION WAXY BROWN
3) ALL RED FLAGS NEGATIVE
4) NO NEED FOR TREATMENT UNLESS INTERFERES WITH LIFESTYLE MOOD
5) SAFETY NET

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Syphilis
Who You Are: You are an F2 working in GP clinic.
Who the patient: Steven McAdams, 24 years old. He has come with a skin lesion on his
private parts. He is concerned about it.
What you should do: Talk to him, discuss management and address his concerns.

D: Hi I am one of the junior doctors working in this GP surgery. Can I confirm your name

and age please?

P: Hello doctor my name is Steven McAdams, I am 24 years old.

D: How would you like me to call you?
P: Steven is fine doctor.
D: OK. How can I help you today?
P: Dr I feel so embarrassed (Reflect and reassure)
D: There’s no need to feel embarrassed we are here to help you. Can you please tell me
what's going on?
P: I have something on my penis. (P1)
D: Can you tell me more about that? OPEN Q the ODIPARA
P: It’s a small ulcer.
D: How did it start ? Onset
P: I’m not sure.
D: How long has it been there? Duration
P: The past 2 weeks.
D: What is the size of the ulcer?
P: Like a small coin.
D: What is the shape of the ulcer?
P: I don’t know.
D: Anything else with the ulcer?
P: Yes I also have a rash.
D: What is the colour of the rash?
P: Red.
D: Any recent change in colour, shape, size?
P: Not sure.
D: Is there any discharge from the rash?
P: No.
D: Is the ulcer itchy?
P: No.
D: Is it painful?
P: No.
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D: Any other skin lesions in the body?

P: No.

FLAWS
D: Any fever or flu-like illness recently?
P: No.
D: Any lumps or bumps in the body?
P: Yes, I have some around my groin for almost 2 weeks now .
D: Does those hurt?
P: No.
D: Any tiredness? ( HIV )
P: No.
D: Any weight loss? ( CANCER )
P: No.
D: Any loss of appetite?
P: No.
D: Any headache? (Neuro syphilis )
P: No.
D: Any rashes anywhere else in the body? (Generalized syphilis)
D: Any weakness in any part of the body? (Neuro/meningosyphilis)?
D: Any long-term exposure under the sun or skin tanning sessions?
P: No.
D: Any joint pain?
P: No.
D: Any rash on the palms or soles?
P: No.
D: Any white patches in your mouth? (Immunocompromised)
P: No.

P2+ MAFTOSA
D: Have you been exposed to someone having similar skin lesions? CONTACT
IMPORTANT
P: No.
D: Have you had a similar health condition in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Are you currently on any medication?
P: No.
D: Are you allergic to any foods or medication?
P: No.
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D: Any family history of any significant health issues or skin problems?

P: No.

DESA
D: Do you smoke?
P: Yes ( what do you smoke , how many , for how much time )
D: Do you drink Alcohol?
P: No.
D: Tell me about your diet?
P: I have a balanced diet.

Sexual history VERY IMPORTANT

D: Are you currently sexually active?
P: Yes.
D: Are you in a stable relationship?
P: No, I have multiple partners.
D: May I ask about your sexual
orientation?
P: I am a gay.
D: Do you use condoms?
P: No I don’t use any condoms to be
honest.
D: Preferred route of sex
P: anal and oral .
D: Any pain during or after sex?
P: No

EXAMINATION:

If you don’t mind, I would like to do a GPE, check your BP, temperature, RR. Pulse rate
and examine the ulcer.

MANAGEMENT
EXPLAIN CONDITION
From what you have told me and from what I have assessed (mention positive findings),
I suspect you have syphilis. Do you have any idea what syphilis is? (Idea)
Syphilis is a bacterial infection that's usually caught by having sex with someone who's
infected.
D; Do you have any concerns so far? Concerns
P: How are you going to treat me?
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Management
Senior:
Investigations:
We will be doing further investigation, like some routine bloods and some antibody
tests (treponema serology test) in GP practice to confirm the diagnosis.
We will refer you to the GUM clinic. They might take a swab from the lesion and some
more blood samples.
Treatment:
− Injection of antibiotics (For syphilis lasting more than 2 years) into your buttocks
- most people will only need 1 dose of Penicillin, although 3 injections given at
weekly intervals may be recommended if you have had syphilis for a long time.
− Course of antibiotics tablets if you cannot have the injection - this will usually
last 2 or 4 weeks, depending on how long you have had syphilis
Lifestyle Advice:
• Avoid any kind of sexual activity until at least 2 weeks after treatment finishes.
• It is very important to bring in your partners and so we can treat them as well if
they have got the infection.
• If you are not able to bring your partners, we can contact them through our
anonymous partner notification program.
D: We usually offer a HIV test to those who have any kind of sexually transmitted
infections. Do you wish to have one?
P: No.

If the patient stops talking, ask about any other concerns.

P: Can I get it again? (concern)
D: You can catch syphilis more than once, even if you have been treated for it before.
P: How can I prevent syphilis? (concern)
D: Syphilis cannot always be prevented, but if you're sexually active you can reduce
your risk by:
− practicing safe sex: male condom or female condom during vaginal, oral and
anal sex.
− use a dental dam (a square of plastic) during oral sex
− avoid sharing sex toys – if you do share them, wash them, and cover them with a
condom before each use.
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− If you inject yourself with drugs, avoid sharing needles with others. Be aware of
needle exchange program.

Safety net:
If you develop any of the following please come back to the GP again:
− sore throat
− white patches in the mouth
− any tingling or numbness in your hands or feet
− any vision problems please come back to us.Leaflets
− Specific expectations
Follow up
We will have further follow-up appointments to make sure that you’re responding well
to treatment. Wish you a speedy recovery.

MORE INFORMATION

• The symptoms of syphilis are not always obvious and may eventually disappear,
however the person will always be infected unless treated properly.
• Syphilis may have no symptoms or can include:
− small, painless sores or ulcers or small skin growths (similar to genital warts)
affecting genital organs (penis, vagina, vulva, or around the anus), blotchy red
rash on the palms and soles.
− white patches or ulcers in the mouth.
− tiredness, headaches, joint pains, a high temperature (fever) and swollen glands
in your neck, groin or armpits.

• If left untreated can spread to the brain or other parts of the body and cause serious
long-term problems.
• How syphilis is spread: Syphilis is mainly spread through close contact with an
infected sore.
− Vaginal, anal or oral sex.
− Sharing sex toys with someone.
− Sharing needles.
− Blood transfusions, but this is very rare in the UK as all blood donations are
tested for syphilis.
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− Pregnant women with syphilis can pass the infection to their unborn baby.

Syphilis cannot be spread by using the same toilet, clothing, cutlery, or bathroom with
an infected person.

Syphilis in pregnancy
It can be very dangerous for the baby if not treated as it can lead to miscarriage,
stillbirth or a serious infection in the baby (congenital syphilis).
Screening for syphilis during pregnancy is offered to all pregnant women so the
infection can be detected and treated before it causes any serious problems.

Complications of syphilis: Meningitis, Stroke, Dementia, Heart diseases.

Syphilis is divided into stages (primary, secondary, latent, and tertiary), with different
signs and symptoms associated with each stage.
A person with primary syphilis generally has a sore or sores at the original site of
infection.

Eczema
Who you are: You are F2 in GP.
Who the patient is: Jeff Peterson, aged 16, came to the hospital with his mother with
some concerns. He is a diagnosed case of Asthma.
What you should do: Please talk to him, take history, discuss your plan of management
with him and address his concerns.

Doctor: How can I help you?

Patient: I have got rash. (P1)
D: Can you tell me more about it? Open question, then ODIPARA
P: It’s on the back of my legs.
D: How did it start? Onset
P: It started on its own.
D: Since when? Duration
P: A week ago.
D: Does the rash come and go? Course
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P: No.
D: Has the rash spread anywhere else?
P: Yes, it’s also at the back of my neck, and in front of my elbows.
D: Does anything make it better?
P: No.
D: Does anything make it worse?
P: No.
D: Any other symptoms? OPEN Q
P: Not sure.
D: Any fever?
P: No.
D: Any discharge?
P: No.
D: Any itchiness?
P: Yes, it is itchy.
D: Any bleeding?
P: No.
D: Any ulceration?
P: No.

P2+MAFTOSA
D: Have you had a similar kind of problem in the past?
P: Yes when I was a kid.
Mother: He had a rash on his hand, and we put some cream E45 and he was fine.
D: Have you been diagnosed with any medical condition in the past?
P: Asthma since childhood. EXPLORE
D: Does anything trigger it?
P: It sometimes gets worse when playing out in the cold.
D: Does it get triggered by dust, pollen, cold weather, pets? (rule out triggers)
P: No.
D: How is it controlled?
P: I am on salbutamol inhaler, and it is well controlled.
D: Any DM, HTN, heart disease or high cholesterol?
P: No.
D: Apart from Asthma meds are you taking any other medications including OTC or
supplements?
P: No.
D: Any allergies from any food or medications?
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P: Yes, I have a nut allergy.

D: Any previous hospital stays or surgeries?
P: No.
D: Has anyone in the family been diagnosed with any medical condition?
P: My father and sister have asthma.

DESAS
D: Tell me about your diet?
P: I try to eat healthy.
D: Do you do physical exercise?
P: I don’t have much time.
D: Do you smoke?
P: No
D: Do you drink alcohol?
P: No, I’m not old enough.
D: Do you have any kind of stress?
P: No.

Examination:
I would like to check your vitals and examine your rash if you don’t mind?
I would like to send for some initial investigations including routine blood tests.

Management:

Diagnosis:
From what you have told me and the rash that you have described and shown me
(explain all positive findings in hx and examinations and whenever given a picture
always describe and explain it to patient), it appears that you have eczema. It usually
occurs in people who are more susceptible to allergies and asthma and it makes the
skin become dry and irritated as you mentioned.

We can usually confirm the diagnosis with a clinical examination.

Senior:
Investigation
Routine bloods
Allergy tests: are not usually needed, although they're sometimes helpful in identifying
whether a food allergy may be triggering symptoms.

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Management:
Eczema is a chronic condition that can be managed by prevention and by using some
topical medications.
Medical:
• Emollients (moisturizing treatments) on a daily basis for dry skin.
• Topical steroids reduce swelling, redness and itching during flare-ups.
• Antibiotics: if super imposed infection occurs.
• Antihistamines: If itching during a flare-up affects your sleep, a GP may suggest
taking a sedating antihistamine, which may cause the patient to become drowsy, so
don’t drive if you have taken them (in this case the patient is too young to drive).

Apply emollient first and ideally wait around 30 minutes until the emollient has soaked
into your skin or apply the corticosteroid at a different time of day (such as at night).
Continue to use it until 48 hours after the flare-up has cleared so the inflammation
under the skin surface is treated.
Lifestyle:
− Avoid scratching whenever possible as it can increase damage caused by eczema;
You could try gently rubbing your skin with your fingers instead.
− Keep your skin covered with light clothing to reduce damage from habitual
scratching.
− Keep your nails short and clean to minimise damage to the skin from unintentional
scratching.
− Keep a diary of what triggers the symptoms
− Avoid triggers once you know them. For example: certain fabrics – heat – soaps,
house dust mites, pollens…etc
− Dietary changes: may be referred to a dietitian (a specialist in diet and nutrition) if
food triggers are suspected.

Specialist
Skin specialist (dermatologist). You may be referred if:
− normal treatment is not controlling your eczema.
− your eczema is affecting your daily life.
− it's not clear what's causing it.
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Safety netting: (Always try to safety net for all the conditions the patient have.)
− If you experience your skin become red, sore , fluid – filled blisters or oozing
fluids ,
− If u have severe or worse
Asthma symptoms like SOB
cough breathlessness come
back to us again

Follow up

Haemangioma:

Who you are: You are an FY2 in the GP clinic.

Who the patient is: Laura Flick ,aged 10 days old, has been brought in by her mother.
What you should do: Talk to her and address her concerns.

Doctor: Hi I’m one of the junior doctors here.

Patient: Hello doctor.
D: Can I confirm your name please?
P: Doctor my name is Matilda.
D: Can I get your daughter’s full name and DATE OF BIRTH PLEASE?
(Confirm date of birth, rather than age, as it’s a more precise way of confirming ID.)
P: I am Serena’s mum, she is 10 days old.
D: Okay, is Serena here with us today?
P: No.
D: Okay that’s fine, how can I help you today?
P: Doctor, my baby has a rash on her thigh . (P1)
D: Could you please elaborate a bit more for me ? OPEN Qs

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P: I was changing my baby’s nappy and I saw some spots/ rash on her thigh I was very
curious to know how a 10 day old baby can have it, that’s why I came here to ask about
it. Onset
D: I am sorry to hear that, I can see you are anxious about it. Can I ask a few more
questions about it so that I can understand it better? Reflect
P: Sure doctor.
ODIPARA
D: Could you please tell me when it started? Duration
P: I don’t know doctor, but I saw it last night.
D: What is the shape of the rash?
Any change in the shape of the rash?
P: Doctor I have a picture of it.
D: What is the Size of the rash? Any change in the size?
P: Like a coin.
D: What is the Colour of the rash? Any change in the color?
P: Red in color.
D: Any discharge/bleeding from the rash?
P: No discharge.
D: Is it itchy or painful?
P: I’m not sure
D: Fever or flu-like symptoms?
P: No.
NAI very important
D: Who is with Serena now?
P: My husband is looking after her. He takes good care of her .
D: Was it a planned pregnancy?
P: Yes doctor.

Head to toe quickly remember paediatric structure

D: Does she cry after moving her neck ?
P: No.
D: Any problems with her wee? Any problems with her poo? How’s the general health
of the baby? Is she feeding well?

BIRDDD
D: How was her birth?
P: NVD.
D: Was she delivered at full-term?
P: No doctor. She was delivered at 35 weeks.
D: Did she have a low birth weight?
P: Yes, she was low birth weight.
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D: Was it multiple or twin pregnancies?

P: No.
D: Any congenital problems?
P: No.
D: Family history of any diseases?
P: No.
D: Do you have any IDEA of what it is?
P: No.
Thank you very much for the information regarding your baby Serena .

Examination:
I would like to have a look at the rash and would ideally examine Serena’s general
health as-well (but she is not here).

Examiner may show you a picture of the rash

Management:

Diagnosis
From what you have told me and from what I have assessed I suspect your baby just has
a birthmark (strawberry or hemangioma ).
D: Have you seen one before? (concern)
P: Oh is that it?! No I haven’t seen one before.
Birthmarks are blood vessels that form coloured marks (raised red lumps) on the skin
that are present at birth or soon afterwards. Most are harmless and disappear without
treatment, but some may need to be treated.

Senior:
I would like to inform my seniors to get an expert opinion as well. Do you have any
concerns so far?
P: Is it serious? (concern)
D: Fortunately it is not, however the size may increase in the first few months but they
then usually disappear by the age of 6 to 7 years .

NB: It is common in girls, premature babies (born before 37 weeks), low birth weight
babies, and multiple births, such as twins get bigger for the first 6 to 12 months, and
then shrink and disappear by the age of 7. May need treatment if they affect vision,
breathing, or feeding.

P: How are you going to treat her now? ( concern )

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D: Usually these birthmarks don’t need any treatment unless they are affecting her
vision, breathing, or feeding.

Investigations
CT and MRI : Only if more than one to exclude internal organs hemangiomas or near
eyes.
Lifestyle advice
Most of the time, haemangiomas just need looking after carefully.
− Haemangiomas can bleed if they’re scratched, so it’s important to keep your
child’s nails short and buffed smooth to protect the surface of the lump.
− If the haemangioma starts bleeding, apply pressure with a clean piece of cloth or
tissue for at least five minutes. If blood soaks through the material, put another
one on top and keep up the pressure. Don’t take it off to have a look, as this
could start the bleeding again.
− If the bleeding continues, even after pressing down on the haemangioma for five
minutes, we recommend people go to your nearest NHS Walk-In Centre or
Accident and Emergency department.
− The surface of the haemangioma is delicate and can get dry, so
avoid using bubble bath,rinse any soap or shampoo off carefully and pat the area
gently afterwards.
− A thin layer of Vaseline® put gently over the top twice a day can stop it drying
out.
− Baby wipes can be irritating, so a better alternative is to use damp cotton wool.
− Sun protection, with high factor sun cream on all areas of exposed skin, use a hat
to protect the child’s face and/or an umbrella over the buggy or pushchair.

Treatment:
Larger, visceral, or life-threatening lesions may be removed.
Options include:
• Medicines – to reduce blood flow to the birthmark, which can slow down its
growth and make it lighter in color.
• Laser therapy – where heat and light are used to make the birthmark smaller and
lighter (it works best if started between 6 months and 1 year of age).
• Surgery – to remove the birthmark (but it can leave scars).
• Embolisation therapy

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A birthmark can be removed on the NHS if it's affecting a person's health. If you want a
birthmark removed for cosmetic reasons, you'll have to pay to have it done privately.

Specialist:
Refer to skin specialist if suspicious or affecting life or getting worse or started showing
red flags.
Safety net:
Come back to the GP if you're worried about a birthmark or you start noticing any of
these:
RED FLAGS
− Your child has 6 or more cafe-au-lait spots.
− You or your child has a large congenital mole.
− If close to the eye, nose, or mouth.
− If getting bigger, darker, or lumpier.
− If sore or painful.
Follow up:
The Birthmark Support Group has information about other type of birthmarks and
getting help and support.

4 POINTS RECAP: ☺
1. NEWBORN WITH SKIN LESION RED LUMPY
2. NOT SERIOUS, DISAPPEAR LATER IN LIFE
3. TREAT ONLY IF AFFECTING LIFE
4. ADVICE AND SAFETY NET

Raynaud’s
Who you are: You are FY2 in GP clinic.
Who the patient is: Mr. Omer Khalil, aged 31, presented with pain in his fingers.
What you should do: Take history, assess the patient’s condition and discuss the
management accordingly.

Doctor: Hello I am one of the junior doctors in this GP surgery. Can I confirm your name
and date of birth please?
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Patient: Yes doctor, my name is Omer Khalil and I am 31 years old.

D: How may I call you?
P: Omer is fine doctor.
D: What brought you here today?
P: Doctor I have had pain in my fingers for the last few months (P1)
D: Tell me more about it. OPEN Q then SOCRATES
P: It’s usually worse in the winter season or when I’m exposed to cold.
D: How did it start? Onset
P: Gradually doctor.
D: You mentioned it affects your hands, both hands or only one hand? / all fingers or a
few fingers? / anywhere else? Site/Radiation
P: (Shows which hand/fingers are affected).
D: Is it always there or does it come and go? course
P: Comes and goes in attacks.
D: How long does it last when it happens?
P: Last for few mins to hours.
D: Can you describe the character of the pain for me?
P: It’s like pins and needles, numbness.
D: Any difficulty in moving affected parts or change in colour?
P: I have difficulty moving my fingers as well during the same time and my fingers
become white.
D: You mentioned it gets worse when exposed to cold weather, is there anything else
that makes it worse?
P: Not off the top of my head doc.
D: Anything that makes it better?
P: When I start warming my hands up doctor.
D: Have you tried anything for the pain?
P: No.
D: Can you grade the pain for me on a scale from one to ten one being the least and ten
being the most pain?
P: 5.
D: Anything else?

Differential diagnosis- GHRROS (gout, reactive arthritis, rheumatoid arthritis,

osteoarthritis, SCLERODERMA, SLE, trauma) as in rheumatology
Explore:
D: Do you have any joint pain and stiffness?
D: Any urine: discharge/burning pain?
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D: Any rashes (SLE)

D: Fever or flu like symptoms (vasculitis/reactive arthritis)
D: heart racing SOB chest pain? (Heart conditions)
SCLERODERMA CREST SX?? VERY IMPORTANT - ALL ARE RED FLAGS
D: Do you have any difficulty swallowing? (Oesophageal dysmotility)
D: Any tummy discomfort?
D: Any skin changes around nose or finger (Rash spots or thickening)?
D: Joint problems

FLAWS
D: Loss of weight? (cancer)
D: Loss of appetite?

P2+ MAFTOSA
D: Autoimmune diseases like SLE, RA , SCLERODERMA ( POSITIVE FOR RAYNAUD’S
PHENOMENON.
D: Any medical condition? (atherosclerosis, DVT)
D: Are you taking any medications? (beta blockers, migraine medications)
D: Allergy to any medications?
D: Family history of diseases?
D: Occupation? (typist, heavy use of hand tools)

DESAS:
D: Diet? (increased intake of caffeine) D
D: Physical activity? E
D: Are you smoking? (risk factor) S
D: Are you taking alcohol? A
D: Have you noticed certain kind of stress or anxiety brings on the pain or colour change
in your fingers? (Stress/Anxiety) S

Examination:
I would like to check your observations pulse, examine your fingers and feet, face
(malar flush) and joints.
MANAGEMENT:

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Diagnosis
From what you have told me you have mentioned that you have had pain in your hands
for a few months now that worsens when in cold weather and improves when warming
the hands. From what I have examined as well, I suspect you have a condition called
Raynaud’s phenomenon.
D: Do you have any idea what Raynaud’s phenomenon is? (Concern)
P: No.
D: Explain that it is autoimmune. It is a localised intermittent episode of interruption of
blood flow to the extremities (vasoconstriction of small arteries) of the feet and hands
that causes colour and temperature changes leading to pain in the fingers, usually
unilateral but it can be bilateral as well.
Senior:
I would like to inform my seniors who will review you again because we will need to
send for some routine bloods CBC, and some immune markers. CRP ,ESR , ANA , RA
factor to rule out other causes.
Investigations:
All above to be taken in order to rule out other cause but there is no diagnostic test for
Raynaud’s phenomenon.
Specialist: Refer to Rheumatologist.
Symptomatic
Medicine to help improve your circulation, such as nifedipine, which is used to treat
high blood pressure.
Lifestyle advice: very important here:
DO
− Keep your home warm.
− Wear warm clothes during cold weather, especially on your hands (use gloves
)and thick socks on your feet.
− Exercise regularly – this helps improve circulation.
− Try breathing exercises or yoga to help you relax.
− Eat a healthy, balanced diet.

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DON’T

− Do not smoke – improve your circulation by stopping smoking

− Do not have too much caffeine (found in tea, coffee, cola and chocolate) – it may
trigger symptoms of Raynaud's

Safety netting
If you have joint pain, skin rashes or muscle weakness, or your symptoms are getting
worse despite treatment or having attacks in only one hand, or one finger please come
back to us.
Support group
SRUK is a charity for people with scleroderma and Raynaud's. It offers further
information and advice about living with Raynaud's.
Follow up:
After a few weeks to make sure you are responsive to treatment.
4 POINTS RECAP: ☺
1. CLASSIC PRESENTATION ALL RED FLAGS NEGATIVE
2. NIFEDIPINE
3. LIFESTYLE
4. SAFETY NET

Decisive factors for Raynaud’s:

• Change colour.
• Other symptoms can include:
− Pain
− Numbness
− Pins and needles
− Difficulty moving the affected area
• Some people also find that their ears, nose, lips or nipples are affected.
• The symptoms of Raynaud's may last from a few minutes to a
few hours.
• Raynaud's is sometimes caused by another health condition, taking certain
medicines, or working with vibrating tools for a long time.
• Triggered by cold, anxiety or stress.

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Animal Bite
Who you are: FY2 in the GP surgery
Who the patient is: 35-year-old Clark Kent came to the clinic with pain in his hand.
What you should do: Talk to the patient, assess, and address his concerns.

Presenting complaint (P1) (ODIPARA):

D: Hello this is I am one of the doctors in this GP surgery. You must be Clark?
P: Yes.
D: Can I get your full name and D.O.B., before we begin the consultation?
P: (Confirms details)
D: Mr Kent, I believe you have some pain in your hand?
P: Yes, doctor, I have some pain in my right hand.
D: Please, tell me more about it?
P: Doctor, I was on a holiday trip to Turkey, and while I was there, I got bit by a cat on
my hand while I was sitting in a park. It has been painful since then.
D: When exactly was that?
P: 2 days ago.
D: What did you do after that?
P: I immediately squeezed the wound and washed it with water. After that I went to a
hospital, they assessed my wound, cleaned it and put a bandage on it. Also they gave
me some painkillers.
D: Do you have anything else apart from this pain?
P: No, doctor.
D: Any fever, swelling at wound site, any discharge?
P: No.
D: Any headache, muscle stiffness, muscle spasm, muscle weakness or rigidity,
photophobia, jaw stiffness.
P: No, doctor.
D: Tell me about your vaccination status, especially tetanus and rabies vaccines?
P: I have had the rabies vaccine but I am not sure about tetanus.
D: Anything else that you would like to add?

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P: No.

Concern
D: Is there anything in particular that you are concerned about?
P: No, it's just that I wanted to make sure that it's nothing serious.

Past medical conditions (P2)

D: Do you have any medical conditions that I should be aware of?
P: No, doctor.

D.E.S.A:

M.A.F.T.O.S.A + Vaccination status

D: Are you on any long-term medication?
P: No.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Any medical conditions in the family?
P: No, doctor.
D: Are you up to date with your vaccinations, especially rabies and tetanus vaccination?
P: Yes, doctor.

Examination:
● Observations (Check vitals)
● Examine the wound
● Neurovascular function in surrounding area of bite
● Lymph nodes

Management:
1. Senior
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2. Investigations
● None required.
3. Definitive management
● Clean the bite thoroughly. If the wound is very dirty, some of the affected area
may need to be removed to reduce the risk of infection.
● Close the wound with stitches, sticky strips, or special glue, or leave it open to
heal. We may give you antibiotics to stop the wound becoming infected.
● Check risk of getting tetanus and rabies.
Tetanus:
● If the patient has not been fully immunised for tetanus, or they're not sure
whether they have, they should be given a dose of the tetanus vaccine. Such
patients may also need antibiotics.
● The wound should be thoroughly cleaned and an injection of tetanus
immunoglobulin should be given.
Rabies:
● Immediately clean the wound with running water and soap for several minutes.
● Disinfect the wound with an alcohol- or iodine-based disinfectant and apply a
simple dressing, if possible.
● Post exposure treatment: cleaning and disinfecting the wound.
● A course of the rabies vaccine – you'll need to have 4 doses over a month if you
have not been vaccinated against rabies before, or 2 doses a few days apart if you
have.
● Immunoglobulin given into and around the wound – this provides immediate but
short-term protection if there's a significant chance that the patient has been
infected.
4. Specialist
Referral to specialist required in following cases:
● Severe bite injuries
● Facial wounds
● Serious hand bites.
● People with an increased risk of infection — for example, diabetes mellitus,
asplenia, immunocompromised status, chronic liver disease, prosthetic heart
valve or joint.
● If there is a possibility that the person has been exposed to rabies.

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● If the person is at risk of tetanus.

5. Safety net
● Wound complications (Abscess, infection)
● Systemic infection (Meningitis, sepsis)

Psoriasis
Who you are: FY2 in the GP
Who the patient is: 37-year-old Donald Bloom came to the clinic with some complaints.
What you should do:
Talk to the patient, assess, and address his concerns.

Psoriasis (Positive Findings):

● Dry skin lesions, known as plaques, that are covered in scales.
● Normally appear on elbows, knees, scalp and lower back, but can appear
anywhere on your body.
● The plaques can be itchy or sore, or both.
● In severe cases, the skin around joints may crack and bleed.

Presenting complaint (P1) (ODIPARA):

D: Hello I am one of the doctors in the GP clinic. You must be Donald?
P: Yes.
D: Can I get your full name and D.O.B. please before we begin the consultation?
P: (Confirms details)
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D: So, Donald, I can see that you have been having a rash?
P: Yes, doctor.
D: Tell me more about this rash. (Open question)
D: When exactly did it start?
P: Well, doctor, it has been going on for the past 3 months (Onset)
D: Is it continuous or does it come and go? (Duration)
P: It's there all the time.
D: Can you tell me exactly where it is? (Site)
P: It's on my knees and elbows.
D: The size, shape and colour of the rash?
P: It's mostly red in colour but there are also white patches as well.
D: Any discharge, bleeding, pain?
P: No, doctor, but it's itchy and a bit sore.
D: Have you noticed any fever along with it?
P: No, doctor.
D: Do you think it has been increasing since it started? (Progression)
P: Yes, doctor, I think it is getting worse.
D: Is there anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: No doctor, I have been using petroleum jelly (Vaseline) on the rash but that is not
very helpful.
D: Any injury to skin (Cut, insect bite, sun exposure)?
P: No doctor.
D: Any recent stressors?
P: I have been a bit stressed because of my job, I have been jobless now for some time.
D: How is this affecting your life?
D: Anything else?

D.Ds
● Seborrheic dermatitis
● Fungal skin infection
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● Candida intertrigo
● Eczema

Past medical conditions (P2)

D: Has this ever happened before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?

D.E.S.A:
Any smoking?
What about alcohol?

M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: No.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Is there anyone in your family with similar problems or other medical conditions?
P: No, doctor.
D: How has it been impacting you? Is it affecting your life in anyway? (Psychosocial)
D: Anything else.

Expectations?
D: Anything specific on your mind that you are expecting from us today?
P: Something to get rid of it, doctor.

Examination:
● Observations (Check vitals)

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● General physical examination

● Examination of the rash

Idea
D: Do you have any idea what might be causing this?
P: No, doctor.

Suspected diagnosis:
Donald, you told me that you have got these lesions on the skin that are scaly and are
itchy. Having had a look at the lesions I am suspecting a condition called psoriasis. It is
related to a problem with the immune system. The immune system is your body's
defence against disease and infection, but it attacks healthy skin cells by mistake.
Psoriasis can run in families and sometimes symptoms start or become worse because
of a trigger. Possible triggers of psoriasis include an injury to your skin, throat infections
and using certain medicines.

Concern
D: Apart from this, do you have anything else that's concerning you?
P: It looks really bad, doctor and I am worried that my partner might get it from me.
D: We'll try some things to see if we can relieve it. Please don’t worry about anyone
catching it, it's not contagious, your partner can not get it from you.

Management:
1. Senior
2. Investigations
A biopsy might be required sometimes by the specialist if the diagnosis is not clear.
3. Symptomatic management
General lifestyle advice to reduce the risk of exacerbations, such as advice on:
● Smoking cessation if appropriate.
● Drinking alcohol within recommended limits.
● Weight loss if the person is overweight or obese.
● Assess for associated stress, distress, anxiety and/or depression, and manage
appropriately.
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4. Definitive management
Topical – Creams & Ointments.
● Emollients (Moisturiser) apply directly to the skin.
● For mild to moderate psoriasis, topical corticosteroids can be applied.
● Vitamin D analogues cream
● Calcineurin inhibitors (Tacrolimus)
● Coal tar – can be used if other topical treatments are not effective.

Phototherapy – Skin exposed to certain UV light.

● Psoralen plus UV A (PUVA)

Systemic – Oral and Injected Medications.

● Non biological medications – Methotrexate, Ciclosporin
● Biological treatments – Etanercept, Adalimumab, Infliximab

The patient should be reviewed after 4 weeks of initiation of treatment.

5. Specialist
Refer to the dermatology department.
6. Safety net
● Unexplained joint pain or swelling (Psoriatic arthritis)
● Heart failure - due to increased skin blood flow, blood volume, and cardiac
output.
● Dehydration
● Hypothermia
● Malabsorption

Intertrigo (Rash in body folds)

Who you are: FY2 in the GP clinic.
Who the patient is: 35-year-old Ariana James came to the clinic with some complaints.
What you should do: Talk to the patient, assess, and address her concerns

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Intertrigo (Positive Findings):

● Soreness/discomfort
● Red or reddish brown rash
● Inflammation
● Itching
● Cracked or split skin
● Weeping skin with or without smell
● Discharge (often with strong smell)
● Swelling, sores or blisters

Presenting complaint (P1) (ODIPARA):

D: Hello, I am one of the doctors in this GP clinic. You must be Ariana?
P: Yes.
D: Can I get your full name and D.O.B., please, before we begin the consultation?
P: (Confirms details)
D: So, Ariana, I understand that you have been having a rash?
P: Yes, doctor.
D: Tell me more about it (Open question)
P: Doctor, I have a rash on my chest and it's very itchy.
D: Where exactly on the chest?
P: It’s below my breasts.
D: When exactly did it start?
P: Well, doctor, it started 4 days ago. (Onset)
D: Is it continuous or does it come and go? (Duration)
P: It is continuous.
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D: Do you think it has been increasing since it started? (Progression)

P: Yes. doctor, it’s increasing.
D: Is there anything that you think makes it better or worse? (Aggravating and relieving
factors)
P: I used some petroleum jelly. It works for a while but it's not helping in the long term.
D: The size, shape and colour of the rash?
P: It has different shapes and is red in colour.
D: Any discharge, bleeding, pain?
P: It's sore doctor.
D: Have you noticed any fever along with it?
P: No doctor.
D: Do you have a similar rash anywhere else?
P: No.
D: Anything else?
P: Yes, It feels sore and the rash feels wet at times.

D.D’s
● Atopic eczema
● Impetigo
● Cellulitis

Concerns?
D: Apart from this, do you have anything else that's concerning you?
P: No.

Past medical conditions (P2)

D: Has this ever happened to you before in the past?
P: No, doctor, I have never had anything like this before.
D: Do you have any medical conditions that I should be aware of?
P: No, doctor.

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D.E.S.A:
Any smoking ?
What about alcohol?
M.A.F.T.O.S.A
D: Are you on any long-term medication?
P: No.
D: What about any known allergies to any food or drugs?
P: I don’t have any known allergies.
D: Anyone in the family with similar problems or other medical conditions?
P: No, doctor.
D: Have you been in contact with anyone with the same problem?
P: No, doctor.
D: Anything else.

Expectations?
● D: Anything specific on your mind that you are expecting from us today?
● P: Something to get rid of it, doctor. It's very itchy.

Examination:
● Observations (Check vitals)
● General physical examination
● Examination of the rash

Ideas?
D: Do you have any idea what might be causing this?
P: No, doctor
Suspected diagnosis:
D: Ariana, after having a look at the rash and after what you told me, I am suspecting it
to be something called Intertrigo, which in simple terms is a sweat rash due to skin to
skin rubbing and moisture. It can sometimes lead to a fungal infection of the skin also.
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P: Is it something serious?
D: Intertrigo is not dangerous but if left untreated, it may get worse and possibly spread
to other parts of the body. In some cases, it can lead to a creamy coloured discharge
with a pungent smell.

Management:
1. Senior
2. Investigations
● Not required usually.
● Take swabs ONLY IF suspecting secondary infection or the patient is
immunocompromised.
3. Symptomatic
● Wash the affected area regularly.
● Pat your skin dry rather than rubbing.
● Avoid sharing towels and flannels to reduce the spread of infection.
● Wear a good, well- fitting and supportive bra. Cotton is better than nylon.
● Change your bra every day.
● Losing weight will help to reduce the areas where skin folds can rub together.
4. Definitive management
● Prescribe a topical imidazole (clotrimazole, econazole, miconazole, or
ketoconazole) or terbinafine.
● For significant itch and inflammation consider a mildly potent corticosteroid
cream (for example hydrocortisone 1%) in addition to the topical antifungal. (For
7 days - Review after 7 days)
● Oral antifungals (Fluconazole) for 2 weeks if topical treatment fails.
5. Specialist
● Refer to dermatology specialists only if widespread or recurrent infection.
6. Safety net
● Severe itching and soreness
● No improvement even after treatment

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PSYCHIATRY

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Psychiatry
PSYCHIATRY STRUCTURE

Key points
1. Follow this structure.

M Mood
C Cognition
F 4F (Family – Friends – Finance – Forensic).
A Allergy - Alcohol and other drugs.
M 2M (Medical – Mental conditions)
I 2I (Insight – Impact )
S Suicide
H Hallucination.
(Look at videos of the course to know how to ask).

2. Depending on what the station is, start the specific questions for
the station. For example,
• Psychosis station → Cognition +Hallucination questions. +
• Depression station → Mood + Suicide questions. Mood
• Dementia station → Cognition + MMSE question. Suicide
• Alcohol station → Alcohol questions. (CAGETWD) Insight
• Heroin station → Heroin questions. (CAGETWD) Impact
• Suicide station → Suicide questions

3. In any psychiatry station, you must ask,

• Mood.
• Suicide.
• Insight.

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• Impact of his condition on → Life, Work, Daily Activities, People

around him.

4. Always, Always, Always

↓
Acknowledge.
1. Behaviour 2. Appearance 3. Language & speech
I can see that you are Only for you to Only for you to observe.
• Is he embarrassed? observe. • Is he talking fast?
•Is he anxious? Any evidence of • Is he loud?
• Is he scared? • Self-Neglect • Does he have a weak tone?
• Is he upset? • Cleanliness.
• Hygiene.

5. Any depressed patient, you must ask,

• How are you feeling?
• Have you been irritable – angry lately?
• How is your concentration recently?
• How is your appetite?
• How is your sleeping?
• How is your sexual relationship?

6. At any psychiatry station, you must ask about → Support system.

(As it will help in management)
• Who do you live with?
• Any friends around?
• Any family around?
• Anyone that you share your feelings with?

7. Always end any psychiatry station with → Safety netting =Suicidal thoughts

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Depression with Low Mood

Mood Swings:
Presentations:
➢ Mood swings before periods (PMS)
➢ NAI and bullying.
➢ Peri and post-menopausal symptoms.
➢ Contraceptives: especially progesterone containing.
➢ Other causes: Cyclothymia, bipolar disorder.

Who you are:

You are an FY2 doctor in GP Surgery.
Who your patient is:
Mrs. Maria Douglas, a 41-year-old lady, has come today with some concerns.
What is your task:
Talk to the patient, take focused history and address her concerns.

Note: The tone of your voice and how you will talk and approach is
important

Approach

P1 MOOD
D: How can I help you?
P: I am feeling low all the time/ sad all the time/ I’m not happy.
D: Acknowledge, show sympathy and then ask, “Tell me more about it.”
P: (Allow her to speak)
D: Since when have you been feeling like this?
P: For the past few months.
D: Is there any reason for these feelings?
P: I feel lonely as my child goes to nursery and I’m home alone. My husband also
goes to work.
D: (Sympathise and ask about relationship with the husband)
P: He is a loving husband and very supportive.
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D: Do you have any one like relatives and friends around?

P: They all live very far away.
D: Can you score your mood? Like 1-10, 1 being the saddest and 10 being the
happiest?
P: 4.
D: Have you felt very sad, hopeless or irritable at any time?
P: Yes.
D: Have you felt like you’re losing interest in everyday activities?
P: Yes.
D: Have you felt worthless or empty?
P: Yes.
D: What else do you feel? Can you explain?

P: I feel like I won’t be living any more, I have a recurring feeling of dying.
SUICIDE
D: Do you feel suicidal/Like hurting yourself? (Sign Post first)
P: No.
D: Anything else or concerns you want to share?
P: (Listen to anything else she wants to share)
Ask DDs now
D: Do you have episodes of feeling very happy, elated or overjoyed? (Bipolar
Mania)
D: Do you sometimes feel full of great ideas and important plans?
D: Do you feel cold even in warm environments? (Hypothyroidism)
D: Have you ever heard voices speaking when there is no – around? (Psychosis-
Ask after proper signposting)
D: How is this impacting your life?
D: Do you feel that you really need to get some help regarding your situation?
(Insight)

2 M Medical and Mental Health

D: Have you had similar feelings in the past?
P: No.
D: Any history of mental illness or chronic medical conditions?
P: No.
D: Any medications, OTC drugs or supplements?
P: No.
D: Any birth control pills?
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P: No.
D: Any allergies from food and medications?
P: No.
D: Does anyone in your family have a similar condition? Or any mental illnesses?
P: No.

Alcohol, Drugs, Lifestyle

D: Do you smoke/drink/recreational drugs (proper signpost first)?
P: No.
D: Are you physically active?
P: No.
D: How is your sleep/ diet?
P: I can’t sleep, and I don’t have a good appetite; (Explore each of them)
D: How much weight have you lost?
P: No.
D: Do you have any other stress in your life?
P: No.

4 F (Family, Friends, Finance, Forensic)

D: How are things at home? / Who do you live with apart from your child and
husband?
P: I live with my child and husband only, they are very supportive. Everything is
alright at home

D: Do you work/ anything you do for a living?

P: No, currently I’m unemployed.
D: Any hobbies? How do you spend your days?
P: No, I just sit and watch movies and series.
D: Are you financially stable?
P: Yes my husband earns well.
ICE
D: Any idea what the reason could be for all of this you’re having?
P: No.
D: Do you have any particular expectation from today’s consultation?
P: I’m not sure.

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Examination
If you don’t mind, I would like to check your vitals and do a general head to toe
examination(GPE) – Everything is normal.

Provisional Diagnosis
D: From the chat we had (mention the positive findings), you told me that you’re
feeling low for a few months now and that you stay alone at home most of the
time and don’t have anyone around; So it appears to me as that you might have
depression. I’m sure you know what it is, it’s a condition which makes someone
feel unhappy all the time, it can be due to any stress, loneliness or something
unwanted happening to somebody.
Do you want to know how we can manage this so that you might feel better?
P: Yes please.

(Most of the time it will get better without any treatment, however this may take
time like several months or even longer. Relationships, employments might also
in this time may be affected sometimes. And there is also a danger that some
may turn to alcohol or illegal drugs, some people think of suicide. Therefore,
people with depression often opt for treatment.)

Management:
1. (No admission required)
2. Senior
3. Investigations: Routine Blood test such as FBC, LFT, TFT, KFT, ECG, Chest X-
ray
4. CBT
It is talking therapy that will help you understand your condition better
and give you an idea that certain ways of thinking can trigger or fuel
certain mental health problems such as depression.
- As it is a moderate depression offer only CBT at first and general advice
but also mention about medications if nothing works.
5. Medication:
• You might need to take some medication for this condition to help
you better, these

medications are called antidepressants (Fluoxetin / Citalopram etc)

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– Patient doesn’t want to take medications for a long time as these

need to be taken for a minimum of 6 months and starts working
after 6-8 weeks explain that to them when you tell them about
medications.
6. General Advice:
• Do
o Try to distract yourself doing other things, like reading good
books.
o Make new hobbies.
o Have a healthy diet, regular exercise.
o You can think about having a pet to look after in your lonely
times so that you can spend time with it.
• Don’t
o Don’t keep yourself isolated, open up to your family and
friends.
o Don’t despair – most people recover from depression
remember that.
o Don’t drink too much alcohol.
o Don’t make important major decisions when you’re feeling
low, like relationships, jobs, money until you’re well again.
7. Referral:
• If my senior thinks that you need a referral, we will offer you an
appointment with the mental health specialist.
• We can also refer you to Good Samaritans Groups where you can
talk about your condition and seek help.
8. Follow Up: We will review you from time to time to see how your
improvement is going and manage accordingly.
9. Reading materials:
• We will provide you with some leaflets/Pamphlets or links from the
NHS so that you can understand it better.
10. Safety net:
• Crisis Card
• Suicidal thoughts

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• Helpline- 999

DEPRESSION (WEIGHT LOSS)

Who you are:
You are an FY2 doctor in GP.
Who your patient is:
Diana Wales, aged 30, came to the clinic because of concerns of weight loss.
What is your task:
Please talk to her and discuss your plan of management with her and address her
concerns.
P1 Mood
D: How can I help you?
P: I think I’m losing weight doctor.
D: Unintentionally?
P: Yes.
D: Could you tell me more about it?
P: My clothes are getting looser on me.
D: Since when have you been losing weight?
P: For the past 1 year.
D: That’s a quite a long time. Have other people noticed it?
P: Yes, people around me keep telling me about it.
D: How much weight have you lost?
P: I have lost half a stone. (1 Stone is 6.35 Kg)
D: Are you eating well?
P: I don’t have an appetite like before. (Explore food habit here)
D: Do you feel tired?
P: Yes (explore a little)
D: Anything else you want to share?
P: I don’t know doctor I just don’t feel good.
D: Tell me more about how you feel?
P: I’m not sure, I think I’m not happy.
D: (Acknowledge, sympathise, then) Could you tell me how your mood is
recently?
D: My mood is low doctor. I always feel I’m exhausted and not feeling good
about anything.
D: Since when have you been feeling like this?

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P: For the same duration (1 year).

D: Is there any reason you know of causing you to feel like this?
P: I don’t know doctor.

D: D: Can you score your mood? Like 1-10, 1 being the saddest and 10 being the
happiest.
P: 4.
D: Have you felt very sad, hopeless or irritable at any time?
P: Yes.
D: Have you felt you’re losing interest in everyday activities at any time?
P: Yes.
D: Have you felt worthless or empty?
P: Yes.
D: Like what did you feel can you explain?
P: I just feel like everything around me is getting out of hand, I’m just living from
day to day for my child at the moment.
D: Do you feel suicidal/ Like hurting yourself? (Signpost first)
P: No.
D: Anything else or concerns you want to share?
P: (Allow her to expand on her feelings, if she wants)
Ask DDs now
D: Do you have any lumps or bumps? (Malignancy)
P: No.
D: Do you feel a swelling in your neck? (Hyperthyroidism)
P: No.
D: Do you have an irregular and/or unusually fast heart rate? (Hyperthyroidism)
P: No.
D: Do you feel hot when others around you feel cold? (Hyperthyroidism)
P: No.
D: Any fever or flu-like symptoms?
P: No.
D: Any diarrhoea or vomiting?
P: No.

P2 (Past Hx)
D: Have you had similar feelings in the past?
P: No.

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D: Any history of mental illnesses or chronic medical conditions?

P: No.
D: Any medications, OTC drugs or supplements?
P: No.
D: Any birth control pills?
P: No.
D: Any allergies from food and medications?
P: No.
D: Anyone in your family having a similar condition? Or any mental illnesses?
P: No.
P3 (DESA)
D: Do you smoke/Drink/Recreational drugs (proper signpost first)?
P: No/Yes- ( If anything is positive- Address them in the management)
D: Are you physically active?
P: No.
D: How is your sleep/diet?
P: I can’t sleep, and I don’t have a good appetite; (Explore each of them)
D: How is your diet?
P: I don’t feel like eating much.
D: Do you have any other stress in your life?
P: No.
MAFTOSA
D: Ask about support system; How are things at home?
P: I live alone with my child now after getting divorced from my husband.
D: I’m very sorry.
D: How are you managing?
P: I have to take care of my child and I don’t work; I stay at home.
D: How are things at home with your child?
P: Fine.
D: Do you get along well?
P: Yes.
D: Is the child eating well?
P: Yes, I make sure he eats healthy.
D: Are you happy with the red book?
P: Yes.
D: Has he received his jabs?
P: Yes.
D: Do you have any other family members around?
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P: Yes/No
D: Are they supportive?
P: Yes.
D: How about friends?
P: Yes.
D. How are you managing financially?
D: I’m on benefits currently as I am unemployed.
D: Do you have anyone like relatives and friends around?
P: They all live very far away.
D: Any hobbies? How do you spend your days?
P: No, I just sit and watch movie and series.
ICE
D: Any idea what could be the reason for the feelings you’re having?
P: No.
D: Do you have any particular expectation from today’s consultation?
P: I don’t know what I’m expecting really.

Examination
Is it OK if I check your vitals and do a general head to toe (GPE) examination –
Everything is normal.

Provisional Diagnosis
D: From the chat we had (mention the positive findings), you told me that you’re
feeling low for the past year now and that you stay alone at home most of the
time with your son; so it appears to me that you might have depression. It can
be due to any stress, loneliness or something unwanted happening to somebody.
Do you want to know how we can manage this so that you might feel better?
P: Yes please

(Most of the time it will get better without any treatment, however this may take
time like several months or even longer. Relationships, employments might also
in this time be affected. And there is also a danger that someone may turn to
alcohol or illegal drugs, some people think of suicide. Therefore, people with
depression often opt for treatment.)

Management:

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(No admission required)

1. Senior
2. Investigations: Routine Blood test such as FBC, LFT, TFT, KFT, ECG, Chest X-
ray.
3. CBT
It is talking therapy that will help you understand your condition better
and give you an idea that certain ways of thinking can trigger or fuel
certain mental health problems such as depression.
- As it is a moderate depression offer only CBT first and general advice but
also mention about medications if nothing works.
4. Medication:
• You might need to take some medication for this condition to help
you better, these medications are called antidepressants (Fluoxetin
/ Citalopram etc) Explain that we will give me medications only if
your CBT doesn’t work.

5. General Advice:
• Do
o Have a healthy diet, regular exercise.
o Try to distract yourself doing other things, like reading good
books.
o Make new hobbies.
• Don’t
o Don’t keep yourself isolated, open up to your family and
friends.
o Don’t despair – most people recover from depression
remember that.
o Don’t drink too much alcohol.
o Don’t make important major decisions when you’re feeling
low, like relationships, jobs, money until you’re well again.
6. Referral:
• If my senior thinks that you need a referral we will offer you an
appointment with the mental health specialist

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• We will also refer you to a nutritionist so that they can assess you
and give you advice on healthy eating and maintaining a healthy
weight.
• We can also refer you to Good Samaritans Groups where you can
talk about your condition and seek help
7. Follow Up: We will review you time to time to see how your improvement
is and manage accordingly.
8. Reading materials:
a. We will provide you with some leaflets/Pamphlets or links from the
NHS so that you can understand it better.
9. Safety net:
a. Crisis Card
b. Suicidal thoughts
c. Helpline- 999

Depression with CBT Failed

Who you are:
You are an FY2 doctor in GP Clinic.
Who your patient is:
Steven Douglas, aged 35, has been divorced from his wife and is depressed. He
saw the psychiatrist, was given CBT treatment, but he is not improving on CBT.
What your task is:
Please talk to the patient and address his concerns.

P1 (Mood, and Cognition)

Dr: Hello Steven, I can see from my notes that you have come today with some
concerns, how can I help you?
Pt: I am not getting well, I am still depressed.
Dr: I am sorry, we will try to help you.
Dr: From how long have you felt this depression?
Pt: For 3 months.
Dr: Why were you diagnosed with depression?
Pt: I got a divorce from my wife 4 months ago.
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Dr: I am sorry about that, is there anything, other than CBT, that you’ve tried?
Pt: No.
Dr: How many sessions have you have for CBT?
Pt: 6 sessions.
Dr: Are you taking them regularly?
Pt: Yes.
Dr: Is this the first time in your life that you have been diagnosed with
depression?
Pt: Yes.
Dr: How is your mood now?
Pt: My mood is always low.
D: Can you score your mood? Like 1-10, 1 being the saddest and 10 being the
happiest day.
P: 3.
Suicide
D: Do you feel suicidal/Like hurting yourself? (Signpost first)
P: No.

Friend/Family/Forensic/Finance
Dr: Do you have family, friends?
Pt: Yes, but I don’t meet up with them much.
Dr: Why?
Pt: I don’t feel like meeting anyone. I have lost interest in everything.
Dr: Is there anything in your life that is particularly worrying you?
Pt: I don’t know. Maybe my divorce. I loved my wife a lot and now I don’t have
anyone in my life.
Insight
Dr: Do you have any idea of what would make you feel happier?
Pt: I don’t know doctor.
Impact:
Dr: Do you have any other stress in your life?
Pt: No.
Dr: How is your sleep?
Pt: I am getting up early in the morning nowadays.
Dr: What you do for living?
Pt: I am a plumber.
Dr: Is it affecting your job and life?
Pt: Yes, doctor I don’t feel like doing anything.
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Medical and Mental

D: Have you had similar conditions or feelings in the past?
P: No.
D: Any history of mental illnesses or chronic medical conditions?
P: No.
D: Any medications, OTC drugs or Supplements?
P: No.
D: Any allergies from food and medications?
P: No.
D: Anyone in your family having a similar condition? Or any mental illnesses?
P: No.
Alcohol and other drugs
Dr: Ask about smoking, alcohol (drinking heavily)
Dr: By any chance do you use recreational drugs?
Pt: No.

Examination
Do you mind if I check your vitals i.e. your BP, pulse, temperature and
respiratory rate? Also, if I do a general head to toe examination?
(All normal)

Management
From what we have discussed, I can see that CBT is not working for you so what
we can do is, I can refer you to a specialist psychiatrist after I talk with my
senior.
What do you think about that?
Along with your talking therapy or CBT you might have to start on antidepressant
medications as your condition is not getting better with just CBT. A combination
of antidepressants and CBT usually works better than having just one of these
treatments sometimes. Please be aware that they may take up to 4-6 weeks to
actually work and make a difference to your mood, so you may feel they aren’t
working at first, but you just need a little patience.

Concerns by patient:
Pt : Does antidepressant have side effects?
Dr: Yes, it has some side effects but they improve with time like nausea,
headaches, dry mouth.
Pt: Will I get addicted to them?
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Dr: No, we will taper the dose of medicine so that you don’t have any addiction.
Pt: For how long should I take them?
Dr: For a minimum of 6 months.
Pt: Does it cause loss of sex drive?
Dr: Some antidepressants like SSRI’s can reduce sex drive. We can take care of
this side effect by giving you another antidepressant like TCA (Amitriptyline)
which doesn’t reduce sex drive.
Pt: OK.

General Advice.
1. Advise patient on cutting down on alcohol, offer him all replacement
and support options.
2. Tell the patient about Sleep hygiene as his sleep is affected.

Investigations: We will do all blood tests as well to make sure everything is fine
with you.

Follow Up:
Also we will arrange a follow up in a few weeks to see how you are doing with
the changes in the treatment plan.

Safety Net: .in the meantime if you feel that you are having thoughts of harming
yourself or others, please contact us. OR:
a. Crisis Card
b. Suicidal thoughts
c. Helpline- 999

OTHER TREATMENTS:
Mindfulness
• Mindfulness involves paying closer attention to the present moment,
and focusing on your thoughts, feelings, bodily sensations and the world
around you to improve your mental wellbeing.
• The aim is to develop a better understanding of your mind and body, and
learn how to live with more appreciation and less anxiety.
• Mindfulness is recommended by NICE as a way of preventing depression
in people who have had 3 or more bouts of depression in the past

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REFERENCE INFORMATION:
Moderate to severe depression If you have moderate to severe depression, the
following treatments may be recommended. Antidepressants: Antidepressants
are medicines that treat the symptoms of depression. There are many different
types of antidepressant.
Combination therapy: A GP may recommend that you take a course of
antidepressants plus talking therapy, particularly if your depression is quite
severe. A combination of an antidepressant and CBT usually works better than
having just one of these treatments.

Mental health teams:

• If you have severe depression, you may be referred to a mental health
team made up of psychologists, psychiatrist, and occupational therapists.

Antidepressants:
• Antidepressants are medicines that treat the symptoms of depression.
There are many different types available. Most people with moderate or
severe depression benefit from antidepressants, but not everybody does.
• You may respond to 1 antidepressant but not to another, and you may
need to try 2 or more treatments before you find one that works for you.
• The different types of antidepressant work about as well as each other.
But side effects vary between different treatments and people.
• When you start taking antidepressants, you should see a GP or specialist
nurse every week or 2 for at least 4 weeks to assess how well they're
working.
• If they're working, you'll need to continue taking them at the same dose
for at least 4 to 6 months after your symptoms have eased.
• If you have had episodes of depression in the past, you may need to
continue to take antidepressants for up to 5 years or more.
• Antidepressants are not addictive, but you may get some withdrawal
symptoms if you stop taking them suddenly or you miss a dose.

Selective serotonin reuptake inhibitors (SSRIs):

• If a GP thinks you'd benefit from taking an antidepressant, you'll usually
be prescribed a modern type called a selective serotonin reuptake
inhibitor (SSRI).
• Examples of commonly used SSRI antidepressants are; paroxetine
(Seroxat), fluoxetine (Prozac) and citalopram (Cipramil).
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• They help increase the level of a natural chemical in your brain called
serotonin, which is thought to be a "good mood" chemical.
• SSRIs work just as well as older antidepressants and have fewer side
effects, although they can cause nausea, headaches, a dry mouth and
problems having sex. But these side effects usually improve over time.
• Some SSRIs are not suitable for children and young people under 18
years of age. Research shows that the risk of self-harm and suicidal
behaviour may increase if they're taken by under-18s.
• Fluoxetine is the only SSRI that can be prescribed for under-18s and,
even then, only when a specialist has given the go-ahead.

Tricyclic antidepressants (TCAs):

• Tricyclic antidepressants (TCAs) are a group of antidepressants used to
treat moderate to severe depression.
• TCAs, including imipramine (Imipramil) and amitriptyline, have been
around for longer than SSRIs. • They work by raising the levels of the
chemicals serotonin and noradrenaline in your brain. These both help lift
your mood.
• They're generally quite safe, but it's a bad idea to smoke cannabis if
you're taking TCAs because it can cause your heart to beat rapidly.
• Side effects of TCAs vary from person to person but may include a dry
mouth, blurred vision, constipation, problems passing urine, sweating,
feeling lightheaded and excessive drowsiness.
• The side effects usually ease within 10 days as your body gets used to
the medicine.

SNRIs:
• Venlafaxine and duloxetine are known as serotonin- noradrenaline
reuptake inhibitors (SNRIs). Like TCAs, they change the levels of serotonin
and noradrenaline in your brain.
• Studies have shown that an SNRI can be more effective than an SSRI, but
they're not routinely prescribed because they can lead to a rise in blood
pressure.

Withdrawal symptoms: Antidepressants are not addictive in the same way that
illegal drugs and cigarettes are, but you may have some withdrawal symptoms
when you stop taking them. These include:
• an upset stomach
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• flu-like symptoms
• anxiety
• vivid dreams at night
• sensations in the body that feel like electric shocks. In most cases, these
are quite mild and last no longer than 1 or 2 weeks, but occasionally they
can be quite severe. They seem to be most likely to occur with paroxetine
(Seroxat) and venlafaxine (Effexor).
Withdrawal symptoms occur very soon after stopping the tablets so are
easy to distinguish from symptoms of depression relapse, which tend to
occur after a few weeks.

SELF HARM / SUICIDE

Two types of presentations:
➢ Medically stable (in psychiatry department)
➢ Medically unstable in A&E (for example, drug overdose, cut wrist,
etc.)

Factors affecting admission decision:

- Planning
- Intent of self-harm
- Previous attempts
- Access to weapons/ means of self-harm.
- Lives alone with no social support
- Domestic violence/sexual abuse
- No insight: as the patient does not regret it- willing to do it
again and does not see a future.

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MANAGEMENT IN ONE INCIDENT WITH NO INTENT FOR SUICIDE, GOOD INSIGHT

AND HOPEFUL.

- Send home if has social support (family/friends/relatives)

+ no access to weapons+ none of the above.
- Talk to senior.

- Investigations (routine bloods- U&E/ABGS/ clotting

factors/LFT/KFT if unstable) + blood drug level+ urine screen
for toxicology- US on tummy if needed; liver affected.

- Symptomatic and social: talk to someone when you feel low/

build on social network.
- If in A&E: Painkiller if in pain- O2 and IV fluid if unstable-
wound care if wounded- pregnancy test if was pregnant after
seeking consent.

- Specialist:
o Poison center: in paracetamol overdose, offer N-
Acetylcysteine if drug level is at or above treatment
level on the nomogram (IV over 21 hours with serial
measurements).
o OBS/GYNE- if pregnant.
o Psychiatry/senior if in psychiatry department: for future
plan of management (CBT- counselling- family therapy-
support worker) + meds if needed (anti- depressants)
- Safety net: helpline- suicidal thoughts- Crisis card- Support.
- Follow up.

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SUICIDAL SCENARIO With Self-Harm

Who you are:

You are an FY2 doctor in Psychiatry.
Who your patient is:
Jessica, aged 16, has taken some tablets last night and cut her wrist this morning.
Medical management has been done and patient is medically stable.
What your task is:
Please talk to the patient, take history and discuss about management with the
patient.
Note:
Patient has a bandage on her wrist. She looks unhappy and she has poor eye
contact.
The tone of your voice and how you will talk and approach is important.

Dr: Hello Jessica, I'm Dr (name). Can you confirm your age for please?
P: I’m 16.
Dr: Jessica, are you OK?
P: Silent.
Dr: How are you feeling?
P: Silent.
Dr: Jessica, I'm here to help you, can you tell me what happened?
P: Missed period → told my boyfriend → he is not happy → I took OCP
overdose to abort pregnancy → cut my wrist.
D: I'm really sorry for what you’re going through, it sounds traumatic. I will try
my best to help you.
P: Doctor, I want to go home.
Dr: I understand that you want to go home but let me first ask you a few
questions and then if everything is fine then you can go home. Is that alright?
P: Okay.

OR

Dr: I see there is a bandage on your wrist, may I ask you what happened?
P: Doctor, I took some tablets and cut my wrist.
Dr: I’m sure it must have been a stressful situation that made you do that. We
are here to help you. Could you please tell me why did you did it?
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P: Doctor. I missed my period and I realised that I’m pregnant. I called my

boyfriend to let him know and then we had a fight over the phone. Then he
broke up with me. . . he left me.
Dr: Relationships can be difficult. I’m sorry to hear that. If you are comfortable to
proceed, may I ask you a few more questions?
P: Okay doctor.

Before incident
Dr: Did you plan it?
P: No.
Dr: Did you tell anyone?
P: No.
Dr: Did you write a note?
P: No.
Dr: Were you under influence of alcohol or drugs?
P: No.
Dr: Were you forced into doing this?
P: No.
During incident
D: You mentioned that you took some tablets, may I know what you took?
P: I took some OCP pills.
D: How many?
P: 21 doctor.
D: Where did you get them from?
P: I took my mum’s pills.
Dr: When did you take them?
P: I took them last night before going to bed.
Dr: Any other tablets?
P: No.
Dr: With what? Water? Alcohol?
P: Water.
Dr: Did you vomit after that?
P: No.
Dr: Okay. You told me that you cut your wrist, how deep did you cut it?
P: It wasn’t that deep doctor.
Dr: May I know when you did that?
P: I woke up this morning and realised that nothing has happened, then I cut my
wrist.
Dr: Where did you do it?
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P: I went to the bathroom and cut my wrist in there.

Dr: Who was there at the time?
P: No-one was there, doctor. I was there by myself. My mum was at work.
After incident
Dr: May I know what you did after that?

P: I was so scared doctor! I held my wrist and tried to press it to stop the
bleeding and then I called a taxi and came here.
Dr: That’s a wise thing that you did. Did you inform any member of your family?
P: No doctor, I just rushed to the hospital.
D: Would you like us to inform your parents?
P: No. Please don’t let them now.
Dr: That’s okay, if you don’t want me to call them. By any chance did you take
any alcohol when you took the pills, or you cut your wrist?
P: No doctor.
Dr: How about any recreational drugs?
P: No.
P: Doctor, I am fine. I don’t want to stay in the hospital. Can I please go home?
Dr: I understand that you want to go home just a few more questions to make
sure that everything is fine.
P: Okay fine.
Dr: Has this happened before?
P: No doctor.
Dr: Do you think you are going to do it again? (Very Important question)
Mood
P: It was so stupid of me doctor. I’m embarrassed about what I did.
Dr: How do you feel about what you did?
P: (She keeps quiet.)
Dr: Would you say you feel bad?
P: Yes.
Dr: How has your mood been recently?
P: Doctor not too bad.
Dr: Could you please score your mood for me, with 1 being the lowest and 10
being the highest?
P: Doctor I would say 5-6.

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As you asked about

M C F A M I S H
↓ ↓
Mood Suicide
Then start the rest of history
Impact
Insight → If + ve insight → maybe no admission.
→ If no insight → You must admit.
4F Mainly Support
Friend (Very Important)
Family
Forensic (Not Important)
Finance

If you have time, ask about rest of history.

Dr: Who do you live with?

P: I live with my mom doctor.
Dr: Does anyone else live with you and your mom?
P: My little brother.
Dr: How is your relationship with your mother?
P: I’m very close to her but I haven’t told her about my boyfriend.
Dr: Do you get on well with your brother?
P: He is just a little kid so we don’t have much to talk about.
Dr: How about your dad? Where does he live?
P: Doctor, my parents got divorced a few years ago. He doesn’t live with us
anymore.
Dr: Are you in touch with him?
P: I see him once in a while.
Dr: What do you do? Are you going to school or do you work?
P: Doctor, I’m going to school.
Dr: How are things at school? Are you catching up well?
P: Not really doctor. I’m lagging behind a bit from my classmates.
Dr: Do have any friend in school? Are you getting on well with your friends?
P: Yes, doctor. I have many friends at school.
Dr: How about any friends outside school?
P: Yes, I’ve got a few.
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Dr: Do you mind if I ask you a few questions about your boyfriend?
P: That's alright doctor.
Dr: May I know for how long you have been together?
P: It’s been a few months now.
Dr: How did you guys meet?
P: We go to the same school doctor.
Dr: May I know how old he is?
P: He is 16 years old.
Dr: By any chance have you ever had any trouble with the law?
P: No.
Dr: Have you ever been diagnosed with any medical condition?
P: No doctor.
Dr: Have you ever taken advice from mental health experts?
P: No.
Dr: Has any member of your family ever been diagnosed with any mental health
illness?
P: No.
Dr: Do you drink alcohol?
P: No.
Dr: How about any recreational drugs?
P: No.
P: Doctor, Can I please go home?

Management:

Dr: I totally understand you want to leave and clearly you have been through a
lot. It has been a difficult situation for you. I think bringing the family into this
picture would help, what do you have to say about that?
P: Doctor, if I ask my mum to come, can I go home?
Dr: How about we call your mother, talk to your mum. Address the safety issues,
and meanwhile my colleagues will come and talk to you regarding the help they
can provide from their side. Once everything is fine, we will send you home
ASAP.
P: Okay.
Dr: My colleagues will come and repeat a pregnancy test, and discuss with you
your options regarding the pregnancy or refer you to your GP who will talk to
you about it in detail.
P: Thank you doctor.
Dr: Any questions for me?
P: No Doctor.
Dr: Let me call your mother, would you mind waiting here till then?
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P: No problem doctor.
D: Great.

SELF HARM/SUICIDAL SCENARIO

Gay male takes paracetamol overdose)

Who you are:

You are an FY2 doctor in A & E.
Who your patient is:
David, aged 19 years, took 16 paracetamol tablets in the morning.
What your task is:
Please talk to the patient and discuss the initial management with the patient.

Only differences between this case and previous one.

1. Only paracetamol overdose.
2. No other issues.
3. Here, you are in emergency, not psychiatry.
Note: Offer confidentiality if patient does not want to talk.

Approach
D: Hi , I'm Dr (name), are you Adam?
P: Yes.
Dr: Adam, are you ok?
P: (Silent.)
Dr: How are you feeling?
P: (Silent.)
Dr: Adam, I'm here to help you, can you tell me what happened?
P: (Silent.)
Dr: Adam I can see you’re really worried about something, but please tell us about it and we will
keep anything you say within our team. We will not share it with anyone, everything remains
confidential, unless it is posing any danger to anybody.
P: I took some tablets.
During incident
D: May I know which tablets?
P: Paracetamol.
D: May I know how many tablets you took?
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P: 16.
D: When did you take them?
P: 2 hrs ago.
D: Did you take them in one go or did you take them at different times?
P: I took them in one go.
D: Did you take anything else with it?
P: I took it with a glass of water.
D: Did you take alcohol with it?
P: No.
D: Did you take any other medications with it?
P: No.
D: By any chance did you take any recreational drugs?
P: No.
D: Did you try to throw them up?
P: No.
D: May I know why you took the Paracetamol tablets?
P: I had an argument with my mother after she found out that I am gay, and I have a
boyfriend. She is not accepting it.
D: I am so sorry to hear that. Where were you when you took the tablets?
P: I was in hostel accommodation.
D: Who was there with you?
P: I was alone.
Before incident
Dr: Did you plan it?
P: No.
Dr: Did you tell anyone?
P: No.
Dr: Did you write a note?
P: No.
Dr: Were you under influence of alcohol or drugs?
P: No.
Dr: Were you forced into doing this?
P: No.
After incident
Dr: May I know what you did after that?
P: I called my boyfriend, and he told me to go to the hospital, then I called the ambulance.
Dr: You did the right thing. I’m glad your boyfriend advised you well. Did you inform any
member of your family about it?
P: No doctor.
D: Would you like us to inform your mother?
P: No. Please don’t let her know.
Dr: That’s okay, if you don’t want me to call her.
D: Do you have any symptoms?
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P: I am fine, and I don't have any symptoms.

D: Do you think you are going to do it again? (Very Important question)
P: No, I won’t.
D: How do you feel about what you did?
P: I feel bad/stupid/ guilty for what I have done.
D: Have you ever tried to harm yourself in the past? Has it happened before?
P: No.
Dr: I’m glad that you’re feeling fine, I just need to ask a few more questions to
make sure that everything is fine.
P: Okay fine.
Rule out Red Flags
D: Do you have any tummy pain?
P: No.
D: Do you feel sick?
P: No.
D: Any vomiting?
P: No.
Mood
D: How has your mood been recently?
P: Not too bad. It’s been fine.
D: Could you please score your mood for me with 1 being the lowest and 10
being the highest?
P: 6-7.
Support System – 4 F (Family, Friends, Finance, Forensic)
D: Who do you live with?
P: I live with my boyfriend in the hostel.
D: Do you have any other family members apart from your mother?
P: No.
D: How about your dad?
P: I’ve never met him, don’t even know his name.
D: How is your relationship with your mother?
P: She hates me being gay.
Dr: I’m sorry that she is feeling this way, I can try to help you by talking with her
to make her understand how upset you are, if you want me to?
P: No just leave her.
D: What do you do?
P: I just started studying in university
D: Do you work?
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P: I am a student.
D: Are you financially stable?
P: Yes, I work part time.
D: Do you have any friends?
P: Yes, I have many friends.
D: Tell me about your boyfriend?
P: He is a very caring person.
Dr: That’s wonderful. How long have you been together?
P: 6 months.
D: How is your relationship going?
P: We have a very understanding relationship.
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Do you use recreational drugs?
P: No.
Impact
Dr: How is all this impacting your life?
P: I am not able to focus and always feel anxious about myself -- Acknowledge
Insight (v. important).
Dr: Do you think what you’re going through will be sorted out eventually?
P: Yes I want to live a normal life and be happy with myself.—Acknowledge
Past/present Medical Condition
D: Have you been diagnosed with any medical condition?
P: No.
D: Do you have any liver, kidney diseases?
P: No.
D: Any blood disorders?
P: No.
D: Have you ever had any mental health problems?
P: No.
D: Do you take any regular medications, OTC or herbal remedies?
P: No.
D: Do you have any allergies?
P: No.

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Management
I would like to check your vitals and examine your tummy, is that alright? As you
told me, you took some paracetamol tablets. We are going to keep you in the
observation unit to keep monitoring you.
We also need to do some necessary investigations. We will do some blood tests:
LFT, KFT, bleeding and clotting profile and the level of Paracetamol in your blood.

P: Doctor I’m fine I just want to go back home.

Dr: It is very important for you to stay in the hospital since we need to check the
level of paracetamol in your blood in the next couple of hours and then treat you
accordingly (after 4 hours of paracetamol ingestion). If this is left untreated, it
can cause many complications and can damage your liver.
We might have to give you a medication called N-Acetyl cysteine also known as
NAC, if the level of PCM found in your blood is high. We need to give you this
medication through a drip. So you need to be in the hospital while we are giving
you the medication. If you need any treatment, the course of medication usually
takes around 21 hours. Once the course of treatment has been completed, we
need to reassess you.
We may do some blood tests to make sure everything is fine.

When we have made sure that you are medically fine, you need to be referred to
one of our colleagues. I will arrange for you to be seen by our psychiatric
colleague. Our colleague will talk to you and their aim is to support you. They will
help you out in relieving your stress and improving your mood.
Don’t you think you need someone to be with you?
Do you want me to inform your mother or your boyfriend to be with you?
You may need their help and support.
We can also have a talk with your mother if you wish us to.
Management in 2 situations
↙ ↘
• Patient regrets. • No regret.
• Patient has insight. • No insight.
• Bright future. • No future.
• Clinically well.

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1. Observe. 1. Admit.
2. Senior. 2. Senior.
3. Investigations 3. Investigations (same).
• Paracetamol level (in 2 hours) 4. Check level at 4 hrs of
• LFTs ingestion (above ttt level).
• RFTs
• U/S abdomen. 5. Refer to psychiatry.
4. Check your level at 4 hrs of 6. Crisis card.
7. Good Samaritans group.
ingestion if under ttt level. 8. Emergency phone.
5. Refer to psychiatry.
6. Crisis card.
7. Good Samaritans group
8 Emergency phone.

Depression with suicide attempts

Who you are:

You are an FY2 doctor in Psychiatry.
Who your patient is:
Mr. Robert Gray, 33 years old, brought to the hospital because he had taken an
overdose of paracetamol. He was admitted and treated medically, and he is
stable medically now.
What your task is:
Please talk to the patient and at 6-minute bell talk to the examiner about your
management plan.
(Same as suicide station).

Approach
D: Hi , I'm Dr (name), are you Robert?
P: Yes.
Dr: Are you ok, Robert?
P: Silent.
Dr: How are you feeling?
P: Silent.
Dr: Robert, I'm here to help you, can you tell me what happened?
P: I don’t want to live anymore.
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Dr: Adam I am so sorry that you’re feeling this way, could you tell me what
happened?
P: (silence)
Dr: Did you try to harm yourself in any way?
P: I took some paracetamol tablets before.

During incident
D: May I know how many tablets you took?
P: 20.
D: When did you take them?
P: 2 days ago.
D: Did you take them in one go or did you take them at different times?
P: I took them in one go.
D: Did you take anything else with it?
P: I took them with a glass of water.
D: Did you have alcohol too at any point?
P: No.
D: Did you take any other medications with it?
P: No.
D: By any chance did you take any recreational drugs?
P: No.
D: Did you try to throw them up?
P: No.
D: May I know why you took Paracetamol tablets?
P: I don’t want to live in this world anymore, I don’t have the will to live.
D: I am so sorry to hear that. Where were you when you took the tablets?
P: I was in my home.
D: Who was there with you?
P: I was alone.

Before incident
Dr: Did you plan it?
P: No.
Dr: Did you tell anyone?
P: No.
Dr: Did you write note?
P: Yes.
Dr: Were you under influence of alcohol or drugs?
P: No
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Dr: Were you forced in to doing this?

P: No.
After incident
Dr: May I know what you did after that?
P: My housemate saw I wasn’t doing well, and he called the ambulance.
Dr: That’s a great thing that your housemate did.
Dr: Did you inform any member of your family of what happened?
P: No doctor.
D: Would you like us to inform them?
P: No. Please don’t let them know.
Dr: That’s okay if you don’t want me to call them.
D: Do you have any symptoms?
P: I am fine, and I don't have any symptoms.
D: Do you think you are going to do it again? (Very Important question)
P: I don’t know.
D: How do you feel about what you did?
P: I don’t know I might, I’m not sure.
D: Have you ever tried to harm yourself in the past? Has it happened before?
P: No.
Dr: I’m glad that you’re fine now, I just need to ask a few more questions to
make sure that everything is fine.
P: Okay fine.

Rule out Red Flags

D: Do you have any tummy pain?
P: No.
D: Do you feel sick?
P: No.
D: Any vomiting?
P: No.
Mood
D: How has your mood been recently?
P: My mood is never okay.
D: Have you felt very sad, hopeless or irritable at any time?
P: Yes.
D: Have you felt you’re losing interest in everyday activities?
P: Yes.
D: Have you felt worthless or empty?

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P: Yes.
D: What did you feel, can you explain?
P: I just feel like everything around me is getting out of control, I’m just living day
by day for nothing.
D: Could you please score your mood for me with 1 being the lowest and 10
being the highest?
P: 1-2
Support System – 4 F (Family, Friends, Finance, Forensic)
D: Who do you live with?
P: I live with my housemates.
D: Do you have any family members nearby?
P: No.
D: Where is your family?
P: My parents got divorced, they live separately with their new partners
D: How is your relationship with your mother?
P: it’s good, but I don’t talk much with her.
Dr: May I ask why don’t contact with them?
P: I don’t want anyone in my life.
D: What do you do for living?
P: I don’t go to work anymore.
D: Are you financially stable?
P: No, I have been on benefits.
D: Do you have any friends?
P: Yes, I have many friends, but I don’t contact them often.
D: Do you have a partner?
P: No.
D: Do you smoke?
P: Yes-- Explore
D: Do you drink alcohol?
P: Yes-- Explore

D: Do you use recreational drugs?

P: No.

Impact
Dr: How is all this impacting your life?
P: I am not able to do anything in my life anymore -- Acknowledge
Insight (v. important).
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Dr: Do you think what you’re going through should will be sorted out
eventually?Do you need help regarding this?
P: No.
2 M : Medical and Mental Condition
D: Have you been diagnosed with any medical condition?
P: No.
D: Do you have any liver, kidney diseases?
P: No.
D: Any blood disorders?
P: No.
D: Have you ever had any mental health problems?
P: No.
D: Do you take any regular medications, OTC or herbal remedies?
P: No.
D: Do you have any allergies?
P: No.
Management
(Here, they say talk to the examiner about management)
1. I will keep my patient admitted as
• He planned to harm himself
• He made suicidal notes
• His mood is very low
• He may do the same again in future as well.
2. Talk to my senior.
3. Medications + CBT.
↓
• SSRIs ( Fluoxetine – Duloxetine)
4. Safety netting
• Crisis card
• Good Samaritan’s group

INSOMNIA
Presentations of insomnia:
➢ It can be part of NAI and the only presentation.
➢ A presentation of drug and alcohol misuse
➢ A presentation of depression
➢ A presentation of anxiety

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D.Ds: BIOPSYCHOSOCIAL CAUSES FOR INSOMNIA

o Sleep environment: Mattress, pillow- room temp-

noise- lights- TV- Electronic devices
o Lifestyle causes: caffeinated drinks + drugs - avoid
heavy meals- alcohol- smoking and exercise before
sleep, avoid daytime sleeping- avoid taking naps- shift
worker?
o Depression
o Anxiety
o NAI
o Nightmares
o Physical causes: Head to toe:
▪ Headaches
▪ Blocked nose/snoring
▪ Chest pain-shortness of breath- cough- wheeze-
▪ Joint pains
▪ Night leg pain (critical limb ischemia, sciatica)
▪ Hyperthyroidism
▪ Bowl problem
▪ Restless leg syndrome (pain, numbness)
▪ Hyperthyroidism
▪ Side effects of medications including, Anti-depressants
▪ Urinary problems (frequency and nocturia in

prostate diseases, DM, CKD)

INSOMNIA SCENARIO
Who you are:
You are an FY2 doctor in GP.
Who your patient is:
Mrs. Ashley Adams, aged 67, has come with some concerns.
Other Information:
She has been diagnosed with Rheumatoid Arthritis. Patient is on the following
medications: Methotrexate PO 7.5 mg per week, Paracetamol PO up to 8 tablets,

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Folic acid PO. Her arthritis is under control and blood levels for methotrexate is
normal.
Special Note:
None
What your task is:
Please talk to patient, take history, do examination, discuss management with
the patient and address her concern.

P1 (ODIPARA)
D: What brought you to the hospital?
P: I have trouble sleeping.
D: Can you please tell me more about it? (Always ask an open question)
P: (Allow her to speak)
D: When did this problem start?
P: It started 3 months ago.
D: Do you have trouble getting to sleep or do you wake up in the middle of the
night?
P: I have trouble in getting to sleep.
D: What time you go to bed?
P: I go to bed around 10pm.
D: What time do you usually fall asleep?
P: I sleep around 2 am. Sometimes I don’t sleep all night.
D: What time do you usually wake up?
P: I wake up around 7am
D: Do you wake up during your sleep?
P: No.
D: How was your sleep before this problem started?
P: It was fine.
D: Do you take any naps during the day?
P: No (If yes, how many? How long?)
D: Anything else?
P: No.
D: Can you think of anything which might be the cause of your problem?
P: My husband passed away 6 months back. But I am managing, he used to be
with me at night.
D: I’m so sorry for your loss. Can you tell me how he passed away?
P: He died because of a heart attack. - Sympathize
D: Tell me what you do before you go to bed?
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P: I drink brandy with milk before going to bed.

D: Is it a new habit or old?
P: I’ve been doing it for so long but now it is not helping me anymore.
Psychosocial, Friends and Family, Finance
D: How do you spend your time every day?
P: I have recently found a reading club in our local library. I go there every week.
D: Do you have friends there?
P: No.
D: Do you interact with people there?
P: Not much.
D: Who do you live with?
P: I live alone.
D: Do you have any relatives?
P: No. (IF yes D: How often do you see them? How is your relationship?)
D: How about any friends?
P: I don't have any.
Dr: What do you do for a living?
P: I’m a retired doctor.
Dr: Are you financially stable?
Pt: Yes, I have my savings and pension.
Dr: As you told me, this sleep problem has been going on for quite some time,
how are you coping with it?
P: I’m not feeling good about it doctor.
Dr: Is it impacting your daily life.
P: Yes doctor, I don’t feel fresh after waking up.
Mood
D: How is your mood?
P: It’s ok.
D: Could you please score the mood on a scale of 1 to 10. Where 1 is lowest and
10 being the highest.
P: It is average.
P2 (Medical and Mental History)
D: Any fever, flu or cough?
P: No.
D: Any problem with urine or bowel?
P: No.
D: How is your joint problem? Are you in pain at the moment?
P: No.
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D: Are you taking your medications for the joint problem regularly?
P: Yes I am taking it.
D: Have you been diagnosed with any other medical condition in the past?
P: No.
D: Any asthma?
P: No.
D: Are you taking any other medications including OTC or supplements?
P: No.
P3 (DESA)
Ask about tea or coffee? How much? What time do you have last cup of the day?
Smoking, Alcohol, Recreational drug, Stress, Watching TV, etc.
Noisy environment.

Examination
D: Is it OK if I check your vitals and examine your chest and joints?.—Normal

Management:
- Run investigations to exclude other causes such (TFT-
FBC)
- Symptomatic
o Counselling, Sleep Hygiene and General Advice
Do:
• Go to bed and wake up at the same time
every day - only go to bed when you feel tired.
• Relax at least 1 hour before bed - for example
take a bath or read a book.
• Make sure your bedroom is dark and quiet –
for example use thick curtains, blinds, an eye
mask, ear plugs.
• Regular exercise during the day.
• Make sure your mattress, pillows and
cushions are comfortable.

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Don’t
• Smoke, drink alcohol, tea or coffee at least 6 hours
before going to bed.
• Eat a big meal late at night.
• Exercise at least 4 hours before bed.
• Watch television or use devices right before going to
bed - the bright light makes you more awake.
• Nap during the day.
• Drive when you feel sleepy.
• Avoid watching the clock as it will make you anxious.
o If asking for sleeping pill: start with sleep hygiene,
manage stress—if it does not work, please come back.
It would be better if you try the lifestyle modifications that we
have just discussed. Hopefully your sleeping pattern will be
regulated and you won’t have any problems. But if your sleeping
problem persists, I will discuss it with my senior and we may
consider giving you sleeping pills
- CBT: If changing your sleeping habits doesn't help, we may be able to
refer you for a type of cognitive behavioural therapy that's specifically
designed for people with insomnia. The aim of CBT is to change
unhelpful thoughts and behaviours that may be contributing to your
insomnia. It's an effective treatment for many people and can have
long-lasting results.
- Specialist: psychiatrist for any depression
- Safety netting for driving. Stopping driving if she is sleepy, and
low mood.
- Follow up.

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INSOMNIA (CANNABIS SMOKER)

Who you are:
You are an FY2 doctor in GP.
Who your patient is:
Adam Jones, a 40-year-old man, came in about his sleep disturbances. He is
concerned about it, and he is requesting sleeping pills.
What your task is:
Please talk to him, assess him and address his concerns.

P1
D: How can I help you today?
P: I have problems sleeping.
D: Could you please elaborate? What exactly is your problem?
P: I am not able to get to sleep these days.
D: I understand that must be very troublesome for you. Could you please tell me
since when have you been struggling to sleep?
P: 6 months.
D: Is there anything specific that's disturbing your sleep?
P: No.
D: Are you also waking up in the middle of your sleep or waking up early in the
morning?
P: No, just falling asleep.
D: What time do you go to bed usually?
P: Around 4-5 am.
D: What time do you wake up?
P: Noon time.
D: What do you do before you go to bed?
P: I play video games.
D: Any naps during the daytime?
P: No.
D: Where do you live?
P: In my house.
D: Any airports or train stations nearby?
P: No.
D: Any kids in the house or any noisy neighbours?
P: No.

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Friends and Family

D: Who do you live with?
P: I live alone.
D: Do you have any relatives?
P: No (IF yes D: How often do you see them? How is your relationship?)
D: How about any friends?
P: I have some.
Dr: What do you do for a living?
P: I do online business.
Dr: Are you financially stable?
Dr: Yes.
P2 (Medical and Mental History)
D: Have you had a similar kind of problem in the past?
P: No.
D: Have you been diagnosed with any medical condition?
P: No.
D: Are you taking any other medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous hospital stays or surgeries?
P: No.
D: Any family history of a similar condition?
P: No.
P3 (DESA)
D: Do you smoke?
P: Yes- Explore
D: Do you drink alcohol?
P: Yes- Explore
D: Any recreational drugs?
P: I smoke weed (Cannabis)- Explore
CAGE T D W
D: Any other drugs?
P: No.
D: Any tea/coffee?
P: No.
D: Tell me about your diet?
P: I eat everything.
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Mood, Psychosocial
D: Do you have any kind of stress or anxiety?
P: I have anxiety.
D: Can you please tell me what you are anxious about?
P: I don't know.
D: How is your mood these days?
P: Its fine.
D: Score 1-10?
P: 6.
Impact and Insight
Dr: It sounds like your sleep problem has been going on for quite some time,
how are you coping with it?
P: I want to sleep properly and wake up early.
Dr: Is it impacting your daily life?
P: Yes doctor, I don’t feel fresh after waking up.
D: Do you have any idea of what could be causing you these sleep problems?
P: No doctor.

EXAMINATION:
D: Can I check your vitals and examine you fully? I would like to send for some
routine investigations as well. —Normal

MANAGEMENT:
Investigations to exclude other causes such TFT, LFT, RFT, FBC, Urine
drug screening
D: Thank you for answering all my questions, do you have any particular concern
before I proceed.
P: Doctor, could you please give me sleeping pills. (Pt repeatedly asks for
sleeping pills).
D: I understand that you want something to help you sleep easily but before
doing that it’s better for you to make some lifestyle changes and see if that helps
first.
P: Ok.
Counselling
D: I will talk with my senior for you and get some advice from him for you as
well.
D: Sleep Hygiene: Firstly, regulating your sleep cycle - Sleeping and waking up at
odd times can cause a lot of disturbance to your sleep. It is very important that
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you go to bed early and wake up early to regulate your sleep cycle. It is better
you set a time to go to bed and to wake up in the morning. You said you are
playing video games till early morning; it is advisable to stop playing video games
till late night and not to do anything that involves a screen or monitor at least an
hour before you go to bed. You can maintain a sleep diary. Can you follow these
steps?
P: Yes I will try.

D: Cannabis management: Secondly, you said you are anxious, and you are
smoking weed. Weed can have many ill effects on your health. It can make you
anxious and it can disturb your sleep. It is advisable for you to stop smoking
weed. We have many services to offer you if you can’t quit alone– Support
groups/Narcotics anonymous group, will that be okay with you?
P: I will think about it.
P: Can you please give me some sleeping pills?
D: Sleeping pills have their own side effects and can be addictive. More
importantly, sleeping pills may not work without lifestyle modification. As I
mentioned to you earlier, we will try these simple measures first and then if it
doesn’t work and you still need sleeping pills, I will discuss it with my seniors and
hopefully we can prescribe them for you then.
Then offer CBT and other advice for managing stress like exercise, yoga,
breathing exercises, avoiding caffeinated drinks like tea and coffee at least 6
hours before going to bed.
Specialist: psychiatrist for cannabis management.
Safety netting for driving. Stopping driving if he is sleepy- do not
drive under influence.
Follow up

Post Natal Mood Changes

Presentations:
➢ Postpartum depression
➢ Postpartum psychosis
➢ Anxiety/Stress
➢ Baby blues (less than 2 weeks only after the birth).
➢ Traumatic birth

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All the above can present with either insomnia or low mood.

POST- PARTUM DEPRESSION (TELEPHONE CONSULTATION)

Who you are:

You are an FY2 doctor in GP.
Who is your Patient:
Mrs. Amelia Langerhan, aged 31, has requested a phone consultation due to
some concerns.
What your task is:
Please talk to her and address her concerns.

Telephone Approach
D: Hi this is Dr(name) calling from the GP surgery, am I speaking to
Mrs Amelia Langerhan?
P: Yes Doctor that’s me.
D: Could you please confirm your age for me please?
P: I am 31 years old.
D: Thank you and could you confirm for me your address so that I
understand this is the right Amelia I am speaking to?
P: Sure, it is 34 Whitefield Road, Oldham.
D: Perfect, how may I call you?
P: You can call me Amelia.
D: Thank you Amelia, so is it a good time to talk to you?
P: Yes.
D: Is this the best number to call you back on if the phone call
becomes disconnected?
D: Yes doctor.
P1
D: How can I help you, Amelia?
P: I have trouble sleeping/tiredness.
D: Please tell me more about it?
P: What do you want to know?
D: When did this problem start?
P: It started 5 months ago.
D: Do you have trouble getting to sleep or do you wake up in the middle of the
night?
P: I have trouble staying sleep.
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D: What time do you go to bed?

P: I go to bed around 10pm.
D: What time do you usually go to sleep?
P: I go to sleep around 10:30pm.
D: What time do you usually wake up?
P: I wake up around 7.
D: So you wake up in between?
P: Yes
D: How often?
P: At least 3 to 4 times.
D: Are you able to fall asleep afterwards?
P: Yes/No
D: How was your sleep before this problem started?
P: It was fine.
D: Do you take any naps during the day?
P: Yes/No (Elaborate)
D: Anything else?
P: I also feel tired.
D: Did this start at the same time?
P: Yes.
D: Can you think of anything which might be the cause of your problem?
P: I gave birth 5 months ago – (Congratulate for the new baby. And ask about
the baby a little here.)
D: Tell me, what do you do before you go to bed?
P: I finish my chores.
D: How do you spend your time every day?
P: I look after my baby.
Mood
D: How is your mood?
P: It is low.
D: Could you please score your mood on a scale of 1 to 10, where 1 is low and 10
is happiest.
P: It is 3-4.
D: Have you had any thoughts of harming yourself? (Signpost before asking)
P: No.
D: Any thoughts of harming your baby? (Signpost before asking)
P: No.

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Hallucination
D: Do you sometimes feel like you can hear voices?
P: No.
D: Have you had any difficulty bonding with your baby?
P: Yes/No
D: Do you feel sad, hopeless, or irritable most of the time?
P: No.
D: Do you have a loss of interest in everyday activities?
P: No.
D: Do you have feelings of emptiness or worthlessness?
P: No.
Impact and Insight
D: How are you coping with your lack of sleep, Amelia? As you told me it’s been
going on a few months now.
P: I don’t feel good doctor. I want to be okay- (That means she has insight)
D: Do you think of anything which is causing you to feel like this?
P: I think being with all of these responsibilities as a new mother maybe.
P2 (Medical and Mental Health)
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Are you currently taking any medications, OTC drugs or supplements?
P: No.
D: Are you taking any birth control pills?
P: No.
D: Any allergies from any food or medication?
P: No.
D: Any previous surgeries or procedures done?
P: No.
P3 (DESA)
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: Good/Bad
D: Are you physically active?
P: Yes/No
4F (Friends, Family, Finance)
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D: What do you do for a living?

P: I stay at home.
D: Who do you live with?
P: With my husband.
D: How is your relationship with him?
P: Good, he is supportive.
D: Do you have any relatives close by?
P: Yes, my mother.
D: Have you talked to her about how you feel?
P: Yes. My mom thinks that it’s normal to be low sometimes.
D: How about any friends.
P: I don’t have any.

Examination
As you’re over the phone, I would like you to visit me in person so that we can
have a better chat face to face and also, I would like to check your vitals and do a
GP examination if you don’t mind.
Investigations:
I would also like to do baseline investigations.

Management
From the history you have given me, it seems that you might be having postnatal
depression. It is a type of depression that many parents experience after having
a baby. Postnatal depression can be lonely, distressing and frightening, but
support and effective treatments are available. Are you understanding?

Red flags for admission or immediate referral if in GP clinic:

✓ Harming yourself
✓ Harming your baby
✓ Delusions/ hallucinations/thought disorder
✓ Suicidal.
✓ Self-isolation
-
- Symptomatic:
In mild forms of depression or anxiety:
o Sleep hygiene and sleep routine.
o Healthy diet, low salt, low caffeine, walks, avoid
alcohol.
o Allow time for yourself, your hobbies, having walks,
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exercise, etc.
o Seek support from family or relatives.
o We can offer you some support, classes to help you with
parenting skills and support groups for women who just gave
birth.
o CBT over the phone or in person, if feasible.
o Surround yourself by family/ partner/
mother/relative- activities.
o
- Specialist: if no improvement: possible anti-depressants needed
which are safe for breast feeding and referral to a psychiatrist.
- Support groups: Local and national organisations, such as the
Association for Post Natal Illness (APNI) and Pre and Postnatal Depression
Advice and Support (PANDAS), can also be useful sources of help and
advice.
- Safety net: Suicide, hallucination, self-harming or others,
feeling overwhelmed or unsupported.
- Follow up.

N.B: Do not forget to exclude NAI and Drug and Alcohol use.

CBT
Psychological therapy/ talking therapy– GP may be able to recommend a self-
help course or may refer you for a course of therapy, such as cognitive
behavioural therapy (CBT) Cognitive behavioural therapy (CBT) is a type of
therapy based on the idea that unhelpful and unrealistic thinking leads to
negative behaviour. CBT aims to break this cycle and find new ways of thinking
that can help you behave in a more positive way. For example, some women
have unrealistic expectations about what being a mum is like and feel they
should never make mistakes. As part of CBT, you’ll be encouraged to see that
these thoughts are unhelpful and discuss ways to think more positively. As part
of CBT, you will be encouraged to see that these thoughts are unhelpful and
discuss ways to think more positively.

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Alcohol Addiction
Who you are:
You are an FY2 doctor in psychiatry department.
Who your patient is:
Mrs Tanya Andrews is a 45 year old lady, who is admitted in your hospital. She had a
hysterectomy 2 days ago. She has been wanting to go home soon.
Other Information:
Your nurse colleague noticed that she has got a bad drinking habit.
What your task is:
Please talk to her and address her concerns.
Approach
Note Please, do not start by asking about alcohol, rapport first.

D: Hi, I'm Dr (name), are you Mrs Tanya Andrew?

P: Yes, hello
D: Can you confirm your age?
P: 45 years old.
D:I can see from my notes that you had surgery, How did it go ?
P: It was okay.
D: Any challenges?
P: No doctor.
D: Any pain?
P: Yes there is some pain in the operation area.
D: How is the care by doctors and nurses?
P: They are very good.
D: Why did you have the surgery in the first place?
P: I had a large fibroid in my uterus.
D: Well, the nurse is worried about you and that's why I'm here to have a
chat with you to see how things with you are?
P: Yes.
D: How do you feel?
P: Some withdrawal symptoms- Explore them - like Anxious, Restless, Feeling Nauseous,
Sweating, and Tremor (important)
Or you can approach by saying:
D: Can we have a chat about your health to make sure things are fine?
P: Yes doctor.
D: Can you walk me through your diet?
P: I like eating fried foods more, like fish and chips
D: Do you smoke?
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P: No/Yes – (If yes then explore)

D: Do you drink alcohol ?
P: Yes (then elaborate)
D: How much do you drink and what?

Then start asking about alcohol in detail according to the structure.

CAGETWD
D: Have you tried to cut it down or stop it?
P: Yes, I tried.
D: Why couldn’t you stop it?
P: I had some withdrawal effects like I get anxious if I don’t drink.
D: Do you get annoyed if anyone tells you to stop drinking?
P: Yes I get annoyed sometimes.
D: Have you ever felt guilty about drinking a lot of alcohol?
P: Yes sometimes I do, but not always.
D: Do you have to drink in the morning after you wake up? – Eye opener
P: Yes I do have to drink at least a little otherwise I can’t function properly.
D: Do you think you need to drink more now than before to feel satisfied? – Tolerance
P: Yes doctor I have to drink at least twice the amount as others around me to get that
tipsy feeling.
D: Do you feel you have any problems other than feeling anxious if you don’t drink? –
Withdrawal
P: Yes Doctor I get very irritated and feel sick sometimes if I don’t drink for a long time.
D: Do you feel like you can’t work without drinking properly? – Dependency
P: Yes I feel that way.
D: Apart from alcohol, do you take any recreational drugs?
P: No doctor.
Mood
D: How is your mood lately?
P: I want to go home fast, I feel annoyed being here now. - acknowledge
D: Could you please score the mood on a scale of 1 to 10, 1 is low and 10 is happiest.
P: It is 5-6.
Suicide (just one question)
D: Have you ever tried to harm yourself (Signpost first)
P: No.
Impact (Very Important)
D: Do you think this drinking habit has impacted your life in anyway?

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P: I think it has a little, I always forget about everything and all day I tend to think about
when I’m having my next drink- (That means she has insight)
Insight (Very Important)
D: Do you think that you need some help regarding this situation you’re going through?
P: I think so, but I also enjoy drinking.

4F
- Family. → Support
- Friends. → System.
- Forensic → not important.
- Finance → as it's one of the stressors.
(For questions look at the videos of the course.)

D: Who do you live with?

P: With my husband.
D: How is your relationship with him?
P: Good, he is supportive.
D: Do you have any relatives close by?
P: Yes, my brother.
D: Have you talked to him about how you feel?
P: Yes. My mum thinks that it’s normal to be low sometimes.
D: How about any friends.
P: I don’t have many.
D: What do you do for a living?
P: I work at a pub as a manager.
D: How are you managing financially?
P: I am always out of money before the end of the month.
D: Do you drive?
P: Yes I do drive.
Hallucination:
D: Do you sometimes feel like you can hear voices? - Signpost first
P: No.
2 M - Medical conditions? (Liver) and Mental Conditions
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Do you have any swelling or bloating sensation in your tummy?
P: No.
D: Are you currently taking any medications, OTC drugs or supplements?
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P: No.
D: Any allergies from any food or medication?
P: No.
D: Any previous surgeries or procedures done?
P: No.
Management
OK so you have mentioned to me that you are experiencing… (Tell the positive
symptoms) which I'm suspecting is due to heavy drinking of alcohol, it could
be that you have alcohol dependence.
Going over the recommended limits with alcohol is dangerous, as it can cause
not only mental health issues, but it will also affect your social life.

The recommended limit for drinking alcohol is 14 units per week and keeping
at least 2 days alcohol free in a week.
Do you understand the recommended limits? Would you like us to help you be
healthier by quitting or reducing how much you drink?

1. Admit for rehabilitation. Or we will keep her in the hospital if she is already in
the hospital.
2. Blood investigations mainly LFTs, FBC, Vitamin B levels
3. We can cooperate to help you on cutting down.

↙ ↓ ↘

It's all about Medications Counselling

your will power • Anti-craving Acamprosate • Alcohol
at the end of the anonymous
day, so would you • Deterrent disulfuram group.
consider it?
• Withdrawal chlordiazopexide • CBT.

4. There are some risk factors we should address like your job.
- Advise her → To find a different job that doesn’t involve alcohol.
→ Citizen Advice Bureau.
5. Safety netting for suicidal thoughts, low mood, driving whilst over the limit.

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Heroin Addiction
Who you are:
You are an FY2 doctor in psychiatry department.
Who your patient is:
30 year old, Henry James, has been referred from GP to hospital because
he is an opioid dependent and wants to quit.
What your task is:
Please talk with him and address his concerns.

Approach
D: Hi, are you Mr Henry James?
P: Yes.
D: Can you confirm your age?
P: 30 years old.
D: I can see from my notes that you want to quit heroin?
P: Yes doctor.
D: I am so glad, this is a very good step and it needs a brave man to take
it.(Praise him).
D: Can we have a chat about it?
(If the patient looks irritable , scratching or itchy → Please acknowledge and manage
any withdrawal later).
P: Okay.
Questions about drug
D: What drugs do you take?
P: I take heroin.
D: Since how long have you been taking it?
P: For 2 years.
D: How do you take it?
P: I inject it and sometimes snort it.
D: Where do you get it from?
P: I used to get it from one of my friends.
D: Do you share needles with anybody while taking it?
P: I used to but now I do it alone so I don’t share with anyone.
D: Do you take part in the needle exchange program?
P: No.
CAGE TWD
D: Have you tried to cut it down or stop it?
P: Yes, I tried.
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D: When was it?

P: A few months back.
D: What persuaded/ motivated you to quit that time? (Ask this must it will help in
management)
P: My girlfriend was going to break up with me if I didn’t quit.
D: Why couldn’t you stop it?
P: I had some withdrawal symptoms like I used to get anxious if I don’t take it and I just
started taking it again.
D: Do you get annoyed if anyone tells you to stop using heroin?
P: Yes I do sometimes.
D: Have you ever felt guilty of taking it?
P: Yes sometimes I did get but not always.
D: Do you have to take heroin in the morning after you wake up? – Eye opener
P: Yes I do have to take at least a little otherwise I can’t function properly.
D: Do you think you need to take more now than before to feel satisfied? – Tolerance
P: Yes doctor I have to snort and inject at least twice the amount as others around me
to get high.
D: Do you feel you have any problems other than feeling anxious if you don’t take it? –

Withdrawal
P: Yes Doctor I get very itchy, feel sick and have diarrhea sometimes if I don’t take for a
long time.
D: Do you feel like you can’t work without taking it properly? – Dependency
P: Yes I feel that way.
D: Apart from heroin, do you take any other recreational drugs?
P: No .
D: Do you smoke?
P: Yes – (elaborate)
D: Do you drink?
P: No.
D: Sorry I need to ask you some personal questions now, are you sexually active?
P: Yes.
D: Do you have a stable partner?
P: No.
D: Do you practice safe sex?
P: Sometimes.
D: Have you ever tested for HIV, Hep B or any other STI?
P: No.
Mood
D: How is your mood lately?
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P: My mood is okayish.
D: Could you please score your mood on a scale of 1 to 10, 1 is low and 10 is happiest.
P: It is 5.
Suicide (just one question)
D: Have you ever tried to harm yourself (Signpost first)
P: No.
Impact on his life, daily activity, people around him and work (Very Important)
D: Do you think taking heroin has impacted your life in anyway?
P: I think it did I broke up with my girlfriend, I lost my job, I don’t talk with my family
and old friends anymore. – (acknowledge and sympathise)
Insight (Very Important)

D: Do you think that you need some help regarding quitting heroin?
P: Yes doctor that’s why I came here—(Acknowledge and praise him again.)
4F
- Family. → Support
- Friends. → System.
- Forensic → important.
- Finance → as it's one of the stressors.
D: Who do you live with?
P: I live alone.
D: Do you have any relatives close by?
P: Yes, my parents.
D: Have you talked to them about how you feel?
P: Yes. My mum thinks that I don’t have any hope left in me.
D: How about any friends.
P: I don’t have any now.
D: What do you do for a living?
P: I lost my job recently.
D: How are you managing financially?
P: I am spending my savings and lending from people I know.
D: Have you ever had any trouble with the law?
P: No.
D: Do you drive?
P: No.
Hallucinations:
D: Do you sometimes feel like you can hear voices? – (Signpost first)
P: No.
2 M - Medical and Mental Conditions
D: Have you been diagnosed with any medical condition in the past?
P: No.
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D: Are you currently taking any medications, OTC drugs or supplements?

P: No.
D: Any allergies from any food or medication?
P: No.
D: Any previous surgeries or procedures done?
P: No.

Examination
• Observations (for HR)
• Injection sites to exclude any infection (phlebitis)

Management
1. Admit for rehabilitation.
2. Senior.
3. Investigations
• Blood → for infection markers, HIV, Hep-B , and other STI screening if
sharing needles and unsafe sex.

4. Symptomatic (withdrawal symptoms)

• Itchy → Antihistamine.
• Loose motion → Loperamide.
• Nausea → Metoclopramide.
5. Replacement therapy → Methadone.
6. Detoxification →Lefoxidine.
7. CBT talking therapy.
8. Narcotic anonymous group.
9. Advice about risk factors. → Friends and people around him taking drug.
10. Safety netting → we will give you a number to ring if you feel any
urge or need to take the drug.

Anorexia Nervosa
Who you are:
You are an FY2 doctor in Psychiatry department.
Who your patient is:
Miss Jessy Paul aged 18, is sent to the hospital by the GP because she was losing weight
for the past 6 months. She has not been diagnosed with any medical condition. She is
not taking any medication. Her BM1 is 17.
What your task is:

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Talk to the patient and discuss initial plan of management with her.

Note You may find her mum in the cubicle with her, then → ask for permission from
the daughter if she wants her mum to be with her in the room.

Approach

D: Hi, I'm Dr (name), are you Jessy Paul?

P: Yes.
D: Can you confirm your age for me?
P: I am 18.
D: I can see from my notes that you have been referred from the GP.
D: Why did you go to GP?
P: My parents have some concerns about my weight loss. They took me to the GP and
he sent me to the hospital.
D: What do you think about it?
P: Yes I am losing weight.
P1 → Weight loss
D: How much weight have you lost?
P: 2 stones (1 Stone is 6.35 KG)
D: In how much time did you lose this much?
P: In the last 2 months.
D: Has it happened before?
P: No doctor.
D: Is it intentional?
P: Yes, I want to lose weight.
D: Do you want to tell me why you want to lose weight?

P: Doctor I want to look thin and attractive. I want to wear nice clothes.
8 things to be asked
1. Diet (in details)
• What do you have for breakfast, lunch and tea?
• How much fluids do you have?
• Any snacks in between?

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D: How are you losing weight? Do you have any diet or exercise plan?
P: Yes, I have a diet plan.
D: Tell me about you diet plan, what do you eat?
P: Every morning I have an apple and I don’t eat lunch. I only have a biscuit or salad for
dinner.
2. Exercise (in details)
• What do you do?
• How often?
D: Do you do any exercise?
P: Yes, I go to gym twice every day, morning and evening.
D: How long is each session?
P: Each session lasts for around one and a half hours.
D: Do you weigh yourself?
P: Yes. I check my weight a few times a day.
3. Ask about period
• When was your last period?
• Is it regular?
D: How are your periods?
P: I haven’t had any the last few months.
4. Medical conditions
• Any medical conditions?
D: How has your health been recently?
P: Fine but I am tired all the time.
D: Do you feel hungry?
P: Yes.
D: Do you feel lightheaded?
P: Yes.
D: Do you feel dizzy?
P: Yes, but I want to lose weight.
D: Do you have any medical conditions?
P: No doctor.
D: Any allergies?
P: No.
D: Do you take any medications?
D: No.

5. Have you been bullied?

D: How are things at school?
P: I’m a bit behind my classmates, as I am unable to study because of this. I’m hungry so
I can’t concentrate.
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D: Have you been bullied by anyone anywhere?

P: No.
6. Role model
D: Do you have any role model?
P: Ariana Grande.
7. Baggy clothes
• Do you have any preference in clothes?
8. Mood
D: How is your mood these days?
P: I’ve had quite a low mood.
D: What’s the matter?
P: I have been upset since it is affecting my studies.
D: Score your mood?
P: 1-3/10
D: Do you keep looking at yourself in the mirror?
P: Yes → what do you see?
+ SCOFF
S → Do you make yourself sick because you feel uncomfortably full?
P: Yes sometimes I do that.
C → Do you worry that you have lost control over how much you eat?
P: Yes
O → Have you lost more than one stone in 3 months ?
P: I lost more than 2 stones doctor already.
F → Do you think you are fat when everyone thinks you are thin?
P: Yes
F → Would you say food dominates your life?
P: No

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Then
Any questions left from

M C F A M I S H

↓ ↓

Impact Suicide
Insight
IMPACT
D: And how is this affecting your life?
P: I am getting distant from my family because of these mood swings.
INSIGHT
D: Do you think you need help regarding the thoughts you’re having on losing weight?
P: No, I don’t think so doctor.
Suicide (just one question)
D: Have you ever tried to harm yourself (Signpost first)
P: No.
ICE
Examination
• Observation.
• BMI.
Management
Provisional diagnosis
• From the information you have given me and according to my
examination, I'm suspecting that you have anorexia nervosa.
• BMI is a measure that uses your height and weight to work out if
your weight is healthy or not. Normally, it should be from 18.5 –
24.5 , but in your case it's 17. This means that you’re underweight for
a person of your height.
• Anorexia Nervosa is an eating disorder where the person keeps
their body weight as low as possible. If it continues, it can lead to
serious medical conditions where your bones get weaker, which

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can make you more likely to develop a condition called

osteoporosis, and it may be difficult to even conceive later on.

We are going to admit you in the hospital and run a series of initial blood investigations
that include; FBC, BMI, U&Es, TFT, LFT.
Along with that one of my colleagues will help you with a diet plan as well.
In addition to that, we will arrange for some talking therapy as well so that we can
have a wholistic approach towards your individual situation.
Once we feel you are well enough to be discharged from the hospital, we will refer you
to suitable services such as:
1. Diet Advice
2. CBT
3. Family Therapy
↓

1. Admit.
2. Senior.
3. Investigations
• LFTs – KFTs – TFTs.
• FBC – RBS.
4. Refer you to MDT
• Psychologist → to change the way you think about food.
• Psychiatrist → CBT, Family therapy
• Dietitian → to tell you what type of food you eat.
5. We have to do what we call it (Supervised weight gain).

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ACUTE CONFUSION
Presentations:
➢ Acute confusion for MMSE
➢ Acute confusion for diagnosis and management

D.Ds of acute confusion

✓ Brain: SOL/stroke/meningitis/head injury
✓ Drug and alcohol: Cannabis- LSD- cocaine- amphetamine
✓ Psychiatric: schizophrenia- Bi-polar (manic)
✓ Infections: UTI, Pneumonia/HIV/ and constipation
✓ Electrolyte and dehydration: hyponatraemia/hyper
✓ Endocrine: steroids, Cushing, thyroid, hypoglycaemia
✓ MOF (Multi organ failure): LCF (Liver Cell Failure), ARF (Acute
Renal Failure), HF (Heart Failure).

MINI-MENTAL STATE EXAM (MMSE) of a Confused Patient

Who you are:

You are an FY2 doctor in A & E.
Who your patient is:
Albert Peterson, aged 77, has been brought to the hospital by the police. He was
wandering in the park and he was confused. He doesn’t know why he is in the hospital.
What your task is:
Please talk to the patient and assess his cognitive function. Explain your findings and
your further plan of management to your examiner.
Do not take psychiatric history. After 6 minutes, stop talking to your patient and talk to
your examiner.

Note: Sometimes patient may not allow you to introduce yourself and he will start
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asking questions.

Approach

P: Where am I?
Dr: You are in the hospital.
P: Why am I here?
Dr: You were wandering in the park. Police found you and brought you to the hospital.
P: Did I do something wrong?
Dr: Not at all. You were just a bit unwell.
P: Who are you?
D: My name is Dr (name) I’m one of the junior doctors at this hospital. May I ask your
name?
P: My name is Albert Peterson.
Dr: Pleasure to meet you.
P: Doctor, what am I doing here?
Dr: Well the police were worried about you so they brought you here so we can help
you.
P: Okay, no problem.
D: I am here to ask you some questions to assess your memory. ? Some of the questions
might sound odd to you but it is just a part of my consultation. I hope that is okay with
you?

Or

Cognition Questions
• Can you confirm your name?
• Can you confirm your age?
• Do you know where you are?
• Do you know who brought you here?
• Do you know where you live?

• Albert, you seem a bit unwell. In these kind of situations, we tend to ask a
few questions to make sure that things are ok. Some of the questions
might sound odd to you but it is just a part of my consultation. I hope that
is okay with you?

Then start mini- mental state examination

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Time Orientation
You need to ask five questions of time from broadest to most narrow (year,
season, month, date and day) and for each correct answer you should give
one score.
Dr: What year are we in?
P: It is 1956.
D: We are in the year (the correct year).
P: Never mind.
Dr: What season is it?
P: Doctor, it should be summer because the weather is so cold. (CORRECT IF
WRONG)
Dr: What month is it?
P: It is June. (CORRECT IF WRONG)
Dr: What day is it?
P: It’s Monday doctor. (CORRECT IF WRONG)
Dr: What would today's date be?
P: It's the 25th doctor. (CORRECT IF WRONG)

Place Orientation
You need to ask five questions of place from broadest to most narrow
(Country, county, town/city, street and building) and for each correct answer
you should give 1 score.
Dr: May I know what country are we in?
P: UK. (CORRECT IF WRONG)
Dr: Which county are we in?
P: Greater Manchester (The correct answer is Merseyside) (CORRECT IF
WRONG)
Dr: What town/city are we in?
P: London. (CORRECT IF WRONG)
Dr: No we are in Liverpool. What street are we in?
P: I don't know.
Dr: No problem we are on London Road.
Dr: Which building are we in now?
P: I don't know.
Dr: That’s okay, we are in the Royal Liverpool Hospital.

Registration
You should name three unrelated objects clearly and slowly and then ask the
patient to repeat them after you. You may remind him to remember them
since you will be asking him to recall them later.
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Dr: I’m going to give you three words and I would like you to repeat them
after me. Try to remember them because I’m going to ask you to recall them
later. The words are: apple, table, penny.
P: Apple, table, penny.
Dr: That's great.

Attention
In order to assess attention, give your patient a 5-letter word and ask him to
spell it backwards. You may use the word ‘WORLD’. The correct answer is: D-
L-R-O-W. For each correct answer, give him one score.

Dr: I would like you to spell the word WORLD backwards for me?
P: D... (Patient will takes a pause and starts thinking.)... .It is difficult doctor.
Who are you? What am I doing here? Why am I doing this thing? / Why are
you asking me these questions?
Dr: My name is Dr (name), I'm one of the junior doctors in this hospital. I am
assessing your recent memory.
P: Who brought me here?
Dr: You were wandering in the park. The police were worried about you and
so they brought you to the hospital.
P: Oh okay doctor.

(Stop if patient doesn’t want to continue from anywhere and score the test
on the basis of how much you have assessed)

Recall
You should ask your patient to recall the three words you asked him to
remember earlier. For each word that he could remember, give him one
score.

Dr: Earlier I had asked you to remember the three words, could you repeat
that for me? P: Which 3 words?
Dr: Try to remember.... (After a small pause if he doesn’t answer, tell him the
words and don’t give him the marks) the words were Apple, Table, Penny.
Dr: It’s okay, moving on.

Language
You should show your patient simple objects, such as a pen and pencil and
ask him to name them. For each correct answer, please give him one score.

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Dr: Could you please name this object (pen) for me?
P: It’s a pen.
Dr: How about this one (Paper)?
P: (Patient is pushing himself.) It's on the tip of my tongue but I cannot
remember.
Dr: Are you looking for the word, paper?
P: Yes Doctor.
Dr: That's good (However do not give them the mark.)

Repetition
Ask the patient to speak back a phrase. You may use this phrase “No ifs, ands
or buts”. If he can repeat it after you correctly, give him one score.

Dr: Could you please repeat this sentence for me. “No ifs. ands. or buts.”
P: “No ifs. ands, or buts.”
Dr: That's good.

Complex Command (3 Stage Command)

You need to give your patient 3 commands. Give one score for each correct
answer.

Dr: Take the paper in your right hand, fold it in half, and put it on the floor.
P: Okay doctor.
(Sometimes patient does as you said. Sometimes he keeps folding the paper
and sometimes he puts the paper back on the table instead of giving it back
to you.) Complex Command (Reading)
You should give your patient a written instruction and ask him to read it and
do what it says. If he follows your instruction correctly, please give one score.

Dr: Could you please follow the task written on this paper. (You may write:
“Close your eyes” on a piece of paper.)
P: (He will close his eyes.)
Dr: That's great, you may open your eyes now.

Complex Command (Writing) You should give your patient a pen and a piece
of paper and ask him to make up and write a sentence about anything.
If he writes a meaningful sentence that contains a noun and a verb without
any spelling or grammar mistake, please give him one score. (Usually he
writes a meaningful sentence, however, sometimes he may make spelling
mistakes.)
Dr: Could you please write a meaningful sentence about anything for me?
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P: (Patient writes different sentences every time.) - The sun is shining today. -
It is a nice day. - Sky is blue today.

Complex Command (Drawing) You should draw the following picture on a

piece of paper. Give your patient a pen and a blank piece of paper and ask
him to copy your picture. If he draws it correctly, please give him one score.
(All ten angles must be present and two angles must intersect.)

MMSE Score
24-30—NORMAL 10-19—MODERATE IMPAIRMENT
20—23 MILD IMPAIRMENT 0-9—SEVERE IMPAIRMENT
Examiner: MMSE 21,
Routine Test – Normal

Examiner: Which investigation do you want to do:

These include some laboratory tests such as FBC, U&Es, LFT, Calcium, Vitamin B12,
thyroid function tests and random or fasting blood sugar, CT scan or MRI of the brain.

Differential Diagnosis:
1. Neurodegenerative disorders for example Multiple sclerosis.
2. Other CNS disorders for example Brain tumours, Epilepsy and Trauma.
3. Infectious disease such as HIV.
4. Metabolic disorders such as Hypercalcemia, Hyponatremia
5. Endocrine disorders such as Addison disease, Cushing syndrome and thyroid
problems.
6. Vitamin deficiencies such as vitamin B12, folate, thiamine, niacin deficiency.
7. Medications such as anabolic steroids, corticosteroids, cimetidine and some
antibiotics such as penicillin.
8. Substance abuse such as Amphetamines, Cocaine, Alcohol, Cannabis.
9. Related psychiatric disorders such as Schizophrenia, delirium, Mood disorders
with delusional symptoms (manic or depressive type), Obsessive-compulsive
disorder.

According to the NICE guidelines,

25-30 - Normal.
21-24 - Mild Cognitive Impairment

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10-20 - Moderate Cognitive Impairment

< 10 - Severe Cognitive Impairment.

Provisional diagnosis
From the above cognitive assessment , the patient has for example , mild ,
moderate or severe cognitive impairment depending on how much the patient
scored. As my patient scored…….
It could be dementia if my patient had this for a long period or acute delirium,
So I will try to contact the next of kin or his GP. And find out some more
information.
So I will
↓
1. Admit.
2. Senior.
3. Investigations → Blood FBC – CRP – U/E – LFTs – KFTs.
→ Urine to exclude UTI.
→ CXR to exclude pneumonia.
→ CT brain to look for any organic cause.
4. Contact his family or GP to ask about the onset of the condition and the
progression.
5. Refer to dementia clinic.

MANGEMENT IN CASE OF ADVANCED DEMENTIA

- Admit: if alone and no support with progressive symptoms and social

services- (support workers/care homes/care at home (aged UK,
Dementia UK, Admiral nurses)
- Investigations – all (blood- urine-CXR)
- Symptomatic: Palliative
o If at home, develop a plan with the carer to manage issues
like feeding, dehydration, toileting, and mobility. This includes
telling the carer to remind the patient if he/she is forgetting/

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feeding and hydration.

o Provide support to manage activities of daily living. This can
be done by carers at home who could be family or paid
carers (Full time or part-time).
o Refer to specialist organisations such as dementia UK to
source out some social needs in collaboration with the carer.
o Support the carer if he/she is presenting to you.
- Specialist: CT (brain specialist), to exclude other causes
mentioned above.
- Safety net: make sure he/she is not alone- to avoid
accidents/falls/getting lost.

(PLEASE SEE MMSE FORM ON NEXT PAGE)

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Concerned Daughter MMSE

Who you are:

You are an FY2 doctor in GP.
Who your patient is:
Mariah Smith, aged 60, came to the clinic with some concerns.
What is your task:
Talk to her and address her concerns.

Approach
P1
D: How can I help you?
P: My daughter wanted me to see you.
D: What was her reason?
P: She said I keep forgetting things.
D: Can you tell me about it more?
P: I forgot my grand-daughter’s birthday the other day, and it was very
embarrassing, I didn’t show up to the party, but I had been planning for it all
week.—acknowledge
D: Do you think there have been any changes in you?
P: No.
D: Are you able to remember things?
P: Yes, I remember most things.
D: Do you have to ask multiple times for information?
P: No.
D: Do you need notes to remember things?
P: No.
D: Do you have trouble following conversations?
P: No.
D: Do you find yourself confused mid-conversation?
P: No.
D: Do you lose things or feel like someone has stolen them?
P: No.
DDs
D: Have you noticed difficulty in walking or keeping your balance?
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P: No. (Vascular dementia)
D: Have you had any trouble with your vision?
P: No. (Vascular dementia)

Medical and Mental health

D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any DM, HTN or stroke?
P: No.
D: Are you currently taking any medications, OTC drugs or supplements?
P: No.
D: Are you taking any birth control pills?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Any previous surgeries or procedures done?
P: No.
P3 DESA
D: Do you smoke?
P: No.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: Good/Bad
D: Are you physically active?
P: Yes/No
Psychosocial
D: What do you do for a living?
P: Work from home.
D: Whom do you live with?
P: With my daughter
Then ask questions about Mood
Ideas Concerns Expectations

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Examination:
If you don’t mind I would like to check your vitals, do GPE, MMSE and
Neurological examination.
Examiner: MMSE- 26
From my assessment, the MMSE score is normal.

Investigations:
I will do some routine and special blood tests.
These include some laboratory tests such as FBC, U&Es, LFT, calcium, vitamin
B12, thyroid function tests and random or fasting blood sugar, CT scan or MRI
of the brain.
Routine Test – Normal.

As everything looked normal, after doing the routine tests, send her home
and safety net for dementia after consulting with senior.

Note: According to the NICE guidelines, 25-30 - Normal. 21-24 - Mild Cognitive
Impairment 10-20 - Moderate Cognitive Impairment < 10 - Severe Cognitive
Impairment.

My management plan would include:

• Take complete medical history including social history from the patient.
• Perform necessary physical examinations.
• Order the routine blood tests
• I would make a referral to the Psychiatric team once the patient is medically
settled.
• There is a possibility of referral to Neuropsychiatry as well.
• They may involve the social services team and Homeless team if need be.
Full examination looking for possible cardiac or neurological abnormalities
should be performed.
Some advanced cognitive assessment should also be done.
Some further investigations may be done in order to rule out physical causes
Confusion Screen: CT Scan, UA, TFT, Ca, B12, folate

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SCHIZOPHRENIA and PSYCHOSIS

Presentations:
➢ Usually presented due to disruption of functioning including
troubles with the law/complication related to the
hallucinations.
➢ Patient seen by close relatives or family to have a strange
behaviour.

First Scenario: Concerned Mother of Psychotic Son

Who you are:

You are an FY2 doctor in GP clinic.
Who your patient is:
Mother is concerned for her son, Michael Smith, aged 40, as he has been
behaving strange for 3 weeks. The other day she made an appointment for
face-to-face consultation for her son.
What is your task:
Talk to him and address his concerns.
Approach
D: Hi Michael, I can see from my notes that your mother had booked this
appointment for you, so can you tell me how I can help you?
P: I don’t have any clue why she did that. I am absolutely fine.
D: Oh I see. So Michael let’s find out what the matter is then okay?
P: Okay.
D: I will ask you some questions, they may sound strange, however kindly bear
with me, is that okay?
P: Sure Doctor.
Cognition
D: Do you know where you are?

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P: I’m at the clinic.
D: Do you know who brought you here?
P: My mother.

Hallucination Questions
D: Sometimes when people go through difficult times in their lives
they tend to hear, see or feel things that are not real, have you ever
experienced such things?
P: Yes doctor I hear voices—Explore
D: Since when?
P: A few weeks.
D: How many voices do you hear?
P: 2 voices – Male or female?
D: Do you feel that someone is putting thoughts into your head?
P: Yes.
D: Do you feel that someone is taking thoughts out of your head? Or do you
feel your thoughts are being voiced aloud? (So that others can hear them).
P: No.
D: Do you feel that someone is plotting against you?
P: Yes.
D: Do you carry anything on you to protect yourself in case things
go bad (v. important).
P: Yes, I keep a knife with me (Here it is—patient sometimes shows
the weapon or tries to scare you)
D: Michael I can see you’re worried, but you don’t have to fear at
all, you’re very safe here, you can hand me the knife please. I will
keep it in a safe place and return it to you later. (Pt agrees and
hand the knife to you)
Idea
D: Michael why do you think all this is happening to you?
P: I am a detective and I know about them that’s why.
Rest of MC FAMISH

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Mood
D: How are you feeling?
P: I am okay.
D: Do you feel low?
P: No.
Suicide
D: Some people when they go through difficult times in their
lives they tend to hurt themselves or hurt others , have you
experienced such thoughts ?
P: No.
Impact
D: Do you feel that this has affected your life, daily activity , people
around you or your work? (Important in management).
P: I don’t go out much nowadays doctor because of this.
Insight
P: Do you feel that you need our help ?
P: No doctor, I am fine, thank you.

4F Family ? Friends ? Forensic ? Finance?

D: Who do you live with?
P: My mother.
D: How is your relationship with her?
P: Good.
D: Do you have friends?
P: No I don’t.
D: Are you working at the moment Michael?
Pt: I am a detective but on leave now.
D: Is this affecting your work?
P: Yes they are threatening me to stop investigating them.
D: Are you on any benefits?
P: No doctor, I have my savings.
D: Have you ever had any problems with the law?

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P: No, I haven’t had any problems so far.

Medical and Mental Health

D: Have you been diagnosed with any medical condition?
P: No.
D: Have you ever had any mental health problems?
P: No.
D: Has anyone in your family been diagnosed with any mental conditions?
P: No.
D: Do you take any regular medications, OTC or herbal remedies?
P: No.
D: Do you have any allergies?
P: No.
D: Do you drink alcohol?
P: No.
D: Any recreational drugs?
P: No.

Management:
Provisional Diagnosis: From the information that you have given me,
I suspect that you might be suffering from Psychosis. With this
condition, usually patients lose touch with reality and they start to
see, hear or feel things that are not real. It happens due to a chemical
imbalance in the brain.
If these symptoms persist for a long period of time and all
investigations come back normal, it is then called schizophrenia.
P: Okay, but I don’t think this is my case doctor!

How about we chat about what I can do for you?

As we are worried about you, we would like to keep you in the hospital for
some time to do some blood tests (to rule out medical cause).

One of my colleagues (from the mental health team) will come and talk to you
and if need be and we will get you some medications.

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(Note This condition can also be due to drug abuse or alcohol abuse)

2. Admit.
3. Senior.
4. Investigations
• Blood
o Abnormal LFT and macrocytosis to exclude alcohol abuse.
o Serological tests for syphilis.
o Screening for AIDS.
• Urine: for drug abuse.
• CT brain: to exclude brain lesions.
5. Medications: Antipsychotic medications
• Risperidone.
• Olanzapine.
6. We will also provide psychological and social support.
7. Talk about support system → Family and friends.
8. Referral and Psychotherapy and CBT
9. Safety netting → Suicide

Second Psychosis Scenario

Delusional Patient
Who you are:
You are an FY2 doctor in Psychiatry.
Who your patient is:
Mr. Alex James, 23 years old, brought to the hospital by the police. According
to the police, he thinks that he has done something wrong. After police
investigations, police found it's a false claim.
What is your task:
Talk to him and address his concerns.

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Note: This station is similar to the previous scenario, and the management plan
is also similar with admission.

Approach

D: Hi, I'm Dr (name) , are you Alex James?

P: Yes. Patient looks worried → please reassure.
D: I'm here to talk to you and try to help you?
P: Okay
D: I will ask you some questions that may sound strange. However, kindly bear
with me, is that okay?
P: OK.
D: You seem a bit agitated? Can you please tell me what happened?
P: The police are after me.
D: No Alex they aren’t, in fact the police are worried about you.
P: I have committed a crime.
D: You have not done anything wrong. They have gone through your records
and found nothing wrong.
P: Okay.
D: Alex, let's see why you are feeling this way and try to get to the bottom of
this.

Hx → MC FAMISH but start with questions of cognition + hallucinations.

Cognition
D: Do you know where you are?
P: I’m at the hospital.
D: Do you know who brought you here ?
P: The police.
D: Did the police come and get you or did you go to them ?
P: I went to them.
D: Have you been harmed in anyway?
P: I’m not sure.

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Hallucination Questions
D: Sometimes when people go through difficult times in their lives
they tend to hear, see or feel things that are not real, have you ever
experienced such things?
P: Yes doctor I hear voices—Explore
D: Since when?
P: A few weeks now.
D: How many voices do you hear?
P: 2 voices – Male or female?
D: Do you feel that someone is putting thoughts into your head?
P: Yes.
D: Do you feel that someone is taking thoughts out of your head? Or Do you
feel your thoughts are being voiced aloud? (So that others can hear them).
P: No.
D: Do you feel that someone is plotting against you?
P: Yes.
D: Do you carry anything on you to protect yourself in case things
go bad (v. important).
P: Yes, I carry a knife on me.
D: Michael I can see you’re worried, but you don’t have any fear at
all, you’re very safe here. Can you hand me the knife please? I will
keep it in a safe place and return it to you later. (Patient agrees
and hands you the knife)
Ideas
D: Michael why do you think all this is happening to you ?
P: I don’t know.

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Rest of MC FAMISH
Mood
D: How are you feeling ?
P: I am okay.
D: Do you feel low ?
P: No.
Suicide
D: Some people when they go through difficult times in their lives, they tend to
have thoughts of hurting themselves or hurting others, have you experienced
such thoughts ?
P: No.
Impact
D: Do you feel that this has affected your life, daily activity , people
around you or your work? (Important in management).
P: I don’t go out much or do anything nowadays doctor because of
this.
Insight
P: Do you feel that you need our help ?
P: No doctor, I am fine, thank you.
4F Family ? Friends ? Forensic ? Finance?
D: Who do you live with?
P: I live alone.
D: Any relatives nearby?
P: No.
D: Do you have friends?
P: No I don’t.
D: What you do for your living?
P: I don’t work currently.
D: Are you on any benefits?
P: No doctor, I have my savings.

Medical and Mental Health

D: Have you been diagnosed with any medical condition?
P: No.
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D: Have you ever had any mental health problems?
P: No.
D: Has anyone in your family been diagnosed with any mental health
conditions?
P: No.
D: Do you take any regular medications, OTC or herbal remedies?
P: No.
D: Do you have any allergies?
P: No.
D: Do you drink alcohol?
P: No.
D: Any recreational drugs?
P: No.

Management
Keep the patient in the hospital if presented there, or emergency
referral to the hospital if in GP surgery. (It is a skill to be able to
convince the patient to be admitted, without getting into conflict or
having to use the Mental Health Act to admit them).
- Talk to my senior.
- Investigations for other causes: (all blood: FBS, TFT, LFTL,
U&E, KFT, cholesterol, FBC, ESR, CRP)- urine dip and D&A
screening- CXR for chest infection. Serology for Syphilis-
Antibodies and PCR for HIV + urine test (infections/drug
screen) + CT brain for brain lesions
- Specialist/symptomatic: Olanzapine- Risperidone to
reduce the symptoms.
- Psychotherapy and CBT
- Call his GP to get background info.
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- Take collateral history from family or partner.
Specialist: referral

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