UTI in Female.

Young lady presented with lower abdominal pain.

Take history and discuss further management with her and also write up a
prescription.

Dr: Hello I am Dr … one of the junior doctors in the department, Are you Ms ?

Pt: Yes

Dr: How are you doing Ms…..Pt: I am OK.

Dr: How can I help you?

Pt: Doctor I am having burning sensation when I pass urine.

Dr: Can you tell me anything more about it ?

Pt: Yes doctor it is happening since …. days now.

Dr: Do you have fever ?Pt: Yes/No since last …. Days

Dr: What is the colour of urine? – Pt: Dark and cloudy it smells bad doctor

Dr: Did you notice blood in the urine ?Pt: Yes/ No

Dr: Any pain in tummy ?Pt: yes/no (SOCRATES for pain if Yes)

Dr: Do you have pain in the loin area ( Pyelonephritis) ? Pt: No

Dr: Do you feel the need to pass urine despite having just done so (strangury)? Yes/No

Dr: Did you have this problem before ?Pt: Yes/ No

Dr: Do you pass urine more times than usual ?Pt: Yes doctor

Dr: Do you have any nausea or vomiting? Pt: Yes/No ( if unable to keep food down
consider admission)

Dr: Do you have any back pain (upper UTI) ? - Pt: No

Dr: Do you have any discharge from your front passage ?Pt : No
Dr: Have you noticed any weight loss( cancer)? - Pt: Yes / No

Dr: Any problem opening bowel? Pt: Yes / No

Dr: Do you have similar problems in the past ?Pt: Yes/No (repeated UTI)

Dr: Do you have any medical conditions? Pt: Yes / No

Dr: do you have high blood sugar? Pt: Yes/No ( diabetes also risk factor)

Dr: Have you had any surgeries in the past? Related to urinary passage? Pt : Yes No

Dr: Did you have any kidney stones before ?Pt: Yes/ No

Dr: when was your Last menstrual period? Pt: … (ask to rule out pregnancy in young,
menopause in old as menopause causes increase risk for UTI)

Dr: Are you married or do you have any partner ?Pt: I am married.

Dr: Do you use any sort of contraception ?

Pt: No I am trying to get pregnant. (spermicide causes increase risk of UTI)

Dr: Are you taking any medications ?

Pt: I am taking Folic acid because I am trying to get pregnant.

Dr: Have been told that you have Folatedeficiency ?Pt : ….

Dr: Does your husband has any urinary symptoms or discharge from his penis do you
know? Pt : No

Dr: Are you allergic to any medications ?Pt: Yes/No

Examination:

Dr: Miss …. I need to examine your tummy

Examiner may say – There is some tenderness supra pubic area

Diagnosis:

Dr: Miss …. I think you have a condition called as Urinary tract infection basically this
is infection in the urine means there are some bugs in the urine.

Pt: Why do I have this infection doctor?

Dr: Sometimes bugs comes from the back passage. They get into the urine through the
urethra (opening of the urine passage) or vagina.

Pt: What are you going to do for me doctor?

Investigations for UTI:

Dr: We can do to test your urine called dipstick and then send it to the lab to see what type
of bugs may be causing this infection.

(Examiner may or may not show the test results. If he does explain the result if not
continue to management)

Dr: If the test shows that you have urine infection we will give you some antibiotic
medications to treat this.

Dr: Let me write the prescription for you.

Write the prescription on the paper provided. Use the BNF.

I will give you an antibiotic medication called Nitrofurantoin.

Dr: Are you allergic to this at all? Pt: No Dr: Have you taken this before ? No

Dr : Do you have any kidney disease ( should not be given in kidney disease) Pt : No

Title Forename Surname DOB

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

Sign and write your name.

 This is a 50 mg tablet you need to take one tablet 4 times in a day with food for the next 3
days. Hopefully your symptoms will subside in the next 2 to 3 days.

Like any medication s this also can give some side effects like

 headache, dizziness;
 upset stomach;
 mild diarrhoea; or
 vaginal itching or discharge.
They usually subside after you finish the course but if it causes you problem then please
call your GP and take advise.

Do

 wipe from front to back when you go to the toilet

 try to fully empty your bladder when you go for a pee

 drink plenty of fluids

 take showers instead of baths

 wear loose, cotton underwear

 pee as soon as possible after sex

Don’t

 use perfumed bubble bath, soap or talcum powder

  hold your pee in if you feel the urge to go

 wear tight, synthetic underwear, such as nylon

 wear tight jeans or trousers

 use condoms or diaphragms with spermicidal lube on them - try non-spermicidal

lube or a different type of contraception

Warning signs.

However if the symptoms do not subside by the next 3 days if your fever gets worse, if
you start having loin pain, you are feeling very unwell and getting too tired please do
come back . Pt: okay

Dr. Also you can take pain killer medications like Paracetamol for your pain. Pt: yes

Dr: Any other concerns Pt: No doctor. Dr: Thank you very much.

------------------------

Additional information

Nitrofurantoin
Dosage

 For treatment of acute urinary tract infection (UTI), prescribe nitrofurantoin

50 mg four times daily, or 100 mg (modified-release), twice daily.
o For uncomplicated UTIs, treat for 3 days.
o For complicated UTIs, treat for 5–10 days.
o In pregnant women, treat for 7 days.

Contraindications

 Avoid prescribing nitrofurantoin to people with:

o Renal impairment —
o Acute porphyria.
o A deficiency of glucose-6-phosphate dehydrogenase

Important information

You should not take nitrofurantoin if you have severe KIDNEY DISEASE, urination
problems, or a history of jaundice or liver problems caused by nitrofurantoin.

Do not take this medicine if you are in the last 2 to 4 weeks of pregnancy.

Before taking this medicine

You should not take nitrofurantoin if you are allergic to it, or if you have:

 Severe KIDNEY DISEASE;

 a history of jaundice or liver problems caused by taking nitrofurantoin;
 if you are urinating less than usual or not at all; or
 if you are in the last 2 to 4 weeks of pregnancy.

To make sure nitrofurantoin is safe for you, tell your doctor if you have:

 kidney disease;
 anemia;
 diabetes;
 an electrolyte imbalance or vitamin B deficiency;
 glucose-6-phosphate dehydrogenase (G6PD) deficiency; or
 any type of debilitating disease.

This medicine is not expected to be harmful to an unborn baby during early pregnancy.
Tell your doctor if you are pregnant or plan to become pregnant during treatment.

Nitrofurantoin can pass into breast milk and may harm a nursing baby. You should not
breast-feed while you are taking this medicine.

Take nitrofurantoin with food.

------------------------------------------------------------------

Trimethoprim

 Prescription: For treatment of urinary tract infection (UTI), prescribe

trimethoprim 200 mg twice daily.

o For uncomplicated UTIs, treat for 3 days.

o For complicated UTIs, treat for 5–10 days.

o In pregnant women, treat for 7 days.

Contraindication: Bleeding disorder( ask pt about it before prescribing trimethoprim)

 Side Effects: Nausea, vomiting, pruritus, and skin rashes have occasionally been
 reported. These are generally mild and reversible when trimethoprim is withdrawn.
( tell if patient asks)
Treatments not recommended

 Cranberry juice or other cranberry products are not recommended as there is no

good evidence to support their use for treating urinary tract infection.
 Although urine alkalization has been traditionally used to relieve the symptoms of
urinary tract infection, there is a lack of good evidence to support its use.

Prescribe an antibiotic to all women with a suspected urinary tract infection

during pregnancy. Follow local prescribing guidelines that take into account local
resistance patterns if these are available. Otherwise prescribe (in order of preference):

Nitrofurantoin 50 mg four times daily, or 100 mg (modified-release) twice daily, for

7 days.

Trimethoprim 200 mg twice daily, for 7 days (off–label use).

Give folic acid 5 mg daily if it is the first trimester of pregnancy.

Do not give trimethoprim if the woman is folate deficient, taking a folate antagonist, or

has been treated with trimethoprim in the past year.

Vomiting in New Born Child – Pyloric stenosis

Causes of vomiting in babies
1 Meningitis Does your child shy away from light, Rashes

2 UTI Fever, smelly urine, does he cry more while

passing wee
Gastroenteritis 
3 Vomiting, Fever, Diarrhoea, Other similar
problem ( contact)
Food or milk intolerance
4 Any change in food, New food introduced

Gastro-oesophageal reflux –
5 Food dribbling, Reflux is just your baby
effortlessly spitting up whatever they've
swallowed. Muscles do not contract.
 Too big a hole in the bottle teat
6 which causes your baby to swallow too much
milk 
Over feeding
7 Do you think you are feeding more than usual
Accidentally swallowing
8 Any chance baby would have swallowed
something poisonous anything poisonous

Congenital pyloric stenosis 

9 Presentation – 2 week old to 2 month old babies,
First child, Boy, Projectile vomiting (vomiting
quite a distance like a fountain), The baby
remains hungry and will usually feed well - only
to vomit the milk back soon after feeding. The
vomiting tends to become worse and worse over
several days. The milk in the stomach often
curdles before the baby is sick.
Strangulated hernia –
1 Baby cries a lot, Swelling in the groin
0
Intussusception– Cries a lot, Mass felt in the tummy, red colour
1
stool,
1

1 Head injury Any injury to head

2

1 Pneumonia Fever
3

1 Middle ear infection Ear discharge

4

Dehydration question

dry mouth, crying without producing Lethargy, floppy, Drowsy, not active
tears, urinating less or not wetting
many nappies,

Exam question

You are FY2 doctor in Paediatric Department.

6 weeks old boy, Rhys was brought in by his mother with history of persistent
vomiting for last 2 days.
Take history from the mother Mrs Nicola Hampshire and talk to her about further
management.
Vital signs are given in question.
Hello I am Dr... one of the junior doctor in the Paediatric department. Are you the
mother of Rhys? Mother: Yes. I am

Dr: How may I call you? Mother: ? You can call me Nicola
Dr: How can I help you Miss/Mrs. . .?

Mother: My son has been vomiting a lot since last 2 days.

Dr: I am really sorry to hear about that. Can you tell me more about that?
Mother: Doctor he is throwing everything out.
Dr: How did it start? Mother: Doctor it started almost suddenly.
Dr: What do you feed him? Mother: I breastfeed him.
Dr: Does the vomiting occur in immediately after ( pyloric stenosis, GER) you
breastfeed him or later ?
Mother: Yes, doctor he vomits when I feed him.
Dr: Is it like throwing up or just dribbling of the food from the mouth (Regurgitation) ?
Mother: He is throwing up.
Dr: Does the vomit go far away like a fountain (Pyloric Stenosis)? Mother : yes
Dr: How many times does he vomit in the day?
Mother: Every time I feed him, (almost instantly) he throws up.
Dr: What is the content of the vomiting?
Mother: It is just the milk.
Dr: Is it ever green coloured (bilious – duodenal atresia) or blood stained? Mother: No.

Dr: Do you think you are feeding him more than usual (Overfeeding) ? Mother : He is
very hungry all the time ( may be because of pyloric stenosis also)

Dr: Does your child shy away from light, Any Rashes ( meningitis) ? Mother : No
Dr: Has he got fever ( Meningitis, UTI, Pneumonia, Ear infection) ? Mother : No
Dr: Doe she cry a lot ( meningitis, Obstructed hernia, Intussusception) ? Mother : No
Dr: Have felt any lump in his tummy ( Pyloric stenosis, Intussusception) ? Mother
Yes/No

Dr: How is his poop? Is it normal or has he got diarrhoea( loose stool) (Gastroenteritis)
? Mother – Normal. ( may be less in quantity in Pyloric stenosis) .
D: Is the poop red coloured( Intussusception) ? Mother: No

Dr: Does his urine smell bad? (UTI) Mother: No.

Dr: Is there any recent change in his feed ( Milk allergy) ? Mother: No doctor.
Dr: Did he have any injury to the head? Mother : No

Dr: Is his mouth dry ( dehydration) ? Mother: Yes/No

Dr: How is he – is he active or drowsy (severe dehydration) ?Mother :He is not active
bit drowsy.

Dr: How has been your child before? Has been diagnosed with any medical conditions?
Has he ever been admitted to hospital before? Mother: No.
Dr: Any medications that your child is on? Mother: No doctor.
Dr: Does your child have any allergies? Mother: No.

Dr: Does any child in your family now or in the past had similar problems as Rhys?
[Family History risk factor for Pyloric Stenosis, gastroenteritis (contagious) ]
Mother: Yes/No
Dr: Is he your fist child or do you have any other children?
Mother : He is my first child. ( First child – risk factor for Pyloric stenosis)

Dr: When you delivered Rhys – was it normal birth or did you have any problems ?
Mother: It was normal.
Dr: Any problems during development? Mother: No doctor.

Dr: Is there anything else you think that may be important that we may need to know ?
Mother : No

Examination:

Well, I need to examine your baby’s tummy.

(Examiner may say there is no abnormal finding)

Diagnosis:

Dr: From the information that I have gathered I think Rhys might be having a condition
what we call as Pyloric Stenosis. Do you know anything about it?

Mother: No doctor.

Dr: It is a condition in the tummy that can sometime affect the new born children. Let
me explain it to you. Our stomach opens into the gut ( bowel). The outlet of the stomach
into the gut is called the Pylorus. Stenosis means a narrowing. Pyloric Stenosis means a
narrowed outlet of the stomach. Because of the narrowing of the outlet of the stomach
food is not going to the gut. So the babies vomit the food out.

Mother: Is it serious doctor?

Dr: It is not a serious problem because we have a good treatment for this. This is not a
worrying condition.

Mother: Why did this happen?

Dr: It is not known why this occurs. This condition is seen more in boys than in girls.
And sometimes, it can run in families.
Mother: What are you going to do?
Dr: We need to admit Rhys. First of all, we need to confirm whether this is the problem
with Rhys.
I think Rhys is very drowsy because of severe dehydration which can happen when they
vomit a lot. We need to do some blood tests to check whether he has severe dehydration.
We will do some blood tests on him to check the blood gases.
[ Examiner may give the test result. Picture is as follows:
pH = High ( Normal 7.35 to 7.45 )
PaCO2= normal or high
HCO3- = high

Tell the mother - Blood test shows he has some problem called metabolic alkalosis this
is due to vomiting. (If asked then mention vomiting of acid from the tummy).

We also need to perform Ultrasound of his tummy to confirm whether this is the
condition. Mother: Ok doctor.

Treatment

Dr: We need to admit him and give some fluids through his veins for the hydration and
nutrition. So, please do not feed him until we tell you to do so. Is that Okay?

Mother: Okay. How will you treat him doctor ?

Dr: We can do a small operation to correct the narrowing of the stomach outlet and it
normally cures the problem. This operation is usually done by keyhole surgery. A small
cut is made in the skin over tummy. The operation allows the obstruction site to widen
into a normal size. This means that milk and food can pass easily out of the stomach into
the bowel.
Mother: Will there be any complication?

Dr: Some complications from surgery include bleeding and infection. However,
complications aren't common, and the results of surgery are generally excellent.

Mother: Will he be normal after this?

Dr: Yes, he will be normal and he will grow normally without having any problems.
Dr: Any other concerns ? Mother: No Thank you.

Breast Cancer with Back Pain management

62 year old female, who is a known case of breast cancer presents with back pain.
Talk to her about the pain management.
Sympathy and empathy is very important in this station
Dr: Hello I am Dr .... I am one of the junior doctors in the department. Are you Mrs ....?
Pt: Yes doctor.
Dr: How can I help you?
Pt: Dr I have pain in my back for the past four months. I don’t want to have this pain.
Please do something doctor.
Dr: I am really sorry about that Mrs ... it must be really distressing for you. We will
definitely help you. Can you tell me more about the pain?
Pt: Yes I have had it for the past four months. I am taking Paracetamol for it - two
tablets in the morning and evening. Now I have to attend this wedding in the next few
days and the pain is very debilitating. I want to get rid of it now.
Dr: That must be very difficult for you. Can you grade your pain for me? Like on a scale
of one to ten how will you grade your pain? Pt: …
Dr: Are you comfortable enough to talk to me now? Pt Yes
Dr: Do you have any idea why you have this back pain?
Pt: Patient may say that she had breast cancer 5 years ago and had an operation and
radiotherapy treatment for that and is told that the cancer has spread to her back
bones now.
Dr: I am very sorry to hear that.

If the patient did not know the cause of back pain –

Dr: Mrs. Your back pain can be to cancer which would have spread to the spine. We
will do investigations to confirm that. However, we can still manage the pain while
we wait for the investigations and hopefully you will be able to attend the wedding
pain free.

Dr: Since when are you having this pain?

Pt: since … Doctor the Paracetamol tablets what I am taking are not helping enough
now.
Dr: I am very sorry to hear that. Do you have any other problem other than pain ?
Pt : Like what? Dr: Any problem passing urine or opening bowel ? ( bowel and bladder
incontinence due to spontaneous fracture vertebra). Pt : No
Dr: Did you have any sort of injuries to your back recently?
Pt : No.
Dr: Mrs.. Sometimes people can have fractures in the back bones very easily because
the back bones are very weak if it has cancer cells. Sometimes even minor trauma can
cause fracture. I need to examine your back to check whether you have any
chance of having a fracture.
( examiner may or may not give any findings).
Also we will do some X Ray of your back to see if you have any broken bones? Is that ok
Mrs ..?
Pt : Yes.
Dr: Mrs... please do not need to worry about the pain. We are going to do everything
possible to control this pain and help you to cope with this condition.
We have a whole special team here to help to control your pain.
I will tell you about the various options we have for pain control. Are you following
me? Pt: yes doctor. What are you going to do?
Dr: We are going to give you stronger pain killers than Paracetamol. First option are
the weak Opioids such as codeine. These are tablets which you can swallow. Like any
medications these too have some side effects however we will keep monitoring you all
the time and we will sort out any problems if you develop.
Do you want me to tell you the side effects ?
Pt: Yes doc please tell me.
Dr: This can cause drowsiness.
Pt: Doctor please do not give me any medicine which will make me feel drowsy
because I need to attend my niece’s wedding in the next 2 week time..
Dr: Mrs.. Unfortunately all the good pain killer medicines makes people feel drowsy.
But most of the time drowsiness wears off after few days of starting the treatment.
Also we can add Paracetamol to the codeine and reduce the content of codeine in the
tablet which gives drowsiness. How do you feel about this ? Pt : That sounds good.
Dr: In the initial few days so you should not drive, and work near any heavy machinery.
However this drowsiness will wear off after few days as I told you. You may be able to
drive if you are not feeling drowsy after few days.
Pt: How can I work if I feel drowsy?
Dr: What work do you do? Pt: ...
Dr: As I said drowsiness will wear off after few days you can take a break from your
work if you wish to in the first few days when you may feel drowsy. Pt: Ok doc
Dr: If you get dryness of mouth you can chew ice cubes or Pineapple slices or chew
sugar free gums. If they do not help we can give some artificial saliva. Pt: OK doc.
Dr: Constipation is another problem with this medication but if you eat lot of
vegetables and fruits with high fibre then this may not be a big problem. We can also
give some laxatives. Sometimes we may be able to adjust the dose to overcome this
problem.
Are you comfortable with this medication? Pt: Yes
Dr – As the condition progresses the pain can get worse and if your pain is not
controlled by codeine we will give you strong opioids such as morphine which can also
be taken by mouth. It has the same side-effects as codeine.
You can take this as an injection too what we call as patient controlled analgesia.
There will be a small devise which contains the medication ( morphine ) which you
need to keep it with you. That will be attached to your vein with tube. You can press a
button on the devise and the medication will be delivered to your veins. The advantage
is that it works faster than taking this as a tablet and more effective. This can be used
at home too.

Pt - Will I get addicted ?

Dr – Unfortunately all the opioid type of medicines causes addiction. However if you if
you take the medications at the right dose and the right time then there are less
chances of addiction. Pt – Ok.
Dr – Hopefully your pain will be managed by this. If at all your pain gets worse, in that
case we can change morphine to even stronger pain killer what we call as Fentanyl
which can be worn as patches over your arm. Is that Ok ? Pt – OK doc.
Dr: Do you have any concerns? Pt: No.
Dr: One of the best things you can do to prevent back pain is to exercise regularly and
keep your back muscles strong.

Some people find complementary and holistic medicine like acupuncture, hypnosis,

massage techniques helpful to control the pain.
Other medications like bisphosphonates  can relieve pain.

Other tips for managing back pain:

 Hot or cold packs, or a combination of the two, can soothe a sore back. Heat
can help reduce muscle spasms and cold can help reduce inflammation.
 Eat a healthy diet that includes enough calcium and vitamin D to keep your
spine and bones as strong as they can be.
 Maintain a healthy weight to ease stress and strain on your back.
 Practice good posture and support your back properly when you have to sit for
a long time.
 Avoid lifting heavy items. If you do have to lift something, keep your back
straight (don't bend over to pick up the object). Instead, bend your knees and then
lift the item. This puts the stress on your legs and hips rather than your back.

Keep a pain diary

Please keep a diary of your pain like when do you get pain how long it lasts, how
severe it is what type of pain, what medication you took – this will help us decide what
is the best way to treat our pain.

Dr: You should get urgent medical advice if you feel difficulty walking or difficulty
controlling urine and/or bowel movements (Warning sign of spinal cord compression
common in breast secondaries)

Dr – Do you have any other question?

Pt – No doctor.
Dr –I wish you cope well with this. As I mentioned earlier there is a specialist team
including Psychologists, Macmillan nurses to help you to cope with the pain. We will
make sure you will be comfortable. If you need any help in the future please do contact
us. Thank you very much.

Osteoporosis
69 year old lady had fracture wrist one week ago.

DEXA scan showed Osteoporosis.

Explain the result to her and address her concerns.

Hello Mrs .. I am Dr ..one of the junior doctor in the medical department.

Dr - How are you doing? Pt – I am fine doctor.

Dr: How is your wrist fracture ? Any pain now ?

Pt: Not in pain now.

DR: Can you please tell me how actually you injured your wrist.

Pt: I was coming down the stairs holding the railing. Suddenly I felt pain in my wrist.
Dr - We did special X Ray that is DEXA scan on you. The results of that test is back now. I am
here to talk to you about the result. Is that OK.

Pt - Ok Doctor.

Dr – Test results shows that you have a condition called Osteoporosis or thinning of bones. Do
you know anything about it ? Pt – No Doctor

Dr - Osteoporosis is a condition where the bone loses minerals which makes the bones less dense
and less strong. So the bones becomes weak and fragile so they break very easily even with a
minor injury.

Pt – Why did I get this doctor?

Dr –It is commoner after the age of 60 years. It sin seen more commonly in women compared to
men. This is usually due to lack of calcium and Vit D and lack of exposure to sunlight. There are
lot reasons why people get this condition.

Can I ask you few questions to see why you would have got this condition ? Pt – Yes doc

Dr- Sometimes people can get this condition if they have some types of medical conditions. Do
you have any medical conditions like thyroid problems, Joint problems ( rheumatoid arthritis),
Bowel problems( crohn’s disease), Bronchitis ( COPD), kidney problems (CKD).

Pt – No doctor

Dr – Sometimes this condition can run in Family. Any of your family members have this
condition? Pt – My mother had hip fracture.

Dr – Okay as I mentioned probably this is one of the reasons. Sometimes it can happen in those
people who takes steroid type of medications. Do You take any medications ? Pt – No

Dr: Can I ask what kind of food do you eat regularly ? Pt: I eat healthy balanced diet doctor.

Dr: Do you drink milk ?

Pt – I drink lot of milk. I use milk for cereals also.

Dr – It is very good that you drink lot of milk. Milk contains calcium which strengthens bones.
Calcium and vitamin D are important for bone health. Your body needs adequate supplies of
vitamin D in order to absorb the calcium that you eat or drink in your diet.

We advise you to drink a pint of milk every day.

Other sources of calcium are hard cheese such as Cheddar or yoghurt, Bread, calcium-fortified
soya milk, some vegetables (curly kale, okra, spinach, and watercress) and some fruits (dried
apricots, dried figs, and mixed peel) are also good sources of calcium.

Butter, cream, and soft cheeses do not contain much calcium. You can check how much calcium
you eat with an on-line dietary calcium calculator.
Pt: Can you give me some calcium supplements?

Dr: We can give you calcium and vit D supplements too.

Dr: Food which contain Vit D are cooked salmon or cooked mackerel or tuna fish or sardines
(both canned in oil). However Vitamin D is mainly made by your body after exposure to the sun.
The ultraviolet rays in sunshine trigger your skin to make vitamin D. So it is better to have sun
exposure.

Dr – Do you do exercise.Pt – Yes I go for swimming and jogging.

Dr –That is really good to know that you do exercise. . Doing exercise helps to stimulate bone-
making cells and strengthens your bones. Regular weight-bearing exercise is best. This means
exercise where your feet and legs bear your body's weight, such as brisk walking, aerobics,
dancing, running. For most benefit you should exercise regularly - aiming for at least 30 minutes
of moderate exercise or physical activity at least five times per week.

Unfortunately swimming is not weight-bearing exercise, this is not so helpful in preventing

osteoporosis.

Dr – Do you smoke? Pt - No/Yes doctor ( 10 to 15/day since many years )

Dr – This one of the risk factors why people get this condition. ( If no – it is really good. Please do
not start smoking, If yes - I would strongly advise you to stop smoking. We can help you if you
wish to stop smoking ).

Dr - Do you drink alcohol Pt – No/Yes doctor 1 to 2 glasses of wine every day.

Dr – This is also another risk factor. ( Please cut down drinking. Again we can help if you wish to
cut down.

Dr - Did you have any operations ?

Pt – No/ I had my womb removed when I was 35 year old.

Dr – Removal of the ovaries also can contribute to this problem. Have they removed your eggs?
( Oopherectomy is risk factor) Pt – No

Dr – Did you attain menopause and when? ( early menopause is risk factor) ( can be treated with
HRT if patient had early menopause) Pt – when I was 45 years old.

Dr – You should take care not to fall because you can have fractures very easily because of weak
bones.

Pt – Any medications to treat doctor

Dr: There are medicines called Bisphosphonates like alendronate can help. They can help to
restore some lost bone and help to prevent further bone loss. They may also help to reduce the
chance of a second fracture if you have already had a fragility fracture.

You need to take bisphosphonate tablets whilst you are sitting up and with plenty of water, as they
can cause irritation of your gullet (oesophagus).

Side effects: This can lead to indigestion-type symptoms such as heartburn or difficulty
swallowing. Other side-effects may include diarrhoea or constipation.

You should not eat or take other tablets for half an hour after taking your bisphosphonate tablet.
Depending on which medicine is used, you may need to take it daily, weekly, or sometimes less
frequently.

A rare side-effect from bisphosphonates is a condition called osteonecrosis of the jaw. This
condition can result in severe damage to the jaw bone and jaw pain. You should have regular
dental check-ups whilst taking a bisphosphonate. Tell your dentist that you are taking a
bisphosphonate. [ Note: the risk of osteonecrosis of the jaw is low in people taking
bisphosphonate tablets as a treatment for osteoporosis. It is greater in people who are being treated
with bisphosphonates by injections into the veins (intravenously)].

Pt: Can you give me HRT ?

Dr: Hormone replacement therapy (HRT) contains oestrogen. HRT was widely used few years ago
to prevent osteoporosis. However, the recent findings showed there are health risks of HRT like
breast cancer, heart disease and stroke. So it is not used nowadays. (except in women who have
had an early menopause).

Newly diagnosed Epilepsy in child

Exam question
You are the FY 2 doctor in medical department.
12 year girl Anna had a fit for the second time and was diagnosed with
Epilepsy. She was treated with medications by the Paediatric
Neurologist. She is about to be discharged.
Talk to her mother and address her concerns.

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

Mother: Ok
Dr : Any other concerns ? Mother : No. Thank you.
Information
Relevant recommendations Children, young people and adults with epilepsy and their
families and/or carers should be given, and have access to sources of, information about
(where appropriate):
 epilepsy in general
 diagnosis and treatment options
 medication and side effects seizure type(s),
  triggers and seizure control
 management and self-care
 risk management first aid, safety and injury prevention at home and at school or
work
 psychological issues
 social security benefits and social services
 insurance issues
 education and healthcare at school
 employment and independent living for adults
 importance of disclosing epilepsy at work, if relevant (if further information or
clarification is needed, voluntary organisations should be contacted) road safety
and driving prognosis sudden death in epilepsy (SUDEP) status epilepticus
lifestyle, leisure and social issues (including recreational drugs, alcohol,

ABDOMINAL DISTENSION – Alcoholic cirrhosis

Exam question

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

Dr: Hello my name is Dr … I am one of the junior doctors in the department. How can I
help you today?
Pt: Doctor my tummy bloated. I feel heavy as if I am carrying some weight. I am really
worried about it.
Dr: Can you tell me for how long have you been feeling like that?
Pt: For about 4 to 6 weeks.
Dr: Can you tell me did the swelling develop suddenly or gradually?
Pt: It developed gradually.
Dr: Any pain in your tummy? Pt: No
Dr: Any particular type of food makes it worse? Pt: No
Dr: Any nausea or vomiting? Pt: No. [ if yes ask blood in vomitus.(hematemesis) ]
Dr: Any yellowish discoloration of your skin? Pt: No
Dr: Have you have itchiness ? Pt: No
Dr: Any bowel problems like diarrhoea or constipation (intestinal obstruction)? Pt : No
Dr: Any change in stool colour (malaena)? Pt: No
Dr: Have you lost any weight? Pt: No
Dr: Have you been diagnosed with any medical conditions in the past ? No
Dr: DM/HTN? Pt: No Dr: Have you ever had any liver problem before ? Pt : No
Dr: Any previous surgeries? Blood transfusion? Pt: No
Dr: Do you drink Alcohol? Pt: Yes
Dr: How much and for how long? ….. ( Pt will tell that he drinks a lot)
Dr: do you smoke? Pt: No/Yes
Dr: Do you use recreational drugs (IV Drug abuse)? Pt: No.
Dr: Have you travelled anywhere recently? Pt : No
Dr: Are you on any medication? Pt No
Dr: Any of your family members has any medical conditions ? Pt : No
Dr: Is there anything else you think is important that we need to know ? Pt : No

EXAMINATION:

Do General physical examination and abdominal examination

I need to examine you tummy, eyes and hands Mr Hutchinson,

Can you please undress above your waist. ( exposure to abdominal examination is from
mid chest to mid thigh)

Position patient – on the bed, sit upright for the first part of the examination

Ask if patient currently has any pain before you begin

General inspection :

Hands

No Clubbing, No nail changes or Palmar erythema,

No flapping tremor ( hepatic encephalopathy / uraemia / CO2 retention )

Eyes: No jaundice, No pallor

Chest - No Spider naevi ( chronic liver disease) and no gynaecomastia

( liver cirrhosis / digoxin/ spironolactone),

No Pedal edema

Detailed abdominal inspection

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

Position the patient supine, with their arms by their side and legs uncrossed,
Inspection of abdomen

No operation Scars, No visible Masses or Pulsation

No – bruising surrounding umbilicus [Cullen’s sign– retroperitoneal bleed

(pancreatitis/ruptured AAA)],

No bruising in the flanks [Grey-Turner’s sign  – retroperitoneal

bleed (pancreatitis/ruptured AAA)]

Abdominal appears to be distended –

[ fluid (ascites) / fat (obesity) / faeces (constipation) / flatus / fetus (pregnancy)]

No Caput medusae 

Palpation

Kneel so that you are level with the patient. Observe the patient’s face throughout for
signs of discomfort.

Light palpation: No Tenderness, No Guarding

Deep palpation - No masses felt are identified then assess:

Liver – Palpate over abdomen for lower and percuss the chest from 2nd intercostal
space downwards ( normal liver span is between 5th rib to costal margin) for upper
border of liver. Liver is enlarged

Palpate for Spleen and Kidneys - not enlarged

Percussion

Shifting dullness

Auscultation - Bowel sounds are normal,

Verbally mention - I will examine the groin area for hernia. I will examine the genitalia
and perform a digital rectal examination (PR) 

Provisional Diagnosis:

Dr: Mr Hutchinson - From the information you have given me and from the
examination I suspect that you have Alcohol-related liver disease (ARLD) what we call
as cirrhosis. Do you know anything about it? Pt: No.
Dr: I am really sorry to tell you that excessive intake of alcohol might have damaged
your liver that is what we call cirrhosis. It may have caused fluid to accumulate in your
 tummy causing it to bulge.

We need to do certain blood tests to check your liver functioning to make sure that
you do not have any other causes for distension of your tummy. Also we need to do
ultrasound and CT scan of your tummy. We also might need to take a fluid from your
tummy and test in the lab.

MANAGEMENT:

Dr: I am really sorry to tell you that there's currently no specific medical treatment for
this condition. The main treatment is to stop drinking for the rest of your life. This
reduces the risk of further damage to your liver and gives it the best chance of
recovering.
Pt: But I have been drinking all my life Doctor.

Dr: Mr … if one is dependent on alcohol, stopping drinking can be very difficult. We can
help you to stop drinking alcohol if you wish to do so.
But if you don’t stop - the condition can progress and lead to failure of your liver.
A liver transplant may be required in severe cases if the liver has stopped functioning.

We will admit you now to do the tests.

We will give you some medications what we call diuretics to reduce the fluid in your
tummy. If too much fluid gets collected in your tummy then we need to drain the fluid.

You can get malnourished due to this condition. So it's important to eat a balanced
diet to get all the nutrients you need. Our dietician will advise you on the diet.
Reducing salt in your food can reduce your risk of developing swelling in your legs, feet
and tummy caused by a build-up of fluid.

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

Weight loss - Hyperthyroidism

You are FY2 Doctor in GP clinic.

40 year lady presented to GP clinic 2 weeks ago with weight loss and tremors.
Thyroid function test was done. She has come now for the blood results.

Talk to her, take history and manage her.

Dr: Hello, my name is Dr… one of the junior doctors in the GP clinic. How may I call
you? Pt: You can call me....
Dr: Miss/Mrs… I can see that you visited us a few days ago.
Pt: Yes doctor, I am here for my test results. Could you give me my test report?
Dr: Yes, I do have your test results with me. However before I go on to that, I would ask
you a few questions. This would help us know your condition better so that we can treat
you appropriately. Okay? Pt: Okay.
Dr: Could you tell me what made you visit the hospital last time?
Pt: Doctor I am losing weight.
Dr: I am sorry to hear that. For how long have you been experiencing these symptoms?
Pt: (For a few months?)
Dr: How much weight have you lost? Pt: Two & half stones doctor.
Dr: Since how long ?Pt: …
Dr: Is there anything else that has been bothering you in any way?
Pt: Doctor I am also experiencing shaky movements in my hands.
Dr: It must be very distressing for you. Has there been any change in your appetite?
Pt: Doctor, I am eating more than usual nowadays and despite that I am losing weight.
Dr: I see. What about your bowel habits?
Pt: Doctor I have been going to toilet more frequently than usual. Also I am passing loose
stools for some time now. Is there a problem doctor?
Dr: Well, I need to know a few more details and then I would let you know about the
results. Is that alright? Pt: Okay doctor.
Dr: Do you have a preference for weather? Pt: I don’t like summer doctor.
Dr: Why is that? Pt: Doctor I feel hot when others don’t really feel hot.
Dr: Do you sweat more than usual? Pt: No/Yes
Dr: Have you been experiencing your heart beating faster than usual? Pt: Yes.
Dr: Do you find it difficulty closing eyes or have you been noticing double vision? Pt: No.
Dr: Can you tell me when was your last menstrual period ?
Pt: Doctor, I have been having infrequent menstrual periods for some time now.
Dr: Have you been noticing any fever? ( T.B) Pt: No doctor.
Dr: Any sweating at night time? Pt: No doctor.
Dr: Have you been having cough lately? Pt: No doctor.
Dr: And have you been noticing any lumps or bumps anywhere on your body? ( Cancers)
Pt: No.

Dr: How has been your mood lately? (Depression) Pt: My mood is fine.
Dr: Are you intentionally trying losing weight by any chance ?( Anorexia Nervosa)? No
Dr: Do you think you have lost weight or only others are telling you this? ( Anorexia
Nervosa) Pt: Doctor, I definitely think there’s something wrong with me. I eat a lot and
despite that I am losing weight.
Dr: Do not worry. Tell me if you have been ever diagnosed with any medical conditions in
the past? Pt: No doctor.
Dr: Do you have Diabetes or High blood pressure or any gland problems in the neck? No
Dr: Do you smoke? Pt: No.
Dr: Do you take Alcohol? Pt: No.
Dr: Have you ever done any blood tests like HIV or Hepatitis? Pt: No
Dr: How are your dietary habits? Pt: My diet is fine doctor.
Dr: Are you taking any medications? Pt: No doctor.
Dr: Any allergies? Pt: No doctor.
Dr: Has anybody in your family ever been diagnosed of any gland problems in the neck or
thyroid diseases?
Pt: (Yes doctor, my mother and sister and my aunt has similar problems)
Dr: Have you travelled anywhere recently? Pt: No.
Dr: Have you recently come in contact with anyone who has T.B? Pt: No.

Examination:

Dr: I would like to perform Examination of your Hands, Eyes and Neck for any abnormal
swelling. I would also be checking your Pulse. Pt: Okay.

Examiner might give findings:

Pulse is raised and rest of the examination is insignificant.

Diagnosis & Explanation of Report:

Dr: Well, Miss/Mrs… from information you have given me and from the examination and
test results, I am suspecting that you have a problem of a gland that is situated in the neck.
We call this gland Thyroid Gland and this illness is called Hyperthyroidism. Do you know
what it is? Pt: No doctor.
Dr: Hyperthyroidism means an overactive thyroid gland. When your thyroid gland is
overactive it makes too much hormone. The extra hormone causes many of your body's
functions to speed up. I would explain you the test results and that would make you better
understand the situation here. Pt: Okay.

Test Report:

TSH 0.2 mU/L ( Normal - 0.4 - 4.0 mU/l (milliunits per litre)
T4 - 35 pmol/l ( Normal - 9.0 - 25.0 pmol/l (picomoles per litre)
T3 - 6 pmol/l (Normal - 3.5 - 7.8 pmol/l (picomoles per litre)

Dr: As I have told you, thyroid gland produces some hormones. They are essential for
normal body functioning. T4 that is written here is actually short for Thyroxine. Thyroxine
is a body chemical (hormone) made by your thyroid gland. It is carried around your body
in your bloodstream. It helps to keep your body's functions working at the correct pace.
You see it is way above its normal range. A high level of T4 confirms hyperthyroidism.

Thyroid-stimulating hormone (TSH) is chemical made in another gland in the brain

Pituitary gland. It is released into the bloodstream. It stimulates the thyroid gland to make
thyroxine. If the level of thyroxine in the blood is high then the gland in brain releases less
TSH. Therefore, a low level of TSH means that your thyroid gland is overactive and is
making too much thyroxine which is true in your case. Are you following me?
Pt: Yes doctor.
Dr: Well, we would like to see further what could be the cause that is leading you to this.
One of the causes of this overproduction of hormones by this gland is a disease called
Grave’s Disease. In order to confirm that, we would perform another blood test. This
blood test may detect specific Autoantibodies which are commonly raised. However,
these can also be raised in some people without Graves' disease so this is not a specific test
for Graves' disease. Is that okay? Pt: Okay.
Dr: Also we might be performing a scan called an Isotope scan in which we would ask
you to swallow a radioactive substance in capsule or liquid form, and we later on would
take images of your neck to see the gland. It would help us better visualize the pathology
of the gland.
Pt: Alright. How will you treat me doctor?
Dr: There are a number of treatment modalities available. Antithyroid medicines can

reduce the amount of thyroxine made by the overactive thyroid gland. The most common

medicine used is Carbimazole.

Pt: Do I need to be careful about anything when I am taking this medication?

Dr: It has some side effects. It can, rarely, affect your white blood cells which fight

infection. Whilst taking carbimazole, you should see a doctor urgently for a blood test if

you develop any of the following: A fever. A sore throat. Mouth ulcers. Is that okay?

(An alternative medication called Propylthiouracilis usually given instead of carbimazole

if you are pregnant. Carbimazole is safe to take if you are breast-feeding.

(Ask whether pt is pregnant or chance of becoming pregnant if pt. is young)

Pt: Okay doctor.

Dr: Also for controlling your symptoms, we can give you medicines called Beta Blocker ,
those will relieve your symptoms of thumping heart, shaky movements of hands,
sweating. etc. Is that okay? Pt: Okay.

Dr: Other treatment modalities include Radio-iodine. This will shrink the size of thyroid
gland.

The last option is Surgery, if other treatments don’t work. This involves removing a part

of your thyroid gland. It is usually a safe operation. However, as with all operations, there

is a very small risk of complications. Are you following me? Pt: Yes doctor.

Dr: Also we will be referring you to endocrinologist who is a specialist of diseases such as
thyroid gland. He will advise you further about it. Is that alright?
Pt: Yes Doctor
Dr: Do you have any other concerns?
Pt: No doctor… Thank you.

Viral Encephalitis

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

Dr: Hello, I am Dr... Are you the father of ...

Father: Yes

Dr: How can I call you please ?

Father: You can call me ...

Dr: How can I help you Mr..

Father: Doctor, me and my son were sitting and watching television just few hours ago. Suddenly
he started talking rubbish, was not making any sense and had a fit ? I am very worried doctor ?

Dr: I am very sorry to hear that. Can you tell me anything more about it?

Father: He was saying he had headache and fever since yesterday. Otherwise he was OK until this
suddenly happened?

Dr: Did he have any other symptoms other than headache and fever ?

Father: I don’t know.

Dr : Was he complaining of headache for a long time or just for one day ? Father – Just since
yesterday?
Dr: Did he have any weakness or arms or legs ( SOL) ( TIA, stroke) ? Father : No

Dr: Did he have vomiting ? Father : No

Dr: Did he have earache ? Father: No

Dr: Discharge from the ear ? Father: No

Dr: Did he have sore throat recently ? Father: Yes/ No

Dr: Did he cough ?Father : No Dr : Chest pain ? Father: No

Dr: Was he shying away from the lights ?Father : I do not know?

Dr: Did you notice an rashes on his body ? Father: No

Dr: Did he complain of burning sensation while passing urine recently ? Father: No

Dr: Did he have high temperature in the evening do you know ( TB) ? Father : No

Dr: Did he have any head injury recently ? Father: No

Dr: Did he had any similar problems in the past ? Father : No

Dr: Has been diagnosed with any medical conditions in the past ? Father : No

Dr: Did he ever had TB before ? Father : No

Dr : Did have fits like this before ? Father : No

Dr: Did he have any mental health illness ? Father : No

Dr: Does he smoke ? Father : No

Dr: Does he use any recreational drugs ? Father: No

Dr: Did he have any medical conditions like HIV infections ? Father No

Dr: Has he lost weight recently ( TB) ? Father : No

Dr: Is he on any medications ? Father : No

Dr: Is he allergic to any medications ? Father : No

Dr: Anyone in the family had similar problems or any medical conditions running in the family do
you know? Father : No

Dr: Did he travel outside UK recently ? Father: No

Dr: Did he come into contact with anyone who had similar problem recently? Father : No

Dr: Did he come into contact with anyone who has or had TB recently? Father : No
Dr: Does he work or is he a student ?Father : ....

Dr: Is there anything else you think is important that we may need to know?

Father : I can’t think of anything else.

Examination and investigations

Dr: Mr I need to examine your son to check his pulse, BP, temperature, and I also need to check
for any brain infection signs, check his conscious level, and whether he has any rashes on his body.
Also I need to check whether he has any swellings in the neck. Then we may need to do
investigations like blood tests, CT and MRI scan of his brain and also we need to do a test called
spinal tap where we take little bit of fluid from his lower spine and test that.

Examiner may give a paper with lot of information.

In the paper it may be written

Patient drowsy, NO neck stiffness, Brudzunski sign and Kernig’s sign negative, No rashes.

He has cervical lympahdenopathy.

CSF result- Pressure normal, sugar normal, protein high, lymphocytes 80%, Monocytes 10%.

We need do gram stain and ZN stain – examiner may that is normal.

We will send it culture.

Talk to father about diagnosis and management

I think your son has a condition what we call as Encephalitis. Do you know anything about this ?

Father : No

Dr: In this condition there is infection of the brain by some kind of bugs. There are lot of different
type of bugs can cause serious brain infection.

Different type of bugs like bacteria, virus and fungus type can cause this infection in the brain.

However, the test results show it is more likely due to some kind of virus type of bugs. Brain
infection due to virus type of bugs can be dangerous some time but most of the time they resolve
with treatment. Are you following me ?
Father : what kind of virus doctor?

Dr: we will do some blood tests to find out what exactly the type of bugs.

Father yes. What will happen to him now?

Dr: We are going to admit him and treat him with Antibiotics through his veins this to be on the
safer side because if at all this is due to bacterial infection which can be very dangerous if we do
not treat immediately. Also we may give some antiviral medication ( Aciclovir) through his veins.
Hopefully he recovers soon. We also be giving him oxygen and fluids through his veins. I will be
informing my seniors also immediately about him. Any other concerns ?Father : No. Thank you.

Cerebral palsy patient. Father thinks unfairly

treated.
20 year old man with cerebral palsy was brought into the A&E 5 days ago because he
fell from a wheel chair. He had foot injury. He was treated with just pain killers
without doing any X Ray to rule out fracture. X Ray was not needed at that time
because there was no bony tenderness. He was treated with Paracetamol.

Father brought him again today requesting for X Ray.

Talk to the father and address his concerns.

Points to cover

1. Ask what happened

2. History during first presentation and what was done and told to him
3. How is the progress
4. Why is he worried
5. Tell the reason why X Ray was not done last time
6. Reassure that you will do X Ray this time if needed
7. With his information – X Ray not needed now.
8. Reassure that it is just soft tissue injury and it takes time to heal.
9. Explain that the discrimination is unlikely. We treat everyone equally
10. If he still feels that the discrimination has been done – apologize and say that he can
complain.

Dr: Hello I am one of the junior doctors in the department. How may I call you?

Father: You can call me Mr Fredrick.

Dr: How can I help you Mr Fredrick?

Father: My son was brought into the hospital few days ago. I am very disappointed with
the treatment given to him.

Dr: I am really sorry that you feel that way. Can you please tell me what happened to your
son?

Father: He has Cerebral palsy. He fell down when I was shifting him from the wheel chair
to his bed 5 days ago. He injured his foot. I brought him in here 5 days ago. Doctors did
not even do any X ray and said he has just muscle pain and gave just paracetamol. Instead
of providing special care my son was treated very unfairly. I am very upset about it. This is
not how it should be.

Dr: Why do you think that he was treated unfairly Mr Fredrick?

Father: He injured his foot and none of the doctors did X ray of his foot. They just gave
him few medicines and sent us away. That shouldn’t be the way in hospital.

Dr: Certainly you are right Mr Fredrick no patient should be ignored or neglected in any
setting. We try our level best to give the good l care to all our patients. Can you please tell
me what were the symptoms he was experiencing when you brought him to the hospital
last time ?

Pt: He was having pain in the ankle and he was crying. Initially he could put weight on the
foot. But later on he couldn’t even put weight on the foot. He had swelling and bruise also
on the ankle. I have been so worried. They should have done an X ray to check if there
was bone damage.

Dr: Mr Fredrick I can understand why you are worried. We normally do the X Ray if there
is suspicion of fracture when we examine the patients. But if there is no suspicion of
fracture then we do not do X Ray. Sometimes it’s apparent from the history and assessment
that there is no bone damage. It might have been the case. Was he able to move his toes
after the injury? Father....

Dr:. How is the swelling around the ankle now ?

Father: Swelling has subsided now but there is still a bruise.

Dr: That is a good sign that the swelling has decreased. It means that the injury is healing.
The bruise will take slightly longer to go away.

Dr: Has the pain been the same since injury or has it changed in intensity? Father:...

Dr: what did the doctor advise him in the last visit?
Father: Doctors said there is no fracture. May be he has a fracture. Isn't it still better to do
an X Ray. Don’t people have X Ray done for smallest of reasons my son actually had a
fall. I feel as if he was treated as a second grade citizen and deemed not worthy of equal
care as others. He can't put weight on his feet though in the beginning he could. It worries
me I want to have an X Ray done for him now.

Dr: I can understand how you feel Mr Fredrick. It is very difficult to see your child in pain.
I want to assure you that all our patients are equally dear to us. We try our best to provide
all of them with best care possible. Also we try to keep our patients safe and try not to give
them unnecessary treatments. If at all the X ray was needed we would have done it.

Father: What if he is having a fracture?

Dr: I can see that you are a very concerned father. I will definitely examine him again and
see whether he needs X Ray now and if he needs it we will definitely do that now.

( Talk about examination – examiner may say there is no bony tenderness and the
swellinghas subsided just a bruise seen – tell the father I examined him now and there is no
pain over the bone and has gone down ). With the information what you are giving me that
his swelling has reduced since the injury and after examining him , I still do not think he
has a fracture and I do not think we need to do X Ray.

Let me explain in detail about when we do the X Ray and when we avoid doing the X ray
- For ankle or foot injury we do preliminary assessment of the patient and see if he was
able to put weight initially. If one can put weight on his foot, it is very unlikely that the
bone is broken. On examining the patient if there is pain when we press on the bony points
which suggests there could be fracture then we do the X Ray. But if there is no pain when
we press on the bony points which suggest the fracture is very unlikely then we avoid
doing the X Ray because doing unnecessary X ray can cause radiation which itself can
cause cancers. So we try to avoid doing unnecessary X Rays for patient’s own benefit.

I see that you are worried about him because of the bruise. It may take few more days for
the bruise to go down. Are you following me Mr Fredrick?

Father: Yes.

Dr: Mr Fredrick I want to reassure you again. There is a standard procedure we normally
follow whether is patient is a normal person or differently abled person. It is very unlikely
that he was treated unfairly because of his condition. However if you still want to escalate
the matter you can make a formal complaint. We have a separate department for this
purpose called Patient Advisory Liaison Service (PALS). They will help you make the
complaint. Any complaint will be taken seriously and respective authorities will assess the
matter and I assure that if there is any sort of discrimination there will be action taken on
the concerned person.

Father: Thank You Doctor I will see about that. I feel relieved after talking to you.

Dr: I am glad I could help Mr Fredrick. I hope your son recovers soon. If you have any
problems please do not hesitate to come to us. We are here for you.

Father: Thank You Doctor.

Patient with Uncontrolled Diabetes

You are FY2 in a medical department.

Mr. George Tindal, 55 year old man has been a diagnosed case of type-1 Diabetes
Mellitus since 14 years of age. He came to the hospital 4 months ago. He was given
Insulin for one month but he did not come back for getting more Insulin. He has come
now to the hospital.

Blood and Urine tests were sent to the laboratory. His urine test reveals Proteinuria
and Glycosuria. His blood has been collected for HbA1c, ESR, Cholesterol tests. In
addition, the patient has been diagnosed with Diabetic Nephropathy, Neuropathy and
Retinopathy (Fundoscopy shows dot and blot hemorrhages).

Talk to the patient, explain him about the sugar control and discuss with him the
further management.

Dr: Hello, I am Dr…. I am one of the junior doctors in the medical department. Are you
Mr. Tindal? Patient: Yes, doctor.
Dr: How are you doing Mr. Tindal? Patient: I am doing fine doctor.

Dr: Well, Mr. Tindal I am here to talk to you about your condition. From the notes, I have
gathered that you have Diabetes. Is that right? Patient: Yes.
Dr: Well, Mr. Tindal, could you please tell me how long do you have this condition?
Patient: Since I was 14 years old.
Dr: I see, and how much do you know about your condition?
Patient: I only know that I have diabetes doctor.
Dr: I see. Well, Mr. Tindal, could you please tell me what medicines are you taking to treat
your condition?
Patient: I was given insulin 4 months ago. But I stopped taking it.
Dr: Could you please tell me why did you stop taking insulin?
Patient: I don’t think it was necessary.
Dr: I see. Well, Mr. Tindal, I would like to ask you some questions in order to see how
much this disease has progressed. Is that alright? Patient: Okay.

Dr: Could you please tell me if you have any symptoms now? Patient: Like what doctor?
Dr: Have you been noticing any change in your vision?
Patient: Yes doctor, my vision has worsened over last few months.
Dr: Have you ever had any heart problem, chest pain or shortness of breath? Patient: No

Dr: I see. Do you have any numbness, tingling, or pain in your hands, legs, or feet ?
Pt: Yes/No

Dr: I am sorry to hear that. Have you had any kidney problems in the past? Patient: No.

Dr: Have you been diagnosed with high blood pressure, high cholesterol? Patient: No doctor.

Dr: Do you smoke? Patient: No/Yes

Dr: Do you take Alcohol? How often and how much do you drink? Patient: No/Yes

Dr: What is your typical diet? What are your eating habits and patterns? Patient: ..

Dr: Do you exercise regularly? Pt:…

Dr: Are you taking any other medicines at all? Patient: No doctor.

Management:

Dr: Well, Mr. Tindal, from the information I have gathered and from the investigations
done on your blood and urine, unfortunately the Diabetes has advanced quite a lot in your
system and has developed certain Complications due to the poor control of sugar. Are you
following?

Patient: But why it happened doctor?

Dr: As you may know Insulin usually controls the blood sugar level. Diabetes occurs when
the level of sugar (glucose) in blood becomes higher than normal. This happens either
when your body does not make enough insulin, or if the insulin that you do make does not
work properly on the body's cells.

Because you stopped taking Insulin since the last few months the blood glucose levels have
begun to increase and caused a lot of problems.

Now the diabetes has affected your kidneys, eyes and the nerves in your legs. That is why
you may be having poor vision and tingling numbness in your legs. Are you following
me? Pt: Yes.

Dr: If the blood sugar level is not controlled it can cause other problems such as heart
attacks, stroke. Do you understand Mr. Tindal?

Pt: Yes. Is that serious doctor?

Dr: Unfortunately, it is serious if it the sugar is not controlled. Therefore, it is very

important to keep the blood sugar under control to prevent this complications progressing
further. Pt: What should I do doctor?

Dr: You will need Insulin injections for the rest of your life. You should take it regularly.
You will need to monitor your blood sugar levels by using a monitor at home and keep the
sugar level under control. Pt: Alright.

Dr: Also, you should eat a healthy diet. Basically, you should aim to eat a diet low in fat,
salt and sugar and high in fibre and with plenty of fruit and vegetables. We will refer you
to a dietician for detailed advice.

Also, you should keep your blood pressure under control ( if he has high blood pressure).

We have taken your blood to check cholesterol levels. If the cholesterol level is high we
will give some medications to reduce the cholesterol levels but you need to cut down eating
fatty food. Is that Ok ? Pt : Okay doctor.

Dr: Smoking can worsen the condition. I sincerely advise you to stop smoking. We can
help you for this if you need. Would you consider doing that? Pt: Yes doctor.

Dr: Exercising regularly also helps in controlling the sugar. Pt: Ok

Pt: What happens to the complications what I already have doctor ?

Dr: If you take Insulin regularly and keep the sugar under control it will delay the
complications from becoming worse. Do you understand Mr. Tindal? Pt: Yes, doctor.

Dr: Mr. Tindal, our hospitals have special Diabetes Clinics. Doctors, nurses, dieticians,
specialists in foot care (podiatrists), specialists in eye health (optometrists), and other
healthcare workers all play a role in giving advice and checking on progress.

Regular checks may include Eye checks to detect problems which can often be prevented
from becoming worse and can usually be treated. Now because you have developed
changes in your eye already, we can refer you to Eye Specialist in order to treat your eyes.

Also, we can schedule Foot checks by referring you to a podiatrist- to help to prevent
foot ulcers because the nerves in your feet seem to be affected. 

Urine tests, blood tests will be performed after a few weeks as well to see how well your
kidneys are functioning and to see the blood sugar control over months.

It is important to have regular checks, as some of these complications can be treated. Is that
okay? Pt: Yes doctor, thank you very much.

Dr: Also, you should be immunized against infection from pneumococcal germs. These
infections can be particularly unpleasant if you have diabetes. Pt: Alright.

Dr: Is there anything else that you need help with? Pt: No doctor, you are very kind.

Dr: Thank you.

Only if the patient asks

Pt: Are there any no alternatives to injecting insulin?

Dr: There has been plenty of research done in recent years to develop ways to administer
insulin other than by injection. These have included insulin nasal and oral sprays, patches,
tablets and inhalers. After many years of work, some of the methods being researched are
showing a degree of success. However, it will be some time before any of these devices
will be available to people with diabetes in the UK. Is that alright?

Inguinal Hernia Pre-operative Assessment & Address

concerns
You are FY2 Doctor in Surgical Department.
45 years old man has been admitted to the ward for the Hernia Operation.
On pre-operative assessment, nurse has found the blood pressure to be 155/88.
He has been assessed already. Your Surgery Consultant is due to come to take
consent for the surgery.
Talk to the patient, describe the operation, and address his concerns.

Dr: Hello. I am Dr...Junior doctor in the surgery department. How may I call you?
Pt: You can call me...
Dr: How are you doing Mr...? Pt: I am fine doctor.
Dr: That is good. Mr. Do you know why you are here today ?
Pt: I have hernia doctor. Your Consultant told me I need to have an operation. They wanted
to assess me before the operation.
Dr: That is right. Do you know about your condition and why we are planning to do the
operation for that ?
Pt: No, doctor, I don't know much really but I know I have hernia.
Dr: OK. Do you want me to explain everything to you?
Pt: Yes doctor, I will like that.
Dr: A hernia occurs when an internal part of the body like intestines in the tummy pushes
through a weakness or gap in the tummy wall and comes out like a swelling. Are you
following me? Pt: Yes.
Dr: This usually happen if pressure inside the tummy is increased for example due to
coughing or straining while opening bowel. Most of the time this swelling goes in and out
because the contents of the hernia goes inside the tummy when you lie down and comes
out again while standing our coughing.
Let me draw it for you on this page and maybe you can understand it better.

(Examiner might give a piece of paper and a pen for you to draw for making the
patient figure it out better)
Dr: Are you following me? Pt: Yes, doctor.

Dr: If we do not treat this condition sometimes this hernia gets obstructed means the
contents do not go inside the tummy and it can become a serious problem. So it is very
important to treat the condition now. Do you follow me? Pt -Yes.

Dr: Do you have any idea how we are going to treat you ?
Pt: Yes doctor, I was told that surgeon would operate on me.
Dr: Yes, that is right Mr... Unfortunately we cannot treat this condition with any
medication. Only option we have is to do the operation. Do you have any concerns at this
stage? Pt – No

Dr: I need to ask you few questions about your health because for this operation, you need
to be fit in regards to your health. Also after the operation, we might have to request you to
make some lifestyle changes to prevent similar problems from happening again in future. Is
that fine? Pt: Yes doctor.
Dr: How is your general health at the moment? Pt: It is OK doc.
Dr Did you undergo any surgeries previously? Pt : No
Dr: Have you been diagnosed with any medical conditions at all? Pt: No doctor.
Dr: I see. Well, Mr... I would like to tell you that nurse examined your blood pressure and
she found that it was a bit on the higher side. Have you ever been diagnosed of high blood
pressure before ? Pt: No doctor.

Dr: I see. Your blood pressure is mildly elevated so you do not need to worry. However,
we might have to take Opinion from Cardiology Consultant that is the specialized doctor
for such problems. We will have to see why you are having the high blood pressure and
control the blood pressure before we can do the surgery. Is that alright?
Pt: Yes doctor. Thank you.

Dr: Do you have any symptoms like Cough? Constipation ? Straining on Urination?
Pt: No
Dr: Do you smoke? Pt: Yes doctor.
Dr: Could you please tell me how much do you smoke and for how long?
Pt: I smoke almost 20 cigarettes or more daily for 20 years.
Dr: Could you tell me what do you do for living? Pt: I work in a warehouse/construction
company
Dr: Does your work involve lifting or pushing heavy weights or standing for long
periods of time? Pt: Yes.

Dr: Okay, Mr... I would now like to explain you how we are going to do the operation. Let
me tell you about your options. Is that alright? Pt: Okay.

Dr: Surgery is the main treatment for hernias. It’s a very common operation and a highly
successful procedure when done by a well-trained surgeon so you do not need to worry
about anything because we have the best surgical team.

We have two types of surgeries either an Open Surgery or a Key-Hole Surgery.

Did my Consultant tell you what type of surgery we are going to do on you ?
Pt: He said open type.
Dr: Do you want to know how we do the open surgery ? Pt – Yes.

Dr: Open repair involves making an incision or cut on the skin into the groin. This
incision is usually about 6-8cm long. After this, surgeon will return the contents inside the
hernia like intestines back to the tummy and then he will repair the tummy wall defect. A
mesh is placed in the wall, at the weak spot where the hernia came through, to strengthen
it. When the repair is complete, your skin will be sealed with stitches. These usually
dissolve on their own over the course of a few days after the operation.
This might leave a bigger scar.
Pt: What is this mesh made up of?
Dr: It is made up of a material called polypropylene a type of synthetic plastic.

Dr: I see. Do you have any concerns related to the surgery?

Pt: Yes, doctor. My Father had hernia too. Doctors gave him a truss to wear. Will you
give me that as well?
Dr: I see. Mr…hernia truss is a supportive undergarment for men designed to keep the
hernia in place and relieve discomfort. This is only a temporary procedure but it does not
treat the hernia. It is used be used temporarily until we do the surgery or for those people
who are not fit to undergo surgery. Are you following me?

Talk about truss only if the patient asks about it.

Pt: Will it hurt during or after the operation?

Dr: Unfortunately all surgical procedures are associated with pain more or less. But you do
not need to worry we will manage your pain very well.

During the operation, we will be giving you local Anaesthesia where the anaesthetic
medication is injected to the swelling area, or spinal anaesthesia where the anaesthetic
medication is injected to the spine and the lower part of the body is made numb. You will
be awake during the procedure, but the area being operated on will be numb so you won't
experience any pain. In some cases, a general anaesthetic is used. This means you'll be
asleep during the procedure and won't feel any pain.
Are you following me ? Pt: Yes Dr: Any concerns so far ? Pt – No

Dr: After the operation as with any surgical procedure, there will be some pain during
recovery. Your pain will be most severe the first few days. Initially we will give you strong
pain killer medicine like morphine then we will give you pain killer tablets called Co-
codamol when you are ready to go home.

Pt: How long will the operation last doctor?

Dr: The operation usually takes about 30-45 minutes to complete if there is no problems
during the operation.
Pt: When will I be able to walk after the operation?
Dr: After the surgery, you'll be encouraged to move about as soon as possible immediately
after the operation same day.

Pt: When can I return to normal activities?

Dr: Most people are able to do light activities, such as shopping, after 1-2 weeks, but you
should avoid heavy lifting and strenuous exercises for about 4-6 weeks.

Pt: When will I be able to have sex?

Dr: You may be able to have sex after about 2 weeks.

Pt: When can I drive doctor?

Dr: It's usually advisable to avoid driving until you're able to perform an emergency stop
without feeling any pain or discomfort (you can practice this without starting your car). It
will usually be about 4 weeks after open surgery.

Pt: When will I be able to go back home?

Dr: You'll be able to go back home on the same day. Some people stay in the hospital
overnight if they have other medical problems or if they live alone. Do you have any one to
look after you after the operation ? Pt: Yes/No?

Dr: You should have someone to look after you at home at least for 24 hours. They should
stay at your home to look after you. Avoid drinking alcohol, operating machinery or
signing legal documents for at least 48 hours after any operation if it involves general
anaesthesia.

Pt: Ok doctor. Will there be any complications of the operation doctor?

Dr: There can be infection, bleeding or pain at the incision site. But we will be giving you
antibiotics, and painkillers so the chances of these problems are very less.

Pt: Can it happen again doctor?

Dr: Yes Mr.... Unfortunately, there is a very small risk of recurrence after surgery.
Although the risk is small, yet I would like you to make certain changes in your lifestyle
that will prevent this from happening again.

You have been smoking for many years now. Smoking can make the body tissues weak
and also leads you to coughing and that can make the hernia come back. I'd request you to
consider quitting the cigarette smoking and if you need any assistance for that then a lot of
help is available. Would you like that?
Pt: Yes doctor.
Dr: In addition if you have to strain while opening bowel then also hernia can come back. I
advise you to eat high fibre diet and drink plenty of fluids to avoid having constipation.
Pt: Yes doctor.
Dr: Also, you should Avoid Lifting Heavy Weights following the operation. As you have
told me, your work involves lifting/pushing heavy weights, it is very important that you do
not do it because this could result in reappearance of this or similar swelling on the
opposite side or elsewhere. Is there a way you could change your work type?
Pt: I don't think so. It is my job doctor. I have done it all my life.
Dr: I can understand. I advise you to talk to Job Centre and see if you can get any other
suitable job where you won't have to do a physically straining work. Okay? Pt: Okay.

Dr: Also you must Maintain a healthy weight.

Pt: Do I need to come back for a follow up after the operation?

Dr: You should make an appointment for your follow-up visit in two weeks.

Warning signs

Pt: Is there anything I need to be careful about after I go back home?

Dr: If you have fever, bleeding, increased swelling, pain in your abdomen, pain not
relieved by painkillers, persistent nausea or vomiting, coughing or shortness of breath,
increasing redness surrounding your incisions or difficulty passing urine you need to come
back to see us. Is that alright? Pt: Yes, doctor.
Dr: Do you have any concerns?
Pt: No, thank you doctor. You have been very kind.

Drug Addict wants a Self-Discharge

You are FY2 Doctor in acute medical care unit.
A 27 year old lady, Miss.… has been admitted to the acute medical care unit. Patient
is a known drug addict and a diagnosed case of Infective Endocarditis. Patient has
been started on intravenous antibiotics. To complete treatment, patient needs IV
antibiotics for several weeks as an inpatient.
Nurse has come to you and informed you that patient wants self-discharge.
Talk to the patient, inquire why does she want self-discharge and address her
concerns.

Dr: Hello, I am Dr…. I am one of the junior doctors in the medical department. Are you
Miss…? Patient: Yes doctor.
Dr: How are you doing Miss…?
Patient: I do not like this hospital doctor. I want to go home.
Dr: Miss… could you please tell me why you do not want to stay in the hospital?
Patient: The nurses are very rude to me.
Dr: I am really sorry if someone misbehaved with you. I will look into this matter. Please
do not be upset. Could you please tell me what really happened?
Patient: No doctor, I do not want to stay in this hospital any more. I want to get discharged.
Please discharge me.
Dr: Well, Miss… could you please explain to me why you do not want to stay in the
hospital. If you tell me what is bothering you, I will be able to help you.
Patient: No doctor, nurses have been very impolite with me. They are calling me drug
abuser. I want to go home.

Dr: Well, Miss… I can clearly understand that you are very much offended by what
happened and I apologize to you for such behavior but it is very important for you to stay
admitted in the hospital as we need to give you medicines through your veins. However, I
want to reassure you that if you can tell me what happened, all the information you give me
will be kept confidential within our team. Could you please open up to me about the
matter?
Patient: Doctor, you see, it is also because nurses object that I cannot smoke cigarettes in
the hospital.

Dr: I see. I can understand that you must be very troubled by all this. I apologize to you
again. However, I would like to tell you that it is important for you to stay admitted.

Could you please tell me how much do you know about your condition?
Patient: I have been told that I have infection in heart.
Dr: Yes, you have been told right Miss… You have a condition called Infective
Endocarditis. This is an infection that affects the tissue that lines the inside of the heart
chambers. This results in significant damage to heart valves. Also, it can cause other
serious complications if it is not treated quickly with antibiotics. Are you following me?

Patient: Yes, doctor. But I do not want to stay in the hospital. Why should I stay in the
hospital?
Dr: You see, Miss… it is a very serious infection and can be even life-threatening if not
treated in time. The earlier the condition is treated, the better the likely outcome.

Patient: But you can give me antibiotic tablets doctor I can take them at home.
Dr: Miss…Unfortunately this condition cannot be treated with just antibiotic tablets.
Tablets are not as effective as injections into veins. That is why we want you to stay in the
hospital so that we can give this antibiotics through your veins.
Pt: I can’t stay here. Nurses don’t let me smoke and it is not bearable for me to continue
without it. Can’t I just pop out and smoke ?
Dr: I can understand why you are so upset. It must really be very distressing for you.
Well you can pop out and smoke but it is not advisable at all.

If you do not mind, I will be asking you some questions about your general health, if that
alright with you. Patient: Okay.
Dr: Could you please tell me how much do you smoke? Patient: 20 cigarettes per day.
Dr: I see, and for how many years? Patient: ?

Dr: Do you take any recreational drugs? Patient: I take heroin. Dr: How much?
Patient:
Dr: For how long have you been taking it? Patient: Years/months
Dr: How do you take it? Patient: I inject it through my veins.
Dr: And do you exchange needles? Patient: No doctor.
Dr: That’s good. And have you ever tried to cut it down or stop it altogether?
Patient: No doctor, I cannot.
Dr: I see. Could you please tell me how has been your mood lately?
Patient: I feel very alone doctor/feel very low
Dr: And why is that? Patient: I do not have any friends.
Dr: I am really sorry about that. Could you please tell me what work do you do?
Patient: I am jobless.
Dr: And where do you live? Do you live with your family?
Patient: I am homeless doctor. I have no family.
Dr: It must be really upsetting for you Miss… I can recognize that you have a very
stressful life. However, I’d like to tell you that a lot of help is available for you to cope
with this state of affairs. Do you know why this condition would have happened to you ?

Patient: Why doctor?

Dr: Miss…. unfortunately, people who inject street drugs may also inject bugs/germs into
their bloodstream if they use dirty or contaminated needles. These bugs may then settle on
a heart tissue. The infection can damage heart valves and may spread to other areas of heart
tissue. Unfortunately, this might have happened and lead you to develop this infection in
the heart.

Pt: But doctor I just want to go home.

Dr: Miss … If you do not get treated now serious complications usually develop -for
example, it can lead to problems such as heart failure. Sometimes the infection can spread
to other organs and can cause damage to the other organs too. It can life threatening too if
you do not stay in the hospital and get treated. That is why it is very important that you stay
in the hospital and get treated.

Patient: But I can’t smoke can’t do anything here.

Dr: I would sincerely advice you to consider quitting smoking. Smoking is not only
hazardous to your lungs but to your heart also. It can worsen your condition in the heart. I
know that it must be really unbearable for you to not smoke. We can give you help to cut it
down and quit it. However, for now if you really want it we can give nicotine patches. Is
that Ok? Pt: May be yes.

Dr: Also, I would like to tell you that we can provide you help to cut down on drugs. We
have a lot of medicines available to help you cope this.
Pt: You will only give Methadone!
Dr: Miss… We have many different options to help you cut down on using drugs. I will
tell you what your options are. In order to reduce the craving of the drug, we can give you
medicines. Also, in order to decrease withdrawal symptoms we can give you another
medicine called Lofexidine. Also, we might later on refer you to some support groups to
help you quit drugs. Would you consider it? What do you think about it?
Patient: Well I will think about it.
Dr: So would you consider staying in the hospital for getting this infection cleared off from
you?
Patient: Yes, doctor I would.
Dr: Is there anything else you want to know?
Patient: No doctor, you are very kind. Dr: Thank you very much Miss…

If the patient still not convinced.

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

AF Patient – Doesn’t want Warfarin.

How to handle if the patient does not want any treatment

1: Ask why they do not want the treatment

2: Explain the importance of treatment

3: Explain what are the risks if they do not have the treatment

4: Sort out the reason why they do not want the treatment.

5: Lastly - find out whether they agree for the treatment

6: If agreed give warning signs

7: If they still not agree then offer that the seniors will talk to them and may be
they will be able to convince them.

8: If still did not agree mention that they have a right to refuse the treatment.

If they do not want to get admitted – tell them that they can sign a “Discharge
against medical advice form” and they can leave the hospital.

Exam question;
You are FY2 doctor in medical unit.

A middle aged man, Mr.… has been diagnosed with Atrial Fibrillation and
Stroke. Consultant has prescribed and patient has been started on
warfarin. But patient has refused the treatment.

Talk to the patient and address patient’s concerns.

Dr: Hello, I am Dr…. I am one of the junior doctor in the medical department.
Are you Mr…? Patient: Yes, doctor.

Dr: How are you doing Mr…? Patient: I am doing well doctor.

Dr: My Consultant has prescribed you some medications which you need to
take. I am here to explain to you about this medicine. If you do not understand
anything at any time, please do let me know. Is that OK? Pt: Ok.

Dr: Well, Mr.… From your notes, I have gathered that you have been diagnosed
with a condition called Atrial Fibrillation and you have suffered a stroke as well. I
am really sorry about that. Has anybody explained to you about your condition?

Patient: I am aware that I have clots in my heart and these can go to my brain.
But I do not want warfarin. That is a rat poison.

Dr: I am sorry that you are not happy with the warfarin medicine. Yes you are
right that the rat poison also has the same composition. But you need this
medicine. Is there any reason you don’t like this medicine ?

Patient: I just do not want this medicine doctor. My dad used this medicine and
he fell down and head injury and then he had too much bleeding in his brain and
he died because of that. I do not want the same thing to happen to me.

Dr: I am really sorry to hear about your father but you have to understand that
this medicine is vital for your health and safety.

Patient: I do not see the point of it doctor. My father was told the same thing. He
was on warfarin and look what it did to him.

Dr: I can understand why you are so reluctant to take this medicine. And I am
really sorry that it happened to him but do you have any idea why he was on
warfarin? Patient: …..

Dr: I see. Well, Mr… there are many other factors which might have lead to
massive bleeding in his head. Sometimes it can happen if the blood is too thin.
However, in your case, it is imperative that you take this medicine. Please let me
talk to you in detail so that we can address this together. Is that Okay ?
Patient: Okay doctor.

Dr: Mr….., could you please tell me how much do you know about your
condition?
Patient: I just know that I had clots in my heart and these travelled to my brain.
Dr: Yes, you have been told right Mr…. You have a condition called Atrial
Fibrillation. Do you know what it is? Patient: No.

Dr: It’s alright. I will explain it to you. This is actually a condition which causes a
fast and irregular heartbeat.Are you following me?

Patient: Yes doctor. Can’t you give me any medicine to control my heart rate?

Dr: Yes, Mr.… Although medicines can be used to control this abnormality in
heart rate, yet one of the most important complications of this condition is that it
can cause blood clots to form in the heart. This blood clot can then travel in the
blood vessels until it becomes stuck in a smaller blood vessel in the brain. Part
of the blood supply to the brain may then be cut off, which causes an injury to
brain. This is what we call as stroke. This is the reason why you suffered from
the stroke. Ae you following me Mr…? Patient: Yes.

Dr: Warfarin tablet is a blood thinning tablets which means that it stops blood
from clotting.

It is essential for you to take this medicine because if you don’t then blood clots
might result in obstruction to the blood supply to your brain and unfortunately, a
stroke may happen again. You know sometimes the stroke can even be life
threatening. And I am sure, you wouldn’t want that to happen to you isn’t it ?

Patient: Yes doctor. But if I take it then if I fall then I can bleeding in the brain
and then I will die like my father. So, why should I take this medicine?

Dr: I can certainly understand your concern. Unfortunately this is one of the
known problem which can happen to those people who take warfarin. The
chances of bleeding becomes high if the blood is too thin. That is why we keep
checking the patient’s blood regularly to make sure the blood is not too thin or
not too thick. This blood test is what we call INR.

Also the patients who are taking warfarin needs to be careful so that they don’t
fall or injure themselves when using any sharp instruments.
However despite keeping the blood not too thin, bleeding can still happen if
someone falls and has head injury.

Pt: So, then it can happen to me !

Dr: Yes Mr… That is true. But the chances of you getting a stroke again
which can be even life threatening as I mentioned earlier is much higher
than you falling and having bleeding in the brain. If you do not taken this
warfarin you are almost certain to get this stroke again.

I sincerely advise you to be careful not to fall and careful not to have any injures
while using sharp objects. Also if you want we can send our Occupational
therapists to your home to see if there is anything which can make you fall and
they can to rectify those things. However you need to be careful whenever you
go outside not to fall.
Pt: But doctor you can’t prevent me falling. That can happen to me any time any
day. You know the falls happens accidentally.
Dr: I do understand what you are saying. However, if there is any medical
causes which makes you fall then we can sort out those issues. But you need to
be careful about accidental falls like slipping and tripping.

Mr… I am saying this to you because this medicine is very important for you and
for your own benefit I am advising this to you. What do you think now? Would
you like to take it.
Pr: Yes, doctor you have convinced me about it. Thank you very much. But
doctor since I had stroke last time my memory is not very good. What if I forget
to take thi medicine ?
Dr : It is good you told me about it. It is very important to take this medicine
regularly every day. If you do not take the medicine blood can become thick
again an cause more strokes. I advise you to make a habit to take it same time
every day so that you do not forget. Also you can keep an alarm which can ring
same time every day to remind you to take this medicine. Also if you live with
someone you can tell them to remind you to take this medicine every day. Is that
OK ?

Pt - Ok doctor. Thank you.

Warning signs

Dr: Thank you Mr.. I am sure you will be fine with this medicine. However, if at
you fall please call the ambulance immediately or tell someone else to call the
ambulance immediately in case if you fall. Is that Okay Mr..
Pt: Ok doctor. Thank you. You have been very kind.
Dr: Thank you very much for talking to me. I really wish all the good health for
you Mr..

If the patient still not convinced.

Dr: I am sorry that I wasn’t able to convince you about the importance of taking
this warfarin. You do have the right to refuse any treatment what we advise.
However, I will talk to my seniors and may be they will be able to convince you
about it. Thank you very much for talking to me. I really wish all the good health
for you Mr..

Wound infection after cyst removal.

25 year old lady underwent an operation to remove a cyst from her knee 2 weeks ago.
She developed infection in her wound after that. She was admitted and again treated
with the IV antibiotics. Infection has cleared now. She wants talk to a doctor.
Talk to her and address her concerns.

Dr - I am Dr… one of the junior doctor in the surgery department in the hospital. I understand
that you want to talk to a doctor. Can I help you Miss… ?
Pt – Yes doctor. I had an operation to remove a cyst from my knee 2 weeks ago.
I was sent home and then I had infection in the operation site. I was admitted again here and
they gave me some medicine. Infection has cleared now. I want to know why did I get this
infection ?

Dr: I am very sorry that you have to go through this problem. Can I ask you little more details
about it so that I can answer your questions better ? Pt : Yes

Dr: Can I ask you did any doctor explain you about the operation properly to you before the
operation ? Pt : Yes
Dr : Did they mention what are the benefits and what problems you may have after the
operation ?
Pt: Yes they told me something but I can’t remember everything now.
DR: No problem Miss… Can you please tell me what happened after the operation – how
long you were in the hospital ? Pt : It was a day case surgery so I was sent home on the same
day.

Dr: I see. What was told to you when you were discharged – did any one explained to you
how to take care of the wound like changing the dressing or how to keep the operation are
clean ? Pt: Yes they told me to change the dressing ….

Dr: Were you given any medications to take at home like any pain killer medication or any
antibiotic medications ?
Pt: I was given pain killer medication but not the antibiotics.
Dr: Ok Thank you for the information. You asked em why you got this infection - Let me
answer your question now Miss…
Usually after almost every operation there are chances of people getting infection. We take
lot of measures so that people do not get infection after the operation we do the operation in
the operation theatre which is very sterile and clean and we keep the hospital very clean to
prevent getting infection from other patients and we change the dressings on the wound
fequently in a very clean manner to prevent the infection. Also in some type of operations if
the chances of infection is very high then we give antibiotics to prevent people getting the
infection. However, despite all our efforts sometimes people do get infections for so many
reasons.

We usually mention about the benefits and risks of operation including the risk of people
getting infection after the operation to the people before they undergo the operation. It is very
unfortunate that you got this infection.
Pt: Why the antibiotics was not given to me ? May that is why I got this infection.
Dr: Miss. We usually give antibiotics to only such operations where the chances of people
getting is very high. We do not give antibiotics if the chances of people getting infection is
very low, ecause if we give antibiotics to everyone even when the chance of infection is very
low then the bugs can develop resistance to these antibiotics. In the future if the people get
infections from similar bugs then these antibiotics do not work and the condition can become
very serious and it can even be life threatening. That is why we avoid giving unnecessary
antibiotics. The type of operation what was done to you – the chance of people getting
infection after the operation is very low. That is why the antibiotics was not given to you.

Pt: But I got the infection.

Dr: It is unfortunate that you got it. We generally advise patients that there is slight chance of
getting infection and we advise them of the signs and symptoms of infection and ask them to
come back if they have such symptoms. We are usually able to treat the infection if it does
develop. That is what was done in your case Miss…

Pt: I am it happy about this.

Dr: I can certainly imagine how you may be feeling about this. I will be reporting about this
incident. I can reassure that the concerned authorities will look at this and take appropriate
steps for this. In the future if lot of patients get infections after this type of surgery may be we
need to think of giving antibiotics to prevent the infection.
Miss.. You have all the rights to put a formal complaint about this if you wish. We have a
dedicated department for this called PALS. They will help you with this.
Pt: Thank you I ill think about that.
Dr Any other concerns Miss.. Pt: No
Dr: Thank you very much Miss. Once again I am sorry that you had this problem.
 Reactive Arthritis
25 years male, Mr Robert, C/O joint pains
Assess him and discuss the management with the patient.

Differentials for Joint pain. ( Pneumonic – GHRRROSS)

Gout
Heamarthrosis
Rheumatoid arthritis
Reactive arthritis ( Reiter’s syndrome – old name for reactive arthritis)
Osteo arthritis
Septic arthritis
Sports injuries

Dr: Hello I am Dr .... Are you Mr Robert ... Pt: Yes.

Dr: How can I help you?
Pt: I am having pain in my knee and ankle joints.
Dr: Is it both the knees and both the ankles ? Pt: Yes
Dr: I am sorry to hear that. Can you tell me anything more about them? Pt: It started
about 2 weeks ago doctor
Dr: Do you know how it started? Pt: On its own doctor
Dr: Do you have any other symptoms other than pain in your joints ?
Pt: My eyes are bit sore since last few days.

Dr: Did you have any injury to your knee or ankles at all? Pt: No
Dr: Are all those joints swollen ( heamarthrosis, reactive arthritis, septic arthritis,
rheumatoid arthritis) ) ? Pt : Yes
Dr: Do you have fever ( septic) ? Pt : No
Dr: Are you able to walk at all ( Can’t walk in septic arthritis because of severe pain) ?
Pt: Yes I can walk.
Dr; You have pains in the small joints of your hands ( Rheumatoid arthritis affects small
joints) ? Pt : No
Dr: Do you have stiffness in the joints ( Rheumatoid, reactive) ? Pt -Yes
Dr : Any pain in your back ( ankylosing spondilitis) ? Pt : No
Dr: Do you have any swelling and pain in the big toe ( Gout) ? Pt : No
Dr: Did you have this type of problem before? Pt : No
Dr : Do you have any medical conditions? Pt: No
Dr: Are you taking any medications at all? Pt : No
Dr : Any of your family members has this type of conditions? Pt : No
Dr: Have you travelled outside UK recently?
Pt : I went to France about 3 months ago.
Dr: Did you have any health problems when you were there?
Pt: I had diarrhoea for few days.
Dr: Did you take any treatment for that ? Pt : No it subsided on its own.
Dr: Did you have any unprotected sex with any one recently ? Pt : No
Dr: Do you have burning sensation while passing urine ? Pt: No
Dr: Any discharge from the urethra that is front opening of urine passage? Pt: No
Dr: Is there anything else you think important that we may need to know? Pt : No

Examination

Check NEWS chart for temperature

I need to examine your knee and ankle joints. I will be very gentle while examination. Is
that OK if I examine now ? Pt : Yes.
Can you please undress below your mid thigh.

Check Gait : Could you please take few steps ( May have antalgic gait)
Can you please stand now.

Inspection of knees and ankles

No swelling, redness, scars or sinuses.

Can you please lie down on the couch.

Palpation: Knees

Check for temperatures ( compare temperature over the knees to thighs).

Check joint line tenderness – No joint line tenderness
Check for fluid collection – milk from thigh down towards the knee and do patellar tap. –
No fluid in the joints.

Check movements ( Active and passive) – Flexion, extension, Internal rotation external
rotation – all movements normal.

Ankles – Check for any bony tenderness – No bony tenderness, No swelling

Check movements – plantar fexion, dorsi flexion.
- Movements normal

Investigations
Robert we need to do some investigations to find out what exactly is the problem. We will
do some blood tests for infection markers, Also we will do the X Rays of your knees and
ankles. Also we need to do some tests to check for some joint conditions like rheumatoid
factors in the blood.
Is that Ok? Pt : Ok doctor.

Diagnosis.

Robert with the information you have given me and after examination I think you have
condition what we call as Reactive arthritis.
Do you know anything about this condition ? Pt : No

Dr : I will explain. If someone had any infections due to some bugs in other parts of body
like bowel - sometimes as reaction to that infection people develop inflammatory ( a type
of reaction which causes swelling of joints) reactions in the big joints like knees and
ankles. Since you had diarrhoea few weeks ago which may be due to bugs – that would
have caused this condition in you. This condition causes pains in the knees and ankles and
also it causes soreness in the eyes. This condition is due to problem in the immune
system.
Do you follow me ? Pt : yes doctor
Dr: Do you have any questions at this point ? Pt : No

Treatment

Dr: Unfortunately there is no cure for this condition. However, the good news is that it
usually subsides on its own but it may take up to six months or may be even up to a year
to subside completely.

We advise you to take plenty of rest and avoid using the joints as much as possible
initially.
As your symptoms improve, you should start doing exercise slowly to strengthen muscles.
We will refer you to the Physiotherapist for that.

We will give you medications called Ibuprofen – that also will help you reduce the pain.

If the Ibuprofen medication do not help then we can give you medications what we call
steroids.
We will give you steroid drops to your eyes – that will help to reduce the soreness in your
eyes.
If none of these medications help then we will give medications called DMARDs
( Disease-modifying anti-rheumatic drugs ) such as sulfasalazine which may help.
Pt: Can it come back again?
Unfortunately it can happen again if you develop any infection in parts of body again.
Dr: Any other questions ? Pt : No Thank you.
Antenatal assessment - lady had miscarriage previously.
28 year lady Mrs... (P 0+2) presented to the antenatal care unit. Nurse has checked BP and
tested urine for infection and protein which are normal.
She is registered first time for the antenatal care.
Do the initial antenatal assessment and address here concerns.

Hello Mrs..... I am Dr... How are you doing? Pt: I am fine.

Dr: how can I help you Mrs. Pt: Doctor, I am pregnant.
Dr: Congratulations. May I know how many weeks pregnant are you ? Pt -6 weeks
Dr: Do you know what we do here in the antenatal care unit ? Pt - No
Dr: Don’t worry, let me explain. First of all I am very glad that you have come here. We
assess the pregnant ladies to see if they have any health or other issues which can affect the
pregnancy and the baby and manage them so that they that they will not have problems
during pregnancy and ultimately have a healthy baby. We also educate the parents about
how to cope with pregnancy and delivery and address any concerns you have. We have
Obstetrics doctors, midwife and the whole team to help you to go through this process.
Do you follow me? Pt - Yes doctor.

Dr: I need to ask few questions about your health and other things for that. Before that do
you have any concerns which you like to ask me?
Pt: Doctor, I was pregnant twice before and I had miscarriage.
Dr: I am very sorry to hear that. Can I know when this happened ?
Pt : One miscarriage was about 3 years and the other one year ago.
Dr: At what week of pregnancy you had these miscarriages? Pt - Both were at 8 weeks.
Pt: Did you come for antenatal visits at that time ?
Pt - No / Yes ( If no – May I know why ?)
Dr: Do you know why you had these miscarriages ? Pt - No ( ? Intentional abortion)
Dr: Is this the third time you are pregnant then ? Pt - Yes
Dr: Do you have any concerns now ?
Pt - Yes doctor. I worried whether the same thing will happen again.
Dr: I can understand your worries. But don’t worry. I will explain about it. Before I explain
about the miscarriage, I need to ask you few questions -
Do you have any bleeding from the vagina now at all? ( r/o- miscarriage now)? No
Dr : Any pain in tummy ( ectopic pregnancy) ? Pt - No

Dr: Do you have a stable partner ? Pt - Yes.

Dr: Is this a planned pregnancy ? Pt - Yes
Dr: Is your partner also happy with this pregnancy ? Pt - Yes ( r/o abuse)
Dr: Was he the father both times previously when you were pregnant? Yes.
Dr: Do you smoke ? Pt - I stopped one year ago.
Dr: Do you drink alcohol ? Pt - No
Dr: Do you use any recreational drugs? Pt - No
Dr: Do you drink too much coffee ? Pt - No
Dr: Mrs.... Most of the time people do have one two miscarriages before they have normal
deliveries. This is quite common. Sometimes the risk of miscarriage is high in those
mothers who smoke, drink alcohol, use recreational drugs or drink too much coffee.

Anyway, just because you had miscarriage twice before it does not mean you will have the
same problem again. There is a good chance that you have normal delivery this time.

However, if it happens more than 3 times then we call it recurrent miscarriage and then we
start investigating for the causes of miscarriage. One of the common causes of miscarriage
in early pregnancy is chromosome abnormality in the baby means there is problem in the
gene of the baby. If miscarriage happens more than 3 times then we check for any gene
problems in the parents. Other cause of miscarriage is development of some antibodies in
the mother called antiphospholipid antibody which causes thickening of the blood.
Again we test for this condition if the miscarriage happens more then 3 times and we give
medications like Aspirin and some heparin injections to thin the blood which helps in
normal delivery.

Also we look for other causes like any problem in the mother womb or any infections
which may cause recurrent infections.
So for now please do not worry about the miscarriage. Hopefully you will have normal
delivery. Is that OK? Pt - Yes
Dr: Do you have any other concerns ? Pt - No

Dr: I need to ask few questions about your health now. How is your general health now?
Pt - I am fine now.
Dr: Do you have any other symptoms like fever pains any where? Pt - No
Dr: Do you have any medical conditions ? Pt - No
Dr: Like high blood pressure, diabetes, any blood disorders like thalassemia, sickle cell
disease, blood clots or bleeding disorders ? Pt - No
Dr: Did you have any kind of infections before? Pt - No
Dr: Did you have any problems in your womb or ovaries were you told of ? Pt - No
Dr: Did you have any surgeries to your tummy or pelvis before ? Pt - No
DR: Are you taking any medications ? Pt: No
Dr : Are you taking folic acid? Pt: Yes/ No
Dr: Are you allergic to any thing ? Pt : No
Dr: Does your partner have any medical conditions ? Pt - No
Dr: Do you and your partner get along well with each other? Pt - Yes. ( ? Abuse)
Dr: Any mental health issues with you, your partner or both of your families ? Pt - No
Dr: Any medical conditions running in your family or in your partner’s family ? Pt - No
Dr: Anyone else in your or partners family had miscarriages or abnormalities in the babies
or twins ? Pt - No
Dr: Have you planned where you want to deliver – at hospital or home?
Dr: Is there anything else you like to tell me ? Pt - No

Examination

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

Investigations
We will do some blood tests to check blood group, sugar, infections like rubella syphilis,
hepatitis and HIV ? Is that OK? Pt - Yes.
We will do tests to check for abnormality in the baby like Downs syndrome, also we will
do ultrasound scan when you are 8 to 10 week pregnant. Pt: OK
Dr: Any questions so far? Pt - No

Advise:

Dr: I advise you to eat a healthy diet. Have good life style. It is good that you stopped
smoking. We advise you not to restart the smoking habit. Also do not drink alcohol use
recreational drugs and drink too much coffee.
We will prescribe some Folic acid tablets for you.
You can join some parentcraft classes where they will teach you about coping at home with
pregnancy, labour feeding and caring of baby and other things. I also advise you to join
some exercise classes. Have proper dental check up. Avoid travelling to malaria prone
countries. Is that Ok ? Pt - Ok
Any other questions? Pt - No

Dr: I will talk to my Consultant and arrange the date for your next visit. However if you
have any problem like bleeding or pain abdomen or any other problem, please come back.
Thank you very much.

PARENTCRAFT classes for pregnant women. They cover many topics including:- Signs
of labour Coping at home in early labour Pain relief in labour Normal labour Infant
feeding workshop Caring for your newborn baby Safer sleeping Tour of the maternity
unit

[ Flight travel is allowed up to 34 weeks in most of the flights]

OVARIAN CYSTECTOMY ( 5th Dec 2017)

Q. 23 years old lady presented with abdominal pain. USG has been done and it shows
dermoid cyst in the right ovary. You consultant has decided to do open ovarian
cystectomy (pfannensteil incision). Talk to patient and address her concerns.

Consultant has planned to keep the patient in the hospital for 2 days after the operation.

Assess knowledge

Dr: How much do you know about your condition?

Pt:
Dr: Certainly, I am here to discuss the result with you. As you know that you came with
severe pain and we did TV scan on your tummy. In which we have found that there is a
fluid filled sac on your right ovary (egg producing gland), known as ovarian cyst.

Pt: What is ovarian cyst?

Dr: An ovarian cyst is a fluid filled sac which develops in an ovary. They are very
common and do not usually cause any symptoms. In most cases, they are harmless and
usually disappear without the need for treatment. However, if the cyst is large
or causing symptoms, it may need to be surgically removed.

Pt: What’s going to happen now?

Dr: My consultant has planned for an operation to remove this cyst.

Pt: Why do you have to do an operation, what happens if not removed?

Dr: The sac is a potentially dangerous, if it is not removed now then it can continue to
grow in that case it might rupture, bleed or twist on itself creating a situation in which
we will have to remove it by an emergency operation. Since you are here now we can
plan ahead to avoid that situation.

Pt: What will you do?

Dr: My consultant has decided to do an operation called laparotomy in which an incision

will be given on the bikini line (Pfannenstiel incision: also called “bikini line incision”).
This is an open operation means we have to open the tummy through this bikini line
incision and then remove the ovary.

Sometimes, in case of larger cyst, my consultant/ the surgeon might decide to remove
the whole ovary.

Pt: How long will the surgery be?

Dr: 45 minutes to 1 hour.

Pt: How big will the scar be? Will it not look bad when I wear bikini?

Dr: Incision will be about 8 inches long. However the scar will be very thin and it will
not be visible even if you wear bikini because it will be covered by the bikini.

Pt: When Can I go back home?

Dr: It depends on your operation and recovery. We are hoping that you will be able to
go home in about 2 days if everything goes well.

Pt: Is it cancerous or benign?

Dr: Most of the ovarian cysts are non cancerous. However we will be sending the cyst
once removed to the laboratory to confirm that.

Pt: Will I be able to conceive after removal of ovary? / Can I become a mother?

Dr: You have the problem in only one ovary so we will be removing the cyst from only
one side. The other ovary is fine. So you will be able to have babies.

Pt: What will happen to my sex life? When can I resume sex?

Dr:   You can start having sex after 4-6 weeks after the surgery ( laparotomy).

(2-3 weeks in laparoscopy)

Pt: When can I go back to work?

Dr: If only cyst is removed, you may be able to return to work within 2 weeks.
However, if whole ovary is removed then 5-6 weeks rest is essential.

Pt: When can I drive?

After about 4 to 6 weeks you may be able to drive.

Pt: Are there any complications?

Dr: 
Pain: You might experience some pain after the operation but do not worry we have
very good pain control team who will take care of you.
Bleeding: Do not worry, in case it does happen, we keep matched blood which can be
given to you if needed.
Infection: Again, do not worry. We will give you antibiotics

Damage to surrounding organs: Very rare. We have an excellent team. If anything

happens we will manage accordingly.

Dr: Do you have any other concern? Pt: No

Dr: Can I ask you few questions jut to make sure that you are fit for surgery ? Pt : Yes

Dr: Do you have any medical conditions ? No

Dr: Are you taking any medications? No

Dr: Have you undergone any surgeries previously? No

DR: That is good. We will be doing some blood tests and other tests to make you that
you are fine and then we will do the surgery. Is that Ok ? Pt: Ok

Thank you.
 If task says laparoscopic surgery has been planned.

Smaller cysts can sometimes be removed using a procedure known as a laparoscopy.

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

Anorexia Nervosa
You are the F2 in the psychiatric dept. 16/25yr old female referred by her GP on
account of weight loss. BMI of 17. Has no symptoms of depression. Take history and
discuss further management with her.

patient doesn't believe she has problems, losing weight intentionally and still believes
she is overweight.

ANOREXIA NERVOSA     

Background

 
         People with anorexia nervosa have extreme weight loss as a result of very strict
dieting.
         In spite of this, they believe they are fat and are terrified of becoming what is, in
reality, a normal weight or shape. They do not accept that they are losing weight and
they do not believe they need any help.
         Distorted body image and abnormal attitudes to food and weight.
          Amenorrhoea and often other signs of starvation are present.
         Bulimia nervosa – They usually accept they have a problem and they recognise
the need for treatment.

Assessment

You must assess the following 6 steps for assessment of eating disorder in real life.

 In the exam only first 3 steps.

Step 1: History of development of the disorder and patient’s ideas (Body Image distortion,
Compensatory mechanisms, Daily diet and exercise)

Step 2:  SCOFF

Step 3 : Mental state examination for depression

Step 4 : Interview parents and other informants

Step 5 : Assess family interaction in especially attitudes in relation to food

Step 6 : Physical examination ( Distribution for body hair, emaciation, vit. deficiency,
Organic cause).

History:
•        Onset
•        Triggers
•        Daily Diet Pattern:                  What/How Much/When/Where/Alone/Progression
•        Binge eating
•        Self Induced Vomiting
•        Feel fat/Fear of fatness
•        Weight loss
•        Food domination
•        Amenorrhoea
•        Medical or psychiatric problems
•        Palpitations, fainting
•        Role Models
•        Baggy clothes
 •        4Fs
•        Mood
•        Risk to themselves or others

Step 3: FAMISH History format

Step 4: Insight

( Pneumonic –

SCOFF

S – Do you make yourself Sick because you feel uncomfortably full?

C – Do you worry that you have lost Control over how much you eat?

O – Have you recently lost more than One stone in a three month period? ( one stone = 6.3
kilos or 14 pounds) ( 1 kilo = 2.2 pounds)

F – Do you believe yourself to be Fat when others say you are too thin?

F – Would you say Food dominates your life ?

If the patient has 2 or more positive answers it indicates a likely case of Anorexia or
Bulimia).

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

Dr: Hello are you Miss Jessica Thomson ?

     Miss: Thompson: Yes

Dr: I am Dr… one of the junior doctor in the psychiatry department. Can you please tell
me what brought you to the hospital?

      Miss: Thompson: I am here because of my parents; they think that I have been losing
too much weight.

Dr: Can you please tell me, how much weight did you lose?

      Miss: Thompson I have lost about 15 pounds ( more than one stone, 6.8 kg) in the last
3 months.
Dr: Have you been trying to lose weight?

      Miss: Thompson: Yes

Dr: Could you please tell me, why are you losing weight?

      Miss: Thompson: Dr, I want to be like my friend.

Dr: Can you please tell me, why do you want to be like your friend?

      Miss: Thompson: She is slim and good looking. My friend has found boyfriend.

Dr: Do you think that you are fat?

      Miss: Thompson Yes doctor.

Dr What do you do ? Do you work or you are a student ?

      Miss: Thompson: I am a university student.

Dr: Can we talk about your general life style?

      Miss: Thompson of course, Doctor.

Dr: What is your diet like? / What do you eat in breakfast/ lunch/ dinner?

      Miss: Thompson: In breakfast, I eat ----. In lunch, generally I do eat ---- I take ---- at
night.

Dr: Have you any time eating too much food and could not have any control on eating.
(Binge eating)

Dr: Do you do any exercise?

       Miss: Thompson Yes, doctor. I enjoy running (doing exercise).

Dr: How often do you do exercise?

        Miss: Thompson I do it every day for about 2 hours.

Dr: Do you take any medications to lose weight ?

        Miss: Thompson No

Dr: Do you make yourself sick because you feel you are uncomfortably full ?

       Miss: Thompson: No

Dr: Do you have any preference for clothes?

       Miss: Thompson: Yes, Doctor, I like to wear baggy clothes.

Dr: Do you have any role models?

        Miss: Thompson I am very big fan of -----

Dr: Can you please tell me, do you like looking yourself in the mirror repeatedly?

        Miss: Thompson : No doctor.

Dr: Do you keep checking your weight frequently?

        Miss: Thompson: Yes doctor.

Dr: How has been your mood? Can you please grade it, 1 being the saddest and 10 being
the happiest?

        Miss: Thompson: It has not been good. (3/10)

Dr: Have you ever thought of harming yourself?

        Miss: Thompson: No

Dr: do you think that you have been losing too much weight?

        Miss: Thompson: No, dr. / I feel uncomfortable when I do not follow my daily routine
of diet and exercise. 

Dr: How is your general health?

       Miss: Thompson Dr, I feel weak nowadays, I want to sleep most of the time.

Dr: How you ever had any mental health problem before?

       Miss: Thompson: No.

Dr: Are the family members supportive?

       Miss: Thompson: Yes they are supportive.

Dr : Any problems with your colleagues in the university? ( Bullying ?)

       Miss: Thompson: No

Dr How is your periods?

      Miss: Thompson:  I am waiting for my periods; it has not come for last 8 weeks. I am
worried about it.
Dr: Do you have any health symptoms like palpitation, Feeling faint or any other
symptoms?

       Miss: Thompson No

Dr: Thank you very much for all the information.

Miss .. We have measured your height and weight. Your weight is far lesser than what it
should be for your height. I think you have lost too much weight. This is not good for you.
In medical terms we call this condition as Anorexia Nervosa.

Do you know anything about this at all? No

Anorexia nervosa is a serious mental health condition. It's an eating disorder where a

person keeps their body weight as low as possible. If it continues like this it can lead
to lot of other conditions like depression and medical problems like Osteoporosis and
sometimes people with this condition may not be able to conceive children. Do you
follow me? Yes

We can help you to treat this condition.

Treatment
We can help you by combination of psychological therapy and supervised weight gain. We
have a team of specialists like Psychiatrists, Psychologists, dieticians and specialist nurses
here to help you

We as Psychiatrists can help you by Psychotherapy otherwise we call as Cognitive analytic

therapy and Cognitive behavioural therapy. We can involve your family members also if
do not mind to help the treatment.

Our dieticians can teach you what type of food you can eat to gain weight. We do not need
to admit you at this moment. We can do all these as an outpatient and see how things goes.
Is that OK? What do you think about this?

Information about treatment of Anorexia Nervosa

Psychological treatment

A number of different psychological treatments can be used to treat anorexia.

Depending on the severity of the condition, treatment will last for at least 6 to 12
months or more.

Cognitive analytic therapy (CAT)

Cognitive analytic therapy (CAT) is based on the theory that mental health conditions
such as anorexia are caused by unhealthy patterns of behaviour and thinking
developed in the past, usually during childhood.

CAT involves a three-stage process:

reformulation  – looking at past events that may explain why the unhealthy

patterns developed
recognition  – helping people see how these patterns are contributing
towards the anorexia
revision  – identifying changes that can break these unhealthy patterns

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is based on the theory that how we think about
a situation affects how we act and, in turn, our actions can affect how we think and
feel.

In terms of anorexia, the therapist will attempt to show how the condition is often
associated with unhealthy and unrealistic thoughts and beliefs about food and diet.

The therapist will encourage the adoption of healthier, more realistic ways of thinking

that should lead to more positive behaviour.

Interpersonal therapy (IPT)

Interpersonal therapy (IPT) is based on the theory that relationships with other people
and the outside world in general have a powerful effect on mental health.

Anorexia may be associated with feelings of low self-esteem, anxiety and self-doubt

caused by problems interacting with people.

During IPT, the therapist will explore negative issues associated with your
interpersonal relationships and how these issues can be resolved.

Focal psychodynamic therapy (FPT)

Focal psychodynamic therapy (FPT) is based on the theory that mental health
conditions may be associated with unresolved conflicts that occurred in the past,
usually during childhood.

The therapy encourages people with anorexia to think about how early childhood

experiences may have affected them. The aim is to find more successful ways of
coping with stressful situations and negative thoughts and emotions.

Family interventions

Anorexia doesn't just impact on one individual – it can have a big impact on the
whole family. Family intervention is an important part of treatment for young people
with anorexia.

Family intervention should focus on the eating disorder, and involves the family
discussing how anorexia has affected them. It can also help the family understand the
condition and how they can help.

Gaining weight safely

The care plan will include advice about how to increase the amount eaten so weight is
gained safely.

Physical health – as well as weight – is monitored closely. The height of children and
young people will also be regularly checked to make sure they're developing as
expected.

To begin with, the person will be given small amounts of food to eat, with the amount
gradually increasing as their body gets used to dealing with normal amounts.

The eventual aim is to have a regular eating pattern, with three meals a day, possibly
with vitamin and mineral supplements.

An outpatient target is an average gain of 0.5kg (1.1lbs) a week. In a specialist unit,

the aim will usually be to gain an average of around 0.5-1kg (1.1-2.2lbs) a week.

Compulsory treatment

Occasionally, someone with anorexia may refuse treatment even though they're
severely ill and their life is at risk.

In these cases, as a last resort doctors may decide to admit the person to hospital for
compulsory treatment under the Mental Health Act. This is sometimes known as
sectioning or being sectioned.

Treating additional problems

As well as the main treatments mentioned above, other health problems caused by
anorexia will also need to be treated.

If you make yourself vomit regularly, you'll be given dental hygiene advice to help

prevent stomach acid damaging the enamel on your teeth.

For example, you may be advised not to brush your teeth soon after vomiting to avoid
further abrasion to tooth enamel, and to rinse out your mouth with water instead.

Avoiding acidic foods and mouth washes may be recommended. You'll also be
advised to visit a dentist regularly so they can check for any problems.
If you've been taking laxatives or diuretics in an attempt to lose weight, you'll be
advised to reduce them gradually so your body can adjust. Stopping them suddenly
can cause problems such as nausea and constipation.

Medication
Medication alone isn't usually effective in treating anorexia. It's often  only used in
combination with the measures mentioned above to treat associated psychological
problems, such as obsessive compulsive disorder (OCD) or depression.

Two of the main types of medication used to treat people with anorexia are:

selective serotonin reuptake inhibitors (SSRIs) – a type of antidepressant

medication that can help people with co-existing psychological problems such as
depression and anxiety
olanzapine – a medication that can help reduce feelings of anxiety related to
issues such as weight and diet in people who haven't responded to other treatments

SSRIs tend to be avoided until a person with anorexia has started to gain weight
because the risk of more serious side effects is increased in people who are severely
underweight. The drugs are only used cautiously in young people under the age of 18.

Patient on carbimazole for hyperthyroidism

( new station came on 25th Jan 2018)

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

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

How can I help you ?

I had overactive thyroid. I am on medication. I have come for follow up.

I am glad that you came for the follow up. Is it Ok to ask few questions to see everything is
OK with your condition ?
Do you have any problems with that now ?
May I know what medications are you taking now ? Carbimazole .
How much ? Pt: 5 mg once a day. Check BNF for the correct dose ?
Are you taking it regularly ? Yes
Since how long you had this problem ? since – One year / ? ...
Do you have any other medical conditions at all ? No
Are you taking any other medications ? No

How are the symptoms you had before we started taking the medications ? They are all
gone now.
Ask about hyper and hypo - thyroid symptoms

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

Ask about Side-effects of carbimazole;

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

Rare side effect: agranulocytosis ( ask about recurrent infections)

Patient may say no for all the symptoms.

Are you pregnant at all? No

Any plans for pregnancy ? No my husband had vasectomy.
Is there anything else you want to tell me

That is good that you do not have any symptoms.

I need to examine you now. I need to examine your hands eyes and your neck – is that
Okay?
Can you please undress that area.

Thyroid Examination
( you tube - www.youtube.com/watch?v=ziaYBkgEZNU )
Position:
Sitting
Inspection:
Hands:
 Dryness (hypothyroid), Sweatiness (Hyperthyroid)
 Clubbing
 Thyroid acropachy: Periosteal hypertrophy of distal phalanges.
 Palmar Erythema (Hyperthyroid)
 Tremor: Ask patient to outstretch arms and place a paper on back of hands
and observe the tremor. (Hyperthyroid)
 Pulse: Tachycardia (Hyper), Bradycardia (hypo), Irregular- AF (Hyper) check the
NEWS chart if present – if not ask for it.

Eyes:
 Exopthalmos (Inspect from front and side)
 Check for diplopia with ‘H’ test.
 Lid lag: Ask patient to look at your moving finger without moving head. Move it
from upper to lower part of visual field and note for delay in descent of upper
eyelid to that of eyeball.
 Lid retraction: It is present if sclera is visible above the iris.
Thyroid:

Inspect the midline of neck: Ask patient to move chin up a bit. Comment on:
 Swelling
 Skin changes
 Scar
 Swallow Test:
 Ask patient to swallow some water.
 Observe any movement of mass. Most swellings move upwards on swallowing.

Tongue Protrusion:
 Look at neck and ask patient to bring out the tongue.
 Thryoglossal cysts will move upwards.
Palpation:
 Inform patient that you are going to feel neck from behind.
 Stand behind the patient and ask patient to bend neck. (To relax the
sternocleidomastoid muscle)
 Place your hands on either side of neck.

Thyroid:
 Place 3 fingers along the midline of neck below the chin and slide downwards
until the area of thyroid gland, which is just located below the thyroid
cartilage.
 With 1 hand fix one side of thyroid and palpate the other side with help of 3
fingers. Do same on the other side.
 Feel for the gland and ask patient to swallow some more water and feel for
any swelling moving with your hands.
 Verbalise that there is no abnormality noted.

Lymph Nodes:
Check all groups of lymph nodes
i) Submental
ii) Submandibular
iii) Anterior cervical chain (Tonsillar and deep cervical lymph nodes)
iv) Posterior cervical chain
v) Pre auricular
vi) Post auricular
vii) Occipital
viii) Supraclavicular

Percussion:
 Percuss down starting from sternal notch to listen for retrosternal dullness.
Auscultation:
 Auscultate both lobes of thyroid. (Thyroid bruit in Grave’s disease)

Pretibial myxoedema:
 Ask patient to roll up trouser.
 Note for the raised, discoloured appearance over legs.

Upper limb reflexes: Biceps, triceps and supinator.

Thank the patient.

Mrs.. With the information you have given me and after the examination everything looks
normal. However we need to do blood tests to check Thyroid function. ( examiner may not
give results).
I will let you know once we get the blood results.
Do you have any concerns ? No
You are doing fine now. Usually we give medications for about 18 months and stop it if
everything is fine. You may be able to continue the medication with the same dose.
I will discuss with my seniors about you and get back to you.

[ If patient is already on Carbimazole for 18 months - We need to consider stopping the

Carbimazole as you may not need it any more – I will discuss with my seniors and get back
to you about it ].

1. Shoulder and thigh pain – Polymyalgia Rheumatica

Exam question

Elderly lady
C/o shoulder and thigh pains – 3 weeks
History and management.

Shoulder and thigh ( may show around pelvis also) pains since 3 weeks.
Oncet – Sudden or gradual [ in PMR – it is usually sudden but can be gradual too]
Worse in the morning. [in PMR it is worse in the morning].
Any swelling in shoulders - ? No

Any other joint pains ? No, Other joint swellings ( osteo arthritis) ? No, Swelling and
pains in the hand joints ( rheumatoid arthritis) ? No
Any changes in the bowel habits like loose stools diarrhoea ? No
Fever – No, Trauma ? No

Soreness in eyes?– No, Skin rashes ( SLE) – No

Difficulty using shoulder ? can she lift weight? Difficulty in walking ?

Pain on the side of the head ? Any vision problems? Any pain in jaw while chewing?
[ to r/o GCA] – No

PMHx – GORD on Omeprazole for 20 years

Any other medications

Allergy?
Family history
Anything else important?

Examination
I want to examine your shoulder joints and other joints and also examine your thighs

Examiner may say – shoulder movements restricted( abduction limited).

I want to examine for any swellings or muscle wastings ? Examiner may say – No

[ In PMR – joints movements may be restricted]

Provisional diagnosis

Mrs,,, I need to check whether the medication Omeprazole what you are taking is causing
this problem. Is it OK? check BNF for side effects – it may show long term use of
Omeprazole causes Vit D and B 12 deficiencies which may cause body aches).

Mrs.. If one takes Omeprazole for long term it may cause vit deficiencies which in turn can
cause body pains but they usually do not cause the pains to be worse in the morning and
restriction movements of the joints.

I think you have a condition what we call as Polymyalgia Rheumatica. Do you know
anything about this? No

Polymyalgia rheumatica is a form of arthritis – joint condition. It causes pain in the joints
and muscles of the lower back, thighs, hips, neck, shoulder and upper arms, and other parts
of the body.

The condition occurs when the lining surrounding the joints and tendons near the shoulders
and hips becomes inflamed.

The disease is centered on the joints (especially the shoulders and hips). But the discomfort
is felt in the upper arms and thighs. This type of pain is called referred pain. It arises in one
area but causes symptoms in another.

Do you follow me? Yes

Typically, polymyalgia rheumatica affects people older than 55. If not treated, it can lead
to stiffness and significant disability. In some cases, symptoms do not get worse. They may
even lessen in a few years.

In a minority of cases, polymyalgia rheumatica is associated with another condition called

giant cell arteritis (temporal arteritis). This is a condition in which blood vessels are
inflamed, especially in the neck and head. If not treated giant cell arteritis can cause
blindness or stroke.

Do you follow me ? Yes

We need to do some blood tests called ESR and CRP to check whether there are any
possibilities of this condition.

{The ESR and CRP tests may be used both to diagnose the condition and to check whether
treatment is working}.

Treatment

We will refer you to the specialist called Rheumatologists.

We can give you pain killer medication like NSAIDS but they are not very helpful.

We can give you medications called Corticosteroids, such as prednisolone. We will give
you low doses of that like 10 mg to 20 mg per day and they are highly effective.

Long term use of steroids can cause Osteoporosis that is thinning of bones. We can give
you medications to prevent osteoporosis like calcium, vitamin D and alendronate
(Fosamax).

If you have serious side effects of steroids and if we cannot just treat with low doses of
steroids then we may give some other medications called methotrexate 

We will also refer you to Physiotherapists. Physical therapy may help to control
discomfort. It can also help maintain the ability to move the joints and function.

Prognosis

Treatment may be required for years. But the outlook for people with polymyalgia
rheumatica is excellent.

Warning signs:

If you develop any headaches on the sides of the head or vision problems or jaw pain while
chewing please come to us immediately because these are the signs of serious condition
called Gaint cell arteritis as I mentioned earlier. We may need to treat to you urgently with
high dose steroids.