Dr Hamed Notes

A peek inside the GMC exam stations

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THE EXAM DETAILS THAT HAVE BEEN COLLECTED WITH MANY EFFORTS PUT IN BY AN AWESOME DOCTOR, WILL COMPLETELY GO TO WASTE. THE GMC WOULD ALSO TRY AND CHANGE THE FINDINGS OR EVEN THE QUESTIONS AND THE PATTERN ITSELF, IF THESE NOTES ARE COMMONLY PLACED ON THE INTERNET. THESE NOTES WERE TYPED WITH THE INTENTION OF HELPING OUT PEOPLE WHO HAVE ANY PROBLEMS REGARDING COLLECTING ALL THIS DATA. AGAIN HOPE YOU WILL ABIDE BY THE REQUEST MADE ABOVE FOR THE SAKE OF THE DOCTOR WHO TAKES THE PAINS TO CALL EVERY CANDIDATE WHO TAKES THE EXAM, TO COLLECT THIS DATA. IT WAS HIS WISH THAT THEY NOT BE PLACED ONLINE.

Plab 2 Topics MEDICINE (Common Stations) History Taking 1) Chest Pain Hx + D/D = PCP Hx + D/D = ACS Hx + Mx (with examiner) = ST Elevation MI Hx + Mx (with examiner) = ACS 2) Fever Hx + Ix + Dx = Pneumonia Hx+ D/D = Malaria 3) Dry Cough Hx = TB 4) Abdominal Pain Hx+ LFTs report = Viral hepatitis 5) Wheeze only Hx = Asthma 6) Headache Hx + Dx = Giant cell arteritis Hx + Mx (with patient) = Subarachnoid hemorrhage Hx + D/D + Dx (w examiner) = Migraine 7) Red Eye Hx + Mx (w. examiner) = Acute close angle glaucoma 8) Knee pain Hx + D/D = Reactive arthritis 9) Hemoptysis Hx + D/D = Lung CA 10)Diarrhea Hx + D/D = Acute viral gastroenteritis Hx + D/D = CA Bowel

11) Constipation Hx + D/D = Drug induced constipation Hx + D/D = CA Bowel 12) Weight Loss Hx + D/D = Hyperthyroidism Hx + D/D = Amenorrhea/Anorexia Nervosa 13) Calf Pain Hx + D/D = Chronic Limb Ischemia 14) Dizziness Hx + D/D = Benign Positional vertigo 15) Fall Hx + Mx (w. examiner) = Non accidental injury Hx + Cx = Hypothermia Hx + D/D = Postural hypotension due to meds 16) Unconscious/head injury Hx + Fx (from examiner) + Mx (with examiner) = Hypoglycemia (induced by alcohol) leading to the loss of consciousness 17)Diplopia Hx + D/D = Muscle palsy of right lateral rectus 18) Sore throat Hx + D/D = Infectious Mononucleosis 19) DKA (Pilot station)

Hx = History D/D =Differential diagnosis Inv = Investigations Cx = Councelling Mx = management Fx = Findings

Pattern of History Taking This pattern has to be followed in all stations and the findings in most, (as given by the patients in exam) are given. Always take a complete history unless it’s a councelling station in which it has to be brief. Rule out D/Ds in all stations after presenting complaint has been explained. Start all stations by introducing yourself as given

in the task and confirming patient’s identity as given in the task as well. P3 MAFTOSA P = Presenting Complaint (ODIPARAA or Socrates if pain) [Onset, duration, intensity, progression, aggravating/relieving factors, radiation, associated symptoms/ anything else] P = Past history P = Personal history M = Medical history/ Surgical history A= Allergic history F = Family history T = Travel history O = Occupational history S = Sexual history A = Anything else

In female stations and gynae & obs 4 Ps are added in the above history pattern Pills, pregnancy, periods & pap smear

Station 1 (Chest pain) PCP 25 yr old man with chest pain. Talk to the patient and discuss D/D with examiner. Fx on Hx taking 1. 2. 3. 4. 5. 6. 7. 8.

Fever since 1 month Chest pain 3 weeks Slight SOB especially when going upstairs C/o cough Unprotected sex 2 weeks ago No discharge from urethra Not in a stable relationship Homosexual

D/Ds to rule out: 1. PCP (Hx of sexual intercourse/homosexual) 2. ACS (Chest pain + ECG changes) 3. Angina (pain lasting less than 30 minutes but radiating to left arm/jaw) 4. Pericarditis (Pain relieved on bending forward) 5. Dissected abdominal aorta (Pain going to the back) 6. Pulmonary embolism (Hx of prolonged immobilization,/ Hx of travelling to New Zealand/ Hx of OCPs in females) 7. Pneumonia (Fever + cough + family history positive) 8. URTI (Hx of ear ache, sore throat, flu like symptoms) 9. Pneumothorax (Hx of trauma) 10.Esophageal spasm 11.Trauma

Station 2 (Chest pain) ACS 40 yr old man with chest pain. Talk to the patient and discuss D/D with examiner. Fx on Hx taking 1. 2. 3. 4. 5. 6. 7. 8. 9.

Chest pain 45 minutes Heavy pain like someone sitting on my chest Pain radiating to left arm and jaw Smoking since he was 20 Drinks occasionally On antacids since last few years No fever and no cough No unprotected sex Married man Lying on couch and talks almost comfortably Please ask if you have received any medicines including pain killers. If not, offer some. Don’t talk to examiner before 4: 30 bell. Fill up the time by summarizing your findings. Don’t forget to rule out D/Ds and finish p3 maftosa before telling examiner the D/D.

D/Ds 1. 2. 3. 4. 5. 6.

ACS (Chest pain + ECG changes) PCP (Hx of sexual intercourse/homosexual) Angina (pain lasting less than 30 minutes) Pericarditis (Pain relieved on bending forward) Dissected abdominal aorta (Pain going to the back) Pulmonary embolism (Hx of prolonged immobilization,/ Hx of travelling to New Zealand/ Hx of OCPs in females) 7. Pneumonia (Fever + cough + family history positive) 8. URTI (Hx of ear ache, sore throat, flu like symptoms) 9. Pneumothorax (Hx of trauma) 10.Esophageal spasm (Associated with food intake) 11.Trauma

Station 3 (Chest pain) ACS 60 yr old man with chest pain. Talk to the patient and discuss Mx with examiner. Fx on Hx taking 1. Patient is lying on the couch and is talking uncomfortably and is sweating. 2. Pain radiating from chest to left jaw 3. Patient is a smoker + takes alcohol 4. ST elevations on ECG given Mx of the patient! a. Admit the patient (Very imp*) b. Give Morphine (iv), Oxygen, Nitrates, Aspirin (MONA) c. Keep monitoring patient’s ECG every 15 to 30 minutes according to hospital guidelines. d. Do cardiac enzymes after 6 hrs of onset of pain. e. If enzymes are normal, maybe repeated according to consultant advise. f. If enzymes negative twice, consultant’s decision to discharge or not. g. If enzymes positive, mention consultant’s decision to go for thrombolysis or PCI (percutaneous coronary intervention).

Station 4 (Chest pain) ACS 30 yr old man with chest pain. Talk to the patient and discuss Mx with examiner. Fx on Hx taking 1. 2. 3. 4. 5.

Patient lying down almost comfortably Heavy chest pain since 2 hrs Radiating to arm and jaw Smoking and drinking since 20 yrs ECG is normal. Mx of the patient! a. Admit the patient (Very imp*) b. Give Morphine (iv), Oxygen, Nitrates, Aspirin (MONA) c. Keep monitoring patient’s ECG every 15 to 30 minutes according to hospital guidelines. d. Do cardiac enzymes after 6 hrs of onset of pain. e. If enzymes are normal, maybe repeated according to consultant advise. f. If enzymes negative twice, consultant’s decision to discharge or not. g. If positive, consultant’s decision to go for thrombolysis or PCI (percutaneous coronary intervention). Learn to identity and pick up myocardial infarctions on ECGs of different cardiac walls.

Station 5 (Fever) Pneumonia Young man presented with fever. Temperature is 38.5 degrees. On auscultation, right basal crackles. Talk to patient. Take Hx and discuss D/D and investigations with examiner. Fx on Hx taking 1. 2. 3. 4. 5.

Had fever (intermittent) since 2 weeks Cough associated with green phlegm 10 people at work place with the same symptoms Himself is a soldier and lives in a camp Blanket sometimes available which you can offer to the patient or he already has it on.

3 important investigations! 1. Full blood count 2. Sputum culture 3. Chest X ray D/Ds 1. Pneumonia 2. URTI 3. Sinusitis 4. TB 5. Otitis media 6. Meningitis 7. Gastroenteritis 8. Hepatitis 9. Urinary tract infection

Station 6 (Fever) Malaria 25 year old girl with fever. Talk to patient. Discuss Dx with examiner. Fx on Hx taking. 1. Fever (comes and goes) 2. Travelled to Africa/ Ghana/Kenya recently 3. Received malaria prophylaxis before going. Despite that, the Dx is still Malaria in this case. If the patient is shivering in this station and a blanket is available, offer it. D/Ds to rule out 1. Malaria 2. Typhoid (Tummy pain, continuous fever, GI symptoms) 3. UTI 4. Pneumonia 5. TB 6. Meningitis

Station 7 (Dry cough) Tuberculosis 28 year old presented with complaints of dry cough. Talk to the patient and discuss D/D and investigations with the examiner.

Fx on Hx taking. 1. 2. 3. 4. 5. 6. 7.

Weight loss present Night sweats No positive sexual history No iv drug abuse/ no tattoos No sputum No family member has it No travel history

Investigations 1. Bronchoscopy and lavage 2. Chest x ray D/Ds 1. TB 2. Asthma 3. COPD 4. PCP 5. ACE inhibitors intake 6. URTI 7. Allergy 8. Cardiac asthma 9. Atypical pneumonia

Station 8 (Abdominal Pain) Viral Hepatitis A 45 year old man/lady with c/o right upper quadrant pain. Talk to patient. Interpret LFTs and discuss Dx with the examiner.

ALT and AST are raised in Viral hepatitis GGT is raised in alcoholic hepatitis ALP is raised in obstructed jaundice (gall stones obstructing CBD or CA head of pancreas) Fx on Hx taking: 1. 2. 3. 4. 5. 6.

RUQ pain since last few days Low grade fever Hx of RTA (Received blood) Surgical history of laparoscopic cholecystectomy No alcohol history No sexual or IV drug abuse history

D/Ds to rule out: 1. Viral hepatitis ( Blood transfusion history, sexual history, yellowness of eyes, iv drug abuse) 2. Alcoholic hepatitis 3. Acute cholecystitis ( Pain increased with fatty meals intake. Pain radiating to the shoulder) 4. Cholangitis ( fever + jaundice + rigors/chills) 5. Biliary colic ( Pain to back which comes and goes)

Station 9 (Wheeze) Asthma 28 year old man comes with complaints of wheeze. Talk to patient and take history. Fx on Hx taking: 1. 2. 3. 4.

2 yrs ago had similar symptoms and went to see the GP Needs inhalers Wheeze when playing Hay fever present D/Ds to rule out 1. Asthma 2. URTI 3. Allergy and hay fever 4. Pneumonia 5. Cardiac asthma

Station 10 (Headache) Giant cell arteritis 80 year old lady presented with headache. Talk to patient and discuss Dx with examiner. Fx on Hx taking: 1. 2. 3. 4. 5.

Pain is all over the head Pain scored between 7/10 More over temple area Pain more on combing hair Not associated with chewing

Note: Double/triple sympathy when elderly patients. Don’t rush the station. Talk slower. D/Ds to rule out: 1. GCA 2. Subarachnoid hemorrhage 3. Migraine (Family hx positive, has been there for yrs) 4. Glaucoma (pain behind eyes, watering of eyes) 5. Space occupying lesion (focal deficits/weakness in body, vomiting, vision probs) 6. Tension headache (Band like headache) 7. Cluster headache (Red, watery eyes) 8. Trauma

Station 11 (Headache) Subarachnoid Hemorrhage 25 year old man/lady with headache. Known case of migraine. On zolmitryptine. Discuss Mx with patients.

Fx on Hx taking: 1. 2. 3. 4. 5. 6. 7. 8.

Pain all over the head. Pain starts from the back of head (some cases) Most severe pain ever experienced. Pain scored 9/10 Covers eyes (photophobia) K/c of migraine Family history of migraine positive No rash. No fever. No red eyes. No vomiting. No hx of trauma.

Note: All 3 stations of headache, talk about pain killers and offer dimming the lights. Rule out D/Ds when taking complete history. Mx: From what you have told me, I suspect SAH which is bleeding in your brain. It is like a stroke. In order to confirm my diagnosis, I’ll have to do a CT scan to confirm any bleed in your brain and if there is, we will need to see how much and the site of bleeding. When we confirm our diagnosis, we will refer you to the neurosurgery team. They’ll probably go for surgery. We may give you some meds in the mean time to decrease the pain. (Ca channel blockers are given (nimodipine)

Station 12 (Headache) Migraine 18 year old with presenting complaint headache. Talk to patient and discuss D/D and Dx with examiner. Fx on Hx taking: 1. Girl covers her eyes by her hand 2. Severe pain since this morning 3. Family history positive. Mom has the same kind of headaches D/Ds 1. Migraine 2. GCA 3. SAH 4. SOL 5. Meningitis (neck stiffness, fever, vomiting) 6. Glaucoma 7. Cluster headache/tension headache 8. Sinusitis

Station 13 (Red Eye) Acute close angle glaucoma 55 year old lady with red eyes (will be wearing sunglasses which you can’t ask to remove) and pain in the head. Talk to patient and discuss Mx with the examiner. Fx on Hx taking: 1. 2. 3. 4. 5. 6.

Red eye since last few days Patient has a headache Sometimes indicate it to be over the temporal area No c/o pain at the back of eyes Patient is on amytrptine Ask her if she sees haloes around light.

D/Ds to rule out: 1. Glaucoma 2. Conjuctivitis (sticky discharge) 3. GCA (pain on chewing/combing) 4. Foreign body 5. Sinusitis 6. Uveitis 7. Allergy 8. Reiters syndrome 9. Cluster headache Mx: Consider giving 3 drops 1. 2. 3. 4. 5. 6.

Pilocarpine (causes pupil constriction) Beta blockers (Timolol) (Decreases fluid in the eye) Steroids (reduces inflammation) Inj acetazolamide IV mannitol (works like beta blockers. Decreases fluid) Refer this patient to ophthalmologist who may do slit lamp examination or gonioscopy and confirm the diagnosis. If so, they may go for surgery or laser treatment.

Station 14 (Knee Pain) Reactive arthritis A young man 28 yrs old, comes to hospital with knee pain. Talk to patient. Discuss D/D with examiner. Fx on Hx taking: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Had knee/ankle pain since last week No pain in small joints Morning stiffness (patient says he thinks so) Calf pain (patient says he thinks so) Got watery eyes Travel history to France Diarrhea in France destroyed his holiday there No sexual history No burning micturition. No urethral discharge. No fever.

D/Ds: 1. Reactive arthritis 2. Reiter’s syndrome (Sexual history positive, joint pain, eye and urethral discharge) 3. Hemarthrosis 4. Rheumatoid arthritis 5. Osteoarthritis 6. Gout 7. Septic arthritis (Fever, joint swelling/pain) 8. Sport injury or trauma

Station 15 (Hemoptysis) Lung CA 60 year old lady presented with hemoptysis. Talk to the patient. Discuss diagnosis with the examiner. Fx on Hx taking: 1. 2. 3. 4.

Blood in sputum in last 8 weeks Sputum quantified and would be filling up to half a cup Smoking since was 20 yrs old Weight loss and fever (+-) Note: Always assess anemia in case of any bleed. Check if patient is lethargic or feels too weak to go about doing daily chores. Or gets short of breath easily.

D/Ds to rule out: 1. Lung Carcinoma 2. Pulmonary embolism 3. TB 4. Pneumonia 5. COPD 6. Bronchiectasis

Station 16 (Diarrhea) (Acute) Viral Gastroenteritis A 60 yr old lady presented with diarrhea. Talk to patient and discuss D/D with examiner. Fx on Hx taking: 1. 2. 3. 4. 5.

Watery diarrhea Vomiting present +-Fever Patient was staying in a hotel Her friends had similar symptoms Note: Sympathize extra with the elderly. Ask if the patient can take fluids and diet without throwing up. If not, admit the patient. Ask if he/she is too lethargic or feels too weak. If abdominal pain, offer pain killers. Always assess dehydration in case of diarrhea. D/D: 1. Acute gastroenteritis 2. Bowel CA (*MUST RULE OUT) 3. Traveler’s diarrhea (Diarrhea will be while on vacation) 4. Pseudo membranous colitis (If antibiotic intake history) 5. Infective (Bacterial) diarrhea (Blood or mucus in stools) 6. Laxative abuse (Take medical history)

Station 17 (Diarrhea) Bowel carcinoma 40 year old man with chronic diarrhea. Talk to patient and discuss D/D with the examiner. Fx on Hx taking: 1. 2. 3. 4. 5. 6. 7. 8. 9.

1 stone weight loss No tummy pain No fever No tummy pain Blood in the stools No family history of bowel carcinoma Smoker No positive sexual history No mouth ulcers/ No skin changes

D/D: 1. CA bowel 2. G/E 3. IBD (fever + tummy pain) 4. Irritable bowel syndrome 5. Malabsorption 6. DM 7. Hyperthyroidism 8. HIV 9. Lactose intolerance

Station 18 (Constipation) Drug induced (cocodamol) constipation 80 year old lady with constipation. Talk to patient and discuss D/D with the examiner. Fx on Hx taking: 1. Pain in ankle 2. GP prescribed cocodamol 3. Ask for medical history. She maybe carrying it with her or remember the name of the drug she is taking. D/D: 1) Drug induced constipation 2) Bowel Ca 3) Diabetic neuropathy 4) Hypothyroidism 5) Low fibre diet 6) Intestinal obstruction 7) Back injury 8) Fecal impaction

Station 19 (Constipation) Bowel Carcinoma 75 year old patient, admitted in hospital and constipation is present. Talk to nurse and discuss D/D with examiner. Fx on Hx taking: 1. 2. 3. 4. 5.

Constipation since 2 months Family history of bowel CA No weight loss Bleeding in stools present Tenesmus, tummy pain, altered bowel habits (+-)

D/D: 1) Bowel Ca 2) Diabetic neuropathy 3) Hypothyroidism 4) Low fibre diet 5) Intestinal obstruction 6) Back injury 7) Fecal impaction 8) Drug induced constipation

Station 20 (Weight loss) Hyperthyroidism 20 year old lady with weight loss. Talk to the patient and discuss D/D with the examiner. Fx on Hx taking: 1. 2-3 kgs weight loss in last 2 months 2. She feels hot 3. Sister has the same symptoms Note: Always ask for weather preference when suspecting hyperthyroidism. D/Ds: 1. Hyperthyroidism 2. Anorexia Nervosa 3. Malnourished 4. Malabsorption 5. IBD (fever + tummy pain +diarrhea) 6. IBS 7. Malignancy 8. TB

Station 21 (Weight loss) Anorexia Nervosa 20 years old lady with amenorrhea. She also had weight loss in the last few months. Talk to patient and discuss D/D with the examiner. Fx on Hx taking: 1. No periods in last 8 months 2. Boyfriend dumped her because he thought she was chubby 3. 6 kgs weight loss over the past few months. 4. No heat/cold intolerance 5. No facial hair/ no acne 6. Periods were normal before 7. Diet according to her is normal and nothing is wrong but dig into it. 8. Takes thyroxine (abuse it) to lose weight as well D/D: 1. Anorexia Nervosa (clever bmw) (Clothing baggy, laxative abuse, excessive exercise, induced vomiting, excessive wt loss, role models are thin people, body image etc) 2. Malnutrition 3. Malabsorption syndrome 4. IBD 5. IBS 6. TB 7. Hyperthyroidism 8. Depression

Station 22 (Calf Pain) Chronic Limb Ischemia 45 year old patient with pain in the calf. Talk to the patient and discuss diagnosis with examiner. Fx on Hx taking: 1. 2. 3. 4.

Pain in last few months, relieved at rest. Smoking in last 20 years. DM +ve (not controlled) Sedentary life style/ no healthy diet

D/Ds to rule out: 1. Chronic limb ischemia (due to atherosclerosis) 2. DVT (Any hotness in calf along with pain, travel hx) 3. Burger’s disease (smoking history, pain not relieved at rest) 4. Ruptured Achille’s tendon (Can you stand on your toes?) 5. Sports injury 6. Ruptured baker’s cyst (Any sort of joint disease?) 7. Sciatica (Pain radiating from back to leg)

Station 23 (Dizziness) Benign positional vertigo 70 years old lady with dizziness. Talk to patient and discuss D/D with examiner. Fx on Hx taking: 1. Had the same S/S previously. 2. Was taking stamatil, prescribed 3 weeks ago by GP 3. Patient stopped meds because of side effects (e.g. headache, drowsiness) 4. Stopped meds last week 5. Dizzy especially during morning while changing dress 6. No bells ringing sensation in ears/ no fever.

D/D: 1. BPV (especially on tilting or change of position of head, loss of balance, vomiting/nausea) 2. Minnere’s disease (bell ringing sensation) 3. Acoustic neuroma (weight loss, loss of balance) 4. Multiple Sclerosis (difficulty & weakness in moving limbs) 5. DM 6. Migraine 7. Otitis Media 8. Drugs e.g. Gentamicin

Station 24 (H/O fall) Non Accidental injury 85 yrs old lady brought in by 60 yrs old daughter. On examination, she notices bruise on arm and forehead. Please talk to daughter and discuss management with the examiner.

 Elaborate the event. Find out if story matches with the injuries or not.  What was done immediately after the event?  Who takes care of the patient?  Is there any previous incidence of the sort/ any previous injury that lead to hospitalization?  Any injury with no record in the hospital? Fx on Hx taking: 1. Daughter said she fell down on the radiator 2. She brought mum 2 to 3 hrs after the incident. No valid explanation for bringing her late. 3. She is not sure about mom’s medical illnesses. She says mom is old and hence has many problems 4. She informs that mom is taking many meds but not sure what they are. 5. Mom lives with this daughter who is her caretaker. D/Ds to rule out: 1. 2. 3. 4. 5. 6. 7. 8. 9.

NAI Osteoporosis Osteoarthritis UTI/Pneumonia in elderly DM Refractory error TIA SAH Hypoglycemia/alcohol/ dehydration/arrhythmias/vasovagal syncope/Adrenal insufficiency

Mx: I will admit my patient. I am suspecting NAI (non accidental injury) or elderly abuse as the history given does not justify or go with the injuries of the patientbut it could be accidental as well. Daughter seems to be careless about mom and she’s the only one taking care of her. I will discuss and confirm this case with my seniors, who may involve social services accordingly. I will order a skeletal survey further if advised by my seniors.

Station 25 (H/O fall) Hypothermia 80 years old lady brought by her son. Rectal temp 34 degrees. Talk to the patient’s son. Give necessary advise. Fx on Hx taking: 1. Son found mom lying on the floor but he doesn’t know the cause. 2. Mom lives alone by herself 3. Son visits once or twice per week 4. Neighbor and friends check on mom now and then 5. (+_) history of DM, osteoarthritis, hypertension) 6. Son informs that mom is becoming forgetful lately. 7. Central heating is on but mom could forget to pay the bill so son pays now. 8. She forgets to close the windows now which the son found open. D/Ds to rule out: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Hypothermia Osteoporosis Osteoarthritis UTI/Pneumonia in elderly DM Refractory error TIA SAH Hypoglycemia/alcohol/ dehydration/arrhythmias/vasovagal syncope/Adrenal insufficiency/NAI Cx: From what you have told me, your mom has got a condition that we call hypothermia, which can be dangerous if left untreated especially at her age. It may affect organs, lead to confusion and may even affect fine movements of hands and limbs. I am sure you do your best and have done your best until now regarding taking care of her but would you like to share this respeciallyonsibility so she is better taken care of? There are people who can be assigned for her care. Or

generally advise him to ask the neighbors and friends to drop in more often to check up on her, if the house is warm and windows are closed

Station 26 (H/O fall) Postural hypotension due to medication 60 yrs old lady presented with history of fall. Talk to the patient and discuss D/D with the examiner. Fx on Hx taking 1. 2. 3. 4.

This patient is on anti hypertensives since 20 yrs Patient went to GP GP reviewed the doses two weeks ago. Patient then developed the complaint of falling.

D/Ds: 1. Postural hypotension due to meds 2. NAI 3. Osteoporosis 4. Osteoarthritis 5. UTI/Pneumonia in elderly 6. DM 7. Refractory error 8. TIA 9. SAH 10.Hypoglycemia/alcohol/ dehydration/arrhythmias/vasovagal syncope/Adrenal insufficiency /Hypothermia/head injury/ epilepsy

Station 27 (Unconscious) Alcohol induced hypoglycemia A young man fell down in front of the pub and went unconscious. Talk to the patient. Ask about fx from the examiner and discuss Mx with the examiner. Fx on Hx taking: 1. Patient was drunk 2. He went dizzy and fell down and can’t remember what happened after that. 3. No DM hx 4. No previous cardiac condition 5. Duration of unconsciousness = 2 to 3 minutes 6. No fever, no rash, no photophobia 7. No jerky movements of body Fx from examiner: 1. GCS 15/15 2. No focal/neurological deficit. D/Ds to rule out: 1. Hypoglycemia induced by alcohol, leading to the unconsciousness/fall. 2. Head injury (ENT Bleed, vomiting) 3. Epilepsy (Prev hx of fits) 4. A Fib 5. Poisoning 6. Meningitis Mx: I will admit this patient. I will check for his random blood sugar, send for a full blood count and do a 24 hrs ECG monitoring while doing neuro observation. I’ll do CT scan if necessary as well, having informed my seniors.

General Knowledge regarding head injuries

(Indication for admission in head injury) 1) LOC 2) GCS less than15 3) Amnesia 4) Any focal, neurological deficits 5) Vomiting 6) Altered bowel habits 7) NAI

NICE guidelines for CT Scan in patients 1) Loss of consciousness> 5 minutes 2) GCS < 14 after admission 3) In peds, GCS < 15 4) Any S/S basal/skeletal fracture 5) Vomiting > 3 times in kids and < 2 times in adults 6) Any focal or neurological deficit 7) Amnesia > 5 minutes 8) Any laceration > 5 cm on the head.

Station 28 (Diplopia) Muscle palsy of right lateral rectus 47 yrs old lady comes with c/o diplopia. Talk to patient and discuss D/D with examiner. Fx on Hx taking: 1. The patient is a teacher by occupation. 2. When writing on the board, sees double on the right side 3. Few months ago, while reversing her car, hit bumper on the wall due to double vision. 4. Doesn’t wear glasses 5. No headache, no vomiting 6. No S/S of hyperthyroidism, SOL, MS D/Ds 1. Muscle palsy of right lateral rectus 2. Multiple sclerosis 3. GCA 4. SOL 5. Cataract 6. Hyperthyroid 7. Inflammatory orbit myositis 8. Refractory error 9. Myasthenia gravis

Station 29 (Sore Throat) Infectious Mononucleosis 25 yrs old man presented with c/o sore throat. Talk to the patient and discuss D/D with the examiner. Fx on Hx taking: 1. 2. 3. 4. 5. 6. 7. 8.

Fever in last few days Reddish and itchy rash on the chest Travelled to Rome 2 weeks ago No difficulty in swallowing No vocal abuse No instrumentation No weight loss Not sexually active/Protected sex

D/D: 1. Infectious mononucleosis 2. Mumps 3. Vocal abuse 4. Smoking 5. Carcinoma 6. Hay fever 7. Tonsillitis 8. URTI

Station 30 (DKA) Pilot Station 35 yrs old lady with p/c vomiting, diarrhea and abdominal pain. She is a known case of DM. She missed insulin dose. Dx of DKA has been made. Talk to the patient and explain the condition and importance of admission and address her concerns.

Fx on Hx taking 1. Dr, I have DM + vomiting + tummy pain.your colleague did some blood tests and put IV cannula on my hand. 2. I have two kids waiting at home. Her partner is not home as well. 3. On your disclosing the Dx, she asks what’s DKA? Tell her it’s a dangerous complication of DM caused by lack of insulin in your body. It happens when body is unable to use blood sugar because of deficiency of insulin. The body breaks down the fat as an alternative fuel. This can build up substances we call ketones. 4. Why can’t you send me home with IV fluids? We have to keep you because we have to monitor you and do investigations repeatedly. We have to check your blood for blood sugar levels and for other substances in the blood (Potassium). We also have to check your urine for some substances and treat accordingly. We may also need to give you different fluids + minerals + insulin (which pushes sugar into cells) until you are out of this condition. It’s important that we keep you in the hospital. 5. Ask her if there is someone who can take care of the kids. Otherwise tell her you will talk to the consultant and see if something can be done to either bring them over for a while or if someone can be arranged to take care for them at home. Ask their ages beforehand. This patient fusses and insists a lot about wanting to go home so take your time explaining her why she needs to be kept in the hospital until 4 30 bell rings.

MEDICINE (Common Stations) Hx + Councelling

1) Sexually Transmitted illness Hx + Cx Cx Only Hx (2 scenarios) 2) Osteoporosis Hx + Cx (2 scenarios) 3) Stroke follow up Hx + Cx 4) Post MI Hx + Cx 5) Needle stick injury (2 scenarios) 6) Epilepsy Hx + Cx Cx Hx + D/D 7) CKD Hx + Cx 8) Paracetamol Poisoning Hx + Mx (with patient) 9) Chronic Fatigue Syndrome Hx + Cx 10)IV cannula blocked

Questions to ask in every STI station 1. How many partners do you have/had in the last few months? 2. Do you use condoms (protection)? 3. Route of sex? 4. Your sexual partner is a male or female? 5. Previous STI? 6. Previous medical illness? 7. Any allergies to meds? (Always ask before prescribing meds) Symptoms you should ask      

Fever Dysuria Eye symptoms Knee joint pain/symptoms Discharge from urethra Ask if he noticed any ulcer, discharge, swelling or lump in groin area.

Investigations: 1. Genital swab test 2. Complete Urine exam (Urine culture and sensitivity) (chlamydia) 3. Blood test for HIV and Hepatitis Tx: Doxycycline 100mg BD for 1 week (1st line for Chlamydia) Azithromycin 1g single dose given (1st line for Gonorrhea) Ceftriaxone 500 mg single dose given

General Advise you need to give in every STI station: 1. Don’t have sex even with condoms or protection.

2. Don’t have sex until receiving a negative test result, and until treatment is completed. 3. Even if sexual partner has no symptoms, the sexual partner should be checked and treated accordingly. 4. Please ask the patient after any unprotected sex outside his relationship, he had sex with his/her own partner. If the answer is no, drop it. If the answer is yes, ask if they can ask their partner to come over to get checked and for any necessary treatment. If the patient is unable to call them himself, talk about partner notification program. (A program that enables hosp to send anonymous letter to the patient’s partner asking them to come in for a routine special check up just for safety reasons).

Station 1 (STI) 55 yrs old man presented with discharge to your clinic. You are SHO in the gum clinic. Talk to the patient and take Hx, discuss investigations with patients (sometimes) or council patient and address his concerns. Fx on Hx taking: 1. 2. 3. 4. 5.

Came to London and had unprotected sex 2 weeks ago. Yellowish discharge since 2 days +- Fever +- Burning sensation on passing urine Had sex with the wife after the event

Cx: From what you’ve told me, you have STI, which is an infection that can pass from one person to another when they have sex. I have to run some investigations. We do Urine tests and we take a sample from discharge. Would you like to have blood tests for HIV and Hepatitis just to be on the safe side? We treat with medications (antibiotics) which can clear this bug. This medication is given according to test results, either in a single dose form or for one week. Please don’t have sex with your partner even with protection (condoms) during this week until the test results come negative. Did you have sex with your partner after this event? Can you ask your partner (wife) to come? Talk about PARTNER NOTIFICATION PROGRAM otherwise. Explain how it is important to treat the partner, otherwise it will remain untreated and might spread from one person to another during intercourse and can bring complications without treatment.

Station 2 (STI) Young girl 24 yrs old, comes to gum clinic with complaints of discharge. She had unprotected sex 3 weeks ago when she met her boyfriend. Now she’s in the clinic to get her report of investigations. He was in the clinic last week as well and some investigations were done. Report shows she has gonorrhea. Talk to the patient. (Take Hx and the fx are given above) Cx: From the lab report, it shows you have STI. For treating the bug that causes this condition, we’ll give you a tablet or injection that you can get here. Give patient general advise about not having sex while being treated and until tests are negative. Tell her the importance of treating herself and getting her partner treated as well. Tell her to complete her meds even if symptoms subside. If STI is left untreated, there are some complications e.g. you may get PID (inflammation of tubes) and may face problems when you get pregnant e.g. ectopic pregnancy (pregnancy outside tubes) and premature baby. You may face infertility and miscarriages are a complication of untreated STI as well. As a part of general advise, risk of STI will increase if you don’t practice safe sex and if you change sexual partners often or have multiple sexual partners. So practice safe sex.

Station 3 (STI) A 50 yrs old man travelled to Berlin. He had unprotected sex with a girl. Take sexual history. You are the SHO in gum clinic. Do not advise about HIV. Fx on Hx taking: 1. I had sex while I was drunk. The condom slipped but I continued. 2. Also had oral sex. 3. No fever, no discharge, no ulcer, no weight loss 4. Had sex in a legal area. 5. He had sex with wife after that day. 6. He claims to be committed to his wife and is a married man. Questions to ask in every STI stations 1. How many partners do you have/had in the last few months? 2. Did you use condoms (protection)? 3. Route of sex? 4. Your sexual partner is a male or female? 5. Previous STI? 6. Previous medical illness? 7. Any allergies to meds? (Always ask before prescribing meds) Symptoms you should ask

     

Fever Dysuria Eye symptoms Knee joint pain/symptoms Discharge from urethra Ask if he noticed any ulcer, discharge, swelling or lump in groin area.

Station 4 (STI) A young lady comes to gum clinic. Talk to patient and take sexual history. Assess for any possibility of STI. Fx on Hx taking: 1. On being asked what brought her to the clinic, patient says her husband told her that he had sex a month ago, with another girl. 2. He was drunk and says can’t remember if used protection or not. 3. She had sex with him a few times after that event. 4. The route of sex was vaginal and sex was unprotected between the husband and wife. 5. No discharge or fever. No eye or knee probs. 6. Both of them were symptom free. 7. If she asks, will you do any tests for me, tell her yes but you would like to first ask her a few more questions and take a detailed history.

Station 5 (Osteoporosis) 47 yrs old patient General knowledge regarding osteoporosis Dexa Scan Less than -2.5 = Osteoporosis -1.5 to -2.5 = Osteopenia Greater than -1.5 = Normal Risk factors:      

Hx of prev wrist/hip fracture. Any parental Hx of osteoporosis Any osteoarthritis Alcohol > 4 units per day Steroid intake There are chances of low bone density in Crohn’s disease, ankylosing spondylitis or OA. Also with BMI 35 yrs. 5. Patient is a smoker (20 cigarettes/day), takes alcohol (>14 units/week) and is overweight. 6. She has uncontrolled DM sometimes. 7. Rule out SLE and APL syndrome and other medical illnesses. 8. She is a police woman by occupation. Doctor, I had bleeding and went to the hospital and they told me the baby’s gone. Ask about any meds given, or instrumentation done when miscarriage confirmed. They said wait and see. No meds given.

Station 8 (PID) 35 years old patient was admitted & was diagnosed with PID. She was given broad spectrum antibiotics. USG showed hydrosalpingitis. Patient was on COCPs. Talk to the patient and address concerns regarding PID. Doc, what is the cause of this condition? PID is an infection of the womb + of the tubes connecting the ovary to the womb. It affects ovaries as well sometimes. There are many causes of this condition. It can be passed through sexual intercourse, can be caused by bugs especially if you have an IUCD inserted or had any instrumentation or procedure done. Do you think I got this from my bf? The boyfriend may have this condition from previous relationships without having symptoms. It doesn’t mean your partner got it just now. (This is to prevent the patient from having an outburst regarding her bf). Dr, what should I do? Can you bring your partner in? If she says yes, tell her it is important to complete the treatment for both of you which in this case will be antibiotics. You’ll have to avoid sexual intercourse until the treatment has ended, even with protection (condoms) and should only resume when tests come negative. Dr how can I prevent this from happening in the future? 1. Practice safe sex. 2. Keep to a single partner/stable relationship and increased number of partners, enchances the risk for all STIs. Complications?

As long as you take meds, it’s fine. If left untreated, it may cause 1. 2. 3. 4. 5. 6. 7. 8.

Infertility Ectopic pregnancy Persistent pain (backache and pain during sex) Miscarriage Still birth Premature baby Abscess Collection of pus around your womb

If we can treat you and if you comply to meds and if you prevent it from having again, hopefully you should be able to conceive. There is a chance of either of the tubes being scarred but one can have babies, even with one tube intact.

Station 9 (Amenorrhea) 20 years old lady with amenorrhea. She also had weight loss in the last few months. Talk to patient and discuss D/D with the examiner. Fx on Hx taking:

1. No periods in last 8 months 2. Boyfriend dumped her because he thought she was chubby 3. 6 kgs weight loss over the past few months. 4. No heat/cold intolerance 5. No facial hair/ no acne 6. Periods were normal before 7. Diet according to her is normal and nothing is wrong but dig into it. 8. Takes thyroxine (abuse it) to lose weight as well D/Ds to rule out and say 1. Anorexia Nervosa (clever bmw) (Clothing baggy, laxative abuse, excessive exercise, induced vomiting, excessive wt loss, role models are thin people, body image etc) 2. Malnutrition 3. Malabsorption syndrome 4. IBD 5. IBS 6. TB 7. Hyperthyroidism 8. Depression

Station 10 (Infertility) 29 years old lady presented with infertility. Talk to patient and discuss D/Ds with the examiner. Questions to ask How long have you been trying to conceive? How often do you have sex? Partner has kids from any previous relationships? Any chronic illness? UTI? Any prev surgery? Also rule out D/Ds. The first two are the usual diagnosis in this station. D/Ds: 1. Ashermann syndrome (Cyclic pain during pregnancy but no periods) 2. Sheehan syndrome (Hx of excessive bleeding during previous delivery) 3. PCOs 4. Hyper/hypothyroidism 5. Chronic illnesses e.g. HTN, DM, Kidney failure 6. Being over weight/ underweight 7. Excessive exercise 8. PID (fever, lower abdominal pain, discharge) 9. Endometriosis (Bleeding from any place other than vagina?) Fx on Hx taking 1. 2. 3. 4.

Patient has sex 3 to 4 times per week Partner has baby from another relationship Abortion = 2 yrs ago with excessive bleeding or Every month has pain with no bleeding

Station 11 (Ectopic Pregnancy) 29 years old lady presented with vaginal bleed and abdominal pain. LMP =6 weeks ago. Pregnancy was confirmed via urine test. USG confirmed ectopic pregnancy. Consultant decided laproscopic surgery. Take Hx and address patient’s concerns. Questions to ask Do you know what’s going on? What have they done for you? She will reply saying USG was done. You have, am sorry to say, what we call ectopic pregnancy which is pregnancy that’s outside the womb. Doctor, why did I get it? This may have many causes. If you have any previous ectopic pregnancy or if you have any scars/damage to your tubes due to PID or previous surgery, you may get this condition. Using IUCD and some meds for treatment for infertility may be the cause. At Age > 35 yrs, there are increased chances of getting it. What are you going to do for me? We will have to admit you and may remove the tube containing ectopic pregnancy or may only remove a section of tube which has ectopic pregnancy. If not dealt with, this can cause serious complications and can even be life threatening as the tube might burst, spreading infection. Can I have a baby? As long as the other tube is working, you can have the baby. Ask consent when 4:30 bell rings if consent not already taken.

Station 12 (Pain Mx during labor) 36 weeks pregnant lady is planned for a delivery in the next 2 weeks. Talk about pain Mx in labor. Mx: 1. Self help. Learn about how to relax and calm yourself especially during pain. 2. Do breathing exercises. 3. Bring in partner or friend to do massage or to help you emotionally get through this. 4. We can give you ENTONOX (which is 50% Oxygen and 50% NO). it is also known as the laughing gas and is harmless for you and the baby. You can simply breathe it in using face mask. You can take it whenever you want, although too much of it can make you dizzy or sick. It isn’t much effective against actual labor pains. 5. We can also go for TENS (Trans-cutaneous electrical nerve stimulation). It is a small device, attached to the belt of your gown and it has a few leads attached around your tummy and back. It prevents pain signals from reaching your brain and also causes your body to release feel good hormones (endorphins). It can be used during early labor but not once the pain has actually started. Its effectiveness is highly reduced in actual pains. Also it can’t be used in pool deliveries. 6. We can also give you IM Pethidine which is given during early part of the labor and it usually wears out by the end. Its affect takes 20 minutes to start. And its dose cannot be repeated as it causes breathing difficulties in the baby and can cross the membrane surrounding your baby. If given, neonatal team will be monitoring your baby during labor. Anti sickness meds are given, if any sickness feeling is caused by it. 7. Last but most effective is the epidural injection, which is given using a needle to your back. It causes complete numbness and even sometimes tingling in lower tummy and legs. You won’t feel any pains or baby coming down so will be asked to push. Urinary catheter

will be inserted before this. Instrumental delivery may be required. If things don’t work out with the delivery due to some complication, LSCS will be considered.

Station 13 (Dysmenorrhea) A young lady presented with c/o dysmenorrheal. Please talk to the patient and discuss different methods of Mx. Sympathize/empathize. Ask her what she already has done for it. Did she take any meds already? Mx: 1. Use hot water bottles 2. NSAIDS. Take them regularly. Start one day before the date of periods. [Check which NSAID she is taking. You can switch normal cocodamol/brufen to mefanamic acid (not available over the counter)] 3. COCPs. They help is contraception but also decrease bleeding and pain as well. S/E: headache, acne, sickness, leg cramps, light headedness and weight gain. 4. Mirena. (Coil fitted in the neck of your womb). It is put in after ruling out contraindications like any womb infections, pregnancy etc. It too helps in decreasing the amount of bleeding. No general S/Es but if you have any, they can be sorted out immediately. 5. Progesterone only pills (Mini pills). This pill doesn’t increase weight and decreases pain and bleeding but can cause greasy hair and skin. May even cause a whitish discharge from vagina to occur.

Station 14 (Hyperemesis Gravidarum) 9 weeks pregnant lady presented with complaints of vomiting. Urine test has been done and ketones came positive (3+). Talk to the patient and discuss Mx. Fx on Hx taking 1. Urine output is less than normal 2. Patient cant eat or drink anything 3. She is very tired and lethargic Rule out D/Ds 1. 2. 3. 4.

Hyperemesis gravidarum DKA (Hx of DM) G/E Hydatidiform mole (Passing of grape like structures from vagina) 5. UTI 6. SOL (Headache, visual probs) What’s hyperemesis gravidarum? It is prolonged and severe sickness in pregnancy which sometimes leads to loss of body fluids. It may develop vitamin deficiency and starving. What’s the difference between morning sickness and this? Morning sickness happens between 9 to 16 weeks of pregnancy. Doesn’t affect the eating habits of the pregnant woman and is normal is every pregnancy. Why does it need to be treated? Body is losing fluids and vitamins due to the continuous vomiting on intake of any food/fluids. It is dangerous to your health and the health of the baby. What are you going to do? We’ll admit you. Do an USG to check if baby’s fine or if there were any chance of multiple pregnancies being

there. We’ll give IV fluids + vitamins (thymine) if necessary. Anti emetics may also be given if and when needed. All the meds given are safe for the mother and baby so don’t have to worry on that note. When better and discharged, at home take small meals at short intervals. Don’t self medicate and avoid caffeine.

Station 15 (Ovarian Cystectomy) 30 yrs old lady planned for ovarian cystectomy. Surgeon decided to do pfannenstiel incision and subcuticular stitches. Discuss about surgery and complications and address concerns. Patient’s concerns in this station are: Can I have a baby still? One tube will be working so yes. Sex life Can be resumed after 2 weeks. Complications? 1. Pain (We have excellent pain management team). 2. Bleeding (We have an expert team of surgeon who will control any bleeding then and there and will hopefully not land into any complications). 3. Infections (We give meds to cover that). Antibiotics are given 4. Damage to surrounding structures (Our surgeons are experts and hopefully will prevent that from happening).

Station 16 (Diabetes in Pregnancy) A young lady is planning to get pregnant. She is a known case of DM. Talk to the patient and address concerns. Cx: When you are planning to get pregnant and have DM, your body needs more insulin. That’s why you should be more careful about controlling your blood sugar and hence need more follow ups with the doctor and need more monitoring and treatment. If DM is not controlled during pregnancy, it may harm you and your baby. Talk about non medical Mx first. 1. 2. 3. 4.

Eat small but frequent meals Reduce weight Exercise Medical Mx is insulin which will be set and given as needed.

If DM is not controlled, it may cause in mother: 1. 2. 3. 4.

Premature birth Miscarriage Infections Too much fluid around baby

In the baby 1. Big baby 2. Congenital deformities 3. Low RBS of baby DM may persist after pregnancy in some women so there is a chance if she didn’t have it before, to continue having it after pregnancy. But it is not for sure.

Station 17 (OCPs) Patient had DVT 4 months ago. Talk to the patient about different methods of contraception. OCPs will be forbidden in this patient. Talk about mirena, or progesterone only pills only.

Station 18 (Dyskaryosis)

Psychiatry (Common Stations) Offer confidentiality in almost all stations. Say the line ‘Whatever you say will remain between you and our medical team’ otherwise patient may not talk or tell you much.

1) MMSE (Learn the folder page) 2) Suicide Hx + Mx (with examiner) Hx Hx + Mx (with examiner) 3) Psychotic patient (Hx) 4) Alcohol dependence Hx + Cx Only Hx 5) Drug dependence Hx only 6) Panic Attack (Hx only) 7) Insomnia Hx + Cx 8) SSRI Hx + Cx 9) Postpartem psychosis 10) Depression 11) Bipolar disorder (Pilot) QUESTION PATTERN TO FOLLOW IN PSYCHIATRIC STATIONS

1. Offer confidentiality in almost all stations. Say the line ‘Whatever you say will remain between you and our

medical team’ otherwise patient may not talk or tell you much. 2. Sympathize/empathize (MA F(4)AMISH) 3. Mood (ask him to grade mood from 1 to 10, 1 being the lowest and 10 being the highest mood.) 4. Anhedonia (Loss of pleasure in activities that previously meant a lot or he/she loved. 5. Family (is the family close/loving/supportive?) 6. Friends (Does he/she have friends to hang out with and he is close to) 7. Finance (Does he have any financial troubles at home?) 8. Forensics (Has he/she ever been on the other side of the Law? Convicted for some crime?) 9. Alcohol and recreational drugs 10.Med Hx and past psychiatric hx (Has he ever had to take councelling sessions before?) 11.Insight (Do you think you need help or that we might help you?) 12.Suicidal tendency/Stress (Have this problem led you to think that life has lost it’s worth. How do you see yourself in the future? Has it become difficult for you to plan for the future?) 13.Hallucinations + delusions (When people are going through hard phases, they tend to experience sometimes, seeing and hearing things that is hard for others to experience. Has this happened to you? Do you have any thoughts or ideas you may have hard time convincing your family/friends of?) M(ood)ISH in the above history is the set of questions we use to rule out suicide tendencies in people. If any one of the 4 questions is positive, the patient will have to be admission and H/O has the right to detain the patient in the hospital until he is out of harm’s way from himself. If mood is < 3, patient again have to be admitted.

If mood is 2 weeks, it’s post natal depression. If thoughts of harming the child are there as well, then it’s post partem psychosis.

Station 13 (Depression) A 32 year old female patient, with low mood, lost her husband a few months back. Take history and council her. A patient with rheumatoid arthritis complains of insomnia. He is on medications. Take history and councelling. (In the 2nd station, also ask since when the patient had RA and if she is taking meds and if they are effective or not. Also if the pain is controlled or not and then the MA FAMISH Hx)

1. Offer confidentiality in almost all stations. Say the line ‘Whatever you say will remain between you and our medical team’ otherwise patient may not talk or tell you much. 2. Sympathize/empathize (MA F(4)AMISH) 3. Mood (ask him to grade mood from 1 to 10, 1 being the lowest and 10 being the highest mood.) 4. Anhedonia (Loss of pleasure in activities that previously meant a lot or he/she loved. 5. Family (is the family close/loving/supportive?) 6. Friends (Does he/she have friends to hang out with and he is close to) 7. Finance (Does he have any financial troubles at home?) 8. Forensics (Has he/she ever been on the other side of the Law? Convicted for some crime?) 9. Alcohol and recreational drugs 10.Med Hx and past psychiatric hx (Has he ever had to take councelling sessions before?) 11.Insight (Do you think you need help or that we might help you?) 12.Suicidal tendency/Stress (Have this problem led you to think that life has lost it’s worth. How do you see yourself in the future? Has it become difficult for you to plan for the future?)

13.Hallucinations + delusions (When people are going through hard phases, they tend to experience sometimes, seeing and hearing things that is hard for others to experience. Has this happened to you? Do you have any thoughts or ideas you may have hard time convincing your family/friends of?)

Cx: It seems you have a condition we call depression or low mood. (Assess if patient needs admission or not after ruling out MISH from the Hx and council accordingly). There is usually a chemical or hormonal imbalance in the body which causes one to feel like this sometimes. However we will do some investigations (if med causes aren’t ruled out) and don’t worry. We will help you (Cognitive behavior therapy) and you will sit and be able to talk to one of our colleagues. He will listen to your problem and talk to you and will hopefully be able to change any negative views you might be having. If that doesn’t work, our consultant might put you on some medication. We will also encourage you to go for self help group sessions. Once you feel better, try improving your social life, adopt hobbies, socialize and make friends.

Station 14 (Bipolar disorder) Pilot Station A 30 year old female presented to the A & E because she cut her wrist. Patient is medically stable now. Nurse noticed that she was acting strangely. Talk to the patient and discuss Dx with the examiner. Fx on Hx taking 1. Doctor, I was going out to a party with my friend and I realized I needed a pair of shoes. 2. Unfortunately all shops were closed. I smashed a window and took shoes. 3. Since 2 weeks now, my mood has been excellent. Never felt better. 4. I have spent a lot of money recently. I have been going out and enjoying a lot. 5. Regarding insight, she says the idea of smashing the window wasn’t acceptable and was wrong. Otherwise she did nothing else wrong. 6. I used to study at a uni. 1 year ago I left and was real depressed for a while and cried a lot. 7. Live with family. Not that supportive. 8. I am bankrupt and have used all my credit. 9. No suicidal thoughts. No hallucinations.

Pediatrics (Common Stations)

1) Inconsolable Cry (Distressed mother) (Hx + Cx) 2) Non accidental injury a) (Scald on chest) Hx + Mx (with examiner) b) (Scald on buttocks) Hx + Mx (with examiner) c) (Fracture femur) Hx + Mx (with examiner) d) (Telephone conversation) 3) Fits Febrile Convulsions (Hx + Cx) Unknown (Hx + Cx) Epilepsy (Hx + Cx) Hypoglycemia (Hx + Cx) 4) Fracture Femur + Ruptured spleen (Breaking bad news) Cx 5) Unconscious patient Vasovagal (Hx + D/D) Head injury (Hx + Mx) 6) Delayed walking (Hx + D/D) 7) Spacer device (Cx) 8) Foreign body (Hx + Cx) 9) Celiac disease (Cx)

In peadiatric Hx, 4 questions in History pattern (P3 MAFTSA) are added! After past Hx, take birth, immunization, developmental and Hx regarding bladder/bowel habits and diet.

Station 1 (Inconsolable Cry) Infantile Colic 3 months old child was brought to the hospital due to excessive cry. This child was discharged last night by your consultant because all the investigations including FBC, CSF and USG were normal and your consultant believes there’s no serious condition. Mother of the child tells you that the child has been crying since 5 am and that’s why she brought to the hospital again. Talk to mom and address her concerns. Note: You aren’t just dealing with a crying baby but distressed mother as well. Do not forget to sympathize/empathize. Could you please tell me what happened? Have you noticed any change since the consultant last saw you? (Rule out meningitis (Vomiting & neck stiffness) and intersucception (pulls legs towards chest while crying) if you want!) Am sure you fed your little one. Is that right? Am sure you change his nappy on time. Is that right? Did you try to distract your little one by taking him out? Am sure you burped your little one, is that right? Did you try distracting your little one with washing machine or hover etc? Do you breast feed or bottle feed? If she says yes to bottle feed, tell her some foods contain a substance called lactose which some kids/people aren’t able to digest and maybe that is why baby’s crying. Try changing the milk to lactose free. You can also try giving two harmless medications that come by the name of infacol or gripe water. You may try them and they may be helpful.

Mom: Is it normal for the baby to cry like this? What is the cause of this excessive cry? Don’t worry. Your little one probably has a condition we call ‘infantile colic’ in which baby cries excessively but is healthy otherwise. Mom: What can cause this colic? Some research shows this may be related to change in levels of some substances that effects movement of gut. There is another theory in which they say there’s an abnormal balance of bugs in the baby’s gut which gradually corrects itself in a few weeks. What to do for mom? Note: Please look at mom’s actions and face. If she’s trying to tell you she’s too tired or exhausted ask her, if she has anyone else at home to take care of the baby.If she says no and tells you she has other kids as well, tell her: If you don’t mind we can keep your little one in the hospital for tonight. We will take care of him. This admission isn’t because of medical conditions. This is so that you may be able to rest and be stress free for a night about the baby. Advise if this happens in the future, call cry-sis line, talk to health visitor or contact her GP. If mom tells you she has someone at home who call help look after the child or she isn’t tired, then don’t offer admission. Reassure the mom again it’s not serious.

(Non Accidental Injuries) Presentations in NAI  Symptoms do not match the story  Unexplained injuries  Late presentations  Inappropriate immediate action  Having other carer apart from biological father/parents  X ray showing calluses with no previous medical history explaining the injuries on X Rays  Odd behavior from parents.  Dysfunctional family  Hx of many recent admissions  Odd behavior from the child e.g. after sexual abuse.  Ask about birth of the baby, if it was planned or not. Questions to ask in NAI 1. Make the parent to elaborate the event. Explain the event in detail 2. Ask about time of incident 3. Ask about mom’s action after incident 4. Ask about who takes care of the baby. Check if biological dad or not 5. About any other unexplained injuries found, look at mom’s response/reactions 6. Any change in behavior of the baby 7. Pregnancy regarding this child was planned or unplanned 8. Was birth complicated or without complications Mx: 1. 2. 3. 4. 5. 6.

Admit the baby. Give pain killers and do dressing if any wound. Do x-rays if suspecting fractures and refer to ortho Do coagulation profile if unexplained bruises. Do skeletal survey if unexplained fractures. Ask seniors to check child’s name in the ‘child protection list’ 7. Ask consultant to confirm this as NAI & involve social services if needed.

Station 2 (Non Accidental Injury) Scald on the Chest 4 years old boy brought to the hospital with a scald on the chest. Talk to the mother and discuss your management with the examiner. What happened? The mom tells you coffee dropped from the table while baby pulled the cloth. That’s how he burnt his chest. What did you do after the incident? Doc, it happened this morning and it didn’t look that serious so I didn’t do anything. I took my kid to school after 1 hour. They called me from school and told me that the baby was crying. Who takes care of your little one? Usually I take care of my baby. The father of the baby is a van driver so not at home usually. So I have to take care of him and my other child as well. The pregnancy was planned/unplanned. No difficulty during birth. Mom: What are you going to do for my little one? We have to keep your little one in the hospital to manage the burn. (Mx with the examiner) I’ll admit the child. I am suspecting NAI but it can be accidental as well. I’ll manage the burns by giving the child pain killers and dressing his burns after cleaning. I’ll discuss with my seniors and ask them to check this child’s name in the ‘Child’s protection list’. I’ll ask my consultant to confirm this as NAI and involve social services if necessary.

Station 3 (Non Accidental Injury) Scald on the Buttocks 4 months old boy brought to the hospital with a scald on the buttocks by mother. The nurse noticed some bruise on the arm as well. You are an SHO in the A &E. talk to the mom and discuss Mx with the examiner. What happened? Doctor I was going to give my little one a bath, but I forgot to open the cold water tap. Baby started crying and I realized what I had done. I was kinda tired at that moment. What did you do? It happened an hour ago and I rushed him to the hospital. There was a traffic jam (is the excuse given if she is late). Me and his father takes care of the baby. It was a planned pregnancy and birth was normal. Mom hasn’t got any idea about the bruise. (Mx with the examiner) I’ll admit the child. I am suspecting NAI but it can be accidental as well. I’ll manage the burns by giving the child pain killers and dressing his burns after cleaning. I’ll send for the coagulation profile of this baby. I’ll discuss with my seniors and ask them to check this child’s name in the ‘Child’s protection list’. I’ll ask my consultant to confirm this as NAI and involve social services if necessary.

Station 4 (Non Accidental Injury) Fracture Femur 2 years old boy brought to the hospital by his mother. There’s a swelling on the leg. You are an SHO in the A & E. Talk to the mother. Discuss Mx with the examiner. How did it happen? I am a night shifter. Work at a 24 hour shop. Last night I had a shift and when a came home this morning, the child was crying. While I was changing the nappy, I realized there was a swelling on the thigh. Who takes care of the child? Did you ask your bf/partner regarding this bruise? My bf does as well. I asked him but he didn’t know or he was sleeping is her answer. Ask how soon she brought the child to the hospital and the rest of the questions. (Mx with the examiner) I’ll admit the child. I am suspecting NAI but there’s a small chance of accidental as well. I’ll give him pain killers and do X ray. If fracture is present, will refer him to ortho. I’ll discuss with my seniors and do a skeletal survey in the child and ask them to check this child’s name in the ‘Child’s protection list’. I’ll ask my consultant to confirm this as NAI and involve social services if necessary.

Station 5 (Non Accidental Injury) Telephone Conversation 6 months old child was brought to A & E. there’s swelling on the arm. X Ray has been done and shows humerus fracture. X ray also shows callus bone formation in ribs. You notice some bruise on buttocks, You talked to the mom and she told you her little one fell down from sofa. She takes care of the little one with a partner who is the biological father of the baby. Pregnancy was unplanned. After taking history, during investigations and examination, you suspect NAI. Please talk to peads consultant on the phone.

 

Pick up the phone up

 

Greet the consultant

Tell him your GMC number. You will be wearing the batch.

Identify he is the right person  Explain the case in terms of Clinical presentation and Hx. What you did for investigations and what you picked up during examination. (All will be mentioned in the task paper).  Explain what you have done so far o I took History and did investigations as I mentioned earlier. I did the X ray and on noticing the fracture of humerus, gave him painkillers and referred him to ortho. I also noticed a bruise and so sent for coagulation profile. I’ll ask the seniors to check the child’s name in the ‘Child protection list’ as there’s callus bone formation in ribs present on chest X ray of the child.  I want you to kindly come and confirm if it’s a NAI and involve social services accordingly.

Station 6 (Fits) Febrile convulsion 2 years old child had a fit episode. He was admitted 24 hrs ago with c/o some URTI or ear discharge in the last few days so he was unwell and he had c/o fever and vomiting. Dx of febrile convulsions was made already. Talk to mom and confirm your diagnosis. Address patient’s concerns. In this station please rule out: 1. 2. 3. 4. 5.

Meningitis DM (hypoglycemia) Epilepsy Head injury Ask about fever

What happened? How long was the fit? Doc, my little one had fever/flu like symptoms. I brought my child to the hospital and he was admitted. From what you told me, your little one has febrile convulsions and it happens when fever is high. What is that? Febrile convulsions happen in kids at age of 6 months to 5 or 6 years. This is not a serious condition as long as the fit doesn’t last long. Usually children grow out of this condition and this doesn’t lead to epilepsy. Mom: Is it serious? Future occurance? Prevention? As long as you control the fever, that’s fine. You can use paracetamol for that. However if there’s ever an episode of fit, during this fever, put the child in the recovery position and turn the child to his side. Do not give him any food/drinks while he is having fits or don’t put anything in his mouth. Remove any sharp furniture from around and try to remove the clothes and open the windows once fits subside. Shall I give my little one any medicine?

Yes you can give him paracetamol (calpol) whenever you feel like he is building fever because that is what causes this. It will control the fever and prevent fits from occurring. Note: Rectal diazepam is only used in recurrent fits or if the hospital is 2 hrs away from the patient’s house. Do not mention it if the patient doesn’t ask about it herself. Reassure her it’s not epilepsy even if she gives you the finding of eyes rolling or biting of the tongue since it says in the task that febrile convulsions has been diagnosed. Epilepsy is due to brain abnormality. Febrile convulsions are due to febrile illness.

Station 7 (Fits) Unknown Cause 4 years old boy brought to the hospital with fits. Talk to the mom and address concerns. Fx on Hx taking 1. It happened when we were in the shopping plaza. 2. It took 2 to 3 minutes. 3. I am not sure child had fever earlier or not. But I am sure he had fever afterwards. 4. He had a jerky movement and it was the 1st time this happened. 5. Wet himself (+-) 6. Confusion after fits (not sure) Make the mom explain what happened before and after this event and take a detailed Hx for fits and rule out D/Ds: 1. Febrile Convulsion 2. Epilepsy 3. Febrile Convulsion 4. Meningitis 5. SOL 6. Head injury 7. Hypoglycemia Mom: What are you going to do for me? I’ll admit your little one to run some investigations to figure out the cause of fits. We’ll do some blood tests. We will do a 24 hrs EEG and other tests e.g. CT scan, CSF (Culture & sensitive) if the consultant feels a need for them to be done. We will keep your child under neuro observation. If everything is fine, it might be febrile convulsions, which is fits caused in child due to fever. Explain how its not a serious condition and can be prevented in the future. Note: In this station, Hx sometimes point towards epilepsy (especially if he wets himself). Tell mom you suspect epilepsy

then from the history that she gave but you are not sure and will confirm only after you have run the investigations.

Station 8 (Fits) Epilepsy 4 years old boy brought to the hospital with fits. This child is a known case of epilepsy. However his epilepsy is poorly controlled. Talk to mom and address concerns. Questions you must ask 1. Since when was the epilepsy Dx? 2. Any change in the pattern of fits? 3. Medications the child is on? (Ask if she knows their names)  Is he taking them regularly as prescribed?  Who supervises the meds?  Do you remember any dose missed?  Have you recently started any new meds?  Any over the counter or herbal meds the child maybe on? 4. Any vomiting, diarrhea or weight gain recently? (the meds dose needs to be increased in a growing child) 5. Trigger questions (Does he watch too much TV, play video games or stay up watching stuff til late? Does he sleep properly? Does he skip meals? Is he exposed to flashing lights ? 6. Is he complying with meds? Ask if he suffers from any S/Es because they meds can be switched in that case or doses adjusted. 7. In general advice, talk about trigger findings and council the mom against the factor causing him to have more regular fits especially if he plays or watches til late. 8. Mention bracelet that he should always be wearing (Being epileptic) + inform GP + School nurse of the child’s condition.

Station 9 (Fits) Hypoglycemia 2 years old baby had a fit. Investigations have been done. This patient was admitted. Blood sugar is 1.4. Child is a k/c of DM and takes insulin. Dx of hypoglycemic fit was made. He was unwell in the last 2 days and had fever and vomiting. Talk to mom and discuss primary and secondary management. Mom gives 3 scenarios: 1. This morning my little one had fits. I gave him insulin even when he couldn’t have breakfast properly. I forgot to check RBS. 10 to 15 minutes after giving the insulin, the fits started. 2. He didn’t eat last night properly as well. He was busy playing with his cousin. And in the morning he had the fit after my giving of insulin. 3. I gave my little one breakfast this morning. Unfortunately he vomited. Nurse told me to always check blood sugar before giving it and I did but it was normal. I gave insulin. Cx: I am sure you’ve done your job properly. But as you know, when your little one vomits, it takes time for blood sugar levels to drop and hence the glucometer can’t pick it up straight away. When your little one vomits and you give insulin as well, blood sugar levels drop more. In the future, if he is unwell or vomiting, bring him to us immediately and do not give insulin yourself. Keep looking for hypoglycemic signs in the future:

   

Sweating Drowsiness Tremors Change in behavior

Please give him sugary drinks straight away if you see the above symptoms.

Station 10 (Femur fracture & ruptured spleen) Breaking bad news A 10 year old child had an RTA on the way back from school to home. The father was informed by school’s staff about the incidence. You are the SHO in the A&E dept. you have done the X Ray which shows femur fracture. USG showed spleen rupture. Please talk to the patient’s father and address his concerns. Do you know what happened? (Break the news in layers and ask for what he knows about the situation already). Explain how you did X ray and it showed femur fracture but you have given pain killers and he’s in safe hands now. We also referred the child to the ortho team who’ll be taking care of the fracture. We also did ultrasound and that showed a ruptured spleen which will have to be removed. Spleen is an organ about the size of a clenched fist in upper left tummy. The main function is to filter blood, create new blood cells and store some type of blood cells (platelets). It also has an important role in our body’s immune system. For now, your child is in the hands of expert surgeons but he is in a critical condition. (Sympathize/empathize continuously). Dad: Can he live without the spleen? When we remove the spleen, the patient usually have an increased risk of developing serious infections like meningitis. So we give them jabs, some regular antibiotics and some strong antibiotics anytime we suspect even the smallest infection. (You should be careful if ever travelling in the future as the child will need prophylaxis or some extra meds). Dad: Doc will he die? Even though he is in a critical condition but just know he is in the hands of a team of experts and his pain is

controlled. Let me tell you what we plan on doing.. (Divert his mind from this question as you cannot say a yes or a no). Then talk about antibiotics and the surgery. Can I see my little one now? Yes, as soon as we are done with the surgery. Look your little one is going to have an operation in the OT. If we let you in, it increases the chances of him acquiring infections as more people mean, more chances of spread of bugs in the theatre. If he insists, tell him you will ask your seniors and he will have to be gowned and prepped.

Station 11 (Unconscious Patient) Vasovagal Syncope A 12 year old boy/girl went unconscious in the school assembly. He was brought to the A &E by her mom. You are the SHO in A & E dept. Talk to the mom and discuss Dx or D/D with the examiner.

Fx on Hx taking 1. The patient became pale before going unconscious 2. He was standing for a while before going unconscious 3. There was no fits, no confusion and no fever after being unconscious. 4. If there is a Hx of fits, its usually for 2 to 3 minutes with no previous Hx. D/Ds to rule out: 1. Vasovagal syncope 2. Meningitis 3. Epilepsy 4. AF/Arrythmias 5. Hypoglycemia 6. DKA 7. SOL 8. Head injury Elaborate event by detail 1. What happened before the event? 2. During loss of consciousness, ask if there were any fits? Duration? Other S/S? 3. S/S after events? 4. Any site of bleeding? 5. Ask about DM (FOR HYPOGLYCEMIA), any cardiac conditions or epilepsy? Child was standing and duration of LOC < 5 minutes, getting pale before collapsing.

Station 12 (Unconscious Patient) Head Injury A 9 months old brought to the hospital by her mom. The kid went unconscious at home. Talk to mom and discuss your Mx with mom. Fx on Hx taking 1. 2. 3. 4. 5.

Child fell down from sofa while mom was in the kitchen. Went floppy and unconscious for 2 minutes 2 episodes of vomiting. No external bleed or lacerations No S/S of any focal or neurological deficits.

Indications for admission (General Knowledge) 1. 2. 3. 4. 5. 6. 7.

GCS Its best he carries his own food as if the food there contains a small amount of gluten, it would be dangerous. 7. Complications? 8. Why he got this condition? Explain autoimmune disease.

9. I have Ulcerative colitis. Do you think he inherited it from me somehow? There’s no direct link btw these 2 conditions!

Pediatrics (Uncommon Stations which still come)

10) UTI (Hx + Cx) (Cx) 11) Ear infection (Antibiotics request) 12) Viral Diarrhea (Telephone Conversation) 13) Per rectal bleed (Hx + D/D) (Hx + Mx with examiner) 14) Peanut Allergy (Cx) 15) Vomitting (Hx + D/D) 4 years old (Hx + D/D) 4 months old 16) Juvenile DM 17) Rash (ITP) (Hx + D/D) 18) Vaginal bleed 19) Needle stick injury 20) Heart Murmur (Pilot)

Station 17 (UTI) A 4 years old child presented with fever + vomiting. Talk to mom and address her concerns. A 5 yr old boy was crying while passing urine. Urine test has been done and shows nitrates. You suspect UTI. Talk to mom and address concerns. Fx on Hx taking 1. 2. 3. 4.

Fever from last 2 days Vomiting since morning Crying while passing urine Going frequently to pass urine. Changing frequent nappies. 5. 2 episodes of same S/S recently. D/Ds to rule out: 1. UTI 2. G/E 3. Intestinal obstruction 4. DKA 5. Meningitis 6. URTI 7. Ear infection 8. SOL Cx: From what you have told me, your little one has UTI which is a condition in which bugs grow in the bladder and surrounding organs. We’ll do some investigations like urine test, ultrasound and may consider doing some other special tests as well (MSU) in order to confirm our Dx. For Tx, we will consider giving antibiotics, pain killers and will ensure for him to take plenty of water/fluids. Ask the mom about any allergies he might be known to have regarding meds!

Child should be toilet trained. He should regularly go to the toilet and not wear tight underpants.

Station 18 (Ear infection) Antibiotics requested A 5 years old child presented with fever + runny nose. Father thinks he had an ear infection because the child was previously seen by the GP and the GP gave him some antibiotics to treat the ear infection. Dad insists on antibiotics. Talk to the dad and address his concerns. Fx on Hx taking 1. 2. 3. 4.

Boy has low grade fever since 4 days No discharge from the ear Cough and runny nose since the last few days Father thinks he has an ear infection and believes should be prescribed antibiotics.

Note: Anytime there’s fever in the child, rule out meningitis. Cx This is not an ear infection. You have mentioned no discharge or any redness or swelling over the ears. This is just flu as he has a runny nose. The bug causing this condition doesn’t respond to antibiotics. If we prescribe him unnecessarily, this can cause resistance in him against the antibiotic and if for some reason he does need it in the future, the antibiotic won’t work on him then. Dad: So you are giving no meds? We will give paracetamol to control fever and will advice for him to take plenty of water. If for some reason fever increases or child gets any ear discharge or any signs of vomiting with neck stiffness, please bring the child back immediately to the hospital.

Station 19 (Viral Diarrhea) Telephone Conversation A 15 months boy has diarrhea for last few hours. Mom is worried. She called the hospital. Talk to mom on the phone and address her concerns. Fx on Hx taking 1. 2. 3. 4. 5. 6. 7. 8. 9.

Child had loose stools 2 to 3 times in the last 12 hrs. No high grade fever No vomiting No blood in stools No tummy pain No lethargy. Child isn’t drowsy He can take water and food Mom can manage it at home Mom has diarrhea as well

Note: Anytime see blood, assess anemia. Anytime see diarrhea, assess dehydration Imp questions to ask 1. Can he drink water and take diet? 2. Is he playful or drowsy? 3. Can you manage at home? D/Ds to rule out: 1. Viral diarrhea 2. Bacterial diarrhea (Tummy pain + bloody stools) 3. Milk allergy 4. UTI 5. Some medications Hx Cx: Explain to the mom how this is viral diarrhea. There is no need for admission as your little one has no problem having water and food. There appears to be no signs of severe condition from what you have told me. Explain how this condition is self limiting. Can you take care of the baby yourself? If not, bring him to the hospital. In case you

notice any drowsiness or he stops to take feed and is all lethargic, immediately request an ambulance or bring him over again.

Station 20 (Per rectal bleed) Gastroenteritis 11 months old child has bleeding in stools. You are the SHO in A & E. Take Hx from mom and discuss D/D with examiner. Fx on Hx taking 1. 2. 3. 4.

2 to 3 episodes of loose stools since yesterday No vomiting No high fever She says yes to red jelly stools (even when she doesn’t know what they are) 5. She says yes to feeling a tummy mass 6. Other members of family have it as well. 7. No change in diet. 8. On formula milk. D/Ds to rule out: 1. Bacterial diarrhea (G/E) (Tummy pain + bloody stools) 2. Viral diarrhea 3. Intussucception 4. Intestinal obstruction 5. Milk allergy 6. UTI 7. Foreign body ingestion 8. Trauma

Station 21 (Per rectal bleed) Intussusception 9 months old child presented with bleeding per rectal. You are the SHO in emergency department. Take Hx and ask about some Fx from examiner and discuss your management. Fx on Hx taking 1. 2. 3. 4. 5. 6.

Red jelly stools present Tummy mass present Baby bends the legs towards chest Ultrasound reports shows abdominal mass Tachycardia HR: 140 Ask about any other member with same S/S

D/Ds to rule out: 1. 2. 3. 4. 5. 6. 7.

Intussusception Bacterial diarrhea (Tummy pain + bloody stools) Viral diarrhea Intestinal obstruction Milk allergy UTI Trauma

Mx: Admit this child. After all relevant investigations are done, the consultant may go for Air Enema or Surgery.

Station 22 (Peanut Allergy) A 9 yrs old child has been brought to the hospital by mom. Mom noticed he had developed some rash over the skin, itching, SOB immediately after eating some peanuts at a restaurant. Dx of peanut allergy was made. Nurse colleague explained how to use epi pen. Talk to patient’s mother and address concerns. Nuts and peanuts can cause allergic reactions. This happens when your body’s immune system which normally fights against bugs, over-reacts to substances like nuts and peanuts and release a substance called histamine. This substance cause tiny blood vessels to leak fluid, leading to swelling and other S/S. Chance of getting it in another child of yours, if one already has it, is more, compared to the normal population. If you are concerned about your other kids, we can refer them to allergic clinic. They can run some investigations e.g. skin prick test or blood tests or some food challenge test. If you have atopy (group of allergic conditions e.g. hay fever, asthma, eczema etc) you are more at risk of having peanut allergy. Allergic reactions can be mild or severe. Mild S/S (General knowledge. Explain if patient asks) 1. 2. 3. 4.

Tingling in the mouth, lips and throat Rash Swelling of the face Colicky pain in the tummy We give antihistamines or anti allergic meds for most S/S.

Severe S/S: 1. All no 1 to 4 + 2. Wheeze and difficulty in breathing

3. Skin redness 4. Heart racing 5. Low BP Use epi pen as explained already in the case of above S/S and bring the patient to hospital. Prevention: 1. Please when you buy products, check the labeling properly. It shouldn’t contain any nuts. 2. When you eat out, again be careful about having nuts in meals/food. 3. Take or pack your own food to parties just in case you are not sure if what they will provide will not have nuts. 4. Inform school nurse, and ensure little one doesn’t accept food with nuts from friends.

Station 23 (Vomiting) DKA/DM A 4 yrs old boy presented with vomiting, polydypsia and polyuria. Please talk to the patient's parent and discuss D/D with the examiner. Fx on Hx taking 1. 2. 3. 4. 5. 6. 7. 8. 9.

Father has DM Hx of passing more urine than usual Lethargic. Not playful as before. Hx of drinking more water Hx of vomiting Hx of URTI 2 weeks ago (+_) Hx of shallow breathing (+_) Hx of tummy pain (+_) Fruity smell from mouth (+_)

D/Ds to rule out 1. DM/DKA 2. G/E 3. Pyloric stenosis 4. Intestinal obstruction 5. Pneumonia 6. Over feeding

Station 24 (Vomiting) Overfeeding A 4 months child comes with vomiting. Take Hx and discuss D/D with examiner. Hx of overfeeding is present. Rule out the same D/D as in the previous question.

Station 25 (Juvenile DM) A 5 year old child is diagnosed with juvenile DM. Polydypsia and polyurea are present and BSR has been done. Talk to mom and address concerns. Ask her to elaborate S/S! Cx In this condition (DM), body can’t produce a substance called insulin. Insulin regulates amount of blood sugar in your body so that’s why people with DM have raised blood sugar levels. We will give you insulin in the form of injections. We’ll refer you to a diabetic nurse who will explain how to take them. What is so important in this condition is that you must take meds (insulin) as prescribed. Otherwise one could end up having many complications. One of the most common complications of DM is damaging blood vessels. If it damages large vessels, it can lead to heart and kidney problems in one. If it damages smaller vessels, it can lead to vision problems eventually. That’s why taking meds is so important. You must follow up regularly as well, to help assess how well the meds are working. Warn her about the signs of hypoglycemia. Mention informing school nurse and wearing bracelet.

Station 26 (Rash) ITP A 3 yrs old child presented with rash and bruises all over body. Please take history and discuss D/D with examiner. Fx on Hx taking 1. While mom was giving bath to the baby, she noticed rashes and bruises all over body 2 days ago 2. He also had bleeding from nose 2 days ago. Mom pinched the nose and the bleeding stopped. 3. She informs of runny nose and fever 4 weeks ago 4. Child appears to be lethargic according to mom. D/Ds to rule out: 1. ITP (Hx of prev infection) 2. Bleeding disorder 3. Malignancy 4. Trauma 5. Non accidental injury 6. Meds e.g. blood thinners

Station 27 (Vaginal bleed) Unknown A 6 yrs old girl brought by mom due to vaginal bleeding and discharge. Talk to mom and discuss Dx with examiner. Fx on Hx taking 1. Whitish discharge 2. Itchy discharge 3. No past medical Hx at all D/Ds to rule out: 1. Candidiasis (DM, poor hygiene, immune-compromised, steroids usage or spleenectomy) 2. Foreign body insertion 3. Sexual abuse 4. Trauma 5. NAI 6. Bleeding disorder 7. Instrumentation

Station 28 (Heart Murmur) Pilot 18 months old child visited GP for routine check up. GP heard a murmur on auscultation. Talk to the mom and address concerns. Fx on Hx taking 1. 2. 3. 4. 5. 6.

Nothing abnormal happened or told during pregnancy Birth was normal Normal delivery Baby does not turn blue Father had angina Fever, runny nose and cough since last few days (+_)

Questions to ask 1. Ask about any S/S and predisposing medical conditions 2. Ask about breathlessness, poor feeding, excessive sweating, blue episodes, generally unwell and family Hx. 3. Ask about being told about Down’s, Turner’s or Marfan syndrome. Investigations: 1. Echo (Gold standard) 2. ECG (and X-RAY) Any child that comes with murmur, we should do echo. When we realize murmur isn’t pathological, reassure the family about murmur. You may tell the mom that murmur may persist even in adulthood and might not disappear. Murmur is explained as additional sound heard over the heart, apart from normal heart sounds. In 18 months child, find underlying pathology. If everything is negative (on history taking), we just have to do a safe investigation (echo). REASSURANCE IN THIS STATION IS VERY IMPORTANT!

This murmur is not pathological. Is it dangerous? Not most of the time but we will investigate.

Surgery (Common Stations) History Taking

1) Anemia Hx + Cx = Herniorrhaphy Hx + D/D = PR Bleed 2) Abdominal Pain Hx + D/D = Ectopic Pregnancy Hx + D/D = Ureteric Colic Hx + Mx (with Patient) = UTI Hx + D/D = Pyelonephritis Hx + D/D = Bowel CA 3) Testicular Pain Hx + D/D/ Mx (with patient) 4) Melena 5) Dysphagia Hx + Inv (with examiner) Hx + Mx (with patient) 6) Hematuria Hx + Inv (with patient) Prev Mx (with patient) 7) Backpain Hx + Inv (with patient) Hx + D/D (with examiner)

STATION 1 (ANEMIA)

45 year old man planned for herniorapphy. Lab reports show Hb 8. Procedure was cancelled and postponed. SHO in surgery. Please talk and address patients concerns. 1- Explain the patient -Procedure was cancelled -reason why -Why we cant offer surgery yet? Address his concerns – convincing the patient for cancelled surgery 2- Find the cause of anemia 3- manage the cause of anemia 4- address patients concerns

Please go and greet the patient. Tell the patient your surgery was cancelled because you have anemia. Do you know whats anemia? In anemia you do not have enough rbcs which are oxygen carrying cells in the blood. That is why we cannot go for surgery. If patient does not agree, explain due to your condition – when we put you to sleep, your blood cannot supply enough oxygen to your body or even after the surgery, you’ll face probably infection or delay in wound healing. Doctor I have a friend, same procedure, received blood and went for surgery. Why not me? Your operation is not emergency, we don’t have to go for blood transfusion bcz it has its own complications. Why didn’t the surgeon explain this 4 moths ago? Basically before the surgery we check how fit you are. One of these procedures are checking your blood. We usually do

this assessment before surgery. Few months before surgery it can change so not done. Cause of anemia. Would like to ask you some questions. Any medical illness? No doctor Do you take any meds? Yes (aspirin for 10 years) 3 general questions about any ca? wt loss? Loss of appetite? Anemia signs? Fatigue/SOB + lightheadedness+ heart racing Any change in bowel habits? Blood in stools? Tenesmus? Family hx? Abdominal pain? Tell me about your diet? Any travels abroad? Management- explain the cause of anemia From what you have told me, the cause of your anemia is from your gut. To confirm our diagnosis, we have to put a flexible tube with a acamera attached to it, through your mouth to see your gut and find out if there is any bleeding and where is the site of bleeding. Don’t worry we will give you some numbing agent on your mouth. We might give you some mild sleep meds(IV). We may take some samples. Please stop aspirin and contact your GP. I’ll provide you some Fe tablets. It would be great if you could have some orange juice( VITc). I can refer you to my dietician colleague if you want. When is the surgery> We’ll repeat your blood tests as soon as we correct your anemia before we go for surgery. It may take a few months. 1 unit Hb- 4 weeks under good condition. (almost 3 months)

STATION 2(ABDOMINAL PAIN) 65 year old man presents with bleeding per rectum. Lab report shows Hb 6.7, MCV 65. Talk to the patient and Discuss Dds with examiner History Something coming out/splash blood – hemmorhoids Pain – anal fissures Bowel movement alteration – colorectal ca Family hx – polyps Tummy pain – diverticulitis Fever, pain diarrhea, pain relieved on opening bowel – IBD Vomitting, fever, family Hx – GIE Med Hx, pain after or before meals – APD (patients Hx) Fresh blood. 5 pound weight loss. SoB even when talking. Getting tired with simple activity. Constiaption for last 2 months. Aspirin history. No family hx of ca. no tummy pain or fever. If asks managementFrom what you told me, you’ve got abnormal growth in the bowel. There’s a possibility of ca but need to confirm. We can do colonoscopy and consider ct scan. We may take some samples as well for tests. If we confirm our diagnosis, then surgery. Investigations 1- CBC 2- Fecal occult blood 3- Colonoscopy/biopsy 4- Ct scan/ lfts 5- CEA

Any calculi history Yellow/pinkish urine, Hx of passing stones, burning micturition, poor stream urine, suprapubic pain

D/ds of abdominal pain RUQ1- Acute cholecystitis- radiates to shoulder, pain with fatty meal 2- Hepatitis- yellow discoloration of skin/eyes, fever, sexual hx 3- Cholangitis- fever, jaundice and pain 4- Biliary colic- RUQ pain to the back, pain comes and goes RT/LT UQ1- Renal calculi- flank area pain 2- Pyelonephritis- recurrent utis, fever, pain, hx of passing stools 3- Pneumonia- chest pain, fever , cough RIF- Appendicitis – Migratory LIF- diverticulitis- pain relieved by defecation, PR bleed Rt/Lt IF Male- Testicular torsion, epididimoorchitis Male/Female- urinary calculi, UTi, Hernia Females- IUCD, Ovarian cyst, PID Epigastric1- Pancreatitis- back and shoulder radiation, relieved by bending forward 2- APD

3- GERD 4- ACS- radiation to jaw and arm 5- Pericarditis- shar stabbing pain, relieved by bending forward

STATION 3 (ECTOPIC PREGNANCY) 25 year old lady presented with RIF pain. SHO in A &E. Talk to the patient and discuss D/ds with the examiner 1- LMP 5 weeks ago (4-10) 2- RIF pain 3- Patient on IUCD 4- No vomiting, fever or discharge 5- Patient wearing hospital gown Diagnosis – Ectopic Pregnancy

STATION 4 ( ureteric colic) 25 year old lady presented with abdominal pain. SHO in A&E. Please talk to the patient and discuss D/ds with examiner 1- Pain in RUQ 2- Pain radiates from loin to groin 3- Hx of passing stones 4- Hx of pinkish urine 5- Hx of full stream urine 6- No hx of fever, alcohol or sexual hx Diagnosis- ureteric calculi

STATION 5 (UTI) 20 year old girl presented with abdominal pain. Talk to the patient. SHO in A&E. Disuss management with the patient. Diagnosis- UTI 1- Same episode of pain 2 weeks ago 2- Lower tummy pain 2 days ago 3- Burning sensation 4- Pinkish urine 5- Flu like symptoms and fever 6- LMP – 2 weeks ago 7- No discharge From what you told me I suspect UTi, in which bugs grow in your bladder and surrounding areas. To confirm, I’ll do some urine tests and send it to the lab. We may consider USG. For treatment, I’ll prescribe you antibiotics. Please have plenty of water. I’ll give you painkiller if you need them. Investigation Dip stick, MSU and culture, USG, IVU

STATION 6 (PYELONEPHRITIS) 40 year old man presented with abdominal pain. Talk to the patient and discuss d/ds with examiner 1- RUQ pain 2- Flu like symptoms 3- Smelly urine 4- Hx of passing stones Diagnosis- pyelonephritis

STATION 7 (BOWEL CA) 75 year old lady with LIF pain. SHO in surgery. Talk to the patient. Discuss dds with examiner 1- Half a stone weight loss 2- Altered bowel habits 3- Abdominal pain 4- Family hx of bowel ca Diagnosis – bowel Ca

STATION 8 (TESTICULAR PAIN) 30 year old man presented with pain in private parts. SHO in A&E. Talk to the patient. Discuss your dds and management options with the patient 1- Pain – 2 days ago 2- Score 4/10, morning 7-8/10 (severe) 3- Flu like symptoms 4- Pain in both testes 5- Sexual hx- not sexually active 6- Have you seen private part? No redness/ hotness 7- Did you try to lift the testes( don’t ask) Dds1- Epididymorchitis- fever , gradual, both testes, 2- Torsion of testes 3- Ureteric calculi 4- Bladder calculi 5- UTI 6- Hernia 7- Mumps From what you told me, I suspect 2 conditions. Epididymorchitis- inflammation of the testes and surrounding organs, to confirm the diagnosis we do urine testsand send it to the lab. If test is positive, I’ll give you antibiotics Testicular torsion- twisting of testes, this is an emergency condition in which you need surgery. We may have to remove your tested. Before surgery we may do some investigations like USG. Assume with the examiner. Investigations. First urine culture, swab if discharge present. Treatment- 35 years ciprofloxacin 300mg Bd 10 days Pain killers Scrotal support Drainage if abscess present Testicular torsion – Treatment- Bilateral orchidopexy ( untwisting in the affected testes), orchidectomy (if needed) and fixation of the rt testes. Investigations- shouldn’t delay your surgery- USG Doppler, isotope scanners

STATION 9 (MELENA) 60 year old patient dark stools. Talk to patient and give D/ds to examiner 1- Patient has osteoarthritis 2- Taking diclofenac 3- No weight loss 4- No family hx of bowel ca 5- No change in bowel habits 6- Feels tired sometimes 7- No alcohol hx DDs for melena 1- Esophageal varices 2- Mallory weiss tears 3- APD 4- Gastric ca 5- NSAIDs Hx

STATION 10 (DYSPHAGIA) ESOPHAGEAL CA 65 year old lady presented with dysphagia. Patient is on H2 blockers and PPIs in last 5 years due to reflux disease. Talkto the patient and discuss DDs with examiner GERD- strictureBarettes esophageal ca 1- Difficulty in swallowing started with solids 2- Wt loss in last 2 months 3- Loss of appetite Diagnosis- esophageal ca DDs 1- Esophageal ca- difficulty in swallowing, continuous pain 2- Stricture – corrosive intake 3- Pharyngeal pouch – foul smell, food regurges 4- Achalasia cardia- difficulty in swallowing starting with liquids 5- Myasthenia gravis- problem getting worse as day progresses 6- Bulbar palsy- initiating swallowing difficult 7- Esophagitis – fever

STATION 11 (HEMATURIA) BLADDER CA 65 year old man presented with hematuria. Take hx and discuss about investigations with the patient 1- Hematuria – painless 2- 2-3 weeks ago 3- Loss of appetite 4- 2 kg weight loss 5- No fever/ passaing of stools 6- Smoking since 25 years 7- Dribbling and incontinence Diagnosis- bladder Ca DDs 1- Renal calculi 2- Bladder calculi 3- Urinary calculi 4- Renal/ bladder/ prostate ca 5- UTI 6- Schistosomiasis ( swimming in public lakes and pools) I suspect some growth in your bladder. Have to run some investigations. May have to do some surgery. From what you told me, am going to run some investigations to confirm diagnosis. These are urine tests, special x rays, a flexible tube, camera attached on it, goes to your bladder through your front passage and CT scan. We may have to take some samples Urine tests – cytology and microbiology IVU Cystoscopy CT Scan

STATION 12 (BACK PAIN) PROSTATE CA 55 year old man presented with back pain. Take hx. Discuss investigations with patient and Dds with examiner 1- Lower back pain becoming worse by changing position 2- Wakes up during night to go to toilet – 2 months 3- 1 stone weight loss in last 2 months 4- No morning stiffness 5- Hx of loss of appetite 6- No hematuria/ no hx of heavy lifting Diagnosis – prostate ca with mets to back DDs 1- Secondary to ca 2- Multiple myeloma 3- Osteoporosis of vertebra 4- Osteoarthritis 5- Disc prolapsed 6- Trauma 7- Tb/ potts disease 8- Asnkylosing spondylitis From what you told me I have to run some tests.. I’ll do blood testsand USG. We may get some samples with help of USG, Xray and MRI. PSA  USG guided biopsy xray MRI

Pre-op assessment Q- 50 year old Mr. John had fractured ankle which was fixed with pins. Now it has healed. He has come for pin removal. Do the pre-op exam to see whether he is fit to be brought as day care for surgery and talk to him. Pt. is usually IDDM patient!! RBS – well controlled in the last 3 months atleast. No other major medical problem For minor surgery , provided there is someone to take care of him after the operation who can stay for 24 hours Are you checking RBS and taking meds? With what you are telling me, you are fit to be brought in for day care surgery Diabetic – Don’t take insulin at home. We’ll give you here if needed. After operation if taken, we’ll give you with food Shouldn’t drink back home You have a surgery on your ankle? Hows your ankle? Do you keep checking sugar? Is it controlled? Apart from diabetes , any other medical condition? Did you have any problems during or after surgery? Apart from insulin any other meds? Anyone to look after you? We’ll give you a date. Come prepared. Please don’t take your breakfast nor your morning insulin dose. You’re to come to the hospital and we’ll give you insulin when and if required.

Once you recoverfrom anesthesia, we’ll give you food and usual insulin dose if you take at that time after a while. Or if you take it in evening we’ll discharge you if everything is fine. Please do not drive for atleast 24 hours after the procedure due to the safety concern from the drowsiness effect of the anesthesia. Household- 1 week Drive- 2 weeks Work- 4 weeks Labor- 6 weeks

Q- 5 year old boy John fractured ankle! Do the pre-op assessment with his mom and talk to her When did he eat and drink last? (if emergency surgery). NPO for 6 hours atleast Since your son has eaten 2 hours ago we’ll wait for 4 more hours. Please do not give him anything to eat and drink from now onwards until we instruct you again after the operation and we’ll give some fluids through his veins as a drip to keep him hydrated and for his nutrition. Please do not give him any more insulin until we instruct you again. We’ll check his sugar and give insulin as required. How long? One hour Hospital stay? 2-3 days maybe Never assume the patient knows the condition? Are you the mother of? How may I address you? Add please to the conversation. He’s comfortable and pain free since we gave him the painkillers Did anyone tell you whats wrong with your son? Show empathy and sympathy If pt says do not do the operation or am worried ask about the concern? Unfortunately type of fracture he has cannot be fixed with plaster. Anything to fix that? Operation. Is that alright? To do the operation he has to be fit healthwise. Any medical condition apart from DM? CVS, asthma or any previous surgery? Taking any meds? Alergic History? Family history of medical conditions? Loose teeth? Dentures? Anything else?

With what you are telling me , he seems to be fit to undergo operation but to do so he needs to on empty stomach for 6 hours. Otherwise he can vomit and aspirate in lungs which can be dangerous. Please do not give any food from now on until we instruct you after the operation. We’ll give some fluids. It is a safeoperation. Are you okay with it so we can go ahead with the operation?

Q- 5 year old john – acute appendicitis. Disclose the diagnosis to his dad and do pre-op assessment. If female- ask for pregnancy, pills and periods. Since you brought him to the hospital, we’ve given him painkillers and he’s comfortable now. We all have an organ in our tummy called as appendix. This looks like a little finger attached to the beginning part of the large bowel located in Rt. Lower part of the tummy. In your sons case it is inflamed/infected. ( bugs that have caused soreness and become swollen) Treatment- here to operate. I am afraid yes. Cant be treated with medicines alone unfortunately. I am sorry but you have to postpone your holiday plans. If we delay this, organ can burst and cause serious infection of the tummy with risk to his life. Make a small cut in his tummy wall. We’ll cut and remove the appendix. Don’t worry this organ has no important function in the body. It’ll not affect his life and he can lead a normal life. 30-45 min operation List of complications after assurances 2-3 days stay 10 days to 2 weeks back to school Past hx – med and surgical Meds Allergy Tell him about G.A

PAIN MANAGEMENT 6 scenarios 4 important areas to talk about 1- Pain ladder 2- Morphine 3- Side effects of morphine 4- PCA WHO pain ladder 1- Paracetamol / aspirin/ NSAIDs 2- Weak opiods ( codeine, dihydrocodeine, tramadol) 3- Strong opioids ( morphine, dimorphine, oxycodeine) a- When the pain is not controlled, go to the next step b- When the pain is controlled but there are side effects, choose drugs from same ladder c- When the pain is controlled but there are side effects, you may change meds as well as route e.g P/o to S/C dimorphine Morphine induced hallucinations oxycodeine or fentaline Side effects of fentaline 1- Renal impairment GFR oral Fenatline patch > opioid Lasts about 17-72 hours

12-24 hours for fentaline patch to wash off d- If the patients pain is not controlled , check for medication compliance first e- More poor compliance in meds with side effects f- Don’t give Side effects without telling the solutions Solutions Sickness/ feeling sick – antiemetic Please take simple food, cold food like sandwiches and avoid rich and spicy foods. Please take meds after the meal or few hours before the meal. If all other options don’t work we may consider anti sickness meds Constipation Have plenty of water. Please have a well balanced diet which contains large amounts of fruits and vegetables. If other measures don’t work, we may consider meds. Dry mouth You can have sugar free chewing gum and ice cube. We may consider prescribing artificial saliva Drowisness/ sleepy It takes a few days and then subsides. Don’t worry. Don’t drive and don’t work with any tools/ heavy machinery. Don’t drink alcohol. Shallow breathing Don’t worry its not a common side effect. If it happens, contact your GP immediately g- In terminally ill patients, for pain control from weak and go to strong h- In post op management, we start from a strong and then go to weak pain killers. i- Adjuvant plays an important role in pain management. Some meds do not fall in the painkiller category but we

can prescribe them to you to relieve the pain. Radiotherapy and bisphosphonates j- There is a strong evidence that suggests emotional support can decrease and optimize the pain. That is why if the pain is controlled you can discharge the patient. k- If you have terminally ill patient, you adjust the painkiller and send the patient home Have to use titration!! 1- 5-10 mg normal release morphine every 4 hrs in 24 hours 2- Anytime patient has pain add 5-10 mg immediate release morphine 3- After 24 hours, calculate your dose. l- Please think about side effects when you prescribe ,eds. Don’t prescribe NSAIDs to asthma and PUD. Aspirin ask about gastric ulcer and taking warfarin mPlease ask the patient to take meds regularly as prescribed. Not take meds when the feel pain.explain to the patient, prevention of pain is better than cure n- PCA- by using this device, size of a radio, you can control the pain yourself. Anytime you have pain  press the button and meds (mostly morphine) goes to your body through your blood channels. Please don’t worry about overdose because our colleague programmed this device for you. Questions frequency Painkiller – 21 BPH and UTI – 8 Testicular pain – 7 post op comp after hernirapphy – 6 hemicollectomy – 6 Abd pain- 5 Telephone (internal bleeding after hemicolectomy) – 5 emergency endoscopy – 3 open nephrectomy- 3 lipoma removal – 3

Herniorapphy procedure – 2 Obstructed /strangulated hernia (telephone) – 2 Appendicectomy talk to parent – 2 Complications of hysterectomy - 1

STATION 1 Terminally ill patient with prostate Ca is on cocodomal. Pain is controlled. Talk to the daughter Show enough sympathy and empathy Can I take my dad home? Yes because pain is controlled Despite allowance, daughter is worried about what if he feels pain again? Please explain in this way. Your dad is on cocodomal, which is paracetamol and a weak opioid called codeine. If for some reason cocodomal caanot control pain, we go for a strong opioid which is morphine. Morphine is the best painkiller. There is always another option available for you. Would you like to talk about it? Is there anything I can do for my dad? can talk about patch Can I take dad home? Yes ofcourse you can but let us first control the pain.

STATION 2 Terminally ill patient(teacher) with lymphoma is on diclofenac and cocodomal. Received in chemotherapy and radiotherapy. Still the patient is in pain. Your consultant prescribed overall morphine for the patient. Please talk to the patient. q- Do you think I can go to work? - What do you do? ( Drowsiness factor). Don’t worry. It’ll subside in a few days. You can take some days off from the school and go back to the school later. q- what will my students think? (morphine- recreational drug) - Look you are using the medication for medicinal purposes, not for recreational reasons. You can take time off from school. Look morphine is the best drug for you. As you know, you tried ibuprofen, didn’t work, you tried cocodomal which is a bit of opioid, didn’t work as well. That’s why we’ve to go for stronger opioid. Talk about side effects. ( Do you want to talk about side effects and their solution?) PCA – cant go to school or teach. hopefully your pain will be controlled. If for some reason, pain is not controlled and you prefer to stay at home and rest, you can go for PCA. Can also use fentaline patch.

STATION 3 Elderly lady on 300 mg P/o morphine. Complains about morphine and wants to discontinue it. Talk to the patient. It doesn’t work - Do you take meds regularly as prescribed? Do you miss any dose? How many times per day? Why? S/e constipation - I am really sorry to hear that. Drink lots of water and have fruits and vegetables. We will also consider medicines. Hopefully we’ll manage the S/e but if we cannot then we’ll use fentaline patch. Sometimes patient says they use meds regularly - morphine intolerance. Fentaline patch. Talk about other side effects of morphine and PCA.

STATION 4 50 year old main comes with back pain. The patient is on and off paaracetamol. Xray shows bone degeneration disease. Talk to the patient and different methods of pain management. Diagnosis – osteoarthritis As you know you are on paracetamol and take it regularly which doesn’t work, we may consider a weak opioid cocodamol. Hopefully pain will be controlled with that but if it is not than we go for a strong opioid which is morphine. You may take paracetamol regularly, it may work. Please talk about PCA and fentaline patch. If the pain is not controlled. Route? ( do I have to take it through mouth?) Non medical methods ( adjuvant) 1- Weight loss 2- Exercise 3- Physiotherapy 4- Tens 5- Dietician 6- Acupuncture

STATION 5 40 year old man is planning for herniorraphy. Is really worried about pain. Talk to the patient and address his concerns. Herniorraphy  Open under G/A Keyhole  recurrent  B/L

Hospital  Day care (most surgeries) Overnight / 2-3 days Why are you worried? Same procedure two years ago. What have you received last night? Don’t know doc What happened? Night of surgery. Was in pain. No one came with me. Tell him about PCA. when we discharge you we will give you oral morphine Do you want me to talk about S/e? In a few days we’ll step down to weak opioids. Hopefully you wont have to take any meds after that. -pain ladder backwards here

STATION 6 75 year old man comes to the clinic with complain of burning sensations while passing urone. Urine test has been done and shows nitrites and leucocytes. UTI diagnosis made. P/R exam done and showed enlarged prostate. diagnosis – BPH Talk to the patient and address his concerns 5 types of councelling stations 1- Councelling of a diagnosis 2- ask patients knowledge about symptoms. 3- Tell the diagnosis 4- Explain the diagnosis 5- Management of UTI 6- Address concerns and any warning signs 7- Disclose BPH 8- Why BPH can cause UTI 9- Management of BPH 10Any concerns What brought you here? Difficulty in passing urine As you know we’ve done some tests and this test shows UTI. Harmless bugs growing on your bladder/in your tummy. When they travel from back passage to front and travel to the bladder or ureters (tube connecting bladder and kidneys), they grow in these organs and cause infections and problems. Allergy to antibiotics need to be asked. We’ve done some tests and we will do some more and send it to the lab. We may consider USG. For treatment will prescribe you antibiotics. Do you have any allergy? Thankyou. I’ll give you something else. Please take plenty of water and may consider taking pain killers. Do you have anyone at home to take care of you? Thankyou so I don’t have to admit you.

As you know we’ve done some other examination that shows that you have an enlarged prostate gland. It is a gland, lies on the bladder. It is the size of a chest nut and urethra passes through this gland. Due to prostate enlargement, the urine gets stuck in the bladder and the bugs grow easily. That is why you’re prone to UTI. Investigations- We’ll do some blood tests and USG and PSA and guided biopsy if needed. If our diagnosis is confirmed we will give you two meds. One of them shrinks the gland ( fenestride) and the other one relaxes the neck of the bladder and tube. Hopefully meds will work otherwise we’ll consider surgery.

Cx in surgery Ask patient about symptoms ( their knowledge) Explain the surgery NPO  OT recovery room  ITU  ward  discharge Talk about anesthesia. Local or G/A (put you under sleep) NPO – because might need G/A Advantages of local - fast recovery - Less hospital time/ complications/ fitness needed Disadvantages of local - pain/ seeing and hearing the procedure. - we’ll top up anesthesia (local) and give G/A. will also give mild sedation. - we can use a curtain don’t worry about seeing. - you can listen to music Method is either open or keyhole surgery. Keyhole surgery – nick on belly ectopic pregnancy in exam / Lap chole Button  put gcd  nick on bikini line  we put a camera and instruments Advantages 1- Less scar 2- Less pain 3- Short recovery 4- Less hospitalization Disadvantages May damage vessels and surrounding organs Open surgery – all 7 in the list before including ovarian cystectomy Stay in the hospital

- Daycare – lipoma remova - 2-3 days – laproscopic - 4-7 days – major surgery (hemicolectomy, open nephrectomy, hysterectomy, hemiarthroplasty) Patient may be discharged in 1-3 days ( enhanced recovery program)  hemiarthroplasty The surgeon and occupation therapist make the decision. The occupation therapist can assess patients fitness for discharge and patients environment Complications of surgery 1- Pain – see prev mx 2- Infections – Antibiotics 3- Bleeding 4- Damage to surrounding organs ( rare and treat accordingly) Recovery After 1 week  can do simple house work / hold job After 2 weeks  can drive / have sex After 4 weeks  can go back to his job Afer 6 weeks  can go back to heavy job / labor

Are you happy to go for surgery or not? Note:- Please read the task. If in the task , the consent has been taken, please don’t take consent. in herniorapphy, consent already taken

STATION 1 (TESTICULAR LUMP) Young patient comes to you with lump in his private part. Transillumination and fluctuation test has been done and are negative. UDG shoes solid tumor. Blood test shows some tumor marker Do you know whats going on? As you know we’ve done some investigations. You have any suspicion of anything? Okay. Investigation shows you have an abnormal growth in your testes. Possibility of having ca. but at this stage if we take it out we can prevent it from spreading We’ve to confirm our investigations We’ve to remove whole testes. If we go for sample, maybe disease will spread. Right now its not hard to manage but if it spreads very difficult to manage. As long as the other testes is here you may have children. We can store your sperm. Cosmetic surgery for shape of testes. Patient may receive radio and chemo after procedure Sympathise and empathise

STATION 2 Young man to underwent herniorapphy 3 weeks ago this man came back with redness, swelling, oozing at the site of incision. The nurse told you this patient is angry and address the patients concerns Doctor I may need to see surgeon. - Do you need surgery? I’ll convey your message to my surgeon It can have many causes. You may get the infection during surgery, at the hospital and even at home. Whatever the reason management is the same. Let me tell you what we can do for you now. Ask her any s/s We’ve to admit you . do some blood tests and send them to the lab. Give you antibiotics and also change dressing and clean the wound. ( patient will be angry at admission) As soon as you are better you can go home Look this is for your health. But don’t worry. Why are you upset? Don’t worry we’ll provide you with the sick note. Show sympathy/empathy if self employed. Your health is important. (patient advice and Larson center)

STATION 3 45 year old man comes with abdominal pain. All the investigations have been done (inv paper in exam). Normal. Talk to patient. Do you know whats going on? Yes we did some investigations and ive got the report of the investigations We did endoscopy and biopsy to see If there is any problem with your gut. Fortunately no problem. We also performed colonoscopy and biopsy(patients language) to see if there is anything problem in your bowel. We also did USG and all organs in your tummy are fine. Fortunately no problem. We also checked your stool. No blood. We checked your blood and couldn’t find any bugs. Do you have any stress in your life? Okay that can be 1 cause of your tummy pain. So please have a well balanced diet with fruits and vegetables. Do regular exercise. Go to the gym. Do exercise and yoga. It may help. I can also refer you to any of my colleagues who can talk to you improve your mood. Irritable bowel syndrome In this problem, people without having any problem can have tummy pain. This disease is not a serious condition and does not lead to any serious complications. Okay why are you worried? - my uncle died of bowel ca I’m sorry to hear that but we did all these tests to rule out any dangerous diseases. Fortunately all are normal. However, if anytime you see any blood in you stool, any change in your bowel habits, tenesmus, weight loss, loss of appetite, anemic symptoms you can come back to us immediately.

STATION 4 75 year old lady was planned for hemiarthroplasty because she had hip fracture. Please talk to the patient about post op management. Pain management has been explained. When can I go home? - 3 to 5 days. Maybe in 1 to 3 days. Explain as before My bathroom is upstairs? - occupational therapist- they’ll change something for you Post op management and complications ( family Hx) patients main concern is about blood clot -one of the complications of this surgery is having blood clot in lungs or legs. Anytime when you feel a pain in chest or leg or cough, mobilize as much as possible. When can I start walking? - ASAP

STATION 5 (HEMICOLECTOMY) 60 year old man was found to have a tumor in his transverse colon. Please explain about surgery and talk about primary anastomosis and possible colostomy. This is an open surgey in which we’ll open your tummy. We’ll remove the diseased part of your large bowel and will join the ends together. If joining of the cut ends of the bowel is not possible, we’ll have to make a hole in your tummy so you can pass stool through that hole on a bag which we call colostomy bag. Always involve colostomy nurse It is odor proof so you may feel something but you cant smell it It is waterproof Anytime you have any problem with body image/ sexual issues/ please come back to us, I’ll refer you to our dietician. You may not be able to have food which has fiber like vegetables in first 8 weeks. You may have some noisy tummy and wind in this period and don’t worry you can resume normal diet after 8 weeks. Skin reactions We discussed this you can have almost a normal life Why surgery? - now we can remove the diseased part but we don’t do so as the disease might spread. It may be temporary or permanent but we aren’t sure You can draw something for the patient as paper/pen available Tumor on the sigmoid / cecum (imp) DONOT DRAW THIS

STATION 6 (OPEN NEPHRECTOMY) A lady was diagnosed with stage 1 kidney tumor. Open radical nephrectomy was planned. Talk to the patients partner. Do you know whats going on? No breaking bad news The patients partner  only remove tumor? - we’ve to remove kidney and surrounding organs. If we don’t do that, it’ll get spread all over the tummy. What about the other kidney? - lets concentrate on this kidney because we aren’t certain. What is important is that your wife should have plenty of H2O after surgery. Let the other kidney be flushed. We’ll put catheter and drainage tubes If after surgery, wife be cured or not? We may be able to treat and cure your wife. We may be able to slow down the disease. If we cant do that let us allow to to give comfort to the loved ones. Can she live with one kidney? -as long as the other one works fine

STATION 7 (LIPOMA) A patient is planned for removal of lipoma in thigh under local anesthesia. Talk to the patient and address patients concerns. Please talk about everything regarding local anesthesia. Are you happy going for local anesthesia or not? I’ll talk to my seniors and we may go for G/A G/A side effects

STATION 8 75 year old man planned for emergency endoscopy. SHO in surgery. Please talk to the patient and address patients concerns. Patient admitted due to vomiting blood. Reassure and relax. Calm him down What was your last medication? When? (med like warfarin?) We are going to find out site of bleeding. Sedate and local anesthesia Can I go home after endoscopy? - if everything is smooth then yes

STATION 9 40 year old man planned for herniorrapphy procedure. The procedure is for RI hernia. It is open surgery and patient will undergo G?A. Address concerns. As you know due to weakness of your tummy muscles, some tummy contents come out. By doing this surgery, we push it down and we put a mesh which helps it to not happen again. My uncle got the same problem but got prescribes TRUS? -he may have been unfit for surgery If we don’t go for surgery it may be very dangerous for you. Make a pic if possible.