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Inguinal Hernia Pre-operative Assessment & Address

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

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

(Examiner might give a piece of paper and a pen for you to draw for making the patient
figure it out better)

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Dr: Are you following me? Pt: Yes, doctor.

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

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

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

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

Dr: Do you have any symptoms like Cough?Constipation? Straining on Urination?

Pt: No

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Dr: Do you smoke? Pt: Yes doctor.

Dr: Could you please tell me how much do you smoke and for how long?
Pt: I smoke almost 20 cigarettes or more daily for 20 years.
Dr: Could you tell me what do you do for living? Pt: I work in a warehouse/construction
company
Dr: Does your work involve lifting or pushing heavy weights or standing for long periods
of time? Pt: Yes.

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

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

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

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

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

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

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

Talk about truss only if the patient asks about it.

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Pt: Will it hurt during or after the operation?

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

During the operation, we will be giving youlocal Anaesthesia where the anaesthetic
medication is injected to the swelling area, or spinal anaesthesia where the anaesthetic
medication is injected to the spine and the lower part of the body is made numb. You will be
awake during the procedure, but the area being operated on will be numb so you won't
experience any pain. In some cases, a general anaesthetic is used. This means you'll be
asleep during the procedure and won't feel any pain.

Are you following me ? Pt: Yes Dr: Any concerns so far ? Pt – No

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

Pt: How long will the operation last doctor?

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

Pt: When can I return to normal activities?

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

Pt: When will I be able to have sex?

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

Pt: When can I drive doctor?

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

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

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

Dr: You should have someone to look after you at home at least for 24 hours. They should
stay at your home to look after you. Avoid drinking alcohol, operating machinery or signing

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legal documents for at least 48 hours after any operation if it involves general anaesthesia.

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

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

Pt: Can it happen again doctor?

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

You have been smoking for many years now. Smoking can make the body tissues weak and
also leads you to coughing and that can make the hernia come back. I'd request you to
consider quitting the cigarette smoking and if you need any assistance for that then a lot of
help is available. Would you like that?
Pt: Yes doctor.

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

Dr: Also you must Maintain a healthy weight.

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

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

Warning signs

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

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

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Lady with pain abdomen - Appendicitis.

? 42 year old lady presented with abdominal pain. Take history and then do the
relevant examination and discuss the further management with her.

Patient was complaining of pain abdomen for the last 5 days. Initially the pain was
coming and going. Now it is constant in the lower part of tummy.
She was feeling feverish for the last few days.
She was also complaining of constipation for the last 3 days. ( sometimes she may start
her story with constipation – do not confuse this station with constipation station).She was
able to pass wind. No vomiting. Had nausea.
No urinary symptoms like burning sensation, increased frequency, haematuria, No
previous bowel problems.
LMP was 3 weeks ago.( check when was her period before that), No vaginal bleeding
now. No vaginal discharge. No unprotected sex.
No diarrhoea, No previous medical conditions, No previous history of kidney stones, no
history of previous surgery.

Ask where exactly was the pain when it started?

Ask was she on any medications ?
Ask family history, how many children she has?
Anything else important ?

Examination:
I want to examine your tummy. I will ensure your privacy and have chaperone with me.
Can you please undress above your waist and lie on the bed.

Examine abdomen:
Inspection – No distension, No visible masses
Palpation - had tenderness all over lower abdomen, right iliac fossa, supra pubic area and
left iliac fossa.
Percussion – normal
Bowel sounds – examiner said no bowel sounds ( for some candidates examiner said
bowel sounds normal)
Per rectal examination – examiner said normal.
Check NEWS chart – temp – 38.9°C, Pulse – 106bpm, BP -130/80mmHg, PO2 was 97%.

Investigations: We need to do blood tests to check for any infection markers. Also we
need to do X Ray of your tummy and chest, and Ultra sound scan of your tummy.
( examiner did not give any findings).

We need to test your urine also to check for any blood or infection markers and also do
pregnancy test to make sure that you are not pregnant. Is it OK?

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Definitive diagnosis

I think you may have a condition called Appendicitis. Do you know any thing abiut this ?
Pt : No
Dr: Let em explain ( draw if possible).
We all have an organ in our tummy called Appendix which looks like a small finger
attached the beginning of the large bowel located at the right lower part of the tummy.
That organ has become inflamed ( it is sore / swollen) This is what we call Appendicits.
Sometimes it is due to some bugs in that organ. If the condition is not treated urgently
then this organ can perforate and can cause serious infection within the tummy.

Treatment.
The only way to treat this condition is doing an operation and removing that organ.

Pt: Won’t there be any problem if you remove that organ.

Dr: This organ has no important function in our body, so even if we remove there will not
be ant problem. You can live a normal life.
Pt: How long will be operation ?
DR: 30 min to 45 min
Pt: How long should I be in the hospital? Dr : two to three days.
Pt: Any complications – Dr: very rarely there could be bleeding or infections but we can
manage that.

Dr: Is that OK to go ahead with surgery ?Pt: OK

Do you have any other questions ?Pt: No
Thank you.

DYSPHAGIA

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Dysphagia Differentials
Differentials Relevant Questions

P Palsy(Stroke/spine Difficulty in talking? Making sound?

injury/botulism/MS/PSP/ALS/Parkinson) Other weakness?
Bulbar palsy Difficulty initiating swallowing
E Endoscopy/instrumentation Did you have any procedure done recently?

G GORD Belching? Heartburn, worse on lying?

G Globus hystericus Do you have a sensation of lump in your

throat?
C Cancer Oesophagus Starts first with solids
Weight loss? Weakness?
Smoking? FH?
Steady, gradual worsening?
O Oesophagitis Or Infection of tonsil, larynx or
epiglottis Fever, pain
(odynophagia)

M Myasthenia Worse in the evening? Feel weakness in

evening or after exertion?
P Pharyngeal pouch Bad breadth? Food on pillow in morning?
Old food regurgitated?
A Achalasia Starts with liquids

S Stricture Long time heart burn? Or past corrosive

Ingestion?
Any procedures/instrumentations done?
S Spasm (diffuse esophageal Intermittent? Cold or hot food makes it
Spasm DES) worse?

50 year old man presents with dysphagia.

Take history, examine and discuss relevant management with the patient.

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Dr: Hello Mr.….. My name is Dr…. what brings you to the hospital today?
P: I have had trouble swallowing doctor.. I also have a lot of discomfort in my lower chest
Dr: I am very sorry to hear that Mr.…. could you please tell me when this started?
P: It has been few weeks doctor
Dr: Has it worsened since then?
P: Yes.. Initially it was mainly to solid food items. Now it is also to liquids

Dr: Did it start with liquids first or solids first? P: Solids first now it is liquids also doctor.
Do you have any pain while swallowing ( Odynophagia – infections) ? Pt: No

Dr: Is it worse towards the end of the day ( Myesthenia )? P: No

Dr: Have you had any vomiting? P: No
Dr: Have you thrown up any blood? P: No

Dr: Do you have any difficulty I talking? ( Palsy, MS) Pt: No

Dr: Did you have any procedures done on you food pipe recently? P: No
Dr: Do you have Heartburn (burning sensation in the middle of your chest)?(GORD)?
P: No
Dr: Do you have a sensation of lump in your throat ( Globushystericus) ? P: No
Dr: ( Pharyngeal pouch) Do you feel your breath smells bad ? P: No

Dr: Fever ( tonsillitis) ? P: Yes/No

Dr: ( cancer ) Have you noticed any change in your weight?

P: Yes my belt has become lose.(quantify)
Dr: Have you noticed any lumps in your neck or your armpits? P: Yes/No

Dr: Have you been diagnosed with any medical conditions ? Pt: No
Dr: Are you on any medications? P: No
Dr: Do you smoke? P: Yes
Dr: Could you tell me what you smoke and how much?
P: I smoke 15-20 cigarettes a day. I have been smoking for > 30 years
Dr: Do you consume alcohol? P: Yes/No
Dr: Any of your family members has any medical conditions ? P: No
Dr: Any of your family members been diagnosed with any cancers? Pt: No
Dr: Is there anything else you think is important that we need to know ? Pt: I don’t know.

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

Diagnosis:
Dr: Do you have any idea of why you may be having this swallowing problem ? Pt: No

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Dr: I guess you have some serious condition? Do you like to know ? Pt : Yes
Dr: I think you may be having cancer of the food pipe.
Pt: May be shocked ---- Silent. ….. Are you sure doctor ?
Dr : That is what I think you may have, but I am not sure now. We will refer to a specialist
doctor – who is Gastroenterologist. He will do some investigations to find out what exactly is the
cause.
Pt: What investigation ?
Dr: He may do a special test called Endoscopy which is a camera test where a tube with camera
will be passed from your mouth to your food pipe and to the stomach. He can visualize the
problem and may take a tissue sample if he finds any growth in the food pipe to check what
exactly the growth is?
He will tell you the exact diagnosis after the investigation.
Pt: What if it is cancer, how will you treat?
Dr: Specialist doctor will tell you how they will treat. Generally it depends on the stage of the
cancer – either they may do surgery or give you chemotherapy – ( special medications for cancer)
or Radiation therapy.

Pt : I can’t swallow anything now.

Dr : We will admit now to do the investigation and the specialist doctor may insert a stent ( a
tube in the food pipe which will help in swallowing? Is that Okay ? Pt: OK
Any other question ? No Thank you.

Skin lesion: ? Suqamous cell carcinoma

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

Dr: Hello Mr… I am Dr…. How can I help you Mr…

Pt: Doctor I am having this swelling in my head. My wife noticed it first and she told me
to come here.

Dr: Since how long have you had this swelling ?

Pt: It is there since about four weeks now doctor.

Dr: Is it the same since it started or have notice any change in that.

Pt: It is becoming little bigger in the last one week.

Dr: Any other changes have you noticed ?

Pt: Yes doctor it is little bit bleeding also since last one week.

Dr: Is there discharge from that? Pt: No

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Dr: What is the colour of that ?Pt: Pink/ Brown/ Dark

Dr: Is there any change in the colour ?Pt: No

Dr: Is it painful? Pt: No

Dr: Any itching?Pt: No

Dr: Do you have any other swelling anywhere else? Pt: No

Dr: Any swellings on your neck area ( lymphandenopathy)Pt: No

Dr: Have you exposed yourself to sun too much ?Pt: Doctor I lived in Australia for 10
years.Dr: When was that? Pt: …

Dr: Have been using hats to cover your head during those time ?Pt: No

Dr: Have you used tanning beds ?Pt: No

Dr: Did you have similar problems before ?Pt: No

Dr: Do you have any medical conditions at all? Pt: No

Dr: Are you on any medications ?Pt: No

Dr: Do you smoke ? (If yes- what do you smoke, How much, How long)Pt: Yes/ No

Dr: Any of your family members has any such swellings ?Pt: No

Dr: Is there anything else you think is important we need to know about?Pt: No

Examination:

Dr: Mr…. I need to examine that and see how it looks like. Also I need to check
whether you have any swellings around your neck.

Pt: Doctor this how it looks like ( he will show a picture).

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Diagnosis:

Dr: Thank you for that. Do you have any idea what it could be ? Pt: No Doctor.

Dr: I afraid it could be a serious condition. Do you want to know about it ? Pt: Yes
doctor please tell me.

Dr: I am very sorry to say this could be a type of skin cancer what we call as Squamous
cell carcinoma. Pt: Cancer !!!Ohh..really doctor!!

Dr: I am afraid it does look like that. However, we need to do some tests to confirm that.

Investigation:

We need to take some tissue sample from that and send it to the lab to test it. Is that OK?

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Treatment :

Pt: Ok doctor. How will you treat that doctor?

Dr: We need to confirm what type of growth is that to decide what type of treatment we
can offer. If it is squamous cell carcinoma as I mentioned before, depending on how
much it has grown or whether it has spread to any other area then we can decide the type
of treatment. Usually we will be able to do some surgery and remove the whole growth
and test the removed growth in the lab to check whether the cancer cells has been
removed.

However,if it has spread then we may not be able to remove it completely in that case
we may have to treat it with some medicationsor Radiation therapy.

Pt: Is it dangerous doctor?

Dr: Mr… Though this is a cancer usually they do not spread so it is usually treatable.
Very rarely only it can spread to the other areas and then it can be dangerous or life
threatening.

Pt: OK

Dr: Any other concerns?Pt: No doctor. You have been very helpful

Warning signs:

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

Dr: Thank you very much Mr… I hope everything will be fine soon.

Squamous cell carcinoma of the skin

Squamous cell carcinoma of the skin is a common form of skin cancer.

usually not life-threatening, though it can be aggressive in some cases. Untreated,

squamous cell carcinoma of the skin can grow large or spread to other parts of your
body, causing serious complications.

Most squamous cell carcinomas of the skin result from prolonged exposure to
ultraviolet (UV) radiation, either from sunlight or from tanning beds or lamps.
Avoiding UV light helps reduce your risk of squamous cell carcinoma of the skin and
other forms of skin cancer.
Symptoms

Squamous cell carcinoma of the skin most often occurs on sun-exposed skin, such as

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your scalp, the backs of your hands, your ears or your lips. But squamous cell carcinoma
of the skin can occur anywhere on your body, including inside your mouth, on your anus
and on your genitals.

Signs and symptoms of squamous cell carcinoma of the skin include:

 A firm, red nodule

 A flat sore with a scaly crust
 A new sore or raised area on an old scar or ulcer
 A rough, scaly patch on your lip that may evolve to an open sore
 A red sore or rough patch inside your mouth
 A red, raised patch or wart-like sore on or in the anus or on your genitals
When to see a doctor

Causes
Ultraviolet light and other potential causes

Much of the damage to DNA in skin cells results from ultraviolet (UV) radiation found
in sunlight and in commercial tanning lamps and tanning beds.

But sun exposure doesn't explain skin cancers that develop on skin not ordinarily
exposed to sunlight. This indicates that other factors may contribute to your risk of skin
cancer, such as being exposed to toxic substances or having a condition that weakens
your immune system.
Risk factors

Factors that may increase your risk of squamous cell carcinoma of the skin include:

 Fair skin. Anyone, regardless of skin color, can get squamous cell carcinoma of the
skin. However, having less pigment (melanin) in your skin provides less protection
from damaging UV radiation.

If you have blond or red hair and light-colored eyes and you freckle or sunburn
easily, you're much more likely to develop skin cancer than is a person with darker
skin.

 Excessive sun exposure. Being exposed to UV light from the sun increases your risk
of squamous cell carcinoma of the skin. Spending lots of time in the sun —
particularly if you don't cover your skin with clothing or sunblock — increases your
risk of squamous cell carcinoma of the skin even more.

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 Use of tanning beds. People who use indoor tanning beds have an increased risk of
squamous cell carcinoma of the skin.
 A history of sunburns. Having had one or more blistering sunburns as a child or
teenager increases your risk of developing squamous cell carcinoma of the skin as an
adult. Sunburns in adulthood also are a risk factor.
 A personal history of precancerous skin lesions. Having a precancerous skin
lesion, such as actinic keratosis or Bowen's disease, increases your risk of squamous
cell carcinoma of the skin.
 A personal history of skin cancer. If you've had squamous cell carcinoma of the
skin once, you're much more likely to develop it again.
 Weakened immune system. People with weakened immune systems have an
increased risk of skin cancer. This includes people who have leukemia or lymphoma
and those who take medications that suppress the immune system, such as those who
have undergone organ transplants.
 Rare genetic disorder. People with xeroderma pigmentosum, which causes an
extreme sensitivity to sunlight, have a greatly increased risk of developing skin
cancer.
Complications

Untreated squamous cell carcinoma of the skin can destroy nearby healthy tissue, spread
to the lymph nodes or other organs, and may be fatal, although this is uncommon.

The risk of aggressive squamous cell carcinoma of the skin may be increased in cases
where the cancer:

 Is particularly large or deep

 Involves the mucous membranes, such as the lips
 Occurs in a person with a weakened immune system, such as someone who takes
anti-rejection medications after an organ transplant or someone who has chronic
leukemia
Prevention

Most squamous cell carcinomas of the skin can be prevented. To protect yourself:

 Avoid the sun during the middle of the day. For many people in North America,
the sun's rays are strongest between about 10 a.m. and 4 p.m. Schedule outdoor
activities for other times of the day, even during winter or when the sky is cloudy.
 Wear sunscreen year-round. Use a broad-spectrum sunscreen with an SPF of at
least 15. Apply sunscreen generously, and reapply every two hours — or more often
if you're swimming or perspiring. Use a generous amount of sunscreen on all exposed

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skin, including your lips, the tips of your ears, and the backs of your hands and neck.
 Wear protective clothing. Cover your skin with dark, tightly woven clothing that
covers your arms and legs, and a broad-brimmed hat, which provides more protection
than does a baseball cap or visor.

Some companies also sell protective clothing. A dermatologist can recommend an

appropriate brand. Don't forget sunglasses. Look for those that block both types of
UV radiation — UVA and UVB rays.

 Avoid tanning beds. Tanning beds emit UV rays and can increase your risk of skin
cancer.
 Check your skin regularly and report changes to your doctor. Examine your skin
often for new skin growths or changes in existing moles, freckles, bumps and
birthmarks. With the help of mirrors, check your face, neck, ears and scalp.

Examine your chest and trunk and the tops and undersides of your arms and hands.
Examine both the front and back of your legs and your feet, including the soles and
the spaces between your toes. Also check your genital area and between your
buttocks.

Diagnosis

Tests and procedures used to diagnose squamous cell carcinoma of the skin include:

 Physical exam. Your doctor will ask questions about your health history and
examine your skin to look for signs of squamous cell carcinoma of the skin.
 Removing a sample of tissue for testing. To confirm a squamous cell carcinoma of
the skin diagnosis, your doctor will use a tool to cut away some or all of the
suspicious skin lesion (biopsy). What type of skin biopsy you undergo depends on
your particular situation. The tissue is sent to a laboratory for examination.
Treatment

Most squamous cell carcinomas of the skin can be completely removed with relatively
minor surgery or occasionally with a topical medication. Which squamous cell
carcinoma of the skin treatments are best for you depends on the size, location and
aggressiveness of the tumor, as well as your own preferences.

Treatments may include:

 Electrodesiccation and curettage (ED and C). ED and C treatment involves

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removing the surface of the skin cancer with a scraping instrument (curet) and then
searing the base of the cancer with an electric needle. This treatment is often used for
very small squamous cell cancers of the skin.
 Curettage and cryotherapy. Similar to the ED and C procedure, after the tumor
removal and curettage, the base and edges of the biopsy site are treated with liquid
nitrogen.
 Laser therapy. An intense beam of light vaporizes growths, usually with little
damage to surrounding tissue and with a reduced risk of bleeding, swelling and
scarring. Laser treatment may be an option for very superficial skin lesions.
 Freezing. This treatment involves freezing cancer cells with liquid nitrogen
(cryosurgery). It may be an option for treating superficial skin lesions.
 Photodynamic therapy. Photodynamic therapy combines photosensitizing drugs and
light to treat superficial skin cancers. During photodynamic therapy, a liquid drug that
makes the cancer cells sensitive to light is applied to the skin. Later, a light that
destroys the skin cancer cells is shined on the area.
 Medicated creams or lotions. For very superficial cancers, you may apply creams or
lotions containing anti-cancer medications directly to your skin.
 Simple excision. In this procedure, your doctor cuts out the cancerous tissue
and a surrounding margin of healthy skin. Your doctor may recommend removing
additional normal skin around the tumor in some cases (wide excision). To minimize
scarring, especially on your face, consult a doctor skilled in skin reconstruction.
 Mohs surgery. During Mohs surgery, your doctor removes the cancer layer by layer,
examining each layer under the microscope until no abnormal cells remain. This
allows the surgeon to be certain the entire growth is removed and avoid taking an
excessive amount of surrounding healthy skin.
 Radiation therapy. Radiation therapy uses high-energy beams, such as X-rays, to
kill cancer cells. This may be an option for treating deeper tumors, those that have a
risk of returning after surgery and tumors in people who can't undergo surgery.

Lady Fracture neck of femur – ? Stoke Adams

syndrome
Causes of falls

EXAM question
A 70 Year old lady fell at home few days back. She was brought to A and E. She was

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diagnosed with fracture neck of femur. The fracture has been treated. Further decisions
have to be made. She is vitally stable at the moment.
You are FY 2 doctor in the medicine department.
Take history to find the cause of the fall and discuss further management with her.

Dr: Hello Mrs Hilda My name is Dr... I'm one of the junior doctors in the medical department.
How are you doing ? P: I am OK now.
Dr: I was told that you had a fall few days ago and you had a broken hip bone is that right?
Pt: That is right.
Dr: I am really sorry to hear that. How are you feeling now? Are you comfortable talking to me?
Pt: yes doctor I am fine thank you.
Dr: what was done for the broken hip bone? Pt: They did an operation.

Dr: I see, How is everything now? Pt : Everything is OK now.

Dr: That is good to know. Mrs Hilda it’s a bit concerning to us why you fell down and it led to
such an unfortunate incident. I am here to see why did you fall and if there is any medical causes
for your fall then we may need to treat that so that you don’t fall again. Is that OK ? Pt: Ok
doctor.

Dr; Can you please tell me how did you fall and the whole incident?
P: Doctor, I was in the kitchen just had my meal and was talking to my husband. Next thing I
know is that I was on a floor and had severe pain in my leg.
Dr: Oh I am really sorry about that. Were you standing when this happened? Pt : Yes
Dr: Do you know anything about why you fell down?
Pt: No doctor to be honest I don’t know anything.
Dr: Ok..did you lose consciousness before you fell?
P: Yes few seconds / Don’t know really but I don’t remember what happened.
Dr: Was there any one with you when you fell down? Pt: Yes/ No
Dr: Did anyone tell you that you had fits when this happened ?Pt : No one was there at that time.
Dr: Did you bite your tongue ( epilepsy)? Pt : No
Dr: Was there any urine incontinence ( epilepsy) ? Pt : No

Dr: Do you have visual problems? P: No doctor I had my glasses checked recently?
Dr: Do you keep slipping or tripping and then fall? P: No
Dr: Did you feel like the room was spinning? P: No
Dr: Do you have a feeling of fullness in your ear? P: No
Dr: Do you hear any high pitched noise in any ear? P: No
Dr: Do you have any balance problem while walking? P: No
Dr: Did you have palpitations ( racing of heart)? P: No
Dr: Did you feel that you may pass out before you fell down? Pt : No
Dr: Did you have any weakness of arms or legs when this happened ( stroke )?
Dr: Did anyone tell you that you went pale before you fell down ? Pt: Yes my husband told
me / No
[ Pale /cyanosis – suggests epilepsy, very pale/ white – suggests syncope or arrhythmia]

Dr: Has it happened before to you?

Pt: Yes doctor I have fallen four to five times in the past one year.
Dr: Did anything significant happen that led to subsequent falling?
Pt: Not that I can think of. Like what doctor?
Pt: Any change in medication? Or any incident in family or friends? Pt: ….
Dr: Did you visit any doctor for the frequent falling? Were any investigations done? Any possible
cause identified?

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Dr: Did anyone tell you that you went pale before you fell previously also ? Pt: Yes my
husband told me that.
Dr: Did you notice that these falls happen after prolonged period of standing? Pt: No (orthostatic)
Dr: Did these falls occur after any unpleasant incident, unexpected sight, sound or smell? Pt:
(Vasovagal syncope-emotional stress)
Dr: Did these incidents happen after meals usually? Pt: (Post-prandial hypotension)
Dr: Did you notice that these falls happen usually when you turn your head? Pt: No
Dr: Was there any warning: light-headedness, nausea, sweating, weakness or visual disturbance?
Pt : ……
[Preceding nausea, sweating and blurred vision have been shown to be predictive of non-cardiac
syncope in the elderly]
Dr: Do you live alone or with someone? Pt: (assess NAI)
Dr: Have you ever been diagnosed with any medical conditions in the past?
Pt: Yes I have high blood pressure .
Dr: Since when ? Pt: Since last 10 years.
Dr: Are you taking any medications?
Pt: Yes I am taking medications for my blood pressure.
Dr: Since when are you taking medications ?Pt : Since the last 10 years.
Dr: Has the medications been changed recently. Pt: No doctor.
Dr: I see. Can you please tell what medication you are on right now? P: I can't remember the name
doctor
Dr: No problem Mrs... Do you have the medication with you? P: No Dr: Are you carrying the
prescription given by your GP? P: No
Dr: Ok that's fine Mrs...I will find that out from your notes.
Dr: Have ever been diagnosed with any heart conditions ? Pt : No
Dr: Do you have diabetes? P: No
Dr: Have you had any heart related problems in the past? P: No
Dr: Have you ever had a stroke? P: No
Dr: Do you have any bone pain or other bone related problems any fractures before ?
Pt: No (osteoporosis)
Dr: Have you been diagnosed with Osteoporosis ? Pt No
Dr: Any of your family members have any medical conditions ? P: No
Dr: Any family history of osteoporosis? Pt: No
Dr: Do you consume alcohol? P: Yes/ No (Explore alcohol according to answer)

Examination and investigations:

Mrs. .. I need to do examine you some tests to find the cause of why you fell.

For that we need to I check your pulse and BP. I will have to check your BP while you are lying
down and while you are standing.[ Examiner may not give you standing and lying blood pressure].

I would also like to examine your chest to check your heart. [Start examining the patient – stop
examining if the examiner stops it] – check for irregular pulse, examine chest –try to auscultate).

We need to check your sugar, check whether you have anaemia and do heart tracing. Also we
may need to check your heart tracing for 24 hours to see if you have any abnormal heart rhythms.
[examiner may not give any result]

Diagnosis: I think you have a condition called stoke adams syndrome. This is condition in the
heart where the heart stops beating momentarily.

We need to do some tests like continous heart tracing to confirm the diagnosis.

If it is stoke adams syndrome we can treat it with some medications called Isoprenaline or

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Epinephrine. We can also treat with inserting a devise called pace maker into the chest which
controls the heart rate.
Any other questions ?

Reactive Arthritis
25 years male, Mr Robert, C/O joint pains
Assess him and discuss the management with the patient.

Differentials for Joint pain. ( Pneumonic – GHRRROSS)

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

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

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

Dr: Did you have any injury to your knee or ankles at all? Pt: No
Dr: Are all those joints swollen ( heamarthrosis, reactive arthritis, septic arthritis, rheumatoid
arthritis) ) ? Pt : Yes
Dr: Do you have fever ( septic) ? Pt : No
Dr: Are you able to walk at all ( Can’t walk in septic arthritis because of severe pain) ?
Pt: Yes I can walk.
Dr; You have pains in the small joints of your hands( Rheumatoid arthritis affects small
joints) ? Pt : No
Dr: Do you have stiffness in the joints ( Rheumatoid, reactive) ? Pt -Yes
Dr : Any pain in your back ( ankylosing spondilitis) ? Pt : No
Dr: Do you have any swelling and pain in the big toe ( Gout) ? Pt : No
Dr: Did you have this type of problem before? Pt : No
Dr : Do you have any medical conditions? Pt: No

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Dr: Are you taking any medications at all? Pt : No

Dr : Any of your family members has this type of conditions? Pt : No
Dr: Have you travelled outside UK recently?
Pt : I went to France about 3 months ago.
Dr: Did you have any health problems when you were there?
Pt: I had diarrhoea for few days.
Dr: Did you take any treatment for that ? Pt : No it subsided on its own.
Dr: Did you have any unprotected sex with any one recently ? Pt : No
Dr: Do you have burning sensation while passing urine ? Pt: No
Dr: Any discharge from the urethra that is front opening of urine passage? Pt: No

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

Examination

Check NEWS chart for temperature

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

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

Inspection of knees and ankles

No swelling, redness, scars or sinuses.

Can you please lie down on the couch.

Palpation: Knees

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

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

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

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

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

Investigations

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

Diagnosis.

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

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

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Treatment

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

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

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

If the Ibuprofen medication do not help then we can give you medications what we call
steroids.
We will give you steroid drops to your eyes – that will help to reduce the soreness in your
eyes.
If none of these medications help then we will give medications called DMARDs ( Disease-
modifying anti-rheumatic drugs ) such as sulfasalazine which may help.
Pt: Can it come back again?
Unfortunately it can happen again if you develop any infection in parts of body again.
Dr: Any other questions ? Pt : No Thank you.

Fluid infusion to child with Appendicitis.

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

Child is 6 years,
Weight – 25 kg

Formula

Daily maintenance fluid requirement in paediatrics.

Formula: 100mls/kg for the first 1 to 10kg;

then 50mls/kg for the next 1 to 10kg;
then 20mls/kg for the next 1 to 10kg.
( Max – 2 litres in females and 2.5 litres in males)

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Fluid bag contains 500ml.

Assess knowledge.

Explain condition if he is not aware – Child has appendicitis. We all have any organ
in our tummy called appendix which looks is like a finger attached to the beginning of
the larger bowel ( gut). Normal it has no important function in the body. In your child
this organ in inflamed or become sore. Only treatment is operation and remove that
organ. He will lead a normal life afterwards.

Take history

How was your child before this ?

Any medical conditions ? Any surgeries in the past ? Any medications ?
Any allergy ?

Need to give him IV fluids

We cannot allow him to eat or drink at the moment until and after about one or two
days of the surgery. If his tummy has food when we Anaesthesia for the operation
sometimes the food comes back from the stomach to the food pipe and then it can
enter the wind pipe and can cause severe infections in the lungs. To prevent this
happening his stomach should be empty when we do the operation.
Also since we cannot feed him by mouth for his energy requirement and to prevent
dehydration we need to give him fluids through his veins.

What type of fluids

We will be giving him fluids which contains glucose for his energy and also salts to
prevent dehydration.
Is that OK ? Any questions ?

I need to write up the fluid prescription for him is that OK ?

Then write prescription on the fluid chart provided. (The paper includes
maintenance fluid replacement formula).
Ask about Full name, DOB,
past history of any medical conditions? Any medications? Allergy
Do not forget to date and sign.

Calculator is kept in the cubicle.

Use the Formula

25kg child = 10kg + 10kg + 5kg

First 10kg = 100mls × 10kg = 1000mls
Next 10kg = 50mls × 10kg = 500mls
Next 5kg = 20mls × 5kg = 100mls
Total fluid = 1000mls + 500mls + 100mls = 1600mls/day.

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1600 divided by 24 hours = 67ml/hour.

Fill up the prescription chart

Name DOB Allergy - NKDA

Date Fluid quantity Rate Additive Sign
Normal 1600ml/24 hours 7ml/hour Nil &&&
saline

PLAB 2 STATIONS - 14TH JUNE

Tiredness and bruising on both forearm

24 Year old man came to the G.P clinic with the complaint of tiredness. Take
history and discuss the management. (Or His Flu jab was 4years ago.)
Causes of bruising and bleeding

Hemophilia Hemophilia is a disorder in which the blood lacks certain clotting factors
making bleeding difficult to stop. ( management)

Viral syndrome Viral syndrome is an unidentified cause of typical virus symptoms sore
throat, stuffy nose, aches and more.
Medication reaction or side-effect Medication side effects include nausea, vomiting,
stomach upset, weakness, dizziness, seizures, and more
Aspirin use Side effects of taking aspirin include nosebleeds, bruises, stomach pain and
upset, bloody vomit and more.
Thrombocytopenia Thrombocytopenia causes bruising, frequent nosebleeds, and tiny
red dots that look like a rash. ( what are the causes of thrombocytopenia)
Lupus (systemic lupus erythematosus) Lupus is a chronic autoimmune disease marked
by swollen painful joints, a rash, swollen lymph nodes, and more.
Pre-leukemia (myelodysplastic syndrome) Myelodysplastic syndromes are diseases
that affect the bone marrow and blood, causing anemia and tiredness. ( management)
Sickle cell disease Sickle cell disease symptoms include repeated infections, yellow skin,
fatigue, dizziness, pain, and more.
Exercise or physical activity
Exercise is vital for good health, but overdoing it can lead to muscle aches, dehydration,
headache, and more.
Scurvy (vitamin C deficiency) Scurvy is a form of vitamin C deficiency leading to anemia,
nosebleeds, loose teeth, bleeding gums, and more.
Toothbrush irritation Toothbrush irritation, from improper brushing, causes receding
gums, worn enamel, and tooth sensitivity.
Influenza (flu) adults
The flu is a respiratory tract infection and causes fever, sore throat, runny nose,
headache, cough, and more.
Periodontal (gum) disease Periodontal (gum) diseases are serious and painful

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infections that can lead to tooth loss if untreated.

Porphyria Porphyria is a condition that can affect the nerves and skin, making the skin
extremely sensitive to sunlight.
Sarcoidosis Sarcoidosis is a rare disease that can cause swelling and hard lumps in the
lymph nodes and organs.
Hypothyroidism (adult) Hypothyroidism your body functions slow down, making you
gain weight and feel tired all the time.
Lyme disease Lyme disease is a bacterial infection spread through tick bites; symptoms
include rash, fever chills, and more.
Cirrhosis (liver) Cirrhosis is a liver condition caused by chronic scarring; causing
weakness, fatigue, and jaundice and more. ( risk factors alcohol and management
Coxsackie virus infection Coxsackie virus infection can cause many cold-like symptoms
as well as blisters on the mouth hands and feet.
Gingivitis Gingivitis is a mild form of periodontal (gum) disease that can cause redness,
swelling, and bleeding gums.
Blood clotting disorder Blood clotting disorders increase the risk that dangerous blood
clots will form in the body.
Tick bite
A tick-related illness may cause a rash that expands out from the site of the bite, fever,
chills, and more.
Cat-scratch disease
Cat scratch disease is a bacterial infection caused by a cat scratch or bite.
Ricin poisoning
Ricin is a dangerous poison in castor beans, and causes trouble breathing, nausea, fever
and sweating.
Toxic shock syndrome
Toxic shock syndrome is a serious bacterial infection and causes fever, low blood
pressure, a rash, and more.
Bird (avian) flu Bird flu is spread to people from birds and causes fever, cough, sore
throat and muscle aches.
West nile virus West Nile virus is an infection spread by mosquitoes, and can cause
diarrhea, fever, abdominal pain, and more.
Endocarditis Signs of endocarditis, an infection of the heart, include swelling, rash, sinus
congestion, nausea, and more.
-
Take history like other tiredness stations

GRIPS
Pt- Doctor I am feeling tired all the time.
Dr- can you please tell me more about it.
Pt- I am having tiredness since about a week
Dr- Any thing else associated with it ?
Pt- like what Dr??
Dr- any pain any where in your body … no
Any bony tenderness ? … No
Any past history of infection like flu or fever? ….. Yes/no
Do have any swelling in your neck area ?? …. No
Any lumps or bumps anywhere on your body ? … No
Is it there all the time? … Yes/ No
MAFTOSA
D- Is there anything else you think I should know?
P- Doctor I am having bruising on my forearms and bleeding from my Gum.
D- May I know since when are you having this ?

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P- Since Past 2-3 days.

D- any bleeding any where else – nose, heamoptysis, hemetemesis, bleeding from back passage,
dark stool ?
D- Any bruises anywhere else – other than forearm ?

D- Any history of trauma injury ? … No

D- any previous medical conditions

D - any medications – like aspirin blood thinners, Steriods

Thank you so much for giving me all the valuable information.

Now I would like to examine you: I would like to examine your vitals, and will do general
physical examination and examine bruises.

O/E : Bruises were present on both the forearm

Diagnosis - ITP

Management:

Treatment:

ACNE – ISOTRETINOIN( retinoid)

Scenario 2: 24 year old female came to the G.P clinic. She is having Acne and wants
Isotretinoin medications for it.

( NOTE: Instructions paper is given in the cubicle. It is given in it as Retinoid- For Mild to
moderate acne treatment and Severe Acne require Oral meds . Start as early as possible.)

GRIPS

Pt: Dr I want Isotretinoin acid to treat my acne.

Dr. : May I know why do you specifically ask for it ?

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Pt: Because my friend is having some problem and she got treated with this medication.
Dr: Ok let me ask few questions about it. Can you please tell me more about your acne?
Pt: I am having Acne since a very long time but it has increased recently since past couple of
weeks.
Dr: I am sorry to hear that.
ODIPARA: were you alright before that/ anything makes it better or worse/ have you tried
any treatment for it earlier.
Dr: Does it bleed ? ….. NO
Dr: Is there any itching on that area?.... Yes/NO
Dr: Any pus or discharge coming out of it ?... NO
Dr: Do you have any fever ? …. No
Dr: Are they painful ?..... yes / No
Dr: Were you bit by any insect by any chance ? … No
Dr: when was your LMP?______ days back.
Dr: any problem with the periods ?
By any chance are you pregnant? Are u planning to become pregnant ?
Dr: How is your diet like ?
Do you have any medical condition called polycystic ovarian syndrome ? No
( PCOS patients can get severe acne)
Do you have any abnormal hair growth in face ? Any weight gain ? ( PCOS)

MAFTOSA ….
Any allergies ( important question )….. No positive history
Dr: Anything else you would like to tell me about your condition?
Dr: No Doctor
Thank you very much for giving me all the valuable information. Now I would like to
examine you. I will be examining your skin .This involves examining your face, chest and
back for the different types of spot, such as blackheads or sore, red nodules. Will that be
ok with you?

O/E: Picture of forehead with –red acne spots on it.

Mild Acne

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Moderate Acne

Severe Acne

Management:

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Well so far from the history you gave me and after examining you I think you are having
Acne.
We will be doing some investigations so as to rule out if there is any reason why you may be
having Acne. It includes Bloods: for FBC, Infection markers, FSH , LH & Testosterone to
rules out PCOS as this is the most common cause of Acne in females. If required we will
also do an ultrasound of your tummy.

We do have lot of help available for it. We will refer you to our senior the Dermatologist –
skin specialist who will start you on Isotretinoin gel (Retinoids) if required. There are some
other medications available for it like Antibiotics, Azaelic acidetc but however it will be
decided by Dermatologist if it will be beneficial for you or not.

Please do report to us if you have any severe irritation with the medication and also if you are
planning to get pregnant.
( Oral retinoids are contra indicated in pregnancy – it is
teratogenic – ladies on this medication should not become
pregnant)
It will take some time for the medications to act so you will start noticing changes so please
don’t stop the treatment until advised for.

There are certain things that you can do to avoid it in future :

Don't wash affected areas of skin more than twice a day. Frequent washing can irritate the

skin and make symptoms worse.

Wash the affected area with a mild soap or cleanser and lukewarm water. Very hot or cold

water can make acne worse.

Don't try to "clean out" blackheads or squeeze spots. This can make them worse and cause

permanent scarring.

Avoid using too much make-up and cosmetics. Use water-based products that are described

as non-comedogenic (this means the product is less likely to block the pores in your skin).

Completely remove make-up before going to bed.

If dry skin is a problem, use a fragrance-free, water-based emollient.

Regular exercise can't improve your acne, but it can boost your mood and improve your self-

esteem. Shower as soon as possible once you finish exercising, as sweat can irritate your

acne.

Wash your hair regularly and try to avoid letting your hair fall across your face.

Dr: Do you have any concerns ?

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Pt: No Doctor Thank you

EXPLAIN DISCHARGE MEDICATION

Exam question

70 year old lady getting discharged from the hospital. Explain medications to her.

How to approach medications

Congratulate.

Assess knowledge of the conditions what they are having.

Why she got admitted ? Ho is she now ?

Ask for contra indications

( Paper of medications was given in the cubicle)

1. Amoxiclav( if medication is given in the exam)

2. Codeine …. 1tab * PRN
3. Alendronate 70mg every Sunday 30mins before breakfast
4. Calcitriol+Vit D medication … OD
5. Lisinopril5mg OD– Previously 10mg and now changed to 5 mg
7. PCM 2 tabs BD/ PRN
8. Atorvastatin 10mg OD previously taking it so no need to explain.

- GRIPS,
-Pt: “Hello Doctor I am getting discharged today and am really happy about it. They gave me
these medications can you please explain me how to take them.”
Dr: Congratulations that you are getting discharged. I can see you really happy about it.
Well yes I will explain you everything about the medications but before that can I ask you few
questions about your health? …… yes doctor
Dr: How are you doing now?
Dr: I am completely fine Doctor.
(Dr: Can you please tell me what were your complaints when you got admitted ? ) … this you can

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ask basing on the question so read question carefully.

Dr: Are you currently on any medications other than what we prescribed? …. Yes/ No
Dr: Do you have any medical conditions?...... Yes/No
Dr: Are you allergic to any medication or anything at all ? … No

Ok so let me explain you about the medicines: for every medication she was asking Why this
medication , for how long do I have to take it , how many times a day?
1. This medication is Amoxiclav… its an antibiotic given for the infection to resolve soon.
You will have to take this medicine ………. times as day for ……. Many days
( check the prescription). Please be aware that you might get nausea, vomiting ,
diarrhoea after taking this medication. So if you get it please come back to us. Note: If
any other antibiotic is given mention side effects according to the BNF. Any
concerns?
2. Codeine: This medication is given for Cough, Diarrhoea and Pain. ( check in the question
why she is getting it for ).

You can take it as is prescribed ( check the prescription). There are certain side effects of it like

sometimes constipation, feeling sick or vomiting, feeling sleepy, Dizziness, vertigo, dry mouth etc. so

if you have of any these side effects please do come back to us.

Dr: Do you have any concerns? Pt: No Doctor.

3. Alendronate : This is the medication we give to slowdown the rate of osteoporosis and
prevent fractures.
Pt: “Doctor can I take it while in sitting position or do I have to stand to take these
medications?”
Dr:” well you can sit and take these medications however it is important that you need
to take it on an empty stomach with lot of water while sitting in upright position. These
medications usually take 6 to 12 months to work, and you may need to take them for 5
years or longer. The main side effect includes irritation of the food pipe, swallowing
problems and stomach. Please report it to us if you get any such problems. One of the
rare side effect is jaw necrosis. Dr: Can you please tell me if you have problem with your
Jaw? Pt: No Doctor.

4. Calcitriol + Vit D: these are the calcium supplement medications that we give for the
bone strengthening. So please take it every day at same time and for …………… number of
days ( as per prescription). If you get nausea , vomiting , loss of appetite, and drowsiness
please stop the medication and come back to us. Dr : Do you have any concerns so far ?.
Pt: Yes Doctor its clear to me.

5. Lisinopril: ( Previously 10mg and now its 5mg)

This medication is being given to treat you to treat your Blood pressure and to prevent

Heart related conditions. However now the dosage is reduced from 10mg to 5mg. but why

did they reduce the dosage Doctor? Now your blood pressure is responding to 5mg dosage

so we reduced. If we continue to give you those medications then your B.P might fall and

you might get dizziness.

Pt:” OH! May be That’s the reason why I was feeling dizzy”. Keep taking this medication and

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if you have any problem like - some people get a dry, irritating cough with lisinopril.

Drinking alcohol with lisinopril can make you feel dizzy or lightheaded. So please avoid

alcohol and if you feel dizziness or get severe cough then please come back to us. Do you

have any concerns ? …. No doctor

- and the last medication is PCM. Please take it as prescribed to treat pain.

If you have any concerns at all about any of the medications then please come back to us.

I hope I was able to explain everything to you. We will be following you up. I wish you good

health.

Thank you.

TEACHING ECG TO NURSE:

SCENARIO 4: Nurse wants to learn about the basics of ECG. Teach her.

( note : she might be holding 3-4 ECGs in hand)

Hello I am Dr. ……. Junior Doctor in this department.

How may I call you ?

Dr you can call me ……..

How are you doing today ?

Doctor I am fine. I want learn about the basics of the ECG can you please teach me.

D: I can see that you are so much interested in learning about the ECG. I really appreciate it.

( keep praising).

(Note : Questions by Nurse: How to check the Heart rate , What are the Waves ? , How it is

produced? What is normal and abnormal ecg?)

Well I will teach you every thing about it but before that can you please tell me how much do

you know about the ECG?

N: Doctor I know how to record ECG on machine but (might say) I don’t know much of how to

read it. Doctor please teach ok. Here is the ECG(Normal ECG)

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D: Ok so firstly we need to know how ECG is recorded. Sensors attached to the skin are used

to detect the electrical signals produced by your heart each time it beats. These signals are

recorded by a machine and are looked at by a doctor to see if they're unusual. We use ECG to

diagnose if there are any heart related issues like Arrhythmias, Heart attack, Coronary heart

disease and Cardiomyopathy. Am I clear so on ? …. Yes Doctor.

D: Ok now moving forward to calculate the heart rate you need to count number of large boxes

between 2 R waves and divide it with 300. So for example if you get 4 boxes between 2 R waves

then it will be 300/4= 75. Which is actually a normal heart rate. However if you see any changes

or if the heart beats you think is fast then report to the Doctor immediately…… Ok Doctor.

N: Doctor what is normal and abnormal ECG?

D: well as I mentioned earlier if the heart rate goes beyond 120 while calculating then it can be

something abnormal and needs to be looked into. This is called tachycardia. It can be related to

some heart issue.

 D: Now I will teach you about the rhythm of the ECG.Regular rhythm at a rate of 60-100
bpm (or age-appropriate rate in children).
 Each QRS complex is preceded by a normal P wave.
If you notice any abnormality in this then please refer to a Doctor.

D: do you want to learn about the S.T elevation which we use to detect M.I ?

No Doctor I am ok with this knowledge on ECG.

Please do let me know if you want to know anything more.
I once again am very happy that you are keen on learning and if you have any doubt in
anything then please come back to us.

Thank you.

Acute Gastro Enteritis

Exam question

Middle aged lady having diarrhoea and vomiting.

Infection controls have already been notified.
History and management.

-GRIPS
- How can I help you?
P: Dr. I am having pain in lower tummy. D: Can you please tell me more about it….
P: I am having it since past 3 days. Its in the lower part…. Do Socrates and also rule out

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Do you have anything else?

P: Doctor I am having Diarrhoea and vomiting since past 3 days.
D: I am sorry to hear that. Can you please tell more about it?
P: Doctor I have been having loose stools and vomiting. And it was 5 episodes on day 1 and
twice on day 2. ( may be she will say that she came to the G.P clinic because now she learnt that
G.E is a notifiable disease.)

D: Do you have any idea why you may be having this? did anything happened?

P: Yes Doctor I had food with my husband and son in a restaurant and after that it started. Even
they had similar complaints but they got better in a day.

D: ok can you give me the name of the restaurant ?

P: Doctor it is ……………… restaurant ( she gave the name of the restaurant )
D: we will inform the food authorities about it.
P: No Dr please don’t inform them as I don’t want restaurant people to face any trouble.
D: Unfortunately we need to notify it.

Rule out D.Ds

D.Ds like , Diverticulitis, PID, APPENCITIES, UTI.

D: Do you have swelling in your neck area ? .. no

D: Any preference for weather? ….. no ( hyperthyroidism)
D: any lumps or bumps anywhere in the body ?..... no
D: any weight loss recently. …..no
D: Any blood along with the stools?
D- Any fever ? ….. no

MAFTOSA: * Do ask her what job she does , any medications ( Antibiotics)
D: Anything else … Doctor I am drinking enough water every day and keep myself hydrated. ….
Praise her
Thank you very much for giving me all the important information.
I would like to examine you now. I will do a general physical examination, check your vitals , and
examine your tummy ------ examiner did not give any findings.

Management:

From the information you have given me and after examining you I think you may be having
what we call as Gastroenteritis because of food poisoning. Do you know what it is ?

Gastro enteritis is a condition which occurs due to inflammation of the wall of the Gut because
of some bugs. This results in vomiting, diarrhoea, fever and pain in abdomen.

For now we need to do some investigations on you like we will do

Bloods – FBC, U&E, Infection markers, ABG.

- For now since you said that your symptoms are subsiding so we don’t see any need to admit
(check it before saying). We will prescribe you some ORS powder to be mixed in water and then
drink.

I encourage you to notify your employer about your condition as this can spread to others.

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Do you have any concerns? No Doctor

( may be she works for the carer home. If yes then you will have to ask her to tell her employer
about it.)
Safety netting: If you have any severe vomiting loose stools or pain then please do come back to
us.

Thank you.

TIREDNESS – CITALOPRAM
Exam question

50 years old female complaining of tiredness you are the Fy2 in G.P Clinic. Take history &
management.

- GRIPS
P-Doctor I am feeling tired all the time.
D- I am sorry to hear that. Can you please tell me more about it?
ODPIPARA
P- I am having tiredness since past 3 months Doctor. My friend died 3 months back and after
that I was depressed and so psychiatrist prescribed me this medication- Citalopram.
D- Ok I am very sorry to hear about your friend. Please accept my condolence.
D- were you alright before these symptoms started?........ Yes doctor
D/Ds
D- do you have any preference for weather ? …. No
D- Any swelling in your neck ? ….. No
D- Any change in your weight recently ? …..No
D- Is it there all the day or at any specific time of the day like morning or evening ?... all the day.
D- DO you have any pain anywhere in the body ?.... no
D- Any pain in bone pain ? …. No
D- Bleeding from anywhere in your body like from back passage? … No
D- Weight loss or lumps or bumps any where in the body ? … no
D- Any problem with the sleep ? …. No
D- How is your mood these days ? If you have to rate it on a scale of 1 – 10 1 being low and 10
being normal how would you rate it ?
P- Its 5 or 6 out of 10 Doctor.
D- Any medical conditions like diabetes , Hypertension, Heart problems, kidney problems.
D- do you smoke, take alcohol, use recreational; drugs? ….. No

MAFTOSA: Ask about work and family history of similar complaints and medications.
Anything else?
Thank you for giving me all the vital information.

Examination: Now I would like to exam you. I would like to check your vitals, Do a general
physical examination to check if there is any bleed from anywhere in the body and to see if there
are any lumps or bumps anywhere.
Management :
I would like to do some investigations to know what exactly may be causing this condition in
you.

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Blood: FBC, FBS, LFT, Urea &Electrolytes, Infection markers, thyroid profile.
( no normal values were given and examiner gave a paper with all the findings)
Na+: 129
K+: 4.8
U&E: ……
Check BNF for Citallopram

Treatment: well for from the history and examination we were not able to elicit any specific
cause for your tiredness however the medication citalopram can cause hyponatremia and this
might have to led to tiredness.
We will refer you to Psychiatrist for further evaluation as your mood is still low and also to
change the medication.
Do you have any concerns?
No doctor.

Thank you.

Information on Citallopram from NHS website:

 Citalopram is a type of antidepressant known as an SSRI (selective serotonin reuptake

inhibitor).

It's often used to treat depression and also sometimes for panic attacks.

 It usually takes 4 to 6 weeks for citalopram to work.

 Side effects such as tiredness, dry mouth and sweating are common. They are usually

mild and go away after a couple of weeks.

 Citalopram-induced syndrome of inappropriate antidiuretic hormone secretion

(SIADH) causing hyponatremia is well documented; however,

severehyponatremia with small doses has not been previously reported.

 Citalopram can affect an unborn baby. Tell your doctor straight away if you’re trying to

get pregnant or become pregnant while taking it.

 Like all medicines, citalopram can cause side effects in some people, but many people
have no side effects or only minor ones. Some of the common side effects of citalopram
will gradually improve as your body gets used to it. Some people who take citalopram for
panic attacks find their anxiety gets worse during the first few weeks of treatment. This
usually wears off after a few weeks but speak to your doctor if it bothers you - a lower
dose may help reduce your symptoms.
Citalopram

 is generally not recommended in pregnancy or while breastfeeding.

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FY1 Colleague delayed discharge(27th June)

FY1 colleague Dr Gupta is in medical ward covering for other doctor who is on sick leave. He
was supposed to discharge Mrs Storm but her discharge got delayed for a few hours. Mrs
Storm wants to complain.
Management also wants beds for patients in the ER and they repeatedly called the nurse to
enquire for beds.
You are the FY2 doctor in same department. Go and talk to your colleague and find out what
happened.

(You enter the cubicle and fy1 colleague is acting very busy)

Dr : Hi Dr Gupta. I am Dr…. I am in the same department. How are you doing today ?
FY1 : I am fine doctor. You can call me Sam.
Dr : Ok Sam . You seem to be really busy. Is everything alright ?
Sam : Yes doctor, this is my first job. All these things were not taught in medical school.
Dr : I think I can understand your situation. Things are tough at the start of your job and with
time you get used to the system and I believe you will start enjoying then.
If you would like, I can guide you to a few workshops which will make this process easier for
you.
Sam : It is just that this is my first job and I think I am overworked. But if it would help me I
might consider joining a workshop.
Dr : Yes Sam I really think it would help. I can see that you are really busy today but there is
one thing that I would like to discuss. Do you have a few moments to spare?
Sam : Yes doctor. I think we can talk now.
Dr : Alright Sam. It is regarding discharging Mrs Storm. She was supposed to be discharged
few hours back. She has been waiting since then and now she wants to complain.
Sam : Yes doctor. I am aware that I had to discharge her. It is just that I was doing work and it
kept me busy.
Dr : Sam do you feel you have any problem prioritizing jobs ?
Sam : No doctor. I have a to do list and I note things on this. Actually , I was busy with critical
patients/important things and her discharge just kept on going down and down on my list.
Dr : Sam do you think if there is a problem or you could have done things in a better way.
Sam : I am not sure of what I could have done better. This is my first job and when I came in
the morning I informed the management that it would be difficult for me as I am the only one
in the ward today.

Dr : Yes Sam I think I can understand what you are going through. You could have told me and
I would have been happy to share your work load.
Sam : Yes doctor I wanted to but you are the first doctor I am seeing today.
Dr : Well Sam , you should have informed the ward nurse or the nurse in charge that you are
held in an emergency and are bit delayed. What do you think about it ?
Sam : Yes doctor I think I could have done that.
Dr : Yes Sam. What’s important is that this should not happen again and we keep on learning
and improving from every experience.
So I think you should report this incident so that it is discussed in Root cause analysis meeting
and we can find ways to avoid this kind of situation in future.

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Sam : Yes doctor I will do that.

Dr : Sam I think you should also go to Mrs Storm and explain your situation. And if she wants
to complain then guide her about PALS.

Sam : Yes doctor I will go to her now but will you tell the consultant ?
Dr : Sam you must tell the consultant yourself. He is going to find about this incident anyway
so it would be better if you did it yourself as you would have a chance to explain the situation. I
am sure he will help you further.
Sam : Yes doctor I will talk to him as soon as possible.
Dr : Sam one more thing if you need help with anything in future, we are always with you. You
cannot expect to do everything yourself. We work as a team here. You should go and talk to
Mrs Storm and I will cover for you in the meantime.

Breast Cancer (DICU)

Exam question

Patient 58 years old female has been called to surgery outdoor clinic to receive results of
her breast screening mammogram and FNAC. Results show ductal carcinoma in situ
(Early cancer).
She has been self-examining her.
You are FY2 in surgery. Talk to her and give her management options.
(when you enter the cubicle patient acts anxious and worried)

Dr: Hello I am dr. ----------Are you Mrs Sharon?

Pt: Yes dr.
Dr: How are you doing today Mrs Sharon?
Pt: Dr. I am really worried. I keep on self-examining. I have not found anything. Few weeks back
I came for routine test they did an X-ray and took some samples. Then weeks and weeks later I
received a letter from your office and I came to get my results.
Dr: It is really good that you kept self-examining it shows how keen you are about your health.
Sharon I know that we have made you wait for quite some time but biopsies usually take time to
be assessed and report to be confirmed. I am sorry we made you wait for your results but I have
your results with me and I would be discussing those shortly.
Would it be alright if I ask you few questions first so that I can explain test results better?
Pt: Sure doctor what would you like to know?
Dr: You mentioned that you haven’t found any lump in your breast. Have you noticed any lump
elsewhere in body? No
Dr: Have you noticed any discharge from breast? No
Dr: Any bleeding? No.
Dr: Have you noticed any change in your weight ? No.
Dr: Is there any history of you taking oral contraceptive pills? No
Dr: Have you ever received hormone replacement therapy? No
Dr: Did you have any surgeries in the past? No
Dr: Does anyone else in your family have breast cancer? No
Dr: Do you smoke? no

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Dr: Do you drink alcohol? no

Dr: And when was your last menstrual period? Pt: It has been years doctor, may be 6 to 7 years
now.
Dr: Sharon is there anything in specific that you are concerned about ?
Pt: Dr. I am worried if I have cancer. I just want to know the results.
Dr: Yes Sharon I do have the results of your tests.
Pt: What is it doctor?
Dr: Unfortunately I don’t have good news for you.
Would you like to hear it alone or shall I call someone to be with you ?
Pt: That is fine you can tell me the results.
Dr: Sharon as you know we did a mammogram and FNAC biopsy,,,,unfortunately the results
show that you have an early form of cancer in your breast.
Pt. Takes a pause (acting as if she is shocked )
Pt: But doctor how it could happen? I have been self-examining since I was young. I never felt
any lump. How is it possible? ( pt starts blaming herself that may be she is not doing test
properly)
Dr: Mrs Sharon I can’t even imagine what you must be going through right now. But you are not
to be blamed for this. It is an early form of breast cancer. It usually has no symptoms. Most cases
are found during routine breast screening or if a mammogram (breast x-ray) is done for some
other reason.
Pt: Dr. I am really worried about breast cancer. Is there any hope for me?
Dr: Mrs Sharon your concern is really valid. We would help you in whatever way we can. Let me
reassure you although it is a cancer but luckily it is at an early stage and as far as I know this
particular cancer carries a good prognosis. But I would like you to have detailed discussion with
my consultant Surgeon and he may be able to tell you about this condition in detail and you can
discuss treatment options as well.
Pt: Oh that’s why I got a call from surgery department.
Dr: Yes Mrs Sharon as far as I know treatment usually revolves around surgery. Surgical
removal, with or without additional radiation therapy or tamoxifen, is the recommended
treatment for this type of cancer.
Dr: Once again Mrs Sharon I really wish that I had better news to tell you today. Is there
anything else I can do for you?
Pt: Dr. I have been going through internet and I was reading about lumpectomy and
mastectomy, can you please tell me more about them.
Dr: Mrs Sharon I am really glad that you are so concerned about your health. It’s not every day
that we come across patients who are so well informed and concerned about their health.
Lumpectomy is a surgical removal of a discrete portion or "lump" of breast. In this surgery
tumour is removed along with the healthy margin surrounding it.
It is considered a viable breast conservation therapy, as the amount of tissue removed is limited
compared to a full-breast mastectomy.
While in mastectomy whole of breast tissue is removed.
Dr: Mrs Sharon is there anything else we can do for you?
Pt: NO doctor, this is all.
Dr: In that case Mrs Sharon I would be arranging an appointment for you with my consultant
surgeon as soon as possible.
Dr: Mrs Sharon I want you to know that you are not alone in this; we are always here for you.
And as I am very glad to see you so much interested about your health, if you would like I can
give you few leaflets regarding your condition which may help you in understanding it better.
Thank you very much doctor.

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Rheumatoid Arthritis (28th June)

A 50 years old woman has presented to clinic with complaint of hand pain.
She is a known smoker for past 20 years and has not followed up with her GP for
some time.
You are FY2 in clinic. Take history and discuss management with her.

Dr: Hello I am dr.-----------,are you Mrs. Anderson.

Pt: Yes, Call me Caroline.
Dr: Alright Caroline , How can I help you today ?
Pt: Dr. I have pain in my both hands.
Dr: I am so sorry to hear about this Caroline, are you comfortable to talk to me?
Pt: Yes dr. it is not much. Actually I did not even want to see a doctor. It is just that my boss was
insisting on it. He is a consultant.
Dr: Caroline may I know why didn’t you want to see a doctor?
Pt: It is just that I feel fine.
Dr: Caroline it is really good that you came to clinic today; we would try our best to help you.
I would like to know a bit more about your hand pain.
Pt: Dr. I have pain in my fingers and wrist joints.
Dr: Since when do have this pain? Pt: It is there for past 6--7 weeks.
Dr: How did it start? Pt: All of a sudden.
Dr: How has it progressed over time. Pt: It is getting worse.
Dr: Have you tried anything which makes it better? Pt: I take ibuprofen but the pain does not go
away completely.
Dr: Have you noticed anything which makes it worse? Pt: Nothing in particular it is just that it is
worse in morning when I wake up.
Dr: Does it get better as the day progresses? Pt: Yes.
Dr: Have you noticed anything else along with this pain. Pt: Like what doctor ?
Dr: Any Rash Pt: NO.
Dr: Fever Pt: NO
Dr: Have you noticed any change in your bowels ? Pt: No.
Dr: Any swelling ? Pt: Yes there is swelling at my finger joints.
Dr: Any swelling any where else in body ? Pt: NO.
Dr: Have you felt that your finger and wrist joints are stiff in morning ? Pt: Yes.
Dr: And how long does that stiffness last for ? Pt: I am not sure about time doctor.
Dr: Do you have pain anywhere else in body ? Pt: NO
Dr. Any Pain in your neck or back ? Pt: No
Dr: Any vision problems ? Pt:No
Dr: Have you noticed any changes in your weight? Pt: NO
Dr: Have you ever had pain like this before ? No.
Dr: Do you have any medical problems ? Pt: Like what ?
Dr: Diabetes ? Pt: NO.
Dr: High blood pressure Pt: No.
Dr: Are you taking any medications? Pt: Yes occasionaly ibuprofen for pain.
Dr: Are you allergic to any medication ? Pt: No.
Dr: Is there any one else in the family with same symptoms ? Pt:No.
Dr: Do you smoke ? Pt:Yes 20 cigarretes a day for last 20 years.(never tried to stop)
Dr: Alcohol Pt: NO.

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Dr: Recreational drugs? Pt: No.

Dr: May I Know what do you do for living ? Pt: I am a medical secretary.
Dr: Has this condition impacted your work ? Pt:Yes I am having difficulty in typing and my boss
is giving me a lot of trouble because of this.
Dr: I am really sorry to hear this Caroline. I assure you we will try to find out what is causing
this pain and will do our best to relieve you of this.
Dr: Is there anything else that you would like to tell.
Pt: Doctor somebody told me I should not be taking ibuprofen as I smoke. What do you think?
Dr: I am sure Caroline who so ever told you this deeply cares about you. Smoking it self is not
good for our body as it not only causes various health risks, it also slows down healing process
and taking ibuprofen while you are smoking increases the risk of stomach ulcers as well.
If you would like our help regarding stopping smoking we have various options and we would
be glad to offer those.
Pt: Ok doctor I will think about this.
Dr: Thankyou Caroline for letting me know all this.
Dr: I would like to examine your hand and would like to see your news chart as well.
Examiner shows a picture of hands. (Vitals Normal)

Dr: Caroline thank you very much for letting me examine you.
Dr: From our discussion and my examination I think that you have a condition we call as
Rheumatoid Arthritis.
Would you like to know about this ? Rheumatoid arthritis is an autoimmune condition in which
our body defence system starts attacking the cells that line your joints by mistake, making the
joints swollen, stiff and painful.
We would like to confirm this further by doing few tests.
I would like to order Full blood counts, Rheumatoid factor, inflammatory markers like CRP and
ESR and a special test called Anti ccp antibody test. We would also like to do and X ray of your
hands and wrist joints. Only after this tests we may be able to say for sure.
What do you think of this?
That’s alright doctor.
Dr: Do you have any questions ?
Dr if it is this condition then do you have any treatment for it.
Dr: Unfortunately there is no permanent cure for it but we can offer you various ways and
options by which we can control these symptoms and enable you to live as active a life as
possible.
These options usually involve lifestyle changes, medication, supportive treatments and surgery.
If you would like I can refer you to our rheumatologist so that you can discuss these options at
length. What do you say ? Yes I would like to visit him.
He may offer you medications like DMARDS which may help in controlling these symptoms.
As you already told me that you are taking Ibuprofen but it is not helping with pain, I will
discuss with my seniors if we can switch you to a stronger pain killer but it is always advised

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that you take this pain killer with PPI like omeprazole so that we can protect your stomach as
well.
I can refer you to occupational therapist he may help you with strategies to cope with your
work.
If you would like I can guide you to our physiotherapist as well as he may have some helpful
exercises for you.
How does that sound to you? Pt: I think I will try all this.
Caroline it is important that you stop smoking as it can cause flares of this condition and if you
would like any help with that I can refer you to smoking cessation clinic as well.
Pt: I will think about it doctor.

GENDER SELECTION 27TH JUNE

Isabelle 36 years old female has come to clinic. She is on combined oral contraceptive
pills for last 6 years.
She has three daughters of 14, 8 and 6 years of age respectively.
You are FY2 doctor in clinic. Talk to her and find out the reason for her visit?
( When you enter the cubicle patient greets you actively and looks very happy )

Dr: Hello I am Dr. -------------, one of the junior doctors in clinic. How may I call you?
Pt: Call me Isabelle.
Dr: Okay Isabelle how can I help you today?
Pt: Dr. I want a baby boy can you help me with it?
Dr: Isabelle can you please elaborate?
Pt: Doctor me any my husband already have three daughters and now we would like to have a
male baby. My husband wants to continue the family name.
Dr: Is that what you want as well?
Pt: Yes I want the same.
Dr: Isabelle as far as I know from medical point of view, with every pregnancy there is a 50 %
chance of it being a male or female. May I know specifically what you want from us?
Pt: Doctor I want to know if there is any procedure or technique to ensure that my next child
will be male ?
Dr: Isabelle yes although there is a technique of pre implantation genetic diagnosis which can be
used for this purpose but its use for purpose of gender selection is banned and illegal in U.K.
I am really sorry but we may not be able to help you with this technique.
But I would be happy to help you if you require anything else.
Pt: Ok doctor what about alternative medicine. Is there anything which may help me?
Dr: Isabelle although there have been many claims by people practicing alternative medicine
regarding this like having sex near the ovulation date and eating specific kind of food but none
of those methods have been medically proven and as such have no scientific basis to them.
Pt: Okay doctor if I get pregnant then how early can you let me know about the gender of baby?
Dr: Yes we can do an ultrasound scan to know the gender of the baby. We can do this earliest by
18th to 21st week of your pregnancy. But it is not true all the times as sonographer will not be
able to be 100% certain about your baby's sex.
Dr: Isabelle may I know if you are under any pressure or stress to have a male child?
Pt: No doctor it is just that I want to have a male child.
Pt: Can I abort if it is a girl?
Dr: Isabelle abortion solely on the basis of preference of gender, where there are no health
implications for the baby or for the woman are unlawful and we will not help you with that.

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But isn’t it my right to have an abortion?

Dr: Yes generally it is woman’s right to have abortion but let me tell you the only conditions in
which law permits someone to have an abortion.
Abortions in England, Wales and Scotland are carried out before 24 weeks of pregnancy only by
registered medical practitioners in cases when termination of the pregnancy is necessary to
prevent grave permanent injury to the physical or mental health of the pregnant woman or if
the child when born would suffer from such physical or mental abnormalities as to be seriously
handicapped.
Dr: Do you have any questions regarding this? Pt: No doctor.
Isabelle if you would like I can arrange an appointment with my consultant and he may be able
to guide you further on this subject.
Thank you

Sub Conjunctival Haemorrhage 28th June

A 72 years old male has presented to A/E with redness in eye.
You are FY2 in the department. Your task is to assess and manage your patient.

Subconjunctival hemorrhage is a benign disorder that is a common cause of acute ocular redness. The
major risk factors include trauma and contact lens usage in younger patients, whereas among the elderly,
systemic vascular diseases such as hypertension, diabetes, and arteriosclerosis are more common.

A subconjunctival hemorrhage often occurs without any obvious harm to youreye. Even a strong sneeze
or cough can cause a blood vessel to break in the eye. ... But a subconjunctival hemorrhage is usually a
harmless condition that disappears within two weeks or s

Dr. Hello Mr. Sterling. I am Dr. --------,one of the junior doctors in the department. How can I
help you today?
Pt: Dr. this is how I woke up today. (Pt shows a picture)

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Dr: Mr sterling how did this happen ?

Pt: I don’t know doctor. I just woke up and saw myself in the mirror and this is how I looked
like.it looks really bad doctor. Please do something about this.
Dr: Mr. Sterling I am really sorry that you have to see yourself like this. We would try our best to
find out why this happened and how we can help you with this.
Dr: Has it been the same since morning or have you noticed any change in it? Pt: no doctor it is
same.
Dr: Are you able to see properly? Pt:Yes
Dr: Do you have anything else along with this? Pt: like what doctor ?
Dr: Any pain in the eye? Pt: No
Dr: Any pain elsewhere in body? Pt: No.
Dr: Have you got any joint pains? Pt: no.
Dr: Any fever? Pt: no.
Dr: Any discharge from eye? Pt:no
Dr: Are you feeling any itching in eye ? Pt:no.
Dr: By any chance did you hit or scratch your eye ? Pt: no.
Dr: Do you use contact lens ? Pt:no.
Dr: Are you having any difficulty looking in the dark ? Pt: no.
Dr: What about looking into bright light ? Pt:NO difficulty doctor.
Dr: Have you noticed any floaters in your vision or if your vision is blurry ? Pt: No ( uveitis )
Dr: Do you have cough or sneezing? No.
Dr: How are your bowel habits ? Are you having constipation ? NO
Dr: Do you have any medical conditions ? like what doctor.
Dr: Diabetes ? no
Dr: High blood pressure ? no.
Dr: Any bleeding problems ? no.
Dr: Are you taking any medications? Especially blood thinners ? No.
Dr: Are you allergic to anything ? NO.
Dr: Do you smoke ? no.
Dr: Do you drink alcohol ? no.
Dr: May I know what you do for living? Pt: I am retired now. I used to work in office.
Dr: Mr. Sterling has it ever happened before? No
Dr: Did you have any recent eye surgery? no

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Mr. Sterling is there anything you would like to tell us? Pt: no doctor but is it serious?
Dr: Mr. Sterling from the look of it, it does not appear so. But we are never too sure until we do
some further tests.
I would like to examine your eyes and also would like to check your blood
pressure. Or diabetes and blood circulation in your legs ( arteriosclerosis)

Sure go ahead doctor.

(B.P normal and fundus also normal)
Dr: Mr. Sterling after our discussion and my examination I think you have a condition we call as
subconjunctival haemorrhage. In this condition there is bleeding underneath the conjunctiva
layer of eye. There can be many reasons for this or sometimes it may be without any reason as
well.
We need to do further tests like CBC, PT, APTT, INR and we need to check your visual acuity. We
may have to take swabs from your eye to look for infections. We would also like to do a test
called tonometry to look for if there is increased pressure in your eye. What do you think
regarding these tests?
Sure doctor, go ahead but will it get better.
Dr: Yes Mr. Sterling I really hope so.
If it is what I am thinking it to be then in most of the cases it gets better on its own and does not
require any specific treatment. But I would like you to see our consultant ophthalmologist as he
may be able to tell you more about this condition and management options that we can offer
you.
Dr: What do you say? Yes I think the same.
Dr: Well then I will be arranging for your appointment as soon as possible.
Dr: Is there anything else that I can help you with?
Thank you.

NEW STATIONS JULY 2018

Child with cerebral palsy………Mother doesn’t want IV cannula.

You are FY2 in Pediatrics department. 4 years old child, Teddie is admitted with severe
pneumonia.
This is the 4th time he is admitted with pneumonia. He has been prescribed course of I/V
antibiotics for 5 days. This is the second day of treatment.
Patient has Fever and Tachypnea. On x-ray there is consolidation.
Talk to mother and address her concerns.

Dr: Hello I am Dr……………., One of the junior doctors in the department. Are you the mother of
Teddie? Mother: Yes.
Dr: How may I call you? Mother: Call me Stacey.
Dr: Alright Stacey, How may I help you today?
Pt: Doctor, I don’t want Teddie to have an I/V Cannula.
Dr: Stacey, is there any reason for you to say that?
Pt: Yes Doctor, He is already in lot of discomfort. He has very thin and small veins. Doctors and

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nurses keep pricking him again and again. He cries a lot, it is really hard for me to see that.
Dr: Stacey your concern is valid, I do understand this process can be painful. You are very
caring mother and I know it is your love for your son which is making you say this… but do you
know why are we trying to pass cannula?
Pt: Yes doctor I know that Teddie has chest infection and you want to give him medicine
through his veins. But it is very painful for him and I cannot allow that. Give him some other
medicine, give him syrup or tablets.
Dr: Yes Stacey you are right, Teddie has pneumonia and I really wish if we could give him
medicine in form of syrups or tablets. But these are not as effective as medicines through veins.
As you know this is the fourth time that he is being admitted with pneumonia and this time it is
severe. So, I am afraid, syrups and tablets won’t help Teddie much with this condition.
These medicines are antibiotics and they are necessary for Teddie. It is really important that we
complete their course for five days.
Pt: Yes doctor I want Teddie to get better but this is too difficult for me to watch. Doctors and
nurses prick him like he is a pin cushion. He doesn’t speak much but pain shows on his face.
Dr: I am really sorry that you have to see all this. We are only doing all this because we want
Teddie to get better as soon as possible. As you are aware that Teddie unfortunately has
cerebral palsy. In this condition muscles of chest wall are weak and if any chest infection is left
untreated or if the treatment is not adequate, it can be very dangerous. So we have to act very
fast. This can only be done if we give him medicines through his veins.
If you would like I would request most senior person to put in the I/V cannula. We would also
apply local anesthetic cream on him arm before the procedure so that he doesn’t feel any pain.
What do you think?
Pt: Okay, doctor you may pass the cannula. I just don’t want to see him in pain.
Dr: Stacey, We will be very careful and once the cannula is in place we will make every effort
that it is maintained and we don’t have to repeat the procedure.
Is there anything else we can do for you?
Pt: No doctor, Thank you.
Dr: Thank you very much Stacey for understanding the need and allowing us to pass I/V line.
If there is anything else, We will be glad to help you.

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DNACPR Simman----------Talk to nurse. (11th July )

You are FY2 in department for elderly medicine
80 years old Mr. Albert Corrigon has been admitted for some time with lung cancer. He
has been receiving treatment.
Nurse wants to talk to you about Mr. Albert Corrigon.
Speak to the nurse, assess the patient and write medical notes.

Hello my name is doctor------------. I am one of the Junior doctors in the department.

Are you nurse------------? Yes
Dr: I understand that you wanted to talk to me, how can I help you today?
Nurse: Doctor, Mr. Corrigon is admitted with us for past few weeks. For last 10 days he is not
well and today he suddenly became like this.
Dr: Ok, let me just have a look at Mr Corrigon.
Dr: Hello Mr. Corrigan………….no response.
Mr. Corrigon, tapped the patient, no response.
Assess airway, check carotid pulse and look for breathing.( patient had no Pulse and was not
breathing.)
Dr: It seems that Mr Corrigon is in cardiac arrest. Please help me connect monitor to confirm.
Nurse: Sorry doctor, there are no monitors here.
Dr: Ok then we must start CPR. Please call crash team but before that I would like to know if Mr
Corrigon had any end of Life Care wishes.
Nurse: Yes doctor, Mr. Corrigon had signed DNACPR form. Here I have the form if you want to
have a look at it. (it is completely filled form with lot of information.)

Dr: Yes, you are right, It appears that Mr. corrigon had wished for no resuscitation and we must
respect that.

(There is a stethoscope and a pen torch inside the cubicle).

Confirm patient death and write in notes

Death Confirmation Assessment:

 Identity confirmed as Mr./Mrs._____ from wrist band.
 Patient lying in bed, eyes closed, no signs of life.
 No respiratory effort noted.
 No response to verbal or painful stimuli.

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 No carotid pulse palpable.

 Pupils fixed and dilated bilaterally.
 No heart sounds noted during 3 minutes of auscultation.
 No Breathing sounds noted during 3 minutes of auscultation.

Death Confirmed at (time), on (date).

No concerns from staff members or patients family.

Signature
Name
GMC Reg No:

Dr: I would like to contact Mr Corrigon’s family so that we can break the news to them.
Nurse: Sorry doctor they are not around.
Dr: Ok, do we have their contact numbers? Nurse: Yes
Dr: We should contact and inform them of Mr corrigon’s death.
Nurse: I will contact them and you can speak to them.
Dr: That would be great, Thank you.
Dr: I will discuss with seniors regarding cause of death before completing and signing the form.
Thank you.

Skin Lesion-----Fungal Infection

A 30 years old male has come to OPD clinic. You are Fy2 doctor in the clinic.
Talk to him and address his concerns.

Hello Mr. -----------,I am Dr.----------, one of the junior doctors in the clinic.
Dr: How can I help you today?
Pt: I have this rash on my forearm. I thought I will get it checked today.
Dr: Can you please describe this rash for me?
Pt: Yes, But what would you like to know?
Dr: Since when do you have this rash? Pt: few weeks.
Dr: where exactly do you have this rash? Pt: Right forearm.
Dr: which color is it? Pt: it is red in color.
Dr: How is this rash bothering you? Pt: it is very itchy and it is getting slightly bigger now.
Dr: Any Bleeding or Discharge? Pt-no
Dr: Have you shown it to any doctor so far? Pt- No.
Dr: ok, and have you tried anything which may have helped with this rash? Pt: No.
Dr: Do you know how it started? Pt: I do not know.
Dr: Any pain at site of rash? Pt: No.
Dr: Did you have any such rash before? Pt-No. (allergies, Psoriasis)
Dr: Do you have anything else along with this rash? Pt: Like what ?
Dr: Do you have Fever? Pt: no (meningitis, infections, abscess)
Dr: Have you noticed any rash or swelling elsewhere in the body? Pt : No
Dr: Have you noticed ant weight loss ? Pt- No.( Cancer )
Dr: Did you hit your forearm anywhere ? Pt- No.(Trauma)
Dr: Did you have an insect bite ? Pt: No.
Dr: Any pain in your joints? Pt- No. (sarcoidosis, Psoriasis)
Dr: Any bowel problems? Pt: no (I.B.D)

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Dr: Do you have any medical conditions? No

Dr: Diabetes? No
Dr: Any surgery before? No
Dr: Any medications? Pt – No.( Immunosuppressant )
Dr: Are you allergic to anything? Pt- No
Dr: Any of your family members or friends had any such problems?(contact) Pt –No.
Dr: What do you do for living?
Dr: Do you smoke? Pt- No.
Dr: Any recreational drugs? No
Dr: Do you practice safe sex? Pt: Yes
Dr: Is there anything else that you would like to tell us? Pt: No.
Dr- I need to examine you to see what exactly it is?
Pt : Sure Doctor. This is how it looks like. (Pt. Shows picture)

Dr: It looks like a ringworm Infection. It is caused by fungal types of bugs. But we would like to
run some tests to confirm this. We may have to take few swabs and scrapings from the area of
rash for this purpose…..What do you think? Pt: That’s alright.
Dr: Do you have any questions?
Pt: How did I get this?
Dr: It is a contagious disease. It usually spreads through close contact with an infected person or
animal and infected objects such as bed sheets, combs or towels. Sometimes it can also spread
by coming in contact with infected soil.
Pt: Dr. I have a wife who is pregnant, will it affect her?
Dr: Unfortunately, as it spreads through contact, there is a possibility. But we can minimize the
chances by starting treatment as soon as possible. There are few other things which you can do
to minimize its spread like wash towels and bed sheets regularly, keep your skin clean and wash
your hands after touching animals or soil. Regularly check your skin if you have been in contact
with an infected person or animal.
Dr: Do you have any other concerns?
Pt: How can you treat this?
Dr: Treatment involves antifungal medications.
If you would like I can arrange an appointment with dermatologist. He may prescribe you anti-
fungal medicines. This might be a cream, gel or spray. If required he may prescribe you some
tablets as well.
You usually need to use antifungal medicine every day for 2 weeks. It's important to finish the

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whole course, even if your symptoms go away.

We can offer you some anti -allergic medicines to control this itching because it is important
that you don’t scratch a ringworm rash as this could spread it to other parts of your body.
Thank you.

Tiredness--------------------Obstructive Sleep Apnea

You are Fy2 in GP Clinic. Mr. Smith, 45 years old male, has come to clinic today with
sleeping problem for past 2 months.
Talk to him, take history and discuss appropriate management with him.

Hello, Mr. Smith, My name is Dr. ---------------, I am one of the junior doctors in clinic today.
How can I help you today?
Pt: Dr. I feel tired all the time.
Dr: Mr. Smith can you please elaborate, what do mean by tiredness?
Pt: Doctor I feel as if I don’t have any energy to do work during day.
Dr: Since when are you feeling like this?
Pt: It’s been there for about 6 weeks now.
Dr: Do you feel any pain in your body as well? Pt: No (Fibromyalgia)
Dr: How did it start? Pt: I don’t know doctor.
Dr: Do you think something happened 2 months back which may have started this?
Pt: can’t think of anything doctor.
Dr: Have you tried anything which has helped you with tiredness? Pt: No, haven’t tried anything.
Dr: Is there anything which makes it worse? Pt: No doctor haven’t noticed anything. It is the
same since it started.
Dr: Mr. Smith you seem to be very worried about this, We will do everything we can to help you
come out of this.
Dr: Mr. Smith have you noticed any change in your weight ? Pt: No. (Hypothyroidism)
Dr: Have you developed preference for any particular weather ? Pt: No. (Hypothyroidism)
Dr: Any changes in your bowel habits ? Pt: No. (Hypothyroidism)
Dr: Do you feel short of breath while doing any work ? (anemia)
Pt: No doctor, I just feel very tired.
Dr: Is there any specific time when you are more tired? (Myasthenia)
Pt: No it stays same, doesn’t change much.
Dr: Do you feel better when you wake up? Pt: No, I am still very tired when I wake up?
Dr: Do you think you get ample sleep? Pt: Yes.

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Dr: what about your sleeping environment? Pt: doctor it is very comfortable.
Dr: Do you think you have any trouble sleeping? Pt: No, I don’t think so but my wife is always
complaining that I snore during sleep and my breathing is very loud and noisy. (Patients don’t
know if they snore in OSA)
Dr: Do you regularly fall asleep during the day against your will? Pt: Yes, sometimes I doze off
during the day as well.
Dr: Do you take any sleeping pills? Pt:…….? (risk factor for OSA)
Dr: do you feel difficulty in breathing from your nose? Pt……..? (risk factor for OSA)
Dr: Do you have any medical conditions? Pt: No
Dr: Diabetes? No.
Dr: High blood pressure? No.
Dr: Do you smoke? Pt: Yes/ No.
Dr: Do you drink alcohol? Pt: Yes only occasionally/ No.(drinking alcohol, particularly before
going to sleep, can make snoring and sleep apnea worse.)
Dr: May I know what do you do for living? Pt: I am a taxi driver.
Dr: Mr. Smith is this condition affecting your work in any way?
Pt: Yes Doctor, Sometimes I start dozing off during the day as well and so I am not able to drive
for whole day.
Dr: Mr. Smith, Is there anything else that you would like tell us? Pt: No doctor.
Mr. Smith from our discussion it seems that you are feeling tired all the time because of a
condition we call as Obstructive sleep apnea. This (OSA) is a relatively common condition where
the walls of the throat relax and narrow during sleep, interrupting normal breathing and it leads
to regularly interrupted sleep. These repeated sleep interruptions can make you feel very tired
during the day.
Pt: But doctor I don’t remember any interruptions.
Dr: Yes Mr. Smith, people with this condition usually have no memory of their interrupted
breathing and they are unaware of having a problem.
But we would like to confirm it before proceeding further and for that purpose we can refer you
to specialist sleep clinic where they will measure your height and weight to calculate your BMI
and they will arrange for your sleep to be assessed over night with help of special instruments.
We would also like to run some blood tests to exclude other conditions like hypothyroidism,
anemia and vitamin D deficiency. What do you think of this?
Pt: I think I shall visit this clinic.
Dr: Okay I will arrange an appointment as soon as possible.
If it turns out to be obstructive sleep apnea then you can do few things which will be of great
benefit. Would you like to know those?

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Pt: Yes, What are those?

Dr: These include life style changes like sleeping on your side, losing weight (if over-weight),
reducing the amount of alcohol you drink and avoiding sedatives at night. These all been shown
to help improve the symptoms of OSA.
Dr: How does all this sound to you? Pt: I think I must try these.
I really hope that these strategies will help you. Otherwise I can arrange an appointment with
my consultant and he may guide you regarding further treatment options like CPAP and
mandibular advancement device. In severe cases we have to resort to surgical options.
Mr. Smith I do understand OSA can have a significant impact on the quality of your life and it has
a significant emotional effect as well. If you would like I can refer you to supports groups like
British Lung Foundation and Sleep Apnea Trust. They will help you with strategies on how to
cope with this condition.
Mr. Smith do you have any concerns? Pt: No doctor.
Dr: Well there is one important thing, I think you must inform DVLA regarding your condition.
As you told me earlier that this condition is also affecting your driving. They may be able to
provide you with specialist guidance regarding your driving.
Pt:--------------.
Thankyou.

Iron Deficiency Anemia

You are FY2 in GP clinic. Mr. Curtis, 45 years old male has come to clinic today to receive
his test results.
He had blood test done three weeks back which showed,
Hb: 10 g/dl (11-15) Tlc: 4000/cmm Plt: 430,000 MCV: 78 (80-100)
He had blood tests done one week back as well which show:
Hb: 10.2 g/dl (11-15) Tlc: 4300/cmm Plt: 400,000 U& E: Normal Range LFTs: Normal
Serum Iron: Low, Serum Ferritin: Low, MCV: 78 (80-100), Test for celiac disease:
Negative.
Discuss these test results with Mr. Curtis, take appropriate history and discuss
management.

Hello Mr. Curtis, I am Dr.------------, One of the junior doctors in the clinic.
How can I help you today?
Pt: I came here for my results today.
Dr: Yes Mr. Curtis I have your results with me but please tell me if there is a specific reason you

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had these tests.

Pt: No specific reason doctor. I feel fine, it’s just that my wife is very conscious about health and
she convinced me to have this well man checkup.
Dr: Mr. Curtis you are very fortunate to have such caring wife. You did a very good thing by
having these tests and this in actual is an excellent practice.
Do you have any specific questions for us today?
Pt: No, I just want to know my test results.
Dr: Ok, Let’s discuss your report then.
(Discuss all test results and explain that everything looks normal but Hemoglobin is low and
there is iron deficiency as well)
Dr: Mr. Curtis we would like to investigate for the cause of low level of iron in your blood. Would
it be alright if I ask you few questions which may lead us to the reason for low hemoglobin?
Pt: Sure doctor, what would you like to know?
Dr: Do you feel tired all the time or as if you don’t have energy to do any work? Pt: No doctor, I
feel fine.
Dr: Do you feel short of breath while doing any work? Pt: No.
Dr: Have you ever felt your heart is racing? Pt: No. (Palpitations)
Dr: How is your diet? Pt: I eat healthy doctor. I eat both vegetables and meat.
Dr: Do you drink lot of tea or coffee? Pt: No.
Dr: Mr. Curtis how is your bowel habits? Pt: They are normal doctor, once a day.
Dr: Have you noticed any change in your bowels? Pt: No.
Dr: Are your stools difficult to flush? Pt: No. (malabsorption syndromes)
Dr: Any bleeding in your poo or if it is black colored? Pt: No. (G.I blood loss)
Dr: Have you ever noticed any bleeding from your back passage? Pt: No. (Hemorrhoids)
Dr: Any weight loss? Pt: No. (Cancer)
Dr: Any lumps or bumps in your body? Pt: No. (Cancer)
Dr: Mr. Curtis do you have any medical conditions? Pt: No doctor, I have enjoyed a very healthy
life.
Dr: Did you have any surgeries in the past? Pt: No.
Dr: Are you taking any medications including over the counter medicines? Pt: Yes Dr. I take
multivitamin supplements.
Dr: Were you prescribed those by a doctor? Pt: No, I buy them from supermarket. I have been
taking them for a long period of time, they are very good.
Dr: It is really good to see that you are so conscious and concerned about your health. It’s not
every day that we come across patients like you.
Dr: Mr. Curtis, Do you smoke? Pt: No.

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Dr: Do you drink alcohol? Pt: No.

Dr: Has any one in your family been diagnosed with cancer? Pt: no.
Dr: Is there anything else that you would like to tell us? Pt: No.
Dr: Mr. Curtis there can be many causes for iron deficiency in blood but mostly it is because of
inadequate diet, loss of iron in bleeding or malabsorption of iron from our gut.
From our discussion there is no apparent reason for low level of iron and hemoglobin in your
blood.
But we can do some specific tests to find out what’s the reason. Would you like to know these
tests?
Pt: Yes doctor, what are those?
Dr: We have done most of these tests already but if you would like I can refer you to
Gastroenterologist.
He may do a camera test (Endoscopy). In that way not only we can find out if there is any
bleeding, we also can take some samples from your bowels to test under microscope and
hopefully it will lead to a diagnosis. How does that sound to you?
Pt: I would think about this and will inform you.
Dr: That’s alright and Mr. Curtis for now we can offer you Iron tablets. I know you are already
taking multivitamins and I’m sure they must be really good but these tablets will be stronger.
Would you like to try them?
Pt: Ok, if it will help me.
Dr: You'll have to take these tablets for about 6 months after which we will repeat your blood
tests. In some people these tablets can cause some side effects like constipation or diarrhea,
tummy pain, heartburn, feeling sick and black poo. Try taking the tablets with or soon after food
to reduce the chance of side effects. It's important to keep taking the tablets even if you get side
effects.
Dr: Mr. Curtis you already told me that you eat healthy which is very good. But I am no expert on
diet. If you would like I can arrange an appointment with dietician. I think it would help us
greatly in finding out if there is anything deficient in diet and it will greatly benefit you in
making a well-balanced diet plan. What do you think?
Pt: Ok, I guess there is no harm in that.
Dr: That’s great Mr. Curtis. I would arrange an appointment as soon as possible.
Dr: Mr. Curtis thank you very much for coming to the clinic today because it is really important
that we treat this low level of iron as it very important for our body defense system and it also
prevents us from developing any complications affecting our heart and lungs.
If you would like I can provide you with few leaflets which will be of great help if you want to
know more about this condition.

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Pt: Yes I would like to read them.

Dr: That’s great, Mr. Curtis. Is there anything else I can help you with?
Pt: No Doctor, Thank you very much.
Dr: Thank you.

Colorectal Polyp - Colonoscopy

You are FY2 in Gastroenterology ward. Alice McCoy, 55 years old female has come to
department today with complaint of bleeding per rectum 6 weeks ago.
She had undergone sigmoidoscopy two weeks ago and it showed she had a polyp.
She requires colonoscopy now.
Talk to her and address her concerns.

Dr: Hello I am Dr-------------, one of the junior doctors in Gastroenterology, are you Alice McCoy?
Pt: Yes Doctor, call me Alice.
Dr: How can I help you today?
Pt: Doctor I had a camera test two weeks ago and first they took two weeks to give me results
and now they have asked me to come back and have camera test again. See this note.
(Pt. hands over the letter from consultant)
On the letter it is written
Your sigmiodoscopy showed that you had a polyp. Biopsy
confirms it to be adenoma (Dysplasia: Benign Lesion). You are requested
to come back for colonoscopy.
Signed: Consultant Gastroenterologist.

Dr: Alice do you know about these tests and what is in this letter?
Pt: Yes doctor I know it is a camera test but I don’t understand other things in this letter.
Dr: Yes Alice you are right this is a camera test and I know that we have made you wait for quite
some time for the results but that’s because we also tested few tissue samples under microscope
and it is a very sensitive test and it takes time to be assessed and report to be confirmed.
I am sorry we made you wait for your results but we have your results now and I am here to
answer if you have any questions or concerns.
Pt: Okay doctor but why do I need another camera test?

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Dr: Alice, You have been invited to have a colonoscopy because we found a small growth called
polyp in your rectum in your sigmoidoscopy test. This means there is a chance you have polyps
further up the bowel as well. A sigmoidoscopy is just for lower part of the large bowel but
colonoscopy checks further up the bowel.
Pt: But doctor it was very uncomfortable last time.
Dr: I am really sorry about that, Alice. We can offer you a sedative medication through your
veins before the procedure which is known to make this procedure more comfortable and we
will also apply numbing gel locally so that you don’t feel any pain or discomfort during the
procedure. Would it be right then?
Pt: Okay Doctor, but is it serious?
Dr: Right now the tests show that it is not very serious but we are never too sure until we test
the whole bowel.
In order to tell you more about this condition I need to ask few questions from you, would you
be comfortable with that?
Pt: Yes doctor, what do you want to know?
Dr: Alice what was the reason that you had first camera test?
Pt: Doctor I had bleeding from my back passage 6 weeks back and at first I thought it’s just
hemorrhoids as I had it previously as well, 30 years back when my daughter was born. But I had
bleeding from back passage again 2 weeks back and then I went to my GP and he suggested
camera test.
Dr: Alice, you did really well by going to your GP. It is a very healthy and positive attitude and it
allows us to find things at an early stage and in turn we have better options to offer to patients.
Alice, you told me about bleeding, how was it like?
Pt: I don’t really know doctor; it’s just that I had it twice.
Dr: Do you have anything else along-with this bleeding?
Pt: Like what doctor?
Dr: Any pain in your tummy? Pt: No.
Dr: Any pain at your back passage? Pt: No.
Dr: Have you noticed any change in your bowels? Pt: Not really doctor.
Dr: What are you usual bowel habits?
Pt: Dr: I have constipation for last 2 years. I take bisacodyl for it and it gets relieved.
Dr: Have you noticed if your constipation alternates with diarrhea? Pt: No.
Dr: Have you noticed any changes in your weight recently?
Pt: No doctor.
Dr: Any mass or lump in your back passage? Pt: No.
Dr: Any mass or lump in your tummy or elsewhere in the body? Pt: No.

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

Dr: Any surgeries previously? Pt: No.
Dr: Are you taking any medications including over the counter medicines? Pt: Just bisacodyl
occasionally.
Dr: Are you allergic to anything? Pt: No.
Dr: Do you smoke? Pt: No.
Dr: Do you drink alcohol? Pt: No.
Dr: Is there any one in your family who has been diagnosed with cancer?
Pt: No, Doctor. Am I having Cancer? (Pt. acts shocked and worried at word cancer)
Dr: I really hope not Alice,,,It is one of routine questions. You know cancer is a very dangerous
condition and we just cannot take risk of missing it. That’s why we always ask questions and
investigate for it.
Pt: Okay. So, doctor what is that I am having?
Dr: Alice, It is really hard to tell for sure without colonoscopy but from our discussion it does
not look to be serious and your biopsy test result also showed that although you had a growth
but it is not a serious one. But there is a chance that it can turn into cancer sometimes. Also
there may be more polyps much higher in the colon – if it is there they also may turn into
cancer. That is why it is important to do this camera test and check and remove them if they are
present.
What do you think?
Pt: Yes doctor I think there is no harm in doing this test.
Dr: That’s perfect; I would be making all the necessary arrangements as soon as possible. It was
really nice talking to you. It pleases us to see patients who are so conscious and concerned
about their health, it makes our work easier.
Is there anything else I can do for you?
Pt: No doctor, Thank you very much.

Bowel polyps
Bowel polyps are small growths on the inner lining of the large intestine (colon) or rectum.

Bowel polyps are very common, affecting around 1 in 4 people at some point in their lives. They
are slightly more common in men than women and are most common in people over the age of
60.

Some people develop just one polyp, while others may have a few.

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Symptoms of bowel polyps

Bowel polyps don't usually cause any symptoms, so most people with polyps won't know they
have them. They are often picked up during screening for bowel cancer.

However, some larger polyps can cause:

a small amount of slime (mucus) or blood in your poo (rectal bleeding)
diarrhoea or constipation
pain in your tummy (abdominal pain)

Bowel cancer risk

Polyps don't usually turn into cancer. But if some types of polyps (called adenomas) are not
removed, there's a chance they may eventually become cancerous. Doctors believe that most
bowel cancers develop from adenoma polyps.

However, very few polyps will turn into cancer, and it takes many years for this to happen.

Because of the risk of bowel polyps developing into cancer, your doctor will always recommend
getting polyps treated.

Treatments for bowel polyps

There are several methods for treating polyps, but the most common procedure involves
physically removing the polyp using a wire loop. This happens during a procedure called
a colonoscopy.

The colonoscopy involves passing a flexible tube called a colonoscope through your bottom and
up into your bowel. The colonoscope has a wire attached to it with an electric current through it.
This wire is used to either burn off (cauterise) or cut off (snare) the polyp. Both of these methods
are painless.

In rare cases, polyps may need to be treated by surgically removing part of the bowel. This is
usually only done when the polyp has some cell changes, if it is particularly large, or if there are a
lot of polyps.

After the polyp or polyps have been removed, they are sent to specialists in a laboratory, who will
inform your consultant if:
the polyp has been completely removed
there is any risk of it regrowing
there is any cancerous change in the polyp

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If there is a cancerous change in the polyp, you may need further treatment (depending on the
degree and extent of change). Your specialist will be able to advise you on this.

Causes of bowel polyps

Doctors don't know the exact cause of bowel polyps. It is thought that they are caused by the
body producing too many cells in the lining of the bowel. These extra cells then form into a
bump, which is the polyp.

You may be more likely to develop bowel polyps if:

a member of your family has had bowel polyps or bowel cancer
you have a condition that affects your gut, such as colitis or Crohn's disease
you are overweight or smoke

Diagnosing bowel polyps

Bowel polyps are usually found when your bowel is being looked at for another reason or
during screening for bowel cancer.

If polyps are found, a colonoscopy or CT colonography is needed to view the whole of the large
bowel and remove them at the same time.

Monitoring bowel polyps

Some people with a certain type of polyp may be at risk of it coming back in the future
(recurring).

This is uncommon, but means you'll need examining (by colonoscopy) at regular intervals of
around three to five years. This is to catch any further polyps that may develop and potentially
turn into bowel cancer.

Adenomatous polyps (adenomas) of the colon and rectum are benign (noncancerous) growths, but may
be precursor lesions to colorectal cancer. Polyps greater than one centimeter in diameter are associated
with a greater risk of cancer. If polyps are not removed, they continue to grow and can become cancerous.

Polyps don't always become cancerous, but your risk of developing cancer increases with the number and
size of colon polyps you have. Approximately one percent of polyps with a diameter less than a centimeter
are cancerous

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Current theories propose it will take about 10 years for a small adenoma to transform into a cancer

Research suggests that making the following changes may have health benefits and may lower
your chances of developing colon polyps:

1. eating more fruits, vegetables, and other foods with fiber , such as beans and bran cereal.
2. losing weight if you're overweight and not gaining weight if you're already at a healthy weight.

If a polyp is removed completely, it is unusual for it to return in the same place. The same factors that
caused it to grow in the first place, however, could cause polyp growth at another location in the colon or
rectum.

1. Flu ( Influenza) Jab to child ( 30th May 2018 - new station)

Question : 3 year old child Like is due for Flu vaccination in one week. Mother wants to
talk to a doctor. Address her concerns.

D: How can I help you ?

M: My son is due for Flu vaccination in one week. Does he really need it ?
D: I will explain that. Before that Can I ask you what do you know about flu ?
M: I know he can have fever and cough.
D: Yes it is a very common infection in babies and children. One can catch flu all year round,
but it's especially common in winter, which is why it's also known as seasonal flu.

Children with flu have can have symptoms like fever, chills, aching muscles, headache, stuffy
nose, dry cough and a sore throat.

Flu (influenza) is a common infectious viral illness spread by coughs and sneezes. Symptoms
usually subside within about a week on its own. However sometimes it can cause serious
complications such as bronchitis, pneumonia ( infection of lungs) and a painful middle ear
infection.

They may need hospital treatment, and very occasionally a child may die from flu.

In fact, healthy children under the age of 5 are more likely to have to be admitted to hospital
with flu than any other age group.

Also if children with long-term health conditions such as diabetes, asthma, heart disease or
lung disease, getting flu can be very serious as they are more at risk of developing serious
complications.

So prevent such serious complications it is very important prevent children getting Flu. That
is why we recommend Flu vaccine to children to prevent them from getting Flu.

D: Can I ask does your child has any medical conditions like Diabetes, asthma, any
allergies?M: No D: Has he got any runny nose ? M : No
D: Has he had Flu jab before ? M : No
D: Has he got Fu symptoms now ? M: No

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(M: Is the Flu same as common cold ?

D: Flu is not the same as the common cold. Flu is caused by a different group of viruses and
the symptoms tend to start more suddenly, be more severe and last longer).
D: Any other concerns ?

M: How do you give the Flu vaccine ?

D: There are two ways we can Flu vaccine - one type if nasal spray and the other type is
injection. However nowadays we give nasal spray rather than injections because nasal sprays
are more effective than injections. We usually give this vaccination before the start of winter.

M: Are there any side effects of this vaccine ( what are the symptoms to watch out for?

The nasal spray flu vaccine has few side effects – most commonly getting a runny nose after
vaccination for a few days.

D: The flu vaccine for children is usually safe but like all vaccines, some children may
experience side effects. The side effects linked with the flu nasal spray vaccine are almost
always mild and short-lived.
Common side effects of the flu nasal spray vaccine

a runny or blocked nose

headache
general tiredness
loss of appetite

Rare side effects of the flu nasal spray vaccine

As with all vaccines, there's a very small chance of a severe allergic reaction (known
medically as anaphylaxis). The overall rate of anaphylaxis after vaccination is around 1 in
900,000 (so slightly more common than 1 in a million).

( Anaphylaxis is very serious but it can be treated with adrenaline. When it happens, it does
so within a few minutes of the vaccination. Staff who give vaccinations have all been trained
to spot and deal with anaphylactic reactions and children recover completely with treatment).

M: What should I do if my child has a side effect from the flu nasal spray vaccine ?

D: If your child has a runny nose after their flu vaccination, simply wipe their nose with a
tissue and then discard it.

M: What if my child has to have the injected flu vaccine what are the side effects ?

D: Some children can't have the nasal spray flu vaccine and are offered the injected flu
vaccine instead.

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Children having the injected vaccine may get a sore arm at the injection site, a mild fever
and aching muscles for a day or two after the vaccination.

M: How is the nasal spray flu vaccine given?

D: The vaccine is given as a single spray squirted up each nostril. Not only is it needle-free –
a big advantage for children – the nasal spray is quick, painless, and works even better than
the injected flu vaccine.

The vaccine is absorbed very quickly. It will still work even if, after the vaccination, your
child develops a runny nose, sneezes or blows their nose.

Are there any children who should delay having the nasal spray flu vaccine?

Children should have their nasal spray flu vaccination delayed if they:

have a runny or blocked nose or if they are wheezy

If a child has a heavily blocked or runny nose, it might stop the vaccine getting into their
system. In this case, their flu vaccination should be postponed until their nasal symptoms
have cleared up.

If a child is wheezy or has been wheezy in the past week, their vaccination should be
postponed until they have been wheeze-free for at least 3 days.

M: Can children with egg allergy have this vaccine ?

(Are there any children who should not have the nasal spray flu vaccine)?

D: There are a few children who should avoid the nasal spray flu vaccine.

The vaccine is not recommended for children who have:

1) a severely weakened immune system

2) severe egg allergy
3) severe asthma – that is, those being treated with steroid tablets or high-dose inhaled
steroids
4) an allergy to any of the vaccine ingredients, such as neomycin

Children unable to have the nasal spray vaccine may be able to have the injectable flu vaccine
instead.
M: How safe is the flu vaccine for children?

D: The flu vaccine for children has a good safety record. In the UK, millions of children have
been vaccinated safely and successfully.

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M : How does the children's flu vaccine work?

D :The vaccine contains live but weakened flu viruses that do not cause flu in children. It
will help your child build up immunity to flu in a similar way as natural infection, but without
the symptoms.

Because the main flu viruses change each year, a new nasal spray vaccine has to be given
each year, in the same way as the injectable flu vaccine.

M: Whatare the advantages of having Flu vaccine ?

D: The nasal spray flu vaccine will not only help protect your child against flu, the
infection will also be less able to spread from them to their family, carers and the wider
population.

Children spread flu because they generally don't use tissues properly or wash their hands.

Vaccinating children also protects others that are vulnerable to flu, such as babies, older
people, pregnant women and people with serious long-term illnesses.
M: How many doses of the flu vaccine do children need?

D: Most children only need a single dose of the nasal spray.

Children aged 2 to 9 years at risk of flu because of an underlying medical condition, who
have not received flu vaccine before, should have 2 doses of the nasal spray given at least 4
weeks apart.

Does my child have to have the nasal spray flu vaccine?

No. As with all immunisations, flu vaccinations for children are optional. Remember,
though, that this vaccine will help protect them from what can be an unpleasant illness, as
well as stopping them spreading flu to vulnerable friends and relatives.

Why can't under-2s have a nasal spray flu vaccine?

The nasal spray vaccine isn't licensed for children younger than 2 because it can be linked
to wheezing in children this age.
Why is it just younger children who are routinely being given the nasal spray flu
vaccine?

The children's flu vaccination programme is being rolled out in stages.

This year (2017/18) it is routinely being offered to all children aged 2 and 3, plus children in
reception class and school years 1, 2, 3 and 4.

In some areas all primary school children will be offered the vaccine.

Over the next few years, the programme will gradually be extended to include children in
other age groups.
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All children aged between 6 months and 2 years who are at risk of flu because of an
underlying health condition are already eligible for the injected flu vaccine.

Why aren't children being given the injected flu vaccine instead of a nasal spray?

The nasal spray flu vaccine is more effective than the injected flu vaccine, so it's the preferred
option.

Will the flu vaccine give my child flu?

No. The vaccine contains viruses that have been weakened to prevent them causing flu.

Does the nasal vaccine contain pork?

Yes, the nasal spray contains a highly processed form of gelatine (porcine gelatine), which is
used in a range of essential medicines.

The gelatine helps to keep the vaccine viruses stable so that the vaccine provides the best
protection against flu.
Can my child have the injected vaccine that doesn't contain gelatine instead?

The nasal vaccine provides good protection against flu, particularly in young children. It also
reduces the risk to, for example, a baby brother or sister who is too young to be vaccinated, as
well as other family members (for example, grandparents) who may be more vulnerable to
the complications of flu.

The injected vaccine is not being offered to healthy children as part of the children's flu
vaccination programme.

However, if your child is at high risk from flu due to one or more medical conditions or
treatments and can't have the nasal flu vaccine for the reasons of faith ( vegetarians or those
who does not have pork) they should have the flu vaccine by injection.

Some faith groups accept the use of porcine gelatine in medical products – the decision is, of
course, up to you.

M: My friends child had fits after receiving Flu jab ? Does the Flu jab cause fits ?

D : Flu vaccination by itself does not cause fits. However, children with Flu have high
temperature and that high temperature can cause fits. Flu vaccination prevents
children getting Flu.

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Chest infection ? Bronchioloitis : 4 months old baby.

Question:
Mother Zara brought in her child Zain( 4 months old) with fever, inconsolable cry and poor
feeding.

In exam electrolytes are given…. May be all normal.

Vitals : O2 saturation: 92%, R.R: 57Pulse: 157 Temp: 38

-GRIPS
- How can I help you?
M- Doctor my little Zain he is crying a lot since past 3 days. He is not even feeding properly.
D- I am Sorry to hear that. We are here to take care of your child. He is safe hands now.
D- Can you please tell me anything more about it?
M- He is having Dry cough since past 3 days.
D – does he cough up any phlegm at all ? Yes/no
D- Is it there at specific time or all the times? M- It is there all the time.
D- Did you notice the cough sounds like barking ? … No
D – any discharge from nose ?
D- Did you notice any shortness of breath?... yes /No
D- have you noticed any rashes on his body and any neck stiffness ?.... no
D- Is he crying while passing urine/ if the urine is more smelly ? passing less urine
( dehydration) …. No
D – Have you noticed that his mouth is dry ( dehydration) ?
D- How is the poo ? any loose stool… No
D – How is the feeding ? Breast feeding or Bottle feeding ?
D - Is he active or drowsy ?

D- Any similar problems in the past?.... Yes/no

D- Any history of similar problems in the family members? … Yes his father has Asthma
D- Is he your only child? …. Yes/no
D- How was the delivery? ….normal
D _ Has he born premature, low birth weight ? ( risk factor for Bronchiolitis)
D- Has he got the jabs so far ? … Yes
D-Any problem with the redbook so far? …. No
D- Any problem with the development? …. No
D- Who takes care of your child …. I take care
D - any other children at home ? Any other children has similar problems ?
Anyone else at home not well ?
D- any previous heart or lung conditions ?

Thankyouvery much for giving me all the information.

Examination:
For now I need to examine your child. I will do the general physical examination, check
pulse, blood pressure and temperature and examine chest.

( Examiner may give a long sheet with all the information on it)
Chest: Crackles and wheeze
Temperature: Increased

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SpO2: 92% (check for any other information that might be written on the paper)

Management:
Investigations:
For now we need to do some investigations to confirm the reason what may be causing this
problem in him.
 Chest X- Ray
 Blood tests including infection markers and electrolytes
 We need to do some type of blood test what we call Blood gases.
 Blood Tests to check for bugs.
 We do some tests on nose discharge (Nasopharyngeal aspirate for:RSV rapid testing) for
virus kind of bugs

Diagnosis
I think your child has a condition what we call as Bronchiolitis. It is an infection of the lungs
by virus kind of bugs. It could be early oncet of Asthma also since his father has Asthma.
However we need to test for that.

Treatment:

Admit
We will start your child on
 Oxygen
 Nebulisation with salbutamol
 Antibiotics – after confirming if it is viral or bacterial
 I.V fluids.

Breast-feeding is considered protective in Bronchiolitis and should be encouraged for this and
other reasons.

M - Doctor please give me antibiotics I will go. I don’t want my child to get admitted as I
have some work. Try to convince her and she will agree to stay back at hospital.

Thank you.

Additional information on cough in Baby of 4 months:

Causes of cough
Coughs are usually a symptom of an infection, typically the common cold virus.

Croup, a viral infection of the voice box and airways.

Whooping cough, a bacterial infection of the windpipe and airways. You will be offered a
vaccination against whooping cough for your baby.
Bronchiolitis, a viral infection of the lungs.

Coughs can also have non-infectious causes, such as asthma.

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Bronchiolitis is an acute infectious disease of the lower respiratory tract that occurs primarily
in the very young, most commonly infants between 2 and 6 months old. It is a clinical
diagnosis based upon:

 Breathing difficulties

 Cough

 Decreased feeding

 Irritability

 Apnoeas in the very young

 Wheeze or crepitations on auscultation

It is usually due to a viral infection of the bronchioles. Respiratory syncytial virus (RSV) is
the most common pathogen, causing 50-90% of cases. A combination of increased
production of mucus, cell debris and oedema produces narrowing and obstruction of small
airways.

Common Causes
 Respiratory syncytial virus (RSV)[3]
 Human metapneumovirus (hMPV) - causes a similar spectrum of illness to RSV and is
thought to be the second most common cause[4]
 Adenovirus - occasionally causes a similar syndrome with a more virulent course

 Parainfluenza virus

Epidemiology
 Peak incidence of RSV infections is in the winter months (November to March), although
the size of the peak varies from winter to winter.
 By their first birthday over 60% of children have been infected and, by 2 years of age, over
80%. The antibodies that develop following early childhood infection do not prevent
further RSV infections throughout life.

Risk factors[2]
Environmental and social risk factors:

 Older siblings

 Nursery attendance

 Passive smoke, particularly maternal

 Overcrowding

Risk factors for severe disease and or complications:

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 Prematurity (<37 weeks)

 Low birth weight

 Age less than 12 weeks

 Chronic lung disease (eg, cystic fibrosis, bronchopulmonary dysplasia)

 Congenital heart disease

 Neurological disease with hypotonia and pharyngeal dis-co-ordination

 Epilepsy
 Insulin-dependent diabetes
 Immunocompromise

 Congenital defects of the airways

 Down's syndrome

Presentation

Symptoms
 Early symptoms are those of a viral URTI, including mild rhinorrhoea, cough and fever.
Fever >39°C is unusual and should prompt a thorough examination and further
investigations to exclude other possible causes.

 For the 40% of infants and young children who progress to lower respiratory tract
involvement, paroxysmal cough and dyspnoea develop within 1-2 days.

 Other common symptoms include the following: wheeze, cyanosis, vomiting, irritability
and poor feeding.

 Apnoeas may occur, especially in young infants.

Signs
 Look for tachypnoea, tachycardia, fever, cyanosis and signs of dehydration. It is unusual
for a child to appear 'toxic' (suggested by drowsiness, lethargy, pallor, mottled skin) and
this should prompt urgent action in terms of the need for immediate treatment and
exclusion of other potential causes.

 Mild conjunctivitis, pharyngitis.

 Evidence of increased respiratory work: intercostal, subcostal and supraclavicular

recession, nasal flaring.

 Widespread fine inspiratory crackles are considered a key finding in the UK, whilst high-
pitched expiratory wheezing is commonly present but not essential to a diagnosis.

 Liver and spleen may be palpable due to hyperinflation of the lungs.

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Investigations
 Pulse oximetry.

 Nasopharyngeal aspirate for:

 RSV rapid testing - to enable isolation or cohort arrangements and to prevent further,
unnecessary testing.

 Viral cultures for RSV, influenza A and B, parainfluenza and adenovirus can also be
undertaken.
Other investigations that are not recommended for typical acute bronchiolitis include:

 CXR: bronchiolitis produces:

 Nonspecific hyperinflation and patchy infiltrates

 Focal atelectasis

 Air trapping

 Flattened diaphragm

 Increased anteroposterior diameter

 Peribronchial cuffing

CXR should only be performed if there is diagnostic uncertainty or an atypical course.
FBC.

Electrolytes and renal function: only perform if the child is dehydrated or on IV

fluids.

Blood and urine culture: consider if pyrexia >38.5°C or the child has a 'toxic'
appearance.

Arterial blood gases: may be required in the severely ill patients, especially in those
who may need mechanical ventilation.

Management

Primary care
 Most infants with acute bronchiolitis will have mild, self-limiting illness and can be
managed at home. Supportive measures are the mainstay of treatment, with attention to
fluid input, nutrition and temperature control.

 Within general practice, a doctor's role is to assess current severity of illness and, for those
with mild-to-moderate disease, to support and monitor. Consider whether the presentation
is in the early stages of disease, when a child is more likely to get worse before improving.
Careful safety netting is important, teaching parents to spot deterioration and to seek
medical review should this occur.

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 For the majority, bronchiolitis lasts 7-10 days, with 50% asymptomatic by two weeks and
only a small subgroup still symptomatic at four weeks.

Referral
Hospital referral is suggested where there is:
 Poor feeding (<50% usual intake over the previous 24 hours) which is inadequate to
maintain hydration

 Lethargy

 History of apnoea

 Respiratory rate >70 breaths/minute

 Nasal flaring or grunting

 Severe chest wall recession

 Cyanosis

 Saturations ≤94%

 Uncertainty regarding diagnosis

 Where home care or rapid review cannot be assured

The threshold for admission should be lower in those with significant comorbidities,
premature infants and those under 3 months old.

PICU admission is necessary if the child has increasing severe respiratory distress with
desaturation or apnoea whilst receiving 50% oxygen. Continuous positive airway pressure
(CPAP) or intubation may be required in these cases, although one study found that the
majority of children could be managed with non-invasive ventilation outside the PICU
setting.

Secondary care
 Even amongst hospitalised children, supportive care is the mainstay of treatment, including
oxygen and nasogastric feeding where necessary.

 Other treatments have shown inconsistent or little evidence of benefit:

 Bronchodilators: modest short-term improvement in clinical scores but no reduction

in the rate or duration of hospitalisation.
 Corticosteroids: trials have consistently failed to provide evidence of benefit. A large
multicentre randomised controlled trial (RCT), comparing the use of a single dose of
oral dexamethasone with placebo in children diagnosed with bronchiolitis in
Emergency Departments, failed to show any significant differences in the rates of
hospital admission, respiratory status after four hours or longer-term outcomes.
 Racemic adrenaline (epinephrine) - racemic = 1:1 mixture of the dextrorotatory and
levorotatory isomers: one study reported that inhaled racemic adrenaline
(epinephrine) was no better than inhaled saline.
 Hypertonic (3%) saline: thought to act by unblocking mucous plugs and reducing

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airways obstruction. A Cochrane Review concluded that there was evidence its use
did reduce length of hospital stay and clinical severity scores.A later study found no
difference in clinical outcome between 3% and 0.9% saline.
 Antibiotics: there is minimal evidence to support their use, except in a small subset of
patients with respiratory failure.
 Ribavirin: may reduce the need for mechanical ventilatory support and the number of
days in hospital but there is no clear evidence of clinically relevant benefits (eg,
preventing respiratory deterioration or mortality).
Chest physiotherapy does not improve the severity of the disease, respiratory
parameters, or reduce length of hospital stay or oxygen requirements in hospitalised
infants with acute bronchiolitis not on mechanical ventilation.

Prognosis
 Most children with bronchiolitis make a full recovery.

 Mechanical ventilation is required for some patients but one study found that the majority
can be managed without.
 Most deaths occur in infants younger than 6 months or in those with underlying cardiac or
pulmonary disease..

Prevention

Vaccine
A vaccine is available for babies most at risk of developing severe, and occasionally fatal,
RSV infection. These will be very young infants born prematurely who have predisposing
conditions such as chronic lung disease, congenital heart disease or children who are
immunodeficient. It is usually given in secondary care.

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