1

Constipation
1 Intestinal Constipation, vomiting, Pain abdomen
obstruction
2 Bowel cancer Change in the bowel habit, Altered bowel habit, blood
in the stool, Tenesmus ( feeling of opening the bowelbut
nothing comes out when trying to open bowel), pain
abdomen, weight loss, loss of appetite, family history,
smoking, anaemiasymptoms
3 Medication Codeine, Morphine, Antacids, Anti-epileptics, Anti-
depressants,
Calcium, Iron
4 Anal fissure Pain in the back passage on defaecation, fresh blood
sticking to the stool

5 Haemorrhoids Fresh blood flashing on toilet bowl, Lump in the back

passage
6 Medical conditions Hypothyroidism
Multiple sclerosis
Parkinsons disease
7 Immobility
8 Dehydration
9 Diet ( No high fibre
diet)
10 Pregnancy
11 Inflammatory bowel
disease
Question
80 year old lady Mrs Edith Thompson had hip operation one week ago. Since then
she is having constipation. Take history and talk to her about the further
management.

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

doing? constipation ?
Dr Sorry to hear that. Can you please tell me Pt Doctor It is both.
what exactly you meant by constipation –
do you mean you did not open bowel for
 long time or you have to strain more than
usual to open the bowel.
Dr Since when Pt Since about one week now.
I am having it sine this
operation I had on my hip.
Dr Are you passing any stool at all or not Pt I did not open bowel for the
opened bowel at all? last 4 to 5 days.
Dr Do you have any pain in your tummy Pt No but it is very
uncomfortable
( Intestinal obstruction)
Dr Have you vomited ( Intestinal obstruction) Pt No
Dr Are you able to pass wind Yes
( Intestinal obstruction)
Dr Is there any bleeding from your back Pt No
passage
( bowel cancer, anal fissure, haemorrhoids)
Dr Do you have any diarrhoea also along with Pt No
constipation
Dr Have you noticed any change in your Pt No
weight
( bowel cancer)
Dr How is your appetite Pt I don’t feel like eating
Dr Do you get the feeling of opening the Pt No
bowel but nothing comes out when trying
to open bowel
(tenesmus – rectal cancer)
Dr Any pain in the back passage while trying Pt No
to open the bowel ( anal fissure)
Dr Did you feel any lump in your back Pt No
passage
( haemorrhoids)
Dr Did you see any mucus in the stool, any Pt No
joint pains ? ( Inflammatory bowel disease)
Dr Do you have any medical conditions Pt No
Dr Like diabetes or thyroid problems any Pt No
bowel problems before
Dr Are you taking any medication Pt Yes I am taking Co
codamol.
Dr Since when are you taking co-codamol ? Since after the operation –
one week
Dr Any of your family members have any kind Pt No
of bowel problems or bowel cancer at all?
Dr Do you eat enough of fruits and vegetables Pt Yes
Dr Do you drink enough fluids Pt Yes
Dr Have you been physically resting for long Pt Well after this operation I
time am not moving around that
much.

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

Diagnosis:
Mrs Thompson, I think the Co -codamol medication what you are taking for
pain is causing this constipation because one of the side effects of co-codamol
is constipation.

Treatment:
First of all we will stop giving this medication and we will give you some
other medication which will not cause constipation - maybe we will give you
Paracetamol if you are not in that much pain now.
We can give you some laxatives like senna, bisacodyl and sodium pico-
sulphate to help you to open your bowel.
You should drink plenty of fluids and eat high fibre diet like fruits and
vegetable or whole wheat bread. That will help you to open bowel.

Pt: What if the laxatives do not work.

Dr: We can give you some medication like Bisacodyl as Suppository – this
type of medicine is inserted into your back passage.
 Pt: What if that also does not help ?

Dr: Then we can give enema where a medicine like Docusate andsodium
citrate in fluid form is injected through your back passage into your large bowel.

Pt: What if they do not help

Dr: We can evacuate the stool manually once then you should be able topass the stool.

Dr: Any other concerns. Pt: No Dr: Thank you verymuch.

Headache – GCA
67 year old lady Mrs Melinda Jones presented to the hospital with headache. Take
history from her and discuss the management with her.
 AACG ( acute angle Do you see coloured circles around light? Worse in
closure glaucoma) darkness? Redness of eye? Flashes
GCA Jaw claudication-Do you get pain on chewing?
[temporal artery] Temporal tenderness-pain while combing or touching
temple area? Any vision problems ( shade coming in front
of the eye, vision loss later)
Head injury [bone] By any chance you got hurt on your head?
Meningitis[meninges] Fever, vomiting, Photophobia-feel discomfort on bright
light? Rash-any rash in your body?
Neck stiffness-difficulty in moving your neck?
SAH[Below meninges] Sudden onset, meningeal signs but no fever.

SOL[brain] Early morning, vomiting Gradual worsening, limb

weakness

Migraine– pattern- one sided, aura, family Hx

Cluster headache- Comes in cluster – previous Hx of headaches, timing,

redeye, tearing

Tension head ache –band like, worse in evening, stress

Refractory error- long do you wear glasses? Any problem in reading or

vision? When did you last
visit optician?
Differential Diagnosis
Imagine- put your finger on glabella and move to eye then to temple and dig deeper so
you will not miss the dd.

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

Management
Mrs Jones with what you told me I suspect you have a condition what we call as Giant
cell arteritis. Do you know anythingaboutthis? Pt – No
Dr: It is a condition in the blood vessels, usually in the head and neck, become inflamed.
It is sometimes called temporal arteritis because the arteries around the temples are
usually affected.
Pt: What are going to do for me?
Dr: We will do some blood tests to check for the possibility of this condition. (ESR and
CRP).
We need to do another test called temporal artery ( blood vessel on the side of the head)
biopsy to confirm the diagnosis. During the procedure, a small sample of your temporal
artery is removed and checked in the laboratory. It can take several days to get the
results of a biopsy.
However, we need to treat you urgently before we can do the biopsy because if we
delay the treatment waiting for the test result sometimes people can lose their vision
which can be permanent. To prevent the loss of vision we need to treat you immediately.
Do you follow me?
Pt: Yes. How will you treat me?
Dr: We will treat you medication called Prednisolone tablets which is a steroid.
Initially we will give high dose steroids ( 60mg ) which will gradually be reduced every
two to four weeks, depending on how well you respond totreatment.
If the diagnosis is confirmed with the biopsy - you may need to take prednisolone for up
to two years to prevent your symptoms returning. Your symptoms should improve
significantly within a few days of starting treatment. However, there is a chance they
will return (relapse) once treatment stops.
Please don't suddenly stop taking steroid medication because it can make you feel very
ill.
There are some side effects of steroids because you may need to take it for long time.
Do you want to know about them?
Pt ; Yes doctor.
Dr: It can cause changes in mental state - you may feel very depressed and very
anxious, or very confused.
It can also cause increased appetite, which often leads to weight gain
 increased bloodpressure
 mood changes, such as becoming aggressive or irritable withpeople
 weakening of the bones(osteoporosis)
 stomachulcers
 increased risk ofinfection
The risk of these side effects will be lesser as your dosage of prednisolone is decreased.
We will also give you another medication called Aspirin in low dose ( 75mg daily).
This prevents complications of giant cell arteritis, such as heart attacks or stroke.
We will give another medication called Omeprazole to protect your stomach
from stomach ulcers.
We may also give some other medication called immune-suppressants, such as
methotrexate to suppress the immune system (the body's defence against infection and
illness). This can help prevent the condition recurring.
We will follow you up regularly to see how you are responding and to reduce the dose
of prednisolone.
We will issue a steroid card which you need to carry with you at all times as it will
explain that you are regularly taking steroids.
Pt: Will there be any complications ?
Dr: Sometimes it can causeVisual loss or heart attacks or stroke. However Aspirin
medication lowers the chances of getting these problems.
Another complication sometimes can happen is a condition called Polymyalgia
rheumatic which causes inflammation of the muscles and joints and causes neck and
hip pain, and stiffness of the affected muscles (which is often most obvious after waking
up).
Any other concerns ?
Pt: No
Dr: Thank you very much. Hope you will recover soon.

Sub Arachnoid Haemorrhage

Headache - history and management

54 year old lady Mrs Joan presented to the hospital with severe headache.
Take history, examine her and discuss the further management with her.

Dr: Hello Mrs Joan, I am Dr…. one of the junior doctor in the medical department.
Can you please tell me what brings you to the hospital?
Pt: I am having severe headache.
Dr: I am very sorry to hear that. Can you please tell me how severe is the pain – in the
scale of one to ten one being the mildest pain and ten being the most severe pain ?
Pt: It is 10 out of 10 doctor.
Dr: Do you want me to give you some pain killers ?
Pt: Yes please doctor.
Offer pain killer.
Dr: Can you please tell me more about your headache ?
Pt: Doctor this headache started suddenly. This is the worst headache of my life. I felt
it like thunder clap / I thought someone hit the back of my head.
Dr: Do you mean to say you used to have headaches like this before ?
Pt: Yes doctor, I have migraine.
Dr: Is this different than migraine headache ?
Pt: Certainly doctor. I never had headache like this before.
Dr: Where exactly in the head you have this headache.
Pt: Back of my head doctor.
Dr: Since when are you having this headache ?
Pt: Almost 2 hours now.
Dr: What were you doing when you got this headache ?

Pt: Doctor I was doing …. (subarachnoid haemorrhage sometimes happens during

physical effort or straining – such as coughing, going to the toilet, lifting something
heavy or having sex).

Dr: Did you take any medications for your headache ?

Pt: Yes I took paracetamol but it didn’t help me at all.
Dr: Do you have any other symptoms other than headache ?
Pt: I feel sick doctor but not vomited.
Dr: Anythingelse? Pt: Likewhat?
Dr: Any fever ? ( meningitis) Pt: No, Dr: Neck stiffness?Pt:No Dr:
Rashonthebody? Pt:No.
Dr: Any head injury recently? Pt:No
Dr: Any pain on the side of your head when combing hair ? ( GCA) Pt: No
Dr: Any pain in your jaw ? ( GCA) Pt:No
Dr: Any vision problem ? ( SAH, GCA)Pt: No Dr: Any coloured halosinyour
vision? ( glaucoma) Pt:No
Dr: Any watering of the eyes ? ( cluster headache) Pt: No
Dr: Do you get headaches in the morning ? ( SOL) Pt:No
Dr: Any weakness on any part of your arms or legs ? ( SOL,stroke,SAH)

Pt:NoDr: Any speech problems ? ( Stroke SAH) Pt:No

Dr: Do you have any medicalconditions? Pt:No

Dr: Have you ever had any medical conditions in thepast?
Pt:NoDr: Diabetes ? Pt:No Dr:
High blood pressure ? Pt:No
Dr: Any strokes or mini strokes in thepast ? Pt:
NoDr: Any kidney problem ? Pt:No
Dr: Do you smoke ? Pt:No Dr: Do you drink alcohol ? Pt: onebottlewine
aday
Dr: Do you use anyrecreationaldrugs? Pt:No

Dr: Are you taking any regular medications ? Pt: No

Dr: Are you allergic to any medications ? Pt: No
Dr: Any of your family members had headaches like this or had bleeding in their
brain ? Pt:No
Dr: What do you do for living ? Pt: I am an accountant.
Dr: Is there anything else you think may be important that we need to know?
Pt: I don’t think so doctor.

Examination:
Dr: Mrs Joan I need to examine you now and check your pulse and Blood pressure.
Examiner says – examination is normal. Her BP is 150/90, Pulse normal
 10

Dr: Mrs Joan, I think you have a condition what we call as Subarachnoid
haemorrhage -that is bleeding in the brain. Are you following me?
Pt: Yes, but why do I have that doctor?
Dr:There are several reasons why this can happen. This usually happens because there
is some abnormal blood vessels in the brain which blood vessels becomes thin and
they bulge out what we call as aneurysm. Sometimes these blood vessels suddenly
rupture and cause severe headache like what you had. Sometimes this condition can
run in the family. Unfortunately this is a very serious condition and sometimes this
could be even life threatening. Do you follow me?

Pt: Yes doctor. Are you sure that is what I have ?

Dr: We need to do some tests to confirm that. We will have to do CT scan of head.
( CT scan is the first line investigation – shows bleeding in 98% of cases but
negative in 2% cases)
Examiner said – CT scan is normal. What will you do?

Dr: We will do Lumbar puncture which is usually done after 12 hours of oncet of
headache to look for Xanthochromia ( Lumbar puncture should ideally take place
over 12 hours after the onset of the headache because if there are red cells in the CSF,
sufficient lysis will have taken place during that time for bilirubin and
oxyhaemoglobin to have formed - xanthochromia (yellow discolouration of the
spinal fluid ).

Examiner says : What will you do if the Lumbar puncture is positive for SAH ?
Dr: We will admit her in the ITU and transfer to the neurosurgical ward.
Do further investigations to find out the exact location shape and size of the abnormal
blood vessels like

 CTAngiography
 Magnetic Resonance Angiography(MRA)
 ECG

Treatment: One of problem with SAH is Cerebral ischemia due to vasospasm.

Treat her with calcium channel blocker – Nimodipine ( 60 mg four-hourly - this is
normally taken for three weeks, until the risk of secondary cerebral ischaemia has
passed ) to relax the blood vessels in the brain to improve blood circulation to the
brain.
 11

Labetolol - to treat hypertension; the level should be low enough to prevent

rebleeding whilst high enough to maintain cerebral perfusion.

Patients should not be given an antifibrinolytic agent or steroids.

She needs operation on the brain either clipping or coiling.

We can give her pain killers ( morphine, cocodamol, anti-emetics, and

anticonvulsants - if she has fits)

There is 50 % mortality even with the treatment.

Complications
- Rebleeding
- Epilepsy ( 1 in20)
- problems with certain mental functions, such as memory, planningand
concentration
- changes in mood, such asdepression

- Hydrocephalus,

- Delayed cerebralischaemia

Thank you very much to the patient and examiner.

Differential diagnosis for SAH

 Other causes ofstroke.

 Meningitis (rarely features thunderclapheadache).
 Trauma.
 Thunderclap headache of otheraetiology.
 Primary sexualheadache.
 Cerebral venous sinusthrombosis.
 Cervical arterydissection.
 Carotid arterydissection.
 Hypertensive emergency (severely raised bloodpressure).
 Pituitary apoplexy (infarction or haemorrhage of the pituitarygland).
 Diabetic Retinopathy
Exam question

You are the FY2 doctor in the GP clinic.

33 year old man was referred by Optometrist for early diabetic retinopathy.
Talk to him and address his concerns.

Dr: Hello Mr…. IamDr. How are youdoing?

Pt: Doctor, I went to the Optometrist and she said I have diabetes in my eyes. She has
given this letter to you. Doctor will I lose my vision ?
Dr: Let me have a look at the letter. [ Letter says – early diabetic changes seen in the eye]
Mr…. Yes, the letter does say you have diabetic changes in your eye. However to say
whether you lose vision or not I need to ask you few questions and examine you. We may
be able to reduce the chances of you becoming blind even if diabetes has affected your
eyes.
Can you please tell me why did you go to the Optometrist?
Pt: Doctor, I am a painter. I can’t see small things when I paint. That is why I went to the
Optometrist.
Dr: I am sorry to hear the problem. Can I ask you since when are you having this problem?
Pt: Since the last few weeks doctor.
Dr: Do you haveDiabetes? Pt:Yesdoctor.
Dr: Since when are you having diabetes?Pt: Since manyyears.
Dr: Are you on medications for that?Pt: No, I was told to control it by diet.
Dr: Do you keep checking your sugar?Pt: Not very often.
Dr: Is it controlled well? Pt: Not really doctor.
Dr: Do you visit your GP here regularly for your diabetes?Pt: No.
Dr: You said you can’t see small things. Do you think it is one eye problem or both eyes?
Pt: Both the eyes.
Dr: OK. Do you have any other problem in your vision ?Pt: No
Dr: Do you see anything floating in your vision area ( floaters)? Pt: No
Dr: Any pain in the eye ?Pt: No
Dr: Anydouble vision? Pt:No
Dr: I need to examine your eyes. [ examiner may say – it shows early diabetic retinopathy.
Some examiners may not say anything ]
Dr: Mr… as per the information what you have given me and the Optometrist letter
probably you have a condition called Diabetic Retinopathy. This means diabetes has
affected your eyes.

If the blood sugar is very high, it causes the blood vessels which supplies blood to the back
of the eye called retina gets bulged out and it can start leaking blood. Sometimes new tiny
blood vessels get formed at the retina which easily gets damaged and starts bleeding. This
is called Diabetic retinopathy. This can cause vision problem. If the condition continues
then it can cause loss of vision.

Are you following me Mr… ?

Pt: Yes, I can understand what you are saying, but I don’t want to lose my vision doctor.
Dr: I can understand how you are feeling. We can definitely try to help you so that the risk
of losing vision will be reduced. This condition is mainly caused by high blood sugar and
also there are other risk factors like high blood pressure, high bad fat content in the body
and smoking which can contribute to this problem. If you control the blood sugar properly
and also reducing other risk factors if there are any then the chances of you losing vision
will be greatly reduced.
I need to ask few questions to see why your blood sugar is not controlled well.
Pt: OK doctor.
Dr: How is your diet? Do you eat healthy diet?
Pt: Not really doctor. I eat fast food. ( burger and chips)
Dr: Mr… It is very important to eat healthy balanced diet to keep your sugar under control.
You should reduce eating food with high sugar content and fat content. So you should
reduce eating fast foods like burger and chips – they have high bad fat content. Eat more of
white meat like chicken and fish and also lots of fruits and vegetables. This will help to
keep the sugar under control. I can refer you to a dietician who can advise in detail about it.
What do you say Mr..
Pt: Yes, surely I will consider thatdoctor.
Dr: Excellent. Do you do exercise at all?Pt: No doctor.
Dr: I suggest you to do good exercise. That will reduce the bad fat in your body.
Pt: Ok doctor.
Dr: Do you smoke Mr…?Pt: Yes doctor.
Dr: What do you smoke and how much do you smoke?
Pt: I smoke 10 to 15 cigarettes per day for many years now.
Dr: As I mentioned earlier this also can contribute to damage to the eye. I strongly advise
you to stop smoking. If you need we can help you to stop smoking. Would you like to
consider that Mr… ?
Pt: Yes doctor. I will try my best.
Dr: Good. Do you have high blood pressure do you know ?
Pt: I don’t know doctor.
Dr: We will check that and if you have it we will treat that also because high blood
pressure also can contribute to the eye damage.
Pt: Ok.
Dr: We will also start you on some medications for your diabetes. I will talk to my seniors
about it and let you know.All these things what we discussed now will help to keep the
sugar under control.
Pt : OK doctor.
Dr: We will refer you to the Ophthalmologist ( eye specialist doctor). They will advise
further about it. You may need keep visiting them more frequently.

Do you have any questions?

Pt: How are you going to treat my condition doctor ?

Dr: Usually in early stages of Diabetic retinopathy - it does not require any treatment.
Controlling sugar will delay the condition getting worse. Whatever damages has already
happened cannot be reversedunfortunately. However if it gets worse means in advances
stages of this condition we can treat it in many ways like Laser treatment where we pass
laser to the back of the eye that is retina and burn the new blood vessels which are formed
there and also seal the leaking blood vessels. This will reduce it getting worse. Sometimes
we may have to inject some type medications {( anti-VEGF - ranibizumab (Lucentis) and
aflibercept (Eylea)}to the back of the eye to prevent new blood vessels forming there. Very
rarely we may do some surgery (Vitreoretinal surgery ) to remove some of the vitreous
humour from the eye. This is the transparent, jelly-like substance that fills the space behind
the lens of the eye.
Pt: Ok doctor.
Dr: Any other questions ?
Pt: If I do everything what you suggested, will I not lose my vision doctor ?
Dr: Mr.. If you do everything what I suggested the chances of you losing vision will be
greatly be reduced. So, I sincerely suggest you to follow everything we discussed.
Pt: Ok doctor.
Dr: Any otherquestions?

Pt:No.Dr: Thank you very

muchMr…

Skin lesion

25 year female presented with swelling on shoulder. Take relevant history and

talk to her about the management. Take informed consent for surgery. There is

no need to fill up the consent form.

Dr – How canIhelp? Pt- I have a swelling onmyshoulder.

Dr-Sincewhen? Pt- manyyears.

Dr- what made you worry about it now?

Pt- it looks ugly. I am getting married soon. It will be visible when I wear my

wedding dress. I want it to be removed.

Dr: Does the swelling bother you in any way.

Pt: It keeps rubbing on my dress. It is very uncomfortable.

Dr – have you shown it to any doctor so far? Pt- No.

Dr- do you know howitstarted? Pt – I donotknow.

Dr-anypain? Pt-No.

Dr- itching? Fever?Bleeding?Discharge? Pt-no

Dr-what colour? Pt-pinkish

Dr- any change in colour and size orborder? Pt-No.

Dr: Have you noticed any swelling in the arm pit or in the neck ( spread to lymph

node in melanoma) ? Pt : No

Dr- Is it on an exposed area is it usually covered with the dress ?

Pt – it is covered with my dress but for wedding I will be wearing a dress below my

shoulder level so it will be visible.

Dr – Have you tried to treat it in any waysofar? Pt –No.

Dr – Do you have any such swelling anywhere elseinbody Pt–

NoDr – Did you have any suchswellingbefore? Pt-No.

Dr – do you have any medical conditions? No Any surgery before? No

Dr: Any medications ( immunosuppression is a risk factor for melanoma) ? Pt – No.

Dr: Have gone on holidays and exposed your skin to sun ? Pt: Yes/No

Dr: Have you used sun beds for skin tanning? Pt: Yes/No

Dr – Any of your family members had any such problems ( family history is ahigh

risk factor formelanoma)? Pt –No.

Dr- What do you do for living?

Dr- I need to examine you to see what exactly it is?

Pt – OK. Doctor. I have a picture. [ patient may showdifferent types of pictures to

different candidates]
Dr- It looks like a growth in the skin. It looks more like a non cancerous type of

growth what we call as Mole or it could be another condition called as Papilloma.

Moles are due exposure of skin to the sun.

I also need to examine your neck and armpit for any swellings ( lymphadenopathy).

Pt – what will happen now?

Dr – This type of growth does not need to be removed for medical reasons.

However if you want it to be removed we can remove that.

Pt: What will happen if I don’t remove it?

Dr:.Most of the time it can remain like that for the whole life without causing any

problem. However if it is mole it can rarely turn into cancerous type what we

call Melanoma. If that happens then we need to removeit.

So you need to keep an eye on that to watch for any changes like changes in size,

colour, border, surface or discharge or bleeding – then you need to come back to the

hospital.

Pt:Ok

Treatment options:
Dr: We have several treatment options. We can surgically remove it under local

anaesthesia. (We just make the area numb by giving anaesthetic injection to the site).

We will then stitch it up.

We have other options like what we call as shave removal with a blade.

Other ways to remove it is by freezing with liquid nitrogen. This is like a spray. It
does not require any anaesthesia. The swelling will fall off after few days.

It can also be removed by Laser. This treatment uses intense bursts of light radiation
to break down the abnormal cells in the skin. This method usually takes two or three
treatments to remove the swelling completely.

Can I remove this at home?

Some people do it on their own. But it is better if we do that to make sure everything
is fine.
Pt – how long istheprocedure? Dr- 10 –

15minutes.Pt – will it leave ascar?

Dr– We have expert doctors to do the operation. There will be small thin scar may not

be noticeable.

Pt – will it come back?

Dr- Unfortunately sometimes they can come back. Any other concerns ?

Dr: Are you happy to go ahead with the procedure ? Pt: Yes.

Dr- OK. I will talk to my seniors and we will arrange further tests and the date for the

procedure. Also please take care of your skin.

You can go out in the sun; however, it is advised to wear proper sun protection like

hats, protective clothing, sun creams to prevent moles from forming in the future and

to prevent removed moles from returning.

If it all you develop any swellings like this please come to us immediately.

Good luck with your wedding.

 Painful Red Eye -Glaucoma

A AACG(acute angle closure Glaucoma) Pain worse in dark, haloes around light,
DH

F Foreign body, chemical, By any chance something has gone

complication of Contact lens into your eyes? Occupation? Gritty
A Allergy[hay fever or any gas] Running nose, itchy eyes
S Sub conjunctival Haemorrhage Scratchy feeling on the surface of your
eye, patches of redness, no pain, no
T Trauma By any chance you got hurt in your eye

C Conjunctivitis[bacterial/viral/ulcer] Discharge, difficulty in opening eyes in

morning

Contact glass irritation

A Autoimmune –Ankylosing AS Back pain worse in morning

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

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

S Sarcoidosis Tender red bumps on skin, SOB, cough

You are F2 in Emergency Department.

56 year old lady presents with sudden onset severe pain in her left eye. Take history,
examine and discuss management with her.

(Patient may be wearing sunglasses )

Dr: Hello Mrs... My name is Dr... one of the junior doctors in the Emergency Department.
P: Hello doctor
Dr: What brings you into the hospital today?
P: I have this pain in my left eye doctor
Dr: Once again I am very sorry Mrs... Could you tell me when it started?
P: It started suddenly around 2-3 hours ago
Dr: Do you have pain anywhere else ? P: I do have pain on my left side forehead as well.
Dr: Any redness of your eye?
P: Yes doctor (She might show you the picture of the red eye)
Dr: Any watering from your eye? P: No
 20

Dr: Have you noticed any coloured halos when you look at a light source?
P: No
Dr: Do you have any problem with your vision?
P: My left eye feels a little blurred.
Dr: I'm sorry to hear that Mrs... when did that start?
P: Same time this morning doctor.
Dr: Do you have any discharge in the eye ( conjunctivitis) ? P: No
Dr: Do you have any itching in the eye ( allergy) ? P- No

Dr: Did you sustain any injury to your eye? P: No

Dr: Do you wear contact lenses ? P: No
Dr: Do you have any fever ( orbital cellulitis) ? P: No

Dr: Joint pains? P: No

Dr: Any rashes on your body? P: No
Dr: Have you noticed any change in your bowel habits? P: No

Dr: Do you have diabetes? P: No

Dr: High BP? P : No
Dr: Are you on any medications?
P: I'm taking amitriptyline for depression
Dr: Since when have you been taking that? P: 6 months
Dr: Has it helped with your depression Mrs...? P: Yes doctor!
Dr: Do you have any allergies? P: No
Dr: Any family history of similar problems? P: No

[Patient may be wearing dark sun glasses]

Dr: Can I ask why are you wearing this dark glasses?
P: I feel comfortable with that.
[You can ask her to remove if it not comfortable]

Examination

I would like to examine your eye Mrs... (Patient might show a picture of a red eye)

Diagnosis:

Dr: Mrs... With the information that you have given me and after the examination, it
seems you have a condition called Glaucoma. Do you know whatthatis? P:No
Dr: In the eye there are two compartments filled with fluid... Sometimes when there is an
increase in the production of fluid or a blockage in the outflow, the pressure inside the eye
can increase and that is what causes the pain and the redness in the eye.

P: Oh.. Yes doctor.. I do feel like there is a lot of pressure in my eye

Dr: Mrs... This is a serious condition because if it is not treated quickly it can cause
irreversible loss of vision.
P: But why did this happen to me doctor?
Dr: There are many reasons why this can happen Mrs... But in your situation, it appears to
be because of the amitriptyline that you are taking for your depression
 21

P: (she might get upset_ console as needed) Oh.. It’s my fault then?
Dr: No Mrs.... it's not your fault.. It is an expected side effect of the medication and though
not everyone on the drug develops the S/E, some people might. Firstly, we have to stop this
medication. We will give some other medication for your depression.

P: Ok thank you doctor. What are you going to do for me now?

Investigation

Dr: We will have to run some tests to confirm the diagnosis. We will do a test called
tonometry to check the pressure inside your eye.

Treatment:

We will also have to start you on treatment immediately to prevent loss of vision. We have
a number of options.
We will give you some eye drops called Pilocarpine to reduce the pressure.
We also have drops called Timololwhich will also help remove the excess fluid inside your
eye.
We can also give you some medication called Acetazolamide into your vein to do that.
We will refer you immediately to the Ophthalmologist for the further treatment.
Are you following me Mrs...?

P: Yes doctor.. Will my vision become all right?

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

Epilepsy

You are the FY 2 doctor in the medical department.

Mr Sandeep Singh 28 year man was diagnosed with epilepsy few weeks ago. He
has come for follow up.
Take history and address his concerns.
There may be medication box written as Sodium Valproate 300 mg BD and BNF

Dr: Hello Mr Sandeep Singh, I a Dr… one of the junior doctor in themedical
department. How areyou doing? Pt: I am OKdoctor.
Dr: I understand you were diagnosed to have epilepsy. I am sorry about it. Howis
your conditionnow? Pt: Doctor I had fits again afterthat.
Dr: I am sorry to hear about it. When exactly was that ?
Pt: Once few days ago and once about a week ago when I was in the party. Why did
that happen doctor ?
Dr: There could be many reasons why people still have fits even after treatment.Can
I ask you few questions to see why this would have happenedtoyou?

Pt:Yesdoctor.
Dr: Have been given medications forthat?

Pt:YesCan I ask you which medications?

Pt: I take this doctor. (Patient may show Sodium Valproate tablets).
It is written 300mg twice a day here. Are you taking the samedose? Pt:Yes.
Dr: Let me check the book whether the dose is right for you. ( check the BNF for
dose and side effects). Mr Singh – dose seems to be right for you. Are you taking
these medications regularly ?
Pt: Yes I am.
Dr: Are you taking it as prescribed byus?

Pt:YesDr: Please tell me when do you takeit?

Pt: Whenever I have fit I take it doctor.
Dr: Does it mean that you do not takeeveryday. Pt: Yes that isright? Dr:
Can I ask you why you are not taking itdaily? Pt: I forget to takeit.
Dr: Mr Singh, It is very important to take these medications regularly every day even
when you do not have fits. There should be certain amount of medications in your
blood all the time to prevent you from getting fits. I advise you to keep alarm to
remind you to take this medications regularly. Is that OK?
Pt: OK doctor I will do that.
[sometimes patient may say – I was told to take the medications only when I have fits.
Sometimes this problem can happen if the medications are not absorbed into the
system if people have vomiting or diarrhoea. Do you have vomiting or diarrhoea ?
Pt: No doctor.
Dr: Do you have any other medical conditions atall?

Pt:NoDr: Are taking anyothermedications? Pt:No

Dr: Sometimes people can get fits if the dose is not enough or the medications donot
work for them. In that case we need to change the medications. We will see that
again after sometime if you still get fits after taking themedicationsregularly. Pt:
Okdoctor
Dr: There are reasons also why people can fits like if they are exposed to some
triggering factors like exposure to too much light in cinema, watching TV for long
time ?
Do you go to cinema or watch TV for long time? Pt: Yes doctor. Dr: I advise you
to avoid them
Dr: Do you work on the computers for long time?
Pt: I am student doctor. I have to work nearly 5 to 6 hours every day on the computer.
Dr: Again I advise you to avoid looking at the computer continuously for long time.
It is better to take print outs and use them.
Dr: Do you go to pubs where there are flashing lights ? Pt: Yes doctor
Dr: I advise you to avoid that because flashing lights can trigger fits.
Also sometimes lack of sleep or starving for long time also trigger fits. I advise you
to sleep well and have food at regular intervals - do not starve for long time.
Dr: Do you drinkalcohol? Pt:Yes
Dr: Alcohol also can trigger fits, please avoid drinking alcohol. Pt: Ok

Dr: You need to be careful when you have fits. Avoid going near the fire.
Who cooks food for you ?
Pt: I live with few other friends. I cook food.
Dr: May be your friends cook food for you and you can do some other work for them.
Also avoid using gas cookers. Electric cookers are better. When transferring the food
to plate please take the plate to the pan and not hot pan to the plate.
You should be careful when taking shower. Do not take bath in bath tub instead take a
shower.
 Pt: OK

Do you swim ? Pt: Yes.

Dr: If you are swimming in the swimming pool or sea or river please tell the
lifeguards that you have this condition. Swimming in the river or sea is more risky
than swimming in the pool. Pt: OK

Dr: Do you drive ?

Pt: I am about to take a practical driving test next week.
Dr: I am afraid you should not drive may be for about a year now. Please inform the
DVLA about it and they will advise you when you can start driving.

Please inform your friends at your college if he is a student ( or colleagues atyour

work place if he is working) that you have this condition and let them know how to
help you. Please wear your bracelet all the time. Any other concerns?
Pt: No doctor.
Dr: Thank you very much. Hope you will not have the fit again.

If the patient is a young lady – ask about Contraception

[ sodium valproate does not affect the combined pills - so she can continue.
Carbamazepine reduces the effects of combined pill so they should increase the dose
9double the dose) of oestrogen in the combined pill and also use other forms of
contraception.]

Needle stick injury in the nurse

You are the FY2 doctor in the A& E department.
Mrs Andrea Jones 23 year nurse in your hospital came to the A& E department because she
had a needle stick injury while she was drawing blood from a patient.
Talk to her and address her concerns.
Dr: Hell Mrs Andrea Jones I am Dr …. How are you doing ?
Nurse: I am not feeling good doctor. I pricked myself with the needle when I was taking blood from
a patient.
Dr: I am very sorry to hear that. Can you tell me anything more about it ?
Nurse: I was just taking the blood from a patient. After that I accidentally pricked myself with the
needle. I happened just half an hour ago.
Dr: Did you prick yourself after you used on the patient or was it a new needle ( not used on
anyone)
Nurse: It is the same needle I used on the patient and then I pricked myself
Dr: Was it ahollow-boreneedle? Nurse: Yes
Dr: Which part of your body did youprickyourself? Nurse: Myfinger
Dr: What did you do afterthat?
Nurse: I washed in soap and water. My senior staff told me to come here.
Dr: Good that you washed it soap and water. You are not supposed to use any antiseptics to wash
and also you are not supposed to put the area in the mouth. Was the wound deep or superficial ?
Nurse: Just superficial / it is deep.
Dr: Were you wearing gloves atthattime. Nurse: Yes
Dr: When was your last hep B vaccine and tetanusvaccine?
Nurse: I had both about 2 years ago.
Dr: Do you have any medicalcondition? Nurse:No
Dr: Have tested for HIV or Hepatitisrecently? Nurse: No
Dr: Are you taking anymedications? Nurse:No
Dr: Are you allergic to anything at all ? Any chance you are pregnant?
Dr: Do you practice safe sex? Nurse: I am married, so don’t practice safe sex / sometimes she may
say I have a partner and practice safe sex.
Dr: Did you have any such incidentspreviously? Nurse:No
Dr: Do you use any drugs and share needles with others ? Nurse : No
Dr: Do you know what is wrong with thepatient?
Nurse: HehasMeningitis? Dr: OK. Is heconscious? Nurse:Yes/No
Dr: Do you know whether he has any infections other than meningitis like Hepatitis or HIV ?
Nurse: I don’t know.
Dr: Did you tell him about thisincident? Nurse: No
Dr: Mrs Jones, I am once again very sorry this happened to you. Do you have any concerns about
this incident ?
Nurse: Yes doctor I am worried. Will I get HIV or Hepatitis or any other infections ?
Dr: I can certainly imagine your worries. However Mrs Jones, Regarding HIV- the chances
people getting HIV infections through the needle stick injury is very low compared to other routes
like sexual route or drug addicts sharing needle. The risk of getting HIV from a needle stick injury
is 0.3%. That means only 3 people out of 1000 people who had needle stick injury will get this
infection.
We will inform the Occupational health department.
Occupational health department will inform the patient about it and take his consent to do blood
test on him for any infections like HIV, hepatitis or others.
We will need to take your blood also to do tests.
We have post exposure prophylaxis against HIV. You need to take this as soon as possible that is
within one hour, the latest you can take this is 72 hours. The medication pack is called Truvuda.
The treatment duration is 28 days.
Side effects include: nausea, vomiting, diarrhoea, myalgia, headaches and fatigue. It is important
to continue treatment even if you have all these side effects.
You should practice safe sex and do not donate blood during this period.
You will be followed up by the Occupational health department. You may be retested at 6 weeks, 3
month, 6 months and 9 months.
Dr: Are you followingme? Nurse: yes Dr: Any questionsaboutHIV? Nurse: No
Dr: Regarding Hep B – since you are already immunised against Hep B chances you are going to
get Hep B infection is almost negligible. Risk is 30% in those who are not immunised. However we
need to do blood tests and check the antibody level for Hep B. If you do not have enough antibody
then we may give you immunoglobulin and booster dose of the Hep B vaccine. Hep B booster
dose can be given within one week of the incident.
Dr: Any questions about HepB? Nurse:No
Dr: Unfortunately there is no pre or post exposure prophylaxis for Hep C. The risk is 1.8% so very
low chance again.
Dr: Since the patient is having meningitis – we will give prophylaxis for the meningitis also.
Dr: Occupational health department will follow you up. They will check for side effects and do
blood tests: FBC, Us and Es, LFTs, HIV, Hep B and Hep C at 3 months and 6 months.
Occupational Health can also provide you counselling and support if
required. Any other concerns. Nurse: No Thank you verymuch.

Head injury in adult

Criteria for performing a CT head scan in adults ( NICE guideline)
For adults who have sustained a head injury and have any of the following risk
factors:-

Perform a CT head scan within 1 hour of the risk factor being identified:

GCS less than 13 on initial assessment in the emergency department.

GCS less than 15 at 2 hours after the injury on assessment in the emergency department.

Suspected open or depressed skull fracture

Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid
leakage from the ear or nose, Battle's sign).

Post-traumatic seizure.

Focal neurological deficit

More than 1 episode of vomiting.

For adults with any of the following risk factors who have experienced some loss of
consciousness or amnesia since the injury, perform a CT head scan within 8 hours of
the head injury:

• Age 65 years orolder.

• Any history of bleeding or clottingdisorders.

• Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an

occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or5
stairs).

• More than 30 minutes' retrograde amnesia of events immediately before the headinjury.

Question

40 year old man Mr Andrew Robert collapsed outside a pub. Take history from the
patient and discuss the management with the patient.
Dr - What brings you to the hospital ? Pt - Doctor I passed out
Dr -When Pt - I just came out of the
restaurant and passed out
Dr – Was there any one with you ? Pt - yes my wife was with me.
Dr - How did this happen - Pt: We are in the restaurant, we
came out and suddenly I
passedout.
Dr: Did you slipped or tripped ? Pt: I am not sure. ( sometimes
he may say I tripped on the
pavement)
Dr - How long did you lose consciousness Pt – I am not sure because
when I was awake I was in the
ambulance.
Dr - Did you recover completely after this, or was there Pt – yes, I did recover
any drowsiness completely immediately after
the incident
Dr - Any head injuries when fell down ? Pt – No/Yes
Dr: Did you had any head injury before you lost Pt:No
consciousness ?

Dr - Any headache … Pt - no
Dr: Did you vomit after this ? Pt: Yes twice
Dr – Did anyone tell you that were jerking ( fit) at that Pt - no
time ?
Did you wet your pants do you know ? Pt - no
Dr: Do you know whether you had any bleeding from ear Pt - no
nose ?
Dr: How much do you remember before this incident ? Pt: Sometimes he may say I
( any amnesia for 30 min beforeincident) remember everything until I
just passed out / sometimes he
may say I just remember going
into the restaurant and then my
wife told me that when we
came out I just passed out.
Dr: How much do you remember before this incident ? Pt. I remember when I was
awake I was in the ambulance
and remember everything after
that.
Dr - Is this the first time …. Pt-Yes
Dr -Any medical problems like – DM, HTN, Heart Pt – No
conditions, Epilepsy, Stroke
Dr -Did you drink alcohol just before this Pt – Yes doctor but it is same
type and same amount as usual
Dr -Did you use any recreational drugs just before that Pt - No doctor.
happened …
Dr – Do you take any medications ? Pt – No ( Any drug Overdose)
Any blood thinners ?
Dr – Any of your blood relatives have any medical Pt - No
conditions like DM, Heart conditions or epilepsy ?
Dr - Do you live with any one ? Pt – Yes, my wife
Dr: Mr Robert, I need to examine you ( Examiner may not give any findings).
With what you told me I think you have injured your head and probably you have some
bleeding inside your head. We need to admit you in the hospital and do CT scan of the
head to check whether you have the bleeding. Is that OK?
Pt: No Doctor I am fine now. I want to go home.
Dr:MrRobertwiththesymptomswhatyouaretellingmelikethatyouhaveheadacheand
vomiting, these are the signs of bleeding inside the head. It will be very dangerous for you
togohome.Weneedtoadmityoutreat youifyouhavebleedinginsideyourhead.Wemay
needtodooperationonyourheadtoremovethebloodclotifatallyouhavethebleeding
inthebrain.Wewillalsodosometeststoseewhydidyoufall–likewewilldoECG(heart tracing,
check your bloodsugar).
However if all these tests are normal then you can go home. Is that OK ? If we discharge
you then you should stay at home at least for 24 hours and your wife should take care of
you. If you have any symptoms like ( warning signs) continued headache, continuously
vomiting, Drowsiness or fits you should come back.
Pt: Ok doctor. Thank you very much.

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

Measure his Blood pressure and Address his concerns.

Dr: Hello MrPatBrown, I am Dr … How are you?

Dr: I understand you had high blood pressure last time when you were in the hospital ? Can
I please check your blood pressure now ?
( examiner says – his blood pressure now is 165/95).
Dr: Mr Brown your blood pressure is still quite high ? Are you taking your blood pressure
medications?
 30

Pt: I stopped taking them few days ago.

Dr: Why ?
Pt: They are giving me too much cough. I can’t sleep and my wife also can’t sleep because
I keep coughing too much
Dr: I am very sorry to hear that. Can you please tell me which medications are you taking?
Pt: I am taking these doctor ( he will show Aspirin, Enalapril and Simvastatin)
Dr: Do you have any other problem other thancough? Pt:
NoDr: Any fever ?(Pneumonia) Pt:No
Dr: Any sweats in the night time ? (TB) Pt:No
Dr: Have you noticed any change in your weight? (TB) Pt:
NoDr: Have been diagnosed with Asthmabefore? Pt:No
Dr: Do you have any othermedical condition? Pt: Yes
Ihavediabetes.Dr: Do you take any mediationforthat? Pt:
No Dr: Are you
allergic anything including to anymedications? Pt:No

Dr: OK let me check the book and let you know. Check the BNF
It is Enalapril medication is giving you cough. One of the side effect of this medication is
cough.
Mr Parker it is very important to take this medication to control your blood pressure. Do
you think you can continue taking this medication. You may get used this cough after some
time.
Dr: No doctor I don’t want this medication. It is causing me too much problem.

Dr: OK don’t worry. We have some other medication to treat what we call Losartan
( Angiotensin receptor blocker – ARB). That will help to control your high blood pressure
as well as it is good for the kidneys also. However if you have any problems in your heart
or liver this medication may not be good. Do you have any problem in the heart or liver
?Dr: No doctor
Dr: Ok then this should be good for you.
Pt: How do I take it ?
Dr: It can be taken by moth with or without food. Dose will be 50mg once a day but then
we will adjust the dose according to your blood pressure.
Pt: Will there be any side effects for that.
Dr: Unfortunately one of the side effects of this medication is also cough but it is not as
much as Enalapril. Very rarely it can cause allergic reaction – in that case you should
stop it. It can also cause body pain – please tell your GP if that happens.
Dr: It is very important to take medications regularly. You should not stop taking
medications on your own without talking to your doctor. If you do not take medications
regularly your blood pressure can shoot up and it can cause other serious problems.
Dr: Anyotherconcerns Pt:No
Dr: Mr Parker – Do you want to know about your other medications ?
Pt: No doctor

[ If he says he wants to know then talk about them -ASPIRIN:- This is a blood thinner
tablet. It reduces the risk of clots forming in your blood. This reduces your risk of having a
stroke or heart attack.
 31

Dose as mentioned in the prescription. ( 75 mg one tablet, Once a day, by mouth, after
food) SE - Can cause tummy irritation, slight bleeding in stomach and youmaynotice
dark stool if it happens please inform yourGP.

SIMVASTATIN: 20 mgnocte. This lowers the cholesterol (bad fat).

Take one dose of simvastatin each day, in theevening.
You can take simvastatin before or after food.
SE – Can cause Muscle cramps - can be serious problem some times ( inform your GP).
Can also cause hair loss,Headache,Dizziness. These medications are taken lifelong].

Dr: Mr Parker it is very important that you should keep your blood pressure under control.
Otherwise it can cause serious health problems like heart problems and even stroke.
Dr: Do you do exercise ? Pt : No
Dr: You should go for regular exercise – jogging or at least brisk walk for 30 min at least
every day for about 5 days a week. This helps to keep the blood pressure under control.
Dr: How is your diet ?
Pt: I eat fast food/ healthy food .
Dr: You should eat less of foods which contains high fat like red meat. Instead you cna eat
chicken and fish. You should also eat more of fruits and vegetables.
Pt: Ok
Dr: Since you have diabetes it is important to keep the sugar also under control otherwise
high blood pressure and diabetes combined together can cause serious health problems.

Dr: Do you smoke ?Pt: No Dr:Good

Dr: Do you drink alcohol ?Pt: Notmuch Dr:Good.
Dr: Any otherconcerns ? Pt: No
Dr: Thank you very much. We will keep following you up. If you need any help any time
please do come back.

Heamaturia
Red flag symptoms
• Painless macroscopichaematuria
• Symptomatic microscopic haematuria in absence ofUTI
• Age >50years
• Abdominal mass on examination
History andexamination
Patients presenting with haematuria should be asked about symptoms of one of the most
likely causes, a UTI. Symptoms of frequency, urgency and dysuria point to this diagnosis.
Haematuria presenting with abdominal pain 'from loin to groin' is classical of renal calculi,
and there may be a previous history of similar episodes.
On the other hand, haematuria presenting without pain raises the possibility of a bladder or
renal malignancy and should prompt urgent referral.
In the absence of a UTI, microscopic haematuria associated with systemic symptoms, such
as joint pains, a rash or fever, should lead you to suspect an inflammatory cause, such as
systemic lupus erythematosus or Henoch-Schonlein purpura.
Consider post-infectious glomerulonephritis or IgA nephropathy if there is a history of
infection. A thorough drug history will reveal any nephrotoxic medications, such as
cyclophosphamide or NSAIDs. Note that warfarin is not in itself a cause of haematuria.
Remember to ask about recent travel (schistosomiasis) and occupational exposure (bladder
malignancy).
Examination of BP (renal disease) and abdomen (urological malignancy) are vital. Genital
examination is often unhelpful although examination of the prostate is necessary if there
are symptoms of prostatism. Examine the skin and joints for signs of systemic disease.
Investigations
Dipstick examination will rule out other causes of red urine and may show associated
proteinuria, which hints at a renal cause.
An MSU should be sent for microscopy culture and sensitivity testing, and a urinary
protein-creatinine or albumin-creatinine ratio obtained.
Bloods including FBC, U&Es and clotting will establish the amount of blood loss, renal
function and any coagulopathy.
Imaging may be required to investigate calculi, and a renal ultrasound may be performed.
Any patient with frank and painless haematuria requires urgent specialist investigation,
which will involve a cystoscopy and/or a CT urogram.

Causes of haematuria

1) Kidney 4) Prostate

Glomerular diseases Benign Prostatic Hyperplasia

Polycystic kidney disease CA prostate
Kidney stones
Trauma (renal biopsy)
Renal adenocarcinoma
Renal TB
Renal vein thrombosis
Embolism
2) Ureter 5) Urethra

Urethral trauma
 Ureteric stones Urethral stones
Neoplasm Neoplasm
Trauma
3) Bladder General causes

Bladder stones Anticoagulants (Warfarin)

CA bladder Thrombocytopoenia
Bladder Trauma Sickle cell disease
Inflammation (Cystitis, stones, TB) Malaria
Schistosomiasis
Blood dyscarias (Hemophilia)
Sternous exercises
Red urine

Hemoglobinuria
Myoglobinuria
Beetroot
Senna
Rifampicin
Phenopthalein

Exam question
You are the FY2 doctor in the Urology department.
Middle age man presented to the hospital with the history of passing blood in the
urine.
Take relevant history and discuss the further management with the patient.
Dr: Hello Mr … I am Dr…. One of the junior doctor in the urology department.
How can I help you ?
Pt: Doctor I am passing blood in the urine.
Dr: Can you tell me anything more aboutit? Pt: Likewhat?
Dr: Since when did you noticethis? Pt: Since last fewdays.
Dr: Is the bleeding at the beginning of urinating ( urethra or prostate) or at the end of
urinating ( bladder or prostate) or throughout ( bladder, kidney ureter) ?
Pt: It is throughout.
Dr: Do you have any pain while passing urine (UTI)? Pt:No
Dr: Do you have fever (UTI)? Pt:No Dr : Increased frequency orurination?
 7

Pt : No/ Yes
Dr: When you pass urine does it flow properly or does it dribble ( Prostate
symptoms) ? Pt : No/ Yes there is dribbling.
Dr: Do you have to run to the loo when you get the sensation of passing urine
(prostatism) Pt : Yes/ No
Dr: Did you have any injury to the penis or totummy?

Pt:NoDr : Did you ever had any kidney stones before ? Pt :No
Dr: Did you have any kidney problems before (polycystickidney) ?

Pt:NoDr: Any pain going from loin to groin at all ( ureteric stone)? Pt :No
Dr: Any pain in your loin area ( renalcancer)?
Pt:NoDr:
Any mass in the loin area (renalcancer)? Pt:NoDr:
Have you noticed any change in your weightCancer)? PT:
No / Yes ( how much in how much time?)
Dr : Do you cough ( TB) ? Pt:No Dr: Night sweats ( TB) ?
Pt:NoDr: Do you smoke ? Pt : Yes ( How many and how long ?)
Dr : Have done any strenuous exercise recently ? Pt : No
Dr: Do you have any pain at the back ( secondary in the vertebra – primary in the kidney
or prostate) ? Pt : No
Dr: Any procedures or operations done recently on kidney, urine bladder or urethra
( front passage) ? Pt : No
Dr: Do you have any bleedingdisorders?

Pt:NoDr: Did you have this problembefore? Pt :No

Dr: Are you taking any kind of medication –bloodthinners?
Pt:NoDr: Are you
allergic to anymedications? Pt : Yes .Penicillin.
Dr: Have you travelled to other countries recently (schistosomiasis)? Pt:No

Examination:
Mr… I need to examine your tummy and back passage to check the prostate gland.
[ Examiner may say prostate is enlarged and smooth and no other abnormal findings ]
 8

Diagnosis :

Mr… While examining I found that your prostate gland ( a gland which is present at the
base of the urine bladder) is enlarged.
However Mr .. There is a possibility that you may be having some growth in the urine
bladder causing this problem. We need to do further tests to find out what exactly is
causing the bleeding from the urethra. ( If you are the FY 2 doctor in the Urology mention
talking to seniors about the further investigations and treatment, if you not in the Urology
department – then mention referral to Urologists specialists in Kidney and urine excreting
organs for further investigations and treatment).

Pt: Do I have cancer doctor?

Dr: At the moment we cannot say anything. However there are many other reasons for the
bleeding like this. Specialist will tell you once they get all the investigation result.
Pt : Ok

Investigations:
Mr… We will have to test your urine first to check for the blood or other things (protein)
which may show any problem in the kidney. We need to do investigations like cystoscopy
to check inside the urine bladder. In this procedure we pass a tube with the camera attached
to that through the urethra ( front passage ) into the urine bladder and we have a look inside
the bladder and take any tissue samples if there is any growth there and test that in the lab.
Also we may need to test the prostate gland to see what type of growth it is whether it is
cancerous or non - cancerous. We will have to do ultrasound scan and do some blood test
specific for the prostate gland.
Also we need to do CT scan of the lower tummy area to check whether the cancer has
spread if at all it is cancer. Do you follow me?
Pt : Yes doctor
Treatment:
Dr: Depending on the test result we will treat you. If at it is bladder cancer, depending on
whether it is spread or not we will treat either by doing surgery – if possible we may
remove just the growth or we may need to remove the whole urine bladder and create an
artificial urine bladder.
We may also need to treat with chemotherapy and radiotherapy.
If at all it is cancer of the prostate - again depending on the result we will treat either by
surgery or chemotherapy or radiotherapy.
Are you following me? Is that OK?
Pt : Ok doctor. Thank you very much.
 9

TIA
10
 11

69 year old lady had presented to A&E with sudden onset facial weakness, unilateral limb
weakness and slurring of speech.
On evaluation, found to have BP of 150/90.
Neurological examination was completely normal. She is worried and has given consent to
talk to her husband.
Talk to him, take history, discuss management and address concerns.

Dr: Hello Mr.... my name is Dr... Are you Mrs. X's husband?
H: Yes doctor..
Dr: How are you doing Mr...?
H: I'm fine doctor.. I was told someone would come by to talk to me about my wife.
Dr: That's correct Mr... I am here to talk to you about your wife. Could you please tell me what
exactly happened?
H: We were at home. She was just sitting and watching TV. And all of a sudden she wasn't able to
articulate words. I noticed some change in the right side of her face and she couldn't move her right
arm as well. So I just called an ambulance within 15 minutes they arrived her and brought her to the
hospital. But after we got here, within an hour, she was perfectly fine! ( sometimes he may say
symptoms lasted 2 hours)
Dr: Ok Mr... You did the right thing. It's very good that you called for an ambulance immediately
and brought her here. I do have a few more questions to ask you about your wife's condition prior
to this incident. Would that be all right? H: Yes

Dr: Did she complain of headache? H: No

Dr: Did she lose consciousness? H: No

Dr: Has your wife had such attacks in the past? H: No

Dr: Does she have any underlying medical conditions like diabetes? H: Yes ( sometimes he may
say - No)
Dr: High Blood pressure ? H: No
Dr: Was she ever found to have high cholesterol? H: No
Dr: Has she had any heart related incidents in the past? H: No
Dr: Did she had abnormal heart beats? H: No

Dr: Ok.. Now Mr... I have a few questions about your wife's lifestyle.
What is her diet generally like?
H: She eats a healthy balanced diet doctor. Plenty of fruits and vegetables.
 12

Dr: Ok. That is very good Mr... Does she get exercise?
H: A little.. Yes.. Moving around the house.. Gardening etc.... ( sometimes he may say we go for
brisk walking every day – so does good exercises)
Dr: Does she smoke? H: No
Dr: Does she consume alcohol? H: No

Dr: Is she on any medications? H: No

Dr: Ok. Does she have any allergies? H: No

Dr: Does she have any family history of heart disease? H: No

Dr: F/H of stroke? H: No

Examination and Diagnosis:

Dr: Mr... as you had mentioned, your wife's symptoms resolved within an hour.. And on
examination, she had no neurological problems. From the information we have gathered, it appears
that she has had what we call a Transient Ischemic Attack (TIA) or a mini-stroke. Do you have any
idea what that is? H: No
Dr: A TIA is a medical condition where there is a momentary decrease or loss in blood supply to
the brain. This could either be because of some narrowing of the blood vessels in the neck that
supply blood to the brain... or because of some rhythm problems in the heart. Are you following me
Mr...?
H: Yes doctor.. Is it serious?
Dr: Mr... A TIA as such is not serious as it usually resolves by itself within 24 hours. But we need
to evaluate and find out why it happened because if it happens again, it might not be a TIA, but
something more serious, like a complete stroke. Do you follow me?
H: Yes doctor. What are the chances that she may get stroke doctor ?
Dr: Unfortunately the risk of she getting the stroke in the next few days itself is very high.
We need to admit her and treat her immediately to reduce the chance of she getting the stroke in
the next few days.

Investigations

Dr: We need run some tests... to find out why this happened.
H: What kind of tests doctor?
Dr: First we will have to do a CT scan of her head... to make sure that there is no evidence of a
stroke. We will then do an ECG or a heart tracing to look for any rhythm problems. We will also
do some blood tests to check her sugar and cholesterol levels.
Additionally, we will have to do a scan called a Doppler... of the blood vessels of her neck to see
if they are narrowed. Are you with me Mr...? H: Yes
 13

Treatment:

Dr: Mr... on examination, we also found that your wife's BP was on the higher side. It was 150/90.
We will have to start her on a medication to control her BP. We will also start her on Aspirin,
which can help prevent such attacks in the future. We will also ask the Neurologist to evaluate
your wife. Do you have any questions for me Mr...?

H: When can I take her home?

Dr: If all the investigations are all right, you can take her home within a day or two Mr... If the scan
of the blood vessels in her neck show significant narrowing, we might have to consider a
surgery to correct it. We will let you know based on the findings.

Warning signs :

If you do take her home Mr... I would like to inform you about the warning signs of a stroke
[FAST – Facial weakness, Arm weakness, Speech problem – Time to call the ambulance]. If
you ever notice any weakness in her face or limbs... or any slurring of her speech, please call an
ambulance and bring her to the hospital immediately as the next time, it can be even stroke. Do
you have any questions for me ?
H: No doctor.. Thank you.

STROKE RISK ASSESSMENT

You are F2 in the GP clinic.

60 year old Mr. Zimmerman makes an appointment with the clinic because he is very
concerned about developing stroke. The nurse has found his BP to be 160/90.
Talk to him and address his concerns.
 14

Dr: Hello Mr. Zimmerman... I am Dr.... one of the junior doctors here in the GP
clinic..
Pt: Hello doctor.. Very nice to meet you.
Dr: Nice to meet you too Mr. Zimmerman. I understand you made an appointment
with the clinic because you had some concerns. Is that correct?
Pt: Yes doctor. I'm very worried that I might develop stroke.
Dr: Could you please tell me why you are worried about it?
Pt: I had a health check by the Occupational health department 2 years ago and they
told me that my blood pressure is bit high at that time. But I was too busy and I
didn’t bother much about it. But now I am very worried it.
Dr: Can you please tell me why are you worried of getting stroke if your blood
pressure is high ?
Pt: My father and elder brother had high blood pressure. My father died of stroke
many years ago and my brother had stroke few years ago. He has just recovered
now.
Dr: I am very sorry to hear that Mr. Zimmerman. But don’t worry Mr Zimmerman
we can help you to reduce any risk of you getting stroke.
Mr Zimmerman, do you know what is stroke and why people get this condition ?
Pt: I know people can have paralysis if they have stroke.
Dr: That is right Mr Zimmerman. This condition happens either because there is
bleeding in the brain and blockage to the blood supply to the brain. People who
have this condition can have paralysis. Sometimes people do improve from this
problem but sometimes the paralysis can last forever. Sometimes this condition can
be even life threatening.
Pt: I see.

Dr: Sometimes this condition can run in the family because of genetic reasons.
However, there are lot of others risk factors why people get stroke. We may be able
to reduce the chances of you getting stroke if you have any other risk factors and if
we can modify those factors. I am really glad that you came to the hospital now. Let
us see if you have any other risk factors and try to sort out those. Is that OK Mr
Zimmerman?
Pt: Ok Doctor.
Dr: Did you have any strokes or mini strokes previously ? Pt: No
Dr: Do you have any heartproblems? Pt :No
Dr: Do you have any palpitations ( Atrial fibrillation) ? Pt : No
Dr: Do youhavediabetes? Pt:No
Dr: You said your blood pressure was high before. Our nurse checked your blood
pressure now which is 160/90 which is quite high. High blood pressure is one of the
major risk factor which can cause rupture of the blood vessels in the brain and cause
bleeding in the brain. It is very important to keep the blood pressure under control.
We can give medications to keep the blood pressure under control. I will talk to my
seniors about it and get back to you.
However, apart from medications you may need to do lot of other things to keep the
blood pressure under control.
Pt: What is that doctor ?
Dr: One important factor is diet. Can I ask you what type of food do you eat
usually?
Pt: You know doctor. I am a NHS manager. I'm usually busy. I don’t have time to
cook food. So I eat out most of the time. I have to eat fast food - I eat chips, burger,
steaksetc
Dr: Mr Zimmerman, the kind of food what you are eating is not good because they
have very high bad fat content that is cholesterol. This can increase the blood
pressure and contribute to stroke. I sincerely advise you to eat more of white meat
which has less bad fat like chicken and fish. I also advise you to include plenty of
fruits and vegetables also in your diet. Also please reduce the salt content in your
food because it can increase the blood pressure. I will refer you to a dietician who
will advise you in detail about the healthy diet. Is that OK ?
Pt: That is fine. Doctor.
Dr: That is good. Can I ask do you do exercise ?
Pt: Not much doctor. As I said I don’t get time to do exercise.
Dr: I understand you are very busy. However, I sincerely advise you to do some
exercise like walking for about 30 min every day at least 5 days a week. If that is
not possible may be you can have a treadmill at home and exercise on that while
you are watching TV. Exercising regularly will keep you healthy and also helps to
keep the blood pressure under control. What do you say ?
Pt: Yes doctor that seems to be a good idea.
Dr: Excellent. Do you smoke Mr Zimmerman?
Pt: Yes doctor I smoke about 10 to 15 cigarettes a day for the last 15 to 20 years
doctor.
Dr: Again smoking is not good for health at all as you may know. Smoking also can
increase the blood pressure and also can cause lot of other health problems. I
strongly advise you to stop smoking. We can help you to stop smoking if you wish.
Do like to consider that Mr Zimmerman.
Pt: Doctor you know my work is very stressful. In fact NHS is going through lot of
financial crisis. I have to do lot of work to prevent this financial problems. I might
even lose my job. I have to smoke to relieve my stress doctor.
Dr: I can surely understand your problem. However, there are many other ways to
relieve stress. May be you can take some break from work and go for relaxation
classes and yoga classes which might help you to relieve from stress. Remember
stress also can increase the blood pressure. What do you say?
Pt: Yes doctor you are right. I will try my best to do that.
Dr: Do you drink alcohol Mr Zimmerman?
 Pt: Yes doctor. I drink about 2 glasses of wine every day and also whisky
sometimes over the weekends.
Dr: Mr Zimmerman, alcohol also is not good for the health. I sincerely advise you
to cut down drinking alcohol and drink within the recommended limits that is not
more than 14 units per week. We can help you to cut down if you wish. What do
you think ?
PT: Yes doctor I will surely think of that.
Dr: Excellent. Do you have any questions?
Pt: Doctor if I follow all the advices what you gave then will I not get stroke?
Dr: Mr Zimmerman. There is something called as modifiable and non- modifiable
risk factors for stroke. Non modifiable factors are like age above 60 years, genetic
cause means inherited risk which we can’t do anything about these. However there
are lot other modifiable risk factors like all the factors what we discussed so far like
diet, exercise, smoking which you can modify and have a healthy life style. This can
substantially reduce the risk of you getting stroke. Also there are other risk factors
like abnormal heart rhythms and narrowing of the blood vessels in the neck which
supplies blood to the brain. We can check whether you have any problems like these
and we can treat them if you have. All these things will greatly reduce the risk of
getting stroke.

Pt: Ok Thank you very much doctor.

Dr: I sincerely advise you to follow all the advices. We will keep following you up.
Please be aware of the symptoms of stroke like facial weakness, arm weakness or
speech problems. If you have any of the symptoms please call the ambulance and
come to the hospital immediately because these are the symptoms of stroke. Is that
Ok Mr Zimmerman.
Pt : Ok doctor.
Dr: Any other questions ?
Pt : No doctor. You have been very kind.
Dr: Thank you very much Mr Zimmerman. Once again I really appreciate that you
came here today. I wish you a very long and healthy life.

Ureteric calculus

Risk factors

Several risk factors are recognised to increase the potential of a susceptible individual to develop
stones. These include:

 Anatomical anomalies in the kidneys and/or urinary tract - eg, horseshoe kidney, ureteral
stricture.
 Family history of renal stones.
 Hypertension.
 Gout.
 Hyperparathyroidism.
 Immobilisation.
 Relative dehydration.
 Metabolic disorders which increase excretion of solutes - eg, chronic metabolic acidosis,
hypercalciuria, hyperuricosuria.
 Deficiency of citrate in the urine.
 Cystinuria (an autosomal-recessive aminoaciduria).
 Drugs - eg, diuretics such as triamterene and calcium/vitamin D supplements.
 More common occurrence in hot climates.
 Increased risk of stones in higher socio-economic groups.
 Contamination - as demonstrated by a spate of melamine-contaminated infant milk formula.

Indications for hospital admission

 Fever.
 Solitary kidney.
 Known non-functioning kidney.
 Inadequate pain relief or persistent pain.
 Inability to take adequate fluids due to nausea and vomiting.
 Anuria.
 Pregnancy.
 Poor social support.
 Inability to arrange urgent outpatient department follow-up.
 People over the age of 60 years should be admitted if there are concerns on clinical condition or
diagnostic certainty (a leaking aortic aneurysm may present with identical symptoms).

Indication for urgent outpatient appointment

 Pain has been relieved.

 The patient is able to drink large volumes of fluid.
 Adequate social circumstances.
 No complications evident.

Initial management of acute presentation

  Non-steroidal anti-inflammatory drugs (NSAIDs), usually in the form of diclofenac IM or PR, should
be offered first-line for the relief of the severe pain of renal colic. NSAIDs are more effective than
opioids for this indication and have less tendency to cause nausea. However, if parenteral morphine is
required in severe renal colic pain, this works quickly and can provide pain relief in the time taken for
an NSAID to work.
 Provide anti-emetics and rehydration therapy if needed.
 The majority of stones will pass spontaneously but may take 1-3 weeks; patients who have not
passed a stone or who have continuing symptoms should have the progress of the stone monitored at a
minimum of weekly intervals to assess the progression of the stone.
 Conservative management may be continued for up to three weeks unless the patient is unable to
manage the pain, or if he or she develops signs of infection or obstruction.
 Medical expulsive therapy may be used to facilitate the passage of the stone. It is useful in cases
where there is no obvious reason for immediate surgical removal. Calcium-channel blockers (eg,
nifedipine) or alpha-blockers (eg, tamsulosin) are given. A corticosteroid such as prednisolone is
occasionally added when an alpha-blocker is used but should not be given as monotherapy.

Managing patients at home

 All patients managed at home should drink a lot of fluids and, if possible, void urine into a container
or through a tea strainer or gauze to catch any identifiable calculus.
 Analgesia: paracetamol is safe and effective for mild-to-moderate pain; codeine can be added if more
pain relief is required. Paracetamol and codeine should be prescribed separately so they can be
individually titrated.
 Patients managed at home should be offered fast-track investigation initiated by the hospital on
receipt of a letter or email completed by the general practitioner.
 Patients should ideally receive an appointment for radiology within seven days of the onset of
symptoms.
 An urgent urology outpatient appointment should be arranged for within one week if renal imaging
shows a problem requiring intervention.

Surgical

 Approximately 1 in 5 stones will not pass spontaneously and will require some form of intervention.
 If the ureter is blocked or could potentially become blocked (eg, when a larger stone will fragment
following other forms of therapy), a JJ stent is usually inserted using a cystoscope. It is a thin hollow
tube with both ends coiled (pigtail). It is also used as a temporary holding measure, as it prevents the
ureter from contracting and thus reduces pain, buying time until a more definitive measure can be
undertaken.
 Procedures to remove stones include:
 Extracorporeal shock wave lithotripsy (ESWL) - shock waves are directed over the stone to
break it apart. The stone particles will then pass spontaneously.
 Percutaneous nephrolithotomy (PCNL) - used for large stones (>2 cm), staghorn calculi and
 also cystine stones. Stones are removed at the time of the procedure using a nephroscope.
 Ureteroscopy - this involves the use of laser to break up the stone and has an excellent
success rate in experienced hands.
 Open surgery - rarely necessary and usually reserved for complicated cases or for those in
whom all the above have failed - eg, multiple stones.
 Several options are available for the treatment of bladder stones. The percutaneous approach has
lower morbidity, with similar results to transurethral surgery while ESWL has the lowest rate of
elimination of bladder stones and is reserved for patients at high surgical risk.[7] 

Complications

 Complete blockage of the urinary flow from a kidney decreases glomerular filtration rate (GFR)
and, if it persists for more than 48 hours, may cause irreversible renal damage.
 If ureteric stones cause symptoms after four weeks, there is a 20% risk of complications, including
deterioration of renal function, sepsis and ureteric stricture.
 Infection can be life-threatening.
 Persisting obstruction predisposes to pyelonephritis.

Prognosis

 Most symptomatic renal stones are small (less than 5 mm in diameter) and pass spontaneously.
 Stones less than 5 mm in diameter pass spontaneously in up to 80% of people.
 Stones between 5 mm and 10 mm in diameter pass spontaneously in about 50% of people.
 Stones larger than 1 cm in diameter usually require intervention (urgent intervention is required if
complete obstruction or infection is present).
 Two thirds of stones that pass spontaneously will do so within four weeks of onset of symptoms.
 A stone that has not passed within 1-2 months is unlikely to pass spontaneously.
 The following features predispose to recurrent stone formation:
 First attack before 25 years of age.
 Single functioning kidney.
 A disease that predisposes to stone formation.
 Abnormalities of the renal tract.

Prevention

Recurrence of renal stones is common and therefore patients who have had a renal stone should be advised to
adapt and adopt several lifestyle measures which will help to prevent or delay recurrence:

 Increase fluid intake to maintain urine output at 2-3 litres per day.
 Reduce salt intake.
 Reduce the amount of meat and animal protein eaten.
 Reduce oxalate intake (foods rich in oxalate include chocolate, rhubarb, nuts) and urate-rich foods
(eg, offal and certain fish).
 Drink regular cranberry juice: increases citrate excretion and reduces oxalate and phosphate
 excretion.
 Maintain calcium intake at normal levels (lowering intake increases excretion of calcium oxalate).

Depending on the composition of the stone, medication to prevent further stone formation is sometimes
given - eg, thiazide diuretics (for calcium stones), allopurinol (for uric acid stones) and calcium citrate (for
oxalate stones).

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

Offer pain killer.

Differentials of left sided abdominal pain:

Kidney or ureteric stone – loin groin pain, hematuria. previousHx of kidney stone. R/o UTI and
Pyelonephritis – Fever, burning sensation, increased frequency, smelly urine.
Diverticulitis – Diarrhoea, pain relieved on defeacation.
Pancreatitis – pain from front to back. Alcohol.
Bowel cancer – change in bowel habit, weight loss.
Dissection of abdominal aortic aneurysm- did you ever had any scans of your tummy and was
told that you have abnormal blood vessels in your tummy.

In the Hx include risk factors

In problem in kidney before ( stones, horseshoe kidney)
Any parathyroid gland problem ( bone pains, pathological fractures – fractures without trauma)
Any high blood pressure, Hx gout,
Family Hx of any kidney problems
Medications?

Any vomiting ? Are you able to drink? Are you able to pass urine?
I need to examine your tummy. (No response from the examiner)
Diagnosis
Mr… I think you have a stone in the ureter. Ureter is a tube which drains urine from the kidney to
the urine bladder.

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

Treatment: If the tests confirm that it is stone we treat it. We have various options to treat it.
Sometimes this stone will pass out on its own if it is very small.
We will give you very good pain killer medication what we call as Diclofenac as a suppository
through your back passage.
If your pain is relieved and you are able to eat and drink and able to pass urine then you can go
home. Drink plenty of water and the stone may pass out on its own. If possible, you should pass
urine into a container or through a tea strainer or gauze to catch any identifiable calculus.We will
give you an appointment for follow up within a week.

However, if your pain is not relieved and if you keep vomiting continuously or if the scan shows
some abnormality in the kidney then we will keep you in the hospital and treat you.

We can give you some fluids through your veins or medications( tamsulosin or nifedipine) which
will help to flush out the stone in the urine.
If that does not work then we have something what we call as shock wave treatment where break
the stone into smaller pieces by giving some type of shock and then it will flush out easily.
If these things do not work then either we can do a key hole surgery and remove it or rarely we
may have to do open operation to remove it.

If we get the stone we will send it to the lab for further analysis. Depending on the composition of
the stone we may givemedication to prevent further stone formation. [ eg, thiazide diuretics (for
calcium stones), allopurinol (for uric acid stones) and calcium citrate (for oxalate stones).

This condition can happen again. To prevent stones in the future

 Drink plenty of fluid.

 Reduce salt intake.
 Reduce the amount of meat and animal protein eaten.
 Reduce oxalate intake (foods rich in oxalate include chocolate, rhubarb, nuts) and urate-
rich foods (eg, offal and certain fish).
 Drink regular cranberry juice: increases citrate excretion and reduces oxalate and
phosphate excretion.Do you follow me? Any concerns?Thank you.

Needle stick injury in child

3 year old child brought in by Nanny. Child had needle stick injury while playing in the garden.
Take history and talk about management.
Take detailed history about the incident.
When, how, ( child was coming down the slide and got injured with the needle)
Ask about needle – was it attached to syringe, and blood in the needle or syringe, was it rusted,
What did she do immediately after that. [ she washed child’s finger – appreciate her]
Ask about the jabs specifically Hep B – she says she does not know anything other than that the
child is up to date with all the jabs. Ask about parents – they are far away. Ask whether you can
talk to them over the phone and take some history from them about the jabs and any other medical
conditions. Tell her we can get the jabs information from the GP.
Ask about other medical conditions, similar incidents in the past.

Ask her about her concerns.

Tell that usually people get worried about children getting any infections because of the needle
stick injury if the needle was used by some drug addicts

Reassure that the chances of child getting HIV infection is almost negligible because HIV bugs do
not survive outside human body. So usually we do not do any tests for HIV and we do not offer any
medications to prevent them getting HIV infection.

Hep B – there are slight chances of child getting hep B infection if the child is not vaccinated.
We will check from the GP whether the child had Hep B vaccine or not and if the child did not had
Hep B vaccine we will give Hep B vaccine and another medication called Hep B immunoglobulin
to prevent child getting Hep B infection.

She may ask – will you give antibiotics

We will have a look at the wound { examination} clean the wound thoroughly and if the wound is
deep then we will give antibiotics to prevent wound infection.
Usually they do not get any other infection.
No need of admission.

Nanny may be taking down notes – ask her why – she may say I need to tell child’s parents
everything you say now. – appreciate. Tell her to bring the parents later so that you can explain
everything to them directly.
Warning signs – if the child develops redness, swelling discharge from the wound site – this is sign
of wound infection – you need to bring the child back.
Any other concerns.

Injury from used needles and syringes found in community settings arouses much concern,
especially when children find discarded needles and injure themselves while playing with them.
The user is generally unknown, and parents and health care providers fear that the needle may have
been discarded by an injection drug user. Although the actual risk of infection from such an injury
is very low, the perception of risk by parents results in much anxiety. Evaluation and counselling
are needed.
The important pathogens to be considered in this situation are hepatitis B virus (HBV), hepatitis C
virus (HCV) and HIV. It is essential that the health care provider be knowledgeable about the risks
of acquisition of these viruses following needle stick injuries, and the recommendations for
management and follow-up. In the absence of up-to-date local data, it is prudent to assume that the
needle may have been contaminated with one or more of these viruses.
There have been single case reports of HBV and HCV transmission and no reported transmission of
HIV following injuries by needles discarded in the community. A review of the literature up until
September 2007 yielded 12 case series from areas of high prevalence of blood-borne viruses. These
involved a total of 483 children with follow-up for HIV, 452 for HBV and 265 for HCV. There
were no infections. The majority of children received HBV prophylaxis, if it was indicated, but
only 130 children received antiretroviral prophylaxis.
Follow-up after any significant needle stick injury is essential. The clinician dealing with the initial
incident should ensure that the parents and child understand the importance of follow-up, and that
appropriate arrangements are made. Parents sometimes assume that if blood tests that are
performed at the time of injury are negative, then there is no possibility of infection and no need for
further testing.
Needle stick injuries may be prevented by educating children, parents, educators and health care
providers about the dangers of handling used needles, syringes and other objects contaminated with
blood. Children need to be made aware at an early age. In the studies of injuries from discarded
needles referred to above, the mean ages of the injured children were five to eight years. In one
study 15% of injuries occurred in children pretending to use drugs. There is a community
responsibility to provide adequate cleanup of parks and schoolyards. In addition, community
commitment is necessary to support addiction treatment and infection prevention programs for
injection drug users.

HBV
HBV is the most stable of the blood-borne viruses and can be transmitted by a minute amount of
blood. The risk of acquiring HBV from an occupational needle stick injury when the source is
hepatitis B surface antigen (HBsAg)-positive ranges from 2% to 40%, depending on the source’s
level of viremia. HBV can survive for up to one week under optimal conditions, and has been
detected in discarded needles. A case of HBV acquired from a discarded needle used by a known
HBV carrier has been reported.
Although HBV vaccine is now recommended for all children in Canada, most programs target
children who are older than the usual age at which they sustain accidental needle stick injuries.
Thus, the majority of injured children are likely to be susceptible to HBV infection. Postexposure
prophylaxis with anti-HBV immunoglobulin and HBV vaccine is effective if provided promptly.

HCV
The risk of acquiring HCV as a result of an occupational needle stick injury when the source was
infected varies from 3% to 10% . HCV is thought to be a fragile virus which would be unlikely to
survive in the environment, but there are little data at this time. There has been a case report of
HCV acquisition after an injury from a discarded needle.
Unfortunately, there is no effective postexposure prophylaxis at present. Alpha-interferon and
ribavirin are used in therapy of chronic HCV infection, but their benefit for prophylaxis is not
known. It is important to determine whether a potential exposure results in transmission of HCV
because 50% to 60% of infected children will have persistent, asymptomatic infection for which
follow-up by a specialist is indicated. Chronic hepatitis will eventually develop in some of these
cases, and antiviral treatment may be required.

HIV
The risk of acquisition of HIV from a hollow-bore needle with blood from a known HIV
seropositive source is between 0.2% and 0.5%, based on prospective studies of occupational needle
stick injuries. The risk is increased with higher viral inoculum, which is related to the amount of
blood introduced and the concentration of virus in that blood. The size of the needle, the depth of
penetration and whether blood was injected are also important considerations. In most reported
instances involving transmission of HIV, the needle stick injury occurred within seconds or
minutes after the needle was withdrawn from the source patient.
In contrast to the situation with health care workers, the source of blood in discarded needles is
usually unknown, injury does not occur immediately after needle use, the needle rarely contains
fresh blood, any virus present has been exposed to drying and environmental temperatures, and
injuries are usually superficial. HIV is a relatively fragile virus and is susceptible to drying.
However, survival of HIV for up to 42 days in syringes inoculated with the virus has been
demonstrated, with duration of survival dependant on ambient temperature. One study found no
traces of HIV proviral DNA in syringes discarded by intravenous drug users, while another study
found HIV DNA in visibly contaminated needles and syringes from shooting galleries.
It is extremely unlikely that HIV infection would occur following an injury from a needle discarded
in a public place. However, if the incident involved a needle and syringe with fresh blood, and if
some of the blood was injected, infection is theoretically possible and prophylaxis is indicated. In
occupational needle stick exposures, zidovudine prophylaxis was shown to reduce the risk of HIV
transmission from a positive source by 80% . Prophylaxis with combination antiretroviral therapy
is presumed to be even more effective. Whether two or three drugs should be used is controversial.
The use of three drugs is based on observations in treatment of HIV infection and the assumption
that maximum suppression will be most effective in preventing infection. On the other hand, two
drug regimens are better tolerated and adherence may be better with two than with three drugs.
:

Prevention

 Parents, educators and health care providers should be made aware of the problem of
discarded needles.
 Children should be educated about the potential dangers of injection drug use.
 Children should be taught not to handle needles and syringes, and to report finding them to
an appropriate, responsible adult (parent, school teacher, police officer, etc), who should
then arrange for the safe disposal of the needle in a puncture-proof, closed container.
 Community programs should be in place to keep parks and public places, where children
generally play, free of discarded needles.
 Programs should be in place for the treatment and control of injection drug addiction, and
to adequately support HIV prevention, HBV vaccination and needle-exchange programs
for injection drug users.

Management

 After the injury, the wound should be cleaned thoroughly with soap and water as soon as
possible. It should not be squeezed to induce bleeding.
 The extent of the wound, if any, or the probability of exposure of open skin lesions or
mucous membranes to blood should be assessed.
 The child’s immunization status for tetanus and HBV should be determined.
 Tetanus vaccine, with or without tetanus immunoglobulin, should be given if indicated.
 The circumstances of the injury should be documented (the date and time of injury or
exposure, where the needle was found, circumstances of the injury, type of needle, whether
there was a syringe attached, whether visible blood was present in or on the needle or
syringe, whether the injury caused bleeding and whether the previous user of the needle is
known).
 Blood should be obtained from the child for:
 Baseline HBV, HIV and HCV status (may be stored for later testing).
 If antiretrovirals are being considered: complete blood count, differential, aspartate
aminotransferase, alanine aminotransferase, alkaline phosphatase, blood urea
nitrogen and creatinine.
 Testing needles and syringes for viruses is not indicated. Results are likely to be negative,
but a negative result does not rule out possibility of infection.
 If the user of the needle is known, attempts should be made to assess for risk factors for
blood-borne viruses and, if possible, to test for these viruses. Pending results, proceed as
for an unknown source.

Hepatitis B virus (HBV) prophylaxis

Child No action required.

known to
be HBV
antibody-
or
HBsAg-
positive

Child has Test for anti-HBs antibody and HBsAg. If results are not available in 48 h:
not been
fully  Give HBIG immediately (ideally within 48 h of injury; efficacy unknown

vaccinate if >7 days after injury). Dose=0.06 mL/kg intramuscularly.

d against  Give HBV vaccine (as soon as possible, and at latest within 7 days of

HBV injury).

If anti-HBs antibody- and HBsAg-negative, complete vaccine series. 

If anti-HBs- or HBsAg-positive, discontinue vaccine series. Arrange appropriate
follow-up if HBsAg-positive.

Child has Test for anti-HBs antibody. If results are not available in 48 h, give dose of HBV
been fully vaccine. 
vaccinate If anti-HBs antibody-positive, no further action required. 
d against If anti-HBs antibody-negative, test for HBsAg:
HBV
 If HBsAg-negative give HBIG and dose of HBV vaccine.
 If HBsAg-positive, arrange appropriate follow-up.

Risk assessment for HIV transmission

Source Device Injury

Source unknown Consider the size of Consider depth and

but known or needle, whether it is extent of trauma (scratch
presumed high hollow-bore, or deep cut, injection of
prevalence of presence of visible blood and bleeding at the
HIV in injection blood in the needle site). Injuries with actual
drug users in the or syringe, blood injection are high
 region, or if probability of risk. Superficial scratches
source known to exposure to drying, are low risk. If exposure
have HIV, heat and freezing limited to mucous
consider high since use. Large membranes or nonintact
risk. lumen devices with skin, consider extent of
visible blood are exposure. For example
highest risk. child put syringe with
visible blood into mouth
and possibly injected
blood – high risk;
suspected but unobserved
splash onto eyes or lips –
low risk. Splashes
involving a large volume
of blood (not just a few
drops) coming into
contact with extensive
areas of nonintact skin –
high risk.

Antiretroviral agents recommended for

postexposure prophylaxis

Agent Dosage Comments

Nucleoside reverse transcriptase inhibitors*

Zidovudine (ZDV)  6 weeks to 12 years: 160 Available in oral solution

mg/m2/dose tid or 240 10 mg/mL; 100 mg
mg/m2/dose bid capsules; 300 mg tablets.
 ≥12 years: 300 mg/dose bid Can be taken with or
without food; may be
better tolerated with food

Lamivudine (3TC)  1 month to 16 years: 4 Available in oral solution

mg/kg/dose bid (maximum 150 10 mg/mL; 150 mg
mg/dose) capsules.

≥16 years and ≥50 kg: 300 mg Can be taken with or

once daily without food; may be
better tolerated with food

ZDV + 3TC 13 years and >37 kg: One Tablet contains 300 mg
(Combivir) † tablet bid ZDV plus 150 mg 3TC

Protease inhibitor‡

Lopinavir/ritonavir 6 months to 12 years§: (230 mg Available as oral solution

2
(LPV/RTV)  LPV/57.5 mg RTV)/m /dose (80 mg LPV/20 mg
bid (maximum 400 mg RTV)/mL; 200 mg
LPV/100 mgRTV)/dose LPV/50 mg RTV tablets.

>12 years: (400 mg LPV/100 Should be taken with a

mg RTV)/dose bid high-fat meal

*ZDV and 3TC are well tolerated. Occasionally children have anorexia, nausea,
vomiting, diarrhea, abdominal pain, fatigue and headache. Asymptomatic mild
neutropenia, anemia or elevation of liver enzymes may occur, which resolve after
treatment is completed;

‡
LPV/RTV may cause nausea, vomiting, diarrhea or abdominal discomfort;
§
Alternative dosing – <15 kg: (12 mg/kg LPV/3 mg/kg RTV)/dose twice a day
(bid); 15–40 kg: (10 mg/kg LPV/2.5 mg/kg RTV)/dose bid. tid Three times a day.
Centor criteria to aid diagnosis of Group A beta-haemolytic streptococcus
(GABHS)as a cause of presentation with a sore throat:

o tonsillar exudate
o tender anterior cervical lymph nodes
o absence of cough
o history of fever
 presence of three or four of these clinical signs suggests that the
chance of the patient having GABHS is between 40% and 60%, so
the patient may benefit from antibiotic treatment
 absence of three or four of the signs suggests that there is an 80%
chance that the patient doesn't have the infection, and antibiotics
are unlikely to be necessary
 in patients with tonsillitis who are unwell, and have three out of four
of these criteria, the risk of quinsy is 1:60 compared with 1:400 in
those who are not unwell
 centor criteria is not ideal, and will lead to some patients with
bacterial pharyngitis not being treated and result in unnecessary
antibiotic treatment for others


Elderly lady Constipation – talk to Nurse

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

Post MI Discharge & Lifestyle Modifications

You are medical FY2 in cardiology ward.

60 years old Mr.... was admitted with a chest pain a few days ago and was treated for Acute
Myocardial Infarction. Now, he is stable on medical therapy and is fit to be discharged. Your
consultant has commenced him on the medical therapy. Talk to the patient, assess him
clinically, and speak to him about lifestyle modifications.

Dr: Good morining, Mr... I am Dr .... One of the junior doctor in the cardiology dept. How are
you doing today? Pt: I am well doctor. I am going home today.

Dr: Congratualtions. My consultant has prescribed some medications. Do you have any
questions about them?Pt: No doctor, I know about the medicines.

Dr: Well that is fine. Could you please tell me how much do you know about your condition?

Pt: I was told there is some problem in my heart.

Dr: Yes, that is right. You had a heart attack. Do you know anything about it?
Pt: No doctor, not really.
Dr: Okay, let me explain that to you.
Heart needs its own blood supply for it to survive. Blood supply is provided by some blood
vessels specially for the heart muscles. Heart attacks are caused by the blood supply to the
heart being suddenly interrupted.This can happen due to narrowing or obstruction which
results in reduced blood supply to heart leading to damage of the heart muscle. Do you follow
me?

Pt: Yes doctor.

Dr: We have given you apropriate treatment to restore the blood supply to heart. Though, you
are doing well, sometimes this condition can be really serious and even life threatening. And we
want what is the best for you and we do not want this to happen to you again. Are you
following me?

Pt: Yes doctor.

Dr: Do you know why people get this condition?Pt: No doctor.

Dr: Well, Mr... there are certain risk factors which can lead to heart attacks. Some of them are
not modifiable while most of them are. And if we are able to control the modifiable risk factors,
we can maximally reduce the risk of getting heart attack. Are you understanding?

Pt: Yes doctor. What are these risk factors?

Dr: There are lot of others risk factors why people get heart attack. I would like to ask you a few
questions to know if you have any of those risk factors so that we can address them and help
you cope with this condition. We may be able to reduce the risk if we can modify those factors.

Pt: I see.
Dr: Do you have any heartproblems in the past? Pt : (No/Yes?)
Dr: Did you have any strokes or mini strokes previously ? Pt: (No/Yes?)
Dr: Do you have diabetes?Pt: (No/Yes?)
Dr: Do you have high levels of cholesterol in your blood?Pt: (No/yes?)

Dr: Cholesterol is involved in the formation of blood clot that can lead to blockade of artery
supplying the heart. Are you following?Pt: Yes doctor.
Dr: Do you have high blood pressure?Pt: (No/Yes?)

Dr: High blood pressure is one of the major risk factor which can cause lead to weakening of
heart muscle. It is very important to keep the blood pressure under control. However, as I have
told you apart from medications you may need to do lot of other things to keep the blood
pressure under control.Pt: What is that doctor?
Dr: One important factor is diet. Can I ask you what type of food do you eat usually?

Pt: You know doctor. I don’t know how to cook food. So, I eat out most of the time. I have to
eat fast food - I eat chips, burger, steaksetc

Dr: Mr, the kind of food what you are eating is not good because they have very high bad fat
content that is cholesterol. This can increase the blood pressure and contribute to heart attack.
I sincerely advise you to eat more of white meat which has less bad fat like chicken and fish. I
also advise you to include plenty of fruits and vegetables also in your diet. Also please reduce
the salt content in your food because it can increase the blood pressure. I will refer you to a
dietician who will advise you in detail about the healthy diet. Is that OK ?Pt: That is fine. Doctor.

Dr: That is good. Can I ask do you do exercise ?

Pt: No doctor. I am an old man. I don't do much exercise.

Dr: I can understand. However, I sincerely advise you to do some exercise. However at least for
the first one month do minimal exercise like walking inside the house but later you can do some
exercise like brisk walking for about 30 min every day at least 5 days a week. Exercising
regularly will keep you healthy and also helps to keep the blood pressure and cholesterol under
control. What do you say ? Pt: Yes doctor that seems to be a good idea.

Dr: Excellent. Do you smoke Mr...?

Pt: Yes doctor I smoke about 10 to 15 cigarettes a day for the last 15 to 20 years doctor.
Dr: Again smoking is not good for health at all as you may know. Smoking also can increase the
blood pressure and also can cause lot of other health problems. I strongly advise you to stop
smoking. We can help you to stop smoking if you wish. Do like to consider that Mr...?

Pt: Doctor you know my life is very lonely. I am going through lot of financial crisis and I get
stressed some times.
Dr: I can surely understand your problem. However, there are many other ways to relieve
stress. May be you can take some relaxation classes and yoga classes which might help you to
relieve from stress. Remember stress also can increase the blood pressure. What do you say?
Pt: Yes doctor you are right. I will try my best to do that.

Dr: Do you drink alcohol Mr....?

Pt: Yes doctor. I drink about 2 glasses of wine every day and also whisky sometimes over the
weekends.
Dr: Mr. alcohol also is not good for the health. I sincerely advise you to cut down drinking
alcohol and drink within the recommended limits that is not more than 14 units per week. We
can help you to cut down if you wish. What do you think ?
PT: Yes doctor I will surely think of that.

Dr: Do you work?

Pt: No (Following a heart attack, most people can go back to work within 2-3 months)

Dr: Could you tell me if you drive? Pt: Yes doctor.

Dr: You should not drive for at least four weeks after a heart attack. Could someone help you
with that? Pt: (Yes doctor, my wife can drive?)
Dr: That is good. It is always sensible to contact the Driver and Vehicle Licensing Agency (DVLA)
to be sure. Also I would like to tell you something about air flight travels. You can usually fly as a
passenger within two to three weeks of a heart attack, as long as you have no complications.
This means that you have returned to your usual daily activities, your condition is stable and
you don't have any symptoms, or your symptoms are controlled. Are you following me?

Pt: Yes.
Dr: Regarding your sex life, I would like to recommend you that for a 3 to 4 weeks it is probably
best avoided. If you are able to walk without discomfort then a return to sexual relationships
should not cause any problems. If sex causes angina chest pains then tell your doctor. Pt: Yes.

Dr: You should have the annual influenza jab and be immunised against the pneumococcal
germ (bacterium). Okay? Pt: Yes.

Dr: Excellent. Do you have any questions?

Pt: Doctor if I follow all the advices what you gave then will I not get heart attack again?

Dr: As I have told you that there are both modifiable and non- modifiable risk factors for
developing heart attack. Non modifiable factors are like age above 60 years, genetic cause
means inherited risk which we can’t do anything about these. However there are lot other
modifiable risk factors like all the factors what we discussed so far like diet, exercise, smoking
which you can modify and have a healthy life style. This can substantially reduce the risk of you
getting heart attack.

Pt: Ok thank you very much doctor.

Dr: I sincerely advise you to follow all the advices. We will keep following you up. If at any time
you develop chest pain or breathlessness, immediately call 999. If you have any of the
symptoms please call the ambulance and come to the hospital immediately because these are
the symptoms of serious condition. Is that okay Mr... ? Pt : Ok doctor.

Dr: Any other questions ? Pt : No doctor. You have been very kind.