Plab 2 Recall 4

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1.Rape of a 16 year old:

History:
 you are FY2 in general practice
 A 19year old boy has sent by the student counsel of his school
 He is looking down and upset
 He was not opening up at the first point , while offering confidentiality he
opened up
 He went to party 4weeks back with his friends and was raped by his
friends brother, he was drunk
 He was not wearing condom and it was an anal sex
 He is depressed , mood is 5/10, he can’t concentrate on anything , don’t
like going school
 He is physically fit and healthy
 He has his parents support, they have reported file to the police
 He was never sexually active
 Asking for a sick note and worried about STI’s
Task:
Talk to him and address his concern
Concern:
Give me a sick note
Will I have STIs?
Examination and investigation
Take observation and routine blood test , offer STI screening
Management:
 Greet and confirm identity
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 Acknowledge , offer confidentiality and Take focused history what

happened exactly , any injury etc
 Ask about support , mood and exclude suicidal tendency
 Ask about his sexual relationship, MAFTOSA , DESA and concern
 Verbalize examinations and assure him he will be fine
 Give him sick note
 Involve senior and refer him to talking therapist for CBT
 Offer STI screening if he is willing to have as it was unprotected
 Comfort him as much as possible and praise his parents for being so
cooperative
 Give him crisis card , where he can call anytime to talk if he feels down
2.Teaching (taking consent)

History:
 You are FY2 in surgery department
 A 4th year student has come to you to know about taking consent
 He wants to know how essential is it to take consent and when to take it
Task :
 Teach the student how to take consent from a patient and its importance
and address his concerns
Concern:
When we will take consent?
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What will happen in case of children and old people not having mental
capacity?
Management:
 Greet and introduce yourself
 Build good rapport and ask about hows his study going , praise him for
coming to learn about something very important to know while practicing
medicine
 Tell him first what is the meaning of giving consent, a health professional
must take consent from all the patient before providing any treatment , or
performing any procedure or any surgery (for example giving blood sample
, donating organ etc)
 Someone has the right to refuse the treatment and you need to respect
that, no matter what will be the outcome of it (even death)
 Take the consent orally and in some cases written (while performing
surgery and organ donation etc)
 While asking for consent the decision from the patient should come
voluntary without any pressure from doctor, friends or family
 Address his concern, a patient can refuse treatment with having full mental
capacity , but if someone lacking mental capacity (like mental health
condition, dementia , learning disability , brain damage, alcohol or on drug
etc) in that case if the patient doesn't have anyone to take decision on
behalf ; a health professional will think what will be the best for him or
otherwise that patient’s next to kin , or power of attorney can make
decision
 There is something call advance decisions or living will. This is a decision
to refuse a particular medical treatment for a time in future when the
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patient might be unable to take the decision; patient having more than 18
of the age and having full mental capacity can take such (like CPR)
 If he patient take a life sustaining treatment in the future , the advance
decision needs to be written down in a form and signed by the heath
professional and a witness
 Check his understanding and answer his questions
 Thank him and offer him some some links about informed consent to have
more knowledge
3.lady wants to conceive

History:
 You are FY2 in general practice
 A 36 year old lady has come with some concern
 She wants to get pregnant, but worried as she has been diagnosed with
hypertension for last 1 year and taking ramipril daily
 No side effect of the drug , no heart racing or dizziness
 Her blood pressure is well controlled and she is otherwise healthy
 No other medical condition or medication , no allergy
 She had one miscarriage previously , and that made her worry too
 She doesn’t have any habit of smoking or alcohol
 She works in a cafe , lives with husband
 Physically active
 Doctor didn’t tell the cause of previous miscarriage
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Task:
Talk to the patient and discuss management
Concern:
Will the drug effect on my pregnancy?
Examination and investigation:
Take observation , blood pressure, and head to toe
Routine blood , RBS, BMI
Management:
 Take focused history, since when she has been hypertensive, which drug
she is taking , does she measure blood pressure regularly? Up to date with
follow ups, any side effects like dizziness , heart racing etc
 Now ask about conception , was she ever conceived, when ? when the
miscarriage happen? Any reason? Etc
 Ask P4 , MAFTOSA , DESA
 Verbalize examination and summerise , at first assure her , she is fit to
have a baby , one miscarriage doesn’t mean she can not have a baby
 And about the medicine she needs to change it to another medicine for
hypertension (labetalol)
 Ask concerns and answer them
 Refer her to preconception clinic they will do what is needed for you
 Advice her to have folic acid supplements, and maintain healthy diet
 Advice her to maintain a stress free lifestyle
 Follow up
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4.Post MI (video)
History:
 A 65 year old man has been calling you
 He was admitted in the hospital 4days back and was diagnosed with ST
elevated MI
 He was discharged with some medication namely statin , ramipril,
ticagrelor, and bisoprolol
 Allergic to aspirin
 no other medical condition ,father died in heart failure
 He smokes when he is stressed, and a social drinker
 A bit overweight, eats outside mostly
Task:
Talk to him and address his concern and explain the follow up plan
Concern:
Why they have prescribed so many medicine?
Do I really need them?
Management:
 Take focused history about MI , how is he feeling now , any new
symptoms, what was done for him in the hospital? Did they explain you
about the medicine ? any advices?
 Now ask about the medicine , is he taking them? Ask about red flags , leg
swelling . breathing problem etc
 MAFTOSA , DESA
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 Ask concerns, and answer ‘well , you need all these medicine to avoid the
complications of MI’
 If he asks about the drugs individually open the BNF (there will be one )
and tell him one by one , like bisoprolol will prevent heart racing , and will
make it easier to pump blood for the heart. But the side effect is dizziness ,
if you feel so come back to hospital or call us
 Statin will reduce the bad fat from the body, take it at night as it might
make you feel drowsy
 Ramipril will prevent heart failure which is complication of heart attack and
ticagrelor is a blood thinner which will prevent blood from clotting, this
medicine is given as he is allergic to aspirin
 Advice him to maintain healthy lifestyle , avoid smoking and eat healthy ,
do exercise regularly
 Explain the plan of follow up that is measuring blood pressure and U&E 2
weekly
 Safety netting and follow up
5.Gilbert syndrome
History:
 A 27year old man has come for follow up
 He did some blood test due to yellow discoloration of urine and dark stool
and the result showed increased unconjugated bilirubin and conjugated
bilirubin is normal
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 He is not expecting anything serious, had some symptoms of jaundice and

was passing dark stool
 He is generally fit and well , no medical condition or using any medication
 His father had some liver problem but he cant mention the name
 Eats outside mostly , and drink alcohol within normal limit
Task:
Talk to the patient and explain test result
Examination:
Take observation and head to toe
Management:
 Greet and confirm identity and paraphrase the scenario
 Ask him what made him to go for the test? Any new symptoms ? how is he
feeling now? Explore symptoms, MAFTOSA DESA, red flags
 Verbalise examination and summerise then explain the test result , the
condition called gilbert’s , it runs in the family where the faulty gene
means bilirubin is not passed into bile at the normal rate. Instead, it builds
up in the bloodstream, giving the skin and whites of the eyes a yellowish
tinge.
 Assure him its self limiting , advice to drink plenty of water as dehydration
is a risk factor
 Refer him to genetic counselling to confirm the diagnosis
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6.Heart failure:
History:
 You are FY2 in emergency
 A 67 year old man has come for follow up
 He had a heart attack 6 weeks back, and was admitted for 5days then
discharged on enalapril, Atenolol, Simvastatin and aspirin.
 He has been taking his medicine as prescribed.
 For last few days he has been experiencing SOB while walking.
 He lives on the 2nd floor and he takes rest for about 15 min when he is
halfway through stairs.
 His SOB is worse when he lies flat.
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 Nowadays he has been sleeping on the couch due to cough

 He also noticed that his legs have started swelling up.
 He doesn’t have any chest pain or other medical condition , no allergy ,
father died in heart failure
 He Lives with his wife and daughter, not working
 He doesn’t drink alcohol but smokes 10 cigarettes /day since teen.
Task:
Talk to the patient and do the management
Take observation and head to toe, examination of heart lung , tummy
Swelled ankle, bi basal creps
Routine blood , ECG , ABG , chest xray, ECHO by specialist
Management:
 Greet and confirm identity and paraphrase the scenario
 Take focused history of MI , what was done for him , about medicine ,
compliants, recent symptoms, health in general
 Ask MAFTOSA , DESA, do ICE
 Verbalise examination and summerise and explain he is having heart
failure which is a common complication of MI, that means his heart is not
functioning or pumping blood properly
 Admit the patient and involve senior
 Give oxygen (if the saturation low) , diuretics
 Call cardiologist for further investigation like echo
 Advice him he can’t stop medicine by his own , if he develops any side
effects then he needs to inform doctor
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7. Mom concerned of her child:

History:
 A mother of 4year old boy has called you with some concern ,he
developed high fever , runny nose, for last 2days
 He was fit and well before that , was going nursery , 4days backhe
suddenly developed fever, she gave calpol but didn’t work , also cough
and lethargy
 He is feeding and peeing well
 No rash , shyness to light , or other associated symptoms
 BIRDDD normal, no medical condition or medication history, orallergy, up
to date with jabs
 Due of this year flu vaccine
 Mom thinks her son needs antibiotic
Task:
Talk to the mom and address his concern
Concern:
Why you wont give antibiotic to my son?
Management:
 Greet and confirm identity start with telephonic approach
 Take focused history of fever, cough , runny nose, rule out redflags and
differentials , chicken pox, measles. Meningitis , dehydration etc
 Ask BIRDDD , MAF
 Do ICE, and explain her son has got viral flu which is verycommon in
children , and its self limiting
 Tell her to give flu vaccine when he becomes okay
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 Give him plenty of fluids and calpol to lower down the fever,can use salt
water to clear the nose
 Keep him feeding good food , and water, check his nappy everyday if he is
passing enough urine
 Address her concern that it’s a viral flu , antibiotic wont work
8.Insomnia:
 35 years old has come with some concerns
 He has been feeling low for few months and can not sleep
 After asking he will say he has too much pressure at work
 He can not cope up with the work, doing mistakes at work
 He works as an accountant, he wakes up early in morning and stay awake
till midnight, can’t sleep due to stress
 Mood is 4/10
 employer didn’t blame him for anything, it was him feeling stressed, rather
the boss and colleagues are very supportive
 He is generally fit and well, MAFTOSA negative, eat food from outside as
no time to cook, don’t do any exercise
 He smokes cigarettes and drinks alcohol to cope up with the stress
 He haven’t discuss with anyone about this issues
Task:
Talk to the patient and discuss management plan
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Concern:
Give me sleeping pills
Takeobservations, thyroid examination and routineblood test, thyroid
function , BMI
Management:
 greet and confirm identity
 Explore presenting complaints, (how long he has been facing this
problem? , did he seek for any help?, does the work give him anxiety? any
support, work environment etc)
 ask about the core symptoms of depression, ask mood and rule out suicide
 ask about sleep, appetite, lifestyle, psycho social
 Do differentials (thyroid) MAFTOSA, DESA
 Do ICE, verbalize examination and investigation
 summerise he has been suffering from depression,explain that
 advice talking to the boss/employer, take a break, givetime to family
friends
 counselling session -offer CBT, refer to specialist, offer anti-depressant
 Follow up in 2 weeks
9.Teaching
History:
 You are FY2 in emergency department
 A young lady brought her 5 years old son to the hospital after anaphylaxis.
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 She went to a restaurant and told them her child haspeanut allergy but
they gave him peanut. This is the 2nd time he developed anaphylaxis.
 The first time was when he went to his friend’s birthday party and he was
given food with peanut.
 He was treated that time and was prescribed Epipen.
 She doesn’t know how to use EPIPEN, now she wants know the use of
EPIPEN
Task:
Talk to the mom , address her concern and teach her how to use the epipen
Concern:
What If she doesn’t respond to it first time. Should I use it again?
If she develops rash should I use it?
what if I use the PEN and it’s not anaphylaxis?
Management:
 Explore anaphylaxis, take history of the incident, and explore symptoms,
do head to toe, BIRDDD, MAF (takefocused and short history)
 Now assess knowledge about the Epipen, explain it’sparts.
 Explain about the signs and symptoms of anaphylaxis (swelling of throat,
lips, eyes, difficult breathing)
 Teach Epipen as taught in academy
 Use Epipen when signs/symptoms of anaphylaxis andcall ambulance
immediately
 Explain she can give epipen even if she is not sure ifeither he is having
signs of anaphylaxis or not
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 It is not going to be harmful for the kid even if you give itto him and later
realize it is not anaphylaxis. He might experience some heart racing, etc
but it would settle in 15 to 20 minutes.
 Always have 2 Epipen, use another one in 5 minutes ifambulance doesn't
arrive
 Avoid triggers and advice about trigger diary
 Offer support and Refer the patient to the allergy clinic. So that we can
know the cause of the reaction and a diagnosis can bemade.
 Give the child a bracelet to wear
 Safety netting
10.abdominal examination
History:
 you are FY2 in in emergency department
 A 56 year old patient has brought to the hospital with confusion and
drowsiness by his daughter , he got mild temperature for last few days
 He didn’t pass urine for last two days, abdomen is distended and bladder
is palpable, painful, fever present
 he was fit and well, but has been facing problems with urine for last few
months , (frequency, urgency, nocturia)
 MAFTOSA normal
 No significant past history, never happened it before
Task:
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Take focused history , perform relevant examinationand discuss

management
Concern:
What happened to my father ?
Examination and Investigations:
Take observations,(temperature, BP) head to toe , perform abdominal
examination, complete with back passage
Routine blood , inflammatory marker, LFT, KFT, RBS,urine dipstick, urine
sample for C/S, serum lactate
Management:
 Take focused history, past history, explore presenting complaints, urine
symptoms, triggering factor, red flags
 Do PPCCE, verbalize observations and perform abdominal examination as
you were taught in the academy
 Verbalize back passage examination
 Do ICE, summarise and explain what you are suspecting, UTI due to BPH
 Admit him immediately
 Involve senior
 Do catheter, run investigation, give fluids, start antibiotics under hospital
protocol, give paracetamol for fever
 address daughter’s concern
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11.Intertrigo
History:
 A 35 year old lady has come with rash under her breast,it started with the
left breast and spread to the other breast for last a month
 it’s irritating, and itchy, no discharge, oozing , bleeding.
 Red in colour , no changes in colour
 no other symptoms, FLAWS , MAFTOSA, DESA normal
 She used emollient but didn’t work, becoming worse
 She works as a school teacher and this rash hasbecome annoying
Task :
Talk to the patient, discuss management
Take observations, head to toe, rash site, BMI Routine investigation RBS
A picture of the rash will be given
Management:
 explore the symptoms, explore rash (size , site, shape , colour,
itchiness,discharge, bleeding) contact, allergies, FLAWS
 Ask past history, MAFTOSA, DESA
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 Do ICE, verbalise examination and summarise this is a condition called

Intertrigo, it happens due to skin skin rubbing and fungal infection
 Treatment, offer anti-fungal topical cream an hydrocortisone cream for
inflammation , and anti itchingmedication
 advice of wearing loose fitting cloths, cotton cloths
 keep the area clean and dry, do not share cloths ,flannel, Towel etc
12.Psychosis
History:
 A 55 year old mom has booked an appointment for her 28 year old son
who has been behaving weird for past 2weeks
 Son Adam thinks he has no problem at all, he is well, hismother thinks too
much
 He says he is an undercover spy in an international agency
 He was anxious all the time , looking here and there
 Nothing happened 2 weeks back, he lives alone , momlives far from him
 He is looking to the window and saying a car following me
 He doesn’t drink or smoke or do drugs
 No friends , as he doesn’t want to disclose his identity
 His mood is fine, he doesn’t have suicidal tendency
 But he mentions about thought withdrawals andbroadcasting
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Can’t mention about any medical condition or familyhistory or mental

illness
Task:
Talk to him and do management
Management:
 Greet and confirm identity, start with video approach
 Paraphrase scenario, tell him why his mom thinks he isnot in himself ?
What does he think? What happened 2 weeks back? Does he think he
has a problem?
 Explore his concerns, ensure safety of other peoplenearby him
 Acknowledge his activities
 Do MCFAMISH
 Verbalize examination, and explain he is having some problem with his
mental health which needs to be takencare of
 Call an ambulance at his address
 Tell him specialist team will assess him and help him
 He will need anti psychotic medication and CBT
 Offer support
13.Urine problem:
History:
 A 62 year old man has presented with burning sensation while passing
urine for 7days , also foul smelly urine
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 He also have nocturia, dribbling , and urgency for peeing for 3months
 he feels feverish but didn’t measure it , no flu or headache , FLAWS
negative
 He has been diagnosed with hypertension which is well controlled with
medicine
 He lives with his wife , no other medical condition, or any medication
 He works as a clerk sits near the toilet for the frequency
 He is allergic to penicillin and worried about cancer
 No family history of cancer , bowel fine , no smoking or drinking habit
Task:
Talk to the patient and do management
Conecrn:
Is it cancer?
Take observation and head to toe , back passage examination (enlarged
prostate)
Routine blood test and urine R/E , urine dipstick, (leukocytes an nitrites)
inflammatory marker
Management:
 Greet and confirm identity ,
 Take focused history ODPARA of symptoms , urine color smell, blood ,
nocturia , hesitency , urgency , dribbling , fever flu , FLWS , bowel habit etc
 Ask MAFTOSA and DESA
 Do ICE , verbalize examination and summerise , he has been having
urinary infection secondary to BPH that is enlargement of the prostate ,
which is common with age, as the prostate has enlarged, the bladder holds
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an amount of the urine which is a good place for bacterial growth causes
infection
 Involve senior , prescribe antibiotic
 Advice him to drink plenty of fluid
 Prescribe medicine to shrink the prostate
 Follow up in 2weeks
 Safety netting for cancer , FLAWS , blood in urine
14.Benign Mole:
History:
 A 25 year old lady has come with a concerns
 She has been having a mole on her back for many years , which is black in
color and 4cm by5cm in size, smooth surface
 Its not changing the size shape or color , no bleeding or discharge, not
painful
 She doesn’t have any other mole on body
 FLAWS negative, MAFTOSA DESA normal
 She is getting married within 1month
 She has tried her wedding gown and sadly the mole looks ugly on her back
 She wants to remove it
Task :
Talk to her and discuss management
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Concern:
Can I remove it?
Take observation and head to toe, examine the mole
Routine blood
Management:
 Congratulate her for getting married
 Take focused history of the mole, size site shape, surface, any bleeding or
discharge , anywhere else, FLAWS , MAFTOSA DESA
 Verbalize examination and summerise , explain it’s a benign harmless
mole , nothing to be worried about
 As it is not harming you so for cosmetic purpose NHS does not cover this
surgery
 Advice her to go private clinic
 Safety netting
15.Hernia surgery:
History:
 You are FY2 in general surgery
 A 45year old man has been scheduled to have a inguinal hernia operation
 he needs a pre operative assessment
 He is hypertensive and takes medicine and blood pressure is under control
 He wants to know about the procedure of the surgery , his dad had hernia
and he was wearing a truss
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 He works in a warehouse, where he needs to pick up heavy object

 He lives with his wife
 He drinks a bottle of wine but doesn’t smoke
Task :
Talk to him and explain the procedure and address his concern
Concern:
How long the operation last’?
When I can return to my activity?
Will you give me a truss to wear?
Management:
 Paraphrase the scenario and before explaining the surgery ask about his
understanding and take a focused history about the hernia, any new
symptoms and psycho social
 Ask about the health in general for systemic review and bowel and bladder
, any challenges
 Ask about support , who can stay after surgery and home condition,
workplace
 Ask MAFTOSA DESA
 Now explain the procedure , it will be a open surgery , and surgeron will
repair the weakened part of the tummy from where the hernia developed
with a synthetic plastic
 Complication can be infection , damage to the surroundings , and
reappearance of the hernia but assure him our good team of surgeons will
make sure to reduce the risk of any complications
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 Tell him we need to do some routine blood test and a consent needs to be
taken
 The operation takes 45min to and hour if goes smoothly , he will be given
anaesthesia and after recovery pain killer will be given
 He can go back to work after 2 to 4weeks depending on his situation
 Advice him not to do any heavy work , he can talk to his employer, and
suggest occupational therapist
 Tell him truss is a temporary solution for those who can not go through
the surgery
 Safety netting
16.Angry son:
History:
 You are FY2 in acute medicine unit
 A 76 year old lady has been admitted to the hospital as she has been
diagnosed heart failure
 Her only son who is very angry has been calling
 He lives very far , doesn’t know about the prognosis of his mom
 He has phoned the hospital a few times to find out what’s happening with
his mom. But every time he calls the hospital the nurse picks up the phone
and she tells that there is no Dr to speak to you.
 Last time when he came to see his mom, he spoke to one of the Doctors
who was very rude.
 He is very upset about the situation and don’t want the Dr to be the part of
his mothers care
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 His mom is receiving water tablets , and a catheter was given , he saw
blood in the urine
Task:
Talk to the son and address his concerns
Concern:
Why the Dr was rude?
My moms care was compromised ,I’m not happy with that
Management:
 Greet and confirm the identity and relationship, confirm that you are talking
with the right person and start with telephonic conversation
 Acknowledge the situation and show empathy , build good rapport
 Ask about his moms condition , how much he knows, what happened ,
what treatment has been provided, how is she doing now, any
improvement etc
 Now explore why is he upset, ask him like- Has anyone at the hospital
explained her condition to you? what did he say? What is his name? how
many times did you speak to him? What things did he say that made you
upset? Etc
 Ask support , care , where does his mom live, who takes care of her ,
appreciate for being so caring son
 Now explain his moms situation , Your mom was admitted for heart failure
which is a condition in which the heart is unable to pump blood around the
body properly. Her condition is getting worse because of the heart failure
which is a chronic progressive condition and can be terminal.
 Explain if he saw blood in the urine write down in notes and you will look
upon this and apologize what he feels about his mothers care
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 Mention a specific time when he can contact with the doctor and can know
about his mom
 Tell him you will raise this matter that you were upset thinking of the
nurses and doctors were rude
 Explain that we try to provide best care to the patient which is our duty and
responsibility
 Tell him if any matter he thinks must be taken care of he can contact on
the given time
 Thank him for calling
17.Test result:
History:
 You are FY2 in well-man clinic
 A 54-year male came for test results as he came 1 week back for check up,
everything is good
 No urinary symptoms , abdominal pain or any swellinganywhere on body
 He has osteoarthritis and has been taking ibuprofen for it for along time
 No other medical condition, medications or family history
 Patient is known smoker and drinks a lot alcohol and wine aswell
Task:
Talk to patient,discuss test results and address his concerns
take observation and head to toe
All blood test report normal except eGFR 52
Concerns:
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Doctor I don't have any symptoms how this could happen?

What should I take for my knee pain?
Can I control my kidney damage here?
Management:
 Greet and confirm the identity
 Take relevant history (shortness of breath, any foot swelling,any swelling
around the eyes in the morning , any problem with your urine, ask about
symptoms of anemia, any medical condition, when ask specifically about
the medication he told yes I am taking ibuprofen three times a day for 3
years, any family history of kidney disease, smoking alcohol status
 Explain the lab results
 Explain that the most probable cause of changes in kidney function is
ibuprofen as everything in the history and test isnormal
 Tell him that I am going to refer you to the pain clinic for yourpain killer
adjustment and to kidney specialist for best advice
 In the meantime please stop ibuprofen and take paracetamol until your
appointment
 Safety net for CKD symptoms and anaemia symptoms
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18.DNAR:
History:
 An 80 year old lady has been diagnosed with end stage heart failure ,
consultant has explained everything to her , she is not gonna make it , no
aggressive treatment is allowed only palliative care has been given to her
 She has full mental capacity to understand everything and giving consent
 She doesn’t want any CPR or ventilation if her heart collapse
 She has children but she doesn’t live with them
 She has carer that come in to help her. She is happy with her life and she
is ready to die. She wants to die at home but doesn’t want to die at the
hospital.
 She has made funeral arrangements.
Task:
Talk to the patient about end of life decisions and fill in the documents
provided.
Management:
 Build good rapport and paraphrase the scenario , I understand you have
been explained everything so far and im here to talk about your future
treatment
 Acknowledge about her condition , ask how much she knows and confirm
understanding
 Ask about her concern and explain CPR , and when its given
 Access mental capacity, what will be the consequences if CPR not given
when her heart stops
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29
 Explain advance care planning , ventilation if she becomes ill , faces

problem with breathing , we can provide her life support that is giving
oxygen directly to lungs
 Ask her if she has discussed to her family or next to kin
 Ask about psycho-social , support system , finances , funeral
arrangements etc
 Take her consent on everything and appreciate her decision and advice to
discuss with her next to kin
 Fill the DNAR form
 Thank the patient and tell her if anytime she change her decision she can
contact with us anytime
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19.Problem colleague:
 You are FY2 in medicine
 A nurse named Stephens has been calling you with some concern
 One of your colleague Henry has posted on social media about a patient
who was discharged yesterday; has given him an expensive gift as a
gratitude of being so caring
 Though he didn’t mention the patient name or any details but it was a
public post
 Stephens didn’t want to talk to him directly , he wants you to talk to him
instead on this matter
 You haven't seen the post
Task:
Talk to the nurse and address his concern
Management:
 Greet and introduce yourself start with telephonic conversation
 Build good rapport and ask about his work life
 Now listen to him carefully , your colleague Henry is a nice sprightly person
but you know what he has done is not a good medical practice
 Tell him a health professional must not encourage patients to give, lend
or bequeath money or gifts that will directly or indirectly benefit him and
also he must not put pressure on patients or their families to make
donations to other people or organizations.
 Encourage him to raise the matter directly to Henry , he can even inbox
him to delete the post or change the audience view status
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 Also you can tell him that you will talk to Henry about this and explain what
is good medical practice about receiving present from the patient and not
to get a penalty from GMC
 tell him you can explain to Henry , and convince him to return the presence
explaining that it is against the good medical practice
 Thank him for calling and raising this issue
20.Father concerned about daughter:

History:
 You are FY2 general practice
 A father of 23 years old girl has been calling you with some concerns
 He has noticed his daughter has been taking anti depressant
 He wants to know for how long she has been taking those , and why she
was prescribed anti depressant
 He seems to be very worried about his daughter, he really cares for her,
daughter is going to university in a different city , she never spoke up about
any hardship of if anything going in her life
 She lives with his wife, and they have a good relationship
 He doesn’t know much about his daughter
 He keeps insisting to know about whats wrong
Task :
Talk to father and address his concern
Concern:
Why my child is taking anti depressant pills?
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Management:
 Greet and confirm identity, start with telephonic approach
 Confirm the relationship and ask his concern
 Before answering ask about how much he knows about her child? Hows
their relationship , who else live in their house , does he know his
daughters friends and close people, about her health etc
 Now appreciate him for being such caring father but explain him you can
not tell him anything about his daughter as its against the good medical
practice and will breech the confidentiality of the patient
 No matter if he is the father he has no right to n=know without his
daughters consent
 Rather advice him to be more friendly and build up a good relationship ,
share more things , she might need support from family specially parents,
try to know by him self
 Discuss about what difficulty she has been facing these days
 Arrange something so that she can spend more time with family and can
open up
 Thank him for calling
21.Ante natal examination

History:
 You are FY2 in obstetrics a gynaecology department
 30 years old female who is 36 weeks pregnant andcame for a follow up.
 2nd Gravida ,1 Para, first baby two years old
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 No signs of pre eclampsia

 Previous pregnancy were normal and she hadspontaneous vaginal
delivery
 She has no known medical conditions or allergies
 This pregnancy has been going normal so far
 Mannequin present in the room
task:
Talk to the patient , perform examination and do therelevant management
Concerns:
What is breech?
Can I have the pool delivery?
Distended abdomen, Breech presentation, perform theexamination as you
were taught in the academy
 Management:
 Build rapport and take focused history
 rule out pregnancy complications and red flags, ask about previous
pregnancy
 Do examination same mannequin as taught
 Comments on the findings and explain baby’s position
 Discuss with senior and further scan to confirm theposition of the baby
 Baby can change the position towards the end of 37 weeks, if that
happens she can have a normal vaginal delivery
 If the position of the baby does not change on its own an external
manoeuvre can be done to change the position
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 If the manoeuvre doesn’t help then we might need to gofor Caesarean-

section delivery
 Safety net
22.Acute asthma
History:
 you are FY2 in emergency department
 A father of 10 years of son has been calling you
 His son has been having breathing problem since morning
 There is no fever , no rash , no shyness to light , no sign of dehydration
 He was fit and well yesterday, wee and poo fine
 No changes in color of lips or skin
 He has been diagnosed with asthma since childhood , takes inhalers
 Father has given inhaler , didn’t work
 saturation was not measured
 He is alone at home with his boy
Task :
Talk to the father and do immediate management
Concern:
What is happening?
Management:
 Greet and confirm identity, start with telephonic approach
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 Take focused history, ODPAR of presenting complaint, ask red flags,

meningitis , encephalitis , dehydration, fever flu etc, ask MAFTOSA, any
injury, past history , has it happened before?, any allergies?
 Now call and ambulance and assure him , tell him to relax his child,keep
him in propped up position , loose the cloths , open windows , nebulize him
if possible , measure saturation if possible
 Explain it is acute exacerbation of asthma , he needs hospital admission ,
ambulance has been called will be arrived within 5minutesat his home
 He will be given oxygen, and salbutamol, IV channel will be made togive
him IV medicine and fluid , also he will be monitored
 Assure him and appreciate for calling
36
23.Confidentiality:
History:
 You are FY2 in AMU
 A 78 years old woman is admitted in the hospital with thecomplaint of
blood with stool and weight loss , anorexia
 She has been under treatment and investigations were done
 A CT scan was done and diagnosis of colon cancer has been made
 Patient has full mental capacity and has been told about her condition
 Further treatment plan has been taken
 Her only son who is a surgeon in the surgery in another hospitalhas
been calling to know about her mothers condition
 He wants to know whats going on and wants talk to the consultant
 Consent has not been taken from his mother
Task:
Talk to the consultant and address his concern
Management:
 Greet and introduce yourself
 Start with telephonic approach and confirm relationship with the patient
 Ask about how much he knows about his mothers condition , how was
she before , whos at home , who mostly takes care of her ‘is he the
power of attorney or not etc , ask about her medical condition and
medication
 Now tell him his mother has mental capacity and consent has not been
taken to discuss anything about her , tell him to takeconsent from her
 If consultant says im her only son tell him I understand but it is the good
medical practice not to disclose any details without theconsent
 If he says to talk to consultant then 37tell him we can do that forsure
 Thank him and appreciate for being so caring son
24.Concerned son
History:
 You are FY2 in orthopedic department
 A 82 year old lady has been brought to the hospital 1week back after a
fall, she developed a fracture in her hand which was treated and a cast
was placed on
 She has been treated well , and medicine has been been given now
ready for discharge to go back home
 Her only son , in on telephone to know about her mothers condition
 He is very concerned about his mother
 His mother lives alone at home , she can do her own work by
herself, it was her first fall
 She is physically well and fit, not on any medication
 Physiotherapist and occupational therapist has been informed
 Son doesn’t want his mother to go back home, what if she might
have another fall
 He wants her to go to care home
 Mother has full mental capacity, and has given consent to talk abouther
condition
Task:
Talk to the son and address his concern
Concern:
What if it happen with her again? 38
Management:
 Paraphrase the scenario, and ask how much he knows about his
mother
 Take focus history of his mom, what happened, has it happened before,
who lives with her, who takes care of her, home condition , medical
history etc
 Tell him how she was treated, multidisciplinary team were involved and
she is ready for discharge
 Address his concern, and ask why he thinks she needs to send to care
home
 Tell him she has full mental capacity , she can do her own work, if she
send to care home she might not take it happily, as she can take her
decisions
 Appreciate him for being so caring son and tell him we can offer career
for her to help in house work and herself
 Offer support
25.Vaccination
History:
 You are FY2 in GP surgery.
 mom calling as her 5weeks old child due for jabs and itis 6 in 1 vaccine
 She is worried that her child will be very sick aftervaccination
 She is also scared why they can’t be separated ; anddoubtful about
the method of immunisation 39
 Baby is healthy , developing well, no symptoms
 Setting: vaccine chart in the cubicle
Task:
talk to the mom and address her concerns
concerns:
Worried about vaccines, are these safe?
Why the vaccines are not separated
Management:
 Approach telephonic conversation
 BIRDDD, head to toe, MAF
 address concerns (Vaccination in children is a routine procedure , all of
them are safe and is done to protect the children from serious condition)
 Explain the vaccines ( 2 injections (Men B and hexavalent) + 1 oral
(rotavirus) from the chart
 Explain side effects of vaccines like arm swelling and redness, pain,
mild fever. Reassure that pain killer can be used and the symptoms go
with a few days
 Vaccines are not separated as they are manufactured together also
reduce distress on child
 What if vaccine is not taken ; he will be in a higher risk of getting those
infections and later by infecting other will put their lives at a risk
 Safety netting
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26.Abdominal examination:
History:
 you are FY2 in in emergency department
 A 55 year old man has come with abdominal swellingand
breathlessness
 he had 2 previous MIs with multiple medications. (Hehas a
prescription for that)
 He hasn't been taking furosemide because it makeshim go to the loo
more often.
 His blood pressure is high. (Hypertensive for 10 years)
 No other medical condition, no other symptoms
 No smoking or drinking habit
 he is not living with anyone else and willing to beadmitted.
 Ascites findings elicited on exam.
 Chest and cardiac findings on verbalizing
Task:
Talk to the patient, take focused history and perform relevant examination
Concern:
What you are gonna do for me?
Take observations (BP High, SPO2 low) , head to toe, chest examination
and perform abdominal examination as you were taught in the academy
(Do shifting dullness for ascites)
Routine blood test, chest and abdominal X-ray, LFT,KFT, Urine RE,
ECG ,cardiac enzymes, ABG
Management:
 Greet and confirm identity 41
 Explore symptoms, swelling and breathlessness
 Take past history, medical condition and medicationhistory (if he is
compliant with the medicine , if not then ask why)
 Do DD, (systemic review) , smoking , alcohol history
 Do PPCCE, perform abdominal examination as you were taught in the
academy (Do shifting dullness for ascites), verbalize investigation
 Explain your findings and cause of it, he has developed heart failure
(that means heart is not pumping bloodproperly causing swelling of
tummy)
 Explain immediate admission, give oxygen, antihypertensive, IV
frusemide, do catheterisation
 Involve senior
 involve heart specialist for further appropriate management
 Do safety netting
27.Simman
History:
 A 54 year old male presented with dizziness, following vomiting blood
3hours back (inside the cubicle there is bucket full of blood)
 There is no chest pain,no shortness of breath,no abdominalpain, no
blood in stool
 He has no bleeding disorders, medical conditions, nomedication, no
family history, no allergies
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 He has been drinking alcohol since adulthood, drinks almost16unit per
weeks
 After 3minutes patient collapse
ABCDE aproach
Blood pressure 89/59
Heart rate high 120
Respiratory rate normal
Temperature normal
SpO2 normal
Concerns:
What is happening to me?
Management:
 Turn the patient to left lateral position
 Take focused history ( what happened, has it happenedbefore, medical
history, medications, allergies)
 Perform ABCDE
 Give oxygen via nasal cannula, fluids after putting cannula,and ‘o’
negative blood
 Investigation includes routine blood , LFT KFT, blood groupingand cross
matching
 Explain the provisional diagnosis and involve senior
 Admission and senior consultation for further assessment and
management
 Safety net
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28.Headache
History:
 A 35 year old lady presented with headache.
 she took Ibuprofen and PCM but they didn’t help.
 This is the second time with headaches in 1 week whichstarted
suddenly last night.
 Pain is dull, static and severe 8/10, Non-radiating andlight make it
worse.
 She is Nauseous but didn’t vomit.
 Her vision is blurred specially on the left side, no history of fever or
rash.
 she was given medication the 1st time she had it.
 she is a library attendant. Work is not stressful
 She is active and sleeps properly, no problem in thefamily or
outside
 Fit and well, no smoking, no alcohol
Task:
take a history an discuss management with the patient
Concern:
Could it be brain tumor?
take Observations , Fundoscopy, Nerves of head andarms ,
Ear and nose
Routine bloods (FBC, LFTs) 44
Management:
 Explore the headache, SOCRATES, triggering factors, red flags , ask
differentials (coaster, migraine , tension ,menstrual etc ), ask about aura
 Take menstrual history, past history, MAFTOSA , DESA
 Do ICE , verbalise examination and summarise that shehas been
experiencing migraine which is a severe to moderate headache felt on
the side of the head.
 Tell her unfortunately , there is no cure but we can help her to prevent
those from happening
 offer Medications, simple analgesia, antiemetic, sumatriptan
 For prophylaxis beta blocker
 advice to keep a migraine diary to note the pattern of headache (date,
time, activity at home of onset, duration)
 Safety netting: progressive change in pattern, worsening headache,
worse in the morning, suddenonset, weight loss
 Follow up
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29.Lung cancer
History:
 A 56 years old middle aged man came to GP, presented with cough
for 2months, non productive, no blood in it.
 He also complained of breathing problem , which is more prominent at
night
 He wakes up in the middle of night feeling of losing breath, also
whistling sound coming from the chest
 He also complained of tiredness and weight loss forsame duration
(FLAWS positive)
 He works as a carpenter , some of his colleagues got the same problem
and under treatment
 No family history of cancer, or lung problem, no other medical history or
allergy
 He is physically fit and maintain good balance diet
 No smoking or alcohol habit
Task
address concern and Discuss management plan
Concerns:
is it lung cancer?
Examination and investigations:
examine chest, take observations, lymph node(enlarged on the right side)
routine blood , inflammatory marker,
chest X-ray (round mass in the right upper lobe, intralobular, small,
rounded or branching opacities; fibrosis
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sputum culture by bronchoscope
ECG
Management:
 ODPARA of cough, FLAWS, DD, MAFTOSA
 Address concerns, explain best case worst case scenario “we are
suspecting a condition called asbestosis which is a chronic lung disease
caused by inhaling asbestos fibers. Prolonged exposure to these fibers
can cause lung tissue scarring and shortness of breath
 urgent referral to chest specialist
 Involve senior
 explain if it’s cancer what can be done( specialist will do CT scan chest
, abdomen and pelvis and a special camera test to look into the lungs
and take samples for testing)
 low dose steroid after consulting with senior
 It can be asbestosis as like his colleague, investigation will confirm
that
 Safety netting
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30.Prescription
History:
 You are FY2 in obstetric ward
 36 years old 35 weeks pregnant female has presented withthepremature
rupture of membrane
 She was taking regular medicine including Metformin 500mgOD andVit
D supplements
 Patient is allergic to penicillin and developed rash
 The consultant has prescribed her: Dexamethasone 12 mg,2 doses24
hours apart and Erythromycin 250 mg PO QID for 10 days
 There is no patient in the cubicle
 Stickers provided for patient identity
 BNF present in the cubicle
Task:
Write the prescription check the doses from BNF
Management:
 Greet the examiner
 Fill the patient details/Use stickers if available
 Fill the allergy details,write your name,date and sign the box
 Open BNF to check the interactions of Erythromycin
 Prescribe Erythromycin, Dexamethasone and regular medications as
instructed
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31.Rash on chest:
History:
 A 60 year old man has presented with chest pain on right side which
has been getting worse for past 1week, it’s gradual in onset, dull in
character, radiating to the back, he tried paracetamol but didn’t help
 He is generally fit and well, no past medical condition, medication
history, no allergies
 He also developed a rash on the right side, not itching but extremely
painful, no discharge, bleeding , it’s getting bigger
 He is lives with his grandson
 No smoking or drinking habit
task:
Talk to the patient, assess him and discussmanagement
Concerns:
Is it heart attack?
Will my grandson will be affected too?
Take observations and do general physical examination,examine the rash
, back
routine blood, ECG, chest X-RAY, antibody for chickenpox
Management:
 Explore chest pain do SOCRATES, red flags and
differentials (MI, Pericarditis, pulmonary embolism)
 Explore rash, take contact history, childhood history ofchicken pox
 Do FLAWS, MAFTOSA, DESA 49
 Verbalize examination and summarise that it’s ashingles, due to
reactivation of previous chicken pox that hide in your body.
 It can be passed to other people especially who are not immunized, or
who never had it, pregnant women and immunocompromised patients.
 It takes 4 weeks for the rash to heal
 Prescribe anti viral for 7 days, and Gabapentine forneuropathic pain
 Advice to keep the rash clean and dry, wear loose fitting cloths
 Put ice packs, do not cover the rash or put dressing
 Offer vaccination, address concern
 Safety netting
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32. Teaching
History:
 You are FY2 in in emergency department
 A 5th year medical student who missed the BLSworkshop
 He has no idea about it , now he wants to learn
 ask him to perform and give him a feedback about it
 Set up: adult CPR mannikin, face shield.
Task:
Teach the student how to perform basic life support
Management:
 Greet and build good rapport
 paraphrase scenario and appreciate as he has cometo learn
 Ask about knowledge and understanding, explain BLS ,when we do it
 explain steps removal of danger staff around thevictim/patient
 Check for patient’s response
 Shout for help , asses airway, check breathing ,circulation, chest
examination
 Start chest compressions, perform it as you were taught
 After 30 chest compressions give to mouth breathingafter pinching
the nose
 Continue the process and reassess
 Call ambulance 999
 Indication of stoping if ambulance arrives, if patientshows sign of life, if
you are tired
 Seek for help, ask for student’s understanding
 Tell him to read more from resuscitation UK
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33.Dizziness
History:
 You are FY2 in General Practice
 A 45 year old man has come with dizziness.
 He explained dizziness as if everything was spinningaround him
which started 5 days ago
 It happens whenever he is trying to get up from bed, it was sudden in
onset. Lasts seconds to minutes.
 He had flu like symptoms 10 days ago.
 Triggered by moving head to the right, left and upwards.
 Felt sick but didn’t vomit.
 Generally Fit and well.
 Works as Scaffolder. Lives with his wife.
 No fullness of ear, ringing in the ear, discharge , trauma
Task:
Please take a focused history, assess patient anddiscuss
management
Concern:
Is it treatable?
take observations , Ear, chest , Blood, ECG
Ear exam is normal, Dix-Hallpike maneuver is positive.
Management:
 Greet the patient and confirm his identity
 Take brief history about his dizziness, do ODPARA
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53
 Check if he drives.
 Verbalise examination, Explain Provisional diagnosis ‘Benign
paroxysmal positional vertigo (BPPV) is one of the most common
causes of vertigo where the sudden sensation that you're spinning or
that the inside of your head is spinning, BPPV is thought to be
caused by little calcium carbonate crystals (otoconia) coming loose
within the canals. Discuss Life style, Do and don’ts
 Its self-limited , it resolves on its own in few days or weeks; however,
will be giving you, Buccal Prochlorperazine. Anti-histamine to
improve your symptoms.
 There is a technique called Epley’s maneuver, it’s very successful in
stopping symptoms with just one treatment sometimes (done by
senior) Specialist (Ear specialist): If symptoms don’t improve or get
worse to exclude other conditions and to do scanning of your brain
CT, MRI.
 Safety netting: Please, don’t drive if you drive, you should inform
DVLA.
 Avoid working from heights, discuss with employer to take leave
 We can give medical notes if you need after discussing with the
employer.
 Safety net: Double vision or loss of vision, Hearing loss, Trouble
speaking, Leg or arm weakness, numbness or tingling.
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34.Dementia
History:
 You are FY2 in medicine
 85 years old female with advanced dementia
 Admitted in hospital with complaints of weight loss
 She has advanced dementia and no other options isviable so she has
been put on palliative care
 Any other organic /medical cause of weight loss has been ruled out.
 Daughter has left her job to look after her mother
 She has been having financial difficulty because of her mothers health
 She is unable to cope with all the psychological and financial burden
 The patient is medically stable and is taking oral feed at this point
 The daughter was very polite and co-operative
Task:
Talk to the daughter and address her concerns.
Concerns:
What about tube feeding?
Can I take her home?
How am I going to feed her?
Management:
 Greet and confirm patient identity
 Take brief focused history for dementia–Be very politeand empathetic
toward the daughter
 Assess how much she knows about dementia and her mother’s
condition
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 Explain her dementia being the cause for her poor feeding andweight
loss
 Discuss management
 Address concerns: Feeding tube is not a long term option, she is
stable and she can go home, offer her comfort foods,dine together,
keep reminding her, put alarms or remindersfor food, She can go
home as she is medically stable
 Dementia nurses,Home Care providers,Dementia clinic
 Financial or psychological support for the daughter
 Safety net
35.Prescription
History:
 you are FY2 in hospice care home
 80 years old female is diagnosed with metastatic pancreatic
carcinoma
 patient is terminal,palliative care has been prescribed,she has been
referred from hospital to hospice for the continuation of palliative
care.
 She can not eat or drink
 Her list of medications can be found in the hospital
 Handover will be inside the cubicle
Setting:
 no patient only examiner, start writing prescription, BNF, Pen,
calculator
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 Morphine for pain via syringe driver 30mg per 24hours

 Write subcutaneous injection
 Cyclizine 50mg TDS SC for nausea and vomiting
 Midazolam 2.5 mg SC 2hourly for agitation(maximum doses 6)
 Hyoscine butyl bromide 400 micrograms SC 2-4 hourly for secretion
 Paracetamol 1gm PO every 4 to 6hourly for pain
 Atorvastatine 10mg PO once daily
 Prescribe morphine breakthrough doses
 All as required
 Patient under palliativecare, don’t prescribe the oral medicine, only
subcutaneous injections
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36. Simman
History:
 you are FY2 in in the obstetrics and gynaecology department
 52 year old lady is admitted and had gone through hysterectomy
operation due to dysfunctional uterine bleeding,now in the recovery
room
 Nurse has called you as she has become hypotensive and saturation
has been falling
 She is drowsy,not feeling well, no fever, no rash
Task:
Talk to the patient,assess her,and discussmanagement with the
examiner
Monitor shows
BP 85/65.
Temp 37 HR 110
O2 sat 92%.
ECG shows sinus rhythm.
Chest clear.
Abdominal bandage covering the scar.
Catheter and urine bag contain clear urine.
Routine bloods(FBC,RBS,LFTs), inflammatory markers,
Blood culture, urine dipstick, ABG, CXR, ECG, Serum lactate
Management:
 Greet and confirm identity from her bracelet,patient not responding
well,only mumbling
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 check patients file and check monitor

 Give oxygen,do ABCDE protocol
 do cannula,Send the investigation and give fluids
 Bandage dry, urine clear
 Call to the blood bank for arranging 4units of blood
 Explain to the examiner you are suspecting post operative
hypotension secondary to internal bleeding
 Maintain fluid
 call senior and take back the patient to the theatre
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59
37.Venupuncture
History:
 A 26 year old boy has been brought to the hospital as he
consumed 40tablets of paracetamol 6hours back
 He took it with water , all together, no vomiting , he is not
making any eye contact not answering to any questions
 He is still not got any symptoms
 Your senior has asked you to take blood sample to check
paracetamol level in the blood
Task :
Talk to the patient and perform relevant procedure
Management:
 Take focused history , when did he take , how many , with what
, why he wanted to commit suicide , who brought you here , do
you feel guilty etc
 Any vomiting or induced vomiting after that , any symptoms etc
 Now explain the procedure , do PPCCE, and perform the
procedure as you were taught
 Label the sample then examiner will give you a paracetamol
level
 Patient needs IV N acetylcysteine
 After treatment you need to repeat the blood test
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38.Eye examination:
 History:
 A 60 years old presented to with vision problem in right eye which
started suddenly two days ago and unable to see from nasal side
 No eye pain, bleeding or discharge, headache or injury, foreign
body
 No problem with other eye
 He was complaining of dark patches in his vision
 He is hypertensive for 10 years well managed and following up
 Has undergone Cataract surgery in the same eye done 2 months
back, doesn’t wear any glasses
 No family history of eye problems
 Not taking any other medication apart from Ramipril for
hypertension
Task:
Talk to patient,do relevant examination and discuss further
management
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Take observation , head to tow , eye examination ,visual field,

acuity , back of eye with fundoscope
Visual acuity R>6/24 L>6/6
Red reflex abnormal in right eye
Concerns:
Am I going to be blind?
What is happening with me?
Management:
 Take focused history (ODIPARA, associated symptoms, red

flags , Medical condition, previous surgeries , medications, family
history, ask if he drives)
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 Do ICE and examine eye (visual acuity , red reflex , back of eye
via fundoscope)
 Explain diagnosis retinal detachment is emergency situation in

which a thin layer of tissue (the retina) at the back of the eye
pulls away from the layer of blood vessels that provides it with
oxygen and nutrients
 Aging is the most common cause of retinal detachment. As you

get older, the vitreous in your eye may change in texture and
may shrink. Sometimes, as it shrinks, the vitreous can pull on
your retina and tear it
 Immediately refer to ophthalmologist
 Further management includes Scleral buckling or Lasertreatment
 Praise him for coming early, treatment can protect him from go
blind
 Safety net for driving
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39.Medical error:
History:
 You are FY2 in respiratory clinic
 A 42 years old Middle aged male came for follow up at
respiratory clinic
 He came previously with some chest complaints and is feeling
well now, X-ray was done and was diagnosed as pneumonia and
was prescribed antibiotics
 He has completed antibiotic course
 Today you were told that your colleague misdiagnosed him
 His x ray is normal, which was mismatched with some other
patient having pneumonia
 Patient is experiencing no side effects of medications
 Patient was not that angry when told about the medical error
examination:
Take observations and head to toe
Concerns:
Asked about side effects?
What will you do to prevent further errors?
Management:
 Take focused history (chest complaint, side effects of medications
like diarrhoea, tummy pain etc)
 Start with medical error approach, Explain a medical error has
happened and be very apologetic
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 Explain he have been prescribed antibiotic unnecessarily, when

he asked about the side effect tell him that can be rash,
diarrhoea and resistance to antibiotics.
 Reassure him this will never happen in future and an incident
form will be filled up to prevent this happening in future
 Safety net
40.contraception (phone)
History:
 A 25 year old lady has been calling you
 She wants to know a contraceptive method that is suitable for
her, she has been sexually active for 5years, she used
diaphragm and condom before but she got pregnant
 she has one child with a stable partner, no other partner
 She wants to know about the failure rate of the contraception
and side effects, she doesn’t want to take child for at least 3-4
years
 She doesn’t have any medical condition but 1year back she
traveled to Australia by air and developed swelling in the leg ,
and she was prescribed blood thinners for about 6months
 She is non smoker , and social drinker
 Physically fit and active
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Task:
Talk to the patient and address her concern
Concern:
I liked the idea of COCP
What are the failure rates? Which method is safe for me?
Management:
 Greet and confirm identity and start with telephonic approach
 Ask her concern, for how long she has been sexually active ,
stable partner or multiple , previous contraceptive methods, side
effects , does she practice safe sex? Etc
 Ask about pregnancy , period , does she want any child near
future, for how long she has been planning to use the
contraceptives
 Now ask about general health and medication in detail , red
flags , high cholesterol , heart problem , artery disease etc
(MAFTOSA DESA)
 Now explain different types of contraceptives in short , their
failure rates if she asks
 She said she like the idea of COCP and explain in her case this
is not suitable contraceptive , then you can suggest inject-able
or the device
 Ask concern and check her understanding
 don’t forget to mention none of this contraceptives will prevent
from STI’s ; so its better to use condom in a proper way
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 Thank her for calling and suggest websites to read for more
details
41. Bullimia nervosa

History:
 16 years of old girl has come to see you,as her motherhas made
an appointment.
 She is vomiting for 18months,she doesn’t think she hasa
problem,mother is exaggerating things
 She knows her BMI is 20
 she claims she induce vomiting by herself by putting herfingers
inside her throat,because she thinks she is fat
 She does that once a week when she feels she ate a lotand
feels guilty
 She has a friend at school,who never put onweights,she is her
role model.
 she doesn’t have any health issues,no past medicalhistory,no
use of medication,no bad habit
 Mood is good
 menstrual cycle is normal
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 She doesn’t like going to the gym,as she feels peopleover there
are thin than her
Task:
take observations,check BMI,head to toe,(mouth and
teeth)abdominal and cardiovascular examination
Management:
 Build good rapport
 Ask ODPARA of vomiting, if anything significanthappened,
nature of vomitus
 Ask about eating habit,if show follows any diet chart,any habit of
binge eating,if yes ask questions of recurrent episodes of binge
eating
 anything else does she do for weight loss like
medication,pills,exercise,fasting,using of laxative
 ask mood , feeling of guilt, psycho social
 take menstrual history, ask about general health, MAFTOSA
 Verbalize examination and summarize and explain Bulimia
nervosa which is an eating disorder where someone thinks their
weight is high but actually they are in normal weight range.As
her BMI is 20 which is normal,she is not obese.
 Arrange a face to face appointment so that you can examine the
patient
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 Refer to child and adolescent mental health team

 Refer to paediatrician or eating disorder specialist
 Arrange a follow up in 2 week
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42.Counselling:
History:
 A 55 year old man has come to you for check ups
 nurse has taken the observations and measured theblood pressure
came 160/80mmHg
 He doesn’t have any medical condition, or not taking any medication
 he has family history of stroke , father died 2years back with stroke
 He is a sedentary worker, can’t maintain healthy lifestyle
 he lives with wife, she has been telling him to exerciseand lose
weight, he doesn’t have time, he is very busy
 He smokes 10 cigarettes per day and drinks alcohol inthe weekends
 he seems stressed and worried he might have strokelike his father
 His mood is fine
Task:
Talk to the patient and address his concerns
Concerns:
Will I have the stroke like my father?
observations shows blood pressure high , BMI high 35 routine blood, LFT
KFT, urea electrolytes, lipid profile, RBS, TFT
Management:
 Explore concern, acknowledge his worry, why does he thinks he might
have stroke, check understanding
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 Rule out red flags doing systemic review

 Ask MAFTOSA, DESA , psycho social, mood
 tell him he has risk factors of having stroke, explain nomodifying
(family history) and modifying (BMI)
 appropriate him for coming
 Involve senior for prescribing anti hypertensive, andadvice him for
follow up
 refer him to dietitian, give advice on lifestyle modification
 Send him to local weight loss group, advice him tomanage time to
exercise
 advice for relaxation therapy , Take a break from t h e w o r k
 Safety netting (MI, Stroke)
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43.Delayed walking:
History:
 you are FY2 in in general practice
 a mother of 14month old child has come with some concerns
 Her son has not got to walk independently
 He can walk with support around the table but can’twalk
independently, whereas other kids of his age groupare walking
independently
 Her child can say few words , laugh and smile
 He interacts with others too
 He plays well with toys and you have no other concernsin terms of
other development.
 No medical condition, systemic review normal ,BIRDDD
normal
Task:
Talk to her and address her concerns accordingly.
Concerns:
When he will be able to walk?
Take observations, head to toe
Management:
 Explore concerns, ask can he able to walk or stand afterthat he fall
down? Is he able to stand without support?
 Ask developmental questions, systemic review, BIRDDD, any bone
problems
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 Do ICE, verbalise examination and summariseeverything looks

normal except he hasn’t startedwalking, however sometimes this
is normal for some children at age of 14 months, they are a bit slow
to startwalking.
 Reassure the mother if there’s no other causes
review in one month
 avoid using child walkers, encourage child walking byholding
hands, discourage isolation of the child
 safety netting
44.Viral flu
History:
 A mother of 4year old boy has called you with some concern ,he
developed high fever , runny nose, for last 2days
 He was fit and well before that , was going nursery , 4days backhe
suddenly developed fever, she gave calpol but didn’t work , also
cough and lethargy
 He is feeding and peeing well
 No rash , shyness to light , or other associated symptoms
 BIRDDD normal, no medical condition or medication history, or
allergy, up to date with jabs
 Due of this year flu vaccine
 Mom thinks her son needs antibiotic
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Task:
Talk to the mom and address his concern
Concern:
Why you wont give antibiotic to my son?
Management:
 Take focused history of fever, cough , runny nose, rule out redflags
and differentials , chicken pox, measles. Meningitis , dehydration
etc
 Ask BIRDDD , MAF
 Do ICE, and explain her son has got viral flu which is verycommon
in children , and its self limiting
 Tell her to give flu vaccine when he becomes okay
 Give him plenty of fluids and calpol to lower down the fever,can use
salt water to clear the nose
 Keep him feeding good food , and water, check his nappy everyday
if he is passing enough urine
 Address her concern that it’s a viral flu , antibiotic wont work
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45. Angry patient

History:
 You are FY2 in Surgery
 35 year old woman had a cyst removal 3 weeks ago on her leg and
5 days ago she started noticing redness, swelling and discharge
from the wound.
 She came to the hospital 3 days back and was admittedwith
infection which was then treated with antibiotics.
 She is upset as she thinks the infection developed because she
was not given antibiotics after the surgery
 Also doctors did not teach her how to clean and changethe
dressing.
 Before the surgery she signed the consent form but the doctor
didn’t explain in details that the infection is serious.
 Now she is fine, no pain, redness, swelling, discharge ,temperature
from the wound side
 No past medical condition, no smoking or drinking habit
Task:
Please talk to the patient and address her concerns
Concern:
Patient is not angry but upset, why she didn’t receiveantibiotics at
the first place?
take observations (temperature), and check the wound site
Management:
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 opening sentence of the patient , ‘I want to know why I had wound

infection?’
 Take operation history, acknowledgement of the complications,
assess knowledge of taking care of wound and changing dressings;
and explore thecomplain.
 build good rapport and ask about present condition like pain ,
temperature, discharge, redness, swelling, history of recurrent
infection
 Ask about the hospital stay and effect of this infection in life , do
systemic review, past medical and medication history
 MAFTOSA ( ask occupation, If she went to work just after the
operation) DESA
 Ask concern, idea
 Verbalise examination and summarise unfortunately, infection is
one of the complications of surgery.
 Explain there are many reasons to have a wound infection after
surgery, it can be from inside or outside the hospital. Despite of
taking all measures patient can still get the infection for certain
health issue like DM (lowimmunity), not maintaining hygiene or not
keeping the dressing clean
 Address concern, that we don’t routinely prescribe antibiotics unless
there is high risk for it.
 Tell her you will check her previous records just to makesure if
anything was missed and apologize as she claimed before taking
the consent explanation of the post surgery complications was not
done.
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 Offer sick note if she was facing any challenges at work.

 Safety netting (high fever, swelling, shortness of breath)
46.NSAID nephropathy
History:
 A 49 year male came for test results as he went to well-man clinic
because his wife asked him to go 2week back
 He was feeling perfectly alright and did consult just for the sake of
wife
 There were no urinary symptoms,abdominal pain or any swelling
anywhere on body
 He has been taking ibuprofen for osteo arthritis for 8 years
 No other medical condition,medications or family history
 He does not smoke or drink and tries to eat healthy
 Agreed to stop medication
eGFR low
Concerns:
Why are my kidneys not performing well?
What will you give me for pain then?
 Management:
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 Paraphrase the scenario and praise him for the check ups
 Take focused history (Kidney problems, medical conditions,
medications, Family history, Urinary symptoms, Signs of renal
disease)
 Do ICE and verbalize examination and summerise the problemthe
test result shows some changes in kidney function and the probable
cause is taking pain medication for long term
 Tell him to stop medicine now and refer to joint specialist for
medication and arthritis review
 Refer to kidney specialist for further investigation and management
47.Head lice
History:
 A mother of 5years old girl has been calling to you with some
concerns about her daughter
 She has been itching her head all day and being irritable all day
 She tried to comb her hair and found head lice
 She is going to nursery, and she things she got it from there
 She wants to know the method of removing all lice
 Child is otherwise fit and well, no other physical problem
Task:
Talk to the mother , discuss management and address concerns
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Concerns:
Does she needs to stop going school?
Management:
 Take focused history and ask about the concerns , since when , any
other associated problem, any rash on head , what she has done
already etc
 Do ICE, summerise , and explain head lice are very common in
children , and it can spread from one person to another
 Probably your child got it from nursery and you can not prevent
 Address concern, she doesn’t need to stop from going school
 Methods of getting rid of head lice and nits (takes 2weeks to
3weeks) is wet combing
 At first wet your childs hear and wash with shampoo , then use
conditioner all over the head and buy fine needle thin comb from
pharmacy , comb hair from scalp to bottom for at least 20 minutes ,
repeat it , it will remove all lice and nits
 Treat other family members if they complain of lice
 Do not need to wash cloths and other stuff with hot water , you can
not prevent lice from that
 If wet combing doesn’t work after 17days you can buy medicated
shampoo or lotion from pharmacy that kills all types of lice and
nits
 Do not use electric iron comb, permethrin, other medicated
oils ;these wont work
 Follow up after 17days
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48.Tiredness:
History:
 A 40 year old man came 6 months ago due to constanttiredness
and GP suggested the cause is not clear.
 The Doctor had suggested to perform some blood test but all
came normal
 he is still experiencing tiredness. He is not able to do hisnormal daily
activities due to fatigue.
 He works as a lawyer, first time you had tirednesswhen he had
a flu like illness,
 2 weeks ago, he had another viral illness he has donea COVID
test.
 He is not able to have sex with his wife due to tiredness and she
thinks that you are having affair with another woman.
 no past medical history, MAFTOSA, smokes and drinks
 Don’t do exercise due to tiredness
Task:
Concern:
Why am I having it?
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Observations (BP standing and lying ), general physicalexamination

and lumps and bumps
All Bloods (inflammatory markers, TFT, vitamin level),Urine test,
RBS
Management:
 Explore tiredness, any recent symptoms, do differentials
 Ask past history, what treatment and investigation were done, how
was the outcome
 Do MAFTOSA, DESA, psycho social, ask mood, how heis coping
up in daily life , do ICE
 verbalize examination and summarize that thediagnosis is not clear
 He would need to do more tests to be able to figure that out, explain
chronic fatigue syndrome a long-term condition where the body and
mind feel unusually tired despite not having a physical problem, the
viral illness he had could have brought thisin
 offer Symptomatic treatment and life style advice, Anti-depressant
(if patient is low), Vit D supplements
 Diet: avoid eating before bed, balanced diet , try to do exercise
 Smoking: avoid smoking , Alcohol/ caffeine: decrease amount of
alcohol to 14 units per week Avoid stressful conditions
 refer to specialist for cognitive behavioral therapy
 Physiotherapist for gradual exercise
 Safety netting: weight loss, low mood
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49.pre-operative assessment
History:
 You are FY2 in surgery
 45 years old male came in the hospital for pre-operative assessment
 He has been scheduled to remove the screws in her ankle in 2
weeks time under general anaesthesia
 He had an ankle fracture twelve months ago and underwent a
surgery because of it
 Patient is diabetic and taking insulin for that
 He had vomiting after the previous surgery
 He lives alone,and has no one to take care of him for the first 48
hours after surgery
 Last time his neighbour stayed with him for a day after thesurgery
 He lives 15 minutes away from the hospital
 His blood sugar levels are under control
 He has no other medical conditions apart from diabetes
 He checked his sugar levels in the morning before breakfast andit
was 6
 He regularly goes for his diabetes checkup
 He developed nausea and vomiting in the last procedure
Task:
Talk and assess the patient for the daycare surgery
Management
 Greet the patient and confirm his identity
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 Take focused history for assessment (General health,Past medical

conditions, medication, compliance withmedication, diabetic control,
surgery or anaesthesia complications, Psycho social)
 Do an examination and routine investigations for the surgery
 Explain that he might have to stay at the hospital for a day or 2after
the surgery as he has no one to take care of him for the first 48
hours after surgery
 Advise him about preoperative NPO and that he should nottake the
morning dose of insulin
 Explain complications of surgery
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50.covid policy
 History:
 You are FY2 in AMU
 A 82 year old lady is on telephone, her husband has been admittedto
the hospital for last 10days, he has diagnosed cancer, he has been
having his end stage
 She wants to see her husband and but in visitor list her son’s nameis
there
 She wants to change that on her
 She wants to stray with him in his last days, she has been having
hypertension and diabetes for last 20 years
 Currently don’t have any symptoms or sickness, vaccinated against
covid
Task:
Talk to the patient and address her concern
Concern:
I want to be with him
Management:
 Build good rapport , acknowledge about how much she knows
about him, and her present health condition
 Ask her when was the last time she saw him, why she wants to stay
etc
 Ask about her health status and explain the covid policy andhospital
visiting policy
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 Be more empathetic and say she can see her husband via video
call , as her health doesn’t support her to come hospital visit
 Be more calm and let the patient talk
 Tell her you will talk to senior regarding her concern as you can notgo
against the protocol
 (covid policy: all visitors must now be registered with therelevant
department. Only one visitor can be registered and onlyone person
can visit. Patients who have been on the ward less than 10days can’t
be visited. The visitor must plan in advance towhen will they be
visiting. Visitors must wait in a secured visitorwaiting areas. A visitor
will be provided with personal protectionequipment before entering the
ward. People who are aged 70yo can’t visit due to the risk of COVID
infection. But exceptions can be made if agreed by the consultant
and the ward managers.Visitors are expected to wash hands and
wear mask all times)
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51. eye infection in child
 History:
 A 22 year old lady has made an appointment to see you.
 She delivered a baby 10 days ago, when the child was 7days old.
 He was found to have eye infection. The eye swab wastaken which
showed chlamydia infection.
 She never gone through STI screening
 Child was treated with chloramphenicol eye drops andis now fine
 she has been with her partner for the last 2 years. Shedoesn’t use
condom
 She never had PID infections.
 Her partner never complained of any symptoms of PID.
 She has been in unstable relationship for the last 2years.
 She doesn’t have any other partner
Task:
Take History and address her concerns
Concern:
How did the child get the eye infection?
Did I get this infection from my partner?
Management:
 Greet and confirm identity, start with telephonicapproach and
paraphrase the scenario
 explore complaints, present symptoms, Head to toe,BIRDDD, MAF ( take
focused history)
 Ask sexual history of mother
 Do ICE and summarise that child is likely to havecontracted chlamydia
infection from you during delivery.
 STI in women can be silent which means you can havethis infection
without having any symptoms
 advice her and her partner to GUM clinic as they both need to get
investigated (Endo-cervical Swab) andtreated (with antibiotics )
 advice to use barrier method of contraception such ascondoms until
both of them have completed treatment.
 Safety netting
 Follow up
52.breast examination
History :
 A 42 year old woman has presented with some concerns , she has
noticed a lump on her right upper quadrant of the breast few days back
 She is a bit concerned and worried and come for a visit
 Lump is very small , soft , not attached, not increasing in size or shape, no
swelling , changes in the breast , any changes in the nipple or any
discharge, no lumps and bumps anywhere in the body , FLAWS negative
 MAFTOSA DESA normal
 No positive family history of cancer or breast cancer
 Her menstruation cycle is fine, LMP was 2weeks back , no use of
contraceptive except condom
Task:
Talk to the patient and examine the relevant
Concern:
Do I have cancer, as my friend got breast cancer and she noticed a lump in
her breast
Perform breast examination as you were taught
Take routine blood
Management:
 Take focused history of lump ODPARA, related history , changes in the
breast , nipple , FLAWS etc
 MAFTOSA DESA P4
 Now verbalize examination and PPCCE, explain the procedure and ask
for chaperone (examiner will be the chaperone)
 Now perform breast examination inspection , palpation , inspect the lump ,
and explain finding , its not something harmful from the examination and
history
 Involve senior and arrange a mammogram
 Advice for self breast examination
 Safety netting FLAWS
53.speculum examination
History:
 You are FY2 in obs and gynaecology department
 A 3rd year medical student who has been asked to perform pelvic
examination but he has never done it before and wants to know how to
perform speculum examination.
 Stem says teach him how to perform, don’t let him do the procedure or
ask to do it
Task:
Teach the student how to perform speculum examination (don’task him to do
it)
Concerns:
why do we perform speculum examination?
What are the contraindication for it?
Management:
 Greet and build good rapport
 Introduce and Ask about knowledge
 before starting the teaching tell him about indication abnormal discharge,
bleeding, vaginal bulge , when the speculum test is done
 Explain the Examination
 Explain PPCCE, Exposure below waist to ensure privacy, offer Chaperon,
ask patient to empty bladder
 Position: lying on the back (modified lithotomy position) , bring your heels
towards your bottom and then let your kneefall to the sides.
 Request student to sit with you ,turn on lamp ,identifyyour equipment ,
wash your hands, put on gloves .
 Tell the patient that you are ready to start, gently lookfrom outside, then
enter the speculum and look inside
 Perform the task as you were taught
 Thank the patient when you finish
 Check for understanding and take questions
54. Epilepsy discharge:
History:
 You are FY2 in neurology department
 A 11 year old girl was admitted 3 days ago as a result ofresult of
generalized tonic clonic seizures.
 EEG showed epileptic focus in the brain.
 She doesn’t have any other medical condition, or onany medication
 No allergies, no family history of seizures
 She likes swimming, riding bicycle and dancing
 She has been prescribed the med (Na valproate) andthe med has
already been explained to her mother
 She is now ready for discharge home
Task:
Please talk to the mom and address her concerns.
Concerns:
Will she be able to swim or dance?
Management:
 Paraphrase the scenario, take a focused history, explore seizures, is it
the first time happened
 Take social history, does she goes school , hobbies etc
 Past medical history, BIRDDD, MAF
 ask concern , and assess knowledge about themedication, ask if has
been explained the use of medication
 Regular use of medications as prescribed to prevent seizures not only
when she has seizures
 Advice on activities to avoid: she like riding her bicycle (if necessary she
can wear a helmet and protective stuffto protect her from falls), she can
swim. But under the supervision of someone (life guard) in case
shedevelops seizure.
 When bathing it is better to shower than having baths.
 Avoid locking the door when bathing so people canreach out in
case she has a seizure.
 Avoid watching movies within flashes of light especiallyin a dark room.
 Avoid cooking due to the risk of falling on fire or stove ifshe develops a
seizure
 Safety netting
 Follow up
 Advice to keep a seizure diary and avoid triggers
 Informing her friends when she goes out so they canhelp as long as
she is comfortable to tell them.
55.Simman
History:
 A 45 year old man has presented with dizziness, anxiety and shortness
of breathe
 It has been happening for the first time , he also complained of some
heaviness in the chest
 He doesn’t have any medical condition or any medication , or allergy
 He went for jogging in the morning and this happen suddenly
 Monitor shows high blood pressure and sinus Arrythmia
Task:
Talk to the patient and take focused history and manage him
Do ABCDE, check for vitals , if oxygen is low give oxygen , monitor shows
high blood pressure 150/95mmhg , and pulse is irregular 140
Chest examination finding normal
Routine blood , chest Xray , ECG, ABG, cardiac enzyme, RBS
Management:
 Greet and confirm identity and introduce yourself
 Take focused history of dizziness and ask DD , Medical history and
medication
 Look at the monitor and do ABCDE after taking consent
 Propped up the patient give oxygen
 Do two large bore cannula in the arm and give fluid and checking the
chest and beta blocker and calcium channel blocker
 Check the blood pressure and pulse again and finish the rest
 Call the senior team and admit the patient , we need to do echo to look
for the heart and further management
56.child had a fall
History:
 You are FY2 in in pediatric department
 a 30 year old lady who brought her 9 months old Childto the hospital
following a fall.
 She was changing nappy of her other kid when she felldown from the
sofa.
 It happened an hour ago.No symptoms after fall,mother didn’t witness
the fall, she was crying after the fall, and there is a bruise on forehead
 BIRDDD Normal, She is up to date with her jabs.
 No past medical history. MAF normal,no findings head to toe
Task:
talk to the mom . Take history and address her concerns
Concern:
Dr you will not perform a CT scan now?
Why not CT scan?
take observations and head to toe, examination of thebruise,look for
rashes, ear
Routine bloods
Management:
 Greet and confirm identity and build good rapport
 explore fall,before-during-after,then explore head to toe,and ask
questions for indication of CT scan (any LOC, fits, vomiting, bleeding
from nose ear, drowsiness etc)
 Do BIRDDD,MAF
 Do ICE, verbalize examination and summarize then explain her child got
a mild head injury
 Tell her it doesn’t look quite serious and she should be fine.
 She doesn’t need a CT scan because we don’t want to expose her to
unnecessary radiation.
 Involve senior
 Observe her for 4h then sent her home if everything is fine
 Safety netting: LOC, Fit , Drowsy, Difficulty in waking herup,
Weakness, Vomiting, Clear fluid nose/ear
57. Prescription
 History:
 You are FY2 in in AMU
 A 50 year old woman has fallen in the ward and in pain
 She has been diagnosed with COPD and bipolar mood disorder
 She has been taking drugs:
lithium 800 mg BD PO
tiotropium bromide 2 puff in the morning,
sere tide 500 2 puff nocte,
salbutamol 1-2 puff as required, atorvastatine 80 mg nocte
 She has allergy in penicillin causes rash
 Task:
 prescribe Ibuprofen and usual medication
 Setting, no patient, BNF, pen and prescriptionpaper, sticker, calculator
58.Disclosing test result:

History:
 A 60 year old has come for follow up, she has come for her test results
of the biopsy from breast tissue
 She regularly checks up her breast for lumps, she is fit and well
 The mammogram showed calcification, and breast surgeon has done a
biopsy , which showed ductal carcinoma in situ
 No past medical history, no family history of cancer, no use of
contraception
 She doesn’t smoke , drinks occasionally
 LMP was 10years back
 She knows breast cancer can be removed by surgery
Task:
Talk to her , explain test results and address concerns
Concerns:
Why did I have it?
What will you do now?
Management:
 Paraphrase the scenario, ask any symptoms, discharge, bleeding from
the breast, FLAWS
 ask MAFTOSA, DESA
 Do ICE, explain test result (BBN approach)
 Tell her unfortunately we don’t have a good news for you, the biopsy
shows cancer
 Give a pause and offer support , show empathy
 Also mention the good news is cancer is confined to thebreast and it
can be removed by surgery
 Do routine investigation
 Refer urgently to the breast surgeon
 Explain management, breast conserving surgery canbe done
according to the extend
 When the cancer is cure she can have breast reconstruction
surgery
 Do Safely netting
59.Eye examination:
History:
 You are FY2 in GP
 A 58 year old lady has come with the concern of blurry vision ,for
1month and its getting worse
 She has mosty gray vision in the centre of the eye , and seesline wavy
while reading books
 No pain , no discharge, no itching , redness , trauma in the eye
 No other asscociated symptoms like pain in the jaw , headache .fever
flu, etc
 She has been diagnosed with PMR for a year now and takingsteroid for
that
 She is up to date with follow ups and doing well than before
 She doesn’t wear glasses , family history of DM , but she doesn’thave
any other medication condition ‘
 Eats healthy , doesn't drink or smoke , do exercise
 Read books but having difficulty now
Task:
Talk to the patient and do management
Concern:
Is it a side effect of steroid
Take observation , examine head to toe , neurological examinationof
cranial nerve , eye examination , visual field and visual acuity
Fundoscopy shows drusen macula
Management:
 Take focused history of blurry vision , rule out DD like glaucoma ,
trauma, GCA, optic neuritis etc
 Rule out red flags, ask MAFTOSA, DESA
 Verbalize examination, see the findings and summerise she hasbeen
having macular degeneration probably due to steroid you are taking for
PMR
 Involve senior for medication review and reduce the dose
 Urgent Refer to the specialist for further review and treatment
 Safety netting for GCA
 Follow up
60.Follow up
History:
 A 64 year old woman has come for follow up
 she came to the GP a month ago with pain I shoulders and hips and
diagnosed with PMR , she was placed onprednisolone OD,
lansoprazole OD, alendronate OD.
 She has HTN and take amlodipine.
 She has DM which is controlled by diet.
 She has a list of meds she takes regularly. Aspirin 75mgdaily.
Amlodipine 10mg daily. And have no symptoms.
 She wants to stop steroids because she heard steroidscan cause side
effects.
 She lives with her husband , and she is a retired primaryschool teacher.
Task:
Talk to the patient and address his concern
Concern:
Why do I need to continue steroid as I’m feeling well?
Observations, Neurological (upper and lower)and respiratory
examination , do fundoscopy
Routine (FBC, LFTs, KFTs, RBS) and inflammatory markers
blood tests done which showed ESR 55 high CRP 45high
Management:
 Paraphrase the scenario, take focused history before explaining the test
result ( ask about symptoms, how she is coping , any challenges)
 Explore medication compliance, ask about the side effects of steroids
 do MAFTOSA DESA, ask and address concern,verbalise examination
and explain test results whichshows undergoing inflammation
 So she can’t stop the steroid, rather we can start reducing the steroids
slowly from today only if symptoms are controlled.
 Referral: No need to see specialist now since her symptoms are
controlled
 Advice Support groups, Occupational therapist and physiotherapist
 Safety netting
61.elderly abuse
History:
 you are FY2 in in acute medicine unit
 A 80 year old lady has been brought to the hospital byher daughter
after a fall
 The nurses have examined her and she was found to have bruises of
different ages on her arms.
 She has chest pain and now in the radio departmenthaving an X-
ray.
 she fell down at home, her daughter found her on thefloor. She lives
with her daughter who is the career.
 Her daughter also have 2 kids and work sometimes.
 There is no one else there to look after her mom.
 Initially, she says her mom fell down with the Zimmer frame and she
didn’t witness the fall , immediately brought her to the hospital.
 Later after more questions, she admits, it’s sometimes difficult for her to
handle her mom. So, she hit theradiator and fell down. It is difficult to
shower and feed her and then go to work.
 These days her mom is slow and she goes late for work every day.
 Last week her employer has given her a written notice and she is
stressed out
Task:
Take history and discuss management with the daughter. Permission has
been taken from the patient tospeak to her daughter.
Management:
 greet and confirm identity , build good rapport
 Take focused history of fall , before-during- after(did youwitness the fall?
Was there anyone who witnessed the fall? What was she doing when
she fell down? Who elsewas at home? Did she hit her head? )
 take past history, MAFTOSA, DESA, psycho social (whocares her
mom, any challenges, how’s everything at home, finances and work life,
any support etc)
 Signpost abuse and explore abuse, tell her that you have found bruises
in different part of the body which is unusual in a fall
 If she admits explore the incident , if she has beendoing it for a
long time, except pushing her does she been not giving her food or
medications. Ask about most challenging things and struggles
 Offer career , support, advice nursing home
 involve social services
62.Per rectal exam:
History:
 50 years old man came for follow up
 had frequency of micturition during the day for 6months
 Also wakes up night 2times to go to the toilet for peeing
 Blood tests were normal except PSA test came a bit high
 Recently a friend got prostate cancer that’s why hecame for check up
 He has seen a TV advertisement from where you got toknow you can
have PSA test done
 Otherwise fit and well
 FLAWS negative, no fever, no other urinary symptoms, no past medical
condition (DM , RENAL STONES, BPH)
Task:
take focused history, perform examination and do themanagement
Investigation:
take Observations , do head to toe
Perform prostate exam (it is uncomfortable but it wouldhelp to check for any
abnormalities) and abdomen
Management:
 take focused history, urinary symptoms and red flags FLAWS
 past medical history and family history
 explain examination, take consent, offer chaperone
 Perform the Per rectal examination as you were taught
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 thank the patient and summarize what you have found
 As there are symptoms and PSA increased urgentreferral to the
specialist
 Specialist will carry out more investigation like scan ,biopsy
 Safety netting FLAWS
64.Teaching :
History:
 A young lady brought her 5 years old son to the hospital afteranaphylaxis.
 She went to a restaurant and told them her child h a s p e a n u t allergy
but they gave him peanut. This is the 2nd time he developed anaphylaxis.
The first time was when he went to his friend’s birthday party and he was
given food with peanut.
 He was treated that time and was prescribed Epipen.
 She doesn’t know how to use EPIPEN, now she wants know the use of
EPIPEN
Task:
Talk to the mom , address her concern and teach her how to use the epipen
Concern:
What If she doesn’t respond to it first time. Should I use it again?If she
develops rash should I use it?
what if I use the PEN and it’s not anaphylaxis?
Management:
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 Explore anaphylaxis, take history of the incident, and explore symptoms,
do head to toe, BIRDDD, MAF (take focused and short history)
 Now assess knowledge about the Epipen, explain i t ' s p a r t s .
 Explain about the signs and symptoms of anaphylaxis(swelling of throat,
lips, eyes, difficult breathing)
 Teach Epipen as taught in academy
 Use Epipen when signs/symptoms of anaphylaxis and call ambulance
immediately
 Explain she can give epipen even if she is not sure if either he is having
signs of anaphylaxis or not
 It is not going to be harmful for the kid even if you give it to him and later
realize it is not anaphylaxis. He might experience some heart racing, etc
but it would settle in 15 to 20 minutes.
 Always have 2 Epipen, use another one in 5 minutes if ambulance doesn't
arrive
 Avoid triggers and advice about trigger diary
 Offer support
 Refer the patient to the allergy clinic. So that we can know the cause of the
reaction and a diagnosis can be made.
 Give the child a bracelet to wear
 Safety netting
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65.Refusal Station:
History:
 A 25 year old male in the A&E
 He is in the A&E for 2 hours. He was diagnosed with hypoglycemic fit
and was managed, advised to be admitted which he refuses.
 He developed LOC and jerky movements.
 He was brought to the A&E by ambulance.
 This is the 1st time he developed such symptoms.
 Diagnosed with type 1 diabetes 10 years ago.
 He skips his insulin doses and meals recently, as he'sbusy with work
arrangements.
 He’s a truck driver.
Task:
take focused history, discuss diagnosis and management.
Concern:
What are they going to do for me in the hospital?
he wants to go home
take observations, examine tummy
Blood (RBS/ ESR, CRP/ cholesterol/ ABG/ KFT), Urine (dipstick culture +
ketone bodies), chest X-ray for infection, Erect abdominal X-ray, RBS,
ABG (metabolic acidosis)
Management:
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 explore presenting complaints and take full history of diabetes (for how
long, medication, if it’s controlled,complications, check ups, any
challenges, what happened today)
 exclude red flags, infection, DESA, MAFTOSA
 Do ICE, verbalize examination and explain what is DKA it’s a serious
condition if not treated can be life threatening
 tell the patient he needs admission, if patient refuses
 use refusal approach
 Explain what treatment will be provided in the hospital (insulin via
drip), fluid to reduce dehydration
 Address concern of the patient, ask for the reason of
 refusal and give solutions
 Advice to inform DVLA
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66.Skin mole:
History:
 You are FY2 in surgery out patient department
 A 55 year old man has come with a complaint of a molefor several
years
 He wants to remove it, it is sometimes itching with tingling sensation.
 It’s black in colour, bleeds sometimes, no pain
 It is increasing in size for the last few months
 FLAWS negative, (+/-) family history of cancer
 No smoking/ alcohol
 No past medical, medication or surgical history
 Patient like sunbaths
Task:
Talk to the patient ,address his concerns , discussmanagement
Concern:
What will you do for me?
Do I have a cancer?
Observations , check skin lesion, neck and armpit forlymph nodes
Routine blood test, chest X-ray
Management:
 Explore the skin lesion (site, size, shape, duration, margin, colour, any
changes, bleeding, itchiness etc)
 Ask psycho social effect
 do differentials and FLAWS
 Ask about past history, MAFTOSA,12DESA, contact, sun bathing
 ask concern and idea then summarize what you are suspecting in a
calm way “ in best case scenario it couldbe some sort of skin infection
or other benign cause butin worst case scenario it could be something
sinister likeskin cancer.”
 Urgent referral within 2 weeks to dermatologist
 Dermatologist can carry out further examination. Hewould send for a
biopsy to determine its type, assess itsspread also to confirm the
diagnosis. The treatment options will depend on its stage and extent
can betreated with surgery, radiotherapy, chemotherapy
 Address rest of the concerns
 Safety netting
67.Allergic rhinitis:
History:
 A 35 year old man has come with sneezing for two months, it’s getting
worse, he has runny nose , and nasal clear fluid discharge, no blood in
it
 It’s not related to the weather
 it becomes worse if he goes out
 No other symptoms
 No medical condition, no drug history, allergic to dust and pollen
 Family history of asthma and hay fever
 He smokes cigarettes, and drinks socially
 Works in a bank and it’s affecting his
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Task:
talk to the patient and assess him , discuss management
Concern:
what are the side effects of steroids?
Take observations and examine head to toe, noseroutine blood test
Management:
 Explore sneezing, ODPARA, associated symptoms (cold, cough, SOB,
FLAWS), exclude DD (polyp, covid, nasal obstruction, sinusitis)
 Past medical history, MAFTOSA, DESA , do ICE
 verbalize examination and summarize you aresuspecting allergic rhinitis
which is an inflammation of inside of the nose caused by allergen such
as pollen and dust
 Avoid triggering factors, smoking , dust , pets, pollens, keep windows
shut
 Offer treatment nasal irrigation with saline using a pump or spray, use
anti histamine, steroid nasal spray toreduce swelling and inflammation
 Say nasal dryness , irritation, nose bleeds
 safety netting
 Follow up in 2 weeks
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68.Acute back pain
History:
 36 year old patient presented with back pain,lifted heavy object 2days
back,took paracetamol but didn’t work.
 Severe pain, patient holding his back 8/10 have weak and sensation loss
in the right leg.
 Unable to control bowel,have numbness around back passage, urine
retention for the last 8 hours
 No past medical condition
 FLAWS negative,no other symptoms
Task:
take focused history, assess , and discuss themanagement with
the patient
examination and Investigations:
take observations, head to toe Tenderness on the lumbar region
Neurological Examination:
lower 2/5 on Right side
Normal on the left side
Tone reduced on the right and normal on the left Loss of sensation on the
lateral side of the thigh.
SLRT positive and PR exam for tone of anal sphincter.
all blood, Supine X-ray
Management:
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 do SOCRATES of pain And differential (AAA, Prostate. Cancer, Cauda
equina syndrome)
 Past medical history and MAFTOSA
 Verbalize examination and summarize
 Explain cauda equina syndrome as you have loss of sensation,inability to
pass urine and SLRT findings positive on examination.Most likely the
cause of your symptoms is slipped disc have caused compression on the
nerves.
 Involve senior
 Immediately refer to orthopedic and neurosurgeon
 Give proper pain killer,diazepam,catheter
 Explain might need operation to relieve the compressed nerve
 occupational therapist to readjust the environment of work
 safety netting
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69. Obstructive sleep apnoea:
History:
 A 42 years has been presenting with complaint of tiredness forlast
4months
 He doesn’t feel refresh in the morning after waking up, he sleepswell ,
doesn’t take naps during the day
 He snores at night, wife complaints she can not sleep due to snoring ,
Doses off at times in the day doesn’t have any other symptoms , infection ,
recent flu or fever,weight loss etc , he eats everything and has minimal
physical activity
 He is also a smoker and has high alcohol intake
 His FLAWS negative
 No Medical condition, medication or family history
 The patient is a lorry driver
 He is overweight and his BMI 35
Task:
Talk to the patient and address his concerns
Concern:
I don’t want to give up driving
Management:
 Take focused history (ODIPARA, associated symptoms, FLAWS,medical
conditions, medication, psychological, Occupation, Driving)
 Verbalize examination (BMI, GPE, Vitals)
 Explain suspected diagnosis of obstructive sleep apnoea
 Involve senior and refer to sleep clinic for polysomnography test
 Advise on DESA especially weight loss, life style advice, use ofCPAP
 Support and advice to inform DVLA.
 Ask employer to give another job or contact citizen advisory bureau
 Safety net
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70.Intussusception:
 History:
 You are FY2 in pediatric department
 A 30year old lady has brought her 18month old baby, as he was having
inconsolable crying for 10min, cries for 5min continuously and then
stops for 1 min and start again for another 5min.
 The child cries while pulling legs. To tummy, had 2 episodesof diarrhea
with bloody stool (currant jelly stool)
 Vomited twice, contained food particle, not projectile
 child is lethargic and is not eating or drinking properly
 He born normal vaginal delivery, no complication during or after
birth, no relevant past medical history or hospital admission
Task:
Talk to mother asses the baby and discuss management plan
Concern:
Whats wrong with my child?
Investigation and examination:
Take observation , signs of dehydration
Head to toe
Routine blood, LFT, KFT, Xray of tummy, urea and electrolytes
Management:
 Take focused history, explore vomiting, do differentials (pyloric
stenosis), BIRDDD, head to toe questions, MAF, diet, injury , recent
infection ,bowel and bladder
114
115
 Do ICE, verbalise examination and explain you suspect intussuseption,
when a portion of bowel goes inside of another like a telescope
 Explain management plan , need immediate admission, involve senior
 Fluids through vein, pain killers, NG tube
 There are two types of treatment , one is specialist will try to pushthe
fluid , if fails then surgery
 Address concerns and reassure
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116
71.Ear examination:
History:
 you are FY2 in in general practice
 35 year old man has come with hearing problem andear pain for last
two weeks
 he works in the bank,this is affecting his work
 He came a week back and was given ear drops due toear wax,but
didn’t work
 He is generally fit and well,no other symptoms,no
dizziness,discharge from the ear,no fever
 No medical condition,or allergies
Task:
take focused history,perform relevant examination and discuss
management
Take observations and head to toe examination Perform otoscope
examination of the ear Routine blood
Management:
 paraphrase the scenario and do ODPARA of the presenting
complaint(explore hearing loss and ear pain,cardinal symptoms)
 take focused history and rule out differentials
 Do ICE and perform ear examination as you weretaught in the
academy
116
117
 Finding is impacted ear wax,as bicarbonate drops didn’t help refer

him to the specialist for ear irritation/micro suction
 Advice maintaining hygiene,avoid using cotton buds
 advice covering ear canal while swimming
 Safety netting
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72.Traveler from uganda
History:
 You are FY2 in General practice
 A 30 year old man presented with fever with chills and rigor, he didn’t
measure the temperature,mostly rises in the evening
 He took paracetamol but didn’t help
 No other symptoms, no rash, no shyness to light orneck stiffness,no
cough or shortness of breath
 he is feeling weak and malaise
 No past medical history of medication history
 He has travelled to Uganda for business trip few weeks back
 He does not receive travel Vaccination, not sure about insect bite
 He is only one having this symptoms , no one close to him has
similar symptoms
Task:
take focused history and discuss management
Take observations and examination head to toe,look for
rashes,abdomen examination
Routine blood tests,thick and thin film to check malarialparasite,LFT,KFT,
covid test,Inflammatory markers
Management:
 explore fever, ask about other symptoms, do differentials
(meningitis,infection,TB, covid ,malaria)
 ask past history and MAFTOSA
11
8
11
 Explore travel history,ask about travel vaccination,purpose of travel,any
9
activities during travel (swimming,hiking,camping), exclude contact

history, insect bite
 do ICE, verbalize examination and summarize that you are suspecting
malaria to confirm tell the investigation he needs
 Arrange hospital admission
 Explain what treatment will be provided,if it is confirmedanti malarial
drugs will be given
 symptomatic treatment to lower down the fever offerantipyretic
medication
 safety netting
11
9
12
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73.Prescription
History:
 40years old man came to the hospital and diagnosedwith DVT
 patient is also hypertensive, on regular medication
Task:
 Prescribe rivaroxaban
 amlodipine 10mg
 Aspirin 75 mg
 Paracetamol 1 gm
Management:
 Greet the examiner
 Setting prescription paper, BNF , pen sticker
 Fill up the prescription and check BNF
 do not prescribe aspirin
 Prescribe Rivaroxaban dose from BNF
12
0
12
1
74.Speculum combined
History:
 A 45 yrs old lady coming for routine Pap smear appointment, she has 2
kids.
 Last pap was 5 years ago, came out normal.
 She has no symptoms no bleeding, discharge
 Last menstruation 2weeks back
 She has been experiencing heavy bleeding for few monthsduring period
 Sexually active no use of devices, use condoms
 Exclude any contraindication to Pap smear (recentsex, spermicidal gel,
menstruation).
Task:
Talk to the patient and collect the Pap smear.
Concerns:
When will the results be ready?
Management:
 Paraphrase the scenario, and take focused history and build goodrapport
 Ask about previous PAP smear, any concern regarding that, active
bleeding, use of spermicides, last sexual intercourse etc
 Explain PAP smear, do PPCCE.Set up the clean area. Gatherthe
equipment.
 Do the procedure
 Speculum show white ring around cervix
 It was surepath preparation;make sure you detach it properly.
 After taking the smear,label it and send it to lab
12
1
12
 Thank the patient and address concern, result will be within 2weeks
2
 Safety netting about any abnormal vaginal bleeding,and FLAWS

symptoms.
12
2
75.Mom had a fall:
History:
 You are FY2 in orthopaedics department
 An 80 year old lady has presented in the hospital after a fall
 She sustained a fracture of the wrist and which has been fixed the
specialist team
 She was admitted to the ward and examined by physiotherapist and
occupational therapist who recommended her to use walking sticks
 Social services has recommended her caregivers tocome twice
everyday
 She is mentally well and capable of understanding information
 All her investigations came back normal
 She is ready to go home, she is normally fit and welland walks
independently, not on any medications
 Her son has been informed , permission has been takenfrom the mom
to talk to him
 He thinks his mom is not safe to go back home, and hethinks nursing
home is a better place for her
 Son Doesn’t live with the mom, he lives in a different city
Task:
Please talk to her son and address his concern.
Concerns:
I don’t want her to go home, she will be safe in carehome. will you
take the responsibility if she has another fall?
Management:
 Greet and confirm identity , confirm the relationships Paraphrase the
scenario 12
3
 Build a good rapport, Check understanding of his mother’s condition
 Explore how much does he know, what happened with her, what test
were done, what was the diagnosis and management,
 Has anyone discussed about her management planafter discharge , or
Did he talked to his mother
 Ask about medical condition, psycho social, who lives with her, who
mostly takes care , tell him that social services has been confirmed
career visit twice a day
 Appreciate him for being so caring son, and explain the multi-
disciplinary approach towards her
 Tell him that right now we will follow what the team suggest, nursing
home can be an option if she fails to cope up with her condition
 Also assure him we will book an appointment with GP for home visit
after few days of her discharge
 Address concerns, assure him we will do the best to make sure she will
not have another fall , but we can’t guarantee that she won’t have a fall.
That’s why we will involve the social service and occupational therapist
to check everything that is suitable for her
 Thank him and appreciate him again
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4
76.Breaking bad news
History:
 A 77 years old man who has collapsed at home andbrought to the
hospital by an ambulance.
 Patient’s wife has come to see her husband
 she was watching Football match with his husband when he suddenly
collapsed. She called the ambulance and he was brought to the
hospital. She came to the hospital byher own.
 The neurosurgeon has assessed him and have classified the condition
as terminal as they felt an operation wouldn’t resolve the situation.
 The CT scan of the head was done and showed massive intracranial
hemorrhage. The neurosurgeon believe it is berry’s aneurysm.
 He had a stroke previously few months back
 Patient is lying unconscious and breathing independently.
 He is hypertensive and on ramipril, diabetic and hasstable angina.
 Non smoker, non alcoholic
Task:
talk to the patient’s wife, tell her about the patient’scondition and
address her concern
Concern:
Are you going to send him to ICU?
How much time does have left?
Would he need surgery?
Management:
 Introduce yourself, greet and confirm identity andrelationships
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5
 Assess knowledge and take history about the incident, (before-during-
after)
 Ask about bleeding disorder, medical condition, medication history,
blood thinners, DESA
 Do breaking bad approach, ‘your husband was brought to the hospital
by an ambulance unconscious. Unfortunately, He is still unconscious
and we have doneCT scan on his head But, the results were not what
we are hoping for.
 explain the massive haemorrhage and what specialist has taken
decision. Offer support.
 Explain palliative care.
 Address concern; Unfortunately, ICU is where we putpatients who
will recover. It won’t be beneficial to him.
 It is difficult to say how much time he has left but I willspeak to
surgeons if they can give us a time frame.
 explain her the possible cause of this , like hypertension
 explain why surgery is not possible
 Talk in a very calm voice and comfort her, answer all herquestions.
12
6
77. simman
History:
 28 year old male has been brought to the hospital
 He has vomited a lot of blood (there will be bowl full of
blood)
 He gastric acidity , heart burn and bloating for few
months and has undergone a endoscopy yesterday
 No past medical history, used to take anti ulcer-ant for
the gastric symptoms, no bleeding disorder, not taking
any blood thinners
 Patient is feeling dizzy
Task:
Talk to the patient, do management
Patients vital in the monitor
O2 94%
BP 80/50
Pulse 110 tachycardia
RR 18
Management:
 Greet , introduce yourself and confirm identity
 Take focused history (vomiting) past medical history,
medication and allergy
 Do ABCDE , give oxygen
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7
 do X-RAY of the chest , ABG, ECG
 Do cannula in both hands
 Give fluid Hartman (do fluid challenge), take blood
sample for investigation including blood grouping and
cross matching
 Give 2 units of O negative blood right away, until you
receive cross matched blood from the blood bank
 Admit the patient for farther management
 Involve senior, call for Gastro-enterologist for further
scan and management
78.Anemia
History:
 A 30 year old lady has come for the test result she has
done a week back
 She presented with tiredness , and dr has requested
blood test
 She still feels tired all the time, no other symptoms, she
works as an accountant and it’s affecting her work.
 She decided to be a vegetarian 2 years ago for
religious reasons. she does not eat eggs or redmeat.
12
8
Not willing to change her diet because of her religious
beliefs.
 she has 2 children and finding it difficult to cope with
caring of them.
 No other medical condition , bleeding disorder or
medication use
 Period is regular, mood fine
Task :
Talk to the patient and discuss test result and do
management
Concern:
Another Dr said I’m anemic but I don’t need injection
Hb 10.1gm (Low),
MCV 120ft (High),
Ferritin 30gm/ml, Iron 13g/dl,
Folic acid 12mmol/L,
Vit B12 100pg/Dl (200-800).
Management:
 Paraphrase the scenario , explore tiredness , recent
condition ,any new symptoms, red flags, tingling and
numbness of hand, problem in balance while walking
 Ask MAFTOSA , DESA
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9
 Do ICE, verbalize examintaion and explain test result,
she hasbeen having vitamin b12 deficiency, as she is
vegetarian that isthe reason of this
 Involve senior, and run special test to check intrinsic factor
toensure that vitB12 can be absorbed in diet, IgA TTG,
a n t i t h y r o i d antibodies
 Treatment: injections 3 times weekly for 4 weeks then
injectiononce monthly
 Address her concern , she needs injection , otherwise if
its not treated can turn into something serious
 Specialist: Blood specialist (anti parietal cells
antibodies,anti-intrinsic factor antibodies)
 Advice: DESA: would u consider eating meat, egg ...
etc.?Otherwise it will be a must to take vit B 12 for life
 Safety netting: persistence tiredness
79.Headache
History:
 A 17 year old lady is calling you with some concerns,
she has been experiencing headache which is dull,
continuous, all around the head, not radiating anywhere
13
0
,no associated symptoms like blurry vision, nausea,
vomiting
 Her headache usually starts before her period and
stops about 2 days into period
 she tried ibuprofen and paracetamol but it didn’t help
 No past medical and medication history, or family
history of similarsymptoms
 Her menstruation regular,otherwise fit and well
 no smoking or alcohol habit, diet normal
Task:
Talk to her, address her concerns and discuss
management
Concern:
I am worried if I take steroids they would increase my
weight.
observations, Fundoscopy, Nerves of headand
arms,Ear and nose
Routine bloods,ESR and CRP
Management:
 Greet and confirm identity, start with telephonic
approach
 Explore the headache,do ODPARA
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1
 Do differentials, ask pre-menstrual symptoms questions
(breast tenderness,loss of appetite,mood swing,trouble
sleeping,low sex drive)
 ask menstrual history, sexual history, pills, mood
 Do ICE; verbalize examination and investigation
 Explain menstrual migraine which precipitated by period
 Offer sumatriptan during the attack of migraine as
ibuprofen and paracetamol are not working
 Advice of keeping a diary of period and headache
 Once the relationship between the headache and
menstrual period has been confirmed then she needs
tostart on COCP to be taken continuously.
 when she will ask about weight gain,tell her about
dietitian and exercise
 Follow up in three months
 Safety netting
80.Confusion
History:
 A 65 years old female has presented with confusion in
themorning,has been brought by her daughter
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2
 she had no history of fever,chest infection or urine
infection and nohistory dementia,no additional
symptoms or red flags
 She has been diagnosed with depression and is taking
citalopramfor 5 months
 She also has hypertension and has been taking anti-
hypertensivemedication(Thiazide)
 Her daughter is in the cubicle and is very concerned
about hermother
 She has the consent to talk about her mother
Task:
Talk to daughter and address her concern
examination and Investigations:
Take observations and head to toe Routine
blood,LFT,KFT,CT Scan,ABG
Blood tests shows hyponatremia 122 mmolCT scan is
normal
Concerns:
What happened to her?
Is she going to be alright?
Management:
 Greet,confirm identity and ask about consent
 Take focused history including red flags and risk factors
(infections,fever,dementia,medical
13
3
conditions,medications), ODPARA of tiredness , past
medical andmedication history
 Do ICE
 Verbalize examination and investigation
 Explain test results to the daughter,including
hyponatremia and itsrelation to her mother’s
presentation(Low salt levels can be cause of the
confusion)
 Explain how her medication(Citalopram and
thazide)could be thecause of low salt levels leading to
confusion
 explain management plan,she needs to be
admitted,and fluids willbe given
 Involve senior,Specialist referral and medication review
will be done
 ask psycho social questions and if she needs any support
13
4

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1

1.Rape of a 16 year old:

 Acknowledge , offer confidentiality and Take focused history what

2.Teaching (taking consent)

3.lady wants to conceive

 He is not expecting anything serious, had some symptoms of jaundice and

 Nowadays he has been sleeping on the couch due to cough

7. Mom concerned of her child:

Take focused history , perform relevant examinationand discuss

 Do ICE, verbalise examination and summarise this is a condition called

Can’t mention about any medical condition or familyhistory or mental

 He works in a warehouse, where he needs to pick up heavy object

Doctor I don't have any symptoms how this could happen?

 Explain advance care planning , ventilation if she becomes ill , faces

20.Father concerned about daughter:

21.Ante natal examination

 No signs of pre eclampsia

 If the manoeuvre doesn’t help then we might need to gofor Caesarean-

 Take focused history, ODPAR of presenting complaint, ask red flags,

 Morphine for pain via syringe driver 30mg per 24hours

 check patients file and check monitor

Take observation , head to tow , eye examination ,visual field,

Visual acuity R>6/24 L>6/6

Red reflex abnormal in right eye

 Take focused history (ODIPARA, associated symptoms, red

 Explain diagnosis retinal detachment is emergency situation in

 Aging is the most common cause of retinal detachment. As you

 Immediately refer to ophthalmologist

 Further management includes Scleral buckling or Lasertreatment

 Safety net for driving

 Explain he have been prescribed antibiotic unnecessarily, when

41. Bullimia nervosa

 Refer to child and adolescent mental health team

 Rule out red flags doing systemic review

 Do ICE, verbalise examination and summariseeverything looks

45. Angry patient

 opening sentence of the patient , ‘I want to know why I had wound

 Offer sick note if she was facing any challenges at work.

Observations (BP standing and lying ), general physicalexamination

 Take focused history for assessment (General health,Past medical

58.Disclosing test result:

 Finding is impacted ear wax,as bicarbonate drops didn’t help refer

activities during travel (swimming,hiking,camping), exclude contact

 Safety netting about any abnormal vaginal bleeding,and FLAWS

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