Medicine

Medicine
Dr. Riley Harrison

Case list
Headache
• Migraine *****
• Meningitis****
• Transfusion headache*
Chest pain
• AMI*****
• Silent MI**
• Pericarditis***
• Pulmonary embolism ***
• Pericaditis pain needs Morphine**
• Spontaneous pneumothorax****
• CVS risk assessment**
• Bradycardia*****
• Prolonged QT****
Tiredness
• Infective endocarditis*
• IDA*****
• OSA*
• Hypothyroid*
• Sleep deprivation*
• Temporal arteritis patient stops steroid*****
Palpitation
• AF*
• SVT*
• Hyperthyroid*****
• Falls
• Recurrent falls***
• Postural hypotension*****
• Funny turn*****
• Hypoglycaemia**
• Shakiness and shoplifting***
• Tremor ***
Respiratory symptoms
• Spirometry – restrictive, COPD****
• Chronic cough with weight loss****
• Effusion****
• Drug induced cough*
• Lungs abscess***
• Haemopneumothorax*
• Pneumonia risk assessment*
• Sorethroat requesting antibiotics**
• Hay Fever*****
• Allergic Rhinitis****
• Asthma****
Counselling and patient education
• Ulcerative colitis counselling*
• Liver metastasis****
• Gout*
• Rheumatoid arthritis*
• Epilepsy and driver license***
• Acne and side effects of retinoid*
• Lithium travel advice *
• Antihypertensive non-compliance****
• BCC*****
• SCC*****
• Melanoma*****
• Haemochromatosis*
• Covid vaccination counselling ***
• COPD patient signed DNR***
• Infectious monocucleosis*
• Rusty nail *
• Domestic violence*
• Hypertension counselling (2 cases)*****
• Chlamydia (STD screening)*****
• Painful rash on groin*
• Colles fracture
• Glucometer and diabetes counselling***
Neurology
• Trigeminal neuralgia****
• Viral encephalitis*
• Stroke (weakness of the limbs)*
• Stroke Ct interpretation**
GI and liver
• Hiatal hernia*****
• Drug induced Hepatitis**
• Heroine patient unwell*****
• Incident at work unwell patient ****
• Diarrhoea **
• Drug induced diarrhoea****
• Heart failure
• Bilateral leg swelling*
• SOB heart failure****
Miscellaneous
• PCP pneumonia*
• Erectile dysfunction*
• Hypercalcaemia**
• ITP*
• Urticaria*
• Lymphoma*
• Acute on chronic renal renal failure*
• Snake Bite*
• Paracetamol poisoning*
• Weight loss work-up*
• Excessive Thirst*****
• IBS with anxiety****
• Male UTI***
• Alcoholic neuropathy****
Headache
Migraine
A 30 years old female patient, Susan, came to your GP with a headache. She has been suffering from
that headache 2 years ago. She tried Panadol for the headache but sometimes it didn’t help. Now she
is seeking help from you. She is having a blood pressure of 120/80 mmHg and a heart rate of 84/min.
• Your tasks:
• Take relevant history
• Explain your diagnosis and differential diagnoses
Approach how many times in a month

• Headache – How many times? Similar? Where? (unilateral, bilateral), When did it start?
Character? Radiation? Severity? Aggravating factor? ( Light source, noise, activities) Relieving
factor? (silence, Dark room, sleep, vomiting), Duration? Offset? give egs of agg factors like light etc
• DDx – give eg of relieving factors as well
examples
• Migraine –Do you feel anything before your headache like Light spots, flashing, tingling,
numbness, weakness, gait disturbance? (aura) Did the headache happened after that? Any
relation with food? (alcohol esp red wine, chocolate, wall nut, cheese), Female – relation with (period
period? Sexually active? Contraception? migraine)
• Injury – any head injury (see bc ocp is c.i if aura0
bc 2 or more in a month, we should consider
• Cervical spondylosis – Neck pain? prophylaxis.
• Cluster headache – Red/watery eye?
• Trigeminal neuralgia – pain in the face?
• Sinusitis, URTI – sneezing, runny nose?
• Any ear infection?
• Meningitis – fever, rash?
• Glaucoma – blurring of vision? pain behind the eyes
• SOL – early morning vomiting? Limb weakness?
• How does it affect your daily life? Any stress?
• Past medical, past surgical?
• Family history of migraine?
• SADMA
• Explanation – Your headache is most likely a condition called migraine – dilatation and swelling
of blood vessels inside and outside of the scalp in some people – results in more blood pumping
through the vessels causing a throbbing headache.
• In some patient – each attack is associated with waring signs (aura)
• Very common in young age, but it is not serious, not due to pathology in the brain
• The frequency and the severity will reduce over the years
• Others - DDx (previously asked in history less likely)
• Management (not usually asked) – reference RACGP
• Acute treatment cascade
• Stage 1 (a puff)
stage 1
• The patient is aware that a migraine is commencing but the level of pain lies between 1 and 2 on
a scale of 0–10.The patient applies nonmedical measures such as lying or sitting down in a dark
room with a cold cloth on the forehead, and some form of relaxation technique. If these
measures are not effective, a combination of antiemetics, simple analgesics, and NSAIDs can be.
Whether or not there is nausea, it is often useful to ‘prime’ the analgesic or NSAID by
administration of an antiemetic 5 minutes earlier. This relieves the gastric stasis that sets in at
the onset of a migraine attack, hindering absorption of medication. Double blind controlled
clinical trials have shown the efficacy of simple analgesic combined with an anti-emetic.13 Apart
from nausea and abdominal irritation, side effects rarely occur. Rectal administration of NSAIDs,
analgesics or antiemetics in cases of severe or early nausea may be useful.
• Stage 2 (a gust)
• When the level of pain is 3 or more on a scale of 0–10, the use of antiemetics followed by
migraine specific medications such as ergotamine or combinations of ergotamine with caffeine,
should be considered. The combination of antiemetic, ergot derivative, NSAID and an analgesic
such as codeine or a codeine-paracetamol combination is useful. At this stage, as an alternative
to the above, the use of triptans may be considered.
• Stage 3 (a gale)
• This is the stage where simple nonpharmacological measures, nonspecific drugs, and disease
specific drugs have been ineffective. This is the stage where medical help should be sought and
parenteral medications and sometimes intravenous fluids considered • Outside hospitals and
emergency departments, narcotics should not be used. In the inpatient setting for very severe
cases of migraine, narcotics such as pethidine are used, but this is under controlled
circumstances. Drug dependency (either psychological or physical) is a real danger, and very
difficult to break in general practice • If feasible, the patient should be in a dark, quiet
environment • Avoid early discharge home as this frequently results in re-presentation.
• Prophylactic management (if more than 2 attacks per month0

• A very important aspect of the management of migraine is the prevention of future attacks. If
considering prophylaxis it is vital to ensure the condition being treated is truly migraine and not
• chronic daily headaches with occasional migraine peaks, or • episodic tension type headaches
where the management differs quite substantially. As a general rule, if there are more than two
migraines per month it is worthwhile considering prophylaxis.
• Prophylaxis
• avoidance of triggers
• Triggers may be as mundane as a sensitivity to perfume or cleaning agents, the eating of certain
foodstuffs, menstruation, or emotional ups and downs. Patients may need prompting to recall
triggers such as lack of sleep or too much sleep, or specific times of the week when migraines
tend to occur; but in the majority of cases the patient will be aware of their unique triggers.
• Medications for prophlaxis

• Medications such as propranolol, metoprolol, amitriptyline, pizotifen and methysergide have
been used for several decades and are well accepted, proven prophylactics.
• Newer medications with demonstrated efficacy are valproate, flunarazine and topiramate
(medications like b blocker and some other medications)
Meningitis
You are a GP. 25 years old lady, Vanessa, came to your GP with the headache and request a sick
certificate.
Tasks
• History
• PEFE,
• Dx and DDx
Approach v. imp point, u dont have to check aura and migraine relations if first time
• Headache – Is it first time? Yes – when did it start? Where is the ache exactly? How is the
nature? (sharp, dull, throbbing, constricting)? How severe? Aggravating factor? ( Light source,
noise, activities) Relieving factor? (silence, Dark room, sleep, vomiting)
• DDx –
• Infection – fever? Muscle aches? Pain on the cheeks - Sinusitis, URTI – sneezing, runny nose?
Otitis – ear pain?
• Injury – any head injury
• Cervical spondylosis – Neck pain?
• Cluster headache – Red/watery eye?
• GCA – Any cord like structure on the face? photosensitivity
• Meningitis – fever, rash? Neck stiffness? Afraid of lights? Vomiting?
• Glaucoma – blurring of vision? Eye pain?
• Stress?
• (((Migraine – Light spots, flashing, tingling, numbness, weakness, gait disturbance? (aura) Did
the headache happened after that? Any relation with food? (alcohol esp red wine, chocolate,
wall nut, cheese), Female – relation with period? Sexually active? Contraception?))) Only if not
first time
• Past medical, past surgical?
• Contact history?
• Family history of migraine?
• SADMA
• PEFE- GA , VS
• ENT, eyeball tenderness
• sign of head injury
• Cord like structure in temporal region
• Neck stiffness
• Kernig sign, Brudinzki’s sign
• Fundoscopy
• Systemic – resp, CVS, Abdomen
• UDT
source could be ear infection etc
• Dx – Meningitis – inflammation of the covering of the brain. It could be Viral or bacterial
infection. Others – Encephalitis, URTI, sinusitis, Ear infection, GCA, SAH (bleeding inside brain),
migraine or head injury unlikely.
• Mx – arrange for investigations (baseline blood tests and LP) , Give antibiotics IV and transfer to
hospital
Transfusion headache
60 yr old female, Wendy, taking blood transfusion for the 1st time blood is correctly matched started
having headache after starting it 10 min ago.
• H/0,
• pefe,
• dds
History
• Headache – Is it the first time? Since when? Were you alright before? Where? (unilateral,
bilateral), Character? Radiation? Severity? Aggravating factor? ( Light source, noise, activities)
Relieving factor? (silence, Dark room, sleep, vomiting), Duration?
• DDx –
• Any history of migraine?
• Injury – any head injury
• Sinusitis, URTI – sneezing, runny nose? Cough?
• Otitis – ear pain, discharge?
• Meningitis – fever, rash?
• SOL – any nausea, vomiting? Any weakness in your body?
• Temporal arteritis – any cord like structure or pulsation in your temporal region?
• Glaucoma or other eye problems – blurring of vision? Pain in the eyes?
• Stress – any stress?
• Any medications you are having right now? Is it your first experience of blood transfusion?
Other reactions of blood transfusion - like chills, malaise, abdominal pain, back pain, SOB,
skin flushings, dark urine?
• Past medical, past surgical
• SADMA
• PEFE – GA, vitals (esp BP)

• Check the blood bag and rate of transfusion and stop
• Any cord like structure in temporal region
• Eye – eyeball tenderness? Cranial nerves – 2nd, 3rd, 4th, 6th
• ENT, Sinus palpation, neck stiffness
• Neurological examination of upper and lower limb, other cranial nerves examination
• Systemic - Respiratory, CVS, abdomen
Explanation
• Most likely the headache you are having is because of blood transfusion. But we have done
cross matching of your blood with donor blood and they perfectly matched. Although the major
things are matched, it could still be possible that your blood and the donor’s blood may have
some minor differences
• These results in common minor reactions of blood transfusion like – fever, headache, chills,
urine color changes, skin flushing and minor tummy pain.
• I am also thinking of a cerebral vasoconstriction i.e, the narrowing of blood vessels in the brain
which is a rare complication of blood transfusion but this is unlike in your case as this condition
usually shows up after 2-7 days of blood transfusion.
• Other possible causes could be hypertension, temporal arteritis, stress headache or eye
problems but unlikely in your case.
Chest pain
AMI 1
50 years old male, Robert, presents to you with a chest pain 30 mins ago, ECG given below, you are in
HMO in a rural hospital. always check ur role if rural refer to tertiary hospital
• Tasks:
• Explain ECG to medical student,
• And management to the student
• Explain ECG to the student – rate is 300 divided by no of small squares, rythum is regular, if no axis
• Rate. deviation just skip, if presnt tell, p wave ,pr interval, followed by qrs, qrs
• Rhythm. widened or not,
st segment elevation in which leads, q wave, t wave matters in hyper and
• Axis (normal, right or left axis deviation).
hypokalemia
• P wave.
• PR interval.
v5, v6 lat leads
• QRS complex. v3 , v4 ant leads
• Q wave and ST segment in which leads??
• T wave.
management= oxygen if less than 93%, GTN sub lingual every 5 min for max 3
• Findings and diagnosis.
doses after excluding recent use of sildenafil, oral aspirin 300mg, i/v opiods like
fentanyl if pain do not respond to GTN.
Management (JM)
if transfer available, transfer, if not manage, if nothing given talk abt both approaches
• So what we can do here is give him enough oxygen (when <93%) , Secure IV lines and take blood
for cardiac enzymes, urea and electrolytes. Aspirin300mg and beta blockers or ACEI will be given
now. (Nitrates Sl or spray every 5 mins as necessary to max of three doses, Morphine 2-5mg IV
bolus and 1mg/min until pain relief up to 15mg will be considered). Registrar will come and
check him.
• We will organize an urgent cardiology consultation for risk stratification and a decision whether
can be teleconsultation
to proceed.
• The ideal management is urgent referral to a coronary catheter within 60 mins which is the
golden hour. The principle is to achieve rapid perfusion via primary angioplasty with a stent.
• Adjunct therapy will include Aspirin/clopidogrel and heparin and possibly glycoprotein IIb/IIIa
platelet inhibitor such as prasugrel, ticagrel or abciximab.
• If we don’t have any option to transfer, after the decision by the consultant, we will consider
fibrinolytic therapy. We have to exclude the contraindications first like prior ICH, any known
cerebral vascular lesion, any malignant intracranial tumor, ischemic stroke within 3 months,
suspected aortic dissection, any active bleeding (including menses in females), any previous
head or face trauma within 3 months, any intracranial or spine surgery within 2 months, severe
uncontrolled hypertension.
• We use second generation fibrin specific agents such as reteplase, alteplase or Tenecteplase)).
Streptokinase is inappropriate for Indigenous people and for those who have received it before.
• After that further management with heparin, beta blocker, nitrates and ACEI will be necessary
and also transfer for angiogram.
• There are some risks like intracranial haemorrhage or other bleeding, nausea, vomiting,
hypotension especially with Streptokinase, allergic reaction to the medication or some
arrythmia
• If unsuccessful, we also transfer urgently for rescue PCI.
AMI 2
50 years old male, Robert, presents to you with a chest pain 30 mins ago, ECG given below, you are in
HMO in rural area, the nearest hospital is 4 hours away and you have no option of transfer at the
moment. Rural hospital setting. Tertiary hospital 400km away.
Tasks: no option for transfer
• Explain ECG to examiner,
• And management to the wife
• (you can ask a brief history from wife if you need anything)
contraindications u should ask because not a separate task
• Explain ECG to the examiner –
• Rate.
• Rhythm.
• Axis (normal, right or left axis deviation).
• P wave.
• PR interval.
• QRS complex.
• Q wave and ST segment.
• T wave.
• Findings and diagnosis.
History if hx separate task

• Authority always need to ask the authority, do u have the authority to discuss abt ur husband
• Brief history from wife – if separate task
• task
if hx separate Details of pain - LOSTRADIO Location, Onset, Severity, Type, Radiation, Relieving factors,
Aggravating factors, Duration, Intensity, Other association
• Is it the first time? Any drug allergy?
• Any other associated condition - ABCDEFS
• Does he have history of bleeding, liver disease. Kidney disease or diabetes? Recent stroke?
Recent surgery? Recent bleeding? (for fibrinolysis)
• Management – Explain AMI. Draw the heart. The heart itself is supplied by the vessels to
perform the pumping action. Now these vessels have been blocked leading to the damage of the
heart muscles. The longer the duration, the more the heart muscles die. We need urgent
intervention. In here, rural hospital and no facilities for PCI, which is the insertion of the stent.
• So what we can do here is give him enough oxygen (when <93%) ,pain killers and Aspirin
now.(Nitrates, beta blockers, Opioids). Specialist will come and check him. And give fibrinolytic
agents which will dissolve the blockage. There are some risks like bleeding inside the head or in
the tummy or in the skin, nausea, vomiting, reduce blood pressure, allergic reaction to the
medication or some rhythm abnormalities in the heart,
• If successful, And then refer him for the angiogram which is the imaging of the vessels and
proceed further management. If not successful, he will be referred for urgent stent.
Silent MI not recent, in 2018 and 2019
60 yrs old female, Nadia, in Mall started feeling unwell - went to GP.
• History
• Investigations
• Explain the cause
History
• Why do you mean by unwell, details of it -
• CVS symptoms – Palpitation, chest pain, shortness of breath if present details.
• Palpitation – how frequent? When did it happen?
• Chest pain – pain questions
• SOB- at rest or in action? Daily chores? How many pillows when you sleep?
• Indigestion symptoms – did it associated with food? Any bloating? Vomitting? Diarrhoea? Heart
burn?, gall stones
• 1st time?
• Medical history
• Cardiovascular factors – ABCDEFS – Alcohol. Blood pressure, Cholesterol, Diabetes, Exercise,
Family, Smoking
• Explain ECG, silent heart attack – There is no symptoms of heart attack but I can see some
changes in ECG that is showing the heart is getting not enough blood supply and the muscles of
the heart are getting ischaemia which is damage. That usually happens in those patients with
underlying DM. That DM may mask that symptoms like pain. We need urgent intervention to
prevent further damage of the heart muscles.
Pericarditis
You are a HMO at ED. Your next patient is a 50 years old man, Chris, who complained of severe chest
pain which was started 6 hours ago.
Your tasks :
• History
• Physical examination from examiner
• Dx/DDx to the patient
• Management plan to the patient
Outline of approach
• Stability check
• Chest pain – when? Sudden onset? Where? Character? Moves anywhere? Severity? Aggravating
factor (activity, deep breathing)/ relieving factor(leaning forward)?
• Ddx – fever? Cough? Runny nose? (Now and recent) palpitation, SOB? (AMI) Recent travel or
immobilization? History of GORD? Any chronic joint pain (Rheumatic), problem with kidneys?
• Risk factors for heart disease –ABCDEFS – Alcohol, Blood pressure, Cholesterol, Diabetes,
Exercises, Family history, Smoking, stress
• Recent covid vaccination?
• General health
PEFE
• General appearance, vital signs, BMI, CVS examination
• Pericardial rub (Leaning fwd and inspiration, more in mitral and tricuspid), Pleural rub (more in
expiration)
• ECG
• Most likely – pericarditis, draw a heart and coverings – these coverings become inflamed
following viral infection or other systemic autoimmune disorders, kidney diseases, medications.
But your case – most likely – viral because you are healthy and just had an infection by virus a
week ago.
• Still we need some investigations to rule of other causes of chest pain like the ischaemic heart
disease – investigations – Blood sugar, lipid profile, Cardiac enzymes (troponin rise in 30% of the
cases due to inflammation of the epicardium), ESR, CRP, ECG monitoring, CXR, Ultrasound,
• Pericarditis pain – NSAID, sit upright. You will be on regular monitoring of cardiac enzymes and
ECG.If increased SOB, we will do Echo/ultrasound to check for increased fluid in between the
heart covering.
• After the blood results and no symptoms – can go home
• Reassure that no relation between pericarditis and AMI. If any risk factor, advice lifestyle
modification and remove risk factor for heart disease.
Pulmonary embolism
You are a HMO. You are going to see a 45 years old female patient presented with pain in
chest from 2 days, first time.
Task:
• Take history
• Tell the Dx and DDx
• Tell the Invx
• Check the stability first

• Details of pain –when? Onset? 1st time? Pain right now? Pain killers? Where is the pain?
Travel to any other areas? How severe from 1-10? Anything that make it better or
worse? (exertion, deep breathing, position changes), persistent or off and on?
• SOB – happened along with chest pain? Anything that make it better or worse?
• DDX – CVS- racing of heartbeat? Sweating?
• Respiratory – fever, cough?
• Emphysema – pre-existing lungs problems?
• Pulmonary embolism – recent travel? Operation? Painful leg?
• Trauma?
• GI – associated with meal?
• General health, past medical, past surgical
• Any family history of heart disease or stroke or clots?
• Risk factors- COST VMPF in recent case: pt have pain in leg so check rf
• C – contraception, O – obesity. BMI? S – recent surgery? T- Travel history?
• V – problems with Veins? M – malignancy – LOW, LOA. Lumps and bumps, P- pregnancy,
F- family history of clotting problems
• SADMA
• This case, travel history and leg pain positive.
• Dx – PE - A pulmonary embolism (PE) is a blood clot that develops in a blood vessel in
the body (often in the leg and since you had the leg pain, it must be the origin too). It
then travels to a lung artery where it suddenly blocks blood flow.
• It can cause a lack of blood flow that leads to lung tissue damage. It can cause low blood
oxygen levels that can damage other organs in the body, too. So it’s a life-threatening
condition. We need urgent treatment.
c-xray and • Other DDx – AMI, Pericarditis, pneumothorax, Pneumonia, trauma or heartburn
ctpa • Invx – D-dimer, CT or VQ scan which are the imaging to be done for the lungs to confirm
the diagnosis , Doppler USG lower limb to know the source, ECG and cardiac enzymes.
Later, thrombophilia screening. inestigation shld be in detail if separate task
Reassure management see from jm iv antocog then oral
Pericarditis insisting morphine

You are a HMO at a hospital. Your patient is 56 year old lady, Beatrice who was admitted to hospital
after diagnosed with pericarditis. All investigations are cleared and she was started with neurofen
200mg twice daily. Now she wants to talk to you as her pain is not controlled and she wants more
pain relief. She is otherwise healthy apart from her back pain for which she has been taking -
Morphine, codeine, gabapentin, paracetamol, neurofen.
Tasks-
this case is diff from the backpain with pethidine addiction
• Hx, in this case pt has pain
• Counsel the patient
• manage her pain.
History
• Greetings! Check the vitals.
• How are you feeling now? Show sympathy. Is the pain increasing than before? When did you
have the medication? OK. I will definitely arrange something for your pain. Any SOB? Any
cough? Racing of heart beat? (pericardial effusion)
• First of all, please let me know more about previous health. I came to know that you have a
chronic back pain. How long? Any condition diagnosed by the doctor? What medications are you
taking? How long?
• Morphine – What is the dose? How long? How frequent you have to take it? When was the last
time you have it? Have you ever felt like you need to increase the Morphine dose? Are you
taking it according to the prescription?
• Other medications as well – codeine, Paracetamol, neurofen, Gabapentin in details, according to
the prescription? Any side effects?
• How is your general health. Any past medical and surgical history apert from this? Any DM?
Hypertension?
• SADMA
• Family support
Explanation
• Alright Beatrice. Thank you for answering my questions. I believe that you are having the real
pain. But don’t worry. You are in the safe hands now. We will try our best for your comfort. You
have been well informed about the condition you are having right? Which is pericardiditis,
which is the inflammation of the coverings of the heart. In this case, we have prescribed you
Neurofen 200mg which is at the mainstay of treatment for this condition as it reduces pain and
also reduce inflammation.
• So, there are a couple of reasons for having pain right now.
another cse, morphine already given and want more....
pca and tens is not an option

here bc cardiac pt need
monitoring so search it as dr
• First of all, I think Neurofen action hasn’t started yet (depending of what time sherilry
wasdont agree
administered)
• Or it could be because of little to moderate fluid present in between the coverings because of
the inflammation. We will do Echo for that. If that is positive, we will do aspiration.
• Or another reason is as you have been taking a lot of pain medications, possibly the body may
already has adapted to this dose of pain medication. So this pain is much more severe than the
back pain I believe. So in that case you may need the adjustment of the dose, frequency or
change the medications or add a medication. Sometimes morphine may help but it is not a
corner stone of the treatment. It is just an add-on treatment for very severe pain. Another drug
named Colchicine can also be added for quicker relief and to prevent recurrence.
• Or very less likely the pericarditis is because of bacterial infection. In that case, you will need
antibiotics but right now, you don’t have any symptoms of this.
• So I will inform my senior, who will come and check you in a very short time and proceed
accordingly. Don’t worry. I know it is hard to stay calm with such severe pain. We will try our
best. Your comfort is our priority.
• (I don’t think TENS or PCA are options for pericarditis pain)
• Review. Reassurance
Spontaneous Pneumothorax
You are a resident at a rural hospital. A 65 years old female, is presenting to emergency department
with sudden shortness of breath developed while jogging in the park. It was also associated with chest
pain.
Your tasks:
• Ask PE from examiner
• Give Dx/DDx
History
• Check the stability first
• Details of pain –when? Onset? 1st time? Pain right now? Pain killers? Where is the pain? Travel
to any other areas? How severe from 1-10? Anything that make it better or worse? (exertion,
deep breathing, position changes), persistent or off and on?
• SOB – happened along with chest pain? Anything that make it better or worse?
• DDX – CVS- racing of heart beat? Sweating?
• Respiratory – fever, cough?
• Emphysema – pre-existing lungs problems?
• Pulmonary embolism – recent travel? Operation? Painful leg?
• Trauma?
• GI – associated with meal?
• Any family history of heart disease
• Cardiovascular factors – ABCDEFS – Alcohol. Blood pressure, Cholesterol, Diabetes, Exercise,
Family, Smoking
• SADMA
Physical examination Card from the examiner

• General appearance – dyspnoeic
• Vital signs - respiratory rate – 26, others normal
• No Features of Marfan’s syndrome ( tall and thin, high-arched palate)
• CVS examination - unremarkable
• Respiratory – Inspection – no respiratory distress, no cyanosis, no accessory muscle working
• Palpation-no trachea deviation
• Percussion – hyperresonance in left lung
• Auscultation – decreased breath sounds on the left side
• ECG - normal
• Dx – spontaneous pneumothorax – the air trapped between the two layers of the lungs without
apparent cause. It is more common in those patients with underlying lungs condition happens as
sudden onset.
• (DDX – CVS – pericarditis, IHD, AMI
• Resp – pleuritic, pneumonia, pneumothorax, pulmonary
• embolism
• GI – GORD, PU
• Muscular – costochondritis, Muscle pain) ]
• Management
• Invx -Diagnosis is confirmed by
• Bedside Ultrasound inv of choice
• More sensitive than CXR and rapidly available at the bedside
• Standard erect inspiratory PA CXR still need c-xray to see how large is the pneumothorax
• (CT scanning is recommended for uncertain or complex cases)
• High flow Oxygen

• >25% with symptoms – needle aspiration and repeat CXR after 4 hours
• >50% - drain (needle aspiration or small bore chest drain) (ICT drainage – 2-3 days)
• Recurrence 50% in 3 years
• Advice upon discharge

• Please return immediately to ED if you develop further breathlessness
• follow up ideally by a respiratory physician to ensure resolution of pneumothorax and institute
optimal care
• a follow up CXR after 2-4 weeks to monitor resolution
• Normal physical activities can be resumed once all symptoms have resolved but avoid extreme
exertion until full resolution
• stop smoking as it is an associated factor in recurrence
• Air travel should be avoided until at least 1 week after the CXR shows full resolution
• SCUBA diving should be discouraged permanently
CVS risk assessment not recent

You are a GP. 45 years old man, Oliver, came for check up. Brother had coronary bypass surgery.
Tasks-
• History
• PEFE and
• tell the risk to patient and further investigation.
• Sorry to hear about your brother. How is he now?

• How are you now ? Any concern?
this is the main focus in this case only
• ABCDEFS –Alcohol? Blood pressure? Hypertension? (ever checked your BP?) Cholesterol?
Diabetes? (extremely thirsty, weight changes, frequently passing urine?) Diet? Exercises?
check fr symptoms
of diabetes Family history of stroke, heart diseases (any family history then your brother? Do you have any
symptoms like chest pain, SOB, racing of heart? How many pillows do you use when you sleep?)
Smoking? Stress from work? (what do you do for a living?)
• PEFE – General appearance, BMI, waist circumference, BP, pulse

• Eyes – Xanthelasma, fundoscopy
• Neck – carotid bruit
• CVS, respiratory, abdomen(listen to bruits too)
• Lower limb – neurological and pulses
• BSL, UDT, ECG chart will not be given in online
• Risks in this case – Your weight is on a higher side (obesity) and smoking and family history that
put you on high risk for heart diseases. If risk chart is available, I can tell the exact percent. There
are some modifiable factors so we can change the life style to reduce the risk. We will run some
investigations including baseline blood tests (FBC, LFT, RFT), cholesterol levels, Blood sugar level,
urine routine examination, ECG, CXR.
Bradycardia recent recall

You are a GP. You are going to see a 72 years old man with the complain of recent syncope.
Tasks :
• Take history for 6 mins
• PEFE
• Tell the DDx
History
• When did this happen? Is this the first time? How many times before? When was the first time?
Were they similar? now without the change of position so not pot hypotension,
• Who saw it? How long?
• What were you doing before?
• How did you recover? Any dizziness or weakness after recovery?
• DDx –
• Epilepsy - Was there any jerky movement? Any loss of consciousness? Any loss of pee or poo?
Any tongue bite?
• Trauma – any possibility of trauma?
dont mix with prolong qt, prolong qt in younger, this is old
• Epilepsy – (already asked in episode)
• Hypo/hypergycaemia – any history of increased frequency of urine? Any excessive thirst? Have
you had your breakfast?
• Electrolyte imbalance - any recent vomiting or diarrhoea?
• SOL – any headaches, any vomiting? LOW, LOA?
• Infection – fever, rash?
• Cardiac – any racing of heart? Any dizziness? Any SOB? i got a pump in my chest
• Vasovagal – any prolonged standing? Blurred vision? Cold clammy extremities?
• Past medical, past surgical post hypotension, what were u doing at that time?
• SADMA
• family history of sudden death?
bsl will be normal
Explanation
300/7 • This is your ECG, we can say your heart rate is very slow which is around 40, normally it is 60-
100 . When the heart rate is slow, the heart cannot pump adequate blood especially to the brain
and cause you fainting attack.
• It could be due to narrowing of the valve called AS. Or sometimes heart block where there is
defect in electrical conduction of the heart.
• Or it could be due to hypothyroidism which is the low thyroid hormone level produced by the
thyroid gland in front of the neck.
• Sometimes, it can be due to a condition we called it vasovagal syncope which happens when
your body overreacts to some distress.
• Postural hypotension which is due to pressure changes while changing the position.
• Or it can be due to low blood sugar level but less likely since you didn’t skip your meal and your
blood sugar is normal.
• Salt imbalances or head injury but less likely according to history
• Other heart conditions but again less likely due to ECG.
bradycardia is not enough, tell the causes of bradycardia
Prolonged QT
HMO in ED, 20 yrs old woman c/o fainting in school. 4th attack, mom is coming with taxi.
H/o, ask pe, ask initial ivx from examiner, explain it to pt. Explain the possible causes to pt.
History
• When did this happen? Is this the first time? How many time before? When was the first time?
Were they similar?
• Who saw it? How long?
• DDx –
• Epilepsy - Was there any jerky movement? Any loss of consciousness? Any loss of pee or poo?
Any tongue bite?
• Cardiac – any racing of heart? Any dizziness? Any SOB?
• SADMA
normal is 9 to 11 small squares between q and t,if more than 11
• family history of sudden death? think of prolong qt
• This is your ECG, we see that you have a condition called long QT syndrome which is a heart
rate abnormality where your heart's electrical system takes longer than normal to recharge
between beats. Fainting (syncope) occurs when the heart temporarily beats in an unorganized
way.
• Sometimes, it can be due to a condition we called it vasovagal syncope which happens when
your body overreacts to triggers some distress.
• Or it can be due to low blood sugar level but less likely since you didn’t skip your meal
• Salt imbalances or head injury but less likely according to history
• Other heart conditions but again less likely due to ECG.
Tiredness
IDA 5star, handbook case
You are a GP a 65-year-old lady comes with complaints of tiredness for the past few months. You
checked the blood test and routine blood investigations were given.
HB, MCV, MCHC, MCH all low. tiredness, focus more on causes of low hb then causes of tiredness
Task –
• history –
• Explain further investigations to the patient
• -Discuss the most probable condition with the patient and DD
Causes of microcytic anaemia

• IDA (reduced intake, increased loss –GI,malabsorption, cancer, NSAID)
• Anaemia of chronic diseases
• Thalassaemia
• Sideroblastic (alcoholics, B6 deficiency, lead poisoning)
History
• Tiredness details - since when have you been feeling like this? do you feel tired the whole day or
at a specific time? Is it happening at rest or with activities? has this happened before?
Continuous or off and on?
•
depending on the Anaemia – SOB? Palpitation? Tiredness? How does it affect your daily activities?
• Heart failure any cough with sputum?
age check menstrua
• Reduced intake – diet? Having meals with tea?, Malabsorption – any changes in bowel motion?
hx, if Post menopaus
ask fr PMB. Tummy pain?
• Increased loss – pain or feeling of indigestion? Bloating? Any mass in tummy? Problem with
swallowing? Any change in stool color? Any lumps all over the body? LOW? LOA? Menstrual
history? Increased flow? Any bleeding from down below?
• Any blood diseases in you or your family?
• Social – occupation (lead poisoning), racial origin?
• SADMA – esp any regular medication? (NSAID in this case) Past medical, past surgical
Explanation
• Explain the blood test about anaemia. According to the blood picture, most likely iron deficiency
anemia. It can be caused by reduced intake- diet, decreased absorption – fault in absorption,
increased loss – bleeding from food tract which is likely cause in you as you are taking painkillers
for quite a while because it can cause ulcers in the food bag. Also it is possible that it could be
nasty or benign growth in the stomach or bowels.
• Other possibilities are it could be anaemia due to chronic diseases, alcoholics, vitamin
deficiency, genetic conditions like thalassaemia and lead poisoning.
• Management – we will do iron study (ferritin) to confirm the iron deficiency. Also I will refer you
to specialist for colonoscopy, Barium air contrast enema and endoscopy because we need to
exclude nasty conditions and ulcers in your food tract. (stool microscopy for ova if suspected
hookworm, NB FOBT is not recommended as sensitivity is poor) v. imp
• Colonoscopy (to be done first) - a thin flexible tube with light source will be inserted from your
anus to check for any lesions in the bowels. It will be done under sedation. A biopsy will be
taken if any lesion.
• Gastroscopy – similar mechanism in which we can through mouth food pipe till the food bag or
stomach.
• **** Iron deficiency with no obvious source of bleeding mandates a careful GI work-up**** hanbook line
• Meanwhile, we can start oral iron tablets after confirmation of iron deficiency but you need to
stop it before the scopies. (side effects : constipation, changes in color of stools) and stop the
NSAIDs.
• I will also give you some medicines to stop the acid secretion in the stomach which will help to
heal the ulcers and bleeding in the stomach. (h2 receptor antagonist)
Hypothyroid
40 year old male, Jones, coming to you with tiredness and weight gain. You are a GP.
Your tasks:
• Relevant history
• Explain the provisional diagnosis
• Management to patient
History 1. HOPI
2. Exclude DDS
3. Confirm the possibility like in hypothyroid.
• Tiredness in details : When? Continuous or off and on ? Better or worse? Progressive? Worse
with activities? At rest?
• HEMIFAD questions
• Haemochromatosis, Endocrine (DM, thyroid), Malignancy, Infective endocarditis, Fibromyalgia,
Chronic fatigue syndrome, Polymygia rheumatica, Anaemia, Atypical pneumonia, Apnoea (OSA),
Depression (mood), Drugs
• Hypothyroid – loss of eyebrows, Slow, weight gain, weather preference, Voice, period in
females, any skin changes? constipation, muscle weakness, any swelling in the legs
• Past medical, past surgery
• SADMA can be a possibility of thyroid removed previously.
Explanation
• Most likely hypothyroid – need to do some blood tests
• Causes – infections, prev surgery, medications, autoimmune which our own immune system is
attacking the own organs
• Thyroid hormone produced from thyroid gland, located in our neck
• Plays important role in body metabolism
• When reduced, all slow down, for example brain – dull, slow,
• Bowels –constipation
• Rx – Refer to endocrinologist for confirmation by blood tests hormone levels and antibodies
then replacement
• Regular Follow-up, start with low dose and increased to optimize
• Risk – Anaemia (reduced iron absorption) and Heart failure (reduced all organs functions)
• Effective treatment – curable and complications preventable
Sleep deprivation
17yr old girl, Nadia, came with the complaint of tiredness
task:
• History
• Dx and DDX
• Give advice
Approach
• Tiredness – when? How long? At rest or with movement? What about at night? Any SOB? Racing
of heartbeat? Is it the first time?
increase thirst
• Tiredness (HEMIFAD) addisons, any
• Haemochromatosis –any discoloration in the skin? (Bronze color) blackouts or fainting
episode
• Endocrine – DM, Addison’s, hypothyroid (increase frequency of urination, postural hypotension
– any episode of blackout, weather preference)
• Malignancy – lumps and bumps
v v imp
• Infective endocarditis – any fever? SOB? Dental procedure? Infection – flu-like illness
• Fibromyalgia, Polymyalgia Rheumatica – joint pains dental procedure hx in infective
• Anaemia (pale), Atypical pneumonia, Apnoea (OSA, snoring) endocarditis
• Depression, Drugs
• Confidential statement cough, travel hx from queensland, can be diarrhea
it can be a possibility nothing get except low mood take confidentiality and DSM5
• Depression questions
• Anhedonia, depressed mood, suicidal ideation, sleep problems (early awakenings), lack of
energy, problems with concentration and decision making, lack of sexual desire and appetite
• Less sleep – how many hours? How long? Any stress? How is everything at home? School?
• Past medical, past surgical can be a possibility only lack of sleep, mood is ok so this
• SADMA will be the cause of tiredness only lack sleep.
Explanation
• So most probably your tiredness is likely to be because of lack of enough sleep.
• Other causes of tiredness can be because of anaemia, hormonal problems, heart diseases,
respiratory problems, infection, drugs or depression but these are unlikely in your case.
• Normally, a person needs 7-8 hours of good sleep a night to keep refreshed and healthy. From
your history, you are sleeping like only 5 hours a day and obviously this is not enough for your
body and your mind. Many days of these leads you to have tiredness. So I would recommend a
good sleep of 7-8 hours a day to overcome this. You’ll feel fresher and also can have good
concentration and focus for your exam. To pass the exam and to study well, you should have the
good mental rest as well. So please take a good rest physically and mentally by enough sleep.
How does it sound?
Temporal arteritis stopped steroid

A 67 years old lady, Rhea, came to you with tiredness and weight loss. You are a general practitioner.
She had been diagnosed with temporal arteritis 6 months ago and was taking steroids for it.
Tasks : order of differentials matters one of the recall have low mood ask
• Take history fails bc of dds, not correct order DSM5 criteria, when not full features
• Tell the possible causes of depression and an obvious cause
1. can be adjustment disorder in dds as
Approach well
wt loss can be • Tiredness in details – How long? Continuous or on and off? At rest or activities? Any particular
due to ch disease
and ca time of the day?
• Weight loss – how many kg? Duration? Intentional?
• Causes of Tiredness (HEMIFAD)
• Haemochromatosis –any discoloration in the skin? (Bronze color)
• Endocrine – DM, Addison’s, hypothyroid (increase frequency of urination, any dizziness, weather
preference)
• Malignancy – lumps and bumps, any bleeding from anywhere like BP or DB? LOA? LOW (+ in
one of the recall history)
have positive hx • Infective endocarditis – any fever? SOB? Any dental procedure? Infection – flu-like illness
so check it and • Fibromyalgia, Polymyalgia Rheumatica – joint pains, muscle pain esp hip and tip of the shoulders
put in top dds • Anaemia (pale), Atypical pneumonia, Apnoea (OSA, snoring)
• Depression (how is yr mood these days?), Drugs
• Temporal arteritis – how was it treated? Still taking steroid? Why stop? How long have you
stopped? Was there any tapering? one of the recall stop steroid, ask if she stop
• Do you have any headaches now? How is your vision? herself or physician taper it.
tapering method is not our task whether done correct or not, bc no exact guideline fr tapering steroids
• Social history – With whom are you living? Who is taking care of your medications? What do you
if steroid withdrawal do for a living? Any stress?
positive ask these• Addison’s Features (steroid withdrawal)–Diarrhoea, Nausea? abdominal pain? weight loss? How
features
much? Dizziness, syncope? Any changes, any discoloration in skin and mouth?
• If low mood positive – DSM V criteria for depression : MSIGECAPS
• M –Mood, S – Sleep, I – Interest, G – guilt, E – energy, C – concentration, A – Appetite, P
psychomotor, S – Suicide
• Past medical, surgical, SADMA another case she is still taking steroids, no other positive hx can be
Differentials steroid induced tiredness in the first place.
• Mild Depression
• Adjustment disorder
• PMR- which is an inflammatory disorder that causes muscle pain and stiffness esp in hips, back
and neck. It is highly associated with temporal arteritis as interrelated inflammatory disorder.
(PMR itself as depression as its clinical feature)
• Steroid induced tiredness (if still taking steroid)
• Addison’s features (if abrupt withdrawal) – Abrupt withdrawal of steroids (steroids – interfere
adrenal functions, the glands that also produce natural body steroids, tapering the drugs gives
the adrenal glands to time to return to their normal pattern)
• Anaemia
• Thyroid problems
• Diabetes mellitus
• Infection
• Nasty problems less likely
Infective endocarditis
50 years old lady with H/O tiredness for 1 week. You are a GP.
• Take history
• Ask Examiner PE
• Discuss prov diag and differential diagnosis
History
• Tiredness– when? How long? At rest or with movement? What about at night? Any SOB? Racing
of heartbeat? Is it the first time?
• Tiredness (HEMIFAD)
• Haemochromatosis –any discoloration in the skin? (Bronze color)
• Endocrine – DM, Addison’s, hypothyroid (increase frequency of urination, postural hypotension
– any episode of blackout, weather preference)
• Malignancy – lumps and bumps
• Infective endocarditis – any fever? SOB? Dental procedure? Infection – flu-like illness
• Fibromyalgia, Polymyalgia Rheumatica – joint pains fever, chills , bld in urine, underlying heat
• Anaemia (pale), Atypical pneumonia, Apnoea (OSA, snoring) cond
• Depression, Drugs
• Dental procedure positive – any fever? Chills? Blood in urine? Chest pain? Sweaty? Changes in
nails or skin?
• past medical history (heart disease) – when?
• SADMA
• family history of heart diseases
Physical examination from examiner

• General appearance
• Vital signs
• hands –clubbing, splinter hemorrhage, osler nodes and janeway lesions
• Face - eyes (pallor/ jaundice/ subconjunctival hemorrhage), Mouth (cyanosis/ dental hygiene).
• fundoscopy (Roth spots)
• Heart
• Apex beat, thrills, murmurs, heart sounds
• chest and lungs
• Abdomen - hepatomegaly, splenomegaly.
• UDT (blood, protein)
• -BSL
• -ECG
• According to your story and PE findings , most likely cause of your symptoms is a condition of
infective endocarditis . In our heart , there are 4 chambers , 2 upper chambers and 2 lower
chambers , which are separated by valves ( which are door like structures ) , most likely you have
got problem in your valves that produces abnormal heart sound called murmur since you told
me that you have a heart problem.
• When one has some problems with valves, those valves become prone to infections.
• You recently had a dental procedure in your history, so most likely the bugs in your oral cavity
got a chance to go into the blood stream and reach to the heart valve and can cause the
infection.
• There are other possibilities that lead to tiredness like
• Infection in the breathing system
• Medications
• Problems with thyroid or Diabetes or
• Anaemia but less likely in your case.
• Palpitation
Atrial Fibrillation recent

56 y old lady, Beatrice, with palpitations and dizziness lying on the bed.
Tasks:
- Hx
- PEFE, Ix from the examiner
- Dx/ Ddx check abcdefs risk factors in every cardac diseses
- Possible causes
History
• Any symptoms right now? Stable?
• 1st time? Any dizziness?
• Palpitations – how fast is your heartbeat? Can you please tap it out on the table? How long did it
last each time? How did it relieve? Anything that make it better or worse? Associated with chest
pain, SOB, sweating?
• Dizziness – nearly fainting? Lightheadedness?
• DDx – weight loss? Appetite? Weather preference? (hyperthyroid), flushing or headache
(phaeochromocytoma), coffee intake? Skipping meals? (hypoglycaemia)
• Psychiatry – Are you generally an anxious person? Do you worry a lot? Any recent stress on
changes in life? How is your mood these days?
• CVS risk factors - ABCDEFS
• PEFE – GA, vitals – PR in details – rate, rhythm and volume on all four limbs, dyspnoeic or not?
• CVS examination, mainly HR and PR synchronized or not?
• Any signs of heart failure
• Lungs and abdomen
• ECG
• Dx – Atrial fibrillation. It is a kind of irregular heart rhythm makes the blood flow inside the heart
somewhat irregular, which can cause blood clots to form there. In some cases, the blood clot
may dislodged and block the vessels in the brain which may lead to stroke.
• Possible causes – hypertension, alcoholic cardiomyopathy, IHD, thyroid problems, excessive
coffee intake
• Another case, SVT

Hyperthyroidism
You are a Gp. A lady 50 years old Julia who is anxious and having palpitation.
• Tasks- take history. Tell Dx and DDx.
History
• Details of palpitations – duration? Continuous or off and on? Any specific time? First time? Any
trigger factor? Relieving factor? Can you tap it out for me?
• Differential Dx
• Cardiac – Any SOB? Any sweating? Dizziness? Any chest pain?
• Metabolic – Any weather preference? Sweaty? Any neck swelling? Do you have any history of
diabetes? Any high blood pressure? Headache.
• Psychiatry – Are you generally an anxious person? Do you worry a lot? Any recent stress on
changes in life? How is your mood these days? wt loss with normal appetite is hyperthy, whereas wt loss
irregular mesnt
• Coffee intake? with dec appetite is CA.
can be due
to perimenopausal• More about thyroid - any weight loss? Appetite? Periods? Sweaty palms? Do you think you are
as a dd, check other'irritable and easily provoked? Any changes in bowel habit? Any eye changes? Any muscle
features, can be in weakness?
the 2, 3,4 place • Perimenopausal – hot flashes, sleep disturbance,
• Any past medical surgical?
• SADMA
• Diagnosis – most likely hyperthyroidism in which the thyroid gland which is located in front of
the neck has been enlarged and produces excessive thyroid hormones. Thyroid hormone plays
important role in our body metabolism. When there is increased thyroid hormones, all
metabolism has been speed up so all these symptoms like racing of heart, weight loss, increase
appetite and increased bowel motions occur.
• Other possibilities –perimenopausal symptoms, GAD (excessive anxiety), panic attack,
Phaeochromocytoma (benign tumor of a gland lies above kidney), excessive coffee intake, some
heart problems.
Falls
Recurrent falls
A 60 years old man, Josh, came to see you today. You are a general practitioner at a rural clinic. The
man recently had a fall yesterday. He had recurrent falls within previous two months. Now he is very
concerned about those falls and want to discuss the matter with you.
Your tasks:
• Physical examination finding card from the examiner
• Explain the patient about the causes of the falls
Card from examiner

• The patient is generally well.
• Vitals are BP - 120/80mmHg, Pulse rate – 76/min, SpO2 – 98%
• Fundoscopy – silver wiring and cotton wool exudates
• On motor examination of lower limb –power 3/5
• On neurological – Glove and stocking sensory loss in proprioception and monofilament tets
• Knee- reduced extension and flexion due to pain
• Blood sugar – 11 mmol/L
History
• Check the vitals
similar ep like
change in position• How are you? I believe you had a fall. Any pain?
• Falls - 1st time? How many times before? How long? What were you doing in each attack?
will be postural hpotension
Similar mechanism? (pronged standing or immediate change in position sitting/lying position),
dizziness? loss of consciousness, any witness? Did you hurt yourself? Any head injury?
• DDx – CVS causes - before you fall, any usual symptoms? (racing of heart beat, sweating,
dizziness, chest pain), OA – any pain in the joints? Stroke/SOL - Any brain attacks/strokes
before? Can you walk well now? Any gait disturbance? Any weakness? Electrolyte imbalance –
any vomiting, diarrhoea?
• Medical history? DM? Hypertension? Well controlled? What medications? Visual problems?
Follow-up regularly.
• SADMA
• Explain the differentials - It could be complication of previous stroke as I found some weakness
in your lower limb, vision impairment because of uncontrolled DM, Osteoarthritis, loss of
sensation because of DM, Electrolytes imbalances (which is the imbalance of salt in the blood),
glucose imbalances, Vasovagal syncope (when your body is overreacting to certain triggers like
long standing) or CVS causes – arrhythmia which is abnormal heart rhythm, postural
hypotension (a sudden drop in blood pressure due to a change in body position)
Postural hypotension
You are a HMO at ED. A lady Bridget in her 60s- came to ED with a history of fall a few hours back. She
is stable now and was brought by her daughter.
Tasks-
• Take history
• Tell Dx and Ddx
History
• Check the vitals
• How are you? I believe you had a fall. Any pain?
• Falls - 1st time? How many times before? How long? What were you doing in each attack?
Similar mechanism? (pronged standing or immediate change in position sitting/lying position),
dizziness? loss of consciousness, any witness? Did you hurt yourself? Any head injury?
• DDx – CVS causes - before you fall, any usual symptoms? (racing of heart beat, sweating,
dizziness, chest pain), OA – any pain in the joints? Stroke - Any brain attacks/strokes before? Can
you walk well now? Any gait disturbance? Any weakness? Electrolyte imbalance – any vomiting,
diarrhoea?
• Medical history? DM? Hypertension?
• SADMA
• Most likely, postural hypotension — is a form of low blood pressure that happens when you
stand up from sitting or lying down. It can make you feel dizzy or lightheaded, and maybe even
cause you to faint.
• Causes - When you stand up, gravity causes blood to pool in your legs and abdomen. This
decreases blood pressure because there's less blood circulating back to your heart. Naturally,
the body increases the blood pressure by its own mechanism like narrowing the blood vessels.
But postural hypotension occurs when something interrupts the body's natural process of
counteracting low blood pressure. Many conditions can lead to this including:
• Dehydration - Fever, vomiting, not drinking enough fluids, severe diarrhea and strenuous
exercise with a lot of sweating can all lead to dehydration.
• Heart problems – heart failure, low heart rate or valve problems
• Hormonal such as Thyroid conditions, adrenal hormone insufficiency in which the adrenal glands
which sit on the kidneys are not producing enough hormones (Addison's disease) and low blood
sugar (hypoglycemia)
• Some nervous system disorders
Vasovagal or postural hypotension

You are a HMO. 15-year-old girl had LOC after a 100 meter run, she is fine now
BSL – 4.6
ECG – normal ( ECG not given, just written as normal)
• Tasks –
• Take history
• Tell mom what examination PE you will look for in this patient
• (You should take no more than 6 min for both these tasks)
• PE finds will appear at the end at 6 min
• Tell diagnosis with reasons
• When did this happen? Is this the first time? How many time before? When was the first
time? Were they similar? diabetes and bp
• Who saw it? How long? breakfast
• DDx –
• Epilepsy - Was there any jerky movement? Any loss of consciousness? Any loss of pee
or poo? Any tongue bite?
• Hypo/hypergycaemia – any history of increased frequency of urine? Any excessive
thirst? Have you had your breakfast?
• Postural hypotension and Electrolyte imbalance - any recent vomiting or diarrhoea? Did
it happen during sudden position change?
• Anaemia – Does she look pale?
• SADMA
• family history of sudden death?
• I will be checking her eyes for any pallor, initial vital signs, orthostatic blood pressure
measurements which is checking her blood pressure while lying and standing to know if
any difference as it can cause that fainting. I will check her pulses and listen for a
pulsation on her neck to check for any disturbance in the blood flow as it could be
reduced blood flow to the brain. Will listen to her heart sounds and lungs.
• I will also do the nerve system assessment including the muscles and nerves checking
movements, muscle strength and sensations.
• Pe card- pallor is positive, and bp 110 systolic on lying down and on standing 90 systolic
after 10 min of standing , rest all was normal
• Postural hypotension – she has got the difference in blood pressure while standing and
lying. It might be because of salt imbalances in the blood which might be resulted as
today is a sunny day and she is playing which might be resulting in lots of sweating.
• Heat syncope –where a person faints suddenly and loses consciousness because of low
blood pressure. Heat causes the blood vessels to expand, so body fluid moves into the
legs by gravity, which causes low blood pressure and may result in fainting.
• Vasovagal syncope – which is caused by a sudden drop in blood pressure, often
triggered by a reaction to something like prolonged standing and sometimes heat
• Anaemia
• Heart problems and
• Nerve problems
• Low blood sugar but her blood sugar is normal.
Funny Turn
You are a HMO at ED. 19 year boy, Robbin, came with funny turn.
Tasks:
• take history
• PEFE
• tell diagnosis and DD to patient
History
• What do you mean by funny turn? How do you feel now?
• Who saw it? How long? Was there any jerky movement? Any loss of consciousness? Any loss of
pee or poo? Any tongue bite? Is it the first time?
• DDx – Trauma – any possibility of trauma?
• Smoking Alcohol and drugs (important!) any binge drinking?( For this case, binge drinking last
night, did u eat well?)
• Past medical, past surgical,
• Family history of epilepsy, any fits when you were little?
• PEFE all normal

• Seizures most likely due to binge drinking and maybe low blood sugar. (if eating less)
• Ddx – electrolyte imbalance, infections, SOL, or very less likely epilepsy.
Shakiness and shoplifting case

You are a HMO. You are going to see 18 years old lady accused of shoplifting, then she had shakes for
3minutes .
• Tasks Hx . DDx to the patient
History
• May I know what happened? How do you feel now?
• Who saw it? How long? Was there any jerky movement? Any loss of consciousness? Any loss of
pee or poo? Any tongue bite? Is it the first time?
• Are you generally anxious? (anxiety after being accused)
• DDx – Trauma – any possibility of trauma?
• Thyroid –Any weather preference?
• Stress? Mood? Any changes in life? Any problem with law before?
• Smoking Alcohol and drugs (important!) any binge drinking?
• Past medical, past surgical,
• Family history of epilepsy, any fits when you were little?
• Seizures (or just shakiness whatever the stem says) most likely due to anxiety, conversion
disorder, unprovoked seizure, Hypoglycemia, electrolyte imbalance which is a salt imbalance in
the body, Space occupied lesions in the brain or recurrence of epilepsy
• Malingering?? (better don’t mention it!) how will u tell pt that she is maligering
Hypoglycaemia
You are a HMO at the hospital. Your next patient is a 42 years old woman who had a syncope an hour
ago at the shopping mall. Now she is fully recovered.
Your tasks :
• Take history
• PEFE
• Explain the diagnosis and management
History
• Witness
• First time?
• During: duration, loss of consciousness, abnormal movements, tongue bite, incontinence,
slurring of speech, blurring of vision
• After: confusion, muscle pain, weakness, tingling, injuries
• Before: warning, circumstances (hot humid weather, crowded place, prolonged standing),
history of infection or illness, blood loss or diarrhoea
• Fever, chest pain, palpitation, Shortness of breath, cough, sputum, leg swelling,
lightheadedness, headache, intolerance to light
• Female: ask about period, young female: rule out pregnancy
• Have you had your meal?
• Frequent fall? Joint pain?
• Smoking, alcohol, medication
• Problem with vision and, drugs
• Past medical history
• Family history
Physical examination:
• General appearance: facial asymmetry, confused, drowsy, pallor, cyanosis, dehydration
• BMI
• Vital signs: BP (postural drop), pulse (regular or irregular), temp, RR, SpO2
• ENT, lymph nodes
• Neck rigidity, JVP, carotid pulse, bruit
• Cardiovascular: thrill or murmur
• Neurological: Fundoscopy, visual acuity, neurological examination of upper and lower limbs
• Abdomen: organomegaly
• Urine dipstick, BSL, ECG
• This dizziness and sudden fall must be because of Hypoglycaemia which is the reduced blood
sugar since you have Diabetes and you didn’t have your meal after the Insulin.
• Hypoglycemia: triggers- missing meal, dosage alteration, unaccustomed exercise, binge drinking
• 1)If the BSL < 4mmol/L and patient can swallow: rule of 15: 15g of quick acting carbohydrate (
half can of regular non diet soft drink, half glass fruit juice, 6 jelly beans >>> wait for 15 min >>>
check BSL again, if less- repeat same
• If improved: give a full snack
• 2)If the patient cannot swallow: 1 vial glucagon I/M >>> check BSL after 15min
• Advice
• Take your meal everyday after each dose of drug
• Avoid binge drinking
• Never alter your dose by yourself
• Hypopack: identification card, 6 jelly beans, glucagon with instructions, glucometer
• Review, red flags – shakiness, dizziness, sweating, racing of heart beat,
• refer to dietician, optometrist, endocrinologist,( podiatrist)
• Reading materials
Tremor
52 -year-old woman with shakes. You are a GP.
• TASKS:
• History
• Diagnosis and differentials with reason
• How long do you have this problem? How did it start? Where exactly is the tremor? One hand or
both hands?
• Is the tremor on activity or with activity? Anything that increases your tremor?
• Anything to make it better?
• How does this condition affect your daily life activity?
• DDx - Do you have any medical conditions like problems with the kidney or liver or chest?
• Have you been diagnosed with DM? Any increased thirst? Any changes in frequency of urine?
• Any thyroid problem? Do you have any weather preferences?
• Are you generally an anxious person?
• Do you have any family history with the same problem?
• Family Hx of thyroid disease? Do you have a family history of parkinson’s disease
• Do you feel that you have stiffness in your hand or leg muscles?
• SADMA (very important esp alcohol)
• DDx – Benign essential tremor, anxiety, hypoglycaemia, hyperthyroidism, drug or alcohol

withdrawal, Parkinsonism, liver and lungs diseases.
Respiratory symptoms
Spirometry COPD
You are a HMO at the hospital. You are going to see a patient with noisy y breathing and shortness
of breath, a 54 years old male with a chronic smoking history. You did spirometry and results are as
follows:
Tasks :
• Explain the spirometry results
FEV1, FVC TLC
• Dx rest is all abt restriction to lung movt so tlc is red.
• Management to him obst is obst in the airways, air trapped in the lungs, leading to
normal or increased TLC.
explain significant findings
check fev1/fvc ratio , if reduced obstructive. if normal or increased its restrictive.

mixed pattern not given usually. everything will be low.
fev1/fvc ratio is less than 70% obstructive
FEV1/FVC RATIO LESS THAN 70% N OR INC

FEV1 DECREASED(MARKED) N OR DEC(SLIGHHT)
FVC NORMAL OR RED DEC
PEFR RED N OR INC
MVV RED N OR DEC
TLC N OR INC DEC
prebronchodilator n post
percentage change with bd
significant is more than 12%,

reversible like in ASTHMA.
if irreversible less than 12%

like copd
patient value, inc so obstructive
fev1/fvc ratio and

tlc then
percentage change DLCO showing diffusing capacity
then DLCO , gas exchange, if red means red
in gas exchange, red in exchange surface
, which is the end of bronchioles
alveoli surface damage, can be
in emphysema
Approach
• Spirometry is the test that checks the function of the lungs. Now I am going to explain the
or can tell 1st sec
after deep breath result. If u have any doubts, u can stop me at any point. FEV1 is the amount of air that your tell full sentence
lungs can breathe out in one sec after deep breath. Its value is so much reduced in you. FVC is
the amount of air that your lungs can breathe out forcefully after deep breath is only a bit
reduced. Then we make the ratio of these two values. As u can see, the ratio is 45% which is so
much reduced comparing to an expected value of 77%. TLC is the total lung capacity which is the
amount of air the lung can contain at the height of maximum inspiratory effort. This is also low
in you because there are larger amount of air trapped in the lung which is called residual volume
due to airflow limitation. DLCO which is the diffusion capacity of carbon monoxide is the lungs
capacity to transfer gas and indicating the surface area available for gas exchange too. It is also
reduced which is showing that some of the air sacs in the lungs are damaged. All these are
showing that your airways are somehow having narrowed or obstructed. And we repeat the test
after the medication, and we don’t find any significant improvement which means that the
obstruction is irreversible.
• All these are pointing out towards COPD probably emphysema.
could be • COPD is the group of lungs conditions that cause breathing difficulties which includes
ch. bronchitis, emphysema – damage of the air sacs in the lungs and chronic bronchitis – which is a long-term
long term inflammation of the airways.
inflammation
• Smoking is the major risk factor causing COPD. You will be seen by the specialist and you will
of airways
have CXR and blood tests.
• Unfortunately, COPD cannot be cured but we have some measures to slow down the progress.
Management of COPD investigation plus treatment

• SMOKES c-xray some bld tests
refer to specialist
• S – smoking cessation is the most effective way
• M – Medication – inhaled bronchodilator, vaccines (influenza, pneumococcus)
• – Oxygen when needed
• K – Komorbidity – We will check cardiac dysfunction, Sleep apnoea, Osteoporosis, Depression,
Asthma, GORD and treat accordingly if present.
• E – exercise and rehabilitation will be necessary too
• S – surgery is the last resort – bullectomy, lung volume reduction, single lungs transplantation
• Regular review, Support groups
copd-x
x: if u develop severe sob, audible noise, change of sputum color and volume, chest tightness. it means
u are having acute exacerbation. during this time take your puffer and call the ambulance.
Spirometry restrictive pattern
You are a HMO. Your patient is 65 years old Liam who presented with shortness of breath for 6
months. Spirometry done and the results are
Vitals capacity reduced, Residual volume reduced, FEV1 reduced, FVC – reduced, FEV1/FVC – normal,
Maximum breathing capacity –normal,
Your tasks:
• Explain spirometry to the patient and further history
interpret this
• Diagnosis and differential diagnoses to the patient
Approach
• Spirometry is the test that checks the function of the lungs. Now I am going to explain the
result. If u have any doubts, u can stop me at any point. First of all, the vital capacity is reduced,
which is the maximum amount of air expelled after a maximum inhalation. Residual volume
which is the amount of air remains in the lungs after full exhaling also reduced. FEV1 is the
amount of air that your lungs can breathe out in one sec after deep breath. FVC is the amount of
air that your lungs can breathe out forcefully after deep breath. Then we make the ratio of these
two values. As u can see, the ratio is normal. So, it can be normal in restrictive lungs disease. But
both FEV1 and FVC are reduced. That means ur lungs volume is reduced and u have restrictive
lungs disease.
• I will explain u details what is restrictive lungs disease. Before that, I want to ask you some
questions.
• SOB history – onset, duration, with activities? How severe ? Daily activities? At rest? Can sleep
well? Aggravating factors, relieving factors?
• Any cough? If yes, how long? Dry or producing phlegm? Continuous or off and on?
• Any fever?
• Chest pain? palpitations?
• LOW? LOA? Any lumps and bumps all over the body?
in resp cases, • Have you travelled anywhere before this SOB and cough? travel hx bc of TB v rare in Australia
check previos job• Occupational history (silica, coal, asbestos), Bird, allergens (not only about current job, please
atleast 2, working ask about any previous jobs associated with these!)
in a mine or
•
factory. have u ever History of Ca treatment and medications (methotrexate, cyclophosphamide),
could lead to some restrictions.
worked in contact• SADMA
with silica, dust, asbestos or birds
• You have restrictive lungs disease secondary to Asbestos exposure. draw the diagram of air way.
Restrictive lungs disease can be caused by problems in the chest wall and muscle or lungs cover(
we call pleura) or lungs tissue or air sacs. In your case, the asbestos build up in the lungs and
causes scarring in the lungs tissue. Overtime, the lungs tissue become thicken and restrict the
breathing. That's why u r having SOB. Other possibilities include Nasty growth like cancer,
idiopathic pulmonary fibrosis( scarring of lungs tissue without cause), Sarcoidosis (which is the
growth of inflammatory cells in the lungs and in other parts of the body)Bronchiolitis
(inflammation of airways), interstitial lung disease (which is also scarring in the lungs), muscle
and nerve problems in the chest or other obstructive problems like Asthma or COPD very less
likely in this pattern.
• Management of COPD dont mention these is best

• SMOKES
• S – smoking cessation
• M – Medication – inhaled bronchodilator, vaccines (influenza, pneumococcus)
• – Oxygen when needed
• K – Komorbidity – cardiac dysfunction, Sleep apnoea, Osteoporosis, Depression, Asthma, GORD
• E – exercise and rehabilitation
• S – surgery – bullectomy, lung volume reduction, single lungs transplantation
• Regular review, Support groups
Haemoptysis recent
You are a GP. A 70 years old lady, Jenny, presented with SOB for quite sometime. She had lost
weight,night sweats as well. She is coughing phlegm which has streaks of blood in it.
Your tasks:
• take hx, sometime pe findgs interpret
• explain X-ray findings to the pt and give dds.
History
• Phelm – yes – color? Amount? Was it produced anytime you cough?
• DDx - Any fever?
• Chest pain? palpitations? How many pillows do you use to sleep? more than 5% in 6 month to 1 yr period
• LOW? LOA? Any lumps and bumps all over the body? LOW +, how much weight did you loose?
What was the duration it took for that weight loss? Is that intentional?
• Any weakness in the hands? (Pancost tumor)
• Have you travelled anywhere before this SOB and cough?
• Occupational history (silica, coal, asbestos), Bird, allergens (not only about current job, please
ask smoking in ask about any previous jobs associated with these!)
detail if positive• SADMA avoid blaming the pt, nasty cond related to smoking,
• Any family history of lungs diseases or cancer? common in people who smokes.
dont tell u have ca bc u smoke faillll
Explanation
can put CA at first• This is X-ray of your chest. Let’s see it together.
place if u r confirmed
• This is your windpipe its central that’s normal position.
but that can scare 4
• These are your collar bones and these bones are ribs. This is the muscle diaphragm that
the pt
so tell others as separates tummy from chest. This shadow is your heart in the center, which is normal. These
unlikely black shadows are your lungs. There is a whitish opacity at the upper part of right lung. Please
tell when ca telling , check the left lung and there is no such opacity as you can see.
i am v concerned./• It could be anything like :
• Consolidation (when sir sacs are filled with fluid Infection by bug called pneumonia but u don’t
have fever.
• It can be collection of pus inside lungs called abscess, but again less likely.
• It can be another infection which is called tuberculosis although rare is Australia but can be a
possibility since you have cough, blood containing sputum and weight loss.
• Another condition that I am concerned is this mass can be a tumor, a nasty condition which is
cancer of lung. But please don’t worry I am just telling u all possible causes still we have to do
further investigations for confirmation.
• Although SOB can be due to other causes like heart problems or anemia but I don’t think your
history is consistent with those.
• Reassure – We will work on it together and still we need many more investigations. Even if it is
cancer, we have specific treatment for it.
Drug induced cough recent

You are a GP. Your next patient is a lady, Venessa, with chronic cough for past 1 year.
• Tasks:
• -History
• -dx/ddx
WHEN DID SHE START MEDICATION, any recent change in dose.
Differential Diagnoses
• Asthma
• COPD
• Recurrent viral infection
• Allergic rhinitis
• Side effects of medication
• Heart burn
• GORD
• Ca lungs
History
• Details of cough – how long? How long in one episode? How many times? How did it relieved?
Dry or any phlegm? Color? At what time of the day?
• DDx - Any fever? Runny nose? Sore throat? Shortness of breath? Noisy breathing? LOW, LOA?
Weakness in hands? Any regular medication? (Lisinopril for hypertension). Heartburn? Allergy
history? Ever work in contact with fumes, asbestos or in mining sites or boilers? What do u do
for a living? How long? Any previous career?
• Any stress
• Past medical and surgical
• SADMA
• Most likely – ACEI induced cough. That medication you have been taking for hypertension has a
side effect causing cough. This is the most possible reason for your cough.
• It could be others like reflux, viral infections, allergy, asthma, COPD or stress induced but less
likely according to the history.
Pleural effusion
45 years old man complains of shortness of breath for 3 months
Tasks:
• -History another case with ht faiure, but bibasal dullness
• -PEFE
• -explain the reasons for his shortness of breath
History
• Phlegm – yes – color? Amount? Was it produced anytime you cough?
• DDx - Any fever?
• Chest pain? palpitations? How many pillows do you use to sleep?
• LOW? LOA? Any lumps and bumps all over the body? LOW +, how much weight did you loose?
What was the duration it took for that weight loss? Is that intentional?
• Any weakness in the hands? (Pancoast tumor)
• Have you travelled anymore before this SOB and cough?
• Occupational history (silica, coal, asbestos), Bird, allergens (not only about current job, please
ask about any previous jobs associated with these!)
• SADMA
• Any family history of lungs diseases or cancer?
PEFE
• Vital signs
• Face – any ptosis?
• Hands – HPOA, hand weakness?
• Chest – inspection, palpation, persussion (dullness in the right lower zone), Auscultation
• CVS – JVP, heart sound and murmurs.
u got dullness, could be stony dullness could be not, if stony
• abdomen dullness then PE, so if dullness say like pl. effusion, fibrosis,
• UDT, BSL pneumonia, Pulm embolism, abscess, lung ca
• from history and examination, you have SOB and when I tap on your chest, it was dullness in the
base of right lung. There could be several possibilities:
• could be pleural effusion, which is accumulation of fluid between 2 layersof the lungs. These
fluid can be accumulated when there is nasty condition in the lungs membrane or lungs
infection or heart failure.
• Or that dullness itself could be fibrosis which is the scarring of lungs tissue
• It could be consolidation where the air sacs in the lungs are filled with fluid because of infections
like pneumonia.
• It could be pulmonary embolism or clots in one of the vessels supplying the lung
• It could be an abscess in the lungs
• Or could be nasty growth or lung cancer but still we need more investigations to know what
happened exactly.
Lung abscess
46 years old lady, Joey, came with pleuritic chest pain, Sob and dry cough. Initial assessment, Bp
130/90. PR 100. Temp 37.8. Spo2 99. Xray was done. Ho of Post cholecystectomy with abscess which
was drained 6 weeks back. Was done open sx and pneumatic stocking, ceftriaxone was given for one
dose.
• Task-Explain xray and dx ddx and order more investigations from examiner
checking rakibs
• Greet, how are you. Stability

• Explain the X ray – This is your Xray of the chest from the side view. The penetration is good and
good quality. These are the ribs and this shadow is your left lung. What I am concerned is the
white area here which is not supposed to be here.
• DDx – So it could be many things. It could be Lower lobe pneumonia which is the infection in the
lungs (The sacs in the lungs filled with fluids instead of air)- consolidation), Lung abscess which is
kinda formation of pus cavity and infection in the lungs, effusion which is the collection of the
fluids between the lungs coverings, pulmonary embolism i.e, the blockage of the lungs vessels
by blood clot, TB, less likely cancer
• Investigations – FBE, RFT, LFT, ESR, CRP, ABG, CTPA, CT scan, if fluid Aspiration of fluid check the
fluid,
haemopneumothorax
You are a HMO in ED. You are going to see a 30 years old man, Jordan, who was involved in a MVA.
Primary survey and secondary survey are done and the patient is now haemodynamically stable. But
still he feels breathless. A truck crashed into his car and the door swing onto the left side of his chest.
On physical examination, there is dullness on the left side of the chest. Ct scan is given.
Tasks :
• Explain CT to the patient
• Explain further management
Approach
• Sympathy
• Vitals
• How are you now? Any pain? Pain killers? Reassure that he is in safe hands.
• Explain the CT scan – lungs, right and left, this black and white area here is showing that there is
blood and air collection between the two coverings of the lungs. They came out from the lungs
because of the injury. Because of that, your lungs can’t expand and you are having SOB.
• Management – We will need to admit you, start on monitoring.

• We need to insert a small tube between those two layers.
• Before the procedure, the site to be inserted is chosen by USG guidance.
• Mark the site and local anaesthesia to numb and done under aseptic condition.
• Small incision – 1-2cm in upper border of the lower rib, split the tissues and muscles with blunt
forceps until the covering is reached.
• The covering will be punctured with blunt forceps or finger then the tip of the tube is inserted
and sutured. The other end of the tube is connected with a machine for drainage. And the
placement of the tube checked by Xray.
• You will feel better as soon as certain amount of fluid is drained.
• Risks – infection, discomfort, kinking, blood clot formation
• To avoid infection, we are going to do it under at most possible aseptic condition.
• It will be there for 2-3 days or sometimes longer according to the amount of fluid. We will
follow-up the residual fluid with Chest Xray.
• Removal is simple, without any pain.
• So for the moment, we will keep monitoring you and do the baseline blood tests especially
blood grouping and matching.
• Reassure – we will try our best for your wellbeing, after chest tube, your SOB be better.
Pneumonia risk assessment
A 67 years old lady, Sandra, is planning a trip to Perth in 2 weeks. She was just discharged from the
hospital 3 weeks ago for pneumonia. Now she is coming to you with recent X ray and the X ray before
discharge.
Your tasks :
• Explain the X ray
• Take a focused history
• Explain the pneumonia risk and give travel advice
• Approach
• Explain X ray comparing both – 3 weeks ago – whitish area in right middle zone – consolidation –
lungs tissue filled by fluid instead of air due to pneumonia – now resolved – no more whitish
area – full recovery .This is the pacemaker
• History – Pneumonia? Why hospitalized? How was it treated? How long was the hospital stay?
Frequent hospitalization?
• Symptoms – any fever? SOB? Any chest pain? Cough? Noisy breathing? Racing of the heart
beat? Swelling in ankles?
• Travel – where are you going? Rural? City? How long will you stay? What activities will you
enjoy?
• Past medical history, pacemaker – how long? Any problem? Any other illness? If present, how
was it treated? Liver, renal disease?
curb-65 not a tool fr pneumonia risk assesment
• Drug history?
• Past surgical?
• Flu vaccination? Pneumococcal? Hib?
• Smoking, alcohol
• Travel – on the plane – increase water intake and move your feet to reduce the risk of blood
clotting
• Stay near the medical facilities‘
• Avoid staying in places with poor ventilation
• Avoid crowded places
• When are you going? Arrange vaccination before travel.
• Take medical history notes in case you see a doctor there, give my number too
• Risk – you have some risk of having pneumonia in the future. GERD- continue PPI as prescribed-
because – acid reflux may lead to aspiration – reflux may also enter into the lungs which may
lead to pneumonia - so taking PPI is important
• OSA – upper airway blocked – cutting off Oxygen during sleep. It increases the risk for
aspiration or inhaling contents or fluid from throat into the lungs. This can put people at risk
from aspiration pneumonia. – so continue proper use ofCPAP and also make sure your
apparatus is properly cleaned – because – organisms – lead to infection in respiratory tract
• Pacemaker – infection – aware of pain , redness at site, fever, chills – staph endocarditis
Sore throat asking for antibiotics

A 25 year old female patient coming to you with sore throat. She asked you to prescribe antibiotics as
she has continuous meetings at her work. She wants it relived very soon.
Your tasks;
• Take history
• Physical examination from the examiner
• Manage the patient (tell the management to the patient)
History
• Complaint - sore throat –side, duration, disturb swallowing? Try any ,medicines? Any Voice
changes
• Fever
• Differentials – bacterial (higher fever, productive cough, runny nose) viral (muscle pains,
headache low grade fever), ENT infections, any SOB, nausea, vomiting, diarrhoea
• Travel history
• Sexually active? Safe sex? Lumps and bumps (HIV)
• SADMA
• PEFE from examiner – GA, vitals, throat examination, chest examination, CVS and abdomen,
UDT
• Management –most likely this looks like a viral infection because you don’t have a high fever
and when I examined you, there is no evidence of a bacterial infection. So, no antibiotics
required as it wont help.
• The condition is self-limiting in nature, it will go away 5-6 days

• So please try simple measures like increase fluid intake, liquid diet (not too cold or hot)
• Gurgling ( warm salt water)
• Simple medications like Panadol to reduce pain and fever
• Rest (medical certificate)
• Avoid crowds
• Wear masks (to avoid transmission to the others)
• Flu vaccination yearly etc
• I will review you after two days
• Red flags – high fever, pain not tolerated, drowsy, productive cough, please come back to me
Hay fever
You are a GP. 27 years old lady, Mary, who is a school teacher, complains of runny nose, nose block
and red, watery eyes. She had this symptoms yearly but it’s worst this spring. Her father has asthma,
mother has hay fever, and her sister has either hay fever as well. She was excluded from school
because of severe symptoms. She has been taking some medicines for a long time but not getting
much relief.
Tasks:
• Take history regarding the medication she is taking
• Immediate management to patient
• Further investigations to patient
• Further management to patient
History
• Greetings!
• Are you comfortable right now? How are you feeling? How can I help you today?
ask triggers
• Do you notice your triggers? Smoking? Alcohol? Illicit drugs? Occupation? Pets?
Carpets?(smoking can impair mucociliary clearance and is a risk factor for malignancy. Alcohol is
a vasodilator and may cause mucosal congestion. A history of illicit drug use is important; for
example, nasal administration of cocaine can lead to septal perforation. Exposure to hard wood
dust (carpenters, wood turners) can predispose to sinonasal adenocarcinoma.)
• Her medications ? Which medications are you taking?
• Steroids – what time? How often? Help your symptoms?
• Nasal decongestant (Otirivin) – how often? How long?(2 weeks) Did it relieve your symptoms?
Side effects – increased runny nose? (rebound) Dizziness? Disturbed vision? Racing of heart?
• Antihistamine – which type? How often? Did it help?
• Any history of asthma? Drug allergy?
Immediate management
• Your condition is as we all know, seasonal allergic rhinitis, hay fever.
• Long term intranasal steroid is the treatment of choice in treating this condition. So I will
prescribe an affordable brand for you. If long term treatment is not alright for you, I can adjust
to the types that can be used when necessary. (beclomethasone and fluticasone over a short
term 4-6 weeks). And also I will prescribe the lowest dose possible just to control the symptoms.
Usually, unlikely to systemic steriods, which means steriods by mouth or injections, the serious
side effects are not seen with nasal steroids, So it is relatively safe to use. I will also demonstrate
the correct method of using it later. (failure of treatment is common with incorrect usage,
spraying upward to Little’s area leading to dryness, epistaxis)
• Your nasal decongestants – it is not good for you in long term. It is only meant for a temporary
relief. In long term, it may even worsen the runny nose symptoms which we call rebound
phenomenon. So please stop using. Instead, you can try saline nasal spray 2-4 times daily which
will also relieves the blocked nose and clear the mucus. It also enhances the effect of nasal
steroids if do 15mins before steroids.
• For antihistamines, you can have it when necessary like when you have sneezing or epiphora
(red, watery eyes)
• Further investigations – refer to allergen specialist for skin prick testing or allergy blood test
(RAST) to know your triggers. Once you know them, you need to avoid them which is in
important part of treatment. I will also run baseline blood tests, Blood counts as certain blood
cells like eosinophils are increased in allergic condition and inflammatory markers.
• Further management – I will follow you up after allergy test, then you’ll have to avoid them,
adjust your steroids regularly according to the symptoms, if not relieved with these measures, I
will refer you to an immunologist/allergist for immunotherapy or if inferior turbinate
hypertrophy (enlargement of nasal bones) referral to to an otorhinolaryngologist for turbinate
reduction may be indicated.
Allergic Rhinitis
You are a GP. You are going to see a 21 years old Thomas who came to you because he is unwell.
• Tasks:
• History
• DDx
History
• Details of runny/blocked nose – How long? Is this the first time? Is it seasonal like happening this
time very year? Do you use any medications for it? How does the discharge look like? Clear or
any color? Any offensive smell? Is it affecting one or both nostrils?
• DDx – Any watery eyes? Any sneezing? (hay fever) Any cough? Any fever? Any SOB? Any joint
pain or muscle pain (URTI), any medication used for blocked nose (decongestant spray overuse),
Any headache? Bad breath? Mucus dripping down the throat? Pain on the face? (sinusitis), Any
foreign body?
• Any allergy or asthma history before? What about your parents? any pets ,carpets at home
• Is it triggered by any allergens? anyone in family having similar
symptoms,
• Do you have carpets or pets at home?
family hx of asthma, eczema, hay fever,
• Anyone in the family having the same condition? (son has URTI) allergic rhinitis,
• Past medical, past surgery
• SADMA
• DDx – It’s seems like you are having a condition called allergic rhinitis or hay fever which is an
allergic response to specific allergens. It causes the inflammation of the inner lining of the nose
causing sneezing and nasal discharge. Allergens are usually pollen, mold, dust or animal dander.
Most common allergen is pollen. It is common in hot, dry season as there are more pollens in
the air. That’s why your symptoms are seasonal. (your current attack may be triggered by URTI
too as son has URTI)
• Other possibilities are sinusitis which is the infection in the linings of the small spaces inside
your nose and head, Asthma, Infection in the airways (URTI) or very less likely foreign body in
the nose, or growths inside the nose.
Asthma
32-year-old female with history of asthma admitted to hospital because of worsening of her asthma.
She is on budesonide and salbutamol and needs to use puffer 5-6 times a week and her asthma
frequently wake her up at night nurse notes makes sure that
-the patient is taking her medication regularly
see jm plz
-knows how to use puffer correctly.
-no change in her home or work condition
tasks
• -take history from the patient to know why her asthma not well controlled
• -tell her about management of her asthma
History
• Details of Asthma – When was it diagnosed? How long has it been that you couldn’t control
Asthma?
• How many attacks of Asthma? Day? Night? Do you wake up at night due to asthma?
• how does asthma affect your physical activity and exercise? how many times do you need to use
puffer? Any hospitalizations? do you use the puffer regularly as prescribed?? Do you have an
how many cigrattes asthma action plan?
per day, do u • Risks : Pet or carpets? Inhaling smokes? Job? Recent viral Infections, travel?
think ur asthma • smoking (have you ever tried quitting)? Why? any recent keeping of pet, any recent
flare up. • Alcohol change in environment, any recent
• past medical history , allergy in himself and family members? excercise, recent viral.
r u able to cope
ur stress.
• From the history the most likely cause why your asthma is not controlled must be because of
smoking. Smoking can affect asthma and worsen it. So this is the main factor that I could get so
far from the history.
• Regarding management of your asthma and to prevent similar attacks in the future, it is very
important to stop smoking and I can arrange another consultation for you to talk about smoking
and to consider quitting again.
• I know you are experiencing some stress at work but it is also important to stop smoking in
order to let your asthma be under control and avoiding recurrent severe attacks. Smoking is not
a correct way to relieve stress.
• We can try other ways to relieve stress such as meditation and counselling with a psychologist.
• Regarding your current inhaler asthma medication, specialist will come and check you to adjust
it with the current level of your asthma, they might need to increase the dose, can also
prescribe or add oral steroid for more asthma control.
• He will review the asthma action plan and change it to a more appropriate one. You know it
right? You will have to follow it
• ((if patient has no idea for Asthma action plan, it’s the action plan(when well, not well, severe
case) and what to do each time
• When well, green zones, no signs, just for activities like before exercise, we will write what to
do at this stage in the plan.
• When not Well means yellow, signs and symptoms present, waking up at night
• Severe Case: 4x4x4 rule take Ventolin 1 puff in spacer 4 breath 1 puff 4 breath 1 puff 4 breath 1
puff 4 breath and wait 4 minutes if improved, see your GP on the same day (red zone, difficult to
breathe, Blue, unable to talk) Remember shake, 1 puff, 4 breaths
• If not improved call 000 and tell acute asthma attack and continue ventolin as per 4x4x4 until
ambulance arrive ))
• Self PEFR monitoring which I will teach you
)
Counselling cases
Modified 5C approach for counselling (8C)
• C – condition
• C – commonality
• C – causes
• C- Clinical features
• C- Confirmations (investigations)
• C – Course of the disease ( how long will it take)
• C- complications
• Common management (generally like lifestyle changes and specifically with medications)
Ulcerative colitis recent

40 years old lady, Tiffany, is at your practice today for reviewing of her Results of colonoscopy in
which the result is ulcerative colitis. She was having recurrent bloody diarrhoea.
Tasks:
• Explain the results
• Discussion of the management
• How are you? How is your diarrhoea?

• We have done a scopy to look for the cause of the bloody diarrhoea. So the result is with me
now.
• 5 C approach
• Condition – ulcerative colitis – which is the inflammation of the large bowel involving the upper
layer of it. It usually presents with diarrhoea with or without blood and mucus, abdominal
cramps, fever, loss of appetite and weight loss, eye problems and joint problems
• Commonality – it is estimated that more than 800 cases are newly diagnosed each year in
Australia.
• Causes – The exact cause is unknown but it may be due to a fault in immune system caused by
genetic, environment and infectious factors.
• Course of the disease – I am sorry to say that there is no cure but the treatment options are
available to help to minimize the impact of the disease.
• Treatment options –
• With careful management, most people with UC are able to enjoy life, including work, travel,
recreation, sex and having children.
• Specialist – will recommend a specific diet that suits your situation.
• UC involves periods of ‘relapse’ when the inflammation in the bowel flares up, and periods of
‘remission’ when the inflammation calms down. The aim of treatment is to treat relapses when
they occur and give the bowel a chance to heal. Medications also help maintain remission,
improve general wellbeing and prevent complications from developing.
• Medications commonly used to control inflammation in UC include:
• steroids
• aminosalicylates to control the frequency of relapses
• medicines that supress the immune system
• antibiotics
• You may also be advised to take medicines that control diarrhoea, relieve pain and supplement
your diet (to boost your iron levels, vitamin D and calcium, for example).
Surgery
• If the colitis is severe and does not respond to medication, the surgeon may recommend surgery
to remove the colon. A ‘pouch’ is then created inside the body using the end of the small
intestine, and this pouch is connected directly to the anus.
• Another option is to create a temporary or permanent stoma. This is an artificial opening in the
stomach that diverts faeces (or urine, in some cases) into a bag. The surgery eliminates the
symptoms of UC so medications are often no longer required.
• But those are the options less likely to consider in young patients
• To keep healthy, consider:

• keeping a food diary to check if there are any foods that make your symptoms worse during a
flare-up
• exercising regularly to lift your mood and help relieve stress
• learning some relaxation techniques to help manage stress
• Complications - A small number of people with colitis can develop inflammation in other parts of
the body, such as the liver, skin, joints and eyes.
• Regular monitoring by a gastroenterologist, as well as colonoscopies, may help prevent
complications from developing. But medications, including steroids and drugs designed to
prevent inflammation – and occasionally surgery – may be needed.
• Osteoporosis (thinning of the bones) can develop as a side effect of long-term corticosteroid
use.
• Cases of marked inflammation caused by UC can also lead to:
• nutritional deficiencies
• weight loss
• heavy bleeding due to deep ulcers
• perforation (rupture) of the bowel
• problems with the bile ducts, affecting the liver
• fulminant colitis and toxic megacolon, conditions that cause the bowel to stop working
• In the long-term, UC is associated with an increased risk of developing bowel cancer. This risk
can be decreased by maintaining a healthy diet, exercising and avoiding alcohol and smoking.
• For information and support, visit Crohn's and Colitis Australia or call the IBD helpline I will give
you the number.
Gout will be discussed in surgery

You are a GP in a sub urban practice and a 48-year-old John, a taxi driver comes in complaining of
continuous severe pain in the right great toe since 2 days.
• Take history from the patient in not more than 4 mins
• Advice the patient about the most likely diagnosis and your management plan
History
• Address the pain
• How much is it from a scale of 1 to 10? Do you need any pain killers?
• Pain questions
• Onset – fairly acute onset
• Location – mainly seen in MCP joints.
• Duration – 8 to 12 hours
• Character – severe pain
• Aggravating factors – movement
• Relieving factors – none till medication
• Radiation – does not radiate
Differential diagnosis
• Is there any redness? Is there any fever with chills? – Septic arthritis
• Is there any history of trauma? – trauma
• Have you ever suffered from psoriasis?
• Have you been diagnosed with a STI recently? – reactive arthritis
• Precipitant for this attack
• Could I know about your diet? – purine rich food
• Do you drink alcohol? How many glasses a day?
• Are you on any medication? – diuretics
• Do you drink a lot of soft drinks? – fructose high drinks
• Have you had any recent surgery in the past?
Risk factors
• Do you have a family history of gout?
• Do you have hypertension / diabetes / been diagnosed with any kidney problem?
• Complications
• Have you abdominal pain / noticed any change in color of urine – stones
• Have you noticed any masses in your joints / ear lobes – tophi
Management
• What is gout?
• Most likely your problem is gout, have you heard of it?
• It is a metabolic disease and it leads to recurrent joint inflammation due to deposition of a
substance called urate.
• There could be many reasons why urate could be high, but most commonly it is genetic along
with associated conditions like hypertension, diabetes and dyslipidemia.
• The problem happens when something precipitates the deposition of this in joints. It could be
alcohol, surgery, purine rich diet, some blood pressure medications etc
• It is very readily treatable, but we need to prevent further episodes as with increasing
incidences, it can lead to joint destruction
• Management
• Investigations
• I shall take a small amount of fluid from your joint to send for analysis to make sure it is not an
infection. I shall also send the same fluid for it to be seen under a microscope to confirm gout.
• I shall also take blood to check for urate levels, but they could be normal as well
• Apart from that I shall run a FBE, blood sugar, serum lipids and urea and electrolytes to confirm
the risk factors.
• Management
• Immediate management
• We are going to stop the diuretics and/or aspirin.
We shall begin you on a high dose of indomethacin for 3-5 days and then reduce and cease it as
symptoms reduce
• Please take a lot of fluids in the meantime as well
If the pain does not settle, panadol can be used as additional pain relief.
In 48 hours, pain may settle down and you can resume work. I shall give you a medical
certificate so you can take time off work.
• You might feel a bit of indigestion because of the medication
• Long term management

• Once acute attack is over, I would advise to reduce body weight sustainably, and exercise
regularly. Also avoid sugary soft drinks.
• I shall also see you then for a talk about reducing alcohol as it can aggravate the attack. Avoid
high purine diet such as red meat, tinned fish.
• I shall review after 4 weeks to check uric acid levels. (Aim is to be <0.4 mmol/L)
• After 6-8 weeks of this attack we shall commence you on allopurinol 50-100 mg then gradually
increase to 300 mg daily. This could be up to 6 months.
• We also may add colchicine / NSAIDs with allopurinol for prevention of recurrent attacks
• Advise to wear comfortable shoes.
a new case shared of ra
Rheumatoid arthritis starsss, new
A 45-year-old Jenny, who is in an orchestra player is complaining of pain, swelling and stiffness of
both hands. Her mother was diagnosed with rheumatoid arthritis and she has been on steroids for a
while. You started Jenny on ibuprofen tablets and organized some blood tests, FBE, U&E, LFT,
ESR/CRP, ANA, RF. The results came back confirming an early stage of rheumatoid arthritis. She has
come to GP clinic to discuss with you the results. She is complaining that the pain is getting worse
extending to the wrist.
TASK:
• Counsel the patient
• Answer her questions
Notes:
Criteria for diagnosis of RA
• Symptom duration more than 6 weeks family hx of inflammatory arthritis,
• Early morning stiffness more than 1 hour swelling in 5 or more joints
• Arthritis in 3 or more regions raised esr/crp in absence of infection.
• Symmetry of joints involved
• Rheumatoid factor positivity
• Anti CCP antibody positivity
• Bony erosions on X – ray ( late feature )
RA – management
• Education and reassurance
• Regular exercise
• Smoking cessation
• Pharmacological
• NSAIDs to reduce pain
• DMARDs – start early to induce remissions and prevent complications
• Steroids – to be used in acute flare ups
• Occupational – in case the occupation is contributing
• DMARDs – started by specialists
• Methotrexate
• First line
• Sulphasalazine
• Hydroxichloroquine
• Azathioprine
• Gold salts
• D – penicillamine
• Biological agents
• Infliximab – anti TNF alpha
• Anakinra – anti interlukin 1
Counselling
• Assess knowledge and build rapport
• Do you know anything about rheumatoid arthritis? Do you have any particular concerns?
• Talk about what RA is
• RA is an autoimmune disease where your immune system starts attacking the body itself which
in your case, is the joints. Most likely affected are the small joints of hands and feet and rarely,
the large joints. This usually presents as stiffness which is more in the morning. The cause of this
condition is unknown, but it is more commonly found in people with a family history.
• What investigations you will do
• The diagnosis is based on a lot of investigations, so I would like to refer you to the
rheumatologist and he will organize further laboratory investigation. Mainly look out for a test
called Anti-CCP.
• Talk about the disease prognosis

• I’m sorry to say that this is a chronic progressive condition. It is not curable, but controllable.
However, the course of RA varies from person to person.
• The good news is that with early diagnosis and treatment, most of the people will be able to live
a normal active life.
• I shall be referring you to the rheumatologist who will be able to talk to you more about this.
• Talk about management

• Symptomatically - for your pain and stiffness, we will give you painkillers. You could also use a
hot water bottle or pads on affected joints as soon as you get up from the bed to reduce
stiffness.
• Long term - The rheumatologist will also consider starting you on DMARDs which is a group of
drugs which slows the progression of the disease and recommended to start at an early stage.
• I should also tell you some people experience attacks on top of chronicity when the joints
become more inflamed, painful and stiffer. This is called as an acute flare up. For these times we
will be using steroids to treat such an episode.
• Talk about occupational management

• In acute flare-up, the use of the joint may leave an impact on the joint causing further
destruction. With the right scheme of medications and rest, it reduces the impact of the disease
on the joint. I understand that it is important for you to use your hands, but I would recommend
you not to play in the orchestra during acute flare-ups. Unfortunately, in the long run it may
affect your joint and may affect your career. I know it is a hard decision but it would be a better
idea to consider changing your profession. We can have a talk with your team if they can find
you a much more suitable position at the orchestra.I shall also write you certificates during an
acute flare ups and Centrelink should be able to help you during those days.
• Talk about healthy lifestyle

• It would do you best to stop smoking. I could arrange another session for that.
• The physio will also tell you exercises to keep your joints less stiff.
• A healthy diet and exercise should go a long way in keeping you fit
• Follow up
• It is a chronic illness so you will need regular follow up but do no worry, you will be managed by
a MDT with the rheumatologist, physiotherapist, occupational therapist and me as your GP.
• There are support groups as well, the contact details of which I can provide.
5star
Liver metastasis
Your next patient is GP is a 75 years old Simon, who had been seen by one of your colleagues in the
practice a week ago. He had a complaint of 6 months history of nausea, jaundice, pale stool, dark urine
and right upper abdominal discomfort. He has undergone colectomy in the past and treated for
colorectal cancer a year ago. Investigations were ordered and he came today for the result.
FBE – Haemoglobin – 9.7 g/dl and a CT
• Your tasks:
• Explain the test results
• Most likely diagnosis to the patient
• Further management to the patient
• Approach
• Breaking bad news
• SPIKES – Setting up and start, Perception, Invitation, Knowledge, Emotions, Strategy and
summary
• Colon cancer – how was it treated? Follow-up?
• CT – Here is the CT scan of your tummy. Actually in CT scan, it’s the mirror image so the organs
from the right side of the body appear on left side of the CT scan. This white area is the back
bone. The large grey area on the left is liver. As you can see, there are some circular lesions in
the liver mostly likely related to the nasty condition, it could be nasty growth originated in liver
or more likely it could be disseminated from the other parts most likely form the previous colon
cancer. Other possibilities : liver tumors itself as primary, Liver cyst or abscess or infections but
less likely.
• Anaemia – you also have reduced haemoglobin levels in the blood which is commonly
associated with the nasty conditions
• I know this news may shock you. Please tell me what is going through your mind?
• Do you want me to discuss the treatment plan now or do you want to make another
appointment?
• I do understand your feelings. Remember I am here to help you. You are not alone. There are
many treatment options available for patients like you.
• First, you need blood tests and imaging.
• FNAC – the cell samples from the lesion of liver will be taken under USG guidance (risk of
bleeding present but we will do it only after coagulation profile, blood test, to make sure that
you won’t have bleeding.) It will be under topical anaesthesia and that won’t cause you pain.
talk abt MDT, assesment whether surgeon decide whether do surg or not, then chemo or radiation, can be
primary or adjuvant
dr am I going to die, we have these treatment options available, which have proven successful in past and
improved quality of life with dramatic increase in survival rates, many people fighting with bowel ca, I can
• send support grps
Colonoscopy againavailable , these options improved quality of life in past, dont say yes or no
• Other investigations – RFT, LFT, urine tests, tumor markers. CXR, full body PET scan, Bone scan
(if bone pain)
• Consequence of the condition is liver failure which means liver cannot function properly. You
will get some problems with digestion, bloating and jaundice etc.
• A team including Oncologist (cancer specialist), Surgeon, physician, Psychologist, well trained
nurses and GP will be taking care of you.
• After the assessment – specialists will decide the best treatment plan for you. If possible, a
surgical resection will be done. The extent of liver resection needs to be balanced against the
functioning capacity of the liver remnant so as to avoid liver failure. It will be followed by chemo
or radiation.
• We also have advanced chemo and radiation techniques for unresectable tumors and as
adjuvant therapies. we have selective internal radiation therapy (SIRT), Radiofrequency ablation
(which will destroy the tumor cells with electric current) and transarterial chemo embolization
(which is a therapy that involves vessel occlusion, delivering high doses of chemotherapy to the
target lesion. These techquines have proven dramatic increase in survival rates.
• Aim – to improve the quality of life to the most, make sure the patient is comfortable – no
depression, no pain, no worries
• There are many people with the same condition fighting against cancer
• Support groups for bowel cancers
Epilepsy and driving license dont worry if u finish early

A 20-year-old woman is referred to your GP clinic as she is diagnosed with idiopathic epilepsy by her
neurologist. She has been put on sodium valproate for treatment. She asks you about her driving
license.
• History
• Address her concern
History
• I understand your situation, I know its hard and I will definitely address your concern but can I
ask you few questions about your condition first?
• How was it diagnosed? What were the symptoms? Is it the first time? after that episode did you
had fits after that? How was it treated? Are you taking it according to the prescription and
regularly? (note: in case of non-compliance, please ask non-compliance questions, doctor factor,
medicine factor, patient’s beliefs
• LMP, sexually active? Contraception?
• past medical, past surgical
• Family history
• SADMA
• DL – which vehicle you are driving? (private or public?)
• I will be checking with VicRoads because you have to be careful with driving. Each case has to be
considered individually but the rule is your D/L might be suspended for 6 months because there
is high chance to get fits while driving which may leads to accident. After 6 months from starting
the treatment, We shall have a review then to see about how the medication is working and
make a decision then. (conditional licence)
• Talk about other activities
• It is best to avoid individual dangerous sports like scuba diving, hand gliding, parachuting, rock
climbing, car racing and surfing
• It would also be good to avoid contact sports like footy
• Please avoid being around open fires and swimming unsupervised as well.
• Talk about family

• you can expect to have normal sexual life and normal children although your children have a
slightly increased chance of having epilepsy (3%).
• Talk about carers
• Please bring your carer / family for a meeting so we can discuss this condition as well as what
they have to do in case you do get a seizure
• Note : please address non-compliance when there is positive history
Retinoids not recnt skip

Acne in face, using retinoid, pt is wearing cap and hoodie telling don't go school that much as acne.
Picture was there. (acne vulgaris)
• Take Hx
• tell about the impact and S/E of retinoid
History
• Site, duration, any evolution? worsened? Better? Anything make it better or worse? Food or
cosmetics? Pain?
• Retinoid – how long? How often ? What form? Sunscreen? Did you use it at night or day?
• SE of retinoids – topical – dry, dermatitis, rash, pain
• Oral –topical side effects + headache, diarhoea, vomiting, abdominal pain, peripheral odema
• How’s it affecting routine life?
• Social – depression, stress? How’s everything at school?
• Show sympathy
• SADMA
• Menstrual history if female! Other features of PCOS – voice changes, male pattern hair changes,
obesity
• Side effects – skin dryness, redness, itching, pain, infection, headache, nausea, vomiting,
diarrhoea, tummy pain, leukopenia, anaemia, hyperlipidemia, hypothyroidism,
• Teratogenic in pregnant woman! Esp with oral!
in 2019
Lithium Travel Advice
36 years old lady came to your GP clinic known case of bipolar disorder for 10 years, on lithium
planning for trip to mountains in India. All her vaccination is up to date. Her last attack of mania was 5
years ago. you have taken history about her mental status which is fine.
Tasks:
• take history about her medication. dont have to do mental state examination bc already taken
• Give advice regarding travel.
History
• Since when you have been diagnosed with bipolar? Lithium dose? Change in dosage? Are you
taking it regularly? Any other medication?
• Last visit to specialist? Last blood check for lithium levels and baseline tests?
• Side effects – nausea, vomiting, shakiness, muscle weakness, urinary frequency? weather
preference?
• How is your mood now?
• With whom are you travelling? Which activities are you going to do? When? How
long?Immunization?
• Past medical, past surgical, SADMA sadma v imp bc alcohol intake interfers with lithium levels
• Advice – Dos - travel with someone who can take care of you. If going with tour, let the tour
leader know your condition. If possible, stay near to the healthcare facilities. Take the numbers
of local GPs and emergency services.
• Take enough amount of medicines and some extra. Put it in two separate luggages, better put
medicines both in carry on baggage and the check-in one. Take the prescription with you.
• Drink plenty of water as Li can cause dehydration. Have enough sleep as well.
• Don’ts – Avoid street foods and unsafe water. Don’t take sleeping pills and other OTCs without
consulting a doctor. Avoid alcohol.
• I will need to check your blood Li levels, TFTs, LFT, RFT, full blood examination. You will need
specialist review before travel as well.
• Red flags for Li toxicity – diarrhoea, vomiting, shakiness, drowsiness followed by gait
disturbance, giddiness and blurred vision – go to the ED ASAP.
• I will see you again with the blood test results.
Anti-hypertensive non-compliance imp case, recent,

You are in GP, patient 32 years old who was diagnosed with hypertension 1 year ago came in for
follow up. She is non compliant on her antihypertensive medication
Tasks:
Take History from the patient
Counsel the patient about general and specific measures to enhance antihypertensive compliance
main concern here is non compliance, focus on y non
• HYPERTENSION Qs: complaint.
• I also noticed you have high blood pressure?
• When was it diagnosed? another case, dementia, she is forgetting the other things
• How was it diagnosed? as well so have to take hx in that case abt dementia.
• What tests were done? When was the last check?
• What medications was prescribed
• Do you remember the dose?
• Do you have any difficulty in remembering to take medicines? Any other memory problems than
that? if yes check other memory problems as well
• Do you have any stress?
positive hx of stress bc moving states
Reason why she is non-compliant of her medications

• Doctor related
• When you were diagnosed, did you understand the causes, the risk and complications of
hypertension?
• Did you understand the explanation and what will be the effects in not taking the medications
regularly?
even if she is not taking med bc of
• Medicine related forgetfullness keep asking qs y non
• Are you taking your medication regularly with the right doses? complaint.
• How many times do you have to take it?
• Any side effects from the medication?
bc score sheet for other factors
• Like coughing? (is this troublesome for you?
• Headache?
• Ringing in the ear?
• Any issues with the cost or understanding the prescription?
• Patient’s Belief
• What is your view about your condition and your medication?
• Do you think this drug is good for you?
• Are you trying any alternative treatment?
• Assessing End organ damage:

• Have you had any visit with specialist:
• eye specialist and
• cardiologist?
• Do you have any chest pain at the moment?
• Any shortness of breathe? 3 to 4 qs
• Any swelling of your feet?
• Any pain on walking?
• How’s your waterworks?
• Adherence to SNAP Model:/SADMA
• How’s your diet? Well balanced?
• Do you smoke?
• 3. Do you exercise regularly?
• PSH: Stress at work? Enough Support
• PMH/FH
add a memory taste , MMSE, bc in one recall ch alcoholic and now

forgetful, can arrange a memory test to make sure that u dont have a
memory prob.
convince the pt
Explanation
• High blood pressure can cause some complications in your heart, kidney and it can also lead to
stroke. That is why it is important to control it by adhering to a healthy lifestyle and taking your
medications regularly.
• Based from the history, I understand that you haven’t been compliant with your medication
because you had a hard time remembering to take it. I would like to help you with that. It might
be because of your stress but I would also like to carry out a memory test as well to make sure
that you don’t have any memory problem.
• I would like to arrange a family meeting with your consent so that we can discuss this with your
family for support and for them to remind you of your medications.
• I will advise you to take the medications regularly at the same time daily.
• Writing down a reminder on a small white board on your room, bathroom and kitchen will help.
• You can put on an alarm in your cellphone as a reminder to take the medication.
• I will also prescribe a medication that is taken once daily so it will be easier for you to monitor
whether you have taken the medication or not.
• Pill organizer and dosette boxes from the pharmacy can also help.
• I will liase with a Pharmacist and arrange a home medicines review/ domiciliary medication
management review for you.
• I will refer you to a social worker and a district nurse to help you with your medications.
BCC
You are a HMO in a hospital and a patient comes in with a suspicious skin lesion on his right cheek.
Task:
• History
• Tell the possible Dx and management
History
• Details of the lesion – duration? Progressive? Any other areas? Pain? Bleeding? Itchiness? First
time?
• Any LOW, LOA, any lumps and bumps
• Occupation? Sun exposure?
• Any previous skin cancer or family history?
• Medical or surgical history?
• SADMA
• BCC -? Basal cell carcinoma is a skin cancer developed from the epidermis and the hair
follicle. It is the most frequent skin cancer in adult patients. It almost never metastazises
and grows slowly on the skin.
• The patients most at risk are adult patients over 50 years old with fair skin and who
leave in sunny areas. Male are more often affected than women
• The main risk factor for Basal cell carcinoma development is sun exposure. Initially
attributed to sun exposure in childhood but more recently the additional risk of
occupational sun exposure has been reported. This is the reason why these lesions are
mainly located on sun exposed areas (face, scalp in bold men).
• The diagnosis is confirmed by a skin biopsy which takes a small piece of the tumor in
order to be analyzed under the microscope. Other imaging techniques exist but are not
routinely used.
• The standard treatment for Basal cell carcinoma is surgery. The majority (>90%) of the
lesions will never recur after an optimal surgical treatment. However for superficial lesions
(only) some alternative non-surgical techniques can be used such as topical imiquimod,
liquid nitrogen or photodynamic therapy where we use photosensitive medications and light,
which allow a good control of the disease and offer the advantage of leaving almost no
scar.
• Prevention The major preventive behavior is avoidance of sun exposure (protective
clothing, sunscreen, avoid tanning beds, no exposure between 10.00 and 15.00).
• Additionally, regular follow up of patients having a previous Basal cell carcinoma is
recommended as the risk to develop a new one is higher in patients with a history of
basal cell carcinoma.
SCC
A 50 year old female, Nancy, came to your clinic for Biopsy result for a lesion on her temporal region.
It shows SCC. On examination, there is no cervical lymphadenopathy.
Your tasks :
• Tell the diagnosis
• Management plan to her
• Greetings
• Nancy, we have done a biopsy of a lesion on your temporal region and now we’ve got the
results.
• I am very sorry. The result is not as good as we expected before.
• Show – nasty condition of skin – we call it SCC.
• I can see the it might be distressing for you. You want me to discuss the treatment now or
should I make an another appointment?
• Can you tell me what is going through your mind? I am here to help you.
• Let me explain what is SCC. There are the nasty condition arise from the outer layer of our skin.
First of all, I want to say that it is one of the most common skin cancers and it has a good
prognosis and slow growing. We can get a cure in early stage.
• I can assure that this is the early stage because the nodes around the neck can’t be felt. When
the nodes in the neck become enlarged, it implies that the cancer has spread.
• In biopsy specimen, it shows that there are some cells around the margin of excised tissue. This
happens because it is difficult to know the real margin of the lesion with naked eye. ‘So you will
need further excision with adequate margin of clearance.
• So I will refer you to the surgeon who will do a wide local excision until the safety margin is
reached. The benefits – curable. Drawbacks- scar, plastic Sx may be needed in some cases. The
biopsy will be sent again and make sure the margin is clear.
• At this stage, I don’t find any neck lumps so it means no metastsis so probably no further
treatment will be required after surgery. To make sure there is no cancer spread, imaging called
CT scan will be done around head and neck region. But this test will likely to be normal.
• The recurrent risk is double with sun exposure.
• Prevention – sun smart – sunglasses, broad brim hat, Sun cream t least SPF 30 and apply 2
hourly, avoid going out between 10 am to 3 pm, long sleeves pants and shirts
• Red flags – pre-existing lesions –any ulcers fail to heal in time, any chronic lesions like burns or
other lesions (keratoacanthoma) – consult with doctor because these may change to nasty
condition.
SCC in-situ (ref from different websites)

• It is very early form of skin cancer that hasn't spread beyond the top layer of skin. It is also called
Bowen’s disease.
• is a growth of cancerous cells that is confined to the outer layer of the skin. It is not a
serious condition, and its importance rests on the fact that, very occasionally, it can
progress into an invasive skin cancer known as squamous cell carcinoma
• Causes
• Long-term exposure to the sun or use of sunbeds – especially in people with fair skin
• having a weak immune system – for example, it's more common in people taking medicine to
suppress their immune system after an organ transplant, or those with AIDS
• previously having radiatherapy treatment
• The HPV – a common virus that often affects the genital area and can cause warts
• It is not usually serious and there are good treatments available. Because it is such an early
cancer, it can very likely be cured.
• The best type of treatment for you will depend on the size and thickness of the disease, where it
is on your body, your age and health, and your preference. Treatments include:
• Freezing it off: Liquid nitrogen is sprayed onto the patch of skin to freeze it. It will scab over and
fall off after a few days. The procedure can be a little uncomfortable.
• Chemotherapy cream: A medicine such as 5-fluorouracil or imiquimod is put on the patch
regularly for a few weeks. The skin often gets red and inflamed before it gets better.
• Curettage and cautery: You are given a local anaesthetic before the patch of skin is scraped
away and then heat or electricity are used to stop any bleeding.
• Photodynamic therapy (PDT): A cream that reacts to light is spread on the patch of skin and then
a laser is shone on the area a few hours later to kill the cancer cells. This may need to be
repeated.
• Surgery: The patch is cut out under local anaesthetic. You may need stitches afterwards.
• Sometimes, it can come back after treatment, so it’s important to go to follow-up for full skin
check.
Melanoma
A 45 year old female, came to your clinic for Biopsy result for a mole. She visited your clinic a week
ago for the mole in her back. You took a punch biopsy and now the results is here. It shows Melanoma
0.45mm, with Clark staging 2, superficial to partial thickness and superficial spreading
Your tasks :
• Tell the diagnosis
• Implications of the condition
• Management plan to her
Approach
• BBN
• Sympathy
• Reassure – good thing is it is common 3% in normal population, Risk - sun exposure
• Ca in outer layer called epidermis begins in the cells called Melanocytes which control the
pigment of your skin.
• Early stage – very good prognosis – cured
• Rx – complete excision with safety margins 5mm, just a day surgery and biopsy again to make
sure that a safety margin is reached and there is no remaining cancer cells
• There is no requirement for CT or other scans at this stage as this is an early stage.
• Complete cure is possible with wide local excision.
• Notes for spread – Cough and blood in sputum, SOB, lumps and bumps, come to see the doctor
again
• Follow-up for this case – 6 monthly for 2 years
Notes:
Follow-ups - <1mm – 6monthly for 2 years
• 1-2 mm – 4monthly for 2 years and 6 monthly for 2 years and yearly for 10 years
• 2mm – Regularly by both specialist and GP for 10 years
• The recurrent risk is higher with sun exposure.

• Prevention – sun smart – sunglasses, broad brim hat, Sun cream t least SPF 30 and apply 2
hourly, avoid going out between 10 am to 3 pm, long sleeves pants and shirts
• Red flags - Any change in size, shape, color or elevation of a spot on your skin, or any new
symptom in it, such as bleeding, itching or crusting, may be a warning sign of melanoma.
Clarke’s staging
• 1 – confined to epidermis
• 2 – extend into the superficial dermis
• 3 – fill the superficial dermis
• 4- extends into deeper tissue (reticular)
• 5- subcutaneous tissue
Haemochromatosis
early in 2020
You are a General practitioner. Your next patient is 25 years old Ashley, coming to see you because
her brother was recently diagnosed with haemochromatosis.
Your tasks:
• -Explain her about the condition
• -Tell her about the management
• Greetings
• Build rapport
• Explain the condition
• Condition
• Haemochromatosis is a condition where your body absorbs too much iron from the food you
eat. Normally, the body limits the amount of iron absorption from the foods you eat. So no
matter ho much iron rich foods you eat, there is a maximum limit of the absorption by the body.
Excess iron is stored in your organs, especially the liver, heart, joints and pancreas leading to
serious complications.
• Commonality
• It is one of the most common hereditary diseases that means it runs in the families. Around one
in 200 Caucasian Australian people have a genetic predisposition to this disease – meaning that
they may get it. Both sexes are equally at risk, but women tend to develop the condition later
than men in life, since menstrual periods and pregnancy deplete the body of iron.
• Causes and risk factors

• Gene - Hereditary hemochromatosis is caused by a mutation in a gene that controls the amount
of iron your body absorbs from the food you eat. These mutations are passed from parents to
children.
• So if you have a first-degree relative — a parent or sibling — with hemochromatosis, you're
more likely to develop the disease.
• Ethnicity - People of Northern European descent are more prone to hereditary
hemochromatosis than are people of other ethnic backgrounds..
• Gender - Men are more likely than women to develop signs and symptoms of hemochromatosis
at an earlier age.
• Clinical features
• The first symptoms include feeling weak and tired(fatigue), pain in the joints and pain in the
tummy.
• Bronzing of the skin (looking like a permanent tan)
• Loss of sex drive
• Loss of body hair
• weight loss
• an inability to get or maintain an erection in men (erectile dysfunction)
• irregular periods or absent periods in women
• Confirmations (investigations)
• We can confirm the condition by genetic testing which detects the fault in a gene called HFE
gene.
• Other tests we do are checking the iron levels and transferrin (proteins which transport iron) in
the blood. Liver scan because liver is the main organ affected in this condition. Liver biopsy in
few cases where there is potential serious complications and echocardiogram which is the
imaging of the heart. We will also do base line blood tests as well to know your blood counts,
liver and kidney functions and also blood sugar level to detect the diabetes which also is a
complication.
• Course of the disease

• There's currently no cure for haemochromatosis, but there are treatments that can reduce the
amount of iron in the body and reduce the risk of damage. People can have a normal life
expectancy if the condition is detected early with lesser complications.
• Complications
• Complications are mainly based on the excess of iron deposits in various organs. They include:
• liver problems – including scarring of the liver (cirrhosis) or liver cancer
• diabetes – where the level of sugar in the blood becomes too high
• arthritis – pain and swelling in the joints
• heart failure – where the heart is unable to pump blood around the body properly
• Depression
• Poor memory
• But we can reduce those by giving treatment at early stage.
• Common Management
• There's currently no cure for haemochromatosis Since the patient will always have the faulty
gene, but there are treatments that can reduce the amount of iron in the body. This can help
relieve some of the symptoms and reduce the risk of damage to organs such as the heart, liver
and pancreas.
• He will be under the care of a specialist - usually a haematologist, who will monitor his blood
levels, and advise on treatment. If there is very high levels of iron, or any evidence of liver
damage, he would also be referred to a liver specialist (a hepatologist).
• Phlebotomy
• The most commonly used treatment for haemochromatosis is a procedure to remove some of
the blood, known as a phlebotomy or venesection.
• The procedure is similar to giving blood. The patient lies back in a chair and a needle is used to
drain a small amount of blood, usually about 500ml, from a vein in his arm.
• The removed blood includes red blood cells that contain iron, and the body will use up more
iron to replace them, helping to reduce the amount of iron in the body.
• There are 2 main stages to treatment:

• induction – blood is removed on a frequent basis (usually weekly) until your iron levels are
normal; this can sometimes take up to a year or more
• maintenance – blood is removed less often (usually 2 to 4 times a year) to keep the iron levels
under control; this is usually needed for the rest of the life
• Regular blood removal will not cure some of the complications of haemochromatosis such as
diabetes or liver 'scarring' (cirrhosis). Therefore, early diagnosis and treatment are very
important.
• Liver transplant may occasionally be needed if the liver is very badly affected.
• Chelation therapy
• A treatment called chelation therapy may be used in a small number of cases where regular
phlebotomies are not possible because it's difficult to remove blood regularly – for example, if
one has very thin or fragile veins.
• This involves taking medicine that removes iron from the blood and releases it into the urine or
poo.
• A commonly used medicine is deferasirox. It comes as a tablet that's usually taken once a day.
• Diet and alcohol

• He does not need to make any big changes to his diet, such as avoiding all foods containing iron.
• But there are usually some advice to:

• have a generally healthy, balanced diet
• avoid breakfast cereals that have been "fortified" with extra iron
• avoid taking iron and vitamin C supplements – these may be harmful for people with high iron
levels as they increases iron absorption
• be careful not to eat raw oysters and clams – these may contain a type of bacteria that can
cause serious infections in people with high iron levels
• avoid drinking excessive amounts of alcohol – this can increase the level of iron in your body and
put extra strain on the liver
• Tea, coffee and all milk products taken with a meal reduce the amount of iron absorbed from
food. So you may find having tea, coffee or a milky drink with meals helps a little with iron
levels.
• Screening
• Since it is inherited, when you have a parent or sibling with haemochromatosis, even if you do
not have symptoms yourself – tests can be done to check if you're at risk of developing
problems. These include iron levels and iron binding protein ferritin levels and will proceed to
gene testing if these levels are high.
• Review, Recheck, Reading materials
Covid vaccination case

77 yr old in aged care facility not vaccinated against covid, you have AstraZeneca and Pfizer at your
facility.
• Task: take hx if you need to,
• counsel.
• Note by recaller : ( Pt wasn’t interested in getting covid vaccine had concerns due to media
hype etc, in the stem it was mentioned he had copd, ccf and atrial fibrillation on apixaban
•Intro
•May I know why you don’t want to get jabbed?
•Have you had a severe reaction to any vaccine in the past?
•Do you have any severe allergies or anaphylaxis to anything?
•Have you ever had abnormal blood clots in veins of your spleen, abdominal organs or brain?
•Do you currently feel unwell or have a fever today?
•Have you had a COVID-19 vaccine? Have you had any other vaccine in the past 7 days?
•Have you had any injections, infusions (including immunoglobulins) or transfusions of blood products in
the previous 48 hours?
•Do you have a condition or take medication or treatment that weakens your immune system
(immunocompromised)?
•Blood thinning medication or bleeding disorder? Which ones? Why? (this case mentioned in the stem)
•Past medical, Past surgical, any family history of cancers?

•SADMA
•Counseling
•Getting vaccinated against COVID-19 can lower your risk of getting and spreading the virus that causes
COVID-19. Vaccines can also help prevent serious illness and death.
•All steps have been taken to ensure that vaccines are safe and effective for people ages 5 years and
older.
•You should get a COVID-19 vaccine, even if you already had COVID-19. Emerging evidence shows that
getting a COVID-19 vaccine after you recover from COVID-19 illness provides added protection to your
immune system. Moreover, the level of protection people get from having COVID-19 (sometimes called
natural immunity) may vary depending on how mild or severe their illness was, the time since their
infection, and their age.
•Getting sick with COVID-19 can have serious consequences:
•It cause severe illness or death, even in children, and we can’t reliably predict who will have mild or
severe illness.
•You may have long-term health issues after COVID-19 infection. Even people who do not have
symptoms when they are initially infected can have these ongoing health problems.
•People who are sick with COVID-19 may spread COVID-19 to others including friends and family who
are not eligible for vaccination and people at increased risk for severe illness from COVID-19
•When you are up to date on COVID-19 vaccination, you can resume many activities with proper
precautions (e.g., mask wearing in indoor public spaces).
•continue to take all precautions recommended for unvaccinated people, including wearing a well-
fitting mask, until advised otherwise by their healthcare provider
•All COVID-19 vaccines currently available in the Australia are equally effective at preventing COVID-19.
Staying up to date with COVID-19 vaccination gives most people a high level of protection against
COVID-19.
•Now in this facility, I have AstraZeneca and Pfizer vaccine.
•Authorities recommend that AstraZeneca is the preferred vaccine for people aged 60 years and older.
•I am aware that you are taking the blood thinners for your condition (have to ask in the history)
•There is no evidence to suggest people who had previously had a blood clot were more at risk of
developing one of the very rare clots potentially linked to AstraZeneca.
•Also, the type of rare clotting seen in people who had been vaccinated with AstraZeneca was very
different to standard blood clots.
•Most side effects are mild and should not last longer than a week, such as:
•a sore arm from the injection
•feeling tired
•a headache
•feeling achy
•feeling or being sick
•You may also get a high temperature or feel hot or shivery 1 or 2 days after your vaccination. You can
take painkillers such as paracetamol if you need to. If your symptoms get worse or you're worried, call
111.
•If you have a high temperature that lasts longer than 2 days, a new, continuous cough or a loss or
change to your sense of smell or taste, you may have COVID-19. Stay at home and get a test.
•You cannot catch COVID-19 from the vaccine, but you may have caught it just before or after your
vaccination.
•continue to take all precautions recommended for unvaccinated people, including wearing a well-
fitting mask, until advised otherwise by their healthcare provider
•get a booster shot after completing their COVID-19 vaccination primary series.
•Booster doses are recommended for those 18 years and older who’ve had 2 doses of a COVID-19
vaccine for their primary vaccination course at least 5 months ago.
•Getting a booster dose is not mandatory for many people, but to maintain protection against COVID-
19, it’s recommended that you have a booster dose.
•Both Pfizer and Moderna vaccines are approved by the Therapeutic Goods Administration and
recommended by authorities as a COVID-19 booster dose.
COPD patient signed DNR 2019, now

You are a HMO in a hospital. You are going to see a son of 80 years old patient. The patient has
chronic COPD and recurrent hospital admissions. Advanced care planning started 6 months ago – she
signed for DNR or no vent support, the consultant assessed her and asked you talk with the son the
decision now is not treat her as she is in terminal illness as patient had 24hrs of antibiotics and
corticoid and not responding.
1. condition
• Task:
2. tell in details y she signed the DNR, even if she didnt
• discuss with son diagnosis and management. sign, those ventilatory supports will not prolong her
meaningul life.
• Greetings
• I am here to talk to you about your mom’s condition. How much do you know about her
condition?
• As we all know, she has COPD, which is a kind of obstructive airway disease and generally
progressing in nature. She had been managed but now the codition has been complicated
unfortunately.
• People with severe stages of COPD may not be able to care for themselves without assistance.
They are at increased risk of developing respiratory infections, heart problems, and lung cancer.
• Currently, she has got the severe lung infection and the antibiotics are not helping anymore. It
seems like this infection has spread to blood and other organs. It is a serious complication and
usually very difficult to be controlled. It may result in multiple organ failure and finally may lead
the patient to sleep forever.
• Being an elderly and low immunity might also lead to this disseminated infection.
• Now I would like to explain about the DNR she sighed. A do-not-resuscitate order (DNR) tells
health care professionals not to attempt cardiopulmonary resuscitation (CPR) or defibrillation if
the person’s heart stops beating. This document is written only when these measures are
unlikely to revive a dying person or to prolong meaningful life. Generally, during the last stage of
a terminal illness, CPR is not very likely to result in successful resuscitation.
• Now we have decided to put her on palliative care which is not a cure but to make sure she has
no pain, no breathing difficulty and to rest peacefully.
• We will make sure that she will not suffer till the end. We have specialists, nurses and also social
workers to help you and your mom with that.
• Also if you or someone could stay with her, that will be the best. Someone is alongside - the
patient no longer feels isolated. This person provides a sounding board for whatever the patient
wishes to discuss and explore
• Sometimes, when a patient cannot sleep, just silent companionship is enough. Patients and the
next-of-kin need to know that all medical, nursing, social work and related professionals working
with you are liaising for the patient’s benefit.
• Anything you would like to know in particular?
• I am very sorry to tell you this. Please keep in mind that we all will be giving the best care we
can.
Infectious Mononucelosis peads

22 years old girl is having sore throat ,mild fever. Her examination and inv done which showed
following results.
• Examination:
• Temp 37.5
• Tonsils enlarged with little pus.
• Cervical lymph adenopathy.
• Hepatosleenomegaly.
• Investigations:
• Cbc:
• Hb,plts normal
• Wbcs and lymphocytes increased
• Hiv,hep b n c, syphilis serology negative
• Cmv Igg n IGM –ve
• Ebv IGg –ve, IGM +ve
• Transaminitis +ve
Tasks:
• Explain findings to pt
• Tell her condition
• Management
• I understand u having some fever, are u ok at the moment. We have done examination and inv. I
am gng to explain them to u. if u don’t understand anything plz let me know.
• So 1st on examination:
• Temp is high.
• Tonsils are enlarged, tonsils are part of immune system which fights against infections. There is
pus over them as well.
• There are small glands in your neck called lymph nodes, they are also enlarged.
• Liver and a small structure part of immune system called spleen are also enlarged in size.
• Did u get it.
• Now invs:
• We have three blood cells. Hb which is iron rich protein carrying oxygen to body is normal.
• Plt:which helps in clotting,normal as well.
• Wbcs: which fight against infections are increased.
• Transaminitis – there is also increased in liver enzymes which is a feature of this condition.
Sometimes there is yellow discoloration of skin and eye may transiently occur.
• Serology for viral infections done( name all above) . but its good they are normal.
• Serology for one virus called EBV Is positive. Ig G which shows the previous infection by this
virus is negative and IgM which shows the current infection is positive. So u are having a
condition called infectious mononucleosis or glandular fever. It’s a viral infection causing these
all symptoms and examination findings.
• Symptoms include fever, sore throat, swollen lymph glands, tiredness, and feeling generally
unwell. The doctor may find swelling of the spleen or liver
• The illness usually lasts between one week and several weeks. A small proportion of people can
be sick for months
• Most people make a complete recovery
• Once infected, the virus remains in the body for life.
• Infectious mononucleosis is spread from person to person through direct contact with saliva. So
people with IM should avoid kissing others, regularly wash their hand and not share drink
containers.
• It can be spread from people who are sick with the illness or by healthy people who carry and
can spread the virus intermittently for life
• The time from infection to appearance of symptoms ranges from 4 to 6 weeks
• Similar symptoms can be caused by other viruses such as HIV, Hepatitis B and C, CMV, Syphilis
but they are ruled out.
• So far you following me?
• So now management:
• This is self limiting condition. Will get better in some time.
• Only thing u need to do is
• Take a lot of rest. I can give u certificate for leave. Take plenty of fluids.
• Paracetamol for fever.
• If fever gets worse or your condition is not improving, or when there is difficulty in swallowing
or tummy pain, just get back to me.
• Please be careful. Don’t take any antibiotics as u don’t need them and also they will cause rash if
taken.
• contact sports and heavy lifting should be avoided for the first month after illness because of
risk of damage to the spleen, which often is enlarged during acute infection.
• Most patients with glandular fever recover uneventfully.
• Reading material, review.
not imp , 2018

Rusty nail
You are a general practitioner in a rural GP clinic. A 60-year-old man just stepped on a rusty nail
yesterday and came to see you. He just moved to your area a few days ago and he wants to be a
regular patient at your GP.
Your tasks :
• Take appropriate history
• Counsel about the patient’s needs
Proper approach
• Greet and be warm
• Be natural like talking to your own patient
• Ask about the wound (How did it happened, size, site, active bleeding, how did he manage, pain,
condition now, fever)
• Ask about previous tetanus shots
• His family conditions
• General wellbeing
• Health problems, past medical (hypertension, diabetes) and surgical history (any urinary
difficulty for prostate screening)
• Familial cancer
• SADMA
• Counselling
- tetanus shot (toxoid and immunoglobulins)
- 6 monthly and yearly check-ups
• hypertension, diabetes, Lungs and heart conditions (now as well)
• physical examinations and blood tests
• prostate screening if he has history and only he is willing (PSA, DRE and ultrasounds in
symptomatic)
• FOBT every two years
• Sunscreening (farmer and rural)
not askd fr years, may ask just read 2018

Domestic Violence
You are a HMO in suburban hospital. This is your patient, Jenny, came to see you about having a black
eye. X ray and CT have been done and they are totally normal. There is no fracture or complications
from the black eye.
Your tasks:
• -Talk to her
• -Tell her about your management plan
• Be warm, nice and professional

• How are you? Ask about the vision or any pain, vomiting, headache
• Explain the X ray and CT, no abnormal findings
• Ask what happened? she will say I fell from the bed, wrong approach is black eye n falling from bed
• Kids, how are they? How isnoeverything at home? possible. dont ask directly, ask
• Partner? Get along with you ? Get along with kids?
• You look stressed, are you alright coping everything?
• Any stressor? Financial burden, job, drinking, smoking, drug (HEADDSS questions) Home,
Education, Work, Alcohol, Drug, Depression, Smoking, Suicide
• Ensure about privacy, I am your doctor here to help you, tell me everything frankly. Everything
we discussed here is confidential unless you harm yourself or others.
• Ask happy family? Sometimes, it is usual that the two persons in a relationship argue. What
about you? Sometimes, some people in argument act violent hurting self or others. By any
chance partner did that to you?
• First time? How often? How about kids? Is he father of the kids?
• Explanation (based on a passed feedback with good score)

• I understand what you are going through. It is called domestic violence and a lot of women are
facing the same situation as you are. You are not alone. You are telling me that he only does it
when he is drunk or angry. But even he is drunk, it’s not acceptable. Don’t worry we are here to
help you every step of the way if you allow us.
• Let me tell you what can I do for you. Your black eye will go away on its own after a few days
since there is no serious condition. You can try ice packing if there is any pain.
• I can arrange social worker to help you and your children.
• I need to call the child protective services as he may also harm the kids.
• There are shelters if you feel unsafe at home we can arrange for you and your kids to stay there.
• You can also inform the police about your partner but that decision lies with you.
• I can arrange some support group so you can talk to them.
• Also I can arrange a family counseling with your consent if possible.
• I can also Contact Centre link to arrange some financial support if required
• -Don’t worry our priority is your safety and your child’s safety. You are a strong confident
woman and we will be there to support you every step of the way.
Hypertension counselling 5 star

Young male, Jonathan, BP on 3 occasion was 150/100 and ambulatory BP also high too. There is
smoking and alcohol history positive. You have examined him and everything was normal except you
found the below picture in fundoscopy.
Tasks: he is not overage, case of young hypertension, can be
• Explain Ambulatory blood pressure because of sec hypertension, sec causes more likely
• Explain the impact of the results to the patient
• Explain about further investigations
• Explain – Hello, so we have done 24 hour monitoring of your blood pressure which we called
ambulatory blood pressure. We did this because you’ve got high blood pressure readings on
previous 3 occasions. We did 24 hours monitoring at your home setting so that we can exclude
that increased in blood pressure due to nervousness and anxiety in a clinical setting. So now
checking the BP in previous 24 hours, it is high again.
• So probably you may have hypertension now. Also in my examination, I have found some
changes in your eyes which is also showing the complications of hypertension (which shows
occlusion of small vessels in the eye which may later lead to visual disturbance)
• Hypertension in a long term may lead to complications like multiple vessels damage in various
organs which in turn causes visual disturbances, Memory loss, impotency, damage to kidneys,
damage to heart which result in failure, also leads to heart attack and stroke, also it may
associates with diabetes in later time and leads to damage to the nerves in the upper and lower
limbs.
• Reassure : I am not telling that these will definitely happen in you. Now we can detect the
hypertension and also we need to find out the underlying cause so that we can fix it if there is
any.
• So we are going to run a few tests including:

• Plasma glucose (sugar levels in your blood preferably fasting)
• Blood fat levels
find the cause of sec hyper
• Kidney functions
• Full blood count to check your blood cells
• Chemicals like potassium and sodium levels in the blood
• Urine tests
• ECG and echo to know the heart condition
• USG abdomen to check for any adrenal tumors and urine tests (24 hr urinary metaephrine and
normetanephrine)
• Doppler to check for narrowing in renal arteries
• Thyroid functions
• Dexamethasone suppression test (to know Cushing’s syndrome which is an excess of body
steroids)
• Blood test to check for hyperaldosteronism (excess of some hormones called
mineralocorticoids) – aldosterone to renin activity ratio (ARR)
Hypertension counselling take hx as well and possible causes

You are a GP. Your next patient is a 32 years old lady, Julia, who had high BP on 3 occasions, 24 hr
monitoring done – and also high BP.
Your tasks:
• History
• PEFE
• explain causes of increased blood pressure
• initial management
Secondary Hypertension causes

• Kidney
• Glomerulonephritis
• Reflux nephropathy
• Kidney artery stenosis
• Polycystic kidney disease
• Diabetes
• Endocrine
• Conn syndrome/Cushing syndrome
• Hypothyroid / thyrotoxicosis sec hypertension causes see from gallery
• Pheochromocytoma
• OCP
• Coarctation of aorta
• pregnancy/raised ICP
• How can I help you? I understand that you had high blood pressure on 3 occasion. How high?
• Symptoms of hypertension – Headache, palpitation, fatigue?
• Cardiovascular – SOB? Racing of heartbeat? Chest pain?
• Causes : Any weather preference? (thyroid), recent weight gain, purple striae in tummy, acne,
excessive hair growth (Cushing’s)
• any kidney disease?
• Any headache? Excessive sweating? Increased thirst? Increased frequency of passing urine?
(Pheochromocytoma, Conn’s)
• Cx – any visual disturbance? Any changes in urine? Tingling and numbness?
• Are you on any regular medications?
• 5P – sexually active? Pregnancy? Pills? Periods? (thyroid)
• Family history of hypertension? prolong hx of ocps
• SADMA + social (exercise, stress)
• PEFE – General appearance, Vitals, BP all 4 limbs(coartation), BMI

• General inspection :
• Cushing’s syndrome – moon face, acne, hirsutism
• Acromegaly
• Hands
• Evidence of hypothyroidism/thyrotoxicosis (cold hands/warm moist palms)
• Face
• Fundoscopy : hypertensive changes
• Neck :
• Thyroid enlargement/JVP
• Chest
• Heart : LVH/4th heart sound
• Abdomen
• Palpation : renal/adrenal mass/AAA
• Auscultate : renal bruit
• Nervous system examination
• Carotid artery bruits
• Urine dipstick, blood sugar, ECG
• Explain the possible causes – OCP, family history, stress, lack of exercise, kidney problems or
hormonal problem
• Investigations – USG, RFT, LFT, Thyroid functions, blood cholesterol, ECG, blood glucose,Doppler
• Life style modification (exercise, walking 30 mins a day, reduce stress, avoid salty foods), Follow-
up after 2 weeks. If still high, will start medications.
australian dietry guidelines.
• OC pills – stop. Other contraceptive methods can be used like condoms.
recent
Genital herpes in male
25 years old man c/o painful rashes on groin area new sexual partner.
Tasks:
• History
• PEFE and
• Investigation and Management (Photo show ulcers on penile shaft no discharge from meatus)
• CONFIDENTIALITY!!!
• Rash - When first noticed, Onset, Duration, Progression, Predisposing events (eg trauma),
Aggravating/ Relieving factors
• Associated sexual health Sx: discharge - from where? Any swelling/ growths/ ulcers
• Any pain ? – SOCRATES
• Any trauma? Any allergy history? New brands of skin products or underwear?
• Partners - last 3 or all partners in last 6mnths:
• How many?
• gender
• any partner STIs ?
• condom use
• Type of the intercourse? (oral, anal, vaginal)
• Any systemic features: SoB, fever, night sweats, loss of weight , loss of appetite? Any diarrhoea?
for HIV
Lumps or bumps in body?
• Recent travel? Occupation?
• Past medical- any underlying medical condition I should be aware of ?Past history of
genitourinary disease, previous STIs? Ever checked before?
• Any surgical history
• Known HIV, HBV, HCV status? Gardasil vaccine?
• SADMA
• Explanation – It could be sexually transmitted infection like genital herpes caused by a virus,
Chancroid caused by bacteria or other STIs like syphilis or traumatic ulcers
• We should test for PCR to confirm the diagnosis of Herpes and need to check for all STI namely
HIV, Hepatitis B and C, Gonorrhoea, Syphilis, Chlamydia, Human Papilloma Virus and etc. Some
can be cured but some conditions cannot. But the earlier we detect the disease, the better the
prognosis we can expect. The samples are blood, urine and discharge.
• It is also important that both partners to be tested. So I would also suggest you to take your
partner on next visit. I really know that it must be exciting to test for STDs. But I want you to
know that even if something positive come out, there are a lot of things we can do to cure or
control it. You have made the right decision.
• Ok. So if u agree to test these, please sign the form for consent and we will move on.
• Do you have any questions? Ok. So I will see u again with results. We will treat accordingly
depending on the result.
• (If the photo looks like genital herpes – start Valaciclovir 500mg BD for 5-10 days. Analgesia –
paracetamol or Ibuprofen, saline bathing, topical lidocaine, urinating in a bath or shower
relieves dysuria, reading material)
Chlamydia
22 y old uni student, Joshua, went abroad on sports tour. come after STI screening He recently visited
overseas where he had casual sex partners. He didn’t take any blood transfusion, no hx of tattoo and
piercing. His general heath is good. Investigation report- gonorrhoea, HBV, HCV,HIV negative but
chlamydia positive.
Tasks:
• explain investigations first tell all negative then tell for chlamydia
• Counsel accordingly (no history)
• I understand that you are here for the results of STI

-do you know why it has been done for you?
-Tell about the negative results one by one.
-I am concerned that it appears to be + for chlamydia
-pause
--do you want to call anyone for you?
-do you want to discuss the Mx now?
• -Chlamydia is an infection of genital tract with a bug bacterial one called chlamydia trachomatis.
-it is usually transmitted by unprotected sexual intercourse
-in most of the case it is asymptomatic. However, it can be presented with discharge or painful
urination
-If left untreated, it can spread to other nearby organs like testicles and prostate gland leading
to infertility and can also lead to stricture of the urine tract. The good thing is we picked it up
early so we can treat it and prevent any Cx.
• Management
3 months is the test of reinfection. check it again
• I will prescribe you antibiotic azithromycin to be taken orally 1 g stat (if asymptomatic)
doxycycline 100 mg BD for 7 days (if symptomatic)SE of azithromycin (nausea/ vomiting,
stomach upset) and repeat the test after 6 weeks. 6 weeks to 3 months
• chlamydia is reported by pathologist
one of the tests HIV needs to be repeated after 3 months
•
chlamydia like any STI is a notifiable disease. But it will be done by the pathologist not by GP.
• Also contact tracing to partners 6 month back is important.
-You need to inform contact if you are comfortable directly or you can use a website called (let
them know)
-The pathologist will notify the department of health service to break the chain of spread as
there is high possibility to spread by others. But let me assure you that your confidentiality will
be maintained.
•
it is important to avoid sexual activity during this time of infection and before the retest,
otherwise use safe sex for which you need to use condoms.
imp, repeat chlamydia test 6 weeks after the
treatment.
• Red flags - any rash, discharge, lumps to come see again repeat HIV after 3 months
• Review, reading materials chlamydia reported by pathologist.
(common mistakes)
recent
Colles fracture
You are an intern at ED. Your next patient is a 62 year old patient who came with wrist pain after
falling on his outstretched hands. Ortho registrar assessed him and arranged X rays which show right
sided Colle’s fracture.
X ray findings are given with displacement and abnormal angulation with normal values in brackets.
The fracture was reduced, and POP technician has applied the Colle’s cast (below elbow).
Neurovascular status was assessed and shown normal. The patient is now ready to go back home and
his partner states that she will take care of him at home.
•Tasks: Explain the care of the forearm and cast at home, Explain the follow up care plan.
Explanation
•Colles fracture usually results from a fall on an outstretched hand resulting in upward titling of the
bone when the hand is in palm down position. Fracture of the distal end of the radius is the most
common injury in patients over 50. Now we have managed the fracture and applied the cast and your
vessels and nerves have been checked and they seem well. So, we will discharge you.
•But let me give you some advice about how to take care of this cast at home and follow-up plan.
MANAGEMENT:
•First is Pain relief – we have prescribed medicine for pain, take it as prescribed. Put ice or a cold pack
on your wrist for 10 to 20 minutes at a time. Try to do this every 1 to 2 hours for the next 3 days (when
you are awake). Put a thin cloth between the ice and your cast or splint.
•Cast care - Keep your cast or splint dry. Follow the splint or cast care instructions that your doctor
gives you. If you have a splint, do not take it off unless your doctor tells you to. Be careful not to put the
splint on too tight. Prop up your arm on pillows when you sit or lie down in the first few days after the
injury. Keep your wrist higher than the level of your heart. This will help reduce swelling. Move your
fingers often to reduce swelling and stiffness. But don't use that hand to grab or carry anything. Follow
instructions for exercises to keep your arm strong.
•Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments
•You might need to attend fracture clinic within a week with a view to completion of a plaster slab or
checking a plaster cylinder for any looseness. Usually, the follow-up Xray is not required but when the
specialist suspects the unstable fracture pattern, he may suggest repeating the wrist Xray at 1-2 weeks.
•The initial recovery from a wrist fracture can take 3 to 4 months or more. The plaster can be removed
after 5-6 weeks and if the fracture is clinically stable and not tender you can start to mobilize. An X-ray
control is of limited value. Referral to physiotherapy will be arranged.
•The work may seem hard and at times painful. But doing the exercises you are given will speed your
recovery. It can take anywhere from a few months to a year for your wrist to fully recover its function..
•The Colles fracture usually heals without complication and full range of motion can be expected
although in very few cases, patients may feel the intermittent pain and stiffness in their rest of their life.
•Red flags : Please come back when there is new or worse pain, your hand or fingers are cool or pale or
change colour, your cast or splint feels too tight, tingling, weakness, or numbness in your hand or fingers
or problems with your cast or splint or when you think do not get better as expected.
Diabetes advice and glucometer recent

You are a GP. You are going to see a 51 years old male patient newly diagnosed with
Diabetes. His HbA1C is 7.5 now and he is having Metformin. He wants advice about lifestyle
modification. He now walks 2-3 hrs a week. see jm plz diabetes
• Tasks:
• Advice on the lifestyle modification
• Tell the patient how to use the glucometer podiatrist
• Adopting a healthy lifestyle can help you manage your diabetes. It may also improve
your critical health numbers, including weight, blood sugar, blood pressure and
blood cholesterol.
• Managing weight - Being overweight or obese make it hard to manage Type 2 diabetes.
It also increases the risk for high blood cholesterol and high blood pressure — risk
factors for cardiovascular disease, which is the leading cause of death for people with
diabetes. Two ways to help manage weight are to eat healthy and be more physically
active. To lose weight, you must take in fewer calories than you use up through normal
metabolism and physical activity.
• Eating healthy - Making healthy food choices, including controlling portion sizes and
reading food labels, is key to maintaining the right weight and preventing or managing
diabetes.
• With prediabetes or diabetes, you have additional issues with food. For example, it’s
important to limit simple carbohydrates that are in foods such as table sugar, cake,
soda, candy and jellies. Consuming them can increase blood glucose.
give egs, dietician referral
• By writing down what you eat, when you eat and how it affects your glucose levels, you
can track how foods affect your body. Check your blood sugar 1 hour to 1.5 hours after
eating to see how your body reacts to various foods.
• Healthy eating and a busy lifestyle - Many of us are on the go and don't spend a lot of
time at home. But even when your kitchen isn't convenient, eating right should still be a
priority.
• With a little forethought, you can properly nourish your body wherever life takes you.
Remember these tips for eating on the go:
• Bring a healthy lunch and snacks to eat throughout the day. This will help you stick to
healthy food options and be less tempted by unhealthy.Reduce your caffeine intake and
stay hydrated. Keep a bottle of water handy to drink throughout the day.Eat healthy on
a budget
• Regular physical activity - Being physically active for at least 30 minutes a day on most
days of the week and losing 5% to 10% of your body weight (about 10 to 20 pounds for a
200-pound person) can significantly lower your risk of developing diabetesFor good
health, healthy adults need at least 150 minutes per week of moderate-intensity aerobic
physical activity or 75 minutes per week of vigorous-intensity aerobic activity, or an
equivalent combination of both.
• Other important facets of a healthy lifestyle are:Quitting smoking
• More likely to get nerve damage and kidney diseaseThree times more likely than
nonsmokers to die prematurely of heart disease or strokeMore likely to raise your blood
sugar level — making it harder to control your diabetesGet help to quit smoking
• Managing stress - Stress affects people in different ways. It can:
• Impact emotional well-being. Cause various aches and pains, from headaches to
stomach aches.Diminish energy level. Interrupt sleep.Trigger various unhealthy
responses, including overeating, drinking too much alcohol, smoking, procrastinating
and not sleeping enough.
• Glucometer Usage Instructions

• First, set out your glucometer, a test strip, a lancet, and an alcohol prep pad.Wash your
hands to prevent infection. If you are not by a sink, it's okay to just use the alcohol
swab. If you are by a sink and wash your hands thoroughly, you do not have to use an
alcohol swab. Sometimes it helps to warm your hands first to make the blood flow
easier. You can rub your hands together briskly or run them under warm water—just be
sure to dry them well as wet hands can dilute the blood sample, resulting in a lower
number.
• Turn on the glucometer and place a test strip in the machine when the machine is ready.
• Watch the indicator for placing the blood on the strip. Make sure your hand is dry and
wipe the area you've selected with an alcohol prep pad and wait until the alcohol
evaporates. Pierce your fingertip on the side of your finger, between the bottom of your
fingernail to the tip of your nail (avoid the pads as this can pinch more). The type of drop
of blood required is determined by the type of strip you are using (some use a "hanging
drop" of blood versus a small drop for strips that draw blood in with a capillary
action).Place the drop of blood on or at the side of the strip
• .The glucometer will take a few moments to calculate the blood sugar reading. You may
use the alcohol prep pad to blot the site where you drew the blood if it is still bleeding
.Write down your results. Keeping a record makes it easier for you and your doctor to
establish a good treatment plan. Some glucometers can store your results in a memory,
for easier record keeping. can tell levels
covid vaccination case
Neurology
Trigeminal Neuralgia 5 star
You are a general practitioner. Your next patient is a middle age lady, Emma, having pain in the face
for 3 weeks.
Your tasks:
• Take history
• Explain the diagnosis to the patient
History nature of pain is v imp, shock stabbing pain, electric shock like
• Pain questions (especially pain when face is touched, trigger zone) all pain qs cluster headache
• Association – Do you notice changes in eye and nose while in pain (migrainous neuralgia), any
headache? any clicking in jaw ( TM joint), Any pain or discharge in the ears? (Otitis), Any dental
problems? Any trauma? any weakness in upper and lower limbs ? (stroke), shoulder pain, any
pain in the body? (MS and polymyalgia), any hearing disturbance? (neuroma), Vesicles on the
face or ear previously or now? (herpes), Any nasal discharge? (sinusitis)
• General, past medical, surgical
• SADMA, social (stress)
PEFE
• General appearance, vitals trigeminal nerve exam is normal in trigeminal
• neuralgia. both sensory and motor is normal.(cause
Face – palpate for tenderness in sinuses and temporal region
of failure)
• Check into the mouth and ears for any infection
• check trigeminal (sensory and motor), 7th cranial nerve (sensory and motor), 2nd – visual acuity,
3rd 4th 6th Fundoscopy and 8th hearing and otoscopy, all other cranial nerves
• Upper limb and lower limb neurological
Explanation
• Inflammation of a nerve supplying the face, called trigeminal nerve, Other possibilities like
Herpes, local infections, facial nerve injury, trauma or stroke are less likely according to the
history and examination.
• Most cases of trigeminal neuralgia are caused by a blood vessel pressing on the trigeminal nerve
• characterized by a sudden, severe, electric shock-like or stabbing pain typically felt on one side
of the jaw or cheek
• The disorder is more common in women than in men and rarely affects anyone younger than 50
causes: jm pg610: 1. unknown, 2. local pressure by dilated small vessels in 75%, 3. multiple sclerosis, 4.Neurosyphilis,
5.Tumors of the posterior fossa. MRI may be helpful.
• Attacks may be triggered by talking, brushing teeth, touching the face, chewing, or swallowing.
They may come and go throughout the day and last for days, weeks, or months at a time, and
then disappear for months or years. However, the prognosis is good
• Reading material, review, medication
• TREATMENT (not in this case) if carbamazepine is

surgical: • Treatment for trigeminal neuralgia includes anticonvulsant medications such as carbamazepine ineffective or
1.decompression of
trigeminal n root or phenytoin. Baclofen, clonazepam, gabapentin, and valproic acid may also be effective and intolerant then
other med.
by gel foam packing may be used in combination to achieve pain relief.
b/w nerve and b.v• If medication fails to relieve pain, more active treatment may be recommended: microvascular
2.neuroablative treatment
decompression; balloon compression; radiofrequency lesion of the nerve, fine-beacon
(thermocoagulation, radiotherapy; or surgical exploration of the nerve. Pain relief is achieved in a high percentage of
radiofrequency cases but in a significant number of cases pain may recur after some time, and some instances
neurolysis),
of temporary or permanent numbness in areas of the face have resulted.
surgical division of
peripheral nerves.
explain meningitis to
Viral Encephalitis in 2019 viral prodrome followed by an irrational behaviour. mother in march came this
22 year old male brought in by friends to ED. He had acute change in behaviour, inappropriate yr words
and confused. All PE done and normal. No neck stiffness.
Long list of investigations done: Bloods –ve, Urine drug screen pending. All Investigations negative
except for lumbar puncture: Protein high, Lymphocytes high, glucose normal. CT scan was normal.
• Explain Investigations to mum, Jenny check csf abnormalities
• Explain dx and differentials and reasons
y viral encephalitis and not viral meningitis
• Explain the implications of your diagnosis no neck stiffness and fits'
implications means
what happen next
it is diff from comp• Authority
lication only • Reassure – he is in the safe hands now and stabilized.
it means • He was here brought in by his friends because of seizures. Now we have done some
we treat him investigations and the results are with me.
all management • Explain all the investigations one by one. We did check his blood for any infection but it showed
and complications
too.
negative. Other investigations are all normal. We also check the CT scan of his head for any
haemorrhage, abscess or tumor but it turned out to be normal.
• What I am concerned here is we did check the nature of the fluid that circulates around the
brain by taking it from the spinal cord through the back bone loin region. It showed a clear fluid
and sugar contents was normal but there is increased number of cells we call lymphocytes and
also the protein is high which we can interpret it as there is viral infection and inflammation of
the brain we call viral encephalitis.
• Most likely viral encephalitis, and also it could be bacterial encephalitis or meningitis (brain
covering), alcohol intoxication, drug overdose, electrolyte imbalance, hypoglycemia (reduced
glucose in the blood), trauma less likely epilepsy and brain tumors or abscess.
• He will be getting the best care we can including Fluids, Panadol, steroids, anti-seizure medicines
and also antiviral if the organism is identified.
• This condition may associate with temporary confusion, drowsiness, some behavioral changes,
irritability, seizures for the moment but will resolve later
• Later after recovery, it may associate with memory loss, some weakness in upper and lower
limbs, vision and hearing problems, tiredness but less likely to happen if treated early.
Stroke pt got headche before weakness.
You are a GP. A 70 year old lady, Irene, came with limb weakness.
Tasks
• H/o and
• DDX to the lady
• When did the symptom start? Was the onset acute or gradual? Is it the first time?
• Duration of symptom(s)
• Severity and involvement
• Weakness: Try to clarify how weak (e.g. subtle, moderate, complete paralysis)
• Sensory disturbance: Was the arm/leg completely numb or did it just feel different to normal?
• Visual disturbance: How much of the vision was affected? Was vision blurred or completely lost?
• Any slurring of speech?
• Any incontinence of pee and poo?
march exam
• Any swallowing difficulty?
• Facial asymmetry?
• Course: Is the symptom worsening, improving, or continuing to fluctuate?
• Precipitating factors: Was there any obvious triggers for the symptom?
• Relieving factors: Does anything appear to improve the symptom?
• Associated features for ddx: headache/nausea/vomiting/neck stiffness if headache positive, how severe,
Headache positive – how severe? (worst headache ever in thunderclapthunderclap
headache) headache
• any recent head or neck trauma
• Have you ever experienced this symptom previously?
• How many previous episodes?
• (note : If falls positive – how frequent? Did you lose consciousness? Injured your head? any
racing of the heart? Any dizziness? Any black outs in changing positions like sitting to standing?
Any problems balancing yourself? Any pain in the joints? )
• Past medical – hypertension, DM, TIA, stroke, heart diseases in you and FAMILY? If present –
how is it treated? (this case there is hypertension, AF and apixaban)
• Risk – cholesterol levels, diet, exercises, work, stress?
• SADMA
• DDx - Most likely this is stroke, it could be due to blockage of the vessels in the brain called
ischaemic stroke or rupture of vessels in the brain leading to blood clot formation called
haemorrhagic stroke, others SOL – abscess or tumors, SAH- bleeding inside the brain due to
trauma or medications, infections in the brain like encephalitis or brain coverings like meningitis
or lesions in the back bone compressing the nerves but these are unlikely. if thuderclap headache positive,
put SAH in first place
Stoke Ct interpretation
You are HMO in ED seeing an old man who lost consciousness a few hours ago with weakness of left
side of his body. He has long standing hypertension and on ACEI and aspirin. There was no HO of fall.
Wife has come to discuss about her husband condition.
Tasks: read once, explain how to discuss and explain and
• Explain CT scan findings to wife prognosis
• Discuss about possible causes
• Explain about prognosis (No management)
• Authority
• Hello. I can see that you are here to discuss about your husband’s condition. Let me reassure
you that he is in the safe hands and stable now, we will do our best to help him. Do you have
any particular concern? Do you have any questions for me?
• So now let me explain you about your husband’s condition. This is his CT scan. And this is the the
skull bone and this is the gray this shadow is the brain and this is the left side and this is right.
This gray colours means soft tissues and the white colour means the solid or bones. As you can
see here in this gray colour there is a whitish circular area here which is not supposed to be
here. This circular area can be something like bleeding or infections or Abscess which is a
collection of pus in the brain or some sort of growth.
• But according to the history and according to the nature of his acute weakness, most likely this
is the stroke which is because of leakage of blood inside the brain. So this white area most likely
is the bleeding from the ruptured brain vessels. There are several causes leading to this
bleeding, one cause is he has a history of high blood pressure so when this blood pressure is so
high and when the brain vessels cannot tolerate it, they got raptured causing the bleeding.
Sometimes it could be due to injuries or malformation of the vessels or some remnants of the
previous stroke or Abscess or nasty growth. Also he is taking aspirin, which is a blood thinner so
it can cause the bleeding as well.
• So the problem is when the bleeding occurs, and that bleeding becomes a blood clot pressing on
the brain tissues, that compressed area stopped working which control the other side of the
body. So that’s why he got the weakness in opposite side of the body.
• So far are you with me?
• As you can see the blood clot is quite large in comparing to the size of the brain. But we still
have hope that he can recovers from it. So first of all, a specialist will check whether we can do
the surgery to remove the blood clot. If it is removed successfully he can get well. But still we
will need to go through a series of physiotherapy to recover from the weakness. Because he
may have residual weakness even when the blood clot is removed.
• After the removal, we have ongoing management for such patients and he will be under the
care of the multidisciplinary team including physiotherapist, neurologist, GP and also
occupational therapists and speech therapist as well. We called this rehabilitation phase. He will
be followed up by GP to prevent infection or clotting problems and also be seen by
psychologists and neurosurgeon as well. We will try our best for his convenience and best
quality of life. He needs to be followed up regularly and for his blood pressure in also for the
residual weakness.
GI and liver 5star
Hiatal Hernia
You are a GP. You are going to see a male patient, Leonard, having a history of heartburn for several
months. Endoscopy done showing Esophageal inflammation and hiatal hernia. No evidence of
ulceration, barrett's esophagus or H Pylori infection.
Tasks:
• Take relevant History hx of aspirin in hx , address in management
• Explain report
• Management plan
Approach
• Heartburn – how long? Did you taste sour or bitter taste in your mouth? (Any water brash?), did
you try anything? How often did it happen? Are you having your meals regularly? Relates to any
food or drinks? Anything make it better or worse?
black color or • Associated symptoms - Pain – epigastrium, Vomiting? Any blood in vomiting? Any blood color
bld in stool stool? Any weight changes? Loss of appetite? Any problem with swallowing of food? barret oesophagus
• Cause –Do you know your BMI? Chronic cough, Heavy weight lifting, Constipation? difficulty in swallowing
• Coffee intake? How is your daily diet? Do you like spicy foods? Do you do regular exercises or
activities?
positive hx of bowel ca, address this is not related to bowel cancer.
• Any family history of cancers?
• SADMA
sadma imp, bc smoking and alcohol in management address.
• Explain hiatal hernia – draw a picture, it is when part of your stomach bulges up into your chest
through an opening in your diaphragm, the muscle that separates the two areas. The opening is
called the hiatus. But we don’t see any ulcerations, no Barret’s oesophagus which is the cell
changes in lower part of the gullet due to reflux and no H.pylori infection which is a bug causing
ulcers in food bag. So this is good thing.
• Normally, that hiatus is just a small opening just wide enough for your food pipe to pass
through. In some conditions like advanced age, obesity, previous surgeries, injuries to the area
or increased pressure to the diaphragm muscles like prolonged coughing, straining or lifting too
heavy objects, that opening can be widened. Or it can just be wide congenitally. In that case, the
stomach bulges through it to the chest and sometimes, may allow food and acid to back up into
your food pipe, leading to heartburn. Self-care measures or medications can usually relieve
these symptoms. A very large hiatal hernia might require surgery but you are not at this stage.
• Most hiatus hernia do not cause symptoms. Only a few have association with reflux.
• First, making a few lifestyle changes may help control the symptoms of reflux. Try to:
• Eat several smaller meals throughout the day rather than a few large meals
• Avoid foods that trigger heartburn, such as fatty or fried foods, tomato sauce, reduce alcohol,
chocolate, mint, garlic, onion, and caffeine
• Avoid lying down after a meal or eating late in the day treat only reflux symptoms, only treat hernia
• Eat at least two to three hours before bedtime. if it is too large. aspirin dicuss alternative
management, PPI, reading materials.
• Maintain a healthy weight (reduce weight if obese)
• Stop smoking
• Elevate the head of your bed 6 inches (about 15 centimeters)
• Notes : some cases has a history of migraine and using Aspirin. Please say to stop it and you will
discuss the alternative management.
• In addition, to relieve your symptoms, I will prescribe Antacids such as Mylanta that neutralize
stomach acid and medications to reduce or stop acid production in the stomach. (PPI or H2
blockers)
• Reassure, reading materials, Review
• I will see you again in two weeks time.
Drug induced hepatitis

A 42 years old man, Oliver, 2 weeks after his sore throat came to see you because he feels ill and tired.
You are a General practitioner. Today he noticed his urine is darkened.
Tasks :
maay mimick obst jaund
• History
• Explain the provisional diagnosis and differentials to the patient
• Outline of management sore throat positive, dont think abt kidney only, stool color changes shld
be askd to differntiate if positive stay on hepatobiliary.
History
• What do you mean by ill and tired? Any fever? How long? Tiredness means shortness of breath?
• Dark color urine? What color is it? Red or Dark yellow or Cocoa colored? Any loin pain? Any pain
while passing urine? Any burning sensation? Increased frequency? Smelly? Reduced flow? Any
injury?
• What about stool? Any stool color change?
• Associated features : fever, Nausea, vomiting, tummy pain, jaundice, itchiness, loss of appetite
• How is your sore throat? How was it treated? Did you take it according to the prescription?
• Other risk factors – Travel history, Sexual history, blood transfusion, Occupation, Alcohol,
Recreational drug, Body piercing, Tattoo, Regular medications, Recent medications, Recent
illness.
• General history, past medical, past surgical. SADMA
PEFE
• General appearance, vitals,
• Pallor, jaundice
• Signs of chronic liver insufficiency _ clubbing, leukonychia, palmar erythema, spider naevi,
Gynaecomastia, testicular atrophy
• Abdomen – liver, spleen, ascites, Murphy’s sign and per rectal exam
• UDT – urobilinogen, bilirubin
• Hepatitis – Transient inflammation of the liver. It can be due to many reasons such as alcohol
abuse, viruses, obstruction by the gall stones and drug side effects. In your case – most probably
drug because one of the side effects of Augmentin is stasis of the bile flow and transient
obstruction. This obstruction causes the inflammation of the liver.
• Not risky – better after medication stopped. Symptoms may be there for a few days.
• Management – investigations – FBE, INR, LFT, Hepatitis serology, USG
• Confirmed the diagnosis
• Supportive treatment – Rest , Sleep, Ample of fluid, No alcohol, No Panadol and follow up
Heroin patient feeling unwell 5 str
You are a GP. 25 years old, Tony after having holiday overseas, where he had heroin presented with
complain of feeling unwell.
Tasks:
• History
• PEFE card
• Differential diagnoses
PEFE card
• General appearance - fair
• Vitals - normal
• Mild jaundice positive
• Abdomen- liver 2-3 cm below the right costal margin, tender
• UDT - bilirubin postive
never used
• What do you mean by feeling unwell? What happened. OK. Did you share the needles? Have before
you ever used it before? What about after that?
• Did you enjoy any street foods or unbottled water? Have you ever done tattooing? Body
piercing? Are you sexually active? Practice safe sex?
• Regarding tiredness, how long? Do you tired all day or with activities? Do you notice any yellow
color skin and eyes? Any changes in color of poo and pee? Any lumps and bumps in the body?
Flu-like illness? (HIV)
for obst jaundice
• Any tummy pain (go details if present)
tummy pain
• If obstructive jaundice – Do you have any history of gall stones? Bloating after meals? Jaundice
before?
• LOW/LOA positive hx of yellow skin discolouration.
• SADMA
tenderness given
• PEFE – GA, vitals, pallor, jaundice, any lymph nodes
• Hands – Asterixis
• Abdomen – inspection, palpation, Murphy’s sign, (any organ enlargement), auscultation
• PR – bleeding (chronic liver insufficiency) (esp if the patient is alcoholic)
• Urine dipstick bilirubun positive
• DDX – Hepatitis C or B via needle sharing, Hepatitis A, cholecystitis, cholangitis,, Cirrhosis of

liver.
• (if trip was more than 2 weeks ago, it could be hepatitis B or C via needle sharing, incubation
period 2 weeks to 6 months)
4-5 str
Incident at work patient unwell
atient middle aged lady has come to discuss about an incident which has in the workplace, She is
unwell now.
• take hx for 5 minute
• PEFE showing tender hepatomegaly urobilinogen positive in the urine
• Dx and ddx fell into sewage tank after some weeks got this
• Note : I need more info for this case diarrhea, vomiting, gastroenteritis, mild tenderness in rt hypoch,
hep A, amoebiasis, amoebic liver disease.
Outline of approach
• What do you mean unwell? Any fever? How long? Tiredness means shortness of breath? First
time? mild fever and bilirubun in urine
• Can you please tell me what happened exactly? What did you do after that?
• Dark color urine? What color is it? Red or Dark yellow or Cocoa colored? Any loin pain? Any pain
while passing urine? Any burning sensation? Increased frequency? Smelly? Reduced flow? Any
injury?
• What about stool? Any stool color change? Any diarrhoea?
• Associated features : fever, Nausea, vomiting, tummy pain, jaundice, itchiness, loss of appetite
• Other risk factors – Travel history, Sexual history, blood transfusion, Occupation, Alcohol,
Recreational drug, Body piercing, Tattoo, Regular medications, Recent medications, Recent
illness.
• General history, past medical, past surgical. SADMA
• DDx – Hepatitis A, Amoebiasis, Amoebic liver abscess, Gastroenteritis (she has diarrhoea and
vomiting too) Campylobacteriosis,Cryptosporidiosis, E coli, giardiasis
Viral Gastroenteritis in peads

You are a GP. You are going to see a 27 years old Female patient, Natalia, unwell with diarrhoea since
two days before.
Tasks:
• History
• Dx
• DDX
• Stability
• Diarrhoea - how long? Nature? Related to diet, affects sleep, weekends, suffered viral infection
previously before, pain, occur at particular time
• Bowel motion - pain while passing stools, blood in stools, hard to flush, distension/flatulence,
mass in tummy, offensive smell?
• Any history of passing hard stools, pain after passing stools, h/o constipation,
• Any tummy pain? If present – ask for details , is it relived by passing stools?
• Urine: pain while passing, blood, smelly?
• Nausea, vomiting?
• Rashes, ulcers in mouth, Joint pain –IBD?
• Any recent antibiotics ?
• weight loss, loss of appetite, lumps and bumps (malignancy)
• Ask Social Hx in detail: work and family, friends
• Personality - Perfectionist? anxious ?
• Recent travel, street food? Unsafe water?
• Past medical – thyroid disorders – weather preference? Period regular?, food allergy? past
surgical, SADMA
• Anyone in the family has diarrhoea? Any family history of bowel problems? Anyone on special
diet?
• Dx: Most likely diarrhea due to viral infection. It happens when you have unsafe food or water. It
will just resolve spontaneously with enough fluid replacement. .
• It could be other like others bacterial but less likely since the nature of stool doesn’t look like it,
antibiotics induced but you didn’t take any, IBS – when the bowels are sensitive to certain stress
or foods causing dirrhoea, IBD – where there is inflammation and ulcers in the luminal surface of
the bowels, less likely Cancer.
Drug-induced diarrhoea str

You are a GP. Your next patient is Patrick, a 50 years old man comes with diarrhoea.
Task: Take hx, tell the pt about dx. drug induced diarrhea and pseudomemb colitis r different, some antibiotics
cause diarrhea, pseudomemb colitis is the next step with overgrowth of
• Stability bacteria, pseudo memb coloitis is c. difficile, need to admit pt.
• Diarrhoea - how long? Nature? Related to diet, affects sleep, weekends, suffered viral infection
previously before, pain, occur at particular time, any constipation
• Bowel motion - pain while passing stools, blood in stools, hard to flush, distension/flatulence,
mass in tummy, offensive smell?
• Any history of passing hard stools, pain after passing stools, h/o constipation, diff of symptoms
• Any tummy pain? If present – ask for details , is it relived by passing stools?
• Urine: pain while passing, blood, smelly
• Nausea, vomiting
• Rashes, ulcers in mouth, Joint pain -IBD
• Any recent antibiotics – this history positive in this case
• Clotridium difficile (pseudomembranous colitis) symptoms - Lower abdominal pain and
cramping, Low-grade fever, Nausea, Loss of appetite, increased thirst, blood in stools
• weight loss, loss of appetite, lumps and bumps (malignancy)
• Ask Social Hx in detail: work and family, friends
• Personality - Perfectionist? anxious ?
• Recent travel, street food, unsafe water?
• Past medical – thyroid disorders, food allergy? past surgical, SADMA
• Anyone in the family has diarrhoea? Any family history of bowel problems? Anyone on special
diet
• Explain - antibiotic-associated diarrhea refers to passing loose, watery stools and increased
bowel motion after taking medications used to treat bacterial infections (antibiotics). This is
because antibiotics can also kill large numbers of the bowel's normal good bacteria.
• Most often, antibiotic-associated diarrhea is mild and requires no treatment. The diarrhea
typically clears up within a few days after you stop taking the antibiotic.
• If investigations are asked or patient is ill (suspicious for pseudomembranous colitis) – FBC,
Stool culture for C.difficile, PCR for C.difficile antigen or toxin, X-ray or CT scan in serious cases,
Sigmoidoscopy and colonoscopy in complicated patients
came once
Bilateral leg swelling
You are a general practitioner. You are going to see Tereza, a 53 years old lady with bilateral leg
swelling.
Your tasks:
• History not more than 4 mins.
• PEFE.
• Dx/D.Dx
Differential diagnoses
• Infection
• Heart failure
• Liver failure
• Kidney failure
• Nutritional oedema
• Pelvic tumors
• DVT
• Thyroid problems
• Drug side effects
History
• Complaint – When? How (sudden or progressive?)? Affect both legs simultaneously? Extent?
Any particular time of the day?
• Infection – painful ? Redness?
• Heart failure – SOB? At rest or with activity? Aggravating or relieving factors? Cough with
sputum? Color? Palpitation? Sleep? How many pillows?
• Renal – swelling around the eyes and face especially in the morning? Notice any changes in your
pee? (frothy?)
• Liver – any yellow discoloration of skin or eyes? History of liver problems?
• Nutrition – any recent weight changes?
• Any swelling in neck? Weather preference?
beningn ovarian• DVT – any pain in the legs? Recent travel?
• Any trauma to your limbs?
tumor, synd cause
name...
• Any swelling in tummy? LOW? LOA?
• Risk factors (for Heart failure) – Alcohol? BMI? hypertension? IHD? Chest pain? Fat levels in the
blood? Diabetes? Exercises? Occupation? Family history? Smoking? Stress?
• Medical/ surgical history
PEFE
• Vital signs – BP, PR, RR, SPO2
• Neck - thyroid
• I will focus on CVS – inspection, palpation, auscultation
• Signs and symptoms of heart failure – JVP, basal crepts, hepatomegaly, ascites, LL – oedema,
extent, pitting or not
• Bedside test – blood sugar, ECG, UDS
• Most likely – heart failure – as the heart is not working properly, there is increased fluid
congestion backwards in the vessels we call veins, Instead of moving forward, blood is
congested in the legs, and also other organs like lungs resulting in swelling of the legs and
dyspnea.
• The other possibilities are – Liver failure, kidney failure, Nutritional oedema, Amlodipine can be after few
induced odema, Thyroid problems, DVT, tumors in pelvis and tummy, cellulitis and truma months of taking it
unlikely
SOB pleural effusion

50 old years old female came with SOB for few months which is getting worse.
• Tasks : History, PEFE, Dx and DDx to patients.
PEFE card
• General appearance- well
• Vital signs – BP, PR, RR, SPO2 – all normal
• Neck – no thyroid enlargement
• CVS – inspection, palpation, auscultation - unremarkable
• Respiratory system examination – Dullness at the base of the left lung
• Abdomen – unremarkable
• UDT - normal
History
• Any cough? If yes, how long? Dry or producing phlegm? Continuous or off and on? If yes, Color
of phlegm?
• Any fever?
• Chest pain? Racing of heart beats? How many pillows do you use to sleep?
• Any swelling in the legs?
• Have you travelled anywhere before this SOB and cough? (infections)
• Do you think you look pale? (anaemia)
• Have you ever work in contact with fumes, asbestos and other pollutants?
• Past medical – hypertension, DM, increased fat levels in blood? Any asthma? Any heart
conditions?
• Any family history of heart diseases, lungs cancer?
• SADMA
PEFE
• Neck - thyroid
extent, pitting or not – all unremarkable
• Respiratory system examination in details
• Most likely –pleural effusion – collection of fluid between the coverings of the lungs which can
be due to infection and other causes
• The possibility is the nasty condition in the lungs because it is common in people with strong
smoking history and you also have weight loss. (Note : Please change the order of DDX according
to your PEFE)
• heart failure – as the heart is not working properly, there is increased fluid congestion
backwards in the vessels we call veins, Instead of moving forward, blood is congested in the
legs, and also other organs like lungs resulting in swelling of the legs and dyspnea.
• The other possibilities are –Bronchiectiasis , Tuberculosis, other respiratory infections, thyroid
conditions, etc
Heart failure (SOB)

50 old years old female came with SOB for few months which is getting worse
• Tasks : History, PEFE, Dx and DDx to patients.
• Any cough? If yes, how long? Dry or producing phlegm? Continuous or off and on? If yes, Color
of phlegm?
• Any fever?
• Chest pain? Racing of heart beats? How many pillows do you use to sleep?
• Any swelling in the legs?
• Have you travelled anywhere before this SOB and cough? (infections)
• Do you think you look pale? (anaemia)
• Past medical – hypertension, DM, increased fat levels in blood? Any asthma? Any heart
conditions?
• Any family history of heart diseases?
• SADMA
PEFE
• Neck - thyroid
extent, pitting or not
• Respiratory system examination in details
• Most likely – heart failure – as the heart is not working properly, there is increased fluid
congestion backwards in the vessels we call veins, Instead of moving forward, blood is
congested in the legs, and also other organs like lungs resulting in swelling of the legs and
dyspnea.
• The other possibility is the nasty condition in the lungs because it is common in people with
strong smoking history and you also have weight loss. (Note : Please change the order of DDX
according to your PEFE)
• The other possibilities are – COPD or Asthma where there is narrowing of airways,
Bronchiectiasis – infection in the airways, pleural effusion – collection of fluid between the
coverings of the lungs which can be due to infection and other causes
Miscellaneous cases
Opportunistic infection
You are GP visited by your patient Tim.
HIV positive patient stopped his medications 6 months ago came with fever hot and cold sweats
,cough physical examination showed fever, tachypnoea and oxygen saturation of 94%.
Your tasks:
• History
• PEFE
• diagnosis
• History – fever in details –how long? the degree? Persistent or come n go? Chills and rigor? Did
you try anything?
• Cough in details – how long? Dry or wet? Continuous or off and on? Anything make it better or
worse?
• SOB? Weight loss?
• Other symptoms of HIV – any rash, diarrhoea, muscle aches, sore throat, Any lumps around the
neck, mouth ulcers?
• Why did you stop your medicines ? Any side effects? Any depression? How is your mood?
• Follow-up? CD 4 counts?
• Past medical and surgical?
• Recent travel?
• Smoking? Alcohol?
• PEFE – GA, vitals ENT and respiratory examination

• Dx – pneumonia most likely opportunistic infection - PCP (Pneumocystic carinii pneumonia or
Pneumocystic jiroveci pneumonia), other types of pneumonia still possible.
• It is a type of fungal infection in the lungs common in people with weak immune system. Many
people live with this fungus in their lungs without any trouble but when it comes to a case of a
person with weak immune system, this fungus takes advantage to attack the lungs. You will
need to be treated right away.
• Mx (not a task in this case) – admission and IV antibiotics (Trimethoprim and sulfamethoxazole)
Erectile Dysfunction not imp but read
A 45 years old man, Paul, presented to you with unsatisfactory ejaculation for 3 months. You are a GP.
Tasks:
• History
• PEFE card
• Management
• Details of main complaint

• Causes – injuries?
• CVS -, Increased BP? Are you aware of BMI ? (Obesity), Any heart disease? Any SOB?
artherosclerosis (pain in legs? Increased fat levels in blood? ),
• Endocrine - diabetes? Have you ever been diagnosed with low thyroid hormone levels? Any
weather preference?
• prostate ds – LUTS- lower urinary tract symptoms –( FUNDAI – Frequency, Urgency, Nocturia,
Dysuria, Intermittency, Incontinence,)
• Have you ever have a medical condition like multiple sclerosis?
• Stress, any conflicts in relationship? , depression – how’s your mood? How’s your sleep?
• SADMA!
• Past medical, surgical?
• ANY REGULAR MEDICATION!
• Explain the possible causes. (spironolactone and diabetes are the possible causes in recalls and
overweight.)
• Investigation for ED - Full blood count, Liver function test, Electrolytes, urea and creatinine,
Lipid profile, Glucose, Thyroid function test, Testosterone, luteinising hormone, progesterone
works in
50% of the patients
(hypogonadism), Ferritin (haemochromatosis may cause hypogonadism in Anglo-Celtic patients)
• Start viagra(sildenafil), Change the drug (alternatives for spironolactone). Lifestyle modification
• I will see you again after life style modification and drug, if it does not help, I will refer you to
specialist for second line therapies (injections and devices)
• RACGP
• Treatment Optimise modifiable risk factors and related comorbidities (as appropriate)
• Lifestyle – smoking cessation, healthy diet, exercise, reduce alcohol intake, avoid recreational
drugs
• Re-enforce blood pressure, dyslipidemia, diabetes control
• Assess for cardiovascular disease
• Treat reversible causes
• Low testosterone
• Medication-induced erectile dysfunction – consider alternatives
• Psychogenic erectile dysfunction – consider referral to a therapist
• First-line therapy (phosphodiesterase type 5 inhibitor)
• Referral to a urologist
• Second-line therapies (eg penile injections, vacuum erection devices, external shock wave
lithotripsy)
• Third-line therapies (eg penile prosthesis)
Hypercalcaemia reappear this yr

You are a general practitioner. A 60 years old Emma coming to you. She has hypothyroidism for 5
years which is well controlled. She had chronic hypercalcaemia for years. She came here today for
blood test results.
• Blood investigation results are as follows:
• TSH – normal
• Free T4 – normal focus on hypercalcemia
• Corrected calcium – Increased
• Task : history
• . : ask more Invx from examiner
• : explain possible Dx with reasons
• Greetings
• Hypothyroid – which drug? What dose? Well controlled? Any symptoms? (not much needed as
well controlled mentioned in the stem)
• Hypercalcemia – Causes (PARATHORMONE)(can just ask the red ones)
• P - Primary and tertiary hyperparathyroidism (to check in Invx)
• A - Any history of amyloidosis
• R – renal failure – any history of kidney disease?
• A – Addison’s disease (any diseases that need to need to take steroids)
• T – TB, Toxoplasmosis
• H – Histoplasmosis (no need to ask) ask highlighted ones
• O - Overdose of vitamin D (any vit D supplements?)
• R – Raynaud’s associated disease (no need to ask)
• M – muscle primaries (no need)
• O - ossifying metastases
• N – Nephrocalcinosis (no need)
• E – endocrine tumors (gastrinoma)
• Features of hypercalcemia – “bones, stones, psychic moans, abdominal groans”

• Any abdominal pain, vomiting? Constipation? How is your waterwork? Stones? Feel thirsty all
the time? Tiredness? weight loss? weakness?
• Features of hyperparathyroidism – usually asymptomatic, shows only features of hypercalcemia
• Features of malignancy – loss of weight, loss of appetite, bone pain
• SADMA
• Investigations (to differentiate between malignancy and primary hyperparathyroidism as well)

• Albumin
• U&E
• Parathyroid levels
• Alkaline phosphatase
Explain
• Hypercalcemia due to increased hormone called parathyroid. The gland is all 4 in numbers
located near thyroid gland. This hormone plays important role in bone metabolism.
• Most likely due to adenoma (80%) benign tumor of that gland, hyperplasia of all glands
(enlargement of all 4 of the glands) and very less likely cancer.
• Sometimes this increased parathyroid hormone level occurs in combination as other hormonal
disorders (multiple endocrine neoplasia MEN-1 and MEN- 2a) but I didn’t notice anything in your
history.
ITP
You are a GP. 25 year old male, Noah, come to the GP because of rash in his legs.
• Task:
• history
• PEFE as rash examination
• dx and ddx
• investigations to patient
History
• Rash questions – site, nature, color, raised? Discharge, itchy? Painful? First time? Similar rash in
a body?
• DDx – Bleeding disorders in you or family? Clotting problems? Any medications? Allergy?
Change in soap or shower gel? Any recent illness? How was it treated? Tummy pain, urine color
change, join pain? (HSP), any bleeding from other areas of body gum? (ITP) Fever? Headache?
Neck stiffness? Afraid of light? (meningitis) recent travel? Fever? (infections), Lumps or bumps?
Safe sex? Tattoos? Drug abuse?
• Contact history
• Past medical (reg medications), surgical
• SADMA
• PEFE – general appearance, vitals, eyes- pallor, jaundice

• Rash – nature of the rash raised or not? Distribution, blanchable or not? Tenderness?
• ENT examination
• Fundoscopy
• Lymph nodes
• Neck stiffness
• Abdominal and groin and DRE for bleeding
• Any other rash in the body
• UDT
• Dx- ITP – platelets from the body destroyed by the antibodies formed to fight against the
infection. Since the function of the platelet is to control bleeding, when its level is lowered,
bleeding under skin resulted. Others – HSP, viral rash (HIV, EBV, Hepatitis B, C),
Meningococcaemia, clotting problems, allergy less likely.
• Red flags – bleeding for other parts of the body, please stay stable as much as possible (risk of
bleeding inside the brain) (spontaneous intracranial bleeding if 10,000 – 20,000)
• Invx - FBC, clotting profile, ESR and CRP, LFT, RFT, (hepatitis serology, monospot test for EBV)
Urticaria
Young lady comes with itchy rash over hands and back. 2 pictures given outside like below.
• Task – take history
• Explain Dx and DDx
peads
• Rash – 1st time? Site? Itchy? Pain? How long? Spread to anywhere? Any relieving or aggravating
factor?
• Causes – any touch to chemicals, plants or animals? Any new food? Drugs? Recent flu-like
illness? New cosmetics or creams? Insect bites? Any recent travel? Any contact with similar
condition?
• Do you have any history of allergy? Any inflammation of joints? Any stress?
• Severe symptoms – changes of voice, swelling of tongue or throat, pale, sweaty, trouble
breathing?
• Any family history of allergy, asthma, eczema?
• SADMA
• Possible causes – Hives (urticarial, allergic reaction to release of chemicals called histamine,
resulting as red and itchy rashes),
• it could be most likely due to allergy to food or chemicals (including cosmetics) or drugs, plants
or animals, or sometimes contact with some metals like Nickel, or insect bite or viral infections
less likely.
Lymphoma
You are a GP. A 23 year old, John, with fever and sweating for 4 months. Also complained of Weight
loss.
Tasks:
• history
• Pefe card
• Diagnosis with reasons
• Details of fever
• Association – cough, Malaise, Nausea/vomiting, Night sweats, Fatigue, SOB. Rigors, Weight loss,
Pain, lumps or bumps, Skin –bruises, rash, itchiness, jaundice, pain in throat, poo and pee any
changes?
• Travel history
• Contact history
• Contact with animals/pets/birds
• Sexual activity without protection
• Tattoos/piercing
• Drug abuse
• Family history of cancers
• SADMA
• Then on Pefe card

• Cervical lymph nodes mentioned enlarged with rubbery consistency
• Enlarged spleen
• Marks of itching all over the body present
• You have weight loss and prolonged fever. When I examined you, I also found some enlarged
lymph nodes around your neck and spleen which is part of body immune system is enlarged. It
could be because of lymphoma which is a nasty growth in the lymph nodes which are also part
of our body immune system. But we will run some investigations and refer you to the specialist
to check for biopsy of these lymph nodes to know what is happening exactly.
Acute on chronic renal failure read as well , hyperkalemia

You are a HMO at the hospital. 50 years old male, Jones, has presented with vomiting since one day.
He have history of chronic kidney disease. He was taking perindopril for hypertension and NSAIDS for
joint pain. Recently he developed edema in legs for which he was started on diuretic.
Tasks
• Take hx
• Ask inv from examiner .(interpretation to examiner)
• Explain diagnosis to the pt.
• Complaint – nausea and vomiting – since when? How many times? What does it contain? Any
specific color? Smell? Blood?
• DDx – any diarrhoea? (GE), Tummy pain? (appendicitis, GI disorders), passing wind?
(obstruction), burning sensation while passing urine? (UTI)
• Oedema – since when? One or both legs? Extent? Sudden or gradual? Any pain?
• DDx – CVS – any chest pain? SOB? Racing of heartbeat? How many pillows you use when you
sleep? Renal – any swelling in eyes?
• Diuretics – which type did you use? Since when? What was the dose? Was your swelling relieved
after that? When was the last time you passed urine? Do you have any feeling like you wanna
pass urine? Do you feel thirsty?
• CKD – when was you diagnosed with it? How is it being treated now? Have you undergone
dialysis before?
• Past medical, past surgical, SADMA
• Investigations from the examiner

• Hyperkalaemia ECG, High potassium in electrolytes and abnormal RFT.
• So Mr Jones, according to your history and the investigation results, your nausea and vomiting is
most likely due to increased level of one chemical call potassium in your blood. There are many
factors contributing to this but in your case, it is most likely due to the side effects of
medications you are having.
• The combination effect of antihypertensive you are taking (Peridopril –ACEI), diuretic and the
NSAID, the side effect is acute renal injury. (acute kindey failure) This is called Triple Whammy
effect of combination these three medications.
• So that’s why you have collection of potassium in the blood as kidney cannot remove the excess
potassium in your blood.
• So now, you are in the safe hands and we will stop the medications and try to correct this
imbalance in your body.
Snake bite
Young man got bitten by a snake. First aid applied by father, brought to the ED.
Tasks:
• Take history
• PEFE
• Interpret investigations to patient (PT and INR prolonged, aPTT – prolonged, FBE – normal, CK
normal)
• Explain diagnosis
• Approach
• Check the stability
• Have you seen the snake? What type? Bite marks? One or multiple?
• Systemic symtoms – nausea, vomiting, headache, abdominal pain, diarrhea, increased sweating
• Any collapse?
• Neurotoxicity – eye muscles – dropping of eyelid, double vision, blurred vision
• Myotoxicity – muscle pain?
• Coagulopathy – bleeding from anywhere? Bleeding from cannula site?
• Have you passed urine?
• Medical history categorize the snakes as acc to toxicity;
like neurotoxicity, myo and coagulopathy,
• SADMA some renal failure.
• PEFE – General appearance, vitals (hypotension)

• Check petechiae, epistaxis, Respiratory distress (Respiratory examination) and CVS
• Ptosis?
• Muscle tenderness and Neurological examination
• Sensation (paresthesia)
• Check bite wound and fang marks
• UDT
• Explain blood test – prolonged prothrombin time, International normalized ratio and activated
partial thromboplastin time – increased chance of bleeding and blood is thin due to venom.
• Other investigations – one by one and say normal
• Diagnosis – snake envenomation with coagulopathy
Test to be done
• Coagulation studies (PT, INR, aPTT, fibrinogen level, d-dimer, FDP, platelet count)
• Full blood count
• CK level
• Renal function test
• Blood grouping and matching
• ABG
• Urinalysis (myoglobinuria)
Paracetamol ingestion
Daughter, Laura, brought in mother found to have take many Paracetamol tablets. now stable.
• History not more than 6 mins (no psychosocial history needed)
• further investigations from examiner and explain these to the patient
• Ensure Confidentiality
• Please tell me what happened today?
• Did you do that with the intention of committing suicide or was it just a method to relieve your
inner conflict?
• Any intentions of harming herself now? (or) Intention of committing suicide?
• Any suicidal Plan?
• Paracetamol toxicity
• How many tablets? When? Any vomiting? Tummy pain? Later – jaundice, encephalopathy
• Risk Assessment :
• Any previous attempts of committing suicide ?
• Is this the 1st time?
• Any other self-harming behaviour for you?
• Where will you go once you are discharged?
• Who will be taking you home? / Going alone?
• Any other relationship problems?
• Do you get adequate support from family?
• Medical conditions? (liver disease) surgical history?
• SADMA
• PySo. Hx: (no need if the stem says so)
• Mood:
• Life worth living?
• Any feeling of hopelessness?
• Any intention of harming others
• Appetite? Weight?
• Sleep?
• Home:
• Education:
• Does she enjoy same hobbies?
• Invx –
• Paracetamol levels and plot it on nomogram, (4 hours after ingestion or ASAP if more than 4
hours at the time of presentation)
• liver function test, UEC, INR,
• ABG, FBE, Glucose
• Explain the normal results if given. Appreciate her for opening these up.
Weight loss work-up
You are a GP at a suburban clinic and on a busy Friday afternoon your next patient is 57 year old
Jasmine who has been complaining of weight loss for over 3 months. She has lost 7 kgs in that time
period.
TASKS:
• Take History
• Ask for physical examination from the examiner, you’ll be provided with a sheet of paper with
the findings.
• Advise her on what further investigations you want to do for her and plan for future
management.
• Always start with confidentiality

• Is that Intentional or unintentional weight loss? Are you on any special diets or weight loss
programme? What about the previous weight? How is your diet? (significant weight loss = 5% of
body weight in 6-12 months)
• DDx –
• Endocrine – DM – any increased thirst? Increased frequency of passing urine? Thyroid- any
racing of heart beat? Weather preference? Adrenal insufficiency – any tiredness? Muscle
weakness?
• Malignancy – LOW, LOA, bleeding from down below? Bowel work? Any color changes? Any pain
in the throat? How is your period? Any changes in breast? Any lumps and bumps?
• Chronic Infection – any fever, cough, night sweats, any diarrhoea
• Heart problems – swelling of face or legs, SOB
• Any recent travel?
• Let me ask you some private and sensitive questions – Are you sexually active? Practice safe
sex? What about recent partners? Do you have any kids? Mammogram and Pap smear.
• Past medical, Past surgical, any family history of cancers?
• SADMA
• What do you do for a living? How’s everything at home? Any stress? How is your mood these
days?
• Management:
• You are in good hands and I do appreciate your concern for the weight loss
• Definitely I will try my best try to find out the cause
• There are many causes that lead to weight loss
• It could be some medical diseases like thyroid or Diabetes, it could be infections in the breathing
system or bowels or heart (Endocarditis), or it could be because of stress or less likely sometime
it may be due to nasty condition in some parts of the body.
• Investigations:
• So we need to run a few investigations including blood and imaging to know the cause. I will do
physical examination on you as well.
• We will check your blood cells, inflammatory markers, Liver and kidney functions, vitamins like
B12, Folate levels and iron levels in the blood, thyroid hormone levels and blood sugar level.
• We will do CXR, ECG and also microscopy of the stool for any traces of blood
• Depending on the result, we may need CT SCANS/MRI and screening colonoscopy.
• (((HIV test is only done with positive sexual history and only after pre-test counselling))))
last yr imp
Excessive Thirst
You are a GP. You are going to see 27 years old PHD student coming to see you because he thinks he is
excessively thirsty these days and increased urination.
Your tasks:
• Take history
• Differential diagnoses
History
• Excessive thirst details – how long? How much do you drink per day? What do you drink? (plain
water?), Does it continue even after you drink? Does your thirst increase or decrease during
certain times of the day?
• Polyuria – How many times? What about night time? Any changes in urine like color or smell?
Any fever? Any pain during passing Urine?
• Causes of excessive thirst –
• Diabetes mellitus - Do you have those symptoms like tiredness? Extreme hunger? Blurred
vision? Slow healing wounds? Skin infections?
• Diabetes insipidus –Causes of diabetes insipidus - any head injury? Previous surgery?
Headache? Nausea? Vomiting? (brain tumor)
• Loss (dehydration) – any diarrhoea or excessive vomiting? Any profuse sweating? Or strenuous
exercises?
• Loss of body fluids into tissue - Any history of recent infections with high fever, heart, liver or
kidney disease? Any recent injury or burn?
• Hyperthyroid – any swelling in the neck? Weather preference?
• Psychogenic – any mental illness before? How’s your mood?
• Any medications you are taking? (lithium, diuretics and antipsychotics?) Are you taking any
supplements? (Vit D and calcium? )How long? How many tablets?
• Do you eat a lot of spices or salty foods?
• Calcium or vit D intake + , symptoms of hypercalcemia – constipation? Tummy pain?
Headaches? Muscle cramps? Or weakness? Any disturbance in thinking process?
• Past medical? Past surgical?
• Any family history of diabetes?
• SADMA
• DDx – There are many causes leading to this increased thirst but most likely in your case is
hypercalcemia which is the increased calcium level in the blood as you have a history of
excessive Vit D/calcium intake. Too much calcium in the blood means that kidneys have to work
harder leading to increased urination and excessive thirst. We also call it nephrogenic diabetes
insipidus happened because of hypercalcemia. (impaired renal tubule response to ADH)
• Other causes can be Diabetes mellitus which is increased blood sugar,psychogenic where you
take it because of stress increased sweating, hyperthyroidism which is increased thyroid
hormone levels in the body, any heart, liver or kidney diseases, or spicy and salty foods but less
likely according to your history.
IBS with anxiety
You are a GP and 52 years old female comes to you because of long standing history of constipation.
During the last 3 months, she had undergone blood tests, gastroscopy and colonoscopy which were
found to be normal. She was diagnosed with IBS. At the moment she complains of bloating and pain in
the left iliac fossa.
• Tasks:
• History for 5 mins
• Explain the diagnosis and Management
• History
How are you doing? Have you noticed any improvement since you last saw the doctor? Have you taken
any medications to help you? Do the medications help? May I ask, how is your mood these days? Do you
feel low or guilty about anything? Any stress in your life, at home, or at work? Any financial stress?
Whom do you live with at home? How is your relationship with your partner? With kids? Do you have
friends or family to support you? Do you socialize much? Any exercise that you do? How many days a
week? For how long? What kind of work do you do? Any problems at work? How is your relationship
with your colleagues or workmates? Can you please describe your typical daily diet to me? Do you
prepare your own food or do you buy them? How much tea and coffee do you take in a day? Have you
noticed any relationship of your symptoms with any type of food (dairy products, spicy food)? SADMA?
Counseling
• From the history and investigation findings, it seems like your gastrointestinal system is working
fine, except at certain times where you are under a lot of stress. As you know, the bowel is a
muscular tube that pushes food along the way with the help of waves or peristalsis. Sometimes,
these movements become overactive causing pain, bloating, diarrhea, and sometimes, even
constipation. As you know, our mind and body are connected. Whenever the mind is stressed,
the body responds producing symptoms, something we call as brain-gut axis. Medically, we term
it as irritable bowel syndrome. Please understand that this is not cancer. Your gut is fine. What is
important is to identify the possible stressors in your life which could be related to work, home,
or financial situations. There are some other factors that might aggravate this condition like
dietary habits (lack of fiber, spicy foods and dairy products, smoking, medications that contain
codeine, overuse of laxatives, and depression).
• It is a very common condition especially with the lifestyle that you have. The management
involves self-help mainly. You need to avoid the trigger factors, make some changes to your diet,
avoid smoking and intake of caffeine excessively, limit alcohol to safe levels, have a daily
exercise regime, and if possible, avoid stress in your life.
• I can refer you to a counselor for some talk therapy. It might be helpful to keep a food diary to
identify possible triggers. Try to eat a high fiber diet (oats and vegetables (pectins), barley, seed,
husks, flaxseed, psyllium, dried beans lentils, peas, soymilk and soy products; Avoid insoluble
fibers like corn and bran).
• If after 12 months of trying lifestyle, dietary and counseling therapy, you are not relieved, we
will start you on anti-depressants.
• Written material. Referral to counselor. Dietitian.
• Give antispasmodics.
Male UTI
This 40-year-old postman is married with two children and has consulted you today in a general
practice setting complaining of the gradual onset of dysuria and frequency of micturition over the last
three days. There has been no urethral discharge and no history of extramarital sexual contact. On
examination the patient is afebrile and you found no abnormality on examination, including rectal
examination of the prostate. A midstream urine specimen was collected and the following office
laboratory tests were done on the urine
• Dipstix — positive for protein, leucocytes and nitrites: negative for blood, glucose and
ketones. Microscopy of uncentrifuged specimen shows large numbers of leucocytes and
bacilli.
• The patient usually keeps in excellent health. He is aware that he is sensitive to penicillin but
otherwise his past history, family history, habits, and use of medication have no relevance to
this problem.
• Tasks:
• Advise the patient of your diagnosis
• Advise the patient of your immediate management,
• Discuss the condition and answer any questions the patient may ask
• Management - You most likely have a UTI. I would like to do urine microscopy and culture to
confirm. We need midstream urine.
• Most common organism is E. coli. Because you don’t have fever and loin pain, it is lower UTI. - I
will start you on antibiotics: trimethoprim 300mg OD x 14 days or cephalexin 500 mg BD x 2
weeks or Amoxiclav 625 mg x 14 days. - Drink ample fluid (2-3 cups in AM, 1 cup every 30 mins) -
Empty bladder often - Personal hygiene (wipe front to back) - Panadol for pain - Ural (sodium
citrotartrate) CI if prescribing nitrofurantoin - Unusual for male to have UTI so we need to
investigate further for any other underlying disease (bladder/prostate malignancy, calculus,
prostatitis, urethral stricture, BPH) o For young adult: higher chances of having STDs or foreign
body Child: congenital abnormalities (VUR) - Refer to urologist, Review and reading materials
• Investigations - Intravenous urethrogram - PSA - RFTs - CT abdomen and pelvis - USG -
Cystoscopy
Alcoholic Neuropathy (possible approach only)

You are a GP. You are going to see a 60 years old patient with the chief complaint of burning pain in
both feet. He is a chronic drinker for 5 yrs 4/5 glasses per day but now quitted already. Physical
examination ankle jerk diminished. Investigations - GGT raised. HBA1c Normal.
Tasks:
• Explain the diagnosis
• Explain short term and long term management
• Diagnosis – Alcoholic neuropathy
• According to your history (there is long stem which mentions everything in the exam), physical
examination and investigation results, you are having an alcoholic liver disease and alcoholic
neuropathy which are the consequences of excessive alcohol drinking. (explain everything given
in the stem).
• Your burning feet is also a symptom of alcoholic neuropathy.
• So let me explain what is alcoholic neuropathy. Chronic alcohol drinking causes damage to the
nerves which leads to unusual sensations in the limbs, reduced mobility, and loss of some bodily
functions.
• Some people with alcohol use disorder also have inadequate food intake. This can lead to
deficiencies in:
• vitamin E
• vitamins B6 and B12
• thiamine
• niacin
• folate
• Deficiencies in these nutrients can harm overall health and stop nerves from functioning
correctly.
• Signs and symptoms include any combination of the following:

• Pain, tingling, weakness, loss of sensation or other unusual feelings in the toes, feet, legs,
fingers, hands or arms
• Lack of coordination of the feet or hands
• Loss of balance/unsteadiness when walking
• Dizziness, particularly when standing with eyes closed
• Trouble walking a straight line, even without recent alcohol use
• Constipation or diarrhea
• Urinary incontinence
• Sexual dysfunction
• We confirm this by doing some investigations(not sure what are the other tests mentioned in
the exam. Only if not yet, please mention below)
• Electromyography (EMG) and nerve conduction studies (NCV): These tests examine nerve
function in detail.
• Nerve biopsy is done only in a few cases
• Additional assessments might include blood tests, urine tests, or imaging studies of the brain or
spinal cord to rule out other causes of neuropathy symptoms.
• We also test the functioning of the kidneys, liver, and thyroid and also check for vitamin and
nutrient deficiencies.
• Every person’s needs are different. Treatment for neuropathy may involve one, or many,
different types of care. These include:
• vitamin supplements to improve nerve health
• prescription pain relievers
• medication for people with problems urinating
• physical therapy to help with muscle atrophy
• orthopedic appliances to stabilize extremities
• safety gear, such as stabilizing footwear, to prevent injuries
• special stockings for your legs to prevent dizziness
• There are no medications that can help improve loss of sensation, strengthen the muscle
weakness, or aid the coordination and balance problems caused by alcoholic neuropathy.
However, some people notice an improvement in symptoms a few months after discontinuing
alcohol intake.

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Dr. Riley Harrison

Approach how many times in a month

• Prophylactic management (if more than 2 attacks per month0

• Medications for prophlaxis

• PEFE – GA, vitals (esp BP)

History if hx separate task

• Check the stability first

Pericarditis insisting morphine

pca and tens is not an option

Physical examination Card from the examiner

• High flow Oxygen

• Advice upon discharge

CVS risk assessment not recent

• Sorry to hear about your brother. How is he now?

• PEFE – General appearance, BMI, waist circumference, BP, pulse

Bradycardia recent recall

bsl will be normal

Causes of microcytic anaemia

Temporal arteritis stopped steroid

Physical examination from examiner

Atrial Fibrillation recent

• Another case, SVT

Card from examiner

Vasovagal or postural hypotension

• PEFE all normal

Shakiness and shoplifting case

• DDx – Benign essential tremor, anxiety, hypoglycaemia, hyperthyroidism, drug or alcohol

explain significant findings

check fev1/fvc ratio , if reduced obstructive. if normal or increased its restrictive.

FEV1/FVC RATIO LESS THAN 70% N OR INC

significant is more than 12%,

if irreversible less than 12%

patient value, inc so obstructive

fev1/fvc ratio and

Management of COPD investigation plus treatment

• Management of COPD dont mention these is best

Drug induced cough recent

• Greet, how are you. Stability

• Management – We will need to admit you, start on monitoring.

Sore throat asking for antibiotics

• The condition is self-limiting in nature, it will go away 5-6 days

Ulcerative colitis recent

• How are you? How is your diarrhoea?

• To keep healthy, consider:

Gout will be discussed in surgery

• Long term management

• Talk about the disease prognosis

• Talk about management

• Talk about occupational management

• Talk about healthy lifestyle

Epilepsy and driving license dont worry if u finish early

• Talk about family

Retinoids not recnt skip

Anti-hypertensive non-compliance imp case, recent,

Reason why she is non-compliant of her medications

• Assessing End organ damage:

add a memory taste , MMSE, bc in one recall ch alcoholic and now

SCC in-situ (ref from different websites)

• The recurrent risk is higher with sun exposure.