Dr MO SOBHY

MENTOR CLASS
21/10/2022 - 31/10/2022
Requested TOPICS
• 1.Telephonic and video consultation approach
• 2. Prescription and BNF dealing
• 3. tacrolimus hair loss
• 4. Parkinson - cannot walk
• 5. Malaria
• 6. New mom having breast pain

Dr MO SOBHY
• 7. Bad comments on facebook ( problem colleague)
• 8 .Headache in hostel but relived when comes out
• 9. Keratitis
• 10. Seperation anxiety ( was in the recall)
• 11. Campylobacter diarrhea
• 12. NAI Daughter
• 13. NSI
• 14. Lap cholecystectomy Jehovah witnesses.
• 15.techniques of inhaler use in children(teaching mother the process)
• 16.Learning difficulties patients
LAST 10 DAYS RECALL
• Change the counselor
• Lesbian bullying
• Bulimia
• Malaria
• Conjunctivitis
• 6 year old asthma phone call- TRIAGE CALL

Dr MO SOBHY
• phone call kidney transplant on tacrolimus concern hair fall
• Heroine addict phone call
• Seborrheic Keratosis or any other skin lesion
• Leg pain intermittent claudication. PAD
• Late colleague
• Learning disability insulin
• Vestibular neuritis
Tacrolimus hair fall
• 25/F comes to GP.
• Hx RENAL transplant
• Lot of hair fall since 2m since she was commenced on Tacrolimus.
• Its getting worse, it was normal before meds.
• Other issues. No rash, fever, weight change.

Dr MO SOBHY
• No operation complications or symptoms of kidney failure.
• P4 was insignificant
• BNF is inside the cubicle. So check the BNF for med side effects.
• Ask if there's any visible bald patches,
• Ask if she changed the type of shampoo.
• Ask why kidney transplant was done? How is she doing now? Psychosocial.
Mood?
• Concerns:
• Why she is having this?- She would like to stop the medication
• Your task:
• Ask about the falling of her ( sites , amount , shape / is it getting worse?
Patches or complete baldness?- they might give you picture.
• Explore cause / ask if there is any recent change in medications , change in
shampoo. Ask if there is any rash explore, how is her general health now
after the transplant / any complications? – why transplant was done?

Dr MO SOBHY
• ask about her mood ,psychosocial? Work? Support system?
• verbalize examination
• tell about suspected diagnosis ( Alopecia ) have a look over this hair falling
• involve senior
• advice regarding things that bring up immunity. tell her it’s most probably
because of the medication as a side effect.
• offer a solution as wearing a Wig. Safety Net ( FLAWS]
• Hair transplant? Cap? Multivitamin? Good diet
Parkinsonism - cannot walk

• GP surgery
• Difficulty in initiating walk, later okay.
• Difficulty on holding chair
• Tremors in right hand
• Family hx of Parkinson's.

Dr MO SOBHY
• Cocnerns:
• 1. Why I have this?
• 2. Will my son get it?
• 3. What will you do?
• Data gathering:

• Do ODIPARA? Since when? MMA? Fam hx? Psychosocial? Mood? Old pt/
chronic – always ask mood and how affecting life? Ddx- Joint pain? Any
trauma? Walk independent or aid? Resting tremor? Any stiffness? Slow in
doing things? Any hx of fall? Balance? Rigidity? Any hx of stroke?
Weakness? Any med hx like antipsychotics?

Dr MO SOBHY
• Examination : Neurological exam/ check Gait.
• Concerns:
• Sometimes run in the family. – Familial
Urgent Neurology referral- CT/ MRI
• Senior/ Specialist/ Levodopa
• MDT- Physio/ Occupation therapist Language and speech therapy and
special nurse.
• Tremor control
Malaria

• Background:32 Y/O man presented to A n E with fever, rigors

and feeling unwell for the last 2 days.
• Travelled to Kenya urgently, did not take any prophylaxis for
malaria.
• Lives with his girlfriend and is concerned that girlfriend will
also get the fever. Girlfriend did not travel

Dr MO SOBHY
w

feeling and being sick, tummy pain and diarrhoea

Dr MO SOBHY
● loss of appetite
● muscle pains
● yellow skin or whites of the eyes
● a sore throat, cough and difficulty breathing
● Cerebral Malaria – Impaired Conscious level, or seizures.
● Oliguria, acidotic breathing
● Haemoglobinuria

Examination:
Vitals
Hepatomegaly/spleen? GCS
• Investigations:
• ● Routine blood investigations including full blood count, and
inflammatory markers.
• ● Specific Investigations: Microscopy of thick and thin blood films
(Gold Standard) – If first blood films are negative further blood
testing to be done in 12-24 hours later.
• Antigen detection test

Dr MO SOBHY
Management:
Admit/ Senior Call
• Symptomatic:
• ● Pain killers
• ● Antipyretics
• ● Anti sickness medication
• ● Hydration
• Definitive management:
• ● Arrange immediate admission for specialist assessment and
review if the patient is: Suspected to have severe or complicated
malaria, a pregnant woman, a child or above 65 years.
• ● Urgently discuss all other people suspected of having malaria
with an infectious disease specialist: People with non-falciparum
malaria may be admitted or observed for at least 8 hours after

Dr MO SOBHY
starting anti-malarial therapy
• ● Ensure that all cases of malaria have been notified to Public
Health England.
• ● Medications to treat Malaria ● Artesunate ● Artemisinin
combination therapy (ACT) Atovaquone-proguanil, ● Quinine plus
doxycycline ● Primaquine
• Specialist: Discuss the case with infectious disease specialist
• Complication: ● Severe anaemia: ● Cerebral malaria:
• Safety net
New mom having breast pain

• Mastitis?
• Infection of the breast tissue resulting in pain, swelling,
warmth and redness. This condition is commonly seen among
breast feeding women.

Dr MO SOBHY
• Symptoms: Ask hx?
• Breast tenderness
• Redness on the skin
• Breast pain
• Breast rash
• Malaise
• Fever
• In this station a breastfeeding mother usually present with
pain redness and tenderness. Mastitis is common in
breastfeeding women as it can be caused by a build-up of milk.

Concerns?
Should I continue breast feeding?

Dr MO SOBHY
Will the antibiotic harm my baby?

Take hx? Any trauma? Fever? Discharge? MMA? Fam hx?

Examine the breast- They might give you a picture.
Management:
• soak a cloth in warm water and place it on your breast to help
relieve the pain – a warm shower or bath may also help
• rest and drink lots of fluids
• take paracetamol or ibuprofen to reduce any pain or fever
• if you are breastfeeding, continue to breastfeed.
• Adjust the breastfeeding technique to make sure the baby
latches on correctly and fully empties the breasts during

Dr MO SOBHY
breastfeeding
• massage your breast to clear any blockages – stroke from the
lumpy or sore area towards your nipple to help the milk flow
• Specialist Mx:
• Antibiotics- to prevent abscess
• Antipyretics.
• do not wear tight-fitting clothing or bras until you feel better
Bad comments on Social media- Problem Colleague
• Whenever its Social media problem colleague no matter what,
ask:
• What was the post about? Did it involve breaching of
confidentiality of any patient?
• Where was this posted? How many people have seen? What
were the comments?

Dr MO SOBHY
• Ask them do you think its right? What if they complaint? What
if it was your relatives?
• Ask to delete the comment and post.
• Discuss with the senior.
• Apology to the patient if involve.
Headache in hostel/home but relived when comes out
• Carbon monoxide poisoning?
• Headache when at home, diasspears when go outside.
• Noticed others having similar symmptoms
• New heater installed/ Completely new house
• Concerns:
• Why I have headache?

Dr MO SOBHY
• Do I need to come to hospital?
• Approach: SOCRATES
• Have you had any cooking/ heating installed?
• Oven/gas stove for cooking?
• Any soot/carbon around the appliances?
• Work? Exposure to smoke fumes/ motor vehicles?
Management

• Come to AnE immediately

• 100% oxygen
• Do Neurological exam
• Blood CO level
• Also invite others to hospital
• Inform local protection team

Dr MO SOBHY
• Inform landlord
• Do not use suspected appliance
• Fit CO alarm
• Well ventilated room
• Check all appliance annually
Headache in hostel/home but relived when comes out

• Carbon monoxide poisoning?

• headache
• dizziness
• feeling sick or being sick

Dr MO SOBHY
• feeling weak
• confusion
• chest and muscle pain
• shortness of breath
• The symptoms may come and go. They may get worse when
you spend time in an affected room or building and get better
when you leave or go outside.
• Common household appliances used for heating and cooking can
produce carbon monoxide if they are not installed properly, are
faulty, or are poorly maintained.
• Appliances that can cause carbon monoxide include:
• gas boilers
• gas cookers and clay ovens
• gas or paraffin heaters

Dr MO SOBHY
• wood, gas and coal fires
• portable generators
• If you think you might have carbon monoxide poisoning:
• stop using appliances you think might be making carbon monoxide
(such as a boiler, cooker or heater)
• open any windows and doors to let fresh air in
• go outside
• get medical advice as soon as possible – do not go back into the
affected building until you have got advice
Dr MO SOBHY
• Call 999 or go to A&E if:
• you are finding it hard to breathe
• you suddenly become confused
• someone loses consciousness

Dr MO SOBHY
Conjunctivitis

Dr MO SOBHY
Dr MO SOBHY
Dr MO SOBHY
Keratitis

• keratitis can be caused by a relatively minor injury, such as from

wearing your contact lenses too long or getting a foreign body in the
eye. Infectious keratitis can be caused by bacteria, viruses, fungi and
parasites.

• Here the patient comes with bilateral painful eye.

• She uses contact lenses and falls off to sleep with it.

Dr MO SOBHY
• Approach: Do SOCRATES and ask
• Other symptoms-
• Redness of the eye
• Blurry vision
• Sensitivity to light
• Excessive tearing
• Gritty sensation
• Decreased vision
• Prevention
• Cleaning and disinfecting contact lenses regularly
• Washing and drying hands before handling contact lenses
• Never wear contact lenses when you go swimming

Dr MO SOBHY
• Replace your contact lens case every 3 to 6 months.
• Discontinue use of contact lenses if they are infected.
• Choose daily wear contacts and take them out before going to
sleep.
• Wash, rinse and dry your hands thoroughly before handling
your contacts can reduce viral outbreaks..
Management

• Use artificial tears or lubricant eye drops to treat dryness.

• Your doctor may prescribe eye drops, oral medications, or
both:
• Antibacterial eye drops: Besifloxacin ophthalmic

Dr MO SOBHY
• Antifungal eye drops: Amphotericin B
• Antivirals: Ganciclovir ophthalmic
Complications

• Open sores on your cornea, called corneal ulcers

• Temporary or permanent reduction in your vision
• Blindness

Dr MO SOBHY
Separation anxiety

Dr MO SOBHY
Campylobacter diarrhea- Telephone

A 25 y.o. female p.t. is calling you in GP. - She wants to know her test
result (stool culture – shows C. Jejuni growth). - She has been c/o
bloody diarrhea for 2 weeks. Previously, she had tummy pain and fever
but not anymore. - She’s hemodynamically stable. No bleeding
disorders. - Ate in a restaurant 2 weeks back. - Otherwise, everything
else is normal.
Test:

Dr MO SOBHY
Stool analysis, ↑ leukocytes & ↑ Erythrocytes. - Stool culture, shows
C. Jejuni growth.
Concerns: - How did I get this? - What are you going to give me to stop
the diarrhea?
Management: -
Greet and confirm patient identity. - Take focused history. Rule out
other GI problems, Dehydration, H.D. instability, rule out Guillain-Barre
Syndrome, and Reactive Arthritis. - Explain the test results. It’s most
likely from the food that you ate in the restaurant. This bacterium is

Dr MO SOBHY
the leading cause of bacterial enteritis in the UK. - It takes in average
2-5 days to develop symptoms after ingesting it. And it takes usually 2-
3 weeks for the diarrhea to subside. –
Invite her to the GP to do further tests and assessment. - It’s generally
self-limited, needs only bed rest and drinking plenty of fluids. But as
you told me that you noticed bloody diarrhea, fever, and it lasted for 2
weeks, then in this case I will discuss with my senior to start you on
antibiotics (Erythromycin or Ciprofloxacin for 5-7 days) plus ORS
• Tell her about the side effects of the ABx, nausea, vomiting,
diarrhea, and headache.
• Open BNF. - Explain the risk factors and advise on them.
• Self-isolation until the diarrhea is no more. –
• Safety net for persistent of symptoms, GBS, or R.A.

Dr MO SOBHY
• Also need to inform local notification center about it- They will check
the quality and hygiene of the restaurant.

• He might say its his friend restaurant- You need to mention the
benefit of other people on their health and safety.
NAI Daughter
• Any NAI- always take a detailed history of the incident.
• Don’t directly jump into NAI/ accusation.
• i.e- Child;
• Hello Mrs. James, I am sorry to hear what has happened to Lucy.
Can you tell me a bit more about the incident?
• When it happened? How it happened? Where was he? Where were

Dr MO SOBHY
you at the time of incident? Happened first time? Who else lives? Is
he biological father? How's the relation? What were you told about
it? What did you notice? Mood?
• Management : We need to admit child for further detailed
assessment.
• Do you have any idea what might have happened?
I am sorry but the kind of fracture happened to him, needs some
source of powerful hit/ twisting hand? Doesn’t happened with just a
fall. Any idea what might have happened?
• Don’t blame anyone, Let Social service decide. So say we need to
involve some colleague (Social service) who will ne taking a further
deeper detailed hx just for the child safety.

• Concerns? Will they take my son away?

• Not always, they will do whatever is safe for child and until they

Dr MO SOBHY
investigate. Whatever we are doing is for child's benefit.

• Any other case- always dig in detailed hx of incident? How it

happened? Anyone else involve? Ask who brought them to hospital?
Are you worried about anything else? Any bruises? Finger print? Talk
about the non verbal clues or anything from notes.
• Offer support – pt will start disclosing
NSI- Child/Nurse

• You are FY2 in A&E. Your nurse colleague Miss Matilda Drake,
aged 25, pricked herself while taking blood from her patient.

• 3 years-old Lucy was brought to the hospital by her nanny. She

had a needle stick injury. Talk to the nanny,

Dr MO SOBHY
• After needle stick injury:
• 1. Dispose the needle in the sharps bin.
• 2. Wash your hand under running water with soap.
• 3. Inform senior

Dr MO SOBHY
• 4. Go to occupational health to seek medical advice, if the
time is between 9-5 AM (If out of hour go to A/E).
• 5. Fill the incident form
Questions to ask
• When did this happen?
• Were you gloved? Was the injury superficial or deep? What kind of needle
was it? Any visible blood on the needle? Did you dispose of the needle into
the sharps bin?
• Did you tell someone else to take the blood from the patient?
• What did you do after you prick yourself?
• Tell me about your patient?

Dr MO SOBHY
• Concerns:
• Will I get meningitis? No, Meningitis is not a blood borne disease, it is air
borne and you had your mask, gloves and gown on.
• HIV? Hep-B? The risk of catching HIV is low because in order to get HIV,
your patient should be HIV positive and all the patients in the hospital are
not HIV positive. You told me that you were gloved, and the injury was
superficial and you washed your finger with soap which was great, so you
should not be that worried.
• We can offer you post-exposure prophylaxis medications (PEP), prescribed
up to 72 hours after exposure. We will also check your HIV status three
months later
NSI- Child

• When did it happen? What did you do after that? What kind of needle was
it? Was it attached to a syringe? Any blood in the needle? Was the needle
rusty? : How deep was the injury?
• NOTE: When you start asking some questions, the nanny will tell you, “I’m
going to write down what you are asking me and telling me to show it to
Lucy’s mom.” She looks very worried. Please reassure her and tell her,
“Don’t worry, you can write down points from what we discuss, but let me
reassure you we will talk to Lucy’s mom and explain everything to her if she

Dr MO SOBHY
wishes.”

• We will take all necessary action to prevent any possible infection. You told
that you washed her finger. This reduces the chances of infection. Needle-
stick Injury can sometimes cause infections such as wound infection,
Tetanus, Hepatitis and HIV.

• Wound Infection: We only prescribe antibiotics

• HIV: The chances of getting HIV through a discarded needle are relatively
rare because this bug cannot survive outside the body. You told me her
finger was washed immediately after the injury. However, we can arrange
for a reliable test at 3 months from the incident. We have prophylaxis
medication for needle stick injuries but as it happened outside of hospital,
there is no need to take it, because the risk of catching HIV is very low, and

Dr MO SOBHY
the medications used for the prophylaxis are very strong with a lot of side
effects.

• Tetanus: There is a possibility of catching the Tetanus bug, especially if the

needle is rusty. I will talk to my senior and we might give Lucy a Tetanus
jab.
• Hepatitis (B or C): Usually this bug cannot survive outside the body that is
why it is very unlikely that transition of this virus will occur through an
injury from a discarded needle. She will be given a Hepatitis jab today and
two more – one at 4 weeks and other at 8 weeks’ time
• The most notorious ones are the hepatitis B, hepatitis C, and HIV. We can
check antibodies against the hepatitis B virus in your blood today whereas
for the other two viral infections, hepatitis C and HIV, we can check you after
1 to 1-1/2 months’ time because there is a phase of seroconversion in which
the viral markers do not appear in the blood, so we need to wait some time
before we go on to do that test. In the meantime, we can just check for your

Dr MO SOBHY
hepatitis B antibodies and if they are very low, we can give you booster dose
of hepatitis B vaccine.
Learning difficulties patients-Dka/Warfarin/OCP
• Mr. James Atkinson, aged 24, was diagnosed with type 1 diabetes
two months ago after a DKA episode. He was admitted and managed
in the hospital. He was put on a short-acting insulin 3 times with
meal and long acting insulin before going to the bed. The diabetic
nurse has been going to his house to check the blood glucose and on
two occasions they were on the higher side.
• Special Note: This patient has a learning disability

Dr MO SOBHY
• A 50 year old patient has been diagnosed with DVT 4 weeks ago. He
was prescribed warfarin 5 mg per day and she is here for her review,
The anticoagulation nurse was following her up on weekly basis. The
INR result was done by the nurse weekly . The patient has a learning
disability.
• Ask about learning problem
• I have difficulty understanding medical terms or any big words.
• Alright, Mr. X I will try to avoid using any medical terms or big
words while talking to you.
• If at any point, you are confused or not clear, let me know, I
will explain it to you again.

Dr MO SOBHY
• We want your (INR) numbers to be 2 to 3. Your number is 1
every time, this is very low. This is because you need to use
your medication daily, not only on having pain. (Warfarin)
• Just follow whatever difficulty she/he tells you and implement
it in your station, shape your consultation accordingly
Techniques of inhaler use in children

• https://youtu.be/MVbXUdV5mHU

• Asthma how-to: How to use an inhaler with a spacer and mout

hpiece – YouTube

Dr MO SOBHY
Triage call
• Acute Asthma Attack (Telephone)
• History:
• ● Known asthmatic child
• ● Child having difficulty in breathing
• ● Gasping for air
• ● Sound coming from his chest
• ● No bluish discoloration

Dr MO SOBHY
• ● Unable to talk
• ● Unable to complete sentence
• ● Tried giving him blue inhalers, not working
• ● Can't drive to hospital
• ● Father says I thought it's not serious
• Concerns- Can I give him some steroids?
• Management:
• Greet and confirm patient identity using telephonic approach
• Take focused history , rule out red flags
• Explain about the urgency of the situation
• Send ambulance right away

Dr MO SOBHY
• Sit up straight – try to keep calm.
• Take one puff of your reliever inhaler (usually blue) every 30 to
60 seconds up to 10 puffs.
• If you feel worse at any point, or you do not feel better after 10
puffs, call 999 for an ambulance.
• If the ambulance has not arrived after 10 minutes and your
symptoms are not improving, repeat step 2.
• If your symptoms are no better after repeating step 2, and the
ambulance has still not arrived, contact 999 again immediately.
• Never be frightened of calling for help in an emergency.
• Try to take the details of your medicines (or your personal asthma
action plan) with you to hospital if possible.

• Repeat if not improved or ambulance not arriving in 15 minutes

Dr MO SOBHY
• Appreciate him that he is concerned and knows about his son's
condition and what additional medication such as steroids can be
given, however, explain that once you bring him in, he will be
assessed and if needed he might be started on steroid, if he needs
them. Offer to be with him on telephone until help arrives
• Safety net
• If your symptoms improve and you do not need to call 999, get
an urgent same-day appointment to see a GP or asthma nurse.
Colleague Coming Late
• let me tell you in the mornings, we have early morning
sessions with our seniors in which many important points are
being discussed about the patients, about their conditions,
then there are many whiteboard meetings. These are all very,
very important. Many times, some important points are being
discussed in those meetings with important take home points
and some of those points are never ever repeated again, they

Dr MO SOBHY
are never discussed again. So, I really want you to focus on
that. I mean since you told me you are only 5 to 8 minutes
late, I really want you to focus on the importance of these 5 to
8 minutes.
• The morning arrival time is very, very important. What are
other reasons that we should be on time. The other reasons
are it is better to make the habit of being punctual now as
this habit is going to be with us throughout our career. It is
going to give you a big boost as it would give a belief amongst
your colleagues that you are always on time, you are always
very punctual, he is always there for his colleagues, for his

Dr MO SOBHY
staff and for his patients. Also, when you will start working in a
hospital, you will know that for a life saving maneuver, even a
matter of two minutes can save the life of a patient.

• If the colleague says to you I come late to the hospital because

I live really far, or he can say I need to come by public
transport and I need to change many buses or trains, he might
tell you that I really have some important tasks to do at night.
• sleep late at night, I would highly suggest you to try to sleep
on time, it will give you some time in the morning to reach
hospital on time and also put an alarm for yourself, and if you
have any activities that you do at night, try to reschedule them
in a way that you are free at night and you are able to sleep

Dr MO SOBHY
well because your freshness in the morning with the patient is
also very, very important. If the colleague has a problem
commuting to the hospital, give him a solution for that. He can
consider changing his route, going through a different
transport, taking help from a friend who is also following the
same route or may be consider talking to his senior.
Concerned mother OCP/ Father concerned

I can see that you are too much worried and concerned if one of
the doctors prescribed the OCPs to your daughter. Mrs. Jordan I
am really sorry that I may not be able to help you with this
information. – (talk about patients confidentiality)
Wait and see if she responds, but I can help you in many other
ways. How does that sound to you?

Dr MO SOBHY
Mrs. Jordan, whenever any patient comes to us to seek any type
of medical help or advice, we always, always try to maintain
their confidentiality to strengthen the confidence to see us next
time when they need help. , I may not be able to help you with
the information that you are demanding but I can help you by
giving you the information about how we deal with these young
people when they come to us to get any oral contraceptive pills.
• Whenever young people come to us, we always take a complete
history, we take them into confidence to talk to us about any
problems that they might be having, we always make sure they are
in relationship with a person who they are safe with. We also ensure
that they are not under any influence of substance abuse, trauma
or torture. We always try to encourage them to talk to their parents
as well. We tell them that parents are the first and last resort for any

Dr MO SOBHY
child. We do not refuse OCPs or any type of contraception to any
young people. Do you have an idea why? Why? Well, Mrs. Jordan if
we refuse contraception to young children, they might start getting
pregnant at very early age, which would be more worrisome for the
child as well as the parents.
• So, I really encourage you to talk to your daughter, try to have a
friendly relationship with her, if you are close and friendly to her, she
might start disclosing her problems, her relationships, her issues
that she is going through at this age.
I need to travel to Australia/Canada, so I need to stop menstruation for
6 months because I will be going on vacation.

• Tell her, I can prescribe you OCPs, after talking to my senior here in
the practice but ideally these OCPs should not be taken continuously
for more than 3 months, So Jessica every pack contains 21 active
pills and 7 dummy pills. You need to skip the dummy pills. You need
to continue the active pills for 3 months.

Dr MO SOBHY
• Give her this information and say since I am prescribing you these
pills for the first time, I would highly advise you to book a telephonic
appointment with me or any other doctor in the practice/hospital.
Try to book the appointment after 3 months because we always like
to follow up our patients after 3 months.
BPPV

• When did it start?

• Is it the first time it happened?
• Did it start suddenly?
• Is it continuous or it comes and goes? If says comes and goes, ask
how long does it last

Dr MO SOBHY
• each time? (most important Q as this duration is going to give idea
what it is. Any episode:
• less than 1 minute, it is nothing else but BPPV. If the patient says
minutes to hours, nothing else but Meniere’s disease, lasting hours
to days is vestibular neuritis).
• DD: Can he related to 4 areas, head, ears, cervical/neck issues, heart
(arrhythmia)
Management

• This is a self-limiting condition that gets better by itself but there are
certain things that we can do for you. Just like the maneuver I did to
diagnose it, there is just another maneuver, which we call as Epley’s.
Please do not drive back home if you came driving, ask anyone to
pick you up. Usually there is no medication for this. maneuver, to get

Dr MO SOBHY
relief of symptoms. I
Vestibular neuritis

• Same as BPPV, ask about flu like illness, she will definitely say yes.
The duration of symptoms would be hours to days.

Dr MO SOBHY
Gender dysphoria/Bullying
• Can you tell me what things you have changed in your life?
• Are you following anyone? How do you dress up?
• What challenges you faced? Mood? Psychosocial? Work? How has this
affected your work/workplace?
• Have you sought any help or joined any support groups up until now?
Have you disclosed this to anyone at your home. Ask about

Dr MO SOBHY
acceptance at home, acceptance at school, acceptance in the
community. If says yes, ask further. Okay have you had any challenges
at school because of this feeling. Do you have any friends, have you
shared with them. How has your mood been recently?
• Are you taking any medications without prescription for this? How did
this initiate? Are you having any relationship? Look for support
system? Bullying- what happened? Are you sure they talk about you?
How do you feel before going to work? Talk to boss? Manager? School
teacher? LGBTQ groups, get support.
• I would be able to help you with that. I will give you a referral to
CAMHS (Child and Adolescent Mental Health Services). Anyone
below 17 years, can be sent to CAMHS. Anyone above 17, can be
sent to Gender Identity Clinic. For anyone below 17 years it takes
time for them to have a mixed feeling. Many times a child having
this feeling may go back and say I am okay being what I actually am,
I do not want to be of other gender. So, they are confused.

Dr MO SOBHY
• Refer to support groups like LGBT (gays and transgender, all even
bisexuals). If ever you feel you have a low mood, if you feel you are
being bullied by anyone, or you feel you are uncomfortable.
• Encourage them to talk to parents about their situation even if they
say that they are going to be angry, not accept it. Yeah it is normal
for that with parents as well because they do not expect that to
happen so it takes time for them to accept this one.
UTI-Transgender
• Risk factors for developing UTI 
• Do you need to hold urine for long periods of time.
• Patient may say I am uncomfortable going to male as well as female
toilets, so I need to hold urine for long periods of time. Male
because she doesn’t feel like male and female because she doesn’t
look like female and might get bullied for that. 

Dr MO SOBHY
• Drinking less water 
• Swiping from back to front 
• Wearing tight clothing
• Are you taking any medications for transition?
• How are you coping?

• Concerns- Why am I having UTI? – Holding urine/ female taking

testosterone – dryness of vagina.
Telephonic and video consultation approach

• Hello this is Dr XYZ, am I talking to………?

• Well, I am calling to discuss your test results that you have
done …..X… weeks back.
• Is this the right time? Right number to call back? Right
address? Am I clear? Do you want anyone else to be beside
while discussing results? (If video call- Am I visible?)

Dr MO SOBHY
• Examination:
• As we are over the call I'm unable to examine you, how about I
will set up an appointment so that I can see you in person for
a better picture about your symptoms. I will talk to my senior
and see when can I place an appointment, will that be okay
with you?
Unilateral tinnitus/ other hearing condition

• Doctor, I have been having this ringing in the ear.

• Tell me more about this ringing sensation? I have been listening to
sounds in my one ear, some ringing/buzzing, he can say anything.
Alright, so can you tell me since when you have been having these
sounds in your ear. Is it in one ear or both ears? Is it continuously
there or is it any particular time of the day? Is it getting worse with

Dr MO SOBHY
passage of time? Anything that makes it better or worse? Have you
ever felt it is a pulsating sound? Then go on to DDs (ear wax, middle
ear infections, acoustic neuroma)
• Any pain, discharge, blood from ears, any wax, any cotton buds
recently, any swimming recently, any air travel. Apart from this
ringing, any fullness, any hearing problem, any head trauma, have
you been exposed to any loud noise. (Being exposed to loud noise
for a long time, in music or other noisy industry?
• Examination (Observations, inspect and feel from inside, inspect from
inside and do hearing test) Look inside your ear with the help of an
instrument called otoscope.
• Everything is normal. So in this case it may be due to loud noise. If
there is wax in that particular ear. If you find out any middle ear

Dr MO SOBHY
effusion, it can be due to that. If you find this patient has unilateral
sensorineural hearing loss, then always think of acoustic neuroma. If
you find earwax is the cause, then remove the earwax, give drops, send
him home, tell him usually the wax falls out once we use these olive oil
or almond oil drops. If it doesn't happen then please do come back to
us, we will again reassess you. If you find out this patient has
sensorineural hearing loss in one ear along with unilateral tinnitus, send
him immediately or in two weeks to ENT specialist. If there is no hearing
loss. Patient may say I have pulsating sensation in my ear, this is red flag.
If so, then please send the patient to ENT specialist because it could be
AVM.
Dr MO SOBHY
• Please try cutting down on caffeine, energy drinks intake.
• Have a very low background music at night (as it will distract the
patient away from ringing
• sounds)-also called sound therapy. It should be very low
background.

Dr MO SOBHY
MMR vaccine and autism
• Autism is not actually at all linked to MMR. Few years back, research
by one particular doctor misled the whole world about this. After
that, many researches were carried out, which clearly established
that there is no relationship between MMR and autism. Many
people who have not vaccinated their children because of this myth,
they have put their children at risk for developing MMR. The source

Dr MO SOBHY
of information you have is not an authentic one, internet is full of
false information, so I would highly recommend you to use NHS
links, patient.info whenever you need to look for an authentic
information about anything. Give her some leaflets right now.

• Other answer- The age usually Autism happens and when we need
to give MMR correlates that’s why many people got confused.
Delayed Walking

• I can see that you are really worried about this whole situation, but
it is very normal.
• Children at this age to develop their milestones differs at different
ages. Every children are unique on their own. Since you told your girl
has started walking and your boy has not started walking, it is
something very normal. I have assessed him and I do not expect any
problem to be there. There is an upper limit for each milestone to

Dr MO SOBHY
be achieved. In terms of walking, the upper limit is 18 months.
Since he is 15 months, let us wait until 18 months and then see
you again.
• I will give you some tips that you can use to encourage your son to
walk. They will really be helpful. Please do not use any walkers if you
are using. Walkers can be dangerous sometimes when they get
unplugged from the bottom they can really damage the legs of the
child and sometimes the child can have a fall with the walker as well.
• You can use some toddler trucks and he will hold the handles of the
toddler truck. The base of the toddler truck is quite heavy, usually it
does not lead to fall, it will encourage the child to fall. It will make
his leg muscles more active and then he will start walking more
quickly. Also, give him some tips like what he can do, please try to

Dr MO SOBHY
stand in front of him, encourage him to walk, make him sit in front
of you and then encourage him to stand.
• I will give you some reading material about the tips you can use to
encourage your child to walk
Haemangioma (Birthmark)

• Birthmarks can be anywhere, can be like patches can go away, like

salmon patch.
• I have noticed this mark on the leg of my baby. Can you tell me a bit
more? Alright, can you tell me more about this mark, exactly where
is it on right or left thigh? When did you notice it? Is it since birth or
have you noticed it now? Is it getting bigger? Have you noticed any

Dr MO SOBHY
bleeding or discharge? What is the size, shape, surface, consistency,
and if it gets stuck or entangled into the clothes. Have you noticed
one mark or are there multiple marks on the body. Have you noticed
any fever recently? Any rashes on the body?
• Examination – a red colored raised capillary haemangioma.
• This is basically a collection of blood vessels in specific area. Usually,
it disappears by itself after some time, some months or couple of
years. Please do not worry about it because it is present on the leg
and it is not troubling him at the moment.
• Treatment of Birthmarks - Most birthmarks do not need treatment -
Can be removed under NHS referral if affecting health (can be
present inside lungs, ask about cough or SOB), but not for cosmetic
reasons.
• Red Flags - If worried about a birthmark - a birthmark is close to the
eye, nose, or mouth - a birthmark has got bigger, darker or lumpier -

Dr MO SOBHY
a birthmark is sore or painful - your child has 6 or more cafe-au-lait
spots - you or your child has a large congenital mole - The GP may
ask you to check the birthmark for changes, or they may refer you to
a skin specialist (dermatologist).
• Treatment - medicines – to reduce blood flow to the birthmark,
which can slow down its growth and make it lighter in colour - laser
therapy – where heat and light are used to make the birthmark
smaller and lighter (it works best if started between 6 months and 1
year of age) - surgery – to remove the birthmark (but it can leave
scarring)
MMSE

• Normal cognition or memory questions to check dementia:

• Have you had trouble recalling the names of the people who are
around you most of the time?
• Do you have trouble recalling any important meetings at all?
• Do you have trouble with recalling any important days which you
were always able to recall very well before, like any birthdays, any

Dr MO SOBHY
anniversaries or special days at all?
• Have you ever forgotten to turn off the stove in the kitchen?
• Have you ever forgotten your keys in the lock?
• Have you ever forgotten your way back home?
Dr MO SOBHY
• MMSE Level
• 24-30 Normal
• 20-23 Mild cognitive impairment
• 10-19 Moderate
• 0-9- Severe

Dr MO SOBHY
If everything is normal:
Try to maintain a diary, and this will help you recall things in a better
way or you can use some applications/games that can help boost your
memory. I will check those links and share with you. Over the NHS
email, send her leaflets on dementia.
If she says that someone assessed my MMSE and it was 19, then
definitely to send her to memory clinic.
Any patient with MMSE 0 to 23 will be sent to memory clinic.
BULIMIA NERVOSA

• CASE:
• A 24 Year old university student Tessa Robert, who lives alone had
been noticed by her mother to be intentionally vomiting. On further
questioning it is apparent that she has been intentionally vomiting
for the last 2 months and she has the perception of being
overweight and experiences intense guilt. She doesn’t have low

Dr MO SOBHY
mood nor thoughts of self-harm. On social history, does not drink
alcohol, no drug abuse, doesn’t have a partner. Menstruation is
regular.
• APPROACH:
• On assessment, BMI is 22  Assessment: Paraphrase and Explore the
vomiting. Duration, Frequency, Contents, Colour, On what occasions,
Blood in vomit, Triggers ( was it intentional) , any specific Timing e.g
after meal
• If Intentional,
• What triggers: Eating certain foods, thoughts 
• Mechanism of vomit:
• How do you vomit?- Do you use your hands? Do you use any
medications to cause vomiting? Do you take any medications to
cause diarrhea or make you pee?

Dr MO SOBHY
• Take focused hx:
• Ask about perception - shape and weight of her body?
• Questions about eating habit unavoidable urge to overeat? ( urge )
When you eat a lot, do you eat alone? (isolation) Immediately after
eating, do you feel a sense of relief? After that do you feel
disgusted? Because of that do you vomit? ( This question will decide
the nature of vomit)
• Exercise : Do you exercise regularly? How many times and how long?
What sort of exercises do you do?
• Psychopathology: Mood : Depressed mood Impaired concentration
Social withdrawal?
• DIFFERENTIALS: Malignancy TB Hyperthyroid Schizophrenia Pregnancy
Primary Ovarian failure PCOS rawal ( friends and social circle) Thoughts

Dr MO SOBHY
of self-harm
• EXAMINATIONS: Observation, BMI. Mouth (sore throat) , teeth, face
(parotid glands), hands (marks, colors formation)
• Dx: Bullimia
• People with this condition in their mind they may believe that they are
overweight or may be preoccupied with their body image and because
of this they may secretly binge eat ( eat large amounts of food) with a
loss of control over eating then try to get rid of the extra amount of
food in an unhealthy way by self-inducing vomiting or misuse
medications, weight loss supplements or by exercise.
• URGENT referral to Community Medical Health team
• Seen by- Eating disorder specialist
• Wait for blood test results in meanwhile to rule out anything else-
Blood works including K+. TFT, Kidney functions Self-help
programme

Dr MO SOBHY
• Advise: - Wash mouth with water after vomiting: do not brush -
Reduce laxative use: it doesn’t reduce calorie absorption

• Note: If BMI is LOW – Anorexia Nervosa

URINARY INCONTINENCE

• Background:
• Scenario 1: Young woman having incontinence for 2 to 3 months on
coughing sneezing and laughing, works as teacher and is bothered
by smell of urine, has 5 children via normal vaginal delivery – [Stress
Incontinence]
• Scenario 2: Elderly woman needs to rush to toilet, LMP 9 years ago,
has 4 children - [Urge Incontinence/Overactive bladder

Dr MO SOBHY
• SPECIFIC HISTORY
• Establish the nature of the problem: What do you mean by
problems with urination? How long have you been having this
problem? How did it start? How often do you experience this? On
what occasions? Anything that brings it on? Cough, sneezing, effort
or exercise? Is there any continuous leakage? How much volume
would you say it is? is the volume increasing? Any other symptoms?

Dr MO SOBHY
Frequency? nocturia? Any difficulty with voiding? Post voiding
dribbling? UTI: Pain? Burning? Vaginal discharge? Dyspareunia? Any
Blood in urine?
• MAFTOSA: history of gynecological procedures, LMP, medication:
diuretics, antihistamines
• Effect of symptoms: mood, sleep, sexual life, work?
• DIFFERENTIAL DIAGNOSIS
• Stress incontinence: leakage of small amount of urine without
warning, on coughing or laughing throughout the day
• Causes: weakness in pelvic floor due to childbirth, pregnancy,
obesity, constipation, menopause, family history, smoking, ACE-I
(Cough)

Dr MO SOBHY
• Urge Incontinence/overactive bladder: Immediate need to rush to
the toilet
• Causes: idiopathic, DM, chronic UTI, neurological problems e.g., MS
and Parkinson’s, Pelvic trauma, carbonated drinks, alcohol,
medication: anti-depressants and hormone replacement
• Overflow Incontinence: Constant dribbling at day and night
• Causes: Constipation
Dr MO SOBHY
Leg pain intermittent claudication. PAD
• Approach:
Any pain station, always ask SOCRATES
• Ask trauma hx? Which leg? Shiny legs? Sensation? Skin color>? Hair
loss? Trigger? Worsens on walk? Better on rest? Resting pain? Risk
factors? Smoking? Calf pain? Chest pain? Dizziness? Leg ulcers?
Diabetes? Family hx? Ask lifestyle? DESA? MAFTOSA
• Mx:
• eat a healthy diet

Dr MO SOBHY
• lose weight, if you're overweight or obese
• moderate your consumption of alcohol
• Stopping smoking
• Getting started with exercise.
• Medication- cilostazol, clopidogrel, atorvastatin,
• Refer to vascular surgeon- Doppler scan- if needed surgery.
• Angioplasty
• Safety net
Seborrheic Keratosis
• Take hx of lesion? Have you noticed any changes in color or nature
of the lesion (itching or bleeding) Any recent weight loss, night
sweats, any swelling in any part of the body MAFTOSA (any family
history of skin related issues) SNAPS (smoking, nutrition, alcohol,
physical activity, stress? Mood? Psycosocial? Always ask
• STI- Snake bite? Sun exposure? Trauma? Infections.
• It looks like a mole, it is blackish brownish in appearance and it seems raised
above the skin. I can appreciate that there are multiple colours inside and

Dr MO SOBHY
you have told me it has recently increased in size. Normally, you don’t send
the patient to the dermatologist if you are 100% sure that there is no
cancerous element in it. Sometimes, very rarely, these lesions can go on to
be cancerous. By NHS, if you see that there are at least two to three new
changes in the lesion, then you send the patient to dermatologist. For us,
even if this patient is coming without a change, we should refer, because it is
only on the basis of dermoscope that we can say if this lesion is benign or
not. When we know a particular type of lesion can become cancerous, and
we do not have a dermoscope, please send the patient to the dermatologist
within two weeks’ time. Let it be seen by dermatologist under the
dermascope.
• On naked eye examination of a skin lesion we see ABCDE
• A-Asymmetry B-Borders C-Color D-Diameter E-Elevation above skin
Management: You seem to be having a condition called seborrheic
keratosis. It is a benign condition and it is very common as well in
your age group and white skinned people. You have been having it
for a long time and recently you have noticed change in size. I am

Dr MO SOBHY
not able to appreciate any change in color in the picture, so I would
highly recommend that you go and see the dermatologist for this.
So, I would give you a two weeks’ time referral for that. What do you
think about it? The dermatologist will see it under dermascope,
might consider taking a sample as well. If patient asks what can be
treatment. Well that is to be decided by the dermatologist, might go
for cautery or might go for excision of the lesion. Let them see under
dermascope and decide about it.
Telephonic Counselor change.

• Change the counselor,

• The lady has depression and on meds and counseling
• Sertraline for 2 years,
• But now stopped it by medical teams’ advice,
• Mood is fine,
• Wants a female counselor,

Dr MO SOBHY
• She fell in love with the counselor (man) and counselor has feelings as well
• She thinks it’s her fault,
• Now has relationship with the counselor.
• Thank her for discussing it with you
• This is a serious issue, I need to escalate to my senior
• Medical code of conduct broken
• You can complain to PALS
• We will arrange female counselor for you
• Ask if She was coerced into this relation