Você está na página 1de 231

A peek inside the GMC exam stations

KINDLY DO NOT PUT THESE NOTES ANYWHERE ON THE


INTERNET ESPCIALLY ON THE ONLINE FORUMS.

THE EXAM DETAILS THAT HAVE BEEN COLLECTED WITH


MANY EFFORTS PUT IN BY AN AWESOME DOCTOR,
WILL COMPLETELY GO TO WASTE.
THE GMC WOULD ALSO TRY AND CHANGE THE
FINDINGS OR EVEN THE QUESTIONS AND THE
PATTERN ITSELF, IF THESE NOTES ARE COMMONLY
PLACED ON THE INTERNET.
THESE NOTES WERE TYPED WITH THE INTENTION OF
HELPING OUT PEOPLE WHO HAVE ANY PROBLEMS
REGARDING COLLECTING ALL THIS DATA.
AGAIN HOPE YOU WILL ABIDE BY THE REQUEST MADE
ABOVE FOR THE SAKE OF THE DOCTOR WHO TAKES
THE PAINS TO CALL EVERY CANDIDATE WHO TAKES
THE EXAM, TO COLLECT THIS DATA.
IT WAS HIS WISH THAT THEY NOT BE PLACED ONLINE.

Plab 2 Topics
MEDICINE (Common Stations) History Taking
1) Chest Pain
Hx + D/D = PCP
Hx + D/D = ACS
Hx + Mx (with examiner) = ST Elevation MI
Hx + Mx (with examiner) = ACS
2) Fever
Hx + Ix + Dx = Pneumonia
Hx+ D/D = Malaria
3) Dry Cough
Hx = TB
4) Abdominal Pain
Hx+ LFTs report = Viral hepatitis
5) Wheeze only
Hx = Asthma
6) Headache
Hx + Dx = Giant cell arteritis
Hx + Mx (with patient) = Subarachnoid hemorrhage
Hx + D/D + Dx (w examiner) = Migraine
7) Red Eye
Hx + Mx (w. examiner) = Acute close angle glaucoma
8) Knee pain
Hx + D/D = Reactive arthritis
9) Hemoptysis
Hx + D/D = Lung CA
10)Diarrhea
Hx + D/D = Acute viral gastroenteritis
Hx + D/D = CA Bowel

11) Constipation
Hx + D/D = Drug induced constipation
Hx + D/D = CA Bowel
12) Weight Loss
Hx + D/D = Hyperthyroidism
Hx + D/D = Amenorrhea/Anorexia Nervosa
13) Calf Pain
Hx + D/D = Chronic Limb Ischemia
14) Dizziness
Hx + D/D = Benign Positional vertigo
15) Fall
Hx + Mx (w. examiner) = Non accidental injury
Hx + Cx = Hypothermia
Hx + D/D = Postural hypotension due to meds
16) Unconscious/head injury
Hx + Fx (from examiner) + Mx (with examiner) = Hypoglycemia
(induced by alcohol) leading to the loss of consciousness
17)Diplopia
Hx + D/D = Muscle palsy of right lateral rectus
18) Sore throat
Hx + D/D = Infectious Mononucleosis
19) DKA (Pilot station)

Hx = History D/D =Differential diagnosis Inv = Investigations Cx = Councelling Mx =


management Fx = Findings

Pattern of History Taking


This pattern has to be followed in all stations and the
findings in most, (as given by the patients in exam) are
given. Always take a complete history unless its a
councelling station in which it has to be brief. Rule out D/Ds
in all stations after presenting complaint has been
explained. Start all stations by introducing yourself as given

in the task and confirming patients identity as given in the


task as well.
P3 MAFTOSA
P = Presenting Complaint (ODIPARAA or Socrates if pain)
[Onset, duration, intensity, progression,
aggravating/relieving factors, radiation, associated
symptoms/ anything else]
P = Past history
P = Personal history
M = Medical history/ Surgical history
A= Allergic history
F = Family history
T = Travel history
O = Occupational history
S = Sexual history
A = Anything else

In female stations and gynae & obs


4 Ps are added in the above history pattern
Pills, pregnancy, periods & pap smear

Station 1 (Chest pain) PCP


25 yr old man with chest pain. Talk to the patient and
discuss D/D with examiner.
Fx on Hx taking
1.
2.
3.
4.
5.
6.
7.
8.

Fever since 1 month


Chest pain 3 weeks
Slight SOB especially when going upstairs
C/o cough
Unprotected sex 2 weeks ago
No discharge from urethra
Not in a stable relationship
Homosexual

D/Ds to rule out:


1. PCP (Hx of sexual intercourse/homosexual)
2. ACS (Chest pain + ECG changes)
3. Angina (pain lasting less than 30 minutes but radiating
to left arm/jaw)
4. Pericarditis (Pain relieved on bending forward)
5. Dissected abdominal aorta (Pain going to the back)
6. Pulmonary embolism (Hx of prolonged immobilization,/
Hx of travelling to New Zealand/ Hx of OCPs in females)
7. Pneumonia (Fever + cough + family history positive)
8. URTI (Hx of ear ache, sore throat, flu like symptoms)
9. Pneumothorax (Hx of trauma)
10.Esophageal spasm
11.Trauma

Station 2 (Chest pain) ACS


40 yr old man with chest pain. Talk to the patient and
discuss D/D with examiner.
Fx on Hx taking
1.
2.
3.
4.
5.
6.
7.
8.
9.

Chest pain 45 minutes


Heavy pain like someone sitting on my chest
Pain radiating to left arm and jaw
Smoking since he was 20
Drinks occasionally
On antacids since last few years
No fever and no cough
No unprotected sex
Married man
Lying on couch and talks almost comfortably
Please ask if you have received any medicines
including pain killers. If not, offer some. Dont talk to
examiner before 4: 30 bell. Fill up the time by
summarizing your findings. Dont forget to rule out
D/Ds and finish p3 maftosa before telling examiner
the D/D.

D/Ds
1.
2.
3.
4.
5.
6.

ACS (Chest pain + ECG changes)


PCP (Hx of sexual intercourse/homosexual)
Angina (pain lasting less than 30 minutes)
Pericarditis (Pain relieved on bending forward)
Dissected abdominal aorta (Pain going to the back)
Pulmonary embolism (Hx of prolonged immobilization,/
Hx of travelling to New Zealand/ Hx of OCPs in females)
7. Pneumonia (Fever + cough + family history positive)
8. URTI (Hx of ear ache, sore throat, flu like symptoms)
9. Pneumothorax (Hx of trauma)
10.Esophageal spasm (Associated with food intake)
11.Trauma

Station 3 (Chest pain) ACS


60 yr old man with chest pain. Talk to the patient and
discuss Mx with examiner.
Fx on Hx taking
1. Patient is lying on the couch and is talking
uncomfortably and is sweating.
2. Pain radiating from chest to left jaw
3. Patient is a smoker + takes alcohol
4. ST elevations on ECG given
Mx of the patient!
a. Admit the patient (Very imp*)
b. Give Morphine (iv), Oxygen, Nitrates, Aspirin
(MONA)
c. Keep monitoring patients ECG every 15 to 30
minutes according to hospital guidelines.
d. Do cardiac enzymes after 6 hrs of onset of
pain.
e. If enzymes are normal, maybe repeated according
to consultant advise.
f. If enzymes negative twice, consultants decision to
discharge or not.
g. If enzymes positive, mention consultants
decision to go for thrombolysis or PCI
(percutaneous coronary intervention).

Station 4 (Chest pain) ACS


30 yr old man with chest pain. Talk to the patient and
discuss Mx with examiner.
Fx on Hx taking
1.
2.
3.
4.
5.

Patient lying down almost comfortably


Heavy chest pain since 2 hrs
Radiating to arm and jaw
Smoking and drinking since 20 yrs
ECG is normal.
Mx of the patient!
a. Admit the patient (Very imp*)
b. Give Morphine (iv), Oxygen, Nitrates, Aspirin
(MONA)
c. Keep monitoring patients ECG every 15 to 30
minutes according to hospital guidelines.
d. Do cardiac enzymes after 6 hrs of onset of pain.
e. If enzymes are normal, maybe repeated according
to consultant advise.
f. If enzymes negative twice, consultants decision to
discharge or not.
g. If positive, consultants decision to go for
thrombolysis or PCI (percutaneous coronary
intervention).
Learn to identity and pick up myocardial infarctions on
ECGs of different cardiac walls.

Station 5 (Fever) Pneumonia


Young man presented with fever. Temperature is 38.5
degrees. On auscultation, right basal crackles. Talk to
patient. Take Hx and discuss D/D and investigations with
examiner.
Fx on Hx taking
1.
2.
3.
4.
5.

Had fever (intermittent) since 2 weeks


Cough associated with green phlegm
10 people at work place with the same symptoms
Himself is a soldier and lives in a camp
Blanket sometimes available which you can offer
to the patient or he already has it on.

3 important investigations!
1. Full blood count
2. Sputum culture
3. Chest X ray
D/Ds
1. Pneumonia
2. URTI
3. Sinusitis
4. TB
5. Otitis media
6. Meningitis
7. Gastroenteritis
8. Hepatitis
9. Urinary tract infection

Station 6 (Fever) Malaria


25 year old girl with fever. Talk to patient. Discuss Dx with
examiner.
Fx on Hx taking.
1. Fever (comes and goes)
2. Travelled to Africa/ Ghana/Kenya recently
3. Received malaria prophylaxis before going. Despite
that, the Dx is still Malaria in this case.
If the patient is shivering in this station and a blanket is
available, offer it.
D/Ds to rule out
1. Malaria
2. Typhoid (Tummy pain, continuous fever, GI
symptoms)
3. UTI
4. Pneumonia
5. TB
6. Meningitis

Station 7 (Dry cough) Tuberculosis


28 year old presented with complaints of dry cough. Talk to
the patient and discuss D/D and investigations with the
examiner.

Fx on Hx taking.
1.
2.
3.
4.
5.
6.
7.

Weight loss present


Night sweats
No positive sexual history
No iv drug abuse/ no tattoos
No sputum
No family member has it
No travel history

Investigations
1. Bronchoscopy and lavage
2. Chest x ray
D/Ds
1. TB
2. Asthma
3. COPD
4. PCP
5. ACE inhibitors intake
6. URTI
7. Allergy
8. Cardiac asthma
9. Atypical pneumonia

Station 8 (Abdominal Pain) Viral Hepatitis


A 45 year old man/lady with c/o right upper quadrant pain.
Talk to patient. Interpret LFTs and discuss Dx with the
examiner.

ALT and AST are raised in Viral hepatitis


GGT is raised in alcoholic hepatitis
ALP is raised in obstructed jaundice (gall stones
obstructing CBD or CA head of pancreas)
Fx on Hx taking:
1.
2.
3.
4.
5.
6.

RUQ pain since last few days


Low grade fever
Hx of RTA (Received blood)
Surgical history of laparoscopic cholecystectomy
No alcohol history
No sexual or IV drug abuse history

D/Ds to rule out:


1. Viral hepatitis ( Blood transfusion history, sexual
history, yellowness of eyes, iv drug abuse)
2. Alcoholic hepatitis
3. Acute cholecystitis ( Pain increased with fatty meals
intake. Pain radiating to the shoulder)
4. Cholangitis ( fever + jaundice + rigors/chills)
5. Biliary colic ( Pain to back which comes and goes)

Station 9 (Wheeze) Asthma


28 year old man comes with complaints of wheeze. Talk to
patient and take history.
Fx on Hx taking:
1.
2.
3.
4.

2 yrs ago had similar symptoms and went to see the GP


Needs inhalers
Wheeze when playing
Hay fever present
D/Ds to rule out
1. Asthma
2. URTI
3. Allergy and hay fever
4. Pneumonia
5. Cardiac asthma

Station 10 (Headache) Giant cell arteritis


80 year old lady presented with headache. Talk to patient
and discuss Dx with examiner.
Fx on Hx taking:
1.
2.
3.
4.
5.

Pain is all over the head


Pain scored between 7/10
More over temple area
Pain more on combing hair
Not associated with chewing

Note: Double/triple sympathy when elderly patients. Dont


rush the station. Talk slower.
D/Ds to rule out:
1. GCA
2. Subarachnoid hemorrhage
3. Migraine (Family hx positive, has been there for yrs)
4. Glaucoma (pain behind eyes, watering of eyes)
5. Space occupying lesion (focal deficits/weakness in
body, vomiting, vision probs)
6. Tension headache (Band like headache)
7. Cluster headache (Red, watery eyes)
8. Trauma

Station 11 (Headache) Subarachnoid


Hemorrhage
25 year old man/lady with headache. Known case of
migraine. On zolmitryptine. Discuss Mx with patients.

Fx on Hx taking:
1.
2.
3.
4.
5.
6.
7.
8.

Pain all over the head.


Pain starts from the back of head (some cases)
Most severe pain ever experienced.
Pain scored 9/10
Covers eyes (photophobia)
K/c of migraine
Family history of migraine positive
No rash. No fever. No red eyes. No vomiting. No hx of
trauma.

Note: All 3 stations of headache, talk about pain killers and


offer dimming the lights. Rule out D/Ds when taking
complete history.
Mx:
From what you have told me, I suspect SAH which is
bleeding in your brain. It is like a stroke. In order to confirm
my diagnosis, Ill have to do a CT scan to confirm any bleed
in your brain and if there is, we will need to see how much
and the site of bleeding. When we confirm our diagnosis, we
will refer you to the neurosurgery team. Theyll probably go
for surgery. We may give you some meds in the mean time
to decrease the pain. (Ca channel blockers are given
(nimodipine)

Station 12 (Headache) Migraine


18 year old with presenting complaint headache. Talk to
patient and discuss D/D and Dx with examiner.
Fx on Hx taking:
1. Girl covers her eyes by her hand
2. Severe pain since this morning
3. Family history positive. Mom has the same kind of
headaches
D/Ds
1. Migraine
2. GCA
3. SAH
4. SOL
5. Meningitis (neck stiffness, fever, vomiting)
6. Glaucoma
7. Cluster headache/tension headache
8. Sinusitis

Station 13 (Red Eye) Acute close angle


glaucoma
55 year old lady with red eyes (will be wearing sunglasses
which you cant ask to remove) and pain in the head. Talk to
patient and discuss Mx with the examiner.
Fx on Hx taking:
1.
2.
3.
4.
5.
6.

Red eye since last few days


Patient has a headache
Sometimes indicate it to be over the temporal area
No c/o pain at the back of eyes
Patient is on amytrptine
Ask her if she sees haloes around light.

D/Ds to rule out:


1. Glaucoma
2. Conjuctivitis (sticky discharge)
3. GCA (pain on chewing/combing)
4. Foreign body
5. Sinusitis
6. Uveitis
7. Allergy
8. Reiters syndrome
9. Cluster headache
Mx:
Consider giving 3 drops
1.
2.
3.
4.
5.
6.

Pilocarpine (causes pupil constriction)


Beta blockers (Timolol) (Decreases fluid in the eye)
Steroids (reduces inflammation)
Inj acetazolamide
IV mannitol (works like beta blockers. Decreases fluid)
Refer this patient to ophthalmologist who may do
slit lamp examination or gonioscopy and confirm
the diagnosis. If so, they may go for surgery or
laser treatment.

Station 14 (Knee Pain) Reactive arthritis


A young man 28 yrs old, comes to hospital with knee pain.
Talk to patient. Discuss D/D with examiner.
Fx on Hx taking:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Had knee/ankle pain since last week


No pain in small joints
Morning stiffness (patient says he thinks so)
Calf pain (patient says he thinks so)
Got watery eyes
Travel history to France
Diarrhea in France destroyed his holiday there
No sexual history
No burning micturition. No urethral discharge. No fever.

D/Ds:
1. Reactive arthritis
2. Reiters syndrome (Sexual history positive, joint pain,
eye and urethral discharge)
3. Hemarthrosis
4. Rheumatoid arthritis
5. Osteoarthritis
6. Gout
7. Septic arthritis (Fever, joint swelling/pain)
8. Sport injury or trauma

Station 15 (Hemoptysis) Lung CA


60 year old lady presented with hemoptysis. Talk to the
patient. Discuss diagnosis with the examiner.
Fx on Hx taking:
1.
2.
3.
4.

Blood in sputum in last 8 weeks


Sputum quantified and would be filling up to half a cup
Smoking since was 20 yrs old
Weight loss and fever (+-)
Note: Always assess anemia in case of any bleed.
Check if patient is lethargic or feels too weak to go
about doing daily chores. Or gets short of breath easily.

D/Ds to rule out:


1. Lung Carcinoma
2. Pulmonary embolism
3. TB
4. Pneumonia
5. COPD
6. Bronchiectasis

Station 16 (Diarrhea) (Acute) Viral


Gastroenteritis
A 60 yr old lady presented with diarrhea. Talk to patient and
discuss D/D with examiner.
Fx on Hx taking:
1.
2.
3.
4.
5.

Watery diarrhea
Vomiting present
+-Fever
Patient was staying in a hotel
Her friends had similar symptoms
Note: Sympathize extra with the elderly. Ask if the
patient can take fluids and diet without throwing up. If
not, admit the patient. Ask if he/she is too lethargic or
feels too weak. If abdominal pain, offer pain killers.
Always assess dehydration in case of diarrhea.
D/D:
1. Acute gastroenteritis
2. Bowel CA (*MUST RULE OUT)
3. Travelers diarrhea (Diarrhea will be while on
vacation)
4. Pseudo membranous colitis (If antibiotic intake
history)
5. Infective (Bacterial) diarrhea (Blood or mucus in
stools)
6. Laxative abuse (Take medical history)

Station 17 (Diarrhea) Bowel carcinoma


40 year old man with chronic diarrhea. Talk to patient and
discuss D/D with the examiner.
Fx on Hx taking:
1.
2.
3.
4.
5.
6.
7.
8.
9.

1 stone weight loss


No tummy pain
No fever
No tummy pain
Blood in the stools
No family history of bowel carcinoma
Smoker
No positive sexual history
No mouth ulcers/ No skin changes

D/D:
1. CA bowel
2. G/E
3. IBD (fever + tummy pain)
4. Irritable bowel syndrome
5. Malabsorption
6. DM
7. Hyperthyroidism
8. HIV
9. Lactose intolerance

Station 18 (Constipation) Drug induced


(cocodamol) constipation
80 year old lady with constipation. Talk to patient and
discuss D/D with the examiner.
Fx on Hx taking:
1. Pain in ankle
2. GP prescribed cocodamol
3. Ask for medical history. She maybe carrying it with her
or remember the name of the drug she is taking.
D/D:
1) Drug induced constipation
2) Bowel Ca
3) Diabetic neuropathy
4) Hypothyroidism
5) Low fibre diet
6) Intestinal obstruction
7) Back injury
8) Fecal impaction

Station 19 (Constipation) Bowel Carcinoma


75 year old patient, admitted in hospital and constipation is
present. Talk to nurse and discuss D/D with examiner.
Fx on Hx taking:
1.
2.
3.
4.
5.

Constipation since 2 months


Family history of bowel CA
No weight loss
Bleeding in stools present
Tenesmus, tummy pain, altered bowel habits (+-)

D/D:
1) Bowel Ca
2) Diabetic neuropathy
3) Hypothyroidism
4) Low fibre diet
5) Intestinal obstruction
6) Back injury
7) Fecal impaction
8) Drug induced constipation

Station 20 (Weight loss) Hyperthyroidism


20 year old lady with weight loss. Talk to the patient and
discuss D/D with the examiner.
Fx on Hx taking:
1. 2-3 kgs weight loss in last 2 months
2. She feels hot
3. Sister has the same symptoms
Note: Always ask for weather preference when
suspecting hyperthyroidism.
D/Ds:
1. Hyperthyroidism
2. Anorexia Nervosa
3. Malnourished
4. Malabsorption
5. IBD (fever + tummy pain +diarrhea)
6. IBS
7. Malignancy
8. TB

Station 21 (Weight loss) Anorexia Nervosa


20 years old lady with amenorrhea. She also had weight loss
in the last few months. Talk to patient and discuss D/D with
the examiner.
Fx on Hx taking:
1. No periods in last 8 months
2. Boyfriend dumped her because he thought she was
chubby
3. 6 kgs weight loss over the past few months.
4. No heat/cold intolerance
5. No facial hair/ no acne
6. Periods were normal before
7. Diet according to her is normal and nothing is wrong
but dig into it.
8. Takes thyroxine (abuse it) to lose weight as well
D/D:
1. Anorexia Nervosa (clever bmw) (Clothing baggy,
laxative abuse, excessive exercise, induced
vomiting, excessive wt loss, role models are thin
people, body image etc)
2. Malnutrition
3. Malabsorption syndrome
4. IBD
5. IBS
6. TB
7. Hyperthyroidism
8. Depression

Station 22 (Calf Pain) Chronic Limb Ischemia


45 year old patient with pain in the calf. Talk to the patient
and discuss diagnosis with examiner.
Fx on Hx taking:
1.
2.
3.
4.

Pain in last few months, relieved at rest.


Smoking in last 20 years.
DM +ve (not controlled)
Sedentary life style/ no healthy diet

D/Ds to rule out:


1. Chronic limb ischemia (due to atherosclerosis)
2. DVT (Any hotness in calf along with pain, travel hx)
3. Burgers disease (smoking history, pain not relieved at
rest)
4. Ruptured Achilles tendon (Can you stand on your
toes?)
5. Sports injury
6. Ruptured bakers cyst (Any sort of joint disease?)
7. Sciatica (Pain radiating from back to leg)

Station 23 (Dizziness) Benign positional


vertigo
70 years old lady with dizziness. Talk to patient and discuss
D/D with examiner.
Fx on Hx taking:
1. Had the same S/S previously.
2. Was taking stamatil, prescribed 3 weeks ago by GP
3. Patient stopped meds because of side effects (e.g.
headache, drowsiness)
4. Stopped meds last week
5. Dizzy especially during morning while changing dress
6. No bells ringing sensation in ears/ no fever.

D/D:
1. BPV (especially on tilting or change of position of head,
loss of balance, vomiting/nausea)
2. Minneres disease (bell ringing sensation)
3. Acoustic neuroma (weight loss, loss of balance)
4. Multiple Sclerosis (difficulty & weakness in moving
limbs)
5. DM
6. Migraine
7. Otitis Media
8. Drugs e.g. Gentamicin

Station 24 (H/O fall) Non Accidental injury


85 yrs old lady brought in by 60 yrs old daughter. On
examination, she notices bruise on arm and forehead. Please
talk to daughter and discuss management with the
examiner.

Elaborate the event. Find out if story matches with the


injuries or not.
What was done immediately after the event?
Who takes care of the patient?
Is there any previous incidence of the sort/ any
previous injury that lead to hospitalization?
Any injury with no record in the hospital?
Fx on Hx taking:
1. Daughter said she fell down on the radiator
2. She brought mum 2 to 3 hrs after the incident. No
valid explanation for bringing her late.
3. She is not sure about moms medical illnesses. She
says mom is old and hence has many problems
4. She informs that mom is taking many meds but not
sure what they are.
5. Mom lives with this daughter who is her caretaker.
D/Ds to rule out:
1.
2.
3.
4.
5.
6.
7.
8.
9.

NAI
Osteoporosis
Osteoarthritis
UTI/Pneumonia in elderly
DM
Refractory error
TIA
SAH
Hypoglycemia/alcohol/
dehydration/arrhythmias/vasovagal syncope/Adrenal
insufficiency

Mx:
I will admit my patient. I am suspecting NAI (non
accidental injury) or elderly abuse as the history given does
not justify or go with the injuries of the patientbut it could
be accidental as well. Daughter seems to be careless about
mom and shes the only one taking care of her. I will discuss
and confirm this case with my seniors, who may involve
social services accordingly. I will order a skeletal survey
further if advised by my seniors.

Station 25 (H/O fall) Hypothermia


80 years old lady brought by her son. Rectal temp 34
degrees. Talk to the patients son. Give necessary advise.
Fx on Hx taking:
1. Son found mom lying on the floor but he doesnt
know the cause.
2. Mom lives alone by herself
3. Son visits once or twice per week
4. Neighbor and friends check on mom now and then
5. (+_) history of DM, osteoarthritis, hypertension)
6. Son informs that mom is becoming forgetful lately.
7. Central heating is on but mom could forget to pay
the bill so son pays now.
8. She forgets to close the windows now which the son
found open.
D/Ds to rule out:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Hypothermia
Osteoporosis
Osteoarthritis
UTI/Pneumonia in elderly
DM
Refractory error
TIA
SAH
Hypoglycemia/alcohol/
dehydration/arrhythmias/vasovagal syncope/Adrenal
insufficiency/NAI
Cx:
From what you have told me, your mom has got a
condition that we call hypothermia, which can be
dangerous if left untreated especially at her age. It may
affect organs, lead to confusion and may even affect
fine movements of hands and limbs. I am sure you do
your best and have done your best until now regarding
taking care of her but would you like to share this
respeciallyonsibility so she is better taken care of?
There are people who can be assigned for her care. Or

generally advise him to ask the neighbors and friends


to drop in more often to check up on her, if the house is
warm and windows are closed

Station 26 (H/O fall) Postural hypotension


due to medication
60 yrs old lady presented with history of fall. Talk to the
patient and discuss D/D with the examiner.
Fx on Hx taking
1.
2.
3.
4.

This patient is on anti hypertensives since 20 yrs


Patient went to GP
GP reviewed the doses two weeks ago.
Patient then developed the complaint of falling.

D/Ds:
1. Postural hypotension due to meds
2. NAI
3. Osteoporosis
4. Osteoarthritis
5. UTI/Pneumonia in elderly
6. DM
7. Refractory error
8. TIA
9. SAH
10.Hypoglycemia/alcohol/
dehydration/arrhythmias/vasovagal syncope/Adrenal
insufficiency /Hypothermia/head injury/ epilepsy

Station 27 (Unconscious) Alcohol induced


hypoglycemia
A young man fell down in front of the pub and went
unconscious. Talk to the patient. Ask about fx from the
examiner and discuss Mx with the examiner.
Fx on Hx taking:
1. Patient was drunk
2. He went dizzy and fell down and cant remember what
happened after that.
3. No DM hx
4. No previous cardiac condition
5. Duration of unconsciousness = 2 to 3 minutes
6. No fever, no rash, no photophobia
7. No jerky movements of body
Fx from examiner:
1. GCS 15/15
2. No focal/neurological deficit.
D/Ds to rule out:
1. Hypoglycemia induced by alcohol, leading to the
unconsciousness/fall.
2. Head injury (ENT Bleed, vomiting)
3. Epilepsy (Prev hx of fits)
4. A Fib
5. Poisoning
6. Meningitis
Mx:
I will admit this patient. I will check for his random blood
sugar, send for a full blood count and do a 24 hrs ECG
monitoring while doing neuro observation. Ill do CT
scan if necessary as well, having informed my seniors.

General Knowledge regarding head injuries

(Indication for admission in head injury)


1) LOC
2) GCS less than15
3) Amnesia
4) Any focal, neurological deficits
5) Vomiting
6) Altered bowel habits
7) NAI

NICE guidelines for CT Scan in patients


1) Loss of consciousness> 5 minutes
2) GCS < 14 after admission
3) In peds, GCS < 15
4) Any S/S basal/skeletal fracture
5) Vomiting > 3 times in kids and < 2 times in adults
6) Any focal or neurological deficit
7) Amnesia > 5 minutes
8) Any laceration > 5 cm on the head.

Station 28 (Diplopia) Muscle palsy of right


lateral rectus
47 yrs old lady comes with c/o diplopia. Talk to patient and
discuss D/D with examiner.
Fx on Hx taking:
1. The patient is a teacher by occupation.
2. When writing on the board, sees double on the right
side
3. Few months ago, while reversing her car, hit bumper on
the wall due to double vision.
4. Doesnt wear glasses
5. No headache, no vomiting
6. No S/S of hyperthyroidism, SOL, MS
D/Ds
1. Muscle palsy of right lateral rectus
2. Multiple sclerosis
3. GCA
4. SOL
5. Cataract
6. Hyperthyroid
7. Inflammatory orbit myositis
8. Refractory error
9. Myasthenia gravis

Station 29 (Sore Throat) Infectious


Mononucleosis
25 yrs old man presented with c/o sore throat. Talk to the
patient and discuss D/D with the examiner.
Fx on Hx taking:
1.
2.
3.
4.
5.
6.
7.
8.

Fever in last few days


Reddish and itchy rash on the chest
Travelled to Rome 2 weeks ago
No difficulty in swallowing
No vocal abuse
No instrumentation
No weight loss
Not sexually active/Protected sex

D/D:
1. Infectious mononucleosis
2. Mumps
3. Vocal abuse
4. Smoking
5. Carcinoma
6. Hay fever
7. Tonsillitis
8. URTI

Station 30 (DKA) Pilot Station


35 yrs old lady with p/c vomiting, diarrhea and abdominal
pain. She is a known case of DM. She missed insulin dose.
Dx of DKA has been made. Talk to the patient and explain
the condition and importance of admission and address her
concerns.

Fx on Hx taking
1. Dr, I have DM + vomiting + tummy pain.your colleague
did some blood tests and put IV cannula on my hand.
2. I have two kids waiting at home. Her partner is not
home as well.
3. On your disclosing the Dx, she asks whats DKA?
Tell her its a dangerous complication of DM caused by
lack of insulin in your body. It happens when body is
unable to use blood sugar because of deficiency of
insulin.
The body breaks down the fat as an alternative fuel.
This can build up substances we call ketones.
4. Why cant you send me home with IV fluids?
We have to keep you because we have to monitor you
and do investigations repeatedly. We have to check
your blood for blood sugar levels and for other
substances in the blood (Potassium). We also have to
check your urine for some substances and treat
accordingly. We may also need to give you different
fluids + minerals + insulin (which pushes sugar into
cells) until you are out of this condition. Its important
that we keep you in the hospital.
5. Ask her if there is someone who can take care of the
kids. Otherwise tell her you will talk to the consultant
and see if something can be done to either bring them
over for a while or if someone can be arranged to take
care for them at home. Ask their ages beforehand.
This patient fusses and insists a lot about wanting to go
home so take your time explaining her why she needs to be
kept in the hospital until 4 30 bell rings.

MEDICINE (Common Stations) Hx + Councelling

1) Sexually Transmitted illness


Hx + Cx
Cx
Only Hx (2 scenarios)
2) Osteoporosis
Hx + Cx (2 scenarios)
3) Stroke follow up
Hx + Cx
4) Post MI
Hx + Cx
5) Needle stick injury (2 scenarios)
6) Epilepsy
Hx + Cx
Cx
Hx + D/D
7) CKD
Hx + Cx
8) Paracetamol Poisoning
Hx + Mx (with patient)
9) Chronic Fatigue Syndrome
Hx + Cx
10)IV cannula blocked

Questions to ask in every STI station


1. How many partners do you have/had in the last few
months?
2. Do you use condoms (protection)?
3. Route of sex?
4. Your sexual partner is a male or female?
5. Previous STI?
6. Previous medical illness?
7. Any allergies to meds? (Always ask before prescribing
meds)
Symptoms you should ask

Fever
Dysuria
Eye symptoms
Knee joint pain/symptoms
Discharge from urethra
Ask if he noticed any ulcer, discharge, swelling or lump
in groin area.

Investigations:
1. Genital swab test
2. Complete Urine exam (Urine culture and sensitivity)
(chlamydia)
3. Blood test for HIV and Hepatitis
Tx:
Doxycycline 100mg BD for 1 week (1st line for Chlamydia)
Azithromycin 1g single dose given (1st line for Gonorrhea)
Ceftriaxone 500 mg single dose given

General Advise you need to give in every STI station:


1. Dont have sex even with condoms or protection.

2. Dont have sex until receiving a negative test result,


and until treatment is completed.
3. Even if sexual partner has no symptoms, the sexual
partner should be checked and treated accordingly.
4. Please ask the patient after any unprotected sex
outside his relationship, he had sex with his/her own
partner. If the answer is no, drop it.
If the answer is yes, ask if they can ask their partner to
come over to get checked and for any necessary
treatment. If the patient is unable to call them himself,
talk about partner notification program. (A program
that enables hosp to send anonymous letter to the
patients partner asking them to come in for a routine
special check up just for safety reasons).

Station 1 (STI)
55 yrs old man presented with discharge to your clinic. You
are SHO in the gum clinic. Talk to the patient and take Hx,
discuss investigations with patients (sometimes) or council
patient and address his concerns.
Fx on Hx taking:
1.
2.
3.
4.
5.

Came to London and had unprotected sex 2 weeks ago.


Yellowish discharge since 2 days
+- Fever
+- Burning sensation on passing urine
Had sex with the wife after the event

Cx:
From what youve told me, you have STI, which is an
infection that can pass from one person to another when
they have sex. I have to run some investigations. We do
Urine tests and we take a sample from discharge. Would
you like to have blood tests for HIV and Hepatitis just to be
on the safe side? We treat with medications (antibiotics)
which can clear this bug. This medication is given according
to test results, either in a single dose form or for one week.
Please dont have sex with your partner even with protection
(condoms) during this week until the test results come
negative.
Did you have sex with your partner after this event? Can you
ask your partner (wife) to come? Talk about PARTNER
NOTIFICATION PROGRAM otherwise. Explain how it is
important to treat the partner, otherwise it will remain
untreated and might spread from one person to another
during intercourse and can bring complications without
treatment.

Station 2 (STI)
Young girl 24 yrs old, comes to gum clinic with complaints of
discharge. She had unprotected sex 3 weeks ago when she
met her boyfriend. Now shes in the clinic to get her report of
investigations. He was in the clinic last week as well and
some investigations were done. Report shows she has
gonorrhea. Talk to the patient. (Take Hx and the fx are given
above)
Cx:
From the lab report, it shows you have STI. For treating the
bug that causes this condition, well give you a tablet or
injection that you can get here.
Give patient general advise about not having sex while
being treated and until tests are negative. Tell her the
importance of treating herself and getting her partner
treated as well. Tell her to complete her meds even if
symptoms subside.
If STI is left untreated, there are some complications e.g. you
may get PID (inflammation of tubes) and may face problems
when you get pregnant e.g. ectopic pregnancy (pregnancy
outside tubes) and premature baby. You may face
infertility and miscarriages are a complication of
untreated STI as well.
As a part of general advise, risk of STI will increase if you
dont practice safe sex and if you change sexual partners
often or have multiple sexual partners. So practice safe sex.

Station 3 (STI)
A 50 yrs old man travelled to Berlin. He had unprotected sex
with a girl. Take sexual history. You are the SHO in gum clinic.
Do not advise about HIV.
Fx on Hx taking:
1. I had sex while I was drunk. The condom slipped but I
continued.
2. Also had oral sex.
3. No fever, no discharge, no ulcer, no weight loss
4. Had sex in a legal area.
5. He had sex with wife after that day.
6. He claims to be committed to his wife and is a married
man.
Questions to ask in every STI stations
1. How many partners do you have/had in the last few
months?
2. Did you use condoms (protection)?
3. Route of sex?
4. Your sexual partner is a male or female?
5. Previous STI?
6. Previous medical illness?
7. Any allergies to meds? (Always ask before prescribing
meds)
Symptoms you should ask

Fever
Dysuria
Eye symptoms
Knee joint pain/symptoms
Discharge from urethra
Ask if he noticed any ulcer, discharge, swelling or lump
in groin area.

Station 4 (STI)
A young lady comes to gum clinic. Talk to patient and take
sexual history. Assess for any possibility of STI.
Fx on Hx taking:
1. On being asked what brought her to the clinic,
patient says her husband told her that he had sex
a month ago, with another girl.
2. He was drunk and says cant remember if used
protection or not.
3. She had sex with him a few times after that event.
4. The route of sex was vaginal and sex was
unprotected between the husband and wife.
5. No discharge or fever. No eye or knee probs.
6. Both of them were symptom free.
7. If she asks, will you do any tests for me, tell her
yes but you would like to first ask her a few more
questions and take a detailed history.

Station 5 (Osteoporosis) 47 yrs old patient


General knowledge regarding osteoporosis
Dexa Scan
Less than -2.5 = Osteoporosis
-1.5 to -2.5 = Osteopenia
Greater than -1.5 = Normal
Risk factors:

Hx of prev wrist/hip fracture.


Any parental Hx of osteoporosis
Any osteoarthritis
Alcohol > 4 units per day
Steroid intake
There are chances of low bone density in Crohns
disease, ankylosing spondylitis or OA. Also with BMI
<13.5, there are greater chances of Osteoporosis.

Tx:
Less than 50 yrs = Hormone replacement therapy and
Bisphosphonates.
50-70 years (dexa +ve + 1 risk factor present) =
Bisphosphonates
Greater than 70 yrs (dexa +ve + 2 risk factors present) =
Bisphosphonates
Hx taking (Take the whole P3 MAFTOSA)
1.
2.
3.
4.
5.
6.
7.

Inquire age of the patient


Any medical illness/ Prev surgical history
Any medications being taken
Alcohol and smoking history
Parental and family history
Diet/Exercise Hx
Ask patients knowledge about symptoms after grips
(introducing yourself etc) and then disclose the

condition or diagnosis that she has a disease that


causes thinning of bones.
8. Explain and address concerns or discuss management
as asked.

47 yrs old lady/man presented to clinic. Dexa scan has been


done and Dx of osteoporosis was confirmed. You are SHO in
the medical dept. Talk to the patient and address patients
concerns.
Ask patient to briefly elaborate her symptoms and ask if she
knows what she might be having. Take the history and ask
the questions especially the ones mentioned above. Then
disclose that she has been diagnosed with a disease called
osteoporosis in which thinning of bones occur. She will ask
why she got it and what are you going to do for her. The
conversation below will show the answer given by the
patient in this station.
I would like to ask you a few questions and hopefully with try
to find a cause. Whats your age? 47 yrs. Any medical illness?
No I am fine. Are you taking any medications? Just
paracetamol sometimes. Do you take alcohol? No.
Appreciate the fact that she doesnt (Thats good to know).
Do you smoke? No I hate smoking (Thats nice to hear how
you have such healthy habits). Have your parents got a
condition called Osteoporosis? No. Your diet? Are you taking
enough dairy products? How about exercise? Any prev
fracture? Patient will respond with having healthy habits. Any
prev surgery? Yes my womb was removed when I was
35.
Address patients concerns at every point and here the cause
was due to loss of hormones due to the hysterectomy done.
Do not go on talking and let patient get her answers from
you. Talk about HRT and Bisphosphonates.

Station 6 (Osteoporosis) 57 yrs old patient


57 yrs old lady/man presented to clinic. Dexa scan has been
done and Dx of osteoporosis was confirmed. You are SHO in
the medical dept. Talk to the patient and address patients
concerns.
Fx on Hx taking:
1.
2.
3.
4.
5.
6.

Do you drink alcohol = Yes


Do you smoke = yes
Parental Hx = Mom had Osteoporosis
Any prev fracture = Wrist fracture
Exercise = pain in bones so cant exercise.
Diet = Drinks coffee

Cx:
Please drink alcohol in moderation and try to cut it down if
cant stop. Get help if needed. I can refer you to a colleague
who can help you with some exercises that wont hurt but
will be good for your bones. Have a well balanced diet with
right amount of dairy products. I can refer you to a dietician.
The treatment for him is bisphosphonates. The treatment is
not curative but slows the progression of disease.

Station 7 (Stroke)
A 60 yrs old man was admitted because of stroke. He is
about to be discharged. Please talk to patient.
In every stroke patient assess risk
NON MODIFIABLE
MODIFIABLE
Age
DM
Gender
Hypertension
Prev Hx/risk factor
Hypercholesterolemia
Weight gain/ Smoking/
Not enough physical
activity.
First of all express how you are happy that he is finally able
to go home. Advise him to comply with his medicines there
and ask if he has people to take care of him. If not, tell him
special nurse can be provided who will take care of his
every day needs and will medicate him as prescribed, if he
has difficulty taking due to any reduced movements. Advise
about diet, exercise, smoking, alcohol and weight
loss. Tell him physiotherapist can be arranged to come
over and teach him how to exercise his limbs regularly until
they return to functioning as near to normal as possible or
otherwise as well. Speech therapist will help if he has
difficulty with speech after stroke. Occupational therapist
will make sure there is no trouble at home, with using the
bathroom (in case its upstairs and he lives downstairs) and
will help modify the house according to his essential needs
due to his current condition. In case he is ever depressed,
Counseling can be provided at home if ever needed. Rule
out if patient has DM, HTN or any cardiac illness and

advise accordingly to take proper medications and follow up


regulary with his GP regarding them. Emphasize on the
importance of their control. In the end, talk about warning
signs (FAST). Any facial weakness, arm weakness,
speech difficulty, the patient should telephone 999 and
get help and ask for ambulance immediately, to be brought
to the hospital.
Let patient talk about his concerns. Be patient and do not
speak out everything in one go. After you have addressed
one concern, ask him if he has any other and if not, bring
out the facilities that can be provided one by one.

Station 8 (Stroke)
A 55 yrs old lady presented to the hospital. Talk to the lady
and assess risk of stroke. Her family history for stroke is
positive but BP is normal.
Ask this lady about non modifiable factors, if she has any
and inquire about lifestyle habits and diet especially when
taking history. Assess risk of stroke via the questions
mentioned above, plus take relevant history e.g. past and
family Hx as required.
This patient has a stressful job, bad diet and is a smoker as
well as an alcoholic and do not go for exercise.

Station 9 (MI)
60 yrs old lady had MI 3 weeks ago. She got discharged after
1 week from the hospital. She is now in out patient clinic for
follow up. She has complaints of SOB, ankle edema and leg
edema. Echo has been done and shows left ventricular
failure. Talk to the patient and give necessary advise.
Fx on Hx taking:
1.
2.
3.
4.
5.

Patient had MI 3 weeks ago


Discharged with meds
Main complaints are orthopnea, SOB and pedal edema.
Stopped meds after 1 week
She didnt know she had to renew prescription from GP
after the one week and thought this was all the meds
she had to take.
6. She may also be forgetful.
Tell her you can buy a box that has different sections for
every day, with a section for morning, evening and night.
She will remember if the medicines are put in them
accordingly, to take them on time. She will remember her
husband got her such a box once. Also tell her alarms could
be set for her on her clock or phone in order to remind her
when its time to take meds. Inquire if she has any family
members to help her take them on time or if she needs help
with that. Tell her she has to renew her prescription once it
finishes or otherwise she wont get better, if she ever forgets
to, or dont take her meds.
She should ideally be admitted but thats not a concern
here. Address her concerns in this station and respond
accordingly, after taking history.

Station 10 (Needle Stick Injury) In the park


Questions to ask
1. May I ask what happened? When?
2. What did you do afterwards?
3. Was it a solid or a hollow needle? (Normal or hospital
needle)
4. Was the needle already used? Any blood on it?
5. Were you wearing any gloves?
6. Scratch or deep puncture wound?
7. Do you have any medical illness?
8. Are you vaccinated? (Against tetanus and hep B)
9. When was the last time you had a booster?
10.
If the patient is in the hosp, then with what illness?
Things to do (General info)
1. Stop the procedure
2. Dispose off the sharps
3. Squeeze your finger
4. Wash your hand
5. Apeopley bandage
6. Inform the patient
7. Request a colleague to continue procedure
8. Fill up an incident form. Take advice from a
microbiologist.
9. Inform the occupational health department
10.
Give your blood and take patients blood for
further investigations
11.
Post exposure prophylaxis for HIV is given within
one hour.

26 yrs old man had a needle stick injury in the park. He


pricked his finger while he was doings something. Talk to the
patient and address concerns.
Fx on Hx taking:

1. He didnt squeeze his finger. May only have washed


with water.
2. Hollow, wide bore needle (Hospital needle) with blood
but with or without syringe.
3. Hes worried as drug abusers may have used it earlier
and they may have HIV and now he might get it. Tell
him HIV bugs cant survive outside human body
and the chance of transmission is next to nil.
There has been no significant incident of spread
of HIV since 1981 via needle stick injury due to
the precise reason.
4. If despite assurance he is still worried, tell him, you will
give him a date and will arrange for him so that the
blood test can be done. Explain how prophylaxis meds
for HIV have severe Side effects so tell him you will ask
your consultant regarding giving him getting any, if he
asks for it since transmission chances are very low.
(Note: The HIV antigens cant be detected before
one month and antigen and antibody are both present
after 3 months and not before. In hep, it takes 4 to 7
weeks to be detectable. People are already vaccinated
against tetanus in UK, at 2,3,4 months, during
preschool and at 16 yrs of life and hence they get a
lifelong immunity against tetanus).
5. If he is concerned about infections, tell him you will take
a look at his finger and ask for any redness, discharge
or swelling and will give medicines (antibiotics)
accordingly which is not needed otherwise.

Station 11 (Needle Stick Injury) Nurse at the


hospital
Theres a nurse who had a needle stick injury while drawing
blood from the patient. Talk to her. (Hx + Cx)
Questions to ask
1. May I ask what happened? When?
2. What did you do afterwards?
3. Was it a solid or a hollow needle? (Normal or hospital
needle)
4. Was the needle already used? Any blood on it?
5. Were you wearing any gloves?
6. Scratch or deep puncture wound?
7. Do you have any medical illness?
8. Are you vaccinated? (Against tetanus and hep B)
9. When was the last time you had a booster?
10.
If the patient is in the hosp, then with what illness?
Cx:
Sympathize and empathize. Reassure the nurse. Tell her
once again you are sorry that this happened to her. Ask her
if she has any worries or concerns about this incident.
Dont worry about HIV. Chances of getting this infection
through needle stick injury are very low. Also if patient
himself doesnt have HIV, there is no need to worry on that
note at all. We have prophylactic meds anyway. If taken as
soon as possible, in case someone is infected, the chances
of getting the infection are much lesser. However we have to
do some blood tests on you and the patient. We will inform
occupational health department and I will talk to the
microbiologist and get back to you real soon.
Tests for HIV are done at 1,3,6 and 9 months.
Regarding Hep B, chances are almost nil as everyone in UK
is immunized (especially health officials before taking up
jobs). So you need not worry on that note. However after the
blood test, well let you know about it.

About tetanus, booster dose has to be taken after every 10


years.
In case the patient has meningitis, Ill find out the detail
about the patients illness and well give you prophylaxis if
required.
Ask her if she has any other concerns.

Station 12 (Epilepsy) Uncontrolled epilepsy


25 yrs old man is a k/c of epilepsy. This man has got some
recurrent seizures in last few months. Talk to the patient and
give necessary advise.
Fx on Hx taking:
1. Do you take regular meds? Yes
2. Did you miss any dose recently? Sometimes, when I
feel absolutely fine or I only take when I feel like I
maybe getting seizures.
3. What meds are you on and why dont you take them
regularly? They have S/E: Make me drowsy and give me
a headache.
4. Occupation? Waiter/bartender. Works till late. Gets little
sleep. Advise him on how lack of sleep, poor
compliance of meds, alcohol, flashing lights,
dehydration, getting tired and exhausted,
skipping meals and working on PC/watching TV
til late all are triggers.
Well review your medicines and give you the ones that
cause the least S/E but you should take them regularly
without skipping doses. If the S/E persists, you should
come back immediately so we can alter them.
In general advice, avoid having sharp furniture at
home. Change ordinary gas cooker, to electric
ones. Take shallow baths. Do not go near height.

Station 13 (Epilepsy) Student in a new town


22 yrs old lady comes to you. Shes a k/c of epilepsy. Talk to
the patient and address patients concerns.
Fx on Hx taking
1. This patient is a student
2. Recently moved to a new town
3. Patient has concerns about S/E of medicines (anti
epileptics). (Shell ask if they will damage the liver).
4. Shes on Na Valproate.
5. She will ask regarding taking OCPs.
Tell her to not worry. We do routine blood tests and check
your liver status frequently. Your meds are very safe and so
therell be no problem with that. It has no interaction with
OCPs so you can safely use em. But please seek advise if
you are going to get pregnant. Your GP who will prescribe
folic acid 12 weeks before planned conception, for the
childs and your better health.
Avoid triggers e.g. lack of sleep and flashing lights. Give
General Advise mentioned in the previous station.

Station 14 (Epilepsy) Young Guy


A young 25 yrs old man comes with history of fits. Talk to
the patient and discuss D/D with the examiner.
Fx on History taking (Take a proper one)
1.
2.
3.
4.

LOC during fits = 2 minutes


Wet himself (Please show sympathy/ empathy)
Cant remember anything when he recovered.
Id a strange feeling before my fit.

D/D:
1. Epilepsy
2. Head injury
3. Meningitis
4. SOL
5. Hypoglycemia

Station 15 (CKD) Blood report given


A 45 yrs old hypertensive patient, presented to the clinic.
Look at the lab reports. Talk to the patient and discuss Mx
with the patient.

Hb: 9.7
K:5.9
Creatinine: 434
Urea: 6.7

Fx on Hx taking
1.
2.
3.
4.

Fatigue since last 6 months


Itching and vomiting present
Patient has to go to the toilet frequently (Is on diuretics)
Patients mom has CRF and had dialysis few
times/week.

Symptoms of CKD
Fatigue
Swelling of leg
Itching
Pedal edema
Vomiting
Blood in urine
Council the patient about how the reports that came
back showed his kidney function was not up to the
mark and so he must take care of his diet and drugs to
prevent worsening of the condition and mention
dialysis and transplant in case it fails. Sympathize and
empathize accordingly.

3 Ds you must mention in the Management!

Diet
Less salt

Less alcohol
No smoking
Well balanced
diet
No over the
counter meds
Especially
NSAIDS.

Drugs
Comply with any
drugs given for
hypertension or
edema (diuretics)
Fe tablets
Erythropoietin
injection
Vit D

Dialysis
Mention
dialysis

+ transplant

Station 16 (Paracetamol Poisoning)


A young girl took 15 PCM 12 hrs ago. The blood tests have
been done and level of PCM is 30. Talk to patient and discuss
Mx with patient. Do not take psychiatric history.

Station 17 (Chronic Fatigue Syndrome)


47 yrs old man presented with c/o tiredness in the last few
months. Investigation shave been done and everything is
normal. Talk to the patient and address patients concerns.
Chronic fatigue syndrome is a condition which causes long term
tiredness with other symptoms like pain in muscles, joints, head, throat
+ some psychiatric problems like sleep disturbances, poor
concentration, forgetfulness and depression and c/o flushing, postural
hypotension and heat and cold intolerance.

Fx on Hx taking
1. Tired since 6 months
2. Resting doesnt help
3. Had flu like symptoms 6 months ago and went to the
GP. Has been sick ever since.
4. Sleep is fine but am still tired.
5. No weight loss. No blood in stools, No Carcinoma
history. No heat intolerance.
D/Ds to rule out:
1. Chronic fatigue syndrome
2. Anemia
3. Diet
4. Hyperthyroidism
5. Malignancy
6. Depression
7. Malabsorption
Cx:
There are some general advises you can give to this patient.
1.
2.
3.
4.
5.

Manage your sleep


Manage your rest
Relax using means that are suitable
Have a well balanced diet.
Cognitive behavior therapy (one of my colleague can
talk to you and help improve your mood and reduce
stress + Graded exercise therapy (gym instructor
helps with low intensity exercises) are two specific
managements.

Station 18 (IV Cannula blocked)


You are a senior doctor in the hospital. An FY1 doc, Dr
Williams was asked to change an IV line but he couldnt.
Please talk to your colleague.
5 points to remember
1.
2.
3.
4.
5.

Safety of the patient


Initiating (change IV line)
Incident form (DATEX)
Communicate with your colleague
Discuss with your seniors

Start the station with greeting your junior and saying I hope
you are doing great and coping well with your tasks or a
hello, how are you? I checked this one patient who needed
an IV cannula change and changed it myself and made sure
that the patient was safe. Could you please tell me what
happened regarding the patient whom you were suppose to
change the IV line in? I was busy and had to take another
patient for an X-ray. If something like this happens in the
future, you are to inform me or any senior, okay? I think it
will be a good idea to go an apologize to the patient for
causing any discomfort, dont you think. I, in the mean time,
will go and fill the incident form explaining what happened. I
will write the reason for the delay, which was how you were
busy with another patient.

(Common Stations) Only Councelling


In all the councelling stations, let the patient ask and inquire and only
then relay all your information, unless patient was quiet. Do not go on
talking without letting him speak. Keep asking about patients
concerns, after every reply.

1) Blood Transfusions
2) Medication
Insulin Councelling
Warfarin in learning difficulty
Discharge prescription (Asthma and MI)
3)
4)
5)
6)

PEFR
MRSA
Multiple Sclerosis
Postponed Surgery
Herniorrhaphy
Lap Cholecystectomy
Obesity
Non medical causes of HTN

7) Diabetic Neuropathy
8) Gout
9) CT Scan
10) Smoking
11) Breaking Bad News (Mesothelioma)

Station 1(Blood Transfusion)


50 yrs old lady with myelofibrosis was scheduled for
receiving 4 units of blood. Shes worried. Talk to patient
about S/Es and complications of BT!
Cx:
Explain to the patient that due to anemia she has to receive
blood. One unit of blood takes 4 hrs of transfusion. Yes you
have to stay in the hospital. You dont have to be NPO. Its
better to have a light breakfast. You can work and eat during
the procedure. Blood that we will give you will be healthy
and clean so dont worry about infection. We do necessary
blood tests and your blood will be matched with the one
being given, before transfusion to minimize any reactions.
Complications of Blood transfusion include allergic
reactions, which if happen are mild and may cause you to
have low grade fever or rash or body pains but we always
have medicines ready to give in such situations to counter
the allergic effect.
As we are giving you 4 pints, their maybe chances of fluid
overload so we may give some water tablets. 2 pints will be
transfused in one day.
Sometimes electrolyte imbalance may occur, which is rare
but we will keep monitoring. We will manage if it happens,
accordingly
Well prevent hypothermia by warming the blood or
bringing to normal temperature.

Station 2 (Postponed Surgery) OBESITY


A 32 years old lady was planned for dental extraction. Her
procedure was turned down after anesthetic assessment.
Her BMI is 35. Talk to the patient and address patients
concern.
Fx on general inquiry about diet and lifestyle:
1. Very very bad diet. Loves junk food. Eats anything at
anytime.
2. No physical activity
3. She will ask what are you going to do for me?

Cx:
As you know you were earlier planned for a dental
extraction, and I am here to talk to you about your fitness
for surgery, for which you were assessed by our consultant
who thinks it will unfortunately have to be postponed for a
while.
You were planned to undergo General Anesthesia but the
consultant thinks it will be too risky to pass the ETT
(tube)that may damage organs and the anesthesia may not
effectively work until some weight was lost.
I can refer you to an excellent dietician who can help you eat
healthy from among your fav foods and may help you
reduce weight so we can go through with this procedure. You
can also join a gym in the mean time, or try brisk walking up
to half an hour a day and drop any unhealthy eating habits.
This procedure can be done under local anesthesia but if you
want GA, youll first have to work a little on the fitness.

Station 3 (Postponed Surgery)


HYPERTENSION
45 yrs old lady admitted to the hospital for lap
cholecystectomy. BP 160/110. Please talk about non
medical/initial management of treatment of hypertension.

Station 4 (Multiple Sclerosis)


Patient was diagnosed with multiple sclerosis. Please talk to
the patient and answer his concerns.
Cx:
I am afraid I dont have very encouraging news however
theres no immediate danger to you. You have a condition
we call multiple sclerosis. It is a condition in which there is a
loss of structure around nerves in your brain and spine,
which carried information from body to your brain and vice
versa.
It is an autoimmune disease. This means your immune
system which is suppose to protect you, starts attacking
your own nerve structures by mistake. It is not your fault
that you got it.
Medications can modify this disease, if not cure it. This
disease is the sort that lets it affects come and go. The meds
can slow the progress of the disease and prevent relapse.
They will be in the form of cap/tablet. (Interferons). Some
(steroids) will help reduce inflammation and decrease
duration of relapse as well.
We may give you pain killers when and if needed and incase
of any problem (Urinary incontinence, sexual dysfunction,
depression, spasms) meds/help will be provided in the form
of meds, occupational therapists, special nurses, speech
therapists + councelling. Only mention these problems if he
brings them up.
Majority of the patients dont use/need wheel chairs unless
they had an attack, However in some patients, if symptoms
become permanent, then they have to use wheel chair.

Station 5 (Diabetic Retinopathy)


40 yrs old man is a k/c of DM for last 12 yrs. He has been
smoking for last 20 yrs and he drinks alcohol as well. Hes
worried about his vision. Investigations have been done and
diabetic retinopathy has been diagnosed.
Fx on inquiry:
1. Does not have a healthy lifestyle
2. RBS not controlled as not taking insulin properly.
Cx:
DM is a diease that occur when your body cannot produce a
substance called insulin which regulates blood sugar. One of
the complications of diabetes is damage to blood vessels. If
it happens in a large vessel, it may cause kidney and heart
problems. If the damage happens to tiny vessels at the back
of your eye, it causes retinopathy.
If you have increased BP, decrease it by taking regular meds.
Control cholesterol levels by eating healthy green diet and
most of all control blood sugar levels by taking insulin
properly and monitoring RBS using glucometer and while
taking a well balanced diet and doing adequate exercise +
keeping up a good physical activity level.
Will I go blind?
Look your job is to control your blood sugar so we can
prevent the condition and damage from worsening and focus
on staying as healthy as possible. Well be calling you for
screening and annual check up.
Do I have to quit smoking/alcohol?
Its better if you do.

Station 6 (Gout)
45 yrs old man diagnosed with gout. Talk to the patient and
address patients concerns.
Cx:
Gout is a condition which causes pain, inflammation and
swelling in one or more joints. This is caused by an increased
level of substance that we call uric acid, in the blood. It
happens when either body produces this in excess amount
for some reason or the kidney is unable to remove it.
Youll have to decrease the intake of sugary drinks, alcohol.
Will have to avoid water tablets (diuretics) and meds like
aspirin and take a well balanced diet especially with Vit C in
it.
Some people with DM, HTN and kidney diseases have excess
amount of urea (Rule out med conditions and diet factors
e.g. red meat and pulses increase uric acid levels).
Mx:
1. Try keeping the leg raised and use ice therapy.
2. NSAIDS may be used for pain except aspirin (and after
CI are ruled out e.g. peptic ulcer, asthma etc) along
with colchicines and steroids to reduce
inflammation.
3. For prevention allopurinol is given 2 to 3 weeks after
the attack but if already on it, may continue.
4. Patient cannot take aspirin as a pain killer. Mini aspirin
may be taken if he is a stroke or MI patient.
5. GP may prescribe other meds to protect the gut from
the harmful effects of some of the given meds.

Station 7 (CT SCAN)


25 yrs old man comes to you and asks about CT scan.
Migraine was diagnosed 5 months ago. Last week he came
again and asked for CT scan. Consultant saw this and patient
and told that it was not necessary. Address patients
concerns.
Cx:
Is there any change since my consultant saw you? NO
Any change in type of your headache? No
Any vomiting & weakness in your hand or leg? No
Any problems with vision? No
Any problem with bladder or bowel habits? No
Do you comply with meds for migraine? Yes
It takes atleast 6 months for migraine meds to start working
properly. What are you so worried about? His friend had a
brain tumor
Sympathize/empathize. Thats why I asked you all the
questions. You dont have any S/S of a tumor. Plus there are
S/E to the exposure of rays of CT Scan. They are like mini xrays and are harmful for you.
If he is still insistent, say I will talk to my seniors and get
back to you regarding it.

Station 8 (Smoking)
60 yrs old lady smoker. Had MI previously. Planned for
angiography. Talk to the patient about smoking.
Tell me about your diet? Go on talking about her positive or
good points. What do you think caused the heart problem?

Gynae & Obs (Common Stations) Hx +


Councelling

1. Urinary incontinence (Only Hx)


2. APH (Hx + Cx)
3. Irregular bleeding (Hx + D/D)
4. Preeclampsia (Hx + Cx)
5. Miscarriage
6. PID (Hx + Cx)
7. Ammenorhea
8. Infertility
9. Ectopic Pregnancy (Cx)
10. Pain in Labor (Cx)
11. Hyperemesis Gravidarum (Cx)
12. Ovarian Cystectomy
13. Dibetes in Pregnancy
14. OCPs (Cx)
15. Dyskariosis
16. Dysmennorhea

Station 1(Urinary Incontinence)


65 yrs old lady with urinary incontinence. Talk to the patient
and take only history.
Cx:
Empathize and sympathize (I am really sorry to hear that
and can totally understand how hard it must be for you and
how you must feel)
Since when did this problem start?
How often do you go to the toilet?
How much urine do you pass each time?
How often does it happen? (the leakage) Offer
Confidentiality if she doesnt speak (All that you say will
remain between you and our medical team)
D/Ds to rule out
1. Stress incontinence (Can you tell me if you have
more leakage while laughing, coughing or doing any
exercise work).
2. Urge incontinence (Can you hold your urine?)
3. Prolapse (Did you have something coming out of the
vagina feeling?)
4. UTI (Burning while passing urine, fever)
5. Vaginal atrophy (in menopause) Any dryness in your
private parts?
6. DM
7. Medication (diuretics)
8. Excessive tea/coffee
9. Do you have kids? When was the last pregnancy? Any
complication then? Difficulty in labor or
instrumentation done during labor?

Station 2 (APH)
32 years old pregnant lady presented with vaginal bleed.
Ultrasound was done. No change in place of placenta.
Discuss Mx with patient and address concerns.
Fx on Hx taking
1.
2.
3.
4.

Bleeding from front passage


Filled one pad
Red/fresh blood. Sometimes its brownish.
No tummy pain
D/Ds to rule out:
1. Anemia * (Always rule out anemia in every
bleeding case. Ask for shortness of breath,
unusual fatigue, tiredness especially on exertion)
2. Placenta abruption (tummy pain)
3. PID (Pain in lower abdomen + fever)
4. Instrumentation
5. Bleeding disorder Hx
6. UTI
7. Trauma
8. Safe sex
9. Baby is kicking or not? * (Depending on the
month of presentation)

What are you going to do for me?


Well have to admit you to find out the cause of bleeding.
We were able to rule out two important causes of bleeding
fortunately. In one of the case, bleeding is after the afterbirth (placenta) changes its position and the other one is
where it gets detached.
But we still arent sure about the cause so keeping you with
us is necessary for a while. Maybe theres some bleeding
behind the placenta thats hidden and we are unable to
locate for now. Just to be sure, we will repeat the USG and do
some blood tests for your and childs safety.
Why are you admitting me?

Reassure. Its for your own and your babys safety and to
rule out the cause. We will keep observing you and your
baby and hopefully itll be fine.
Indication for immediate delivery?
1. Babys distressed
2. Severe bleeding
Doc, can I have the baby at full term?
So far everythings fine. You didnt have a large amount of
bleed. If everything goes smoothly, why not!

Station 3 (Irregular bleeding)


47 year old lady presenting with irregular bleed. Talk to the
patient and discuss D/D with examiner.
Fx on Hx taking
1.
2.
3.
4.
5.
6.
7.
8.
9.

Patient had periods = 2 weeks ago


Again had periods which started yesterday
No heavy bleed (fibroids)
Other symptoms: Hot flushes, night sweats, mood
swings (Premenopausal bleed)
No fever, no discharge (PID)
No family history of polyps
No acne, no weight gain (PCOs)
Any bleeding from some place else? No.
(Endometriosis)
Any trauma or meds taken?

D/Ds
1. Dysfunctional uterine bleed (premenopausal
bleed)
2. APH
3. PID
4. Trauma
5. Instrumentation
6. PCOs
7. Endometriosis
8. Fibroids
9. Polyps
10.
Safe sex
11.
UTI
12.
Bleeding disorders
This is dysfunctional uterine bleed or premenopausal bleed.
At the beginning and end of periods, women bleed like that
(irregular periods).

Station 4 (Pre eclampsia 1)


32 weeks pregnant lady presenting with headache to the
hospital. Talk to the patient and discuss Mx with the
examiner.
Fx on Hx taking
1.
2.
3.
4.
5.

Patient went for antenatal clinic


No tummy pain or visual problems
Babys kicking just fine
No past Medical Hx or any family Hx of illnesses.
She developed sudden puffiness and headache.

D/Ds to rule out:


1.
2.
3.
4.
5.
6.
7.

Preeclampsia
Migraine
Stress
SOL, meningitis, head injury
Hypertension
Dm
Renal, liver problems

Ask examiner, the patients blood pressure (160/110)


and protein urea (3 +)!
Mx:
My patient, I suspect, has preeclampsia.
Ill admit the patient and give
1. Labetolol (oral) or methyldopa
2. Hydralazine (IV)
3. Discuss immediately with seniors and even talk
about prophylaxis for fits (if they need to be given
or not).
4. Definitive treatment = delivery of the baby.
5. Ill also connect the CTG machine and vitals
monitor to the patient, in order to keep a look at the
vitals and check babys progress. May request USG if
needed.

Station 5 (Preeclampsia 2)
36 weeks pregnant lady referred by the GP with BP
160/110mmHg and proteinurea 3 +. Talk to the patient and
address concerns.
Fx on Hx taking
1.
2.
3.
4.

Babys kicking? Yes


Puffiness? Yes
Mild headache present
Attended antenatal clinic but BP then was fine.
Cx:
You have a condition called preeclampsia. It is a
complication of pregnancy in which you have a high
blood pressure. It isnt serious right now but this
condition is potentially dangerous.
This happens due to some problem with the after-birth
(placenta).
Well admit you. We will keep monitoring you and your
baby and may give you medication to lower your BP.
More medication may be given to prevent any
complications.
This condition can cause you to have early labor or fits
(Dont mention it unless patient asks for the
complications). Dont scare the patient! Try and tell
her youll try your best to control them.
Dr how long and why should I stay?
Its important because otherwise you may face some
liver, kidney or lung problems. May even have fits as
well. Other complications include premature birth, IUGR
(smaller baby), still birth etc.
Youll have to stay until we are able to control your BP.
Can I go for pool delivery?

From what youve told me, it is very unlikely that you


could go for it. But if she insists, tell her you will ask
your seniors regarding it and let her know.

Station 6 (Miscarriage)
9 weeks pregnant lady comes to the hospital with spotting.
USG done and showed dead fetus. Dx of miscarriage made.
Talk to the patient and discuss management with the
patient.
Ask if she knows whats going on. Sympathize/empathize on
disclosing. 1 outta 7 females end up getting a miscarriage
during pregnancy. Its not only happening to you and it
wasnt your fault.
Can I have a baby next time?
Yes off course, you can have a baby next time. However we
will keep monitoring/observing you from now and do some
investigations to find out the cause behind this miscarriage
(e.g. Antiphospholipid syndrome). Next time you plan to get
pregnant, just seek advise from your GP.
Mx:
You have 3 options:
1. Conservative treatment
Usually this treatment is when you let the products
of conception pass out over 2 weeks time. (If the
patient had a history of previous miscarriage or
bleeding disorder, then you cant go for this option and
have to do ERPC/abort using meds straight away).
2. Well give you meds by mouth or insert medication
in your vagina to abort the baby. No need for
admission in this process as you may leave once the
products of conception are safely out.
3. We can do a small surgery (ERPC). Neck of the
womb is gently opened and narrow tube is placed into
your womb to remove pregnancy tissues.

Call patient for USG after 1-2 weeks time and for the
pregnancy test, when next present and tell her to keep
following up regularly as advised.
Explain to the patient the management in the simplest of
terms and no medical terms should be used with them. Not
without explanation.

Station 7 (Miscarriage)
10 weeks pregnant lady comes to the hospital. Talk to the
patient and take medical, social and Obs Hx and talk about
the importance of antenatal clinic.
Fx on Hx taking
1. Hx of 2 previous miscarriages (at 8 and 10 weeks)
2. She did not attend any antenatal clinic in previous
pregnancies.
3. She is not taking any medication.
4. Age >35 yrs.
5. Patient is a smoker (20 cigarettes/day), takes alcohol
(>14 units/week) and is overweight.
6. She has uncontrolled DM sometimes.
7. Rule out SLE and APL syndrome and other medical
illnesses.
8. She is a police woman by occupation.
Doctor, I had bleeding and went to the hospital and
they told me the babys gone.
Ask about any meds given, or instrumentation done when
miscarriage confirmed.
They said wait and see. No meds given.

Station 8 (PID)
35 years old patient was admitted & was diagnosed with
PID. She was given broad spectrum antibiotics. USG showed
hydrosalpingitis. Patient was on COCPs. Talk to the patient
and address concerns regarding PID.
Doc, what is the cause of this condition?
PID is an infection of the womb + of the tubes connecting
the ovary to the womb. It affects ovaries as well sometimes.
There are many causes of this condition. It can be passed
through sexual intercourse, can be caused by bugs
especially if you have an IUCD inserted or had any
instrumentation or procedure done.
Do you think I got this from my bf?
The boyfriend may have this condition from previous
relationships without having symptoms. It doesnt mean
your partner got it just now. (This is to prevent the patient
from having an outburst regarding her bf).
Dr, what should I do?
Can you bring your partner in? If she says yes, tell her it is
important to complete the treatment for both of you which in
this case will be antibiotics. Youll have to avoid sexual
intercourse until the treatment has ended, even with
protection (condoms) and should only resume when tests
come negative.
Dr how can I prevent this from happening in the
future?
1. Practice safe sex.
2. Keep to a single partner/stable relationship and
increased number of partners, enchances the risk for all
STIs.
Complications?

As long as you take meds, its fine. If left untreated, it may


cause
1.
2.
3.
4.
5.
6.
7.
8.

Infertility
Ectopic pregnancy
Persistent pain (backache and pain during sex)
Miscarriage
Still birth
Premature baby
Abscess
Collection of pus around your womb

If we can treat you and if you comply to meds and if you


prevent it from having again, hopefully you should be able to
conceive. There is a chance of either of the tubes being
scarred but one can have babies, even with one tube intact.

Station 9 (Amenorrhea)
20 years old lady with amenorrhea. She also had weight loss
in the last few months. Talk to patient and discuss D/D with
the examiner.
Fx on Hx taking:

1. No periods in last 8 months


2. Boyfriend dumped her because he thought she was
chubby
3. 6 kgs weight loss over the past few months.
4. No heat/cold intolerance
5. No facial hair/ no acne
6. Periods were normal before
7. Diet according to her is normal and nothing is wrong
but dig into it.
8. Takes thyroxine (abuse it) to lose weight as well
D/Ds to rule out and say
1. Anorexia Nervosa (clever bmw) (Clothing
baggy, laxative abuse, excessive exercise,
induced vomiting, excessive wt loss, role
models are thin people, body image etc)
2. Malnutrition
3. Malabsorption syndrome
4. IBD
5. IBS
6. TB
7. Hyperthyroidism
8. Depression

Station 10 (Infertility)
29 years old lady presented with infertility. Talk to patient
and discuss D/Ds with the examiner.
Questions to ask
How long have you been trying to conceive?
How often do you have sex?
Partner has kids from any previous relationships?
Any chronic illness? UTI? Any prev surgery?
Also rule out D/Ds. The first two are the usual diagnosis in
this station.
D/Ds:
1. Ashermann syndrome (Cyclic pain during pregnancy
but no periods)
2. Sheehan syndrome (Hx of excessive bleeding during
previous delivery)
3. PCOs
4. Hyper/hypothyroidism
5. Chronic illnesses e.g. HTN, DM, Kidney failure
6. Being over weight/ underweight
7. Excessive exercise
8. PID (fever, lower abdominal pain, discharge)
9. Endometriosis (Bleeding from any place other than
vagina?)
Fx on Hx taking
1.
2.
3.
4.

Patient has sex 3 to 4 times per week


Partner has baby from another relationship
Abortion = 2 yrs ago with excessive bleeding or
Every month has pain with no bleeding

Station 11 (Ectopic Pregnancy)


29 years old lady presented with vaginal bleed and
abdominal pain. LMP =6 weeks ago. Pregnancy was
confirmed via urine test. USG confirmed ectopic pregnancy.
Consultant decided laproscopic surgery. Take Hx and
address patients concerns.
Questions to ask
Do you know whats going on?
What have they done for you? She will reply saying USG was
done.
You have, am sorry to say, what we call ectopic pregnancy
which is pregnancy thats outside the womb.
Doctor, why did I get it?
This may have many causes. If you have any previous
ectopic pregnancy or if you have any scars/damage to
your tubes due to PID or previous surgery, you may get
this condition. Using IUCD and some meds for treatment
for infertility may be the cause. At Age > 35 yrs, there are
increased chances of getting it.
What are you going to do for me?
We will have to admit you and may remove the tube
containing ectopic pregnancy or may only remove a
section of tube which has ectopic pregnancy. If not dealt
with, this can cause serious complications and can even be
life threatening as the tube might burst, spreading infection.
Can I have a baby?
As long as the other tube is working, you can have the baby.
Ask consent when 4:30 bell rings if consent not already
taken.

Station 12 (Pain Mx during labor)


36 weeks pregnant lady is planned for a delivery in the next
2 weeks. Talk about pain Mx in labor.
Mx:
1. Self help. Learn about how to relax and calm yourself
especially during pain.
2. Do breathing exercises.
3. Bring in partner or friend to do massage or to help
you emotionally get through this.
4. We can give you ENTONOX (which is 50% Oxygen and
50% NO). it is also known as the laughing gas and is
harmless for you and the baby. You can simply breathe
it in using face mask. You can take it whenever you
want, although too much of it can make you dizzy or
sick. It isnt much effective against actual labor pains.
5. We can also go for TENS (Trans-cutaneous
electrical nerve stimulation). It is a small device,
attached to the belt of your gown and it has a few leads
attached around your tummy and back. It prevents pain
signals from reaching your brain and also causes your
body to release feel good hormones (endorphins). It
can be used during early labor but not once the pain
has actually started. Its effectiveness is highly reduced
in actual pains. Also it cant be used in pool deliveries.
6. We can also give you IM Pethidine which is given
during early part of the labor and it usually wears out
by the end. Its affect takes 20 minutes to start. And its
dose cannot be repeated as it causes breathing
difficulties in the baby and can cross the membrane
surrounding your baby. If given, neonatal team will be
monitoring your baby during labor. Anti sickness meds
are given, if any sickness feeling is caused by it.
7. Last but most effective is the epidural injection,
which is given using a needle to your back. It causes
complete numbness and even sometimes tingling in
lower tummy and legs. You wont feel any pains or baby
coming down so will be asked to push. Urinary catheter

will be inserted before this. Instrumental delivery may


be required. If things dont work out with the delivery
due to some complication, LSCS will be considered.

Station 13 (Dysmenorrhea)
A young lady presented with c/o dysmenorrheal. Please talk
to the patient and discuss different methods of Mx.
Sympathize/empathize. Ask her what she already has done
for it. Did she take any meds already?
Mx:
1. Use hot water bottles
2. NSAIDS. Take them regularly. Start one day before the
date of periods.
[Check which NSAID she is taking. You can switch
normal cocodamol/brufen to mefanamic acid (not
available over the counter)]
3. COCPs. They help is contraception but also decrease
bleeding and pain as well. S/E: headache, acne,
sickness, leg cramps, light headedness and weight
gain.
4. Mirena. (Coil fitted in the neck of your womb). It is put
in after ruling out contraindications like any womb
infections, pregnancy etc. It too helps in decreasing the
amount of bleeding. No general S/Es but if you have
any, they can be sorted out immediately.
5. Progesterone only pills (Mini pills). This pill doesnt
increase weight and decreases pain and bleeding but
can cause greasy hair and skin. May even cause a
whitish discharge from vagina to occur.

Station 14 (Hyperemesis Gravidarum)


9 weeks pregnant lady presented with complaints of
vomiting. Urine test has been done and ketones came
positive (3+). Talk to the patient and discuss Mx.
Fx on Hx taking
1. Urine output is less than normal
2. Patient cant eat or drink anything
3. She is very tired and lethargic
Rule out D/Ds
1.
2.
3.
4.

Hyperemesis gravidarum
DKA (Hx of DM)
G/E
Hydatidiform mole (Passing of grape like structures
from vagina)
5. UTI
6. SOL (Headache, visual probs)
Whats hyperemesis gravidarum?
It is prolonged and severe sickness in pregnancy which
sometimes leads to loss of body fluids. It may develop
vitamin deficiency and starving.
Whats the difference between morning sickness and
this?
Morning sickness happens between 9 to 16 weeks of
pregnancy. Doesnt affect the eating habits of the pregnant
woman and is normal is every pregnancy.
Why does it need to be treated?
Body is losing fluids and vitamins due to the continuous
vomiting on intake of any food/fluids. It is dangerous to your
health and the health of the baby.
What are you going to do?
Well admit you. Do an USG to check if babys fine or if
there were any chance of multiple pregnancies being

there. Well give IV fluids + vitamins (thymine) if


necessary. Anti emetics may also be given if and when
needed. All the meds given are safe for the mother and baby
so dont have to worry on that note.
When better and discharged, at home take small meals
at short intervals. Dont self medicate and avoid
caffeine.

Station 15 (Ovarian Cystectomy)


30 yrs old lady planned for ovarian cystectomy. Surgeon
decided to do pfannenstiel incision and subcuticular stitches.
Discuss about surgery and complications and address
concerns.
Patients concerns in this station are:
Can I have a baby still?
One tube will be working so yes.
Sex life
Can be resumed after 2 weeks.
Complications?
1. Pain (We have excellent pain management team).
2. Bleeding (We have an expert team of surgeon who will
control any bleeding then and there and will hopefully
not land into any complications).
3. Infections (We give meds to cover that). Antibiotics are
given
4. Damage to surrounding structures (Our surgeons are
experts and hopefully will prevent that from
happening).

Station 16 (Diabetes in Pregnancy)


A young lady is planning to get pregnant. She is a known
case of DM. Talk to the patient and address concerns.
Cx:
When you are planning to get pregnant and have DM, your
body needs more insulin. Thats why you should be more
careful about controlling your blood sugar and hence need
more follow ups with the doctor and need more monitoring
and treatment. If DM is not controlled during pregnancy, it
may harm you and your baby.
Talk about non medical Mx first.
1.
2.
3.
4.

Eat small but frequent meals


Reduce weight
Exercise
Medical Mx is insulin which will be set and given as
needed.

If DM is not controlled, it may cause in mother:


1.
2.
3.
4.

Premature birth
Miscarriage
Infections
Too much fluid around baby

In the baby
1. Big baby
2. Congenital deformities
3. Low RBS of baby
DM may persist after pregnancy in some women so there is
a chance if she didnt have it before, to continue having it
after pregnancy. But it is not for sure.

Station 17 (OCPs)
Patient had DVT 4 months ago. Talk to the patient about
different methods of contraception.
OCPs will be forbidden in this patient.
Talk about mirena, or progesterone only pills only.

Station 18 (Dyskaryosis)

Psychiatry (Common Stations)


Offer confidentiality in almost all stations. Say the line
Whatever you say will remain between you and our medical
team otherwise patient may not talk or tell you much.

1) MMSE (Learn the folder page)


2) Suicide
Hx + Mx (with examiner)
Hx
Hx + Mx (with examiner)
3) Psychotic patient
(Hx)
4) Alcohol dependence
Hx + Cx
Only Hx
5) Drug dependence
Hx only
6) Panic Attack (Hx only)
7) Insomnia
Hx + Cx
8) SSRI
Hx + Cx
9) Postpartem psychosis
10) Depression
11) Bipolar disorder (Pilot)
QUESTION PATTERN TO FOLLOW IN PSYCHIATRIC STATIONS

1. Offer confidentiality in almost all stations. Say the line


Whatever you say will remain between you and our

medical team otherwise patient may not talk or tell you


much.
2. Sympathize/empathize
(MA F(4)AMISH)
3. Mood (ask him to grade mood from 1 to 10, 1 being the
lowest and 10 being the highest mood.)
4. Anhedonia (Loss of pleasure in activities that
previously meant a lot or he/she loved.
5. Family (is the family close/loving/supportive?)
6. Friends (Does he/she have friends to hang out with
and he is close to)
7. Finance (Does he have any financial troubles at
home?)
8. Forensics (Has he/she ever been on the other side of
the Law? Convicted for some crime?)
9. Alcohol and recreational drugs
10.Med Hx and past psychiatric hx (Has he ever had
to take councelling sessions before?)
11.Insight (Do you think you need help or that we might
help you?)
12.Suicidal tendency/Stress (Have this problem led you
to think that life has lost its worth. How do you see
yourself in the future? Has it become difficult for you to
plan for the future?)
13.Hallucinations + delusions (When people are going
through hard phases, they tend to experience
sometimes, seeing and hearing things that is hard for
others to experience. Has this happened to you? Do you
have any thoughts or ideas you may have hard time
convincing your family/friends of?)
M(ood)ISH in the above history is the set of questions we use
to rule out suicide tendencies in people. If any one of the 4
questions is positive, the patient will have to be admission
and H/O has the right to detain the patient in the hospital
until he is out of harms way from himself.
If mood is < 3, patient again have to be admitted.

If mood is <5, its counted as low mood, and MISH should be


ruled out.

Station 1 (MMSE) 55353123111


An old gentleman is sitting down with complaints of recent
confusion and forgetfulness. Do cognitive assessment or
mini mental state exam.
This patient is a jolly fellow so greet him nicely but dont
laugh at anything he says.
Sir, I am here to ask some questions in order to see
how good your memory is. Please bear with me as
some of the questions might sound silly but answer
as much as you easily can. Should I start?
Ask what Year, Month, Day, Date and time is? (5)
Ask what Country, City, Area, Building, Floor he is on (5)
I am going to mention 3 words and will ask you to kindly
please repeat them after me. I may ask you to repeat them
once again later.
Apeoplee, ball, pen (Repeat thrice if he doesnt get it in
the first or 2nd time) (3) Tell him you will ask him these words
later again.
Can you spell the word WORLD for me? Can you spell it
backwards? (5)
Can you repeat the three words I asked you to repeat
earlier? (Apeoplee, ball, pen) (3)
Ask him to repeat the line no ifs, ands or buts only once.
(1)
Ask him to name any two objects near you (2)
Take a page from examiner in your hand. Ask him to take
this using his right hand. Fold it and then give it back
to you, using his left hand. (3)

Write a command close your eyes and ask him to


follow it without speaking. (1)
Ask him to write a meaningful sentence. (He usually
writes I love you or I will see you again, depending on how
things went) (1)
Make overlapping pentagon with a pen on a paper. Ask
him to redraw them. (1)

Station 2 (Suicide)
Questions to ask
1. Could you please elaborate on the event? Explain what
happened?
2. Could you please tell me why you did this?
3. When did you do it?
4. How did you do it? Or what did you take (if pills)?
5. Who was with you?
6. What did you do after that?
7. Are you into alcohol and drugs?
8. Are you happy about being saved?
A 17 yrs old girl cut her wrist. She is in the hospital. She is
medically stable. You are an SHO in the psychiatry
department. Take history and discuss inference with
examiner.
Fx from Hx taking
1.
2.
3.
4.

Cut my hand after a fight with my bf


Did it this morning
Did it because of some misunderstanding
Was in my flat. My bf was downstairs while I cut my
hand. I screamed and he rushed upstairs.
5. It was a superficial cut.
6. Last night, had a few glasses of wine.
7. Didnt plan on doing this. It was silly. Not proud of what
Ive done. Not gonna do it again.
8. Mood 6-8. Sees a bright future.
9. Very supportive family.
10.
No financial problems

You can let this patient go home.


She needs to be referred to outpatient psychiatry
department in a letter to GP.

Station 3 (Suicide)
18 years old lady presented to the A & E. Took OCP pills and
cut her wrists. Medical Mx had been done. Patient is stable.
Talk to the patient and take Hx.
Fx on Hx taking
1. Took 25 OCPs last night
2. Cut the wrist this morning
3. Reason was because she panicked on missing a period.
Thought she was pregnant.
4. Did it in front of mom and bf.
5. No alcohol involved
6. She is anxious and regretful
7. Going for college soon
8. Mood is fine
9. This wasnt planned.
10.
No hallucinations and no problems with the law.
11.
Lives with family.
If cause is gynaecological, refer to gynae/obs dept for
assessment.

Station 4 (Suicide)
A 35 yrs old lady took 40 paracetamols. She is medically
table now but has a low mood. Talk to the patient and do
mental state exam and talk about suicide risk with examiner.
Fx on Hx taking
1. What happened? I dont want to live
2. Why? Had enough.
3. Made attempt this morning
4. No one was around
5. Husband brought me to the hospital
6. (+-) Tried before
7. Dont know if I will do it again
8. I have no future (on asking how do you see the future)
9. Mood between 0 to 3
10.
Hallucinations and delusions not present
11.
Cognition is fine
12.
I dont like my family
13.
Insight: I want to die.
Admit this patient since the suicide risk is high and do
MCSHIT.

Station 5 (Psychotic patient)


A young man is brought to the hospital by a policeman.
Policeman explained that he came to us and informed how
he did something wrong. Please talk to the patient and do a
psychiatric assessment and MSE.
Fx on Hx taking
1.
2.
3.
4.

Dr, in the last few months police was following me.


I did something wrong
I am respeciallyonsible for 9/11
Says people are watching him but they are not here
now
5. Hallucinations arent present
6. Patient has no insight on anything being wrong. (Ask do
you think you need any help, or we might help you in
any way now that the police have brought you to us?)
7. Mood is fantastic. No drugs and no alcohol.

Station 6 (Alcohol addict)


A 60 years old lady was admitted due to some nail infection.
Blood tests were done after admission and MCV & GGT were
raised and MCH deranged. Please talk to the patient and
council the patient about quitting alcohol.
Questions to ask in a drug/alcohol addict stations
CAGE QTF
1. Cutting down (Have you ever thought of decreasing
the amount you take?)
2. Annoyance ( Are you annoyed/irritable when other
people comment on your habit?)
3. Guilt (Did you ever feel guilty drinking?)
4. Eye opener (Is alcohol/drugs the first thing you take,
when you wake up in the morning?).
5. Quitting (Ever thought of/ tried to stop drinking?)
6. Tolerance (Have you increased the amount you take
progressively over the years?)
7. Free periods (Any alcohol and drug free period so far,
since you started on it?)
Fx on Hx taking
1.
2.
3.
4.
5.
6.
7.
8.

Patient has been taking alcohol since 40 yrs


Takes whisky, vodka, wine and beer
He loves alcohol and asks why he should quit taking it
Sometimes says he tried quitting once but got back to
drinking after wife died.
Only people like you annoy me, who keeps nagging me
about my drinking.
He doesnt feel guilty drinking.
Mood is good. No suicidal risk. No hallucinations.
He owns a bar or works in a wine factory.

Cx:
You came to us with big toe infection and we took some
tests. Some markers on the test came really high especially
liver tests are not up to our expectations. It may be related
to diet and lifestyle habits. Can I ask you a few questions?

Ask the above questions and what he answers, is also


mentioned above. Advise him about
1. Alcohol is notorious to your liver. It starts producing
toxins and causes the liver to be unable to perform
vital functions of the body. Affects even healing process
especially in your case. So you really need to decrease
and ideally quit it, for a healthy life.
2. You can join Alcohol anonymous and other self
help groups where you can meet people in a similar
condition as yourself who all help each other in trying
to quit and these groups are very supportive and
helpful.
3. UK narcotic alliance is another group that helps
people with addiction problems.
4. I can refer you to people who can help you with
different occupational advises in order to stay
healthier. (Mention this if he owns a bar).
5. We can give you anti craving and other medicines
that decrease the withdrawal effects.
6. So are you with me on this? Do you think you can and
will try?

Station 7 (Alcohol addict) Only Hx station


A 30 year old man admitted in medical ward with gastric
erosion. Talk to the patient. Take relevant history about
alcohol dependence.
Fx on Hx taking
1. Patient has been taking alcohol since the last few years.
2. He recently increased the amount since the partner left
him
3. He is a bartender.
4. Tried to stop a few months ago but couldnt.

Questions to ask in a drug/alcohol addict stations


CAGE QTF
1. Cutting down (Have you ever thought of decreasing
the amount you take?)
2. Annoyance ( Are you annoyed/irritable when other
people comment on your habit?)
3. Guilt (Did you ever feel guilty drinking?)
4. Eye opener (Is alcohol/drugs the first thing you take,
when you wake up in the morning?).
5. Quitting (Ever thought of/ tried to stop drinking?)
6. Tolerance (Have you increased the amount you take
progressively over the years?)
7. Free periods (Any alcohol and drug free period so far,
since you started on it?)
8. Ask him what causes him to drink so much?

Continue asking relevant MA FAMISH questions after these.

Station 8 (Drug dependence) Only Hx station


A 25 year old man with opiod dependence, was referred by
GP. Talk to the patient and assess patients suitability for
stop abusing drug.
Fx from Hx taking
1.
2.
3.
4.
5.
6.
7.
8.
9.

Heroine addict
Route = Strating with sniffing, now IV drug abuser
Takes it couple of times a day
Has been an addict since he was 17.
Tried to stop once 5 yrs and then 7 months ago
He is embarrassed about the addition
Sometimes takes it early morning.
Is quite dependent on it (Has to take it).
On trying to quite before, he had tummy pains,
palpitations and diarrhea.
10.He is married and has a kid. Or lives with the gf.
11.He isnt working and living on benefits.
12.My friend helps me buy stuff it.
13.He has had problems with law
14.Mood = 6 to 7
15.No hallucinations
16.Patient has insight.
Take MA FAMISH & CAGE QTF Hx as explained in the prev
stations. If councelling is asked in the question
1. Commend on his intent to quit.
2. Drugs are notorious to ones life and health. Its his
chance to finally stop taking them and the entire
medical team will support and help him.
3. It may not be easy initially but we will give anti
craving meds and meds to decrease the
withdrawal effects which bothered him earlier.
4. He has to be determined fully now about quitting.
Mention self help groups and support groups
where he can meet people in a similar condition as
himself who all help each other in trying to quit and
these groups are very supportive and helpful.
5. We can also help with councelling sections and
psychotherapy if required.

6. Will also give leaflets to help him better.


7. Mention Needle exchange program if the patient
continues to take drugs where they can bring the used
needles to the hospital and they can provide with a
new set of needles in order to stop the spread of
infections in needle sharing incidents.

Station 9 (Panic Attack)


25 years old girl, referred by GP due to being anxious. GP
has done all investigations. Everything is fine and all medical
causes for anxiety have been ruled out. You are the SHO in
psychiatry. Please talk to patient and take Hx.
Fx on Hx taking
1. Patient had c/o heart racing, dry mouth, chest tightness
and shortness of breath.
2. Was divorced 6 months ago
3. Lost job 3 months ago
4. Has 3 kids
5. When I go out especially in crowds, I feel stressed
6. Even last week, I went to a party and had similar
symptoms.
7. No phobia to any particular thing
8. Worried about having a heart problem as well
Questions to ask in this station
1. Since when did these S/S started happening?
2. What started it?
3. Are they related to any particular condition? What
causes these symptoms for you?
4. Any fears?
5. Take relevant MA FAMISH Hx
6. Do you take alcohol/drugs? Excessive caffeine?
7. Any weather preference? Weight loss? (Rule out
hyperthyroidism)
8. Are you tired easily. Any shortness of breath? (Anemia)
9. Does it affect your day to day life? (Rule out
Generalized anxiety disorder)
10.
Rule out depression.
Medical causes have already been ruled out but you
may ask them if you still have time after asking MA
FAMISH Hx.

If councelling is asked
1. Re-breathe into paper bags, when you get these
kind of attacks.
2. We can help you talk to people who can help you
feel better. (Cognitive behavior therapy)
3. We can arrange councelling and psychotherapy
sessions to help you overcome this.
4. We can also give you medication if needed.
5. Well provide you leaflets regarding this problem to
help you understand your problem better and for better
coping with your condition.

Station 10 (Insomnia)
A 65 years old lady comes to the hospital because she had
difficulty in sleeping. Talk to the patient and give necessary
advise.
Questions to ask in this station
1. Do you have problem falling asleep (insomnia) or
staying asleep (depression)?
2. Since when have you had this problem? Elaborate the
event.
3. Anything you think that caused this problem? (Her
husband died 6 months ago). Ask about her mood!
4. Any medical illness? (OA but the pain is controlled).
5. Do you drink excessive tea/coffee? Especially before
bed?
6. What kind of occupation do you have? Night shifts
are common?
7. Is it a shared accommodation that she lives in?
8. How is the room temperature? Do you have heating/
cooling on according to the weather?
9. Rule out D/Ds
Insomnia
Depression
Obsessive compulsive disorder
Generalized anxiety disorder
Bereavement
DM, HTN, Cardiac failure, BPH (in med Hx)
Cx:
You have a condition, that we call insomnia. Luckily we dont
not have to start on any meds immediately unless very
necessary. You can try controlling noise by closing windows
or requesting the neighbors if its loud at night. You can
switch your shift hours for day-time in case you work til late
hours. Avoid taking coffee/tea before going to bed. Drink
warm milk before bed instead .Turn off TV and
tablets/pc/phone if you stay up on them every night. It will
take a few days but you will adjust to the habits. Visit us in a
week if the complaint still persists. Well follow up and give

you medicine after consultant advise. You can also keep a


sleep diary in the mean time.

Station 11 (SSRI)
A 30 years old man was prescribed paroxetine/ fluoxetine 10
days ago. Patient presented to the hospital because he
doesnt want to continue. Please talk to the patient and
address patients concerns.
Fx On Hx taking
1. It was prescribed 10 days ago
2. Dont want to continue, doesnt work for him
Cx:
1. This medicine takes 4 to 6 weeks to start
showing results. You should continue taking it for
now.
2. It is not addictive. If you are worried about
withdrawal effects, we will lower the dose before
stopping it. You wont face this problem.
3. This drug does have S/Es but its not necessary that
you will have them. Some of them are diarrhea,
headache, feeling of sickness, drowsiness or
rarely bleeding in the gut. It may cause vaginal
dryness and erectile dysfunctions in males as
well. But we will counter them if they happen, and on
the whole the benefits of carrying on with this drug
are far greater than the S/Es.
4. In case you do get S/S e.g. anxiety, sleep problems,
diarrhea, tummy pain or nausea, we may reintroduce
it for a while and stop it again. Then youll be fine.
5. Avoid taking aspirin, warfarin or NSAIDS.
6. You should never stop this drug on your own.
You will have to come to the hospital where you will
be admitted and the medicine will be tapered off
under supervision.
7. If you ever have thoughts of causing self harm,
come to the hospital immediately. (Rule out MISH
Mood, insight, suicide tendencies and hallucinations).
8. Most important contraindications of this medicine is
suicidal tendencies.

Station 12 (Post partum psychosis)


A patient will present with this condition.
Only triggering point in this case is the child birth.
Hx Questions to ask apart from relevant MA FAMISH
I am very sorry. I will ask you a few questions to get
to the bottom of this.
1.
2.
3.
4.
5.

Was this pregnancy planned?


Are you and your partner happy?
Any complication during or after labor?
Who takes care of the child?
Do you get any feelings as that would be harmful for
the baby? Do you feel like anyone putting any thoughts
in your mind?

Cx:
1. Well like to admit you
2. You are having a severe form of depression.
3. Will have to give you treatment which isnt child
friendly so baby will be kept away from you for a
while.(We say this as an excuse to keep mom away
from the baby for a while.)
4. If you dont have anyone to take care of the child, he
can be taken care of in the hospital under the best of
nurses. He can be kept in a separate ward right here.
Post natal blues: Changes in hormones after child birth
causing mild depression.
If they persist > 2 weeks, its post natal depression.
If thoughts of harming the child are there as well, then its
post partem psychosis.

Station 13 (Depression)
A 32 year old female patient, with low mood, lost her
husband a few months back. Take history and council her.
A patient with rheumatoid arthritis complains of insomnia.
He is on medications. Take history and councelling.
(In the 2nd station, also ask since when the patient had RA
and if she is taking meds and if they are effective or not.
Also if the pain is controlled or not and then the MA FAMISH
Hx)

1. Offer confidentiality in almost all stations. Say the line


Whatever you say will remain between you and our
medical team otherwise patient may not talk or tell you
much.
2. Sympathize/empathize
(MA F(4)AMISH)
3. Mood (ask him to grade mood from 1 to 10, 1 being the
lowest and 10 being the highest mood.)
4. Anhedonia (Loss of pleasure in activities that
previously meant a lot or he/she loved.
5. Family (is the family close/loving/supportive?)
6. Friends (Does he/she have friends to hang out with
and he is close to)
7. Finance (Does he have any financial troubles at
home?)
8. Forensics (Has he/she ever been on the other side of
the Law? Convicted for some crime?)
9. Alcohol and recreational drugs
10.Med Hx and past psychiatric hx (Has he ever had
to take councelling sessions before?)
11.Insight (Do you think you need help or that we might
help you?)
12.Suicidal tendency/Stress (Have this problem led you
to think that life has lost its worth. How do you see
yourself in the future? Has it become difficult for you to
plan for the future?)

13.Hallucinations + delusions (When people are going


through hard phases, they tend to experience
sometimes, seeing and hearing things that is hard for
others to experience. Has this happened to you? Do you
have any thoughts or ideas you may have hard time
convincing your family/friends of?)

Cx:
It seems you have a condition we call depression or low
mood. (Assess if patient needs admission or not after ruling
out MISH from the Hx and council accordingly). There is
usually a chemical or hormonal imbalance in the body which
causes one to feel like this sometimes. However we will do
some investigations (if med causes arent ruled out) and
dont worry. We will help you (Cognitive behavior therapy)
and you will sit and be able to talk to one of our colleagues.
He will listen to your problem and talk to you and will
hopefully be able to change any negative views you might
be having. If that doesnt work, our consultant might put you
on some medication. We will also encourage you to go for
self help group sessions. Once you feel better, try improving
your social life, adopt hobbies, socialize and make friends.

Station 14 (Bipolar disorder) Pilot Station


A 30 year old female presented to the A & E because she cut
her wrist. Patient is medically stable now. Nurse noticed that
she was acting strangely. Talk to the patient and discuss Dx
with the examiner.
Fx on Hx taking
1. Doctor, I was going out to a party with my friend and I
realized I needed a pair of shoes.
2. Unfortunately all shops were closed. I smashed a
window and took shoes.
3. Since 2 weeks now, my mood has been excellent.
Never felt better.
4. I have spent a lot of money recently. I have been going
out and enjoying a lot.
5. Regarding insight, she says the idea of smashing the
window wasnt acceptable and was wrong. Otherwise
she did nothing else wrong.
6. I used to study at a uni. 1 year ago I left and was real
depressed for a while and cried a lot.
7. Live with family. Not that supportive.
8. I am bankrupt and have used all my credit.
9. No suicidal thoughts. No hallucinations.

Pediatrics (Common Stations)

1) Inconsolable Cry (Distressed mother)


(Hx + Cx)
2) Non accidental injury
a) (Scald on chest)
Hx + Mx (with examiner)
b) (Scald on buttocks) Hx + Mx (with examiner)
c) (Fracture femur) Hx + Mx (with examiner)
d) (Telephone conversation)
3) Fits
Febrile Convulsions (Hx + Cx)
Unknown (Hx + Cx)
Epilepsy (Hx + Cx)
Hypoglycemia (Hx + Cx)
4) Fracture Femur + Ruptured spleen (Breaking bad news) Cx
5) Unconscious patient
Vasovagal (Hx + D/D)
Head injury (Hx + Mx)
6) Delayed walking (Hx + D/D)
7) Spacer device (Cx)
8) Foreign body (Hx + Cx)
9) Celiac disease (Cx)

In peadiatric Hx, 4 questions in History pattern (P3


MAFTSA) are added!
After past Hx, take birth, immunization, developmental
and Hx regarding bladder/bowel habits and diet.

Station 1 (Inconsolable Cry) Infantile Colic


3 months old child was brought to the hospital due to
excessive cry. This child was discharged last night by your
consultant because all the investigations including FBC, CSF
and USG were normal and your consultant believes theres
no serious condition. Mother of the child tells you that the
child has been crying since 5 am and thats why she brought
to the hospital again. Talk to mom and address her concerns.
Note: You arent just dealing with a crying baby but
distressed mother as well. Do not forget to
sympathize/empathize.
Could you please tell me what happened?
Have you noticed any change since the consultant
last saw you? (Rule out meningitis (Vomiting & neck
stiffness) and intersucception (pulls legs towards chest while
crying) if you want!)
Am sure you fed your little one. Is that right?
Am sure you change his nappy on time. Is that right?
Did you try to distract your little one by taking him
out?
Am sure you burped your little one, is that right?
Did you try distracting your little one with washing
machine or hover etc?
Do you breast feed or bottle feed? If she says yes to
bottle feed, tell her some foods contain a substance called
lactose which some kids/people arent able to digest and
maybe that is why babys crying. Try changing the milk to
lactose free.
You can also try giving two harmless medications that come
by the name of infacol or gripe water. You may try them
and they may be helpful.

Mom: Is it normal for the baby to cry like this? What is the
cause of this excessive cry?
Dont worry. Your little one probably has a condition
we call infantile colic in which baby cries excessively
but is healthy otherwise.
Mom: What can cause this colic?
Some research shows this may be related to change in
levels of some substances that effects movement of
gut. There is another theory in which they say theres an
abnormal balance of bugs in the babys gut which
gradually corrects itself in a few weeks.
What to do for mom?
Note: Please look at moms actions and face. If shes
trying to tell you shes too tired or exhausted ask her, if she
has anyone else at home to take care of the baby.If she says
no and tells you she has other kids as well, tell her:
If you dont mind we can keep your little one in the
hospital for tonight. We will take care of him. This
admission isnt because of medical conditions. This is
so that you may be able to rest and be stress free for
a night about the baby.
Advise if this happens in the future, call cry-sis line, talk to
health visitor or contact her GP.
If mom tells you she has someone at home who call help
look after the child or she isnt tired, then dont offer
admission.
Reassure the mom again its not serious.

(Non Accidental Injuries)


Presentations in NAI
Symptoms do not match the story
Unexplained injuries
Late presentations
Inappropriate immediate action
Having other carer apart from biological father/parents
X ray showing calluses with no previous medical history
explaining the injuries on X Rays
Odd behavior from parents.
Dysfunctional family
Hx of many recent admissions
Odd behavior from the child e.g. after sexual abuse.
Ask about birth of the baby, if it was planned or not.
Questions to ask in NAI
1. Make the parent to elaborate the event. Explain the
event in detail
2. Ask about time of incident
3. Ask about moms action after incident
4. Ask about who takes care of the baby. Check if
biological dad or not
5. About any other unexplained injuries found, look at
moms response/reactions
6. Any change in behavior of the baby
7. Pregnancy regarding this child was planned or
unplanned
8. Was birth complicated or without complications
Mx:
1.
2.
3.
4.
5.
6.

Admit the baby.


Give pain killers and do dressing if any wound.
Do x-rays if suspecting fractures and refer to ortho
Do coagulation profile if unexplained bruises.
Do skeletal survey if unexplained fractures.
Ask seniors to check childs name in the child
protection list
7. Ask consultant to confirm this as NAI & involve
social services if needed.

Station 2 (Non Accidental Injury) Scald on the


Chest
4 years old boy brought to the hospital with a scald on the
chest. Talk to the mother and discuss your management
with the examiner.
What happened?
The mom tells you coffee dropped from the table while baby
pulled the cloth. Thats how he burnt his chest.
What did you do after the incident?
Doc, it happened this morning and it didnt look that serious
so I didnt do anything. I took my kid to school after 1 hour.
They called me from school and told me that the baby was
crying.
Who takes care of your little one?
Usually I take care of my baby. The father of the baby is a
van driver so not at home usually. So I have to take care of
him and my other child as well.
The pregnancy was planned/unplanned. No difficulty during
birth.
Mom: What are you going to do for my little one?
We have to keep your little one in the hospital to manage
the burn.
(Mx with the examiner)
Ill admit the child. I am suspecting NAI but it can be
accidental as well. Ill manage the burns by giving the
child pain killers and dressing his burns after
cleaning. Ill discuss with my seniors and ask them to check
this childs name in the Childs protection list. Ill ask my
consultant to confirm this as NAI and involve social
services if necessary.

Station 3 (Non Accidental Injury) Scald on the


Buttocks
4 months old boy brought to the hospital with a scald on the
buttocks by mother. The nurse noticed some bruise on the
arm as well. You are an SHO in the A &E. talk to the mom and
discuss Mx with the examiner.
What happened?
Doctor I was going to give my little one a bath, but I forgot to
open the cold water tap. Baby started crying and I realized
what I had done. I was kinda tired at that moment.
What did you do?
It happened an hour ago and I rushed him to the hospital.
There was a traffic jam (is the excuse given if she is late).
Me and his father takes care of the baby.
It was a planned pregnancy and birth was normal.
Mom hasnt got any idea about the bruise.
(Mx with the examiner)
Ill admit the child. I am suspecting NAI but it can be
accidental as well. Ill manage the burns by giving the
child pain killers and dressing his burns after cleaning.
Ill send for the coagulation profile of this baby. Ill
discuss with my seniors and ask them to check this
childs name in the Childs protection list. Ill ask my
consultant to confirm this as NAI and involve social
services if necessary.

Station 4 (Non Accidental Injury) Fracture


Femur
2 years old boy brought to the hospital by his mother. Theres
a swelling on the leg. You are an SHO in the A & E. Talk to the
mother. Discuss Mx with the examiner.
How did it happen?
I am a night shifter. Work at a 24 hour shop. Last night I had a
shift and when a came home this morning, the child was
crying. While I was changing the nappy, I realized there was a
swelling on the thigh.
Who takes care of the child? Did you ask your
bf/partner regarding this bruise?
My bf does as well. I asked him but he didnt know or he was
sleeping is her answer.
Ask how soon she brought the child to the hospital and
the rest of the questions.
(Mx with the examiner)
Ill admit the child. I am suspecting NAI but theres a
small chance of accidental as well. Ill give him pain
killers and do X ray. If fracture is present, will refer him to
ortho. Ill discuss with my seniors and do a skeletal survey
in the child and ask them to check this childs name in the
Childs protection list. Ill ask my consultant to
confirm this as NAI and involve social services if
necessary.

Station 5 (Non Accidental Injury) Telephone


Conversation
6 months old child was brought to A & E. theres swelling on
the arm. X Ray has been done and shows humerus fracture. X
ray also shows callus bone formation in ribs. You notice some
bruise on buttocks, You talked to the mom and she told you
her little one fell down from sofa. She takes care of the little
one with a partner who is the biological father of the baby.
Pregnancy was unplanned. After taking history, during
investigations and examination, you suspect NAI. Please talk
to peads consultant on the phone.

Pick up the phone up

Greet the consultant

Tell him your GMC number. You will be wearing the


batch.

Identify he is the right person


Explain the case in terms of Clinical presentation
and Hx. What you did for investigations and what you
picked up during examination. (All will be mentioned in
the task paper).
Explain what you have done so far
o I took History and did investigations as I mentioned
earlier. I did the X ray and on noticing the
fracture of humerus, gave him painkillers and
referred him to ortho. I also noticed a bruise and
so sent for coagulation profile. Ill ask the
seniors to check the childs name in the Child
protection list as theres callus bone formation in
ribs present on chest X ray of the child.
I want you to kindly come and confirm if its a NAI
and involve social services accordingly.

Station 6 (Fits) Febrile convulsion


2 years old child had a fit episode. He was admitted 24 hrs
ago with c/o some URTI or ear discharge in the last few days
so he was unwell and he had c/o fever and vomiting. Dx of
febrile convulsions was made already. Talk to mom and
confirm your diagnosis. Address patients concerns.
In this station please rule out:
1.
2.
3.
4.
5.

Meningitis
DM (hypoglycemia)
Epilepsy
Head injury
Ask about fever

What happened? How long was the fit?


Doc, my little one had fever/flu like symptoms. I brought my
child to the hospital and he was admitted.
From what you told me, your little one has febrile
convulsions and it happens when fever is high.
What is that?
Febrile convulsions happen in kids at age of 6 months to 5
or 6 years. This is not a serious condition as long as the
fit doesnt last long. Usually children grow out of this
condition and this doesnt lead to epilepsy.
Mom: Is it serious? Future occurance? Prevention?
As long as you control the fever, thats fine. You can use
paracetamol for that. However if theres ever an episode of
fit, during this fever, put the child in the recovery
position and turn the child to his side. Do not give him
any food/drinks while he is having fits or dont put
anything in his mouth. Remove any sharp furniture from
around and try to remove the clothes and open the windows
once fits subside.
Shall I give my little one any medicine?

Yes you can give him paracetamol (calpol) whenever you


feel like he is building fever because that is what causes this.
It will control the fever and prevent fits from
occurring.
Note: Rectal diazepam is only used in recurrent fits or if the
hospital is 2 hrs away from the patients house. Do not
mention it if the patient doesnt ask about it herself.
Reassure her its not epilepsy even if she gives you the
finding of eyes rolling or biting of the tongue since it says in
the task that febrile convulsions has been diagnosed.
Epilepsy is due to brain abnormality. Febrile
convulsions are due to febrile illness.

Station 7 (Fits) Unknown Cause


4 years old boy brought to the hospital with fits. Talk to the
mom and address concerns.
Fx on Hx taking
1. It happened when we were in the shopping plaza.
2. It took 2 to 3 minutes.
3. I am not sure child had fever earlier or not. But I am sure
he had fever afterwards.
4. He had a jerky movement and it was the 1st time this
happened.
5. Wet himself (+-)
6. Confusion after fits (not sure)
Make the mom explain what happened before and
after this event and take a detailed Hx for fits and rule
out D/Ds:
1. Febrile Convulsion
2. Epilepsy
3. Febrile Convulsion
4. Meningitis
5. SOL
6. Head injury
7. Hypoglycemia
Mom: What are you going to do for me?
Ill admit your little one to run some investigations to
figure out the cause of fits. Well do some blood tests. We
will do a 24 hrs EEG and other tests e.g. CT scan, CSF
(Culture & sensitive) if the consultant feels a need for them to
be done.
We will keep your child under neuro observation. If
everything is fine, it might be febrile convulsions, which is
fits caused in child due to fever. Explain how its not a serious
condition and can be prevented in the future.
Note: In this station, Hx sometimes point towards epilepsy
(especially if he wets himself). Tell mom you suspect epilepsy

then from the history that she gave but you are not sure and
will confirm only after you have run the investigations.

Station 8 (Fits) Epilepsy


4 years old boy brought to the hospital with fits. This child is a
known case of epilepsy. However his epilepsy is poorly
controlled. Talk to mom and address concerns.
Questions you must ask
1. Since when was the epilepsy Dx?
2. Any change in the pattern of fits?
3. Medications the child is on? (Ask if she knows their
names)
Is he taking them regularly as prescribed?
Who supervises the meds?
Do you remember any dose missed?
Have you recently started any new meds?
Any over the counter or herbal meds the child
maybe on?
4. Any vomiting, diarrhea or weight gain recently? (the
meds dose needs to be increased in a growing child)
5. Trigger questions (Does he watch too much TV, play
video games or stay up watching stuff til late? Does
he sleep properly? Does he skip meals? Is he exposed
to flashing lights ?
6. Is he complying with meds? Ask if he suffers from any
S/Es because they meds can be switched in that case or
doses adjusted.
7. In general advice, talk about trigger findings and
council the mom against the factor causing him to have
more regular fits especially if he plays or watches til late.
8. Mention bracelet that he should always be wearing
(Being epileptic) + inform GP + School nurse of the
childs condition.

Station 9 (Fits) Hypoglycemia


2 years old baby had a fit. Investigations have been done.
This patient was admitted. Blood sugar is 1.4. Child is a k/c of
DM and takes insulin. Dx of hypoglycemic fit was made. He
was unwell in the last 2 days and had fever and vomiting. Talk
to mom and discuss primary and secondary management.
Mom gives 3 scenarios:
1. This morning my little one had fits. I gave him insulin
even when he couldnt have breakfast properly. I forgot
to check RBS. 10 to 15 minutes after giving the insulin,
the fits started.
2. He didnt eat last night properly as well. He was busy
playing with his cousin. And in the morning he had the fit
after my giving of insulin.
3. I gave my little one breakfast this morning.
Unfortunately he vomited. Nurse told me to always
check blood sugar before giving it and I did but it was
normal. I gave insulin.
Cx:
I am sure youve done your job properly. But as you know,
when your little one vomits, it takes time for blood sugar
levels to drop and hence the glucometer cant pick it up
straight away. When your little one vomits and you give
insulin as well, blood sugar levels drop more.
In the future, if he is unwell or vomiting, bring him to
us immediately and do not give insulin yourself.
Keep looking for hypoglycemic signs in the future:

Sweating
Drowsiness
Tremors
Change in behavior

Please give him sugary drinks straight away if you see


the above symptoms.

Station 10 (Femur fracture & ruptured spleen)


Breaking bad news
A 10 year old child had an RTA on the way back from school
to home. The father was informed by schools staff about the
incidence. You are the SHO in the A&E dept. you have done
the X Ray which shows femur fracture. USG showed spleen
rupture. Please talk to the patients father and address his
concerns.
Do you know what happened? (Break the news in
layers and ask for what he knows about the situation
already).
Explain how you did X ray and it showed femur fracture
but you have given pain killers and hes in safe hands
now. We also referred the child to the ortho team wholl be
taking care of the fracture.
We also did ultrasound and that showed a ruptured
spleen which will have to be removed. Spleen is an organ
about the size of a clenched fist in upper left tummy. The
main function is to filter blood, create new blood cells and
store some type of blood cells (platelets). It also has an
important role in our bodys immune system. For now, your
child is in the hands of expert surgeons but he is in a
critical condition. (Sympathize/empathize continuously).
Dad: Can he live without the spleen?
When we remove the spleen, the patient usually have an
increased risk of developing serious infections like
meningitis. So we give them jabs, some regular antibiotics
and some strong antibiotics anytime we suspect even the
smallest infection. (You should be careful if ever travelling in
the future as the child will need prophylaxis or some extra
meds).
Dad: Doc will he die?
Even though he is in a critical condition but just know he is in
the hands of a team of experts and his pain is

controlled. Let me tell you what we plan on doing.. (Divert


his mind from this question as you cannot say a yes or a no).
Then talk about antibiotics and the surgery.
Can I see my little one now?
Yes, as soon as we are done with the surgery. Look your little
one is going to have an operation in the OT. If we let you in, it
increases the chances of him acquiring infections as more
people mean, more chances of spread of bugs in the theatre.
If he insists, tell him you will ask your seniors and he will have
to be gowned and prepped.

Station 11 (Unconscious Patient) Vasovagal


Syncope
A 12 year old boy/girl went unconscious in the school
assembly. He was brought to the A &E by her mom. You are
the SHO in A & E dept. Talk to the mom and discuss Dx or
D/D with the examiner.

Fx on Hx taking
1. The patient became pale before going unconscious
2. He was standing for a while before going unconscious
3. There was no fits, no confusion and no fever after being
unconscious.
4. If there is a Hx of fits, its usually for 2 to 3 minutes with
no previous Hx.
D/Ds to rule out:
1. Vasovagal syncope
2. Meningitis
3. Epilepsy
4. AF/Arrythmias
5. Hypoglycemia
6. DKA
7. SOL
8. Head injury
Elaborate event by detail
1. What happened before the event?
2. During loss of consciousness, ask if there were any
fits? Duration? Other S/S?
3. S/S after events?
4. Any site of bleeding?
5. Ask about DM (FOR HYPOGLYCEMIA), any cardiac
conditions or epilepsy?
Child was standing and duration of LOC < 5 minutes, getting
pale before collapsing.

Station 12 (Unconscious Patient) Head Injury


A 9 months old brought to the hospital by her mom. The kid
went unconscious at home. Talk to mom and discuss your Mx
with mom.
Fx on Hx taking
1.
2.
3.
4.
5.

Child fell down from sofa while mom was in the kitchen.
Went floppy and unconscious for 2 minutes
2 episodes of vomiting.
No external bleed or lacerations
No S/S of any focal or neurological deficits.

Indications for admission (General Knowledge)


1.
2.
3.
4.
5.
6.
7.

GCS <15
Any unconsciousness?
Any amnesia?
Any focal or neurological deficits
Any vomiting?
Any change in behavior or altered behavior?
Rule out NAI

Cx:
From what you have told me, your little one went
unconscious because of head injury. Everything so far is
fine. However ill admit your little one to run some
investigations and to keep him under neuro
observation. Well do CT Scan if necessary.

Station 13 (Delayed Walking) Constitutional


Delay
A 2 years old child brought to the hospital because of
difficulty in walking. You are the SHO in outpatient clinic in
pediatrics department. Talk to the mom, Miss Alient and
discuss your D/D with the examiner.
Fx on Hx taking
1. Patient started smiling at 3 months, neck holding at 4
months, sitting at 6 months, crawling at 9 months and
starting saying words like mama at 1 year.
2. Baby stands by taking support from the sofa
3. Birth was without complications.
D/Ds and questions to rule out:
1. Constitutional Delay
2. Cerebral palsy (Hx of complicated birth)
3. Congenital hip dislocation (When changing nappy, do
you notice any lump or hear a clicking sound around hip
or other joints?)
4. Muscular dystrophy (The child has to be 4 yrs to have it
but you can ask if baby tries standing up by putting
hands on knees first)
5. Malnutrition/malabsorption
6. Chronic infections
7. Septic arthritis (Any pain or swelling over a joint)
8. Rule out milestones and ask if anyone else in the family
started walking late?)
9. Ask if he ever walked before?

Station 14 (Spacer Device) Councelling


A 4 years old child was diagnosed with asthma. All the meds
have been explained. Talk to the mother and address her
concerns regarding spacer device usage.

Are you the mother of (child mentioned in the task)?


How may I address you?
Introduce yourself
I am really sorry to hear how your child was diagnosed with
asthma. Dont worry, I understand your concerns (in case she
shows any) but one of my colleagues will come and explain
the meds (inhalers) to you and discuss in detail any concerns
regarding them (incase the task doesnt mention them as
already been explained).
I am here to talk to you about this thing here we call as
spacer device. It assists in giving the inhalers properly
to kids, who cant take them directly otherwise.
Its either 2 plastic conical pieces joined together or
just one cylindrical piece with a mouth piece and an
end to attach the inhaler at. There is sometimes a
pediatric mask attached at the mouth end as well, in
order to assist the child in taking the medicine, as making a
tight seal for them around the mouth piece is hard.
Just make sure before giving the inhalers, that you check its
expiry date and shake it well. If its new, you should
release the first puff and fix it to the end of the spacer
(which is made for the inhaler).
Dont touch the mouth piece but ask the child to make a
tight seal around the mouth piece by closing mouth over it
properly or simply just fixing the mask if available, over his
mouth and nose.

Each breathe he takes in and out, youll hear a click. 1 puff


should be = to 20 clicking sounds. Give the puffs according to
prescription.
Make sure an adult is always supervising and helping the
child take his meds. Have you understood what I told you? Do
you need to ask anything?
Mom: What if the child starts coughing?
Dont worry. Just take it out of his mouth and let him
cough. Theres a valve which only works one way so the
medicine is still inside. It will still work when he places it in
his mouth. Just make sure you start counting the clicking
sounds from 1 again and make sure inhaler is intact.
Mom: When do I know the spacer isnt working?
When you cant hear the clicking sounds or it appears to be
broken or stained.
Mom: How should I clean it?
The frequency of cleaning depends on usage so if you use it
much, clean it once a week or otherwise, once in 2 to 4
weeks. Use luke warm water and a soft clean cloth to clean
and dry it. Theres no need to use strong detergents.
Mom: What if my child is afraid to use it?
It comes with stickers on now but the child can put his fav
stickers. Let him take it in his hands but make sure he doesnt
play with it like a toy.
Mom: How to explain a tight seal?
You dont have to. Request a pediatric mask if its not
already available from the GP. Fix it on the mouth piece.
When he starts breathing, you should still hear the clicking
sound.
Mom: My child goes to day care!
Request a duplicate spacer and inhalers from your GP and
give it to the day care staff or they can directly request us as

well since the child might need his meds at any time. They
already have been trained to help kids in such situations.
Advice:
Always supervise. The patient has to be standing or sitting
propped up and spacer device should be straight. Ask
mother to demonstrate all that you told her or you
wont pass. Child can rinse mouth after inhalers are taken.
Use one spacer for both inhalers and dont have to wash it
every time.

Station 15 (Foreign body ingestion)


A 2 years old child brought to the hospital by mom. The mom
told you the baby had swallowed some foreign body. Please
talk to mom and discuss your Mx and address the patients
concerns.
Fx on Hx taking
What happened? Explore into the event!
He was playing about 4 hours ago. I was in the kitchen and I
saw he started coughing and choking. Sometimes mentions
him going blue for a while. I found my wallet around the little
one. In the wallet there was a coin.
Was there anything else in the wallet like a button
battery?
No.
As you told me, your little one swallowed a coin 4 hrs ago and
since he stopped coughing straight away, its unlikely to be
stuck in his wind pipe. It might be in his food pipe,
stomach or gut. We would do some investigations (X ray
may be given) in order to check its location and if its still in
the food pipe, we can take it out using a flexible tube with
camera attached to it and we will give him some numbing
agents and put him to a mild sleep in case that is required.
If the coin is in the stomach, theres no need for
undergoing any of that since the coin is not sharp, poisonous
and theres little chance of it getting stuck anywhere when
passed through the gut. What you should do is track your
little ones poo for next 48 hrs. (X-ray on the laptop
showing coin in the stomach)
Warning advice
However if he starts to cry or you notice any pain in
tummy, any vomiting or no stool is passed or tummy
feels distended, then immediately bring him back to the
hospital.

General Advice
Please put your things in the safe box from now on. Kindly be
more aware regarding childs doings from now on and dont
leave him alone even when answering phones or opening
doors.

Station 16 (Celiac Disease)


A 5 years old child was diagnosed with celiac disease. Talk to
the dad and address his concerns.
Ask dad if he knows whats going on? Disclose the
disease and explain it.
It is a condition that causes inflammation in the lining of
small intestine or small bowel. It is an autoimmune
disease. In autoimmune disease, your immune system
(which helps you fight bugs and foreign bodies) produces
some substances against your body. In this disease, the
antibodies or substances are formed against a
substance called gluten which when ingested, leads
to inflammation of the lining of small bowel.
Celiac disease can sometimes run in the families. People
with this disease, should be put on gluten free diet. Foods
containing gluten are wheat, barley and ray. Even a
small amount of gluten can be dangerous and bring
about many complications. This disease is more common
in people who have conditions such as RA, DM and thyroid
problems.
The main S/S of celiac disease are diarrhea, pale and
bulky stools, smelly stools which are hard to flush and
tummy pain.
Complications of Celiac disease:
1. Poor absorption (Deficiency of vitamins, Fe and
minerals).
2. Poor growth in baby (Please dont give gluten
because hell be fine otherwise). It is dangerous to give
even a little bit so avoid it.

3. Osteoporosis (Thinning of bones).


4. Lymphoma (Type of CA) Mention it in the very end.
5. Development of other immune related diseases
e.g. DM, under active thyroid and PBC.
6. Some people are more likely to have celiac disease.
They should have some investigation tests done even
with no S/S. e.g. people with DM, close relatives and
siblings, Thyroid and RA probs.
Investigations:
1. Blood test to check antibody.
2. Endoscopy + biopsy
3. Dexa scan (to rule out osteoporosis)

Treatment
1. Avoid gluten diet for life
2. Refer to dietician
3. Taking supplements e.g. Fe, Ca, Vitamins in next 6
months
4. Using some jabs because spleen in this condition
doesnt work properly sometimes.
5. Important to have follow up every 3 to 6 months.
Questions asked by dad!
1. What is celiac disease?
2. What is gluten?
3. What are you going to do for my little one?
4. If he says he cant afford buying gluten free diet tell
him GP will prescribe it for him, so he wont have
to pay and so he shouldnt worry.
5. Will it be dangerous to give even a little gluten? Should
he remain on a gluten free diet for his whole life? Yes
6. If the child was sent to some friends house or party ->
Its best he carries his own food as if the food
there contains a small amount of gluten, it would
be dangerous.
7. Complications?
8. Why he got this condition? Explain autoimmune
disease.

9. I have Ulcerative colitis. Do you think he inherited it


from me somehow? Theres no direct link btw
these 2 conditions!

Pediatrics (Uncommon Stations which still


come)

10) UTI
(Hx + Cx)
(Cx)
11) Ear infection (Antibiotics request)
12) Viral Diarrhea (Telephone Conversation)
13) Per rectal bleed
(Hx + D/D)
(Hx + Mx with examiner)
14) Peanut Allergy
(Cx)
15) Vomitting
(Hx + D/D) 4 years old
(Hx + D/D) 4 months old
16) Juvenile DM
17) Rash (ITP)
(Hx + D/D)
18) Vaginal bleed
19) Needle stick injury
20) Heart Murmur (Pilot)

Station 17 (UTI)
A 4 years old child presented with fever + vomiting. Talk to
mom and address her concerns.
A 5 yr old boy was crying while passing urine. Urine test has
been done and shows nitrates. You suspect UTI. Talk to mom
and address concerns.
Fx on Hx taking
1.
2.
3.
4.

Fever from last 2 days


Vomiting since morning
Crying while passing urine
Going frequently to pass urine. Changing frequent
nappies.
5. 2 episodes of same S/S recently.
D/Ds to rule out:
1. UTI
2. G/E
3. Intestinal obstruction
4. DKA
5. Meningitis
6. URTI
7. Ear infection
8. SOL
Cx:
From what you have told me, your little one has UTI which is
a condition in which bugs grow in the bladder and
surrounding organs. Well do some investigations like
urine test, ultrasound and may consider doing some
other special tests as well (MSU) in order to confirm our
Dx.
For Tx, we will consider giving antibiotics, pain killers
and will ensure for him to take plenty of water/fluids.
Ask the mom about any allergies he might be known to
have regarding meds!

Child should be toilet trained. He should regularly go to


the toilet and not wear tight underpants.

Station 18 (Ear infection) Antibiotics


requested
A 5 years old child presented with fever + runny nose.
Father thinks he had an ear infection because the child was
previously seen by the GP and the GP gave him some
antibiotics to treat the ear infection. Dad insists on
antibiotics. Talk to the dad and address his concerns.
Fx on Hx taking
1.
2.
3.
4.

Boy has low grade fever since 4 days


No discharge from the ear
Cough and runny nose since the last few days
Father thinks he has an ear infection and believes
should be prescribed antibiotics.

Note: Anytime theres fever in the child, rule out


meningitis.
Cx
This is not an ear infection. You have mentioned no
discharge or any redness or swelling over the ears. This is
just flu as he has a runny nose. The bug causing this
condition doesnt respond to antibiotics. If we prescribe
him unnecessarily, this can cause resistance in him
against the antibiotic and if for some reason he does need it
in the future, the antibiotic wont work on him then.
Dad: So you are giving no meds?
We will give paracetamol to control fever and will advice
for him to take plenty of water.
If for some reason fever increases or child gets any ear
discharge or any signs of vomiting with neck stiffness,
please bring the child back immediately to the hospital.

Station 19 (Viral Diarrhea) Telephone


Conversation
A 15 months boy has diarrhea for last few hours. Mom is
worried. She called the hospital. Talk to mom on the phone
and address her concerns.
Fx on Hx taking
1.
2.
3.
4.
5.
6.
7.
8.
9.

Child had loose stools 2 to 3 times in the last 12 hrs.


No high grade fever
No vomiting
No blood in stools
No tummy pain
No lethargy. Child isnt drowsy
He can take water and food
Mom can manage it at home
Mom has diarrhea as well

Note: Anytime see blood, assess anemia. Anytime see


diarrhea, assess dehydration
Imp questions to ask
1. Can he drink water and take diet?
2. Is he playful or drowsy?
3. Can you manage at home?
D/Ds to rule out:
1. Viral diarrhea
2. Bacterial diarrhea (Tummy pain + bloody stools)
3. Milk allergy
4. UTI
5. Some medications Hx
Cx:
Explain to the mom how this is viral diarrhea. There is no
need for admission as your little one has no problem
having water and food. There appears to be no signs of
severe condition from what you have told me. Explain how
this condition is self limiting. Can you take care of the
baby yourself? If not, bring him to the hospital. In case you

notice any drowsiness or he stops to take feed and is


all lethargic, immediately request an ambulance or
bring him over again.

Station 20 (Per rectal bleed) Gastroenteritis


11 months old child has bleeding in stools. You are the SHO
in A & E. Take Hx from mom and discuss D/D with examiner.
Fx on Hx taking
1.
2.
3.
4.

2 to 3 episodes of loose stools since yesterday


No vomiting
No high fever
She says yes to red jelly stools (even when she doesnt
know what they are)
5. She says yes to feeling a tummy mass
6. Other members of family have it as well.
7. No change in diet.
8. On formula milk.
D/Ds to rule out:
1. Bacterial diarrhea (G/E) (Tummy pain + bloody
stools)
2. Viral diarrhea
3. Intussucception
4. Intestinal obstruction
5. Milk allergy
6. UTI
7. Foreign body ingestion
8. Trauma

Station 21 (Per rectal bleed) Intussusception


9 months old child presented with bleeding per rectal. You
are the SHO in emergency department. Take Hx and ask
about some Fx from examiner and discuss your
management.
Fx on Hx taking
1.
2.
3.
4.
5.
6.

Red jelly stools present


Tummy mass present
Baby bends the legs towards chest
Ultrasound reports shows abdominal mass
Tachycardia HR: 140
Ask about any other member with same S/S

D/Ds to rule out:


1.
2.
3.
4.
5.
6.
7.

Intussusception
Bacterial diarrhea (Tummy pain + bloody stools)
Viral diarrhea
Intestinal obstruction
Milk allergy
UTI
Trauma

Mx:
Admit this child. After all relevant investigations are
done, the consultant may go for
Air Enema or Surgery.

Station 22 (Peanut Allergy)


A 9 yrs old child has been brought to the hospital by mom.
Mom noticed he had developed some rash over the skin,
itching, SOB immediately after eating some peanuts at a
restaurant. Dx of peanut allergy was made. Nurse colleague
explained how to use epi pen. Talk to patients mother and
address concerns.
Nuts and peanuts can cause allergic reactions. This
happens when your bodys immune system which
normally fights against bugs, over-reacts to substances
like nuts and peanuts and release a substance called
histamine.
This substance cause tiny blood vessels to leak fluid,
leading to swelling and other S/S.
Chance of getting it in another child of yours, if one already
has it, is more, compared to the normal population.
If you are concerned about your other kids, we can
refer them to allergic clinic. They can run some
investigations e.g. skin prick test or blood tests or some food
challenge test.
If you have atopy (group of allergic conditions e.g. hay fever,
asthma, eczema etc) you are more at risk of having peanut
allergy. Allergic reactions can be mild or severe.
Mild S/S (General knowledge. Explain if patient asks)
1.
2.
3.
4.

Tingling in the mouth, lips and throat


Rash
Swelling of the face
Colicky pain in the tummy
We give antihistamines or anti allergic meds for
most S/S.

Severe S/S:
1. All no 1 to 4 +
2. Wheeze and difficulty in breathing

3. Skin redness
4. Heart racing
5. Low BP
Use epi pen as explained already in the case of above
S/S and bring the patient to hospital.
Prevention:
1. Please when you buy products, check the
labeling properly. It shouldnt contain any nuts.
2. When you eat out, again be careful about having
nuts in meals/food.
3. Take or pack your own food to parties just in
case you are not sure if what they will provide will
not have nuts.
4. Inform school nurse, and ensure little one
doesnt accept food with nuts from friends.

Station 23 (Vomiting) DKA/DM


A 4 yrs old boy presented with vomiting, polydypsia and
polyuria. Please talk to the patient's parent and discuss D/D
with the examiner.
Fx on Hx taking
1.
2.
3.
4.
5.
6.
7.
8.
9.

Father has DM
Hx of passing more urine than usual
Lethargic. Not playful as before.
Hx of drinking more water
Hx of vomiting
Hx of URTI 2 weeks ago (+_)
Hx of shallow breathing (+_)
Hx of tummy pain (+_)
Fruity smell from mouth (+_)

D/Ds to rule out


1. DM/DKA
2. G/E
3. Pyloric stenosis
4. Intestinal obstruction
5. Pneumonia
6. Over feeding

Station 24 (Vomiting) Overfeeding


A 4 months child comes with vomiting. Take Hx and discuss
D/D with examiner.
Hx of overfeeding is present. Rule out the same D/D as
in the previous question.

Station 25 (Juvenile DM)


A 5 year old child is diagnosed with juvenile DM. Polydypsia
and polyurea are present and BSR has been done. Talk to
mom and address concerns.
Ask her to elaborate S/S!
Cx
In this condition (DM), body cant produce a substance
called insulin. Insulin regulates amount of blood sugar in
your body so thats why people with DM have raised blood
sugar levels.
We will give you insulin in the form of injections. Well refer
you to a diabetic nurse who will explain how to take them.
What is so important in this condition is that you must take
meds (insulin) as prescribed. Otherwise one could end up
having many complications.
One of the most common complications of DM is
damaging blood vessels. If it damages large vessels, it
can lead to heart and kidney problems in one. If it damages
smaller vessels, it can lead to vision problems eventually.
Thats why taking meds is so important. You must follow up
regularly as well, to help assess how well the meds are
working.
Warn her about the signs of hypoglycemia. Mention
informing school nurse and wearing bracelet.

Station 26 (Rash) ITP


A 3 yrs old child presented with rash and bruises all over
body. Please take history and discuss D/D with examiner.
Fx on Hx taking
1. While mom was giving bath to the baby, she noticed
rashes and bruises all over body 2 days ago
2. He also had bleeding from nose 2 days ago. Mom
pinched the nose and the bleeding stopped.
3. She informs of runny nose and fever 4 weeks ago
4. Child appears to be lethargic according to mom.
D/Ds to rule out:
1. ITP (Hx of prev infection)
2. Bleeding disorder
3. Malignancy
4. Trauma
5. Non accidental injury
6. Meds e.g. blood thinners

Station 27 (Vaginal bleed) Unknown


A 6 yrs old girl brought by mom due to vaginal bleeding and
discharge. Talk to mom and discuss Dx with examiner.
Fx on Hx taking
1. Whitish discharge
2. Itchy discharge
3. No past medical Hx at all
D/Ds to rule out:
1. Candidiasis (DM, poor hygiene, immune-compromised,
steroids usage or spleenectomy)
2. Foreign body insertion
3. Sexual abuse
4. Trauma
5. NAI
6. Bleeding disorder
7. Instrumentation

Station 28 (Heart Murmur) Pilot


18 months old child visited GP for routine check up. GP
heard a murmur on auscultation. Talk to the mom and
address concerns.
Fx on Hx taking
1.
2.
3.
4.
5.
6.

Nothing abnormal happened or told during pregnancy


Birth was normal
Normal delivery
Baby does not turn blue
Father had angina
Fever, runny nose and cough since last few days (+_)

Questions to ask
1. Ask about any S/S and predisposing medical
conditions
2. Ask about breathlessness, poor feeding, excessive
sweating, blue episodes, generally unwell and family
Hx.
3. Ask about being told about Downs, Turners or
Marfan syndrome.
Investigations:
1. Echo (Gold standard)
2. ECG (and X-RAY)
Any child that comes with murmur, we should do
echo. When we realize murmur isnt pathological, reassure
the family about murmur. You may tell the mom that
murmur may persist even in adulthood and might not
disappear.
Murmur is explained as additional sound heard over
the heart, apart from normal heart sounds.
In 18 months child, find underlying pathology. If everything
is negative (on history taking), we just have to do a safe
investigation (echo).
REASSURANCE IN THIS STATION IS VERY IMPORTANT!

This murmur is not pathological.


Is it dangerous? Not most of the time but we will
investigate.

Surgery (Common Stations) History Taking

1) Anemia
Hx + Cx = Herniorrhaphy
Hx + D/D = PR Bleed
2) Abdominal Pain
Hx + D/D = Ectopic Pregnancy
Hx + D/D = Ureteric Colic
Hx + Mx (with Patient) = UTI
Hx + D/D = Pyelonephritis
Hx + D/D = Bowel CA
3) Testicular Pain
Hx + D/D/ Mx (with patient)
4) Melena
5) Dysphagia
Hx + Inv (with examiner)
Hx + Mx (with patient)
6) Hematuria
Hx + Inv (with patient)
Prev Mx (with patient)
7) Backpain
Hx + Inv (with patient)
Hx + D/D (with examiner)

STATION 1 (ANEMIA)

45 year old man planned for herniorapphy. Lab reports show


Hb 8. Procedure was cancelled and postponed. SHO in
surgery. Please talk and address patients concerns.
1- Explain the patient
-Procedure was cancelled
-reason why
-Why we cant offer surgery yet?
Address his concerns convincing the patient for cancelled
surgery
2- Find the cause of anemia
3- manage the cause of anemia
4- address patients concerns

Please go and greet the patient. Tell the patient your surgery
was cancelled because you have anemia.
Do you know whats anemia? In anemia you do not have
enough rbcs which are oxygen carrying cells in the blood.
That is why we cannot go for surgery.
If patient does not agree, explain due to your condition
when we put you to sleep, your blood cannot supply enough
oxygen to your body or even after the surgery, youll face
probably infection or delay in wound healing.
Doctor I have a friend, same procedure, received blood and
went for surgery. Why not me?
Your operation is not emergency, we dont have to go for
blood transfusion bcz it has its own complications.
Why didnt the surgeon explain this 4 moths ago?
Basically before the surgery we check how fit you are. One
of these procedures are checking your blood. We usually do

this assessment before surgery. Few months before surgery


it can change so not done.
Cause of anemia. Would like to ask you some questions.
Any medical illness? No doctor
Do you take any meds? Yes (aspirin for 10 years)
3 general questions about any ca? wt loss? Loss of appetite?
Anemia signs?
Fatigue/SOB + lightheadedness+ heart racing
Any change in bowel habits? Blood in stools? Tenesmus?
Family hx? Abdominal pain?
Tell me about your diet?
Any travels abroad?
Management- explain the cause of anemia
From what you have told me, the cause of your anemia is
from your gut. To confirm our diagnosis, we have to put a
flexible tube with a acamera attached to it, through your
mouth to see your gut and find out if there is any bleeding
and where is the site of bleeding. Dont worry we will give
you some numbing agent on your mouth. We might give you
some mild sleep meds(IV). We may take some samples.
Please stop aspirin and contact your GP. Ill provide you
some Fe tablets. It would be great if you could have some
orange juice( VITc). I can refer you to my dietician colleague
if you want.
When is the surgery>
Well repeat your blood tests as soon as we correct your
anemia before we go for surgery. It may take a few months.
1 unit Hb- 4 weeks under good condition. (almost 3 months)

STATION 2(ABDOMINAL PAIN)


65 year old man presents with bleeding per rectum. Lab
report shows Hb 6.7, MCV 65. Talk to the patient and Discuss
Dds with examiner
History
Something coming out/splash blood hemmorhoids
Pain anal fissures
Bowel movement alteration colorectal ca
Family hx polyps
Tummy pain diverticulitis
Fever, pain diarrhea, pain relieved on opening bowel IBD
Vomitting, fever, family Hx GIE
Med Hx, pain after or before meals APD
(patients Hx)
Fresh blood. 5 pound weight loss. SoB even when talking.
Getting tired with simple activity. Constiaption for last 2
months. Aspirin history. No family hx of ca. no tummy pain
or fever.
If asks managementFrom what you told me, youve got abnormal growth in the
bowel. Theres a possibility of ca but need to confirm. We
can do colonoscopy and consider ct scan. We may take
some samples as well for tests. If we confirm our diagnosis,
then surgery.
Investigations
1- CBC
2- Fecal occult blood
3- Colonoscopy/biopsy
4- Ct scan/ lfts
5- CEA

Any calculi history


Yellow/pinkish urine, Hx of passing stones, burning
micturition, poor stream urine, suprapubic pain

D/ds of abdominal pain


RUQ1- Acute cholecystitis- radiates to shoulder, pain with fatty
meal
2- Hepatitis- yellow discoloration of skin/eyes, fever,
sexual hx
3- Cholangitis- fever, jaundice and pain
4- Biliary colic- RUQ pain to the back, pain comes and
goes
RT/LT UQ1- Renal calculi- flank area pain
2- Pyelonephritis- recurrent utis, fever, pain, hx of passing
stools
3- Pneumonia- chest pain, fever , cough
RIF- Appendicitis Migratory
LIF- diverticulitis- pain relieved by defecation, PR bleed
Rt/Lt IF
Male- Testicular torsion, epididimoorchitis
Male/Female- urinary calculi, UTi, Hernia
Females- IUCD, Ovarian cyst, PID
Epigastric1- Pancreatitis- back and shoulder radiation, relieved by
bending forward
2- APD

3- GERD
4- ACS- radiation to jaw and arm
5- Pericarditis- shar stabbing pain, relieved by bending
forward

STATION 3 (ECTOPIC PREGNANCY)


25 year old lady presented with RIF pain. SHO in A &E. Talk
to the patient and discuss D/ds with the examiner
1- LMP 5 weeks ago (4-10)
2- RIF pain
3- Patient on IUCD
4- No vomiting, fever or discharge
5- Patient wearing hospital gown
Diagnosis Ectopic Pregnancy

STATION 4 ( ureteric colic)


25 year old lady presented with abdominal pain. SHO in
A&E. Please talk to the patient and discuss D/ds with
examiner
1- Pain in RUQ
2- Pain radiates from loin to groin
3- Hx of passing stones
4- Hx of pinkish urine
5- Hx of full stream urine
6- No hx of fever, alcohol or sexual hx
Diagnosis- ureteric calculi

STATION 5 (UTI)
20 year old girl presented with abdominal pain. Talk to the
patient. SHO in A&E. Disuss management with the patient.
Diagnosis- UTI
1- Same episode of pain 2 weeks ago
2- Lower tummy pain 2 days ago
3- Burning sensation
4- Pinkish urine
5- Flu like symptoms and fever
6- LMP 2 weeks ago
7- No discharge
From what you told me I suspect UTi, in which bugs grow in
your bladder and surrounding areas. To confirm, Ill do some
urine tests and send it to the lab. We may consider USG. For
treatment, Ill prescribe you antibiotics. Please have plenty
of water. Ill give you painkiller if you need them.
Investigation
Dip stick, MSU and culture, USG, IVU

STATION 6 (PYELONEPHRITIS)
40 year old man presented with abdominal pain. Talk to the
patient and discuss d/ds with examiner
1- RUQ pain
2- Flu like symptoms
3- Smelly urine
4- Hx of passing stones
Diagnosis- pyelonephritis

STATION 7 (BOWEL CA)


75 year old lady with LIF pain. SHO in surgery. Talk to the
patient. Discuss dds with examiner
1- Half a stone weight loss
2- Altered bowel habits
3- Abdominal pain
4- Family hx of bowel ca
Diagnosis bowel Ca

STATION 8 (TESTICULAR PAIN)


30 year old man presented with pain in private parts. SHO in
A&E. Talk to the patient. Discuss your dds and management
options with the patient
1- Pain 2 days ago
2- Score 4/10, morning 7-8/10 (severe)
3- Flu like symptoms
4- Pain in both testes
5- Sexual hx- not sexually active
6- Have you seen private part? No redness/ hotness
7- Did you try to lift the testes( dont ask)
Dds1- Epididymorchitis- fever , gradual, both testes,
2- Torsion of testes
3- Ureteric calculi
4- Bladder calculi
5- UTI
6- Hernia
7- Mumps
From what you told me, I suspect 2 conditions.
Epididymorchitis- inflammation of the testes and
surrounding organs, to confirm the diagnosis we do urine
testsand send it to the lab. If test is positive, Ill give you
antibiotics
Testicular torsion- twisting of testes, this is an emergency
condition in which you need surgery. We may have to
remove your tested. Before surgery we may do some
investigations like USG.
Assume with the examiner.
Investigations.
First urine culture, swab if discharge present.
Treatment- <35 years doxycycline 100 mg BD 10 days
(covers Chlamydia)

>35 years ciprofloxacin 300mg Bd 10 days


Pain killers
Scrotal support
Drainage if abscess present
Testicular torsion Treatment- Bilateral orchidopexy
( untwisting in the affected testes), orchidectomy (if needed)
and fixation of the rt testes.
Investigations- shouldnt delay your surgery- USG Doppler,
isotope scanners

STATION 9 (MELENA)
60 year old patient dark stools. Talk to patient and give D/ds
to examiner
1- Patient has osteoarthritis
2- Taking diclofenac
3- No weight loss
4- No family hx of bowel ca
5- No change in bowel habits
6- Feels tired sometimes
7- No alcohol hx
DDs for melena
1- Esophageal varices
2- Mallory weiss tears
3- APD
4- Gastric ca
5- NSAIDs Hx

STATION 10 (DYSPHAGIA) ESOPHAGEAL CA


65 year old lady presented with dysphagia. Patient is on H2
blockers and PPIs in last 5 years due to reflux disease. Talkto
the patient and discuss DDs with examiner
GERD- strictureBarettes esophageal ca
1- Difficulty in swallowing started with solids
2- Wt loss in last 2 months
3- Loss of appetite
Diagnosis- esophageal ca
DDs
1- Esophageal ca- difficulty in swallowing, continuous pain
2- Stricture corrosive intake
3- Pharyngeal pouch foul smell, food regurges
4- Achalasia cardia- difficulty in swallowing starting with
liquids
5- Myasthenia gravis- problem getting worse as day
progresses
6- Bulbar palsy- initiating swallowing difficult
7- Esophagitis fever

STATION 11 (HEMATURIA) BLADDER CA


65 year old man presented with hematuria. Take hx and
discuss about investigations with the patient
1- Hematuria painless
2- 2-3 weeks ago
3- Loss of appetite
4- 2 kg weight loss
5- No fever/ passaing of stools
6- Smoking since 25 years
7- Dribbling and incontinence
Diagnosis- bladder Ca
DDs
1- Renal calculi
2- Bladder calculi
3- Urinary calculi
4- Renal/ bladder/ prostate ca
5- UTI
6- Schistosomiasis ( swimming in public lakes and pools)
I suspect some growth in your bladder. Have to run some
investigations. May have to do some surgery. From what
you told me, am going to run some investigations to confirm
diagnosis. These are urine tests, special x rays, a flexible
tube, camera attached on it, goes to your bladder through
your front passage and CT scan. We may have to take some
samples
Urine tests cytology and microbiology
IVU
Cystoscopy
CT Scan

STATION 12 (BACK PAIN) PROSTATE CA


55 year old man presented with back pain. Take hx. Discuss
investigations with patient and Dds with examiner
1- Lower back pain becoming worse by changing position
2- Wakes up during night to go to toilet 2 months
3- 1 stone weight loss in last 2 months
4- No morning stiffness
5- Hx of loss of appetite
6- No hematuria/ no hx of heavy lifting
Diagnosis prostate ca with mets to back
DDs
1- Secondary to ca
2- Multiple myeloma
3- Osteoporosis of vertebra
4- Osteoarthritis
5- Disc prolapsed
6- Trauma
7- Tb/ potts disease
8- Asnkylosing spondylitis
From what you told me I have to run some tests.. Ill do
blood testsand USG. We may get some samples with help of
USG, Xray and MRI. PSA USG guided biopsy xray MRI

Pre-op assessment
Q- 50 year old Mr. John had fractured ankle which was fixed
with pins. Now it has healed. He has come for pin removal.
Do the pre-op exam to see whether he is fit to be brought as
day care for surgery and talk to him.
Pt. is usually IDDM patient!!
RBS well controlled in the last 3 months atleast. No other
major medical problem
For minor surgery , provided there is someone to take care
of him after the operation who can stay for 24 hours
Are you checking RBS and taking meds?
With what you are telling me, you are fit to be brought in for
day care surgery
Diabetic Dont take insulin at home. Well give you here if
needed.
After operation if taken, well give you with food
Shouldnt drink back home
You have a surgery on your ankle?
Hows your ankle?
Do you keep checking sugar? Is it controlled?
Apart from diabetes , any other medical condition?
Did you have any problems during or after surgery?
Apart from insulin any other meds?
Anyone to look after you?
Well give you a date. Come prepared. Please dont take
your breakfast nor your morning insulin dose. Youre to come
to the hospital and well give you insulin when and if
required.

Once you recoverfrom anesthesia, well give you food and


usual insulin dose if you take at that time after a while. Or if
you take it in evening well discharge you if everything is
fine. Please do not drive for atleast 24 hours after the
procedure due to the safety concern from the drowsiness
effect of the anesthesia.
Household- 1 week
Drive- 2 weeks
Work- 4 weeks
Labor- 6 weeks

Q- 5 year old boy John fractured ankle! Do the pre-op


assessment with his mom and talk to her
When did he eat and drink last? (if emergency surgery). NPO
for 6 hours atleast
Since your son has eaten 2 hours ago well wait for 4 more
hours. Please do not give him anything to eat and drink from
now onwards until we instruct you again after the operation
and well give some fluids through his veins as a drip to keep
him hydrated and for his nutrition.
Please do not give him any more insulin until we instruct you
again. Well check his sugar and give insulin as required.
How long? One hour
Hospital stay? 2-3 days maybe
Never assume the patient knows the condition?
Are you the mother of?
How may I address you? Add please to the conversation.
Hes comfortable and pain free since we gave him the
painkillers
Did anyone tell you whats wrong with your son? Show
empathy and sympathy
If pt says do not do the operation or am worried ask about
the concern?
Unfortunately type of fracture he has cannot be fixed with
plaster. Anything to fix that? Operation.
Is that alright? To do the operation he has to be fit
healthwise. Any medical condition apart from DM? CVS,
asthma or any previous surgery? Taking any meds? Alergic
History? Family history of medical conditions?
Loose teeth? Dentures?
Anything else?

With what you are telling me , he seems to be fit to undergo


operation but to do so he needs to on empty stomach for 6
hours. Otherwise he can vomit and aspirate in lungs which
can be dangerous. Please do not give any food from now on
until we instruct you after the operation. Well give some
fluids.
It is a safeoperation. Are you okay with it so we can go
ahead with the operation?

Q- 5 year old john acute appendicitis. Disclose the


diagnosis to his dad and do pre-op assessment.
If female- ask for pregnancy, pills and periods.
Since you brought him to the hospital, weve given him
painkillers and hes comfortable now.
We all have an organ in our tummy called as appendix. This
looks like a little finger attached to the beginning part of the
large bowel located in Rt. Lower part of the tummy. In your
sons case it is inflamed/infected. ( bugs that have caused
soreness and become swollen)
Treatment- here to operate.
I am afraid yes. Cant be treated with medicines alone
unfortunately.
I am sorry but you have to postpone your holiday plans. If
we delay this, organ can burst and cause serious infection of
the tummy with risk to his life.
Make a small cut in his tummy wall. Well cut and remove
the appendix. Dont worry this organ has no important
function in the body. Itll not affect his life and he can lead a
normal life.
30-45 min operation
List of complications after assurances
2-3 days stay
10 days to 2 weeks back to school
Past hx med and surgical
Meds
Allergy
Tell him about G.A

PAIN MANAGEMENT
6 scenarios
4 important areas to talk about
1- Pain ladder
2- Morphine
3- Side effects of morphine
4- PCA
WHO pain ladder
1- Paracetamol / aspirin/ NSAIDs
2- Weak opiods ( codeine, dihydrocodeine, tramadol)
3- Strong opioids ( morphine, dimorphine, oxycodeine)
a- When the pain is not controlled, go to the next step
b- When the pain is controlled but there are side effects,
choose drugs from same ladder
c- When the pain is controlled but there are side effects,
you may change meds as well as route e.g P/o to S/C
dimorphine
Morphine induced hallucinations oxycodeine or fentaline
Side effects of fentaline
1- Renal impairment GFR <30 (criteria to change in
ladder)
2- Morphine intolerance
3- Poorly compliant patient on meds like morphine
Morphine P/O 30 mg x 1
I/V 15 mg x 2
S/C 10mg x 3
Oxycodeine P/O 15mg x2
I/V 10 mg x 3
Fentaline patch 0.20 mg x 150
IV > oral
Fenatline patch > opioid
Lasts about 17-72 hours

12-24 hours for fentaline patch to wash off


d- If the patients pain is not controlled , check for
medication compliance first
e- More poor compliance in meds with side effects
f- Dont give Side effects without telling the solutions
Solutions
Sickness/ feeling sick antiemetic
Please take simple food, cold food like sandwiches and avoid
rich and spicy foods. Please take meds after the meal or few
hours before the meal. If all other options dont work we
may consider anti sickness meds
Constipation
Have plenty of water. Please have a well balanced diet which
contains large amounts of fruits and vegetables. If other
measures dont work, we may consider meds.
Dry mouth
You can have sugar free chewing gum and ice cube. We may
consider prescribing artificial saliva
Drowisness/ sleepy
It takes a few days and then subsides. Dont worry. Dont
drive and dont work with any tools/ heavy machinery. Dont
drink alcohol.
Shallow breathing
Dont worry its not a common side effect. If it happens,
contact your GP immediately
g- In terminally ill patients, for pain control from weak and
go to strong
h- In post op management, we start from a strong and
then go to weak pain killers.
i- Adjuvant plays an important role in pain management.
Some meds do not fall in the painkiller category but we

can prescribe them to you to relieve the pain.


Radiotherapy and bisphosphonates
j- There is a strong evidence that suggests emotional
support can decrease and optimize the pain. That is
why if the pain is controlled you can discharge the
patient.
k- If you have terminally ill patient, you adjust the
painkiller and send the patient home
Have to use titration!!
1- 5-10 mg normal release morphine every 4 hrs in 24
hours
2- Anytime patient has pain add 5-10 mg immediate
release morphine
3- After 24 hours, calculate your dose.
l- Please think about side effects when you prescribe
,eds. Dont prescribe NSAIDs to asthma and PUD.
Aspirin ask about gastric ulcer and taking warfarin
mPlease ask the patient to take meds regularly as
prescribed. Not take meds when the feel pain.explain
to the patient, prevention of pain is better than cure
n- PCA- by using this device, size of a radio, you can
control the pain yourself. Anytime you have pain
press the button and meds (mostly morphine) goes to
your body through your blood channels. Please dont
worry about overdose because our colleague
programmed this device for you.
Questions frequency
Painkiller 21
BPH and UTI 8
Testicular pain 7
post op comp after hernirapphy 6
hemicollectomy 6
Abd pain- 5
Telephone (internal bleeding after hemicolectomy) 5
emergency endoscopy 3
open nephrectomy- 3
lipoma removal 3

Herniorapphy procedure 2
Obstructed /strangulated hernia (telephone) 2
Appendicectomy talk to parent 2
Complications of hysterectomy - 1

STATION 1
Terminally ill patient with prostate Ca is on cocodomal.
Pain is controlled. Talk to the daughter
Show enough sympathy and empathy
Can I take my dad home?
Yes because pain is controlled
Despite allowance, daughter is worried about what if he
feels pain again? Please explain in this way.
Your dad is on cocodomal, which is paracetamol and a
weak opioid called codeine. If for some reason cocodomal
caanot control pain, we go for a strong opioid which is
morphine. Morphine is the best painkiller. There is always
another option available for you. Would you like to talk
about it?
Is there anything I can do for my dad?
can talk about patch
Can I take dad home?
Yes ofcourse you can but let us first control the pain.

STATION 2
Terminally ill patient(teacher) with lymphoma is on
diclofenac and cocodomal. Received in chemotherapy and
radiotherapy. Still the patient is in pain. Your consultant
prescribed overall morphine for the patient. Please talk to
the patient.
q- Do you think I can go to work?
- What do you do? ( Drowsiness factor). Dont worry. Itll
subside in a few days. You can take some days off from
the school and go back to the school later.
q- what will my students think? (morphine- recreational
drug)
- Look you are using the medication for medicinal
purposes, not for recreational reasons. You can take time
off from school.
Look morphine is the best drug for you. As you know, you
tried ibuprofen, didnt work, you tried cocodomal which is
a bit of opioid, didnt work as well. Thats why weve to go
for stronger opioid.
Talk about side effects. ( Do you want to talk about side
effects and their solution?)
PCA cant go to school or teach.
hopefully your pain will be controlled. If for some reason,
pain is not controlled and you prefer to stay at home and
rest, you can go for PCA. Can also use fentaline patch.

STATION 3
Elderly lady on 300 mg P/o morphine. Complains about
morphine and wants to discontinue it. Talk to the patient.
It doesnt work
- Do you take meds regularly as prescribed? Do you miss
any dose? How many times per day? Why?
S/e constipation
- I am really sorry to hear that. Drink lots of water and
have fruits and vegetables. We will also consider
medicines. Hopefully well manage the S/e but if we
cannot then well use fentaline patch.
Sometimes patient says they use meds regularly
- morphine intolerance.
Fentaline patch. Talk about other side effects of morphine
and PCA.

STATION 4
50 year old main comes with back pain. The patient is on
and off paaracetamol. Xray shows bone degeneration
disease. Talk to the patient and different methods of pain
management.
Diagnosis osteoarthritis
As you know you are on paracetamol and take it regularly
which doesnt work, we may consider a weak opioid
cocodamol. Hopefully pain will be controlled with that but
if it is not than we go for a strong opioid which is
morphine.
You may take paracetamol regularly, it may work.
Please talk about PCA and fentaline patch.
If the pain is not controlled. Route? ( do I have to take it
through mouth?)
Non medical methods ( adjuvant)
1- Weight loss
2- Exercise
3- Physiotherapy
4- Tens
5- Dietician
6- Acupuncture

STATION 5
40 year old man is planning for herniorraphy. Is really
worried about pain. Talk to the patient and address his
concerns.
Herniorraphy Open under G/A
Keyhole recurrent
B/L

Hospital Day care (most surgeries)


Overnight / 2-3 days
Why are you worried?
Same procedure two years ago.
What have you received last night?
Dont know doc
What happened?
Night of surgery. Was in pain. No one came with me.
Tell him about PCA.
when we discharge you we will give you oral morphine
Do you want me to talk about S/e?
In a few days well step down to weak opioids.
Hopefully you wont have to take any meds after that.
-pain ladder backwards here

STATION 6
75 year old man comes to the clinic with complain of burning
sensations while passing urone. Urine test has been done
and shows nitrites and leucocytes. UTI diagnosis made. P/R
exam done and showed enlarged prostate.
diagnosis BPH
Talk to the patient and address his concerns
5 types of councelling stations
1- Councelling of a diagnosis
2- ask patients knowledge about symptoms.
3- Tell the diagnosis
4- Explain the diagnosis
5- Management of UTI
6- Address concerns and any warning signs
7- Disclose BPH
8- Why BPH can cause UTI
9- Management of BPH
10Any concerns
What brought you here?
Difficulty in passing urine
As you know weve done some tests and this test shows UTI.
Harmless bugs growing on your bladder/in your tummy.
When they travel from back passage to front and travel to
the bladder or ureters (tube connecting bladder and
kidneys), they grow in these organs and cause infections
and problems.
Allergy to antibiotics need to be asked.
Weve done some tests and we will do some more and send
it to the lab. We may consider USG. For treatment will
prescribe you antibiotics. Do you have any allergy?
Thankyou. Ill give you something else. Please take plenty of
water and may consider taking pain killers.
Do you have anyone at home to take care of you?
Thankyou so I dont have to admit you.

As you know weve done some other examination that shows


that you have an enlarged prostate gland.
It is a gland, lies on the bladder. It is the size of a chest nut
and urethra passes through this gland. Due to prostate
enlargement, the urine gets stuck in the bladder and the
bugs grow easily. That is why youre prone to UTI.
Investigations- Well do some blood tests and USG and PSA
and guided biopsy if needed. If our diagnosis is confirmed
we will give you two meds. One of them shrinks the gland
( fenestride) and the other one relaxes the neck of the
bladder and tube. Hopefully meds will work otherwise well
consider surgery.

Cx in surgery
Ask patient about symptoms ( their knowledge)
Explain the surgery NPO OT recovery room ITU
ward discharge
Talk about anesthesia. Local or G/A (put you under sleep)
NPO because might need G/A
Advantages of local
- fast recovery
- Less hospital time/ complications/ fitness needed
Disadvantages of local
- pain/ seeing and hearing the procedure.
- well top up anesthesia (local) and give G/A. will also give
mild sedation.
- we can use a curtain dont worry about seeing.
- you can listen to music
Method is either open or keyhole surgery.
Keyhole surgery nick on belly
ectopic pregnancy in exam / Lap chole
Button put gcd nick on bikini line we put a camera
and instruments
Advantages
1- Less scar
2- Less pain
3- Short recovery
4- Less hospitalization
Disadvantages
May damage vessels and surrounding organs
Open surgery all 7 in the list before including ovarian
cystectomy
Stay in the hospital

- Daycare lipoma remova


- 2-3 days laproscopic
- 4-7 days major surgery (hemicolectomy, open
nephrectomy, hysterectomy, hemiarthroplasty)
Patient may be discharged in 1-3 days ( enhanced recovery
program) hemiarthroplasty
The surgeon and occupation therapist make the decision.
The occupation therapist can assess patients fitness for
discharge and patients environment
Complications of surgery
1- Pain see prev mx
2- Infections Antibiotics
3- Bleeding
4- Damage to surrounding organs ( rare and treat
accordingly)
Recovery After 1 week can do simple house work / hold job
After 2 weeks can drive / have sex
After 4 weeks can go back to his job
Afer 6 weeks can go back to heavy job / labor

Are you happy to go for surgery or not?


Note:- Please read the task. If in the task , the consent has
been taken, please dont take consent.
in herniorapphy, consent already taken

STATION 1 (TESTICULAR LUMP)


Young patient comes to you with lump in his private part.
Transillumination and fluctuation test has been done and are
negative. UDG shoes solid tumor. Blood test shows some
tumor marker
Do you know whats going on?
As you know weve done some investigations. You have any
suspicion of anything?
Okay. Investigation shows you have an abnormal growth in
your testes.
Possibility of having ca. but at this stage if we take it out we
can prevent it from spreading
Weve to confirm our investigations
Weve to remove whole testes.
If we go for sample, maybe disease will spread. Right now its
not hard to manage but if it spreads very difficult to
manage.
As long as the other testes is here you may have children.
We can store your sperm.
Cosmetic surgery for shape of testes.
Patient may receive radio and chemo after procedure
Sympathise and empathise

STATION 2
Young man to underwent herniorapphy 3 weeks ago this
man came back with redness, swelling, oozing at the site of
incision. The nurse told you this patient is angry and address
the patients concerns
Doctor I may need to see surgeon.
- Do you need surgery?
Ill convey your message to my surgeon
It can have many causes. You may get the infection during
surgery, at the hospital and even at home. Whatever the
reason management is the same. Let me tell you what we
can do for you now. Ask her any s/s
Weve to admit you . do some blood tests and send them to
the lab. Give you antibiotics and also change dressing and
clean the wound. ( patient will be angry at admission) As
soon as you are better you can go home
Look this is for your health. But dont worry. Why are you
upset?
Dont worry well provide you with the sick note.
Show sympathy/empathy if self employed. Your health is
important. (patient advice and Larson center)

STATION 3
45 year old man comes with abdominal pain. All the
investigations have been done (inv paper in exam). Normal.
Talk to patient.
Do you know whats going on?
Yes we did some investigations and ive got the report of the
investigations
We did endoscopy and biopsy to see If there is any problem
with your gut. Fortunately no problem.
We also performed colonoscopy and biopsy(patients
language) to see if there is anything problem in your bowel.
We also did USG and all organs in your tummy are fine.
Fortunately no problem. We also checked your stool. No
blood. We checked your blood and couldnt find any bugs.
Do you have any stress in your life?
Okay that can be 1 cause of your tummy pain. So please
have a well balanced diet with fruits and vegetables. Do
regular exercise. Go to the gym. Do exercise and yoga. It
may help. I can also refer you to any of my colleagues who
can talk to you improve your mood.
Irritable bowel syndrome
In this problem, people without having any problem can
have tummy pain. This disease is not a serious condition and
does not lead to any serious complications.
Okay why are you worried?
- my uncle died of bowel ca
Im sorry to hear that but we did all these tests to rule out
any dangerous diseases. Fortunately all are normal.
However, if anytime you see any blood in you stool, any
change in your bowel habits, tenesmus, weight loss, loss of
appetite, anemic symptoms you can come back to us
immediately.

STATION 4
75 year old lady was planned for hemiarthroplasty because
she had hip fracture. Please talk to the patient about post op
management. Pain management has been explained.
When can I go home?
- 3 to 5 days. Maybe in 1 to 3 days. Explain as before
My bathroom is upstairs?
- occupational therapist- theyll change something for you
Post op management and complications ( family Hx)
patients main concern is about blood clot
-one of the complications of this surgery is having blood clot
in lungs or legs. Anytime when you feel a pain in chest or leg
or cough, mobilize as much as possible.
When can I start walking?
- ASAP

STATION 5 (HEMICOLECTOMY)
60 year old man was found to have a tumor in his transverse
colon. Please explain about surgery and talk about primary
anastomosis and possible colostomy.
This is an open surgey in which well open your tummy. Well
remove the diseased part of your large bowel and will join
the ends together. If joining of the cut ends of the bowel is
not possible, well have to make a hole in your tummy so
you can pass stool through that hole on a bag which we call
colostomy bag.
Always involve colostomy nurse
It is odor proof so you may feel something but you cant
smell it
It is waterproof
Anytime you have any problem with body image/ sexual
issues/ please come back to us, Ill refer you to our dietician.
You may not be able to have food which has fiber like
vegetables in first 8 weeks. You may have some noisy
tummy and wind in this period and dont worry you can
resume normal diet after 8 weeks.
Skin reactions
We discussed this you can have almost a normal life
Why surgery?
- now we can remove the diseased part but we dont do so
as the disease might spread.
It may be temporary or permanent but we arent sure
You can draw something for the patient as paper/pen
available
Tumor on the sigmoid / cecum (imp) DONOT DRAW THIS

STATION 6 (OPEN NEPHRECTOMY)


A lady was diagnosed with stage 1 kidney tumor. Open
radical nephrectomy was planned. Talk to the patients
partner.
Do you know whats going on?
No breaking bad news
The patients partner only remove tumor?
- weve to remove kidney and surrounding organs. If we
dont do that, itll get spread all over the tummy.
What about the other kidney?
- lets concentrate on this kidney because we arent certain.
What is important is that your wife should have plenty of
H2O after surgery. Let the other kidney be flushed. Well put
catheter and drainage tubes
If after surgery, wife be cured or not?
We may be able to treat and cure your wife. We may be able
to slow down the disease. If we cant do that let us allow to to
give comfort to the loved ones.
Can she live with one kidney?
-as long as the other one works fine

STATION 7 (LIPOMA)
A patient is planned for removal of lipoma in thigh under
local anesthesia. Talk to the patient and address patients
concerns.
Please talk about everything regarding local anesthesia.
Are you happy going for local anesthesia or not?
Ill talk to my seniors and we may go for G/A
G/A side effects

STATION 8
75 year old man planned for emergency endoscopy. SHO in
surgery. Please talk to the patient and address patients
concerns. Patient admitted due to vomiting blood.
Reassure and relax. Calm him down
What was your last medication? When? (med like warfarin?)
We are going to find out site of bleeding.
Sedate and local anesthesia
Can I go home after endoscopy?
- if everything is smooth then yes

STATION 9
40 year old man planned for herniorrapphy procedure. The
procedure is for RI hernia. It is open surgery and patient will
undergo G?A. Address concerns.
As you know due to weakness of your tummy muscles, some
tummy contents come out. By doing this surgery, we push it
down and we put a mesh which helps it to not happen again.
My uncle got the same problem but got prescribes TRUS?
-he may have been unfit for surgery
If we dont go for surgery it may be very dangerous for you.
Make a pic if possible.