SURGERY

Post op Wound Infection

Scenario: You are FY2 in surgery. Mike Tyson had a herniorrhaphy 3 weeks ago. He came in with foul smelling discharge. Please
manage the patient.

Steps: GRIPS. Ask about the wound. Ask about recovery. How does it affect daily life. Assess risk factors for poor wound heal-
ing. Exam. Mx
Doctor How can I help you today?
Patient My wound is infected doctor!
Doctor I am really sorry to hear that your wound has become infected.
I understand that your operation was 3 weeks ago, is that correct?

Can you tell me how is your wound looking right now?

Is there any discharge or bleeding from the wound?
What colour is the discharge?
When did you first notice it becomes infected/discharging?
Do you have a fever?
Is there any pain around the wound?
Assess Risk Factors:

 Did you manage to complete your antibiotics which was given to you after the operation?
 Did you go for your regular dressing? Who does the dressing? (district nurse)
 Have you been coughing a lot recently? Why?
 Is there by any chance you have been lifting heavy things?
 Ask about occupation, smoking and drinking
How has this problem been affecting your daily life? *empathy
Exam: VS, wound, abdo exam
Based on what you have told me and from my examination, unfortunately it seems that the wound has be-
come infected. I am sorry that this has happened to you. It is one of the few complications of any operation,
as I believe my collegue must have told you prior to the operation.

There are also few things that may contribute to poor wound healing. Address risk factors if any and offer
solution.
Smoking for eg - can delay wound healing and when its taking a long time to heal, it usually gets infected.
Have you ever thought of quitting smoking? We have a lot of services avilable to help you quit. If you like, I
can refer you to smoking cessation clinic where they can give you further guidance and support with this.
We are here to help you. Regarding your wound, we have to

1. Admit you for IV antibiotic. I will consult the microbiologist team as to which antibiotic is best for you
2. Blood routine and culture
3. Swab C&S from the wound
4. Isolation room to prevent you getting further infection and also to prevent spread to other patients
5. Medications to bring your temperature down
6. Clean your wound and apply new dressing
Patient Where did I get this infection from?
Doctor It is difficult to say where you got this infection from. Unfortunately it could be from anywhere
Patient Is this very common to happen in your hospital?
Doctor It does not happen very often as we practise aseptic technique. But I can come back to you with the statistics
if you would like to know
Patient When can I go home

Nik Athirah
Doctor It is difficult to give an exact time of when you can go home. Once the infection has cleared out, we will be
happy to discharge to home. Hopefully it will not be long

***MRSA station:
 Methycillin resistant staphylococcus aureaus.
 This means that it is a bug that is resistant to a number of commonly used abx
 It means that it will be more difficult to treat than the common infection
 Where did I get this infection from? - It is difficult to say where you get this infection from as this bug can live on our skin
and nose without causing infection. But in a case where there is a wound, the bug can infect the wound.
 Mx: Clean your wound regularly, Put in isolation room, Consult microbiologist for abx (vancomycin)
***MRSA coliniser: Ointment in nostril, antiseptic wash on skin Chlorhexidine.

Pre op assessment

Scenario: Mr Brown is a 47 year-old gentleman broke his ankle 4 months ago and had external fixation with screws done on his
ankle. He is due for ankle pin removal. Please do a preop assessment on this patient. Do not examine patient.
*h/o vomitting post op

Steps: Paraphrase. Ask previous operation ie comp of surgery and GA. Systemic review. P3MAFTOSA. Exam?. Ix. Caunselling
Doctor I understand that you broke you ankle 4 months ago and had a surgery done. And also you are scheduled
another operation for ankle pin removal. Is that correct?
Well, I am here to assess if you are fit for the next surgery.
Can I ask you that exactly happened 4 months ago?
Is that correct that you had GA for your surgery previously?
Did you develop any side effects of GA such as
 headache, nausea&vomitting, confusion, feeling cold, bruising, chest infection, damage to mouth struc-
tures, confusion

Yes doctor. I vomitted a lot after the surgery.

I am very sorry that it happened to you. We will try our best to prevent that from happening again.

How did the surgery went for you? Did you had any complications?

After how many days did you went home?

Have you been unwell recently in any way?
Resp: Cough/SOB/Fever
CVS: Chest pain/palpitaion/dizziness/headache/claudication/leg swelling
GI: diarrhoea/constipation/vommit/tummy pain
GU: dysuria/frequency/nocturia/hesitancy
***any dentures/loose tooth
P3MAFTOSA
PMH: HPT/DM
Medications: insulin/metformin/antiHPT
Allergy
Fhx of bleeding tendencies, complication to anaesthesia
Alcohol/smoking
Personal history: Drug use esp sharing needles
Social hx - is there any help available at home after surgery
Occupation
Thank you for answering my qs. I would like to examine your lungs and listen to your heart sound. I would
also like to take some vital signs such as BP,HR,RR,T, SaO2

Nik Athirah
 I would like to do some investigations to make sure that everything is well with you.

Blood:
 FBC, U&Es, LFTs, Clotting profile
 If diabetic: Glucose/HbA1c - to look at your sugar control over the past 3 months
 If sharing needles: Hepatitis screening
ECG
CXR (if >65/smoker/lung or heart problem)

If all the investigations nomal, you will need to be admitted 1 day before the operation.
There are few things I would like you to know about the operation.
 It is important that you keep fasting 6 hours before the operation.
 If you are HPT, please do take your antiHPT meds on the day of operation
 If you are DM, please do not take your medication on the morning of the operation. We
would monitor your blood sugar and give you insulin instead. We would also try to put you first on our
list.
 Your operation will be done under GA. This means you will not be awake during the surgery.
The anaesthetist will betaking care of your breathing and give you sedations and painkillers.
 After the operation, you will be transferred to the recovery area where you will regain your
consciousness fully and we will monitor your vital sign.
 We will be listening to your gut sound and we will allow sips of fluid and if you are able to
tolerate, we will allow you to at solid food again.
 Usually you can go home on the same day but since you experienced vomitting the last time
you had your surgery, we might have to keep you for couple of hours or for a day just to observe you.
Hopefully it will not happen again but if it does, we are there to manage you carefully.

Dysphagia

Scenario: Robert Mansini is a 60 y/o male presented with difficulty in swallowing, Please take a focussed history and discuss
management with patient

Steps: GRIPS. ODPARA. Assess hydation. Ddx. P3MAFTOSA.Exam.Ix.Mx

Doctor: Onset: When did you start having difficulty swallowing?

Duration: Did it come on suddenly or gradually?
Progression: Is it getting worse, improving or stays the same?
Aggravating: Anything makes it worse?
Relieving: Anything makes it better?
Associated sx: DDx
1. Esophageal ca (liquid then solid, LOW, elderly)
 Do you find swallowing liquid more difficult or is it difficult to swallow solids?
 Have you lost weight recently? How much weight have you lost and over how long?
2. Achalasia cardia (solid and liquid from the onset)
3. Pharyngeal pouch
 Do you find food particles on your pillow in the morning?
 Have you noticed any swelling in the neck?
4. Oesophagitis (h/o GERD)
 Do you suffer from any reflux symptoms?
5. Myasthenia gravis
 Is it getting more difficult to swallow by the end of the day?
6. Systemic sclerosis (CREST)
 Do you have any joint pain?
7. Trauma
 Oesophageal strcture: Swallow corrosive substance
 Post-procedure: Do you have any procedure where instrument was put down your throat?
8. Sore throat
 Any cough, sneezing or runny nose?

Nik Athirah
 Assess hypovolaemia:
 Do you feel thirsty?
 Do you pass urine like normal?
 Do you feel dizzy?
P3MAFTOSA
 Examine: VS, BMI, Neck, Chest, Abdo, Lymphoreticular
From what you have told me, it is difficult to say what the cause is as there are a number of things which can
present in a similar manner. Therefore I would like to perform some investigations to find out what is the
cause.
I would like to do :
1. Blood tests
2. CXR
3. Barium swallow: This is an investigation where you will be given some liquid called contrast to swal-
low. We will then do multiple xray to see the flow of the liquid passing through your food pipe
4. After that we would like to do an endoscopy to see inside your food pipe. This is a lubricated tube
which is attached to a camera at the end to visualize the inside of your foodpipe, stomach and first part
of your small bowel. If there is any swelling, we will do a biopsy where we take out some tissue sample
and send it to the lab.
5. For these reasons, we will have to admit you.
6. While you are admitted, we will refer you to nutritionist and pharmacist where they will assess your
nutritition status. If needed, they might have to give you some nutrition through your blood channel.
Patient Could it be cancer?
Doctor Unfortunately cancer is one of the things which could cause difficulty in swllowing. However, it is advisable
to wait for the results of the investigations as there are many other things which could be the cause.
May I know why you are worried of cancer?
Patient My friend died of cancer
Doctor I’m very sorry to hear that. It is difficult to say for now. That is why we need to do these investigations
urgently so that if you need treatment, there will not be any delay

Renal Colic

Scenario: A 25 years old male p/w loin pain. The nurse has given him Diclofenac 30 mins ago. Please take a history and discuss
management with patient

Steps: GRIPS. Address the pain. Offer painkiller (IM Morphine 10 mg, Metoclopramide 10 mg), SOCRATES. DDX.
P3MAFTOSA. EXAM. IX. MX

Doctor: Site: Where exacxtly is the pain?

Onset: When did it start? Did this come on gradually or suddenly?
Character: Can you describe me the character of the pain? (colicky)
Radiation: Does it radiates anywhere else in your body? (loin to groin)
Associated : Ddx
Timing: Is there any specific time of the day you experience the pain? Is it becoming worse, improving or
stays the same?
Exacerbating/Relieving: Anything makes it worse or anything brings it on? Anything makes it better?
Severity: On a scale of 1 -10, 1 being the lowest and 10 being the highest, how would you score your pain?

Nik Athirah
DDX:

1. Renal colic
 Do you notice any blood in your urine?
 Did you passed out any stones when you pee?
 Does the pain radiate anywhere? (loin to goin)
 Does the pain comes and go? (colicky)
2. Pyelonephritis
 Did you experience a sudden feeling of cold with shivering?
 Do you have any fever?
 Do you feel like you have to pass urine more frequent than usual?
3. UTI
 Is there any burning sensation when you pass urine?
4. Acute cholecystitis/Gallstone
 Does the pain radiate anywhere? (to the scapula)
 Did you have any vomitting?
 Is the pain worse when you eat a certain types of food such as fatty food?
5. Acute pancreatitis
 Does the pain radiating to the back?
 Is the pain relieved when you lean forward?
6. Cholangitis (RUQ pain, fever, jaundice)
 Have you noticed yellowish discoloration of your skin or eyes?
7. Hepatitis
 Hepatitis A: RUQ pain, jaundice, vomit, history of travel and eating out, diarrhoea
8. PUD
 Does the pain occurs in relation to your meals? Before or after meals?
 Do you have any indigestions?
9. Basal pneumonia (cough, SOB, sputum, chest pain)
10. Liver ca (weight loss, jaundice, anaemia, elderly, RUQ pain)
P3MAFTOSA

PMH: Diabetes, HPT, cholesterol

SH: Alcohol/SMoke
Diet hx: How much water do you drink every day?
Travel: Have you travel anywhere recently?
Occupation:
FHx of renal stone
Exam: VS, Abdominal exam
Dx: What I’m suspecting for the time being is that you might be having renal stones. The stones can be
located anywhere from your kidney, in the tube draining urine from your kidney to bladder, or in the bladder.
The pain you are having is what we call a renal colic. This is due to stones that are either stuck in the kidney
or being squeezed out through the tube into the bladder.
Ix: To confirm this, I will need to do some tests on you.
Routine blood + sugar
Urine sample for dipstick and C&S
USG KUB to see presence of stone in your kidney or tube connecting to your bladder or in the bladder itself

***examiner will prompt saying there are renal stones on USG

Nik Athirah
 Mx: The investigations have come back and the scan that we did showed you have renal stones.

To treat this, we have to

1. Admit you under urology dept
2. Insert IV canula and give you fluid through your vein
3. Manage your pain with painkiller
4. Give anti-vomit medication
5. Insert urinary catheter (a soft flexible tube into your bladder through your penis) to monitor your urine
output. (Encourage 3-4L urine)
6. Arrange for CT KUB scan for better visual

Definitive management will be depending on the location and size of the stones.

 If the stone is small (<5mm), fluids alone will help you to pee it out naturally.
 If the stone is too big to pass naturally there are few procedures we can do.

7. ESWL is the most common way of treating kidney stones that can't be passed in the urine. It involves
using ultrasound (high-frequency sound waves) to pinpoint where a kidney stone is. Ultrasound shock
waves are then sent to the stone from a machine to break it into smaller pieces, so it can be passed in
your urine.
ESWL can be an uncomfortable form of treatment, so it's usually carried out after giving painkilling
medication.You may need more than one session of ESWL to successfully treat your kidney stones.
ESWL is up to 99% effective for stones up to 20mm (0.8in) in diameter.
8. If a kidney stone is stuck in the ureter, you may need to have a ureteroscopy, which is also sometimes
known as retrograde intrarenal surgery (RIRS). This is done under GA. It involves passing a long, thin
telescope called a ureteroscope through your urethra and into your bladder. It's then passed up into your
ureter to where the stone is stuck. The surgeon may either try to gently remove the stone using another
instrument, or they may use laser energy to break it up into small pieces so that it can be passed natural-
ly in your urine.
For stones up to 15mm (0.6in), a ureteroscopy is effective in 50-80% of cases. A plastic tube called a
stent may need to be temporarily inserted inside you to allow the stone fragments to drain into the blad-
der.
9. PCNL is an alternative procedure that may be used for larger stones. It may also be used if ESWL isn't
suitable. PCNL involves using a thin telescopic instrument called a nephroscope. A small incision is
made in your back and the nephroscope is passed through it and into your kidney. The stone is either
pulled out or broken into smaller pieces using a laser or pneumatic energy. PCNL is always carried out
under general anaesthetic. PCNL is 86% effective for stones that are 21-30mm (0.8-1.2in) in diameter.

Hemiarthroplasty

Scenario: You are FY2 in ortho. Emma Johnson is a 70 y/o lady admitted yesterday for hemiarthroplasty. She had a fall at home
and sustained left hip fracture. The surgeon has explained to her regarding the operation and the anaesthetist has discuss anaes-
thesia and post op pain management to her.
Your task is to dicuss about recovery process and post operative management

Steps: GRIPS. Paraphrase. Recovery process. Post op management

Doctor I understand that the surgeon and the anaesthetist have come to you to discuss regarding the nature of the
operation and general anaesthesia, is that correct?
Well I am here to explain to you what is going to happen after the surgery. Is that alright?

Nik Athirah
  After the operation, we will bring you to the recovery room. In the recovery room, we will check your
vital signs and monitor if you have pain or develop any bleeding. Once you are more awake and stable,
we will then send you back to the ward.
 In the ward, you will be able to eat and drink few hours after the surgery.
 On the first day after the operation, we encourage you to rest. We will also provide adequate pain killer
to manage your pain.
You will also be on antibiotics to prevent infection.
Since you will not be able to mobilize yet, we will give you blood thinners and provide you a compres-
sion stocking to ensure good blood circulation in your legs and prevent blood clots in your legs.
 On the second day after the operation, the physiotherapist will visit you in the ward. They will teach you
initially how to bear weight on your new hip and then they will teach you how to walk using a frame
(Zimmer frame). Progressively, once youre comfortable, they will teach you how to climb the stairs
 While in the hospital, we will also teach you some breathing exercise to prevent lung infection.
 We will also be doing some Xray after the operation to confirm if the operation is successful.
Patient When can I go home, doctor?
Doctor Once you are able to mobilize on your own, we will be happy to discharge you home.
May I know what kind of house do you live in? Is there any stairs at home?
The Occupational Therapist will come to your house and assess your housing condition to see if you need
help mobilizing at home. They will continuously do a home visit to make sure you are well.
Patient When can I walk normally again?
Doctor It normally takes about 6 weeks to resumae back to normal walking
Doctor There are few things that I want you to avoid after the operation.
1. Do not squat
2. Do not cross your legs
3. Do not sit in low chairs
This is to avoid dislocating your hip
Doctor Who do you live with?
If needed, we can refer you to social service and they can come and help you with your everyday activities.
Patient When can I start driving again?
Doctor Usually once you are comfortable to walk again you can resume driving but we will re assess you in 6 weeks
time to see how you are.
Doctor I would also like to refer you to orthogeriatric team. They will assess your bone density by doing a scan
called DEXA scan. This is too see how thick or thin your bone is. They will also prescribe you some medica-
tions that are good for your bone such as Calcium, Vit D and Bisphosphonate

Lipoma

Scenario: You are FY2 at surgical unit. Ashley White presented to your clinic complaining of a lesion on her shoulder. Take histo-
ry and discuss management

Step: GRIPS. ODPARA. DDx. P3MAFTOSA. Examine. Mx

Doctor  When did you first notice the lesion?

 Has it changed in size, color or shape over time?
 Does it have an irregular edge?
 Does it bleed?
 Is it painful?

Nik Athirah
Ddx

1. Malignancy (ask about lumps and bumps elsewhere)

 BCC - pearly white
 SCC - bleed easily, exposure to sun
 Melanoma - weight loss, anaemia (dizziness, palpitaion, tiredness, SOB), ABCDE (asym-
metry, border irregular, colour, diameter >6mm, evolution
2. Benign
 Lipoma - (overgrowth of fat cells), soft, doughy feeling
 Warts/verrucas - round or oval, firm and raised, rough irregular surface
 Skin tag - small, soft, skin coloured growth
3. Ulcers
 Venous - medial malleolus, varicose beins, bluish discoloration, pain/itchy/swelling/hardened
skin
 Diabetic ulcer
 Pressure ulcer
 Tubercular - cough low grade fever, weight loss, cough
4. Trauma
P3MAFTOSA
Complete history Lungs: cough/SOB, CVS: palpitation, GI: bowel habit, pain, nausea, CNS: headache,
visual problem, GU/prostate sx
Examine: VS and general examination of lesion
***examiner will show a photo of lipoma
Explain to patient examination findings:
From the examination, there seems to be a round swelling on your shoulder. It feels smooth and not attached
to skin. Your overlying skin looks normal. It is about 5x3 cm in size and there is no ulcer, pus or bloody
discharge from the lesion
Dx:
This is most probably a lipoma. It is a benign condition which caused by an overgrowth of fat cells.
Mx:
- Ask about how is this been affecting her life? Shows empathy

 Since this has been affecting you negatively, we can offer an excision biopsy which can be done under
local anaesthesia.
We will cut the skin over the lump and remove the lipoma. Then we will close the wound with stitches.
After the wound has healed, you'll be left with a thin scar.
Local anaesthesia is when we give you some numbing agent through injection around the skin that we
will perform the cut. Benefits: awake, less complications than GA.

 If you are anxious, we can offer some sedative to makes you relax. This can be given through your
vein.

 Done as a day case. Can go home on the same day if there is no complication developed.

 Complications: bleed, infection, damage to surrounding structure

 We will send the tissue sample to the lab to confirm that it is a lipoma. It will take 1 -2 weeks for the
result to come back.

 After the procedure, we will prescribe you some pain killer.

 No need to remove the stiches as we use an absorbable material. You can come to the clinic for dress-
ing instead.

Nik Athirah
 Skin tags
Skin tags are made of loose collagen fibres and blood vessels surrounded by skin. Collagen is a type of
protein found throughout the body.
They tend to occur in older people and people who are obese or have type 2 diabetes. Pregnant women may
also be more likely to develop skin tags as a result of changes in their hormone levels. Some people develop
them for no apparent reason.
Treatment: Skin tags can easily be burnt or frozen off in a similar way to how warts are removed. They can
also be surgically removed, sometimes using local anaesthetic.
If your skin tag is small with a narrow base, your GP may suggest that you try to remove it yourself by:
 tying off the base of the skin tag with dental floss or cotton to cut off its blood supply and make it
drop off (ligation)
 cutting it off with fine sterile scissors
Not funded by NHS as it is regarded as a cosmetic surgery

Warts/Verrucas
Caused by HPV
May clear itself without treatment
OTC: salicylic acid gel/cream/paint, dimethyl ether propane spray, or cryotheraphy (liquid nitrogen freeze)
at GP

Abnormal LFT

Scenario: Robert Frost, a 33 year old gentleman presented to your surgery. He had a blood test done 3 weeks ago. The results
came back as the following:
ALT 430 (5-35)
AST 110 (5-35)
ALP 83 (30-150)
Bilirubin 35 (17)
Your task: Take a focussed history, explain the results and discuss management with the patient.

Steps: Greet patient. Explain results. Take history of risk factor. Discuss management
Doctor: As you know, we did some blood tests recently. Has any of my colleagues been here to discuss them with you?
Alright, I am here to discuss the results with you.
Doctor: I’m sorry to tell you this but unfortunately, the results of the blood tests were not good.
(show patient the results)
The enzymes that are produced by your liver are high which indicate that your liver is inflamed. We are wondering
what might be causing it. May I ask you a few questions about this?
Doctor: (Take history of risk factors)
1. Do you have any fever?
2. Do you notice any yellowing in your skin or eyes?
3. Do you have any pain in your tummy? Do you have any diarrhoea?
4. Any weight loss, anaemia, tiredness?
5. Have you ever had a blood transfusion?
6. Have you travel abroad recently?
7. Did you have any tattoos done?
8. Are you taking any medication such as paracetamol?
9. Any change in the colour of your urine or stool?
10. Any history of stones in your gallbladder?
11. Do you drink alcohol? How much and how often and for how long? -> CAGETW
12. Are you sexually active? Male or female? Do you practise safe sex?
13. Is there any chance you use recreational drugs? Do you share needles?
Doctor: To confirm our diagnosis, we need to run some blood tests. I would like to take some blood samples for hepatitis
screening.
I would also like to arrange for ultrasound scan of your liver.
I would like to refer you to gastroenterology department for further management by the specialist.

Nik Athirah
Patient: Ask doctor how did he get the infection (hepatitis) from
Doctor: Hepatitis A: It's usually caught by consuming food and drink contaminated with the poo of an infected person.
Treatment is symptomatic as it usually passes within few months
Hepatitis B: Spread in the blood of infected person. Rarely, from unprotected sex and injecting drugs.
Hepatitis C: Spread through blood to blood contact of infected person. Most commonly spread through sharing
needles
Hepatitis D: co infect with hepatitis B
Hepatitis E: It's usually caught by consuming food and drink contaminated with the poo of an infected person.
Patient: Do I need to get admitted?
Doctor: If you are drinking and eating well, you do not need to be admitted.

Extra information
A. Obstructive jaundice (High GGT/ALP/Bili)
There is a problem with the flow of bile from your gallbladder into the bowels. The gallbladder is a small organ located just under
the liver. Its main function is to store bile which aids in digestion of food. Gallbladder is connected to the bowel by a bile duct.
The blood tests show that there is a blockage in the bile duct and bile is not able to flow properly.

B. Isolated rise in bilirubin :

Unconjugated: haemolysis, Gilbert
Conjugated: Dubin-Johnson

C. Isolated rise in GGT : alcohol abuse

D. Isolated rise in ALP:

Bony mets
Paget’s
Osteomalacia

Ankle Sprain

Scenario: You are a FY@ at ER. Mrs Black, 35 years old fell at home, sustained bruises and pain over her left malleoli. You have
seen the patient. Her ankle Xray came back as normal. Talk to the patient and address her concerns

Steps: Greet. Explain investigation. Give diagnosis. Discuss management. Address concerns.

Doctor: Hello Mrs Black. It is me again, Dr Nik, one of the junior doctors working in the ER. I understand that you
fell down at home nd injured your left ankle. How are you feeling at the moment? How is the pain?
Would you like to have some painkiller for the pain? Do you have any allergies to any medications? (Offer
Ibupofen, if allergic, offer PCM)
As you know, we have done X-rays of the ankle. Good news is that they have come back normal which
means that there is no fracture seen. (show patient the xrays)
Patient: Why am I experiencing pain?
Doctor: The reason why you are experiencing pain right now is because you have sustained an ankle sprain. A sprain
is an injury to a ligament, which are strong tissues around joints that attach bones together and give support
to the joints.

Nik Athirah
Doctor: For the next three days, you need to follow some measures for pain relief.
 Painkillers
 Rest at least 72 H. The physiotherapist will show you how to bear weight and walk using crutches.
 Ice. Make an ice pack by wrapping ice cubes in a plastic bag or a towel. Apply at swelling area for 10-
30 mins every 2 hours.
 Compress with a bandage
 Elevate the leg to at least at hip level

Avoid
 Heat for the next 72 hours
 Alcohol
 Running
 Massage

Further treatment:
 Gently get the ankle joint moving again by doing gentle exercise
 Refer to physiotherapist to help with some exercises and speed up your recovery
 Avoid playing sports or vigorous activities until pain free
 Review at ortho department in 5 days time
 Consult radiologist to confirm no fracture
Patient: Can you please change my note for me? Actually I did not fell at home but at work
Doctor: I am sorry I am unable to change your note once it has been written down. What I can do is that I can add up
this information in your note. Is that alright
Patient: I just thought it will be more accurate.
Doctor: Do not worry as it will not change the management
Patient: Can you get your senior to change it instead?
Doctor: I’m afraid anyone who is working in this hospital are bounded by the same ethical tules. My senior will not
be able to change your note as well. Is there any particular reason why do you want me to change it?
Patient: I am a single mother and I have 3 children. I work as a cleaner. I am struggling financially and if I said I fell
down at work I could get a compensation.
Doctor: I am so sorry to hear that you are struggling financially. What I can do is that I can refer you to social service
to see if you are entitled for any benefits. Would you like that?
Patient: Yes, please. Thank you doctor.
Doctor: Is there any other concerns?
Patient: Yes, can I please see my note?
Doctor: I’m afraid I cannot show you your notes at the moment. If you would like to see them, you can visit the
record department. They will give you some request forms for you to fill up and they can arrange it for you.

Back Pain

Scenario: Ian Smith, a 50 year-old male presented with back pain. Take a history, do relevant examination and discuss manage-
ment with the examiner

(+ve symptoms: weight loss, smoker)

Steps: Greet. SOCRATES. DDx. P3MAFTOSA. Exam (mannikin?). Ix. Mx

Nik Athirah
Doctor: Site: Where exacxtly is the pain?
Onset: When did it start? Did this come on gradually or suddenly?
Character: Can you describe me the character of the pain?
Radiation: Does it radiates anywhere else in your body?
Associated : Ddx
Timing: Is there any specific time of the day you experience the pain? Is it becoming worse, improving or
stays the same?
Exacerbating/Relieving: Anything makes it worse or anything brings it on? Anything makes it better?
Severity: On a scale of 1 -10, 1 being the lowest and 10 being the highest, how would you score your pain?
Doctor: DDx:
1. Prostate ca (tx is laparoscopic prostatectomy, depending on stages)
 Do you notice any weight loss? How much weight did you lose? Intentionally or unintention-
ally?
 Do you have to wake up at night frequently to pass urine? (nocturia)
 How often do you go to the toilet to pass urine? (frequency)
 Do you need to strain during urination? (strain)
 Do you feel you haven’t completely emptied your bladder after urination? Very little urine
comes out (obstruction)
 Have you noticed any weakness in your stream? Any dribbling of urine?
 Any blood in your urine?
2. Intervertebral disc prolapse
 Does your day involve lifting heavy things?
3. Trauma
 Did you sustained any trauma to your back?
4. Cauda equina
 Do you have any constipation?
 Do you experience any weakness or numbness in your legs?
 Do you feel you have to rush to the bathroom once you feel the urge to urinate and sometimes
you wet your pants?
6. Ankylosing spondylitis/Osteoporosis/Osteoarthritis
 Family history of back pain?
 Any pain in other joints?
 Any redness in the eye?
 Any morning stiffness?
7. Tuberculosis
 Any history of travelling abroad?
 Do you have any night sweats? Any fever?
8. Multiple myeloma
9. Spinal mets
Doctor: I would like to examine you now. I will be checking your vital signs, examine your spine, lymph nodes, and
the nerves in your legs. I will also be examining your tummy and your prostate, which is a male gland locat-
ed at the base of your bladder by inserting a lubricated gloved finger through your back passage gently. For
this purpose of examination, I will need you to undress below your waist and I will ensure your privacy and
provide you with a chaperone.
Doctor: There is a list of things that are in my mind at the moment which might be causing your symptoms. There-
fore, I would like to do some further investigations.
I would like to run some blood tests: FBC, RFT, LFT, Coag, PSA
I would like to take some urine sample for: Bence Jones protein, dipstick, culture & sensitivity
I will also do a tracing on your heart (ECG)
Xray
USG KUB
Transrectal USG and prostate biopsy

For the purpose of investigations, I would like to admit you.

Patient: Could it be cancer doctor?
Doctor: It is difficult to say what it is at the moment as there are many causes which may present the same way. That
is why we need to do these investigations to know what it is. Is there any particular reason you are worried
about cancer?

Nik Athirah
 Unfortunately cancer is one of the many causes which may be causing your symptoms. However, until the
results come back, it is again difficult to say what it is. That is why it is good to do these investigations im-
mediately so that the treatments will not be delayed

BPH with UTI

Scenario: You are a FY2 at urology department. 63 year-old male Robert Frost p/w dysuria. Take a focussed history, do relevant
examination, Discuss diagnosis and management with the patient

Steps: Greet. ODPARA. DDx. P3MAFTOSA. Abdominal exam and PR exam (maybe on manikin?). Diagnosis. Management

Doctor: Onset: When did you start having painful urination?

Duration: Did it come on suddenly or gradually?
Progression: Is it getting worse, improving or stays the same?
Aggravating: Anything makes it worse?
Relieving: Anything makes it better?
Associated sx: DDx
DDx:
1.UTI
- Do you have any fever?
- Do you feel that you need to pass urine more frequently?
- Any pain in the tummy?
- Any change in the colour of the urine? (cloudy/maladourous)
- Any history of waterwork infection in the past?

2. BPH
- Do you have to wake up at night several times to urinate? (nocturia)
- Have you noticed any weakness in your stream? Any dribbling of urine? (poor flow)
- Do you need to strain during urination? (hesitancy)
- Do you have to wait for a long time before you can start passing urine? (hesitancy)
- Do you feel as though you need to urinate but then very little urine comes out? (intermittency)
- Do you feel you have to rush to the bathroom? Do you have control of your bladder? (urgency)

3. Renal stones
- Any sudden gripping pain when you start passing urine?
- Any blood in the urine?
- Have you ever passed small stones in your urine?

4. Prostate ca/ Bladder ca

- Weight loss, Back pain, Haematuria

5. Trauma
- Have you had any medical procedures done through your water pipe?
Complete P3MAFTOSA
I would like to examine you now. I will be checking your vital signs. I will also be examining your tummy
and your prostate, which is a male gland located at the base of your bladder by inserting a lubricated gloved
finger through your back passage gently. For this purpose of examination, I will need you to undress below
your waist and I will ensure your privacy and provide you with a chaperone.

**there maybe a minikin for prostate exam**

Thank you for cooperation.
From the examination, I found that your tummy is.. and your prostate is...

Nik Athirah
 Now, I would like to do some investigations to find out the causes of your symptoms.
I would like to take some blood samples (FBC, RFT, LFT, Coag, Glucose)
I would also like to take some urine sample for urine dipstick and culture and sensitivity

**examiner will give urine dipstick result** eg nit/leu +ve, trace bili/blood

So the result of your urine has come back, as you can see here the results shows positive in nitrites and
leukocyte, which means that you are having a urinary tract infection (waterwork infection)
Based from what you have told me and from my examination, it is most likely that you are having urinary
tract infection (waterwork infection) due to your enlarged prostate. The enlargement of prostate is what we
call a Benign Prostatic Hyperplasia.
With age, the prostate usually become enlarged and if it becomes too big, it can block the fow of urine. Since
urine is not able to flow properly, it stays longer in the bladder. This creates and environment for infection
and this is what has happened in your case.
The symptoms of an enlarged prostate include passing urine frquently during the night, dribbling, difficulty
in passing urine and poor flow of urine.
I will start you on antibiotics for your infection (for 3 - 6 days)
 Trimethoprim - 200mg bd or
 Nitrofurantoin - 50 mg qid or
 Amoxicillin - - 500 mg tds
It is advisable to drink plenty of fluids
For your enlarged prostate, I can give you a medication called Tamsulosin. This is to relax your sphincter
and improves your urinary symptoms.
Once the infection has settled down, we will see you again in a week time for some procedures.
I would like to arrange a ultrasound (sonar) scan on your kidney, ureter and bladder.
I would also like to perform a transrectal ultrsound scan and biopsy. It is a sonar scan in which the probe will
be inserted through your back passage gently to visualize the prostate better and take some tissue sample to
be sent to the lab.
I would also take some blood sample for Prostate specific antigen level.
In the future, if your glands are still enlarged and causing a problem despite the medication, we can do a
procedure called Transurethral Resection of Prostate under General Anaesthesia. This is a procedure where
we insert a thin tube through your private part and cut out a section of your prostate. This will relieve the
pressure of your bladded and you will be able to pass urine better

Urinary Obstruction & Catheterisation

Scenario: Mr Johnson is a 70 year-old gentleman who has been unable to pass urine for the past 24 hours. Please take a history,
explain diagnosis and management to patient.

Steps: Greet. ODPARA. DDx. P3MAFTOSA. Dx and Mx

Doctor Onset: When did you start having difficulty to pass urine?
Duration: Did it come on suddenly or gradually?
Progression: Is it getting worse, improving or stays the same? Are you able to pass any urine at all today?
Aggravating: Anything makes it worse?
Relieving: Anything makes it better?
Associated sx: Any pain/discomfort anywhere in your tummy?

Nik Athirah
DDx:
1.UTI
- Do you have any fever?
- Do you feel that you need to pass urine more frequently?
- Any pain in the tummy?
- Any change in the colour of the urine? (cloudy/maladourous)
- Any history of waterwork infection in the past?

2. BPH
- Do you have to wake up at night several times to urinate? (nocturia)
- Have you noticed any weakness in your stream? Any dribbling of urine? (poor flow)
- Do you need to strain during urination? (hesitancy)
- Do you have to wait for a long time before you can start passing urine? (hesitancy)
- Do you feel as though you need to urinate but then very little urine comes out? (intermittency)
- Do you feel you have to rush to the bathroom? (urgency)

3. Renal stones
- Any sudden gripping pain when you start passing urine?
- Any blood in the urine?
- Have you ever passed small stones in your urine?

4. Prostate ca/ Bladder ca

- Weight loss, Back pain, Haematuria

5. Trauma/Stricture
- Have you had any medical procedures done through your water pipe?

6. Spinal cord compression

- Do you have any loss of senstation or weakness in your legs?
- Any back pain?

7. Urinary incontinence
- Do you experience any leakage of urine when you lifting heavy things, cough or sneeze?

8. Drug induced
- Are you on any medications? (antidepressant/anticholinergic)
P3MAFTOSA
I would like to examine you now. I will be checking your vital signs. I will also be examining your tummy
and your prostate, which is a male gland located at the base of your bladder by inserting a lubricated gloved
finger through your back passage gently. For this purpose of examination, I will need you to undress below
your waist and I will ensure your privacy and provide you with a chaperone.

**abdo distended, enlarged prostate**

Explain findings and diagnosis

Based from what you have told me and from my examination, it is most likely that you are having urinary
obstruction due to your enlarged prostate. The enlargement of prostate is what we call a Benign Prostatic
Hyperplasia.
With age, the prostate usually become enlarged and if it becomes too big, it can block the fow of urine.
The symptoms of an enlarged prostate include passing urine frquently during the night, dribbling, difficulty
in passing urine and poor flow of urine.
Immediate Management (Urinary Catheterisation)

Since you are having a discomfort, I would like to insert a soft flexible tube through your private part to
relieve the obstruction. This will help the urine to flow out and you will feel a lot better afterwards. I will
then to take some samples of your urine to check for any infection.

Nik Athirah
How are you feeling now?

**If the urine is >1000mls, admit patient. If less, book and outpatient appt with urologist for trial without
catheter**

I would like to do further tests which includes:

- Blood tests: FBC, RFT, LFT, Coag, Glucose
- PSA
I would also like to arrange for:
USG KUB, Transrectal USG and biopsy

I will be giving you some medications

1. If patient have UTI - abx
2. Medications to shrink prostate: Tamsulosin (anticholinergic - alpha blocker), Fenestride (5-alpha reductase
inhibitor)

We will do a trial without catheter, to see if you can pass urine without catheter. If you are unable to pass
urine, you have to stay with the catheter.

I will then discuss with my senior if we can offer you Transurethral resection of prostate (can only be done
by urologist)

A TWOC should take place as soon as possible following catheter insertion or when a reassessment of the patient indi-
cates that it is safe to do so (NHS Quality Improvement Scotland, 2004). There is a lack of consensus about the best time
of day to remove a catheter but research involving urology patients suggests midnight (Kelleher, 2001).

Nik Athirah
Haematuria

Scenario: Mr Brown is a 60 y/o male who has come to the hospital c/o blood in his urine. Please take a history and discuss man-
agement with the patient

Steps: GRIPS. ODPARA. Quantify blood, anaemic and hypovoleamic qs. DDx. P3MAFTOSA. Mx

Timing of hematuria:
 Before urination: Stones
 During urination: Bladder ca
 Terminal urination: Schistosomiasis
Quantify:
 Was there a lot of blood in your urine?
 What colour is it?
 Are there any clots?
Anaemic qs:
 Do you feel light-headed?
 Any SOB/palpitation?
 Do you feel tired?
Hypovolemia
 Do you pass our less urine?
 Is your urine becomes more concentrated?
Ddx: (TITI)

1. Tumour/Malignancy
a) Bladder ca: smoking/dye industry
b) Prostate ca: back pain/ hesitancy/ urgency/ frequency/ dribbling
c) Renal ca: lumps/bumps

2. Infection
a) UTI: dysuria/ fever/ frequency
b) Schistosomiasis: Have you travel recently? Did you by any chance swim in a tropic water?

3. Stones
a) Renal calculi: Loin pain, colic
b) Ureteric calculi: Loin to groin
c) Bladder calculi: Suprapubic pain when passing urine

4. Bleeding tendencies
a) Drugs
b) Bleeding disorders
P3MAFTOSA
Examination:
VS, Abdo, PR, Lymphoreticular
Dx: From what you have told me, there are several things that may be causing your symptoms
Mx:
We will need to do further tests to identify what the cause is.
1. Blood tests
2. Cystoscopy + biopsy
Cystoscopy is a medical procedure used to examine the inside of the bladder using an instru-
ment called a cystoscope.
A cystoscope is a thin, fibre optic tube that has a light and a camera at one end. It's inserted into the
urethra (the tube that carries urine out of the body) and moved up into the bladder.
The camera relays images to a screen, where they can be seen by the urologist (specialist in treating
bladder conditions).
3. Urine dipstick
4. USG KUB
5. (if suspect prostate: TRUS+biopsy)

Nik Athirah
Abdominal pain LIF (diverticulitis query colonic ca) with abdominal examination

Scenario: Mr Owen Wilson is a 50 year old male p/w pain over LIF. Please take a history, do relevant examination and discuss
management with the patient.

Steps: GRIPS. SOCRATES. P3MAFTOSA. DDx. Exam. Mx

DDx

1. Diverticulitis
 Any feeling of bloatedness relieved by defecation?
 Any changes in bowel habit? (Constipation to diarrhoe during inflammation)
 Any blood in the stool?
 Do you feel sick or vomit?
 Any fever?
2. IBD
 Do you have a chronic diarrhoea?
 Any mucous or blood in the stool?
 Any joint pain/rashes/pain in the eyes?
3. Colon ca
 Any swelling in the tummy? Lumps or bumps?
 Weight loss? Loss of appetite?
 Altered bowel habit?
 Blood in the stool?
 Any sensation of incomplete defecation?
4. UTI/Renal stones
 Any burning sensation when you pass urine?
 Any sudden gripping pain when you wee?
 Did you pass any stone?
 Any blood in the urine?
P3MAFTOSA
Exam:

1. VS
2. Abdominal examination + PR
 Exposure: Midarm to midthigh
 Hands + Flapping tremor
 Eye
 Mouth
 Inspection from end of bed + cough + raise head
 Palpation: Supeficial and deep. Liver. Spleen. Kidney. Abdominal aneurysm
 Percussion: All quadrants. Liver. Spleen.
 Auscultation: Bowel, Abdominal and renal arteries bruit
 PR
Dx: We are suspecting that you might be suffering from a condition called diverticulitis. It is high
likely that you have small bulges that stick out of the side of your large bowel. When bacteria be-
comes trapped inside one of these bulges, it can lead to infection and inflammation, causing the
pain and fever that youre having now
Mx:

1. Bloods: routine, inflammatory markers

2. Urine dipstick
3. Pain relief: PCM
4. Antibiotics: Co-Amoxiclav or Ciprofloxacin + Metronidazole for 7 days
5. Clear fluids for 2-3 days, then introduce solid once symptoms improved
6. For the three to four days of recovery, a low-fibre diet is suggested, until you return to the
preventative high-fibre diet. This is to reduce the amount of faeces (poo) your large bowel has
to deal with while it is inflamed.

Nik Athirah
7. Refer to gastroenterologist dept for further investigations such as CT scan and colonoscopy
once you have recovered

Criteria to admit to hospital:

If you have more severe diverticulitis, you may need to go to hospital, particularly if:
 your pain cannot be controlled using paracetamol
 you are unable to drink enough fluids to keep yourself hydrated
 you are unable to take antibiotics by mouth
 your general state of health is poor
 you have a weakened immune system
 your GP suspects complications
 your symptoms fail to improve after two days of treatment at home
Surgery criteria:
 if you have a history of serious complications arising from diverticulitis
 if you have symptoms of diverticular disease from a young age (it is thought the longer you
live with diverticular disease, the greater your chances of having a serious complication)
 if you have a weakened immune system or are more vulnerable to infections

Nik Athirah
PSYCHIATRY
Alcohol History and Management

Scenario: Mrs. Wright is a 55 year-old female admitted for hysteroscopy. Hysteroscopy was successfully done and she is ready to
be discharged. A nurse noticed that she has been drinking an excessive amount of alcohol and ask you to see the patient.
Task: Assess alcohol consumption and address her concerns

Steps: Greet. Establish rapport. Establish alcohol intake. Alcohol dependence. FAMISH. Depression and Psychosis. Common
complications. Management

Doctor: Hello, are you Mrs Wright? Can I confirm your age please? Nice to meet you. My name is Nik, I am one of the
junior doctors working in the department.

I understand that you have been admitted for hysteroscopy. How are you feeling now?
I would like to ask you some question, is that alright.
Ask other questions first (eating, drinking, pain)
I would like to ask some questions about your social history.
Do you drink alcohol?
What, How much, How long
C - Have you ever felt that you need to cut down on your drinking?
A - Have you ever got annoyed because other people are concerned about your drinking?
G - Have you ever felt guitly because of the way you drink?
E - Have you ever used alcohol as an eye-opener in the morning?
T - Do you feel that you have to increase the amount of alcohol that you drink to achieve the same effect?
W- What happens if you dont drink for a day or two?
Withdrawal symptoms: Tremor, sweat, low mood, insomnia, anxious, visual halluciantion
Ask FAMISH
Family/Friends/Forensic/Financial
Alcohol/Smoking
Medical illness
Insight
Suicidal risk
Hallucination
Depression: How is your mood?...
Psychosis: Do you have any beliefs, which other people do not agree with?...
Common complications: Liver, HPT, Stroke, Pancreatitis
Doctor: From what you have told me, it seems that the amount of alcohol that you’re drinking is too much. This can
impact your health negatively.
If you continue drinking, you can develop serious conditions such as
 Bleeding from the blood vessels in the stomach and this can be life threatening.
 Damage to your liver which may cause:
- low blood sugar level
- damage to the brain due to an accumulation of toxic substances in the body, since the liver is not able to
work effectively to prevent this
 It can also be difficult to build a healthy family ot sustain job

Nik Athirah
Doctor: I strongly recommend that you try to stop drinking. Do not worry, we are here to help you. There is a lot of
help available to help you stop drinking.

1. I can refer you to the alcohol and substance misuse team where they have good specialists to help you
stop drinking. They can support you and prescribe some medications that can reduce the desire to drink
alcohol (acamprosate). Disulfiram: when you consume alcohol, you will not like the taste of it)

2. I can also refer you to a talking therapist. CBT is a talking therapy that uses a problem-solving approach
to alcohol dependence.Your therapist will teach you how to avoid certain triggers and cope effectively
with those that are unavoidable.

3. There is also a self-help group called Alcohol Anonymous where you can meet people who are in the
same boat like you, trying to quit alcohol and laso people who have successfully quit alcohol who can
share their tips and experiences.

4. Al-Anon is an organization affiliated with AA that provide help and support for the relatives and friends
of people with a dependence on alcohol.

Heroin Addiction

Scenario: You are FY2 in substance and misuse clinic. Rob Stewart is a 32 y/o gentleman who have been using drugs for a while.
He came to the clinic with intention to stop using drugs. Please talk to the patient

Steps: GRIPS. History of drugs use. FAMISH. Assess depression. Examine. Ix. Mx

Patient I want to quit using drugs doctor

Doctor It is good that you come to us for help. Is it alright if I ask you some further question regarding your drug use?

Drug history:
 What recreational drugs have you been using?
 How long have you been using them? How often do you use them and how much?
 How do you take them? Do you smoke or inject the drugs? If injecting, do you share needles?
 What happens if you dont use them for a day or two? Do you experience any problems? What would
happen?
 Who do you do drugs with?
 Where do you do drugs?
 How did you dipose the needles?

Which drugs would you like to stop using?

FAMISH
 Family: Who do you live with? Do you have a family?
 Friends: Do you have any friends? Do they use drugs like you?
 Forensic: Have you ever been in trouble with the law?
 Finances: How are your finances? Do you have any problem?
 Alcohol: Do you drink alcohol?
 Smoke: Do you smoke?
 Sexual history
 Drugs/Allergy
 Medical illness and medications
 Interest in life: How do you see your future?
 Stress at work/home
 Hallucination or delusions: Have you ever come across an experience where you feel like you have a firm
belief that others do not agree with? Can you hear voices or see things that other people cant hear or see?
Or if anyone commenting on your thoughts and actions?
How is your mood at the moment?
Have you ever felt like life is not worth living? Have you ever thought of harming yourself/others?

Nik Athirah
 Exam:
VS. Head to toe examination
Ix:
I would like to do some investigations on you. I would like to do some routine blood tests just to make sure
that everything is alright with you.
I would like to recommend you further test such as HIV test and hepatitis screening just to make sure you do
not have these. This is important especially when people share needles, they can contract these infections.
Mx:

There are many ways that we can help you to quit.

1. We can sign you up for drug addiction programme where we have specialist who can advise you on ways
to stop using drugs and handle life in general. You can remain in contact with them as long as you want.
2. To help with withdrawal symptoms, (if heroin addiction) we can offer you a heroin substitute such as
methadone or buprenorphine. The substitute can help you to stabilise your drug use, stop using illegal
drugs, change risky behaviour, such as injecting and sharing needles and equipment and stop the need to
commit any crimes to fund your habit.
*Methadone comes in an oral form. Usually given once a day. You have to take it in front of the pharma-
cist so that the dose will be correctly taken. Initial dose will depends on your withdrawal level
3. We can also refer you to talking therapies such as caunselling to understand and overcome your addic-
tion. There are also couple or family therapies if you want to include them in your treatment. care plan
will be developed to identify any other help you need, and your keyworker will make sure you receive
this help. Your keyworker may arrange help for you with issues such as housing, benefits, education and
employment. You may be offered the opportunity to learn computer skills or try activities, such as sport
and exercise.
4. There is also self-help group called narcotics anonymous for people with the same problem who wants to
help each other
5. Once you are stabilized, and in the right circumstances, you have the option of coming off methadone (or
other substitute drugs). You may be given the community or inpatient detox. But that will be further
down the line and we can discuss this later on.
6. Needle exchange programs where you can come and change your needles with fresh needles
7. Phone number to contact when you feel vulnerable

Insomnia

Scenario: You are FY2 in GP. Mrs Sherry is a 65 y/o female who made a non-urgent appointment to meet you. She has rheuma-
toid arthritis for 9 years. She is on MTX, PCM and Folic acid. MTX blood level monitored and is normal. Please take a history,
address concerns, perform relevant ix and discuss mx with patient.

Steps: GRIPS. History of sleep pattern. Ddx. FAMISH. Ix. Mx

Doctor I’m sorry that you are having difficulty in sleeping. Can I ask you some questions regarding your sleep pat-
tern?
History of sleep pattern:
 How was your sleep pattern before this?
 When did you first notice your sleep pattern has changed?
 What happen when you try to go to sleep?
 What do you do before you go to sleep?
 Do you wake up earlier than usual?
 Do you wake up in between?
 Is there anything that you tried to improve your sleep?
 Was there any life changing event that has caused the disruption in your sleep pattern?
Ddx:
1. Depression (early morning awakening, SUICIDE)
 How is your mood? Can you rate your mood from 1 -10?
2. Pain
 Do you have any joint pain?
 Any flare up recently?

Nik Athirah
 Are you on any medications for the pain? Is it helpful?
3. OCD (RIPSOUR)
 Do you get up to check the lock repeatedly at night?
4. PTSD (DREAMS)
 Did you had any traumatic experience? Flashback?

5. Coffee/tea
6. Panic attack
 Do you feel like you are going to die?
 Any racing of the heart or SOB?
7. Shift worker
8. Living environment (noisy, bright room)
9. Anxiety
10. Nocturia (DM/BPH)
FAMISH
Exam:
VS
Hand examination
Rheumatoid hand examination***

I would like you to expose your hands, wrists and elbows. Please put your hands on top of the pillow.
Do you have any pain?

1. Look
Dorsum:
Deformity - Swan neck, Boutonnieres, Bouchard’s nodes, Herberden’s nodes, Z-deformity
Muscle wasting
Skin changes - psoriatic plaque or rheumatoid nodules - elbow
Nails - pitting and onycholysis
Palm:
Deformity - Dupuytren’s contracture
Skin - erythema
Muscle wasting - Thenar hypothenar
Scars/swelling

2. Feel
Elbow: nodule, tenderness, psoriatic plaques
Palm: Thenar, hypothenar muscle bulk, Temp, Tenderness, Palmar thickening, Radial pulse
Dorsum: Tenderness over wrist, MCP, PIP,DIP, anatomical snufbox
Sensation:
Median - thumb, index, middle finger
Ulnar - little finger and hald of ring
Radial - first dorsal web space

3. Move (passive then active)

Wrist extension/flexion
Finger flexion (make a fist), extension (spread your fingers)
Supination, pronation

Check nerves:
Median - Perfect sign
Ulnar - Grip fingers tightly
Radial - Thumb up sign, push it downwards

Check function:
Pick up coin/unbotton and button shirt

Special test: Tinel’s and phalen’s test

Mx:

Nik Athirah
 Advices/Lifestyle changes
Don’t
 Go to bed unless sleepy
 Coffee/alcohol before sleep
 Watch TV late into night
 Sleeping during the day
Do’s
 Warm bath before sleep
 Glass of milk or calming music
 Regular daily exercises
 Comfortable bedtime environment
 Mark your sleep pattern in a sleep diary for a week and bring it to us

If these dont work, we may prescribe you some medication to help you to sleep. This will be decided by my
team later on
 BZD : Alprazolam/Ternazepam
 Mild dose everyday for 1 week (avoid dependency)
 Follow up in 2 weeks to review sx

Psychosis

Scenario: You are FY2 at PSY dept. 20 y/o John Stewart was brought in to hospital by the police after been wandering alone in
the park. Please attend the patient.

Steps: GRIPS. Reassure patient is safe. Rule out Ddx. FAMISH. Mx

Patient Police! Police! Police! They are coming to get me!

Doctor Hello, my name is Nik. I am one of the junior doctor working here. Please do not wory, I am here to help you.
You are safe here. Please have a sit sir.
Can you please tell me your name. How old are you?
Could you tell me what are you seeing?
Are you seeing them now?
How many of them?
What are they doing?
Are they saying anything to you? Or are they talking about you among themselves?
What do they ask you to do?
How long have they been following you?
Do you feel safe with them following you?
Ddx
1. Drugs
 Is there by any chance you use recreational drugs? Which one? How long? How do you take them? How
often? What happened when you stop taking them? Have you tried to stop using the drugs before?
2. Alcohol
 Do you drink alcohol? How much per week? How long? CAGETW
3. Schizo
 Do you see or hear voices when nobody can see or hear them?
 Do you have any beliefs that others do not agree with?
 Do you feel like people are putting thought in your head?
 Do you feel that people around you know what you are thinking despite the fact that you have not told
anyone about this?
 Do you feel like people are taking thought from your head?
4. Mania/BPAD
 How is your mood?
5. Delirium
 Do you have fever?
FAMISH
Insight: Do you think that these people are real? Do you think that this is a problem and you need medical

Nik Athirah
 help?
Assess risk of harm:
 Do these people tell you to harm yourself/others around you?
 Have you ever thought of harming yourself/others?
 Do you carry weapon to protect yourself?
Mx:

Do not worry John, you are safe in here. We will help you in every way we can.
We need to:
1. Admit
2. Blood tests
3. Toxicology screening - blood and urine
4. Do full examination on you and get your VS
5. CT ?
6. IM Haloperidol to calm you down
7. d/w senior regarding antipsychotic meds

OCP Overdose

Scenario: Liz Tyler is a 30 y/o lady who has been brought to hospital by her husband following an overdose of 40 tabets of
COCP. She also cut her wrist. She has been treated successfully and is no medically fit. Please assess her suicide risk and mental
statu. Discuss your assessment and further management with examiner

Steps: GRIPS. Offer confidentiality. Assess current intent and plan. Assess risk factors. FAMISH. Assess mental state. Mx

Doctor I understand that you have taken some tablets and this is why you are here, am I right?
I would like to assure you that whatever we speak about today will be kept confidential between you and the
medical team.
Current intent and plan
1. Would you like to tell me more about what happened?
2. What was your mind when you took the medications?
3. What medications did you took, and how many?
4. When did you take them?
5. Were you alone when you took the tablet?
6. Did you plan this?
7. Did you write any notes or will?
8. What were your intentions when you took these tablets?
9. How long have you had these thoughts of harming yourself?
10. Have you ever tried to harm yourself before?
11. How do you feel now?
12. Are you still having thought of harming yourself?
13. Do you think you will do it again?
14. Did you inform anyone about this?
15. How do you see your future?

I can see that you have a bandage on your writs. Can you tell me what happened?
Risk factors + FAMISH

Alcohol
Drug abuse
Depression
Mental illness
Employment
Financial
Fhx of suicide or self harm

Assess psychosis
Assess insight

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 MSE
1. Appearance
2. Behavior
3. Mood (subjective and objective)
4. Speech (rate, tone, volume)
5. Thought
6. Perception
7. Insight
8. Cognition - Date/Place/ApplePennyTable/Count backwards 20
9. Suicidal risk
Management

Low risk patient:

Can go home where there is support
Tell GP
Include crisis team - offer a crisis card with names of people to contact if she ever felt so low and needed
someone to speak to anytime
Arrange community mental health team to follow up within a week

High risk patient:

Admit

*If at ED, refer to PSY for further risk assessment and caunselling

MMSE

Scenario: Mr Stephen Wilkinson is a 70 year-old gentleman was brought in the hospital by the police after has been found wan-
dering in the park. Please assess the cognition of this patient

Steps: Orientation in person, time and place. Registration. Attention. Recall. Language (Repeat, Identify, Read, Write, 3part task),
Copying. Scoring. Mx

Doctor I am here to perform an assessment on you. I will be asking a few questions and will ask you to do few things.
This may sound silly but it is only for the purpose of assessment, so please bear with me
Orientation (10pt)

Person: Can you tell me what is your name and how old are you
Place: Country, County, City, Building, Floor (5pt)
Time: Year, Season, Month, Date, Day (5pt)
Registration (3pt)

I am going to name 3 objects. After I have said all the three objects, please repeat them to me. Please remem-
ber these 3 objects as I am going to ask you to name them again in a few minute.
Apple, Penny, Table
- score 1 point each for correct reply on first attempt
- repeat 5 times if patient did not say them correctly
Attention (5pt)

Can you please spell the word WORLD for me please *can help patient to spell it first
Now can you please spell the word WORLD backwards (1 pt for each correct letter until the order is lost)
Recall (3pt)

Can you please name the three objects that I had mentioned earlier
Language (8pt)

1. Object identification (paper and pen) - What is this called?

2. Repeat a phrase after me - No, ifs, ands or buts

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 3. Reading - Write CLOSE YOUR EYES. Please read the words on the paper and do what it says
4. Write a sentence - Can you please write me a full sentence on this piece of paper?
5. 3 part tasks - Can you please pick up this piece of paper, fold it into half and place it back on the table?
Copying (1pt)

Draw intersecting pentagons. Allow several tried until patient is finished. Max 1 minute.
Scoring

Normal: 25-30
Mild cognitive impairment: 21-24
Mod: 10-20
Severe: <10
Management

Investigations:
Routine blood + Vit B12, TFTs, Iron, Folate, Prions, Copper
Toxicology screening
Hepatitis, Syphilis
Urine dipstick
ECG, EEG, CXR
CT Brain

Arrange to contact family members

MEDICINE
Elderly abuse

Nik Athirah
Scenario: You are FY2 in geriatric department. Lina White is a 80 year-old lady who was brought to hospital by her daughter
following a fall. Nurse found bruises of different age on her arm. Take a history and discuss management with her daughter,
Emma White.

Approach:
1. GRIPS
2. Confirm relationship
3. Paraphrase
4. Take history of fall. Before/During/After.
5. Ddx:
 Stroke/Joint problem/Hypogylcaemia/Arrythmia/Infection
6. H/o brusises ***Do you know anything about it?
7. P3MAFTOSA
8. Ask about independency and mobility
9. Ask about social history:
 Who is caring for her? How is the daughter coping with it? Is there any financial problem? What kind of house she
lives in?
10. If the daughter confess of NAI:
 Ask if this is the first time it happened?
 Any other types of abuse: Neglect (not giving her basic need like food, bath), Verbal (yelling at her), Physical
11. Management:
 Admit patient
 Ix: Blood tests, ECG, Do a skeletal survey, CT Brain
 Can’t take her mother home yet as the consultant, social service and occupational therapist need to see her

Wheeze on first presentation

Scenario: Mr William is a 20 y/o male presented to your hospital with a wheeze. Please take a focussed history, discuss manage-
ment with patient

Steps: GRIPS. ODPARA. Triggering factors. DDx. Dx. Ix. Mx

Doctor ODPARA
*Are you currently comfortable to talk?
*Have you ever experienced this before?
Triggering factor: “Do you notice anything triggers the wheeze or make it worse?”
 Pets
 Dust
 Occupation
 Allergies
 Exercise
 NSAIDS or aspirin
 Smoking
 Cold weather
 Infection
Ddx
1. Asthma (history of allergies, family history of asthma or eczema, intermittent symptoms of SOB, wheeze,
dry cough)
 Is there any particular time of the day when your wheeze is worse?
 Do you experience wheeze when doing exercise?
2. COPD (chronic smoker, chronic SOB, middle aged man)
3. Anaphylaxis (rash, swelling of face and neck, h/o previous ep)
4. Cardiac asthma (elderly, chronic SOB, orthopnoea, leg swelling)
5. FB (in kids)
P3MAFTOSA
Exam: VS, General physical examination, Chest

***Examiner will say: Audible wheeze on auscultation

Nik Athirah
 Dx:
Asthma
It is a chronic disease of the airway where there is an inflammation of the airway which causes temporary
narrowing of the airway and this can cause breathing problem.
Mx:

In acute asthma:
1. Nebulisers Salbutamol and Ipratropium Bromide. Can give up to 2 times with 15 minutes break in be-
tween. Reassess symptoms and lungs post nebulisers. (If needed >2 times, need to admit patient)
2. IV HVT 200 mg STAT

If patient settles:
1. Prescribe salbutamol inhaler PRN. Explain how to use it. Advise to use it as needed and before exercise.
2. Measure PEFR. Explain how to use PEFR device and diary (how to record it)
3. Avoid triggers for example: avoid NSAIDS, use PCM instead
4. Refer to GP for follow up in 2 -3 days and also for possible adddition of a steroid inhaler to prevent
further exacerbation

Diarrhoea - colonic cancer

Scenario: Steve Job came to you with a complain of diarrhoea. Please take history, perform relevant examination, and manage the
patient.

Steps: GRIPS. ODPARA. DDx. Assess dehydration.P3MAFTOSA. Exam. Mx

Doctor ODPARA
How was your bowel habit previously?
Ddx:
1. Gastroenteritis
 Do you have any vomitting?
 Is there any pain in your tummy?
 Is there anyone else in the family has the same problem?
 Is there any mucous or blood in the stool?
 Do you prepare your own food or do you eat outside?
 Traveler’s diarrhoea: Did you travel abroad recently?
2. IBD
 Chronic diarrhoea, mucous, bleeding, abdo pain, extraintestinal symptoms ( eye pain, skin changes, joint
pains)
3. Colonic ca
 Do you sometimes have constipation and some other times have diarrhoea?
 Do you notice any weight loss?
 Do you notice any blood in the stool?
 Any lumps or bumps in your body?
 Do you have a feeling that you have not completely emptied the bowel after passing stool?
4. Hyperthyroidism
 Do you feel hot when others are comfortable?
 Do you feel your heart racing?
 Any shakiness in the hands?
 Any weight loss
5. IBS
 Do you feel your tummy is bloated?
 Do you have any tummy pain? Does it relieved after defecation?
6. Pseudomembranous colitis
 Have you been taking antibiotics recently?
7. Laxative
 Are you any medications recently
Dehydration:
Do you feel thirsty?

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 Are you passing urine as usual? What color is your urine?
Do you feel weak?
Are you able to take enough fluid?
P3MAFTOSA
Exam

VS
Abdominal exam + PR
Lymphoreticular

***may need to perform abdominal examination here

Dx: From what you have told me, there are a number of things that may be causing your symptoms. To find
out the cause, we need to do some tests

1. Routine blood test

2. Stool examination (FOB)
3. Colonoscopy and biopsy
- This is a procedure where we will be passing a lubricated flexible tube, which has a camera attached at
the end of the tube, up through your back passage into your bowels to see the inside of your bowels. We
will be able to see the visual of your bowel on the screen. We may need to take some tissue samples and
send them to the lab if we found any abnormalities.
4. CT scan
- uses X-rays and a computer to create detailed images of the inside of the body. You will need to lie
down on a flat bed that passes into the scanner
5. For the purpose of investigation, it is better to admit you
***If gastroenteritis:
Mx is mainly hydration and symptomatic treatment (Loperamide) as it will resolves after a week.
Ix: stool culture, blood tests mainly U&Es if sx or signs of dehydration
Hygiene advices: Dont share towels, avoid preparing food for others, clean toilet seats after use

Post Mortem + Breaking bad news

2 Scenarios:
a) We request a consent for post-mortem
b) Patient’s side wanted a post mortem

a) Steps: GRIPS. Confirm relationship. Assess understanding. Paraphrase. Break bad news. Explain post-mortem. Ad-
dress concerns

Doctor I am here to discuss about your mother’s condition with you.

How much do you know about what had happened to your mother?
Would you like to have someone with you before we discuss further?

Break news***
The reason I am asking is because I’m afraid we have a bad news for you.
As you know, your mother went for surgery to remove her womb. The operation went very well and she was
recovering well. Unfortunately, she suddenly became unwell and deteriorated. We tried our very best to revive
her but I am afraid it was not successful.
I am really sorry to say that unfortunately your mother had passed away.
*Let patient react*
Would you like me to call someone to be with you?
Is there anything you would like to ask me?
Patient Where is she now?
Doctor She is at the mortuary at the moment

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Patient How did she die?
Doctor Unfortunately, we don’t know what is the reason for it. For this reason, it is important to carry out the post
mortem examination on he to find out the cause of her death.
A post-mortem is also known as an autopsy. The pathologist, which is the specialist doctor, opens up the body
and performs an internal examination. They will perform an incision from shoulders to the centre of the chest
and down to groin. At the same time, they may take a few sample for testing. These are done to find out the
diagnosis for the cause of death. This procedure will be carried out in an examination room which looks like
an operating theater
The advantages of doing this is that
 it provides better understanding about illness that would not be discovered in any other way. For exam-
ple, if it is a condition which is likely to run in family, we can try to take measures and prevent other
family members suffering from the same condition.
 It is also important to know the cause of death to issue a death certificate
Concerns:

1. It will not delay the funeral

2. The post-mortem will not disfigure the body as they will do it in a respectful manner. They will close the
body back neatly after it is done,
3. It will not delay in inssuing a death certificate. We can give you one death certificate now and once the
cause of death is known, we will give you another one.
4. Unfortunately, we can’t give you her organs at the moment. Is there any reason that you would like to
request for her organ? We will inform the forensic doctor and after they are done with the procedure and
tests, they will be able to give you her organs. (Custom)
5. We will not put back the samples that we have taken into the body.
I understand that this must be difficult for you. We have a service called Bereavement Support that can help
people to come to terms with their loved one’s loss. If you like that, we can refer you to them.
Thank you very much for talking to me during this difficult time

b) Steps: GRIPS. Paraphrase. Concerns. Explain cause of death. Explain post mortem. Explain why its not needed in her
case.

Doctor I understand that you are Mrs Smith’s son, is that correct?
Are you aware of what had happened?
I am very sorry about what had happened, this must be a difficult time for you.
Is there anything I can help you with?
Patient I want to request for a post-mortem
Doctor Is there any particular reason why you want to request for a post-mortem?
Have you spoken to any other doctors about this?
Was there any problems with her treatment?
Are you aware of her cause of death? As you know, she passed away due to ...
Post mortem is usually conducted when someone has died and the cause of death is unknown. This a proce-
dure where a specialist doctor called pathologist opened up the deceased body and performs an internal exam-
ination. They may take some samples for further testing.
In your mother’s case, this is not reccomandable to do as her cause of death is known.
Patient I really want the post-mortem to be done, doctor!
Doctor As I said earlier, it is not recommendable to do the post-mortem as post-mortem is usually done for people
who’s cause of death is not known. However, you can request it if you want. I will discuss this matter to my
senior.
Is there anything else that I can help you with?
How are you coping since her death?
I understand that this must be difficult for you. We have a service called Bereavement Sup-

Nik Athirah
 port that can help people to come to terms with their loved one’s loss. If you like that, we can
refer you to them.

***Death that is sudden, unnatural, occur in a violent way or if unknown of cause has to be informed to the Coroner. In this case
post mortem is compulsory

Chronic fatigue

Scenario: Mrs Smith is 35 y/o lady who has come to hospital complaining of tiredness. Please take a history
***In GMC the patient actually has an anaemia. Mr X 20 y/o male p/w chronic weakness for 6 months. IT system is down so you
are unable to assess his notes. He was meant to have blood tests but could not make it. He drinks tonic for energy booster.

Steps: GRIPS. ODPARA. Ddx. P3MAFTOSA. Dx. Ix. Mx

Ddx
1. Hypothyroidsm (weight gain, cold intolerance, menorrhagia,weakness)
2. Malignancy (weight loss, LOA,weakness, anaemic sx, lumps/bumps)
3. Myasthenia gravis (proximal muscles weakness, drooping of eyelid)
 Is your tiredness worse at any particular time of the day?
 Any problem with your vision
 Any weakness
4. Anaemia (SOB, weakness,lightheadednes)
 Have you ever been told that your blood levels are low?
5. Fibromyalgia (joint pains, fatigue, morning stiffness)
6. Depression (mood, sleeping, energy levels)
7. Chronic fatigue syndrome (tiredness worse with rest)
8. Obstructive sleep apnoea (daily somnolence, snoring)
9. CKD (anuria,anaemia,tiredness)
10. CTD (joint pain, rash)
11. Infections
How has this affect your daily life?
P3MAFTOSA
Exam:
VS, general examination, MSK
Management:
Blood, TFT, Infection screening, Toxicology, Hormonal levels
ECG
If all Ix is normal, it is a Chronic Fatigue Syndrome

Chronic fatigue syndrome (CFS) causes persistent fatigue (exhaustion) that affects everyday life and
doesn't go away with sleep or rest. It sometimes is worse with rest or sleep.
It is a diagnosis of exclusion in which we have exclude or other problems that might be causing your
symptoms.
It's not known exactly what causes CFS. Various theories have been suggested, including:
 a viral or bacterial infection
 problems with the immune system
 an imbalance of hormones
 psychiatric problems, such as stress and emotional trauma
It is a functional problem and not a structural problem.
Some of the main treatments include:
 cognitive behavioural therapy (CBT) :aims to help you deal with overwhelming problems in
a more positive way by breaking them down into smaller parts. You're shown how to change
these negative patterns to improve the way you feel.
 a structured exercise programme called graded exercise therapy
 medication to control pain, nausea and sleeping problems

Nik Athirah
 Most people with CFS improve over time, although some people don't make a full recovery. It's also
likely there will be periods when symptoms get better or worse.

Stroke with HTN

Scenario: MR Lampard is a 56 yo male who had a stroke 6 months ago. Take history, discuss management with patient

Steps:
1. GRIPS
2. Paraphrase
3. History of stroke and how is he currently
Weakness/Numbness/Speech/Vision/Swallowing
4. P3MAFTOSA esp DIET, EXERCISE, SMOKING, ALCOHOL, DRIVING, SOCIAL HX
5. Mx - Medications, OT, Physio, Smoking cessation, Alcohol 3-4units/week, Diet plan, Exercise, Driving

***Extra notes
Definition A stroke is a serious life-threatening medical condition that occurs when the blood supply to part of the
brain is cut off. If the supply of blood is restricted or stopped, brain cells begin to die. This can lead to
brain injury, disability and possibly death.
Causes There are two main causes of strokes:
1. Ischaemic – where the blood supply is stopped because of a blood clot, accounting for 85% of all
cases
They occur when a blood clot blocks the flow of blood and oxygen to the brain. These blood clots
typically form in areas where the arteries have been narrowed or blocked over time by fatty deposits
known as plaques. This process is known as atherosclerosis.
As you get older, the arteries can naturally narrow, but certain things can dangerously accelerate the
process.
These include:
 smoking
 high blood pressure (hypertension)
 obesity
 high cholesterol levels
 diabetes
 excessive alcohol intake
Another possible cause of ischaemic stroke is a type of irregular heartbeat called atrial fibrillation. This
can cause blood clots in the heart that break up and escape from the heart, and become lodged in the
blood vessels supplying the brain.
2. Haemorrhagic – where a weakened blood vessel supplying the brain bursts
They occur when a blood vessel within the skull bursts and bleeds into and around the brain.
The main cause of haemorrhagic stroke is high blood pressure, which can weaken the arteries in the
brain and make them prone to split or rupture.
Things that increase the risk of high blood pressure include:
 being overweight or obese
 drinking excessive amounts of alcohol
 smoking
 a lack of exercise
stress, which may cause a temporary rise in blood pressure
Symptoms 1. Face – the face may have dropped on one side, the person may not be able to smile, or their
mouth or eye may have drooped.
2. Arms – the person with suspected stroke may not be able to lift both arms and keep them there
because of weakness or numbness in one arm.
3. Speech – their speech may be slurred or garbled, or the person may not be able to talk at all de-
spite appearing to be awake.
4. Time – it's time to dial 999 immediately if you notice any of these signs or symptoms.
5. Other symptoms and signs may include:

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  complete paralysis of one side of the body
 sudden loss or blurring of vision
 dizziness
 confusion
 difficulty understanding what others are saying
 problems with balance and co-ordination
 difficulty swallowing (dysphagia)
 a sudden and very severe headache resulting in a blinding pain unlike anything experi-
enced before
 loss of consciousness
Examination VS esp BP, Neurological examination, Swallowing test
Investigation 1. Blood tests including cholesterol and sugar level
2. ECG
3. Carotid USG
4. ECHO
5. CT Brain
A CT scan is like an X-ray, but uses multiple images to build up a more detailed, three-
dimensional picture of your brain to help your doctor identify whether the problem is ischaemic
or haemorrhagic. It can also tell which part of the brain is affected and how severe the brain is af-
fected.
Treatment A. Ischaemic stroke

Acute stroke
1. Admit to acute stroke unit
2. O2
3. BP and sugar monitoring and control
4. Antiplatelet: Aspirin 300 mg
5. Thrombolysis if within 4.5 hours from onset (After CT BRAIN axclude haemorrhage)
 Ischaemic strokes can often be treated using injections of a medication called alteplase,
which dissolves blood clots and restores blood flow to the brain. This use of "clot-
busting" medication is known as thrombolysis.
6. Statin - do not start during acute stroke but continue if already on statin
7. Anticoagulant (after CT Brain, if indicated)
B. Haemorrhagic stroke

 Occasionally, emergency surgery may be needed to remove any blood from the brain and repair
any burst blood vessels. This is usually done using a surgical procedure known as a craniotomy.
 During a craniotomy, a section of the skull is cut away to allow the surgeon access to the cause of
the bleeding. The surgeon will repair any damaged blood vessels and ensure there are no blood
clots present that may restrict the blood flow to the brain.
 After the bleeding has been stopped, the piece of bone removed from the skull is replaced, often
by an artificial metal plate.
Secondary prevention
1. Clopidogrel 75 mg OD (if not tolerated, use Aspirin and Dypiridamole)
2. Control BP and Cholesterol
3. Lifestyle modification:
 Diet: Advise eating at least five portions of fruit and vegetables per day. Advise eating
at least two portions of fish per week, including a portion of oily fish.
 Exercise: Advise people to take 30 minutes of at least moderate-intensity exercise a day
at least five days a week. Encourage people who cannot manage this to exercise at their
maximum safe capacity. Recommend exercise that can be incorporated into everyday
life, such as brisk walking, using stairs and cycling. Tell people that they can exercise in
bouts of 10 minutes or more throughout the day.
 Alcohol: Advise men and women to limit alcohol intake to no more than 14 units a
week. Advise everyone to avoid binge drinking.
 Smoking: Advise all people who smoke, to stop. If people want to stop, Offer support
and advice. In addition, provide medication to help with smoking cessation when indi-

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 cated.
 Weight: Lose weight
Post stroke care/ Stroke rehabilitation
Vision: Double vision - refer for orthoptic assessment. Hemianopia - eye movement therapy
Emotional : Support/educate carer. Assess depresson- talking therapy
Swallowing: Assess swallowing. Swallowing therapy 3x/week. Ensure adequate nutrition
Communication:Speech and language therapy - train, communication aids
Motor: Physiotherapy : to help with exercises to regain motor function. OT will teach you how to use
your arm and adapt it to your job
Pain mx: Shoulder pain, positioning, neuropathic pain

Social service
Prognosis
1. Inpatient death is 24%
2. Risk of stroke recurring within 30 days depends on the cause of stroke
3. Half of stroke survivors left with dependency to others for everyday activities

Driving resume 1 month after stroke/TIA if no persistent deficit

Headache/visual loss - GCA

Mrs Cooper is a 70 year-old lady came in with a headache for 3 months. Please take history, examine and discuss mx with the
patient

***Patient info: pain on coming hair, LOW, unable to sleep

Steps: GRIPS. SOCRATES. Ddx. P3MAFTOSA. Eye examination. Ix. Mx

Doctor SOCRATES
Ddx:
1. GCA
 Which side of your head do you get the headache? Is it on your temporal area?
 Is the headache worse on combing and chewing?
 Do you find it difficult to walk or getting out of chair or bed?
 Do you notice any weight loss?
 Do you notice any changes in your vision?
2. SAH
 Does the headache come on suddenly?
 Does it feels like its the worst headache you ever had?
 Do you feel nauseated? Any vomitting?
 Do you find bright light is bothering you?
3. Meningitis
 Do you have any fever?
 Have you notive any rash in your body?
 Any pain or stiffness in your neck?
4. Migraine
 Is the headache one-sided?
 Is it a throbbing headache?
 Do you feel like you are sensitive to light/sound/smel or touch?
 Has this happened before?
5. Acute closed angle glaucoma
 Any pain in your eyes?
 Have you noticed any redness in your eyes?
 Any changes in your vision?
6. Cluster headache
 Do you have headache every day? How many days do you continuosly have headache?
 Any redness in your eye on the side of headache?
7. Sinusitis

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 Have you had ny cough, running nose or sneezing recently?
 Is it worse when lying forward?
8. Trauma
 Have you fallen down or injured your head recently?
9. CO poisoning
 Any problem with the boilers or cooking gas in your house?
 Do you feel sick? Any vomit?
P3MAFTOSA
Examine:
VS
General physical examination:
1. Scalp tenderness - palpate
2. Jaw tenderness : Can you please chew for me, is there any pain?
3. Muscle weakness: Can you please stand up without support? “Put your arms across your chest and stand
up for me”
Eye examination

1. Inspection:
DRSSS
Front and back (ask pt to look up the ceiling)

2. Reflexes:
Light reflex
Accomodation reflex
Red reflex

3. Visual acuity:
Snellen chart - Finger counting - Hand movement - Light

4. Fundoscopy:
“I will need to examine the back of your eye”
Comment on - Optic disc (clear, contour,colour), Cup:disc ratio, Origin of vessels, Vessels calibre, Macula,
Retina
Dx: Giant cell arteritis (GCA) is a condition where there is an inflammation of the arteries especially around
your temple area and those whcih supple blood to your eyes.

If left untreated it can cause complications such as visual loss, stroke, heart attack and abdominal artery
aneurysm.

We have not confirmed the diagnosis yet but based on your symptoms and examinations, it is very possible.
Management:
Ix:
 Blood tests: Routine, CRP, ESR
***examiner will give ESR result which is high
 Temporal artery biopsy within 2 weeks of dx
An incision is made close to the hairline in front of your ear, and a small sample of your tem-
poral artery is removed. The incision will then be sealed with stitches. This will be done under
local anaesthesia.
The sample is then sent to the lab to be studied under microscop

Treatment:
Due to the serious nature of the disease, we would like to start you on:
Steroids
1. Start on T. Prednislonone 40mg OD. May need to take up to 2 years
2. If presence of claudication: T. Prednisolone 60 mg OD
3. If vision affected: Admit and start patient on Oral Methylprednisolone 60 mg OD for 3/7
4. Tapering guidelines:
 Continue prednisolone, 40-60 mg (not <0.75 mg/kg) for 4 weeks (or until symptoms and laboratory

Nik Athirah
 abnormalities resolve), then
 Reduce dose by 10 mg every 2 weeks to 20 mg, then
 Reduce dose by 2.5 mg every 2-4 weeks to 10 mg, then
 Reduce dose by 1 mg every 1-2 months, provided no relapse occurs

S/E:
 1/20 experienced changes in mental state such as depression, hallucination, anxious or confused.
Please contact your GP if you start to experience this.
 Increased appetite, which often leads to weight gain
Please eat healthy balanced diet and perform regular exercises. Refer to dietician
 Increased blood pressure
We will monitor your BP regularly
 Weakening of the bones (osteoporosis)
Give osteoporosis prophylaxis such as Ca, Vit D, Bisphosphonate
 Stomach ulcers
Take the medication in the morning with breakfast
Prescribe medication to protect your stomach
 Increased risk of infection – particularly to the virus that causes chickenpox and shingles (varicella-
zoster virus)
Avoid close contact to those who are ill. Let your GP knows when you are unwell.
Ensure your vaccines are up to date

Low dose aspirin

- to prevent heart attack or stroke

Omeprazole

Refer to ophtalmologist, will need to follow up regularly

Intracerebral bleed - SAH

Scenario: Miss Smith is a 26 y/o lady who came to ED with a headache. Please take history and discuss management with pa-
tient.

Steps: GRIPS. SOCRATES. DDx. P3MAFTOSA. Exam. Mx

***Patient usually sitting in chair or lying in bed covering her eyes due to photophobia - need to offer to dim the light or painkill-
er. Do not perform examination like in meningitis scenario

Doctor Exam:
VS
GCS
General examination
Neurological
Dx: From what you have told me, unfortunately, it is likely that you are suffering from a bleeding in your
brain.
Mx:

 We need to do urgent CT scan of your brain

 If the scan came back normal, we will need to do another investigation called a Lumbar Puncture. This is
when we insert a needle into your back and collect some fluid from your spine to look for signs of bleed-
ing in your brain.
This is because sometimes when the bleeding is small, it won’t show up on CT scan
 If there is presence of bleeding in your brain, we will need to refer you to neurosurgeon
 We will also manage your pain adequately

Headache - Meningitis

Nik Athirah
Scenario: Mr Lawson is a 46 y/o gentleman who has been complaining of headaches for the past 2 days. Please take history,
examine and manage the patient.

Steps: GRIPS. Universal precaution. Check response. Pain killer/Dim light. GCS. Take history. Look at VS chart. Meningitis
examination. Neuro exam. Mx

Doctor Hello, my name is Nik, I’m one of the junior doctor in this department.
Can I confirm your name and age please?
Patient *Lying on a side, eyes covered with arm
Urgh..
Doctor Are you okay sir? Is the light is bothering you? I will dim down the light a bit for you.
Patient Urgh...
Doctor I am here to help you. I would like to do some examinations on you, is that alright with you? I will need you
to lie down on your back. Do you think you can turn and lie on your back for me? Don’t worry, I will help
you.
(Help patient to lie on his back)
Doctor GCS:
Now, do you know who you are?
Do you know where you are?
Can you open your eyes for me?
Can you please lift your right hand for me?
Doctor History:
Can you tell me what happened?
How long have you been having this headache?
Which side of the head you are having the headache?
Do you have any fever?
Do you have any pain or stiffness in your neck?
Do you notice any rashes in your body?
Do you have any vomitting?
Any blurring of vision?
I would like to examine you now. It may be a little bit uncomfortable but please bear with me.
- Look at chart if presence
Meningitis exam

1. Meningeal sign
Can you bring your chin to your chest? (neck stiffness)

2. Brudzinski sign
I will move your head now so that your chin touches your chest. Please bear with me.
***involuntary lifting of the leg and neck pain

3. Kernig’s sign
I will be lifting your leg up. You may feel some pain but please bear with me
***knee 90 hip 90 then try to straighten the knee. This will lead to pain and resistance
Head to toe exam:

I would like you to please take your clothes off as I will be examining you from head to toe. You can remain
in your brief. I will ensure your privacy and request for the examiner to be my chaperon.

Eyes: Pupillary reflex

Ear: discharge
Mouth: dental abscess
Hands/arms: IV injection marks, rashes
Chest/abdo: rashes
Thighs: rashes, abscess

Nik Athirah
 Neurological exam:

Tone
Reflexes - plantar/ankle
Muscle bulk
***if GCS<15, do not check power
Dx: Meningitis
Mx:
1. I will manage my patient’s airway, breathing and circulation.
2. Connect him to the monitor and monitor his VS and GCS closely.
3. Inform my senior
4. Admit patient in isolation room
5. Start on IV abx according to hospital protocols
6. Do investigations such as routine blood, ESR, CRP, blood C&S, urine dipstick and C&S, CT Brain.
7. If CT Brain normal, arrange for LP
8. Manage pain by giving analgesia (PCM, Codeine, ibuprofen)
9. I will arrange contact prophylaxis for family members and any one in immediate contact - Rifampicin or
ciprofloxacin

Chronic cough with Haemoptysis

Scneario: Mr Blake, a 50 year-old gentleman presented to hospital with a cough and haemoptysis. Please take a history and dis-
cuss management with the patient

Steps: GRIPS. ODPARA. DDx. P3MAFTOSA. Exam. Dx. Ix. Mx.

Doctor Onset: When did you start to have cough?

Duration: How long has it been? Did it come suddenly or gradually? How often do you cough?
Progression: Is it getting better or worse? Do you still have the cough?
Aggravating: Anything make it worse?
Relieving: Anything make it better?
Associated sx: Ddx
How much blood did you cough up?
What color is it?
Ddx:
1. Bronchogenic carcinoma
 Hae you lost any weight recently?
 Any lumps or bumps anywhere in the body?
 Chronic smoking history
2. Pneumonia
 Do you have fever?
 Do you cough up any phlegm? What colour is the phlegm?
 Any chest pain?
 Any SOB?
3. TB (homeless,alcoholic)
 Have you travel abroad recently?
 Any night sweats?
4. COPD
 Chronic smoking history
 Any SOB
 Have you been coughing for a long time?
5. Pneumocystic jirovecii pneumonia
 Have you travel abroad recently to places like Africa?
 Personal question: Unprotected sexual intercourse, HIV
 Dry cough/SOB/Wt loss
6. Interstitial lung disease
 Occupational history - exposure to asbestos, coal miner

Nik Athirah
 **Occupation at risk for asbestos exposure: plumber, electrician, shipyard workers, boilermakers
7. Asthma
 Family history of allergy or asthma
 History of atopy
 Wheeze
8. Cardiac asthma
 H/o hert failure or IHD
 Any leg swelling?
 Any chest tightness
9. Atypical pneumonia
 Legionella: Recent travel history and hotel stay
 Chlamydia psittaci: Contact with pets
P3MAFTOSA
Medications - ACEI
Smoking history
Occupation history
Exam:
VS, SaO2
Lungs
Chest
Lymphoreticular
Ix:
Routine blood tests, ABG
CXR
***Examiner will show an Xray: shadow in upper part of lung

Dx: It is difficult to say what the cause might be at the moment. We need to do further test to find out what
is the cause for your symptoms
Mx:
1. Admit
2. CT Thorax (assess site, size, involvement of surrounding structures, metastases)
3. Bonchoscopy and biopsy
 During a bronchoscopy, a thin tube called a bronchoscope is used to examine your lungs and take a
sample of cells (biopsy). The bronchoscope is passed through your mouth or nose, down your throat
and into the airways of your lungs.The procedure may be uncomfortable, but you'll be given a mild
sedative beforehand to help you relax and a local anaesthetic to make your throat numb

Cough Hx & Ddx (Mesothelioma)

Similar approach to bronchogenic ca

***Mesothelioma is a type of cancer that develops in the lining that covers the outer surface of some of the body's organs. It's
usually linked to asbestos exposure.
***Extra notes
Ix:
Blood tests
ABG
CXR
CT TAP
Pleural fluid analysis
Thoracoscopy: the inside of your chest is examined with a long, thin camera that's inserted through a small
cut (incision) under sedation or anaesthetic; a sample of tissue (biopsy) may be removed so it can be ana-
lysed
Mx:
Chemotherapy
Radiotherapy
Surgery not useful

Nik Athirah
 Claim compensation from the employer

Cough in a homeless man

Scenario: Mr. Blake is a 45 year old gentleman who has come to hospital with a cough. Please take a history and discuss man-
agement with the patient.

***Patient info: Dry cough 2 months, loss 3 kg over 3 months, smoker of 40 cigs/d for 20 years, homeless, unemployed, heroine
drug abuser, fever.

GRIPS
ODPARA of cough
ODPARA of fever
Ddx
P3MAFTOSA
***Detailed history here
Examination:
VS
General physical
Chest examination
***bilateral coarse crackles
- Explain findings to patient
Diagnosis: What are you having at the moment is a condition called Pneumonia which is an infection of the
lungs
Ix (To confirm my diagnosis, we need to run some investigations)
1. Routine bloos tests + glucose
2. CXR
***The examiner will say there is bilateral consolidations
So the CXR has come back and it shows signs of infections in your lungs. We need to do further tests on
you
1. BAL
“We will be inserting a small tube into your nose or mouth into your airway/windpipe and directly into
your lungs. There is a camera attached at the end of the tube to visualise your airway. We will then
flush some saline fluid so that it will mix with your lungs tissue and we will then aspirate these fluid
out and send it to the lab.
2. CT Thorax
3. Consent to take bloods for HIV and hepatitis screening because you have been injecting drugs, we
need to rule out these infections
4. Admit in isolation room
5. IV Abx per hospital protocol : Co-trimoxazole (Trimethoprim-sulfamethoxazole)
6. Substance misuse clinic once discharge
7. PSY referral to prevent withdrawal of heroin while warded - Give Methadone
8. Smoking cessation
9. Refer to social services - homeless/jobless

Extra infos:
Pneumocystis jirovecii
 Bloods: Routine, ABG, HIV tests, LDH
 Sputum sample - silver based stain. If sputum -ve: bronchoscopy with BAL or transbronchial biopsy
 CXR
 Tx: Oxygen,analgesia, antibiotics per hospital protocol
Co-trimoxazole (Trimethoprim-sulfamethoxazole)

TB
 Bloods: Routine, ABG, HIV, glucose
 Sputum for acid-fast bacilli. If no sputum, do induction of sputum or BAL

Nik Athirah
  CXR
 Tx:
Abx: Pyrazinamide and Ethambutol (First 2 mo) + Isoniazid(+Pyridoxine) and Rifampicin (Whole 6
months)
Prevent spread for the first 2-3 weeks (contagious)

Hypertension with BNF

Scenario: Tracy Jones is a 53 y/o female presented for follow up. She was admitted 4 weeks ago for cellulitis on her right leg. She
was successfully treated with antibiotics. During her hospital stay, she was found to have high BP. Please talk to patient, check
her BP and discuss management with patient.

***Patient info: She has diabetes on med. Meds includes aspirin, enalapril, simvastatin. She has stopped taking her medications 3
weeks ago due to cough and was unable to sleep.
***BNF, BP cuff and medication list are provided at the station

Steps: GRIPS. Paraphrase. ODPARA cough. HPT sx. P3MAFTOSA. Exam. Dx. Mx.

Doctor I understand that you were admitted 4 weeks ago for cellulitis on your right leg. How are you feeling now?
Has the infection resolved?

Also, you were found to have a high blood pressure during your hospital stay. Are you currently on any
medications for your BP?
Do you have the list of all your medications?
Patient I stopped taking my medications. They are causing me to have a cough
Doctor I am sorry that you are having a bad cough. Could you tell me more about your cough?
Doctor Onset: When did you start to have cough?
Duration: How long has it been? Did it come right after you started taking the medications or have you had
cough before that?
Progression: Is it getting better or worse? Do you still have the cough?
Aggravating: Anything make it worse?
Relieving: Anything make it better?
Associated sx: Ddx
Ddx:
1. Pneumonia
 Any fever?
 Do you cough out any phlegm?
 Any chest pain?
 Any SOB?
2. COPD
 Is it a chronic cough?
 Smoke?
3. Carcinoma
 Do you notice any weight loss?
 Lumps or bumps anywhere?
4. Asthma
 Any wheezing?
5. Cardiac asthma
 Do you have any swelling in the leg?
 Any chest pain?
P3MAFTOSA
Exam: VS
Take BP measurement *** BP is 150/90
CVS/Lungs
Dx: ACEI induced cough

Based on from what you have told me, it is likely that one of the medication that you are taking has causing

Nik Athirah
 you to have the cough. The medication is Enalapril, which is your antiHPT medication. Because you are
not taking your medication, your BP is on the higher side.

Ask about HPT sx?

Mx
We will change your antiHPT medication. Give me a moment, I will check the medication for you.
(Check BNF)

Alright, we will change Enalapril to Losartan 50 mg OD (best meds for diabetes and HPT)

The side effects of this medication is you might get headache and racing of the heart but it its becoming
troublesome please contact your doctor.
Are you having any side effects with other medications?

1. Asprin
- tummy upset (try to take it after meals, if still having problem, please come to us)
- please take it in the morning

2. Simvastatin
- tiredness, muscle ache
- please take at night
Is there any other concerns?
I will speak to my senior regarding what we have discussed. If you have any issues with these medications,
please do not hesitate to come to us so that we can help you. It is wise not to stop the medications on your
own as it might compromise your health

Constipation

Scenario: You are FY2, ortho dept. 60 y/o Margaret Thatcher broke her hip 1 week ago. She had a hip replacement done 5 days
ago. Patient has not open bowel since admission. Please take a history, examine and discuss management with patient.

Steps: GRIPS. ODPARA. Ddx. P3MAFTOSA. Exam. Mx.

Doctor How was the operation?
Are you tolerating hospital diet well? Are you drinking enough fluid? (diet)
Are you coping well with the physiotherapy?
Have you start to ambulate? (immobility)
Doctor Onset: When did you last pass stool?
Duration: How many days have you not passed any stool?
Progression: How was your bowel habit before this?
Aggravating: Anything make it worse?
Relieving: Anything make it better?
Associated sx: Ddx
Ddx
1. Intestinal obstruction
 Have you passed any wind since the operation?
 Do you feel bloated?
 Is there any vomitting?
 Do you have pain in your tummy?
2. Anal fissure
 Did you had the same problem in the past?
 Is it usually painful when you pass stool?
3. Malignancy
 Do you notice any weight loss?
 Do you sometimes have diarrhoea and some other times you have constipation?
 Any swelling in your tummy?
4. Dietary
 Do you drink enough water?
 Do you eat enough fruits and vegetables?

Nik Athirah
 5. Medications
 morphine, codeine, tramadol
 What medications are you taking for pain relief?
6. Hypercalcaemia
 Do you feel thirsty all the time?
 Are you passing a larger volume of urine rhan usual?
 Any tummy pain
7. Hypothyroidism
 Do you feel cold when others are comfortable?
 Do you gain any weight recently?
P3MAFTOSA
- Diabetic neuropathy?
Exam
VS
Abdo and PR

***generalized mild abdo tenderness. PR : feacal loading

dx: Based from what you have told me, it is likely that the cause for your constipation is due to the pain
medication that you are on.
Mx:
 We will revise your pain medication by changing the weak opiod to NSAIDs
 Give you phosphate enema. This will be inserted gently through your back passage to soften your stoll
and help you to pass stool better.
 We will also give you some laxative for you to drink so that your bowel can move better.
 If you are still having a problem, we would like to do some blood tests and Xray of your tummy

Smoking cessation

Scenario: You are FY2 in cardiology clinic. 52 y/o Will Smith was diagnosed with angina 2 months ago. He is scheduled for an
angioplasty. He is a known smoker and reluctant to quit smoking. Claims that his lungs are fine. PMH of high cholesterol on
statin. Please advise him to stop smoking and address his concerns.

Steps: GRIPS. Paraphrase. Ask about angina. P3MAFTOSA. Ask smoking history. Advise regarding complications of smoking.
Address his concerns. Advise benefits of stopping smoking.

Doctor As you know, we are planning to perform a procedure on your heart to unblock the blood vessels. How are
you feeling at the moment?
Are you still having chest pain?
Ask P3MAFTOSA
I understand that you are a smoker. Is that correct? I would like to ask you further about your smoking
habit, is that alright?
- How long have you been smoking for?
- How many cigarettes a day do you smoke?
- What time of the day do you find it most difficult not to smoke?
- Is there anyone at home who smokes?
- Do you smoke the first thing in the morning?
We are a little bit concerned about your smoking, especially with the heart condition that you have.
When you smoke, the toxins from cigarette smoke enter your blood. The toxins in your blood then:
 Make your blood thicker, and increase chances of clot formation
 Increase your blood pressure and heart rate, making your heart work harder than normal
 Narrow your arteries, reducing the amount of oxygen rich blood circulating to your organs.
Since you arteries are already blocked with cholesterol, together with the effect of smoking, this canin-
crease the chance of your arteries to further narrow and enhances clots formation, which can cause a heart

Nik Athirah
 attack or stroke.
Therefore, eventhough we perform angioplasty on you, your blood vessels will become blocked again.
Unfortunately, if you have this problem again after the procedure, it could be much worse. That is why we
are concerned about you smoking as we dont want you to be in such situation.

Have you tried quitting smoking before?

Could you please tell me what made it difficult for you to stop smoking?
(Show empathy)
***Patient said she tried but failed due to stress and weight gain
Do not worry, I would like to reassure you that you would not be alone in trying to quit smoking.
We have help available for you. If I may ask, the last time you tried quitting smoking, did you seek any
help?
What we can do is that,
1. Refer you to smoking cessation clinic
 The clinic will start you on nicotine replacement therapy.
 It comes in many forms such as patches, tablets, chewing gums, spray, inhalers and lozeng-
es. This will help to reduce craving.
 There are electronic cigarettes that are designed to look and feel like ordinary cigarettes.
They have a heating element inside that can vapourises a solution containing nicotine.
 We also advise that you do not smoke while using nicotine replacement product
 Nicotine replacements are usually used for 8 weeks and then stopped
 The risk of addiction to nicotine replacement therapy is low
 There is also a medication called bupropion which is effective to reduce the craving of cigarettes
 It is best to choose a day where you will completely stop smoking. Choose a date within 2 weeks of
making the decision.
 We can also refer you to support groups where you can meet people who are trying to quit smoking
and also who have successfully managed to quit
 Stress relief alternative: Stress ball
 Refer dietician and gym for weight management
There are many benefits of quitting smoking
 It will lowers risk of heart problems and breathing problem
 You are less prone to get circulation problem in the leg or blood clot
 It will prevent the deterioration of your skin which is caused by smoking
 Within two years of stopping smoking, your risk of stroke is reduced to half that of a non-smoker and
within five years it will be the same as a non-smoker.
 Decrease risk of lung cancer
 No smell from mouth/staining of teeth/fingers and lips
 Helps to save money
 Reduce effect on people surrounding you.

TIA

There are 2 scenarios for TIA:

a) You are FY2 in AMU. 65 y/o Margaret Smith p/w LOC. She had difficulty in speaking and moving her right arm. Symptoms
laster for 2 hours. This happened 3 hours ago. She is currently asymptomatic. BP 150/100. Blood test and CT scan came back
normal.
Please talk to husband, address concerns and recommend vascular/lifestyle changes

b) Margaret Smith 65 y/o p/w speech problem and weakness on her face for 15 mins. This happened 3 hours ago. CT scan is
normal. Blood tests pending. Husband wants to speak to doctor. Please take history and address concerns.

Nik Athirah
 >4, admit stroke unit, <3 f/up clinic

Steps: GRIPS. Paraphrase. Take focussed hx of TIA. DDx. P3MAFTOSA. Explain ix. Explain dx. Mx. Lifestyle changes
Doctor Can I confirm what is your relationship to Margaret Smith
As you know, she came here because she had problem in ...
Can you tell me more about what had happened?
Rule out DDx
 Infection
 Trauma
 LOC
 Hypoglycaemia
 Migraine with aura
 Focal epilepsy
 Brain tumour
 MS
P3MAFTOSA (Rule out Risk Factor for Stroke)
 PMH: Diabetes, HPT, High cholesterol, Bleeding disorder, Irregular heart beat, MI
 Fhx of stroke
 Smoking
 Alcohol
 Diet
 Exercise
 Driving
As you know, we have carried out some investigations on her.

CT Brain was normal

Blood tests result is still pending
Based on her symptoms and from what you have told me, it is likely that she had an episode of Transient
Ischaemic Attack, or mini stroke.
It is due to a temporary disruption of the blood supply in her brain but it has not caused any permanent
damage to her brain.
During a TIA, one of the blood vessels that supply her brain with oxygen-rich blood becomes blocked,
either by blood clots, fatty material or air bubble. It somehow has unblocked itself which causing the symp-
toms to resolve.

It is a dangerous condition because it increases the chance to get a stroke.

Do not worry as we are here to manage her to the best we could.

She needs to be
1. Admitted
2. Medications
- ACEI for high BP
- Aspirin 300 mg OD for 2 weeks
- Statin

- Aspirin 75 mg od + dipyridamole 200 mg bd for secondary prevention (if not tolerate Aspirin, give Dipyr-
idamole only)

She will also need to modify several things in her diet and lifestyle such as:
 Diet consists of :

Nik Athirah
 5x/day fruits
5x/w vegies
3x/w fish
2x/w white meat
1x/w or never red meat
Reduce salt intake.
 Stop smoking - refer to smoking cessation clinic
 Reduce alcohol intake: male 3-4units/week, female 2-3 units/week
 Exercise 20-30 mins of moderate intensity per day for at least 5 days/week. Eg: brisk walking, cy-
cling, using stairs. Can do it in bouts of 10 minutes
 Driving after 1 month if no persistent deficit.
What are the chances to develop stroke?
Based on ABCD2 score:
0-3 is 1%
4-5 is 4%
6-7 is 8%

Weight Loss

Scenario: You are FY2 in GP. 24 y/o Ms Jane Smith presented to you with weight loss. Please take history, diagnosis, and discuss
management with patient.
***Patient info: weight loss x3months, BF notice it, feel hot, fhx of hyperthyroidism

Steps: GRIPS. ODPARA. DDx.P3MAFTOSA. Exam. Dx. Ix. Mx

Doctor Onset: When did you first notice it?
Duration: How much weight did you lose and over how many months?
Progression: Is it getting worse, improving or stays the same?
Aggravating: Is it intentional or unintentional
Relieving: How is your diet and appetite?
Associated sx: Ddx
Ddx:

1. Malignancy
 Do you feel that you are easily tired?
 Any lumps or bumps anywhere in your body?
 Any fever?
 Any loss of appetite?
2. Endocrine:
a) Hyperthyroidism
 Do you feel hot when others are comfortable?
 Any loose stool?
 Any twitching or trembling
 Do you have any irregular or unusually fast heart rate?
 Do you easily get nervous/anxious or irritable?
b) Diabetes Mellitus
 Do you feel thirsty all the time?
 Do you pass out a large volume of urine?
4. IBD/Malabsorption
 Do you any pain in your tummy?
 Any loose stool
 Any blood in your stool
5. Systemic AI disease
 Any rashes/joint pain
6. Infection
a) TB
 Any recent travel history?
 Do you have any cough/ cough out blood?
 Any night sweat?
b) HIV
 Do you by any chance use recereational drugs? Do you share needles?

Nik Athirah
6. Psychiatric illness
a) Aneroxia : How is your mentrual period?
b) Bulimia: Do you binge eating? Do you use any laxative
P3MAFTOSA
Exam:
VS, Eye, Neck, CVS, Reflex
Diagnosis:
Based on from what you have told me and from my examination, it it most likely that the cause of your
weight loss is due to a condition called Hyperthyroidism. It means that the gland in front of your neck
which is called thyroid, is producing too much hormones. The extra levels of these hormones can affect
things such as metabolism of your body, heart rate and body temperature, which may cause all the symp-
toms you are having at the moment.
Ix:
To confirm this, we need to do some tests
1. T3,T4, TSH

*** examiner will give TFT result:

TSH 0. 6 (0.5-4.5)
T4 22 (4.6-12)
T3 235 (80-180)
**Explain the results to the patient

2. Routine blood tests + Ca and ESR

3. ECG
Mx
1. Medications:
- Propanolol to control your heart rate
- Carbimazole to bring down the hormone level (ask if pregnant)
S/E: feeling sick, joint ache, upset stomach, itchy rash, headache
If you get fever, sore throat or persistent cough pls contact us immediately as there can be a side effect
called agranulocytosis where your white blood cell dropped to a low level and can be dangerous. We can
then check your white cell level to confirm this.

2. TCA 2 weeks again to check thyroid hormones level

3. If medication does not work, and symptoms still persist, give radioiodine
- It is a form of radiation to damage your thyroid and reduce the amount of hormones they make. You're
given a drink or capsule that contains a low dose of radiation, which is then absorbed by your thyroid. It
can take a few weeks or months for the full benefits to be felt, so you may need to take one of the medica-
tions mentioned above for a short time.
- avoid prolonged close contact with children and pregnant women for a few days or weeks
- women should avoid getting pregnant for at least six months
- men shouldn't father a child for at least four months
4. If RAI doesnt work and symptoms may still persist, we may need to do surgery to remove all or part of
your thyroid. Removing the entire gland is usually recommended to cure it but it means that you will have
to be on thyroid hormone replacement for your entire life.
5. Refer to the endocrine team for further Investigations and management. They will do:
Serology: Thyroid peroxidase ab, Thyroglobulin ab, TSHRab (rare)
Radioisotope iodine scan
- Inject/swallow a small amount of slightly radioactive substance that will be absorbed by your
thyroid and scan in carried out to see how much being absorbed and to examine the size and
shape of your thyroid
USG Thyroid
- If nodule but hypo or euthyroid
- If cold uptake on scan
- For biopsy (FNAC)

Nik Athirah
Red eye

Scenario: You are a FY2 doctor at GP. 22 years old Mila Kunis p/w severe pain and redness in her right eye. Please take history
and discuss the management with the patient
***Patient will be wearing sunglasses. Need to ask her to remove it and offer to dim the light
Steps: GRIPS. SOCRATES. Ddx. P3MAFTOSA. Exam. Ix. Mx

I am sorry that you are in pain. Are you comfortable to talk? Is it alright if I ask you some questions regarding your symptoms?
Doctor: Site: Where exactly is the pain?
Onset: When did it start? Did this come on gradually or suddenly?
Character: Can you describe me the character of the pain?
Radiation: Does it radiates anywhere else in your body?
Associated : Ddx
Timing: Is there any specific time of the day you experience the pain? Is it becoming worse, improving or
stays the same?
Exacerbating/Relieving: Anything makes it worse or anything brings it on? Anything makes it better?
Severity: On a scale of 1 -10, 1 being the lowest and 10 being the highest, how would you score your pain?

Ddx:

1. Acute closed-angle glaucoma

 Is your vision affected?
 Are you feeling sick? Did you vomit?
 Is there any redness in your eye?
 Are you seing rings around light?
 Any headache?

2. Bacterial conjunctivits
 Is there any discharge from your eyes?
 Is it a clear or thick pus-like discharge?
 Does your eye feels sticky especially in the morning?

3. Viral conjunctivitis (watery discharge, foreign body sensation)

4. Trauma/ Foreign body

 Did you by any chance sustain injury to your eye?
 Any gritty sensation in your eye?

5. Inflammatory diseases
 Rheumatoid arthritis (iritis): Any joint pain?
 Ankylosing spondylitis (ant uveitis/iritis): Any back pain?
 SLE (iritis) : Any rashes on your face? Any joint pain?
 IBD (iritis) : Are you experiencing any diarhoea? Have you notice any blood in your stool?
 Reiter’s syndrome (conjuctivitis) : Any dischare from your private part? Any joint pain?

6. Cluster headache
 Is this associated with headache? Does it comes at a particular time of a day?
P3MAFTOSA
Medication: anticholinergic can cause glaucoma eg. Amytriptilline
Examine VS and Eye:
“I would like to examine your eyes. For that reason, would it be okay if you could remove your sunglasses”

(Ideally in red eye: Do Light and Red reflex, Visual acuity and fundoscopy. Fundoscopy shows optic disc
margin is blurry, increased cup to disc ratio, unclear origin of vessels)

**Examiner will give a picture of congested red eye, describe it to the patient

Nik Athirah
 Based from what you have told me and from what my examination of your eye, it it likely that you might be
having an acute glaucoma.
It usually occurs when the fluid in the eye cannot drain properly, which increases the pressure inside the eye
and puts pressure on the optic nerve. Optic nerve is the nerve that connects the eye to the brain. If not treated
urgently, this can cause damage on the optic nerve and affect your vision.

Mx:

I will need to urgently refer you to the opthalmology dept in the hospital . They will:
 Measure the pressure in your eye
 Give medication (IV Acetazolamide) through your vein to reduce the pressure
 Eye drops (Timolol/Pilocarpine)

In the meantime, I will give you some painkiller

Please remove the glasses as dark glasses may increase the pressure in your eye and it can make your eye
condition worse

I will also refer you to Psychiatric team to review your medication as the medication youre on (Amytriptil-
line can cause increase pressure in your eye

Falls in the elderly

Scenario: Your are a FY2 in medical unit. 80 y/o lady presented with a fall. Please take a focussed history, do relevant Ix and
discuss management with patient.
***Patient info: Dx with HPT 6 mo ago, AntiHPT meds changed 3 mo ago, 2 falls in last 3 mo, falls upon getting up from bed,
Total 3 falls, feels dizzy

Steps: GRIPS. ODPARA. DDx. Head injury qs. P3MAFTOSA. Exam. DDx. IX. Mx
Doctor: History of fall:
1. When did it happened?
2. Has it happened before? If yes, how many times have you fallen?
3. What were you doing at the time?
4. Do you tend to fall in a particular situation?
5. Do you experience any dizziness before falling down?
6. Is there any particular time of the day when you tend to fall more? Maybe waking up in the morning or
at then end of the day?
7. Did you lose consciousness during the fall?
8. Was there any witness?
9. What happened after you fell?
10. Did you injure yourself?
 Any blurring of vision, bruises on your head? bleeding from ENT, vomitting, headache?
11. Were you drinking alcohol before you fell?

Nik Athirah
 Ddx
1. Hypoglycaemia
 Did you feel hungry, sweaty or shaky before fainting?
 Have you been diagnosed with high blood sugar?
2. Epilepsy
 Did you had a jerky movements in your body?
 Did you wet yourself? Did you bite your tounge?
3. Stroke/TIA
 Do you have any weakness in your limbs or face?
 Any speech difficulty?
4. MI/PE/Arrythmia/AA
 Any chest pain?
 Any palpitation?
5. SAH
 Did you experience any headache? Any vomitting? Any pain in your neck
6. Anaemia
 Do you have any light-headedness? Any tiredness? Any dizziness?
7. Postural hypotension
 Do you feel dizzy when you try to stand up from sitting or lying position?
8. Mobility issue
 Do you use any walking aids?
9. Joint problems (RA/SLE/OA)
10. Visual impairment
11. NAI by carer
12. Mechanical fall (carpet)
13. Myasthenia gravis
 Do you have a tendency to fall down by the end of the day?
 Do you feel you get more tired or weak by the end of the day?
14. Balance
 Hearing problem: Tinnitus?
P3MAFTOSA
Exam:
VS: BP standing and lying
CVS/Lungs/Abdo/Ear/Eye/Neuro

***Difference in BP >20mmHg
Dx: Postural Hypotension

It means theres a drop of blood pressure on standing up, sufficient to cause inadequate blood supply to your
brain. This is what’s causing the fall. When you fall down, your blood pressure normalize again and you feel
better afterwards.

This is maybe due to a change in your antiHPT medications. Water tablets for eg thiazide has a common side
effect of causing postural hypotension.
Ix:
Blood + glucose
ECG
Skeletal survey if repeated fall
Mx
1. Admit
2. If all the investigations are normal, it may be because of the tablet you are taking.
3. We will contact your GP to acquire about the meds you are on. We also need to change your meds
4. Refer to OT and physio

Head injury in adult

Scenario: You are FY2 in ED. 45 y/o male was BIBA after a fall. Please talk to patient and discuss management.
***Patient has retrograde amnesia, headache, vomitted once, clear D from nose, had 2 pint of beer prior

Nik Athirah
Steps: GRIPS. Pararphrase. ODPARA. HI qs. DDx. P3MAFTOSA. Dx. Ix. Mx
Doctor: History of collapse:
1. When did it happened?
2. Has it happened before? If yes, how many times have you collapsd?
3. What were you doing at the time?
4. Did you experience any warning before you collapse?
5. Did you lose consciousness during the fall?
6. Was there any witness?
7. What happened after you fell?
8. Did you injure yourself?
 Any blurring of vision, bruises on your head? bleeding from ENT, vomitting, headache?
9. Were you drinking alcohol before you fell?
10. Is there any chance that you could be using recreational drugs?
Ddx:
1. Infections
 Meningitis: Headache/Rashes/Vomitting/Fever/Photophobia
 Sepsis: Fever/Unwell
2. Endocrine
 Hypoglycaemia
 Alcohol induced hypoglycaemia
 DKA (poluria/polydipsia/abdo pain)
 HONK (elderly, progressive drowsiness, polyuria,polydipsia, obesitiy)
3. CVS
 Stroke/TIA
 Aortic aneurysm
 MI
 Arrythmia
 Postural hypotension
 Valvular heart disease/CHD
 Pulmonary embolism
4. Neuro
 Epilepsy
5. Head injury/Trauma
 SAH
 Intracerebral bleed
P3MAFTOSA
Exam:
VS
Full neurological exam
General examination to examine your head, ear, nose and mouth
Dx: We need to do some tests to rule out any bleeding in your brain or any fracture on your head
Ix
To confirm this, we need to arrange for CT Brain to make sure there is no bleed or abnormalities in the brain.
(if indicated)

We also like to take routine blood tests and ECG

Mx
For this test, we have to
1. Admit for at least 24 hours to monitor closely
2. Keep you fasted for the time being while awaiting CT scan
2. Manage accordingly after CT scan
3. Refer to neurosurgery

***If history highly suggestive of bleeding

- If CT scan shows no bleed, it may means that the bleed is so small that the scan could not visualize it.
- Do lumbar puncture 12 hours after. This is when we insert a needle through your spine to look for traces of
blood, which may flow from your head down to your spine.

Nik Athirah
***Cerebral concussion: It is a sudden but short-lived lost of mental function that occurs after a blow or injury to the head. It is
also known as minor traumatic brain injury.There is no permanent damage to the brain

CT Brain Adult indications:

1. GCS<13 or <15 after 2H of injury
2. Suspect open/depressed skull #
3. Signs of basal skull #
4. Post traumatic seizure
5. Focal neurological deficit
6. Vomit >1

Epilepsy

Scenario: Joanna White is a 20 year-old lady presented at GP for a review as she had a fit 21 days ago. She had MRI scan done
which was normal. Routine blood was normal. EEG shows epileptic foci. Please explain the diagnosis and address her concerns
***There will be a discharge summary with discharge date and medication (Na Valproate 300 mg BD)

Steps: Paraphrase. Take focussed hx. Explain Ix. Explain epilepsy. Mx

Doctor: I understand that you were admitted 21 days ago for a fit.
Could you tell me more about what had happened 3 weeks ago?
1. History of fit:
 Before, During After
2. Was there anything that might trigger you to get a fit?
 TV/loud music/stress/inadequate sleep/poor diet
3. How are you feeling now?
4. Is there anymore episode of fit since?
 ***Patient will say that she had another few episodes of fit
5. I understand that you have been discharged home with a medication. Are you taking your medication
regularly? How do you take it?
 ***Patient will say that she only took the medication after every fitting episode
P3MAFTOSA
As you know, we did some tests while you were in hospital. Has any of my collegue been here to discuss to
you about it?
Alright, I am here to explain them to you.
Your MRI scan and your blood tests came back as normal which is good news.
Unfortunately, your EEG test has reported to show presence of epileptic foci.

This means that there is an abnormal electrical discharge in your brain which lead to involuntary jerky
movement of your body and sometimes it can lead to loss of consciousness. This condition is known as
EPILEPSY.
Patient Can it be cured?
Doctor Unfortunately, it can’t be cured but we can help you to prevent fit from happening again
Patient Why do I get it?
Doctor It is difficult to answer that as the cause is unknown

Nik Athirah
 To manage your condition, there are few things I would like to advise you.

1. First of all, it is important that you take your medication correctly. I understand that you are on sodium
valproate 300 mg twice daily. I would like to check if the dose if adequate for you. Can I please confirm
your weight please?
 Check BNF: Dose is 10mg/kg/day
 So the appropriate dose for you is x twice a day
 You have to make sure that you take it regularly. Please try to take the medication at the same
time every day and dont miss any doses. You can keep an alarm or diary to remind you about
this.
 Since I have revised the dosage, you have to come back in 3 days. Based on the level of your
blood, we will increase the medication every 3 days by 10mg/kg until the dose reach between
500 mg to 1 g twice a day.
 S/E of this medications include nausea/vomitting (take before eat), liver/kidney problem (we
will monitor your blood), temporary hair loss
2. Do you drive?
 It is important to avoid driving for the time being. You have to inform DVLA and they will
advise you on when you can resume driving again. From my knowledge, it usually take about
a period of 1 year free from fits before you can start driving again.
3. It is best to avoid things that can trigger your fit such as alcohol
4. Please do not take any other medications without informing your GP and this includes OTC meds
5. Contraceptive pills will not be affected with your meds
6. If pregnant need to be on carbamazepine and need to start on Folic Acid early
7. What do you do as hobbies?
 You need to avoid sports such as rock climbing or diving because in case you suffer from a fit
during these activities, your life can be in danger
 Swimming instuctor need to know your condition
8. Avoid being alone when youre cooking, swimming or working with fire
9. It is best to tell people around you such as your family, employer, school or friends about your condi-
tion so they can be aware when it happens
10. Also, you can wear a bracelet so that when you have an attack, people know how to help you
11. It is improtant to eat healthy and have a good sleep.

Will I be on this medication forever?

“No you will not. If you are fit free for 2 years, the specialist will decide to stop the medications. To stop
your medications, we will taper down your medication gradually until you will not need to take it anymore

Asthma discharge

Scenario: You are a FY2 at General Medical Ward. James Wilkinson, a 20 year-old male was admitted for acute exacerbation of
asthma. He is being discharged home today with T. Prednisolone 30 mg for 3 days, Salbutamol 2 puffs PRN, Beclomethasone 2
puffs BD. Please assess if patient is fit for discharge and assess his concerns.

Steps: Greet. Paraphrase. Assess understanding. Tell pt you need to assess for D. Ask some qs. Examine lungs. Teach Peak Flow
Meter. Teach how to use peak flow diary. Asthma prescriptions.

Doctor: Hello. Are you James Wilkinson? How may I address you? Can I conform your age please? My name is..
I understand that you are admitted for your asthma. Is that correct?
(If patient is just diagnosed with asthma: Asthma is a common lung condition in which there is an allergic
reaction affecting the smaller airways of the lungs. From time to time, the airway constrict and causing the
typical symptoms of wheeze, cough, chest tightness and shortness of breath. There are certain things taht
make the symptoms worse such as infections, pollens, exercise, certain meds like aspirin, nsaids, beta block-
ers, emotions, smoking, animals and house dust mites
How are you feeling at the moment? I am here to assess you if youre fit to go home. Will it be alright if ask
your some questions?
- wheeze, SOB, cough, fever, chest pain
I would like to examine your lungs and check for your vital signs. Is that alright with you?

Nik Athirah
Have anyone explained to you how to use a peak flow meter?
It is important that you know how to use a peak flow meter so that you can record your readings into your
peak flow diary.
- This is used to measure how your lungs are functioning and how well youre responding to medications.
- This side is called the mouthpiece, which u can easily replace. This is how you change it.
- To use this device, you can either sit upright or stand up. Hold it horizontally, take a deep breath in, make a
tight seal around the mouthpiece with your mouth, and blow it out in one breath, as hard as you can.
- Make sure you slide the marker down to the bottom of the numbered scale before you use it and try not to
obstruct the meter reading when you hold it.
- (Demontrate to the patient)
- Can you please give it a try now? (Remember his readings)
Do you know how to use your peak flow diary?
- Horizontal line: am and pm, record twice a day
- Blow three times, record the highest reading
- Chart the reading on the vertical line
- If your value is increasing, it means you are responding to the treatment
- If your value is the same over the next 3 days, you need to consult your GP
- If your value is decreasing over the next 3 days, you need to come to ED immediately

-
Normal values for PEFR
- This is a peak flow chart showing different values for different age groups, sex and height.
- It tells you whether your peak flow rate is within normal limits or not.
- Horizontal line shows age in years, Vertical line shows the peak flow rate which corresponds to
the ones on the peak flow meter device. The top graph is for men and the lower graph is for wom-
en.
- Can I get your height and age please?
- So we have to take the line which corresponds to your age and your height, then join the lines
together and see where they meet. Then we need to go across the left to see which value corre-
sponds to this point.
- You can see here it corresponds to xL/min, which means you should blow at least xL/min on the
peak flow meter device

Nik Athirah
Doctor: Alright, it seems like your peak expiratory flow rate is within normal limit.
You will be discharged with three medications. Have anyone here explained to you the medications and how
to use them?

1. Prednisolone
-It helps to calm the infalmmation and help you gain better control of your asthma.
- Each tablet is 5 mg and you need 30 mg, which means you will be taking 6 tablets a day
- Take it in the morning after breakfast and take it for 3 days only
- Side effect nil as only taken for short term
2. Salbutamol
- It helps to relieve your symptoms
- Puffs as required
- Take it whenever you have the symptoms
- Can cause racing of the heart, tremors and headaches. It is becomes a problem please see your GP
3. Beclomethasone
- A preventer
- Takes 2 puffs, twice a day
- Takes everyday (morning and evening)
- Can cause oral trush, hence please rinse your mouth after every use for 30 seconds. Will not have side
effect like oral steroid as you are only inhaling it

How to use inhalers

1. Check expiry date
2. Remove the cap
3. Shake the inhaler
4. Prime in the air
5. Breath out completely
6. Seal your mouth tightly around the mouthpiece
7. Press on the canister and then take a deep breath in slowly
8. Hold your breath for 10 seconds then breathe out
9. Wait 30 seconds before repeating

Chest Pain - ACS (MI) - with ECG

Scenario: You are an FY2 at ED. Mr Smith is a 55 year-old male presented with chest pain. Take history, do relevant examination
and discuss management with patient

Steps: Greet. SOCRATES. DDx. P3MAFTOSA. Exam. Ix. Mx

Doctor: Site: Where exacxtly is the pain?

Onset: When did it start? Did this come on gradually or suddenly?
Character: Can you describe me the character of the pain?
Radiation: Does it radiates anywhere else in your body?
Associated : Risk factors of MI - HPT, DM, Alcohol, Smoking, Fhx of IHD
Timing: Is there any specific time of the day you experience the pain? Is it becoming worse, improving or
stays the same?
Exacerbating/Relieving: Anything makes it worse or anything brings it on? Anything makes it better?
Severity: On a scale of 1 -10, 1 being the lowest and 10 being the highest, how would you score your pain?

Nik Athirah
Ddx
1. MI
 Central crushing pain radiating to left arm or throat, lasting >20mins
 Do you feel sick?
 Do you have any sweatings in your palm?
2. Angina
 Chest pain lasting <20mins
3. Pulmonary embolism
 Do you have cough up any blood?
 Any shortness of breath
 Did you travel recently?
 Did you have an operation done recently?
 Do you find it difficult to mobilize anywhere?
4. Pneumonia
 Do you have any fever?
 Do you cough out any sputum/phlegm?
5. Trauma/MSK
 Did you sustain any injury to your chest recently?
 Do you do heavy exercises?
6. GERD
 Do you suffer from heartburn?
 Do you have any sour taste in your mouth?
7. Pericarditis
 IS the pain relieved when you lean forward?

P3MAFTOSA
 HPT, DM, Smoking, High Cholesterol, previous angina or MI, Fhx of IHD
I would like to examine you now. I will be checking your VS.
I will also be examining your lungs and listen to your heart sounds.
For the purpose of this examination, I would like you to undress above the wait and I ensure your privacy
and provide a chaperone

Thank you for your cooperation

To confirm my diagnosis, I would like to do some tests:
 I would like to do ECG, which is tracing of your heart to look for any abnormalities.
 (***examiner will give you ECG to interprate)
 I would like to do some blood test such as FBC, RFT, LFT, Coag, Glucose and cardiac enzymes espe-
cially Troponin
(***examiner may give you the Troponin level***)

Nik Athirah
Management of ACS (STEMI, NSTEMI, Unstable angina - Normal Troponin)

STEMI NSTEMI/ Unstable angina

I will manage patient according to ABC. I will manage patient according to ABC.

Admit CCU Admit CCU

Sit patient up at 45 degee bed and manage in a
monitor area or resuscitation room
High glow O2 15L/min via a non rebreathing
bag
Attach ECG monitor and perform a 12 lead ECG Attach ECG monitor and perform a 12 lead ECG
Insert IV lines and send blood for FBC, RFT,
LFT, glucose, lipid profie, clotting screen and
cardiac enzymes
GTN spray sublingual
IV Morphine 5-10mg titrating according to pain
and IV Metoclopramide 10 mg STAT
Aspirin 300mg chewed or dissolved in water
Clopidogrel 300mg oral
Beta-blocker: IV Atenolol 5mg
Statin
?DVT prophylaxis
I will arrange for percutaneous coronary inter-
vention (angioplasty) (if within1 12 hours:
90mins + 30 mins transfer door to needle).
If not available in my hospital, we will arrange
transfer to another hospital or consider a throm-
bolysis.
Sit patient up at 45 degee bed and manage in a monitor
area or resuscitation room
O2 2-4L aiming for Sa02>95%
Insert IV lines and send blood for FBC, RFT, LFT,
glucose, lipid profie, clotting screen and cardiac en-
zymes
GTN spray sublingual
IV Morphine 5-10mg titrating according to pain and
IV Metoclopramide 10 mg STAT
Aspirin 300mg chewed or dissolved in water
Clopidogrel 300mg oral
Oral B-blocker: Metoprolol 50-100mg TDS or
Atenolol 50-100mg OD
S/C Enoxaparin 1mg/kg/12H
or Deltaparin 120u/kg/12H
Low risk:
(no pain, -ve troponin, normal or flat or inverted T
wave)
 If repeat troponin >12H -ve, discharge
 Treat medically and arrangr stress test, angiogram
High risk
(persistent/recurrent ischaemia, ST depression, tro-
ponin high)
 intravenous eptifibatide or tirofiban
 Add clopdogrel
 Optimize drugs: b-blocker, ACEI, nitrates, statin
 Urgent angiography +/- PCI or CABG

 You may need to undergo PCI. It is when a dye is injected through your blood channel in the groin to
visualize any blockage in the blood vessels of the heart. We will then use a balloon to stretch open a
narrowed or blocked artery. We may also need to insert a short wire-mesh tube, called a stent, into the
artery during the procedure. The stent is left in place permanently to allow blood to flow more freely.
 However, it there are more than 2 arteries blocked, you may then need to undergo a coronary artery
bypass graft in which it involves taking a blood vessel from another part of the body – usually the chest,
leg or arm – and attaching it to the coronary artery above and below the narrowed area or blockage to
bypass the blockage. This new blood vessel is known as a graft.
 If initial troponin on arrival is negative, admit patient for repeat ECG and troponin in 8H, 12H and 24H.
If all negative, arrange for exercise ECG or myocardial perfusion scan.

Nik Athirah
PAEDIATRICS
Rectal bleeding in a child - Intussusception

Scenario: You are FY2 at paeds department. You received a referral from GP. On the letter it was written;
“18 month old child came with his mother, Emma White. He has been crying for 2 days. Child passed loose stool with blood. BP
90/60, HR 140. Child is pale and lethargic. There is a mass in right upper quadrant”.
Your task is to address concerns, discuss diagnosis and management with mother.

Steps: Greet. Confirm relationship. Child’s name and age. Paraphrase. ODPARA. DDx. Dehydration hx. P3MAFTOSA + Paeds
history. Exam. Ix. Mx.

Doctor: Hello, my name is Nik. I am one of the junior doctors working in this department. Can I confirm your name
please? What is your child’s name and how old is he? What is your relationship to Andrew?
I understand that you have been referred from your GP. Can you tell me more what happened to Andrew?
Doctor Onset: When did he starts having loose stool? When did you notice blood in his stool?
Duration: Did it come on suddenly or gradually? Is it the first time it has happened?
Progression: Is it getting worse, improving or stays the same?
Aggravating: Anything makes it worse?
Relieving: Anything makes it better?
Associated sx: How much blood is there? Is the blood mixed with stool or seperate from the stool? Is tit dark
red or bright red blood?
DDx
1. Intussusception
 Does your child cry with his legs pulled up towards his tummy? (abdo pain)
 Have you noticed any swelling in his tummy? (abdo mass)
 Was there any blood in the stool? (red currant jelly stool)
2. Gastroenteritis (pain, diarrhoea, vomitting)
 Is your child vomitting or having a diarrhoea
 Is there anyone else in the house having diarrhoea and vomitting?
 Does he have any fever?
3. Volvulus (abdo pain)
4. Necrotising enterocolitis (premature baby)
5. Anal fissure
 Does he cries when he pass stools?
 Is he constipated?
6. Bleeding disorder
 Has he been diagnosed with a bleeding disorder?
 Is there anyone in the family with a bleeding disorder?

Assess dehydration:
 Does he play actively as usual?
 Is he passing wee?
 How many wet nappies have you changed today?
 Does he cry without tears?
P3MAFTOSA
Medical history, Medications, Allergy, Fhx, Social history,
Paeds history:
 Was everything fine during your pregnancy and delivery?
 Did he need any kind of help with his breathing right after the delivery?
 Is he up to date with all his vaccination
 Are you happy with his development?
I would like to examine Andrew now.
I will be checking his VS and his tummy

Nik Athirah
 1. His vital signs are not so good. His BP is low and his heart rate is high which means he is currently
dehydrated. Therefore, I would like to insert IV Cannula (a plastic tube into his blood channel) to rehy-
drate him with fluid.
2. I could also feel a mass in his right upper tummy, and based on the history that you have told me, it is
likely that Andrew is having a condition known as intussuception. It means that one part of his bowel is
telescoping into another part. This is what has been causing the pain and other symptoms. I will howev-
er need to confirm this by doing an ultrasound scan of his tummy.
3. We will need to admit him for this.
4. If the diagnosis is confirmed, we need to keep him fasting, insert a soft flexible tube into his nose
through his foodpipe, and also into his private part to monitor his hydration status and for the purpose
of the treatment.
5. To treat this condition, we can do what we call an air enema. We will pass a small tube into his back
passage and we will inject air into his bowel. This will hopefully force the telescoping of the bowel into
its normal position. Once this is achieved, Andrew will be free of pain.
6. We will also be giving him antibiotics and painkiller prior to the procedure
7. Unfrtunately, every procedures are associated with complications. This procedure may fail, or theres
also a small chance that his bowel perforates, but this is very rare as our specialists are very well
trained.
8. If any of these complications occured, we will need to do open surgery.
9. I will discuss this entire plan with my senior.
10. He will be able to go home after 2-3 days, once he is eaing and drinking well.

Febrile Convulsions

Scenario: Mrs Jones has brought in her 2 years old daughter, Lucy due to a fit while at home. On examination, there is a redness
over right eardrum. Take a history, discuss management with mother.

Steps. Greet. Confirm relationship. Fit history. Ddx. P3MAFTOSA. Paeds hx. Ix. Mx

Doctor Fit history:

 When was the fit?
 How long did she had the fit for?
 Has this happened before?
 Does she has any fever? How high was the temperature?
During
 Did the whole body jerk or was it only one part of her body?
 Did she lose consciousness?
 Did she wet hersel?
 Did she poherself while having a fit?
After
 How was she after the fit?
DDx
1. Acute otitis media (ear pain, discharge)
 Did you notice if she pulls at her ears?
 Was there any discharge from her ears?
2. UTI (dysuria, frequency, vomitting)
 Does she cry when she passes wee
 Did she vomit?
3. Pneumonia (cough, fever, sputum)
 Have she been coughing?
4. Meningitis (drowsy, rash)
 Have you noticed any rash on any part of her body?
5. URTI (cough , runny nose)
 Does she sneeze a lot? Does she have a runny nose?
6. Gastroenteritis
 Any loose stool?
 Did she vomit?
 Does she has any pain in the tummy?

Nik Athirah
 P3MAFTOSA
 Does your child have any medical illness?
 Does she have epilepsy, high blood sugar, asthma, heart problem?
 Does anyone in the family had a similar problem as a child?
Paeds history:
 Was everything fine during your pregnancy and delivery?
 Did he need any kind of help with her breathing right after the delivery?
 Is he up to date with all her vaccination
 Are you happy with her development?
From the examination, there is a redness over her right eardrum
Based on what you have told me and from the examination, Lucy most likely has a condition called febrile
convulsion. Do you know anything about it?
This is a condition in which children (6mo-6yrs) develop a fit when they have a high temperature. The con-
dition itself is not serious, but your child could sustain an injury during the fit and someimes this can be as
bad as a head injury.

In addition, the illness that caused the fever can also be serious and need to be treated. Common conditions
which can cause high temperature includes waterwork infection, common cold, meningitis or ear infection.

In her case, it looks like that she has got an ear infection.
To treat this, I would like to give her an antibiotic. Do es she has any allergies to any meds?
I am going to give her Amoxicillin in a liquid form so that she can take through her mouth. (Erythromycin if
allergic to Penicillin)
Is there anything in particular you want me to address at this point?
Patient: What should I do to prevent this from happening again?
Doctor: There are several things you can do to prevent this.
 Keep her lightly dressed in a warm environment
 Give her paracetamol every 6 hours when she has high temperature. If the temperature is more than
38.5, you can give her ibuprofen
 Give her lots of cool drinks
If the seizure happens again
 Make sure there is no dangerous objects lying around her. And please make her lie on her side.
 Call the ambulance if the seizure lasts for more than 5 minutes, if she is having a difficulty in breathing,
or if she develops a repeat seizure immediately after the first one. You can also give this medication
called diazepan through her back passage to stop the seizure.
 Otherwise, bring your child to hospital immediately after a seizure
 Look out for any signs of rashes
Patient: Can it cause epilepsy?
Doctor: Epilepsy is a condition where there is an abnormal electrical activity in the brain which causes the body to
jerk. Contrary to febrile convulsion, epilepsy occurs without fever. There is however 2% chances of children
who have febrile convulsion to develop epilepsy in later life.

MMR Vaccination

Scenario: You are a FY2 at GP. 11 months old girl is due for vaccination next week. Mother wants to talk to the doctor. Talk to
the mother and address her concerns.

Steps: Greet. Ask concerns. Address concerns. Ask general questions about her child.

Doctor Hello. My name is Nik, one of he junior doctors working here. Can I get your name please?
Patient Hello Doctor, my name is Mrs White.
Doctor Nice to meet you Mrs White. I understand that you would like to speak to me. How may I help you today?
Patient My daughter Alice is due for vaccination next week.
Doctor Alright. How old is Alice? Which vaccination she is due for?

Nik Athirah
Patient She is 11 months old. It is the one with MMR.
Doctor I see. Is there any particular issue you would like to discuss with me?
Patient Yes, doctor. Can you tell me more about MMR vaccination?
Doctor Yes of course. MMR stands for Measles, Mumps and Rubella. This vaccine is to immunise against measles,
mumps and rubella infection. It is given in one injection.
The first dose of MMR is usually given between 12 - 13 months of age.
The second dose is given between 3 y 4mo and 5 years.
Even if your child already had any of these diseases, she should still receive MMR immunization.

Is there any questions at this point?

Patient Is it safe doctor? I heard that it can cause autism and bowel disease?
Doctor The MMR vaccination is very safe and it is not linked to autism or bowel disease.
The controversy about the link to autism was initially based on a paper published in The Lancet by a doctor
named Andrew Wakefield in 1998.
However, Andrew Wakefield's work has since been completely discredited and he has been struck off as a
doctor in the UK.
Subsequent studies in the last eight years have found no link between the MMR vaccine and autism or bowel
disease.

Do you have any other questions?

Patient Are there any active infection of MMR virus currently?
Doctor Since the MMR vaccine was introduced in 1988, it's rare for children in the UK to develop these serious
conditions. However, outbreaks happen and there have been cases of measles in recent years, so it's im-
portant to ensure that you and your children are up-to-date with the MMR vaccination.
Patient Can my child get the measles or mumps or rubella vaccines seperately?
Doctor In the UK, single vaccines are not available on the NHS just because there is a risk that fewer children
would receive all the necessary injections, increasing the levels of measles, mumps and rubella in the coun-
try.
Besides, the delay in having 6 seperate injections would also put more children at risk of developing the
conditions, as well as increasing the amount of work and inconvenience for parents and those administering
the vaccines.
You can however get it from the private practise.
Patient What should I expect after she received her injection?
Doctor Most children are perfectly well after receiving a dose of MMR vaccine.
However some children get a very mild form of measles. This includes a rash, high temperature, loss of
appetite and a general feeling of being unwell for about two or three days.
About three to four weeks after having the MMR injection, one in 50 children develop a mild form of
mumps. This includes swelling of the glands in the cheek, neck or under the jaw, and lasts for a day or two.
Patient Is it dangerous if my child got infected with one of these viruses?
Doctor They can be serious infection which may cause serious complications.
For example,
1. Mumps can cause swelling of glands around the face, infection and inflammation in brain, and pancreas.
2. Rubella can cause rash, sore throat and swollen gland. If a pregnant woman gets infected, the virus can
cause damage to the unborn child such as damage to the brain eyes and hearing
3. Measles can case infection in the brain and cause brain damage. It can also cause infection in the lungs.
Patient Thank you docto for the explaination you gave me.
Doctor You are most welcomed. It would be very helpful to get your child vaccinated. I know I have given so much
information. Here are some leaflets where you can read further on MMR vaccination. I hope to see you and
your child next week for the vaccination.

Nik Athirah
Non-Accidental Injury (NAI)

Scenario: You are a FY2 in Paeds department. Michelle, a 4 months old girl was brought by her mother with a complain of swell-
ing her left arm. Xray showed spiral fracture of left humerus. Child is currently with the nurse. Take history and manage the
patient.

Steps: Greet. Confirm relationship. Paraphrase. Check prior understanding. Take incident history. Paeds history. Antenatal history.
Identify red flags.

 Bruises of different ages

 Child being looked after by a step father or boyfriend
 Child brought late to the hospital
 Mother is reluctant to get the child admitted
 Housing or financial problem
 Alcohol abuse in parents

Doctor Hello, my name is Nik. I’m one of the junior doctor working here. Can I get your name please?
Patient I’m Jane.
Doctor Can I ask what is your relationship with Michelle? How old is Michelle
Patient She is my daughter. She just turns 4 months old
Doctor From what I understand, you brought Michelle here because she has a swelling in her left arm, am I right?
Patient Yes doctor
Doctor Incident history:

Can you tell me more what about the swelling? Do you know what might be causing it?
 When did it happened?
 How did it happened?
 Did she has any swelling elsewhere?
Antenatal/Paeds hx:

Do you have other children?

Was there any problem during your pregnancy?
Was there any problem with ther delivery?
Was it a normal delivery?
How many weeks pregnant were you when Michelle was born?
Did she require any help with her breathing when she was born?
Are you happy with her development?
Is she up to date with her vaccination?
MAFTOSA:

Is she otherwise well? Has she been diagnosed with any illness?
Is she on any meds? Any allergies?
Red flags:

 Who else living with you at home?

 Who takes care of Michelle at home other than you?
 (if boyfriend/stepdad: How is he with Michelle?)
 Has this happened before?
 Are you coping well with having to take care of her?
 What do you work as? What does your husband/partner work as?
 Do you have any financial problem?
 Do you any housing problem?
 Do you drink alcohol?

Nik Athirah
 Explain Ix:
As you know, we did an X-ray on Michelle over the swelling area.
As you can see here, there is a fracture in the long bone of her arm.
It is very rare for a child to sustain a significant fracture in the long bone of the arm.
Moreover there was no witness and she did experienced any sorts of trauma.
Mx:
 We have to admit Michelle to fix the fracture
 Will insert a cannula into her vein for hydration
 Will be taking some blood tests including group and save
 I will do few more xrays to look at her bones in other parts of her body
 I will give her some painkillers so that she will be comfortable
 I will refer her to the bone specialist/doctor to treat the fracture
 Keep her fasting for the time being in case she’s going for operation
 Because the cause of injury is unable to explained, we will have to involve social service
*Check child’s name on the child protection register
*If struggling financially, offer social service to apply for benefits if entitled

Head Injury in a child

Scenario: Peter is an 11 month-old child who fell of a sofa. He was brought by his mother to ED. He sustained a head injury. The
child is now actively playing in ED. He vomitted once after the incident. Please talk to the mother and address her concerns.

Steps: Greet. Confirm relationship. History of fall. Paeds hx. MAFTOSA. Dx. Mx.

Doctor Hello, my name is Nik. I’m one of the junior doctor working here. Can I get your name please?
Patient Hello doctor. I’m Sophia.
Doctor Nice to meet you Sophia. Can I ask what is your relationship with Peter? How old is he now? How can I
help you?
Hx of fall/injury:
Before:
 What time did it happened?
 Did you see him fall? Can you describe it to me?
During:
 Did he lose consciousness?
After:
 Did he vomit?
 Did he have any fit?
 Any breathing problem after
 Was he drowsy?
 Does he have any headache
 Any bleeding/fluid coming out ot his nose or ear?
 Any problem with his vision/hearing
 Did you feed the child after?

Paeds hx

Do you have any other children?

Was there any problem during your pregnancy?
Was there any problem with ther delivery?
Was it a normal delivery?
How many weeks pregnant were you when Michelle was born?
Did she require any help with her breathing when she was born?
Are you happy with her development?
Is she up to date with her vaccination?

Nik Athirah
 MAFTOSA

Who elese looks after Peter at home?

Examination:

VS
General examination
Neurological
Dx:

Based from what you have told and and from my examination, it is most likely that Peter had a cerebral
concussion.
It is a sudden but short-lived lost of mental function that occurs after a blow or injury to the head. It is also
known as minor traumatic brain injury.
There is no permanent damage to the brain.
Mx:

1. Observe for 4 hours (if incident 1 hour ago, observe for another 3 hours).
2. Monitor: alertness, vomitting, apetite, fitting
3. It is best not to feed the child yet as he may need to go for a CT scan of the brain
4. We will give him sips of fluid to keep him hydrated
5. Icepack for swelling area
Patient Why can’t you just do a scan on him now?
Doctor For the time being, Peter does not have the criteria for us to do a scan yet. However, if he develops;
 lost consciousness for more than five minutes

 are unable to remember what happened before or after the injury and this has lasted more than five
minutes

 are unusually drowsy

 have been sick three times or more since the injury

 had a seizure or fit after the injury

 have signs and symptoms that suggest the base of the skull is fractured, such as "panda eyes"

 have memory loss

 have a large bruise or wound to the face or head

***A CT scan is also usually recommended for babies less than a year old who have a bruise, swelling or
cut on the head bigger than 5cm (2 inches).

Unless indicated, it is best not to do the scan as it might exposed Peter to unnecessary radiation.
Patient Is it dangerous if he has to go for the scan?
Doctor Most of the time it is safe to go for the scan but there is a small risk of developing thyroid cancer when a
child less than 12 years old undergo a CT scan.
*If moter insist on CT scan, talk to senior
Patient Is it safe to go home after this?
Doctor When you go home, there are certain things you have to do.
1. Make sure Peter is not alone for the next 48 hours and please be very watchful
2. Come back to ED if Peter became drowsy or more sleepy than usual, develop any fit, or if he develops
breathing or hearing problem, vomitted more than once, or ifyou notice any blood or fluid coming out from
his ears and nose.

Nik Athirah
 Offer leaflets

RTA in a child

Scenario: Joshua is a 5 year-old child was involved in RTA. CT Brain shows Extradural Haemorrhage. Examination shows no
added injury. He has been reviewed by the neurosurgeon and need to be prepared to theater. You have not seen the child yourself.
Please talk to parents.

Steps: Be very sympathetic and empathetic. GRIPS. Check identity. Explain why you are here. Ask them if its ok to sit down and
talk. Paraphrase scenario. Take AMPLE history. Explain Ix and current condition. Ask for any concerns

Doctor: Hello, I am Nik, one of the junior doctor working in the department.
Please may I know your names?
Can I confirm how are you relation to Joshua?
I am here to explain Joshua’s current condition and talk to you. Is it okay if we sit down and talk?
I understand Joshua has been involved in an accident. I am very sorry that this has happened. Is it alright if I
ask you few questions about Joshua?
A - Does Joshua has any alleriges?
M - Is he taking any regular medications?
P - Has he been diagnosed with any illnesses in the past?
L - When was the last time he eat or drink?
E - I know it must be difficult to talk about it but could you tell me exactly what had happened?
As you know, Joshua is currently under our care. We will do our best to manage him. Can I ask how much
do you know about his condition?

So far, we did a CT scan on his brain. Unfortunately, we found that there is a bleeding in his brain. (pause)

Fortunately, there is no other injuries. The neurosurgery team has reviewed him and they are planning to
bring him to the operation theater.

I am sure that the team members will speak to you in further details about that

I know this is difficult to digest at the moment. Again, I am sorry that this has happened.

Is there any questions you like to ask me?

Parents Can we see him now?
Doctor At the moment, it is a matter of emergency as he is being prepared to go to the theater but I will ask my
senior if there is by any chance that you could see him before the operation.
Patient Will he suffer from brain damage?
Doctor It is difficult to say at the moment. The outlook is usually good in children if treatment is carried out quickly.
There can be some neurological deficits. In some cases it can be temporary but unfortunaly in some others
the risk can be permanent (weakness, speech, fit). Again, it is difficult to say at the moment.

Nik Athirah
OBSTETRICS AND GYNAECOLOGY
Abdmonial pain (PID)

Scenario: You are a FY2 doctor working in ED. Ms Emma, a 30 years old lady presented with lower abdominal pain. Please take
a history, examination and discuss management with the patient

***positive sx: fever, frothy greenish discharge, pain (6/10) 3 days ago. new partner 3 mo ago. IUCD insertion 2 weeks ago

Steps: Greet. SOCRATES. DDx. P3MAFTOSA. Gynae hx. Exam. Ix. Mx

Doctor: Site: Where exacxtly is the pain?

Onset: When did it start? Did this come on gradually or suddenly?
Character: Can you describe me the character of the pain?
Radiation: Does it radiates anywhere else in your body?
Associated : Ddx
Timing: Is there any specific time of the day you experience the pain? Is it becoming worse, improving or
stays the same?
Exacerbating/Relieving: Anything makes it worse or anything brings it on? Anything makes it better?
Severity: On a scale of 1 -10, 1 being the lowest and 10 being the highest, how would you score your pain?

***offer painkiller ask allergy

Ddx
1. Ectopic pregnancy (pain, PV discharge/bleed, amenorrhoea)
 When was your LMP?
 Is there any chance that you might be pregnant?
 Any bleeding or passage of clots through your front passage?
2. PID (pain, PV discharge/bleed, fever, risk factors)
 Have you noticed any discharge from your front passage?
3. UTI (dysuria, fever, frequency)
4. Appendicits (migrating pain, N/V, fever, loss of appetite, diarrhoea)
5. Tubo-ovarian abscess (swinging fever, mass in iliac fossa)
6. Ovarian torsion (severe pain, mass)
7. Ureteric colic (loin to groin, pass stones, haematuria)
8. IBD (pain, chronic diarrhoea)
9. Gastroenteritis (travel hx, vomitting, diarrhoea, fever)
P3MAFTOSA
Gynae hx:
 LMP
 Contraception
Personal questions
 Sexually active? Male/Female? Safe sex? Regular partner? Last relationship?
 Hx of infection (STI)
Examination:
VS
Abdominal exam
Per vaginal exam: I will be inserting my two lubricated gloved finger through your front passage. While
doing this, my other hand will be on your tummy

***positive signs: temp 38 celcius. tender LIF. no mass. +ve cervical excitation, greenish discharge on the
glove.

Nik Athirah
 Explain dx:

From what you have told me and based from what I have found during the examination, it is likely that you
might be having a condition called Pelvic Inflammatory Disease. It means that there is an infection in your
genital tract, including your womb, fallopian tube and ovaries.

However, I would also like to rule out the chances that you might be having what we call an ectopic pregan-
cy which means a fertilised egg implants itself outside of the womb, usually in the fallopian tube.

This is because people who are on IUCD and have PID are at higher risk to develop an ectopic pregnancy.
But do not worry, we are here to help you

To confirm the diagnosis, there several investigations that I would like to do.

I will need to do a urine pregnancy test to check for pregnancy

I will also do a USG scan on your tummy and through your front passage to look for the IUCD and also
checking for pregnancy if the urine is positive.
and take a swab sample from your front passage to check for infection.
Mx:
PID
1. Admit (as she’s in pain and have high temperature)
2. Antibiotics:
 DMC: T. Doxycycline 100mg BD, T. Metronidazole 400 mg TDS for 2 weeks, IM Ceftriax-
one 500 mg STAT
 If pregnant, chance doxycycline to Ofloxacin
3. Remove IUCD
4. If the causes are STIs, abstain from sex for 2 weeks during treatment, partner get tested/notification
program, use barrier in the future
Extra notes: Ectopic pregnancy (if confirmed)
1. IV Cannula, routine blood plus group and save, beta hcg
2. IV fluid
3. Diagnostic laparoscopy
 If the ultrasound (TVUS) confirms that the pregnancy is not in the womb, we need to do an-
other procedure which called a diagnostic laparoscopy to confirm the pregnancy is in the tube.
 This is done under GA where the anaesthetist will take care of your breathing and give you
some painkillers and sedation
 The surgeon will make a small cut near the navel.The laparoscope is inserted through this in-
cision, and the abdomen is inflated to make the organs easier to view.A second cut might also
be made at the pubic hairline. This incision provides an additional opening for instruments
needed for completing minor surgical procedures.
 Depending on the size of the pregnancy and how the condition of the tube, we will either do a
surgery to remove the pregnancy alone or we will remove the pregnancy with the tube as well.
 If symptomatic but stable, HCG>5000iu/l, >3.5cm mass, FH +ve :
 Salpingostomy: if risk infertility but high recurrence rate
 Salpingectomy: best option if ruptured or other tube is healthy
 If HCG<1500, mass<3.5cm, no pain : Methotrexate
 If unstable: laparotomy

PID Risk factors

1. Being a sexually active woman younger than 25 years old
2. Having multiple sexual partners
3. Being in a sexual relationship with a person who has more than one sex partner
4. Having sex without a condom
5. Having had an IUD inserted recently
6. Douching regularly, which upsets the balance of good versus harmful bacteria in the vagina and may mask symptoms that
might otherwise cause you to seek early treatment
7. Having a history of pelvic inflammatory disease or a sexually transmitted infection

Ectopic pregnancy RF:

Nik Athirah
1. Previous ectopic pregnancy. If you've had one ectopic pregnancy, you're more likely to have another.
2. Inflammation or infection. Inflammation of the fallopian tube (salpingitis) or an infection of the uterus, fallopian tubes or
ovaries (pelvic inflammatory disease) increases the risk of ectopic pregnancy. Often, these infections are caused by gonor-
rhea or chlamydia.
3. Fertility issues. Some research suggests an association between difficulties with fertility — as well as use of fertility drugs
— and ectopic pregnancy.
4. Structural concerns. An ectopic pregnancy is more likely if you have an unusually shaped fallopian tube or the fallopian
tube was damaged, possibly during surgery. Even surgery to reconstruct the fallopian tube can increase the risk of ectopic
pregnancy.
5. Contraceptive choice. Pregnancy when using an intrauterine device (IUD) is rare. If pregnancy occurs, however, it's more
likely to be ectopic. The same goes for pregnancy after tubal ligation — a permanent method of birth control commonly
known as "having your tubes tied." Although pregnancy after tubal ligation is rare, if it happens, it's more likely to be ectop-
ic.
6. Smoking. Cigarette smoking just before you get pregnant can increase the risk of an ectopic pregnancy. And the more you
smoke, the greater the risk.

Ectopic pregnancy

Scenario: You are FY2 in ED. Chloe Jerkin is a 18 year-old lady p/w right sided lower abdominal pain. the nurse did UPT which
came back as positive. USG has been requested but has not yet done. Please take a history, talk to patient and discuss mx with
patient.

Patient info: LMP 6 weeks ago, BF not happy when she told him that. Had h/o Chlamydia infection @ 14 y/o

Steps: GRIPS. PARAPHRASE. SOCRATES. Ddx. P3MAFTOSA. RF Ectopic. Exam. Offer confidentiality. Explain Ix and Dx.
Mx. Advise to inform parent

Doctor I would like to reassure you that whatever we discuss here remains between you, me and the medical team
As you know, your urine has been tested for pregnancy test. The test has come back as positive. Based on
from what you have told me and my examination, as well as the urine test, it is likely that your are having a
condition that we call an ectopic pregnancy. (pause). Do you know what it means?

It means that your pregnancy is outside of the womb and commonly it will be in the tube. This will not be a
viable pregnancy as your tube cannot hold a pregnancy.
However, we need to do an USG to confirm this. If the USG shows the pregnancy is outside of your womb,
unfortunately we will have to admit you and do a keyhole surgery to remove the pregnancy.
***may need to explain in more details. Refer to previous note on diagnostic laparoscopy***
Patient No doctor. I dont want to get admitted
Doctor Is there any particular reason why you dont want to be admitted?
Patient I don’t want to go through the surgery.
Doctor Unfortunately, it is the only way to treat you. If this condition is not treated, your tube which holds the preg-
nancy can rupture. When this happens, this can be life threatening and you will need an open surgery to treat
it. This bigger surgery will leave you with scar and may cause few other complications such as infertility,
painful menstruation and risk of having an ectopic pregnancy in the future.
Patient My parent does not know I am sexually active. They will freak ot if they know I am pregnant!
Doctor I’m sorry that you are in this difficult situation. It must be a scary thing for you. If it’s alright with you, we
can talk to your parents and tell them about your condition. I am sure they would want the best for their
child. What do you think about that?

Pre-eclampsia

Nik Athirah
Scenario: Alice Smith is a 25 years ol lady who presented to antenatal follow up. She is at her 36 weeks gestation. During her
follow up, it was found out that BP 170/100 and urine dipstick shows protein 3+. Please take focussed history and discuss man-
agement

Steps: Paraphrase. Antenatal history. HPT Qs. P3MAFTOSA. Explain Ix. Explain dx. Mx.

Doctor I understand that you are here for your antenatal follow up. Is it alright if I ask you few questions regarding
your pregnancy?
How has your pregnancy been so far?
What number of pregnancy is this?
How many weeks are you now?
Is the baby moving alright?
Do you have any pain in your tummy?
Any discharge or bleeding from your front passage?
Are you taking your folic acid regularly?
Are you up to date with your vaccination?
How was the previous scans?
Is your blood tests all normal?
What was your booking BP and urine test?

**If has been pregnant before?

How was your previous pregnancy? Any problem?
HPT Qs:
Do you have any headache?
Any pain in the tummy?
Any blurring of vision?
Any leg swelling?
Any SOP or palpitation?
P3MAFTOSA
Do you have any high blood pressure or high blood sugar?
Is there anybody in the family with high blood pressure during pregnancy?
As you know, we took your BP and done some urine test. Has anyone explained the results to you?

You BP is high. Normal BP is 140/90. We also found protein substance in your urine which is 3+.
Dx: Unfortunately, this means you have a condition called pre eclampsia.
It is a serious condition as it can lead you to have a fit. Once you have a fit, this can pose serious effects on you
and your baby. If the condition is not controlled, this can be life threatening.
Mx:
Because of this, we would like to
1. Admit you
2. Start on medications: IV Labetolol to control your BP and IV MGSO4 to prevent fit
3. Monitor your VS closely such as your BP, Pulse, RR, Reflexes
4. Need to put a urinary catheter which is a soft flexible tube into your bladder to measure your urine.
5. Insert IV canulla for medications and fluid
6. Monitor wellbeing of your baby by CTG and USG scan

*Dexa 28-32 weeks

Address concerns

1. Is my baby going to be alright?

We will do CTG and USG scan to monitor your baby condition

2. Can I give birth via water birth?

Unfortunatley, it will be difficult to give birth with waterbirth as we are unable to monitor you closely when
you are in the water.
We will try to prolong the delivery until you are 37 weeks but if we thing that if you or your baby’s life at risk,

Nik Athirah
 the best method for delivery in your condition is via Csection.

3. What is a C-section?
It is a surgery to deliver your baby from your tummy. We will be making a horizontal incision below your
bikini line, about 7-10 cm. We will cut open your womb and delivery the baby. We will then close back the
incisions into layers neatly. Before the surgery, the anaesthetist will give anaesthesia through your spine so will
now feel pain from waist below. You will be awake during the surgery so that when the baby is delivered, you
can see the baby.

4. When can I go home?

You will be in hospital 5-7 days after delivery but it depends on how you are. We wish to discharge you once
you are well.
After you have been discharged, we will make an appointment to see you again after 6 weeks to assess how
you are.

5. My maternity leave wont start until next week

We can provide a letter from the hospital to your employer so that they will be understanding of your condition

Sexually Transmitted Disease (gonorrhoea)

Scenario: You are FY2 in GUM clinic. 30 y/o lady came 3 weeks ago to be tested for STI. Results are back and positive for gon-
orrhoea. Please break the news to the patient and address her concers.

Steps: GRIPS. Offer confidentiality. Take history. P3MAFTOSA esp sexual history and partner details. Explain Ix and dx. Mx.
Complications. Advices. Address concerns
Doctor I understand that you came 3 weeks ago for a test. I would like to assure you that whatever we
dicuss today is confidential and will remain between you and the medical team.
Could you tell me what brings you to have the test?
Is there any discharge from your front passage? Colour? Smell?
Do you have any tummy pain?
Do you have any fever?
P3MAFTOSA
I would like to ask you some personal questions, would that be okay?
Are you sexually active?
Is your partner female or male?
Do you practise safe sex?
What method of contraception do you use?
How long have you been in this relationship?
Was there any other partner previously?
How many partners do you have?
Does your partner has any symptoms?
Has anyone explained the results to you?
Well, the test has come back. Do you have any idea what the results might be?
Unfortunately, the result shows that you have a sexually transmitted disease called gonorrhoea.
Partner Does my partner gave me this?
Doctor It is difficult to say as the bug can stays in your body for 6 months before the infection shows up. To
know whether your partner has the same infection or not, it is best for him to be tested as well. Do
you think you could bring him here to be tested?
Partner I dont want him to know I have the infection!
Doctor Dont worry. If you would like to be anonymous, there is a thing called partner notification program
where we invite people for screening. He would not have to know that it was you who invite him to
be tested
Partner Can this infection be dangerous?
Doctor It can cause some serious complications if left untreated.
PID - The infection can travel from vagina up to your womb, tube and ovaries and cause more

Nik Athirah
 serious infection
Ectopic - It can also increase your risk to have pregnancy outside of the womb
Dyspareunia - Sometimes it can cause pain during sexual intercourse
Do not worry, if the infection is treated, the probability of getting complications is low.
We will give you 2 antibiotics.
IM Ceft 500 mg. The first abx is called Ceftriaxone. This is injected into your muscle.
T. Azithro 100 mg. The second abx is called Azithromycin. You will take it through your mouth.
These antibiotics are taken once only
S/E: nil as its only take once only.
Doctor Advise:
It is important that you refrain from having sex in the next 2 weeks (condom might break)
In the future, the best way to prevent another infection is to practise safe sex via condoms.
We will arrange to see you again in 2 weeks time to see if the infection has cleared up

Contraception

Scenario: You are FY2 at GP. Mrs Berry is a 30 y/o lady came to your GP requesting for contraception. Please talk to her and
address her concerns

Steps: GRIPS. Assess understanding. Ask current contraceptive method. Assess Risk Factors. Ask preference (ST<3years, LT>3
years)

Doctor How much do you know about contraceptive methods?

What kind of contraceptive method are you using at the moment?
Assess risk factors
 Breastfeeding in first 6 weeks
 Pregnancy
 VTE
 Thrombophilia
 IHD, PVD
 Migraine with aura
 HPT >160/95
 Liver disease (acute hepatitis, cirrhosis)
 TIA/Stroke
 H/o breast cancer in the last 5 years, Fhx of breast ca
 Smoke >15/day if >35 y/o
 Diabetes with neuropathy, retinopathy, nephropathy
 Ask allergies
Would you like to be on short term or long term contraceptions?
Short term include:

1. COCP
 Contain estrogen and progesterone hormones
 Availabe in 3 forms: Pill, Patch (Change every 3 days), Vaginal ring
 Failure rate 3/1000 (80/100 if no contraception)
 Make sure no contraindications as above
 S/E:can cause clots in the legs/lungs (if develop any pain or redness or swelling please come to hosp immediately), in-
creased risk of breast ca and cervical ca (but it reduces risk of ovarian, endometrial and colonic ca)

2. POP
 Contain progesterone hormone
 Taken if COCP is c/i
 Failure rate 3/1000
 S/E: bleeding between periods, stopping of periods

3. Depo Provera injection (ask about needle phobia)

Nik Athirah
 Contain progesterone hormone injected into your muscle
 Stays in body for 13 weeks, need another injection every 3 months
 Failure rate 2/1000
Long term include:

1. Implant
 Contain progesterone
 It is implanted in your upper arm.
 Can be used up to 3 years
 Failure rate 1/2000

2. IUS / Mirena coil

 A T-shaped plastic device inserted into your womb by trained doctor or nurse
 The IUS releases a progestogen hormone into the womb.
 This thickens the mucus from your cervix, making it difficult for sperm to move through and reach an egg.
 It also thins the womb lining so that it's less likely to accept a fertilised egg.
 It may also stop ovulation (the release of an egg) in some women
 Failure rate 2/1000
 Last for 5years

3. IUCD
 A T-shaped plastic device which has a section coated by copper
 It stops sperm from surviving in the cervix or womb
 It also stop a fertilised egg from implanting
 Failure rate 6-8/1000
 Last for 5 years

*Permanent method of contraception : Laparoscopic sterilization (Bilateral tubal ligation). Failure rate 1/200
***COCP
 Take everyday for 21 days, 7 days placebo or pill free days (Bleed during the 7 days)
 If miss 1 pill, take ASAP
 If miss 2 pills, take the last pill ASAP, have 7 days break as usual. But, it it is within the last 7 days of 21 days, need to take
next pack without a break. Take precautions.
 If unprotected sex, take emergency pill

Antenatal examination - Breech

Scenario: You are FY2 doctor in obstetric department. 20 y/o Mrs Lopez who is G3P2 is 30 weeks pregnant came for routine
antenatal visit. She was found by the midwife to have fetus in a breech position. Please examine, explain finding and discuss
further management.

Steps: GRIPS. Short history with P3MAFTOSA. Examine. Explain findings. Discuss management

Doctor I understand that you are here for your antenatal follow up. I would like to ask you some questions
regarding your current pregnancy. Is that alright with you?
Current pregnancy:
How many weeks are you now?
Have you had your scans? How are they?
Have you been attending your regular follow ups?
Have you had your vaccinations?
Are you taking your folic acid?
Is your booking BP and bloods alright?
Do you have any pain in your tummy?
Is the baby moving normally?
Any discharge or bleeding from your front passage?
Previous pregnancy:
Is this your third pregnancy?
How was the previous pregnancy?
Were there any problems before?
What were the methods of deliveries?

Nik Athirah
P3MAFTOSA
Any medical illness - DM/HPT
Alcohol/Smoking?
I would like to examine your tummy for the sake of your wellbeing and the wellbeing of your baby.
For the purpose of examination, I would like you to undress from mid arm to midthigh and lie on
your back comfortable, would that be alright with you.
I will ensure your privacy and ask the examiner to be my chaperone.
Antenatal examination

Inspection:
The abdomen is distended corresponding to gestation age
There is no cutaneus signs of pregnancy such as linea nigra and striae gravidum
There is no scars
Palpation:
Superficial : I will be touching your tummy now. Please let me know if you feel any pain.
Deep palpation: Fundal grip (presentation), umbilical grip (lie), Pawlik’s grip (engagement - only if
cephalic)

Auscultation:
Put Pinard on the side of where the back is. Pinard is not useful until 28 weeks gestation. Place the
bell of the instrument over the anterior fetal shoulder. (Ideally listen for 1 minute)
Explain diagnosis and examination to patient:

From my examination, I could hear your baby’s heart beat. The baby is lying longitudinally and the
back is on your right side. Unfortunately, your baby is in a breech position. This means that your
baby is lying feet first or bottom first downwards. A normal position is when the baby’s head is
down, not the bottom.
This is a problem because there will be more complication with vaginal breech birth.

Complications:
To mother - LSCS, haemorrhage, trauma
To baby - trauma, asphyxia, higher mortality rate
Management:

What we can do now is that, we can offer you a procedure called External Cephalic Version.
This is a procedure where we try to turn the baby into a head down position by applying pressure on
your abdomen.
During the procedure, we may give you medication to relax the muscles of the womb, this medica-
tion will not affect the baby.
We usually offer this procedure after 36 weeks.

Benefits?
It is successful for about a half of all women.
It will increase the likelihood of having vaginal birth

Does it work?
If the baby does not want to turn, it is possible to have a second attempt on another day.
If after the second attempt does not work, our specialist will discuss further with you for options of
birth

Is it safe?
It is generally safe and does not cause labour to begin.
We will monitor baby’s heart rate before and after the ECV.
Unfortunately, like other procedures, complications can sometimes occur.

Complications with ECV?

0.5% of baby need to be delivered via EMLSCS immediately after ECV due to bleeding from pla-
centa or changes in baby’s heart.

Nik Athirah
 Is it painful?
It can be uncomfortable. During the procedure, please tell us if you experience any pain we can
move our hands or stop

Can I go home after ECV?

Yes. However, if you have any bleeding, tummy pain, contractions, or reduced baby’s movement,
please call the hospital.

Is there anything else I can do to help my baby turn?

There is no scientific evidence that lying down or sitting in particlar position can help your baby
turn.
Patient What if ECV does not work?
Doctor If this does not work, our specialist will discuss the birth options with you. The safest method to
give birth with breeach baby is through Ceasaren section.
Patient What is a ceasarean section?
Doctr It is a surgery done under anaesthesia. The anaesthetist will give some anaesthesia or numbing
medications through your spine before the procedure. You will be awake during the surgery but you
will not feel any pain from waist down below.
Then, we will be making an incision of about 5-7cm in size under your bikini line. Then, we will
make an incision on your womb to deliver the baby from your tummy. We will then close these
incisions neatly.

Complications: Bleeding, infection, scar.

Breast lump

Miscellanous

Nik Athirah
Warfarin

Scenario: You are FY2 in Gen Med. Lin White is a 50 y/o female presented with leg pain 5 days ago. USG Doppler shows DVT.
He is prescribed with warfarin and is planned for discharge today. Please explain the medication to the patient and address her
concerns.

Steps: GRIPS. Paraphrase. Check understanding. Some focussed history to know cause of DVT. P3MAFTOSA. Assess LD.
Explain meds (use BNF). Warfarin diary

Doctor I understand that you came in 5 days ago because of the pain in your leg?
Do you know what condition are you having?
Do you know what might be the cause for the clots in your legs?
Assess RF: (provoked or unprovoked)
 long haul flight
 immobilization
 trauma
 smoking
 alcohol
 bleeding disorder (thrombophilia)
 OCP (in female)
 recent surgery
P3MAFTOSA
Assess Learning disability:
 Do you find it hard to learn, understand or remember new things?
 Do you have any problem in reading?
 Ask patient to repeat the name of warfarin/read the label
As you might know, the team has decided that you are fit for discharge. We are also giving you a
blood thinning medication called Warfarin for you to take at home.
Do you know anything about it?
 Warfarin is a blood thinner that is used to prevent clots from developing in the lungs or legs
Dose: (Check BNF)
The initial dose that we will give you is 5 mg per day. The subsequent dose will depends on how
thin or thick your blood is.

To know how thin or thick your blood is, you will need to have a regular blood tests called INR
(international normalized ratio). Depending on your INR, we will decide to adjust the dose and
inform you. The dose will be adjusted from time to time. You will have a blood test every morning
for the first 1-2 weeks and then once a month or so.

We need to maintain your INR between 2.5-3.5.

You will need to take this medication at 6 pm everyday.

This is because on the day when your blood is tested in the morning, once the result is back, we can
adjust the dose immediately, and you can take the medication in the evening, rather than having to
wait for the next day
S/E:
Bleeding. But we will monitor your INR level very carefully. But if you notice any bruises, bleed-
ing from nose, or blood in your stool, please come to hospital immediately

Please do not take a double dose.

If you miss a dose, please contact us and we can advise you. If you miss it and remember before go
to sleep, do take it. If not, do not take it.

Avoid cranberry juice as it can interfere with the medication

Please tell the pharmacist or your GP that you are on this medication

Nik Athirah
 Please do not take >14 unit of alcohol per week as this can affect the medication.
Warfarin diary:

We will give you a warfarin diary. This is for you to record the INR blood test results, including the
dates and dose of the warfarin. The changes in doses will be written by us.
In LD:
Explain as usual
Ask the patient to repeat the details of warfarin after you
Check understanding
Write down the information on a piece of paper and to give it to carer
Ask is there is someone at house to help adminiter the meds
If no carer, refer to social service

Needlestick injury

Scenario: You are FY2 in ED. Emma Jones is a 25 y/o student nurse who prick herself while taking blood from patient who has
meningitis. Please talk to the nurse, take relevant hisotry, discuss management and address her concerns. Patient is very worried.

Steps: GRIPS. Complete incident history. Universal precaution. P3MAFTOSA. Mx. Concerns

Complete incident hx:

 How it happened?
 When it happened?
 What type of needle was it?
 Was there blood on the needle?
 What did you do after the incident?
(Wash with soap, allow the wound to bleed under running water, do not suck the
wound, cover the wound)
 Are you up to date with all your vaccination?
 When was you last booster for Hep B?
 Has this ever happened before?
 Do you know the patient’s status?
 Is there by any chance you could be having Hep B/C or HIV infection?
Ask concerns: Patient is worried about acquiring meningitis as the patient is treated as meningitis.
 It is transmitted through airborne, not blood.
 Did you take universal precaution before getting in contact with the patient?
 If concerned, offer prophylaxis antibiotic as hospital protocol (Cipro 500mg PO)
P3MAFTOSA
Ix:
 We need to take blood from both of you and the patient for Hepatitis B and HIV. However,
this need consent from the patient.
 We will store the blood sample and test it in 2 month time for hepatitis and 3 month time for
HIV
Mx:
 If worried about HIV risk, we can offer Post-exposure Prophylaxis for HIV (PEP)
 It must be given within 1 hour, but can also be given up to 72 hours. 28 days tablet.
 85% effective if given in time.
 S/E: damage to the liver and kidney
 Some companies may not offer loans or mortgages or any form of borrowing if HIV
tests come out as positive
 Fill up incident reporting form for documentation
 Inform occupational health
 Risk of transmission. HIV 0.3%, Hep C 1.8%, Hep B 30%
Extra notes:
If injury occurs in garden/park
 Ask about tetanus and hep B vaccination

Nik Athirah
  Children usually up to date with immunizations as they finished by 17 or 18 y/o
 For adult, need booster if the last booster was more than 5 years ago.
 If never being immunized, give Ig and arrange for vaccination at GP (tetanus and hep B)
 The risk of Hep B and HIV is low as the bug doesnt survive long outside of body or in the soil

Patient who is not happy with your junior colleague + IV Cannulation

Scenario: Mark Winrows is a 39 years old man admitted following an insect bite on his arm. He has been receiving abx for the
past 24 H. The consultant has reviewed him and decided that he can go home after receiving one more dose of antibiotic today at
10 am. The nurse who noticed that his IV cannula is blocked and has informed Dr Wilson, a FY1 regarding this problem. Please
talk to patient.

Steps: Allow patient to vent anger/talk. Active listening. Offer solution. Do not blame colleague or defend them. Apologise on
behalf of the team. PALS

1. GRIPS
2. Paraphrase: I understand that you have been admitted following an insect bite on his arm. How are you doing in terms of
your infection?
3. I am sorry that this had happened to you. I am here to help. I will change your cannula and the nurse will administer your
antibiotics straight away so that you can go home as soon as possible.
4. Why is your colleague has not attended me?
Again, I am sorry that this has happened to you. I am unable to answer that as I had not spoken to him yet. I will find him
and ask him to explain the situation to you. I would like to apologise on behalf of the tea,.
5. I am not satisfied with this! This must have happened very often. I have heard a lot of bad things about this hospital!
I am so sorry that this has happened. It does not happened very often. We have a service called Patient Advisory Liason
where you can give your feedback and make a complain. Your feedback is very important so that we can improve our ser-
vice.
6. Why can’t you just give me an oral antibiotics?
It is important to give this medication through your vein as the efficacy is better and to make sure that your infection is well
treated.
7. Is there anything else I can help you with?
8. Again, I am sorry on the behalf of the team and we will definitely investigate this situation

Dealing with your colleagues

Scenario: Dr Wilson is a FY1 doctor in hospital. You are his FY2 senior colleague. He saw a patient 2 hours ago but has not
returned to see him now. Patient has a blocked IV cannula and not happy with him. Please talk to your colleague.

Steps:
1. Build rapport, be friendly.
Hello, my name is Nik. I am one of the junior doctors in this department. What’s your name?
How’s things going on for you here? Are you able to cope?
2. Well, Wilson, I wanted to talk to you about one of the ptient that you saw, Mrs Jones. Do you remember her? She is the lady
with a cellulitis on her right arm?
Well, she is not too happy at the moment. As you know, she has a blocked IV cannula and has been waiting for it to be
changed for quite a while. She is not happy that she is not seen immediately as she is keen to go home soon.
Can I ask is there a reason why you could not go back and see how she was doing?
3. You need to try and get help from your colleagues to make sure that your jobs are done on time and properly.
How are you getting along with your colleagues? Have you managed to make friends?
Once you start being friendly with your colleagues, it will be easer for you to ask for help when you need it. It is going to
take a while, but I am sure you will get there. You can also try to be nice and frienfly with the nurses. They can be of great
help. Some of them are trained to insert cannula.
4. Do you have my bleep number? You can contact me anytime if you need help. Also, please try to collect the bleep numbers
of the rest of our colleagues as well.
5. Now, it would be helpful if you could go and see Mrs Jones and apologise for this. Try to explain your situation. It is im-
portant that we try to maintain our team and hospital reputation. If you feel like things has gone out of hand, you can always
talk to your supervisors and tell them your situation and get advise from them.

PCM Overdose + Venupuncture

Nik Athirah
Scenario: Emma Stone is a 30 year-old lady who took 15 tablets of paracetamol 5 hours ago, following an argument with her
partner. Please take a history, and discuss management. Please do not take a psychiatric hx.

Steps: GRIPS. Paraphrase. History. Symptoms. Risk factor. P3MAFTOSA. Venupuncture. Mx

Hx:
 What tablets did you take?
 How many of them?
 When did you take them?
 Did you take any other tablets other than PCM?
 What did you do after you took the tablet?
 Are you any regular medications?
Sx
 Do you feel sick? Did you vomit?
 Any pain in the tummy?
P3MAFTOSA
Any problem with your liver or kidney?
Do you drink alcohol? How much do you drink? Did you drink before or after you took PCM?
I would like to take a blood sample from you, to check for the level of Paracetamol and also to run some
routine blood tests (FBC, LFT, U&E, Clotting)

 Do you have any needle phobias?

 Do you have any bleeding disorders?
 Are you on any blood thinners?
 What is your arm preference for blood taking?
The examiner will give a result of PCM level.
Check the level on the paracetamol normogram to identify if patient needed treatment

Well, the result has come back. As you can see here, your blood test shows that the paracetamol level is
Xmg/L. If you can see this graph here, the vertical axis here shows the concentration level of PCM in the
blood and the horizontal axis represents numbers of hours from ingestion. The curve line is called the
treatment line. Therefore, using your result, which is Xmg/L, we can see that it is above the treatment
line.

This means that we need to give you a medication called N-Acetylceistein through your vein. This is to
prevent liver injury and reduce the toxic effect of the paracetamol overdose.

Treatment for PCM overdose

PCM overdose:
1 tablet is 500mg
Significant overdose is >75mg/kg in 24 hour period or 12 g

General management:
1. I will take care of ABC of this patient
2. Insert IV canula and send bloods

If <1 hour of ingestion:

 Give activated charcoal 50g orally if significant overdose
 Send PCM level blood 4 hour after ingestion
If 4-8 hours
 Take sample ASAP
 If level above treatment line, give acetylcysteine in the following manner:
150mg/kg in 200ml D5% over 1 hour
50mg/kg in 500ml D5% over 4 hour
100mg/kg in 1L D5% over 16 hour
 Repeat PCM level 4-6 hourly until the level is below treatment line
If 8-15 hours
 Give above regimen if significant overdose taken

Nik Athirah
  Take PCM level and can stop tx if below the line
If 15-24 hours
 Give above regimen if significant overdose
 Always finish the treatment anywy
>24 hours
 Check routine blood tests and PCM
 Acetylcystein is controversial

FBC, LFT, RFT, Coag, Glucose, HCO3-

***N-Acetylcysteine can cause allergy. Give Chlorpheniramine

Diabetic foot examination

Scenario: Mr William is a 50 year-old male presented to your clinic for routine follow uo. He was diagnosed with DM 5 years
ago. Please take a focussed history, do relevant examination and discuss management with patient.

Steps: GRIPS. History about DM. Screen for complications. P3MAFTOSAExamination. Management.

History of DM:
 How long have you been diagnosed with DM?
 What medications are you on?
 How is your sugar control? What was the last reading?
 How is your diet?
Any particular concerns that you want to discuss today?
Screen for complications:
1. Eye: How is your vision
2. Kidney: Are you passing urine normally? Any swelling in the legs?
3. Heart: Any chest pain?
4. Autonomic neuropathy: How is your bladder control? Any diar-
rhoea/constipation/nausea/vomitting?
5. Motor neuropathy: Any weakness in your body?
6. Sensory neuropathy: Any numbness in your hands or foot? Any tingling? Any burning sensation
7. Foot: Any sore/cuts/ulcers in the foot?
P3MAFTOSA (esp alcohol)
Examination: Undress below waist, remain in brief

1. Gait
2. Inspection (Lie 45 degree)
 Shoes
 Ulcers
 DRSSS
3. Palpation
 Temperature
 Tenderness
 Pulse (DPA)
 CRT
4. Sensation
 Cotton wool
 Neuropin
 Monofilament
5. Vibration (128Hz)
6. Proprioception
7. Reflexes

Dx:
My examination has revealed that you have loss of sensation below xxx. Your joint position sense is also
affected in your xxx. Your xxx reflex is loss.

Nik Athirah
 You are most likely suffering from a condition called diabetic neuropathy.
This is a result of high blood sugar levels damaging the small blood vessels which supply the nerves.
This prevents essential nutrients reaching the nervess causing the nerves to be damaged
Mx:

1. Blood tests: routine + HbA1c + glucose

2. Healthy balance diet - Refer dietician
3. Refer neurologist
4. Refer opthalmologist + Do fundoscopy
5. Refer podiatrist
6. Foot care advise:
 Wash your feet everyday with luke warm water and soap
 Dry you feet well, esp between the toes
 Mosturise your feet, but not between the toes
 Check for any cuts, blisters or sores
 Keep your toenails at a reasonable length
 Wear clean socks that is the correct size
 Wear comfortable correctly fitting shoes
 Never walk barefoot indoors or outdoors
 Examine your shoes for things that might hurt your feet
7. If pain: PCM/Ibuprofen (mild to moderate) or Duloxetin, Amytriptylline, Gabapentin, Pregabalin

Alcoholic foot examination

Scenario: Mr Larry Osborne is a 50 male who present with a burning sensation in his legs. PMH: He went to Alcohol Rehabilita-
tion clinic 5 years ago. Please take a focusses hx, perfrom relevant examination and discuss mx with the patient.

Steps: GRIPS. ODPARA.CAGETW. P3MAFTOSA. Exam. MX

ODPARA
1. Autonomic neuropathy: How is your bladder control? Any diar-
rhoea/constipation/nausea/vomitting? Dizziness/fainting?
2. Motor neuropathy: Any weakness in your body? Twitching/cramps?
3. Sensory neuropathy: Any numbness in your hands or foot? Any tingling? Any burning sensation
4. Gait: Any loss of balance on walking
CAGETW
P3MAFTOSA
Exam: Similar to above
DxL Alcoholic neuropathy is caused by the prolonged use of alcoholic beverages. Ethanol, the alcoholic
component of these beverages, is toxic to nerve tissue. Over time, the nerves in the feet and hands can
become damaged
Mx:

1. Blood test routine + sugar + Thiamine, B12, Folic acid levels

2. Refer to Alcohol and substance misuse team, Al Anon
3. Refer to neurologist
4. Refer to podiatrist
5. If pain: PCM/Ibuprofen (mild to moderate) or Duloxetin, Amytriptylline, Gabapentin, Pregabalin
6. Give vitamins: Vit B12, Thiamine, Folic acid
7. Footcare advise if loss of sensation

Primary Survey

New scenario: Patient is conscious. There is a nurse to assist you.

Steps

Nik Athirah
Before approaching:
 I will ensure that I have taken all the universal precaution before approaching the patient and I will make sure that the trau-
ma team is informed
Greet the nurse
Hello, my name is Nik, one of the junior doctor working in the department. What is your name?
Who do we have here?
What information do you have for me so far?
Thank you

Approach the patient

 Do ATLS walk if patient dont have any neck collar on
 Do inline mobilization before speaking to the patient
 Greet the patient:
Hello, my name is Nik, one of the junior doctor here. Please do not move your head. Can I have your name please? How old
are you?
 Assess GCS:
Do you know where you are?
Do you know what time of the day it is?
Can you lift your right arm for me?
If eye not opening on voice: Apply pressure to sternum
If patient do not follow command: Apply pressure to nailbed to check motor response
 Ask the nurse to get a neck collar, apply a neck collar.
Ideally I would like to do a triple immobilization
Can you please connect this patient to all the monitors?
 Take AMPLE history if patient is conscious
Allergy?
Medication?
Past medical hx?
Last meal?
Event relating to incident?
Airway
 Since my patient is speaking, the airway is patent.
 Can you please open your mouth please?
 Please connect the patient to high flow oxygen 15L/min and do Xray of neck and chest
 Check the trachea
 I would like to expose you fully. Is it okay if I cut your clothes with scissors? I will ensure your privacy and provide you
with a chaperone. (Ask nurse to assist you)
Breathing
 Inspection: From the end of bed. Please take a deep breath in and out
 Palpation: Chest expansion. Tenderness
 Percussion
 Auscultation
Circulation
 Do you notice if patient is bleeding or if there was blood on the floor?
 Check peripheries, CRT
 BP
 2 wide bore IV canula. Take blood for FBC, U+E, LFT, Clotting, glucose and group and save. Please request for crossmatch
4 units of blood
 IV Fluid : Maintenance, Resuscitation
Abdomen
 Inspection
 Auscultation
 Palpation: Palpate all quadrant, liver, spleen, kidney.
If tender, Please arrange for FAST scan of abdomen, and refer this patient to general surgery. (Focussed assesment with so-
nography for trauma)
 Percussion: Shifting dullness
Pelvis
 Inspection
 Ideally I would like to look for perineal brusing, scrotal haematoma and urethral meatus bleeding
 Palpate for tenderness
 If no tenderness, do a spring test. I will document in the notes that spring test was ...
If tender: Please do a pelvic Xray, get me a pelvic strap and apply pelvic strap and refer to orthopaedics

Nik Athirah
Legs
 Inspect and palpate thigh and leg looking for any fracture in femur/tibia/fibula
 Check DPA
Do neurology examination:
 Tone
 Power (if GCS 15)
 Reflex including pupillary reflex
 Sensation (if GCS 15)
Exposure
 I will cover my patient to prevent hypothermia
Speak to examiner
Diagnosis
Management
I will put NG tube and urinanry catheter
Refer neulosurgery team if suspect head injury and arrange for CT BRain

Whiplash injury (with examination)

Otoscopy - OME

Upper motor neuro examination / Cerebellar ataxia

BLS - teach

Adult BLS
Introduce to the person who you are teaching to. Ask for name.
I will be teaching you how to perform an adult basic life support. This is used in a scenario where you encounter a person who
has collapsed. It can happen in the hospital or outside of a hospital. Therefore, it is very important to remember the steps.
1. Safety
2. Response: Shout in both ears
3. Time
4. Shout for help in 3 directions
5. Airway : Head tilt, chin lift. Check for any foreign body
6. Breathing: Look, Listen, Feel for 10 seconds
7. Call ambulance: 999 or 2222 (cardiac arrest team). Tell the ambulance: Who you are, What had happened, Where you are
and your contact info, The time you initiated CPR
8. Compression. 30:2, 100-120/min, 5-6cm depth
When you do the compression, make sure that you kneel beside the patient, interlock two hand together, put the heel of your
hand about 2 fingerbreaths above the xiphisternum and compress down the chest. Make sure that when you do this, your el-
bow has to be straight and press down using the force of your shoulder and back.
9. Continue this until help has arrived, patient shows sign of life or you are completely exhausted

Paeds BLS

1. Safety -> Response -> Time -> Shout for help

2. Airway
3. Breathing: LLF 10 seconds, 5 rescue breaths
4. Circulation: Carotid pulse 10 seconds
5. Compression - 15:2 for 3 cycles
6. Call ambulance
7. Airway
8. Breathing: LLf 5 seconds, 2 rescue breaths
9. Circulation 5 seconds
10. Compression 15:2
11. If pulse >60bpm : stop compression, give rescue breaths 1 every 3 seconds

Post op Bleeding

Visual field

Telephone conversation- nursing home

Nik Athirah
URTI requesting for antibiotics

Breast lump

Ethics
Elderly abuse

Scenario: You are FY2 in geriatric department. Lina White is a 80 year-old lady who was brought to hospital by her daughter
following a fall. Nurse found bruises of different age on her arm. Take a history and discuss management with her daughter,
Emma White.

Approach:
1. GRIPS
2. Paraphrase
3. Take history of fall. Before/During/After
4. H/o brusises
5. P3MAFTOSA
6. Ask about independency and mobility
7. Ask about social history: Who is caring for her? How is the daughter coping with it? Is there any financial problem? What
kind of house she lives in?
8. If the daughter confess of NAI: Ask if this is the first time it happened? Any other types of abuse?
9. Management: Offer social service and nursing care
10. Can’t take her mother home yet as the specialist, social service and occupational therapist need to see her

Colonic cancer- Dont tell my mom

Scenario: You are FY2 in Medical unit. 67 year old Mrs Ali c/o abdominal pain and diarrhoea. She was dx with colonic cancer. At
the time of initial assessment, she was confused. The consultant dicussed her condition with her daughter Alice that the team is
still investigating the staging of the disease. Today the son is here to talk about her condition with her consent. She is now men-
tally capable. Please talk to the son.
*Mrs Ali does not know that she has cancer

Steps:
1. GRIPS
2. Confirm relationship
3. Assess understanding
4. Reassure the son that we will break the news gently
“We will break the news gently and in a sensitive manner. We will also ask her beforehand if she wants to know and how
much she wants to know”
5. Ask why does he not want the mother to know
6. Explain why she needs to know
“It is important that we give her the basic information because she needs to consent on further investigations and manage-
ment. This is because she needs to know the complications and the importance of each and every investigations or treat-
ments”
7. Explain support group: Mc Millan nurses
8. Ask if his mother has appointed him as her Lasting Power of Attorney or if she made any advanced directive
9. Admit that son has genuine reason to be concerned
10. Ask about other family members who would like to be involved in her care

Domestic violence

Scenario: You are FY2 at ED. Sandra Brown is a 30 year-old lady who is 12 weeks pregnant. She is concerned about the wellbe-
ing of her baby. She requested for urgent meeting. Nurse has examined her and found out that she has PV bleed, bruises and burn
marks on her arm. She told the nurse that her husband kicked her in the tummy. USG Abdo normal. Please take a focusses history
and discuss initial management with the patient.

Patient information: She has another 5 year old child at home. Abuse has been going on for 6 years. Husband threatened to kill
her if she tell other people. Abuse occured in front of other child. Scared that social service will take the child away from her.

Steps:

Nik Athirah
1. Offer confidentiality
2. Ask about the pregnancy
3. Ask about what had happened. Use direct questions if patient is reluctant to answer. Establish methods of abuse (men-
tal/physical/sexual)
“Often people who have a similar injury admit that they had been hit by their partner. Does this happened to you?”
“Does your partner put you down? Controlling you? What did he do to you? Did he force you to do things you dont want to?
4. Ask if there is other child.
“How does he act towards your child?”
5. Have you told anyone about this?
6. Do you have anywhere else to stay if you were to stay away from your partner?
7. Assess danger:
Does he ever threaten to kill you? Does he threaten to use weapon?
Does he have any criminal records?
Is your child is endangered physically or mentally?
8. Management:
 Documentation of abuse for records including photographs of injuries (ask consent)
 Help available:
Police Domestic Unit,
Local Woman Aid Refugee,
National Domestic Helpline number.
 Create a safety plan:
Keep important documentation and some valuables at a safe hidden place.
Call 999.
Consider referral to soscial service if children is at risk.

Dementia

Scenario: You are FY2 in geriatric unit. You have been looking after Mary White who is 79 years old. She has dementia for the
past 3 years. She is currently not able to eat or drink and subsequently has been admitted with weight loss 2 weeks ago. CT scan
and blood tests were normal. She has been diagnosed with an end stage dementia. Your medical team has decide for palliative
treatment. Explain to daughter that she has end stage dementia and for palliative.

Steps:
1. GRIPS
2. Assess understanding
3. Break the news
“Unfortunately the disease has affected her so much that we have come to conclusion that active treatment will not help her
in any way. I am sorry to say that she is in terminal stage of her disease. It means that she can die from this disease. The pro-
cess may take days, months or even years.”
4. However, there are many measures that we can do to make sure she is comfortable.
5. Maintain constant environment
6. Make sure she is safe.
“She may trip on carper, fall out of bed or wander outside”
7. Has she ever appointed anybody to make a decision for her on her behalf? Was there any legal document that she signed?
Has she ever made any advanced decision regarding her treatment?
8. The disease will progress further and at some point she would not be able to recognize you.
9. She may not want to eat or drink. But this does not means that she is suffering. Not eating or drinking is a sign of at the end
of life.
You can help her by giving her to drink using a straw or damp her mouth with water.
10. Breathing may change. She may make rattling sound which may be upsetting to hear.
You can improve this sound by changer her position from lying to sitting.
11. She would sleep much more
12. She maybe able to hear you.
It is important to hold her hand or play her favourite music
13. Her skin may feel cold or change in colour to blue or mottled.
This is a normal dying process. She may not be in pain. You can put glove on her hands but you dont need to warm her up.
14. If she is agitated, we can give her medication to calm her down.
15. It is important not to correct her if she gets things wrong.
16. Please speak in clear, calm and audible manner so that she can understand you.
17. Sometimes, if she yells, it may just be her way of communicating, not necessarily means that she is in pain.
18. If she lose control over her bladder/bowel, make sure to keep her clean.
We can send palliative nurse to show you how to change her position to avoid her getting pressure sores and also to teach

Nik Athirah
 you how to maintain her hygiene.
19. Her eyes can be closed at last stage but she can still listen
20. If she collapsed, aggresive treatment is unlikely to help if she is at her last days of life. Your mother may not want it. Do you
know if your mother prepare any such document regarding care of her at her end of life or when she loses mental capacity? e
need to have a legal document for this to be vaild.
21. ITU is unlikely to help as her demetia is at terminal stage as it will not improve her condition. Instead, it will cause her more
pain and risk her dignity. Do you think she would like togo through all these interventions?
22. Do you know if she would like to spend her last days at home or in the hospital?

Contraception 15 year old

Scenario: You are FY2 in GP. Leslie Brown is a 50 year-old who came to your GP. He family, Mr Bown and Emma Brown have
been under your pravtise for 15 years. Today she came with some concerns. Please address her concerns

Steps:
1. GRIPS
2. Explain how it works in sexually active young patient:
Patient will be assesed if they understand the risk and benefits of contraceptions and competent to make a decision for them-
selves.
We usually recommend them to inform their parents and ideally come with their parents. If they refused to inform their par-
ents, we still see them and assess their understanding and if the patients are being judged competent, we will prescribe the
contraception.
3. We also ask them regarding their partner. If we think that they are in an abusive relationship, or if the partner is much older,
we have a duty to inform these to the social service or police and even to the paretns depending on the circumstances
4. If she was prescribed the contraception, it is likely that she must have been judged to bve competent an understand the risk.
5. Have you speak to Emma herself regarding this matter?
6. Do you know if she is in any relationship
7. I am afraid this is a metter of confidentiality and we are not allowed to break confidentiality. It is important to us that our
patients trust us so that we can give them the best care we could.
8. I would advise you to speak to your daughter and be supportive towards her
9. We always give advise practising safe sex so that it could prevent our patients from getting any STI

Missed ECG findings

Scenario: You are FY2 in CCU. Michael is a 55 yo was admitted 2 days ago due to MI. 5 days ago he went to the ED and was
seen by the doctor who has reported that ECG was normal. Blood tests were done but patient was discharged home on a basis of
normal ECG. Troponin result hasnt came back then. He was dx as MSK. The cardiologist has reviewed him now and notice that
the ECG that was done before showed T wave inversion and troponin was positive.
Task: Explain medical error, assess any complications, address his concerns, discuss further management

Steps:
1. GRIPS
2. Paraphrase: I understand you have been admitted 2 days ago, is that correct?
3. Check understanding: Have you been told about the reason why you are in hospital at the moment?
4. Explain current diagnosis: You had a heart attack and currently being treated for that
5. Do you know what treatments have you gotten so far? What medications you are given while in the hospital? Was there any
procedure done to your heart?
6. Could you tell me what happened that brought you to the hospital?
SOCRATES
P3MAFTOSA
7. I understand that you had come to the ER 5 days ago due to the same complain and was discharged home after the6y took
your blood and did an ECG on you, is that correct?
Unfortunately, I am sorry to say that during that time, the medical team has misinterprated the ECG findings. Our consult-
ant has reviewed the ECG again and unfortunately during that time you had a heart attack. The blood result that they did also
showed an increased cardiac enzyme which confirms the diagnosis.
8. I am sorry that this has happened to you. Could I ask you some questions just to know if you had any complication due to
this.
 Did you had any SOB at night?
 Any swelling in the legs?
 Do you feel extra tired?
 Do you feel dizzy?
 Any racing of the heart?

Nik Athirah
  Was there any persistent chest pain?
9. What we will do now is that we will repeat the ECG again, do an ECHO to check for any heart failure. CABG if needed.
10. Ensure it will not happen again
11. Offer PALS, talk to senior

Patient refusing treatment (DNR)

Scenario: You are FY2 in Medicine. Joseph Brown is a 75 y/o male admitted for pneumonia. He had a CABG done 15 years ago
after suffering from severe MI. 3 years ago he suffered heart failure for which he is taking medications. He is currently being
treated with antibiotic. He does not want to take his medications anymore. Task: Explore why, discuss consequences of not taking
medications.

Patient info: On Statin. Feel drowsy when take meds.

Steps:
1. Paraphrase
2. Ask concern
3. Identify which medications he refuses to take - the regular meds or the abx
4. What medical conditions does he have and what medications he is on.
5. “Do you understand what will happen if you dont take the medications?” (Assess capacity)
6. Explore the reasons why he refuses treatment
7. Promote best interest
“There are several things we can do to improve how you feel.
 We can stop the statin and change it to a different medication (Simvastatin to Lovastatin) as one of the side effect
is drowsiness
 However, you may still feel drowsy as it is one of the symptoms you experience due to your heart condition”
8. Explain that it is against medical advise to stop taking the medications. However, because of patient autonomy, you will
respect his decision. Need to sign some forms to say that it is against medical advise to stop taking the meds.
9. Ask about in the event of collapse, if he would like to be resuscitated. DNAR.
10. I will relay this information to my senior, and I will arrange an appointment for you to meet the senior so that he/she can
authoriz the forms.
11. Have you discussed this with your family members?
12. Assess mood and suicidal risk

Son wants mother to be sent to hospice

Nik Athirah