Notes by Dr Faiza Ahmad :

(Stations i have shared so far)

🌟Primary enuresis :
Intro
Ask pt’s main complaint; must ask child’s age (the management is child’s age dependent; they
on purpose will not add child’s age in the task just to check if we ask the age or not; vvvvv imp
ques)

(Not dry at nights - main complaint)

Explore it- since when, daily or off and on, any dry nights before or in between, did anything
significant happen before the onset, bathroom routine of child before going to bed.
any fever, excessive crying, complaint of burning while passing urine (if child is able to speak),
cloudy/smelly urine complaing ever, any lethargy, loss of appetite, weight loss, abnormal
swellings in tummy, day time wetting.

BIRD history: if just a young baby, you can ask about birth details, mode, for any reason mother
or baby was kept in special baby unit, immunizations history, personal health record book if
child is less 3 or less, developmental history
(I will provide paeds pattern at some point for detail)

Complete DIET history and feeding history - you can remember this using the D of BIRD.
Explore about the amount of fluids the child takes and how many hours before going to bed
does the child take fluids.

Pmh- has the child been diagnosed with any medical condition or bladder or kidney issues.
MAFTOSA - medications history, allergy history, family history - are you the main carer of the
child, who else lives with the child, how is the relationship and environment at home, if child is
going to school- everything okay at school? Any issues going on at school? (Must rule out NAI)
(No travel, occupation history in this; I have merged social history in family history)
Anything else?

Examination- ask if child is here; if not ask her to bring the child so that you can examine him in
general(vitals, tummy)

Diagnosis -
Now the exam scenario is primary enuresis with no day time symptoms (dry during day, no
fever, only wet at nights)
This is when child has never been dry before.
In the exam, the child is 4 years old.
Explain to the mother that many children at this age take time to be dry at nights and they
usually grow out of it. We can devise a plan to help your child with this.

Plan :

• senior advice
• Fluids intake stop 2 hours before going to bed; can feed normally throughout the day; no need
of restricting fluid; just don’t give fluids 2 hours before going to bed.
• If the child wakes up at night, encourage them to go to toilet.
• Make a habit of asking your child to go to toilet before going to bed.

We will be following your child up and if these measures did not help, or your child developed
day time wetting, or your child did not outgrow of this after 5 years of age, then we will further
test your child.

Do you want to know what further measures will be taken?

• referral to enuresis clinic/ specialist

• Urine test
• Alarm clock for encouraging the child to visit the loo
• Positive reward to child for waking at night and going to the loo and making their bed

Safety netting :

Come back to us with your child if he develops fever, lethargy, tummy swelling, day time
symptoms.

Note: if child is above 5 years, then you have to make referral, offer general advice same as
above and also include alarm clock and positive reward system. If child is of any age and has
day time symptoms as well, make referral to enuresis clinic. If child was dry before and now
started wetting the bed, make referral.

Must do safety netting.

You can talke about leaflets.

🌟Surgery pattern :
Today i happened to write down a general approach to surgery cases.
Check this out :
Let me know if you like it. Your respinse really motivates me to help more!

Whenever you have a planned surgery case

You have to ask one important question which is how the patient has been since the last time
we saw the patient?

How has his health changed in this duration? Eg if there is pt with planned ankle pin removal,
then we will make sure pt’s condition has not worsened since the last time we saw him.
Another important question is to make sure there is a carer in the first 24 hours after the surgery
whether it is pin removal, colonoscopy, endoscopy etc we need to ask this and make sure there
is a carer.

Intro
Ask how pt is
Ask symptoms related to the pt condition
Rule out any complications related to the condition the patient has for example if patient has
hernia, ask them about pain, vomiting, constipation etc

Rule out red flags - in every case do FLAWS (fever, lethargy, loss of appetite, loss of weight,
abnormal swellings and night sweats)

Ask pt’s concerns regarding the procedure

PMH- past medical history (rule out bleeding disorders) and

PSH- past surgical (previous surgeries, previous surgical complications, previous anaesthesia
complications, bleeding disorders, kidney problems, liver problems, neck problems, loose
dentures, hypertension and diabetes these questions are MUST- invest yours time in a good
PMH)

DESA (diet, exercise, smoking and alcohol)

MAFTOSA (medications esp blood thinners, allergies v imp) do a good maftosa . (Medications,
allergies, family history, travel, occupation, social history and anything else?)

Ask about pt’s knowledge about the procedure

Ask the pt if they want you to explain the procedure, explain why this procedure is needed
Explore concerns/ questions in detail

Then examination (vitals and related examination verbalise)

In management make sure that you do the initial tests (blood, urine, imaging) and also tell the pt
about pre-requisites regarding the procedure eg bowel preparation in colonscopy, gluten diet in
endoscopy for celiac disease confirmation , diabetic pt preparation eg in ankle pin removal case
where patient is diabetic etc stuff like that

NPO for how long if under general anaesthesia

Safety netting

⚡⚡ please let me know if you find this helpful! Again it motivates me to write more!

🌟Long post, brace yourselves:

PMR :

1. History taking case

Presenting complaint : pain in shoulder

• can you tell me more about it ? (Open question)

(Note : sometimes the simulator says like what doctor? Do not be taken back by this. Instead
confidently ask what you want to know; sometimes the simulator will tell you all about the pain
so please listen carefully)
• If simulator is describing the pain- please do some sympathy with them because they are in
pain. It must be very hard for you/ it must be very difficult for you/ i am sorry to hear that. (Note:
it does not matter if these words seem oft repeated to you, all that matters is the way you say
them. If you say them naturally and with expressions, it really works)
• Are you comfortable to talk to me?/ Do you want painkillers? (Mostly simulators say yes we
are comfortable, and say no to painkillers in the start- when they say no, you can reply -
throughout this consultation, if you feel that the pain is becoming unbearable, let me know, then
i will give you something for the pain)
• Is the pain in one shoulder(left or right) or both ? ( the importance of this question is to rule out
NAI; remember PMR is bilateral symmetrical cape like pain in both shoulders; in case of NAI,
the pain will be unilateral)
• Cover SOCRATES - this is how i recommend to cover the details of the pain :
• Since when have you had this pain?
• Was it sudden in onset or something that developed slowly over time?
• Is it getting worse?
• How does the pain feel like? Does it feel dull, sharp, stabbing?
• Does the pain go anywhere like from shoulder to neck and head, shoulder to back, shoulder
to arms, chest or tummy?
 • Is the pain continuous or off and on? (If off and on- how often do you have it? For how long
each episode of pain lasts?)
• Does anything make your pain worse like movement or body position?
• Does anything make your pain better like any body position or medications?
• (If they say medicines help/they have tried medicines but they don’t help much- explore about
the medicine- which medicine? Dose? When was the last dose taken? How many?)
• Can you grade the severity of the pain on a scale of 1-10 with 10 being the worse pain? (Do
sympathy again at this step on hearing the grade of the pain)
• Do you have any other symptom alongwith the pain? (Open question)

PMR will present with bilateral shoulder pain/stiffness, dull ache and gradually progressive
(sometimes can be sudden). The pain may be felt in a cape-like manner i.e shoulders, upper
arms, and hips.

Alongwith pain most pts have stiffness as well- morning stiffness lasting upto 45 minutes .

What dds to rule out?

• When suspecting PMR always ask GCA questions because these conditions are highly
associated.
• GCA : Headache especially on the sides, pain while combing, pain in jaw while chewing,
vision problems- when asking these symptoms tell the patient these are WARNING signs and
please look out for them. (This is safety netting and you can sprinkle it a bit in the history while
ruling out GCA- i recommend this)
• Trauma - ask if they hurt themselves, did they recently fell etc
• Rule out NAI while taking family history- i will tell later on about this.
• Rheumatoid arthritis - pain and stiffness in hands, other joints?
• Red flags - FLAWS ( in PMR the pt might have positive red flags like loss of appetite,
lethargy)
• Ruling out 2-3 imp differentials is more than enough.
• Coping question- how are you coping with this? Ask about day to day activities? Carer? How
this pain has affected their mood? (PMR can cause depression)
• Previous similar pain?
• Past medical history (it is not enough to ask do you have any long term illness? Always
specify which illness you want to ask even if pt says no to your open question- like High blood
pressure? High sugar levels, lung or kidney problems?)
If you want to sound a bit different while asking past medical history, you can rephrase this
question as follows (recommended if you are aiming for 10 and above) :

Have you been following up with your GP for general check ups? (If yes- appreciate)
Have they ever told you that you have any issues with your blood pressure, blood sugar, lungs
or kidneys?
 • DESAR - diet, exercise, smoking, alcohol and drugs - select depending upon situation which
questions from these are needed in each case - in PMR, ask DESA and keep it quick.
• Tip : if pt says yes they smoke / drink alcohol- don’t turn it into a smoking cessation or alcohol
cessation station until or unless it is part of ur task/ management. Instead, just say, have you
ever considered stopping- whenever you are ready to stop, please let us know we have very
good support system.
• MAFTOSA - medicines, allergies, family history - who do they live with? How is their
relationship with them? How is the environment at home (This is how you rule out NAI) does any
blood relatives have similar symptoms and chronic conditions like high blood pressure, high
sugar levels; travel (not needed in this case); occupation (does it involve lifting a lot of things?
How are they coping with work?)
• Anything else that they would like to add?

This is the complete history of PMR. Follow this pattern with confidence and be natural in your
approach.

Thankyou for all the information. Now i need to examine you is it ok to check your pulse, blood
pressure, oxygen levels and temperature ; and also to examine you head to toe and also your
shoulders, neck and arms? I will ensure your privacy and have a chaperone with me and i will
be as gentle as possible.

(Tip: if examiner gives any positive finding, say thankyou and tell the patient if there is any
positive finding- keep them informed)

Diagnosis:

(I do not do “I” of ICE. I leave it up to you to do it or not. It really doesn’t matter as long as your
are doing the “C” of ICE that is the concerns)

From the information that you have given me and from my assessment, it seems that you have
a condition called Polymyalgia rheumatica, which is a condition that causes pain, stiffness and
inflammation in the muscles around the shoulders, neck and hips.

do you have any questions so far?

Management :

• Treatment at home with regular follow-ups

• Inform seniors
• Investigations : full blood count, ESR, CRP, blood minerals esp calcium levels, tests to see
how your liver and kidneys are functioning (this is a good way to Talk about lfts and rfts), tfts,
rheumatoid factor and anti-ccp. (Rule out thyroid issues as these can cause muscle pain, rule
out RA).
(In PMR, esr and crp are elevated)
Imaging may be ordered (xrays)
• Symptomatic treatment : painkillers (pcm, nsaids (rule out peptic ulcer disease)
• Steroids after senior advice - for how long- depends upon response and usually given for 2
months. Talk about checking in your book (bnf)
• Steroid card
• Safety netting (general)
• Leaflets
• Do you have any questions?
• Steroids side effects - i will cover these in detail in the next station that we will discuss. You
can mention side effects of steroids if pt asks and you have time left.
• Do not stop taking steroids abruptly
• Avoid close contact with people with chicken pox, shingles and measles - if contact- come
back to us.

Note :

Specialist (rheumatologist) referral is only made when symptoms are not controlled with the
recommended dose of steroids.

Notes By Dr Faiza ✨✨✨

Key2plab2

🌟Pmr new question in which pt is diagnosed with PMR and taking steroids, bisphosphonates
and omeprazole.

• take history recap again (trust me in diagnosed cases you have to take history again - a short
one. But you have to - otherwise you will get no marks in data gathering)
• Ask about the pt’s symptoms when they first came to the gp clinic, what was given to them,
did they take those medications, how is the pain now? Pain anywhere else? Questions about
Side effects of medications; rule out GCA and do safety netting for GCA. Take lifestyle history,
MAFTOSA(for details refer to the other PMR case i posted above) and coping and carer
history.
• Examination (vitals, GPE and the painful area)
• Ask the patient if they know what their condition is/ if they want you to explain their condition
to them?
• Ask the pt’s concerns. In this case, the patients concerns are side effects of steroids.
• Ask if there is any particular side effect they are worried about. In this case, the patient is
worried about steroids causing weight gain and steroids being similar to those steroids that body
builders take. Ask if there is a particular reason of this concern? Explain to them that steroids do
cause weight gain unfortunately, but with healthy diet and healthy lifestyle that weight control
can be controlled and we will be making a proper diet plan for him. If needed, a dietician can
also be involved after senior advice.
• Explain to the patient that the steroids that body builders take are called anabolic steroids
which simply means that they strengthen their bodies. However, the steroids he is given are
used only for treatment purposes and the dosages are adjusted accordingly and these two are
completely different.
• Ask the patient if he wants to know other side effects. With each side effect that you tell,
explain the management and also say you will check this all in your book while holding or
looking at BNF which will be on the table.
•
You may feel depressed and suicidal, anxious or confused. Some people also have
hallucinations, (seeing or hearing things that are not there).
Contact a GP as soon as possible if you experience changes to your mental state.
Other side effects of prednisolone include:

• high blood pressure - healthy diet can help control blood pressure and we will be following you
up and checking it.
• High sugar levels- healthy lifestyle and follow ups
• mood changes, such as becoming aggressive or irritable with people- this gets better with
time and as dosage is adjusted
• weakening of the bones (osteoporosis)- we are giving you a medication called
bisphosphonate to strengthen your bones
• stomach ulcers - we are giving you a medication called omeprazole which is a stomach
protectant
• increased risk of infection, particularly with the varicella-zoster virus, which is the virus that
causes chickenpox and shingles
• Get immediate medical advice if you think you've been exposed to the varicella-zoster virus or
if a member of your household develops chickenpox or shingles.
• The risk of these side effects should improve as your dose of prednisolone is reduced.

Now ask pt if they have any concerns/ questions? (Mostly pt will ask for how long will he have to
take these steroids- tell it depends upon his response to treatment and usually it is given for 2
years)

Now it is very important to say the following things if you want a high score in this station.

Ensure the person is provided with a blue steroid card, and , advise them:
• Not to stop taking prednisolone abruptly and to seek medical advice if they are experiencing
problems taking it.
• Provide written information on PMR and regional patient support groups.
• Follow up planned - after 3 weeks and then will have continued follow up plans.
Advise the person to arrange a review at other times:
• Urgently, if they develop symptoms of GCA.
• Routinely, if they develop symptoms of relapsing PMR, including proximal pain, fatigue, and
morning stiffness.

• Explain that specialists will be involved if he will not respond to the advised treatment.

🌟Delayed speech:
Case- delayed speech at 12 months

(By 12 months child should say atleast mama, baba)

• intro
• Parent’s concern
• Does your child make sound on crying?
• Does your child say any word at all?
• Is your child able to open their mouth?
• Any problem with the tongue?
• Is your child stuttering?
• Does your child recognize you?
• Does your child respond to you when you come in room?
• Did your child have any ear infection, which was left untreated?
• Any history of ear discharge, ear trauma?
• Any history if drooling from mouth?
• Fever, lethargy
• Now do BIRDD
• B: Birth history : Ask age of gestation when your child was born? Was your child kept in
special baby unit for any reason? Any chance of injury during birth?
• I: Immunization history : Has your both received jabs ?
• R: Are you satisfied with their personal health record book? (Red book)
• D: Other developmental history : response to any sound at all, smile, attachment to you,
supporting head, sitting, picking things? Etc
• D: Diet history : can you describe his diet a bit?
• Now do PMH and relevant parts of MAFTOSA : Past medical history : were any of them
diagnosed with any medical condition after birth?
• (MAFTOSA) Medications, allergies, family history of similar problems in childhood, How many
family members at home and main carers
• Examination : ask if child is there with her; if not, ask her to bring the child so that you can
assess the child’s vitals and general assessment.
• Offer hearing tests and evaluation of mouth and tongue
• Senior advice
• Specialist referral : ENT specialist, speech pathologist
• General advice :
Talk to your child everyday
Saturate their environment with speech
Watch educational videos together
Look at books with pictures together
Ask your child questions
Look at them in eyes and mouth your words to them
General safety netting

🌟Twin developmental milestones(walking delay)

• Mother says one child runs around And other does not.
• What happens when he tries to stand/ walk? Does he fall or his legs get floppy?
• When changing diaper, did you notice any extra folds of skin in the hip area?
• Does his hip look a little bit unsteady/unbalanced? Does he tilt to one side? Does his leg look
curved in or out?
• When your child tries to stand does he support himself on his arms?
• Can you descrive his routine to me? Do you carry him around a lot? Does he soend time in
walker? Does he have enough opportunity/ soace in the house?
• Is there any difference in the way you are doing things with both twins? Are you giving more
time, attention or holding him more?
Now do BIRDD

• B: Birth history : Ask age of gestation when twins were born? Who was born first? Was the
child with delayed walking kept in special baby unit for any reason? Any chance of injury during
birth? Everything okay with the other child?
• I: Immunization history : Have they both received jabs especially polio vaccine?
• R: Are you satisfied with their personal health record book? (Red book)
• D: Other developmental history : response to sound, smile, attachment to you, making
sounds, picking things? Etc
• D: Diet history : can you describe his diet a bit? What does he eat? Enough exposure to sun?
(Tell about inportance of vitamin D and calcium fortified milk and cereals)
• Now do PMH and relevant parts of MAFTOSA : Past medical history : were any of them
diagnosed with any medical condition after birth?
• (MAFTOSA) Medications, allergies, family history of similar problems in childhood, family
history of joint problems abd bone fragility problems? How many family members at home and
main carers of the twins?
• Examination : ask if child is there with her; if not, ask her to bring the child so that you can
assess the child’s vitals and legs.
• Now it’s time for counselling
You should know what is normally expected so that you can counsel confidently.
Children are expected to walk well by 14-15 months. Some children take time and can start
walking well by 16-17 months, so we have to wait till that time before any further treatment.

Now in the next message I will be summarizing management with IPS that I use. Feel free to
talk the way you like, this is only the IPS that I use.

Management (delayed walking) :

I can see that you are worried. It is true that learning to walk is a big achievement and an
importan step in a child’s development. As parents, it can be very much concerning that their
child is not taking steps. But babies develop skills at different pace. Some develop skills very
quickly, but some take time to do so. This is something normal for babies to walk at different
rates and this is usually nothing to worry about. Give your child some time. You can encourage
them to walk by appreciating them, holding their both hands and kneeling and standing with
them. Avoid putting your child in baby walkers or holding them too much. Encourage them to
stand with the support of sofas and chairs. You can put their toys away from them, so they can
make efforts to reach them. Avoid keeping shoes on all the time. Keep them barefoot, so that
they get a chance to grow and balance themselves.

I will discuss this all with my senior for further advice.

Talk about sending routine blood tests and CPK levels if child is supporting themselves with
their hands while standing.

If he does not walk by 18 months, specialist will be involved.(paediatricians and

physiotherapists)

What you can do is give your child some time and in the meanwhile, you can write down all your
concerns in a diary and these questions will be answered in your next follow-up appointment in
GP clinic.

Safety netting (generally unwell, not walking at all by 18 months, going all floppy)

🌟I Have seen many people score consistently low in management despite doing everything
related to the case. Many people tell that they told the patient everything and still got 1 or even a
0 in management. So, I am writing this to address this issue.

Management is a complex thing and your IPS is directly related to it. The stations in which you
poorly perform in management, your IPS go down too, unfortunately.
You can begin improving your management by following the 7 steps of management in your
practice. Many of you already know those 7 steps of management and some of you don’t. For
the purpose of clarity, let me summarize those for you and explain them a little bit as well from
my understanding. I was always told about these steps but no one ever explained these to me
at one place, so for you guys I am going to put my months of hardwork in one place! This is how
i got 3 and 4 in most of my management !

1. Telling the patient whether you are going to ADMIT them, OBSERVE them or treat them from
HOME.

Note: It is not only important to inform the patient this, but it is also necessary to get their
consent at this point. Just adding one sentence “is it okay with you?” Makes a huge decision.
Afterall, you cannot admit someone or discharge someone without asking them if it is what they
want as well? Remember you are not the most important person in the room, the patient is. So,
involve them.

Moreover, if you are not sure whether this patient should be discharged or admitted, go for the
middle ground please. Your middle ground is OBSERVE! for example, patient had diarrhea
episodes and now you are not sure whether to admit them or discharge? OBSERVE! This is
what a SAFE doctor will do.

2. Informing SENIORS

Please, please involving senior early on does not make you sound weak! You are a junior
doctor, which means you need to work under the umbrella of your seniors. The management
they are expecting from us is indeed within the junior doctor’s calibre, but these things still need
to be cross-checked by a senior. In every single station, involve your seniors. They should
check your decisions no matter what.

3. Investigations

Here you talk about the investigations that can be done by a junior doctor

What are they?

• bloods
• urine
• stool
• any swab

Again while talking about investigations, please take patient’s consent. Ask them if it is okay to
do them. Imagine you are talking about sending urine test of a patient and looking for all the
things in the world in the patient’s urine and the patient is thinking to himeself I don’t want to pee
in a cup, no way. Don’t you think this will cause you trouble when you walk out of the cubicle
thinking you have done everything and the patient looks at the examiner and says this doctor
was rude to me, didn’t even take consent etc?

4. Symptomatic treatment

It is essential to keep this in mind that the most important job of a junior doctor is to do
symptomatic treatment. Imagine there is a patient with acute abdominal pain and you diagnose
him with intestinal obstruction and you keep talking about surgery and relieveing the obstruction
with tubes etc. But if you did not give the patient painkiller, then do not expect to get high score
in management.

Again ask patient if it is fine with them!

5. Specific management

This is the time when you talk about specific medicines, specific investigations which are carried
by speciliasts, specialist referral.

While making referrals always take consent and ask patient if they have any question. They
probably would want to know at this step how long will it take, which specialist and what will they
do? This is a natural reaction when you are being referred.

6. Safety netting

Most important step. Never ever miss it. You can sprinkle your safety netting even in your
history while asking about red flags. Simply ask the patient to look out for the red flags when
you ask about red flags or complications in the history. Do general safety netting in the end (eg
if you feel very unwell suddenly, dial 999).

7. Follow-ups and leaflets

Even if you don’t get time to talk about leaflets it is absolutely fine. If you have time in the end,
you can talk about these in case of pts you are treating from home.

In the end, ask the patient if they have any questions once again!

This might seen a lot, but start practising this way and you will feel the difference in your
management skills. Keep this somewhere in your notes or pinned here! This is going to help!

By Dr Faiza! ✨✨✨
Repost for new members!!!

🌟General overview of unlabelled blood sample case which came in my exam ... i scored 11
with this approach.

Phone conversation
I introduced myself (dr..., talking from gmc hospital)
I confirmed pt name
Pt age
Pt’s address
Pt’s telephone number in case phone line disconnects
(These are must do steps in case of telephone conversation)

How is the pt doing

A bit of recap of yesterday’s events that the patient came in and I took blood sample (at this
point the patient said yes doctor and i was expecting a call from you)
I Told the patient that I have something to discuss with him. Then, said i am really sorry to tell
him this that when I took your blood sample and sent it to the lab we usually label it but in your
case I made a mistake and unfortunately i forgot to label it ... i apologized once again
The patient did not get angry my tone of voice was very sweet and apologetic.
And then I offered solution. (I said give me a chance to fix things for you)
First i asked him if he lives near the hospital... when is he coming near this area next time... he
refused to come bfre his surgery so i talked abt offering phlebotomist( a person who takes blood
sample) to his house for taking blood
He agreed and told me i am v kind.
I was v apologetic throuhout and reflected his anger and emotions and inconvenience etc
He asked how can i make sure this doesnt happen again... i talked about following his sample
this time, making sure it is labelled, and documenting this, diacusing this with seniors and taking
necessary actions to improve our services ...
then i did maftosa in the end, asked abt his carer as it was knee operation... and did safety
netting. Finished it in 6 min... The examiner was v happy in the end gave me a big smile.

🌟Approach of lost renal biopsy by someone who scored 11 in it:

(I dont remember his name)

I introduced myself to the guy and I said I know that you're here for your test result. He said yes
doctor please tell me about the results. I told him I'm here to talk to you about your test result
but would it be okay if we have a quick discussion about your general health first? He agreed
So I asked him why did you have this procedure done in the first place?
How did he find the procedure?
How are you doing now?
Then
Medical condition
Medocation
Allergy family hx
Occupation
Smoking
Alcohol.
Then I said I will also examine his vitals to make sure he is fine.

Then I told him I wish I had better news for you today but your sample is missing.

He got very angry and asked what do you mean? I told him that we called the lab today and ...

He said how is that even possible and he was yelling all the time I was answering with I'm sorry
I can imagine what you are feeling right now. Then he said who is responsible for that? I told
him when we take a sample from someone there's a chain of action till results come back. We
take the sample, label it, send it to lab, they process it and send the results back. The mistake
could happen at any point of this chain and we are looking at that right now. Such mistakes are
taken seriously by the hospital. He was shouting and kept saying you are careless and is that
frequent? I told him That such mistakes are not common
I tild him I see you are frustrated and disappointed.I know it was a painful experience but I'm
afraid to tell yoy that we need to take another sample.
He saud this is impossible.
Is it my mistake? I told him no it's a mistake from our side.
He told me you will lose it again you are careless. I said I really understand why you are think
that way but we will take extra care of your sample this time. If you give us another chance we
will give you the first possible appointment and I will supervise your sample myself at every step
of this chain and I can update you at every step that yoyr sample is sent to the lab and that is
now processed and so on. I also told him that it's very important step of his treatment and his
health is a priority. He told me even If I go through that again it will be in a different place. I
appologized and validated his worries and asked him to give us another chance he said I will
complaint about this I told him it's your right. He was yelling and the bell rang on him speaking.

🌟For depression case, always rule out suicide risk, domestic violence and work place bullying.
Always ask if something significant happened in their life recently.
Always rule out one imp dd of hypothyroidism, rule out any medications use and chronic
medical illness.
Evaluate their support system (family, friends)
Do FAMISH (friends, family, finances, addictions - alcohol, smoking, drugs, mood, medications,
medical illness, insight, suicide risk, homicide risk, hallucinations)
How you can start the station is by verbalising that the patient seems upset, is everything
alright- because the pt will look upset from the start looking down and uneasy.

Tell the pt thar you and your team are here for her, we will support her and do everything in our
power to help her, whenever ready she can share everything with us.

Tell her that you are extremely concerned about her.

If still not opening, offer confidentiality.

(Yes. Confidentiality is never the first step- it might be shocking for people who have taken
academies. They never open up to you if u go in and offer confidentiality straight away. Be their
friend first)

Then in the history you can explore about mood, sleep, appetite, weight changes,
hypothyroidism symptoms, activities they do all day, significant life changes, FAMISH, outlook
for future...

Then verbalise general examination (vitals) and explain what is going on. If you feel pt has no
insight (like she says someone else asked her to come here - cue that she herself doesnt feel it
was needed- tell her your mood is low and we can do a lot of things to help her; never say you
are depressed bluntly... it comes back to you ... pt can say NO and it is then a straight zero)
And then offer solutions.

No referral to hospital for admission if no suicide risk (mostly case will be in gp clinic)
Informing senior
Sending baselines investigations and tfts
For mood, some activities like walking, any hobbies to keep them busy, talking to friends, family,
maybe taking some time off work for themselves etc like some general advice. Offer solution for
the cause of depression. In my exam, it was because her daughter started going to school. So,
you can offer her to go visit her daughter in school and see how well she is doing it will help you
feel better etc
Then do specific management which is referral to psychiatrist. Ask her if it is ok.... and if she
wants to know what psychiatrist will do.... tell about talking therapy. If needed, some
medications will be given ny specialists.

(My pt asked me what is talking therapy and how long referral will take- whenever someone
asks how long just say as soon as possible, be diplomatic)

Do safety netting- if at home she feels like everything is quite overwhelming and she can’t
handle things, we are just a call away.
Follow-ups (we can liase our management with the psychiatry department by following you up)

Leaflets for self-help

🌟Infective endocarditis case:

Pt will be ready to go; pt will say i dont want to stay and i want to self discharge myself; pt will
say i am feeling much better or the pt will say the people here are rude and i want to leave.

Dont fight with the pt or the pt will not listen to you further down the line. Give the pt something
to hold on to. In this case, tell the pt politely that you may be discharged, but before we let you
go it is important for me to ask some questions for your safety.

Then do data gathering. You will be asking the pt questions like why does the pt want to leave;
what had happened to the pt, does the pt know her diagnosis; does the pt know what treatment
is being given to her and the further treatment plans? How is the pt currently feeling- any chest
pain, fever, cough, breathlessness, swelling. Rule out red flags.
Take recap of pmh, lifestyle (DESAR - diet, exercise, smoking, alcohol and drugs), and
MAFTOSA. If the pt says why are you asking these questions, just say as this is the first time
you are seeing her, you just want to be thorough for her best management.

Then, you talk about examining her heart and lungs and vitals in order to make sure everything
is ok with her.

Then, you discuss things with her.

First, ask her who is coming here to pick her. Then, ask if she wants them to be here with you
while you discuss things (rapport). Tell her diagnosis to her in simple words- infection of the
lining of her heart. Tell her unfortunately it is quite serious and let her know that it requires a
long treatment as heart is quite sensitive and she is only halfway through the treatment and
leaving at this point can lead to very serious consequences. Let her know that treatment at
hospital is required because first antibiotic medications through her veins need to be given,
secondly we need to monitor her response to the treatment and check her blood like FBC, how
liver and kidney are functioning, mineral levels, imaging of the heart regularly, which is not
possible at home. (Note how we covered the investigations smoothly here)

Now address the issue of rude nurses (if the pt says the nurses are rude that’s why she doesn’t
want to stay) - in the data gathering when pt mentions this, ask her to tell you more about this.
For its management, you will tell her that you are sorry for her experience and you will look into
this matter in detail and also let your seniors know and you will make sure nothing like this ever
happens again. Be sensitive here, but do not throw you colleague under the bus and also do
not defend your colleagues. Learn to be diplomatic.

Then, there is another issue one is of smoking . The pt wants to smoke and keeps asking you if
she can have one smoke please. Guys it is very unprofessional to say yes to this request. She
will be testing you again and again if you say yes just to make her happy, but you will lose the
station if you say yes to this request. Let her know that smoking is very injurious to her health in
particular because her heart is quite weak at the moment and is in healing process and smoking
will delay the healing and will also prolong her stay in the hospital, which she does not want. Let
her know that you cannot force her to do anything she doesnt want to or can’t force her to quit
something she does not want to, but this is in her own best interests and safety that she does
not smoke. Keep saying you do not recommend smoking for her whether in the premises or
outside the premises of the hospital. Just keep telling her smoking is harmful for her, even if she
begs for it. But make sure you are not forcing her for anything, make sure you make it sound
like its her decision but you do not recommend this at all. This is a trick played by the simulators
in this station. Don’t fall for it. Be polite and explain to her why it is injurious for her.

Then, there is an issue of drugs. She is facing some withdrawal side effects due to not having
heroine or something. First, ask what side effects. Then, do some sympathy and empathy.

After that, talk about checking in her drug chart if she is receiving medications for that such as
methadone. Sometimes she says it doesnt work she is getting that medication. Then, let her
know that you will talk to your seniors about this and they might increase the dose of that
medication. Also, give symptomatic treatment here like if she is nauseous, talk about giving her
antiemetics.

In the end, if she still says she wants to go. Don’t fight with her or feel that you are going to fail.
Some stations are designed this way to test you . Just say you will talk to your seniors, maybe
they will be able to convince you. And if she still decided to leave, then the senior will let her be
discharged her against medical advice , and there is a form that she will need to sign. Guys all
discharges are done by seniors. Never discharge a pt by yourself always use the umbrella of
seniors. In the uk, fy2 do not discharge pts and i have heard people say that i am going to make
you sign the discharge against medical advice form. No, it’s not your call. You can only
give/explain it to the pt and the final sign is done by the senior.

Also, do safety netting. One tip i can give you here is that it is a long station. So, do safety
netting while doing data gathering. Like when you ask about symptoms and red flags, just tell
the pt if you feel any of this, let us know.

Hope it helps!

There will be a lot of different info regarding this station, but this is what I followed.
🌟Paeds general pattern:
Intro
Explore main complaint
Head to toe assessment :
• Fever, shying away from light, crying on neck movement
• Ear discharge, ear pulling
• Cough, flu like symptoms
• Tummy distension, swelling in tummy, drawing of legs towards tummy while crying, loose
stools, constipation, vomiting
• Swelling in groin, smelly diapers, more wet diapers than usual
• Red flags : lethargy, drowsiness, dry diapers, not feeding
• BIRDD: birth history- term, pre-term, mode of delivery, any birth complications, was the baby
kept in special baby unit after delivery.
• Immunizations
• Red book/ personal health record book
• Development history (smile, social interaction, standing, neck holding, speaking)
• Diet / feeding history
• PMH : child ever diagnosed with any medical condition
• MAFTOSA : medications, allergies, family history+social history( rule out NAI in all cases
here), smoking parents? Anything else
• Maternal history : maternal complications during pregnancy like high blood pressure, high
sugar levels etc
• Examination: is the child here with you? If not, ask them to bring him in for assessment of
vitals and general examination.

Learn This general history pattern for all paeds cases and modify it according to the given case.
This will make things easier.

🌟These are the steps for primary survery unconscious pt

1. Trauma team and universal precautions
2. Check response
3. Check airway
4. Attach monitors
5. Breathing - oxygen and chest and neck examination complete
6. Circulation- blood glucose and blood grouping and cross matching and baselines
Peripheries, capillary refill, external bleeding signs, pulses
7. Abdomen exam
8. Pelvis exam
9. Legs - look, feel and move.
10. Gcs, pupils

PS: do have a look on head for bruise and if there is a bruise on head order CT-scan. This is a
variation from pelvic fracture.

The steps are same for both conscious and unconscious pt. in the conscious one, you will take
history as well that’s the difference. You always start with ABCD approach.

🌟Teaching stations
Nowadays teaching stations are quite common in the exam. To teach something to someone
you need to know the topic inside out. When you feel confident about something, you are able
to convey the information confidently.

Apart from confidence and good knowledge of the subject, one important thing is involving the
student. You can give all the information in the world to the student, but if they are not involved,
then it is difficult to pass that station. So, your number one goal is not to tell everything you
know about a topic to the student. Your number one goal should be to make sure that the
student is involved. What I mean is, ask them after every information that you give them : are
you with me? Do you have any questions? Something to check their understanding.

Tip: before starting your topic, you can also tell the student generally if you have any questions
at any point or if something is not clear to you, feel free to ask questions.

Now let’s talj about the way to start your teaching station. Keep the introduction short and to the
point. Teaching stations are long and you don’t have time to chit chat. Tell your name, confirm
the student’s name, ask in which year of medical school/nursing school they are in, how is their
studies going, do they need help with anything, if they do i am here for you, thankyou for coming
for my class and now start your main teaching.

Gain knowledge- ask the student how much they know about this topic. Usually they pretend to
be clueless about it.
Ask them if there is anything particular they are hoping to learn today? (For example, if they
want to learn about ecg. Is there anything particular they want to learn? Sometimes the nurse
says she wants to learn rate and rhythm only). Also tell the student that, learning this topic is not
a one time thing but it is a long process, so after today’s lesson, you will give them some books,
online materials so that they can read more about this subject.
Now organise your lecture. There is no fixed way to organise it. Do what you find is easy, but
your lecture should have a structure. I use the basic structure for teaching i.e history,
examination and management.

First, tell the student how the patient will present eg if you are teaching respiratory examination,
tell the student that patients with respiratory conditions may present with cough... or if there is a
patient in the cubicle, take some history from the patient and tell the student these are the
questions we ask from patients when suspecting some issue with respiratory system. There are
4 marks for data gathering so do not miss it. Do this part in a sentence or two. You do not have
a lot of time.

I am only giving general outline at the moment. Not specifically talking about any topic. I will
cover some topics specifically later on.

Now talk about examination in detail. For example, speculum teaching station. Tell the student
about the protocols we follow while doing speculum examination- telling the pt procedure,
comfort, consent, pt’s position (v inp), chaperone(v imp) and privacy. Then open the speculum
(disposable one), throw the cover in clinical waste bin, explain to the student how to hold,
open and close the speculum, put lubricant jelly on it and then put it in the vagina of the
mannequin. If there is a pt in the station, you can explain the procedure, comfort, chaperone,
consent etc part to the patient directly and tell the student this is how we tell the patient about
these things. Before putting the speculum in, tell the patient and while inserting ask the patient if
they are comfortable. Keep asking the pt’s comfort . (Note: sometimes there is no patient in this
station. Only student and mannequin)

When the speculum is in, involve the student. Ask them do they see anything? At this point, tell
them about findings that are visible and findings which you expect like any redness, lesion,
discharge. Similarly, when teaching respiratory exam, talk about the findings that you expect like
any wheeze, stridor etc.

Tell the student what do you do if there are positive findings. For example, tell them if in case
you see discharge, send sample (pelvic exam). For example, you hear wheeze, stridor, then
there might be respiratory pathology, inform seniors and document this. 2-3 sentences like
these while teaching is how you cover your management in these stations.

🌟This is a general over-view of teaching stations.

Next i will talk about 2 of any teaching stations to clarify the concept. Please comment below
which 2 stations you want me to discuss in detail.
🌟ECG teaching station:
Intro (hello i am ....., (use your first name only) one of the junior doctors here, are you nurse .....?
In which year of nursing school are you? How is studies going? Do you need help with anything
in particular? (At this point she will say i need help with ecg)
Oh yes, ecg is quite important and i am glad that you have come here to discuss it with me. I will
try to explain it to you. But ecg is not a one day learning process, so in the end i will give you
names of some books and online links to help you learn more about ecg.
Is that ok?
Then, tell her that throughout the discussion if something is not clear, feel free to ask questions.

Now ask her : is there anything in particular you want to learn about ecg?
At this point she might say she wants to learn about rate and rhythm only. Or she may say only
the basics, or she may say i have no idea etc.

Now start with do you know what ecg is .... tell her basic definition of ecg... it is the electrical
activity of the heart that we can see using a machine. Draw p, qrs and t waves and tell her these
are the waves of ecg. Do you want to know how they are formed? If yes, then explain about
how they are formed (depolarization, repolarization etc)

Do you want to know about the electrical system of the heart? If yes, then briefly explain SA
node, av node etc.

Then move on to rate . Ask if she knows what is the normal rate of heart (60-100); tell her if it is
less than 60 or more than 100, then inform seniors . (This is how you will be covering
management as you go along).

Now ask her if she wants to learn how to calculate rate? Then, talk about regular vs irregular
ecg (paper method; marking distance between r waves on a paper and then checking if distance
is equal throughout) if it is regular than you calculate rate by counting the number of big boxes
between two r waves and dividing 300 by that number. Hold the ecg and calculate the rate with
her eg 300/4 = 75 bpm.
Are you with me ? (She will have some ecgs in her hand)

Then talk about if irregular rhythm? 6 sec ecg strip method. Count the number of r waves in a 6
sec ecg strip and multiply this number by 10.

(She sometimes ask How many big boxes in a 6 sec strip- these are 30)

Then talk about rhythm. Every p waves should be followed by qrs complex and every qrs
complex should be followed by t wave.
Then, look at one of the ecg(normal one) and see if rhythm is regular or not.

Then, quote one example of abnormal rhythm it can be any example like heart blocks.

Then, tell her what to do if she sees that rhythm is abnormal - inform seniors because it needs
to be addressed and sometimes medications or devices are needed to correct it. (Notice how
management is being covered as we go along)

Do you have any questions?

Then move on to talk about abnormalities of each wave systematically p wave like in atrial
fibrillation, atril flutter. St elevation MI and st depression, tall t waves. (This is just bonus
information; not the priority; cover these in simple terms only if you have time)

Do not make ecg complex guys. Many cardiologist fail this station bcz they over complicate it.

Note : I have collected this information from candidates who got this station in their exam and
scored 12.

🌟Unique way of taking family history:

• who do you live with?
• How is your relationship with them? (If good relationship, add something like that’s great, you
have got a lovely family)
• How is the environment at home?
• How is their health? (If healthy, add something like I am glad to know)
• Any issue with blood pressure, sugar levels, lungs, heart and kidneys in your blood relatives?
• Does any of your family members have the same symptoms as yours?

What have you done? You have merged your social history and family history. You will be
covering NAI and family history in all stations- and you will not sound robotic.

🌟I posted this on my facebook page. Reposting if here for new members.

I followed this approach and got 11 in BBN. Somebody can get 12 even if they are really
thorough with their history.

Here is a video about breaking bad news. Even though we will be adding much more to this
video and refine the approach further,
I have added this video just to ask you all one question. After watching the entire video, how
many of you really felt emotional? If you are not feeling the emotions, then you are not ready to
do the breaking bad news stations.

Feeling the sentiments of the other person is extremely important while delivering bad news. In
addition to feeling the emotions, it is also very important to be extremely calm and composed. If
the doctor is not calm whilst delivery bad news, how do you expect to calm down you patient.
Ask yourself this question, why would a doctor in this situation feel all anxious and challenged?
There should not be any nervousness and you should be really calm, composed and
understanding.

Give the patient/ relative time to comprehend what is going on. Do not worry about time. If you
give them time in the beginning, they will make things easier for you in the end. It will flow
easily.

Let me summarize the points I follow in breaking bad news stations in general.

• introduction - I have to write about this part separately because in stations like these the
patients can be very anxious and they might even be standing when they see you. What can
you do about this? You need to calm them down before anything else. Tell them you can see
they are really worried, let’s have a seat and talk. I am dr ——, one the junior doctors here. May
I just confirm you name?

Please, do not forget introduction in the attempt to make them sit or while trying to make them
relax. It is very, very common to forget about introduction in these stations. Also, please, do not
be taken aback if you see the patient/relative standing, act like it is expected. You need to be
ready for this.

• data gathering is so, so important to help things come less strong when you break the bad
news and also to bring rapport with the pateint/relative and also to build your case. What kind of
data gathering is needed in this case? Well, it should be a complete recap of what happened,
their knowledge about what is happening now. You have to cover entire pmh, lifestyle and
MAFTOSA as well.
Tip: while collecting data, if this is a case like accident of a child, you can say something like it
must be very difficult to go through all of this again and i am sorry for that, but it is very important
for me to ask these questions for your child’s safe and effective management.
Another tip is that if the patient or relative is in too much hurry to hear the news and pushing
you, then tell them that it is very important for you to ask these questions for the patient’s safe
and effective management or it is very important for me to ask these questions so that we can
be on the same page and only then i will be able to explain everything to you in the best
possible manner.

It’s all about how you play with the words.

• early on you can ask if someone is in the waiting area and if they want that person to be with
them while we discuss everything.

• before breaking the bad news you can say something like eg when you first came in Mr .....,
we did some tests because of your symptoms. One of the test was a CT-scan. The CT-scan is
seen by experts and unfortunately I do not have good news for you, the scan revealed that you
have a mass in your brain, which might be a tumor.

PAUSE. (Count 1,2,3,4 before continuing)

See their reaction. They will definitely give you reaction at this point. It can be anything shock,
disbelieve, anger, crying.... you need to give them a chance to react.

Ask them if they want to call anyone for support.

If they are crying, offer tissues if only you see a box infront of you and do not take the tissue out
for them. Just slide the box.

Offer them water only if there is a glass of water infront of you and again only slide it.

Tell them that it must be very hard for them and please take your time to absorb everything. I
will only continue when they are ready.

Then continue when they tell you it is okay to continue.

Ask them what questions they have at this point. Answer those questions.

Formulate a management plan with them. Keep asking them if it is okay to do those further tests
and referrals.

Offer them a good support system- friends, relatives, support groups and offer yourself as their
support.

Ask them if they want someone to talk to and discuss things further you and your team are here
for them.

If they are a cancer pt who have just been given this diagnosis and you will be referring them,
do a very good safety netting and offer them support.

Ask what they are going to do today after this meeting. If they are going to work, maybe talk
about taking some time off work. SUPPORT is so important in these cases and much, much
more important than the complex managements people are giving in these cases. Keep things
SIMPLE. Give a general management plan, talk about seniors, symptom management,
specialist referrals and specialist tests, specific management- just talk about it in general and
the complex procedures can be explained to them by the specialists- it is not your job to be a
surgeon, do good safety netting and give them support system. Make sure you have asked
them their concerns.

Breaking bad news if done correctly can give you a 11/12 easily! Please, be sensitive and make
sure you offer them a lot of support. Please, give them time to absorb the news. Treat them the
way you would wish yourself to be treated if, God forbid, you were to receive a bad news.

I hope it helps!

https://youtu.be/2DGcvMoiGbc

Faiza Niaz! 💫💫🌟

♦♦TRANSGENDER PT WITH PE
- First take past history of alarm symptoms (chest pain, SOB, calf or abdominal pain)
- Differentials should include: was there any previous flight, immobility due to fractures
- Medications: “male to female transgender treatment” you have to find out WHAT MEDICINE-
she may say high dose estrogen therapy with 200mg progesterone
- History: please check for HTN, hyperlipidemia, diabetes and clotting disorders, cancer, recent
surgery, + smoking
- please you don’t need : sexual history in this case, it is too sensitive, don’t ask her why she
wants to change her sexual orientation and don’t even dare tell her to change her mind!
- Investigations: ECG, CXR, venous dopplers, PT, INR
- Tell her there is a risk with using estrogen therapy (but it is important to rule out other causes);
stopping the hormone treatment is an option but we have her best interests at heart. We can
always explore other options. FIRST finding out if there is another cause of the PE and making
sure it is treated with anticoagulation therapy, we have to make sure that this therapy doesn’t
interact with her hormone therapy; we can also research into other hormonal therapies that are
low in estrogen (the transdermal route may be better than oral doses); there is also the option of
IVC- inferior venacava filters that will help manage any emboli to the lungs.
- IPS: this may be challenging, but we are here to help you continue this transition safely, PE’s
are life threatening and the hormone replacement is important to you. keep her on DVT
surveillance in the future and teach her safety netting for PE….Thanks Dr. Lianne♦♦

🌟For respiratory teaching, I followed this template shared by Dr Ali.

Basic template——- pleas learn concept don’t repeat same sentences—-it will help you in other
teaching cases aswell
Steps for chest exam teaching

First go in show card to examiner

Then go to student

Shake hands with the student

Politely introduce yourself that am your colleague ((not senior etc)))

Then ask about studies and challenges (((2 questions and listen to him as attentively as you are
very much interested in his studies)))))

After this rapport building phase

Tell

am been asked to teach you chest exam John....right

And say ok may I know what do you know about chest exam (((he will say no nothing I
know—even if you are the last doctor on your day and already 17 people have taught him but
still he doesn’t know anything...anyway—-

Then say

Chest examination is a vast topic

So what would you like me to teach about it specifically

Okay that’s fine so let’s start it

Then tell him the cases where we do chest exams for example pneumonia ,TB, asthma etc

Are you following me

John whenever these problem happen in people they do come in with symptoms like
Chest pain
Coughing
Shortness of breath

And John we take history before doing exam

Such as asking questions about coughing is it dry or bloody or producing sputum

Then we ask generally about fever loss of appetite and weight and lethargy to rule out red flags

Then previous health conditions like lung or heart problems

And we do ask about lifestyle habits of patient like smoking or alcohol etc

Then is he on regular medicine

Any allergies and what he is doing for living???

Any questions so far John...

Now after that we do chest exam

Which mainly cosist of four parts
Inspection
Palpating
Percussion
Auscultation
(((Teach these four along-with expected findings in chest as been discussed in simman class))))

Okay John now we need to explain what’s going on with the patients

And we will make a plan of management with the patient

Like admission depending upon his condition

Informing seniors and carrying out some investigations like checking bloods and doing chest x
Ray

Then for pain etc pain killer

And for pneumonia or Tb we do prescribe a course of antibiotics and inhalers in case of

asthma...

Any questions john (courtesy dr ali)

🌟Lesbian bullying at work place :

There will be a lady looking down and a bit depressed. Talk to her like you talk to a friend.
Inquire if everything is ok. Is there anything she would like to talk about. Let her know that you
are here for her. Tell her that you will do everything to make things right for her. Let her know
you are deeply concerned for her. When she doesnt open up, then you can offer her
confidentiality. Make sure you keep confidentiality as your 3rd/4th option- never offer
confidentiality as the first option. All the candidates are doing that and it does not work now for
many!

The history in this case is a bit different. It does not follow the general pattern of maftosa. She
will present with panic attacks or low mood. Take short history of these. Once she opens up
about bullying being the cause of this. Then take complete history of bullying first- she says
people at her work place are bullying her.
Ask- can you tell me more about it ?
Since when? What type of bullying is this- verbal, physical? Have they ever done damage to
your property? (If property or physical damage, then let her know that it is a police case as well)
is this bullying confined to the work place or they do it at home too like via messages, email,
social media? Why are they bullying her? Is it because of her beliefs, race, gender or sexual
orientation? (Here is how you will know that she is a lesbian). Is there anyone else at workplace
to who is being bullied as well? Have you ever confronted them? Have you talked to anyone
about this? Have you talked to your employer? Or human resource department?

Then after taking thorough history of bullying, you move towards your FAMISH. I hope that you
all know about famish. If not let me clarify it for you:

F: friends, family, finance and forensics( have you told your friends/ family about this? Are they
supportive?)
A: addictions (alcohol, smoking, drugs) and allergies (sometimes to cope with situations like
these, people resort to things like alcohol, drugs, is this the case with you?)
M: medications, medical conditions, mood (focus on mood in this one; it is your personal choice
if you want to grade mood or not; but do enquire about mood in general)
I : insight
S: suicide risk (good way to ask about this is : sometimes when people ago through similar
situations, they try to harm themselves- is this the case with you?)
H: Homicide risk (good way to ask about this in this case is : have you ever thought about
retaliating?)

No need to ask about hallucinations, thought problems, delusions in this case (if she is severely
depressed, then you can rule out these things)

Now your history is complete.

talk about generally examining her.

Then, address her panic attacks / low mood- senior advice and referral to psychiatrist for talking
therapy.
Then, address the main underlying cause of these symptoms -

• bullying is not acceptable at all, and nobody deserves to go through this.

• It is very brave of her to come here and talk about this.
• Me and my team will stand by her in this and we will help you as much as possible.
• Advice her to collect evidences of the bullying- if she is receiving emails or anything like this,
keep them safe.
• Talk to the colleagues bullying her and talk to your employer- talk to your employer in written
via email and keep that email safe.
• If no response from them, then contact HMRC department.
• If still no response, we can involce legal attorneys and LGBT communities.
• Joint complaint - if someone else at workplace is being bullied as well.
• This all will not only help her but also other people in similar situations.
• Safety netting: contact us if things seen overwhelming; or if she feels she can’t handle this.

By dr Faiza

I will upload depression case tonight. Before that, watch this osce video to have an idea how
depressed pts act in the exam.

https://youtu.be/4YhpWZCdiZc

🌟Depression case
It is more or less the same as the lesbian bullying case. Using the pattern i shared above, let’s
cover the depression case. Do watch the depression video that I have shared, the simulators
act like this in the real exam.

Firstly, the depressed patient will be looking down and not making eye contact. This is a non
verbal cue, please comment on that. Let her know that you can see that she is a bit upset; she
looks disheartened or sad, ask her if everything is ok. Use the same approach of making her
comfortable as i explained in the lesbian bullying case. Similar to that case, confidentiality
comes late. Believe me when i say this. Academies tell opposite, but this is something that I
have personally tried and discussed with people working in nhs.

The case I am particularly talking about is the case of the depressed lady whose daughter
recently started going to school and her husband thinks that she needs to see a doctor because
her mood has been low.
First, appreciate her husband. Do not ignore the fact that her husband is caring enough to
convince her to come to a doctor. Tell her she did the right thing by coming here. These are little
ips points.

Then ask her to tell more about this. Take history of low mood. Ask since when, is it getting
worse, ask about her sleep, appetite, any activities that she used to enjoy and now no longer
enjoys? Is she weeping? Anything significant happened before this change in her mood? If yes,
elaborate it.
Cover your FAMISH+ hallucinations/ delucions/ thought problems.
It is very important to cover support in this case (family, friends)
Ask about her work life as well.

Please rule out hypothyroidism as a differential and CFS as well. Just two questions - weather
preference, weight changed and aches and pain in body.
Rule out red flags (in famish focus on mood and suicide and homicide risk and cover FLAWS in
general)

Do not forget to rule out dds and red flags, please. When it is a clear cut depression case,
people tend to forget to rule out dds and get 1 in history. This is the reason.

Then verbalise general physical examination and vitals.

Diagnosis : please, do not tell her she is DEPRESSED. This is a dangerous thing to tell a
person who is depressed that you are depressed. It can back fire easily. She can say NO i am
not and just leave. This can cost you the entire station. Instead, let her know that from the
information she has given it does seem that her mood is low and we can do several things to
help her with her mood. Will she be willing to try some things?

Referal for Admission only if suicidal (ask is it ok?)

Senior advice
Blood tests - baselines and TFTs (ask is it ok?)
Referral to psychiatrist for talking therapy- ask her is is ok with her if we make this referral? (if
she asks when? Tell her as soon as possible)
She might ask what is talking therapy- tell her Talking therapy is a conversation with experts,
which can help you work out how to deal with negative thoughts and feelings and make positive
changes in your life.

This is very important to take consent while making referrals and sending investigations.

Then specific treatment (if you want 10 or more in this station, then it is very imp to do specific
treatment as well, the above treatment is a generic one) - in this case the pt is depressed
because her daughter has just started school, so give her suggestions like going to her
daughter’s school to see her there, talking to her teachers and looking at how she is doing will
help her.

Then in the end to be a safe doctor, do your safety netting- simple way to do it is : if you ever
feel that everything is very difficult to handle and you feel overwhelmed, then we are just a call
away and we will help you as much as we can.

Leaflet about talking therapy/ CBT can be given.

Breaking bad news general + both joshua cases using that approach :

Feeling the sentiments of the other person is extremely important while delivering bad news. In
addition to feeling the emotions, it is also very important to be extremely calm and composed. If
the doctor is not calm whilst delivery bad news, how do you expect to calm down you patient.
Ask yourself this question, why would a doctor in this situation feel all anxious and challenged?
There should not be any nervousness and you should be really calm, composed and
understanding.

Give the patient/ relative time to comprehend what is going on. Do not worry about time. If you
give them time in the beginning, they will make things easier for you in the end. It will flow
easily.

Let me summarize the points I follow in breaking bad news stations in general.

• introduction - I have to write about this part separately because in stations like these the
patients can be very anxious and they might even be standing when they see you. What can
you do about this? You need to calm them down before anything else. Tell them you can see
they are really worried, let’s have a seat and talk. I am dr ——, one the junior doctors here. May
I just confirm you name?

Please, do not forget introduction in the attempt to make them sit or while trying to make them
relax. It is very, very common to forget about introduction in these stations. Also, please, do not
be taken aback if you see the patient/relative standing, act like it is expected. You need to be
ready for this.

• data gathering is so, so important to help things come less strong when you break the bad
news and also to bring rapport with the pateint/relative and also to build your case. What kind of
data gathering is needed in this case? Well, it should be a complete recap of what happened,
their knowledge about what is happening now. You have to cover entire pmh, lifestyle and
MAFTOSA as well.
Tip: while collecting data, if this is a case like accident of a child, you can say something like it
must be very difficult to go through all of this again and i am sorry for that, but it is very important
for me to ask these questions for your child’s safe and effective management.
Another tip is that if the patient or relative is in too much hurry to hear the news and pushing
you, then tell them that it is very important for you to ask these questions for the patient’s safe
and effective management or it is very important for me to ask these questions so that we can
be on the same page and only then i will be able to explain everything to you in the best
possible manner.

It’s all about how you play with the words.

• early on you can ask if someone is in the waiting area and if they want that person to be with
them while we discuss everything.

• before breaking the bad news you can say something like eg when you first came in Mr .....,
we did some tests because of your symptoms. One of the test was a CT-scan. The CT-scan is
seen by experts and unfortunately I do not have good news for you, the scan revealed that you
have a mass in your brain, which might be a tumor.

PAUSE. (Count 1,2,3,4 before continuing)

See their reaction. They will definitely give you reaction at this point. It can be anything shock,
disbelieve, anger, crying.... you need to give them a chance to react.

Ask them if they want to call anyone for support.

If they are crying, offer tissues if only you see a box infront of you and do not take the tissue out
for them. Just slide the box. Offer them water only if there is a glass of water infront of you and
again only slide it.

Tell them that it must be very hard for them and please take your time to absorb everything. I
will only continue when they are ready.

Then continue when they tell you it is okay to continue.

Ask them what questions they have at this point. Answer those questions.

Formulate a management plan with them. Keep asking them if it is okay to do those further tests
and referrals.

Offer them a good support system- friends, relatives, support groups and offer yourself as their
support.
Ask them if they want someone to talk to and discuss things further you and your team are here
for them.

If they are a cancer pt who have just been given this diagnosis and you will be referring them,
do a very good safety netting and offer them support.

Ask what they are going to do today after this meeting. If they are going to work, maybe talk
about taking some time off work. SUPPORT is so important in these cases and much, much
more important than the complex managements people are giving in these cases. Keep things
SIMPLE. Give a general management plan, talk about seniors, symptom management,
specialist referrals and specialist tests, specific management- just talk about it in general and
the complex procedures can be explained to them by the specialists- it is not your job to be a
surgeon, do good safety netting and give them support system. Make sure you have asked
them their concerns.

Breaking bad news if done correctly can give you a 11/12 easily! Please, be sensitive and make
sure you offer them a lot of support. Please, give them time to absorb the news. Treat them the
way you would wish yourself to be treated if, God forbid, you were to receive a bad news.

• breaking bad news child accident cases - pelvic fracture and extradural hemorrhage

In these cases, it is important to know that data gathering is very important and also it is very
important not to talk about complex surgeries and procedures. Please, you are not a consultant
or a specialist. Be a fy2 doctor. Do your job. Nobody wants a lot of bookish knowledge. It
sounds so rehearsed.

Note : please, follow the general approach of feeling the emotions, sentiments given above. In
this section, I will talk about the general pattern of this case.

In history, you absolutely need to gain the following information.

• what happened before the incident

• What happened during the incident - trauma, fits, vomiting, loss of consciousness
• Who else was there, how are they? (Siblings will be present there)
• What happened after the incident? How did they bring him to hospital and how long it took
them to do so?
• When was the last meal of your child?
• Immunizations- especially tetanus and hepatitis vaccine
• Pmh
• Psh, past anaesthesia problems
• Medications
• Allergies
• Family history
• Anything else?

Thank the parents for giving all this information. Now explain the parents what you have done
for their child so far (stabilise/ resuscitation), tests and test results (give diagnosis here following
the pattern of breaking bad news- now here the two cases differentiate it can be extradural
hemorrhage which is simply bleeding between the outer covering of brain and skull or unstable
pelvic fracture which is break in the bones around the hip area)

Wait for their reaction. Take permission before continuing.

Now the management part. Talk about pain management, keeping him symptom free, seniors,
maintaining blood pressure (esp if it is pelvic fracture- talk about blood loss and your priority to
stabilise his blood pressure), specialists involvement and surgery.

Parents will react at the word surgery.

Explain in cases of EDH, the surgery will drain the blood and the specialists will be able to
explain all the details of the procedure and if they want you can arrange their meeting with them.
In case of pelvic fracture, explain that surgery will be needed to stabilise the hip bone and
orthopaedic surgeons will be able to explain the type of surgery.