New Stations – October 2018

Lady with Accident asking for a Sick Note – Station on 3rd Oct

 You are FY2 doctor in the Accident & Emergency Department

A young female patient (? Name/ Age) had an accident 2 weeks ago.

Records in the Emergency Unit state that she had no injuries and was certified fit then. She has come
now to ask for a sick note.

Talk to her and address her concerns.

GRIPS

Pt- Doctor I need a sick note for my job.

Dr- I would definitely do everything to help you. Can you please tell me why you need a sick
note?

Pt- I actually had an accident 2 weeks ago and I want to take time to recover. So I want a sick
note to show at my workplace.

Dr- Can you describe the accident in detail?

Pt- I was actually drunk and was driving my car when I got involved in the accident. So I took 2
weeks time off from work to recover. But now I want to take a leave for a few more days and
need a Sick note from the Hospital.

Dr- Can you tell me what work do you do?

Pt- ???

Dr- I will check the records at the Emergency Unit. It says in the records that you were certified
fit then and that you had no injuries at that time.

Pt- Doctor can you please change the notes and give me a sick note which says that I had
injuries and need rest for few more days.

Dr- Miss, we cannot change what we already wrote in our notes. Can I ask you why do want us
to do that?

Pt- Doctor, I will lose my job if you don’t give me a sick note. I don’t have any support.
 Dr- Miss, I am really sorry but unfortunately we cannot give a sick note with changed findings –
We need to be honest when we report the injuries.

Pt– Doctor, you don’t understand. My car was taken away by the police and now I don’t have
any way to go for my work. So please give me a sick note.

Dr- Miss, I can imagine that things are very difficult for you. Is there any way for you arrange
another means of transport. Maybe, your colleagues can help you by picking you up.

Pt- Doctor please give a sick note ( the lady is very persuasive and repeatedly mentions that she
doesn’t have any support and that she will lose her job).

( One doctor asked CAGE questions – She says no to the CAGE questions. She gave positive Hx
of smoking.)

This is an alternate version of the case given by another doctor. I don’t know which is the accurate
version.

 A female patient had a road traffic accident 2 weeks ago and sustained minor
injuries. She has recovered now and has come for a review.

Address her concerns.

The patient had some minor injuries at the time of car accident (some bruises on the upper
limbs). She was under the influence of alcohol while driving. There were no passengers
with her and no one else got injured. She was given a sick note for 2 weeks initially and
now she says she is back to normal but wants a sick note for 6 weeks.

Take some Hx to assess her condition (no pain now/ able to use both limbs normally/ no
sensory or motor deficit / bruises healed)

Dr- I would like to examine your both upper limbs and check motor and sensory functions.
I will ensure privacy and make sure a chaperone is present.

The examiner says Normal / No findings.

Dr- Mrs.____, From the information you have given me and the examination findings I find
that you are fully recovered and don’t need any further treatment. I will inform my
seniors. I am sorry but I cannot give you a sick note for 6 weeks.

Pt – Doctor, you don’t understand. The police have booked a case against me as I was
drunk while I was driving. I will definitely lose my driving licence. I will lose my job. If you
give me a sick note for 6 weeks I will be able to support myself and look for another job.
(She doesn’t specify what her job is, she just says that her job requires her to drive around
and without the driving licence she will lose her job)

Dr – Mrs____, I can imagine that things are very difficult for you. However, we have to be
honest and I cannot give you a sick note as my examination findings show you don’t need
any further treatment.

The patient starts crying and asks why cannot you just write a simple sick note and help
her out. She has two teenage daughters and there is no one to support them. She says she
is paying her taxes and is entitled to the sick leave.
 She refuses to take help from Citizens Advisory Bureau or the Jobs centre. She says she
can find a new job on her own. She just needs some time and wants you to give you a sick
note for 6 weeks. She keeps crying in between and is very persistent about the sick note.

SIMWOMAN – 3rd Oct

 You are an FY2 in the Medicine Department.

An elderly lady (? Name/ Age) was admitted 3 days ago for UTI

The nurse has called you and says that the patient has been “feeling poorly”
and that you are the only doctor available to see her.

Assess the patient and manage her appropriately.

When you enter the cubicle there is no nurse to ask history. Breathing
sounds are heard from the speaker.

Only SIMWOMAN is inside with the monitors attached –

Temperature- 39 C

B.P- Low, for some the B.P was normal

Oxygen saturation – 88%

Sw- “ I cannot breathe”

Dr- Don’t worry Mrs.____, You are in safe hands, we will do everything we
can
to help you. I am going to give you some oxygen to help you breathe.

Attach the oxygen mask and start O2 at 15 litres per min.

The examiner increases the SpO2 to 93 %

Dr- Mrs.____, I hope you are feeling better now. Your blood pressure is low
so I will be giving you some fluids through your vein.

A stand with IV fluid bag is present, connect the IV line to the cannula (no
need to open the cork) .The examiner increases the blood pressure to
 normal.

Dr- The patients temperature is very high so I would like to give Paracetamol
IV.

The examiner doesn’t respond.

Dr- Mrs.____, I would like to do a head to toe examination to find out the
reason for your condition. I would like to examine your Chest and Abdomen.
For this I would like you to undress completely. I will ensure your privacy and
make sure a chaperone is with me.

The examiner doesn’t say anything ( doesn’t even say assume). You undress
the patient and proceed with the examination.

Chest examination- Bilateral crackles are present all over the lungs.

Abdominal examination- Look for any distension, Guarding or Rigidity or any

Suprapubic tenderness. Observe if any catheter is attached.

The examiner doesn’t confirm/deny the findings.

Dr- Mrs.____, thank you for your cooperation. You can get dressed now
( you cover the SIMWOMAN)

From the monitor observations and the examination findings, I think you
may be having a condition called septic shock, this means that the infection
from your urinary tract has spread throughout your body.

I would like to inform my seniors about your condition. We may have to

shift you to the ICU so that you can receive the appropriate care.

I would like to arrange for a Chest X-ray. I would like to do a FBC, Urea and
Electrolytes, Blood culture, and ABG and also test you urine for bugs. I would
also like to insert a catheter so that we can monitor your urine output (If it is
not already inserted).

We will review the antibiotics you are receiving. We will be starting you on
some stronger antibiotics through your veins to treat you. We may change
these later when the culture reports come back.

The examiner doesn’t say anything throughout the station- He doesn’t even
ask for management at the end.

 SEPSIS / SEPTIC SHOCK

Sepsis is a serious complication of an infection.

 Without quick treatment, sepsis can lead to multiple organ failure and death.

Early symptoms of sepsis may include:

 a high temperature (fever) or low body temperature

 chills and shivering
 a fast heartbeat
 fast breathing

Many of the symptoms of sepsis are also associated with meningitis. The first
symptoms of meningitis are often fever, vomiting, headache and feeling unwell.

Septic shock - In some cases, symptoms of more severe sepsis or septic shock (when
the blood pressure drops to a dangerously low level) develop soon after.

These can include:

 feeling dizzy or faint

 a change in mental state – such as confusion or disorientation
 diarrhoea 
 nausea and vomiting
 slurred speech
 severe muscle pain
 severe breathlessness
 less urine production than normal – for example, not urinating for a day
 cold, clammy and pale or mottled skin
 loss of consciousness

Sepsis can be triggered by an infection in any part of the body. The most common sites
of infection leading to sepsis are the lungs, urinary tract, tummy (abdomen) and pelvis.

Sepsis may develop when you're already in hospital. For example, you're more likely to
develop sepsis if:

 you've recently had surgery

 you've had a urinary catheter fitted
 you have to stay in hospital for a long time

Sources of infection

Types of infection associated with sepsis include:

 lung infection (pneumonia)

 appendicitis
 an infection of the thin layer of tissue that lines the inside of the abdomen
(peritonitis)
 an infection of the bladder, urethra or kidneys (urinary tract infection)
 an infection of the gallbladder (cholecystitis) or bile ducts (cholangitis)
  skin infections, such as cellulitis – this can be caused by an intravenous catheter
that's been inserted through the skin to give fluids or medication
 infections after surgery
 infections of the brain and nervous system – such as meningitis or encephalitis
 flu (in some cases)
 bone infection (osteomyelitis)
 heart infection (endocarditis)

Sometimes the specific infection and source of sepsis can't be identified.

Tests to diagnose  sepsis

Sepsis is often diagnosed based on simple measurements such as your temperature, heart
rate and breathing rate. You may need to give a blood test.

Other tests can help determine the type of infection, where it's located and which body
functions have been affected. These include:

 urine or stool samples
 a wound culture – where a small sample of tissue, skin or fluid is taken from the
affected area for testing
 respiratory secretion testing – taking a sample of saliva, phlegm or mucus
 blood pressure tests
 imaging studies – such as an X-ray, ultrasound scan or computerised tomography
(CT) scan

Treatment for sepsis

Treatment for sepsis varies, depending on the site and cause of the initial infection, the
organs affected and the extent of any damage.

If sepsis is detected early and hasn't affected vital organs yet, it may be possible to treat the
infection at home with antibiotics. Most people who have sepsis detected at this stage make
a full recovery.

Almost all people with severe sepsis and septic shock require admission to hospital. Some
people may require admission to an intensive care unit (ICU).

Because of problems with vital organs, people with severe sepsis are likely to be very ill and
the condition can be fatal.

However, sepsis is treatable if it is identified and treated quickly, and in most cases leads
to a full recovery with no lasting problems.

Management of sepsis after admission to hospital usually involves three treatments and
three tests, known as the "sepsis six". These should be initiated by the medical team within
an hour of diagnosis.

Treatment involves:

 giving antibiotics 
  giving fluids intravenously
 giving oxygen if levels are low

Tests will include:

 taking blood cultures – to identify the type of bacteria causing sepsis

 taking a blood sample – to assess the severity of sepsis
 monitoring your urine output – to assess severity and kidney function

You may require admission to an intensive care unit (ICU) if:

 the sepsis is severe

 you develop septic shock – when your blood pressure drops to a dangerously low
level

ICUs are able to support any affected body functions, such as breathing or blood
circulation, while the medical staff focus on treating the infection.

Because of problems with vital organs, people with severe sepsis are likely to be very ill.
Up to 4 in every 10 people with the condition will die.

Septic shock is even more serious, with an estimated 6 in every 10 cases proving fatal.

However, sepsis is treatable if it is identified and treated quickly, and in most cases leads to
full recovery with no lasting problems.

Antibiotics

The main treatment for sepsis, severe sepsis or septic shock is antibiotics.

If you have severe sepsis and septic shock, antibiotics will be given directly into a vein
(intravenously). 

Ideally, antibiotic treatment should start within an hour of diagnosis to reduce the risk of
serious complications or death.

Intravenous antibiotics are usually replaced by tablets after two to four days. You may have

to take them for 7 to 10 days or longer, depending on the severity of your condition.

Types of antibiotics

There won't usually be time to wait until a specific type of infection has been identified, so
broad-spectrum antibiotics are given first. 

These are designed to work against a wide range of known infectious bacteria and usually
cure most common infections.

Once a specific bacterium has been identified, a more focused antibiotic can be used.

Intravenous fluids
If you have sepsis, your body needs increased amounts of fluid to prevent dehydration and
kidney failure.

You'll usually be given fluids intravenously during the first 24 to 48 hours after admission if
you have severe sepsis or septic shock.

It's important that the doctors know how much urine your kidneys are making when you
have sepsis so they can spot signs of kidney failure.

If you're admitted with severe sepsis or septic shock, you'll usually have a catheter
inserted into your bladder to monitor your urine output.

Oxygen

Your body's oxygen demand goes up if you have sepsis.

If you're admitted to hospital with sepsis and the level of oxygen in your blood is low, you'll
usually be given oxygen. This is either given through a mask or tubes in your nostrils.

Treating the source of infection

If a source of the infection can be identified, such as an abscess or infected wound, this will
also need to be treated.

For example, any pus may need to be drained away or, in more serious cases, surgery may
be needed to remove the infected tissue and repair any damage.

Increasing blood pressure

Medications called vasopressors are used if you have low blood pressure caused by sepsis.

Vasopressors are normally given intravenously while you're in an ICU. Extra fluids may also
be given intravenously to help increase blood pressure.

Other treatments

You may also require additional treatments, such as:

 corticosteroids or insulin medication

 a blood transfusion
 mechanical ventilation – where a machine is used to help you breathe
 dialysis – where a machine filters your blood to copy the function of your kidneys.
These treatments are mostly used in ICUs
Station 3 ( Similar to Otitis media Station) :

A lady comes with the Hx of reduced hearing in the left ear for few days and wants you
to remove the wax.

When asked why she feels there is wax, she says that her friend said that the pain is
usually due to wax.

No Hx of fever / balance problems / tinnitus/ vertigo

She gives travel Hx to Spain the previous week, Hx of swimming and also Hx of use of ear
buds. Hx of mild pain.

There was no manikin for examination.

The examiner shows a picture. There was congestion with some white area. Not sure if it
was congested Ear canal with pus discharge/ congested Tympanic membrane with
perforation or discharge.

Examiner gives findings- Webers lateralised to the same ear conductive hearing loss in
the left ear.

Differential Diagnoses:

- Otitis externa

- Otitis media

- Otitis media with perforation

 Sick Child – Telephonic conversation ( 16th October)

 You are an FY2 in a Paediatric Ward.

A young baby 10 months old has been sick for two days and is on a triage care
call. His mother is concerned.

Task – Talk to the mother and discuss the initial management plan with her.

Phone is present in the station.

Dr- Hello, I am Dr___, F2 at the paediatric department. Are you Mrs___. (Confirm
the child’s name & age)

Mother- Doctor, can you please come and see my baby, he is very ill.

Dr- Mrs__, Please don’t worry. We will do our best to help you. Can I ask a few
questions to know about your baby’s condition to see how we can help you?

Dr- Can you tell me what happened?

M- My baby has fever since 2 days. I recorded it with my home thermometer and it
showed 39 C. I have been giving him paracetamol but the fever is not improving.

Dr- Did you notice any rash on his body? P- No

Dr- Did you notice if he had any difficulty moving his neck? P- No

Dr- Did he have any vomiting?

M – No ( For some, she gave Hx of 2 episodes of vomiting).

Dr- Did he have any loose stools? P- No

Dr- Did he have any nasal discharge? P- No

Dr- Did he have any ear pain? P-No

Dr- Did he have any cough?

Mo- Yes, there is cough. ( Didnt ask for sputum) . He is also having harsh breathing
and seems to be gasping. I am very worried doctor.

Dr- Mrs___, I can imagine this must be very distressing for you. Is your baby feeding
 well ?

M– No doctor. He hasn’t been feeding at all since yesterday.

Dr- Is your baby active ?

M - No doctor. He has been listless and is lethargic.

Dr- Did he complain of any pain while passing urine?

M- No. I haven’t changed his diaper since yesterday.

Dr- Can you tell me about his birth?

M- It was normal.

Dr- Are his jabs up to date? P- Yes

Dr- Do you feel his development is normal? P- Yes

Dr- Are you happy with his red book? P – Yes

Dr- Did your baby have any similar complaints in the past?

M– No

Dr- Is your baby on any medications ? M- No

Dr- Is your baby allergic to anything? M- No

Dr– Thank you for the information you have given me. I think your baby needs
immediate admission. Can you bring your baby to the hospital now.

M- I cannot bring him on my own doctor.

Dr- Dont worry Mrs___, We will arrange an ambulance so you can come as soon as
possible. Can you please tell me your address?

M- ....... Doctor what is wrong with my baby.

Dr- I am not very sure about why your baby is ill. It looks like he has some infection.
We would like to do some tests to find out the cause. We will be doing FBC, Urea &
Electrolytes, ABG and Chest X-ray.

He is having difficulty breathing so he needs immediate oxygen support.

He has got dehydraton so he needs IV fluids.

We have to give him antibiotics through his veins.

 M- How long will it take for the ambulance to come?

Dr- It will arrive in 30 mins.

Post – Op TIA ( BBN Station on 16th Oct)

 You are a FY2 working in Surgery department.

Mrs. Dollores, 80 year old had been diagnosed with an intracranial tumour. She had been
operated on. While in the recovery after the operation she was noted to have developed left
sided facial weakness. She has been seen by a multidisciplinary team and all tests have been
done (FBC, Urea & Electrolytes, LFTs, RFTs , ECG area all normal. A CT scan was done and she
was found to have had an ischaemic stroke. Her son is concerned about his mother and would
like to speak to you.
Assume consent has been taken to talk to the son

Task : Talk to the son and address his concerns. Discuss further management

Dr: Hello Mr I am Dr…. one of the junior doctor in the surgical department.

How are you doing?

Pt: I am OK

Dr: I am one of the team of doctors looking after your mother

I am here to talk to you about her condition. Do you know anything about how her condition is now?

Pt: She had a surgery for a brain tumor. I don’t know doctor how she is now. How is she doctor?

Dr: Is it okay if I ask you a few questions about your mother’s health before discussing her condition?

Pt: Okay doctor

Dr: Does your mother have any medical conditions?

Pt: Yes, she has arthritis since few years.

Dr: Do you know what medication she is taking for the arthritis?

Pt: No

Dr: Did she have any high blood pressure? Diabetes? Any Kidney or Liver disease?

Pt: No

Dr: Any stroke or mini strokes before ? Son: No

Dr: How was she before ? Was she very active? Son: Yes

Dr: I am sorry to say I don’t have good news.

Pt: Please tell me doctor, Is my mother okay?

Dr: Mr____, As you know we have done an operation to remove the tumor in her brain. While she was recovering
from the surgery we noticed that she developed weakness on the left side of her face. Our team of doctors did some
blood tests and they came out normal. However I am sorry to say that when we did a CT scan we noticed that she
had an ischaemic stroke in her brain.

Pt: What does this mean doctor?

Dr: Ischaemic stroke occurs when a blood clot blocks the flow of blood and oxygen to the brain. This starves the
brain of the oxygen and the nutrients it needs, which damages the brain cells.

Son: Why did this happen?

Dr: There are many reasons why an ischaemic stroke occurs. Blood clots typically form in areas where the arteries
have been narrowed or blocked over time by fatty deposits known as plaques. As one gets older, the arteries can
naturally narrow, but certain things can dangerously accelerate the process. These include smoking, high blood
pressure, obesity, high cholesterol levels, diabetes, excessive alcohol intake.

Son: How will you treat my mother now?

Dr: We have started her on a combination of medications to treat the condition and prevent it from happening
again. Also at the time of discharge we will review her medicines. We will start her on Physiotherapy to improve her
condition.

Son: Will she recover soon?

Dr: Although some people may recover quite quickly, many people who have a stroke need long-term support to
help them regain as much independence as possible. This process of rehabilitation depends on the symptoms and
their severity.

Son: My mother lives on her own a few houses down the lane from my house. How can we provide care to her?

Dr: Mr__, I can see that you are a very caring son. We will talk to the Social Services and they will arrange the
appropriate care and support for your mother.

The son is polite throughout the station.

New station : HIV- Discuss Lab results. (16th Oct)

There was no CD4 count. Two tests for HIV were done 2 weeks apart for confirmation.

Patient was married and had unprotected sex with his wife 3 months ago.

Patient struggles to tell his wife. Agrees only when told about the partner notification program.

He repeatedly asks if we are sure that the results are accurate and he has HIV.
 Changed Scenario for MMSE station- 9th October

There was a patient with COPD and confusion with chest signs ( bilateral crackles).

The patient came with a referral note from the GP. Findings on the referral note- Oxygen saturation,
B.P, respiratory rate are normal. There was no one accompanying the patient.

Examiner gives a pen and paper ONLY when you say you want to do MMSE. Those who didn’t
mention the MMSE, the examiner doesn’t respond.

Dr-Which year? Pt- 2015

Dr- Which month? Pt- August

At RECALL, the patient says that you are wasting his time.