1

Hyperthyroidism Weightloss
22 year Miss Emilia Mills was brought in by her boyfriend because of loss of weight.

Take a detailed history and discuss further investigations with the patient.

TSH 0.2mU/L ( Normal - 0.4 - 4.0mU/l (milliunits perlitre)

T4 - 35pmol/l ( Normal - 9.0 - 25.0 pmol/l (picomolesperlitre) T3
- 6pmol/l (Normal - 3.5-7.8 pmol/l (picomoles perlitre)

D/D

1. Thyrotoxicosis - heat intolerance, palpitation, ↑appetite, anxiety, family history of

thyroid disease or weightloss.

2. TB – cough, night sweats, travel history,contact,

3. Diabetes – Increased thirst and hunger, increased frequency of urination. Family

history ofdiabetes.

4. Cancer – lumps & bumps, change in bowel habit, cough, haemoptysis, Breastlumps,

5. HIV – sexual Hx,drugs.

6. Depressions - ↓mood, early morning awakening, suicidal thoughts. Recentjob,

changes/loss, separation frompartners

7. Anorexia nervosa – intentional, insight (do you think you have lost weight or only

others telling you this), role model. dieting, exercise, laxatives, diuretic, vomiting

(purging)

8. Drugs – metformin, opiates. slimmingagents,

9. Alcohol/smoking

10. Malabsorption- difficult to flush the stool in thetoilet.

11. Malnutrition – how is the diet ( healthy eatinghabits)

12. Addison’s disease – weakness, dizziness. ↑d pigmentation over palmercrease.

13. Coeliac/crohn’s – diarrhoea with blood mucus, painabdomen

PositveHx - How much, how long - Lost 5 kg in 2months,↑appetite,Palpitation,

Examination

Miss – I need to examine your hands, eyes and yourneck.

( examiner did not give anyfinding’s)

Invt.

TFT - T3 N, T4 ↑, TSH ↓

Isotope scan (swallow radioactive substance in capsule orliquid),Technetium

Rx – thionamides (carbamazole, prophylthiouracil)

Beta blockers

Radio-iodine – shrinks Thyroid – so ↓ hormones

Surgery – if recurrent overactive thyroid.

IV cannula – Talk to FY 1
Your junior colleague (FY1 doctor) Dr Wilson did not insert IV cannula to Mrs
Williams who supposed to receive IV antibiotics. Talk to your colleague.

You – Hi Wilson I am Peter. How are you doing?

Him- I am fine Peter
You – How’s the workgoingon? Him- it is good notbad.
You – was it verybusytoday? Him – Not so much. I couldmanage.
Him- it is good not bad.
You – was it verybusytoday? Him – Not so much. I couldmanage.
You – She has put a complaint saying that you didn’t insert a IV cannula and she is
waiting for a long time.
Him – oh really. But there is 2 hours’ time for the next antibiotics. I don’t
understand why she has to complain.
You – What did you tell her about the cannula.
Him – Well I told her that I will be back in about 15 min to insert cannula but then I
saw an interesting X ray, I went to the library to read about it.
You – It is good to know that you are interested in learning. But I think since
youhad already told her that you will be back in 15 min to insert the cannula you
should had done that first or you could have told her that you will be back to insert
the cannula before the next dose indue.
Him – Well yes, I think I should have done that.
You - Do you have any problem in prioritising, because when I started working I too
had the problem of prioritising, then I went to a course, it helped me a lot. May be you
too can attend one course like that if you want to.
Him – ok, I will surely try that.
You – I think you need to talk to Mrs Williams and explain to her and may be
apologise to her if you think so.
Him – Yes, I will.
You - I think you can insert the cannula now and tell her that no harm has happened
also I suggest you to fill up a clinical incident form.
Him – yes, thank for your suggestion. Will you tell the consultant?
You – I guess he may come to know that from others. It may be better you that to him
yourself rather than he hearing it from others.
Him – yes, thank
you. You – thank
you.

Sometimes the colleague says he forgot to insert the cannula.

You can ask him to maintain a diary so that he will not forget the jobs.

Sometimes he says he was caught up in doing CPR.

You can tell him that he could have told you to insert the cannula or he could have
informed the nurses in the ward to tell the patient that he will be late.

IV cannula – talk to upset patient

Yourjuniorcolleague(FY1doctor)DrJohnDaviddidnotinsertinsertIVcannulatoMrs
WilliamswhosupposedtoreceiveIVantibioticsforinsectbite.TalktoMrsWilliams.

Hello Mrs Williams I am doctor… How can I help you.

Pt - Doc your colleague told me that he is going to come back and inset cannula in my
hand and he did not come back since then. I am due for antibiotics through my veins. I
am supposed to go home now. I have a meeting to attend in the next one hour.
Dr - I am very sorry for what happened, but I will insert the cannula to you now.
Pt - Thank you for that, but why is that your colleague did not come back to insert the
cannula.
Dr - I am not sure why he did not come to insert the cannula may be he is caught up in
some other emergencies. But as I told you I will insert the cannula now and I will ask
him to come and tell you what happened. I would like to reassure that nothing serious
has happened to your health now. Is that OK?
Pt: What about him?
DR: I will ask him to come and explain to you about what
happened. Pt: I don’t’ want to see him. Will you take any action on
him.
Dr: We do take all such incidents very seriously. We will all the measures so that
these type of problems will not happen again.
Pt - I don’t want such things to happen to me or anyone else again.
Dr - Yes, sure we will make sure that these things will not happen. I will inform my
seniors about this.
Pt – I want to put a written complaint.
Dr – You can surely do that if you wish to. We have patient advice liaison service
you can talk to them about it and they will help you.
 Pt – Thankyou.

PALS
The Patient Advice and Liaison Service (PALS) offers confidential advice,
support,and information on health- related matters. They provide a point of contact
for patients, their families and theircarers.
How can PALS help?
PALS provides help in many ways. For example, it can :
 Help you with health relatedquestions
 Help resolve concerns or problems when you’re using theNHS
 Tell you how to get more involved in your ownhealthcare
PALS can givfe you informationabout:

TheNHS
The NHS complaints procedure, including how to get independent if youwant
to make acomplaint.
 Support groups outside theNHS
PALS also helps to improve the NHS by listening to your concerns and
suggestions. Making a complaint
If you’re not happy with an NHS service, you can make a complaint. You should
complain to the person or organisation providing the service first, such as GP, dentist,
hospital or pharmacist. Alternatively, you can complain to the commissioner of that
service – either NHS England or the area clinical commissioning group (CCG)
In general, NHS England commissions most primary care services, such as GP and
dental services. CCGs oversee the commissioning of secondary care, such as
hospital care and some community services.

NAI in adult

 You are the FY 2 doctor in the surgerydepartment.


 MsCarolineAndersonisa35yearsoldfemalewhois12weekspregnantpresented to the
OBG department with the history of bleeding per vagina. On examination midwife
did not find any blood in the vagina but she noticed multiple bruises which
lookedlikefingermarkingonherwristsandotherpartsofbody.Midwifeaskedyou to talk
to the patient. USG done and her baby isfine.

 Talk to the patient.Do not examinerher.

Dr: Hello Mrs Anderson, I am Dr …. One of the junior doctor in the Obstetrics and
Gynaecology department. How are you doing ?
Can you please tell me what brings here to the hospital ?
Pt: I had some bleeding from my front passage.
Dr: Ok. Did you have any other problem? Pt: No
Dr:MrsAndersonMidwifeexaminedyouandshesaidthereisnobloodinthefrontpassage and
you are fine and your baby is also fine.Is there anything else I can helpwith?
Pt: No doctor I want go home.
Dr:MrsAndersonmidwifetoldusthatshenoticedsomebruisesonyourwrists.Wouldyou like to
tell us about it? Be assured that we will keep the information confidential unless you
want us to disclose it toanyone.
Pt: No doctor I am fine I just want to go home.

Dr:MrsAndersonweareheretohelpyouandyourbabyandanyoneelseyouareclose to if
needed. You seem to be in some danger. Please do not be worried. If you talk to us we
may be able to help you. Can I have a look at your wrists please? I can see bruises, can
you please tell me how did you get thisbruises?
Pt: I just banged the door that is how it happened?
Dr: Your bruise does not look like it happened because of banging the door. It looks as if
some has pressed with the fingers. Mrs Anderson, don’t be worried. We are here to help
you. You can feel free to talk to me.
Pt: Doctor my partner Derek beats me some times but he is otherwise OK.
Dr: How long this ishappening ? Pt: Since my first child was born?
Dr: You mean you have a child ?
Pt: Yes doctor. I have 3 year daughter Lacy.
Dr: Did you try to stop him in any way ? Did you try to take help from any one about this?
Pt: No doctor?
Dr: Can I ask why you didn’t ?
Pt: I don’t want to put him in any trouble. I don’t want anything bad to happen to my
daughter.
Dr: Has he hurt her also? Pt: No he does not hit her. He loves her.
Dr: Is he the biological father ofyour daughter? Pt:Yes
Dr: Is he the father of the baby inyour womb? Pt:Yes
Dr: Is this aplannedpregnancy? Pt:Yes.
Dr: Is your first daughter was a planned pregnancy ? Pt : Yes.
Dr: Is there anyone else at home apart from your daughter ? Pt: No
Dr: Do you know why does he beat you ?
Pt: Sometimes he gets too stressed and he beats me. Sometimes it is my fault. I do not do
the work at home properly.
Dr: Is he under the influence of alcohol or drugs when he beats you. ? Pt: No
Dr: Does he hurt you in any other ways like sexually oremotionally? Pt:No
Dr: Do you work ? Pt: No.
Dr: Does he work ? Pt: Yes he is a plumber.( mechanic)

Dr: Mrs Anderson does this problem affect you in any way ? Do you feel low because of
this ? Pt: yes I feel low ( Mood may be5)
Dr: Did you ever think of harming yourself ? Pt: No
Dr: Do you have any emergency plans if something serious happens ? Pt: No
Dr: Have you spoken about this to your family members or friends ? They may be able to
helpyou. Pt: I haven’t told anyone. He has barred me from telling any ofthem.
Dr: Mrs Anderson I am very sorry that this is happening to you. You do not deserve this.
There are lot of help is available for such problems in the community.
There is national domestic helpline and women’s Aid group. You can talk to them.
We can involve the Police and social services to help you.
Pt: I do not want to inform the police or anyone? Social services may take away my child.
I don’t want them to know. If I inform them then where will I go ? I don’t have any other
place to live.
Dr: I can imagine your problems. However, Mrs Anderson this is for your own safety and
child’s safety that social services must get involved. Also if you are not safe to go back
home they can make some arrangements for you and your child to stay in a safe place. I
am sure they will take care of everything. Is that OK?
Pt: Ok Thank you doctor. I will talk to my mother.
Dr: Please do let us know if you need any kind of help in the future. Thank you.

DNAR

You are the FY 2 doctor in medicine department.

Mr James Walker 72 year old man recently been admitted to the medical ward for
Pneumonia and has been treated. He is about to be discharged.
He has some concerns. He wants to talk to a doctor.

Talk to him and address his concerns.

 10

Dr: Hello Mr James Walker ? I am Dr…. Junior doctor in the medical department. How
are you doingtoday? Pt: I amOK.
Dr: How is your Pneumonia ?
Pt: I am OK now.
Dr: I was told that you have some concerns and you want to talk to a doctor is that right?
Pt: Yes
Dr: Can I help you?
Pt: Doctor, I don’t want to take this medications
anymore? Dr: Why isthat? Pt: They make mesleepy?
Dr: Can you please show me which medications ?
Patient shows – Enalapril, Aspirin and Simvastatin,
Dr: Why are you taking these medications ?
Pt: I was given those medications 12 years ago when I had heart failure.
Dr: Did you have any other medical conditions?
Pt: Yes I had bypass surgery to my heart 20 years ago.
Dr: OK. We will see which one of this medication is making you sleepy. We will change
that medication and give some other medication. Will you take them?
Pt: Doctor I am tired of taking these medications. I don’t want to take medications any
more.
Dr: Why do you say that?
Pt: I had enough in my life. I just want to go without suffering?
Dr: Can I ask you why do you feel that way?
Pt: Doctor, I already had whatever I need in this life. I had enough. I have accomplished
everything in my life.
Dr: Is there any medical problem you have which is making you feel this way?
Pt: No doctor.
Dr: Is there any other reason making you feel this way like are you feeling low for any
reason? Pt: No - Not atall
Dr: Is there anything we can help you with if you want to change your decision?
Pt: No nothing likethat.
Dr: Can you please tell me do you do any job?
Pt: No I am retired now.
Dr: What about your family ?
 11

Pt: My wife died of cancer few years ago. I have a daughter but she has Rheumatoid
arthritis.
Dr: Do you live with any one at all ?
Pt: I live on my own. My daughter has arranged someone to take care of me.
Dr: She is very caring. What do you mean by you had enough ? What do you have in
your mind?
Pt: Doctor I want to die in dignity.
Dr: What exactly do you mean by that ?
Pt: I was told you doctors do CPR if the heart stops beating. I don’t want that to be done
on me.
Dr: I see. Do you understand what is the meaning of CPR ?
Pt: Yes I was told you compress the chest if the heart stops beating to make the heart
beat again.
Dr: That is right. But do you understand what will happen if we do notdoCPR? Pt:Yes
I understand then the patient willdie.
Dr: Is that what youreallywant. Pt: Yes that is whatI want.
Dr: Have you discussed this with your family members at all?
Pt: I don’t need to discuss with them
Dr: Is that you don’t want us not to CPR only or do want us not to give you any active
treatment if you fall ill like giving medications through your veins?
Pt: Well, I don’t mind having active treatment but I don’t want CPR to be done. Can you
please bring that form ?
Dr: Surely, I do respect your views. However this the decision has to be taken between
you and my consultant. I will speak to my consultant and get back to you. I need to tell
you one thing, even if you decide not to have CPR now, you can always change your
decision later on if you feel like it.
Pt: OK thankyoudoctor. Dr: Thank you verymuch

Post-mortem examination
A post-mortem examination, also known as an autopsy, is the examination of a body after
death. The aim of a post-mortem is to determine the cause of death.
Post-mortems are carried out by pathologists (doctors who specialise in understanding the nature
and causes of disease).
Post-mortems provide useful information about how, when and why someone died, and they
enable pathologists to obtain a better understanding of how diseases spread.
Learning more about illnesses and medical conditions benefits patients too, because it means
they'll receive more effective treatment in the future.
When post-mortems are carried out
A post-mortem examination will be carried out if it's been requested by:
 a coroner – because the cause of death is unknown, or following a sudden, violent or
unexpected death
 a hospital doctor – to find out more about an illness or the cause of death, or to further
medical research andunderstanding
 Sometimes, the partner or relative of the deceased person will request a hospital post-
mortem to find out more about the cause ofdeath.
Coroner’s post-mortem examination
A coroner is a judicial officer responsible for investigating deaths in certain situations. Coroners
are usually lawyers or doctors with a minimum of five years' experience.
In most cases, a doctor or the police refer a death to the coroner. A death will be referred to the
coroner if:
 it's unexpected, such as the sudden death of a baby (cotdeath)
 it's violent, unnatural or suspicious, such as a suicide or drugoverdose
 it's the result of an accident orinjury
 it occurred during or soon after a hospital procedure, such assurgery
 the cause of death isunknown
The main aim of a post-mortem requested by a coroner is to find out how someone died and
decide whether an inquest is needed. An inquest is a legal investigation into the circumstances
surrounding a person's death.
If someone related to you has died and their death has been referred to a coroner, you won't be
asked to give consent (permission) for a post-mortem to take place. This is because the coroner is
required by law to carry out a post-mortem when a death is suspicious, sudden or unnatural.
A coroner may decide to hold an inquest after a post-mortem has been completed. Samples of
organs and tissues may need to be retained until after the inquest has finished.
If the death occurred in suspicious circumstances, samples may also need to be kept by the police,
as evidence, for a longer period. In some cases, samples may need to be kept for a number of
months or even years.
The coroner's office will discuss the situation with you if, following an inquest, tissue samples
need to be retained for a certain length of time.
Hospital post-mortem examination
Post-mortems are sometimes requested by hospital doctors to provide more information about an
illness or the cause of death, or to further medical research.
Hospital post-mortems can only be carried out with consent. Sometimes, a person may have
given their consent before they died. If this isn't the case, a person who is close to the deceased
can give their consent for a post-mortem to take place.
Hospital post-mortems may be limited to particular areas of the body, such as the head, chest or
abdomen. When you're asked to give your consent, this will be discussed with you. During the
post-mortem, only the organs or tissue that you've agreed to can be removed for examination.
You will be given at least 24 hours to consider your decision about the post-mortem examination..
What happens during a post-mortem?
A post-mortem will be carried out as soon as possible, usually within two to three working days
of a person's death. In some cases, it may be possible for it to take place within 24 hours.
Depending upon when the examination is due to take place, you may be able to see the body
before the post-mortem is carried out.
The post-mortem takes place in an examination room that looks similar to an operating theatre.
During the procedure, the deceased person's body is opened and the organs removed for
examination. A diagnosis can sometimes be made by looking at the organs. Some organs need to
be examined in close detail during a post-mortem and these investigations can take several weeks
to complete. The pathologist will return the organs to the body after the post-mortem has been
completed. If you wish, you'll usually be able to view the body after the examination.
Once release papers have been issued, the undertakers you've appointed will be able to collect the
body from the mortuary in preparation for the funeral.

What happens after a post-mortem ?

After a post-mortem, the pathologist writes a report of the findings.
If the post-mortem was requested by the coroner, the coroner or coroner's officer will let you know
the cause of death determined by the pathologist. If the post-mortem was requested by a hospital
doctor, you'll have to request the results from the hospital where the post-mortem took place.
That in some cases you will be asked to make some decisions. These may be to discuss any need
for consent, or to decide what happens to organs and tissue samples that may need to be
removed for investigation. Your wishes will be respected.
Any particular needs that you have, which could be cultural, religious or practical, will be taken
into account as far as possible. Where consent is not given for storage of organs or tissue samples
they are disposed of in a timely and respectful manner.
In some circumstances a Coroner may open an inquest into the death of an individual after a post-
mortem examination. If the Pathologist certifies that they have a bearing on the cause of death, the
Coroner may require that any retained organs and tissue blocks and slides are kept until the
Coroner’s function is complete. Similarly if there is a possibility of criminal involvement in the
death, tissue may be needed by the police as evidence, separate to the Coroner’s requirements.
In both cases, the tissue samples, blocks and slides or organs may need to be kept for several
months, in some cases, years. As a result this may affect what you want to happen to them.
Why do organs and tissue need to be retained?
In around 20% of adult post-mortem examinations and in most paediatric post-mortem
examinations, the cause of death is not immediately obvious. A diagnosis can only be made by
retaining small tissue samples of relevant organs for more detailed examination. The Pathologist
may need to retain a whole organ for a full assessment to allow an accurate diagnosis of the cause
of death to be made. When this happens the organ or tissue is normally sent to a specialist unit.
These full assessments often take weeks or even a few months to complete, depending on the
extent of the investigations required. Once they are complete, the Pathologist will produce a report
for the Coroner or the medical staff responsible for the care of the person before they died.
What happens when the post-mortem examination is complete?
When the post-mortem examination is complete, you will be told whether tissue samples and
organs have been retained. If tissue samples and organs have been retained then you should expect
to be given a choice about what happens to them when they are no longer needed by the Coroner
or the hospital. Your consent will be needed for any tissue samples or organs to be kept for future
use such as research or education and training of medical staff.
Blocks and slides
With your consent, the tissue blocks and slides may be stored as part of the record of the post-
mortem examination, sometimes called the pathology or medical record, in case they are useful to
your family in the future. If the post-mortem examination takes place in a Local Authority Public
Mortuary, rather than an NHS Mortuary, then your consent will be taken to mean that you agree to
the transfer and storage of the blocks and slides within the healthcare sector.
The samples may also be useful for one or more of the following: teaching, research, clinical audit
or quality assurance etc. The organisation storing the blocks and slides may dispose of them.
If a funeral has already taken place, then the blocks and slides can be returned to you, usually via
your funeral director. There may also be health and safety issues that may prevent this option.
The blocks and slides may be returned with the body before the funeral. It is important to realise
that choosing this option could significantly delay the funeral. Some crematoria do not allow
blocks and slides to be cremated with the body.
Whole organs and tissue samples
Organs and tissue samples cannot be stored as part of the medical record in the same way that
blocks and slides are. They can be re-united with the body, or buried or cremated separately.
Alternatively they can be retained for future use in teaching, ethically approved research, audit and
other clinical purposes, but only with your consent.

Who can give consent for retention of organs?

The most important wishes to consider are those of the person who has died. If it is known that the
person who has died gave consent or specifically did not want to give consent to the retention of
tissue samples or organs, then those wishes must be respected.
If their wishes are not known, then a person nominated by them when they were alive, or someone
in a relationship with them or closely related, must give consent. The spouse or partner is highest
on the list, and a long term friend is at the bottom.

Post-mortem exam question

You are the FY 2 doctor in the medical department.
Mr Peter Green 64 year old man was treated for Pneumonia by the GP with antibiotics
because he had shortness of breath for 2 weeks. He was hospitalised one week ago because it
got worse. He died of suspected Respiratory failure.
His wife Mrs Green want to talk to a doctor about this issue.
Talk to his wife Mrs Green and address her concerns.
( post mortem may not be mentioned in the question ).

Dr: Hello Mrs Green, I am Dr …. Junior doctor in the medical department? How are you doing ?
Wife: I am not feeling good doctor. I don’t know what happened to my husband suddenly he died.
Dr: I am very sorry about it. Please accept my condolences for the loss of your precious one. I
can’t even imagine how you are feeling. I was told that you want to talk to a doctor about it. Do
you have any concerns?
Wife: I am just wondering doctor why this happened so suddenly. He was doing good.
Dr: We think it could be due to infection in his lungs which has led to failure of the lungs has led
to this. But we are not very sure about it. However we need to know more about this. Can you
please tell me what happened before he was brought into the hospital?
Wife: He was short of breath since last 2 weeks. We went to GP and he said he has chest infection
and gave him antibiotics. He was getting more ill since last one week and we brought him to the
hospital and he was admitted a week ago. Now suddenly this happened.
Dr: Did he have any medical conditions? Any operations done recently? Any medications ? Any
allergies?
Wife: Doctor, He had no medical problems at all. He has never been to the hospitals or GP before
this. He was completely fit and well. Why this happened doctor.
Dr: As I mentioned before. We think it could be due to infection in the lungs. We are not sure. I
think it is a better idea to do the post-mortem and find out about it. What do you think ?
Wife: My niece works as a nurse – she also told me that it is good to have the post-mortem.
Dr: OK, surely we can request for that if you wish to. Do you know what we do in the post-
mortem?
Wife: I don’t know ?
Dr: We do the post-mortem to find the exact cause of death when we are not sure about the exact
cause of death. We do that in an examination room that looks similar to an operating theatre.
Pathologists ( specialist doctor) does the post-mortem.
During the procedure, they open the body and remove the organs for examination. Sometimes they
know the cause of death by looking at the organs. Some organs need to be examined in close detail
during a post-mortem and these investigations can take several weeks to complete. They also will
take some tissue samples from the organs and keep it for future testing.
The pathologist will return the organs to the body after the post-mortem has been completed.
Wife: Who decide to hold the post-mortem?
Dr: It can be requested by a coroner (judge) or hospital or the close relative in this case like you
can request for the post-mortem.
Wife: When will you do the post-mortem?
Dr: We usually do the post-mortem within two to three working days of a person's death.
Wife: Can I see him ?
Dr: Surely you can see him before we do the post-mortem if you wish to or you can see him after
the post-mortem also.
Wife: Will it delay the funeral ?
Dr: After the post-mortem they will give release papers and after that you can hold the funeral.
Wife: When will I get the death certificate?
Dr: They usually give the death certificate once they know the cause of death. However you do not
need to wait until you get the death certificate to hold the funeral for him.
Wife: Will they keep the organs?
Dr: Usually they return the organs back to the body after taking some tissue samples. If they need
to retain any organ they will ask your consent for that. Do you know what was your husband’s
wishes about the organs- did he mention any thing about what to do for the organs before he died?
If he had mentioned anything like that before he died - then his wishes will be respected.
Wife: We did not discuss about this issue because this happened unexpectedly.
Which parts for the body do you open ?
Dr: We open only head, chest and tummy area only. We do not touch face, arms and legs. We
stitch it up once the organs are returned to the body. Stitched areas are usually covered by the
dressing of the body by the mortician. So there will not be any disfigurement to the face and arms.
Wife: How will this post-mortem help us doctor?
Dr: It will help you and others a lot in many ways.
1) First of all you will have a peace of mind and feeling of closure if you know the cause of
hisdeath.
2) If it all he died of some genetically inherited condition, we can check for that problem in
his family members or if you have children we can check your children also and maybe
we will be able to treatthem.
3) Also if it all he died of contagious disease we can protect others who came in
contact withhim.
4) Also it helps us a lot in our studies and future training.
Wife: Will you request to do the post-mortemdoctor?
Dr: Yes surely. I will talk to my Consultant and then we will request the concerned authorities to
do that.
Dr: Is there anything else I can do for you?
Wife: No doctor. You have been kind.
Dr: Thank you very much. We will keep you informed at every stage. I am very sorry again for
what happened to your husband. If you need any support we have bereavement support team in
the hospital you can contact them. They may be able to help you.

Wife: Ok thank you doctor. Dr: Thankyou.

Ankle Sprain
You are the FY 2 doctor in the A&E department.
30 year Mrs Anna Henley presented to the hospital in the morning because she fell on grass
while she was going home from work. She had pain, swelling and bruise in her ankle. X
Ray was done in the morning.
She has come back to get the X Ray result.
Take history and talk to her about the further management.

Dr: Hello Mrs Henley I am Dr.. How can I help you ?

Pt: I came in the morning to the hospital because I had injury to my ankle. They did X Ray
But I could not wait for the X Ray result at that time. I have come now for the X Ray
result.
Dr: Could you please tell me how did you injure your ankle?
Pt: I work as a cleaner in a school. I fell inside the school premises while working and that
is how I injured my ankle.
Dr: Mrs Henly it is written in our notes that you fell on the grass outside the school
premises !
Pt: Oh Yes I made a mistake in the morning. I was not thinking properly that is why I told I
fell outside the school premises. Doctor can you please change what is written in the notes
and write that I fell inside the school premises.
Dr: Mrs Henly we cannot erase what we already wrote in our notes. However we can write
that you have requested us to change the story of how it happened.
Pt: No doctor don’t write like that. Please erase what you wrote in the morning and write
what I told you now.
Dr: Can I ask you why do want us to do that?
Pt: If I mention that I fell inside the school premises I will be entitled for compensation for
the injury happened at the work place.
Dr: I can imagine why you want to do that. Unfortunately we cannot do that – we should
be honest.
PRICE stands for:

 Protection – protect the affected area from further injury by using a supportor,
wearingshoes.
 Rest – Avoid activity for the first 48 to 72 hours. We can give you crutches tohelp
you towalk.
 Ice – for the first 48 to 72 hours after the injury; apply ice wrapped in a damp towel
to the injured area for 15 to 20 minutes every two to three hours during the day.
Don't leave the ice on while you're asleep, and don't allow the ice to touch yourskin
directly because it could cause a coldburn.
 Compression – We will put elasticated bandage to the ankle to limit the swelling
and movement that could damage it further. You can use a simple elasticbandage
or an elasticated tubular bandage. Remove the bandage before you go tosleep.
 Elevation – keep the injured area raised and supported on a pillow to helpreduce
swelling.

You should avoid ( HARM )

 Heat – such as hot baths, saunas or heatpacks.

 Alcohol – drinking alcohol will increase bleeding and swelling, and slowhealing.
 Running – or any other form of exercise that could cause moredamage.
 Massage – which may increase bleeding andswelling.

Generally, you should try to start moving a sprained joint as soon as it's not too painful to
do so.

Pt: When can I walk properly doctor?

Dr: Usually you'll probably be able to walk one or 2 weeks after the injury. We can give
you crutches to help you walk until then. You will be able to use your ankle fully after
6 to 8 weeks,

Avoid driving until strength and mobility have returned which may take 6 to 8 weeks.

You can return to sporting activities after 8 to 12 weeks if you do any sports.

Contact your GP if your injury doesn't improve as expected or your symptoms get worse.

Surgery – is not needed to treat sprains unless the injury is very severe.

Lady with bowel cancer –

 20

Son does not want mother to know.

You are the FY 2 doctor in the medical department.
72 year old lady Mrs Ali was recently been diagnosed as bowel cancer. She had a
short period of confusion. Information was revealed to her daughter. Now Mrs Ali
has recovered from the confusion and she has the mental capacity.
Her son Mr. Mohammad Ali wants to talk to you.
Talk to her son.
Mrs Ali has given consent to talk to him about her condition.

Dr: Hello Mr. Mohammad Ali, I am Dr…. one of the junior doctor in the medical
department. How are you doing?
Son: I am, fine doctor.
Dr: I am one the team of doctors looking after your mother Mrs Ali. I was told that you
want to speak to me about her. Is that right ?
Son: Yes doctor.
Dr: How can I help you Mr..
Son: How is my mother now doctor.
Dr: She has recovered from her confusion now and she is much better now.
Son: I was told that she has bowel cancer, is that right doctor?
Dr: Yes that is right Mr. Ali. I am very sorry about that.
Son: Have you told her that she has cancer?
Dr: No, not yet. We could not tell her because she was bit confused but she is fine now so
we are just about to tell her now.
Son: Doctor please don’t tell her that she has cancer.
Dr: Why do say that Mr. Ali ?
Son: Doctor my dad also had cancer. She was looking after him for a long time and she has
seen all the suffering what my dad went through. My dad has died now. If she comes to
know that she also has cancer she will be very distressed.
Dr: Mr. Ali I am really sorry to hear about your dad. I can imagine how you are feeling. I
do understand she will be distressed to hear the news. However, Mr. Ali we need to tell her
that she has a cancer because she needs to know about her condition.
Son: Doctor please tell her some other condition other than cancer.
 21

Dr: Mr Ali we need to tell her the truth we need to be honest with our patients. She has a
right to know about her condition.
Son: OK doctor - if you have to tell her then tell her that she has some abnormal growth.
Dr: I can certainly see how caring son you are. I do appreciate your concerns to your
mother. Your opinion really very important for us. However, Mr Ali she is in a right frame
of mind to understand everything now. She has a mental capacity to understand and to take
decision for herself about her treatment. To give her the right treatment we need her
consent. We need to tell the name of her condition to offer the right treatment. Unless we
tell the name of the real condition we cannot get her consent to treat her.
Son: But why can’t tell her abnormal growth?
Dr: Mr abnormal growth has different meaning it can be cancerous or noncancerous
growth. People usually know the word cancer. People may not understand any other
word for this condition other than the word cancer.
Even if we tell her that she has abnormal growth she can ask us what is that abnormal
growth and that time we have tell her that it is cancer type of growth.
Son: Doctor, I am her eldest son. Now I am the eldest in the family. In our culture it is the
elder person who takes decisions. Doctor you don’t need her consent. I am telling you that
you treat her without telling her the word cancer. I am giving you permission. Anywayshe
is going to ask me only about what todo.
Dr: We do respect all cultures and family relationships. However when we take medical
decisions it has to be person’s own decision if they have the mental capacity.
Son; You doctors are only care about your duty but you don’t understand our feelings. You
don’t care for our feelings at all?
Dr: Mr Ali I am really sorry if I made you feel that way that we don’t care about your
feelings. We definitely care for the feelings also. However if we don’t tell her the name of
the condition then we may not be able to offer her right treatment with which we may be
able to prolong her life or if she is in pain we may not be able to provide her right kind of
medication and she will suffer more and she will be more distressed. I am sure you don’t
want her to be distressed a lot isn’t it ?
Son: Doctor I will tell her that she has cancer myself in private.
Dr: Mr Ali Unfortunately we have to tell the diagnosis to the patient our self. It is our duty.
We are trying to do the best for her and I am sure you also want the best for her.
What you say ? You tell me should we tell her or not ?
Son: Yes doctor I can understand. You do whatever you feel is right.
Dr: Thank you very much Mr Ali. As I said your input is very important for us to manage
her condition. If she agrees, you can also join us when we discuss with her about her
condition and all the treatment options. I am sure she needs your support to cope with this
condition. Thank you very much.
 SMOKING
You are the FY 2 doctor in the medical department.
Mrs Joan Thomas has been planned for angioplasty.
She is a chronic smoker.
Talk to patient and advise her to quit smoking.

Dr:HelloMrsJoanThomas,IamDr.....oneofthejuniordoctorinthemedicaldepartment. How are

you doing?
Pt: I am OK.
Dr: I am here to talk to you about your condition.
Pt: If you have come here to tell me not to smoke, please don’t talk to me.
Dr: It seems that you have been annoyed by others, don’t worry I am not going to annoy
you.Iamheretotalktoaboutyourhealthconditionandtoadviseyouhowyoucanprevent that
problem in the future. Is that OK?
Pt: OK
Dr: Mrs Thomas, Can you please tell me how much do you know about your condition?
Pt: I was told there is some problem in my heart.
Dr: That is right. You had some thing like a minor heart attack. Let me explain that to you.
Heart needs its own blood supply for it to survive. Blood supply is provided by some blood
vessels specially for the heart muscles. These blood vessels have become narrowed in your
casewhichhascausedreducedbloodsupplytoyourheartmuscle.Thatiswhyyouhadthis
paininyourchest.Wearedoingaprocedurecalledangioplastywherewearewideningthis blood
vessels in our heart to restore the blood supply to the heart muscles. Do you follow me?
Pt: Yes
Dr: Do you know why this blood vessels would have become narrowed?
Pt: No
Dr: There several reasons why this blood vessels can become narrow. Sometimes this
happenswiththosepeoplewhodonoteathealthybalanceddietorwhodonotdoexercise or who
have some medical conditions like high blood pressure or diabetes. Can I ask you how is
yourdiet?
Pt: I eat healthy diet doctor.
Dr: That is very good to know. Please continue eating healthy food. Do you do exercise ?
Pt: Yes doctor.
Dr:Thatisalsoverygood.Pleasedocontinuedoingexecrcises.(Ifshesaidno–Iadviseyou to do
some good exercises . That will be very good for your heart and yourhealth).
Pt:OK
Dr: Do you have any medical conditins like high blood pressure or diabetes?
Pt: No
Dr:Thatisexcellent.Thatmeansitisnonoftheseproblemswhicharecausingtheproblem
inyourheart.Oneotherreasonwhypeoplegetthisproblemintheheartissmokingforlong time.
Can I ask you do you smoke Mrs Thomas.
Pt: Yes
Dr: Can I ask you what do you smoke and how much do you smoke ?
Pt: 20 cigarettes a day.
Dr: For how Long?
Pt: For about 20 years now.
Dr: Well Mrs. Thomas, there is very high chance that this smoking habit has caused the
problem in your heart. Cigarette contains harmful substances like - Tar: A substance that
causes cancer, Nicotine: it is addictive and increases bad fat cholesterol levels in your body
and Carbon monoxide: which reduces oxygen in the body. I sincerely advise you to stop
smoking so that you do not get this problem again.
Pt: Why do you say it is smoking caused this? My dad was smoking whole of his life he had
no health problem at all ? ( there are so many people smoke they do not have any health
problem)
Dr: I am really glad to know that your dad had no health problem at all despite smoking for
many years. However, Mrs Thomas there is evidence that people who smoke for long time
do get lot of health problmes like stroke, cancers, high blood pressure and including heart
attack.Insomepeopleskinbecomesmorewrinkled.Alsopeoplestayneartoyougetpassive
smoking which can hppen even to your children if you have at home. You may be spending
lot of money on smoking Iguess.
You already had some minor heart problem in your heart now. If you continue that you can
get major heart attack next time and it may be even life threatening. I am sure you don‘t
want that to happen to you isn’t it ?
Pt: You said you are going to widen the blood vessels in my heart. So why should I get this
problem again?
Dr: Mrs Thomas we are treating this condition now, but if you continue smoking - blood
vesselsinyourheartwillbecomenarrowagainanditcancauseseriousproblemnexttime.
There are many benefits of stopping the smoking:
Carbon monoxide and nicotine will be eliminated from the body, blood circulation will
improve.Lungsstarttoclearoutsmokingdebris.Skinbecomeslesswrinkled.Coughingand
wheezingstop.
Excess risk of heart attack and lung cancers reduces by half. Also you could save lot of
money which you spend on buying cigarettes and you can use that money for something
else.
Pt: But doctor I enjoy smoking? I can’t stop it.
Dr: Many people say that they enjoy it but that enjoyment comes at the expense of your
health. If you want to enjoy your life you need to remain healthy. You can try doing some
otherthingstoenjoylifewhichwillbegoodforyourhealth–maybegoingforsomeexercise
classes,relaxationtherapyoryogaclasseswhereyoumeetlotofpeopleandyoumayenjoy that.
If you wish we can help you in stopping smoking. We have some thing called as smoking
cessation clinic. I can refer you to them. There are support help groups. You may be
benefitted from that.
WealsohavesomemedicinescalledBupropionandVareniclinewhichcanhelpinstopping the
craving for cigarettes, but at the end of the day it is your willpower that is the most
importantthing.WhatdoyousayMrsThomas?Do you wanttoconsiderthis?
Pt: I will think over it.
Dr: That is really good. Please do let us know and we will do every thing possible from our
side to help you.
(ifshesaidnoIcan’tstopsmoking-Icanunderstandthatitisnoteasytogiveupthehabits.
However,youmayneedmoretimetothinkoverthat.Iadviseyoutothinkaboutitseriously and let
us know any time if you need our help, we are always here to helpyou.
Thank you very much.
[ do not mention - I will tell my seniors – they will come to talk to you]

BENEFITS FROM SMOKING CESSATION WITH TIME SINCE QUITTING.

Time since BENEFITS
quitting
20 minutes Pulse return to normal.
8hours Nicotinelevelisreducedby90%, carbon monoxide levels in the
blood reduce by 75%, and oxygen levels return to normal,
circulation improves.

24hours Carbon monoxide and nicotine are eliminated from

the body. Lungs start to clear out smoking debris.
48hours All traces of nicotine are removed from the body. Sense
of taste and smell improves.
72hours Breathing is easier. Bronchial tubes begin to relax and energy
2–12weeks Circulation improves.
1month Physical appearance improves owing to improved skin
perfusion. Skin loses its grey pallor and becomes less
3–9months wrinkled.
Coughing and wheezing declines.
1year Excess risk of heart attack reduces by half.
10years Risk of lung cancer falls to about half that of a continuing
15years Risk of MI falls to the same level as someone who has never

ISSUE SOLUTION
 “All the damageis “There are immediate benefits from the day
already done”. you quit”.
 I am already 70, I want enjoythe You are only 70, you have many more
rest of mylife. years to live happily. You can enjoy your
 “A lot of doctorssmoke”. “Very few doctors’ smoke and many
more have given up”.

 “I’ve switched to a lowtar “The health claims about low tar

cigarette”.
 “I smoked in my lastpregnancy “Each pregnancy is different. It’s like
and my baby was a normal
weight”.
 Problem–Stress
 Many patients use
tobacco to cope
withstress.
cigarettes are very misleading. People
tend to inhale more deeply and more
often. Low tar cigarettes have no effect on
heart disease in smokers and anytiny
gambling with your baby’s health”.
Recommend simple relaxation
exercises, e.g. “Take a slow, deep
breath and, as you breathe out, say to
yourself “relax” .Give a stress
  Problem–Weight Gain
[Smoking appears to
lower the efficiency of
caloric storage and/or to
increase metabolic rate.
after cessation, average
weight gain is only2.3kg.]
Stress that the health benefits of
quitting smoking far exceed the risks
of the average weight gain.
There are better ways to reduce weight
rather than smoking cigarettes.
Or First, the patient should quit tobacco
while allowing the weight to accumulate;
Second, when the habit is gone for
good, he/she should focus on losing
weight.

UTI and BPH

Symptoms of UTI Symptoms of BPH
Strong and frequent urge to urinate.  difficulty startingurination
Cloudy, bloody or strong smelling urine.  a frequent need to urinate (
Pain or burning sensation when urinating. nocturia)
Nausea and vomiting.  difficulty fully emptying the
Muscle aches and abdominal pains. bladder

Important differentials :Acute appendicitis,Diverticulitis.Pelvic inflammatory disease,

Gastroenteritis.

Examination DRE ( Digital rectal examination) – shows enlarged prostate

Investigations For UTI - Urine dipsticks – shows Nitrite – positive, leucocytes –

positive. U&E, Creatinine, Urineculture

For prostate :LFT ( Alkaline phosphatase may be raised in Cancer

prostate), Blood PSA, Ultrasound of prostate.

Question :
Mr Mike Atherton, 75 years old man, came to the Surgery department with complaint
of fever and lower abdominal pain for the last 3 days.
You are the SHO in the Surgery department. Take a brief history for the patient and
talk to him about the further management and address his concerns.

Dr: Hello Mr ……. I am Dr … junior doctor in the Urology department. How are you doing?
Pt: I amOK.
Dr: How can I help you?
Pt: Doctor I am having burning sensation when I pass urine.
Dr: Can you tell me anything more about it ?

Pt: Yes doctor it is happening since 3 days now.

Dr: Do you havefever? Pt: Yes since last 3days
Dr: What is thecolour – Pt: Dark and cloudy it smellsbaddoctor
Dr: Did you notice blood in theurine? Pt:No
Dr: Any pain intummy? Pt: yes mylowertummy
Dr: Do you have pain in the loin area (Peylonephritis)? Pt: No
Dr: Did you have this problembefore? Pt:No
Dr: Do you pass more times thanusual? Pt:Yesdoctor Dr:
Do you have to get up in the night to go toloo? Pt: Yes sincefewmonths
Dr: Any dribbling? – Pt: Yes Is it poor stream?- Pt: yes
Dr: Do you have any back pain (secondaries in the vertebra) ?- Pt: No
Dr: Have you noticed any weight loss(cancer)? - Pt: No
Dr: Any problem openingbowel ? Pt: No
Dr: Do you have anymedical conditions? Pt: No
Dr: Did you have any kidneystonesbefore? Pt: No
Dr: Are you taking anymedications? Pt: No
Dr: Are you allergic to any medications ? Pt: Yes to Penicillin
Dr: Do you have any one to look after you ? Pt: yes, I live with my wife/ I live
on my own.

Examination:

Dr: Mr Edwards I need to examine your tummy and back passage to see why this may be
happening ?
Examiner says – There is some tenderness in the supra pubic area and prostate is enlarged and
smooth surface.

Diagnosis:

Dr: Mr Edwards I think you have a condition called as Urinary tract infection basically this
this is infection in the urine means there are some bugs in the urine.
Pt: Why do I have this infection doctor?
Dr: Sometimes bugs comes from the back passage. They get into the urine through the
urethra (opening of the urine passage). In your case there is one other problem which may be
causing this infection.
Pt: What is that doctor?
Dr: While examining your back passage I noticed that one glad called prostate gland which
is the base of the urine bladder is enlarged. When this glad is enlarged it narrows the urine
passage so the urine does not flow out properly. Urine gets accumulated in the urine bladder
and the bugs grows very easily in such situations. Sometimes this condition causes recurrent
urine infections.
Pt: What are you going to do for me doctor?

Investigations for UTI:

Dr: We need to confirm whether you have urine infection - for that we need to test your urine
for bugs and send it to the lab to see what type of bugs may be causing this infection?
Examiner shows a paper - Urine dipstick shows – nitrites and leucocytes and pus cells.
Dr: Mr Edwards your urine tests does show that you have urine infection. We will treat you
with antibiotic medication. Since you said you are allergic to Penicillin we will give you
some other type of antibiotics which are called Trimethoprim( 200mg twice a day for about
a week) which are good for this kind of infection.

We will keep you in the hospitals to treat your urine infection. You can also take some
Paracetamol tablets for the pain and fever and drink plenty of fluids.

Investigations for Prostate gland:

Also we need to do some test to check your prostate gland to see what type of growth it is
whether it is cancerous type or non cancerous. It looks like non cancerous on examination.
We need to do scans on the gland and also we may take some tissue samples from that. We
will also do some blood test specific for Prostate gland.
We will treat the gland according to the test result either with medications –
One of them shrinks the prostate gland (5 a – reductase inhibitor –Fenestaride) and the other
relaxes the water bag / bladder (its neck) alpha blockers –tamsulosin).
Pt: What if the medications don’t work ?
Dr: We may also consider doing a procedure ( TURP) where we pass some instruments
through the urethra and widen the urine passage or we may do an operation to remove the
prostate gland.
Pt: Will I get this infection again.?
Dr: If the prostate gland has been treated then you may not get the infection again and again.
Dr: Any other concerns
Pt: Nodoctor. Dr: Thank you verymuch.
-----------------------------------------------------------------
If the patient lives with his wife – There is no need to be admitted to the hospital for this
you can take this medications at home. It may take up to a week to clear this infection.
However if you become very unwell or if you becoming confused you need to come back to
the hospital. Please tell this to your wife.

Asthma discharge medication and

PEFR ( new exam question)
Mr George Harrison was admitted to the hospital 2 days with shortness of breath. He
was diagnosed as Asthma and was treated.

Assess whether he is fit to be discharged and explain him about the medication he has
to take at home.

( You will have to do PEFR also and tell him how to plot the reading s on the chart –
however this part may not be mentioned in the question).

Greet the examiner.

Dr: Hello Mr George Harrison, I am Dr ..... How are you doing today.
Pt: I am OK.
Dr:Wearethinkingofdischargingyoutodayifyouarefine.Iheretocheckwhetheryouare fit
enough to go back home. Is that OK?
Pt: Yes Doctor.
Dr: How is your shortness of breath now ?
Pt : It is much better doctor.
Dr: Any chestpain ? No
Dr: I need to examine yourchest? ( examiner says – chest isclear).
Dr:IneedyoutodoatestcalledPEFRtoseehowwellyourlungsarefunctioningnow.How you done
this test before?
Pt: No doctor.
Dr Let me explain this to you.
Explain PEFR : This is a device called PEFR meter which has 2 parts – one cylindrical
part with readings in litres /min which has a pointer which moves along the reader to show
the reading and the other one mouth piece.
You need to stand or sit straight but not lying down to do the test.
Attach the mouth piece to the devise, hold it in both the hands horizontally without
blocking the pointer in the reader, take few breaths in and out, take deep breath in, keep the
mouth piece in your mouth, make tight seal of your lips around the mouth piece and blow
though that as hard and as fast as possible at one go and the check the reading and note it
 30

down. Repeat the test 3 times and record the highest of the 3 readings on a chart which will
give you later.
Demonstrate the test and ask him to do the test and correct if he makes mistakes.
Check the readings, ask his normal readings. If he does not know his normal reading then
ask his/her height and age and determine what should have been normal using the chart
for them and tell the patient this should have been your normal readings but this is your
readings now.

( His PEFR readings may be almost equal to predicted normal readings. PEFR should be at
least 75% of his normal to discharge him)
Dr: Mr Harrison, You are doing fine now. Test shows that your lungs are functions well
now. Congratulations -you are fit to go home now. But you need to do this test at home and
record it in the chart which I will explain later.
You should take the medications also at home.

[Check - a) prescription chart for patient identity and for all the medications .
b) Medicines for expiry date and strength of tablets]

Salbutamol inhaler 2 puffs PRN

Beclometasone BD ( 400 micrograms)
Tab Prednisolone 30mg PO OD for 3 days.

Explain medications
 31

Dr: This is called as Salbutamol inhaler which widens your airways. This is blue
coloured. They are called relievers because they relieve Asthma symptoms.

You need take 2 puffs of spray into your mouth whenever you have shortness of breath.
Maximum 4 times in a day.

Dr: Do you know how to use this inhaler ?

Pt: No doctor.

Dr: Let me explain the inhaler techinque

1) Remove the cap and shakewell
2) Take few breaths in and out. Then take a deep breathout
3) Put mouth peice in mouth and make tight seal of your lips around the mouth peice and
take a deep breath in. As you begin to breath in - press this canister down once for one puff
and continue to inhale deeply. Then take it out of yourmouth.
4) Hold breath for 10 seconds and then breathout.
5) For second dose ( Puff) wait for approximately 30 seconds before repeating thewhole
procedureagain.
Can you please show me how you are going to use it !
[ make him repeat – correct if he does any mistakes]
Dr: Make sure that you keep your salbutamol inhaler with you all the time in case you need
to use it.

Like any other medications this can also give some side effects but they are not serious.
You may feel your hands shaking, you may get palpitations and headache but they all
will go away after some time on their own. Are you following me?
Pt: Yes.
Dr: Next medicne is Beclometasone inhaler. This is steriod inhaler which is brown in
colour, this prevents asthma attack. You should take it regularly 2 puffs in the morning and
2 puffs in the evening for two weeks. ( if the strength of each puff is 200micrograms). The
way to use it is the same as the Salbutamol inhaler. You should wash your mouth after using
this inhaler otherwise it will cause fungal infection in the mouth.
Are you following me ?
Pt: Yes
Dr: Next one is Prednisolone tablets ( eg 30mg once day PO for 3 days in the morning)
(If one tab is 5mg - take 6 tablets)
You should take 6 tablets once a day for 3 days by mouth in the morning after food.
This also helps to prevent Asthma.
This may cause pain in the tummy especially if you take it on empty stomch. Usually there
is no other serious side effects since you are taking these for a short period.
Are you with me.
Pt: Yes doctor
 Explain Asthma Dairy
Please keep takings medicines at home as prescribed and do this PEFR test home every day
twice ( each time 3 times) and plot the highest of the three readings on this chart.

In this chart – please write the dates – at the bottom, and mark it properly for each day
morning or evening line corresponding to the readings. Check patient understanding by
giving him the example reading an asking him to show where will you mark it.
If the readings are going up you are improving, please bring the chart with you in your next
visit which will be after 2 weeks.
If the readings are not going up –you are not improving. Please see your GP or come back
her if you do not see improvement in the next 3 to 4 days.
If the readings are going down that means you are getting worse. If you are severely short
of breath and if the medicines do not help please call the ambulance and come to the
hospital A&E department.

WARFARIN
Question: Mr/Mrs 48 year old lady/man has been diagnosed as DVT.

He/She is being discharged from the hospital today. Your consultant has commenced
her on warfarin tablets.

Talk to the patient and address his/her concerns.

Patient is slow to understand and keeps forgetting.

Greet the examiner. ( Warfarin packet, BNF and INR book may be kept inside the cubicle)
Check the Warfarin dose ( usually 5mg OD) also check the BNF briefly for the side effects.
Dr - Good morining Mrs Jones. I am Dr .... One of the junior doctor in the medical dept.

Dr - How are you doing today. Pt - I am well doctor. I am going home today.

Dr - Congratualtions. My consultant has prescribed some medications which you need to

take at home. I am going to explain to you how to take them at home.

If you do not understand any thing any time please do let me know. Is that OK ?

Pt – Ok doc.

Dr - I need to ask you few questions before I explain these medications to you.

a) Any allergy to any medications - Pt - no

b) Do you have any other medical conditions - Pt – No
(CI for warfarin - Liver disease, Peptic Ulcer, Sever HTN)
c) Are you taking any other medications – Pt – No ( Sometimes he may say I take
mini Asprin).
d) Any chance of Pregnancy, breast feeding , or taking OCP – Pt – No
( warfarin should not be given in first and third trimester pregnancy).

Explain medicines to the patient

Dr: This warfarin tablet is a blood thinning tablets. This stops blood from clotting. ( patient
may say you are using big words – then explain clotting means blood may become thick
again like what you already had)
This should be taken regularly, everyday same time for about six months. Better to take it in
the evening. You need to take it by mouth. It is important to take it every day without
forgetting.
( Can you remember to take the tablet. Can you keep an alarm to remind you to take it
every day, or do you have any one to remind you to take the medicine every day. If so I
will explain everything to that person. If no one to remind - then we will do something
to remind you take it every day).
Warfarin can be taken with or without food.
Dosage will depend on the blood test what we do on you regularly. This is called as INR for
which you will have to come to the hospital every week or so and bring the INR booklet
( yellow booklet) with you.
Pt: What will I do if I miss taking the tablets ?
Dr: First of all - it is very important that you should take this every day without forgetting,
otherwise you may develop blood clot again which may travel up to the lungs which can be
life threatening.
If Keep a regular alarm to remind you every day.

If you are taking evening dose and if you forget to take it in the evening but remember
before midnight on the same day, take the missed dose. If midnight has passed, leave that
dose and take your normal dose the next day at the usual time.
Pt - Doctor, what if I forget to take the medicines with me when I go on a holiday ?
Dr – If you forget to take the medicines with you when you go on a holiday you should go to
the hospital there and get the medicine and take it every day.
Side effects –
Bleeding - Since this a blood thinning medicine so you are prone for bleeding.
Be careful while handling sharp objects ( do not injure yourself). If you notice bleeding,
black stool, bruising on the skin, please report to your GP.
Other uncommon side effects are Skin rash, Jaundice, Hair loss, Diarrhoea - please
inform your GP.
If you develop chest pain or shortness of breath (PE), please call the ambulance and come to
the hospital immediately.

Specific advise:-
If you need pain killer, you can take Paracetamol but not Aspirin. [ If patient is taking mini
Aspirin – you will have to stop it. I will inform my seniors about it].
If you are going to see a new doctor or dentist, please tell them that you are taking warfarin.

[ If the patient is sexually active lady taking combined pill – may be the pill itself has caused
the clot and the pill can interact with the warfarin and reduce the effect. Please stop taking
combined pill and talk to your GP for other suitable contraception.
For sexually active young lady not using any contraception – please use some contraception.
Do not become pregnant when you are taking this medicine].

Changingyourdiet suddenlycanaffect
yourINR,especiallyifyoubegintoeatmorevegetablesandsalad. So do not keep changing
your diet frequently.

Drink Alcohol in moderation if she is drinking alcohol. Never binge drink.

Itisbestifyouavoidcranberryjuicealtogether.

If you still have time left then tell the following :

Advice on illness
a. Wear pressure stockings
b. Avoid long journey flight
Dementia - Palliative care
 You are the FY 2 doctor the medical ward.

 Mrs Mary Black is an 88 years old female with a diagnosis of advanced

dementia. She was admitted to the hospital 4 weeks ago with general
deterioration and poor oral intake as she is refusing to eat or drink. She is
losing weight and she is also agitated.

 Your consultant thinks planned not to give any aggressive treatment. He has
decided for palliative treatment.

 Speak to the daughter, Mrs Sarah Black, about her condition and address her
concerns.

Dr: Hello Mrs Sarah Black. I am Dr …. One of the junior doctor in the medical
department looking after your mother Mrs Mary Black.
How are you doing?
Daughter: I am fine doctor ? How is my mother ?
Dr: She is OK now but can you please tell me how much do you about what is
happening to her.
Daughter: I was told that she has dementia.
Dr: Do you know what is dementia ? Daughter: No
Dr: Dementia is a condition of the brain that causes gradual loss of mental ability.
This can cause memory loss, reduced interest in eating enough, Incontinence,
Swallowing difficulty, inability to communicate.
Did she have any other medical condition before ?
Daughter: No
Dr: Do you have any concerns about her.
Daughter: Yes doctor. She is not eating properly. She is losing weight. I am very
concerned. She has looked after me a lot. She has done lot for me. I want to do the
best for her.
Dr: I can imagine. How was she at home before she was brought in – was she
eating well ? Was she active in her life ? Was she mobile ?
Daughter: She was eating OK but she was not very active.
Dr: We have examined her and found out that she has no other medical problem
apart from Dementia. Yes we have noticed that she is not eating well and losing
weight. This is because of her dementia which is in advanced stage now.
Because of all these my consultant thinks it is not good to give her any active or
aggressive treatment as her condition is not going to be any better. So he thinks it is
better we give her only palliative care.
Daughter: What is palliative care ?
Dr: Palliative care means we do not give active aggressive treatment or any invasive
procedure to the medical condition which is advanced and progressive but we give
complete supportive care for patients and their families. We manage their pain and
any other distressing symptoms. We provide all types of supports like psychological,
social and spiritual support. We try to give the best quality of life for patients and
their families. We offer a support system to help patients live in dignity and as
comfortable as possible as long as they live.
Daughter: Doctor Who Provides Palliative Care ?
Dr: We have a specialist team called Multidisciplinary palliative care team who
provides this type of care. There are specialist consultants and nurses and also
physiotherapists, occupational therapists, dieticians, pharmacists, social workers
and those who are able to give spiritual and psychological support. Someone can
even stay at patient’s home to give care at home.

Daughter: Does this mean it is the end of her life ?

Dr: Palliative care is not just given for end of life care it is also given to those who
needs such help early in the disease means well before many months of expected
death.
Daughter: But she is not eating properly. She is losing weight.
Dr: In advanced stage dementia these things do happen. They lose appetite and
they refuse to eat. Also Dementia patients lose weight even if they eat normally.
Daughter: Don’t you have any methods to feed her ?
Dr: We do have lot of methods to feed patients artificially. We can give fluids
subcutaneously that is under the skin and also we can pass a tube from her nose
to stomach ( NG tube) and feed her through that and we have another method
what we call as PEG where we make a small hole from the tummy and pass a tube
directly from the tummy wall to the stomach and feed her through that.

However all these methods are not good for her because she will only be distressed
more with these types of feeding. Instead we allow them to eat and drink as they like
though there are some risks involved. This is what we call as comfort feeding. If
required she can be hand fed rather than tube feeding.
Daughter: Why it is better ?
Dr: Because dementia patients have reduced appetite and they lose weight
despite feeding artificially. Artificial feeding will not improve appetite. Also even in
artificial feeding there are risks that food may still go into the lungs. It does not
improve quality of life. Survival is not prolonged in artificially fed patients.
Feeding through the nose tube can be applied temporarily for few weeks in
someone who’s swallowing are likely to recover. In your mother’s case we are not
expecting her to improve or recover. It cannot be put for long time and also it is
distressing to the patient and can make them more agitated.
PEG: Disadvantage is that it is invasive procedure, can be dislodged by an agitated
patient, also it needs training to carers or family.
It is better to feed her by hand. Feeding by hand improves the communication and
interaction with the patient by being close to them while feeding. Also they require
much less energy. She can be fed high energy foods or fortified food. Our
dietician can advise what types of food is better for her.
Daughter: Can you feed her forcibly?
Dr: It is not good to do that. As I mentioned she will not improve even if we force
feed her. It will only distress her more.
Daughter: Can I take her home?
Dr: Yes surely you can take her home if you wish to. Have you thought of keeping
her in the hospice – this is similar to home where only this type of patients are
cared for.
Daughter: What is hospice ? What do they do there?
Dr: In Hospice there are doctors, nurses, social workers, therapists, counsellors, and
trained volunteers. Hospices aim to feel more like a home than hospitals do. They
can provide individual care more suited to the person who is approaching the end of
life, in a gentler and calmer atmosphere than a hospital.
Daughter: OK. I would like to take her home now and think about the hospice later.
Dr: Ok that is fine. We will make arrangements for that. Do you need any help to
take care of her at home ? If you need we can arrange nurses and social care
workers to help you to look after her.
Daughter: Thank you doctor.
Dr: Thank you.

Exercise induced Asthma

Mr …. Presented to the hospital with shortness of breath.

Take history from him and discuss you further management with him.

Dr: Hell Mr… I am Dr …. Can you please tell me what brings you to the hospital? Pt: I am
feeling very short of breath whenever I play football.
Dr: I am sorry to hear that. Are you short of breath now? Pt: No I am Ok now.
Dr: Anything more you can tell me about this problem. Pt: It just started last few weeks.
Dr: Do you feel short of breath when you are not doing exercise ? Pt : No
Dr: Do you feel short of breath when you lie down
( heart failure) ? Pt : No
Dr: Do you have any cough ? Pt: Yes whenever I feel short of breath I get cough also. Dr:
Do you bring out any sputum? Pt: No
Dr: Any fever ? Pt: No Dr: Chest pain ? Pt: No I feel my chest is tight. Dr: Are
you allergic to anything at all? Pt: No
Dr: Do you have any pets at home ? Pt: No
Dr: Do you get SOB when you get exposed to plant pollens ? Pt: No Dr: Did you
have any swelling or pain in your calf muscles ? Pt: No Dr: Did you travel
anywhere recently? Pt: No
Dr: Did you have any operations recently ? Pt: No
Dr: Any other problems like any skin rash. Pt: Yes I have skin rash ( eczema ). Dr: Did
you have this problem before ?
Pt: Yes I used to feel short of breath whenever I do any exercise. Dr: Do you have any
medical conditions ? Pt: No
Dr: Like bronchitis? Asthma ? Heart problems ? Pt: No Dr: Do you smoke ? Pt: No

Dr: Are you taking any medications ? Pt: No Dr: Any of your family members have
any medical conditions? Pt: My dad has asthma and eczema.
Dr: Is there anything else important that we need to know? Pt: No Dr: Mr… I need to
examine your chest.
[Examiner may say – there is rhonchi on both sides]. Dr: Mr… I think you have asthma.
I want you to do a test to check how your lung is functioning. This test is called PEFR.
Make him do PEFR. Check his predicted normal reading on the chart provided. PEFR may
be normal. ( may be low sometimes).

Dr: Mr… Your reading is good now. Mr … you may be having a condition called Asthma.
Do you know what is asthma ? Pt: No doctor.

Dr: Asthma is a condition in the lung where the patient becomes short of breath because
the wind pipe become narrowed. This is usually happens to people who are allergic to
something like pollens, animal fur or sometimes this can be triggered due to exercise –
probably the exercise is causing you this problem. Are you following me ? Pt: Yes.

Investigation: We will do chest X Ray to make sure that you do not have any other
problem in the chest. ( rule out – pneumothorax).
Also we need to do a test called Spirometry when you are exercising on a treadmill to see
your lung function. That will tell us whether it is exercise induced Asthma.

Management

Dr: At the moment since you ae not short of breath there is no need for admission to the
hospital. However you may get this problem again when you exercise.

Prevention

In the future to prevent getting this asthma attacks you need to take some steps.

You can do exercises. It is better to avoid football because it involves long period of
activity. Instead short duration sports may better for you. However you need to take some
inhaler medications like salbutamol ( broncho dilators) about 20 minutes before you do any
kind of exercise.

In addition to taking medications, warming up prior to exercising and cooling down after
exercise can help in asthma prevention.

If you have allergy to pollen then the exercise should be limited during high pollen days or
when temperatures are extremely low.

If the weather is cold, exercise indoors or wear a mask or scarf over your nose and mouth.

Infections can cause asthma (colds, flu, sinusitis) and increase asthma symptoms, so it's
best to restrict your exercise when you're sick.
Is that Ok ? Pt : Ok doctor

Dr: Are you following me? Pt: YesDr: Any other questions ? Pt: No Thank you.

Another scenario for exercise induced Asthma

On history patient may say he is short of breath now.

Ask him since when ?
What was he doing when he became short of breath ?
He may say he was playing foot ball.
Ask him if he is comfortable to talk.

Rest of the history is same.

Do PEFR – which may be normal or low.

Diagnosis and investigation are the same as above.

Treatment

We will admit you ow and treat with some medications called salbutamol nebuliser. They
are called broncho dilators. This will help to widen your wind pipe.

We will also give you some steroid tablets. This will help prevent asthma attacks. We will
discharge you once you are better which may be a day or two.

Then talk about prevention.

Information

What Are the Best Exercises for Someone With Asthma?

For people with exercise-induced asthma, some activities are better than others. activities
that involve short, intermittent periods of exertion, such as volleyball, gymnastics, baseball,
walking, and wrestling, are generally well tolerated by people with exercise-induced
asthma.
Activities that involve long periods of exertion, like football, distance running, basketball,
and field hockey, may be less well tolerated, as are cold weather sports like ice hockey,
cross- country skiing, and ice skating. However, many people with asthma are able to fully
participate in these activities.
Swimming, which is a strong endurance sport, is generally better tolerated by those with
asthma because it is usually performed in a warm, moist air environment.
Maintaining an active lifestyle, even exercising with asthma, is important for both physical
and mental health. You should be able to actively participate in sports and activities

Patient requesting Antibiotics

Exam question:

You are the FY 2 doctor in the GP clinic.

22 year old Miss Chris Barns presented to the GP clinic 2 days ago with sore
throat. Practitioner nurse did the throat swab which showed no bacterial
growth.
Nurse advised her to take mild pain killers and steam inhalation. She has
come back again and wants to talk to the doctor.
Assess her current condition and address her concerns.

Dr: Hello Miss Chris Barns I am Dr…. How can I help you Miss Barns ?

Pt: I am having sore throat doctor. I came here 2 days ago and the nurse told me to take pain
killers and steam inhalation. I am not getting any better. Can you please give me antibiotics.
Dr: Can I ask you why are you asking for antibiotics?
Pt: Last time I had some infection and I was given antibiotics and I improved very quickly. Please
give me antibiotics. I have to attend some function in the next few days. I want to get better
before that.
Dr: I can understand your concerns. Do you know what infection you had last time? Pt : I can’t
remember now.
Dr: No problem. Can I ask you few questions to see whether you need antibiotics. If you need it
we will definitely give it.Pt: Yes doctor. Thank you.
Dr: Since when are you having this sore throat ? Pt: Almost 4 days now doctor.
Dr: Do you have any pain while swallowing ? Pt: Yes slightly. Dr: Are you able to swallow food
or drink ? Pt: Yes
Dr: Do you have any breathing difficulties? Pt: No
Dr: Is your symptoms getting any better or the same or getting worse ?
Pt: It is the same doctor not getting better. I feel slightly better when I use steam inhalation. Dr:
Do you have any other problem apart from sore throat?
Pt: I am having pain all over the body.
Dr: Any other problems? Pt : Like what ?
Dr: Do you have fever ? Pt: No Dr: Do you have cough and cold ? Pt: Yes Dr: Do you bring
out any phlegm ? Pt: No Dr: Do you have pain in the ear ? Pt: No Dr: Any
chest pain ( Pneumonia) ? Pt: No Dr: Any discharge from the nose ?
Pt: Yes Dr: Any headache ( meningitis) ? Pt: No
Dr: Any rashes on the body ( meningitis, glandular fever? Pt: No Dr: Any swellings on the
neck or arm pit ( glandular fever) ? Pt: No Dr: Did you have similar problem before at all? Pt: No
Dr: Do you have any medical conditions? Pt: No
Dr: Are you taking any medications other than pain killers and steam inhalation? Pt: No Dr: Are
you allergic to any medications ? Pt: No

Examination:

Dr: Miss Barns , I need to examine your throat and chest. Examiner may say – Examination is
normal.

Diagnosis:

Dr: Miss Barns with the information what you have given me and after the examination, I think
you have sore throat due to viral type of bugs. This type of virus infection will subside on its own
without any special treatment. Only treatment required are for the symptoms like pain killers
and the steam inhalation which you are already taking.

Pt: But I am not getting better doctor !

Dr: Miss Barns sometimes it may take about a week for the condition to subside. I advise you to
continue taking the pain killers and the steam inhalation for few more days and you will feel
better in the next few days.
Dr: Doctor, I have to attend a function in the next few days. I want to feel better soon to attend
that function. Please give me antibiotics.

Dr: Miss Barns Antibiotics are given only for infections due to bacterial kind of bugs not for
infection due to virus type of bugs. They do not help for viral infections. Besides that antibiotics
has its own side effects. So you may develop unnecessary side effects.

Pt: Doctors last time I improved very quickly after taking the antibiotics !
Dr: I am not sure why the antibiotics were given to you last time. May be you had infection due
to bacterial type of bugs. This time it is not bacterial infection. Nurse took a swab from your
throat last time to check whether you have bacterial infection. That test also shows this is not
bacterial infection..

Miss Barns, if we give antibiotics unnecessarily, bugs may develop resistance to these antibiotics
and next time if at all you get bacterial infections these antibiotics may not work and it may lead
to serious complications. If it all you needed antibiotics we would have definitely given that to
you. Your condition does not require it. You will feel better soon.
Pt: Ok doctor.
 Warning signs.

Dr: Thank you miss Barns. You can go home now and continue taking pain killers and the steam
inhalation. However if you are getting very unwell, or start developing chest pain and high fever
or if you see rashes on the body these could be the signs that you are developing some
complications like chest infection, so please do come back.
Hope you recover soon and be able to attend the function.

Postural Hypotension
Causes of falls

Non Medical Medical

Poor vision
Poor light Balance problem ( cerebellar)
Slippery floor Postural hypotension ( medications)
tripping Diabetes Heart arrhythmia
Pushed( Abuse) Alcohol
Osteoporosis
Dementia

Drugs causing Postural Hypotension

• Hypertensive/Cardiac medications
o Methyldopa
o Clonidine
o Alpha blockers- Prazosin, Terazosin
o Beta-1 blockers (Atenolol)
o Nitrates
o Cardioselective CCBs (Verapamil, Diltiazem)
• Genitourinary
o Alpha blockers- Prazosin
o Phosphodiesterase Inhibitors (Cialis, Viagra)
o Anticholinergics (Oxybutynin)
• Neuropsychiatric
o TCAs- Amitriptyline
o Antipsychotics- Clozapine
o Muscle relaxants- Baclofen
o Antiparkinsonian drugs- Levodopa/Carbidopa

Causes and risk factors of postural hypotension

Although the condition can occur in healthy older people, it is more common in those who
have additional risk factors. It particularly affects people on prolonged bedrest and those
aged over 74. However, it is not confined to the older population.
 It can be caused by:

Hypovolaemia;  Diabetes; Peripheral neuropathy

 Parkinson’s disease; Anaemia; Adrenal insufficiency

EXAM question

You are FY2 in the medical department.

64 year old lady presents with complaints of few falls last week.
Take history, do relevant examination and discuss management with the patient.

Dr: Hello Mrs.... My name is Dr... I'm one of the junior doctors in the GP clinic. What
brings you in today?
P: Hello doctor... I have been falling suddenly for a couple of weeks now... Dr: I'm sorry to
hear that Mrs.... could you please tell me more about it?
P: Doctor, in the last two weeks.. I have fallen all of a sudden a few times. Especially when
I have gone out with my friends. When I'm standing, suddenly I feel a little dizzy and then
I fall. Today also I was doing window shopping in the town centre and I suddenly fell.
Ambulance brought me here. I like to go out with my friends. Now I am scared to go out
with my friends.
Dr: I am very sorry to hear that. We will sort out the problem very soon.
Dr: Ok.. Have you lost consciousness before or after the falls ? P: No
Dr: Do you have visual disturbance? P: No
Dr: Do you keep slipping or tripping and then fall? P: No
Dr: You mentioned feeling a little dizzy prior to your fall. Did you feel like the room was
spinning? P: No
Dr: Do you have a feeling of fullness in your ear? P: No
Dr: Do you hear any high pitched noise in any ear? P: No
Dr: Do you have any balance problem while walking ? P: No
Dr: Do you have palpitations? P: No
Dr: Have you been diagnosed with any medical conditions?
Pt: Yes I have high blood pressure.
Dr: Do you have diabetes or any other conditions like Parkinsons ? Pt : No
Dr: Have you had any heart problems in the past? P: No
Dr: Have you ever had a stroke? P: No
Dr: Any of your family members have any medical conditions ? P: No

Dr: Can you think of something that happened two weeks ago that might have triggered
this problem? P: No I can’t think of anything.

Dr: Are you taking any medications?

P: Yes I am taking medications for my blood pressure.
Dr: Can you please tell what medication you are on right now? P: I can't remember the
name doctor

Dr: No problem Mrs... Do you have the medication with you? P: No

Dr: Are you carrying the prescription with you ? P: No
Dr: Ok that's fine Mrs... We will get in touch with your GP to get the details. Can you
please tell me for how many years you have had high BP?
P: > 10 years
Dr: Has the medications been changed recently.
P: Yes about 2 weeks ago GP changed my blood pressure medication.
Dr: Have been falling like this before the GP changed the medications? P: No. It started
after that.
Dr: Do you smoke Mrs..? P: No
Dr: Do you consume alcohol? P: Yes, whenever I go out with my friends (Explore alcohol
according to answer)

Examination and investigations:

Dr: Ok Mrs... I need to check your pulse and BP. I will have to check your BP while you
are lying down and while you are standing.
(Examiner findings: Lying- 150/90; Standing- 110/70 ) ( postural hypotension if standing
blood pressure is drop is more than 20/10 compared to lying down).
I would also like to examine your chest to check your heart..
(Examiner findings: normal)

I would like to get an ECG or a heart tracing. (Examiner may hand over an ECG- usually
normal)
And check your blood for the sugar levels and check for anaemia. (Examiner says –
Normal).

Diagnosis:

Dr: Mrs... based on the information you have told me and the findings on examination, I
think you have a condition called postural hypotension. Do you know what that is?
P: No
Dr: Postural hypotension is a condition where your BP tends to fall when you switch from
a lying down or sitting position to a standing posture. It is very common in people after the
age of 70 years. It can also caused by other medical conditions like Diabetes o Parkinson’s
disease. However in your case it might be due to your new BP medication. Certain blood
pressure mediations can lower your BP too much while standing causing you to feel
weak/dizzy and fall.
Are you following me Mrs...? Pt: But Doctor I did not stand from a sitting position when I
fell down.
Dr: Sometime this can happen if you stand for long time or even when you change your
posture like bending down. Pt: OK

Treatment:

Dr: We will admit you now to the hospital. We will get in touch with your GP to find out
which medication you are taking for your blood pressure. We will then have to stop it if it
is the cause and start you on some other medication for your BP. We will keep monitoring
you and when we think you are safe to go home we will discharge you.

Dr: Unfortunately, this condition can happen even after discharge, so you need to take
some precautions to reduce this problem happening again.

Take particular care in the morning because blood pressure tends to be lowest in the
morning and the symptoms are likely to be worst in the morning. Get out of beds in stages.
Cross and uncross legs firmly before you sit up and again before standing.
Avoid sudden changes in posture.
Avoid sitting or standing for long periods.
Raise the head of your bed with blocks.
Wear support stockings or tights. This helps return blood to the heart. But do not wear
them when you go to the bed.
Drink plenty of fluids and also drink strong tea or coffee. Take small frequent meals
because some people have large drops in blood pressure after meals.
Avoid drinking excess alcohol.

If none of these measures helps you then we can consider giving some medication
( although fludrocortisone is not licensed for the treatment of postural hypotension it is
usually the drug of choice. Its actions include volume expansion and the promotion of
arteriole vasoconstriction) Are you following me ?
Pt : Yes. Dr: Any other questions ? Pt : No Thank you

MRSA – COPD patient

You are the FY 2 doctor in the medical department.

Mr Charles Roper 56 year old man has been admitted to the hospital for COPD.
His nose swab showed MRSA.
He has been isolated and been treated appropriately.
His wife Mrs Helen Roper is concerned about him.
Please talk to her and address her concerns.

Dr: Hello Mrs Helen Roper !

Wife: Yes.
Dr: I am Dr. …. One of the junior doctor in the medical department. How are you doing
Mrs Roper?
Wife: I am OK. I am worried about my husband ! I just came to see him. He has been
shifted to some other room. I can see doctors and nurses wearing aprons and gloves. What
is happening to him doctor?
Dr: I can see that you are very concerned, I will explain everything. Before that can you
please tell me how much you know about what is happening to him?
Wife: I know he has COPD !
Dr: Yes, That is right Mrs Roper. He has COPD and was treated as you know. But we did
some swab test on his nose and it showed that he has some bugs in his nose.
Wife: What kind of bugs?
Dr: These bacterial kind of bugs are called MRSA in other words they are called super
bugs. Do you anything about these bugs MrsRoper ?
Wife: Super bugs ! I have heard of them. From where did he get this bugs ? Is it because
the hospital is dirty?
Dr: Sometimes the bacteria normally live on the people’s skin without causing any
problem. Sometimes these bugs are spread through skin-to-skin contact with someone who
has an MRSA infection. These bugs also spread through contact with contaminated objects
such towels, sheets, clothes, dressings, surfaces, door handles and floors.
Sometimes people may get this infection outside the hospital also.

We do keep the hospital very clean to minimise the spread of this infection. When doctors
and nurses enter the room of the patient’s with this of infection they wash their hands
thoroughly and wear aprons and gloves to minimise the chance of spreading the infection.

However, sometimes people can get this infection because new patients keep coming into
the hospital and they may have this bugs on their skin and it spreads to others.

Wife: Is it a serious problem doctor?

Dr: At the moment these bugs are just present in his body and it is not causing any
problems to him. So it is not a serious problem to him at the moment.
However, if the bugs gets inside the body and cause infection then it can become serious
problem. Sometimes the bugs can get inside the body and cause infection if their body
resistance goes down or if they have some break in their skin like operated wounds or it
can enter inside the body through urine catheter or IV cannulas ( the tubes through which
we give medication into the veins).
In your husbands case because he has COPD, his body resistance would be low. So there is
a chance that bugs may get inside his body and cause infection.

Wife: Do you mean to say he may die doctor?

Dr: Mrs Roper, As I told you at the moment there is no problem because the bugs are just
present in is body. It is not very common that people die because of this bugs. It can
happen only if the people gets serious infection with this bugs and bugs do not respond to
any treatment.

Wife: How are you treating him doctor ?

At the moment bugs are just present on his body. So we are treating him appropriately to
get rid of these bugs. Usually we put some antibiotic cream to the nose and use
antibacterial body wash products and powders to get rid of these bugs from the body.
However, if the bugs get inside the body and cause infection it can cause problems because
these bugs are resistant to most of the antibiotics what we usually use to kill the bugs. But
they usually do respond to one type of antibiotics called Vancomycin. We will treat
patients with Vancomycin injections if they have infection with this kind of bugs.

Wife: Why he has been shifted to the other room?

Dr: Mrs Roper, I can imagine why you are so worried. As I explained, this infection can
spread from one patient to another patient easily if they are close to each other in the same
room. We have to keep him in a separate room so that the bugs will not spread. It is
beneficial to him also because there are no other patients in that room, so he may not get
any other kind of bugs from others.

Wife: How long will he need to be in the hospital?

Dr: It may take few days to get rid of this bugs. We will keep checking that. Once he get
rid of this bugs and he has no other problem then we will discharge him.
Wife: Can I see him doctor?
Dr: Surely you can see him. However, we suggest you to wash your hands thoroughly
before and after you enter the room and minimise touching him or anything else inside
the room so that this bugs will not spread. Is that alright Mrs Roper?
Wife: Ok doctor.
Dr: Any other concerns?
Wife: No doctor.
Dr: Thank you very much Mrs Roper, I hope he will recover soon. If you need any other
help please let me know.

Clostridium difficile Infection - Talk to Son.

You are FY 2 doctor in the medical department.

Mr. Andrew Reece 65 year old man had been admitted to hospital for exacerbated
COPD ( or Pneumonia) 10 days ago. He has been treated with the appropriate IV
antibiotics and has now developed acute diarrhoea.

His stool samples are taken and revealed presence of C. difficile Toxin.

He has been shifted to a bay with other people with similar condition and been
started on treatment.

His son is concerned about him.

Please talk to him and address his concerns.

Dr: Hello. Are you Mr. Andrew Reece’s son?

Son: Yes.

Dr: I am Dr. …. One of the junior doctors in the medical department. How can I call
you?

Son: (?)

Dr: How are you doing Mr...?

Son: I am fine. I am worried about my father. I just came to see him. He has been
shifted to some other room. I can see doctors and nurses wearing aprons and gloves.
What is happening to him doctor?

Dr: I can see that you are very concerned, I will explain everything. Before that can you
please tell me how much you know about what is happening to him?

Son: I know that he has COPD. Now, he has developed diarrhoea. I think he has got
food poisoning because of the food that you give him in the hospital.

Dr: You are right that he had COPD and yes, he has developed diarrhoea but it is not
food poisoning and neither it is because of the food that we are giving him in the
hospital. We actually did some tests on him and it showed that he has got some bugs in
his colon.

Son: What kind of bugs?

Dr: These are bacterial kind of bugs called C. Difficile. Do you know anything about
these bugs?

Son: No doctor. I don't know about the bugs but I know that you are responsible for this.
He was perfectly fine before.

Dr: You are a very caring son. I can imagine why you are so anxious. But let me assure
you, we take really good care of all our patients.

Son: Then from where did he get these bugs?

Dr: Please let me explain it to you why your father has developed diarrhoea.

Son: Okay.

Dr: Infection with this bug most commonly occurs in people who are in hospital and
recently had a course of antibiotics like your father. Are you following me?

Son: Yes.

Dr: Actually, this bugis normally present in gut of many people. But it lives harmlessly.
The number of these bugs that live in the gut of healthy people is kept in check by all
the other harmless bugs that also live in the gut. So, in other words, some of us normally
have small numbers of these bugs living in our guts, which do no harm.

If someone takes antibiotics for any infection as in your father's case, this antibiotic that
he took not only killed the bacteria that caused the chest infection, but also killed many
of the harmless bacteria that lived in his gut. C. difficile type of bugs did not get killed
by this antibiotic. When other harmless bacteria are killed then this allowed C. difficile
type of bug to multiply. This bug also started to produce poisons which are called as
toxins and these toxins caused him diarrhoea.
Son: But doctor many other patients have developed diarrhoea as well. It has to be
because the dirty hospital food.

Dr: I can see why you are thinking that it is because of the hospital food. But let me tell
you that we do keep the hospital very clean. We take really good care of hospital
hygiene. The food provided in our ward is prepared under strict aseptic techniques.
Every member of the health care team wash their hands thoroughly and wear aprons and
gloves to minimize the chance of spread of any kind of the infection to patients.

Son: Well, other people get it. Why did they get this bug?

Dr: Despite the good medical care, sometimes, it can spread to other people. It can
happen that the spores produced by the bugs can spread from the faeces of infected
person to a non-living surface and from there can spread to the patients who are prone to
this infection.

Sometimes people can get this infection because new patients keep coming into the
hospital and they may have this infection and it spreads to patients already admitted in
the hospital. These bugs also spread through contact with contaminated objects such
towels, sheets, clothes, dressings, surfaces, door handles and floors. And so regretfully,
sometimes further spread can occur via the hands of healthcare workers despite all the
caution.

Son: Are you sure that he had this bug?

Dr: Yes, as I have mentioned we have tested the blood of Mr. Herman. We have found
C. Difficile type of bug in his blood and it is risen because of the antibiotic that he used
in order to treat his chest infection.

Son: But why did he get this bug?

Dr: Well, as I have told antibiotics are the main cause of this infection. And above 60
years, there is increased threat of getting infected with this bug. Also, in your father's
case because he has COPD, his body resistance would be low. So there is a fair chance
that bugs got inside his body and caused this infection.

Son: How are you treating him doctor ?

Dr: Well, Mr. Herman is closely monitored. We have stopped the antibiotics that we
were giving him previously for his chest illness. This will allow the normal harmless
bugs to thrive again in the gut. The overgrowth of C. difficile should then reduce and
diarrhoea will stop.

However, we will be starting him on a different antibiotic that is known to kill C.

difficile. This is usually vancomycin or metronidazole. Symptoms then usually ease
within 2-3 days.

As with any cause for diarrhoea, it is important that we replace the fluids that are lost in
the diarrhoea. So, we will be giving him fluids through a drip into his veins to keep him
hydrated. Are you following me?
Son: Is it serious doctor?

Dr: At the moment these bugs are just present in his colon and it is not causing any
problems to him. So it is not a serious problem to him at the moment. However, in very
rare cases if the infection is not treated at the right time, it can become very serious.

Son: Can there be any complication?

Dr: In small number of cases, if not managed at the right time, it can progress into a
serious illness in which swelling of intestine develops and for that, surgery may be
needed.

Son: Why he has been shifted to the other room?

Dr: I can imagine why you are so worried. As I explained, this infection can spread from
one patient to another patient easily if they are close to each other in the same room. We
have to keep him in a separate room so that the bugs will not spread. It is beneficial to
him also because there are no other patients in that room, so he may not get any other
kind of bugs from others.

Son: Can't you give him any medicine to stop his diarrhoea?

Dr: Anti- diarrhoeal medicines are not recommended in this infection. This is because it
is thought that they may slow down the rate at which the poisons (toxins) produced by
the bacteria are cleared from your gut.

Son: How long will he need to be in the hospital?

Dr: It may take few days to get rid of this bugs. We will keep checking that. Once he get
rid of this bugs and he has no other problem then we will discharge him.

Son: Can I see him doctor?

Dr: Surely you can see him if you yourself do not have any medical conditions because
if you have any medical conditions then you may catch this bugs easily. You can enter
his room and see him. However, we suggest you to wash your hands thoroughly before
and after you enter the room also you should wear apron and gloves and minimise
touching him or anything else inside the room so that this bugs will not spread. Is that
alright?

Son: Ok doctor.

Dr: Any other concerns?

Son: No doctor.

Dr: Thank you very much, I hope Mr. Herman will recover soon. If you need any other
help please let me know.

Information on C Difficle management

Management of mild, moderate, and severe CDI

1. If a patient has strong a pre-test suspicion for CDI, empiric therapy for CDI
should be considered regardless of the laboratory testing result, as the negative
predictive values for CDI are insufficiently high to exclude disease in these
patients. (Strong recommendation, moderate-quality evidence)

2. Any inciting antimicrobial agent(s) should be discontinued, if possible. (Strong

recommendation, high-quality evidence)

3. Patients with mild-to-moderate CDI should be treated with metronidazole 500

mg orally three times per day for 10 days. (Strong recommendation, high-quality
evidence)

4. Patients with severe CDI should be treated with vancomycin 125 mg four times
daily for 10 days (Conditional recommendation, moderate-quality evidence)

5. Failure to respond to metronidazole therapy within 5–7 days should prompt

consideration of a change in therapy to vancomycin at standard dosing. (Strong
recommendation, moderate-quality evidence)

6. For mild-to-moderate CDI in patients who are intolerant/allergic to

metronidazole and for pregnant/breastfeeding women, vancomycin should be
used at standard dosing. (Strong recommendation, high-quality evidence)

7. In patients in whom oral antibiotics cannot reach a segment of the colon, such as
with Hartman’s pouch, ileostomy, or colon diversion, vancomycin therapy
delivered via enema should be added to treatments above until the patient
improves. (Conditional recommendation, low-quality evidence)

8. The use of anti-peristaltic agents to control diarrhoea from confirmed or

suspected CDI should be limited or avoided, as they may obscure symptoms and
precipitate complicated disease. Use of anti-peristaltic agents in the setting of
CDI must always be accompanied by medical therapy for CDI. (Strong
recommendation, low-quality evidence)