1

Septic Shock – telephone conversation

Exam question:

You are the FY2 doctor in the A& E department.

88 year old lady Mrs Olive Green was referred from a care home to the hospital. She is in
the A & E department. There is no referral note from the care home.
She is confused and agitated. She did not allow you to examine her.
Her Pulse is – 120, BP – 90/60, Oxygen saturation is 88%, Temperature is 38 C.

Talk to the care home over the telephone and take her details and then talk to the examiner
about her further management.

Dr: Hello, Is it the care home ?

Carer : Yes,
Dr: I am Dr … one of the junior doctor in the A& E department. May I speak to the person
who was looking after Mrs Olive Green.. please.
Carer: Yes it is me. How can I help you ?
Dr: May I Know your name please:
Carer : I am ….
Dr: I need some information about Mrs Olive Green she was actually referred to our
hospital today but there was no referral note from the care home. Could you give me some
information about her – why she was referred to the hospital today ?

Carer: Well doctor I was on leave for the last 3 days. I just came back to work today. I can
look at her notes and tell you about her.
In the records it says she was chesty in the last few days.
Dr: You mean she had cough. Carer : Yes
Dr: Any information about what happened today? Carer : No
Dr: How long was she chesty ? Carer: Last few days
Dr: Did she have chest pain ? Carer: Yes.
Dr: Did she have fever: Carer: yes
Dr: Was she coughing up any phlegm or blood do you know?
Carer: Yes she had some phlegm.
Dr : What colour is that? Carer : Greenish/ Yellowish.

Dr: Did she have any burning sensation while passing urine ( UTI) ? Carer: No
Dr: Any urinary incontinence? Carer: No
Dr: Was the urine very smelly? Carer: No

Dr: Was she complaining of headache ( meningitis) ? No

Dr: Did she have any rashes on her body ( meningitis) ? No

Dr: Did she have any diarrhoea ( Gastro-enteritis) ? - No Vomiting ? Carer: No

Was she complaining of any pain abdomen ? Carer: No
 2

Dr:You have been very helpful. Can you please tell me was she mobile or bed ridden ?
Carer: She was mostly bed ridden but we are trying to mobilise her as much as possible.
Dr:Did she have any bed sores ( infected bed sores ) ?Carer: No
Dr:Was she eating drinking well ?
Carer: She has swallowing problem. She had choked on food few times and 3 months ago
she had this problem. ( sometimes - there is no swallowing problem).

Dr:Has she got any medical conditions ?

Carer: Yes she has High blood pressure and she had stroke 3 years ago.
Dr:Did she have diabetes or any heart problem ?Carer: No
Dr: Does she smoke or drink alcohol ( for cause of confusion and aspiration) ? Carer: No
Dr:Is she on any medication ?
Carer: Yes she is taking Ramipril, Aspirin and Atorvastatin.
Dr:Is she allergic to any medication?
Carer: Yes Penicillin.
Dr:Do you know whether any of her family members has any medication conditions ?
Carer: I do not know

Dr: Is there anyone else who is not well at care home recently ?
Carer : No

Dr:Can I know about her family members please – any one visiting her ?
Carer: No one has visited her for the last 3 months…
Dr:Can I get the tel number of the next kin please ?Carer: Yes…..

Dr:Is there any information in her records about any decisions about what should be the
treatment if she is not well ?
Carer: DNAR decision was taken last time when she was in the hospital.
Dr: Any other information about any treatment to be given or not ?
Carer Nothing else is written.

Dr:Ok Thank you very much Miss … You have been most helpful. Is there any thing else
you think is important that we may need to know ?

Carer: No. What is happening to her doctor?

Dr: I do appreciate your concerns about her. As you know she is not well. We are treating
her. Unfortunately I cannot give more information about her because we are supposed to
keep the patient’s health information confidential. You have been most helpful. Thank you
very much for the information.

Talk to the examiner.

Dr:I think Mrs Olivia … is inSeptic shock because of aspirationPneumonia.

( if she was not vomiting just Pneumonia but do not mention aspiration Pneumonia)

Examiner: Why do you think so ?

 3

Dr:She has been choking on food and she was chesty in the last few days and she had
cough and chest pain and she has fever on examination. That is why I think she has
aspiration Pneumonia.
Because she is confused and she has tachycardia and hypotension, I think she has septic
shock.

Examiner: What will you do?

Dr: First of all I would have resuscitated her by giving her Oxygen and IV fluids before
calling the care home.
Now I would check her notes for DNR or any other decision about active treatment to be
given or not. Will proceed according to that.
I will try to examine her again.

I will give her Oxygen

Take blood for – FBC, U&Es, Sugar, Creatinine, CRP, Blood culture, LFT and Blood
lactate. I will also check the ABG.
Start her on IV fluids. ( Normal saline).
I will catheterise her and monitor urine output.
Test the urine – dipsticks and send the urine for culture and sensitivity.
I will arrange for Chest X Ray and sputum culture.
Stop Ramipril.
Will inform the seniors immediately
Start her on broad spectrum antibiotics as per hospital protocol bearing in mind that she
is allergic to Penicillin.
May start her on Vasopressors after consulting with seniors.
May shift her to ITU for further treatment.

Will contact her family members to inform about her and get further information about
her.
Thank you.

Lady with fracture wrist – Talk to son.

Exam question:

You are the FY2 doctor in the Orthopaedic department.

84 year old lady Mrs Margaret Edwards had a simple fall at home and sustained fracture
wrist on the non-dominant hand.
She has been treated and the Multidisciplinary team consisting of doctors, Physiotherapists
and Occupational therapists have assessed her and decided to send her home with twice a
day visit by the carers.
She is also been arranged for the follow up at the fracture clinic every week.
She was given walking stick.

She is Lucid. She also wants to go home. She has given consent to talk to her son.
 4

Her son wants to talk to a doctor about her.

Talk to him and address his concerns.

Dr: Hello Mr Edwards ?

Son: Yes
Dr: I am Dr… junior doctor in the Orthopaedic department. Are you the son of Mrs
Margaret Edwards? Son: Yes
Dr: I am one of the team of doctors looking after your mother. I was told that you want to
speak to a doctor about your mother. Can I help you Mr Edwards ?
Son: Yes doctor. How is she ?
Dr: She is doing well at the moment. May I ask - do you know what has actually happened
to her so that I can answer all your questions better ?
Son: I was told that she had a fracture in her wrist.
Dr: That is right Mr Edwards. Do you know what happened after that ?
Son: No
Dr: Okay, let me explain. Fracture has been treated now. Our Multidisciplinary team
consisting of doctors, physiotherapists and occupational therapists have assessed her and
decided to send her home. We have arranged twice a day visits by the carers until she is
better and also we have arranged follow up for her in our fracture clinic every week until
she completely recovers.

Son: Are you sure she can take care of herself at home ?
Dr: Yes we think so. She has been fully assessed by our team including her home
conditions and the team believes she will be able to manage herself at home with the help
of carers visiting her twice a day to help her. Also her fracture was in a non-dominant
hand. We have given her a walking stick also. So we are hoping it should not be any
problems.
Son: What will the carers do?
Dr: They will do everything help her daily activities like cooking, feeding, dressing,
shower, shopping, giving her medications and any other necessary things.
Son : why was she given walking stick?
Dr: Because she has a fracture in one hand she was given walking stick so that she can
support herself if she loses balance while walking. This is given temporarily until her
fracture heals. She may not need it afterwards.

Son: Doctor I live about 50 miles away from my mother’s house. It will be very difficult
for me to visit her and look after her. Can you please keep her in the hospital until she is
completely fine.
Dr: I can understand your concerns. However, Mr Edwards, we have assessed her and she
does not need to stay in the hospital for further treatment. we believe she will be able to
manage herself at home with carers help. We are not expecting you to take care of her on a
daily basis. Beside that she herself want to go to her home. We appreciate if you can visit
her whenever you have time.
Son: She may say that she will manage herself, But I am sure she won’t be able to manage
herself. What if she falls again ?
Dr: May I ask why do you think she will fall again?
Son: She already fell once she may fall again? Are you sure she will not fall again at
home?
Dr: I can understand why you are so worried. Mr Edwards, we have assessed her and we
 5

did not see any medical causes for her fall. Our team has visited her home also and made
sure everything is safe. We do not see any medical reasons for her to fall again ?
Son: Well, I don’t know. But if she falls again then the hospital will be responsible for that.
Dr: Mr Edwards as we have mentioned we have checked for all the medical causes and we
do not see any medical causes for her to fall. If you have any other reasons to believe she
may fall again at home, please do let us know. We will look into that again.

Son: Doctor can you please tell her to go to a care home or residential home ?
Dr: May I ask - why do you want her to go to the care home ?

Son: She lives alone and I live so far away from her home. I have wife and children to look
after. I am too busy. It will be better for her to live in a care home or a nursing home.
Dr: Mr Edwards, I can see that you are a very caring son. I can imagine why you want her
to be in the care home. However, it is her decision because she has a mental capacity to
decide for herself what she wants. Have you discussed this with her ?
Son: No doctor. It is embarrassing for the family members to suggest her this. It is better
you doctors suggest that to her.
Dr: If we have seen any medical reasons that it is not safe for her to live alone in her house
then we could have suggested for to live in the care home or nursing home. I sincerely
advise you to discuss this matter with her.
Son: I believe she will not be safe at home.
Dr: Mr Edwards. I can see you are very concerned about her. We also want the best for her
as much as you want that for her. If you wish we can have a meeting again with the whole
team and you can raise any concerns and see if anything more we can do for her.
Son: But you already had a meeting !
Dr: That is right, but at that time you were not in the meeting. We can arrange the meeting
again if your mother agrees for that. Mr Edwards, please be reassured that we will do
everything possible from our side to keep her safe at home. If needed maybe we can
increase the frequency of carer’s visits to her home.

Son: Ok Doctor.
Dr: Thank you very much Mr Edwards. I will talk to my Consultant now and inform him
about your concerns. Thank you very much for coming here and sharing your concerns.
We really appreciate that. Thank you again.

Pre- operative assessment

Object is to make sure whether the patient is suitable for the elective operation as well as for
anaesthesia and to optimise his condition for the operation. In some cases surgery may need to be
postoned until the patient is optimised.

Assessment consist of taking a full history, examining to see whether any new changes has
happened since his operation was decided. To do necessary investigations to help in anaesthesia
and to prescribe some pre op medications if needed.

Also patient needs to be explained about the procedure and the need for operation and to take his
consent.

History taking.
 6

Any changes Any changes in symptoms, health or situations since the operation was
decided.

Present Any symptoms now ( Feve, SOB, Diarrhoea, Pain anywhere etc)

Past Any medical conditions ( if so – is it controlled, any medications)

Past surgery – ( if so – what, when , what Aneasthesia, any problems)

Personal Smoking, Alcohol Rec drugs, Sexual history

( Have done any tests for Hepatitis, HIV)

Period LMP,

Pregnancy Any chance of pregnancy

Pills Any Pills

Medication Any medication including the over the counter

Allergy Any allergies to medication or plaster or latex

Family history Any medical conditions in family members

Occupation What do you do for living, Sick note

Social history Any to look after after surgery, Stairs, toilet

Aneasthesia related Any dentures, Neck problems

Any thing important

Drug History: Steriods, antihypertensves, for diabetes, Thyroid medications.

Anti-coagulants, Antibiotics. Oral contraceptive pills ( should be stopped 4 weeks before

surgery and alternative contraception should be prescribed.

Systemic enquiry.

In order to make sure you do not miss any new acute symptioms, you may want to go through
the following list of symptoms with your patient.

Cardiovascular: chest pain, shortness of breath, paroxysmal nocturnal dyspoea, oederna,

palpitations.

Respiratory: cough, sputum, haemoptysis, wheeze stridor

Gastrointestinal : nausea, vomittin gdysphagia, acid reflux, haematernesis, abdominal pain,

abdominal swelling, altered bowel habit, melaena/rectal bleed, weight loss, appetite.
 7

Genitourinary: Dysuria, haematuria, dribbling, voiding difficulties, incontinence, nocturia.

Neurological : fits or seizures, faints, funny turns, loss of poer, vision, or sensation. Any
problems in the neck.

Investigations
Recommended tests before an operation (just a guide )
Test Patients
Full blood count All patients over 40
Urea and electrolytes Patients over 60 having major surgery Diuretic therapy , high
blood pressure , congestive cardiac failure, renal failure , gut
/urology, surgery, dehydrated
Electrocardiogram All patients over 40
Coagulation studies Patients on Warfarin , alcohol excess , hepatobiliary disease
Glucose Diabetes , Arteriopathies
Liver function Liver disease , alcohol excess , hepatitis
Calcium Malignancy
Urine analysis DM, UTI,
Sickle cell testing Where needed
Pregnancy testing All females of child bearing age group
Chest x ray Patients over 60 having major surgery congestive cardiac failure
and chronic obstructive airways disease with localising signs,
high blood pressure , malignancy
Arrange Cross matched Depends on operation
blood

Pre-operative Management
Diabetic patients having surgery need close blood glucose (BM) control peri-operatively. The
anaesthetist will usually advise when this is to be started. This is usually achieved by using a
sliding scale insulin infusion or a glucose –potassium-insulin (GKI) protocol depending on local
preference. Generally this should be continued until the patient is eating and drinking normally
in the postoperative period, at which point the patient’s usual diabetic medication can be
restarted. Ideally, all diabetic patients should be first on an operation list.
Oral medication:
Metformin: It should not be discontinued and it should be given following surgery as soon as
the patient can take oral medication.
Gliclazide, glipizide etc : need to be stopped on the day of operation.
Recommencing oral medication :
All tablets should be given on the first postoperative day to control the blood sugar. The patient
should remain on a dextrose/saline infusion until they are drinking adequately.
Patients on iv sliding scale :
Patient should remain on an IV sliding scale for up to 48 hours, after which it can be stopped.
Patients taking steroids
Change to IV hydrocortisone to avoid adrenal shutdown, and recommence when eating
normally. It is essential to appreciate that any patient on long-term steroids will have impaired
adrenal function and is likely to cope badly with the stress of surgery when endogenous steroid
production is increased. This means replacing oral steroids with IV steroids to avoid an
 8

addisonian crisis.

Patients on anticoagulation:
 International normalised ratio (INR) should be < 1.5 for most operations, and 1 if a
spinal/epidural is to be used.
 Stop warfarin 3 days before surgery
 Intravenous heparin needed while off warfarin if patient has a prosthetic heart valve.
Maintain activated partial thromboplastin time (APTT) ratio at 2-3

Patients taking antiplatelet medication (Clopidogrel, Aspirin)

 Discuss with anaesthetist
 Stop 1 week prior to surgery
 In the emergency setting a platelet transfusion will reverse effects

Women on hormone replacement therapy/ Oral contraceptive pill :

 Combined OCP needs to be stopped 1 month before operation
 Progesterone only OCP can be continued
 HRT needs DVT prophylaxis (LMWH)

Alcohol dependent patients requires vitamin supplementation and sedation.

Jaundiced patients requires Vitamin K.

May need DVT prophylaxis.

Consent ( Ideally the person who operates should take the consent).

Day case surgery

Day surgery is best definedas ‘the admission of selected patients on the day of
the operation to the hospitalfora
plannedsurgicalprocedure,returninghomeonthesameday.

Common operations done as Day case surgery

InguinalHernia

Varicoseveins

Terminationofpregnancy

Cataract

SMR

Extractionofwisdomteeth

Cystoscopy/TURofbladdertumor

Arthroscopicmenisectomy
 9

Excision ofdupuytren’scontracture

Myringotomy/grommets

 Assesspatient’s homecircumstances, andforcertain types

ofsurgery,accessto thepatient’s home.
 Check that
anemergencycontactnumberhasbeengiven,andthatthepatientunde
rstandswhattodoshouldaproblemarise.Post-operativesupport:24-
hoursupportshouldbeprovidedfromthedaysurgeryunit.
 Patientswithstablechronicdiseasesuchasdiabetes,asthmaorepilepsyareof
tenbest managedasdaycase astoensureminimaldisruptiontotheir
dailyroutine.
 Patientsshouldusuallybeabletomobilize themselvesbeforedischarge
althoughfull mobilization isnotalwaysessential.

Criteria for Day case surgery

1. Age less than 70 years

2. ASA Grade 1 or 2

3. BMI less than 30

4. Availability of a responsible adult to care

5. Access to a telephone

6. Live within an hour’s travelling time from the hospital

7. Patients requiring extensive investigation are not

suitable for day case surgery

GENERALLYOPERATIONSSHOULDBE:

 Shortduration
 Lowincidenceofpost–operativecomplications
 Notrequirebloodtransfusion
 Not require major postoperative analgesia
Day case surgery – Pin( screw) removal [ exam question]
Mr Alex Thomas 50 year old man had fracture ankle 18 months ago which was fixed with
the pins. Now the fracture has healed. He has come for pin removal.
Do the pre - operative assessment to check his suitability to bring him as day case surgery
and also tell him the preparation for the operation and post operative management.

Dr: Hello Mr Thomas. I am Dr ….. How are you doing ? -- Pt: I am fine doctor.
Dr: How is your ankle now ? Pt: It is good doc . I can walk on that without any problem.
Dr: Good. It is time now to pull out the pins from your ankle.
 10

We need to do a small operation to pull out the pins. You need to be fit in regards to your health
as we may need to give general Anaesthesia( put you to sleep during the time of the operation).
I am here to see whether you are fit to undergo this operation and well as to see whether this can
be done as a day case procedure.
Pt: Are you going me give me general Anaesthesia?
Dr: We may be able to do it under local anesthesia however if we find any problem during the
procedure we may need to give you general anaesthesia. So we need to prepare you for the
general anesthesia also.
Dr: Do you know what is day case surgery ? Pt: No doctor.
Dr: We will give you a date for the surgery. You need to come to the hospital on the same day of
the surgery and after the surgery we will discharge you on the very same day if everything is
fine. Pt: OK
Dr: I need to ask you few questions regarding your health and I will be examining you later and
also we may do some tests on you. Is that Ok? - Pt: Yes doctor.
Dr: How is your general health at the moment? Pt: It is OK doc.
Dr: Do you have any symptoms like Fever? Shortness of breath? Diarrhoea? Pt: No

Dr: Do have any medical problems at all now or did have any medical problems in the past ?
Pt: Yes doctor I have diabetes.
Dr: Do you take any medications for that ? Pt: I take Insulin doc.
DR: How many times do you take Insulin?
Pt: I take short acting 3 times a day and long acting one at night ( Lantus or ultra lente ).
Dr: Do you keep checking your sugar regularly and is controlled well at least in the last few
months ?
Pt: Yes doc.
Dr: Did you have any problems during or after the last surgery when we fixed the fracture. –Pt:
No
Dr: Do you have any other medical conditions apart from diabetes? Pt : No
Dr: Do you smoke ? Pt: No
Dr: That is good. Do you drink alcohol ? Pt : No
Dr: Good. Are you taking any other medications apart from Insulin ? Pt: No
Dr: Are you allergic to anything at all? Pt: No
Dr: Do you have any loose teeth or denture ? Pt: No
Dr: Any problems in the neck ? Pt : No
Dr: Do you have any one to look after you after the operation ?
Pt: Yes, my neighbor will pick up and drop me back to home after the operation.
Dr: You should have some adult to look after you at home at least for 24 hours after we send you
home. They should stay at your home to look after you. Do you have any one like that to look
after you?
Pt: Ok doctor I will ask my neighbor. They will do that. ( If patient says he cannot arrange any
one to stay at his home to look after him – tell him that we may not be able to do it as day case
surgery then we may need to keep you in the hospital for a day at least before we can discharge)
Dr: How far away do you live from the hospital ?
Pt: It is about 10 minutes drive from the hospital doc.
Dr: Is there anything else which may be important that we need to know ? Pt: No

Counselling:-
- Dr: Mr Thomas, with the information what you have given it seems that you are fit to undergo
this operation and we can bring you for day care surgery. However, after I examine you, and
check your height and weight and do some tests like Blood tests ( like your sugar and other
tests), ECG and Chest X Rays we will tell you whether you are definitely fit for this procedure
and for day case surgery.

Preparation :You need to come prepared properly for this surgery. You should be on empty
stomach at least for 6 hours before we do the operation. So please do not have your breakfast and
 11

your morning Insulin on the day of the surgery. When you come to the hospital we will check
the sugar and give the Insulin if required.
DR: Do you have any concern?
Pt: Doctor last time after the surgery I was sick many times. Will it happen again after this
surgery? In that case can you still do this as day case surgery?

Dr: Mr Thomas, Sometimes people do vomit after the operation because of the effect of the
Anaesthetic medication or as a side effect of pain killer medication. Just because it happened last
time it does not necessary mean that it will happen this time also. We can still post you for day
case surgery. However, if you do vomit this time we will give you anti-sickness medication and
if it helps then we can send you home but if you continuously keep vomiting even after the
giving you the anti-sickness medication we will keep you in the hospital. So we may not be able
to send you home that evening.

Post – operative management : After the operation once you recover from the Anaesthesia you
can have some food and take your usual Insulin if you take at that time and wait for some time
and if everything is fine, we will discharge you on the same day.

After the procedure and do not sign any important documents or work near heavy machinery
at least for 24 hours.

Pleasedo not drive until you are able to apply emergency break without any problem which may
take about 2 weeks.
Also make someone stay with you to look after you at least for 24 hours after the procedure.
After the operation – when you go home we will give you our telephone number – you can
contact us if you need any help after the operation. Are you ok with these ?
Pt: Will there be any complications?

Dr: Very rarely there can be damage to the nerves when we remove the pins and infection in
the operated area later. If there is any redness, pain or pus discharge from the operated site these
are the signs of infection – if you have these - please come back. Pt: Ok
Dr: Any other questions? Pt: No Dr: Thank you.

Post herniorrhaphy wound infection

35 year old man underwent herniorrhaphy one week ago. Now he presents with
discharge, swelling, oozing and redness at the site of incision in the groin area.
Talk to the patient.
Infection rate in this hospital is not more than National infection rate.

Dr - I am Dr… one of the junior doctor in the surgery department in the hospital. How can I
help you?
Pt – You are a junior doctor. I don’t want to speak to you. I had surgery a week ago and see
now what has happened? Some dirty discharge is coming out of my wound, it is smelling
horribly, my wife is not coming near to me, I can’t even go to my work. My wound is
healing. I want to talk to your consultant.
Dr – I can certainly imagine how you ae feeling. I’m sorry for what is happening to you. I do
understand that you want to speak to my consultant but my consultant is busy at the moment.
 12

Don’t worry I’m here for you. I will try to explain to you what is happening and we will do
our best to help you. My consultant will see you as soon as he gets free.
Dr: Can I ask few questions about it? Pt: Yes
Sine when are you having this discharge from the wound ?
Pt: Last few days
Dr: Do you have any pain there ?Pt: Yes / No
Dr: Do you have any fever? Pt : No
Dr: Do you have any other medical conditions ?Pt: No
Dr Do have diabetes ? No
Dr: Are you taking any medications? Pt: No
Dr: Are you allergic to any medications ? Pt : No
Dr: I need to examine your tummy?
[ Patient will show a picture – doctor this is how it looks like]

Dr: I can see your wound is bit red and there is some pus discharge there.
Pt – Why has this happened to me?
Dr – This happens when there is an infection of the wound, which means there are
germs/bugs growing there.
Pt – How/From where did I get this infection?
Dr – It could be due to many reasons. These bugs could be from inside or outside the hospital.
We do take all the measures to prevent people getting infections after the operations. We do
the operation in a clean theatre, we give antibiotics and keep cleaning and changing the
dressing regularly to prevent infections. Unfortunately sometimes people get infections
despite all the measure what we take.
However sometimes this infection can happen from outside the hospital. If the dressing on the
wound becomes dirty and if it is not kept clean bugs can get into the wound.
Can I please ask you were you able to take care of the wound ? Who was changing the
dressing for you? Patient: Yes I was able to take care of the wound properly / I was not able
to take care of the wound properly.

I am sorry this happened to you. You have done a good thing by coming to the hospital.
Right now what’s important is that we take care of you.

Pt: My friend had some operation in some other hospital and he was given antibiotics and he
did not have infection. Is it because I was not given antibiotics that I got infection ?
Dr: Mr… I am glad to know that your friend did not have any infection after the operation.
We do give antibiotics after the operation to prevent infection only for the type of operations
where the chancesof infection is very high like if it is dirty wound or if the patient has low
body immunity. We do not give antibiotics if the chances of infection is low. If we give
antibiotics even for types of operations where the chances of infection is low – the bugs can
develop resistance and later on if the person has infection with similar kind of bugs then those
 13

antibiotics will not work and the infection can become very serious. That is the reason we
avoid giving antibiotics unnecessarily. However we do advise those patients to come back if
they have signs of infection as the infection can be treated even later.

Pt – What will you do for me now?

Dr - We need to admit you now. We will clean the wound, change the dressing and give you
pain killers & antibiotics medications. We will also take a blood sample and sample from the
wound to check which exact bugs causing this infection and send it to lab.
Pt – What! Admit me again? I have to work! I have to look after my family.
Dr – We are trying to do best for you. If you wish we can give you a sick note.
Pt – But I am self - employed. I will lose my income.
Dr – I can imagine your problems. However your health is more important. We need to give
antibiotics through your vein which cannot be given at home.
If you go to work it might get worse because you may catch other bugs which will be more
difficult to treat then.
You may be entitled to tax benefits and child tax credit. You can take advice from Citizen
Advisory Bureau.
Pt – How long will I be admitted for?
Dr – It may be for few days. As soon as the infection is cleared you can go home
Pt: What will you do so that these things will not happen again?
Dr: We look into all these type of problems very seriously. We have something called as
Root cause analysis meeting where we discuss these type of issues. If there is anything need
to be changed in our practice we will do that.
Pt – I want to complain
Dr – Yes you can if you wish to do so. You can talk to the Patient Advisory Liaison Service
(PALS) and they will help you.
Pt – OK
Dr – Any other concerns
Pt – No
Dr – Thank you very much.

Elderly Abuse
Elderly lady brought in her by her daughter with history of falls.
Causes of falls
Non Medical Medical
Poor vision Balance problem ( cerebellar)
Poor light Postural hypotension ( medications)
Slippery floor Heart arrhythmia
tripping Diabetes
Pushed( Abuse) Alcohol
Osteoporosis
Dementia

Causes of bruise
Accidental injuries Medical
Non Accidental Bleeding disorder
Medications -Steroids, Blood thinners
Social history

Where does she live, with whom. Who looks after, Does daughter work, Is she busy,
 14

Are you able to look after your mother, or do you find it difficult, How does your
children get along with your mother, Any one else at home,
Any past injuries, past medical problems, past Hx of bruises.

Elderly Abuse - New exam question

You are the FY 2 doctor in the medical department.
Mrs Diana Roberts brought in her 85year old mother Mrs Margaret Roberts
with the history of falls. Nurse noticed some bruises on her body including her
axilla. Bruises were of different ages.
You are suspecting some fracture and mother is in the X Ray at the moment.

Take history from the daughter and discuss the further management with her.

Dr: Hello Mrs Diana Roberts . I am Dr… one of the junior doctor in the medical
department. How are you doing ?
Daughter : I am fine doctor.
Dr: How can I help you Mrs Roberts.?
Daughter : My mother fell down today. I brought her in to have a check up.

(Elaborate on presenting complaint )

Dr: I am sorry to hear that. Can I ask how did she fall ?
Daughter : She is very old and frail. She keeps falling?
Dr: Can you please elaborate about the fall today?
Daughter : She was in the room and she fell on the radiator.
Dr: What time did this happen? Daughter : Few hours ago.
Dr: What did you do immediately after that? Daughter : I brought her in here.
Dr: That is really good. Can you please tell me was she standing when she fell
Daughter : Yes
Dr: Did she lose consciousness and then she fell do you know?
Daughter : No she was conscious
Dr: Did she lose consciousness after she fell? Daughter : No
Dr: Was she able to get up after she fell down? Daughter : Yes.

Dr: Did she slipped or tripped on anything ? Daughter : No

Dr: Was it dark and she could not see anything? Daughter : No
Dr: Does she have any problem with her vision? Daughter : No
Dr: Did she have dizziness just before she fell do you know? Daughter : No

( Past history of falls and injuries)

Dr: Has it happened before ? Daughter : Yes few times/first time.

Dr: Was she brought into the hospital before for this? Daughter : No
Dr: May I know why ? Daughter : She was fine after she fell.

( Past medical history)

Dr: Has she got any medical conditions ? Daughter : No
 15

Dr: Is she on any medications ? Daughter : No

( History for bruises - if it is mentioned in the question)

Dr: Have you noticed any injuries this time? Daughter : I am not sure.
Dr: Nurses noticed some bruises on her body do you know how she got this?
Daughter : I don’t know about that / She fell on the radiator that is how she got it.
Dr: Is she taking any blood thinner medication or steroid medication? Daughter : No
Dr: Has she got any bleeding disorders ? Daughter : No

( NAI questions)
Dr: Can I ask where does she live ? Daughter : She lives with me in my house?
Dr: Who looks after her? Daughter : I look after her
Dr: Do you work? Daughter : Yes I work.
Dr: Who else lives at home ?
Daughter : I have 2 teenage age daughters. They live with me.
Dr: Anyone else at home ? Daughter : No
Dr: Anyone else looks after your mother apart from you? Daughter : No
Dr: How do you and your daughters get along with your mother? Daughter : We are
fine.

Dr: You seem to be very busy. Do you find it difficult to manage everything at
home ?
Daughter : Yes doctor I have to work, look after my kids and my mother and I have to
do house work also.
Dr: I can imagine it must very tiring. Have you thought of keeping her in the care
home or do you think you need any help to look after your mother at home ?
Daughter : That will be very helpful doctor if I can get help to look after her at my
home.

Management:
Dr: Mrs Roberts, we need to keep your mother in the hospital and examine and treat
her because she could be having some fractures for any injuries and do some test to
find out why does she keep falling and why does she has bruises on her body. We
may need to do some tests like blood tests to check her sugar, for anaemia ECG, her
blood pressure and other things. I will inform my seniors about this.
Daughter : Ok
Dr: We will have to involve the social services also.
Daughter : Why involve the social services?
Dr: We need to involve them because we need to check if there are any other reasons
like any type of physical abuse because we cannot explain the reasons for some type
of bruises she has on her body like bruises under her armpit.
Daughter: That bruises is because I was holding her arms.
Dr: That may be possible. However Mrs. We need to involve the social services just
to be on the safe side for your mother.
Daughter : Are you saying I am abusing my mother.
Dr: I am not saying that Mrs Roberts. I can see that you work and look after your
mother and daughters. That shows that you are a very caring daughter and a caring
mother to your daughters. Your mother may be having fractures which is very serious
type of injuries if it is physical abuse. So it is for your mothers own benefit we need
to involve them. They will look into this issue and they may talk to you and your
 16

mother also. They will take further decisions about your mother. In fact they may
even help you by arranging social cares to look after your mother if you wish.
Daughter : Can I take her home?
Dr: As I mentioned we need to admit her now do tests and treat her and then the
social services will take further decisions after talking to you and your mother.

------------------------------------------------------------------------------------------------------

Same question - another story.

Dr: Hello Mrs Diana Roberts . I am Dr… one of the junior doctor in the medical
department. How are you doing ?
Daughter : I am fine doctor.
Dr: How can I help you Mrs Roberts.?
Daughter : My mother fell down today. I brought her in to have a check up.

(Elaborate on presenting complaint )

Dr: I am sorry to hear that. Can I ask how did she fall ?
Daughter : I hit her and she fell down.
Dr: Can you please elaborate about the whole incident please.
Daughter : We had some argument and I just hit her. She fell down on the radiator.
Dr: What time did this happen? Daughter : Few hours ago.
Dr: What did you do immediately after that? Daughter : I brought her in here.
Dr: Can you please tell me was she standing when she fell
Daughter : Yes
Dr: Did she lose consciousness after she fell? Daughter : No
Dr: Was she able to get up after she fell down? Daughter : Yes.
Dr: Has this incident happened before? Daughter: No/ Yes
Dr Has been brought into the hospital for such incidents before/ Daughter : Yes/ No
Dr: How do you feel about it now ? Daughter : I should not have done that. / I feel
bad about it / I have been bit harsh on my mother.

( Past medical history)

Dr: Has she got any medical conditions ? Daughter : No
Dr: Is she on any medications ? Daughter : No

( History for bruises - if it is mentioned in the question)

Dr: Have you noticed any injuries this time? Daughter : I am not sure.
Dr: Nurses noticed some bruises on her body do you know how she got this?
Daughter : I don’t know about that / She fell on the radiator that is how she got it.
Dr: Is she taking any blood thinner medication or steroid medication? Daughter : No
Dr: Has she got any bleeding disorders ? Daughter : No

( NAI questions)
Dr: Can I ask where does she live ? Daughter : She lives with me in my house?
Dr: Who looks after her? Daughter : I look after her
Dr: Do you work? Daughter : Yes I work.
Dr: Who else lives at home ?
Daughter : I have 2 teenage age daughters. They live with me.
Dr: Anyone else at home ? Daughter : No
 17

Dr: Anyone else looks after your mother apart from you? Daughter : No
Dr: How do you and your daughters get along with your mother? Daughter : We are
fine.

Dr: You seem to be very busy. Do you find it difficult to manage everything at
home ?
Daughter : Yes doctor I have to work, look after my kids and my mother and I have to
do house work also.
Dr: I can imagine it must very tiring. Have you thought of keeping her in the care
home or do you think you need any help to look after your mother at home ?
Daughter : That will be very helpful doctor if I can get help to look after her at my
home.

Management:
Dr: Mrs Roberts, we need to keep your mother in the hospital and examine for any
injuries and do some test to find out whether she has any medical conditions. I will
inform my seniors about this.
Daughter : Ok
Dr: We will have to involve the social services also.
Daughter : Why involve the social services?
Dr: Mrs… you said that you hurt your mother - I do appreciate your honesty . I can
see that you work and look after your mother and daughters. That shows that you are
a very caring daughter and a caring mother to your daughters. However we need to
involve them in such incidents of physical abuse. Also if she has fractures then this
will be very serious type of physical hurt. This is for your mother’s own benefit we
need to involve the social services. We have to make sure that she is safe.
They will look into this issue and they may talk to you and your mother also. They
will take further decisions about your mother. In fact they may even help you by
arranging social cares to look after your mother if you wish.
Daughter : Can I take her home?
Dr: As I mentioned we need to admit her now do tests and treat her and then the
social services will take further decisions after talking to you and your mother.
Thank you.

Abnormal LFT
You are the FY 2 doctor in the GP clinic.
47 year old lady Miss Rachel Campbell came to the GP clinic few days ago with abdominal
discomfort. Some blood tests were done.
She has come for the follow up.
Talk to her about the further management.
Liver Function Test ( given in the question) Miss Rachel Campbell
Bilirubin – 25 ( Normal 3 – 17 micromols/L)
 18

ALT – 581 ( Normal 3 - 35 IU/L )

AST – 110 ( Normal 3 - 35 IU/L )
ALP – 50 ( Normal 3- - 150 IU/L)

Normal Obstructive Acute Alcohol

hepatocellula
r damage

[ Hepatitis ]

Bilirubin 3-17 umol/l

AST :ALT = 2:1

AST 3-30 iu/l N

ALT 3-40 iu/l N or

30-100
N N
ALP umol/l

GGT 8-60 u/l

N

Albumin 35-50 g/l

PT 10-14 s/ 1

How do we compare the rise in ALT and ALP?

 A greater than 10-fold increase in ALT and a less than 3-fold increase in ALP
suggests a predominantly hepatocellular injury
 A less than 10-fold increase in ALT and a more than 3-fold increase in ALP
suggests cholestasis
 It is possible to have a mixed picture involving hepatocellular
injury and cholestasis (e.g. ALT < 10-fold increase and ALP > 3-fold increase)

What about Gamma-glutamyl transferase?

If there is a rise in ALP, it important to review the level of gamma-glutamyl transferase
(GGT). A raised GGT can be suggestive of biliary epithelial damage and bile flow
obstruction. It can also be raised in response to alcohol and drugs such as phenytoin. A
 19

markedly raised ALP with a raised GGT is highly suggestive of cholestasis.

A raised ALP in the absence of a raised GGT should raise your suspicion of non-
hepatobiliary pathology. Alkaline phosphatase is also present in bone and therefore
anything that leads to increased bone breakdown can elevate ALP

The ALT/AST ratio can be used to determine the likely cause of LFT derangement:

 ALT > AST is seen in chronic liver disease

 AST > ALT is seen in cirrhosis and acute alcoholic hepatitis

Dr: Hello Miss Rachel Campbell I am Dr… junior doctor here in the GP clinic. How can I help
you?
Pt: I have come to collect my blood test report.
Dr: Yes it is here. We had done your Liver function test last time. Dr: Can you please tell me
what is happening to you ?
Pt: Doctor I have pain in my tummy
Dr: Can you please tell me more about it ?Pt: It is here right side upper part.
Dr: Since when are you having this pain? Pt: Since the last two weeks.
Dr: What type of pain is that ?
Pt: It is like a dull pain sometimes it is just discomfort
Dr: Is it there all the time or come and go ? Pt: It is there all the time
Dr: Does the pain go anywhere else at all? Pt: No
Dr: To the back (pancreatitis, gall stones)Pt: No
Dr: Do you have any other problem other than pain? Pt: I feel bit tired. Dr: Since when ? Pt:
Since last few weeks.
Dr: Any fever Pt: No
Dr: Any yellowish discolouration of skin or eye ( Jaundice) Pt: No
Dr: Nausea or Vomiting Pt: I feel sickly
Dr: Diarrhoea Pt: No Dr: Any itching? Pt: No
Dr: What is the colour of the stool ? Pt: Normal brown
Dr: What is the colour of the urine ? Pt: Normal
Dr: Do you keep eating outside in restaurants?
Pt. Yes .I like to eat uncooked shell fish ( oyster) in restaurants. I have been doing it for
 20

many months. Dr: Was it in one particular restaurant or do you keep changing the restaurants ?
Pt: One particular restaurant / different restaurant.
Dr: Have you travelled outside UK recently ? Pt: Not for the last one year.
Dr: Did you have any blood transfusion ? Pt: No Dr: Are you sexually active ? – Pt: Yes I am
married. Dr: Do you practice safe sex ? Pt: No.

Dr: Did you have Hep A or B vaccine ? Pt: No

Dr: Did you have any problem in your liver or gall bladder previously? Pt: No
Dr: Do you feel that your tummy is bloated or any ankle swelling ( liver failure) ? Pt: No
Dr: Did you have such problem before Pt: No
Dr: Do you have any medical conditions at all ? Pt: No
Dr: Do you have Diabetes or high blood pressure ? Pt: No
Dr: Have you had any surgeries before ? Pt: No
Dr: Do you use any recreational drugs or share needle with others ? Pt: No
Dr: Do you drink alcohol ? Pt: No
Dr: Any chance that you are pregnant ? Pt: No
Dr: Are you taking any medications ? Pt: No
Dr: Any family members have such problem or liver problem in family members? Pt: No
Dr: Did you come into contact with anyone who had Jaundice Pt: No
Dr: What do you do for living ? Pt: …
Examination: Miss Campbell I need to examine your eyes for jaundice and your tummy.
[ examiner may say no jaundice mild tenderness in right upper quadrant]
Diagnosis:
Dr: Miss Campbell. We checked your blood test to see how your liver is functioning. It shows
that something is abnormal in your liver. Do you want to see the result ?
Pt: Yes doctor.
Dr: Bilirubin is high – Bilirubin is a break down product of red blood cells.It is normally cleared
by the Liver. If the liver is damaged or diseased then the bilirubin will not be cleared from the
blood. Bilirubin is a yellow coloured pigment - so when its level increases in the blood it gives
yellowish colour to the skin which we call as jaundice.
AST and ALT – these are some type of enzymes produced by the liver when they are damaged,
They are elevated and ALT is higher than AST – means it could be due to some type of
infections in the liver. ALP is normal means you do not have problems like gall stones etc.
It could be due to what we call as Hepatitis A. This is a liver infection caused by a virus
that's spread in the stool of an infected person. Sometimes it can happen due to uncooked
shellfish which may be contaminated with stool. This could be due to the food you are having
 21

in the restaurants.
Do you follow me ? Pt: Yes doctor.
Dr: We need to do some more blood tests called Immunoglobulin test to check whether you
have viral infection.
( Examiner may give IgM level which is high )
We got the result of Immunoglobulin. It shows a type of immunoglobulin called IgM is raised –
which shows that you have an acute infection of the Liver.

IgA: raised in elderly, chronic infection, cirrhotic liver disease.

IgM: raised primary biliary cirrhosis, acute infection, EBV, CMV, TB.

IgG: marked polyclonal elevation is seen in HIV and Sjögren’s syndrome less marked
elevation in chronic inflammatory and infective conditions including TB, occult abscess and
protozoal infection.

As well as we may need to do scan of your tummy and liver to exclude any other problems
Dr: This is not a serious condition because itwill normally subside on its own within a couple of
months. So there is no treatment required and no hospital admission required.
You can usually look after yourself at home. Treatment is for the symptoms only -
 get plenty of rest for tiredness.
 take painkillers such as paracetamol if you have pain.
 eat smaller, lighter meals to help reduce nausea and vomiting
 stay off work
 practise good hygiene measures, such as washing your hands with soap and water
regularly to prevent the spreading of this infection to others.
Hepatitis A can occasionally last for many months and, in rare cases, it can cause serious
condition that the liver to stop working properly (liver failure).
Once it subsides, you normally develop life-long immunity against the virus. However I still
advise you not to eat uncooked Oyster.
Dr: Any concerns ? Pt : No
Dr: I will inform my seniors about this and you can go home and follow the advise and we will
keep following you up. Thank you.

ACS – ECG normal

You are the FY 2 doctor in the medical department.
 22

44 year old Man Mr … presented to the hospital with severe chest pain.
Take history from him and discuss the further management with him.

Dr: Hello Mr …. I am Dr … one of the junior doctor in the medical department. Can
you please tell me what is happening to you ?
Pt: Doctor I am having severe chest pain.
Dr: I am very sorry to hear that. How severe is your pain – in the scale of 1 to 10 one
being the mildest and 10 being the most severe pain?
Pt: Doctor it is 10 out of 10.
Dr: I see, don’t worry, we will give you some strong pain killer medication and you will
be better. Can I ask few more questions to see which is the best pain killers for your pain ?
Pt : Yes

Dr: Can you please tell me more about your chest pain?
Pt: Doctor, I was just sitting on sofa and watching television. Suddenly the pain started. It
is almost 3 hours now. I took paracetamol, it didn’t help me at all doctor.
Dr: Anything more can you tell me ?
Pt: I don’t know what else to tell you.
Dr: OK. Can you please tell me where exactly is this pain in your chest ?
Pt: It is here over the central part of my chest doctor.
Dr: OK. What type of pain is that?
Pt: I feel as if someone is crushing my chest.
Dr: Does the pain go anywhere else at all.
Pt: Yes doctor I am having pain my left jaw also.
Dr: Does it go to your left hand? Pt: No
Dr: Does it go to your back between your shoulder blades ? Pt: No
Dr: Does the pain gets relieved on leaning forward ? Pt: No

Dr: I will ask the nurses to get some good pain killer medicines for you.
Ask examiner – I want to give pain killer to my patient what can I do ?

Examiner says – assume doctor. ( if the examiner ask which pain killer – you can say
Morphine injection 5-10 mg IV)
Dr: Mr… We have given pain killer. Are you any better now?
Pt: I am slightly better.
Dr: Are you comfortable to talk to me now?
Pt: Yes doctor, I can talk to you now.

Dr: Do you have any other symptoms other than pain? Pt: Like what ?
Dr: Any vomiting ? Pt: No Dr: Fever? Pt: No Dr: Cough ? Pt: No
Dr: Pain in your calf ( DVT – PE) ? Pt: No
Dr: Do you feel short of breath at all ( PE, Tension Pneumothorax, Heart failure) ?
Pt: No
Dr: Did you have a long journey flight just recently ( PE)? Pt: No
Dr: Do you get heart burn ( GORD) ? Pt: No
Dr: Did you have any injury on your chest ? Pt: No

Dr: Did you have this type of problem before ? Pt: No

Dr: Do you have any medical problems at all ? Pt: No
Dr: Like high blood pressure ? Pt: No Dr: Diabetes ? Pt: No
 23

Dr: High cholesterol? Pt: I don’t know. Dr: Any heart problem ? Pt: No
Dr: Did you have any blood clots in your lungs or legs before ? Pt: No
Dr: Do you smoke ? No Dr: Do you drink Alcohol ? Pt: No
Dr: Do you use any recreational drugs ? Pt: No

Dr: Do you take any kind of medications at all ? Pt: No

Dr: Are you allergic to any medications? Pt: No
Dr: Any of your family members have any medical conditions? Pt: No
Dr: Any heart problems in family members ? Pt: No
Dr: Is there anything else you think that may be important that we need to know?
Pt: I don’t know doctor.

Dr: Mr… I need to examine your chest and heart and also need to check your pulse and
blood pressure.
Examiner says – chest is clear. Pulse and BP stable. Thank the examiner.

Dr: Mr… I think you a serious condition in your heart. I am sorry to say that you could be
having heart attack. Pauce ……

However, I need to do your heart tracing (ECG) to confirm that.

ECG – examiner shows ECG. ECG – normal.

1)

2)

3)
 24

4)

5)

1) Antero – lateral infarction 2) Inferior wall infarction 3) Posterior wall

infarction 4) Lateral infarction. 5) Anterior wall ischemia

Dr: Mr… Your heart tracing looks normal. However it still looks like you have a minor
heart attack. Do you know what heart attack means?
Pt: I heard of it but I don’t know what exactly it means.

Dr: Let me explain. Heart needs it’s own blood supply for its muscles to survive. This
blood supply is provided by some blood vessels called coronary arteries. In heart attack
this blood vessel gets blocked by a clot which stops the blood flow to a part of your heart
muscle. This causes serious damage to the heart muscles.
 25

Sometimes this condition is life threatening as you may know. However, you don’t need to
worry. You have come to the hospital in good time. You are in a safe place now. We are
going to look after you. You will be fine.

Pt: What are you going to do for me ?

Dr: We will admit you in the hospital and repeat the heart tracing and also we will do
some blood tests to check some heart attack markers. We will keep monitoring you.

For now we will give you Oxygen (if saturation low) and Aspirin tablet to chew. To
relieve your pain we will give some medication called GTN spray under your tongue and
a strong pain killer medication called Morphine as injection .

Are you following me?Pt: Yes.

Dr: If your ECG changes in time, or blood tests comes positive for heart attack markers we
will be able to say this is a major heart attack. If not this is a minor heart attack.

Major heart attack usually need urgent treatment to open the blockage in the heart muscles
to restore the blood supply to the heart muscles. For this we do a procedure called
angioplasty.

Pt: what is angioplasty doctor ?

Dr: This is a procedure where we pass a catheter (tube) with a balloon at its tip, from the
artery in your groin or arm to the heart into the blocked section of the coronary artery. The
balloon is blown up inside the blocked part of the artery to open it wide again. A stent may
be left in the widened section of the artery. A stent is like a wire mesh tube which gives
support to the artery and helps to keep the artery wide. Are you following me? Yes

Dr: However we may not need to do that procedure straight away because your ECG is
normal. But we may do it later after few days. Are you following me? Is that OK?

If you have time then mention the following :

If this is a heart attack we will give you some blood thinner medications called
clopidogrel 600 mg and some injections called enoxaparine. These will help
preventing the formation of new clots.

We will alse give you medication called metoprolol which is a beta blocker and
cholesterol medicine called atorvastatin (high dose), ACE inhibitor called ramipril
which also protects your heart.

Dr: There might be some complications of heart attack.

Do you want to know about them ? Pt: Yes

Dr: It can cause abnormal heart rhythms or it can cause heart failure, or a further heart
 26

attack may occur sometime in the future. However we will try to prevent them and manage
them if any of these problems do happen.

Dr: Do you have any other questions? Pt: No doctor. Thank you very much.

Dr: Thank you very much. I hope you recover very soon without any problem. If you need
any help please let me know.

Hemi-arthroplasty of Hip Joint

You are the FY 2 doctor in the Orthopaedic department.

A 70 year old lady Mrs Katherine Jones fell at home and could not walk after that. She
was brought into the hospital and the X Ray was done which showed fracture neck of
femur. Your Consultant planned to do hemiarthroplasty of hip joint.
Your colleague has already told her about the operation and Anaesthetic colleague has
already explained her about the pain management.
Talk to her about the post - operative management.

Dr - Hello Mrs Katherine Jones I am Dr …one of the junior doctor in the Orthopaedic
department. How are you doing ? Pt: I am OK doctor.
Dr- I am sorry to hear about what happened to you. Are you in pain now ? Do you need
any pain killers? Pt : It is OK doctor. Nurse just gave me some pain killers.
Dr: Are comfortable to speak to me? Pt: Yes doctor.

Dr: Mrs Jones -do you know what has happened to your hip ? Pt - Yes doc, I was told
that I have a broken bone in my hip.
Dr - That is right, I am sorry about that. Mrs. Jones do you know what we are going to
do for that?
Pt - Yes, your consultant told me I need to have a surgery.
Dr - Yes that is right. We are going to put a new joint to your hip. I was told one my
colleague has already told you about the operation and how we are going to manage you
pain. Is that right ? Pt - Yes doc.

Dr – Mrs. Jones do you have any concerns of what may happen after the surgery?
Pt – Doctor, I am worried because one of my friend had some surgery and she had some
blood clot in her lungs and she became very serious with that. Will the same thing
happen to me also doctor?
Dr: I am really sorry to hear about your friend. Unfortunately people do get blood clots
in the legs or lungs after major surgeries like the one what we are planning do for you.
However, not everyone has this type of operation will get clots. Mrs Jones we take all
types of precautions so that you will not get this problem. Even if you get it we will try
to manage that.
Pt: Thank you very much doctor.
Dr: Mrs Jones It is usually the blood clots which develops in the legs which travels to
the lungs. There are lot of risk factors why people get this type of problems. Can I ask
few questions about your health to see if you have any risk factors to develop this clot.
 27

Dr: Can I ask you did you have any blood clots in your legs or lungs before ? Pt: No
Dr: Do you have any medical conditions? Pt: No
Dr: Are you taking any kind of medications? Pt: No
Dr: Do you have any kind of blood disorder?Pt: No
Dr: Any of your family members had blood clots ? Pt: No
Dr: OK. That is good. You do not have much risk factors to develop clots. The chances
of you getting blood clots are low. However, since this is a major operation around the
hip there are still some chances of getting blood clots. As I mentioned earlier we still
take all precautions to prevent you having this problem.

Pt: What will you do so that I will not get clot doctor ?
Dr: We do take lot of measures so that this problem does not happen - like we give some
blood thinner injections to you every day before the surgery itself and also we continue
to give that after the surgery for few days to prevent you getting clots. We will give you
some special stocking ( T.E.D stocking) to wear on your legs – this improves blood
circulation in the legs and also we have some special types device which also improves
the circulation in the legs by changing air pressure ( intermittent pneumatic compression
therapy).
If people lie down on the bed for long time they can get clots in the legs. We will try to
mobilize you as soon as possible after the surgery to prevent you getting clots.

Pt: Thank you very much doctor. How will I know if I get clots in my legs or lungs?
Dr: If you have blood clot in the legs you will have pain and swelling in your calf and if
you get blood clot in the lungs you will have pain in the chest and shortness of breath. If
you develop any of this symptoms you need to inform us immediately. If you develop
this problem at home after we discharge you need to call the ambulance and come to the
hospital immediately.

Dr: Do you have any other concerns? Pt: When will I walk again?
Dr: As I mentioned earlier we will try to mobilize you as soon as possible either the
same day after the surgery if not the next day itself to prevent clots. However you will
not be able to walk without any support. You will use some type of crutches to support
and also there will be physiotherapist supporting you.
Pt: When will I walk on my own without any support?

Dr: It usually takes about 6 weeks for the operation site to heal properly and the tissues
around that to become strong. So after about 6 weeks you may be able to walk on your
own without any support.
Dr: Any other concerns? Pt: When will I go home ?
Dr: - If you are generally fit and well, we will discharge you within about three to five
days. However we need to make sure that you will be able to cope at home before we
discharge you. Our Occupational therapist will visit your home before we discharge you
to check whether you can cope at home when we discharge you. They will make any
adjustments required so that you can cope at home. You may not be able to walk up and
down the stairs for some time if you have stairs at home. Do you have stairs at home ?
Pt: Yes, I have stairs at home. ( sometimes she may say no I live in a bungalow
( bungalow is one floor house).
Dr: Occupational therapist will look at these problems. They may arrange everything to
be in one floor ( like bedroom kitchen and bathroom) so that you don’t have to go up
and down the stairs until your joint becomes strong ( may be about 3 months).
 28

Occupational therapist will also advise you on how to do daily activities, such as
washing yourself.
They will also advise about any equipment you may need to help you to be independent
in your daily activities. This may include a raised toilet seat and aids to help you dress.

Dr: Any other concerns?

Pt: Is there anything I need to be careful about?

Dr: One other problem after this hip surgery is that the joint can easily dislocate means
the bones may pop out of the joint. You should be very careful that this will not happen.
You should take care not to fall. Also physiotherapist will teach you some exercises
after the operation so that that hip becomes strong.
You should do take the joint will not dislocate like:

• avoid bending your hip more than 90° (a right angle) during any activity

• avoid twisting your hip

• do not swivel on the ball of your foot

• when you turn around, take small steps

• do not cross your legs over each other

• avoid sitting on low chairs and toilet seats.

Pt : When will I be completely be normal doctor ?

Dr - Generally, you should be able to stop using your crutches within four to six weeks
and feel more or less normal after three months, by which time you should be able to
perform all your normal activities. It is best to avoid extreme movements or sports
where there is a risk of falling, such as skiing or riding.

Pt: Can I play ball game?

Dr: You can play ball game after your hip should become strong which may take about
3 months to 4 months.
[ Sports which are allowed after hip surgery (but only after about 5 to 6 months) - low‐
impact activities such as swimming, bowling, stationary biking, dancing, rowing and
walking are allowed. Downhill and cross‐country skiing, weightlifting, ice‐skating are
activities that are allowed with experience.
Not allowed - racquetball/squash, jogging, contact sports, high‐impact aerobics,
baseball/softball and snowboarding].

Dr: Do you drive Pt: No

Dr – You should be careful while getting in and out of your car. It is best to ease
yourself in backwards and swing both legs round together. ( Driving is allowed after
about 6 weeks).

Dr Any other concerns ? Pt : No doctor.

Dr: Mrs Jones there could be some other complications which may happen rarely like
 29

infections or bleeding but again we take all care so that these things will not happen.
Thank you very much. Hope you recover soon and go home soon.
Say these only if the patient ask :
[ Pt - When can I go back to work? - After six and 12 weeks after your operation.
Pt: When can I have sex after this operation ? After about 6 weeks.
Pt - Will I need another new hip? - Nowadays, most hip implants last for 20 years or
more. You may need another operation after about 20 years.]