KINDLY DO NOT PUT THESE NOTES ANYWHERE ON THE INTERNET ESPCIALLY ON THE ONLINE FORUMS.
THE EXAM DETAILS THAT HAVE BEEN COLLECTED WITH MANY EFFORTS PUT IN BY AN AWESOME DOCTOR, WILL COMPLETELY GO TO WASTE.
THE GMC WOULD ALSO TRY AND CHANGE THE FINDINGS OR EVEN THE QUESTIONS AND THE
PATTERN ITSELF, IF THESE NOTES ARE COMMONLY PLACED ON THE INTERNET.
THESE NOTES WERE TYPED WITH THE INTENTION OF HELPING OUT PEOPLE WHO HAVE ANY PROBLEMS REGARDING COLLECTING ALL THIS DATA.
AGAIN HOPE YOU WILL ABIDE BY THE REQUEST MADE ABOVE FOR THE SAKE OF THE DOCTOR WHO TAKES THE PAINS TO CALL EVERY CANDIDATE WHO TAKES THE EXAM, TO COLLECT THIS DATA.
Plab 2 Topics
MEDICINE (Common Stations) History Taking
1) Chest Pain Hx + D/D = PCP Hx + D/D = ACS
Hx + Mx (with examiner) = ST Elevation MI Hx + Mx (with examiner) = ACS
2) Fever Hx + Ix + Dx = Pneumonia Hx+ D/D = Malaria 3) Dry Cough Hx = TB 4) Abdominal Pain
Hx+ LFTs report = Viral hepatitis
5) Wheeze only
Hx = Asthma
6) Headache
Hx + Dx = Giant cell arteritis
Hx + Mx (with patient) = Subarachnoid hemorrhage Hx + D/D + Dx (w examiner) = Migraine
7) Red Eye
Hx + Mx (w. examiner) = Acute close angle glaucoma 8) Knee pain
Hx + D/D = Reactive arthritis 9) Hemoptysis
Hx + D/D = Lung CA 10)Diarrhea
Hx + D/D = Acute viral gastroenteritis Hx + D/D = CA Bowel
11) Constipation
Hx + D/D = Drug induced constipation Hx + D/D = CA Bowel
12) Weight Loss
Hx + D/D = Hyperthyroidism
Hx + D/D = Amenorrhea/Anorexia Nervosa 13) Calf Pain
Hx + D/D = Chronic Limb Ischemia 14) Dizziness
Hx + D/D = Benign Positional vertigo 15) Fall
Hx + Mx (w. examiner) = Non accidental injury Hx + Cx = Hypothermia
Hx + D/D = Postural hypotension due to meds 16) Unconscious/head injury
Hx + Fx (from examiner) + Mx (with examiner) = Hypoglycemia (induced by alcohol) leading to the loss of consciousness
17)Diplopia
Hx + D/D = Muscle palsy of right lateral rectus 18) Sore throat
Hx + D/D = Infectious Mononucleosis
19) DKA (Pilot station)
Hx = History D/D =Differential diagnosis Inv = Investigations Cx = Councelling Mx = management Fx = Findings
Pattern of History Taking
This pattern has to be followed in all stations and the findings in most, (as given by the patients in exam) are given. Always take a complete history unless it’s a
councelling station in which it has to be brief. Rule out D/Ds in all stations after presenting complaint has been
in the task and confirming patient’s identity as given in the task as well.
P3 MAFTOSA
P = Presenting Complaint (ODIPARAA or Socrates if pain) [Onset, duration, intensity, progression,
aggravating/relieving factors, radiation, associated symptoms/ anything else]
P = Past history P = Personal history
M = Medical history/ Surgical history A= Allergic history F = Family history T = Travel history O = Occupational history S = Sexual history A = Anything else
In female stations and gynae & obs
4 Ps are added in the above history pattern
Station 1 (Chest pain) PCP
25 yr old man with chest pain. Talk to the patient and discuss D/D with examiner.
Fx on Hx taking
1. Fever since 1 month 2. Chest pain 3 weeks
3. Slight SOB especially when going upstairs 4. C/o cough
5. Unprotected sex 2 weeks ago 6. No discharge from urethra 7. Not in a stable relationship 8. Homosexual
D/Ds to rule out:
1. PCP (Hx of sexual intercourse/homosexual) 2. ACS (Chest pain + ECG changes)
3. Angina (pain lasting less than 30 minutes but radiating to left arm/jaw)
4. Pericarditis (Pain relieved on bending forward) 5. Dissected abdominal aorta (Pain going to the back) 6. Pulmonary embolism (Hx of prolonged immobilization,/
Hx of travelling to New Zealand/ Hx of OCPs in females) 7. Pneumonia (Fever + cough + family history positive) 8. URTI (Hx of ear ache, sore throat, flu like symptoms) 9. Pneumothorax (Hx of trauma)
10.Esophageal spasm 11.Trauma
Station 2 (Chest pain) ACS
40 yr old man with chest pain. Talk to the patient and discuss D/D with examiner.
Fx on Hx taking
1. Chest pain 45 minutes
2. Heavy pain like someone sitting on my chest 3. Pain radiating to left arm and jaw
4. Smoking since he was 20 5. Drinks occasionally
6. On antacids since last few years 7. No fever and no cough
8. No unprotected sex 9. Married man
Lying on couch and talks almost comfortably Please ask if you have received any medicines
including pain killers. If not, offer some. Don’t talk to examiner before 4: 30 bell. Fill up the time by
summarizing your findings. Don’t forget to rule out D/Ds and finish p3 maftosa before telling examiner the D/D.
D/Ds
1. ACS (Chest pain + ECG changes)
2. PCP (Hx of sexual intercourse/homosexual) 3. Angina (pain lasting less than 30 minutes) 4. Pericarditis (Pain relieved on bending forward) 5. Dissected abdominal aorta (Pain going to the back) 6. Pulmonary embolism (Hx of prolonged immobilization,/
Hx of travelling to New Zealand/ Hx of OCPs in females) 7. Pneumonia (Fever + cough + family history positive) 8. URTI (Hx of ear ache, sore throat, flu like symptoms) 9. Pneumothorax (Hx of trauma)
10.Esophageal spasm (Associated with food intake) 11.Trauma
Station 3 (Chest pain) ACS
60 yr old man with chest pain. Talk to the patient and discuss Mx with examiner.
Fx on Hx taking
1. Patient is lying on the couch and is talking uncomfortably and is sweating.
2. Pain radiating from chest to left jaw 3. Patient is a smoker + takes alcohol 4. ST elevations on ECG given
Mx of the patient!
a. Admit the patient (Very imp*)
b. Give Morphine (iv), Oxygen, Nitrates, Aspirin
(MONA)
c. Keep monitoring patient’s ECG every 15 to 30
minutes according to hospital guidelines.
d. Do cardiac enzymes after 6 hrs of onset of
pain.
e. If enzymes are normal, maybe repeated according to consultant advise.
f. If enzymes negative twice, consultant’s decision to discharge or not.
g. If enzymes positive, mention consultant’s
decision to go for thrombolysis or PCI (percutaneous coronary intervention).
Station 4 (Chest pain) ACS
30 yr old man with chest pain. Talk to the patient and discuss Mx with examiner.
Fx on Hx taking
1. Patient lying down almost comfortably 2. Heavy chest pain since 2 hrs
3. Radiating to arm and jaw
4. Smoking and drinking since 20 yrs 5. ECG is normal.
Mx of the patient!
a. Admit the patient (Very imp*)
b. Give Morphine (iv), Oxygen, Nitrates, Aspirin (MONA)
c. Keep monitoring patient’s ECG every 15 to 30 minutes according to hospital guidelines.
d. Do cardiac enzymes after 6 hrs of onset of pain. e. If enzymes are normal, maybe repeated according
to consultant advise.
f. If enzymes negative twice, consultant’s decision to discharge or not.
g. If positive, consultant’s decision to go for thrombolysis or PCI (percutaneous coronary intervention).
Learn to identity and pick up myocardial infarctions on ECGs of different cardiac walls.
Station 5 (Fever) Pneumonia
Young man presented with fever. Temperature is 38.5 degrees. On auscultation, right basal crackles. Talk to patient. Take Hx and discuss D/D and investigations with examiner.
Fx on Hx taking
1. Had fever (intermittent) since 2 weeks 2. Cough associated with green phlegm
3. 10 people at work place with the same symptoms 4. Himself is a soldier and lives in a camp
5. Blanket sometimes available which you can offer to the patient or he already has it on.
3 important investigations! 1. Full blood count 2. Sputum culture 3. Chest X ray D/Ds 1. Pneumonia 2. URTI 3. Sinusitis 4. TB 5. Otitis media 6. Meningitis 7. Gastroenteritis 8. Hepatitis
Station 6 (Fever) Malaria
25 year old girl with fever. Talk to patient. Discuss Dx with examiner.
Fx on Hx taking.
1. Fever (comes and goes)
2. Travelled to Africa/ Ghana/Kenya recently
3. Received malaria prophylaxis before going. Despite that, the Dx is still Malaria in this case.
If the patient is shivering in this station and a blanket is available, offer it.
D/Ds to rule out 1. Malaria
2. Typhoid (Tummy pain, continuous fever, GI symptoms)
3. UTI
4. Pneumonia 5. TB
Station 7 (Dry cough) Tuberculosis
28 year old presented with complaints of dry cough. Talk to the patient and discuss D/D and investigations with the examiner.
Fx on Hx taking.
1. Weight loss present 2. Night sweats
3. No positive sexual history 4. No iv drug abuse/ no tattoos
5. No sputum
6. No family member has it 7. No travel history
Investigations
1. Bronchoscopy and lavage 2. Chest x ray D/Ds 1. TB 2. Asthma 3. COPD 4. PCP
5. ACE inhibitors intake 6. URTI
7. Allergy
8. Cardiac asthma 9. Atypical pneumonia
Station 8 (Abdominal Pain) Viral Hepatitis
A 45 year old man/lady with c/o right upper quadrant pain. Talk to patient. Interpret LFTs and discuss Dx with the
examiner.
ALT and AST are raised in Viral hepatitis GGT is raised in alcoholic hepatitis
ALP is raised in obstructed jaundice (gall stones obstructing CBD or CA head of pancreas)
Fx on Hx taking:
1. RUQ pain since last few days 2. Low grade fever
3. Hx of RTA (Received blood)
4. Surgical history of laparoscopic cholecystectomy 5. No alcohol history
6. No sexual or IV drug abuse history
D/Ds to rule out:
1. Viral hepatitis ( Blood transfusion history, sexual history, yellowness of eyes, iv drug abuse)
2. Alcoholic hepatitis
3. Acute cholecystitis ( Pain increased with fatty meals intake. Pain radiating to the shoulder)
4. Cholangitis ( fever + jaundice + rigors/chills)
Station 9 (Wheeze) Asthma
28 year old man comes with complaints of wheeze. Talk to patient and take history.
Fx on Hx taking:
1. 2 yrs ago had similar symptoms and went to see the GP 2. Needs inhalers
3. Wheeze when playing 4. Hay fever present
D/Ds to rule out 1. Asthma 2. URTI
3. Allergy and hay fever 4. Pneumonia
Station 10 (Headache) Giant cell arteritis
80 year old lady presented with headache. Talk to patient and discuss Dx with examiner.
Fx on Hx taking:
1. Pain is all over the head 2. Pain scored between 7/10 3. More over temple area 4. Pain more on combing hair 5. Not associated with chewing
Note: Double/triple sympathy when elderly patients. Don’t rush the station. Talk slower.
D/Ds to rule out: 1. GCA
2. Subarachnoid hemorrhage
3. Migraine (Family hx positive, has been there for yrs) 4. Glaucoma (pain behind eyes, watering of eyes)
5. Space occupying lesion (focal deficits/weakness in body, vomiting, vision probs)
6. Tension headache (Band like headache) 7. Cluster headache (Red, watery eyes) 8. Trauma
Station 11 (Headache) Subarachnoid
Hemorrhage
25 year old man/lady with headache. Known case of migraine. On zolmitryptine. Discuss Mx with patients.
Fx on Hx taking:
1. Pain all over the head.
2. Pain starts from the back of head (some cases) 3. Most severe pain ever experienced.
4. Pain scored 9/10
5. Covers eyes (photophobia) 6. K/c of migraine
7. Family history of migraine positive
8. No rash. No fever. No red eyes. No vomiting. No hx of trauma.
Note: All 3 stations of headache, talk about pain killers and offer dimming the lights. Rule out D/Ds when taking
complete history. Mx:
From what you have told me, I suspect SAH which is
bleeding in your brain. It is like a stroke. In order to confirm my diagnosis, I’ll have to do a CT scan to confirm any bleed in your brain and if there is, we will need to see how much and the site of bleeding. When we confirm our diagnosis, we will refer you to the neurosurgery team. They’ll probably go for surgery. We may give you some meds in the mean time to decrease the pain. (Ca channel blockers are given
Station 12 (Headache) Migraine
18 year old with presenting complaint headache. Talk to patient and discuss D/D and Dx with examiner.
Fx on Hx taking:
1. Girl covers her eyes by her hand 2. Severe pain since this morning
3. Family history positive. Mom has the same kind of headaches D/Ds 1. Migraine 2. GCA 3. SAH 4. SOL
5. Meningitis (neck stiffness, fever, vomiting) 6. Glaucoma
7. Cluster headache/tension headache 8. Sinusitis
Station 13 (Red Eye) Acute close angle
glaucoma
55 year old lady with red eyes (will be wearing sunglasses which you can’t ask to remove) and pain in the head. Talk to patient and discuss Mx with the examiner.
Fx on Hx taking:
1. Red eye since last few days 2. Patient has a headache
3. Sometimes indicate it to be over the temporal area 4. No c/o pain at the back of eyes
5. Patient is on amytrptine
6. Ask her if she sees haloes around light.
D/Ds to rule out: 1. Glaucoma
2. Conjuctivitis (sticky discharge) 3. GCA (pain on chewing/combing) 4. Foreign body 5. Sinusitis 6. Uveitis 7. Allergy 8. Reiters syndrome 9. Cluster headache Mx:
Consider giving 3 drops
1. Pilocarpine (causes pupil constriction)
2. Beta blockers (Timolol) (Decreases fluid in the eye) 3. Steroids (reduces inflammation)
4. Inj acetazolamide
5. IV mannitol (works like beta blockers. Decreases fluid) 6. Refer this patient to ophthalmologist who may do
slit lamp examination or gonioscopy and confirm the diagnosis. If so, they may go for surgery or laser treatment.
Station 14 (Knee Pain) Reactive arthritis
A young man 28 yrs old, comes to hospital with knee pain. Talk to patient. Discuss D/D with examiner.
Fx on Hx taking:
1. Had knee/ankle pain since last week 2. No pain in small joints
3. Morning stiffness (patient says he thinks so) 4. Calf pain (patient says he thinks so)
5. Got watery eyes
6. Travel history to France
7. Diarrhea in France destroyed his holiday there 8. No sexual history
9. No burning micturition. No urethral discharge. No fever.
D/Ds:
1. Reactive arthritis
2. Reiter’s syndrome (Sexual history positive, joint pain, eye and urethral discharge)
3. Hemarthrosis
4. Rheumatoid arthritis 5. Osteoarthritis
6. Gout
7. Septic arthritis (Fever, joint swelling/pain) 8. Sport injury or trauma
Station 15 (Hemoptysis) Lung CA
60 year old lady presented with hemoptysis. Talk to the patient. Discuss diagnosis with the examiner.
Fx on Hx taking:
1. Blood in sputum in last 8 weeks
2. Sputum quantified and would be filling up to half a cup 3. Smoking since was 20 yrs old
4. Weight loss and fever (+-)
Note: Always assess anemia in case of any bleed.
Check if patient is lethargic or feels too weak to go about doing daily chores. Or gets short of breath easily.
D/Ds to rule out: 1. Lung Carcinoma 2. Pulmonary embolism 3. TB 4. Pneumonia 5. COPD 6. Bronchiectasis
Station 16 (Diarrhea) (Acute) Viral
Gastroenteritis
A 60 yr old lady presented with diarrhea. Talk to patient and discuss D/D with examiner.
Fx on Hx taking:
1. Watery diarrhea 2. Vomiting present 3. +-Fever
4. Patient was staying in a hotel 5. Her friends had similar symptoms
Note: Sympathize extra with the elderly. Ask if the patient can take fluids and diet without throwing up. If not, admit the patient. Ask if he/she is too lethargic or feels too weak. If abdominal pain, offer pain killers. Always assess dehydration in case of diarrhea. D/D:
1. Acute gastroenteritis
2. Bowel CA (*MUST RULE OUT)
3. Traveler’s diarrhea (Diarrhea will be while on vacation)
4. Pseudo membranous colitis (If antibiotic intake history)
5. Infective (Bacterial) diarrhea (Blood or mucus in stools)
Station 17 (Diarrhea) Bowel carcinoma
40 year old man with chronic diarrhea. Talk to patient and discuss D/D with the examiner.
Fx on Hx taking:
1. 1 stone weight loss 2. No tummy pain 3. No fever
4. No tummy pain 5. Blood in the stools
6. No family history of bowel carcinoma 7. Smoker
8. No positive sexual history
9. No mouth ulcers/ No skin changes
D/D:
1. CA bowel 2. G/E
3. IBD (fever + tummy pain) 4. Irritable bowel syndrome 5. Malabsorption
6. DM
7. Hyperthyroidism 8. HIV
Station 18 (Constipation) Drug induced
(cocodamol) constipation
80 year old lady with constipation. Talk to patient and discuss D/D with the examiner.
Fx on Hx taking:
1. Pain in ankle
2. GP prescribed cocodamol
3. Ask for medical history. She maybe carrying it with her or remember the name of the drug she is taking.
D/D:
1) Drug induced constipation 2) Bowel Ca
3) Diabetic neuropathy 4) Hypothyroidism 5) Low fibre diet
6) Intestinal obstruction 7) Back injury
Station 19 (Constipation) Bowel Carcinoma
75 year old patient, admitted in hospital and constipation is present. Talk to nurse and discuss D/D with examiner.
Fx on Hx taking:
1. Constipation since 2 months 2. Family history of bowel CA 3. No weight loss
4. Bleeding in stools present
5. Tenesmus, tummy pain, altered bowel habits (+-)
D/D:
1) Bowel Ca
2) Diabetic neuropathy 3) Hypothyroidism 4) Low fibre diet
5) Intestinal obstruction 6) Back injury
7) Fecal impaction
Station 20 (Weight loss) Hyperthyroidism
20 year old lady with weight loss. Talk to the patient and discuss D/D with the examiner.
Fx on Hx taking:
1. 2-3 kgs weight loss in last 2 months 2. She feels hot
3. Sister has the same symptoms
Note: Always ask for weather preference when suspecting hyperthyroidism. D/Ds: 1. Hyperthyroidism 2. Anorexia Nervosa 3. Malnourished 4. Malabsorption
5. IBD (fever + tummy pain +diarrhea) 6. IBS
7. Malignancy 8. TB
Station 21 (Weight loss) Anorexia Nervosa
20 years old lady with amenorrhea. She also had weight loss in the last few months. Talk to patient and discuss D/D with the examiner.
Fx on Hx taking:
1. No periods in last 8 months
2. Boyfriend dumped her because he thought she was chubby
3. 6 kgs weight loss over the past few months. 4. No heat/cold intolerance
5. No facial hair/ no acne
6. Periods were normal before
7. Diet according to her is normal and nothing is wrong but dig into it.
8. Takes thyroxine (abuse it) to lose weight as well
D/D:
1. Anorexia Nervosa (clever bmw) (Clothing baggy, laxative abuse, excessive exercise, induced
vomiting, excessive wt loss, role models are thin people, body image etc)
2. Malnutrition 3. Malabsorption syndrome 4. IBD 5. IBS 6. TB 7. Hyperthyroidism 8. Depression
Station 22 (Calf Pain) Chronic Limb Ischemia
45 year old patient with pain in the calf. Talk to the patient and discuss diagnosis with examiner.
Fx on Hx taking:
1. Pain in last few months, relieved at rest. 2. Smoking in last 20 years.
3. DM +ve (not controlled)
4. Sedentary life style/ no healthy diet
D/Ds to rule out:
1. Chronic limb ischemia (due to atherosclerosis) 2. DVT (Any hotness in calf along with pain, travel hx) 3. Burger’s disease (smoking history, pain not relieved at
rest)
4. Ruptured Achille’s tendon (Can you stand on your toes?)
5. Sports injury
6. Ruptured baker’s cyst (Any sort of joint disease?) 7. Sciatica (Pain radiating from back to leg)
Station 23 (Dizziness) Benign positional
vertigo
70 years old lady with dizziness. Talk to patient and discuss D/D with examiner.
Fx on Hx taking:
1. Had the same S/S previously.
2. Was taking stamatil, prescribed 3 weeks ago by GP 3. Patient stopped meds because of side effects (e.g.
headache, drowsiness) 4. Stopped meds last week
5. Dizzy especially during morning while changing dress 6. No bells ringing sensation in ears/ no fever.
D/D:
1. BPV (especially on tilting or change of position of head, loss of balance, vomiting/nausea)
2. Minnere’s disease (bell ringing sensation)
3. Acoustic neuroma (weight loss, loss of balance) 4. Multiple Sclerosis (difficulty & weakness in moving
limbs) 5. DM
6. Migraine 7. Otitis Media
Station 24 (H/O fall) Non Accidental injury
85 yrs old lady brought in by 60 yrs old daughter. On
examination, she notices bruise on arm and forehead. Please talk to daughter and discuss management with the
examiner.
Elaborate the event. Find out if story matches with the injuries or not.
What was done immediately after the event?
Who takes care of the patient?
Is there any previous incidence of the sort/ any previous injury that lead to hospitalization?
Any injury with no record in the hospital?
Fx on Hx taking:
1. Daughter said she fell down on the radiator
2. She brought mum 2 to 3 hrs after the incident. No valid explanation for bringing her late.
3. She is not sure about mom’s medical illnesses. She says mom is old and hence has many problems 4. She informs that mom is taking many meds but not
sure what they are.
5. Mom lives with this daughter who is her caretaker.
D/Ds to rule out: 1. NAI 2. Osteoporosis 3. Osteoarthritis 4. UTI/Pneumonia in elderly 5. DM 6. Refractory error 7. TIA 8. SAH 9. Hypoglycemia/alcohol/ dehydration/arrhythmias/vasovagal syncope/Adrenal insufficiency
Mx:
I will admit my patient. I am suspecting NAI (non
accidental injury) or elderly abuse as the history given does not justify or go with the injuries of the patientbut it could be accidental as well. Daughter seems to be careless about mom and she’s the only one taking care of her. I will discuss and confirm this case with my seniors, who may involve social services accordingly. I will order a skeletal survey further if advised by my seniors.
Station 25 (H/O fall) Hypothermia
80 years old lady brought by her son. Rectal temp 34 degrees. Talk to the patient’s son. Give necessary advise.
Fx on Hx taking:
1. Son found mom lying on the floor but he doesn’t know the cause.
2. Mom lives alone by herself
3. Son visits once or twice per week
4. Neighbor and friends check on mom now and then 5. (+_) history of DM, osteoarthritis, hypertension) 6. Son informs that mom is becoming forgetful lately. 7. Central heating is on but mom could forget to pay
the bill so son pays now.
8. She forgets to close the windows now which the son found open. D/Ds to rule out: 1. Hypothermia 2. Osteoporosis 3. Osteoarthritis 4. UTI/Pneumonia in elderly 5. DM 6. Refractory error 7. TIA 8. SAH 9. Hypoglycemia/alcohol/ dehydration/arrhythmias/vasovagal syncope/Adrenal insufficiency/NAI Cx:
From what you have told me, your mom has got a condition that we call hypothermia, which can be
dangerous if left untreated especially at her age. It may affect organs, lead to confusion and may even affect fine movements of hands and limbs. I am sure you do your best and have done your best until now regarding taking care of her but would you like to share this
respeciallyonsibility so she is better taken care of? There are people who can be assigned for her care. Or
generally advise him to ask the neighbors and friends to drop in more often to check up on her, if the house is warm and windows are closed
Station 26 (H/O fall) Postural hypotension
due to medication
60 yrs old lady presented with history of fall. Talk to the patient and discuss D/D with the examiner.
Fx on Hx taking
1. This patient is on anti hypertensives since 20 yrs 2. Patient went to GP
3. GP reviewed the doses two weeks ago.
4. Patient then developed the complaint of falling.
D/Ds:
1. Postural hypotension due to meds 2. NAI 3. Osteoporosis 4. Osteoarthritis 5. UTI/Pneumonia in elderly 6. DM 7. Refractory error 8. TIA 9. SAH 10.Hypoglycemia/alcohol/ dehydration/arrhythmias/vasovagal syncope/Adrenal insufficiency /Hypothermia/head injury/ epilepsy
Station 27 (Unconscious) Alcohol induced
hypoglycemia
A young man fell down in front of the pub and went
unconscious. Talk to the patient. Ask about fx from the examiner and discuss Mx with the examiner.
Fx on Hx taking:
1. Patient was drunk
2. He went dizzy and fell down and can’t remember what happened after that.
3. No DM hx
4. No previous cardiac condition
5. Duration of unconsciousness = 2 to 3 minutes 6. No fever, no rash, no photophobia
7. No jerky movements of body
Fx from examiner: 1. GCS 15/15
2. No focal/neurological deficit. D/Ds to rule out:
1. Hypoglycemia induced by alcohol, leading to the unconsciousness/fall.
2. Head injury (ENT Bleed, vomiting) 3. Epilepsy (Prev hx of fits)
4. A Fib 5. Poisoning 6. Meningitis Mx:
I will admit this patient. I will check for his random blood
sugar, send for a full blood count and do a 24 hrs ECG monitoring while doing neuro observation. I’ll do CT scan if necessary as well, having informed my seniors.
(Indication for admission in head injury) 1) LOC 2) GCS less than15 3) Amnesia 4)
Any focal, neurological deficits 5)
Vomiting 6)
Altered bowel habits 7)
NAI
NICE guidelines for CT Scan in patients 1)
Loss of consciousness> 5 minutes 2)
GCS < 14 after admission 3)
In peds, GCS < 15 4)
Any S/S basal/skeletal fracture 5)
Vomiting > 3 times in kids and < 2 times in adults 6)
Any focal or neurological deficit 7)
Amnesia > 5 minutes 8)
Station 28 (Diplopia) Muscle palsy of right
lateral rectus
47 yrs old lady comes with c/o diplopia. Talk to patient and discuss D/D with examiner.
Fx on Hx taking:
1. The patient is a teacher by occupation.
2. When writing on the board, sees double on the right side
3. Few months ago, while reversing her car, hit bumper on the wall due to double vision.
4. Doesn’t wear glasses
5. No headache, no vomiting
6. No S/S of hyperthyroidism, SOL, MS
D/Ds
1. Muscle palsy of right lateral rectus 2. Multiple sclerosis
3. GCA 4. SOL 5. Cataract 6. Hyperthyroid
7. Inflammatory orbit myositis 8. Refractory error
Station 29 (Sore Throat) Infectious
Mononucleosis
25 yrs old man presented with c/o sore throat. Talk to the patient and discuss D/D with the examiner.
Fx on Hx taking:
1. Fever in last few days
2. Reddish and itchy rash on the chest 3. Travelled to Rome 2 weeks ago 4. No difficulty in swallowing
5. No vocal abuse 6. No instrumentation 7. No weight loss
8. Not sexually active/Protected sex
D/D: 1. Infectious mononucleosis 2. Mumps 3. Vocal abuse 4. Smoking 5. Carcinoma 6. Hay fever 7. Tonsillitis 8. URTI
Station 30 (DKA) Pilot Station
35 yrs old lady with p/c vomiting, diarrhea and abdominal pain. She is a known case of DM. She missed insulin dose. Dx of DKA has been made. Talk to the patient and explain the condition and importance of admission and address her concerns.
Fx on Hx taking
1. Dr, I have DM + vomiting + tummy pain.your colleague did some blood tests and put IV cannula on my hand. 2. I have two kids waiting at home. Her partner is not
home as well.
3. On your disclosing the Dx, she asks what’s DKA?
Tell her it’s a dangerous complication of DM caused by lack of insulin in your body. It happens when body is unable to use blood sugar because of deficiency of insulin.
The body breaks down the fat as an alternative fuel. This can build up substances we call ketones.
4. Why can’t you send me home with IV fluids?
We have to keep you because we have to monitor you and do investigations repeatedly. We have to check your blood for blood sugar levels and for other
substances in the blood (Potassium). We also have to check your urine for some substances and treat
accordingly. We may also need to give you different fluids + minerals + insulin (which pushes sugar into cells) until you are out of this condition. It’s important that we keep you in the hospital.
5. Ask her if there is someone who can take care of the kids. Otherwise tell her you will talk to the consultant and see if something can be done to either bring them over for a while or if someone can be arranged to take care for them at home. Ask their ages beforehand. This patient fusses and insists a lot about wanting to go home so take your time explaining her why she needs to be kept in the hospital until 4 30 bell rings.
MEDICINE (Common Stations) Hx + Councelling
1) Sexually Transmitted illness Hx + Cx Cx Only Hx (2 scenarios) 2) Osteoporosis Hx + Cx (2 scenarios) 3) Stroke follow up Hx + Cx 4) Post MI Hx + Cx
5) Needle stick injury (2 scenarios)
6) Epilepsy Hx + Cx Cx Hx + D/D 7) CKD Hx + Cx 8) Paracetamol Poisoning Hx + Mx (with patient)
9) Chronic Fatigue Syndrome
Hx + Cx
10)IV cannula blocked
Questions to ask in every STI station
1. How many partners do you have/had in the last few months?
2. Do you use condoms (protection)? 3. Route of sex?
4. Your sexual partner is a male or female? 5. Previous STI?
6. Previous medical illness?
7. Any allergies to meds? (Always ask before prescribing meds)
Symptoms you should ask Fever
Dysuria
Eye symptoms
Knee joint pain/symptoms Discharge from urethra
Ask if he noticed any ulcer, discharge, swelling or lump in groin area.
Investigations:
1. Genital swab test
2. Complete Urine exam (Urine culture and sensitivity) (chlamydia)
3. Blood test for HIV and Hepatitis Tx:
Doxycycline 100mg BD for 1 week (1st line for Chlamydia)
Azithromycin 1g single dose given (1st line for Gonorrhea)
Ceftriaxone 500 mg single dose given
General Advise you need to give in every STI station:
2. Don’t have sex until receiving a negative test result,
and until treatment is completed.
3. Even if sexual partner has no symptoms, the sexual
partner should be checked and treated accordingly.
4. Please ask the patient after any unprotected sex
outside his relationship, he had sex with his/her own partner. If the answer is no, drop it.
If the answer is yes, ask if they can ask their partner to come over to get checked and for any necessary
treatment. If the patient is unable to call them himself, talk about partner notification program. (A program that enables hosp to send anonymous letter to the patient’s partner asking them to come in for a routine special check up just for safety reasons).
Station 1 (STI)
55 yrs old man presented with discharge to your clinic. You are SHO in the gum clinic. Talk to the patient and take Hx, discuss investigations with patients (sometimes) or council patient and address his concerns.
Fx on Hx taking:
1. Came to London and had unprotected sex 2 weeks ago. 2. Yellowish discharge since 2 days
3. +- Fever
4. +- Burning sensation on passing urine 5. Had sex with the wife after the event
Cx:
From what you’ve told me, you have STI, which is an infection that can pass from one person to another when they have sex. I have to run some investigations. We do Urine tests and we take a sample from discharge. Would you like to have blood tests for HIV and Hepatitis just to be on the safe side? We treat with medications (antibiotics) which can clear this bug. This medication is given according to test results, either in a single dose form or for one week. Please don’t have sex with your partner even with protection (condoms) during this week until the test results come
negative.
Did you have sex with your partner after this event? Can you ask your partner (wife) to come? Talk about PARTNER
NOTIFICATION PROGRAM otherwise. Explain how it is
important to treat the partner, otherwise it will remain untreated and might spread from one person to another during intercourse and can bring complications without treatment.
Station 2 (STI)
Young girl 24 yrs old, comes to gum clinic with complaints of discharge. She had unprotected sex 3 weeks ago when she met her boyfriend. Now she’s in the clinic to get her report of investigations. He was in the clinic last week as well and some investigations were done. Report shows she has
gonorrhea. Talk to the patient. (Take Hx and the fx are given above)
Cx:
From the lab report, it shows you have STI. For treating the bug that causes this condition, we’ll give you a tablet or injection that you can get here.
Give patient general advise about not having sex while being treated and until tests are negative. Tell her the importance of treating herself and getting her partner treated as well. Tell her to complete her meds even if symptoms subside.
If STI is left untreated, there are some complications e.g. you may get PID (inflammation of tubes) and may face problems when you get pregnant e.g. ectopic pregnancy (pregnancy outside tubes) and premature baby. You may face
infertility and miscarriages are a complication of
untreated STI as well.
As a part of general advise, risk of STI will increase if you don’t practice safe sex and if you change sexual partners often or have multiple sexual partners. So practice safe sex.
Station 3 (STI)
A 50 yrs old man travelled to Berlin. He had unprotected sex with a girl. Take sexual history. You are the SHO in gum clinic. Do not advise about HIV.
Fx on Hx taking:
1. I had sex while I was drunk. The condom slipped but I continued.
2. Also had oral sex.
3. No fever, no discharge, no ulcer, no weight loss 4. Had sex in a legal area.
5. He had sex with wife after that day.
6. He claims to be committed to his wife and is a married man.
Questions to ask in every STI stations
1. How many partners do you have/had in the last few months?
2. Did you use condoms (protection)? 3. Route of sex?
4. Your sexual partner is a male or female? 5. Previous STI?
6. Previous medical illness?
7. Any allergies to meds? (Always ask before prescribing meds)
Symptoms you should ask Fever
Dysuria
Eye symptoms
Knee joint pain/symptoms
Discharge from urethra
Ask if he noticed any ulcer, discharge, swelling or lump in groin area.
Station 4 (STI)
A young lady comes to gum clinic. Talk to patient and take sexual history. Assess for any possibility of STI.
Fx on Hx taking:
1. On being asked what brought her to the clinic, patient says her husband told her that he had sex a month ago, with another girl.
2. He was drunk and says can’t remember if used protection or not.
3. She had sex with him a few times after that event. 4. The route of sex was vaginal and sex was
unprotected between the husband and wife. 5. No discharge or fever. No eye or knee probs. 6. Both of them were symptom free.
7. If she asks, will you do any tests for me, tell her yes but you would like to first ask her a few more questions and take a detailed history.
Station 5 (Osteoporosis) 47 yrs old patient
General knowledge regarding osteoporosis Dexa Scan
Less than -2.5 = Osteoporosis -1.5 to -2.5 = Osteopenia Greater than -1.5 = Normal Risk factors:
Hx of prev wrist/hip fracture. Any parental Hx of osteoporosis Any osteoarthritis
Alcohol > 4 units per day Steroid intake
There are chances of low bone density in Crohn’s disease, ankylosing spondylitis or OA. Also with BMI <13.5, there are greater chances of Osteoporosis. Tx:
Less than 50 yrs = Hormone replacement therapy and
Bisphosphonates.
50-70 years (dexa +ve + 1 risk factor present) =
Bisphosphonates
Greater than 70 yrs (dexa +ve + 2 risk factors present) =
Bisphosphonates
Hx taking (Take the whole P3 MAFTOSA) 1. Inquire age of the patient
2. Any medical illness/ Prev surgical history 3. Any medications being taken
4. Alcohol and smoking history 5. Parental and family history 6. Diet/Exercise Hx
7. Ask patient’s knowledge about symptoms after grips (introducing yourself etc) and then disclose the
condition or diagnosis that she has a disease that causes thinning of bones.
8. Explain and address concerns or discuss management as asked.
47 yrs old lady/man presented to clinic. Dexa scan has been
done and Dx of osteoporosis was confirmed. You are SHO in the medical dept. Talk to the patient and address patient’s concerns.
Ask patient to briefly elaborate her symptoms and ask if she knows what she might be having. Take the history and ask the questions especially the ones mentioned above. Then disclose that she has been diagnosed with a disease called osteoporosis in which thinning of bones occur. She will ask why she got it and what are you going to do for her. The conversation below will show the answer given by the patient in this station.
I would like to ask you a few questions and hopefully with try to find a cause. Whats your age? 47 yrs. Any medical illness?
No I am fine. Are you taking any medications? Just paracetamol sometimes. Do you take alcohol? No.
Appreciate the fact that she doesn’t (That’s good to know). Do you smoke? No I hate smoking (That’s nice to hear how you have such healthy habits). Have your parents got a condition called Osteoporosis? No. Your diet? Are you taking enough dairy products? How about exercise? Any prev
fracture? Patient will respond with having healthy habits. Any prev surgery? Yes my womb was removed when I was 35.
Address patient’s concerns at every point and here the cause was due to loss of hormones due to the hysterectomy done. Do not go on talking and let patient get her answers from you. Talk about HRT and Bisphosphonates.
Station 6 (Osteoporosis) 57 yrs old patient
57 yrs old lady/man presented to clinic. Dexa scan has been
done and Dx of osteoporosis was confirmed. You are SHO in the medical dept. Talk to the patient and address patient’s concerns.
Fx on Hx taking:
1. Do you drink alcohol = Yes 2. Do you smoke = yes
3. Parental Hx = Mom had Osteoporosis 4. Any prev fracture = Wrist fracture
5. Exercise = pain in bones so cant exercise. 6. Diet = Drinks coffee
Cx:
Please drink alcohol in moderation and try to cut it down if can’t stop. Get help if needed. I can refer you to a colleague who can help you with some exercises that won’t hurt but will be good for your bones. Have a well balanced diet with right amount of dairy products. I can refer you to a dietician. The treatment for him is bisphosphonates. The treatment is not curative but slows the progression of disease.
Station 7 (Stroke)
A 60 yrs old man was admitted because of stroke. He is about to be discharged. Please talk to patient.
In every stroke patient assess risk
NON MODIFIABLE MODIFIABLE Age DM Gender Hypertension
Prev Hx/risk factor Hypercholesterolemia
Weight gain/ Smoking/
Not enough physical
activity.
First of all express how you are happy that he is finally able to go home. Advise him to comply with his medicines there and ask if he has people to take care of him. If not, tell him
special nurse can be provided who will take care of his
every day needs and will medicate him as prescribed, if he has difficulty taking due to any reduced movements. Advise
about diet, exercise, smoking, alcohol and weight loss. Tell him physiotherapist can be arranged to come
over and teach him how to exercise his limbs regularly until they return to functioning as near to normal as possible or otherwise as well. Speech therapist will help if he has
difficulty with speech after stroke. Occupational therapist will make sure there is no trouble at home, with using the bathroom (in case its upstairs and he lives downstairs) and will help modify the house according to his essential needs due to his current condition. In case he is ever depressed,
Counseling can be provided at home if ever needed. Rule
advise accordingly to take proper medications and follow up regulary with his GP regarding them. Emphasize on the
importance of their control. In the end, talk about warning
signs (FAST). Any facial weakness, arm weakness, speech difficulty, the patient should telephone 999 and
get help and ask for ambulance immediately, to be brought to the hospital.
Let patient talk about his concerns. Be patient and do not speak out everything in one go. After you have addressed one concern, ask him if he has any other and if not, bring out the facilities that can be provided one by one.
Station 8 (Stroke)
A 55 yrs old lady presented to the hospital. Talk to the lady and assess risk of stroke. Her family history for stroke is positive but BP is normal.
Ask this lady about non modifiable factors, if she has any and inquire about lifestyle habits and diet especially when taking history. Assess risk of stroke via the questions
mentioned above, plus take relevant history e.g. past and family Hx as required.
This patient has a stressful job, bad diet and is a smoker as well as an alcoholic and do not go for exercise.
Station 9 (MI)
60 yrs old lady had MI 3 weeks ago. She got discharged after 1 week from the hospital. She is now in out patient clinic for follow up. She has complaints of SOB, ankle edema and leg edema. Echo has been done and shows left ventricular failure. Talk to the patient and give necessary advise.
Fx on Hx taking:
1. Patient had MI 3 weeks ago 2. Discharged with meds
3. Main complaints are orthopnea, SOB and pedal edema. 4. Stopped meds after 1 week
5. She didn’t know she had to renew prescription from GP after the one week and thought this was all the meds she had to take.
6. She may also be forgetful.
Tell her you can buy a box that has different sections for every day, with a section for morning, evening and night. She will remember if the medicines are put in them
accordingly, to take them on time. She will remember her husband got her such a box once. Also tell her alarms could be set for her on her clock or phone in order to remind her when its time to take meds. Inquire if she has any family members to help her take them on time or if she needs help with that. Tell her she has to renew her prescription once it finishes or otherwise she won’t get better, if she ever forgets to, or don’t take her meds.
She should ideally be admitted but that’s not a concern here. Address her concerns in this station and respond accordingly, after taking history.
Station 10 (Needle Stick Injury) In the park
Questions to ask
1. May I ask what happened? When? 2. What did you do afterwards?
3. Was it a solid or a hollow needle? (Normal or hospital needle)
4. Was the needle already used? Any blood on it? 5. Were you wearing any gloves?
6. Scratch or deep puncture wound? 7. Do you have any medical illness?
8. Are you vaccinated? (Against tetanus and hep B) 9. When was the last time you had a booster?
10. If the patient is in the hosp, then with what illness?
Things to do (General info) 1. Stop the procedure
2. Dispose off the sharps 3. Squeeze your finger 4. Wash your hand 5. Apeopley bandage 6. Inform the patient
7. Request a colleague to continue procedure 8. Fill up an incident form. Take advice from a
microbiologist.
9. Inform the occupational health department
10. Give your blood and take patient’s blood for further investigations
11. Post exposure prophylaxis for HIV is given within one hour.
26 yrs old man had a needle stick injury in the park. He
pricked his finger while he was doings something. Talk to the patient and address concerns.
1. He didn’t squeeze his finger. May only have washed with water.
2. Hollow, wide bore needle (Hospital needle) with blood but with or without syringe.
3. He’s worried as drug abusers may have used it earlier
and they may have HIV and now he might get it. Tell
him HIV bugs can’t survive outside human body and the chance of transmission is next to nil. There has been no significant incident of spread of HIV since 1981 via needle stick injury due to the precise reason.
4. If despite assurance he is still worried, tell him, you will give him a date and will arrange for him so that the blood test can be done. Explain how prophylaxis meds for HIV have severe Side effects so tell him you will ask your consultant regarding giving him getting any, if he asks for it since transmission chances are very low.
(Note: The HIV antigens can’t be detected before one month and antigen and antibody are both present after 3 months and not before. In hep, it takes 4 to 7 weeks to be detectable. People are already vaccinated against tetanus in UK, at 2,3,4 months, during
preschool and at 16 yrs of life and hence they get a lifelong immunity against tetanus).
5. If he is concerned about infections, tell him you will take a look at his finger and ask for any redness, discharge or swelling and will give medicines (antibiotics)
Station 11 (Needle Stick Injury) Nurse at the
hospital
There’s a nurse who had a needle stick injury while drawing blood from the patient. Talk to her. (Hx + Cx)
Questions to ask
1. May I ask what happened? When? 2. What did you do afterwards?
3. Was it a solid or a hollow needle? (Normal or hospital needle)
4. Was the needle already used? Any blood on it? 5. Were you wearing any gloves?
6. Scratch or deep puncture wound? 7. Do you have any medical illness?
8. Are you vaccinated? (Against tetanus and hep B) 9. When was the last time you had a booster?
10. If the patient is in the hosp, then with what illness?
Cx:
Sympathize and empathize. Reassure the nurse. Tell her once again you are sorry that this happened to her. Ask her if she has any worries or concerns about this incident.
Don’t worry about HIV. Chances of getting this infection through needle stick injury are very low. Also if patient himself doesn’t have HIV, there is no need to worry on that note at all. We have prophylactic meds anyway. If taken as soon as possible, in case someone is infected, the chances of getting the infection are much lesser. However we have to do some blood tests on you and the patient. We will inform occupational health department and I will talk to the
microbiologist and get back to you real soon.
Tests for HIV are done at 1,3,6 and 9 months.
Regarding Hep B, chances are almost nil as everyone in UK is immunized (especially health officials before taking up
jobs). So you need not worry on that note. However after the
About tetanus, booster dose has to be taken after every 10 years.
In case the patient has meningitis, I’ll find out the detail about the patient’s illness and we’ll give you prophylaxis if required.
Station 12 (Epilepsy) Uncontrolled epilepsy
25 yrs old man is a k/c of epilepsy. This man has got some recurrent seizures in last few months. Talk to the patient and give necessary advise.
Fx on Hx taking:
1. Do you take regular meds? Yes
2. Did you miss any dose recently? Sometimes, when I feel absolutely fine or I only take when I feel like I maybe getting seizures.
3. What meds are you on and why don’t you take them regularly? They have S/E: Make me drowsy and give me a headache.
4. Occupation? Waiter/bartender. Works till late. Gets little
sleep. Advise him on how lack of sleep, poor
compliance of meds, alcohol, flashing lights, dehydration, getting tired and exhausted,
skipping meals and working on PC/watching TV til late all are triggers.
We’ll review your medicines and give you the ones that cause the least S/E but you should take them regularly without skipping doses. If the S/E persists, you should come back immediately so we can alter them.
In general advice, avoid having sharp furniture at home. Change ordinary gas cooker, to electric ones. Take shallow baths. Do not go near height.
Station 13 (Epilepsy) Student in a new town
22 yrs old lady comes to you. She’s a k/c of epilepsy. Talk to the patient and address patient’s concerns.
Fx on Hx taking
1. This patient is a student
2. Recently moved to a new town
3. Patient has concerns about S/E of medicines (anti epileptics). (She’ll ask if they will damage the liver). 4. She’s on Na Valproate.
5. She will ask regarding taking OCPs.
Tell her to not worry. We do routine blood tests and check your liver status frequently. Your meds are very safe and so there’ll be no problem with that. It has no interaction with OCPs so you can safely use ‘em. But please seek advise if you are going to get pregnant. Your GP who will prescribe folic acid 12 weeks before planned conception, for the child’s and your better health.
Avoid triggers e.g. lack of sleep and flashing lights. Give General Advise mentioned in the previous station.
Station 14 (Epilepsy) Young Guy
A young 25 yrs old man comes with history of fits. Talk to the patient and discuss D/D with the examiner.
Fx on History taking (Take a proper one)
1. LOC during fits = 2 minutes
2. Wet himself (Please show sympathy/ empathy) 3. Can’t remember anything when he recovered. 4. I’d a strange feeling before my fit.
D/D: 1. Epilepsy 2. Head injury 3. Meningitis 4. SOL 5. Hypoglycemia
Station 15 (CKD) Blood report given
A 45 yrs old hypertensive patient, presented to the clinic. Look at the lab reports. Talk to the patient and discuss Mx with the patient.
Hb: 9.7 K:5.9
Creatinine: 434 Urea: 6.7
Fx on Hx taking
1. Fatigue since last 6 months 2. Itching and vomiting present
3. Patient has to go to the toilet frequently (Is on diuretics) 4. Patient’s mom has CRF and had dialysis few
times/week. Symptoms of CKD Fatigue Swelling of leg Itching Pedal edema Vomiting Blood in urine
Council the patient about how the reports that came back showed his kidney function was not up to the mark and so he must take care of his diet and drugs to prevent worsening of the condition and mention
dialysis and transplant in case it fails. Sympathize and empathize accordingly.
Diet Drugs Dialysis
Less salt Comply with any
drugs given for hypertension or edema (diuretics)
Mention dialysis
Less alcohol Fe tablets + transplant No smoking Erythropoietin injection Well balanced diet Vit D No over the counter meds Especially NSAIDS.
Station 16 (Paracetamol Poisoning)
A young girl took 15 PCM 12 hrs ago. The blood tests have been done and level of PCM is 30. Talk to patient and discuss Mx with patient. Do not take psychiatric history.
Station 17 (Chronic Fatigue Syndrome)
47 yrs old man presented with c/o tiredness in the last few months. Investigation shave been done and everything is normal. Talk to the patient and address patient’s concerns.
Chronic fatigue syndrome is a condition which causes long term
tiredness with other symptoms like pain in muscles, joints, head, throat + some psychiatric problems like sleep disturbances, poor
concentration, forgetfulness and depression and c/o flushing, postural hypotension and heat and cold intolerance.
Fx on Hx taking
1. Tired since 6 months 2. Resting doesn’t help
3. Had flu like symptoms 6 months ago and went to the GP. Has been sick ever since.
4. Sleep is fine but am still tired.
5. No weight loss. No blood in stools, No Carcinoma history. No heat intolerance.
D/Ds to rule out:
1. Chronic fatigue syndrome 2. Anemia 3. Diet 4. Hyperthyroidism 5. Malignancy 6. Depression 7. Malabsorption Cx:
There are some general advises you can give to this patient.
1. Manage your sleep 2. Manage your rest
3. Relax using means that are suitable 4. Have a well balanced diet.
5. Cognitive behavior therapy (one of my colleague can talk to you and help improve your mood and reduce stress + Graded exercise therapy (gym instructor helps with low intensity exercises) are two specific managements.
Station 18 (IV Cannula blocked)
You are a senior doctor in the hospital. An FY1 doc, Dr Williams was asked to change an IV line but he couldn’t. Please talk to your colleague.
5 points to remember 1.
Safety of the patient 2.
Initiating (change IV line) 3.
Incident form (DATEX) 4.
Communicate with your colleague 5.
Discuss with your seniors
Start the station with greeting your junior and saying I hope you are doing great and coping well with your tasks or a hello, how are you? I checked this one patient who needed an IV cannula change and changed it myself and made sure that the patient was safe. Could you please tell me what happened regarding the patient whom you were suppose to change the IV line in? I was busy and had to take another
patient for an X-ray. If something like this happens in the
future, you are to inform me or any senior, okay? I think it will be a good idea to go an apologize to the patient for
causing any discomfort, don’t you think. I, in the mean time, will go and fill the incident form explaining what happened. I will write the reason for the delay, which was how you were busy with another patient.
(Common Stations) Only Councelling
In all the councelling stations, let the patient ask and inquire and only then relay all your information, unless patient was quiet. Do not go on talking without letting him speak. Keep asking about patient’s
concerns, after every reply.
1) Blood Transfusions 2) Medication
Insulin Councelling
Warfarin in learning difficulty
Discharge prescription (Asthma and MI)
3) PEFR 4) MRSA 5) Multiple Sclerosis 6) Postponed Surgery Herniorrhaphy Lap Cholecystectomy Obesity
Non medical causes of HTN
7) Diabetic Neuropathy 8) Gout
9) CT Scan 10) Smoking
Station 1(Blood Transfusion)
50 yrs old lady with myelofibrosis was scheduled for receiving 4 units of blood. She’s worried. Talk to patient about S/Es and complications of BT!
Cx:
Explain to the patient that due to anemia she has to receive blood. One unit of blood takes 4 hrs of transfusion. Yes you have to stay in the hospital. You don’t have to be NPO. Its better to have a light breakfast. You can work and eat during the procedure. Blood that we will give you will be healthy and clean so don’t worry about infection. We do necessary blood tests and your blood will be matched with the one being given, before transfusion to minimize any reactions. Complications of Blood transfusion include allergic
reactions, which if happen are mild and may cause you to
have low grade fever or rash or body pains but we always have medicines ready to give in such situations to counter the allergic effect.
As we are giving you 4 pints, their maybe chances of fluid
overload so we may give some water tablets. 2 pints will be
transfused in one day.
Sometimes electrolyte imbalance may occur, which is rare but we will keep monitoring. We will manage if it happens, accordingly
We’ll prevent hypothermia by warming the blood or bringing to normal temperature.
Station 2 (Postponed Surgery) OBESITY
A 32 years old lady was planned for dental extraction. Her procedure was turned down after anesthetic assessment. Her BMI is 35. Talk to the patient and address patient’s concern.
Fx on general inquiry about diet and lifestyle:
1. Very very bad diet. Loves junk food. Eats anything at anytime.
2. No physical activity
3. She will ask what are you going to do for me?
Cx:
As you know you were earlier planned for a dental
extraction, and I am here to talk to you about your fitness for surgery, for which you were assessed by our consultant who thinks it will unfortunately have to be postponed for a while.
You were planned to undergo General Anesthesia but the consultant thinks it will be too risky to pass the ETT
(tube)that may damage organs and the anesthesia may not effectively work until some weight was lost.
I can refer you to an excellent dietician who can help you eat healthy from among your fav foods and may help you
reduce weight so we can go through with this procedure. You can also join a gym in the mean time, or try brisk walking up to half an hour a day and drop any unhealthy eating habits. This procedure can be done under local anesthesia but if you want GA, you’ll first have to work a little on the fitness.
Station 3 (Postponed Surgery)
HYPERTENSION
45 yrs old lady admitted to the hospital for lap
cholecystectomy. BP 160/110. Please talk about non
Station 4 (Multiple Sclerosis)
Patient was diagnosed with multiple sclerosis. Please talk to the patient and answer his concerns.
Cx:
I am afraid I don’t have very encouraging news however there’s no immediate danger to you. You have a condition we call multiple sclerosis. It is a condition in which there is a loss of structure around nerves in your brain and spine,
which carried information from body to your brain and vice versa.
It is an autoimmune disease. This means your immune system which is suppose to protect you, starts attacking your own nerve structures by mistake. It is not your fault that you got it.
Medications can modify this disease, if not cure it. This
disease is the sort that lets it affects come and go. The meds can slow the progress of the disease and prevent relapse. They will be in the form of cap/tablet. (Interferons). Some (steroids) will help reduce inflammation and decrease duration of relapse as well.
We may give you pain killers when and if needed and incase of any problem (Urinary incontinence, sexual dysfunction, depression, spasms) meds/help will be provided in the form of meds, occupational therapists, special nurses, speech therapists + councelling. Only mention these problems if he brings them up.
Majority of the patients don’t use/need wheel chairs unless they had an attack, However in some patients, if symptoms become permanent, then they have to use wheel chair.
