Samson courses

Day 4

1. Guillian-Barre syndrome GBS

Scenario 224 (P4)
Red flags: mainly breathing problems, eating, drinking
MAFTOSA: don’t forget occupation
Send to hospital to admit the patient, treatment has to be explained, no
ambulance needed but he needs to be driven to hospital
Main treatment: steroid through the vein
Patient can not drive, someone has to check you to the hospital, call a taxi
If the patient is a taxi driver, he has to inform DVLA

2. Obstructive sleep apnea

Scenario 188
FY2 in the GP surgery, your patient is a 556 yo man has presented to the
surgery with some concerns. The patient had sleeping problem in the past
Assess the patient, address his concern
Patient’s info: you had the sleeping problems for the last 4 months, and you
snore a lot, you also gasping during the sleep, during the daytime, you feel
sleepy, you sleep about 7 to 8 hours a day. You don’t have any medical
condition, you feel tired all the time during the day. You are a taxi driver, you
do feel sleepy while driving
Q: Is this something dangerous?

Approach
GRIPS, how can I help you? , ODPARA
What do you mean by sleeping problems: it can be 2 things: Insomnia
(=problem of falling asleep), or sleep apnea (=not good quality of sleep) , how
many times do youhave to wake up at night? What makes you wake? What do
you think could be the cause of your sleeping problem
DD: other medical problem like COPD, Obesity/ increasing in weight/ Nocturia,/
Anxiety/ any stress in your life / systemic review
MAFTOSA (occupation++), ICE, effects of symptoms
Examination: obs, other systems : heart lungs tummy, BMI
Diagnosis: You may be have a condition called obstructive sleep apnea, this is a
condition in which the muscles of your throat become overrelaxed which leads
to narrowing of the airways. This is usually causes difficulties in breathing and
snoring , because of this you may feel tired and sleepy during the day
I’ll need to do all the routine bloods: TFT
Explain that the main treatment will aim at help him improve the breathing in
the night, so we will refer to the specialist, we need to do something called
sleep study: with assess your breathing and takes your oxygen level during
sleep,
Advise not to sleep on the back, elevate the head side of the bed, reduce the
number of pillows and ask the patient to lose weight, avoid drinking alcohol in
the evening, explain what is the main treatment if he gets diagnosed with this
condition: you will be given a device: a pump called a CPC, you will be
connected to the device in the night , it will prevent the airway from closing
while you sleep, sometimes you may be given a device to wear inside the
mouth it is called :mandibular advancement device.
Urgent referral: if he is a taxi driver
Advise not to drive, After the dg confirmed, has to inform the DVLA
To answer his question: it is potentially dangerous, if you don’t sleep you will
feel tired and this condition can have serious complications: dementia, .;
If you fall asleep while driving, it can cause accidents

3. Rheumatoid arthritis
FY2 in GP, 40 yo has presented with pain in her hands, she’s a smoker
Take a history, assess the patient and discuss management with patient
Patient’s info: got pain in your hands on your both sides, it’s been there for the
last 4 weeks, she’s a secretary in the hospital, the pain is worse when typing,
you also have morning stiffness, you smoke about 10 cig/d and you tried
paracetamol but didn’t work
Approach:
GRIPS, How may I help you, SOCRATES (show me with your fingers) other
joints? Swelling redness pain fever, ask steroids (don’t wait for MAFTOSA for
this), deformities (changes in the shape of hands)
DD: trauma, septic arthritis, RA, carpal tunnel syndrome (changes in sensation)
Systemic review
MAFTOSA, ICE, effects of symptoms
Examination : they will give you a picture with rheumatoid hands and in the
bottom: squeeze test positive
Most likely you be having a condition called rheumatoid arthritis which means
inflammation of the joints, it usually affects the hands and feet, we need to run
some tests now: there is a specific marker called rheumatoid factor and we’ll
do other inflammatory marker ESR CRP, Xray
Usually for this condition Urgent referral to the specialist (with 3-4 days), he is
called rheumatologist who usually deals with the inflammation of the joint: he
will assess you and start you on medication to control the inflammation
Arrange occupational therapist, he will advise her on how to manage with work
What she can do: do some exercise to improve the pain
Give pain killers: ibuprofen and PPI to protect the tummy called omeprazole or
lanzoprazole
Safety netting: fever redness
No need to f/u if you’re referring to specialist

4. Post herpetic neuralgia

Scenario 280
F2 in GP, 61 yo has come for f/u, patient came 2 months ago with chest pain ,
he was diagnosed with shingles and treated with acyclovir, one week ago he
came back with chest pain, patient was given paracetamol and codeine and he
was asked to come for f/u in one week time. Today he’s here for f/u
Patient’s info: pain initially 8/10 now it is 2/10, it is a burning pain, the pain is
annoying, and you feel like the paracetamol and codeine are not helping
2 scenarios can happen: pain better or worse

Approach:
GRIPS, paraphrase : How have you been since we last saw you, I understand
you’ve been diagnosed with a condition called shingles, do you still have rash?
Pain? SOCRATES for the pain,
Ask about the previous ttt, has it helped? Are you still having the pain? What
was the score before? Today?
Ask: are you taking the medication as prescribed?
Ask about the SE of medication? it can be nausea vomiting drowsiness and
constipation
Effect of pain on patient’s life
No DD (f/u consultation)
Complete the MAFTOSA
Examination: tell him that you would like to have a look at the place you had a
rash
Tell the dg: from what I gather, it seems like you have a condition called post
herpetic neuralgia it means nerve pain because when you have shingles it can
affect the nerves even after shingles has resolved it can leave you with pain
If the pain is increasing or medication not work: give amytriptilline for one
week and review the patient
If pain Is mild/ Ok/ getting better: give a topical cream called capsaicin cream
or lidocaine plaster
Avoid sharing clothes and towels, wear loose fitting clothes , avoid putting
some other creams or adhesive dressing, if you still got rash keep it clean and
dry and if the pain is not controlled, you need to come back and refer you to
specialist (control the medication) you can try to protect the sensitive area but
applying a protective layer such as cling film
If the pain is still not controlled, refer to specialist
!! the approach is different if it is a f/u consultation

5. UTI
Scenario 85 (page 10)
Q: ATB names are not expected until asked by the patient,
Here, the patient is trying to have a baby, give nitrofurantoine (don’t give 3 or
4, stick to one ATB)
Sex is not advisable during ttt of UTI, because it is one of the reasons

Scenario 237
FY2 in GP, 30 yo female made an apt to see you
Talk to the patient and address her concern
Patient’s info: you’ve got tummy pain, she will show with hands both sides of
the back, burning sensation, frequency, you came 2 days ago to GP but got
offered no medication, you got RA for 5 years and you have taken MTX, you’re
allergic to penicillin, menstruation was 2 weeks ago
When you mention urine dipstick: examiner will tell you N and L positive

Appoach: same
Diagnosis: urine infection
Explain: :you may have a complication of urine infection called pyelonephritis
which means that the infection may have gone up to your kidney
Explain the medication you’re taking for RA which is MTX can lower down your
immune system,so simple infections can cause some complications sometimes
Send the patient to the hospital : immediate referral
They will admit you, you probably need ATB in your vein, they may lake a scan
for your kidney, analyse your urine
You can give paracetamol Durant la pause
They will give trimetoprime or nitrofurantoine IV
You will be discharged when it is safe to go home

6. Gout
Scenario 247
F2 in GP, 54 yo female presented with pain in the right big toe, patient was
diagnosed with hay fever 7 years ago and she’s taking cetrizin, 4 months ago
she was diagnosed with hypertension and she’s taking thiazides
Assess the patient and outline the management plan
Patient’s info: pain in my right big toe becoming worse, started one week ago,
the toe is red and swollen, works as a taxi driver, she also drinks beer 4 pints
everyday
Approach
GRIPS, how may I help, SOCRATES
DD: RA, sceptic arthritis, trauma, gout (previous episodes?), OA, hemarthrosis,
Complete MAFTOSA , ICE, effects of symptoms
Examination: obs, give the picture
What I gather from you and after looking at your leg you may have a condition
called gout, it is a type of arthritis = inflammation of small joints , there is some
crystal formation in the joints and this leads to inflammation, this is caused by
an increased level of an acid called uric acid in the blood
To control the pain and the inflammation we’ll give you a medication called
colchicine, tell him it takes about 2 days for be efficient we can do the blood
test
Advise about risk factors: the blood medication you’re taking, we’ll give you a
medication called amlodipine and we also can arrange an Xray
Offer leaflets
Advise about diet , talk about alcohol
No need to refer to specialist
Advise the patient to inform the DVLA
Safety netting: septic arthritis

7. Seizures
Scenario 117 (P14)
GRIPS: ask about name of father? How are you related to Mr David? (do not ask
how are you related to the patient or to your son?)
Explain: Unfortunately he has fever and his heart is beating a little fast, he’s a
bit confused and drowsy, we also performed something called LP which is.. he
also has swollen glands (=LN)
Sometimes they can ask: is there any vaccine for this condition?
 Unfortunately there is no vaccination so far for this condition
Is it a serious condition: unfortunately it is, people can develop serious
complications
If father if his son is going to die: It is quite a serious condition, Most people
show very good improvement after treatment mortality 10% of case
Will he be Okay after treatment -> he should be okay

Scenario B
Pretty much same scenario 117, LP changed: CSF cloudy, WCC white cell count
3000, neutrophils abundant, on examination: purpuric rash on body, Neck
stiffness positive,
Dg: meningitis
Explain: means inflammation of the covering layer of the brain,
Give ATB (in case they ask about the name: ceftriaxone)
Yes for vaccination in this case
You can also talk about contact tracing

8. PCOS
Scenario 257:
FY2 in GP, your patient is 25 yo female, came for test results reveal, she has
blood test done, initially presented with acne and irregular periods,
LH high, FSH normal, LH/FSH ratio 3/1, BMI 32
Explain the results, take the history, discuss the manafement with patient
Patient’s info: started getting weight for the last year, growing excessive hair
on face and pubis, your periods stopped 6 months ago, before that it was
irregular, you’re not sexually active
Q: can I get pregnant? Will I be able to have a child
Is there any medication
When you mention hormone medication, she says I don’t like taking hormones

Approach:
GRIPS, Paraphrase
Explain the test and then take history or take history and then explain the
results
If somebody is coming for test results, it is better to explain the results before
but do not make a diagnosis
Do you know what tests we asked for you?
Do you what we’re looking for from this tests?
Explain the test : so the tests we have done is to check some the female
hormaones, there are two types , one is called LH which is unfortunately at the
higher side, the other hormone FSh which came normal, we also checked the
ratio which is high, and your BMI is also high (don’t say you’re obesity, but say:
you’re falling under category of obesity)
Tell me, have you had any symptoms? Weight gain? Acne facial hair.. since
when? Are they getting worse?
Ask about menstrual history :brown pigementation in your armpit and behind
elbows
Other complications: diabetes, hypertension, feeling low, obstructive sleep
apnea
MAFTOSA, ICE, effects of symptoms

From what I gather and considering the blood test, it suggests that you may
have a condition called polycystic ovarian syndrome, it is condition in which
you develop cysts in your ovaries, cyst means fluid filled cavities, it affects how
your ovaries work, usually affect your periods, which means your ovaries do
not regularly release eggs, excessive male hormones can cause excessive hair in
your face
To treat, we need to give you tablets, it is hormone treatment called
cycloprogesterone
Is patient not willing to take hormones, then offer Mirena coil, it got hormones
but low dose
Encourage healthy lifestyle
For the treatment of acne, weight loss, patient can take COCP or medication as
Rocutane
For hair on the face, waxing
Check the sugar level, check whether she has got any other complication like
HBP
Offer some counselling for the psychological issues
To answer her questions:
You can get pregnant but it is difficult sometimes, people with this condition
find it difficult to conceive,you may need some fertility treatment, advise about
weight loss, exercise,

9. Analgesic nephropathy
Scenario 290
F2 in GP, 50 yo has come for f/u, he had some bloods last week, they have
given you all the tests:
Hb<10, Urea 4.6 (nle 7), creat 80 (nle 120), EGFR 52 (nle >60, 15-55 kidney
disease, <15 kidney failure), all rest normal
Talk to the patient, discuss the results and the initial management with patient
Patient’s info: he came for routine blood test, in past medical history he’s got
OA for the last 5 years and takes cocadamol and ibuprofen, poor life style: eats
outside, no exercise,

Approach
GRIPS, paraphrase, explain the test results: we did routine blood test, we
checked your kidney, liver… all came normal except one parameter , EGFR 52
and it is better to be more than 60, the filtering ability of the kidney has
reduced so we were just wondering what could be the reason, I would like to
ask you some questions:
Symptoms of renal failure: any symptoms at all? Swelling? Passing lots of urine
or less than usual? Tiredness?
Family history? Medication ? heat failure?
Complete MAFTOSA
Examination: obs, legs
From what I gather, it seems like you have a condition called analgesic
nephropathy: damage to kidneys due to painkillers, if you take painkillers
everyday for a long period of time, it can cause damage to kidney
Stop analgesic,: Let’s come off these painkillers and see what happens, if you
find the pain is unbearable you can just take codein only,
We’ll refer you to the kidney specialist (routine referral), they will do further
investigations like urinalysis and scan
We’ll repat the blood test in 2 weeks time
Request Urinalysis
Refer to physiotherapy for OA
Offer leaflet about kidney damage

10.Nose bleed
Scenario 340
FY2 in GP, 54 yo presented with some concern; patient had DVT 3 years ago
and he’s on apixaban for 3 years
Talk to the patient, address his concerns, discuss the management with the
patient
Patient’s info: 2 episodes of nose bleed: first one one week ago while rubbing
nose, second episode was yesterday, it happened spontaneously when you rub
your nose,
First time you squeezed your nostrils and bleeding stopped
Q: what is the cause of this bleeding ?
Do I need to stop apixaban
When you mention examination: they’ll give a note: scar formation in the Little
area of the nose

Approach:
GRIPS, how may I help you? When did have the bleeding? What were you
doing? Is this the first time? How many time? Any other bleeding anywhere?
Urine? Vomit? Bruises in body?
DD: medication? Since when? Dose? Any change in the dose? Is there any
chance you have taking too much accidentally / liver problem? Bleeding
condition? Trauma? Do you pick your nose
Complete MAFTOSA , effects of symptoms, ICE
You are on blood thinner medication you may bleed easily when you pick your
nose
Prevention: avoid picking/ blowing/ avoid heavy lifting, drinking too much
alcohol, over the counter medication such ibuprofen
Explain: if you ever have any bleeding sit down and lean a little bit forward,
hold the first part of the nose firmly for 10 to 15 minutes, then try releasing the
pressure while you breathe through your mouth, do not press on the bony part
of the nose, it will not stop bleeding. We also can prescribe you a cream called
naseptin: a cream to apply to the damaged area for 10 days
If the bleeding does not stop in 10 to 15 minutes, you need to call an
ambulance and go to hospital where there seal the area with heat or they can
do what we call nasal packing ..
If you see any bleeding in stool/vomit/urin, you need to seek medical help
You don’t need to stop apixaban because the bleeding is caused by trauma

11.Jaundice
Scenario55 Hepatitis A (P19)
ALT is one of the enzymes in the liver cells, if there’s a damage in the liver cells,
ALT is released in the blood
Bilirubin is a pigment
Ask about raw sea food,
It is a self limited condition meaning it usually resolves on its own
If painkillers needed give NSAIDs not paracetamol
It is a notifiable disease
Is it a serious? Usually it is a common problem, people recover very well
(always leave a loop)
I won’t go to restaurant again? It is up to you , you can eat something else!
(friendly comment) (don’t say it is a one time condition, it is not ethical)

Scenario 245 Gilbert syndrome

F2 in GP, 25 yo male, he had blood test done last week: everything normal ALT
AST , bilirubin unconjugated is increased , total bilirubin increased
Talk to the patient, explain the results and discuss management
Patient’s info: you just had a blood test, your bloods were checked 3 times,
they came the same way, you’re not expecting anything serious, your father
has problems in the liver, you drink a bottle of wine over the weekend,
Explain the test results, tell the abnormalities
Same as previous scenario , complete MAFTOSA
Explain that you be having a condition called Gilbert syndrome, it usually runs
in the family, the pigment called bilirubin is not properly processed in the liver
Need to do hepatitis screen
Arrange US scan
Give advice to patient : changing your diet or the amount of exercise, avoid
heavy exercise, avoid situation like dehydration and stress, bear in mind that
taking some medication such as cholesterol medication as it can affect the liver
There is no specific treatment for this condition, he might develop some yellow
ete discolouration
Refer to specialist that might do some genetic testing

Scenario 250
F2 in the GP, 35 yo male has come for f/u, patient had blood test done last
week, FBC normal, MCV high, ALT AST slightly increased, they haven’t given
GGT,
Take a history, discuss results and management with patient
Patient’s history: patient drinking lots of alcohol: almost one bottle of vodka
everyday or maybe one or 2 bottles in weekend

Approach same as previously,

From the history and the test results, alcohol liver disease that means that
excessive intake of alcohol has affected your liver. We need further testing ,
one called GGT
We need to find out the other effects of alcohol in your body: check GGT,
vitamin levels , liver scan
Alcohol counselling: cutting down on alcohol is the main way of controlling this
condition, there are a few things that we can do, And a few other things that
you can do: we can give medication for cravings, offer counselling, support
group ..you can get involved in other activities: sports or hobbies

Scenario 327 alcohol misuse

F2 in GP. 46 yo lady has come for f/u, MCV high, ALT slightly high 61,
Talk to the patient, explain the results and address her concerns,
Patient’s info: you drink about half a bottle everyday and one bottle of win on
weekends, have been drinking for the last 15 years, because of your drinking
habits, there are some arguments with your partner and you’re worried about
your relationship , mood is good,

Same approach as previously

If the cause is not clear, do hepatitis screen
You need to talk about alcohol counselling: start with there are lots of ways to
help you: things we can do and things we can not do

Suspected cancer

Scenario 268 MM
F2 in GP, 70 yo lady has come for f/u, one week ago, she presented with back
pain and tiredness, Hb 10, ESR 84, urinalysis L and N negative, protein+++,
Bence jones proteins positive
Explain and assess, take a history and discuss the initial management plan
Patient’s info: back pain and tiredness for the last 3 months, you had chest
infection twice treated with ATB, HBP treated with amlodipine, back pain for
the last 2 months, this has prevented you from looking after your
grandchildren,
Approach
GRIPS, paraphrase, ask the patient how has he been since he last saw you,
Take the history first (avoid the emotions):
I have the test results with me, before going to details, I would like to ask you
some questions is that Okay
I understand that you had some blood and urine test done, what made you
have these tests done? She’ll tell you tired
Any other symptoms? Back pain
Explore the symptoms because you need the evolution
Ask other symptoms cancer related: weight loss, fever,
Ask about MM complications like spinal cord compression / hyperviscosity of
blood like stroke MI/ infection/ kidney damage/ bleeding/ bone fractures/
symptoms of hypercalcemia: polydipsia polyuria nausea vomiting muscle pain
confusion
Complete the MAFTOSA, ICE is very important : concerns++ expectations++
Examination:
Explain the test results
2 main findings: blood levels hb are low, a marker called ESR is high, the urine
test also shows a protein called Bence Jones is high,
Unfortunately, we are a bit concerned about the test results, I am afraid this
could be more serious than what we hoped, The urine test shows a high
protein called BJ, I’m sorry to tell you that this indicates that you’re having a
condition called multiple myeloma, so unfortunately I am sorry to tell you that
this is a type of cancer that mainly affects the bones and different organs
Pause
We will refer you to the specialist urgently : hematologist/ blood specialist (2
weeks), they will do a bone marrow biosy which means they will take a tissue
sample from you hip, they will do other scans like MRI , treatment is mainly
steroids and chemotherapy
For back pain, they’ll give strong painkillers like morphine
You’ll also need some vaccination like influenzae and pneumonia
When you have suspected cancer:
You have to tell that you’re suspecting cancer and what is the reason for this
Explain the procedure to come
Urgent referral (2 weeks), which specialist, anticipate what they will do and if it
will be confirmed how will it be treated
Safety netting++

We’re a bit concerned about the symptoms you’re having, the reason is that :
you have lost weight, you have been coughing blood… Unfortunately, I’m sorry
to tell you that Cancer of the “..” also can present this way

Scenario 46 (P25)
Lung cancer: cough blood / smoking++
Mesthoelioma : dry cough/ builders (asbestosis)
Refer to chest clinic and arrange Xray
Bronchoscopy: it is a camera test : using a thick flexible tube camera, the
camera will be the size of your little fingers and will attached at the end of the
tube. We are going to pass the camera through the lungs and we’ll see what’s
in there, if somethings comes off, we’ll take a sample
Unfortunately, if the condition confirmed, chemo

Scenario 43 (P37)
Dysphagia: patient will tell you I have difficulty swallowing
All cases of suspected cancer, do the systemic review before MAFTOSA,
The diagnosis part Page 29 is wrong, don’t say it is not clear yet, use the same
way as before
Refer to surgeon: the will do endoscopy,
Oesophagus= food pipe

Bladder cancer: pink urine, age>50 , smoker

Scenario 77 (p33)
Correct: patient in GP,
Cystoscopy camera : the size of the camera is not the size of the little finger
(the only one that it is not), just say a tiny little camera
Say: cancer of the bladder also presents this way..
In case A&E, refer internally: somebody from urology will come and see him
Safety netting, unable to pass urine, feeling unwell..

Scenario 201 Acute leukaemia

F2 in the GP, your patient is a 26 yo presented with tiredness,
Take a focused history, discuss the initial management with the patient
Patient’s info: you started feeling tired for the last one week, the first time you
experienced it after participating in a football competition, getting 2 bruises on
your arm which you can not understand where they came from, you also
noticed bleeding when you brush your teeth
Q: I got my friend’s wedding in 5 days time, will I be able to go to that wedding?
Approach:
GRIPS, how may I help, ODPARA,
DD: Anemia, cancer lymphoma, leukemia, chronic inflammation, infection,
chronic fatigue syndrome fibromyalgia,
Systemic review, MAFTOSA, ICE, effects of symptoms
Examination: obs, check for bruises: patient will give you a picture with gum
bleeding, examin glands
Explain that you’re suspecting leukemia : you feel that a condition called
leukaemia could be presented this way, unfortunately leukaemia is a type of
cancer of blood..
Explain patient need to go to hospital right now : because we don’t know the
hb / Plt levels: we need to do the blood test immediately
You may need blood transfusions
Refer urgent to haematologists: they’ll do bone marrow biopsy/ other scans/
treatment is chemotherapy/ sometimes radiotherapy
Answering his question: We need an urgent assessment in the hospital , you
may need a blood transfusion
Patient will tell you : I didn’t expect that
Say : I can understand, we can not expect that
Answering about his friends’ wedding: It’s difficult to tell at this moment, the
medical condition that we’re discussing is quite serious, you need some further
assessment by the specialist, may be the hospital will say if it is safe to go to
your friend’s wedding

Scenario 281 chronic leukaemia

F2 in the GP, your patient is a 65 yo has come for a f/u, list of bloods: Hb 105,
MCV low, Lym very high, WC high
Talk to the patient, discuss management
Patient’s ingo: getting tired easily in the last 2 3 months, last week you came to
do the blood test, you used to play golf but because of the tiredness you can
not play, if the doctor says it is serious he’ll say is it cancer
Ex: obs normal, cervical lymph node enlargement, enlarged spleen

Approach
GRIPS, paraphrase,
Ask some questions first
Do you know what tests? Any particular reasons? Ask about the symptoms
Complete MAFTOSA, ICE, effects of symptoms
Examination
Explain the tests: the blood tests show that you are anaemic, which means that
your blood levels are low, the type of cells which protect us from infection
called white cells are on the higher side,
We’re a bit concerned about this finding and the symptoms you have,
unfortunately cancer of the blood also can present this way. We’re worried
that it can be a condition called leukemia
Urgent referral (not immediate because we know hb and plt levels already) : 2
week referral
They will do a biopsy, biopsy from you bone marrow and LN
Treatment is chemo sometimes is radioT
Safety netting: fever; sore throat, bleeding, unable to cope with life

Scenario (not in the list)

F2 in the acute medical unit, 65 yo man came to the hospital following a
collapse at home, he collapsed 3 hours ago, patient’s bowel habit have changed
but not sure if there is blood.
All examination and digital rectal examination are normal
Blood test: MCV is low, iron low, Hb low, rest is normal
Plan: discharge home , give iron tablets
Urgent colonoscopy
Take history, explain , address concern
Patient’s info: you have diarrhea and constipation for the last 3 months, have
lost some weight
You are a farmer and you feel that you are working a little bit too much, patient
is in a hurry to go home because some visitors are coming and you feel like
doctors are just delaying
He’ll say: I’m fine doctor, I’m a healthy person, I don’t drink I don’t smoke
Exam: cervical LN enlargement, splenomegaly
Approach
GRIPS, paraphrase, ask the patient what happened,
Fall: before during after
DD: mechanical, heart problem, postural hypotension, anemia, hypoglycemia
Systemic review
Complete MAFTOSA, ICE, effects of symptoms
Explain the test results: your blood levels are low, your iron level are low, Tell
the patient you’re suspecting colonic cancer (same way: you’re a bit concerned,
the reason is that you have …unfortunately, I’m sorry to tell you Mr ..that
cancer of the bowel also could presents this way) we need to arrange an urgent
colonoscopy within the next two weeks, you’ll also be going home today with
iron tablets
When the plan is given, don’t change the plan
The situation is quite serious, so we need to make sure that everything is okay
before you go home
If plan not given, we can refer to surgeons

Dermatology
Ignore the notes in the given pdf
Sets of questions:
Where? How would you describe it? How long it has been there? Size? Shape?
Borders? (regular or irregular)? Colour? Has it changed? Has the size changed?
Painful? Any discomfort or bleeding? Any itching? Any swelling underneath?
Any other swelling? (LN)? ask about exposure to sun
A Asymetry
B order
C oulour
D iameter
E volving

You’ll need systemic review and complete MAFTOSA

DDs not much
Exam: LN surrounding
Always name the lesions (otherwise you will not pass)

Scenario 54 Papilloma:
Papilloma is the only lesion happening in the surgical unit
You’re F2 in the outpatient surgical unit, the patient is 30 yo referred by the GP
Take a focused history and discuss the treatment options
Patient’s info: lesion on the shoulder for a long time, she wanted to removed it
because she’s going to get married (you’ll need to say congratulations and
smile), the wedding is in one year time, there’s no change in the colour, not
painful, no itching,
Q: will I have a scar
What are the options I have?
Approach:
Standard skin lesion approach (see above)
Papilloma is a small bump,
Treatment options: either put some topical cream with salysilic acid to apply
for 3 days and up to 3 months/ or freezing treatment which is cryotherapy : it is
commonly used, it needs about 4 to 6 treatment sessions,/ or surgical removal
/ or laser therapy: it is not offered by the NHS: it can leave you with the
minimal scar
Unfortunately, you may have a scar,

Scenario 54a Basal cell carcinoma

F2 in GP, man 55 yo with skin lesion
Assess and discuss management
Patient’s info: this lesion for the last 6 months, behind the head, no sun
exposure,
You tell him this is a type of cancer, he’s not reacting , the reason that it is not
the first time: I had a similiar condition 3 years ago, they froze my head

Approach same
Management:
I’m concerned..the reason..i’m sorry to tell that this could be a condition called
basal cell carcinoma, it is a type of skin cancer
Treatment is either surgical remove or freezing therapy which Is cryotherapy
Urgent referral (2 week) to dermatology
They will do a biopsy, surgery can be done by plastic surgeons

Scenario 45c squamous cell carcinoma = scenario 232

F2 in GP, 55 yo lady, she has RA and has been on mTX for 5 years,
Patient’s info: you noticed a lump on your forearm 2 months ago, just below
the elbow, the size has been increasing, pinkish, itching, bleed on touch, you
like sun volley, you work outdoor as a supervisor in a construction company
and you go out for vacation for sunbathing
She thinks it is an infection and she needs ATB,
Approach: same
Management:
Name the condition (same as above)
[MTX is a risk factor]
Urgent referral to dermatologist, skin bioosy
Sometimes you need further investigation to make sure it doesn’t spread;
Surgical removal, then radioT may be useful
Today we’ll do the blood tests

Scenario 54b melanoma (2 types of scenarios):

F2 in GP, 55 yo lady presented with skin lesion,
Assess the patient, discuss the management
Patient’s info: lesion on your shoulder, it has been there for 10 years, it’s
itching sometimes,some tingling sensation, the colour is changing and is
irregular, sometimes it bleeds, margins irregular, increasing in size in the last 6
weeks, hurts when you wear your bra

Male: lesion behind the ear, you go to spain for sunbathing, , otherwise same
Approach: same skin lesion
Explain the dg: unfortunately, it could be a type of skin cancer called melanoma
[The only skin lesion given behind the ear is melanoma]
Urgent referral to dermatologist: biopsy run other tests/ scans
Treatment: surgical removal, chemotherapy, radiotherapy

Scenario 54d Lipoma

You’re F2 in the GP, 25 yo male has got lesion on his shoulder, he’s got a
swelling; it’s been there for many months and it is slowly growing
Patient’s information: it’s been there for 3 months, slowly growing.
Lesion on the shoulder
Tell him It is a condition called lipoma: fat tissue
Usually doesn’t need any treatment
If it bothers you can refer to surgeon (they will surgically remove it) or
dermatologist
It doesn’t look like a cancer
Scenario 352: seborroeic keratosis
F2 in GP, 70 yo lady presented with some concerns,
Talk to patient, address concerns
Patient’s info: skin lesion on her breast for many years, you feel that it is
getting bigger, it is round in shape, black in colour, it is increasing in size, your
father and mother and sister had skin cancer, you like sunbathing
Q: Do you think it Is skin cancer
What are the treatment options
Approach : same
Look at the lesion: this condition is called seborrheic keratosis, it is a type of
wart , it doesn’t look like a cancer, usually doesn’t need any treatment, but this
patient need to be referred to dermatologist urgently because of family history
and age: they will assess, may be biopsy and look at the microscope, they might
remove it via cryotherapy
If younger person and no family history: reassure
Advise not to scratch it nor remove it

Other skin lesions

Scenario 183 acne
F2 in GP, an 18 yo had made an apt to see you. The patient came to ask about
Roaccutane
Patient’s info: you got acne, feel like your skin doesn’t look nice, you have
been using a cream that you bought over the counter and it is not working, you
have got migrain and you take ibuprofen, you want to see if the doctor can
prescribe you that medication: your friend has been using Roaccutane and it
has been helpful. She ‘s studying grammar and this has been affecting her
confidence
Approach
GRIPS, how may I help you, where are the lesions, how long have you had this,
what type of symptoms,
Rule out some serious red flags (indication for referral ): fever, painful skin,
poor response to medical treatment, psychological issues,
Ask about previous treatment: what ttt? How long?
Risk factors: PCOS, contraceptive pills such as progesterone POP, implants
Complete MAFTOSA, effects of symptoms
Exam: they will give you a picture:
You have a condition called acne, it is an inflammation of the skin it can be
sometimes hot and painful to touch,
She will tell you about the medication, ask: where did you hear about it?
There will be a paper with info about the medication:
Roaccutine is isotretoin which is a retinoid. Indication: mild acne: topical gel.
Severe acne: oral tablet
Contraindication: hyperlipidemia, hypervitaminosis, headache
It is contraindicated in migraine
SE: blisters, dry skin , erythema,
Steps of acne treatment :
Step1 : topical retinoid
Step2 : topical ATB
Step3 : oral ATB by specialist
Step 4: oral retinoid by specialist
All these information will be given on a paper.
Unfortunately, the medication you’re asking is not indicated in your case
Refere (routine) to specialist: they will assess and offer oral treatment
Advise: wash you face with soap and warm water twice dailt, do not scrub your
face, if your skin is dry, use water based emollient
Safety netting: fever, arthritis,
Don’t forget to ask her about her mood
Rash:
ODPARA questions, where is the lesion, colour, any elevation or bumps on the
skin? Itching? Pain? Spreading? Changes in colour?
DD: anaphylactic question: breathing, swelling face tongue, Allergy inside
(something ate) / outside (contact)
/ infection: fever, recently been unwell /
Systemic review
Complete MAFTOSA

Scenario 197 ringworm (infective rash)

You’re F2 in GP, your patient is a 50 yo male, had an apt to see you
Take a focused history, assess and discuss management
Patient’s info: you have a lesion on your arm for the last one month and it is
gradually progressing, round in shape, reddish in colour, itching. His wife is
pregantn 38 weeks, you’re worried you may pass it to your wife
Q: Is it contagious? Will I pass it to my wife?
Will this affect the pregnancy
Approach, How can I help you, questions rash
DD: infection, allergy, SLE
Complete MAFTOSA, ICE,
Exam
After looking at your lesion, your condition is called ringworm, it is a fungal
infection
Treat: we’ll give you a cream clotrimazol apply 2 to 3 time a day for at least 4
weeks
General advice: keep the affected area clean and dry, do not share towels/
sheets, clean your shower or bath well after use, do not scratch the rash as it
may spread the fungus
You may pass it to your wife
It is not a serious condition to affect the pregnancy, but it can become
bothersome

Scenario 283 impetigo

F2 in GP, 28 yo has come with a rash on her face
Talk to the patient and address her concern
Patient’s info: you got a rash on you upper lip, started 2 weeks ago , a few days
after swelling it started getting blisters, one week ago you went to pharmacy
and got some cream but it didn’t help. The lesion is not painful to touch ,
you’ve been married for 3 years and you have 6 month old baby, you practice
oral sex as well, you are a teacher,
Approach: same rash
When the patient shows yu the rash: let me have a look , can I ask you a few
question about it?
Sexual history+++
You have a condition called impetigo, it is a skin infection
What you need is ATB cream called fusidic acid
Can I go to work? Advise not 3 or 4 days
Normally, it not infectious after 48h of ttt or when the patches become dry and
crusting over
About oral sex: you can pass it to your husband, avoid breastfeeding for 3 to 4
days
Normally it doesn’t leave a scar
Wash your hands with soap and water after touching the lesion
Avoid kissing child or husband as you can pass it to them
You can cover the lesionwith Loose clothing Or gauge piece

Scenario 329: urticaria in a 5 year old

FY2 in GP, 5 yo brought by mother
Talk to mother, address her concern
Patient’s info: child developed rash 2 days ago after taking a hot shower but
the rash went away after a few hours
Rash was all over the body, it is pinkish in colour, today, 3 hours ago, he
developed the rash again, when he came back from playing outside, the child is
with his grandmother at the moment. Grandmom just texted you saying that
the rash disappeared,
Q: will it be contagious
Is it meningitis? Because the school is asking

Approach: same rash approach

You can add other differentials: meningitis: neck pain , shading away from light,
insect bite ; contact dermatitis
Complete MAFTOSA
Pediatric history
Look at the lesion: This is a condition called cholinergic urticaria, also called
heat bumps
We can give antiallergic medication like cetirizine
They have to be careful when travelling to other countries
Send the child for allergy tests, blood test
Doesn’t seem contagious
Doesn’t seem like meningitis, usually the become more sensitive to light,
drowsy with neck pain

Scenario 343 scabies

F2 in GP, 5yo brought by her mother,
Take a focused history and address her concern
Patient’s info: you went for camping for a week, and while over there, the child
started to have a rash on his body, mainly between the fingers,
Q: can she pass this to others
Approach:
Same rash approach, add specific questions: anyone with similar lesions? Have
you visited someone else howe, any discharge from lesions, itchy? Specially at
night? Anyone at home complaining of itchiness? Have you been to any
overcrowded places?
Ask about: chicken pox: fever/ feeling unwell
Look at lesions: picture of hand
It is a condition called scabies: a type of parasite infestation (not infection) to
treat it, we give a ttt call trimetrim , you need to apply over all the body after
drying the body, but the cream should be left 8 to 10 hours before you wash
your body. The whole family might need treatment to make sure it is clear,
family members and their sexual partners need to be treated *. Repeat
application until symptoms relieved
Bedding, clothing and towels should be decontaminated by washing at high
temperature,
Itching may persist at least 2 weeks sometimes
Offer leaflets

Scenario chicken pox

F2 in GP, 3 yo child brought by his mother, she would like to get advice about
child’s condition
Speak to mother, address her concern
Patient’s info: your child has got rash for the last 2 days, appeared on the face
and then spread to the rest of the body, got fever cough and running nose, the
child was in nursery and they call you to come and pickup your child
Child is uptodate with immunization including MMR
Q: when he can go back to nursery?
Approach
Same as rash
Examination: picture
This condition is called chicken pox. It is caused by a virus common in children
but you can get at any age, it usually gets better by itself within a week
Give paracetamol if pain/fever
Antihistamines to relieve itching
Cut the nails to avoid skin damage due to scratching
Advise avoid contact with other children/ pregnant/ infants<2y
Drink plenty of fluids
Advise to wear smooth cotton fabrics
Most infectious period: 1 to 2 days before rash appear but infectivity continues
until all lesion and dry and have crusted: usually take about 5 days after the
onset of rash
Explain the crust usually falls of about 1 to 2 weeks
Advise to keep the child away from nursery until all vesicle are crusted
Safety netting: bacterial infection: high fever, pus formation in lesion

Scenario haemangioma
F2 in GP, 1 week old baby boy, has been brought to GP by his mother
Talk to mother, address her concern
Mother’s info: 2 days ago you noticed a lesion in his thigh, reddish in colour,
the child is doing well, gaining weight, no medical problem, he’s playing with
your husband at the moment and you got a pictured
Q: Is it cancer?
Is it something serious?
What if it get stuck in the clother or will it bleed?

Approach
Approach same as skin lesion (not rash)
As about infections / trauma/
Pediatric history, MAFTOSA
Exam: inspection of lesion
This lesion is called hamangioma: it is a harmless growth of blood vessel, it will
stop growing on it own, usually common in premature, eventually it will shrink
without any scar, most of the time, no treatment is required, but if it become
large, then it might need treatment which is surgery or laser treatment or we
can inject some medication (betablockers)
Offer leaflet
Usually it doesn’t bleed, if it bleeds or ulcerates, you need to take him to
hospital

Scenario Measles
F2 in student health center, 25 yo student who had visited the center 2 days
ago with rash, […] the nurse has taken a picture of his lesions
Patient’s info: law student, rash started behind the ear then spread to rest of
the body, noticed the rash 2 days ago, high fever, cough and runny nose for the
last 5 days, had immunization in childhood but never MMR (not sure of it), the
nurse checked the temperature 39.9
Pic showed

Approach: same as rash

Bilateral cervical LN, T° 39.9
Tell the patient that your condition is called measles: viral infection, very
contagious, explain that it can cause symptoms like fever cough, conjontivitis
infection of the eye, symptoms can be unpleasant
Drink adequate fluids
Take paracetamol or ibuprofen
Aspirin should be avoided in children<16
Stay away from school or work for at least 4 days, after the initial dvp of rash
avoid contact with susceptible people: pregnant/ infant/ low immune system
Safety netting: shortness of breath, uncontrolled fever, convulsion:
This condition needs to be notified to the local health protection team
Offer leaflet
F/U not necessary

Scenario diabetes
F2 in acute medical unit, 9 yo boy admitted yesterday with abdominal pain and
vomiting, has been diagnosed with acidocetosis
Bloods: glucose very high 17, pH 7.2
Talk to mother, address her concern
Patient’s info: your son was admitted yesterday with abdominal pain and
vomiting, you’ve been told that he has bdiabetes tyoe , you’ ve been seen by
the nurse who explained DM and DT1, she also explained how to use dipsticks,
your son is much better now, tomorrow you’re supposed to go to holiday:
Greece/spain
Q: what can’t you just discharge him now?

Approach:

Scenario optic neuritis: eye pain

F2 in the GP, 28 yo made an apt to see you
Take history, discuss management
Patient’s info: you have come to the practice with eye pain , started yesterday,
ang getting worse. You had similar symptoms 3 months ago who sold after
about 1 week, you didn’t see a doctor at that point of time, you also noticed
you have problems differentiating different colours, your bf gave you flowers 2
days ago, you thought they were yellow but actually they’re red, You work as
an IT , you have a presentation in one hour, you want to go and present to your
colleagues, your mom has MS and has similar eye problem
Q: can I gi for my presentation
Will I lose my vision
Exam: funduscopy: optic disc partially not visible and light reflex sluggish on the
left, normal on the right , eye movement painful, visual acuity : R 6/6, left 6/18

Approach
GRIPS, how may I help you
SOCRATES
DD: other symptoms for MS: difficulty in walking, problem controlling the
bladder, numbness or tingling in different part of the body, muscle stiffness
and spasms, problems with balance, coordination
Complete MAFTOSA
Exam
Explain: from what I gather you may have a condition called optic neuritis,
inflammation of nerves responsible of the vision, you may have a condition
called MS which affects the brain and the nerves, caused by your immune
system mistakenly attacking the brain and the nerves, as a complication if this
condition, you may have loss of vision
Immediate referral to eye surgeon, urgent referral to neuro
Main treatment is steroids IV to speed up the recovery of this inflammation
In terms of treating MS, we have a variety of modifying therapies
Treatment also involves treating of individual symptoms , so you will be treated
by neurologist
Advise her not to go to her presentation, you may not be able to manage
Will I lose my vision? If the condition gets worse, you may have serious visual
impairement
Scenario 353 cellulitis
F2 in GP, 36 yo lady presented with some concerns
Assess the patient and address her concerns
Patient’s info: you think that you have an insect bit yesterday and now you
have a rash in your leg
From yesterday the rash has been increasing, otherwise you are fit and well

Approach
Same as rash
Also check for DVT , ask for breathing problems,
MAFTOSA , ICE, effects of symptoms
Obs: high temperature, heart is beating fast
Give you picture of cellulitis
Tell the patient you have a condition called cellulitis, it is an inflammation of
skin , probably due to insect bite
Refer immediately to hospital
You’ll be admitted in the medical team and you’ll be given ATB through your
veins
leaflet