Fever in a traveller / Malaria 4

Vasectomy in 26 yr old 5
Bulimia Nervosa - Hypokalaemia in 23 yearly 7
Toxoplasmosis Gondii 9
Breast cancer in a 55 year old 11
Rape: sexual abuse 13
Venous Ulcer 17
Cauda equina 20
Ankylosing spondylitis 21
Travel immunisation 22
Pseudomembranous colitis B 23
Lithium toxicity 26
Referrals 28
Teaching immunisation 29
Addison’s disease 32
Endometriosis 35
Head lice 37
Uterine prolapse 39
ADHD 41
Somatic symptom Disorder 44
Obstructive Sleep Apnea 47
Cat Bite 50
Chronic Tophaceous Gout 51
Arcus Séniles 52
Allergic rhinitis 53
Toxoplasmosis Gondii 54
Ocular herpes Simplex 56
Scleritis 57
Separation anxiety 60
Baby Teething 62
 Recurrent infections in a child 64
Erythema Nodosum 67
Paronychia 72
Epidermoid cyst (sebaceous cyst) 73
Folliculitis 75
Oral candidiasis 76
Alopecia 78
Psoriasis 79
Molluscum contagiosum 80
Lyme disease - Rash on LL 82
Gastroenteritis Approach 83
Food poisoning - campylobacteriosis 85
Irregular periods 87
Breast engorgement 91
PCOS 95
Post abortion infection 96
Low lying placenta 98
Placenta Previa 99
Menorrhagia 101
Uterine broid 103
Post coital bleed 106
Vulvar lesion / Vulvar Carcinoma 108
Anal ssure in pregnancy 110
Genital warts in a 15 year old 113
Erectile Dysfunction 115
Parkinson’s disease 117
Parkinson’s disease follow up 120
Headache -Carbon monoxide 122
Idiopathic raised ICP 125
Epilepsy 126
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Epilepsy Annual Review 129
Dementia 130
Moton’s neuroma 132
Frozen shoulder / Adhesive capsulitis 134
Ankle injury: 136
Suicidal Risk assessment - OCP overdose 140
Suicide risk assessment: Paracetamol overdose 145
Milestones in a toddler 148
Suspected Cancer Approach 150
Fever in a traveller / Malaria
Fy2 in GP Surrey
30 year man presented with fever for 3 days
He returned form Uganda/Kenya, he went for 2 weeks, he went only as a tourist, he travelled with
his wife
He has fever and riggers mainly in the evening
His work is not a ected
He has not measures his temperature
Ibuprofen not helping

History:
Symptoms of malaria:
Riggers or shivering speci cally in the evening, does it happen everyday

Travel history
Where did you travel?
When did you travel?
When did you come back?
How long did you stay there?
Did you pass through other countries?
Purpose of travel?
What activities did you do abroad, swimming, mountain climbing, any being in the bush?
Do you remember being bitten by insects? Mosquito bites? Any protection against mosquito?
Malaria prophylaxis?
All the vaccinations? Including hep A, Typhoid.
Did he get vaccinated before travelling?

D/D
Viral hemorrhagic fever
Rashes
Bleeding

Malaria
Abdominal pain
Hemolysis spleen and liver
Jaundice
Mosquito bite

TB
Night sweats
Weight loss
Cough-sputum/blood
Meeting other people with same symptoms

Typhoid
Diarrhoea
Vomiting

Hepatitis A
Eating food on the streets

Schistosomiasis
Swimming in the river
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 PMAFTOSA
ICE
E ects
Summarise

Lymphoma/TB: fever and sweating at night

Symptoms of malaria:
Fever (what time of the day)
Sweats
Chills
Malaise
Headache
Vomiting
Diarrhoea
Cough

Examination
Observations
Chest examination: cardiovascular
Respiratory examination
Abdominal examination: liver and the spleen

Diagnosis: Malaria
I suspect it could be malaria, but we need to do more investigation
Arrange hospital admission
Malaria is an emergency
They will do for you some routine blood tests
Special tests: Thick and thin blood lm
Give antimalarial
Advice to inform other family members to get help if they develop symptoms

Antimalarial medication:
Artesunate
Quinine

Vasectomy in 26 yr old
Non urgent appointment
No other info

Very determined and focused on career, doesn’t want kids, kids might have a
negative e ect on his career
Married for 5 years
Had a discussion 5 years ago before marriage about not having kids and wife
agreed
Read about everything NHS site about vasectomy
Wife is not contraception but he needs a reliable method

Will you tell my wife?

Do I need to discuss with wife
If I dont tell my wife, will it a ect my referral for vasectomy
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 GRIPS
How can I help you

Assess for suitability and regret

Age
Do you have any children
Are you married or in a relationship
Did you discuss with your partner
Any reason why you havent discussed with your partner
What is your understanding about vasectomy
Are you currently using any form of contraception
Is there any particular reason why you dont want to continue using the
contraception you are currently on
Have you discussed having children with your wife at all?
If yes, what was the discussion at that point of time?
Do you feel that your wife might want have children in the future
Any chance you might want children down the line when youre established

Other forms of contraception

Have u thought of any other contraception
Do you know about female sterilisation

O er info about vasectomy

How the procedure is done
How e ective it is
Advantages and disadvantages
Explain that some people may regret after undergoing the procedure

Risk of regret
Vasectomy is a permanent procedure and reversal is only 50% successful
Emphasise that he should get it done thinking it is irreversible and is permanent
Explain that he might regret the decision as he’s young and doesn’t have any
children

NHS will not fund the reversal so he should therefore consider all future prospects.

Explain the procedure

The area around the testicles is numbed.
The cord that goes up from the testicle to the penis is cut just above the testicle,
and each end is stitched up. Two months after the surgery you need to provide two
semen samples approximately 4 weeks apart. If these are clear from sperm, your
vasectomy is considered a success. Until that point, you will need additional
contraception.
Some of the possible complications include bleeding, bruising, pain and infection
at the site of infection. Longer term there is the risk of chronic testicular pain and
sperm granuloma.
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 Chronic testicular pain can be quite common with around 10% of patients
experiencing it to some degree, although for most it won't be severe enough to
come back to see their GP about.
The procedure can (and is usually) performed under local anaesthetic, and in many
areas, is performed by consultant urologists in a primary care setting
Once they have had the procedure they need to continue using contraception until
they have had two semen
samples showing azoospermia. These samples are usually taken at 2 and 3
months post-op, but that does vary depending on local protocol

Explain advantages and disadvantages

• Advantages
• Very e ective in preventing pregnancy.
• The lifetime failure rate is approximately 1 in 2000 men following negative semen
testing.
• It is (for practical purposes) permanent.
• Sex need not be interrupted to use contraception.
• Disadvantages
• It requires a minor surgical procedure.
• It takes a while for a vasectomy to be e ective.
• E ective contraception is required until azoospermia is con rmed, and this could
be 2 or months after the procedure. Explain the procedure:
• The area around the testicles is numbed.
• The cord that goes up from the testicle to the penis is cut just above the testicle,
and each end is stitched up. Two months after the surgery you need to provide two
semen samples approximately 4 weeks apart. If these are clear from sperm, your
vasectomy is considered a success. Until that point, you will need additional
contraception.

It is advisable to talk to your wife she might want to have children. She’ll
appreciate you talking but its your hocus

You’ve con dentiality so we won’t inform wife but it is advisable

O er lea et about vasectomy

Bulimia Nervosa - Hypokalaemia in 23 yearly

FY2 in Gp surgery
Alina Jones 23 years
Other info
Presented last week with
snt4hgwbHhCq

Presented last week with tiredness and blood tests were (blood test available in
cubicle)
Blood tests
Sodium 136
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 Potassium 3
All tests are normal

Pt inför
24 years, experiencing tiredness for the last 6 weeks
Previous hx of bulimia nervosa and depression when she was 16, treated but not
isn’t on any medication
Shes been binge eating for the last 6 weeks followed by induced vomiting, shes
been putting nger down her throat to vomit
She also takes laxative
Periods are regular and lasts 6 days and she changes 2-3 pads per day
Mood 9/10

When you refer, she asks what will the specialist do

GRIPS
a. Paraphrase I understand that you have come for followup
b. Ask if any one explained the results
Explain the results
a. All test are normal
b. But potassium is low it is 3 mol/L and normal is 3.5-5
Take history
a. I need to ask you some questions to see what caould have caused the
potassium
b. Can you tell me what made you have the blood tests in the 1st place/

HOPI tiredness
When
Anything makes It better/worse
Does it uctuate or is it constant
Does it improve with rest (chronic fatigue syndrome)

Symptoms of hypokalaemia
Any muscle pain?
Any constipation?
Generalised weakness?
paresthesia?
Tetany?

FMAM
Have you been diagnosed with any medical condition
Bulimia Nervosa - Since when? Were you referred to the specialist? What kind of
treatment were you o ered? When is the last time you got treated for bulimia
Depression -
Are you
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 D/Ds of hypokalaemia
Medicine : thiazide or loop diuretics, laxatives, salbutamol
Vomiting, diarrhoea
Bulimia
Anorexia
Kidney problems (renal tubular acidosis)
Malnutrition
Villous adenoma

ICE
E ect of symptoms - how has tiredness a ected your life

BMI
Observation BP
Oral emaciation (erosion of dental enamel
ECG

Diagnosis hypokalemia, your potassium is low and its moderate hyppokalemia and
its due to excessive vomiting and the use of laxatives
Needs to go to the hose
Risk of arrhythmia and palpitations and that life threatening
And there’s a chance the levels mightt be lower

Negotiate that the person needs to go to the hospital in an hour

Explain she will need potassium supplements through the vein
Ill ring the medical team ahead of her to let them know youre coming

Avoid brushing after vomiting, just rinse

Reduce acid food and drinks
Not use laxatives, they do to reduce calorie absorption
Avoid excessive exercise

Refer for psychological treatment

Bulimia nervosa focused guided self programme

Refer to eating disorder service after treatment for hypokalaemia

Advice regular dental reviews
O er lea et

Toxoplasmosis Gondii
FY2 in GP surgery
55yr man made an appointment
Talk and address concerns

Blurring of visions in both eyes

Doesn’t use glasses
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 PMR and is on steroids, well controlled
Has cats, lives alone

GRIPS
HOPI of reduced vision
ODPARA
Both eyes blurring of visions. What do you mean by blurring of vision? Zigzag
legs?
Do yo use glasses? How long? Past 3 months or way longer?
Any oaters? (Toto) any ashing (RD)
Ask about GCA

D/Ds
Cataract
ARMD - unlike at this age
Vitreous haemorrhage
Ocular toxoplasmosis - gradual
Optic neuritis - acute. On and o f vision loss
Poor vision from glasses

When did you last see the ophthalmologist? When was your vision checked last

Ocular toxoplasmosis:
RF immunocompromised, cats

How long have you been taking steroids?

Examination :
Fundoscopy manikin
Picture:
Typical ocular ndings : Focal retinoschoriditis, a nearby retinochoroidal scar and
moderate to severe vitreous in ammation
Reduced vision and oaters
Neurological examination

Reduced bilaterally visual acuity

Fundoscopy

Diagnosis Toxoplasmosis
It is caused by a parasite called toxoplasma gondii
Domestic cats are the main source.
Youre at risk as youre immunocompromised due to your long term intake of
steriods
You might’ve gotten scratched during handling of infected cat faeces or urine
Management
Refer to infectious diseasee specialist
Specialist will do : blood test/serology
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MRI - multiple enhanced ring lesions

Treatment is not required in immunocompetent adult

But since youre immunocompromised , the specialist will most likely start you on
Pyrimethamine, sulfadiazine and folinic acid for 4-6 weeks

Hygiene:
Wash hands before handling food
Wash fruits and vegetable
Cook raw meats thoroughly
Avoid cat faces
Wear gloves

Get your cats checked out by veterinary clinic, and I would advice giving up as
they pt you at risk

Will my vision improve? Yes, with treatment. It may improve

What do you have? Most likely it Toxoplasmosis but specialist will con rm

Breast cancer in a 55 year old

FY2 in GP practise
55 year lady made an urgent appointment
She found a lump in her breast while taking a shower yesterday. Her aunt was
recently diagnosed with breast cancer. Otherwise t and well.

Patient wearing a breast manikin.

GRIPS

HOPI
Lump
Site size
Which breast
Duration
How many lumps?
When did you notice it
Associated symptoms pain redness, nipple discharge, skin changed, bleeding,
itching

Risk factors
Family history
Previous lumps
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D/D
Fibroadenoma
Breast cyst
Breast cancer
Fat necrosis- recent trauma
Breast abscess- fever, discharge
Fibroadenosis- multiple lumps

PMAFTOSA
ICE
Examination
Observation
Breast examination
Axially lymph node

Symptoms suggestive of breast cancer:

Symptoms Possible cancer Referral
recommendations
Axillary lump Breast cancer Consider a suspected
(unexplained age 30 cancer pathway referral
years and above) (for an appointment
within 2 weeks)
Breast lump Breast cancer Refer people using a
(unexplained) with or suspected cancer
without pain, age 30 year pathway referral (for an
and above) appointment within 2
weeks)
Breast lump Breast cancer Consider non-urgent
(unexplained) with or referral
without pain, under 30
years changed of
Nipple Breast cancer Refer people using a
concern (in one nipple suspected cancer
only) including discharge pathway referral (for an
and retraction, age 50 appointment within 2
years and above weeks)
Skin changed that Breast cancer Consider a suspected
suggest breast cancer cancer pathway referral
(for an appointment
within 2 weeks)
I am concerned about the lumps you have in your breast because you are above
50 years and there’s a risk that unfortunately it could be breast cancer, it could be
benign, like broadenoma, it’s not always a cancer, and many people who referred
for great cancer do not have cancer.

Management
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Urgent referral
The specialist is going to ask you questions, examine you, and carry out a few
investigations like mammography as you’re above 35, they might also do an USG
and a biopsy.
If it turns out ti be a cancer, then treatment may include
Surgery-wide local excision or mastectomy
Chemotherapy or radiotherapy

Give other information

Take a friend to the appointment, its an urgent appointment they will be seen
within 2 weeks, they are being referred through the cancer pathway but not
everyone referred through this ends up having cancer. O er lea ets. If they aren’t
seen within 2 weeks, they need to come back so they can check up on the
appointment.

Rape: sexual abuse

FY2 in GP
19 year old presented with some concerns
Doctor, I need a sick note.
Looks anxious, not maintaining eye contact.

Sexually abused by someone at a birthday party

He went to school, he feels like he cannot manage to have exams, he hasn’t told
anyone.
Yesterday he went to a birthday party, while they were there, his friend’s brother
forced himself on him. Everybody else was outside. Forced him to remove his
clothes, forced penis in mouth and penetrative anal sexual intercourse. He tried to
shout but nobody could help.
He himself didn’t drink, smoke or use recreational drugs. He’s not sure if his
friend’s brother was on something. Friend’s brother:25 years of age, rst year
medical student

What will you write on the sick note?

What will you out on the sick note?
How long will you give me this sick note for?

Not maintaining eye contact, speaks very slow, so wait for him to answer rst.

Is there any particular reason why you need a sick note?

You look a little bit anxious, is everything okay?

Pick up the nonverbal cues

EVE protocol
Explore emotions, validate the behaviour, and show empathy

Explore
You do not seem too happy/you look a little bit worried/ you do not seem yourself
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 Con dentiality
Just to reassure you, whatever we will discuss is con dential, it is purely
information needed to assist you

Once they’ve opened up

Validate
You have done well to seek help, this is a very distressing situation

Empathy
I am very sorry to hear what has happened

GRIPS

History of incident
What happened exactly
When did it happen
How did it happen
What time?
Who else was there?
What happened afterwards?
Have you spoken to anyone about this?
Have you though of reporting to the police?
Do you know that you can report this to the police and press charges?
If he says no, any particular reasons?
Did he threaten you not to tell anyone?
If yes, ask what did he say would happen if you were to tell someone?
Who have you spoken to? Parents/friend?
Any particular reason why you haven’t?
Did you drink alcohol?
Was your friends brother drunk?
Were there recreational drugs at the party?
E ects of sexual abuse?
How do you furl after all of this?
How has this a ected you?
You mentioned you need a sick note, is this because you can’t focus?

Do you experience panic attacks? Anxiety? Palpitations? SOB?

What symptoms are you experiencing when you think about the time?

Has this a ected your sleep?

How much sleep have you managed to get in the last 24 hours?
You said you told someone at school? Who did you tell? And what did they tell
you?
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 Fears: I know it can be distressing experiencing sexual abuse, and you asked for a
sick note. Do you feel like not going to school or are you struggling concentrating?
Is there anything you are worried about? If it could happen again? How far away
do you live from your friend’s house? Have you been threatened?

Past medical history

Do you have any medical problems like anxiety or medication?
Social history
Who do you live with?
Relationship history
Sexually active?
Relationship?
Do you tend to be in relationships with male to female?

Have you thought of reporting this to the police? Do you know it could be
reported?
Would you like to report to the police?
Why?
Have you been threatened? What threat?

Examination:
Inspection:
Oral
Genital
Anal examination

Don’t do intimate examination. It would be done by trained police men

Possible ndings:
Genital, anal, perianal bruising laceration, swelling, abrasions
Anal gaping
Anal tissue
Anal/genital bleeding or discharge

What you have gone through is not acceptable. You have been abused. I’m sorry.
No body should be placed in your situation. No body should go through what you
went through. It is unlawful. This type of incidence should be reported. I’m sorry for
what has happened
Its a very traumatic and stressful situation.
I think you may bene t from counselling. Would you consider going jus tot cope
with everything?
This is sexual assault/rape. Advice to discuss with the parents and explain that you
can explain to the parents but not without his consent. Do you wish to report this
to the police?
O er him to go to GUM clinic for screening. They will consider post exposure
prophylaxis for HIV at the GUM clinic. They can also do some tests to check for
STI. Discuss with seniors.
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Refer the patient for assessment sexual abuse assessment centre where you will
be examined o cially even if you don’t want to press charges today, this
examination will be important when you do want to press charges.

Doctor what will you write on sick note?

Yes I can give you a sick note. I will not be writing speci c details about what
happened. Just write a letter that he is unwell, he needs more attention to attend
to his health.

Sexual abuse is a criminal o ence. I’m sorry to hear what happened

It is unacceptable. No one should force anyone to engage into any kind of sexual
activity, its against the law.

Chunk and check.

Yes I will be able to give you a sick note. I will write you may not be t to attend
school. You will not write details of what happened on the t note.
I will give you a sick note of 2 weeks, then you can come back, we speak through
things and see how you feel, if you wan to extend it, you’re not feeling well, I can
give you another sick note.

It can be reported to the police.

I would like to refer yo to Sexual Assault Referral centres (SARC) o ers medical,
practical, and emotional support to anyone who has been sexually abused. SARCs
gave specially trained nurses and support workers to care for you. You can’t help
from a SARC by booking an appointment with your nearest centre.

What would happen:

When you got here, they can o er things like
1. Forensic examination by a quali ed practitioner
2. Post-expose prophylaxis-depending on the risk
3. Psychological counselling-it’s not easy to live after sexual assault
4. Legal advice

Having an examination at SARC is not compulsory. If you do not want one, you
don’t have to. However It can provide useful evidence if the case goes to court. Its
possible to collect evidence, such as DNA, loose hair as part of the medical
evidence. Its your choice whether to be examined or not. You can also choose to
have some parts of the examination but not the others.

Advice to report the case to the police or to o er SARC.

Advice to discuss it with the parents (ask if he needs help explaining this to his
parents)
Ask if the person wishes to report the assault, emphasise that it is his decision, if
the person wishes to report the case then refer to forensic institute for examination
by the experts. O er to go to GUM clinic for possible prophylaxis for HIV and
screening of STIs.
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 Discuss with someone senior.

O er counselling
Would you like me to refer you?
Emotional and psychological support, someone to talk to about what happened.

Venous Ulcer
Venous ulcers

Fy2 in the GP surgery

Elliot Green, aged 60 has an ulcer on his right leg (medical malleoli)
Last visit to the GP, he was referred to the tissueviabilit nurse, but he did not go.
He wants to be referred to the specialist

GRIPS
History of the ulcer
Where is the ulcer location?
When did the ulcer appear?
Is this the rst time he has had an ulcer?
How many ulcers are there?

Symptoms of ulcer:
Any bleeding?
Any pain?
Any itchiness?
Any discharge?
What was he told before?

Previous medical treatment:

What was he told was the cause of the ulcer on his previous visit?
Was any treatment o ered?
Did he go to the tissue viability assessment specialist?
What stopped him from going?

History of risk factors for venous ulcers

Do you have any di cult in moving around? Dp you have any condition that
restricts your movement?
Have you had previous DVT? (Clots in your legs)
Have you been diagnosed with having varicose veins before?
Previous injury to leg such as broken or fractured bone which may have a ected
your walking?
Have you had hip or knee replacement which has prevented you from moving
around?
Have you been diagnosed with osteoarthritis?
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 ICE
I- have you thought of anything that could have caused the ulcer?
Did the doctor that saw you last time mention anything to you?

E-You have had this for sometime, what made you seek help now?
Is there anything speci c you would like me to do for you?
Would you like to see the tissue viability nurse this time?

D/D
Venous ulcer
Any swollen or enlarged veins on your legs? (Varicose)
Any discoloured or darkened skin?
Any hardness of the skin?
Any swelling of the ankles?
Any feeling of heaviness in your legs?
Aching or swelling of legs?
Is it in one or both legs?
Any ulcers anywhere else?
Any itchiness?

Arterial ulcers:
Are the ulcers painful?
Any pain in legs on walking?

Cellulitis
Any redness of the kin?
Is the skin warm to touch>
Fever?

Deep vein thrombosis;

Any swelling?
Any pain?
Any redness?
History of immobility?

Neuropathic ulcers:
Painless and deep ulcers
Is the ulcer deep or shallow?
Where is it located?>
Usually on the heel
History of DM

Super cial thrombophlebitis:

Tenderness of redness along the veins with swelling

Assess for signs of infection:

Worsening pain?
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Unpleasant discharge or greenish discharge from the ulcer?
Warmth?
Redness?
Swelling?
Fever?
An unpleasant smell coming from ulcer?

PMAFTOSA
EFFECTS

Examination:
Have a look at the ulcer
Picture showing varicose veins and ulcers on medial malleoli

Diagnosis:
Venous ulcer secondary to chronic venous insu ciency (blood is not owing
properly)
This is suggested by varicose veins. Blood ows through veins, and veins contain
valves. If the valves are not working properly, blood fails to ow back to the heart,
and it goes back, and causes dilation of the veins, known as varicose veins, and
this has caused the venous ulcer.

Management:
Investigations:
ABPI using a doppler USG to exclude peripheral arterial disease as the cause of
ulcers
Routine investigation:
FBC
U&E
LFT
Glucose
CRP
ESR
HbA1c

Treatment;
Reassure that with appropriate treatment, venous ulcers heal within 6 months.

Refer to the tissue viability specialty nurse for:

The key to managing this ulcer is special care, which the nurses can do.
Cleaning and dressing of the ulcer
Graduated compression bandage: applying bandage to the leg, maximising
pressure to the ankle, wen compression bandages are rst applied, it may cause
some pain so you can take paracetamol.
Prescribe the medication pentoxifylline to help with healing. If this doesn’t work,
we can refer you.
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 Refer to vascular specialist for assessment for possible venous surgery
assessment

How do you feel about this?

Prevention:
Be compliant with the compression bandage/stocking.
Elevate the legs. Use pillows under feet and leg to keep it raised when you are
sleeping.
Use emollient frequently for itchiness
Regular exercise will help reduce leg swelling
Examine the leg regularly for broken skin, blisters, swelling, or redness.
Adapt aa healthy lifestyle.
Quit smoking. (If he smokes)
O er lea et about venous ulcers.
Refer to support groups.

Safety netting:
Come back if there any signs of infection such as fever, discharge or increased
pain.

Follow up:
One week time

FOR YOUR KNOWLEDGE:

ABPI
<0.5 severe arterial disease, compression is contraindicated
0.5-0.8 arterial disease
0.8-1.3 suggests no evidence of arterial disease
>1.3 suggests the presence of arterial calci cation

Cauda equina
Back pain

FY2 in the ER
70 year old man has presented with back pain
Mechanic, working on his car, he was standing up, when he bent, he suddenly felt
back pain
He has not been able to open his bowels, he had 1 episode of urinary
incontinence, he has got some weakness in the leg and she sensory loss as well

History of back pain

D/D
Systemic review
ICE
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 PMAFTOSA

Examination:
Neurological examination:
Reduced re exed, tone and power B/L
PR examination: loss of peri-anal sensation and reduced anal tone
Abdominal examination: palpable bladder
Spine examination: normal

Diagnosis: Cauda Equina

He may have a disc prolapse when he bent down, maybe could’ve caused a
fracture, that caused compression of the nerve and now has gotten caudal equine
maybe due to compression of the nerves

Management:
Blood test
Catheterisation
Admit
Orthopaedic referral
Explain what they would do:
They are likely to keep him in the hospital
Perform an operation to relieve the compression of the nerve, so this is when one
of the back cushions slip out and compress on the nerve, and as we say it
commonly this is intervertebral disc prolapse at level, l4-l5 or l5-s2, leading to
cauda equina, so they have to relieve the pressure on the nerve and before that
they have to con rm, by doing and MRI scan.

Ankylosing spondylitis
Back pain

FY2 in the GP surgery

33 year old man has presented with back pain for the last 6 months
Pain is worse in the morning
Morning sti ness
Works as taxi driver, if he doesn’t go to work, and lies in bed all day, then his pain
is worse. Going to work makes it better, however sitting for long time, standing up
can cause little bit of pain but walking around helps. This sis the rst time

GRIPS
SOCRATES
Back pain
ICE
PMAFTOSA
E ect of symptoms
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 Examination:
Spine examination
LL neurological examination
PR examination

Findings:
Tenderness on the sacroiliac joints : typical ankylosing spondylitis

Diagnosis:
Its an in ammation, its the chronic condition of the joints of the spine. It can cause
sti ness and pain in the back.

Management:
Refer to rheumatologist
Th diagnosis is di cult, and the specialist will con rm it. There’s no one symptom
or one investigation that can con rm the diagnosis, so its looking at everything
together, his symptoms and also the investigation, so today you’re going to refer
him to the rheumatologist, non urgent.

Routine blood test

FBC ESR CRP
Special blood test: HLA-B27
NSAID, ibuprofen
Encourage exercise

Atm it is a suspected diagnosis, that’s why we need him o go tot the

rheumatologist to con rm the diagnosis.

Travel immunisation
Mark Simon, 50 yr , wants to take ABx with him to Thailand incase he develops
infection
Was given abx when he went to Brazil
Talk and address concerns
He plans on swimming
Scared of getting stomach bug and other infections

When are you planning to travel? recommended to take vaccines 1 month before
Have you been vaccinated before? Are you up to date of all usual vaccines?
Who are you traveling with? (His wife)
Has she gotten any vaccine

Vaccination required
Hep A
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 Hep B
Typhoid
Rabies

Lea et about other vaccines you might need

Needs malarial prophylaxis

Doxycycline

Common risks in Thailand

Rabies
Zika
Dengue
Traveller’s diarhhea

Avoid insect bite

Can I use probiotics? Yes, they can be used normally to main normal gut ora
Can I have ABx? Unfortunately, we do to prescriber antibiotics in that way. Its
against national/expert recommendation
Why was I given abx when I wen to Brazil
It could be prophylaxis or could’ve been indicated. But I do not know exactly.
Brazil could have other risks requiring abx.

Hes worried about stomach bug so reassure that most diarrhoea is caused by viral
bigs and it resolves on its own without the need of abx. Maintain good hygiene

I have Imodium so should I use it in diarrhoea

It can mask serious disease so seek medical advice before using it

Travel advice
Make sure you have travelling medical insurance and under go all necessary
vaccination that are recommended to Tavel to Thailand

Ask if he’s upto date on all immunisation

Do you have medical insurance

Take measures to avoid insect bite

Dengue fever is common, but there is no prophylaxis
Avoid eating unwashed fruit from the street
Perform hand hygiene frequently
Advice his wife to do the same as well

Pseudomembranous colitis B
Dog bite in a 25 year old man.
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FY2 in GP surgery
Owen Michael, 25 years, has made an appointment to see yiu. He attended ER 4
days ago following a dog bite. The would was cleaned and sutured. He was
discharged with anelgesia and antibiotics (co-amoxiclav 625mg TDS for 5 days)

He has come with watery diarrhoea

1 day after being started on antibiotics
8 episodes/day
Today is the 4th day

GRIPS
How can I help you?

EVE protocol
Explore
Empathetic response
Validate

Take history of bite

When did the dog bite you?
What antibiotics were you given?
Have you nished the course of antibiotics?
How many days did you take the antibiotics?
How is the wound? Is it healing? Is it still painful?
Can I have a look at your wound?

History of acute diarrhoea

When did you start experiencing diarrhoea?
How many times?
Is it watery or loose stools?
Is there any blood/mucus?
Any vomiting?
Any abdominal pain?
Any fever?
How many days after starting antibiotics did you start experiencing diarrhoea?

Rule out other causes of diarrhoea

Have you been in contact with anyone with diarrhoea
Did you eat out in a restaurant before developing a diarrhoea?
Did you travel abroad recently?
Have you been on any medications?
What is your diet like?
Have you been undergoing any stress?

Examinations
Observation. N
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Wound: mild tenderness
Pre rectal

I feel what you’ve developed is what we call clostridium di cle, or

pseudomembranous colitis, we also call it antibiotic associated diarrhoea.
Sometimes when you take antibiotics, they can kill the other normal bugs, that
normally keep clostridium di cile under control. Clostridium then multiplies and
produces toxins which can make some one sick, and cause diarrhoea. Clostridium
usually lives in our gut but in controlled numbers.
Antibiotics have killed other bugs and then C di cult has multiplied.

What we can do now, is stop these antibiotics, seek microbiologist specialist

advice.
Send stool samples to the lab. reassure that the infection can be treated with
another antibiotic (vancomycin 125mg orally QDS for 10 days)
It will resolve within 1-2 weeks.
Prevent dehydration.
Drink plenty of uids.

Usually this infection is spread via feral oral route.

Prevention is by washing hands with soap and water and wearing gloves and
apron whenever visiting someone with such diarrhoea. This particular bug is not
killed by using alcohol gel, he needs too wash hands with soap and water. Patient
remains infectious, while he is still ill and has symptoms. He should go back to
work until he is free from diarrhoea.
Don’t share towels, wash toilet after every use.

Safety netting:
Dehydration
Blood in the stools
Weight loss
High fevers

O er lea et

You cannot tell how someone responds to antibiotics.

You’re not allergic to medication.
Why was I not informed?
I am really sorry that you weren’t told. I should’ve informed about this.
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Lithium toxicity
You are an FY2 in an emergency department.
Michael price age 78 has presented with confusion and problems with
coordination.
His daughter would like to talk to you about her father’s condition.

He has been confused and has had problems walking for the past 2 days.
He was diagnosed with bipolar disorder about 20 years ago.
He is on regular lithium treatment
His wife passed away 6 months ago, and since then he has not gone for follow up
For the last 2 days he has been confused, and is very unsteady on his feet.
Daughter also noticed that the hands are shaking.
He is generally very weak compared to his normal self
Doctor is concerned her dad could have taken too many pills since her mother
used to give him the medications
All this started 2 days ago
Generally he is ok, no memory problems.
Mood has been low recently due to passing away of his wife.

What is wrong with him?

How are you going to treat him?

GRIPS
HOPI
Confusion
Walking di culties
Tremors

Ask about:
When did it start?
Is there anything which makes it worse or better.
Has any of these happened before?
Is he able to walk?
Before 2 days was he able to walk properly?

D/D
Lithium toxicity
Anorexia, diarrhoea, vomiting
Drowsy, confuse
Dysarthria (slurred speech)
Dizziness, ataxia, tremors, twitching, visual problems, hyperre exia
Convulsions

Infections
UTI (frequency, urgency)
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 Pneumonia (fever, cough)
Gastritis (any stomach pain)
AOM (any ear pain)

Addison’s disease (nausea, vomiting)

Hypothyroidism (feeling cold, constipation)
Stroke (any weakness of any side of the body)

Systemic review
Resp: SOB, chest pain
CVS palpitations
GIT: diarrhoea vomiting, abdominal pain
GU: urinary problems
CNS: headaches, dizziness
MSK: joint pain, rashes
PMAFTOSA
Travel history
Work history
Social history
Who does he live with?
Does he have anybody to help him?

ICE
E ect of symptoms

Examinations:
Observations
Systemic examination
CHEST
CVS
ENT
ABDOMINAL
NEUROLOGICAL EXAMINATION
EYE EXAMINATION (eye movement)

Diagnosis:
Lithium toxicity
The levels of lithium in his blood could be high. It could be possible, that he has
taken too many tablets or it could be because the levels of lithium haven’t been
monitored for a while so the levels could have gone up.
We are going to check lithium levels in the blood
And take other blood tests to check all organs are working properly. U&E, LFT
check his glucose, signs of in ammation CRP, ESR
Take his ECG.

Management
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 He is a little bit confused so we will move him to a calm area so he is not irritated
and refer to acute medical team for admission. We need to stop the lithium for
now, and catheterise him to check his urine output. And we will need to closely
monitor him
There is no speci c treatment for lithium toxicity, treatment is mainly supportive
until he recovers.
But what we can do is give him IV uids like 5% dextrose to increase to help
eliminate the lithium levels in the body. It involves giving a lot of uids that results
into excess urination, so lithium is excreted.
If the levels are too high, dialysis may be needed.

Referrals
FY2 in ward
3rd medical

How do you discuss referral prices with patients?

How do you make the pateitn understand
What are the type of referral other Han urgent referrals?

GRIPS
Use rst name
Rotation going
Con rm what they want to learn and what they already know
Check their understanding from time to time

1. Explain suspected diagnosis

2. Explain nature of the diagnosis(how serious it is)
3. Explain reason for referrals

For eg
I suspect you may have hyperthyroidism/unfortunately I think you may have
cancer of the bladder
It is quite serious condition that needs to be reviewed or your condition is treatable
Were referring you to assessment, con rming diagnosis or for treatment. So
specify what your reasons are

Explain types of referral

Immediate Acute admission,
referring within few hours
Very urgent Within 48hours
Urgent Up to 2 weeks For suspected cancer
Non-urgent Up to 18 weeks For all non urgent cases
If youre unsure which type of referral to make, discuss with seniors.
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 Time starts after the specialist receives the referral so try making it early as in the
same day
Let the specialist know which type of referral it is
Let the patient know which type of referral it is

Give information
What would happen at the appoint
They would ask you questions, reassess you, examine uou and perform
investigations
Tell which investigations to them and explain the procedure so they know what to
expect
Now tell likely treatment
Tells options
Support for the patient. Advice patient to talk to their family and to take a family
member or friend along fro their appointment
O er lea et and sites for them to gather more info and read more about before
their referral appointment
Say that They can always come back to the GP of they have questions

Safety netting Tell them red ags, any symptom to look out for while waiting
appointment
Safety netting for missed appointment

Summarise

Teaching immunisation
FY2 in GP surgery
4th year medical student want to learn about vaccination
Teach him how to explain vaccination to the parents

GRIPS
Use your rst name
Build rapport
Con rm he would like to learn immunisation
Check what a student would like to learn: what would you like to learn about
immunisation?
Check prior knowledge: what do you know already about childhood
immunisations?

Vaccination
Explain the purpose of vaccination to the parent
Explain the reasons for immunisation in children

One is to prevent communicable diseases

It is given for the purpose of preventing serious infections in children
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Some of the infections can cause serious complications, as to prevent life
threatening conditions, like meningitis, measles, polio, all of these can be
prevented

The reason why children need vaccination:

By vaccinating the child, you’re also protecting the vulnerable group like the
elderly, the immunocompromised, people with cancer, or in school
Thought the infections may be simple, to people with low immune system, it can
be serious, and may cause death
It is to protect the child
Because of the vaccinations, some of the diseases eg polio have disappeared.
Having said that, sometimes you may want to go for holidays, outside the UK,
where these infections are still prominent, therefore its a risk, if you’re not
immunised against particular infections, you can catch these infections.
You don have to travel to catch these, others travel to the UK from abroad, and if
they come from countries where these infections do exist, you can catch these.

Simply to protect the vulnerable group

To protect the child himself
Travel infections

Parents who refuse child to be vaccinated

You need to explore their concerns
What worries you the most about vaccination
Have you read something about these vaccinations, or have you asked anybody,
any medical professional?
Tell me what did you learn about vaccinations?
Do you know anyone who su ered due to vaccinations?

Ask about other history

Is the child t and well?
Does he have any medical problems?
Any allergies?
Any regular medications?

Pregnancy:
Any problems during pregnancy?
Any problems during delivery?
Is the child growing well? Gaining weight?

Empathise
I do understand your concern. Your concerns are genuine for me. In fact many of
the parents are concerned about vaccinations, when they hear about side e ects.

Get permission to share information

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 Can I give you more information?

Give general information

First of all, I would like to tell you these vaccines are safe.
There are some side e ects but these are usually mild. Very rarely you see
someone who su ers from severe side e ects. They are usually self limiting.

Tell the parents where to get reputable source of information (health care providers,
doctors, nurses, assistants, NHS website, patient info website)

Tell them bene ts of vaccination

Protect the child from serious infection for example meningitis. There are some
types of meningitis which can be prevented with vaccination.
To protect vulnerable people

O ers information-lea et

Give time to think

MMR-does it cause autism?

It does not. Have you read somewhere that it causes autism?
It has been researched and proven to be wrong.
Mild side e ects:
Mild soreness on the site
Mild fever
Mild headache
They will resolve within a few days

If its an infection and causes severe symptoms, you become unwell, that’s when
you know you su er from infection itself.

My neighbour had vaccine and developed a fever:

I won’t be able to comment because we don’t have much information, but rarely
does a vaccine cause fever high enough to cause seizure.

Rare in the UK?

You may travel abroad, or people from abroad may travel here

If parents refuse you cannot of course force the child to have vaccination. You
need their consent unless in situations where the child is old enough and judged to
be hillock competent because the child understands the information.

Address parent’s concerns

Summarise
Purpose of vaccination
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 Explore their concerns
Show empathy
Ask before giving more information
Show them where to read about these things
Always extend the bene ts about these vaccinations
O er lea ets
Never force them, give them time to decide
If they refuse you cannot force them

Addison’s disease
FY2 in Gp surgery
Sarah James 27 years came for follow up
Hx of DM 1
Recent blood test
NA 130
K 5.7
Rest normal

Explain the results and discuss further management

Opening sentence “Dr. I have been feeling tired for 2-3 months and it has been
getting worse.”
Polyuria and Polydipsia
Also noticed darkening of the oral mucosa
Hyperpigmentation of the knuckles
He has got salt cravings
He has DM1, taking insulin for long period of time
High cholesterol-statin
Aunt-Hypothyroidism

GRIPS
Di erent approaches:

We can either start by explaining results or with history.

I understand that you’re here for follow up and you had some blood tests done.
Has anybody explained the results of these tests to you.
Okay let’;s go through the blood tests an then I will ask you some questions, in
terms of what has been happening for the last couple of months.

To begin with, I need to ask you questions about your general health, how you’ve
been in the last 2-3 months, and then we will go through with the blood tests and
also discuss what we need to do going forward.

If patient is anxious and wants to know the result.

Your blood shows low sodium and high potassium, but I need to ask questions to
understand why these particular changes have occurred in the blood.
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ODPARA for tiredness
The tiredness, when did you rst start experiencing tiredness. Is it constant or it
comes and goes?
Does it start suddenly or gradually?
Is it getting worse or any better?
Anything that makes it worse?
Any particular time of the day when the tiredness is worse?
Is there anything that makes it better? What do you do to make it better?

D/D
Hypothyroidism
Weight gain
Menorrhagia
Feeling cold when others are comfortable

Hyperthyroidism
Weight loss
Diarrhoea
Palpitations
Menstrual irregularities

Anemia
Palpitations
Lightheadedness

Depression
Low mood
Feeling worthless
Loss of interest

Addison’s disease
Skin or oral mucosa pigmentation
Nausea vomiting
Abd pain
Dizziness
Weight loss

Chronic fatigue syndrome

Tiredness that does not improve with rest

Malignancy
Weight loss
Loss of appetite
Tiredness
Fatigue
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Anorexia nervosa
Weight loss
Dieting
Low BMI
Amenorrhea

DM1
Weight loss
Tiredness
Polyuria
Polydipsia

Systemic review
Msk: Pain, Skin rashes
Rs: SOB wheezing
CVS:chest pain palpitation swelling of the legs
GIT: nausea vomiting problem of bowels and pain
CNS: dizziness, lightheadedness, visual problems, weakness of nay part of the
Boyd
GUS: Urinary problems

PMAFTOSA
ICE
EFFECTS OF SYMPTOMS
Summarise (history of what we have discussed)
So you told em you’ve been getting tired for 2-3 months and its getting worse,
you’re also experiencing polyuria and polydipsia, and you’ve also noticed
hyperpigmentation, and your aunt has hypothyroidism, which is autoimmune, and
you also have DM1, for which you’re taking insulin. Am I right? Is there anything I
missed?

Examinations:
Observations:
Standing lying BP
Head to toe inspection
Oral mucosa examination
Abdominal examination

Examiner’s prompt
Observation:
Lying: 120/80
Standing: 100/69
-postural drop-

Abdominal examination: normal

Oral examination: hyperpigmentation of gums
 Management
It’s likely you’ve got what we call Addison’s disease, it is also known as primary
adrenal insu ciency. The adrenal gland is the gland located just above the
kidneys. So from what wyouve told me so far, and from the blood results, its likely
you’ve got this condition. This condition is usually what we call an autoimmune
condition. Which means an immune system which normally defends us from
infection is attacking itself
There are somethings that predisposes someone to have this condition. Having a
family member with another autoimmune condition like hypothyroidism, it does put
you at risk of developing autoimmune disease.
In terms of the blood tests, you’ve got low salts, which is Na low and K high.
In examination we saw hyperpigmentation, all these are suggesting the diagnosis
of Addison disease.
What we’re going to do is refer you to the specialist, endocrinologist to con rm the
diagnosis. The specialist will perform specialist investigation such as Synacten
test, for adrenocorticotropin tests, they will do a hormonal pro le, ACTH, DHEA,
plasma renin, aldosterone, thyroid blood tests. So they will check di erent
hormones, and they may perform autoantibodies test. They may also perform CT
and MRI scan.
If the diagnosis is con rmed, they will o er you treatment such as hormones
Glucocorticoid: hydrocortisone
Mineralocorticoid: such as udrocortisone or aldosterone
Androgen replacement: DHEA is an androgen made in the adrenal cortex, therefore
levels are decreased un Addison’s disease

O er lea ets
O er written information or advice patient to read on NHS website for more
information

Endometriosis
FY2 in obs and Gynae
25 year old lady
Referred by the GP with a referral letter
Asses and among the patient

Lower abdominal pain for 6 months

GP is suspecting endometriosis and has started ibuprofen and COCP

Will I be able to have children?

Why is the pain not getting better?

GRIPS
HOPI
I understand that your GP has referred you here. Did she explain why she referred
you here, did she explain what’s wrong with you?
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 What made you go and see your doctor?
How lon have you had these symptoms for?
Where do you normally develop the pain?
SOCRATES
Imp to ask about relation of pain to menstrual period.

Other symptoms of endometriosis:

Chronic pelvic pain (>6months)
Period related pain (dysmenorrhea)
Deep pain during or after sexual intercourse (dyspareunia)
Period related or cyclical GIT symptoms (painful bowel movement, abdominal pain)
Period related or cyclic urinary symptoms (dysuria, blood in urine)
Infertility

Risk factors
Early menarche (at what age did you experience your rst menstrual period)
Family history (has anyone in your family ever been diagnosed with endometriosis)
Late rst sexual intercourse (at what age did you become sexually active)
Smoking
Autoimmune disease
Nulliparity
Delayed child bearing
Late menopause

D/D
Adenomyosis/uterine broids (HMP, enlarged uterus, abdominal pain)
Primary dysmenorrhea
Uterine myoma (HMP)
PID (discharge, fever)
Ovarian cancer (lower abdominal pain, swelling, family history)
Ovarian cyst (intermittent pain)
IBS (diarrhoea, constipation, bloating, abdominal pain relieved w defecation)

PMAFTOSA
ICE
E ect of symptoms

Examinations
Observations
Abdominal examination
Pelvic examination
PV

Diagnosis
The GP referred you here for suspected endometriosis, and from the history you’ve
given me and the examination, I also do suspect that yo have endometriosis. It is
the growth of the endometrium, these are the tissues which are found in the
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womb, but they may grow outside the womb, it is the growth of the endometrium
like tissues outside the uterus. Simply means growth of uterine tissues outside the
womb where they are usually not found, it can be anywhere in the pelvis, in the
tubes, in the ovaries. This can cause symptoms of lower abdominal pain, pain
during menstrual period, during sexual intercourse.
The GP referred you here to con rm the diagnosis and for further assessment. We
have assessed you but we would like to order a few more investigations.

Management
Perform investigation:
TVUSS
Laparoscopy

Explain further management

Painkiller (paracetamol or ibuprofen)
Hormonal management (COCP or POP)

Other medical treatments

GnRH agonists therapy
Danazol
Surgical treatment
Other information (lea ets local support groups)

Head lice
Fy2 in GP clinic
44 year old has made a phone call appointment to talk to you
He has a 5 year old daughter he’s concerned about
His daughter has got head lice
Doctor my child is having a problem with head lice
He tried over the counter shampoos
Child is scratching the head
He is reluctant to bring the child to GP
Can you prescribe her some medications

Approach
GRIPS

HOPI
What makes you feel she has head lice?
Have you seen the head lice?
Is there itching?
How long have the symptoms been going on for?
Have you see any live lice?
Have you seen any lice eggs?

Ask about possible sources

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 Anyone in the family with head lice?
Has she slept at another house recently?
Any visitor coming in your house that could have brought the lice?
Does the child go to school?
Do you know if there’s anyone at school with head lice?
Where could she have caught the lice?

Treatment tried
What treatment have you tried so far?
Did it help?
Was everyone else treated at home?

D/D
Seborrheic dermatitis
White scales

Eczema
Any rashes on any other part of the body

Systemic review
Any joint pain?
Any swellings?

PMAFTOSA
ICE
Where the child could have gotten the head lice?
E ect of symptoms

Paediatric history
Child developing and growing well
Up to date with all vaccination
Eating and drinking well
Pregnancy
Delivery

Social life
Who else is art home with you?
Where is the mother?
Any other children at home?
Is it possible to bring the child at the clinic os we can visualise the lice here.

Child abuse
Head lice can be a result of poor child handling
Has child protection ever been involved in the care of the child?

Diagnosis
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that may present like head lice and it may be di cult to di erentiate, hence it is
important to bring the child to the GP for examination so we can visualise live head
lice.

Arrange face to face appointment

Treat the person only if live head lice is found
Treat a temed household members simultaneously
Child who is being treated for head lice can still attend school
There is no need to wash clothes or bedding that has been in contact with the lice

Methods you can try:

Wet combing
Systemic combing of the head to remove head lice
Head lice removal using Bug Buster Kit.
Usually 4 sessions at day 1, 5, 9, and 13.
Insecticides: silicone
Chemicals or traditional insecticides, they poison the lice by chemical means e.g.
Malathion 0.5%
Treatment needs to be applied to all areas of the scalp and to all hairs

In pregnant women:
Wet combing
Dimeticone 4% lotion is recommended

Treatment failure
Could be due to the fact that not all family members are treated
Should be treated by repeating the treatment or switching to di erent treatment of
choice.

Uterine prolapse
Fy2 in the GP surgery
Elaine Johnson aged 60 has presented with some concerns

Doctor, I feel discomfort in my front passage.

I feel like something coming down.
What do you mean by discomfort in the front passage?
Symptoms started gradually 6 weeks ago following lifting of heavy objects, and
symptoms are getting worse.
She came today, because she started experiencing leaking of urine when she
coughs. She has 5 children and they were all born via vaginal deliveries.
Her LMP was 15 years ago
She is currently not active sexually
She is retired now but worked as a carer
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 She feels uncomfortable because of the urinary leakage whenever she coughs

If she starts with saying “embarrassing”

We are medical professionals, this is what we do. We do see people with many
di erent personal problems, so there is nothing embarrassing about it, and we are
used to treating personal problems, because we are professionals, so there is
nothing to be embarrassed about. Can you tell me about the problem.

Why his this happening to me, and what’s causing it?

What can you do to help me?
Is it life threatening?
Do I need surgery

GRIPS

History of dragging sensation

When did it start?
Gradually or suddenly?
What do you mean by dragging?

Risk factors:
Multiple deliveries (do you have children? How many children?)
Heavy lifting (any heavy lifting recently)
Previous surgeries

D/D
GENITOURINARY PROLAPSE SYMPTOMS

1. Urinary symptoms
Incontinence (when does this happen), frequency, urgency, feeling of incomplete
bladder emptying or urgency of urination

2. Bowel problems:
constipation, any straining or incomplete evacuation, urgency of stool,
incontinence of stool or atus

3. Vaginal/general symptoms:
sensation of pressure, fullness or heaviness, sensation of buldge/protusion,
dragging or something coming down, dragging sensation, spotting or bleeding

4. Coital di culty:
loss of vaginal sensation, dyspareunia, vaginal atus, loss of arousal

PMAFTOSA
ICE
E ect of symptoms
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 Examination:
Observations
PV examination (standing and lying down)
Abdominal examination
Pelvic examination (speculum examination)

Findings
Observation: Normal
Speculum examination: mass protruding from the vagina

Diagnosis
You have what we call uterine prolapse, which sometimes happens if there is
weakness of the pelvic oor muscles. One of the risk factors that she has is
multiple deliveries, it weakens the muscles of the pelvic oor, and sometime with
age, the muscles become weaker, there is a risk that the uterus may fail to stay in
position, because the muscle keeping it in position is weak.
This is general ageing process. So uterus drags down into the vagina, and may
come completely out.

We are going to perform routine investigations, FBC, U&E, LFT, glucose

Perform USG scan of kidney
Person MSU since there is urinary incontinence
Urine dipstick and send urine for culture

All investigations are normal.

Management
We are going o rst refer you to the gynaecologist for more detailed assessment
and con rmation of diagnosis. Usually treatment o ered is conservative like
Pelvic oor training, exercises that can be done to improve strength of the muscles
in the pelvis. They can also o er a treatment called vaginal pessary, its a ring that
is inserted into the vagina to hold the uterus in place. If the conservative treatment
fails, you may be o ered surgical treatment which includes hysterectomy.
O er lea ets

ADHD
FY2 in GP practice
19 year old boy presented with some concerns

A young boy, he has got attention problems.

He is shaking his legs and looking everywhere

Scenario A
The school teacher told you to see a doctor because they feel that you are lacking
concentration during lessons
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 Scenario B
You approached the nurse at your school yourself because you feel that your
concentration is lacking a lot

Looks unsettled. At times he forgets pan in the oven. He is struggling in school

with any exercises that need a lot of concentration. He likes mathematics but not
theoretical stu .
Parents do not think anything’s wrong with him. He also nds himself forgetting
things easily, like events.

Approach
GRIPS
HOPI
Lack of concentration (inattention)
What do you mean by lack of concentration?
When did you rst notice it?
How long have you had it?
Can you describe situations when you lacked concentration
Has anyone made comments about it? Who?
How’s your school performance? Has anyone made comments about lacking
concentration during lessons?

Making careless mistakes (does he make careless mistakes)

What do you mean by lack of concentration?
When did you notice that you lack concentration?
Can you describe a situation where you lacked concentration?
What about school, has anyone commented about you not concentrating in class?
Are there any situations at school where you feel like you do lack concentration?

Symptoms and signs of ADHD

1. Inattention symptoms
Do you feel like sometimes you t to give close attention to detail or make
careless mistakes in school work or any other activities
Do you have di culty maintaining concentration when performing tasks or
activities?
Can you give an example?
Do you have di culties in organising tasks ?
Do you sometimes feel reluctant or dislike or avoid tasks that require sustained
mental e ort?
Do you tend to lose items necessary for tasks or activities such as pencils, mobile
phones or wallets?
Do you get easily distracted by activities happening around you?
Do you tend to be forgetful with regards to daily activities?
Has anyone at school ever mentioned to you that you do not appear attentive?
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 2. Hyperactivity impulsive symptoms
Do you tend to be dgeting with things around you?
Do you do activities such as tapping hands or feet or squirming when seated?
When playing games do you ever experience di culties waiting for your turn?
Do you feel that sometimes you interrupt others when talking?
Do you feel that sometime you talk excessively?
Do you fail to follow through on instructions or nish a task?
Blasting out answers before questions are completed?
Find it di cult to play or engage in leisure activities quietly?
Has anyone ever mentioned that you appear restless?

Criteria for suspecting ADHD

At least 6 (5 in adult) inattention symptoms
At least 6 (5 in adult) hyperactivity-impulsivity symptoms?
Symptoms started before 12 yrs
Occurred in two or more settings such as home and school
Been present for at least 6 months
Clearly interfered with or reduced quality of social, academic or occupational
functioning
Not occurred exclusively during coarse of a psychotic disorder and are not being
explained by another disorder

When did the symptoms start?

Do you experience similar symptoms at home?
Is it a ecting your school?
Do you have any mental health conditions?

D/D
Anxiety disorders (anything you’re worried about?)
Depressive disorders (low mood? Lack of sleep?)
Autism spectrum disorder (language problems, playing on your own)
Personality disorder
Bipolar disorder

PMAFTOSA
ICE
EFFECT OF SYMPTOMS

Social history
Relationship?
Who else is at home?
Friends?
Hobbies?
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 Do you drive? Any o ences of dangerous driving?
How is your progression at school? Do you cope with schoolwork well?
Are you in a relationship? Any excessive disagreements?
Friends?
Any problems sleeping?

I am suspecting you have what we call ADHDH, a situation in which you lack
attention, and sometimes you may be more hyperactive than normal. You like
attention, it a ects your concentration. Sometime you nd di cult to stay calm,
you might feel agitated.

We need to refer to mental health team specialist to comfort the diagnosis and
once they con rm, they’ll be able to start treatment.
He may o er you what is called group based support. Her you will be given more
information about ADHD and how it can a ect you. You can attend with your
parents, they will also be taught some strategies of how to assist you.
You need to liaise with the university, explain a little bit more about your condition,
so you get the support you need,
The specialist will give you medications:
1st line: methylphenidate
If not working
Alternatives: lisdexamdetamine, dexamfetamine, atomoxetine

Avoid bombarding w names.

Somatic symptom Disorder

FY2 in GP
28 yr old man
Previously presented with lump on chest and with mole on the hand twice in the
last 2 weeks
Investigations came back normal
Has now presented with lump on the neck
Talk and address concerns

Is it cancer?
What re you doing to do for me?
How will you rule out cancer
Will you not take a sample

Start with how can I help you

“Doctor, I’m worried about cancer”
Is there any particular why youre worried it could be cancer
Im sorry that you feel this way
Pick up body language. I can see you look a little worried/anxious to me

HOPI
When did you notice the lump?
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 Where is the lump?
How big is the lump?
Is there pain?
Have you developed any lump in the past?

FHx
You’re worried about cancer, is there anyone in the family who had cancer?

Systemic
RS
CVS
GIT
GU
ENT

I was going through your notes and I noticed that you visited the practice twice in
the last 2 weeks
Can you tell me what was the issue that made you come and see the GP?
What did they tell you what was wrong?
Did they do any test?
Did they tell you the results of the tests?
If no, tell the patent all the tests were normal and there is nothing wrong with him

Use the BATHE technique

Background : how would you describe what is going in your life at the moment
A ect : how do you feel about all of it?
Trouble : what troubles you the most about this situation?
Handling : what helps you handle all this?
Empathy : I know this is tough situation to be in. Your reaction makes sense to me
so I understand the you’re worried

E ects of symptoms
Anxiety or panic attack
Chest pain? SOB? Palpitations? Tingling and numbness around the lips? Feeling
anxious? (Patient will have anxiety symptoms)
Sleep
How has this a ected your sleep? How many hours do you sleep?
Job
Has this condition a ected your job?
Social Life
Who is at home with you?
What do you normally do in your free time?
Do you have any siblings?
Are your parents around?
Have you spoken to anyone about how you feel?
If no, is there any particular reason
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 Has this a ected the way you spend your free time?

Alcohol
Do you drink
If yes, then do you feel like you’ve started drinking more

Smoking
Do you smoke?
If yes, does this situation make you smoke more?

Mood
How is your mood rn? and the last few days?
On the scale of 1 to 10, one being the lowest and ten being the highest, how would
you rate your mood
If mood low, ask how long has your mood been like this?

Other history
Ask about anxiety or depression
Complete what is not covered, past medical, family,

Re ection question
What do you think abut what the told you
How do you feel about the fact that the tests done came back all normal
Is there anything you feel that could be the reason of the problems

Examination
No lumps, No swelling
Findings : mild tenderness with scratch marks

Diagnosis
The results of all my examinations are normal
(Avoid giving diagnosis or make them feel sick)
The tests done also came back normal
You don’t have any life threatening condition
You do have a serious and impairing condition which we see frequently but little is
understood about it. You have a worry about cancer but the tests are not
indicative of any
Also there is no treatment for your condition the can cure it completely but there
are a few interventions to help deal with your condition
O er counsellling sessions called CBT. They can give you strategies on how to
cope with your symptoms “would that Be ok?”
Advice regular exercise
The tests aren’t needed but regular f/u will be done so we don’t miss anything new
or any problems.
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 Obstructive Sleep Apnea
Approach
Presenting complaint
Tiredness
Sleepiness during the day
Snoring at night
Waking up at night
HOPU
How long has he/she has\d this sleep/snoring problem?
Severity
How may times do you wake up at night
How tired are you during the day?
How sleepy are you during the day
Have you fallen asleep during doing something

E ect of symptom
Are you able to function during the day
What job do you do
How are you coping with your job
Do you snore at night
How does your partner feel about snoring
Has it a ected your relationship with your partner
Has this a ected your performance at work?

Driving
Do you drive
Do you ever feel sleepy while driving
Did you ever get involved or almost got involve in an accident due to sleeping
during driving

Sleepiness during day

Do you ever fall asleep while sitting on the couch for short period of tie

Risk factors of OSA

obesity - do you what is your BMI? You weight?
Family history - do you have any family history of OSA
Diabetes type 2 - do you have diabetes

Mood
How is your mood?
If you were to scale your mood from 1-10, 1 being lowest and 10 being highest

Tiredness
Do systemic review to rule out cancer and autoimmune condition
Hyperthyroidism
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 Chronic fatigue syndrome
Joint problems

ICE
PMAFTOSA
Summarise

Examination
Blood pressure
Systemic examination - RS, CVS and Abdomen
ENT examination
BMI
Epworth sleepiness scale to check severity of OSA

Management
You have a condition called Obstructive Sleep Apnea
You’ll be referred urgently to a sleep clinic to be seen within 4weeks esp of
a ecting his life
Advice not to drive until they have been assess to see if excessive sleepiness is
impacting on their role a a professional driver

Specialist will do
Con rm the diagnosis
Perform special investigations such as polysomnography or sleep study

Once diagnosis is con rmed, they’ll o er treatment

CPAP therapy is 1st line
If you can’t tolerate CPAP then they’ll o er you intra-oral mandibular advancement
devices

Scenario A
FY2 in GP
56 yr male with sleeping problem
Taxi driver, has slept a little during driving red signal
Inadequate information to make diagnosis

History
Sleeping hx, Tiredness? Snoring?
ICE PMAFTOSA

Examination

You have OSA, which is a condition in which the muscles of your throat during
sleep relax and collapse your airway thus blocking it causing you to snore and then
you’ll wake up gasping for air during the blockage. And if you wake yp frequently
during the night, you’ll feel sleepy and tired during the day
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 You’ll be referred urgently to a sleep clinic to be seen within 4weeks esp as its
a ecting his life
Advice not to drive until they have been assessed to see if excessive sleepiness is
impacting on their role a a professional driver

Sleepiness can cause accidents

Specialist will do
Con rm the diagnosis
Perform special investigations such as polysomnography or sleep study

Once diagnosis is con rmed, they’ll o er treatment

CPAP therapy is 1st line
If you can’t tolerate CPAP then they’ll o er you intra-oral mandibular advancement
devices

Scenario B
FY2 in GP
59 yr male , F/U of diabetes(type 2) being managed with diet and exercise
BMI 37, he smokes and drinks (bottle of wine everyday)
Delivery driver
He doesn’t like cooking (eats junks)
He’ll mentioned tiredness but will minimise it (he’ll tell it reluctantly, dont miss it as
you’ll miss the diagnosis)
HbA1C : 45
Patient doesn’t want to change lifestyle habits
You need to ask any other problem
“Yeah I’m feeling a bit sleepy”

How do you feel about your condition or how are you coping
Any other problem other than diabetes
Is there anything else about tiredness
Ask f/u qs about OSA

History
Examination

Youve got OSA, you have risk factors such as diabetes and high BMI, you smoke
and drink, which re all risk factors
You’ll be referred urgently to a sleep clinic to be seen within 4weeks esp as its
a ecting his life
Advice not to drive until they have been assessed to see if excessive sleepiness is
impacting on their role a a professional driver
Advice about lifestyle changes(Lose weight, stop smoking and alcohol)
Is a driver, can’t leave as he earns
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 Cat Bite
FY2 in GP surgery
36yr man with cat bite
Travelled, returned yesterday, with family
Wild cat, no diseases or skin issues, put a bandaid
All childhood immunisation complete. Tetanus 5 doses (up to date). Last
vaccination was 12 months ago (booster needed if 10+years)

When did it happen

How did it happen
Was it domestic or wild car
Did the cat look healthy or did it have unusually symptoms
Was the attack provoked
Did u bleed
Where did it bite you
What rst aid di you do(running water plus bandaid)

Vaccination hx:
Hx tetanus vaccine
When was your last tetanus
Did you have vaccination for rabies

Any other symptom other than the bite? Any pain? Any issue with movement of
your hand?

Systemic review?
Fever? Cause? Vomiting?
Enlargement of any glands, in the armpit or neck/
Headache? muscle pain?

PMAFTOSA
ICE
e ects of symptoms
Summarise
You went out, you got bite, you cleaned

Examination
Hand
Inspection
Movement of hand And neurological examination to check if any ligament of
muscle damage
Enlargement of glands
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 You’ve got an animal bite. There a delay in your prevention. More than 6 hours in
coming means a delay, make u at his of infection
Well give you some analgesia PCM, ibuprofen
Clean the wound
We’ll give your oral ABX (co amoxiclav for 3 days)

Safety netting
Any pus, fever, severe swelling the you need to come back

Chronic Tophaceous Gout

Chronic tophaceous Gout
FY2 in GP
69 man with concerns
Swelling of the joints in both hands for the last 5 years
No pain, no sti ness, no fever
HTN, initially on bendro umethiazide, stopped when he developed gout and
placed on amlodipine
Placed on colchicine for gout but stopped after developing a reaction to it
Went to Well woman clinic last week and nurse saw the swelling and asked u to
see the doctor

Why have you presented now?

GRIPS
HOPI

DD
Septic arthritis : pain, fever, redness
Acute gout : swelling, pain, redness
Chronic tophaceous gout : swelling, deformity of smaller joint, no pain, no redness,
past hx of gout
Rheumatoid artrtiits : morning sti ness, joint pain
Osteoarthritis : heberdens node and bouchards nodes, pain in the joint, large joint
involved, usually mono-arthritis

PMAFTOSA
FMAM- past medical hx of HTN and gout, allergic to colchicine and is on
amlodipine
ICE
E ects of symptoms

Hand, elbow kneee examination

Swellings of the joint

Diagnosis:
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 This is a condition in which large crystals deposit in your joints leading to irregular
thick nodule mostly sound extensors surface of ngers, hands, forearms, elbows
and sometimes achilles tendons and a
Top develops after 10 yrs of rst attack

Management:
Xray of joints
Blood test for routine investigations and serum uric acid
O er allopurinol to reduce serum uric acid is high
O er lea et
Refer to rhemuatologist
Life styles, (lose weight, east balanced diet)

Arcus Séniles
You’re an FY2 in the GP surgery
Amanda wright 69yrs came for a follow up.
Blood tests came back normal
Talk to the patient and address her concerns

Doctor, I have white rings in my eyes, she noticed white rings in both eyes 4-5
days ago after she started wearing her glasses
She’s concerned it might a ect her vision

What caused it doctor?

Will it a ect my vision?

GRIPS
All the tests have come back normal which is a good news. Is there anything that
concerns you t all?
I noticed white rings
When did you notice the white rings?
Is it in one eye or both eyes
Does it cause pain or irritation
Is the vision a ected
Do you wear glasses, for how long
Do you take any regular medications
Any allergies

PMAFTOSA
Anyone in the family with same rings

ICE
E ect of symptoms
Examinations
Observations
Look into the eyes
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 Examination ndings:
Cornea-white rings
Causes:
Age related
High cholesterol
You have what we call Arcus seniles, this is a grey or white ring on the cornea, also
known as cornea arches. It is common in older people, usually due to ageing. It
can be caused due to high cholesterol, but your levels are normal. It is therefore
only age related.

Does not need any treatment. It is not harmful.

Advice to keep healthy, eat balanced diet.
O er lea ets about Arcus seniles

Allergic rhinitis
Scenario B

Fy2 in GP surely
36 yr old has presented with some concerns
Has been sneezing for the past 6 weeks, 6 weeks ago bought a cat
Symptoms are worse when he’s at home, they get better when he leaves home
Allergic to penicillin, you get rashes

GRIPS
History of sneezing

D/D
Flu
Allergic rhinitis
Sinusitis

PMAFTOSA
ICE
E ect of symptoms
Summarise

Typical symptoms of allergic rhinitis

Sneezing
Nasal itching
Nasal dischage
Nasal congestion
Symptoms develop within a minute of exposure

Associated symptoms such as B/L eye itchiness, redness and tearing

Personal or family history of atopy (asthma, eczema, allergic rhinitis)
Symptoms occur following exposure
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 Causative allergen could be tree pollen, intermittent or chronic symptoms occurs
seasonal
House dust mites
Pets

Examination
ENT examination
Eye examination

Findings:
Redness of nasal mucosa B/L

Diagnosis: Allergic Rhinitis

Its likely to be reacting to the pet, since he mentioned the symptoms started when
he got a pet.
Management:
Advice to use nasal irrigation with saline using spray or pump (can buy over the
counter)
Advice to avoid triggers e.g. avoid pets (give away or sell the pets)
O er antihistamine intranasal e.g azelastine
To come for review in 2-4 weeks if symptoms persist
O er lea et

Toxoplasmosis Gondii
FY2 in GP surgery
55yr man made an appointment
Talk and address concerns

Blurring of visions in both eyes

Doesn’t use glasses
PMR and is on steroids, well controlled
Has cats, lives alone

GRIPS
HOPI of reduced vision
ODPARA
Both eyes blurring of visions. What do you mean by blurring of vision? Zigzag
legs?
Do yo use glasses? How long? Past 3 months or way longer?
Any oaters? (Toto) any ashing (RD)
Ask about GCA

D/Ds
Cataract
ARMD - unlike at this age
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Vitreous haemorrhage
Ocular toxoplasmosis - gradual
Optic neuritis - acute. On and o f vision loss
Poor vision from glasses

When did you last see the ophthalmologist? When was your vision checked last

Ocular toxoplasmosis:
RF immunocompromised, cats

How long have you been taking steroids?

Examination :
Fundoscopy manikin
Picture:
Typical ocular ndings : Focal retinochoriditis, a nearby retinochoroidal scar and
moderate to severe vitreous in ammation
Reduced vision and oaters
Neurological examination

Reduced bilaterally visual acuity

Fundoscopy

Diagnosis Toxoplasmosis
It is caused by a parasite called toxoplasma gondii
Domestic cats are the main source.
Youre at risk as youre immunocompromised due to your long term intake of
steriods
You might’ve gotten scratched during handling of infected cat faeces or urine
Management
Refer to infectious diseasee specialist
Specialist will do : blood test/serology
MRI - multiple enhanced ring lesions

Treatment is not required in immunocompetent adult

But since youre immunocompromised , the specialist will most likely start you on
Pyrimethamine, sulfadiazine and folinic acid for 4-6 weeks

Hygiene:
Wash hands before handling food
Wash fruits and vegetable
Cook raw meats thoroughly
Avoid cat faces
Wear gloves

Get your cats checked out by veterinary clinic, and I would advice giving up as
they pt you at risk
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Will m yvsiosn imprivr? Yes, with treatment. It may improve

Most likely it stood but specialist will con rm

Ocular herpes Simplex

FY2 in GP surgery
32yr man with eye pain, 2-3days continuous R sided pain, hx of recurrent cold
sores(last episodes was last week), initial pain and tingling and now has rash, took
paracetamol but no relief.
Assess and give initial management plan

What will you do for me?

What caused it?

GRIPS
HOPI- eye pain
SOCRATES

D/Ds
ACAG - headache, vision a ected
herpes zoster - its an activation of latent infection, no previous episodes of cold
sores
Orbital cellulitis - fever, swelling and redness around eye
Keratitis -
Conjunctivitis - purulent discharge
Corneal abrasions - hx of trauma
Scleritis/episcelritis

Pictures suggesting herpes simplex infection

Typical features of ocular herpes simplex infection

⁃ Past history of ocular herpes infection
⁃ History of recurrent or recent cold sores
⁃ Malaise and fever
⁃ eye pain
⁃ Eye irritation or photophobia
⁃ Eye watering - suggestion of keratitis
⁃ Blurred vision - more common with keratitis

Pmaftosa
Ice

Ocular herpes Simplex

Herpes looking Blisters
Redness and swelling around eye
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 Inspection
Visual acuity
Check eye movemtm

Diagnosis
You’ve got Ocular herpes Simplex . You recently had cold sores. What likely
could’ve happened is the you couldve touched your lip sore and then your eye
transferring the infection.
(Within 3 days, give acyclovir)
Refer to eye casualty or emergency eye service for same day assessment
Do not initial drug treatment in primary care will awaiting specialist ophthalmology
assessment. Steroids can sometimes led to dendritic or geographical ulcers if
given to someone improperly.

When you go to the specialist

They’ll take history, ask about your symptoms
Examine your eyes
Take swabs and send for testing and rule out bacterial infection
O er treatment
Warm compresses
Topical or oral acyclovir if presenting within 72 hours

Advice
It can be easily transmitted to other
Avoid touching the lesions where possible
Wash hangs with soap if you touch the area
If the person uses glasses, advise not to use contact lenses until 24 hours after all
the symptoms have resolved.

Complications
Blindness
Corneal scarring
But treatment in time can prevent complications

Scleritis
Scleritis
Fy2 in the GP surgery
44 year old woman presented with right eye pain
Past history of rheumatoid arthritis and on methotrexate 7.5mg once weekly every
Tuesday
Assess and manage the patient

Server eye pain 8/10

Worse in bright light
Prefers being in dim light
Wearing dark glasses
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 Questions
What’s is wrong with me
What you’re going to do for me
Doctor can you dim the lights

GRIPS
HOPI
SOCRATES (eye pain)

Ask about rheumatoid arthritis

What symptoms did she have?
Does he have any symptoms at the moment?
Any joint pain? Wrist pain? Sti ness in the joints?
Is she taking medications probably?

D/D
Episcleritis
Scleritis
Acute angle closure glaucoma
Optic neuritis
Conjunctivitis
Anterior uveitis
Trauma to the eye
Retinal detachment

Episcleritis Scleritis
In ammation of the super cial, In ammation involving the sclera, it is a
episcleral layer of the eye, it is relatively severe ocular in ammation, often with
common, benign and self limiting ocular complications, which nearly
always requires systemic treatment
Acute onset Subacute, or gradual onset
Symptoms are mild Symptoms are severe
Discomfort, grittiness, aching, very Severe pain, worse with eye
rarely marked pain movement, boring pain radiating to the
40% bilateral forehead
50% bilateral
Associated with watering and
photophobia
Visual acuity usually normal Gradual decrease in vision
Most cases have: Very often associated with
1. No identi able cause in ammatory conditions such as
2. Small number associated with rheumatoid arthritis and
systemic in ammatory condition granulomatosis
Usually idiopathic You must assume there is underlying
cause until proven otherwise
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 Appearance:

Episcleritis Scleritis
Episcleral vessels can be moved with Scleral vessels appear darker, follow a
cotton bud. When phenylephrine 10% radial pattern, are immobile and do not
is applied, they blanch blanch. Sclera may take a bluish tinge
Management:

Episcleritis Scleritis
Arti cial tears Arti cial tears if gritty sensation
Topical or oral NSAIDS Oral NSAIDS
If symptoms are severe, short course of If NSAIDS are not e ective, oral
topical steroids/ prednisolone can be used
F/U in 1 week Immunosuppressant drugs like
methotrexate and azathioprine
It is a self limiting condition and
resolves within 1-2 weeks
Investigations:

Episcleritis Scleritis
No investigations FBC
In ammatory markers: CRP, ESR
Rheumatoid screen
Syphilis screen
Urine dipstick for blood and protein
Ultrasound scan of the eye
Plain X-ray of the chest and sacroiliac
joint.

Other history:
PMAFTOSA
ICE
E ect of rheumatoid arthritis (e ects on dressing, holding equipments like knife,
forks, spoon etc)

Social history
How is she coping at home?
Is she independent with everything?

Examination:
Eye examination
Hand examination: normal
Other joints: normal
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 Examination Findings:
Pupil equal and reactive to ligt
Pupil: left 3cm, right 3cm
Vision: left 6/6, right 6/6
Fundoscopy: not possible because patient couldn’t tolerate the light

Scleritis:
It is an in ammation of the sclera. It is a common complication of systemic
in ammatory conditions like rheumatoid arthritis.

Management:
O er NSAID for the pains
Refer to ophthalmologist immediately
Arti cial tears will be o ered by ophthalmologist if she has gritty sensation
Explain that you will also take advice from the specialist rheumatologist

Separation anxiety
FY2 in the GP surgery
8 month old boy
Father has made a telephone call appointment

For the past two weeks, she has not been herself
Seems irritable and clingy
Your wife started work 2 weeks ago
At the moment she is at work
She’s a secretary

“The child is not herself. She is irritable and clingy all the time”
What is wrong with my child?

GRIPS
History of irritability and being clingy:
How long has this been going on?
Does it happen in any particular situation?
Is it all the time or on and o ?
Has it happened before?
Is there anything you feel could be the cause?
Is the child sleeping well?

D/D
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Intussusception
Irritable
Pulling legs towards tummy
Diarrhoea
Red currant jelly stools

Separation anxiety
Who is the usual carer of the child?
Does this usually happen when the mother is away?
Or is it not associated with that?

Baby teething - Has soreness and redness of the gums

Drooling of saliva more than usual
Tantrums
Infections (AOM, pneumonia, UTI, meningitis, URTI, gastroenteritis)
Baby nappy rash

Other history:
PMAFTOSA
ICE
Child eating and drinking well
Up to date with immunisation
Ask if parents are happy with the development

Symptoms of Separation anxiety

Baby being clingy, irritable
Clingy and crying when parent leaves them (their carer)
It usually develops between 3 months -3 years
It is normal part of child development

Diagnosis:
Separation anxiety:
It occurs when the child is away from the carer (the person who usually spends
time with the child). In this case, it’s the mother. Because the mother is away, this
is why the child is behaving like this. It is a sign that your baby now realises how
dependent they are on the carer. It occurs when people closely involved in the care
are away. And they would usually be clingy or cry.

Management:
Usual carer before they leave:
Leaving something comforting before you-favourite toy.
Smile and say goodbye con dently and positively
Tell the child you would be back
Tell the child what you would do when you come back later
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Tell the child, dad, or grandma is here whoever is going to be looking after them

Present carer after the usual carer leaves.

Just reassure the bay
Tell the child the mom/dad is coming soon
Play with the child
Give the child their favourite toy

Baby Teething
FY2 in the GP surgery
Mother has made an appointment
Child has not been well, she is irritable

“My child is irritable”-2 weeks

Has soreness and redness of the gums
Drooling of saliva more than usual
Up to date with immunisations
Child is teething

What is wrong with my child?

GRIPS
HOPI
History of irritability and being clingy:
How long has this been going on?
Does it happen in any particular situation?
Is it all the time or on and o ?
Has it happened before?
Is there anything you feel could be the cause?
Is the child sleeping well?

D/D
Intussusception
Irritable
Pulling legs towards tummy
Diarrhoea
Red currant jelly stools

Separation anxiety
Baby teething
Tantrums
Infections (AOM, pneumonia, UTI, meningitis, URTI, gastroenteritis)
Baby nappy rash

Symptoms of baby teething:

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 Most babies start teething at 6 months of age
Teething symptoms:
Baby not comfortable
Gum is sore and red
Mild temperature of less than 38C
One ushed cheek
Rash on face
Drooling of saliva more than usual
Not sleeping well

Separation anxiety
Baby being clingy, irritable
Clingy and crying when parent leaves them
It usually develops between 3 months -3 years
It is normal part of child development

Temper tantrums
Usually starts at 18months
Very common in toddlers
Hitting and biting are common
Toddlers wants to express themselves but nd it di cult. They get frustrated
By the age of 4 years, the tantrums are less common

Other history:
PMAFTOSA
ICE
Child eating and drinking well
Up to date with immunisation
Ask if parents are happy with the development

Diagnosis: baby teething

This is when the tech starts coming out. It can cause discomfort and pain. The
common symptoms include sore gums, redness, mild fever, and drooling of saliva.
It is common in 6 months of age.

Management:
Give teething rings: it eases discomfort, and helps the baby chew safely
Give the baby healthy things to chew such as fruit or vegetables
Teething gels
Give paracetamol for pain

Care of the baby new teeth:

Visit the dentist

Prevent teething rashes

Since the child is drooling a lot, advice to wipe the face to avoid rashes of the face
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 Comforting a teething baby
Give the child a toy to play
Gently rubbing their gums with a clean nger

O er lea ets

Recurrent infections in a child

You are an FY2 in a GP surgery
Thomas Branson 56 years old, has come to the gp practice worried about his 3
year old child.
Talk tot he father and address the concerns.

“My little Carl is always sick”

Your son has had 6 episodes of infection in the last year.
Symptoms:
Runny nose
Fever
Sneezing
Coughing

Patient’s concerns
Why does he keep having these infections?
What do you think is wrong with him?
Will it a ect him in the future?
Will he grow out of it?
Is my child immunocompromised?
Doctor can you do some investigations for me?
He came 3 weeks back, and some investigations for done.

Approach:
GRIPS
HOPI
What symptoms does the child usually develop?
How frequent does he get these infections?
In the last one year how many time sowed you say he has had an infection>?
How is the child treated when he gets an infection? Do they need antibiotics?

6 common infection
Otitis media
URTI
Meningitis
Pneumonia
UTI
Gastroenteritis
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 Systemic review
Respiratory symptoms:
Ask about cough, SOB, fever, runny nose, sneezing.
How often does this happen?
Any wheezing?
Coughing out phlegm

GIT symptoms
Any tummy pain?
Diarrhoea and vomiting

Biliary disease
Any jaundice

Pancreatic problems
Pale, fatty stools

Genitourinary
Any waterworks infection int he past?

MSK
Any joint pain
Any rashes

CVS
Any palpitations
Any dizziness
Any swelling of the leg
Any heart problems

D/D
Normal situation
Primary immunode ciency
Cystic brosis (meconium ileus)
Any problems opening the bowels after he was born
Any history of constipation
Secondary immunode ciency: HIV, DM
Recurrent infection secondary to medication : steroids

Risk factors:
Family history: anyone in the family who su ers from recurrent infections
Any medical conditions?
Day care attendance: does the child go to nursery or day care?
Smoking adults in the house: is there anyone who smokes in the house?
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 Paediatric history:
Eating and drinking: is he eating and drinking well
Other children:
Do you have any other children, are they having similar problems?

Social skills:
Is the child playing well with others
Are there any other condition?

Development:
Any concerns about the development of the child
Is he walking well
What about his speech
Is he playing with others
What about his smile?

Pregnancy:
Any problems during pregnancy or delivery

Vaccinations:
Is the child up to date with all vaccinations?

Birth:
Any problems during delivery
Did he need oxygen after delivery?

Social history:
Who else is at home with you?
What about his mother?
Where is the mother atm?

Past medical history:

Does the child have any medical conditions?
Any previous surgeries?

Drug history:
Allergies
E ect of symptoms:
How many time does he have to miss school or daycare?

Diagnosis:
This looks like a normal situation. Recurrent infections are common in children,
most children will have 4-8 infections in a. Year. He may just keep getting it from
others, especially those children who go to daycare or school.
Explain if the child has infections of 6 or more, it is important to rule out other
causes, which cause low immune system.
ff
 We are going to arrange a face to face appointment-perform ENT examination
Routine blood tests: FBC, U&E, fasting glucose, LFTs.
Reassure it is normal yet.
Refer to a paediatrician
Explain what a specialist would do some specialist investigation to exclude
immunode ciency condition such as:
Immunological blood tests to rule out immunode ciency syndromes and cystic
brosis.
Sweat test to exclude cystic brosis

If this happens to be an immunode ciency condition, then it is managed by the

multidisciplinary team which includes specialist such as
Paediatrician
Specialist nurses
Specialist physiotherapy
Specialist dietician
Specialist pharmacist
Specialist clinical radiologist
It is unlikely that It it other than normal.

Erythema Nodosum
FY2 in GP surgery
32yr old w rash
Assess and manage
Presented with rash in the knee
First on right knee now has spread to left knee and shins
Red and painful rash
Sometimes she has SOB
No allergies, no medications

Is it contagious?
What caused it?

GRIPS
History of rash

Location?
Colour
How many rash
How does it look like
Is it like a swelling
Increasing in size
Are the margins regular
Bleeding? Painful? Itching?
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D/Ds
Erythema nodosum
Erythema multiform
DVT
cellulitis
Necrotising fasciitis
Drug reaction
Pyoderma gangrenosum
Bruise
Bleeding disorder

Pyoderma gangrenosum
Small
Under pustules that ulcerates
Ulcer enlarged edge
Typically trunk and legs
History of in ammatory bowel disease
Usually starts quite suddenly
Common on lower limbs
Common over the age

Erythema nodosum
Painful
Red
Warm nodules and plaques on the skin
Typically on the shin, knees and ankle
Multiple and symmetrical
Common in female
Common between 15-45
fl
Common causes of erythema nodosum
Idiopathic
Infection (UTI) streptococcal
Sarcoidosis
Pregnancy
Medication
IBD
malignancy

Erythema multiforme
Hypersensitivity reaction usually triggered by infection, most commonly herpes
simplex virus followed by mycoplasma
Red pink, well demarcated
The typical lesion of erythema multiform is targetoid or iris (target lesion)
A target lesion has central dark red zone and lighter outer zone
Lesions can have 2-3 zones
Lesions are common on the distal extremities, esp the hands
Upper limb more commonly a ected than the lowerlimb
Commonly caused by HSV followed by mycoplasma pneumonia
Other causes included drugs eg antibiotics, NSAIDs and sulphonamides. Fungal
infection eg tinea
ff
Erythema multiform major/Steven Johnson
Causes oral lesions
 Meningitis
Purpuric rash
Doesn’t blanch
Systemically unwell(fever, headache, vomtitin)
Hemorrhagic rash
Do tumbler test

ICE
PMAFTOSA
E ect of symptoms

Examination
Observation
Inspection of rash
Joint examination
Systemic examination (joints, respiratory, eyes, GIT)
Chest examination - for sarcoidosis

Irregular shins on knees and shin

Diagnosis
Erythema nodosum
Its an in ammatory disorder of the subcutaneous adipose tissues(tissues under the
skin)
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 Most of the times there could be no obvious causes, something we call as
idiopathic but it could be caused by infection or autoimmune conditions like
sarcoidosis
What we can do is run some tests
Throat swab for streptococcal infection
Urine test for infection
Blood test _ FBC and in ammatory markers ESR, calcium, ACE (high in
sarcoidosis)
CXR to rule out TB. And sarcoidosis
Anti-streptococcal O (ASO) titre
O er patient information lea et
NSAIDS for pain
Best rest with elevation of foot of the bed
Cool compresses
Reassure that most cases are self limiting and require only symptomatic relief but
meanwhile we’ll rule out other causes
Erythema nodosum usually resolves within 6 weeks
If diagnosis is in doubt, biopsy is needed
I’ll have my senior GPs come and have a look at these lesions but its highly
suspected that its erythema nodosum.

Paronychia
Fy2 in the GP surgery
Brandon white aged 25 has presented with some concerns

Pain in his right big toe.

It started 5 days ago when he accidentally hit his big toe against.a desk.
Pain 6/10
Right toe is red and swollen
Paracetamol provided some relief
He has a penicillin allergy, causes a rash.

Concerns:
Why is the pain not going away?
What are you ogling to do for me?

GRIPS
SOCRATES

D/D
Acute gout any swelling, redness, any previous trauma
Cellulitis-redness, fever
Acute paronychia-trauma to nail
Fungal infection-any itching
Insect bite-working in the forest, park
Herpetic whitlow-any blisters at any point in time
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 Typical history of acute paronychia
Pain and tenderness on the nail folds, base of the ngernail and toe nail.
History of trauma to the nail bed 2-5 days earlier

Examination
Inspection -redness, swelling, and visible pus
Palpation-joint movement of the toe

Findings:
Tenderness and swelling of the right big toe
No joint involved
Movement not a ected
If the candidate asks for observation, its normal.

Diagnosis
Its acute paronychia, its an in ammation of the folds of the tissues surrounding the
nail, this has occurred following trauma to the skin surround the nail when you hit
the toe against the wall or desk

Management
Apply moist heat for 10-15 mins, 3-4 times a day
O er a course of antibiotics for 7 days
Flucloxacillin
Clarithromycin if allergic to penicillin
Erythromycin if pregnant
Our patient is in signi cant pain and there are signs of cellulitis (clarithromycin
50mg x BD 7 days)
There is no pus, therefore no need for I & D

Take paracetamol or NSAIDS

Keep the a ected area clean and dry
Avoid further trauma
Trim hangnails to a semi lunar smooth edge
Follow up not needed
O er an information lea et

Safety netting
If infection is getting worse, or any systemic symptoms, you need to come back

Epidermoid cyst (sebaceous cyst)

Fy2 in GP surgery
25yr old lady
Talk to the patient
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 Painless swelling on your right shoulder for a couple of weeks
Firm, round
Sometimes the lump gets into your clothes
Want to remove it because will be getting married soon

GRIPS
HOPI (lump)
How long?
Size?
Mobile
Colour? (Colour of your esh or your skin?)
Pain?
Bleeding?
Increase in size?
Discharge?
Discomfort?
Irritation?
Any previous lesions?
What made you come this time?

D/D
Epidermoid cysts
Lipoma
Neuro bromatosis
Cysts
Benign mole
SCC
BCC
Abscess

Other history
PMAFTOSA
ICE
E ect of symptoms
Summarise the history

Examination
Inspection of lump:
Swelling, with a black punctum (typical of sebaceous cyst)

Diagnosis:
You’ve got what we call epidermoid cyst or sebaceous cyst. They are very
common and they will resolve spontaneously, leaving no mark. But it you use
surgery, even if done very well, it will leave scar.
It is a painless skin lump, rm, round, mobile, whitish or yellow or esh coloured.
Often occur on the face, the scalp, neck and back. If infected becomes red,
in amed and painful.
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 Safety netting:
Red
Hot
In amed
If these are the symptoms, it is probably infected, you need to seek medical
advice, and might need incision and antibiotics.

Management:
No treatment is recommended. The cyst may disappear on its own without leaving
any trace, if it is removed it will leave a scar.

O er lea et.

Folliculitis
18y woman with concerns
I have an embaraasing problem
You dont have to embrassed. We are medical professionals and we’re used to
seeing all types of problems
“I have a rash on my groin”

HX
Any bleeding? pus? Pain? Itching?
When did the rash start?
Has the rash spread anywhere?
Has it happened before?

D/Ds - rashes in groin

Allergic reaction
Contact dermatitis
Post waxing or shaving irritation
STI (herpes infection)

Any new soaps? New lotion? Underwear

Have you thought what could be the causes
ICE
I
Did you do anything unusual a fw days before the rashes started? Anything out of
the ordinary
(Waxing done)
Waxing hx
Any shaving in your groin?
What type of waxing?
What areas did you wax
Is the rash the samepalce where you got waxed
Is this the rst time you’ve waxed?
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 Is there anythign di erent this time ou waxed?
Do you feel like this could be the cause?

Sexual history : Are sexually active

PMAFTOSA
E ect of symotms( can’t walk propels, its itching)

You have super cial folliculitis. It’s in ammation of the hair follicles. it can happen
after waxing and shaving. Advice to avoid scratching
Usually it heals without scarring
Apply warm wet compressed
Avoid tight underwear
Wear cotton underwear
Apply salicylic acid to the waxed area that may prevent this
Lea ets
Topical antiseptic to treat any bacterial infection
Stop waxing for sometime (3 months)

Oral candidiasis
GY2 In GP
8 year old boy brought by his mother
Soreness in his mouth for th last 5 days
He has asthma and uses blue and orange inhaler
Blue-salbutamol
Orange LABA and ICS
Last time child had asthma attack was 6 months ago and that was the last time he
used the blue inhaler
Orange 2 pu s in the morning and 2 in the evening
Doesn’t rinse the mouth after using the inhalers
Doesn’t use a speci c technique

Why did it happen?

Can the child still go to school?

History:
Soreness in the mouth
ODPARA
When did it start?
Is it when the child is eating or all the time?
Better/worse?
Any rashes or ulcers in the mouth?
Swallowing di culties?
Eating and drinking?
Has this happened before or is this the rst time?
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 Have you looked into the mouth of the child, are there any ulcers, patches or
bleeding

Paediatric history:
6 infections
UTI
URTI
AOM
Gastroenteritis
Meningitis
Pneumonia

Dehydration
Is he able to eat and drink
Is he passing urine normally
Do the lips look dry
Is he normally lethargic

P BIND
Any problems during pregnancy or delivery
Is he up to date with all immunisations
Any problems after delivery
After how many days did you go home
Any breathing problems after delivery
Are you happy with how the child is developing so far
Any concerns regarding the development of the child

Examination:

Oral thrush/candidiasis
Its a fungal infection. The likely cause us orange inhaler because it contains
steroids.
When you use inhaler, the particles may stay in mouth and it is important when you
use an inhaler, that you rinse the mouth, to remove those particles. If they stay in
mouth, there’s a risk of developing oral thrush.

Management:
Refer to a paediatrician to review the medication and adjust the dose
Prescribe topical anti fungal treatment for 14 days
O er miconazole gel for oral thrush
Is oral gel unsuitable, o er oral nystatin suspension

Lifestyle advice
Advice on good dental hygiene
This child is suing an inhaled corticosteroid, advise the following: good inhaler
technique.
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 Rinsing the mouth with water (or cleaning the teeth) after inhalation to remove
Andy drug particles.
Advice to use a spacer device to reduce the impaction of particles in the oral
cavity
Stepping down the dose of the ICS when appropriate
O er lea et

Mucosal candidiasis (except genital)

• ▶ BY MOUTH, OR BY INTRAVENOUS INFUSION

• ▶ Child 1 month–11 years: 3–6 mg/kg, dose to be given on

rst day, then 3 mg/kg daily (max. per dose 100 mg) for 7–14 days in
oropharyngeal candidias
• ▶ Child 12–17 years: 50 mg daily for 7–14 days in oropharyngeal
candidiasis

l INDICATIONS AND DOSE

Oral candidiasis
▶ BY MOUTH USING ORAL GEL
▶ Child 2–17 years: 2.5 mL 4 times a day treatment should
be continued for at least 7 days after lesions have healed or symptoms have
cleared, to be administered after meals, retain near oral lesions before
swallowing (dental prostheses and orthodontic appliances should be removed at
night and brushed with gel)

Alopecia
FY2 in GP practice
57, Elena Bedford had kidney transplant 5 months ago
In the last 2-3months, patient noticed his hair is falling o
Is taking medication: tacrolimus

GRIPS
History of hair loss
When did the hair start falling o ?
Is there any speci c part of the head where hair is falling?
How much hair is falling o ?
Has that happened before?
Any particular part of the head where the hair is falling o ?
How much is it? Too much, or little bit?

D/D
Diet and nutrition-have you change your diet recently, do you eat a balanced diet
Tinea capitis- patchy hair loss (is it generalised or speci c areas)
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 Traction alopecia- hair loss secondary to pulling on the roots (periphery)
Ask about family history of hair loss
Stress in life
Medication: what type
Drug induced hair loss
e.g chemotherapy, TCA, allopurinol, B blocker, nitrofurantoin, retinoids

Diagnosis:
Hair loss secondary to Tacrolimus
BNF- check side e ects
Unfortunately its a side e ect of Tacrolimus
You are taking this medication to prevent rejection, organ rejection, so your body
doesn’t reject kidney transplant. So its not something that can be stopped
immediately.

Management:
Refer to the specialist so that they can review the medication
Advice technique to camou age areas of hair loss e.g. by using cosmetic hair
styling
Use a hat to protect hair loss patches from sound damage
O er lea et
Advice on using hair pieces and wigs

Advice not to stop taking the medication because it is very important that she
doesn’t su er organ rejection
Tacrolimus medication is to make sure that the kidney transplant is not rejected by
the body

Psoriasis
FY2 in GP
32yr woman present with rashes
Knees, elbows, rashes for 6 weeks
It doesn’t itch
Normally t and well
Tried cream but the rash didnt respond

Rash hx
When
Where is it? Where was it rs
Did it spread
Tell me about the rash? Red? Scale?
Has it happened before?
Itchy? Bleeding? Pain?
Have you tried anything for it?

Systemic review
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 Respiratory
CVS
MSK, joint
GIT
GU

ICE
Have you thought anything that could eb the cause
PMAFTOSA

Examination
Picture showing rash on knees, scaly

Youve got psoriasis, its a chronic condition a ecting the knees and elbows. It may
cause rashes such as redness, scales, or plaques. It is chronic

Management
There is no cure. The treatment is aimed at controlling the rash
Emollient is aimed at controlling the rash
Steroids for 1-2 weeks
Advice to stop the steroid once the rash has disappeared but continue using the
emollients
F/U in 4 weeks time
O er lea et

Molluscum contagiosum
Fy2in GP surgery
30 year old lady
Phone call appointment

Your child, Alicia, aged 5 had developed a rash in the last one week
Itchy rash on the chest and armpit
Other children in the preschool have got chicken pox
You are 28 weeks pregnant and you are concerned that the rash can a ect your
unborn child

Will the rash a ect the unborn baby

Is it chicken pox?

GRIPS
HOPI
When did the rash appear
Where does the child have the rash now?
Is the rash itchy?
What’s the colour?
Where did the rash start from?
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 How many spots have you noticed?
How would you describe the rash?
What does the rash look like?

D/D
Molluscum contagiosum
Acne vulgaris
Infection causes (fever, cough, running nose)
Urticaria

Typical features:
1-30 individual lesions
Lesions are smooth surfaced, dome shaped, fresh coloured or pearly white papule
with central umbilication
Lesions are usually 2-5mm in diameter
Any part of the body can be a ected but commonly it a ects the trunk and the
exures

Examination
Round, smooth. Depression on top

Risk factors
Close contact with infected persons
Immunocompromised people

Other history
PMAFTOSA
ICE
E ect of symptoms
Travel history

Paediatric history (BIRD)

Birth
Immunisation
Development
Eating and drinking
Pregnancy

Examination:
Inspection
Observations

Diagnosis:
Molluscum contagiosum is a viral skin infection caused by a virus called
molluscum contagiosum

Management:
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 Reassure: it is a self limiting condition
Treatment is usually not required
Spontaneous resolutions occurs within 18 months
Topical treatments such as;
Imiquimod 5% cream
Podophyllotoxin 0.5%
Cryotherapy

General advice
The lesions are contagious and spread by direct contact.
Avoid sharing towels, clothing or beddings.
Exclusion from school is not necessary
O er a lea et
If the child is itching, o er antihistamine to avoid scratching

Questions:
Will it a ect my unborn child?
It does not usually a ect babies born from a ected mother

Lyme disease - Rash on LL

40 yr woman, rash on leg, increasing in size for the past 1 week, went for
woodland walk, fever for 3 days, took PCM and its better

Hx Skin rash

Painful? itchy?
D/Ds :
Cellulitis - fever
DVT - calf swelling, leg pain
Fungal infection - itch
Urticaria

Systemic review - Fever, joint pain

PMAFTOSA - have u been somewhere ?
ICE
e ect of symptoms

Examination
I want to look at a the rash (erythema migraines - typical of Lyme disease)
Vitals

it is an infection caused by a special bacteria borrelia burgerfordii transmitted to

humans following a bite by a infected tic
We’ll refer to infectious diseases specialist
Special investigation of Lyme disease - blood Elisa test to check antibodies
Prescribe oral abx of doxycycline, Doxycycline for 21 days/3 weeks
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 O er lea et

Take baths after returning from tick infested areas

Cover your exposed skin and use insect repellent that protects against ticks
Check your body for repellent

Gastroenteritis Approach
History of diarrhoea
fODPARA
Onset - did it start over hours or several days
Association - any nausea? Any vomiting? Any blood or mucus in stools? Any
fever?

Ddx
IBD
Bloating triggered by stress or certain food
Abdominal pain relieve by defecation
IBS
Chronic diarrhea (over 4 weeks), blood and mucus ii stool, extra intestinal
manifestations (oral ulcers, or perianal signs like stula - dribbling, joint pain,
conjunctivitis)
Colorectal ca
Weight loss, alternating diarrhoea with constipation, family hx
Colic disease
Abdominal bloating related to food
Other autoimmune disease, such as vitiligo, pernicious anaemia, Hypothyroidism,
asthma, hay fever
Hyperthyroidism
Palpitations, tremors, sweating, irregular periods
Food poisoning
Diarrhoea, eating from resturant, frozen food, anyone at home with similar problem
Travellors diarrhoea
Any recent travel history? Eating outside?
Eating fruits without washing?
Medication abuse
Laxative, anti-motility eg loperamide, antiobiotics

Rule out dehydration

Are you able to rake orally
Feeling faint? Feeling drowsy?

Recent food intake

Eating from a resturant?
Eating fruits not washed?
What food was eating?
Anyone else sick?
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 Details of the restaurant:
Where is it located?
What is the name of the restaurant?
Do you know the address?

Diagnosis
Gastroenteritis - not connected to any food contamination
Food poisoning - eating from resturant or contaminated food

Management
Admit if:
-If a patent not able to tolerate oral uid then arrange admission
-Admit if severe dehydration
O er lea et
Encourage oral intake
Advice hygiene
• Don't share towels
• Wash hands frequently
• Don't prepare food for others
• Wash hands after going to the toilet
• Wash toilat seats, ush handles
• Do not share towels
• Do not attend work for 48 hours after the last episode of diarrhoea
Antibiotics - do not routinely prescribe antibiotics
Safety netting - dizziness or severe lethargy

.Doctor, but are they going to close the restaurant?

Explain that they do not always close the restaurant. it may not be their fault that
food or water is contaminated.
There are di erent ways food can be contaminated
It could be due to storage problem.
It may have come already contaminated from where they bought the food.
Sometimes it may be that food is not cooked properly or maybe food was not
stored at right temperature, especially food which needs to be refrigerated.
So the infection control team will visit the restaurant and they will make sure they
get to the bottom of the cause of food poisoning and take measures that it does
not become out of control.

Food poisoning
Notify the local health protection team immediately by completing a form if any of
the following
1. Suspects bacillus cereus
2. Campylobacter spp
3. Clostridium prefringens
4. Haemolytic uraemic syndrome
5. Infectious bloody diarrhea shigella
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6. Enteric fever (typhoid or paratyphoid fever)
7. Cholera
8. Cryptosporidium spp
9. Entantoeba histolytica
10. E.coli
11. Salmonella spp
12. Giardia lamblia
13. Yersinia

Compylobacteriosis
Antibiotics is not need for people with mild symptoms as the infection is usually
self limiting
If symptoms are severe(high fever, bloody diarrhoea, high output diarrhoea) or
immunocompromised : Prescribe clarithymycin 250 500mg twice daily for 5-7 days

Cryptosporiadisis
No treatment needed

Amoebiasis or amoeba dysentery

Drug treatment is usually ecommede for all con rmed cases

E Coli
Abx treatment is not needed

Giardiasis
Tinidazole

Salmonella
Abx treatment is not needed

Shigilosis
Abx treatment is not needed

Food poisoning - campylobacteriosis

FY2 in GP surgery
42 yr old woman
telephone consultation/ F/U case
Came 2 weeks ago with diarrhoea
Was passing stools 8 times a day
Now she’s passing 3-4 times
Had bdominal pain and blood in stool
Remembers eating food from fridge kept for a really long time, after eating she had
diarrhoea and pain
Stool sample was taken and shows campylobacteriosis

Do I need nay treatment?

fi
 I do have the results of your stool sample but I wanna ask you a few questions
regarding the symptoms you had when you got these test done

Ask about diarrhoea

Ddx
Rule out dehydration
PMAFTOSA
E ects of symptoms

Examination (not needed as its a telephone case)

Observation
Abdominal
PR

Stool sample result:

Leukocytes positive
Erythrocyte positive
Campylobacter positive

The cause of diarrhoea is a bacteria/bug called campybacter and you can see that
erythrocyte is positive as you have blood in your stools and leucocyte positive as
you have an infection

You have campylobacteriosis

Continue taking uids
O er lea et about food poisoning
Most likely cause is the food kept in your fridge
Anyone else at home? It can spread to other
So clean toilet and handles after use
Wash hands frequently with warm water and soaps
Do not prepare food for others

Abx not needed as she doesn’t have high output diarrhoea or is

immunocompromised
Will have to notify local health protection team as it has campylobacter as
guidelines suggests it even though it could be a single isolated event

Everything should be improving so there’s no need for treatment

Safety netting, if symptoms get worse come back

Scenario B

FY2 in GP surgery
40 year old woman
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 Bloody diarrhoea for 2 weeks
Passes diarrhoea 4 times a day
She has abdominal cramps which got worse over the last 2 weeks
No change in frequency of diarrhoea

Stool sample was taken 2 weeks ago, and it showed campylobacter jejune
positive, leucocytes positive and erythrocytes positive
She lives w her husband and a 7 year old daughter
She ate in KFC when the diarrhoea started
Able to tolerate uid

Diagnosis: Campylobacteriosis

Management:

Indication of antibiotics:
Severe symptoms
High fever
Bloody stools
>8 stools/day
If immunocompromised
Symptoms are worsening
Diarrhoea has lasted >1 week

Antibiotic of choice: clarithromycin 500mg BD x 7 days

Prevention of spread:
Do not go to work until 48 hours after the last episode of diarrhoea
Do not share towels
Washing hands frequently and toilet seats after use

Rehydration:
Take oral uids
O er lea ets
Safety netting: worsening symptoms

Irregular periods
P4 periods, pills, pregnancy, pap smear
Just few q. about your menstrual periods

Menstrual hx
When was your last period
Are they regular or not
Are your periods heavy? Do you pass any clots?
Are they usually painful
How may days is your menstrual cycle
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 How many days do you bleed

Do you use contraception

When was your last cervical smear
What were the results

At rst age did you rst experience periods

Vasomotor symptoms
Hot ushes? night sweats? Sudden feeling of heat in the upper body (face, neck
and chests) that spread upwards or downwards
Does spicy food and alcohol trigger it

Cognitive impairment or mood disorders

Do you experience..
anxiety
Mood swings
Irritability
Sleep disturbance (does it disturb your sleep?
Low mood

Urogenital symptoms
Vaginal irritation
vaginal discomfort
Are you sexually active?
Do you experience any discomfort or pain during sexual intercourse?
Any pain burning while passing urine
Any increased frequency in urine
Any itchiness or dryness of your vagina
Any recurrent UTI

Altered sexual function

Vaginal dryness from atrophy can lead to dyspareunia
Do you experience any discomfort or pain during sexual intercourse?
Loss of sexual desire and libido
“How would you rate your desire for sex?”
This is due to declining levels of oestrogen and testosterone as ovaries fail

E ects of symptoms
Has hot ushes and night sweats distrupted your less
Mood swings have a ected your private life

Other symptoms
Joint pain, muscle pain, headaches, fatigue

CVS risk assessment

Previous MI, BP, diabetes, IHD, family history of any
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 Osteoporosis risk
Any fractures, hip or wrist
Family hx

Diagnosis
1. Perimenopausal : woman has vasomotor symptoms and irregular periods,
age, less than 12 months of no periods
2. Menopause : no period for 12 months 45-55 years
3. Premature Ovarian failure : LMP >12 months with menopausal symptoms,
less than 40 years

Investigation
Serum FSH
⁃ Aged 45 with atypical symptoms
⁃ Aged 40-45 with menopausal symptoms
⁃ Younger than 40 years with suspected premature ovarian failure

Menopause
49 years of age
LMP 14 months ago
Mood swings and irritability
Arguing with husband and snapping at Children
Does not want medication (when o ered hormonal therapy)

Menstrual hx
PMAFTOSA

It seems like youve reached menopause. It’ll happen between the ages 45-55 yr
and its normal
And the symptoms youre experiencing are because of your failing ovaries and low
hormone levels

I can refer you for counselling for your mood

And since it has a ected your relationship with your husband, would you like to
have couple counselling
For your other symptoms , hot ushes I can o er HRT
(Patient will decline but its okay)
O er lea et about menopause
Usually the symptoms resolve with time.

Perimenopause
LMO 8 months
Mood swings, irritabliity
Snapping at husband and children
Doesn’t want medication
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 Doctor has asked me to come see

Why does he think youre not yourself

What are the things that worry your children?

Menstrual?
Sexual?
Hyperthyroid : Diarreha? Tremors in hands? Sweating? Weight loss?
Youre perimenopausal youre approaching menopausal, which usually happens
45-55 and youre 49 and youre at the age whee one can have but for one to ay they
have meopause, they need to have 12 months of no pause

HRT
Counselling for irritability anxiety
Couple counselling
Lea et on what to expect from menopause

Premature Ovarian failure

23yr old, mother had POF
Lip 5 years ago
Worried about having children
Will ice able to have children

Menstrual
Vasomotor symptoms
D/Ds - hyperthroidism
Pmaftosa
E ects of symptoms
F/U
Blood tests oestrogen low, high FSH
Because oestrogen is low, sh is high to stimulate it
So doctor has to diagnose

You have premature ovarian insu ecnt

Your ovaries have failed earlier than they should
Usually they start failing at the age of 40 but they can do so earlier and that’s
called pOF
And you mentioned your mothers ovaries failed at the age od 40 and it puts you at
risk

It would be di cult to have children on your own. You can a donor egg from
somebody and that’s one way of doing it. Your own ovaries aren’t producing eggs

Refer to specialist (gynaecologist) for management of her condition and symptoms

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Investigations: Bloods (FBC, LFT, TFT, RBS) + Hormonal assay (FSH only) to
check if the levels are high.

Refer to specialist to reassess you and give appropriate info to menopausal

woman and what career and family can do. Can explain the stages of menopause
and its common symptoms.

Treatment:
hormonal replacement therapy (tablets, skin patches, implants to relieve
menopausal symptoms by replacing estrogen)
Non-hormonal treatment like anti-depressants for your mood + non-
pharmacological like CBT and relaxation technique

Advice: NHS breast screening program which is o ered every 3y to woman aged
50y or above
Cervical screening program which is o ered to every woman older than 25y every
3y up to women aged 49y and every 5y up to >65y
Contraception method because women are considered fertile 2y after the rst
episode of missed period
Follow up with your GP to avoid bone weakness and fractures
Life style: Hot ushes and night sweats: regular exercise + weight loss + wear
light clothes + avoid co ee, alcohol, smoking
Sleep disturbance: avoid exercise late + maintain regular bed time.
Mood and anxiety: Yoga, CBT, Psychiatrist
Vaginal dryness: lubricant can help
NB/ vasomotor symptom: in a woman: with uterus (oral or transdermal
combination HRT (estradiol and progesterone), without uterus (estrogen only pill),
Premature menopause (steroids + COCP)
NB/ in this station the patient doesn’t want hormones: o er her non-
pharmacological + non-hormonal

Breast engorgement
FY2 in the GP surgery
30 year old lady has presented w concerns
She had a baby 5 weeks ago
For the past 2 weeks she has had pain and swelling around the nipple of the right
breast
Her whole breast feels slightly bigger than the other breast.
The pain is around the nipple.
It is worse when breastfeeding
No fever, discharge, or previous breast problems
The baby is not latching on well to the breast
She feeds the baby on demand
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 History of breast/nipple pain
Where do you have pain? Super cial or deep?
Is the pain generalised all of the breast?
Is it in both breasts?
What type of pain? Dull ache, sharp?
When did you start experiencing the pain?
Is the pain constant or intermittent?
Anything that make sit worse?
Anything that makes it better?
How old is your baby?
What have you tried so far for the pain? Previous treatment (analgesia, topical or
oral)

Maternity history:
Any problems?
Pregnancy?
Delivery?
After delivery?
Previous breast surgery?

Infant history
How old is your baby?
How many weeks was the baby when the baby was born?
Any injuries during delivery?
Is the baby gaining weight well?
Is the baby sucking and swallowing well?
Any vomiting after feed?
Do you have concerns about how the baby is breast feeding?
The pattern of breast feeding? How frequently do you breast feed, do you breast
feed on demand?
Does the baby breastfeed from one or both breasts? Does he breastfeed from the
a ected breast?
Do you breastfeed at night?

Any breast or nipple pain before the pregnancy?

Milk supply issues
Engorgement: painful and enlarged breast
Low supply: do you feel you aren’t producing milk enough?
Oversupply: do you feel you are producing too much milk than what the baby
needs?

Expressing milk:
Do you ever express milk?
If yes, how frequently?
Is it by hand or by the pump?
Does that help with the pain?
How much milk does she express
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Other than breastfeeding, do you give the baby other milk?
Any previous breastfeeding
Do you have any other children?
Did you have any problems with breastfeeding with other children?

D/D
Cyclical mastalgia
Breast engorgement
Breast abscess
Eczema (itchy, scaly, red, dry, bilateral)
Mastitis
Breast cancer
Trauma
Nipple infection (purulent discharge, redness, and ssuring)
Blocked duct
Nipple damage

Mastitis:
Painful breast
Fever
Generalised malaise
Tender, swollen, red and hard areas of the breast

Cyclical mastalgia:
Associated with menstrual periods
Pain is not continuous
Usually B/L

Blocked duct:
Associated with small white yellow or clear spots at the end of the nipple
Localised, tender cord of the breast tissues which is relieved by expressing the
milk
Small tender lump in the breast
Overlying skin erythema

Nipple damage:
Nipple pain at the start of breast feeding
Fissuring
Flattening of the nipple

Breast abscess:
Localised swelling
Purulent discharge
Fever
Redness
Warm to touch
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 Breast engorgement
Painful at the start of few days after birth but it can occur later
Often B/L
Worse before feeding
The whole breast is swollen and tender
Nipple is stretched and looks at
Infant attachment may be di cult due to breast fullness and milk ow may be
reduced
The infant may cough and pull o the breast on feeding or clamp down on the
nipple during feeding to control ow

Other history
PMAFTOSA
ICE
EFFECT OF SYMPTOMS
Summarise

Examination ndings:
Observation normal
Breast examination:
Tenderness and swelling around the areola
No redoes, discharge, ssures
No lymphadenopathy

Diagnosis; most likely its a breast engorgement.

This is when the breast becomes overly full with milk. The breast may feel hard,
tight, and painful. When the breast is engorged it may become di cult for the baby
to latch on to the breast. The nipple can become overstretched and attened.

Management:
Simple analgesia (paracetamol, ibuprofen)
A little express of milk may relief the pain
Excessive expression of milk may lead to overproduction of milk supply.
Expressing of little milk before breastfeeding to soften the areola
Use heat packs, before breast feeding or expression may stimulate milk let-down.
Wearing a well tted bra and loose wearing that doesn’t restrict breastfeeding
Continuing breast feeding the baby in demand
O er a lea et and website where you get more information like the NHS website
Advice to see the health visitor or the breastfeeding specialist

How to latch the baby to the breast:

Hold the baby close to you with their nose level with the nipple
Let the baby’s head tilt backwards
Baby’s mouth should be wide and mouthful of breast
Baby’s chin touching the breast and nose not squashed to the breast
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 Seeing more of the dark skin around the nipple or areola above the baby’s upper
lip

Baby’s positioning during breast feeding

Baby’s head and body should be in straight line
Hold the bay close to you facing your breast
Support the baby’s head, the body and the back
You should sit comfortably yourself and avoid leaning forward towards the baby
Always bring the baby to the breast and let the baby letch themselves

PCOS
First presentation

FY2 in GP surgery
A 30 year old has presented.
Her BMI is 32
Amenorrhoea 6 months ago
Gained 3 kgs in last 1 month
Has acne but it has been treated with the cream she bought from the pharmacy
No other symptoms

Will I be able to have children?

GRIPS
HOPI (weight gain)

D/D
Obesity
PCOS
DM
Acromegaly
Hypothyroidism
Medications: steroids

Other history:
PMAFTOSA
ICE
E ects
Summarise

Systemic examination:
Abdominal
Respiratory
Head to toe

Common Symptoms PCOS:

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 Weight gain
Irregular periods
Acne
Hirsutism
Spots on face
Infertility

Complications:
DM

Suspected PCOS:
Condition in which you develop cysts in the ovaries and the cysts a ects the way
the ovaries function, causing irregular periods, acne, excessive hair growth on the
face.

Management:
To con rm the diagnosis:
Blood test to check her hormones: FSH, LH, oestrogen levels
Lose weight
Most of the symptoms can be controlled with weight loss
Refer to a dietician
Advice exercise
Advice weight loss and healthy diet
For amenorrhea o er cyclical progesterone (medroxyprogesterone)
O er lea et

Post abortion infection

FY2 in antenatal clinic
Elena, 30yr, routine review
She had medication for termination of pregnancy a week ago
USA shows products of conception in uterus

Talk and address concerns

At 8weeks, unplanned pregnancy

Got a termination
Now has fever, abdominal pain and brownish vaginal discharge
Was given mifepristone, followed by misoprostol

Concerns,
What happens next
What did use show

GRIPS
Explain USG
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Unfortunately it shows that there are still tissues of conception in your womb.
When this happened there is a risk of infection so we need treatment to remove
tissues of conception. Ideally it should’ve been removed from the medical
termination

How many weeks was your pregnancy

Is there any particular Eason you could not keep the pregnancy
When was the termination
Was it medical or surgical
What medications were you given
Have you passed any tissues

Risk of infection
Do you have screening for infection before the procedure
Were you given antibiotics as prophylaxis
Did you use any tampons
Have you been diagnosed with diabetes mellitus

Ask signs of infection

Increased bleeding
Foul smelling discharge
Fever
Worsening abdominal pain
Feeling hot
Sivering or shaking
Vomiting

Infection
Temp above 37.5C
Localised or general abdominal tenderness, guarding or rebound
Unusual , unpleasant odour or pus visible in the cervical os
Uterine tenderness

Sepsis
Hypotension
Tachycardia
Increases respiratory rate

General Health
FMAM
Sexual
Have you come alone

Examination
Observation
Abdminal : lower abdominal pain
Per vaginal : os open
 Temperature 38.1, Rr normal, bp normal, pulse 98/min, spO2 normal

Diagnosis
You have an infection of the womb called endometirits, and it’s common following
termination of pregnancy. About 1 in 10 develop this infection. In your case not all
tissues of conception have been compelled. Which increases the risk

Transfer to hospital via ambulance

This infection can get worse and develop into sepsis
At the hospital, they’ll take some blood test
FBS, U&E, LFT, RFT, CRP, glucose
Serum lactat
Urine culture and MSU
Urine output moinotiring
Take swab from the vagina and womb
IV abx (borad spectrum)
IV uids
Perform evacuation of the retained products of conception
Close monitoring

Low lying placenta

FY2 in antenatal clinic
Emma brown, aged 29, has come for a regular check up

She is 20 weeks pregnant. A TVUSS shows placenta age less than 20mm from the
cervix.
Talk to the patient and address concerns.

This is her 1st pregnant. Normally t and not on regular medication.

GRIPS

History then explain results.

History of current pregnancy:
How many weeks?
Any problems in the current pregnancy such as high BP, abdominal pain, bleeding,
vomiting.
Do you have any medical condition, like DM or BP.

Risk factors:
Any previous history of placenta prevue?
Any previous CS?
Smoking?
Use of recreational drugs?
Any previous abortions?
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Any assisted conception?
How did you conceive, was it natural by sexual intercourse or was it assisted?
Any operation of your womb before?

Ask about prevue symptoms.

Any bleeding?
Any pain?

PMAFTOSA
Summarise the history

So USG scan shows that the placenta, the place where the baby sits, is closer to
the cervical os, position from where the baby comes out, its a bit lower. Generally it
lies 20mm above. But in your case it is 20mm below. I must say, that this is
common. About 9/10 women with a low lying placenta, at 20 weeks gestation, by
the time you reach 32 weeks pregnant, the placenta will move up. So as of now
there’s nothing to be worried about.

We will arrange a follow up TVS at 32 weeks to diagnose low lying placenta. If the
placenta has not moved up, you could be o ered another scan at 36 weeks to
check again if the placenta has moved up. Because sometimes it takes longer.
The USG is important because it helps plan a safer delivery. You can have a normal
delivery, because most of the time, the placenta moves up, so g the placenta
moves up, 20mm above the cervical os. But if the placenta remains below at 36
weeks, the doctors may suggest a CS.

Safety netting
Any bleeding
Any pain
Vaginal spotting
Any contractions

Contact the hospital.

It is a good practice to avoid sexual intercourse as placenta is lying low, to avoid
bleeding.

Is everything okay?
Yes everything is okay, the baby is doing okay.

For now its early to say. You do not need to have a CS rn, so as long as the
placenta moves up, you’ll be able to have a normal vaginal delivery.

Placenta Previa
3o yr, 36 weeks pregnant
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26, 30 and 32 shows placenta covering os
Its still covering os

Low lying - more than 20cm away from os

Placent previa - within 20 cm at 36 weeks

What does the USG show

How is C-section done
Any complications of c section
Can I have normal vaginal in the next pregnancy

Describe the USG rst

So the placenta is covering the internal cervical os, the beginning of the birth
canal.its the opening where the baby comes out. So it’s di cult for the baby to
come out without causing massive haemorrhage.
It’s less than 20 cm away from the os and At 36s week if it placental is still
covering the os, its called placenta previa
Explain again.

I just need to ask you a few question

Did yo plan the mode of delivery before this

Is this your rst pregnancy
Any previous operation on your womb (assess for reason of placenta)
Any pain or bleeding

Management
You’ll need c section as ive explained before the os disc covered by the placenta
and the baby needs to come out of the os but now there’s a high risk of bleeding
or haemorrhage putting you and the baby at risk

C section
A 10 cm incision is made above the bikini line and it’ll leave a scar
And its s safe procedure and its recommend mode of delivery in this type of
pregnancy.
Risks
Wound infection of incision site
Blood clot in legs and lungs
Heart attack
Damage to surrounding structure (nerves, blood vessels, ureter)
The risk of developing these complications are low

Having a placenta prevue in one pregnancy puts you at risk of having it in the next
pregnancy
Because you have a c-section, this will also increase the risk of placenta previa
There is a chance that in your next pregnancy you can have a vaginal delivery if
you wish to try, the option is there
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Safety meeting
If your experience any pain or bleeding per vagina, seek medical help

Sexual intercourse can precipitate bleeding

Menorrhagia
Fy2 in Gp surgery
30 year old woman complains about lower abdominal pain during menstrual period

Opening sentence “Dr. I have got heavy menstrual periods”

HMP for the last 6 months
Period regular, acting 7-8 days
Uses 8-10 pads a day
Periods are not really painful, only mild discomfort
Last menstrual period was 5 days ago
28 day menstrual cycle

No IMB, no PCB
Last cervical smear was 5 years ago and it was normal
Sexually active and uses condoms
What are you going to do for me?
Why is this happening?

Set up
Pelvic manikin
Speculum
Hand gel
Gloves
Lamp

Approach
GRIPS

Menstrual history:
Regularity
Duration
Days of the circle
Heavy bleeding?
Passing clots?
Painful?
LMP?
Inter-menstrual bleed?

Cervical screening
When was the last cervical smear?
Is there any particular reason why you didn’t come for your last cervical smear
What was the result of your last cervical smear?

Sexual history:
Are you sexually active?
Post coital bleeding?
Married?
Contraception?
Use of IUCD?

Pregnancies and children

Any previous pregnancies?
Any children?

Previous treatment:
Is this the rst time you’re seeking medical attention
Have you tried any medications?

D/D

Hypothyroidism
Weight gain
Cold intolerance
Constipation

Coagulation disorders:
Does anyone in your family have any bleeding disorders?

Fibroid:
Anyone in your family has ever been diagnosed with broids?

Endometrial polyps
Endometriosis
Infertility?
Has she been pregnant before, has she tried?

PID
Any chronic lower abdominal pain?
Any previous STIs?

IUCD
HMP, dysmenorrhea

PKD

Fibroid
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 Pelvic pain?
Abdominal pain or discomfort?
Bloating?
Back pain?
Urinary symptoms?(Frequency, urgency, incontinence, retention)
Bowel symptoms? (Bloating, constipation, painful defecation)
Sub fertility or infertility?
Pressure symptoms (lower abdominal discomfort, heaviness)
Family history

Rule our cervical cancer

Inter-menstrual bleed
Post coital bleed
Systemic review

Anemia history:
Palpitations
Lightheadedness
Dizziness

PMAFTOSA
ICE
E ect of symptoms

Examination
BMI -normal
Bimanual/per vaginal examination
Speculum examination -clot or reddish cervical os
Abdominal examination -normal

Diagnosis:
You have got menorrhagia which simply means HMP. There are several causes of
HMP, including things such as broids, which is a benign tumour of the uterus. So
what we need to do is perform investigations to get to the bottom of this.
FBC, clotting screen, TFT, ultrasound scan

Treatment
If everything comes back normal, then without any structural abnormalities of the
uterus, we can o er mirena coil for heavy menstrual periods
Arrange cervical smear
O er lea et about menorrhagia

Uterine broid
FY2 in GP surgery
40 year old woman, video call
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 Had presented with menorrhagia
USG showed two broids 17cm, anteriorly and 14cm on lateral posterior part of
the uterus
FBC normal
2 weeks ago presented with HMP (had this for the past 4 years)
Periods last for 6-7 days and pass clots
No children

What are you going o do for me?

Is it a must to have a surgery?

GRIPS
I understand you had an USG scan 2 weeks ago, can I ask you some questions
about your health and symptoms and then we will go through the rusts of the scan.
Is that ok?

History taking:
Can I ask is there any particular reason why you had this scan?
Menstrual history:
How many days do you bleed?
Regular?
Heavy?
Do you pass clots?
Painful?

Ask about pregnancies and children

Symptoms fo broids:
Pelvic pain?
Abdominal pain and discomfort
Bloating?
Back pain?
Urinary symptoms:
Frequency
Urgency
Urinary retention
Bowel symptoms (bloating, constipation, painful defecation)
Sub fertility or infertility (do you have any children, have you ever been pregnant,
have you ever tried to be pregnant)
Pressure symptoms (lower abdominal discomfort, heaviness)

Other history
PMAFTOSA
ICE
E ect of symptoms
Screening for cervical cancer
Family history of broid
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 Examination:
Abdominal and pelvic examination

Explain the results:

You have got broids, in particular, 2 broids, they are quite big, 17cm and 14cm.
Fibril is a benign tumour which is caused by proliferation or overgrowth of smooth
muscle cells and broblasts of the uterus, which forms a hard round tumours, in
the myometrium or the muscles of the uterus.
They can be single, or multiple and sizes can vary from few mm to 30cm or larger
Typically broid develop in women of reproductive age.

Management:
Referral to gynaecologist (indicated if broid measuring 3cm or more)
O er lea et
Treatment is only if symptomatic
Explain what the specialist would do
There are many treatment options.

NSAID e.g ibuprofen: they reduce menstrual blood loss

Anti brinolytic agents (e.g. tranexamic acid) may also reduce menorrhagia
Combined hormonal contraception: if patient requires contraception, but mirena
is more e ecting as long as there is no distortion of the structure of uterus

Levonorgestrel releasing IUS

Is e ective at reducing blood loss

GnRH agonist
Produce reduction in the size of broid
But once it is stopped, the broid regrows

Surgical management:
Fibroid is submucosal growth and fertility is reduced.
Excessively enlarged uterine size
Medical treatment is not su cient to control the symptoms
Pressure symptoms are present (low abdominal discomfort and heaviness)

Surgical:
Interventional radiology procedures: uterine artery embolisation (o ered if a
woman who does not want surgery)
Surgical options:
Myomectomy (removal of the broid)
Hysterectomy (removal of the womb)

Not very keen for operation: needs to be explained medical treatment

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She wants to keep her uterus so uterine artery embolisation and myomectomy
options should be explained
Has menorrhagia: medical treatment needs to be explained

Refer to the gynaecologist they will go through the options and explain more
details about the advantages and disadvantaged. They might need to do a biopsy
in order to con rm that cytological it is broid not any other tumor.

Post coital bleed

FY2 in gp
65 year old woman
Episode of vaginal spotting after sexual intercourse
Has not had intercourse fr the last 5 years, husband passed away 4 years ago
Recently she met a new boyfriend, been together for the past 5 months, and
following that, she had vaginal bleeding
Last cervical smear 1 year ago and was normal
Hypertension-amlodipine

GRIPS

History of bleeding
When did it happen?
Has it happened before?
What is the colour for he bleeding?

D/D
Vaginal atrophy
Endometrial carcinoma
Cervical cancer
Vaginal cancer
STI
Cervical polyps

Features of vaginal atrophy:

Dryness of the vagina
Dyspareunia
Post-coital bleed
Urinary symptoms-frequency, nocturia, dysuria, recurrent UTI, stress incontinence
Desire for sexual intercourse
Decreased arousal, orgasm

Examination ndings of vaginal atrophy:

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 Thin mucosa with di use erythema
Petechia or ecchymoses
Dryness
Lack of vaginal folds

History of menopausal symptoms

Hot ushes
Night sweats
Depressive

Other history:
PMAFTOSA
ICE
E ect of symptoms

Cervical smear
Last cervical smear
Family history of cervical cancer (sorry to ask, but can I just ask)
Previous STI

Endometrial cancer
LMP
Use of HRT
Family history
Tamoxifen use
Urinary symptoms
Discharge
Dysuria
Lower abdominal pain
Fever

Systemic review
Respiratory system
GIT
MSK

Examination:
PV examination
Abdominal examination
Speculum examination

Examination ndings:
Erythema
Petechiae
Vaginal dryness
Cervix is normal
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 Diagnosis: Atrophic Vaginitis
It is a common postmenopausal, due to the falling of oestrogen levels.
We need to test for STI, as sometimes post-coital bleed can come as result of STI
-new partner
Use lubricant-it can improve dryness during intercourse
Moisturisers: apply three times a day
Topical estrogen (hormone)
Most people experience relieve of symptoms after about 3 weeks of using vaginal
oestrogen
O er lea et

Do not make a referral.

Vulvar lesion / Vulvar Carcinoma

Fy2 in GP surgery
72 year old lady presents with concerns

Has come in with an embarrassing problem

“I have a lump down there”
Has notice the lump for the past 2 months, on the outer lip, cases little bit of
discomfort, sometimes bleed.
Has lost a little bit of weight, hasn’t checked, but clothes are loose.
Has lichen sclerosis around your genital. On treatment with topical steroid. Not
worried about it.
Being managed by the dermatologist.
Husband died 10 years ago and not sexually active
Never diagnosed with any STI
Smoke 20 cigarettes for a long period of time

GRIPS
HOPI (lump)
Where is the lump?
Noticed it when?
Size?
Bleeding?
Itching?
Pain?
Discomfort?
Is this the rst time?
Colour?
Discharge?

D/D
Lichen sclerosis (white shiny lesions, itching)
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 Dermatitis (itching)
Fungal infection (whitish lesion)
Bartholin cyst or abscess (redness, fever, painful)
Genital herpes

Lichen sclerosis
Usually It is con ned to the vulva.
Lesions are usually white, thickened.
It causes itching, usually worse at night.
Perianal lesions are common and may cause constipation. It has a gradual onset.

Vulvar cancer:
Risk factors: lichen sclerosis
HPV infection
Paget’s disease of the vulva (adenocarcinoma in situ)
Gradual onset

Bartholin cysts or abscess

Bartholin glands are a pair
About the size of a pea
Situated at 4 o’clock and 8 o’clock.
Usually not palpable
Onset of an abscess is rapid over hours or days
Initially there’s a swelling
Swelling can be very painful
If cyst or abscess bursts spontaneously, there is sudden relief of pain

Other history
PMAFTOSA
ICE
E ect of symptoms

Examination:
Inspection of the genital area

Suspected vulvar cancer

Unfortunately, I’m a little bit concerned about your lump. The reason I’m
concerned is that you have lichen sclerosis, unfortunately its a risk factor to
develop serious conditions, such as cancer. You also smoked for a long period of
time, so I’m concerned with the way it is looking, because of the smoking, and the
condition you have, sometimes this can put you at a risk of developing serious
condition, such as cancer. I am concerned this could be cancer of the vulva. You
also mentioned, that you lost some weight, and this particular swelling sometimes
bleeds, so these are all concerning symptoms.

Management:
Urgent referral to the gynaecologist
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 They will ask questions about your lump and symptoms
They will examine you, and also perform some investigations such a biopsy of the
lesion and other investigations like CXR, proctoscopy, MRI scan/CT scan,
cystoscopy to assess other areas. They are going to o er treatment such as
surgery.
Advice that they can take a friend or family member to the appointment.

Safety netting:
If not received an appointment within 2 weeks, come back.

Questions:
Do you think it is the steroid cream, should I stop it?
This is not because of the steroid cream so you don’t have to stop it. Lichen
sclerosis is a risk factor.

Anal ssure in pregnancy

FY2 in GP surgery
Samantha Adam, aged 30 has presented with bleeding
24 weeks pregnant
Talk to the patient and address her concerns

The bleeding is from her back passage. It is worse when she is opening her
bowels.
The bleeding has been there for about 1 month, intermittent, it appears as a fresh
red blood, she reports pain in her bottom, pain and bleeding when opening the
bowels. She was diagnosed with haemorrhoids for which she is using lignocaine.
She also complains of constipation. She is 24 weeks pregnant, attends regular
antenatal follow up.

GRIPS

HOPI
When did the bleeding start?
When do you experience bleeding?
Is it dark red or bright red?
Any dark stools?
Has this happened before?
How much blood do you experience?

D/D
Anal ssure
Pain? What type? Severe sharp/tearing sensation while passing stools
Bleeding that occurs with defecation, bright red
Triggers-constipation, pregnancy, previous trauma to anorectal area
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Examination:
Acute anal ssure 6 weeks has super cial well demarcated edges.
Chronic anal ssure >6 weeks, wider, deeper and often with skin tags.

Haemorrhoids
Has she ever been diagnosed before?
Bright red, painless bleeding, typically occurs with defecation
Seen as streaks of blood on the toilet paper
Anal itching or irritation
Feeling of incomplete evacuation or bowel movement
Rectal discharge

Anal or colorectal cancer

Weight loss
Family history
Alternating bowel habits (diarrhoea and constipation)

Anorectal stula
Anorectal discharge
Itching
Bleeding
Pain
Presence of external opening and treat or cord may be palpable
Intermittent swelling

Perianal abscess
Perianal pain, swelling, fever, marked tenderness
Redness, fullness
Diverticulitis
Profuse per rectal bleed
LIF pain
Fever
History of diverticulosis

IBD
Abdominal pain
Chronic diarrhoea
Per rectal bleed (UC)
Perianal skin tag

PMAFTOSA
ICE
EFFECT OF SYMPTOMS
SUMMARISE

Examination:
Inspection of peri anal area
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 PR examination
Abdominal examination
Observations

Findings:
Observations: normal
Inspection: cracks around the anus and peri anal skin tags
PR declined due to pain

Diagnosis:
You most likely have what we call anal ssure. It simply means a tear around the
anus. It can either be acute or chronic. She is likely to have chronic, due to
presence of skin tags and the duration of 6 weeks or more. Constipation is
common in pregnancy. I can se you have a history of haemorrhoids and
constipation causes both. This could most likely be due to constipation, which is
making her pass hard stools, which is causing tear around the anus.

Management:
The key is to manage constipation
That would stop straining
You don’t have to pass hard stools
And would prevent further tears from happening and allows the existing tears to
heal

Treatment of constipation:
Drink plenty of uids
Eat high bre diet
Exercise regularly
Ask if she tried to change her diet and lifestyle, if yes, do you think it helped?
If they have tried and no relief, o er medications (laxative)
Lignocaine can also help to reduce the pain for anal ssure

You mentioned about constipation. How many times do you open the bowels in a
week. Can you describe the type of stools you pass?
Are they like
Separate hard lumps, like nuts
Or sausage shaped lumps
How would you describe your stools

Advice about peri anal hygiene

Keep perianal area clean and dry. It encourages healing

Pain
O er simple analgesia (paracetamol)
Can try to sit in a shallow warm bath several times a day, this may relieve pain
Note:
Advice not to use lidocaine ointment because there is a risk to a ect the baby
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 Advice to use paracetamol but not NSAIDS in pregnancy for pain

Follow up
6 weeks

O er lea ets about anal ssure and haemorrhoids

Genital warts in a 15 year old

FY2 in GP surgery
Sandra, aged 15 has made an appointment to see you
You have come with swellings on your private area-1 week ago
You’re not practicing safe sex, you don’t use condoms
Your partner is 33 years of age
It is a consensual sexual relationship
You have been with your partner for 6 months
You just want to sort the swelling on your private part

GRIPS
HOPI
When did you notice the swelling
What does the swelling look like?
How many swellings have you noticed?
How big are the swellings?
What’s the colour?

Associated:
Bleeding?
Itchy?
Pain?
Dysuria?
Frequency of micturition?

Sexual history:
Sexually active?
Are you in a stable relationship?
Is your partner male or female?
Do you guys practice safe sex?
How old is your partner?
How did you meet?
How long have you been together?
What kind of sexual intercourse do you normally practice, oral, anal, or vaginal
sex?

Abusive relationship
How are things with your partner?
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 Has your partner ever forced you to have sexual intercourse?
Has he ever been abusive to you in any way? Verbally, physically , or emotionally?

Raise your concerns:

Your partner seem to be much older than you? How did you meet?
Do you feel comfortable in your relationship?
Do you ever get concerned that he might be far older than you?
Do you ever worry that the relationship could be wrong because of your partner’s
age?
Parents:
Do your parents know about your relationship?
Do they know that you’re sexually active?
Is there any particular reason why you have not told your parents?
Do you ever worry how your parents are going to react if they found out about your
relationship?

D/D
PMAFTOSA
ICE
E ects of symptoms

Examination:
I will have a look at your private area, also to perform a speculum examination just
to have a look inside your vagina to see if you have got any other swellings inside
your vagina. I will look in your mouth, oral examination is important.

Findings: warts.

Genital warts:
A common way of transmission is sexual intercourse, they are benign lesions and
they do not cause any symptoms. It spreads via direct skin to skin contact.
Management:
I will refer you to GUM clinic, where she can be tested for STIs.
Ask if she’s comfortable, if she’s not comfortable we can test her and manage her
at the GP.

Treatment:
O er no treatments: explain that in 30% of people warts may disappear
spontaneously within 6 months.
O er: topical solution or cream that can be applied to warts: podophyllotoxin

Ablation methods:
Cryotherapy
Excision
Electrocautery
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But best in this case is topical creams.
(Give information when asked, e.g when they ask what cream, give them name)

Podophyllotoxin application:
Twice a day for 3 consecutive days
Then 4 days no application
Repeat up to maximum of four 3-day courses
Follow up in 4-5 weeks

Advice to use condoms, and that the partner needs to be tested for STI and
screened for genital warts.

Address the sexual abuse issues

There is a big age di erence between yourself and your partner. And he is also
your teacher which means he has authority over you. Your partner holds a position
of trust (such as teacher, sports coach, minister of religion)

Explain why its not a right relationship

Because of the age of your partner, you being under 16 and your partner holding a
position of trust.
The relationship you are is not legal

Further:
Second opinion from seniors, they may want to speak to her as well
As a medical professional, you’ll have to inform the social services and the local
authority

Erectile Dysfunction
I have an embarrassing problem

Black blah we re professional, were used to seeing patients with di erent problems
….Despite all the your problems will be kept con dential between the medical
team

What brought you to the hospital

You need to clarify what od you mean by you can’t perform down there

Severity of Erection
Assess if he has problems getting an erection or sustaining it
1. How would you rate your desire for sex on a scale 1 to 5, 1 being the lowest
2. How often do you get an erection when you want tot have sex?
3. How often do you get hard enough to penetrate your partner?
4. How often you manage to sustain an erection?
5. Do yo get morning erection?
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 Sexual orientation
Is your partner male or female
Do you experience pre mature ejaculatins
Is this the rst time you are experiencing this problem?

Past and current relation

How long have you been in your current relationship
Did you have similar problems in your past relationships

Causes of erectile dysfunction

1. Psychological causes
Any recent changes in relationship
Sudden onset
Decreased libido
Good quality spontaneous or self sustained erection
Major life events or stress?
2. Medical condition
HTN? dM? IHD? BPH
3. Lifestyle
Too much Alcohol, smoking, recreational drugs
4. Medication
Beta blocker, antidepressants

Examination
BMI
examine genitalia
DRE

Investigations
Hba1c
Lipid pro le
Morning testosterone
Routine investigations

Scenario A :
erectile dysfunction due to beta blocker (bisoprolol) for high BP
FY2 in GP
A ecting his relationship
Gay, partner also male

ICE
Im worried about my relationship

Management
Stop the beta blocker, start ACEi or Calcium channel)
Ace if less than 55 or have DM
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 CCB if 55 or more
F/U in 2 weeks time (to check U&E if ACEi were prescribed)
O er viagra
O er couple counselling

Scenario B :
Erectile dysfunction in IHD, HF
FY2 in GP
Referred to cardiologist for heart problem, shared beta blocker(bisoprolol)
Developed erectile dysfunction and raynauds phenomenan
“I want to stop taking this medication:
Doesn’t reveal the problem unless asked directly

HF, you’ll think end of life but it’ll be a young patient so its sometime else

What medication are you on?

Any sob? Or wheezing?
Your pain in ngers is a side e ect of beta blockers, but it can cause other
problems

Hx

Management
Investigations
Talk to cardiologist before stopping bisoprolol so ask for other medication the
patient can be started on
O er viagra (if you use Gtn, don’t use viagra and vice versa)

Scenario C
No obvious cause of erectile dysfunction

Same history
ICE
E ects

Examination for prostate

Management
O er viagra
Investigations
O er lea et
F/u in 6-8 weeks
Refer for couple therapy if cause is psychological

Parkinson’s disease
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 FY2 in gP surgery
65 year old man
“Doctor, I have problems starting to walk”
But once I start walking, I am okay.
Have di culty holding on to the chair to stand up from the chair

You have tremors in the right hand especially the thumb

Started 3-4 months ago
Father had Parkinson’s and passed away 10 years ago
Main problem: initiating to walk

Why did I get this condition?

Will my son get this condition?

GRIPS
HOPI
ODPARA of the walking problem
What do you mean by di culty in starting movement?
What makes it challenging for young o start walking/
Do you have any pains in the joins?
Any sti ness?
Which joints?
After you have managed to start walking, does it get better/
Is there any particular time of the da you experience this problem?
When did all of this start?
Do you was independently generally? Or do you use any walking aids like walking
sticks and Zimmer-frames?

Other than di culty initiating problems, are there any other tasks you nd
challenging to do?
Do you have problems getting out of the chair, turning in bed?what makes it
challenging?
Do you have pain and sti ness? If so, where’s the pain?

What about holding on to objects, any problems with that?

Holding a spoon or forks?
Opening doors?
Buttoning shirts?
Dressing in the morning?

D/D
Parkinson’s disease
Tremors in the hands?
Do you experience tremors at rest?
Do you experience tremors, when you ry to reach or point at something?
Which part of the body do you experience tremors?
Do you feel that you are slow in doing things? (Hypokinesia)
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 Do you experience sti ness in your joints? (Rigidity)
Have you had any falls recently? (Balance problems)
Any di culty buttoning clothes and opening jars?
Any di culty turning in bed?

Drug induced Parkinsonism

First generation antipsychotics are more likely to cause Parkinsonism
(haloperidol, chlorperazine, upentixol, uphenazine, zuclopenthixol)
Second generation antipsychotics are less likely to cause parkinsonism
(olanzapine, amisulpride, aripiprazole, clozapine, olanzapine, quetiapine)
Anti-emetics (prochlorperazine, metoclopramide)

Medical conditions
Stroke
Lewy body dementia

Rheumatoid arthritis
Swelling of the joint
Symmetrical joints a ected
No tremors

Cerebellar problems
Tumor
Stroke

Wilson’s disease
Liver problem
Dementia
Kaiser- esher rings
Joints problem

Huntington disease
Family history

CJD
Blood transfusions, tattoos

Examination:
Blood pressure
Neurological examination
Cranial nerves, U/L and L/L
Gait

Findings:
Resting tremors of the right hand
Cogwheel rigidity
ffi
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 Shu ing gait
Monotonous speech
Di cult initiating movement
Slow movement

Diagnosis:
Its a chronic condition in which part of the brain becomes progressively damaged.
The cause is not known. The body needs a chemical called dopamine, which is
produced by some special cells in the brain, when these brain cells are damaged,
the brain cannot produce enough dopamine.
That may a ect your movement. Sometimes it runs in families. Having a family
member with Parkinson’s disease puts you at risk of developing the condition. It is
a slow progressive condition.

Refer to the neurologist urgently

They will do:
History
Examination
Investigations
MRI or CT san
Con rm the diagnosis

Start treatment (dopamine)

Treatment is multi disciplinary involving physiotherapist, occupational therapist,
speech and language therapist, special nurses e.t.c.
Treatment to control tremors.

Trip
Can you cross arms and get up
I need you to walk til the end of the room and back and ill be behind you to catch
you if you fall
Now I need you to do this with you index and thumb, do as fast and wide as you
can (do it 10 times)
Now I need you to tap you toes
I need to check your tremor ( nger nose)
Now id like to examine you arm, can you place you arm on my arm and let it lose

Parkinson’s disease follow up

FY2 in GP surgery
62 year old man has come for follow up after 3 months of diagnosis of Parkinson’s
diseases, played on methyl dopa
Tremors in hand, di culty initiating movement
He was referred to the neurologist and was diagnosed

What is ti?
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 Is it curable?

GRIPS
History of Parkinson’s
What do you understand about Parkinson’s disease?
When were you diagnoseD?
What symptoms did you experience?
Any symptoms at the moment?
What treatment are you on?
Are you taking the treatment regularly?

Social life
How are you coping at home?
Who do you live with?
Are you independent?
E ect on life?
Like not being able to hold spoon, knife, etc?
Do you have any carers?
Any problem with walking?
Any falls recently?
Any problems with holding equipment?
Any pain anywhere?\

Drive:
Do you drive?
Advice to inform DVLA
Car or motorcycle may drive if safe control is maintained

Other history
PMAFTOSA
ICE
E ects

Examination:

Inspection:
Around the bed for mobility aid
Tremor (pill rolling tremors)
Watch the hands of the patient when they’re sitting down

Gait:
Shu ing (reduced side length)
Hesitant (di culty initiating the movement or turning)
Festinating (walks faster and faster as not to fall)
Lack of arm swing (early sign due to increased tone)
Unsteadiness (tenderness to fall forward or backward)
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 Note:
Ask the patient to walk to the end of the room and turn around
Follow the patient so he doesn’t fall

Posture: observe while walking (stooping posture)

Now work down the body

Face:
Mask face (decreased blinking)
Speech (soft faint voice)

Upper limbs
Tone
Power
re ex
Bradykinesia (Open and close thumb and index nger as fast as possible/ Play
imaginary piano)

Lower limbs:
Tone
Power
Re ex
Bradykinesia (heel tap)

Diagnosis:
Parkinson’s disease is a progressive neurological condition. This means it causes
problems in the brain and gets worse over time. A person with Parkinson’s disease
do not have enough of the chemical dopamine in the brain because the cells of the
brain that produces dopamine have died
It causes symptoms like slowness, rigidity of the muscles and tremors in the hand.
The cause is not known.

Management:
Continue treatment and take medication regularly
Next follow up in 3 months time
O er lea et about Parkinson’s disease
Refer to multidisciplinary team (if not already referred)

Headache -Carbon monoxide

Fy2 in the gP practice
18 year old
Headache 1 month
Sometimes she does experience dizziness
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 Non localised headache, 4/10, starts gradually, she has no headache when she
leaves home. She only gets the beach when she goes home. She’s in a new home,
with her friends, and her friends sometimes also experience headaches, symptoms
only started a month ago, the landlord tted a new heater. She doesn’t open the
windows since it is very noisy.

Why do I have these headaches?

Do I need to go to the hospital?

GRIPS
SOCRATES (headache)
D/D
PMAFTOSA
ICE
E ects of symptoms

CO poisoning
COMA
C-co habits, co-occupants: anyone else in the house is a ected, other than the
patient?
O-outdoors: if the symptoms improve when they’re out of the house
M-maintenance: if there are fuel-burning appliances, and ventilations that are not
properly tted
A-alarm: if they have a CO alarm

Have you recently had heating or cooking appliances installed?

Have you ever used the oven or gas stove for heating or cooking?
Have you had ventilation changed at home recently?
(E.g new tted heated in the home)
Other people in the house a ected?
Have you noticed any soot stains around appliances or an increase in
condensation
Do you do any work whee there is exposure to smoke fumes or motor vehicles
exhaust at work?
Do symptoms improve when you leave home?

Other symptoms of CO exposure: Low level

Dizziness
Flushing
Headache
Nausea and vomiting
Muscle pain
Personality change
Vertigo
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 Other symptoms of CO exposure: High levels:
Confusion
LOC
MI
Movement problems
Respiratory failure
Headache

Suspected: CO poisoning
The likely cause of the headache is CO exposure most likely the source is the
heater which has been recently tted. We are saying this because you’re
experiencing headache only at home and gets better when you leave and other
members of the house are a ected so all of this supports the diagnosis of CO
poisoning.

Management:
Advice to go to the emergency department
If by the time you reach the ED and you still have a headache, they will give 100%
oxygen to make you feel better.
A neurological examination will be done and blood tests will be done to check
carboxy haemoglobin levels.

Prevention:
Don’t use the suspected appliances: heaters
Advice the other people at the house to go to the hospital as well for assessment
as well.
Contact the local health protection team.

Diagnosis:
Normal level: <1-3%
Smokers: 10%
Toxic e ect appear at CO haemoglobin levels at 15-20%
CO levels at 30% indicate severe exposure.

Advise:
The landlord should t in audible CO alarm
Keep room ventilated while using gas appliances
Have all gas appliances correctly installed and checked regularly
Never use a gas appliance that is suspected of being faulty. Signs to look for here
is:
-Yellow or orange ames
-Soot or stains around appliances
Advice people that it is the legal duty of the landlord to have gas appliances
checked annually and to provide the latest certi cates to their tenants
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Idiopathic raised ICP
You are an FY2 in GP surgery
Ella Williams aged 30 made an appointment

Headache 3-4 moths

Throbbing, constant headache
Worse with bending forward, sneezing, and coughing
Also worse in the morning
Relieved when she stands up
Has been taking COCP-10 years
Her weight is on the higher side
Has also been experiencing blurring of vision for the past 3-4 months

Approach

GRIPS

SOCRATES (headache)
What have they tried so far? Has the medication helped?

D/D
Migraine
Tension headache
Brain tumour
Idiopathic intracranial hypertension
Cluster headache
CO poisoning
Medication overuse headache
Giant cell arteritis

Benign raised ICP

Typical symptoms
Young patient, female
Obese
Risk factors: obesity, irregular periods, postpartum period or rst trimester of
pregnancy
Coincide with recent weight gain

Brain tumour
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 Middle age, older patient
Progressive constant headache
Focal neurological symptoms (weakness, hyperre exia, reduced power U/L)
Headache: worse in the morning and bending forward and blurring of vision due to
papilloedema

Other history:
PMAFTOSA
ICE
E ect of symptoms
What do you do for living?has it a ected their work, sleep, daily activities?
Summary

Examination
Visual acuity-reduced B/L
Fundoscopy-papilloedema B/L
Cranial nerve examination-normal or 6th nerve palsy
Neurological examination of L/L and U/L-normal
Visual eld examination- enlarged blind spot B/L
BMI

Diagnosis: Idiopathic raised ICP

It is caused by overproduction of uid in the brain. The uid is called cerebral uid.
The cause is unknown.
The risk factors include: obesity (recent studies have shown no link of COCP and
increased ICP)
High pressure in the brain leads to headache and damage to the optic nerve (nerve
responsible for vision) which in turn causes blurring of the vision.

Management:
Routine investigations (FBC, U&E, LFT, iron studies, antinuclear antibodies, clotting
screen)
MRI scan of the brain
Refer to the ophthalmologist for further visual eld assessment
O er lea et
Refer to neurologist for management
Lose weight
Acetozolamide medication
Surgical options:
Intracranial venous sinus stenting (placement of stent in one of the veins in the
brain)
CSF shunting

Epilepsy
scenarios
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 Suspected epilepsy
Con rmed epilepsy
Epilepsy review

Scenario A
Suspected epilepsy

55 year old man had seizure while watching tv.

He either had urinary or feral incontinence.
Biting of the tongue.

Take history as usual

Approach:
What was the patient before the seizure
What happened during and after the seizure

D/D
Hypoglycaemia
Viral encephalitis
Meningitis
Brain tumour
Head injury
Alcohol
Drug abuse
Epilepsy

PMAFTOSA
ICE

Examination:
Face to face
Telephone : arrange a face to face appointment to examine the patient o see any
neurological symptoms

Neurological examinations:

In this particular case because there was biting of the tongue/urinary incontinence,
from what you’ve told me I suspect that you have what we call epilepsy. Abnormal
electrical discharge in the brain that leads to seizures. You lose control of your
bowels during the seizure. The cause is usually not known. In certain people, they
develop electrical activity that leads to a seizure.

Management:
Refer to neurologist
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 The specialist will perform investigations to rule out other possible causes of
seizure
MRI
EEG electrodes on your head to see activities of your brain
Routine investigations

In the meantime, if the patient is driving, to stop driving and inform the DVLA.
O er lea ets about how to manage seizures.
Seizure itself is not serious but you may get injured, like head injury, which could
lead to bleed in the brain.
You, your family members, or anyone close to you should protect your head. Place
the person on the left hand side.
Monitor your seizures, if its >5 mins, call the ambulance, it can cause breathing
problems.
Do not put anything in the mouth, do not restrain the patient.
If it is possible, the witnesses, if they can take a video that will be very helpful for
the consultant.
When you go tot he specialist, its helpful to go with someone who witnessed the
seizure.
Try to keep a diary of the seizure.
If this is epilepsy, there is a medication that can be given to prevent seizure: anti
epileptic

There are things that can trigger seizure

Avoid drinking alcohol or cut down

O er lea et about what to do in emergency

Scenario B
Con rmed diagnosis of epilepsy

13yr old, con rmed epilepsy, has had 2 seizures in the past
MRI and EEG done.
On treatment already, ready to discharge.

Approach:
Ask about seizure
What circumstances child had to have a seizure
Lifestyle/hobbies of the child : swimming/dancing
Check what they understand about epilepsy: what have you been too so far, do
you have an questions for me?

Address the concern

Can the child dance?
Yes, but ask what type of dance?
If there’s any ashing lights, it can cause epilepsy.
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 They can swim but its important to inform the life guard.

Do I need to follow her everywhere she goes?

No, only inform the people around her.
Watch out for dangerous activities: riding a bicycle, mountain climbing, take a
shower instead of a bathtub. (Risk of drowning) avoid locking of door while
showering,

Scenario C
Epilepsy review

Diagnosed with epilepsy 3 weeks ago

Discharged from hospital
Stated on sodium valproate
Routine blood tests came back normal
MRI, EEG, ECG done
EEG showed epilepsy

Approach:
I can see you were discharged from the hospital 3 weeks ago, have you had a
seizure since you were discharged. What were you told so far about your
condition, did you understand what it is?

Assess seizure control?

Any more seizures?
Are you compliant to your medications: do you take them daily (is there any
reason why you don’t take them daily)
How has this e ected your life?

O er advise how to manage seizure

Driving: atm its unfortunately not advisable for you to drive, it will put you and
other people at risk. I’m sorry this is disappointing for you. Inform the DVLA
Alcohol: cut down
Tv: ashing lights? Avoid it.
Explain precipitating factors.
Avoid saying don’t take bath, just need to inform just take a shower.

Epilepsy Annual Review

Scenario B
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28 year old gentleman has come for annual review
Diagnosed with epilepsy 6 years ago
Was placed on sodium valproate
All investigations were done
MRI normal
EEG showed epilepsy
Was seizure free for 3 years, he was given back licence
About a month ago, he stopped taking sodium valproate, because he had been
seizure free for a while
He had 2 episodes of seizures, and then started sodium valproate again
He works as a delivery driver
So he cannot tell DVLA

Approach
GRIPS
History taking
How are you feeling generally
Any seizures
Any side e ects of medication
Compliance with medication: are you taking your medication regularly
Understanding of epilepsy: do you understand well about what epilepsy is, and
what triggers it
Any more seizures since last review
Risk factors: lack of sleep, watching tv with throbbing lights on, loud noises
Ask about risk activities: driving, bicycle, mountain climbing, swimming

Explanation:
Advice to stop driving and inform DVLA
Unfortunately, they may suspend your licence for a certain period of time
at the moment it’s a risk to himself
Sometimes, if you don’t inform DVLA, we are forced to tell the DVLA as it is a
potential risk to you and to others, but we would like for you to inform yourself
Take medication regularly
Give information abut what to do in case he has got a seizure: ill give you a lea et
about what to do in case of an emergency which you can give to people around
you so they know what to do in case you have seizure
They need to make sure your head is safe, by putting it on a pillow
Remove dangerous objects, put nothing in mouth, monitor seizure, if its >5mins,
cal 999 and bring you to hospital for assessment. Seizure may not be dangerous,
but it can cause head injury.
Sometimes seizures are not due to epilepsy, there can be other causes.
Advice about safety: take shower instead of a bath, avoid alcohol, ashing lights
(parties/ night clubs)

Dementia
daughter has concerns
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are you normally t and well?
what things are u forgetting? other than that are there any other concerns

D/Ds
are you on any medication?
vascular dementia : high blood pressure, high blood sugar, any hx of stroke, fhx of
stroke, fhx of vascular dementia
lewy body : do your feel like you memory is progressively getting worse, do u feel
like your memory is good sometimes, sometimes its not,
Has anyone or your daughter commented on your personality
have u noticed any self neglect
do you drink alcohol
any hx head injury
any medical problem (IHD, HTN, DM, Stroke, TIA), Parkinson
fhx of dementia
Explain diagnosis
theres a possibility that you are forgetting things could be due to dementia, it tends
to run in families and since you have a family hx of dementia, you're more likely to
be predisposed
you're only 65yrs old which is young for the onset of dementia. sometimes it can
happened early known as early onset dementia

refer to a memory clinic to be assessed by specialist, a brain specialist,

they'll run some test, routine investigations
FBC, U&E, LFT, TFT, serum B12
do blood test, check for any signs of infection
might do a brain scan,

if dementia is con rmed, they'll o er tx for dementia

medication
non-medication, stimulating your cognition (cognitive-stimulation)

GP, MMSE mini mental state assessment to assess your memory

phoeecall, don't need to do MMSE
notify DVLAdont drive

MMSE
22/30 is low
perform MMSE to assess your awareness of what’s happening around u and your
memory

i would also like to do MMSE but specialist can do it all together with all other
investigation (call)

F/U of con rmed dementia

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frustrated that mother doesn't remember, locks mother home
how can you help me
daughter has lasting power of attorney
mother also has hyperthyroidism

what do u know about dementia, how long has she has it for? what can she do?
(bathing dressing cooking)? what help does she need? is she the only carer?
safeguarding issues? any challenging behaviour ( screaming, hitting)
Safeguarding :
‘sometime it can be challenging to look after someone w dementia, they don't
follow or understand which could be frustrating. they don't wanna be helped.”
they can make you act out of character and act aggressive or abusive? has this
happened to you
who stays w mother when u go away? have ever been verbally abuse you mother?
does u mother ever get abusive w you?
how are you coping/ do u need help?
does she have any medical condition? is she on any medication . is it controlled

mother has dementia, not eating

your mother is dying from dementia, she has end stage dementia. it is highly
unlikely shell get better from here.
we've discussed her with the medical team and we've placed her on palliative
treatment
do you know what palliative therapy is?
explain
why not an NG tube
not going to help you mother, it'll cause agitation and discomfort

ask about distressing behaviour, mothers wishes and advanced decisions

you can take u mother home but we have to make sure that it wont cause you
distress or emotional duress. support yourself. training. ew
do you have LPA? Next of kin?only carer?
Place mother in nursing home

Moton’s neuroma
Foot pain

Fy2 in Gp surgery
Elsie Pearsons 30 yrs presented with some concerns
Talk to the patient and address the concerns.

Dr. I have got pain in the left foot between the 3rd and 4th tie. Gradual dull pain,
sometimes shooting. Doesn’t radiate anywhere. Worsened by running. Recently he
has not been able to run, otherwise t and well. Severity 5/10. Pain has been there
for the last 2 months.
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You are a distance runner athlete.

Approach
GRIPS
SOCRATES

D/D
Stress fracture
Moton neuroma
Osteoarthritis
Rheumatoid arthritis
Osteomyelitis (fever, systemic symptoms)

Moton’s neuroma
Enlargement of the nerve, common in people running large distances. Thickening
of the digital plantar nerves. You can actually palpate it. Shooting pains.
Stres fracture:
Microsomal fractures

PMAFTOSA
ICE
EFFECTS OF SYMPTOMS
Summarise

Examination
Inspection of the foot for swelling
Palpation for tenderness (apple pressure to the involved inter-
metatarsophalangeal space)
Asses for neurovascular status
-Loss of sensation to the a ected toes
-Palate the dorsals pedis and posterior tibialis.
Examine joint movement and compare with the opposite side.
Perform Mulder’s click.
-grip neuroma between the fore nger and thumb (with thumb on the plantar aspect
of the foot)
-with the other hand squeeze simultaneously the metatarsal heads.
-a click can be felt and heard as the nerve stabilises between metatarsal heads.

Findings:
Pain between 2nd and 3rd metatarsal.

Diagnosis:
It is likely the you have Moton’s Neuroma. It is the thickening of the digital plantar
nerve. It occurs commonly between the 3rd and the 4th inter metatarsal space. It is
believed to be caused by chronic repetitive trauma. It is common in athletes.
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 Management:
NSAIDS
Advice to avoid high heels and shoes with constriction toe box or thin soles.
Advice to use metatarsal pad, pad should be placed just proximal to metatarsal
heads.
O er lea ets
Explain that if the symptoms may persist after 3 months, we will refer to the
specialist. Orthotist.
The specialist will o er orthotic device, if it doesn’t work, then you would be
referred to the orthopaedic surgeon for other treatments such as corticosteroids or
alcohol injections and surgery.

Frozen shoulder / Adhesive capsulitis

FY2 in GP surgery
48 year old man, shoulder pain for 2 weeks on the left side
Very painful 9/10, cannot move the shoulder
Worsens at night , especially when he sleeps, on the same shoulder
He has lost some weight, and he exercises.
He is left handed and cannot use his right arm
He works in a bank and he is forced to use his left arm a lot
He has di culty putting on clothes in the morning
It’s a ecting his driving as well
He tried paracetamol and ibuprofen but its not helping
Has diabetes type 2 controlled by diet and it’s well managed

GRIPS
HOPI
SOCRATES (pain)
Neck pain or UL pain
Sti ness
Previous shoulder injuries or dislocation
Dominant or on dominant hand
Systematic symptoms: fever, night sweats, weight loss, rash or respiratory
symptoms (polymyalgia rheumatic)
Occupation or sporting activities

Other history:
PMAFTOSA
ICE
E ect of symptoms (occupation, sleep, daily activities)
Summarise
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 Examination:
Start examination with normal shoulder
Look: inspection
Feel: tenderness and temperature
Move:
1. Active: patient is doing ti
2. Passive: doctor moves the shoulder

Special tests: (to know the cause)

Painful arc test: supraspinatous tendinitis
Raise the shoulder slowly, with elbow extended 60 degrees pain starts, and 120
degrees pain stops
Impingement test: supraspinatous tendinitis
Raise the arm to 90 degrees, raise the thumb, then ask patient to make a thumb
down sign. During this movement, patient experiences pain
Drop arm test: rotator cu tear
Elbow extended, shoulder at 90 degrees, if there is tear, the arm will drop
Apprehension test: anterior shoulder dislocation
90 degrees with the shoulder and the arm, you stand behind the patient and pull
the arm backwards
Speed test: bicep tendinitis
Bend the elbow 45 degrees, ask the patient to bend it further, with resistance.

Neurovascular:
Palpate radial pulse
Neurological exam:
Ulnar nerve
Median nerve
Radial nerve
Sensation of the three nerves

Motor examination:
Make a perfect (okay) sign, I will try to break it, do not let me break it (median
nerve)
Make a thumb up sign on both hands, ask the patient to resist you putting the
thumbs down (radial nerve)
Grip my ngers, and I will try to pull away, don’t let my ngers pull away (ulnar
nerve)

Sensory examination: tap your ngers on the distribution of radial, median and
ulnar nerves.

Examination ndings:
No redness, not warm to touch, no swelling
Restricted shoulder movement in all directions
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 Unable to move the shoulder
Normal pulses
Normal peripheral nerve, motor and sensory examination

Diagnosis: Frozen Shoulder (adhesive capsulitis)

Pain is the main problem, sti ness improves with time.
It is a self limiting condition.
Takes months to years to resolve,
It is a painful condition, that leads to sti ness and disability, because you’re not
able to preform certain functions.
It is characterised by a progressive restriction of both active and passive shoulder
movement and typically a ects people aged 40-60 years. Diabetes is a risk factor,
and frozen shoulder is more di cult to treat in patients with diabetes.

What caused it:

Sometimes it can be idiopathic or secondary to
Any trauma
Rotator cu disease
Any heart problems
Any weakness in any part of the body
Diabetes (13% chance)
Thyroid dysfunction
Symptoms are often more severe and resistant to treatment compared to people
without diabetes
It is more common in women and in people who previously had frozen shoulder in
the opposite shoulder.

Investigations:
Xray of the shoulder
Blood test:FBC, U&E, in ammatory markers (CRP, ESR) to rule out giant cell
arteritis, myositis, rheumatoid arthritis, polymyalgia rheumatic
Management
Analgesia (paracetamol, ibuprofen)
Cold packs
Since pain is worse at night, support the arm with pillow to prevent rolling onto
a ected side
Avoid movement which worsens the pain
Physiotherapy
If patient doesn’t improve, refer them for intra-articular steroid injection, to reduce
in ammation

No needful referral for now, but in 3 months if there is no improved, we can make a
referral to specialist (Ortho)

Ankle injury:
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 Fy2 in GP
62 year old man has made an appointment
Talk to him, address his concerns
Tripped while walking and heard a pop, like something snapped

Has severe dill pain around the ankle, posterior aspect

Has got a cruise trip in 1 week, and worried if he would be able to go
Tried ibuprofen didn’t help
Not keen to go to the hospital

Question:
Why can’t you just treat it here?

GRIPS
History:
When did it happen?
What was he doing?
Did he/she twist the foot?
Did that foot twist inwards or outwards?
Did you hear a snap sound? (If yes-ligament injury most likely/ achilles tendon
rupture)
Where is the maximum pain?
Were are you able to put weight on your leg?
Did you need help to walk?
Was there immediate swelling?
Did you have an ankle injury before in the same foot?

D/D
Ankle sprain
Achilles tendon rupture
Ligament tear
Fracture
Baker’s cyst
DVT
Achilles tendinopathy

Other history
OMAFTOSA
ICE
E ect of symptoms

Examination
Look
Feel
Move
Special test
Neuromuscular
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 Joint above and below
Oppose joint

Look (inspection)
Gait: watch the patient walk (limping)
Look at the ankle (deformity, swelling, bruises, open wounds)

Feel (palpation)
Temperature (back of the hand)
Tenderness
Palpate for:
Crepitus
Medial and lateral malleoli
Base of the big toe
Tarsal bones
Fibula all the way
Ligaments (ATFL, PTFL, CFL, deltoid ligament)
Calcaneum
Achilles tendon

Movement:
Active
Passive

Joint
Plantar exion
Dorsi exion
Inversion
Eversion

Flexion of the toes

Extension of the toes

Neurovascular
Pulses:
Dorsalis pedis and posterior tibialis
Senations:
Touching on the plantar and dorsal aspects

Special tests:
Achilles tendon
PTFL
CFL
ATFL
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Anterior drawer test
Hold the leg, and pull the heel up (tests integrity of ATFL)

Talar tilt test

Hold the leg, and invert the foot (tests integrity of CFL)

Squeeze test on the mid calf

(High Ankle sprain - syndesmosis injury)

Squeeze test of the foot

(Morton neuroma) squeeze across the metatarsophalangeal joints (note any signs
of discomfort)

Thomson’s test
Patient lying on the tummy (prone)
Let the foot hang at the end of the couch
Squeeze the calf
Normal:
Foot will move backward
Achilles tendon rupture:
Foot doesn’t move

Squeeze test of the calcaneum

Fracture

Diagnosis:
You could have su ered a ligament rupture or achilles tendon rupture because you
heard a snap.
If maximum pain at the back, this could be tendon rupture.
I have assessed you, you have got severe pain, I asked you to walk, you cannot
put your weight properly, your not able to make any movement, so I suspecting
because you felt a pop or snap, it could be a ligament injury but we cannot
exclude a fracture,

Investigations
Plain X-ray to rule out fracture
MRI/USS scan to rule out rupture of the tendon

Management:
Ankle X-rays: Ottawa rules
Ankle radiography is indicated only:
Bone tenderness at the posterior edge of the tip of medial or lateral malleolus
Inability to bear weight (four steps) immediately after the injury and at the time of
the assessment
Foot radiography:
Bone tenderness at the base of the 5th metatarsal or one the navicular bone
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 Inability to bear weight (four steps) immediately after the injury and at the time of
the assessment

Treatment:

PRICE
Protection
Rest
Ice
Compression
Elevation

Avoidance of heat, alcohol, running and massaging (HARM)

Heat: which encourages blood ow which will tend to increase bruising and
in ammation
Alcohol: which can increase bleeding and swelling and decrease healing
Running: which may cause further damage
Massage: which may increase bleeding and swelling

Analgesia if requires

Non weight bearing

Urgent referral to orthopaedic specialist for assessment
They will perform investigations: MRI/USS to con rm
Treatment options:
Conservative (less active)
Walking boots-2 weeks
Weight bearing as tolerated for 4-6 weeks
Might need plaster cast as brace might be needed

Surgical (more active/athletic)

O er lea et

Suicidal Risk assessment - OCP overdose

Fy2 in Pysch
16yr old came to A&E
Overdose of OCP (16 tablets)
To get rid of pregnancy, no intention of killing herself
Told her bf about the pregnancy and he was not interested
Cut wrists as she wanted attention from bf, again no intention killing herelf

DO pregnancy test

GRIPS
be loud and con dent
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Avoid shaking hands
“ I understand that you took some overdose of some medication
The ER department has assessed you and the good news is that you have no
come to any harm. You do not need treatment from medical point of view (don’t
assume the patient knows that she has been cleared by the A&E)

HOPI
I understand you have taken an overdose of medication
1. What medication did you take?
2. Where did you get the medication
3. How many tablets did you take?
4. What did you take the medication with? Water? Alcohol
5. What did you think the medication will do? “Get rid of the pregnancy”
6. What made you decide to take the medication?
7. How long have you been thinking about taking an overdose? “Wasn’t
thinking”

After the attempt:

1. Did you seek help after yourself or did someone get help or you?
2. How did you feel afterwards?
3. Do you regret being saved/alive?
4. Are you happy to receive help?
5. Do you think you would do it again?
6. Do you regret your actions?

Previous attempt
Are there other times in the past when you have tried to harm or kill yourself
Do you get thoughts of harming yourself?
What type of thoughts?
If you were to get a thought of harming yourself,, what would you do?

Suicide risk assessment

1. Did you plan to take the overdose?
2. Did you write a note to anyone before doing it
3. Did you tell anyone before taking the medication
4. Did you take actions so that youre not founds
5. Did you come to the emergency department on your own

History of wrist cut

I can see a bandaid on your wrist
1. What happened?
2. Did you cut your wrist?
3. How many cuts did you make?
4. How deep are the cuts?
5. Did you bleed a lot after cutting yourself?
6. Can you describe how did you feel?
7. How did you feel when you saw your blood?
 8. What ere you hoping the cutting would do?

Pregnancy history
When was your LMP
Did you perform a pregnancy test at home
Did the perform a pregnancy test
When did you have unprotected sex

Ask about parents:

Are you parents aware that you’re in a sexual relationship?
Is there nay particular reason you haven’t told them

Past history
Are you generally healthy and well? Any medical conditions

Social history
Who do you live with?
When you are discharged, where would you go?
Do you go to school?
How is School?

Explain
I’ve assessed you now so you have a low suicide risk
Did not take tablets to commit suicide
And since your intentions were to get rid of the pregnancy
And you regret your actions

No contraception is recommended to get rid of pregnancy because of your late

periods. Contraption can prevent pregnancy but can not get rid of pregnancy

Arrange a pregnancy test

we’ll discharge you home after taking a second opinion from senior colleague
Arrange community psychiatry follow up
Advice to inform her parents about her relationship and they’ll understand
O er crisis card if you ever get thoughts of harming yourself

Did she do a pregnancy test

How old was the boyfriend
Can I go home? Yes cause low suicide risk

Suicide risk assessment

Suicide A&E
1. 25 yearsYoung aged female, who will come and tell you, she rst of took
paracetamol overdose
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 2. 16 years old, she also cut her wrist. (Bandage on her hand) and on coco

Procedure:
When did you take them?
How many tablets?
How did you take them? (With alcohol)
From where did you get them?
And since you took the medications, any tummy pain? Any vomiting? Any
dizziness or drowsiness?
FMAM
6 questions of
Needle phobia, and site preference? Take the sample.

Psychiatry scenario
16 years old, she cut her wrist, and took COCP overdose.

What about this bandage I can see in your hand?

Assess and perform suicide risk assessment:

Before
During
After
I undertand you came her e today because sadly, you took COCP overdose and
unfortunately cut your wrist,. Sorry about that, and im here to talk about this, but
before I go ahead, so rst of all I want to ask you, how are you doing today?
Im going to ask you a few questions to ensure we are on the same page.
I understand that you took COCP overdose
So please take em through what happened?
What happened exactly? What did you take?
From where did you get the COCPS?
So before taking the medication, did you plan for it? Did you lock the door, or draw
the curtains? Did you leave a note?
so you believe that it was not planned, it was quite impulsive right?
So how many tablets did you take?
How did you take it?
When did you take it?
After you took the tablets, what did you feel, what did you do?
Did you have nay symptoms? Any vomiting, any tummy pain, any drowsiness?
So after taking these tablets, what did you feel?
And I believe I was pregnant, that’s why I took them.
Okay why do you think, if you took the COCP, they will help you?
(In the end, counsel her regarding COCP, any COCP can prevent pregnancy in the
rst place but it cannot get rid of the pregnancy)
Why do you feel you’re pregnant? Did you take a pregnancy test?
So apart from the late periods, did you perform any test?
After your boyfriend did that for you, what did you do?
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 -I cut my wrist-
She took COCP at night and cut her wrist in the morning.
I can see there’s a bandage in your hand, so why did you cut your wrist? Take me
through what happened?
Sorry about that, how did you cut your wrist?
Is it super cial or deep cut? I am going to have a look at your cut but I have to ask
you, is it super cial or deep cut?
How did you feel when you saw the blood?
Did a lot of blood come out? Was it severe?

Risk factors of any suicide

Is this the rst time you are doing something like this, whether the COCP or the
cut?
How’s your mood?
Scale the mood for me.
In the last one month, do you feel like you’re feeling low or depressed? Or you feel
like you’re losing interest in the things you used to enjoy?
What is the situation at home?
Who else is at home?
how’s everything at home? Are they supportive?
Also, the relationship with this boyfriend. What about your boyfriend?
Is he your classmate?
RISK Factors:
Depression. Previous attempts. Abusive relationship, things at home
FMAM chronic depression making her depressed
Social hx DESA, ask smoking drinking
O er empathy im sorry it happened. Im here to o er you a chat
So I would like to ask you, when you took this medication or when u cut ur wrist
can I ask what was your intention
Paraphrase I believe Ashly that u only did this to get attention from ur boyfriend
and get rid of the pregnancy. Am I right that these were the only reasons?
If the time goes back, would you do hat again
Do u regret what you have done/happened/HOW DO YOU FEEL ABOUT IT, DO U
REGRET IT?
In the future, if that happened agin will u do it again

Do you regret? Pt says i’m not sure > ADMIT

(If there’s doubt about intention, admit the patient)
Ask about the future, is the stress bearable
We have to keep you in the hosp and await assessment from the psychiatric

paracetomol doubt
COCP - pt never doubt

What what you’ve told me, im happy and glad that the intention wasn’t to kill
yourself and also you regret what you’ve done . However nothing in life deserves
that u do that to yourself. Every problem hs a solution. For eg if you feel like you’re
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pregnant, you can seek immediate medical attention, we can help you with that.
Because taking COCP overdose
e or cutting wrist is putting your life in danger so I would be happy to discharge u
home after my seniors have talked to you. However now let me speak to you about
the COCP. You told me that u took them as they will Reid of the pregnancy but
unfortunately its not the case. COCP are used to prevent pregnancy in the rst
place, its method of contraception. It won’t get rid of the pregnancy. We have other
options, we have em contraception. So if you’re really concerned, we can help you
and do the best for you. Also what we can do is visit ur GP and get contraception
(you’re in A&E)
SO, from my assessment, its highly unlikely you will do that again and you should
be able to go home. Ofcouse after discussing it my seniors. And what we can do is
arrange a F/U with the community psychiatric clinic to check up n you. Ill also o er
you a crisis card, whenever you feel like its alot. We are available 24/7.
Paracetamol Pt will tell assess you. Meanwhile well h
Im worried about you ad il ask the specialist to come and .Keep you in the hosp

Suicide risk assessment: Paracetamol overdose

Scenario B

Fy2 in psych
24 year old woman has presented to emergency department following
paracetamol overdose
ED doctors have assessed her and medically t for discharge
Paracetamol level is low below the treatment line
Talk to the patient and discuss management

Took 14 tablets of paracetamol following an argument with her boyfriend

She had two similar episodes int he past following argument with boyfriend
Denies tried to kill herself
Has come to hospital with boyfriend
Boyfriend is in the waiting area

GRIPS
History of suicide
When did she take the overdose?
What was the intention?
What made you take the overdose?

Before the attempt:

Can you describe what happened
What were you doing at that time?
Did you plan it?
Where were you?
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Were you alone?
Do you drink alcohol?
Were you drinking at the time?
Where did you get the tablets from?
You got the tablets, then what happened?
What did you want to see happen?
Did you want to kill yourself before you took the tablets?
What thoughts were you having beforehand that led to the attempt?
What did you think would happen if you died?
What did you think would happen after you had injured yourself?
Was there any speci c reaction you wanted to get from someone?
Ere other people present at that time?
Did you make any preparation to make sure you were not found?
Did you make any preparation such as writing a will, or writing a note?
Did you make any preparations such as coming Facebook accounts, or bank
accounts or switching o your phone?
What did you think would happen if you were found dead?
Is there anyone in particular you would’ve wanted to nd you?

During the attempt:

What medication did you take?
Where did you get the medication from?
What did you take the medication with?
How many tablets did you take?
Did you think that this number of tablets would harm you?
Did you take nay other medications other than paracetamol?
Did you hurt yourself in any other ays such as cutting yourself with a knife? If yes,
ask more:
What did you use to cut yourself?
Why did you cut yourself?
Did you think that was going to kill you?

After the attempt:

Did you seek help afterward yourself, or did someone get help for you
Who bought you to the hospital? Did you come yourself, or did someone bring
you?
Had you planned to be discovered, or were you found accidentally?
How did you feel afterward?
Do you regret your actions?
Do you regret being alive?
Did you receive treatment afterward in the emergency department?
Are you happy to receive help?
Has your view changed or is anything di erent for you since the attempt?
Do you think you would do it again?
How often do you try to harm yourself?
Has this happened before?
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How many times has this happened
Can you tell me about those incidents
When was the most recent time
Can you describe your thoughts at that time most seriously about suicide.
When was your most serious attempt at harming or killing yourself
What led up to it, and what happened afterward?

Protective factors:
What keeps you from harming yourself?
Is there anything that would make life worth living?

Risk factors:
Intake of alcohol at the time of the overdose
Did you drink alcohol just before you took the tablets?
Did you take medication with alcohol?

Any use of drug abuse:

Is there any chance you use recreational drugs?

Any previous low mood (depression):

Have you ever been diagnosed with depression?
Have you ever had any symptoms of low mood, poor sleep, or waking up in the
morning very early?
How are your energy levels?
How is your appetite?
How long have you had these symptoms?

Any mental health problems?

Any regular medications?
Previous self harm and methods?

Any other relationship

Do you have siblings?
Are they supportive?
Do they know you’re in hospital?
If you were to go home, where would you go?
Have you informed anyone?

Family history of suicide or self harm:

Sorry to ask you this question:
Is there anyone in the family who ever su ered self harm?
Is there anyone in your family with mental health problems?

Risk factors of suicide:

Anyone in the family who has ever committed suicide
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 Previous attempt
Any mental health problems

Other history:
PMAFTOSA
ICE
E ects of symptoms

Family and friends:

Who do you live with at the moment?
Are your parents around?
Do your parents know you’re in the hospital?
Is your boyfriend here with you?
If you were to go home, where would you go?

Management:
I will need to discuss with my seniors, but at the moment I feel you are low risk. Of
course what we are concerned about that if you go home, you may do it again. But
from what you’ve told me, everything was emotional, so you didn’t have any
intention to kill yourself, so its unlikely you will do this when you go home, and I
don’t feel you’re high risk, and I would be happy to discharge you home but I
would like to discuss with my seniors rst.

Educate about the risk of self harm

Paracetamol can cause damage to the life, as it can cause damage to your liver,
and sometimes it could be life threatening
On this occasion, the level of paracetamol you have taken is below the treatment
level
Which means it is unlikely to cause any harm
But it is a big issue because one day, you can cause serious harm to your health

Milestones in a toddler
FY2 in paediatric department
Suzy is a 5th year medical student who wants to learn how to perform a toddler
development
She has been posted for 6 weeks in a paediatric department and the has been on
this rotation for 1 week

Introduction
Use your rst name
I am one of the FY2

Build rapport
How is the rotation going etc?
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 I understand you want to learn how to perform milestones assessment in a
toddler?
Is there anything speci c you would like to learn?

Check prior knowledge?

What do you know already about milestones assessment?

Indication
We usually perform it in a child if:
Routine assessment
Concerns from the parent

Approach:
General toddlers, aged 2-3 years.
How old is the child you are supposed to perform development assessment on?
2-3 years.

What to look for?

Gross motor
Fine motor and vision
Hearing and language
Social

Gross motor:
2 years: runs
3 years: stand on one foot, climb one foot per stairs

Fine motor:
2 years: makes circles, lines and scribbles
3 years: build bridges with blocks, draws circles

Hearing and language:

2 years: 2 word phrases
3 years: short sentences, knows colours

Social:
2 years: knows identity, parallel play
3 years: interactive play

Red ags in toddlers:

At 2 years:
Language: not able to follow a simple command

Lack of words or lack of two words meaningful sentences

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 Motor: inability to walk
Social: poor eye contact

Not imitating actions or words of caregivers

At 3 years:
Language: inability to use 3 words sentences
Motor: di culty using stairs or frequently falling (DMD)
Social: lack of pretend play

Using the growth chart:

BMI
Weight
Height
Head circumference
This will give you centile location of the child development

More reading:
Royal college of paediatrics and child health website

Suspected Cancer Approach

Background knowledge:
FY2 in GP surgery
3rd year medical students wants to learn how to assess a patient with suspected
cancer
Teach on how to assess and manage a patient with suspected cancer

Introduction
Use your rst name, I am one of the FY2s
“Hello Im Dr Rabia, I’m an FY2 in this department”

Build Rapport (ask 1-2 questions only)

How is school
How is it going
Which rotation are you in

Introduce the topic

I understand you want to learn how to approach suspected cancer
Is there anything speci c you would like to learn

Check prior knowledge

What do you know already?

Approach
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Take history of the presenting complaint
“To suspect cancer, you need to take good history”
Now cancer may present in so many ways.
And in most of the cases, Symptoms are usually non-speci c. They could be
vague.
The initial presenting complaint may depend on the location of the cancer
For eg. Lung cancer, bladder cancer, bowel cancer may all present with related
symptoms. They may present with speci c or vague symptoms.
Some may present with persistent symptoms that aren’t resolving
For eg chronic back pain that isn’t going away or diarrhoea that isn’t resolving or
any pain in any part of the body
These persistent and chronic symptoms are more likely to indicate cancer, so your
index of suspicion should be high
What can help you pick up cancer is doing a systemic review. So take history of a
systemic review, that is asking symptoms about RS, CVS, git, gu, CNS, MSK, so it
can help

It is also important to screen for non speci c symptoms of caner

Cancer may present with loss of appetite, tiredness, fatigue, and weight loss.
These are non speci c but you need to ask if youre suspecting cancer

Cancer causes anemia so ask about SOB, palpitations and ligthedness

ICE
Ideas - some people may have an idea about what could be the cause of the
problem so ask “have you thought what could be the problem”

Concerns - “is there anything youre worried about”

They might a have a family hx of CA so theyll be worried

Examination
You might need to do a systemic examination along with speci c examination to
rule out metastasis
Ao your examination will depend on the presenting complaint and will also include
a thorough examination covering all systems If youre suspecting bowel cancer, it
may involve back/spine examination and chest to rule out bone and lung mets

Diagnosis
If youre suspecting cancer, you’ll need to tell the patient the diagnosis. So tell the
patient it could either be simple things like infection, eg pneumonia, depending on
your location but you’ll telll them that youre worried that it can be caused by
something serious as well
“Im a little bit concerned about your symptoms, you have blood in your urine, you
smoke ad you’ve lost weight, which could be caused by a simple infection but
could also be caused by bladder cancer. So im cornered your symptoms may be
caused by something serious,
Give examples
Cough, blood in sputum could be infection but could also be lung ca
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But tell youre concerned and worried that the symptoms can be caused by
something serious, dont give de nitive diagnosis
Do not hide the diagnosis fearing the patient may get anxious
Now depending on the patients diagnosis, you can order appropriate
investigations
Because of this, ill be ordering a CT scan of your chest or I’ll be referring you
They’ll then understand why youre taking the step

Be sensitive, but remember its not breaking news. Just tell them what youre
worried about and what you’ll be doing. Its only suspicion.

Management
Referring urgent using a suspected cancer pathway within 2 week which means
you’ll be seen in 2 week
S reassure that not everyone referred via this pathway dont get diagnosed with
caner
They can take their relative or friend with them to the appointment
You’ll receive an appointment via post
They’ll do questions about your symptoms, examine you and do special
investigations depednig on your cancer
Do safety netting for the pateint: if youre not seen within 2 weeks, come back to
GP
At GP, you might need to do some initial investigations before referral such as CT
scan or blood tests bt these test shouldn’t delay referral

They’ll start treatment

In that unfortunate event that it is cancer, we’ start treatment depending on your
stage. The patient may be o ered surgical options along with radio or chemo
therapy
Reassure the pateitn again that not everyone gets diagnosed with caner if they are
referred via this pathway
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